Enfield Diabetes Support Group

Living with Diabetes

In collaboration with

ENFIELD DIABETES SUPPORT GROUP A LOCAL DIABETES SUPPORT GROUP IN THE AREA FOR THOSE WITH DIABETES, THEIR FAMILY AND CARERS

WOULD YOU LIKE SUPPORT/COULD YOU GIVE SUPPORT?

MONTHLY MEETINGS ARE HELD ON EVERY SECOND TUESDAY AT: THE DIABETES CENTRE CHASE FARM HOSPITAL THE RIDGEWAY ENFIELD EN2 8JL FROM 7.30 pm TO 9.00 pm GUEST SPEAKERS TALK ON ALL ASPECTS OF DIABETES CARE AND OTHER RELATED ISSUES EVERYONE IS WELCOME FOR MORE INFORMATION CALL: RUTH – 020 8386 4416 or [email protected]

THIS GROUP IS RUN BY PEOPLE WITH DIABETES FOR PEOPLE WITH DIABETES

Issue 5 –September 2015 © No part of this publication may be reproduced in any form without the permission of the Enfield Diabetes Support Group and Diabetes Nursing Team BEH-MHT – 2006 onwards

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FOREWORD

The aim of the booklet is to help those with diabetes, their family and their carers to be better informed, know what questions to ask and know where to go for help. This booklet has been produced by people with diabetes from the Enfield Diabetes Support Group in collaboration with the Barnet Enfield and Haringey Mental Health Trust Diabetes Team. Since its first publication, this book has been endorsed by the Enfield MP’s – Joan Ryan, David Burrowes, Andrew Love and Nick de Bois. In order to manage your diabetes well, you will need to learn more about what diabetes is, how it is treated and what YOU can do to help yourself. Do not try to take in all the information in this booklet at once but read it when you need it. Remember – you are not alone in having diabetes.

Enfield MP’s - correct at time of going to press

Issue 5 –September 2015 © No part of this publication may be reproduced in any form without the permission of the Enfield Diabetes Support Group and Diabetes Nursing Team BEH-MHT – 2006 onwards

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CONTENTS

TOPIC

PAGE NUMBER

Useful contact numbers Introduction Explanation of diabetes terms What is diabetes? Who is most at risk of developing diabetes? Questions you might want to ask Coping with diabetes The importance of your regular diabetes check-ups Getting the most out of your annual review Regular check-ups Some medications used in the treatment of diabetes Taking insulin Your diet Healthy Eating Principles Physical activity Smoking Health Trainer Service Foot care Controlling your blood pressure Taking care of your heart Blood glucose monitoring Pharmacies What does my HbA1c (Glycated haemoglobin) mean? Hypoglycaemia Hyperglycaemia Feasting and fasting Eating with friends Eating out Social life Feeling unwell Driving and diabetes Motor Insurance Travel Entitlements Dental care Personal insurance Employment Job application What to tell an employer Complications of diabetes

5 6 7 8 9 10 11 12 13 14 15 18 19 20 22 24 24 25 27 28 29 31 32 33 34 35 36 36 36 37 38 39 40 42 42 42 43 44 44 45

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Eyes – Retinopathy Eyes – Cataracts Hardening/Furring of arteries Kidney problems – Nephropathy Nerve damage – Neuropathy Foot ulceration Sexual health for men Sexual health for women Contraception HRT – (Hormone Replacement Therapy) Thrush Cystitis Index Additional information sources

45 46 46 47 47 48 48 50 50 51 51 51 52 55

Diabetes UK is an independent, registered charity and is the largest charity devoted to the care and treatment of diabetes. Diabetes UK is committed to providing education and support to all people with diabetes. Members of Diabetes UK receive a bi-monthly magazine packed with news, celebrity interviews, lifestyle features and recipes. Membership also helps to fund research that aims to find a cure for diabetes. Diabetes UK produces a wide range of books, magazines and leaflets on everything from cooking to travel – all aiming to help people live with diabetes. Telephone 0800 585 088 for a free catalogue.

A considerable amount of the information included in this booklet is attributed to Diabetes UK.

Issue 5 –September 2015 © No part of this publication may be reproduced in any form without the permission of the Enfield Diabetes Support Group and Diabetes Nursing Team BEH-MHT – 2006 onwards

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ORGANISATION

Barnet & Chase Farm North Middlesex University Hospital Royal Free Whittington University College Hospital

Chase Farm Hospital Urgent Care Centre NMUH Urgent Care Centre Edmonton NHS Walk In Centre

Community Dietetics

Diabetes Nursing Team Enfield Diabetes Support Group Enfield Quit Smoking Service Heart Throbs - Joan Firth Citizens Advice Bureau Health Trainers

Best Treatments Department of Health Food Standards Agency

TELEPHONE

WEBSITE/EMAIL

ACUTE HOSPITALS 0845 1114000 www.bcf.nhs.uk 020 8887 2000 www.northmid.nhs.uk 020 7794 0500 www.royalfree.nhs.uk 020 7272 3070 www.whittington.nhs.uk 0203 456 7890 www.uclh.nhs.uk or 0845 155 5000 URGENT CARE AND WALK IN CENTRES 020 8375 1010

Open 8 am – 10pm

020 8887 2000 020 8887 8355

Open 8am – 10pm Open weekends and bank holidays only from 8am to 8pm

LOCAL INFORMATION 020 8702 5660 http://www.beh-mht.nhs.uk/enfield-communityservices/ecs-services/nutrition-and-dieteticservice.htm 020 8702 5830 http://www.beh-mht.nhs.uk/enfield-communityservices/ecs-services/diabetes-service.htm 020 8386 4416 [email protected] 0800 652 8405 01992 718155 0208 375 4170 020 8379 5269

www.quitsmoking.uk.com www.heart-throbs.org.uk http://www.enfield.gov.uk/healthandwellbeing/info/1/yo ur_health/120/health_trainers

NATIONAL INFORMATION www.besttreatments.co.uk www.dh.gov.uk www.food.gov.uk www.salt.gov.uk www.eatwell.gov.uk 020 7424 1000 www.diabetes.org.uk 0345 123 2399 [email protected] N/A N/A N/A

Diabetes UK Diabetes UK Support and Careline DVLA - Driving Licence enquiries 0300 790 6801 www.direct.gov.uk/motoring Vehicle enquiries 0300 790 6802 NHS Direct 0845 4647 www.nhsdirect.nhs.uk NICE - National Institute for N/A www.nice.org.uk Clinical Excellence PLEASE NOTE – THESE DETAILS ARE CORRECT AT TIME OF PRINTING AND SOME DETAILS MAY CHANGE

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INTRODUCTION HOW THIS INFORMATION BOOKLET HELPS YOU This information booklet is for you, your family and for your carers. It contains useful information about diabetes care and how to maintain good health. Diabetes cannot yet be cured but it can be treated successfully. No one really knows why some people develop diabetes. Diabetes affects around 3 million people in the UK and Ireland so you are not alone. In most cases it will not interfere with your family, work or social life. You will be able to continue with your daily activities and will be able to participate fully in an active home, family and work life if you work together with the people who are there to support you e.g. consultant, diabetes nurse, dietitian, doctor, optician and podiatrist. In order to manage your diabetes well, you will need to learn more about what diabetes is, how it is treated and what YOU can do to help yourself. Do not try to take in all the information in this booklet at once but read it when you need it.

REMEMBER YOU PLAY THE MOST IMPORTANT PART IN YOUR OWN TREATMENT AND YOUR HEALTHCARE TEAM IS THERE TO HELP 

Taking responsibility for your diabetes on a day-to-day basis can dramatically improve your general health and well being



Poorly managed diabetes can lead to complications



Please do not ignore your diabetes

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EXPLANATION OF DIABETES TERMS

Type 1 Diabetes

This used to be known as insulin dependent diabetes mellitus and is caused by a total failure of the body to produce insulin.

Type 2 Diabetes

This used to be known as non-insulin dependent diabetes mellitus. Type 2 diabetes is the most common type. The body can still make some insulin but not enough. The insulin it does make does not work properly.

Blood Glucose Levels

This is the amount of glucose found in your blood sample when tested. It is measured in millimols per litre of blood – shown as mmols/l. Normal blood glucose levels in people without diabetes are between 4 and 6.5 mmols/l.

HbA1c or Glycated Haemoglobin

This is your long-term blood glucose level. It is measured as a percentage or in mmols/mol. It should ideally be around 48 mmols/mol or 53 mmols/mol depending on your age and duration of diabetes

Hyperglycaemia

This is the medical term for high blood glucose (hyper).

Hypoglycaemia

This is the medical term for low blood glucose (hypo).

Insulin

This is a hormone produced by the beta cells of the pancreas. It helps the body to control blood glucose levels and to control energy production.

Nephropathy

This is a complication that results from damage to the blood vessels in the kidney.

Neuropathy

This is a complication that results from damage to the nerves and mainly affects the feet.

Retinopathy

This is a complication that results from damage to blood vessels that are in the back of the eye and can lead to blindness.

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WHAT IS DIABETES? Diabetes is a condition in which the body loses its ability to convert glucose into energy. This is because the hormone insulin (a chemical messenger) is either not being produced in sufficient quantity or cannot work efficiently. Insulin is manufactured in the pancreas and is responsible for controlling the amount of glucose in your bloodstream. When the glucose levels in the bloodstream rise after eating, the pancreas (situated behind the stomach) releases insulin. Insulin helps glucose enter the cells of your body where it stays until it is needed for energy. Without enough insulin, the level of glucose in your bloodstream rises and becomes too high. Glucose comes from the digestion of food and drink that have higher amounts of carbohydrate (starch). Examples are potatoes, rice, pasta, bread, sweet foods like cakes, biscuits and desserts as well as sugary drinks. When blood glucose levels are too high, you can develop some of the following symptoms:       

Thirst/dry mouth Tiredness Passing large amounts of urine Blurred vision Weight loss Itchiness (skin and genitals) Cramps

You may not have experienced any of these symptoms at all. There are two types of diabetes 

Type 1 diabetes. Type 1 diabetes develops when the insulin producing cells of the pancreas have been destroyed. Nobody knows for sure why these cells have been damaged but the most likely cause is an abnormal reaction of the body to the cells. This may be triggered by a viral or other infection. This type of diabetes generally affects younger people.



Type 2 diabetes. Type 2 diabetes used to be called ‘maturity onset’ diabetes because it usually appears in middle aged or elderly people. It is becoming more common in younger people. The main causes are that the body no longer responds normally to its own insulin and/or the body does not produce enough insulin. Being overweight is often a trigger to this type of diabetes.

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WHO IS MOST AT RISK OF DEVELOPING TYPE 2 DIABETES?

People most at risk of developing diabetes are: 

Those with a family history of diabetes



People who children



Women who developed diabetes pregnant (gestational diabetes)



More common in those over 40



People of African/ Caribbean, Mediterranean or Asian origin have been found to be more susceptible to the onset of diabetes

are

overweight,

including

when

Type 2 diabetes is often wrongly described as ‘mild’ diabetes. All types of appropriately.

diabetes

should

be

taken

seriously and

treated

TREATMENTS A suitable healthy diet and physical activity are both very important in managing diabetes. Some people will need tablets to improve their blood glucose levels, others will need to have insulin injections or a combination of both. Recently new treatments for people of type 2 diabetes have been developed. These include injections (Incretin mimetics or GLP-1 Agonists) and tablets (DPP4 inhibitors, Gliptins and SGLT-2 inhibitors). These are explained in the section on page 16.

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? QUESTIONS YOU MIGHT WANT TO ASK WHEN DIAGNOSED

?

About my condition What is my diagnosis? What caused my condition? Can my condition be treated? Is there a cure for diabetes? How will diabetes affect other health problems I have? Should I watch for any particular symptoms and notify you if they occur? What lifestyle changes should I make? About my treatment What is the treatment for diabetes? When will the treatment start? What are the benefits of this treatment and how successful is it? What are the risks and side effects associated with this treatment? Are there any foods, drugs or activities I should avoid? Are there any other treatments? About the tests What kinds of tests will I have? What do you expect to find from these tests? When will I know the results? Do I have to do anything special to prepare for any of the tests? Will I need more tests later?

OTHER QUESTIONS YOU MIGHT HAVE AT ANY TIME How can I find out more about my diabetes and access structured education? Can I stop taking the insulin? Will the pain in my feet get better? Can I eat out? Can I drink alcohol? How do I cope on holiday? If I need insulin by injection, will I change from having type 2 diabetes to type 1 diabetes?

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COPING WITH DIABETES Diabetes is your condition and although it would be nice for others to manage it, it is your responsibility to do so with the help and support of your health care team, family and friends. When first diagnosed it is quite common to feel shocked and perhaps a little lost. Some people can accept the diagnosis and others are fearful and scared because they feel that their life is out of control and they cannot cope. It is not unusual to feel helpless and overwhelmed or resentful. It will take time to come to terms with your condition and some people have a harder time than others. You may experience a number of emotional changes, for example, anger, sadness, fear, anxiety or depression (more than feeling a bit low). However, there are many ways you can help yourself but if the emotions you are experiencing last more than a month, talk to your GP. If you feel you need support you can contact the Enfield Diabetes Support Group – details are on pages 1 and 56. Educating yourself about diabetes can help immensely in reducing your anxieties. Structured education sessions are available in Enfield and these can be delivered in different ways. For example, Conversation Maps for type 2 diabetes and DAFNE and BERTIE for Type 1 diabetes. Your healthcare team will be able to give you more details. Diabetes UK has an excellent support and care line team. Telephone 0345 123 2399. (Calls to this number are charged at local rates.) Remember, no question is silly and the more you know, the more successful you will be at managing your diabetes. Understanding and discussing your condition with your family, friends and other people with diabetes can help you bring your fears into perspective. TIPS         

Diabetes only restricts your life if you allow it Not every day will be a good day so be prepared to be a bit flexible You can only cope well if you understand your condition If you are not sure about anything or don’t understand what you have been told – ask If you think something sounds wrong – query it Don’t take ‘no’ for an answer – always ask ‘why’ Build a relationship with your pharmacist - they are a wealth of information Your health professionals will want you to change your life style. Work with them Physical activity can be just walking to the shops or doing some gardening

If you find you are not coping with your diabetes, phone your surgery for advice.

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THE IMPORTANCE OF YOUR REGULAR DIABETES CHECK-UP (ANNUAL REVIEW) Your healthcare professional, regardless of whether you are seen by your GP, Diabetes Nurse or a Hospital Consultant should ensure that you are reviewed at least once every year. Your diabetes care plan will be discussed with you. These check-ups should include the following:               

Long term blood glucose control (HbA1c) Weight Blood Pressure Cholesterol levels How you are coping and the impact that diabetes is having on your life Smoking cessation advice Eye sight/vision test (not with dilated pupils) Retinopathy screening (digital photograph with dilated pupils) Urine testing for kidney function Feet (pulses, sensation and general foot health) Your diet and eating habits should be discussed Your current treatment/medication should be discussed Your current physical activity programme should be discussed Your injection sites checked if insulin treated Contraception advice given if appropriate

At these check-ups you will be assessed on how well your diet, medication and lifestyle are controlling your blood glucose levels. In order to ensure that your blood glucose levels are staying as close to normal as possible, your healthcare professional may find it necessary to do any of the following:    

Suggest improvements to your diet Change your physical activity programme Start you on tablets Change your medication e.g. dosage, type of tablet or add insulin

If it is felt that you need to start new medication or insulin therapy, help and support will be available before, during and after the change. If you require an injectable therapy, you will be referred to the Enfield Community Services Diabetes Team

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GETTING THE MOST OUT OF YOUR YEARLY CHECK-UP (ANNUAL REVIEW)

Your yearly check-up is extremely important to you and is your opportunity to find out how well you are doing. It is a good idea to write down your questions on a piece of paper prior to your appointment with your healthcare professional. You can also discuss any worries, fears or anxieties that you have. Your yearly check-up also enables the healthcare professional to ensure that they are providing the most appropriate care for you. Here is a suggested checklist:  

   

Have you had the blood tests taken as requested by your doctor or nurse? Have you brought along a fresh specimen of urine in a clean specimen pot? This should always be the first sample you pass when you get up. (The sample pot is available from your surgery, Health Centre or Diabetes Centre that you attend) Have you had a diabetes retinopathy screening examination? (This test is a digital photograph taken after your pupils have been dilated with eye drops) A list of your current medication Bring your home blood glucose record diary (if you are recording your blood glucose at home) Bring your personal diabetes care plan/record with you if you have one

Here are some questions that you may wish to think about prior to your check-up:  

  

Are you experiencing any side effects from your medication? Are you experiencing any of the following health problems: Chest pain, shortness of breath, swollen ankles, headaches, pain in legs, problems with your feet, blurred vision, symptoms of hypoglycaemia or hyperglycaemia? Do you feel generally well? Do you have any worries about your health that you wish to discuss with your healthcare professional? Are there any new developments in diabetes care that you need to know?

13 Issue 5 –September 2015

© No part of this publication may be reproduced in any form without the permission of the Enfield Diabetes Support Group and Diabetes Nursing Team BEH-MHT – 2006 onwards

REGULAR CHECK-UPS - THIS IS NOT THE SAME AS YOUR ANNUAL REVIEW Routine check-ups should ideally take place every three to six months. If you test your blood glucose or urine at home, take your record book with you to the check-up. This is the ideal time to discuss any health worries that you may have with your healthcare professional. If you are worried about your health, contact your surgery. It is essential in an emergency to get prompt medical advice. CONTACT YOUR SURGERY IF THE FOLLOWING APPLY 

If you begin to feel thirsty or unwell



If you test your blood glucose levels at home and the readings are CONSISTENTLY high. i.e. before you eat over 10 mmols/l for a period of 6/7 days or if levels are over 15 mmols/l for 2 days



If you test your urine at home and it shows an increased frequency of positive readings



If you have persistent nausea and vomiting and you are unable to keep medication down



If you notice any problems with your feet that are causing you concern, e.g. skin breakdown, swelling or change in colour

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SOME OF THE MEDICATIONS USED IN THE TREATMENT OF DIABETES

It is now widely accepted that all people who have been diagnosed as having Type 2 diabetes should be started on a suitable healthy eating plan for a period of 3-4 months. If a change in lifestyle is ineffective in bringing down blood glucose levels, your healthcare professional will discuss suitable medication for you to take. Along with a suitable healthy eating diet you may be prescribed tablets or insulin or both. Even when you start taking medication for your diabetes, you will need to continue to follow suitable healthy eating recommendations. It is important to note that diabetes is a progressive disease, which may require increasing treatment regimens throughout your life span. There are several types or groups of medication that work in different ways to lower the blood glucose level. Your doctor will decide which type of tablet will be best for you. Most medicines have at least two names. One is the scientific (generic) name, the other is the brand (proprietary) name that is given to the drug by the company that manufactures it. Your local pharmacist is an expert on drugs and can offer you additional advice. Remember to read the information leaflet supplied with your medication. Brief descriptions are shown below: SULPHONYLUREAS: Examples of tablets in this group are: Generic name Glibenclamide Gliclazide Glipizide

Brand name Daonil Diamicron Minodiab/Glibinese

Sulphonylureas work by stimulating the pancreas to produce more insulin and by improving the action of whatever insulin is being produced naturally. They then lower the blood glucose by allowing glucose to enter the cells of your body. The side effects, which tend to be generally mild and infrequent, include weight gain, gastro-intestinal complications such as nausea, vomiting, diarrhoea and constipation. Risks can include hypoglycaemia, facial flushing after drinking alcohol and disturbance of liver function i.e. jaundice.

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BIGUANIDES: Examples of tablets in this group are: Generic name Metformin

Brand name Glucophage Glucophage SR

Biguanides work by increasing the amount of glucose taken in by the muscles in the body and reduce the absorption of glucose by the intestines. The side effects can include nausea and vomiting, occasional diarrhoea, wind, abdominal pain, metallic taste in the mouth, itchiness and swelling of the skin. OTHER MEDICATIONS Generic name Acarbose

Brand name Glucobay

This drug delays the rate at which you digest glucose. It slows down the rate at which your blood glucose rises after you have eaten. The side effects can include wind, a feeling of fullness and diarrhoea. Generic name Repaglinide Nateglinide

Brand name Prandin Starlix

These drugs work in a similar way to a sulphonylurea. They are taken before meals and increase the amount of insulin that is produced during a meal. The side effects can include a risk of hypoglycaemia and sensitivity. Generic name Pioglitazone

Brand name Actos

This drug helps the insulin that your body produces to work more effectively. Side effects can include a risk of hypoglycaemia, stomach upset, swelling of ankles (oedema) weight gain, anaemia, fatigue/tiredness. It may also increase your risk of bone fractures. If you notice that your ankles become swollen or you get breathless, contact your doctor immediately.

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OTHER MEDICATIONS continued Generic name Exenatide Exanatide (extended release) Liraglutide Lixisenatide

Brand name Byetta (twice daily injection) Bydureon (weekly injection) Victoza (once daily injection) Lyxumia (once daily injection)

This medication increases the amount of insulin produced and stops the liver producing a hormone called glucagon which releases glucose into the blood stream. It also slows down the stomach emptying and also acts on the brain to bring about a feeling of fullness. This commonly causes weight loss due to a reduced appetite. It is given by injection. Side effects can include nausea, vomiting, diarrhoea, decreased appetite, headache, dizziness. Generic name Sitagliptin Vildagliptin Saxagliptin

Brand name Januvia Galvus / Eucreas Onglyza

This medication helps to reduce the blood glucose concentration by blocking the breakdown of a chemical messenger that enhances insulin production. It does not cause weight gain. Side effects can include nausea, vomiting, ankle swelling. Generic name Dapagliflozin Canagliflozin Empagliflozin

Brand name Forxiga Invokana Jardiance

This medication works by blocking the reabsorption of glucose from the kidney. As a result, glucose is flushed out of the body in the urine. Side effects can include thrush (Candida), Urinary Tract Infection, nausea, vomiting, diarrhoea and dehydration. Due to the way these medications work, your urine will test positive for sugar while taking these medications. Some people with diabetes may need a combination of different groups of medication. Your diabetes healthcare professional will advise you on which medications you require. REMEMBER - when you do start taking medication for better control of your diabetes you still need to continue with your suitable healthy eating plan as well, so no cheating. NEVER STOP TAKING YOUR MEDICATION EVEN IF YOU ARE FEELING SICK. CHECK WITH YOUR HEALTH CARE PROFESSIONAL IF YOU ARE EXPERIENCING DIFFICULTIES IN SWALLOWING YOUR MEDICATION OR YOU ARE VOMITING. 17 Issue 5 –September 2015

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TAKING INSULIN As part of your treatment plan your healthcare professional MAY suggest that you need to commence insulin therapy. Many people with diabetes are fearful of injecting themselves with insulin. Discuss this with your healthcare professional who will give you the information you need and put you at ease before you agree to start insulin. All the possibilities will be discussed with you to enable you to make an informed choice. You will be taught how to inject yourself with insulin and you will be supported with an on-going education plan while you get used to it. Some of the main discussions which you will have before and once you have started insulin therapy are:  What type of insulin is going to fit in with my lifestyle?  Which insulin pen is best for me to use?  How do I use the insulin pen?  How do I store my insulin?  How do I dispose of the needles?  Does anyone else need to know how to inject my insulin? You will be given a demonstration on how and where to inject by a healthcare professional. Insulin is always started with very small doses whilst you get used to doing the injections. Insulin doses may be increased very gradually depending on your blood glucose levels. This will be under close supervision of your healthcare professional. Your healthcare professional will also go into detail about the following:  How to recognise and treat low blood glucose (hypoglycaemia)  What to do if you become ill  How often you should be reviewed at your diabetes clinic  Travel, eating out, etc. For people with diabetes who have been taught to adjust their own doses of insulin as a result of their tests, it is useful to test blood glucose levels prior to or after meals, before and after exercise or as advised by your healthcare professional. Where to inject – Injections are given in fatty areas of the body, i.e. stomach, thighs, buttocks or arms. People are no longer advised to self-administer insulin into the arms as there is a risk of injecting into the muscle rather than the fatty layer of the skin. It is good practice to rotate the injection sites as continually using the same place may damage the tissue underneath. Disposal of needles – Ask your healthcare professional about the safe disposal of needles. Remember – if you have any problems, contact your healthcare professional. Issue 5 –September 2015 © No part of this publication may be reproduced in any form without the permission of the Enfield Diabetes Support Group and Diabetes Nursing Team BEH-MHT – 2006 onwards

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YOUR DIET KNOW YOUR OWN BODY - DIFFERENT FOODS CAN AFFECT PEOPLE DIFFERENTLY Following a suitable healthy eating plan is what we should all be eating. Here are some healthier options for reducing sugar and fat in your diet.

To reduce your sugar intake it is better to choose: Artificial sweeteners, e.g. Canderel, Hermesetas, Sweetex, Splenda

Reduced sugar jams and marmalades, pure fruit spreads

Plain biscuits e.g. Rich Tea, Digestive, Garibaldi, Ginger Nuts, Hobnobs, scones, tea cakes, English muffins, crumpets, fruit loaf, crackers or crisp breads, sugar free sweets. Take care or avoid these if you need to lose weight Sugar-free puddings, e.g. sugar-free instant whip, jelly custard, low fat natural or fruit yoghurts Tinned fruit in natural/fruit juice stewed fruit without sugar, fresh fruit Maximum 3 portions of fruit per day Low calorie, sugar free or no added sugar squash or diet fizzy drinks, low sugar hot chocolate drink, e.g. Options, Highlights. Pure or unsweetened fruit juice, smoothies – maximum 1 small glass (160mls) per day – taken with food.

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To reduce your fat intake it is better to choose Grilled, poached, boiled, microwave or oven baked foods. limit oil to 1 level tablespoon for a meal (enough for 4 people) Oils and margarines labelled ‘high in monounsaturated or polyunsaturated fat (use sparingly) e.g. olive, vegetable, rapeseed, sunflower or oil sprays. Low fat mayonnaise and salad cream, reduced fat salad dressings, vinegar, lemon juice Lean meat, chicken and turkey (no skin), ham, gammon, low fat sausages

Semi-skimmed or skimmed milk

Low fat natural or fruit yogurt (check label), low fat Greek yogurt Wholemeal crackers, plain rice cakes, breadsticks, crispbreads, plain popcorn, plain oatcakes

© No part of this publication may be reproduced in any form without the permission of the Enfield Diabetes Support Group and Diabetes Nursing Team BEH-MHT – 2006 onwards

HEALTHY EATING PRINCIPLES Eat regular meals based on starchy carbohydrates, which include wholegrain varieties. Choose low fat reduced sugar high fibre breakfast cereals, wholemeal bread, pitta bread, crackers and crispbread, pasta, potatoes, Basmati rice, brown rice, chapattis, couscous, noodles, plantain, yam, sweet potato. 

Cut down on fats especially saturated (animal) fats and use monounsaturated and/or poly-unsaturated fats e.g. olive oil, vegetable oil, corn oil or sunflower oil. Use semi-skimmed or skimmed milk, low fat reduced sugar yoghurts and reduced fat cheeses. Grill, steam, microwave, stir fry or oven-bake foods instead of frying them.



Eat foods that are high in fibre. For example beans, peas, lentils (pulses), wholemeal and wholegrain products, vegetables, salad and fruit.



It is recommended by the Department of Health that you eat a combination of at least five portions of fruit and vegetables a day. No more than 3 fruit portions are recommended. A portion fits into the palm of your hand. For example, a small banana, an apple, a slice of melon, 2 plums, a handful of grapes, a cereal bowl of salad or 3 heaped tablespoons of vegetables.



Take care with fruit juice and only have one small glass a day of an unsweetened version. Have fruit juice with meals only, never between meals. Fruit juices are included as one of your fruit portions.



Choose sugar free food and drinks and use artificial sweeteners instead, as this will reduce your intake of sugar.



Reduce your salt intake by reducing or leaving out salt in cooking, buy salt reduced versions of processed and tinned foods and do not put the salt on the table. Remember, cheese, stock cubes, packet soups, salty snacks, ‘smoked’ products and foods in brine are all high in salt. Flavour food with herbs and spices.

Always check food labels because some low fat foods may be higher in sugar and some low sugar foods may be higher in fat. YOUR GUIDE TO READING FOOD LABELS FOOD TYPE Fat Saturated fat Sugars Salt Sodium

HIGH - per 100g More than 20g More than 5g More than 15g More than 1.5g More than 0.6g

LOW - per 100g Less than 3g Less than 1.5g Less than 5g Less than 0.3g Less than 0.1g

Issue 5 –September 2015 © No part of this publication may be reproduced in any form without the permission of the Enfield Diabetes Support Group and Diabetes Nursing Team BEH-MHT – 2006 onwards

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HEALTHY EATING PRINCIPLES 

Keep within the recommended limits of alcohol intake, i.e. 2 units per day for a woman and 3 units per day for a man. One unit is equal to a small glass of wine, half pint of beer or lager or a pub measure of spirit. Never drink on an empty stomach as alcohol can cause very low blood glucose levels. Have 2 or 3 alcohol free days per week.



If you are overweight, losing weight helps control diabetes and also reduces the risk of heart disease and high blood pressure. Aim to lose weight slowly, for example a weight loss of 1-2 lbs (0.5-1.5 kg) per week. You may find it helpful to use a smaller plate for your meals. You can also contact Diabetes UK who have up to date information on portion sizes.



It is not necessary to buy food or drinks labelled as being ‘diabetic food’ as they can be expensive and may have a laxative effect. These products have no added benefit for people with diabetes.

TRAFFIC LIGHT LABELLING Red means high

Amber means medium Green means low

The food is high in fat or salt or sugar (or a combination). Be careful how often you have these It is alright to have some of the time but try to go for green when you have a choice a healthier choice

If the quantity is between the ‘high’ and ‘low’ figures, it is a medium amount REMEMBER – EATING FRESH IS BEST IF YOU REDUCE YOUR WEIGHT BY JUST 10%      

You will reduce the risk of heart attack, stroke and circulatory problems. You will improve your mobility You will reduce joint damage You will feel less tired You will feel less stressed You will feel better about yourself

Enfield Diabetes Support Group can also give you additional support and advice. Ask your healthcare professional if you would like to see a dietitian for either one to one dietary advice or group education or structured education, for example, conversation maps. For more information the Community Dietitians working in Primary Care can be contacted on 020 8375 2973. 21 Issue 5 –September 2015

© No part of this publication may be reproduced in any form without the permission of the Enfield Diabetes Support Group and Diabetes Nursing Team BEH-MHT – 2006 onwards

PHYSICAL ACTIVITY Physical activity is good for you.    

It can improve your circulation It can help you to control your weight It can make you feel good and give you a greater sense of well-being Physical activity can help in controlling blood glucose levels

Physical activity improves your general health and helps your muscles to use up glucose that has been stored in them. You do not need to join a gym to increase the amount of physical activity that you do. If it has been a while since you have undertaken any form of physical activity, it is recommended that you check with your GP before starting any form of physical activity. Housework or gardening can be included in the 30 minutes. According to the World Health Organisation on physical activity, this is now split into age groups: AGE Children aged 5 - 17 years

Adults aged 18 - 64 years

Adults aged 65 and above

ACTIVITY At least 60 minutes of moderate- to vigorous-intensity physical activity daily. Includes play, games, sports, transportation, chores, recreation, physical education, or planned exercise, in the context of family, school, and community activities. Should do at least 150 minutes of moderate-intensity aerobic physical activity throughout the week or do at least 75 minutes of vigorous-intensity aerobic physical activity throughout the week or an equivalent combination of moderate- and vigorous-intensity activity. Aerobic activity should be performed in bouts of at least 10 minutes duration. Includes walking, dancing, gardening, hiking, swimming, cycling, occupational (i.e. work), household chores, play, games, sports or planned exercise, in the context of daily, family, and community activities. Older adults should do at least 150 minutes of moderateintensity aerobic physical activity throughout the week or do at least 75 minutes of vigorous-intensity aerobic physical activity throughout the week or an equivalent combination of moderate- and vigorous-intensity activity. Aerobic activity should be performed in bouts of at least 10 minutes duration. Includes leisure time physical activity walking, dancing, gardening, hiking, swimming, cycling), occupational (if the individual is still engaged in work), household chores, play, games, sports or planned exercise, in the context of daily, family, and community activities.

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Here are some other tips on how to increase your physical activity levels:    

Walking is an excellent way to start exercising, especially if you are older or have other medical problems Use stairs instead of lifts When using buses or trains, get off one stop before the end of your journey and walk the remaining distance Park your car a little further away from work or the shops

It is important to test your blood glucose levels prior to exercise to ensure that there is no risk of hypoglycaemia. Once you are exercising regularly, you may decide to try other forms of physical activity, for example swimming or cycling. If you are not physically able to carry out these activities, ask your healthcare professional about armchair physical activities which will help to build up your strength. If you have a heart problem or angina, contact Joan Firth for details of the Heart Throbs physical activity classes on 01992 718155 or www.heart-throbs.org.uk.

23 Issue 5 –September 2015

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SMOKING Diabetes and smoking simply do not mix. Diabetes increases the possibilities of suffering a heart attack, stroke or peripheral vascular disease (reduced blood supply to the legs and feet). When smoking is added to this, you may double the risk of illness and shorten your life expectancy. Giving up smoking is not easy and you may not be able to give up at your first attempt. It is important that you never stop trying to give up.

Smoking cessation groups are held at specialist smokers’ clinics - this is the most effective way to stop. Your local chemist may also be a specialist stop smoking adviser. They can give you the necessary support on a one-to-one basis. Either treatment option provides you with essential advice and support as well as nicotine replacement therapy (patches, gum, etc.) free of charge. Phone Freephone 0800 085 6258 or ask at your local chemist or visit www.quitsmoking.uk.com ENFIELD HEALTH TRAINERS The Health Trainer Service in Enfield CCG area was originally launched in August 2007. This service was a result of recommendations from a Government ‘White Paper’ on health that identified that a new initiative was needed to improve the inequalities within health in the United Kingdom. There are 12 Health Trainers within the Enfield CCG area. They speak many languages including Turkish, Urdu, Punjabi, Somali, Hindi, Gujarati and English. The role of the Health Trainer is to give practical advice and support to people who want to lead a healthier lifestyle. They provide this via one to one sessions, allocating six sessions for each client. They can advise people on weight loss, healthy eating, increasing physical activity levels and quitting smoking. There is a health trainer attached to the Diabetes Nursing team at Forest Primary Care Centre Road who has been in post since January 2008. For further information on this service please telephone 0208 379 5269. Issue 5 –September 2015 © No part of this publication may be reproduced in any form without the permission of the Enfield Diabetes Support Group and Diabetes Nursing Team BEH-MHT – 2006 onwards

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FOOT CARE Care of your feet is very important. In people with diabetes, the nerves to the feet often become less sensitive (neuropathy) so you may not be aware of any cut, burn, blister or infection. GENERAL CARE DO        

Wash your feet every day with mild soap and warm water Dry your feet gently and carefully especially between the toes Moisturise your feet and legs with a good quality moisturiser but avoid putting any moisturisers between your toes Check your feet daily especially between the toes. Use a mirror if needed Cut toenails after a bath or shower as the nails are softer Always keep your toenails trimmed Always cut your toenails straight across Make sure that the corners of the nails are gently rounded by using a file

DO NOT     

Cut your toenails too short Cut the sides of your nails Attempt to cut your nails if you cannot see them clearly Treat corns yourself or use corn plasters Use creams or lotions between the toes

REMEMBER     

Electric blankets and hot water bottles need to be used with caution Never put your feet directly on to hot water bottles as this can cause serious burns See a podiatrist or chiropodist if you have any problems. The podiatrist will assess those people with diabetes who need podiatry care. With the podiatrist’s or chiropodist’s approval, you may use a pumice stone gently Many people will never see a podiatrist as not everyone needs to see one.

It is essential to make sure your feet are checked by your healthcare team at least once a year. 25 Issue 5 –September 2015

© No part of this publication may be reproduced in any form without the permission of the Enfield Diabetes Support Group and Diabetes Nursing Team BEH-MHT – 2006 onwards

WHAT TO LOOK FOR WHEN YOU CHECK YOUR FEET 

Any change in the colour of your feet and toes. Certain conditions may cause your feet to become red, purple, blue or even black



A change in temperature, as hot feet may indicate infection and cold feet could be a problem with your circulation



Unusual dampness in socks or tights could be due to a break in the skin, blisters or infection



Any change of feeling in the feet, e.g. burning, pins and needles, sharp pain, cramps or throbbing

FOOTWEAR

DO      

Wear shoes/slippers at all times Wear shoes with leather uppers Make sure that your shoes fit you correctly, i.e. they do not rub New shoes should be worn in gradually Check the insides of your shoes for foreign objects or signs of wear before putting them on Wear loose top socks made from natural fibres, e.g. wool or cotton

DO NOT     

Walk barefooted Wear tight or worn shoes Wear open toe sandals Wear tight garters or suspenders Wear slip-on type footwear

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CONTROLLING YOUR BLOOD PRESSURE Having your blood pressure checked is an important part of your diabetes care. High blood pressure (hypertension) is more common amongst people who have diabetes. High blood pressure can increase the risk of heart attacks and strokes and can worsen retinopathy (eye disease) and nephropathy (kidney disease). You need to make sure that when you attend for your annual diabetes review, your blood pressure is taken as part of this check-up. If you have been advised that your blood pressure is too high and you are taking medication, you will need to have your blood pressure checked every three to six months to ensure that it is stable. Your blood pressure is usually recorded like this: 130 80  The top number is the systolic pressure. This is the pressure that is recorded when your heart contracts in order to pump blood round your body 

The lower number is the diastolic pressure. This is pressure that is recorded when your heart relaxes between beats

Your healthcare professional will endeavour to keep your blood pressure below or equal to 130/80. If you have problems with your kidneys or your eyes, your blood pressure needs to be lower. It is important to take your blood pressure medication regularly, even if you feel well. If you have been told that you need to lower your blood pressure, try the following: 

If overweight, aim to lose weight by reducing your calorie intake



Eat a healthy, balanced diet



Reduce your salt intake



If you smoke, STOP



Only drink alcohol in moderation. Be honest with yourself about the amount of alcohol that you drink. Keep within the recommended government guidelines i.e. 2 units per day for women; 3 units per day for men



Take regular physical activity



Take prescribed medication

27 Issue 5 –September 2015

© No part of this publication may be reproduced in any form without the permission of the Enfield Diabetes Support Group and Diabetes Nursing Team BEH-MHT – 2006 onwards

TAKING CARE OF YOUR HEART Cardiovascular disease is the damage to the heart and blood vessels by a build-up of cholesterol (fatty deposits) on the linings of the blood vessels. This can restrict the flow of blood around the body and can result in a heart attack, stroke or problems with the circulation in the legs (Peripheral Vascular Disease or PVD). In the UK, cardiovascular disease is a major cause of ill health and early death in the general population. However, those with diabetes are four times more likely to develop the risk of coronary heart disease, strokes and circulation problems. You can help prevent cardiovascular disease by following the healthy living advice in this booklet.

Cardiac Support Group If you have a heart problem or angina, the Heart Throbs cardiac support group (contact Joan Firth, 01992 718 155) hold monthly meetings which are friendly and informative with speakers talking on a wide range of health related topics. People attending the group can also discuss any worries they may have about their health or lifestyle with others who have had similar experiences. These meetings are free but a small charge is made for refreshments. Partners are also welcome. The group also runs several afternoon and evening exercise sessions each week with fitness trainers who are specialised in cardiac rehabilitation exercises. A reasonable charge is made for these sessions.

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BLOOD GLUCOSE MONITORING If your healthcare professional feels that it is appropriate for you to test your blood glucose levels using a blood testing meter, either they or your local Pharmacist will be able to advise you on the most suitable meter. You will be advised about the amount of times that you need to test by your healthcare professional. According to the National Institute of Clinical Excellence 2008, you should aim for a level of between 4 and 6.5 mmols/l before meals and up to 8.5 mmols/l two hours after meals. If you find that your blood glucose levels are persistently high (that is greater than10 mmols/l) at different times of the day, make an appointment to see your healthcare professional. Should the results at any time start to fall outside an acceptable range on a regular basis, then it is helpful to increase the frequency of the testing. Seek help and advice from your healthcare professional taking the blood test results with you.

Here are a few facts to bear in mind if you are testing your blood glucose levels at home: 

Do not get too concerned if you have a high reading every now and again



Do not become alarmed when your blood glucose levels rise after you eat as this is entirely normal



Test on one day before eating and another day, test 2 hours after eating



Test before and after exercising



Don’t forget, any emotional stress can affect your blood glucose levels

29 Issue 5 –September 2015

© No part of this publication may be reproduced in any form without the permission of the Enfield Diabetes Support Group and Diabetes Nursing Team BEH-MHT – 2006 onwards

Summary of the NHS Enfield advice for blood glucose monitoring for those with Type 2 diabetes is given below.

Diabetes controlled by either diet and physical activity or tablets and diet and physical activity: 

People with well controlled diabetes may wish to test their blood glucose levels. Discuss this with your healthcare professional.



If you wish to test your blood glucose levels then it is recommended to test 2-3 times a week at different times in the day.



If you find that your results start to fall outside of the acceptable range, monitor and increase the frequency of testing. Speak to a member of your healthcare professional taking your blood testing results with you.



If you experience hypoglycaemia symptoms whilst taking a sulphonylurea, test your blood glucose levels and act accordingly. See page 33.

People with diabetes on conventional insulin therapy combined with tablets. Maybe having fixed doses once or twice daily. 

Blood glucose monitoring should be at least daily at differing times of the day. If you find that your results start to fall outside of the acceptable range, monitor and increase the frequency of testing. Speak to a member of your healthcare professional taking your blood testing results with you.

People with diabetes on intensive insulin therapy, having multiple daily doses of insulin depending on the blood results: 

Testing your blood glucose levels is essential.



You may wish to test your blood glucose levels 4-6 times a day to prevent hypoglycaemia or hyperglycaemia.

It is important when using a blood glucose meter that it is working correctly and uses up to date technology. NHS Enfield has organised for some pharmacies to ensure that meters are working correctly, and if not will replace free of charge. A list of these pharmacies can be found on page 31. Issue 5 –September 2015 © No part of this publication may be reproduced in any form without the permission of the Enfield Diabetes Support Group and Diabetes Nursing Team BEH-MHT – 2006 onwards

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PHARMACIES THAT UNDERTAKE BLOOD GLUCOSE METER CHECKS

PHARMACIES INVOLVED IN EQA PROJECT FOR BLOOD GLUCOSE METERS IN ENFIELD Atkinson Chemist

20 The Grangeway N21 2HG

Atkinson Chemist

750 Green Lanes N21 3RE

Co-op Pharmacy

255-257 Hertford Road EN3 5JL

Co-op Pharmacy

417 Hertford Rd EN3 5PT

Co-op Pharmacy

66 Silver St EN1 3EP

Forest Pharmacy

308a Hertford Road N9 7HD

Hayward Pharmacy

10 Queen Anne Place, EN1 2HB

Sainsbury Pharmacy

681 Green Lanes N21 3RS

31 Issue 5 –September 2015

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WHAT DOES MY HbA1c (Glycated Haemoglobin) MEAN? In your blood there is something called a haemoglobin molecule which contains iron and carries oxygen around the body delivering it to the cells. The molecule lives for about three months and when it dies it is cleared from the blood stream by your spleen. During its life span, glucose molecules stick one by one to the haemoglobin molecules. The more glucose that is in your bloodstream, the more glucose becomes stuck to the haemoglobin from the blood. When a blood sample is taken from you for your regular diabetes check-up, it is measured to find out how much glucose is stuck to the haemoglobin molecule. This gives an estimate of how much glucose has been in the bloodstream for the past 3 months. This test used to be reported as a percentage reading. This has now been changed to mmols/mol and you will receive your results from your healthcare team in this way. The diagram below compares the two readings.

A simple guide is given below: Between 48 - 59 mmols/mol

IDEAL CONTROL

Between 59 – 64 mmols/mol

REASONABLE CONTROL

Above 64 mmols/mol

POOR CONTROL

Previously referred to as: Between 6.5% - 7.5%

Between 7.5% - 8%

8% or above

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HYPOGLYCAEMIA - Causes, signs, symptoms and treatment This is the medical term used for low blood glucose levels. It can also be shortened to ‘Hypo’. The onset of these symptoms can be very rapid. Hypoglycaemia occurs when the level of glucose in a person's blood falls too low. The person often experiences 'warning signs' which occur as the body tries to raise the blood glucose level. The ideal blood glucose level is between 4.0 mmols/l and 6.5 mmols/l. “Hypos” occur when the blood glucose level drops below 4.0 mmols/l. Causes        

If you take insulin or a sulphonyurea tablet, you may have taken too much Lumpy injection sites (insulin absorption is affected). You may have reduced the amount of carbohydrate in your diet You may have delayed or omitted a meal Increased stress levels Increased your physical activity Increased alcohol consumption Hot weather can affect some people Some drugs can cause hypoglycaemia

The following warning signs may vary from person to person.       

Double vision/blurred vision Drowsiness Sweating Hunger Dizziness Personality change/irritability Lack of concentration

      

Fast pulse Tingling of mouth and/or lips Weakness in the legs Feeling shaky Going pale Heart pounding Confusion

Treatment for hypoglycaemia    

Check blood glucose level if possible Eat or drink something sweet, e.g. Lucozade 50 –100mls (check you are not taking reduced sugar) or 3–6 glucose tablets or 200mls orange juice or 1 tube of Glucogel (Hypostop) Repeat if symptoms are not resolved after 5–10 minutes When feeling slightly better eat your next meal or have a snack like a sandwich or a banana

If hypos are occurring regularly, contact your doctor as your treatment may need to be adjusted. It is advisable to carry identification which includes medical information, details of medication and the name and phone number of your GP. These are available from your healthcare provider or Diabetes UK. 33 Issue 5 –September 2015

© No part of this publication may be reproduced in any form without the permission of the Enfield Diabetes Support Group and Diabetes Nursing Team BEH-MHT – 2006 onwards

HYPERGLYCAEMIA - Causes, signs, symptoms and treatment This is the medical term used for high blood glucose levels. Hyperglycaemia occurs when the body is unable to use glucose effectively. This leads to raised levels of glucose in the blood. When somebody has diabetes, the glucose in their body is not turned into energy either because there is not enough insulin or because the insulin that the body produces is not being used properly. Hyperglycaemia occurs when the blood glucose is greater than 10 mmols/litre before you eat. When you eat, the blood glucose level rises as your body digests food. Causes   

You have stopped taking your medication or you are taking the wrong dosage You have reduced the amount of activity that you do You have changed your diet

The signs and symptoms of hyperglycaemia        

Thirst and dry mouth Passing large amounts of urine especially at night Tiredness Blurred vision Weight loss Itching of genitals Headaches Short tempered

You may have experienced some of these prior to being diagnosed. Treatment for hyperglycaemia    

Ensure that you are taking the correct dosage of medication at the right time Take regular physical activity (do not exercise if your blood glucose level is above 13mmols/l) Avoid changes to your healthy eating plan and the timing of your meals See your healthcare professional if symptoms persist

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FEASTING AND FASTING Feasting Everybody over-indulges a little bit on special occasions but when you have diabetes you will have to give more consideration to the amount and type of food and drink that you consume. If you drink too much alcohol this can affect your blood glucose levels. Remember that there is no harm in drinking in MODERATION.  

Men should drink no more than 3 units a day Women should drink no more than 2 units a day

1 unit of alcohol is half a pint of beer or lager or 1 small glass of wine or 1 single measure of spirits If you are having a celebration meal, try to fill your plate with more vegetables or salad or choose healthy alternatives.

Remember to take care during religious festivals. This can be a very difficult time for people with diabetes, especially if you are expected to attend lots of functions or need to change your diet for a period of time. Fasting Many religions have periods of fasting. If you have diabetes and you are considering fasting or taking part in a festival that will affect your diet or medication or the times that you take them, you should see your healthcare professional.

Do not stop taking or alter your medication without consulting your healthcare professional.

35 Issue 5 –September 2015

© No part of this publication may be reproduced in any form without the permission of the Enfield Diabetes Support Group and Diabetes Nursing Team BEH-MHT – 2006 onwards

EATING WITH FRIENDS Your friends may be concerned about what you can eat. Explain your needs and ask what time you are going to eat so that you can plan your meals throughout the day. If you are going to eat later than your usual time, make sure you have a snack at your regular eating time.

EATING OUT It is a good idea to ring the restaurant to ascertain the menu. Make sure you know how long you will have to wait for your meal once you have ordered your food.

SOCIAL LIFE Some aspects of your social life will change. You just need to plan and make contingencies for emergencies. You will need to be well organised and prepared. Whenever you go out, as an added precaution in case you get delayed, always carry one of the following: GlucoGel (HypoStop) which is supplied by your GP or glucose tablets or biscuits.

Your friends and family should be aware of your diabetes and your needs. Do not over indulge and remember, eat before you drink any alcohol. You may wish to test your blood glucose levels before you go to bed especially if you have been drinking alcohol. If your blood glucose result is below 7mmols/l, you should eat a healthy snack before going to bed.

Issue 5 –September 2015 © No part of this publication may be reproduced in any form without the permission of the Enfield Diabetes Support Group and Diabetes Nursing Team BEH-MHT – 2006 onwards

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FEELING UNWELL If you are feeling unwell, here are a few simple rules that you should remember: 

You should contact your healthcare professional if you are sick and cannot eat. This is especially important if you are taking any medication.



If you do not feel like eating solid food, try alternatives, for example milk, soup, ice cream, fruit juice.



Test your blood glucose levels more frequently if you are ill as blood glucose levels can be affected by illness.



If you have Type 1 diabetes, test your urine for ketones if your blood glucose levels are greater than 14 mmols/l, or if advised to by your healthcare professional.



Drink plenty of water or sugar free fluids. Aim to drink 5 to 7 pints (3-4 litres) in a day

CONSULT YOUR GP IF 

You are vomiting for more than 2 meal times and are unable to take your medication



You do not improve quickly



Your blood glucose levels remain high. i.e. before you eat over 10 mmols/l over a period of 6/7 days or over 15 mmols/l for 2 days



Your blood glucose level is low. i.e. 4 mmols/l or under



You or your carers are worried

Remember - any emotional stress can affect your blood glucose levels. 37 Issue 5 –September 2015

© No part of this publication may be reproduced in any form without the permission of the Enfield Diabetes Support Group and Diabetes Nursing Team BEH-MHT – 2006 onwards

DRIVING AND DIABETES Driving Licences You must advise the DVLA that you have been diagnosed as having Type 1 diabetes and you take insulin. If you have Type 2 diabetes, you must inform them if you begin to take insulin. This is your responsibility and not the responsibility of your healthcare professional. This is a mandatory requirement. Contact the DVLA by telephone: 0870 240 0009 or www.dvla.gov.uk and follow the links for ‘Health conditions that could affect your driving’. Their address is: Drivers Medical Branch, DVLA, Swansea, SA99 1TU. For people with Type 2 diabetes who are controlled by diet or diet and tablets, there are no driving licence restrictions until you require insulin treatment. You can retain your ‘until age 70’ privileges. When you approach 70 years of age, licence renewal forms are sent automatically by DVLA to the address shown on your driving licence prior to the expiry date. There is no fee for renewal. When completing your form, you must sign the consent section for your doctor to be consulted by the DVLA if required. The DVLA may request that you have a medical check-up. Further information about the medical rules for driving: https://www.gov.uk/diabetes-driving Different rules apply for people who need insulin to control their diabetes. Diabetes UK can advise you on all aspects. At the time of going to press, if you have to take insulin your driving licence will be reviewed every 3 years. Contact your healthcare professional when renewing your licence. If you take insulin, you must check your blood glucose level prior to setting out on a journey and every two hours on a long journey. You must carry appropriate treatment for hypoglycaemia with you. The DVLA may ask to see evidence of blood glucose monitoring. Check the DVLA for more information or Diabetes UK. It is important to note that if you have been advised to contact DVLA and you do not, your healthcare professional is legally bound to do so if they are concerned about your fitness to drive. It is essential for all drivers of any vehicle to regularly check for up to date information on the DVLA website.

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Motor Insurance You must advise your Insurance Company that you have been diagnosed as having diabetes as failure to do so may result in your insurance being invalid. It is not compulsory to inform Insurers of any change in your medication but it would be sensible to do so to reduce the risk of your policy being voided if an accident occurred and the company was unaware of your diagnosis. However, you must inform them if there has been any alteration or restriction to your Driving Licence by the DVLA.

It is important to always carry some glucose tablets with you and to keep some digestive biscuits and something to drink in your car just in case you start to feel a hypo coming on. If you have hypo symptoms when driving, the law requires that you 

Stop the car in a safe position



Remove the keys from the ignition.



Get into the passenger seat if you are on your own



Eat or drink something containing sugar.



Do not commence driving for up to 45 minutes after the hypo

Refer to the hypoglycaemic advice on page 32.

You can be prosecuted if you are having a hypo and are behind the wheel with the keys in the ignition. This is seen as being the same as being in charge of a vehicle whilst under the influence of drugs. It might be best to move to the passenger seat or get out of the car.

39 Issue 5 –September 2015

© No part of this publication may be reproduced in any form without the permission of the Enfield Diabetes Support Group and Diabetes Nursing Team BEH-MHT – 2006 onwards

TRAVEL You can travel anywhere in the world that you wish as there are no restrictions on your ability to travel. It is wise to make some extra preparations before you start your journey. 

It is extremely important that you take out adequate travel insurance for your trip



Check that ‘pre-existing conditions’ are not excluded from your cover



Also check for any other specific exclusions that relate to diabetes. If in doubt contact the insurance company before you travel.

Diabetes UK will be able to give you advice and they also run a travel insurance scheme for people with diabetes. All vaccinations normally recommended are safe for people with diabetes. Check with your healthcare professional to establish whether you require immunisation prior to travelling. If you do, ensure that these are given in good time as they may upset your diabetes control for a short time. Your blood glucose levels may need to be checked more often for a few days after immunisation. If, on advice from your healthcare professional you do have to increase your medication, ensure that you reduce it again once your blood glucose levels return to normal. Medical attention is officially free in all EU countries providing you have obtained the correct European health card before you go. This card proves that you are eligible for free treatment and is available free of charge from most Post Offices or your DSS office. If travelling with a group, it would be sensible to inform your tour leader that you have diabetes. Diabetes UK has a useful booklet entitled ‘Travel and Diabetes - Managing Away From Home’.

Issue 5 –September 2015 © No part of this publication may be reproduced in any form without the permission of the Enfield Diabetes Support Group and Diabetes Nursing Team BEH-MHT – 2006 onwards

40

What to take with you when you travel 

Identity card stating that you have diabetes with details of your medication. (Identity cards are available from the Enfield Diabetes Support Group or Diabetes UK)



Doctor’s letter explaining that you take insulin and need to carry needles and blood testing equipment in your hand luggage. Your doctor is perfectly within his rights to charge you for the letter



Take a copy of your prescription list



All diabetes medication and blood testing equipment must be in your hand luggage at all times. Remember, insulin and blood testing equipment acts adversely to extreme temperatures



Twice as much medication as you think you may need



Your testing equipment. Advise the airline that you have this equipment prior to travelling



A first aid kit. Include medication for travel sickness, diarrhoea, etc.



Supply of food and drink in case of delays. Check airlines for up to date information regarding taking liquids through customs.



Depending on your destination, you may need anti-malarial medication and water purification tablets

If you are taken ill whilst on holiday, never stop taking your tablets or insulin even if you are unable to eat and cannot take solid foods. You should seek medical advice if sickness and/or diarrhoea persist. When you are travelling, try to be flexible. Do not get too upset if your blood glucose control is not perfect when travelling across time zones. Diabetes UK has free destination leaflets for many countries throughout the world giving useful information including useful phrases in the local language.

ENJOY YOUR HOLIDAY

41 Issue 5 –September 2015

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ENTITLEMENTS Currently, only those who take medication to control their diabetes, regardless of their age, are entitled to free prescriptions. This also includes free blood glucose testing strips and lancets. Ask your GP for an exemption form. All people with diabetes, regardless of age, are entitled to an annual flu vaccination free. It is strongly recommended that people with diabetes have this vaccine. You are also entitled to a pneumococcal (pneumonia) vaccine every ten years. People with diabetes are entitled to a free annual eyesight check.

DENTAL CARE Your dentist needs to know that you have diabetes before treating you. You must also let your dentist know the medication you are on. As dental infections may affect your diabetes control, regular check-ups are essential. Currently there is no free dental treatment for people with diabetes.

PERSONAL INSURANCE – this includes all health insurance and life assurance. It is important that you declare your diabetes when applying for any policy. Any policy you hold at the time of diagnosis is unaffected but you should advise the company. If you have any renewal problems, contact Diabetes UK for advice.

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EMPLOYMENT Having diabetes does not mean that you will not be able to find or keep a job. As some employers do not know enough about diabetes, they may be reluctant to employ someone with the condition. It is essential to emphasise that having diabetes does not make any difference in your capability to work. Ideally, you should have good diabetes control and be able to adjust your medication around your working day if necessary. Diabetes UK believes that everyone should be treated according to their own merits and ability to do the job in question. If your diabetes is controlled by diet alone or diet and tablets, it is possible to do most jobs providing you do not have any complications connected with diabetes. Since the extension to the Disability Discrimination Act in October 2004, people with diabetes have greater employment protection than ever before. There is a ban on some jobs for people who control their diabetes with insulin. For example:            

Armed Forces including RAF pilots Merchant Navy Prison Service Airline Pilot, Cabin Crew (some airlines) and Air Traffic Control Train driving Driving large goods vehicles Driving vehicles carrying the general public (buses) Any job with the Post Office that involves driving Working offshore e.g. on oil rigs, channel ferries or liners Working at a coal face Working at heights Being a jockey

It might be difficult or impractical to plan your insulin injections to fit in with your job, especially if you work shifts. This is much easier if you are on a flexible injection regimen and perform regular blood tests. Your Diabetes Team can help you to plan this. However, if you are already in a job when your diabetes develops, in most instances it is possible to continue with that employment. Transport for London is now responsible for licensing of Taxis and Private Hire vehicles. If you require information on this issue contact them directly. Further details can be found on the Transport for London website. Phone: 0343 222 4444. Monday to Friday 08:00 -18:00.

43 Issue 5 –September 2015

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JOB APPLICATION There may be a health question on the application form. You should write that you have diabetes and add ‘well controlled’ if appropriate. If you wish, you can state Type 1 or Type 2.

WHAT TO TELL AN EMPLOYER AND WORK COLLEAGUES Let your colleagues know you have diabetes in a positive and simple way. This will help them to understand your condition. Resentment about why you are having snack breaks or going through a bout of being vague or even argumentative will be prevented if your colleagues have the understanding and knowledge they need about the effects of your diabetes. You may find it useful to explain to your colleagues what treatment you need in the case of a hypo. Find out your employer’s policy regarding First Aiders administering treatment. If your diabetes is diagnosed whilst you are in a particular job, inform your Manager and Human Resources Department as you may have to have some time off from work. Keep them up to date with your progress. Studies have shown that people with diabetes do not take any more time off work than anyone else. Do not use your diabetes as an excuse. It does not make you more prone to sickness. As with all health appointments, organise your diabetes appointments to fit in with your job.

If you have any concerns regarding your employment, discuss these with your healthcare professional. Contact Diabetes UK if you need further information or advice.

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!

COMPLICATIONS OF DIABETES

!

It is important that you know about some of the long-term effects of poorly controlled diabetes in order to make informed and important decisions about your own health care. There have been several long-term research studies that have proved beyond doubt that good blood glucose control reduces the risks of developing most of the diabetic complications. Poor blood glucose control is likely to lead to any or all of the following problems:

RETINOPATHY You are entitled to a free eye examination if you have diabetes and it is essential that you attend. Retinopathy occurs when poorly controlled diabetes damages the tiny blood vessels in the back of the retina (the seeing part of the eye). These blood vessels can become abnormally fragile and leak. These abnormalities may cause blurring and occasionally loss of vision. Changes due to diabetes can usually be prevented from affecting your eyesight if problems are detected early enough. This may be before you notice any deterioration in your vision. It is essential that you have your eyes checked every year for retinopathy as the back of the eye is checked very thoroughly by dilating (widening) the pupils using eye drops. This check is quite different from a sight test for glasses or glaucoma check. You are advised not to drive for at least 2 hours following this test. Plus, remember to take your sunglasses with you. Presently, annual call/recall for diabetic retinopathy screening for patients registered with an Enfield GP is provided by North Middlesex University Hospital. Your GP, with your consent, will request that you are placed on the retinal screening system. You will be contacted by the hospital’s retinal screening team to arrange for an appointment at one of the following sites: 

The Diabetes Centre of your local hospital



One of the community diabetic retinopathy screening clinics e.g. Forest Primary Care Centre

If this has not happened, discuss this with your GP urgently.

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CATARACTS

Cataracts are degenerative changes in the lens of the eye. This causes the lens to become cloudy which causes diminishing vision. A simple operation where the faulty lens is replaced by an artificial lens can be performed to treat cataracts and there are other surgical treatments If, during your routine eye screening, you are found to have any sign of cataracts you may be referred to an ophthalmologist.

HARDENING/FURRING OF ARTERIES (ATHEROSCLEROSIS/ARTERIOSCLEROSIS) People with diabetes are at greater risk of developing arterial diseases such as stroke, heart attack and poor circulation in the legs. Although hardening of the arteries occurs to some extent in every person as they get older, evidence suggests that it occurs earlier in people with diabetes. Maintaining a healthy lifestyle will help you to minimise these risks. Also at risk include people who: 

Are overweight



Have a high fat intake



Smoke



Have high blood pressure



Have a family history of heart disease

If you are concerned about these issues, talk to your healthcare professional or pharmacist who will be happy to give you guidance on how to reduce your risks.

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KIDNEY PROBLEMS - DIABETIC NEPHROPATHY Your kidneys can be affected by diabetes in the following ways. In long-standing and poorly controlled diabetes, high blood glucose and high blood pressure levels can affect the small blood vessels that supply the kidneys. In the early stages this may not produce any symptoms. It is important that at your annual check-up your healthcare professional checks your urine for protein. This problem can be made worse by poorly controlled blood pressure. If you are considered to have high blood pressure, it is essential that you attend your surgery/clinic regularly for review. Infection - When the blood glucose levels are high you can also have glucose in your urine. This can make you more prone to developing infections of the bladder (e.g. cystitis). These infections can then spread upwards towards the kidneys.

NERVE DAMAGE - NEUROPATHY Your body is full of tiny, fragile nerve endings that can be damaged by high glucose levels in your blood stream. When this damage occurs it is known medically as neuropathy. Neuropathy can be very common on diagnosis of Type 2 diabetes. It can affect many parts of the body, for example:      

Feet Legs Eyes Hands Bowel Sexual organs

As neuropathy affects the feet and legs more often than any other parts of the body, it is essential that you pay particular attention to the problems that may develop in these areas.

47 Issue 5 –September 2015

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FOOT ULCERATION Any or all of the following problems can combine and cause foot ulceration. People who have poorly controlled diabetes are particularly prone to foot ulceration because: 

They are more prone to infection



The nerves to your feet are not functioning as well as they should be and as a result of this, the sensation to your feet may be altered. This reduces any protection that normal sensation would give you



Hardening/furring of the arteries may reduce the amount of oxygen, blood and nutrients that supply the tissues of your legs and feet

SEXUAL HEALTH FOR MEN Erectile dysfunction or impotence Erectile dysfunction means being unable to have or keep an erection long enough to have sexual intercourse with your partner. Approximately one in ten men over the age of forty will experience erectile dysfunction whether they have diabetes or not. All men experience failure to achieve an erection at some point in their lives and this problem may increase with age. There is a wide range of treatments available and there are many people that can advise you. Erectile dysfunction may have physical or psychological causes, or a combination of the two. Diabetes can cause damage to the blood supply to the penis or to the nerves that control an erection. Other factors that can cause this problem are:       

Smoking Drinking too much alcohol Use of recreational/illegal drugs Some medications used to treat high blood pressure and depression Lack of the hormone testosterone can cause loss of interest in sex Previous operations on your bowel, prostate or bladder Damage to the spinal cord

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The psychological causes of this problem may include:    

Stress and anxiety Depression Marital/relationship problems Guilt and fear of failure

You should discuss any problems that you have with your healthcare professional. You may need to be referred by your GP to a specialist who could be:  

An urologist (a doctor who specialises in kidney, bladder, prostate and genital problems) A counsellor or psychologist

The treatments available include:     

Counselling Medication review including insulin Drug therapy Vacuum therapy Self-injection

The most appropriate form of treatment will be discussed fully with you. Impotence is now well understood.

REMEMBER - HELP IS ALWAYS AVAILABLE

49 Issue 5 –September 2015

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SEXUAL HEALTH FOR WOMEN Diabetes may not affect your ability to become pregnant, provided that you have good control over your blood glucose levels. All women need to look after themselves prior to becoming pregnant. When you have diabetes, you have to be extra careful with your health and well-being prior to becoming pregnant. Speak to your healthcare professional as pregnancy can complicate diabetes. Any woman with diabetes who wants to become pregnant must have prepregnancy counselling together with her partner. Your GP will give you the go-ahead when it is considered that your diabetes control is good. 

Excellent control of your blood glucose levels is essential before and during pregnancy



Do not smoke



Take care with your food intake, the quality of your diet and your weight. When you become pregnant, your blood glucose levels need to be tightly controlled. If your diabetes is controlled by diet alone or diet and tablet, prior to becoming pregnant you will need to commence insulin therapy



It is important to take folic acid tablets prior to becoming pregnant

CONTRACEPTION The contraceptive pill does not suit all women and it may not be advised if you:     

Are older Smoke Are overweight Have high blood pressure Have heart or circulatory problems, or a family history of them

Most of the low dose contraceptive pills may be suitable for short-term use. You will need to keep a check on your blood glucose and blood pressure levels. Low dose progesterone only pills may be used. The coil (IUD/Intra-uterine contraceptives) can be used providing that there is no history of pelvic infections. Barrier methods (caps/condoms) are safe to use but not as effective as other methods.

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HRT – (Hormone Replacement Therapy) Your healthcare professional will advise you if you wish to consider HRT.

THRUSH Thrush (candida) is caused by a yeast infection that thrives in the presence of a lot of glucose. If your diabetes is poorly controlled or you take tablets from a group called SGLT-2 Inhibitors, you will be passing a lot of excess glucose out of your body via your urine. Creams, pessaries and tablets will help with your symptoms and many of these are available from chemists. Ask your pharmacist for advice.

CYSTITIS Cystitis is a lower urinary tract infection that causes the bladder to become inflamed. Common symptoms include pain when passing urine, more frequently passing urine, itchiness, pain in the lower abdomen and blood in the urine. Cystitis is more common in women. High blood glucose levels increase the risk of cystitis because glucose can spill over into the urine creating a sweet environment in which bacteria can grow and multiply. Improving diabetes control will reduce the likelihood of cystitis developing. Your healthcare professional will be able to say whether the increased need to pass urine is due to poorly controlled diabetes or is due to cystitis. Sometimes cystitis goes away by itself but other times a short course of antibiotics is needed. It is especially important to see your GP if you are pregnant or think you could be, as there is a small risk that cystitis can lead to problems with the pregnancy. Thrush, cystitis and urinary tract infections can be a side effect of certain diabetes medications.

51 Issue 5 –September 2015

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INDEX Additional Information Alcohol Annual Review/Yearly Check-up Anxieties Blood Glucose Control

Blood Pressure Blood Testing and Monitoring Blood Vessel Damage Blurred Vision

55 10, 15, 21, 27, 33, 35, 36, 48 13, 14 11, 13 7, 8, 9, 12, 13, 14, 15, 16, 18, 22, 23, , 30, 31, 33, 34, 35, 36, 37, 38, 39, 40, 41 42, 45, 47, 50, 51 12, 21, 27, 46, 47, 50 17, 29, 30, 41, 36, 38 7 8, 13, 33, 34

Cardiac Support Group Cardiovascular Disease Cataracts Check-ups Cholesterol Complications of Diabetes Contact Numbers Contraception Coping with Diabetes Cramps Chiropodist see Podiatrist Cystitis

28 28 46 12, 14, 42 12, 28 45 5 12, 50 11 8, 27

Dental Care Diabetes Support Group Diabetes UK Diabetic Food Diabetes Terms Diagnosed (Initially) Diet Driving Dry Mouth DVLA

42 1, 2, 5, 11, 21, 41, 55, 56 4, 5, 11, 21, 33, 38, 40, 41, 42, 43, 55 21 7 10, 11 9, 12, 15, 19, 20, 21, 26, 35, 36 38, 39, 43 8, 34 38, 39

Eating Out Eating with Friends Emotional Stress Employment Entitlements Exercise – see Physical Activity Eyes/Eyesight

36 36 29, 37 43, 44 42

46, 51

12, 13, 27, 42, 45, 46, 47

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Fasting Feasting Feeling Unwell Feet Flu Vaccine Food Labels Footwear Foreword Fruit and Fruit Juice

35 35 37 7, 10, 12, 13, 14, 24, 25, 26, 47, 48 42 20 26 2 19, 20, 33, 37

Glucogel (Hypostop) Glucose Tablets Glucose Meter Check Glycated Haemoglobin

33, 36 33, 36, 39 31 7, 32

HbA1c Healthy Eating Health Worries Heart Heart Throbs High Blood Levels – see Hyperglycaemia Holidays/Travel Hormone Replacement Therapy (HRT) Hyperglycaemia/Hyper Hypertension Hypoglycaemia/Hypo Hypostop – see Glucogel

7, 12, 32 19, 20, 21 14 21, 23, 24, 27, 28, 46, 50 23, 28

Illness Immunisation Impotence Infection Insulin, Injection and Sites Insurance Introduction Itchiness

14, 37 40 48, 49 25, 26, 42, 47, 48, 50, 51 7, 8, 9, 12, 10, 15, 16, 17, 18, 30, 32, 34, 38, 41, 43, 49, 50 39, 40, 42 6 8, 16, 34, 51

Job Application

43, 44

Kidney Problems

7, 27, 49

Life and Personal Insurance/Assurance Low Blood Levels – see Hypoglycaemia

42

Mature Onset Diabetes Medical Identification Medication

8 33, 41 12, 13, 14, 15, 16, 17, 27, 33, 34, 35, 37, 39, 40, 41, 42, 43, 47, 48, 49 9 39

‘Mild Diabetes’ Motor Insurance

53 Issue 5 –September 2015

40, 41 51 7, 13, 30, 34 27 7, 13, 15, 16, 18, 23, 30, 33, 38

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Needle Disposal Nephropathy Nerve Damage/ Neuropathy

18 7, 27, 47 7, 25, 46, 47

Pancreas Pharmacist Physical Activity (Exercise) Pneumonia Vaccine Podiatrist/Chiropodist Pregnancy

7, 8, 15 11, 15, 29, 46, 51 9, 11, 12, 13, 22, 23, 24, 27, 30, 33, 34 42 6, 25 9, 50, 51

Questions You Might Have

10

Regular Check-ups Retinopathy

12, 14 7, 12, 13, 27, 45

Salt Reduction Self-Monitoring Sexual Health Side Effects from Medication Smoking Social Life Support Groups

20, 21, 27 29, 30 48, 50 10, 13, 16, 17 12, 24, 27, 48 6, 36 11, 23, 24

Tablets Thirst Thrush Tips Tiredness Travel Treatment Type 1 diabetes Type 2 diabetes

9, 12, 15, 16, 30, 33, 36, 38, 39, 41, 43, 50, 61 8, 14, 34 17, 51 11, 23 8, 34 18, 40, 41 9, 10, 12, 15, 18, 33, 34, 38, 44 7, 8, 37, 38, 44 7, 8, 9, 15, 30, 38, 44, 47

Unwell Urine and Testing Urologist Useful Contact Numbers

14, 37, 8, 12, 14, 21, 17, 34, 37, 47, 51 49 5

Vaccinations Vegetables

40 20, 35

Weight (Reduction/Loss) Who Is Most At Risk Work Colleagues Yearly Check-up You/Your Responsibility

8, 17, 21, 24 9 44 13 11, 38

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Additional information sources Diabetes UK – Produce a wide range of information on all aspects of diabetes. Further information on diabetes can be obtained from local libraries and bookshops. www.diabetes.org.uk National Institute for Clinical Excellence (NICE) – www.nice.org.uk This information has been jointly prepared by Enfield Diabetic Patient Information Working Group including David Petts, Ruth Waxman. Enfield Diabetes Support Group BEH-MHT Enfield Community Services Diabetes Nursing Team Based on original documentation by Kit McAuley All information correct at time of going to press.

55 Issue 5 –September 2015

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ENFIELD DIABETES SUPPORT GROUP A LOCAL DIABETES SUPPORT GROUP IN THE AREA FOR THOSE WITH DIABETES, THEIR FAMILY AND CARERS

WOULD YOU LIKE SUPPORT/COULD YOU GIVE SUPPORT? MONTHLY MEETINGS ARE HELD ON EVERY SECOND TUESDAY AT: THE DIABETES CENTRE CHASE FARM HOSPITAL THE RIDGEWAY ENFIELD EN2 8JL FROM 7.30 pm TO 9.00 pm GUEST SPEAKERS TALK ON ALL ASPECTS OF DIABETES CARE AND OTHER RELATED ISSUES EVERYONE IS WELCOME FOR MORE INFORMATION CALL: RUTH – 020 8386 4416 [email protected]

THIS GROUP IS RUN BY PEOPLE WITH DIABETES FOR PEOPLE WITH DIABETES

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57 Issue 5 –September 2015

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Contact Enfield Council Civic Centre Silver Street Enfield EN1 3XY Tel: 020 8379 1000 www.enfield.gov.uk