Living with Diabetes
An introduction to life with the Big D
Living with diabetes is said to be a lifestyle. In reality, to successfully live with diabetes on a daily basis that extends to a lifetime, certain coping mechanisms are also required. Drugs may be needed to help with the body’s disposal of blood glucose – either insulin injections or tablet medication. In addition, the person with diabetes must juggle diet and energy expenditure (and the timing of these) with blood glucose levels on a day-to-day basis.
Living successfully with diabetes will become a journey through life itself. You will discover more about yourself and about others than you might ever have imagined.
Treatments for diabetes
The essential goal is always to maintain blood glucose levels as near normal as possible but without causing either immediate or long-term problems.
Dietary intake affects how much glucose is taken up into the bloodstream. Insulin activity and exercise determine how much glucose is taken from the blood and used by body cells. Exactly the right balance has to be found to keep the blood glucose level from rising too high, or falling too low.
Type 1 diabetes
The basic therapy for Type 1 diabetes is insulin replacement, since the insulin-producing cells have been destroyed. Normally the body will produce insulin on demand; this means in response to blood glucose levels and the digestion of food. People with Type 1 diabetes need to inject insulin to cope with food intake. The insulin dose needs to be just right for the amount of food eaten, and should be timed to coincide with its digestion.
Insulin is a protein and would be destroyed by digestive juices in the stomach if taken by mouth. Insulin is therefore injected into the fat layer underneath the skin and from here it’s absorbed into the bloodstream. Drawing up from syringes is almost a thing of the past; special injection devices are now widely available which are very accurate and discrete to use (disguised as pens). Many people use insulin pumps to deliver their insulin.
For more detailed information on insulin, take a look at ‘Using Insulin‘.
Type 2 diabetes
Treatment for the person with Type 2 diabetes should depend on the underlying cause of the diabetes. Different factors may contribute to the condition but in most cases diabetes is the result of a combination of problems:
- Muscle and fat cells are resistant to insulin action
- Insufficient insulin is produced to meet the body’s needs
- Liver cells release too much glucose from their stores
For some, a diet and exercise plan may be sufficient to keep blood glucose levels within normal limits. Others may be prescribed tablets that aid insulin in keeping blood glucose levels under control.
Up until the mid-late 1990s, sulphonylureas and metformin were the only oral medication available to people with Type 2 diabetes in the NZ. In recent years, a number of alternative drugs have become available, which target different aspects of the problem. With these, a great potential for combination therapy is evolving.
|Type of drug||What it does|
(there are several types of these)
|Acts on the cells of the pancreas, stimulating more insulin to be released.|
|Enhances insulin secretion; faster-acting than the sulphonylureas.
*NOTE: Not currently available in NZ
|Slows down the release of glucose from the liver into the bloodstream.|
|Makes muscle cells more sensitive to insulin, thereby overcoming insulin resistance.|
|Hinder the action of specific digestive enzymes, which break down starches, slowing down the rise in blood glucose after a meal.|
|Hinders the action of specific digestive enzymes, which break down fat, facilitating weight loss.|
Many people with Type 2 diabetes are eventually prescribed insulin. However, as more is discovered about the nature of the underlying disease mechanisms involved, it is possible that new tablet medications may reduce the need for insulin therapy in this form of diabetes. Medications which act other than by enhancing the body’s natural secretion of insulin may serve to prolong the life of beta cells, delaying, or even preventing the onset of insulin dependence in Type 2 diabetes.
For more detailed information on oral hypoglycaemic agents, take a look at ‘Tablets for Type 2’s’.
“You’re diabetic – you can’t eat sugar!”. Unfortunately, this is still the misconception of many. There is no ‘can’ or ‘can’t’ about the dietary recommendations for people with diabetes. It’s a question of ‘how much of what’ and, equally important, ‘when’.
Aims of the ‘Diet’
The aims of dietary management in diabetes are simply to promote long-term health without causing short-term problems (such as hypoglycaemia – see below). This centres on keeping blood glucose levels as close to normal as possible and to do this people with diabetes need to establish the relationship between the food that they eat, the medication that they take and their blood glucose levels. Thus some kind of a routine needs to be established and this should usually include finger-prick blood glucose monitoring.
Additionally, ‘healthy eating’ is essential to provide the body with all the nutrients that it requires. A well balanced diet will promote normal growth and development in children, and will help adults achieve, or maintain, a normal weight.
- Consistency of meals and snacks from day to day is the single most important factor for blood glucose management. This means in terms of quantity, type and timing of food.
- Snacks should be used to prevent low blood glucose levels, particularly in the event of taking exercise (see below).
- Cholesterol and saturated fats in the diet can add to the risk of heart disease. As people with diabetes are already at an increased risk of heart disease, these dietary fats should be kept to a minimum.
- A well balanced diet should include plenty of fresh fruit and vegetables.
- Foods high in salt should be avoided.
- Weight loss can only be achieved if total daily calorie intake is reduced or total daily activity level is increased.
Some people with Type 2 diabetes have found that a low carbohydrate diet is most successful in controlling their blood glucose levels, although this is not recommended for people with signs of kidney damage*. A major concern with this approach, however, is that large amounts of saturated fat may increase blood cholesterol levels and further add to the increased risk of heart disease and associated problems.
Carbohydrates provide dietary fibre and a number of essential nutrients; they also provide fewer calories than fat on a weight-for-weight basis.
A diet high in unrefined carbohydrates and low in fat is therefore generally recommended.
*New research is suggesting that high protein diets may not be as damaging to the kidneys as was previously thought… but more research is needed in this area before we can be sure.
For more detailed information on diet take a look at ‘Food Choices‘.
Paying attention to levels of physical activity is an important aspect of living with diabetes.
Effects of exercise
Exercise increases muscle cell uptake of glucose from the bloodstream in a similar – but independent – manner as insulin. In other words, exercise lowers the blood glucose. (Do note that ‘exercise’ in this context does not mean a five-mile run, it means any way in which your muscles are put to work.)
For people with Type 2 diabetes exercise can be of tremendous benefit. It aids weight control and can help to reduce insulin resistance. Regular exercise can also improve the health of people with Type 1 diabetes, although blood glucose levels need to be carefully managed. In addition to improving self-esteem and reducing psychological stress, exercise also helps the heart and circulation system and can reduce high blood pressure.
Low blood glucose, or ‘hypoglycaemia’, (see below) can result from unplanned or mismanaged exercise. This may occur during, immediately after, or some hours after, exercise. Only careful monitoring of blood glucose levels can enable the person with diabetes to really KNOW what’s going on. Exercise increases blood flow and people on insulin need to remember, for example, that if they inject in their leg then go for a run, the insulin will be absorbed more quickly – this will add to the risk of a low blood glucose attack or ‘hypo’.
More on hypoglycaemia can be found on the “Hypoglycaemia” page.
Stress increases levels of adrenaline (the ‘fight or flight’ hormone) which opposes insulin action and can cause sudden and dramatic increases in blood glucose level. This is often very hard to deal with, as we have little control over our stress hormones. A person with diabetes exercising at competition level may therefore find that (contrary to many clinicians predictions) blood glucose levels soar, rather than fall.
We are all different and blood glucose responses to exercise can only be ascertained by the individual’s own monitoring. Ideally, exercise needs to be incorporated into a routine, but often, of course, this is hard to achieve.
Strenuous exercise may worsen long-term complications by increasing blood pressure and stress on the heart. In addition, people with diabetic nerve damage must be extra careful of their feet – foot injuries, which may go unnoticed, can eventually result in ulcers and amputation.
Achieving ‘control’ means keeping blood glucose levels within normal limits. Diabetes medication (tablets or insulin) needs to be balanced with diet and exercise such that blood sugar levels are kept ‘as near normal as is possible’. This requires intensive management and is definitely not easy (especially when uncontrollable factors, such as stress and infections, come into play).
The key to good control is frequent measuring of blood glucose levels during the day and sometimes even in the night. Thanks to recent advances in technology, home blood testing is now painless and quick, with easy-to-use electronic meters. Take a look at the section on ‘Blood Glucose Monitoring‘.
Many clinicians suggest that people with diabetes test their blood glucose at different times each day. But this only gives a useful picture if some kind of routine is maintained so that each day is the same. This is, of course, expected of many people with diabetes, although it’s not always a practical (let alone desirable) way to live.
Most people with diabetes find a routine that suits their lifestyle and are flexible around it. For example this would mean having a ‘usual’ mealtime and if this is delayed for some reason then an extra snack can be taken to prevent a hypo.
What happens if diabetes is not “controlled”?
Poor control of diabetes can have two immediate effects – the blood glucose either falls too low, or rises too high. Frequent fluctuation between these two extremes is suffered by people who have brittle diabetes.
HYPO(low)GLYCAEMIA(blood glucose) – Hypoglycaemia can happen as a result of
- Eating less carbohydrates than usual
- Exercising more than usual
- Insulin in the body having a greater effect than usual
Note the inclusion of ‘than usual’ in the above – it is important to realise the significance of routine.
When the blood glucose falls, cells in the body are starved of glucose. In particular, cells in the brain and nervous system suffer. Early signs include sweating, shaking, hunger and dizziness. If not treated immediately, the person can suffer from convulsions, and may progress into a state of unconsciousness.
Treatment of a hypoglycaemic attack or ‘hypo’ is glucose – sugar in its most simple form. If the person is unconscious then they may require an injection of glucagon, a substance which tells the liver to release glucose into the bloodstream.
More on hypoglycaemia can be found on the “Hypoglycaemia” page.
HYPER(high)GLYCAEMIA(blood glucose) – Hyperglycaemia can happen as a result of
- Eating more carbohydrates than usual
- Exercising less than usual
- Insulin having a lesser effect than usual (this is often the case if a person with diabetes is suffering from stress, or an infection of some sort)
When blood passes through the filtering system in the kidneys, glucose is normally retained. But when the blood glucose level rises too high, glucose ‘spills over’ into the urine. This makes the urine so concentrated that extra water is drawn out too. People with high blood glucose therefore produce large volumes of urine and become dehydrated and very thirsty.
When the blood glucose rises in the absence of insulin, cells turn to fats as a fuel instead. Burning up fats yields chemicals known as ketones. If these are produced faster than they can be disposed of by the body, they build up in the bloodstream and become toxic. Ketones make the blood too acidic so messages are sent from the brain to the lungs to breathe faster. You can smell ketones on the breath – fruity, like pear-drops. If left untreated then vomiting, drowsiness and eventually coma can result. This life-threatening state is called ketoacidosis and is usually only a potential problem for people with Type 1 diabetes.
Prolonged severe high blood glucose levels in people with Type 2 diabetes may lead to a condition known as ‘hyperosmolar non-ketotic coma’ (HONK). This is caused by extreme loss of fluid (dehydration) and the resulting chemical imbalance in the blood.
Hyperglycaemia is less of an immediate threat to the patient, compared with hypoglycaemia, but in the long term it can add to the risk of developing diabetic complications such as loss of sight, kidney failure and heart disease.
In many cases one of the hardest things to have to accept about living with diabetes is the responsibility that comes with it. Doctors and nurses can prescribe medication and advise on lifestyle, but at the end of the day it does boil down to the individual. Now that studies have shown that the risk of developing complications can be reduced by good blood glucose control, much of the load weighs on the shoulders of the patients themselves.
Having diabetes does not preclude you from driving, although some recent new legislation has increased the restrictions on drivers with diabetes. The NZTA need to be sure that every licensed driver is going to be safe on the road. If your diabetes is well controlled, and you have no complications that might reduce your safety as a driver then there should not be a problem. The NZTA do require notification of diabetes and any change in your condition.
NZTA Factsheet :Diabetes and Driving (Factsheet 16) – provides information for drivers with diabetes. It gives advice on some of the risks and precautions for diabetic drivers and outlines limitations and conditions which may apply to your licence when you are driving.
See your doctor or other specialist. A handbook that includes a chapter on diabetes, Medical aspects of fitness to drive, has been issued to all doctors in New Zealand. You can also download this directly from the NZTA website (click link above).
Today, we are travelling further a field for both business and pleasure. Although you may need to take some special precautions when going abroad, there is no reason why you should not enjoy a relaxing or fun-packed holiday. Long haul flights pose much less of a problem now, with the convenience of pen injectors and the flexibility of multiple daily injection regimens. Make sure that you take a travel pack with all your essential diabetes kit and follow our travel tips.
Insurance is one area in which people with diabetes sometimes encounter some difficulty. You must declare your diabetes to your motor insurance company. Standard travel insurance often excludes ‘pre-existing medical conditions’ so you may need to take out a special policy. Don’t leave it until the last minute and shop around for the best deal. Difficulties are sometimes experienced by people with diabetes when trying to obtain life assurance and critical illness cover.
In addition to the practicalities we face in day-to-day living, we are also frequently confronted with a number of more emotional issues that can be affected by diabetes. Psychological and emotional health forms an essential part of our general well being. Diabetes and the rigours of daily management responsibilities often take their toll and can lead to all sorts of problems. We can help you to deal with some of these difficulties and avoid some of these problems.
People with diabetes may be more prone to anxiety and depression. The stresses and strains of coping with a chronic condition need to be acknowledged. In some people this may be complicated by a chemical imbalance in the brain, resulting in clinical depression which may need to be treated with medication.
Family and relationships
Family relationships have an impact on all family members and diabetes has an impact on family relationships. Brothers and sisters of diabetic children often feel neglected or envious of the special attention that their sibling appears to receive. Marital relations may suffer in the face of diabetes. Some couples report diabetes as a third member and an intruder. Sexual intimacy may be reduced, especially if neuropathy is contributing to impotence.
The challenges that people with diabetes have to face are numerous. However, with the appropriate knowledge, support and back up from the healthcare team, diabetes should not prevent you from leading an active and fulfilling life.
Dealing with diabetes on a day-to-day basis requires a number of skills which are all too easily described by health care professionals, in books, and on web pages. Living with diabetes each day of every week, month, year… … for the remainder of one’s life requires a separate set of skills which are less easily acquired, and all too easily overlooked.
Diabetes doesn’t go away. Treatment aims to prolong life and reduce complications, but – at the time of writing – at best we are still aiming to make the most of a not-so-good situation. Today, people with diabetes are continually receiving mixed messages. If you believe all you read, then on the one hand we are entering a diabetes epidemic in westernised countries, with potentially fatal implications at every corner. On the other hand, if you have already been diagnosed, then having diabetes is no big deal; you can carry on your normal life with only a few lifestyle alterations. Clearly the media, the medical profession, and the health advocacy agencies are working together to confuse us all!!
A diagnosis of diabetes (or pre-diabetes) is a serious event for any individual person, plus family and whanau. However, in reality there are implications for all people that interact with that individual – carers, teachers, employers, friends and colleagues. When diabetes is understood, the support network works well for the individual. But when misconceptions, or basic ignorance of diabetes presides, the individual’s coping skills may be compromised, both in the present, and in the future.
TOP TIPS for successful living with diabetes