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A Little Bit of History

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GM Vs animal insulin

Choices – The Evidence
Evidence from people with diabetes
A little bit of history
Action and duration times of animal and GM ‘human’ insulins
Hypoglycaemia and loss of warnings
‘Dead in Bed Syndrome’
The concerns of patients are justified
Availability of animal insulins in the UK
Changing your insulin
What to do if your consultant refuses to change your insulin
Availability of animal insulin if admitted to hospital
Frequently asked questions
Allergic reactions to insulin


A little bit of history

  • For nearly 80 years people with diabetes who required insulin treatment used animal insulin, originally beef insulin. In the 1970s highly purified pork insulin became available. All insulin is now highly purified whether beef, pork or GM ‘human’.
  • In 1982 genetically modified insulin, so-called ‘human’ insulin, received marketing approval. Approval was given in five months, a remarkably short time when one realises that it was the first genetically produced drug to be licensed and used on people.
  • It was claimed that GM ‘human’ insulin was better because it is an exact copy of the insulin molecule produced by the body and therefore it would produce less antibodies. It was also claimed that it would be cheaper, therefore more accessible to people in poor countries and that animal insulin supplies were likely to run out. None of these claims have proved to be the case.
  • During the mid-1980s there were widely circulated but untrue rumours that animal insulins were being discontinued. This resulted in the over 80% of people in the UK being transferred from animal to GM ‘human’ insulin but in the majority of cases for no good clinical reasons.
  • Within a year or so of the changeover people started reporting loss or reduced warning symptoms of hypoglycaemia, more severe hypos and generally, more problems in controlling their diabetes safely. As time progressed other symptoms were being reported, including extreme tiredness, weight increases, feeling unwell and behavioural changes.
  • The majority of people who reported these problems to their doctors were either ignored or not believed and they were even refused their right to change to the beef or pork insulin that had previously suited them. Nearly 3,000 people wrote to the then British Diabetic Association (BDA, now Diabetes UK) but little or no action was taken.
  • As a result of pressure from people with diabetes, in the early 1990s the British Diabetic Association (now Diabetes UK) commissioned Dr Natasha Posner to carry out a study of only 384 of the 3,000 letters it had received. However, the study was never published because the BDA claimed that it was ‘too alarmist’.
  • In the early 1990s around 700 people attempted to take a class action against the manufacturers of ‘human’ insulin but failed for ‘lack of scientific evidence’. IDDT has since discovered that during this period insulin manufacturer, Novo Nordisk employed a PR company, Key Communications, to "defend the safety profile of human insulin". Key Communications described this as a crisis management programme and it included media training of UK medical spokespeople.
  • The adverse effects experienced by some people have not disappeared over the years and more than 25 years after the introduction of ‘human’ insulin, people are still battling for recognition of these problems. It is now evident that some more recently diagnosed people who have never used animal insulin, also suffer the well-recognised adverse reactions to ‘human’ insulin. Once again these have been shown to regress with a change to natural animal insulin.

The Response

The evidence from patients and their carers was not, and is not, listened to even though it is clear that for some people a change to animal insulin makes their symptoms disappear.

Most of the medical profession, healthcare professionals, researchers, the insulin manufacturers and, indeed, the UK Department of Health maintain that there is no scientific evidence to demonstrate a difference between animal and GM ‘human’ insulin. It has to be noted that there is equally no scientific evidence to prove that ‘human’ insulin does not cause the adverse effects of which patients complain. No large scale, long-term studies were ever carried out to investigate the adverse effects and an absence of evidence, is not the same as absence of evidence. Indeed, some professionals go even further and declare that GM ‘human’ insulin is better than animal insulin although NO evidence is ever produced to justify this statement. The fact that there is no admittance of the adverse effects is surprising when both insulin manufacturers, Eli Lilly and Novo Nordisk, voluntarily included in Patient Information Leaflets the warning that:

"A change from animal insulins to human insulin may cause a loss of warnings."

The next phase in the development of insulin was the introduction of insulin analogues. The first rapid-acting insulin analogue was introduced in the late 1990s and later long-acting insulin analogues were introduced. Insulin analogues are also synthetic insulins made by genetically modifying, genetically modified ‘human’ insulin.

Some people have adverse reactions to insulin analogues and are better suited to either ‘human’ or animal insulins but the trend now is for everyone to be prescribed insulin analogues despite the fact that they are significantly more expensive and have not been shown to have benefits for the majority of people.

Loss of Warnings or Hypoglycaemia Unawareness

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Loss of Warnings or Hypoglycaemia Unawareness

Hypoglycaemia itself, or the avoidance of it, is an acute daily problem for people with diabetes but when accompanied by loss or partial loss of warnings, it can have a dramatic effect on the lives of both the person with diabetes and their families. There can be a marked reduction in the quality of life for all concerned.

Total loss of warnings – A condition where the warning symptoms of an impending hypo are not present and so when the blood glucose levels drop there are no warning signs that the person must eat. This makes the likelihood of severe hypos much greater. People with loss of warnings have to rely on the help of others and frequent blood glucose monitoring.

Partial loss of hypo warnings – This means that warning symptoms are present sometimes and not at other times. In some ways this is more difficult than total loss of warnings because the person may not even be aware that they have some loss of warnings and so have unexpected and unheralded moderate or severe hypos. This is particularly dangerous when driving.

Reduced warning symptoms – Is where the early warning signs of hypoglycaemia are reduced or missing [sweating, trembling etc] and the blood glucose drops to the stage where the symptoms are less obvious [confusion, behavioural changes etc]. This means that the person often then requires the help of others to treat the hypo.

The effects of loss of warnings
Information gathered from the experiences of people with diabetes and their carers says that loss of warnings may result in the following:

  • A feeling of insecurity and loss of independence
  • Embarrassment
  • A fear of leaving the home
  • Being a danger to oneself and others
  • Aggressive or violent behaviour
  • Family conflict, breakdown of relationships
  • Loss of driving licence – it is illegal to drive with loss of warnings
  • Loss of job
  • A deliberate raising of blood glucose levels to avoid such situations

Causes of loss of warnings or hypo unawareness

There are several known causes of loss of awareness of hypoglycaemia:

  • Duration of diabetes – long term diabetes can result in loss of warnings.
  • Hypoglycaemia itself can cause loss of warnings and therefore increase the risk of more hypos. This then becomes a vicious circle of hypos leading to loss of warnings and more hypos!
  • Intensive therapy with multi-daily insulin injections and aiming for near normal blood glucose levels, has been shown to cause a threefold increase in the risk of severe hypoglycaemia. This increased hypoglycaemia can therefore increase the risk of loss of warnings.
  • Neuropathy – damage to the autonomic nervous system is a complication of diabetes and this can cause loss of warning symptoms.
  • Changing insulin species can cause a loss or change in warning symptoms.
  • ‘Human’ insulin can cause loss of warnings of hypoglycaemia. This is often not readily admitted by many health professionals but since the early 1990s, Patient Information Leaflets in ‘human’ insulin packs have included a warning of that ‘human’ insulin can cause changed or loss of warnings of an impending hypo.

Kidney Disease and Diabetes

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Kidney Disease and Diabetes

One of the long-term complications of diabetes can be kidney disease and most of us are aware that prevention of the development of kidney disease is one of the reasons we need to keep good blood glucose control. Aggressive treatment of blood pressure and stopping smoking, are also methods by which kidney disease can be either prevented or treated.


  • Diabetes is the single most common cause of end-stage renal disease [ESRD] in Europe and the US.
  • Between 30 and 50 % of people with diabetes are at risk of kidney disease.
  • People with Type 2 diabetes often have microalbuminuria and overt nephropathy shortly after the diagnosis of their diabetes, because diabetes is often present many years before diagnosis.
  • The key to preventing kidney damage is early detection of the excretion of protein in the urine and early intervention with treatment.
  • People with kidney disease are at higher risk of heart disease. Therefore attention should be given to lowering blood pressure and cholesterol, taking exercise and not smoking.

Definition of kidney disease or nephropathy [its medical name]

Diabetes at Your Fingertips, a very useful book, defines it as:
“In the first instance nephropathy makes the kidney more leaky so that protein [albumin] appears in the urine. At a later stage it may affect the function of the kidney and in severe cases leads to kidney failure.”

What are the ways in which diabetes can affect the kidneys?

  • If there is a lot of sugar in the urine, because you are running high for whatever reason, then this can lead to infection that can spread from the bladder to the kidneys. Chronic kidney infections do not always produce symptoms and may only show up on routine clinic tests.
  • In both longstanding and poorly controlled diabetes the kidneys have to work hard to get rid of the excess sugar and the small blood vessels in the kidneys can be damaged, in a similar way as the small vessels in the eyes which causes retinopathy. It is logical therefore that if both diabetes and high blood pressure are present the risk to the kidneys is greater.

Does kidney damage produce symptoms?

  • In the early stages there are no symptoms and any kidney damage should be picked up in the urine tests carried out at your normal clinic visit when albumin levels are measured.
  • If large amounts of urine are lost then this leads to frothing of the urine and a build up of fluid in the body with swelling of the ankles [oedema] but this should be spotted in the routine clinic urine tests.

What is microalbuminuria?
This is the name for the condition described above where abnormal amounts of protein [albumin] leak from the kidneys into the urine. It is the first sign kidney disease may be developing. If kidney damage progresses then there are increased amounts of protein excreted in the urine and this is called macroalbuminuria.

The presence of microalbuminuria is detected by testing all the urine collected during a 24hour period. The test carried out in the laboratory checks the ratio of albumin to creatinine, another substance which, if higher than normal, is a good predictor of kidney damage. Creatinine is a waste product produced as a result of muscle activity. The albumin/creatinine ratio is measured in micrograms per milligram, g/mg. People without diabetes normally excrete less than 25 g/mg per day although this ‘normal’ figure is less in men [18 g/mg] than in women [25 g/mg].

Understanding the results
From personal experience, when my daughter was given the results of her first 24 hour urine collection, we knew they were high but did not know how high. The actual figures were meaningless to us because we didn’t know the normal range and how high they can go. For example a figure of 29 sounds dreadful but not if you look at the worst possible figures! So that other people are able to understand their results and maybe not worry quite so much, with the permission of Diabetes Interview we are printing their table of ranges of albumin/creatinine ratios:


Normal albuminuria 17g/mg or less
Low microalbuminuria 18-65 g/mg
High microalbuminuria 66-250 g/mg
Proteinuria More than 250 g/mg


Normal albuminuria 25 g/mg or less
Low microalbuminuria 26-29 g/mg
High microalbuminuria 93-355 g/mg
Proteinuria More than 355 g/mg

Note: Don’t panic at one high result! Results of urine tests for protein can be high for various reasons – for example it could be due to an infection of the kidney, bladder and urethra or if you had been exercising vigorously around the time of the test. If subsequent tests are consistently higher than expected, then your doctor should carry out further tests and, if necessary, treatment.

Your doctor will decide when, and if, you should receive treatment for microalbuminuria. The key to preventing kidney damage is early detection of the excretion of protein in the urine and early treatment to slow down the progression of microalbuminuria to prevent further kidney damage. Microalbuminuria can progress to renal failure if left untreated.

Heel Fissures

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Diabetic Neuropathy

What is Diabetic Neuropathy?
Neuropathy Affecting The Feet
Advice on Cutting Your Toenails
Symptoms of Neuropathy Affecting Your Feet and Hands
Heel Fissures
Charcot Foot
Wrong Sized Shoes
Neuropathy and Antidepressants
Diabetic Holiday Foot Syndrome
Patient and Family Carer Experience
Diabetes and Hearing Loss May be Due to Neuropathy


Back to Related Health Issues

Heel Fissures

The Isle of Wight Diabetes Monitoring Group, kindly gave permission for IDDT to reprint an article in their magazine, Sweet Pea. The article is by Oliver Davies, Senior Diabetes Chiropodist.

What are heel fissures?
Heel fissures are a common occurrence in all the population, but in diabetes they can cause serious problems if they are not dealt with effectively. They are essentially cracks or splits in the skin often extending through to the dermis [the inner layers of the skin] and are often painful when pressure is applied to the heel on standing. They can frequently bleed and once the fissure opens it is often difficult to get the two edges of the split to knit back together.

With so many people with diabetes suffering from neuropathic damage [causing loss of feeling, commonly in the feet] these fissures often go unnoticed until they have become quite severe. Frequently they can become infected, and where many people with diabetes can suffer with ischaemia [a reduced blood supply] they are subsequently difficult to heal and may ulcerate.

What causes heel fissures?
Invariably heel fissures are symptomatic of dry skin conditions. Loss of innervation [nerve supply] to the sweat glands in the feet can result in people with diabetes having drier skin than the rest of the population. Hot weather, wearing of sandals, inadequate skin care, abrasive hosiery, poor circulation and possibly some forms of medication can all contribute to the drying of skin.

How can I prevent heel fissures?
Generally, after washing or a short soak of the feet, the application of a good moisturing cream should be sufficient to keep skin more supple and hence prevent their formation. The cream should be applied every day, particularly if you have been instructed to do so by your chiropody/podiatry clinic. The Podiatry Department often recommend Aqueous Cream B.P. which is a water based cream that helps to rehydrate the skin [and not just in the feet!] Basically, you can use any moisturising cream providing it is done on a regular basis!

How do I deal with a heel fissure already present?
If on your daily foot inspedtion you discover a crack in the heel, keep a close eye on the area and initiate the daily moisturising routine maybe 2 or 3 times a day. If there is no improvement after a week it is advisable to contact your local Chiropody/Podiatry Clinic and let them assess it and advise you. At the clinic they will be able to apply suitable dressings to heal the fissure and suitable padding materials to prevent the inevitable shoe rubbing that might prevent them healing.

Remember if in doubt about any foot problems always contact your local chiropody/podiatry clinic for advice.

Depression and Diabetes

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Depression and Diabetes

How do You Know You Are Depressed?
The Need for Diagnosis
Depression in Parents of Children With Diabetes
GE Insulin, Hypoglycaemia and Depression
Useful Research – Depression and Diabetes


Back to Related Health Issues


Major depression in the UK population at any one time is about 5%, although as many as one person in three may experience an episode of depression in their lifetime. The presence of other illnesses may complicate or worsen depression and vice versa.

Research has shown that depression may occur in:

  • Up to 60% of stroke patients
  • Up to 40% of people with Parkinson’s disease
  • Up to 42% of cancer patients
  • Up to 21% of people with irritable bowel syndrome
  • Up to 14-18% of people with diabetes

A study by Brazilian researchers, presented at the American Diabetes Association Conference 1998, showed that among a group of people with diabetes those whose HbA1c levels averaged less than 9%, only 21% tested positive for depression according to the results of a standardised test. By comparison of those with HbA1cs over 9%, 42% tested positive for depression.

The researchers used cognitive therapy to reverse the depression. In those people where depression improved, there was an average HbA1c of 8.3% while those who showed little improvement had an average of 11.3%.

Other research has shown that people with chronic conditions, including diabetes, are three times more likely to suffer depression than the general population.

Research now suggests an association between higher blood glucose levels and depression which can increase the risk of diabetic complications. It is also possible that high blood sugars cause the depression rather than depression causing high blood sugars.

An international report showed that having diabetes and depression has the greatest negative on quality of life compared to diabetes or depression alone, or other chronic conditions.
[Lancet 2007;370:851-8]

Many studies highlight the need to ensure that depression does not go undiagnosed. They also highlight the need to provide children, adolescents and adults with diabetes with greater psychological support and where necessary, a psychological assessment and treatment for depression.


For more information on depression, please visit the NHS Choices website:

NHS Choices: Depression

Connective Tissue Disorders

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Joint and Muscle Problems Associated with Diabetes

Connective Tissue Disorders
Tests Your Doctor May Carry Out
Frozen Shoulder
Trigger Finger
Dupuytren’s Contracture
Carpel Tunnel
Stiff Man’s Syndrome [SMS] Also Known as Stiff Person’s Syndome
Diffuse idiopathic Skeletal Hyperostosis [DISH]


Back to Related Health Issues

Connective Tissue Disorders

Connective tissue is the material between the cells of the body that gives tissues form and strength. It also is involved in delivering nutrients to the cells around the body. It is made up of a dozens of proteins including collagens. These proteins vary in quantity to provide different structures with varying functions: bone, cartilage, tendons and ligaments as well as fatty and elastic tissues.

Many connective tissue disorders are caused by mutations [alterations] in genes for building tissues and these mutations may change the structure and development of skin, bones, joints, heart, blood vessels, lungs, eyes and ears. Some connective tissue disorders are not directly linked to these mutations but some people may be genetically predisposed to becoming affected. Inherited connective tissue disorders may not be evident at birth but may appear after a certain age or after exposure to a particular environmental stress.

Women, Sex and Diabetes

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Related Health Issues

The Eyes and Diabetes
The Kidneys and Diabetes
Weight and Diet
Exercise Your Heart
Diabetic Neuropathy
Diabetes and Coeliac Disease
Stress, Anxiety and Depression
The Prostate and Diabetes
Polycystic Ovarian Syndrome
Joint and Muscle Problems Associated With Diabetes
Women, Sex and Diabetes
Osteoporosis – Is There A Link with Diabetes?
An experience of the menopause


Women, Sex and Diabetes

While impotence may not receive sufficient attention in relation to men and diabetes, we rarely hear about problems relating to women with diabetes and sexual problems, yet it is a very real problem for women who suffer from it. Many women have difficulty talking to their partner about sexual difficulties and do not seek help due to shame, embarrassment or fear.

As with men, there are many factors that can cause sexual problems in women –they can be psychological or physical. Stress, tiredness, anxiety, relationship problems can all affect energy levels and sexual desire. Some medical conditions such as diabetes, cardiovascular disease, MS and some prescription drugs are linked to sexual dysfunction in women.

Do women with diabetes have problems that are different from women without diabetes? There are very few sources of information about this, yet sex is part of human nature and belongs to a healthy lifestyle so it is to nobody’s advantage to avoid discussing these issues. Research published in 2002 [ref 1] interviewed 120 women with Type 1 diabetes and compared them with a control group of women without diabetes. The results showed that women with diabetes reported significantly more problems with sexual dysfunction than women without diabetes, 27% compared to 15%. There was no association between sexual dysfunction and age, weight, duration of diabetes or blood glucose control. However, there was a close link between sexual dysfunction and depression in both women with diabetes and those without it. The study highlights that sexual dysfunction is common in women with diabetes and that this affects the quality of life.

Common problems

Autonomic Neuropathy [nerve damage] As we know this is a common complication of diabetes and it can lead to poor bladder control and poor vaginal lubrication. This can result in discomfort and inconvenience which may affect a woman’s labido.

Poor bladder control occurs when the nerves to the bladder are damaged and this may lead to an inability to empty the bladder completely. Women are advised to urinate before intercourse and within 30 minutes after. The American Diabetes Association advises people suffering from inconsistent urine release to follow a planned bladder emptying programme whereby they try to urinate every hour until the bladder feels full.

Poor vaginal lubrication can occur if neuropathy affects the nerve fibres that stimulate the genitalia so that arousal may not occur so making intercourse painful [dyspareunia] because the lubrication fluids are not produced. This situation can be helped by the use of a lubrication jelly from the pharmacy [eg KY Jelly] or for women that find that lubricating jelly diminishes their labido, a mild skin cream may be more helpful.

Note: Poor vaginal lubrication can also be caused by low hormone levels which can affect women with and without diabetes. This needs to be diagnosed by a doctor and if necessary, treated with hormone replacement therapy.

Low sex drive
A lack of interest in sex can affect both men and women. It may be a factor throughout life but if a temporary phase, it can be caused by psychological factors such as depression, tiredness or hormonal problems or linked to certain medicines. The medicines that can affect a low sex drive are tranquillisers, the Pill, antidepressants and pills for high blood pressure – some of which are commonly used by people with diabetes. It is advisable to discuss this with your doctor to consider changing medications.

Poor sleep may lower women’s libido – a study has found that low libido during menopause may be linked to disturbed sleep. This is the first time that sleep disturbances have been independently associated with diminished sexual desire. Of the 341 women in the study, 64% reported a low libido and 43% said they had trouble sleeping.
[American Journal of Obstetrics and Gynecology, June 2007]

Painful sex in women
Pain during sex [dyspareunia] can be superficial or deep pain. Superficial pain is often caused by infections such as thrush, common in women with diabetes or by vagismus, a condition that causes the lower vaginal muscles to go into spasm. Deeper pain can be caused by a lack of lubrication or stimulation or by conditions such as pelvic inflammatory disease or endometriosis.

Hypoglcaemia and sexual intercourse
For men it is well recognised that intercourse uses up large amounts of energy – the old joke about it being the same as running a 4 minute mile! So it is necessary to be aware that this could cause a hypo.

But women should also be aware of hypos during and after sex. Some women put out an adrenalin response while they are having intercourse and this produces a loss of control, sweating and erratic heartbeat. These symptoms are similar to those of a hypo and so it is important that the two are not confused. Checking blood glucose levels before and after sex is recommended. While this may sound a little contrived and perhaps takes away some of the spontaneity, it does serve to emphasise that women with diabetes do have added difficulties compared to women without diabetes.

Ref 1 Diabetes Care 2002;25:672-676

Hypoglycaemia and Driving

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Driving and Diabetes

Driving and the EU law
News release: EU changes night-time hypos driving rules for people with diabetes
Driving and hypoglycaemia – what are doctors being advised to do?
Test Strips – Department Of Health Warning For Doctors And Pharmacists
Vehicles You Can Drive
Insulin and Driving Taxis
Hypoglycaemia and Driving
Driving and Medicines
Driving and Visual Field Loss


Living with Diabetes

Hypoglycaemia and driving

The concerns for people with diabetes driving are largely based on the possibility of hypos occurring whilst driving. The presence of hypo warnings and the ability to recognise them is very important if people with diabetes are to be safe drivers and this applies to driving any vehicle.

Tips for safe driving:

  • Always drive with glucose or sweets to hand – not in the glove compartment.
  • Carry out a blood glucose test before driving and test every 2 hours on long journeys.
  • If you feel a hypo coming on, pull off the road, get out of the car or move into the back seat. (So that you are obviously seen not to be driving the car if the police should come along.)
  • Treat the emergency hypo immediately, wait until blood glucose levels have risen and then drive on and stop for a proper meal.
  • Remember that following a hypo your judgments may be impaired for an hour afterwards even though you feel OK and your blood glucose levels are back to ‘normal’.
  • Consider raising the blood glucose levels a little while driving.
  • Remember that diagnosis of diabetes treated with insulin or tablets that may cause hypoglycaemia means that you must inform both the DVLA and your motor insurers. This is a material change in your circumstances and failure to inform the DVLA could result in prosecution and your insurance being invalid.

Driving and loss of warnings of hypoglycaemia
Some years ago, IDDT received a letter from a lady whose husband was killed in a motor accident by a driver with diabetes who went hypo at the wheel. He was acquitted of dangerous driving because he had a hypo at the time. This emphasises the need to raise awareness of the need for blood glucose testing before driving.
But it really is not as simple as that, as we all know. Blood testing itself does not stop you going hypo, it tells you what your blood sugars are at that moment in time so that you can eat if necessary. Equally, many of us know that they can drop quite quickly, especially under a stressful situation – the M6 on a Friday afternoon! So it is essential to be vigilant all the time and to test before driving and at frequent intervals on a long journey. But the real problem when driving is loss of hypo warnings, reduced warnings or sometimes you have warnings and sometimes you don’t. Loss of hypo warnings or reduced warnings is dangerous and if this is the case, then driving should cease.

Driving and diabetes poses conflicts
A person with Type 1 diabetes writes:
"People with insulin dependent diabetes who want to keep their driving licences may feel that any disclosure to their GP or consultant about hypos could affect the renewal of their licence. There have been times in the past when I would very much have liked to discuss problems with hypos with my doctors but disclosure may have jeopardised my driving licence and so my livelihood. I am sure that most people with diabetes take sensible and appropriate precautions when driving. But being placed in this situation where discussions of hypos may lead to the doctor having to inform the DVLA of hypos, means that we are probably not receiving help and advice from them that we need to improve the situation. I can see the sense in both the DVLA questionnaire about hypos and the need for disclosure but we do seem to be in a vicious circle. If we have hypos and tell the truth, then we risk losing our driving licences but if we don’t seek the advice of our doctors on prevention of hypos, then nothing will change."

This highlights the very real conflicts that arise – the doctor is the person from whom we need help to try to resolve the problems with hypos but he/she is also the person that says ‘yes’ or ‘no’ to our driving licence renewal. Unless we resolve this conflict so that patients feel able to discuss with their doctors ways of trying to avoid hypos and/or regain their hypo warnings, then the risks of traffic accidents will continue.
"Good control is not just the avoidance of hyperglycaemia but also the avoidance of hypoglycaemia."

This statement was made by Professor Stephanie Amiel at IDDT’s annual meeting some years ago but it is one that perhaps we all need to remember, patients, doctors and healthcare professionals.
The achievement of ‘excellent’ HbA1cs may be at the expense of increased frequency of hypos which in turn, increases the risk of loss of warnings. We have to remember that the HbA1c test does not measure low blood sugars, only the highs, so a good result could mean that there are frequent undetected mild/moderate hypos.

Diabetes poses many conflicts and driving is certainly one of them:

  • the conflict between ‘good’ control that reduces the risk of long-term complications but increases the risk of hypos and perhaps relaxing control a little to avoid hypos.
  • the conflict of quality of life now against the unknown quality of life in the future if blood sugar levels are relaxed.

The effect of loss of driving licence should not be underestimated in terms of quality of life – it can affect self-esteem, jobs, income and pleasure and therefore the quality of life of the whole family.

IQWiG: Rapid-acting analogues are not superior to ‘human’ insulin for Type 1 diabetes

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IQWiG: Rapid-acting analogues are not superior to ‘human’ insulin for Type 1 diabetes

June 2007

Report from the Institute for Quality and Efficiency in Health Care [IQWIG]
Yet again we are reliant on Germany for another review that helps to inform our decisions about insulin treatment. Unlike the UK where the Dept of Health has refused our lobbying request for a National Institute of Clinical Excellence [NICE] assessment of all insulins, the German Federal Joint Committee actually commissioned IQWiG to compare the benefit of rapid-acting insulin analogues versus human insulin for Type 1 diabetes. So one has to wonder why this doesn’t happen in the UK?

The insulins investigated were, Humalog [lispro], NovoRapid [aspart] and Apidra [glulisine].

What did the review find?

Adults – there is currently no evidence available to demonstrate a superiority of rapid-acting insulin analogues in the treatment of adults with Type 1 diabetes. The value of the evidence and design of studies so far are inadequate and do not allow conclusions regarding most important patient goals, such as the reduction in long-term complications or overall mortality.

Children and adolescents – due to lack of data, the benefit of rapid-acting insulin analogues in children and adolescents is unclear [an uncertainty!]. Novo Nordisk has carried out long-term comparative studies in this group of patients but they are withholding some of the results.

Pump therapy – no long-term studies were available therefore it remains unclear whether adults would benefit and what advantage patients would have by using analogues with insulin pumps [an uncertainty!]. The same applies to children and adolescents as only fully published short-term studies are available. Novo Nordisk sponsored 2 long-term studies in children and adolescents but to date, both studies have only been partially published and unlike Sanofi-Aventis and Lilly, Novo Nordisk were not prepared to provide the information needed for the review.

Quality of life, not a fair comparison – in some studies patients treated with insulin analogues assessed their quality of life as higher and they were more satisfied with treatment than those using human insulin. IQWiG did not evaluate this finding as evidence of an additional benefit, because it was not based on a fair comparison – patients in the human insulin group were asked to adhere to a fixed injection-meal regimes but the analogue group were not. [As we know, it is quite possible to use a flexible regime with all types of insulin.] So it is unclear whether the patient satisfaction was due to the insulin or to the more flexible regime prescribed by the physicians.

What conclusions can be drawn from this?
Basically it is simple, there is no evidence that rapid-acting insulins are any better than human insulins for adults with type 1 diabetes. It is unclear whether they are of any benefit to children and adolescents. It is also unclear whether they are of benefit any groups of pump users. They are, of course, significantly more expensive to the NHS! So once more, we this review raises big questions:

  • Why is the Dept of Health so unwilling to follow Germany’s lead and have all insulins assessed by NICE for risks/benefits and cost effectiveness?
  • Why are Primary Care Trusts that are so obviously short of funds, spending unnecessary amounts on insulin analogues that have no proven benefits over less expensive human and animal insulins?
  • Why are adults and children with diabetes being changed to insulin analogues when they have no proven benefit?
  • Could all this be anything to do with heavy marketing of insulin analogues because they are the only insulins in patent, therefore more expensive and more profitable?

Family Relationships

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Family Relationships

As an organisation whose members have the practical experience of living with diabetes, one thing that we are all very aware of is that diabetes affects everyone in the family. This is probably especially so when it is your child who has diabetes and being aware of this may help to prevent some of the pitfalls which make life more difficult. Everyone in the family has their own way of coping with diagnosis and the subsequent changes in the life of the family. We all react differently, so it is impossible to cover all the various dynamics in all families. Here are just a few examples that may help you to realise that your family is not alone with your experiences and concerns.

Mums and Dads
However strong a marriage or relationship is, it is important to recognise that diabetes, like any other chronic condition, can put a strain on that relationship and diabetes in the child that you both care about so much, is no exception. However, it can, and often does, bring couples closer together at time of diagnosis:

Quote from a friend of a family where one of the children had been diagnosed 12 months earlier. "You seemed a very close family. It was as if you had all closed ranks and didn’t want to let anyone else in."

But is that the case when living with diabetes 24 hours a day, 365 days a year every year? Sometimes the day to day stress can affect the parent’s relationship with each other and cause conflicts. 

It is best if the responsibility for your child’s diabetes can be shared but very often, because of circumstances, one parent takes most of the responsibility. This is usually for very practical reasons – work. So, by force of circumstances, it is the often Mum who shoulders most of the responsibility, although the following can apply just as much to Dads who shoulder most of the responsibility. Here are just some of the possible effects, citing Mum as been the main ‘carer’:

  • Dad feels excluded and Mum feels he doesn’t do enough or is not interested. Resentment builds up.
  • Mum feels that their child’s diabetes has become her sole responsibility and then resents Dad having an opinion on decisions about control or approaches to diabetes within the family.
  • The worry and energy spent on ‘getting everything right’ makes Mum tired and irritable and arguments easily develop.  

Visiting the diabetic clinic
This should be seen as helpful but it often feels like the third degree and a test of the competence of the parents. You have been set blood glucose targets for your child and these may well have not have been achieved. [I say this as an old hand at parenthood because I concluded that all too often the targets are unachievable if you want any sort of life that is not totally ruled by diabetes!] However, the fact that you are questioned about these and why the results are not what the health professionals at the clinic would like to see, makes you feel guilty, ashamed, a failure. Worst of all, you feel you are letting your child down and at risk of affecting their future health. You may also feel angry with the health professionals for making you feel this way when you have being trying really hard ‘to get it all right’. The parent who does not attend the clinic does not have to go through all this and they probably cannot understand the effects it can have. It is easy for resentment to grow against the parent who escapes this ritual.

Fear of hypoglycaemia
This is very common and understandably so. It is a time when we have to make decisions and take action and we feel a great weight of responsibility for the outcome. Severe hypos at night are frightening, especially if accompanied by seizures and, whether the fear is rational or not, we sometimes fear that our child will die. All of this can result in:

  • Conflicts from one parent wanting to raise blood sugar levels to avoid future night hypos and the other parent not agreeing because of their fears of the long-term complications.
  • Both parents not sleeping well and being tired etc. The parent who has to go to work the next day assuming that their sleep should be less disturbed and the other seeing this as a ‘cop out’!
  • Because of fears of night hypos, one parent sleeping in the child’s bedroom – not good for the relationship between the parents.

Quote from a Mum: "It seemed at one point every time we had sex Gabby knew and walked into our bedroom in a hypo. I found it difficult to have sex and my husband could not understand why – he thought I was being irrational and that I no longer cared for him."

Not feeling able to go out for an evening together because of the fear that the babysitter will not be able to handle a hypo, gives parents no break and freedom, not even for a few hours. If both parents are not happy with this, it can lead to fewer activities as a couple and doing more things separately. Even worse, it can mean that one partner is always the one to go out.

Quote from one Mum: "We didn’t used to argue very much and then only about one thing – money! Now we argue a lot more and about only  two things – diabetes and money!"

Siblings and their rivalry
It is unavoidable that sometimes your child with diabetes comes first:

  • At diagnosis everything centres on the child with diabetes.
  • Hypos have to be dealt with immediately, even if you are helping his brother or sister with their homework.
  • Mealtimes often are influenced by diabetes and so is the food the family eats.
  • Clinic visits have to fit into the family routine.
  • At times of illness or emergency, the needs of your child with diabetes do come first.
  • Depending on their ages, it is easy to ask the brother or sister to ‘keep an eye out’ without realising that this is a responsibility that they don’t need or want. If the children go to the same school, it is not uncommon for the teachers to ask the brother or sister to help with a hypo.  

The list is almost endless and it is obvious that diabetes in the family is going to affect the brothers and sisters in many different ways. It can, and often does, bring them closer and they show a protective approach if anyone criticises their sibling with diabetes. But at the same time, it is natural that there may be some resentment and jealousy. Families have to work their way around these problems but being aware of them and attempting to meet them before they develop into permanent sources of conflict and sibling rivalry is half the battle. Talking about the problems within the family is important and it is not unreasonable to apologise to the brother or sister for perhaps not spending as much time with them as you would like. They need an explanation, albeit, within the limits of their age and level of understanding. They need to know that you love them just as much as you always have, and as much as your child with diabetes, and that because diabetes is serious, it sometimes has to come before everything else.

Tip from a Mum: "I found that blaming diabetes rather than my daughter [with diabetes] was the best way around problems – we could all hate it together then. It helped to make my son realise that when things were difficult, it was not his sister’s fault but the fault of diabetes."

Quote from a sibling: "Often one of the first signs that my sister was hypo was that she would get bad tempered and argumentative – this often happened before Mum realised that she was hypo and so we would both get into trouble. Then the penny would drop and my sister was given sugary foods. She came around feeling happy again, totally unaware that we had been very angry with each other, but I remember being left still feeling angry with her. Even though I knew she’d been hypo she had still made me angry and a biscuit for me didn’t sort out how I felt!"

But let us not forget that sibling rivalry works both ways!
Just as we can see that the child without diabetes feels jealous and envious, the child with diabetes can feel jealous and envious of their sibling because they are well and don’t have diabetes. They may even feel that you love their brother or sister more, because they don’t have diabetes – perhaps a difficult concept for us as parents because so much more time, energy and worry seems to go into the child with diabetes!

Here is a point worth remembering at times of conflict. What is the first thing we do in the mornings with our child with diabetes – blood test, injection, then breakfast. Essential but not the nicest way to start the morning! If injections and blood tests are difficult and a struggle to achieve [in young children and teenagers, for example] then there may also be a battle! So it is hardly surprising that they feel that you don’t care about them compared to their sibling. The role of a Mum is expected to be loving and caring – the person who protects, supplies comfort and does all the nice things. This image falls down when your child has diabetes – Mum has to do or instigate nasty things, starting straight away in the morning! No wonder they can feel unloved and resentful. 

As parents going through our own grief at the time of diagnosis and having to learn so much, we are perhaps unaware of the effect it can have on our parents [our children’s grandparents].

A personal experience
My daughter was diagnosed when she was 5 and her brother was 6 – they had two grandmothers but no grandfathers. My mother had difficulty believing that Bev had diabetes and she was upset and emotional for a very long tome. Perhaps only now that I am a grandmother myself do I truly understand what she felt like. Grandchildren are very special – we can enjoy them, we can spoil them and we are free from the responsibilities we had with our own children. So I can now understand why my mother felt so upset when Bev was diagnosed. To a grandparent, it also seems so unfair that we are older, but it is someone so young who should have a lifelong condition like diabetes.

I’m quite sure that my mother sometimes felt I was being hard with Bev without realising that I was doing what I had to do and what I thought was best for her. But I was lucky, she never interfered or criticised. But I know of other families where this has not been the case, probably because of the difficulty the grandparents have in accepting diabetes in the family. The grandparents have interfered, have paid more attention to the child with diabetes, so leaving the other grandchildren feeling left out and ignored. However unintentional, they can leave emotional chaos behind them after a visit.

I have to say that my mother-in-law, Bev’s other Grandma, reacted in a very different way. There were similarities in that it was as if she had difficulty accepting it too, but her way of handling this was to ignore it. I don’t think that she ever understood the seriousness of diabetes or the effects it had on our family life. This was her way of coping and we are all different. It later became a family joke because it was tradition that she made the first cup of tea on Christmas morning and she always asked if Bev took sugar, every single year up to adulthood!

One of the most useful roles that grandparents play is as babysitters, especially nowadays when both parents need to work. But this is often difficult for parents and grandparents.

We, as parents, naturally find it difficult to leave our child with diabetes, even with our own parents. But grandparents may also feel that they cannot babysit because the weight of responsibility is too great or they do not feel to know enough about diabetes. These reactions are understandable but it does limit what the parents can do and it denies the grandparents the pleasure of looking after their grandchildren.

Quote from a parent: "My mother learnt about hypos, testing and food and I learned to leave my daughter with her for a couple of hours during the day to start with. Of course, I was always at the end of a phone. I could not leave her for overnight stays because she sometimes had severe night hypos and this would not have been fair on my mother and nor could I have slept!"

Research quote:
Winthrop University Hospital in the US held an educational programme for grandparents of children under 6 with diabetes. They learnt about injections, food, hypos and glucagon. None had provided overnight care but 50% had provided daytime care. There was a 3 month follow up after the programme and none had ‘graduated’ to overnight care – the reasons given were geography and parental fear of allowing others to care for the diabetic child overnight. However, most grandparents felt much more confident and more able to look after their grandchild, especially if an emergency occurred, and they all felt to benefit from meeting and talking with other grandparents.

Juggling the Blue Carbohydrate and Red Insulin Balls

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Diabetes commonsense

Introduction: Enter Dr Lawrence
Balance: Signpost to Success
Juggling the Blue Carbohydrate and Red Insulin Balls
The Great Debate: Natural Animal or Artificial ‘Human’ Insulin?
Conclusion: Commonsense Rules


Diabetes Common Sense

Juggling the Blue Carbohydrate and Red Insulin Balls

Jugglers need to know the shape, size and weight of the balls they are juggling. I have met diabetics who were hopelessly lost because the word carbohydrate had never been explained to them and they had no idea of how much carbohydrate to eat each day. Their blue carbohydrate balls were therefore falling about in all directions, unrelated to the insulin or tablets they were taking and completely out of control. This chaos need not happen to you. With the help of your doctor and dietician, you can be sensible and decide what to do. Modern treatment gives you freedom. You do not have to be starved, deprived or over-fed. The only thing that matters is to adopt a mindset that encourages us to keep our carbohydrate intake the same each day. Commonsense shouts the message that anybody who eats a lot of carbohydrate on Monday and very little on Tuesday is not going to feel well. Because diabetics have lost the automatic blood sugar control system which others enjoy, this is especially true for them. To keep carbohydrate intake steady is as important as to keep the blood sugar steady.

This message had not reached an elderly lady who shared a hospital ward with me. She became bad-tempered and cranky when her blood sugar went out of control, although she insisted that she always obeyed the rules. I watched her and was horrified to notice that she was constantly helping herself to the fruit that her visitors showered upon her. She would not listen to me when I told her that the extra carbohydrate in the fruit was enough to explain her unwelcome high blood sugar. Her doctor had told her that fruit was good for her and that was that.

How much you want to eat each day is for you to decide. Your dietician can suggest various choices but only you can make a true commitment and determine to fulfil it. I know this is difficult because I have been a Captain in the Fight-Against-Flab Army for many years and my indiscretions have always prevented my promotion to Colonel. Keeping the balance right, not eating too much or too little, will never be easy but the good health reward for success makes the effort worthwhile. You have only to scrutinise your naked body in the mirror to see whether the billows and bulges are attractive or just floppy rolls of ugly fat getting in the way. The stark truth is that slimming means eating less and exercising more. Huge profits are made at our expense from special diets and slimming aids. These are costly ways of telling us that our will power is weak and it is time we tried harder.

Once you have taken your first flight and are on the way to becoming a fully-fledged diabetic, you will become aware that insulin and carbohydrate work together. If you decide to take extra carbohydrate, you will need extra insulin to digest it. Imagine you are invited to a birthday dinner on Saturday. When you return home after the feast, you will have to consider how much extra carbohydrate you consumed. Do not panic or feel guilty; an occasional high blood sugar is not a crime. To digest the extra carbohydrate and restore the balance, you could take a brisk walk, eat less carbohydrate at the next meal, or inject a little extra insulin – two or four units will probably be enough.

When we know the amount of carbohydrate we need to balance the insulin, how do we help ourselves to keep the balance right? For me, the easiest way is to divide the day into three parts – morning, afternoon, evening. If my dietician and I have selected 300 grams as the daily norm, then 100 grams is eaten for breakfast and elevenses, 100 grams for lunch and tea, and 100 grams for supper and bedtime. This plan allows flexibility and a sensible spread over time. If you are hungry, more can be eaten for lunch and less for tea; if you are not hungry or in a rush, you can eat less for lunch and make up by eating an extra bun or sandwich for tea. Diabetics are often told they must have three main meals and three snacks daily. These instructions suggest a timetable that is difficult to carry out for a person leading a hectic life. All that is necessary is to know what you are doing and avoid stuffing yourself at one moment and starving yourself the next. Your body cannot be expected to perform well if you throw different amounts of food at it every day and never allow it to integrate with the insulin flowing through your veins.

Being diabetic has the great advantage that it requires you to stick to a pattern of eating that is healthy for everybody. There is no such thing as a diabetic diet. A healthy diet for you is also a healthy diet for your family. You need not waste money on special diabetic foods. An emancipated diabetic can eat anything; the only limitation is to eat the right amount at the right time. The signpost pointing to healthy eating will read ‘low fat, high fibre, with plenty of fresh fruit and vegetables.’ It is the carbohydrates that need to be carefully managed, whether you are on insulin, tablets or diet. Proteins (meat, fish, eggs, nuts, beans, lentils) and fats can be eaten in normal helpings.

A true, cautionary tale might be useful here to embroider the word ‘normal’. At a diabetic clinic, I found myself sitting beside a handsome, but overweight, young man. He complained that he never felt really well and could not lose weight although he always kept strictly to his diet sheet. I asked him to tell me everything he had eaten yesterday and what he planned to eat tomorrow. I was appalled to discover he thought he could eat as much cheese as he liked, and he was eating nearly a pound of cheese each day. No wonder he felt ill and could not lose weight! He badly needed an injection of commonsense.

I have found the easiest way to eat the right amount of carbohydrate is to follow the ten-gram exchange system invented by Dr. Lawrence. This method has fallen out of favour lately, perhaps because it can be followed without the help of a qualified dietician. It simply tells you how much of each food is equivalent to ten grams carbohydrate and leaves you to mix and match the ten gram portions to your taste. For example, one slice of bread counts as about one ten-gram portion. It can be exchanged for any one of the following: two cream crackers, one egg-sized potato, one medium apple, one orange, half a large banana, ten strawberries or ten grapes, three large plums or apricots, and so on. This list of ten-gram exchanges can be extended at will. The idea is even simple enough for young children to use.

I remember, as a rebellious seven year old, kicking against injections and food rules, how Dr. Lawrence took the wind out of my sails by telling me I could eat whatever I liked; all I had to do was to remember what I had eaten and tell my mum about it, and not try to deceive her or myself. It did not take me long to put this teaching into practice. At school, my teacher and my classmates knew about my diabetes and that I had to eat one large banana, twenty grams carbohydrate, at break. This routine bored me stiff. I cut my banana in two, ten grams each, and started to swap with what my class friends had brought for their mid-morning break. Banana was a novelty for them and they were as keen to try it as I was to be rid of it. This developed into a fascinating barter system. One day half a banana was swapped for a digestive biscuit, next day for half a sandwich, then for three toffees. Becoming braver, both halves of the banana were exchanged for a biscuit and an apple, or an orange and ten smarties. Break became exciting, not boring. I did not feel deprived any longer and have not done so since. I remembered the second part of Dr. Lawrence’s instructions. I always told my mother exactly what I had eaten and I was always praised for doing this. When she called to collect me from school, my friends would rush over to tell her all about that day’s banana exchanges!

Health and happiness are dislocated if you eat too much or too little carbohydrate. What matters is that the bullseye of the carbohydrate target is hit each day. When this is achieved, the insulin and the carbohydrate will fall into each other’s arms and waltz along happily together. A clever juggler will be able to keep the blue balls balanced and have the confidence to try wonderful new ways of eating and living.

We juggled with the carbohydrate first because this is easier to balance than the insulin. We can control and measure what we put into our mouths even if we sometimes cheat. Although insulin, too, can be accurately measured, it is more difficult to balance because its behaviour is influenced by many factors, some of them outside our control. Remember, insulin does not work on its own. It plays an essential part in our hormone orchestra. If other hormones, for example, adrenalin or thyroid, are discordant, we will have a hard job trying to keep the insulin in tune. We also need to be aware that exercise, infection, stress and weather are four awkward customers, difficult to deal with because they change all the time, upsetting the insulin balance and defying scientific measurement. Perhaps this could explain why diabetic experts often ignore these factors when teaching us how to live with our diabetes.

It might be helpful to explore the features of these four awkward customers. Consider exercise first. If you think about it for a minute, you will realise that whenever you take physical exercise not part of the normal routine, you will burn up extra energy (sugar) and therefore need less insulin or more carbohydrate to keep the balance right. For example, before playing a strenuous game of tennis, you should take a carbohydrate snack to provide the extra energy you will be using. This is the moment to indulge in a chocolate digestive biscuit without the bitter taste of guilt that might spoil the flavour at other times.

The second awkward customer is infection which can play havoc with the required insulin dose. Be prepared. Note carefully what is happening and do not be taken by surprise. A sudden increase in insulin dosage is nothing to worry about and when you get better, the fall back to normal may be equally sudden. Recently, a bad bout of influenza caused my insulin need to double almost overnight. Three days later, as healing progressed, my body picked up its normal rhythm and the insulin went back during the next day to its usual dose.

Stress is the third awkward customer that you need to be aware of as it arrives uninvited, upsets the balance and is difficult to counteract. Dr. Lawrence used to warn us, “When the stock exchange falls, the blood sugar rises!” Moving house, unemployment, exams, family problems, bereavement and accidents are some of the experiences that may trigger stress-related insulin upsets.

The fourth awkward customer, the weather, is the one that is completely beyond our control. It creates variable conditions that affect the rate at which we burn up energy and use up insulin. As my husband used to say, on a frosty morning or a hot, dry summer day, “Watch out! This is hypo weather. Be careful. Be sure to have your glucose sweets in your pocket.” In my experience, on a crisp, dry day, I would feel symptoms of an approaching hypo half an hour earlier than on a sultry, humid day. Knowing this, I could be prepared and avoid trouble. ‘Fore-warned is fore-armed,’ says the old proverb.

These variables, the four awkward customers, make juggling the red insulin balls a difficult but fascinating challenge. Their existence reminds us that we are not a chemical experiment, whatever the diabetic clinic thinks. No insulin dose is ever perfect, but we can feel pleased and proud when the blood sugar obeys our instructions and remains reasonably steady.

It will be easier to manage these delicate red insulin balls when we investigate how our blood sugar levels rise and fall during the day. To do this, I suggest we set aside a testing week when the weather, your carbohydrate intake, and your stress levels are pretty stable. Test your blood sugar four times a day for seven days. It is clearer if you enter the results on graph paper. If the first test is on waking and the second around midday, the third at teatime and the fourth at bedtime, you join these four dots and this shows the blood sugar profile for the first day. Repeat this for seven days. The results at the end of the week make it possible to draw an average daily blood sugar profile. Next time you attend the diabetic clinic or see your consultant, ask them to draw their version of your blood sugar profile and compare notes. It will be interesting to find out which of you is more accurate.

Nobody likes to test but it has to be done, whether we use a urine or blood sample. We need to do this to control our diabetes and not let it control us. We should not test to please a relative, a doctor, a scientific study or an enthusiastic salesman. Be careful not to become a diabetic bore, obsessed with constant testing. Doing a test is a waste of time and money unless the result can be used to plan future action and manage our diabetes better.

Finger-pricking blood tests are faster, more accurate, more expensive and more painful than using a urine sample. This does not always make them the best. Nowadays, home testing blood sugar meters have become popular. They are in universal use in rich countries where the expensive test strips can be afforded. The decrease in hypo warnings and the quicker action of the new ‘human’ insulins make frequent testing more necessary. The manufacturers of these high-tech machines must be rubbing their hands in glee as they watch their profits mount. The remarkable accuracy of these meters is one of their chief selling points. The fact is, however, that such accuracy is irrelevant.

Every doctor knows that blood sugar, like blood pressure, does not remain static for diabetics or non-diabetics. By the time the result has been recorded, the precise measurement will have changed. If the test result is 5.6 mm now, it will have moved up or down to perhaps 6.2 or 4.3 mm half an hour later. The amazing accuracy of these high-tech blood testing meters does not greatly help us when what we really want to know, to understand our diabetes, is whether the blood sugar is low, medium or high and whether it is rising or falling. Their detailed information only serves to distract us from the truth that blood sugar is always rising or falling, constantly changing, whatever test method is used.

These modern machines are not yet clever enough to respond to this fundamental truth. Professionals do not seem to acknowledge how important it is for diabetics to know about the rise and fall of blood sugar, or if they do, they do not always tell this to patients. After many years experience, I have found that dipping a test strip in urine, though the results are less accurate and less immediate, tells me all I need to know. If the bladder is emptied and a second sample taken fifteen minutes later, the answer is immediate enough for normal purposes and I am not diverted by misleading accuracy.

The diabetic establishment favours synthetic ‘human’ insulin and finger-pricking blood sugar testing machines. Some of us, not part of the establishment, may think differently. Just as we may prefer to stay with the slow, gentle action and more satisfactory warnings of hypos that animal insulin gives us, so we may also wish to use the urine testing method to avoid the sore fingers caused by frequent finger-pricking. Expert advisers, perhaps influenced by pharmaceutical companies, seem to have forgotten that clever machines have no natural instincts. We would have to stop the clock and hang in suspended animation to give meaning to the delicate precision presented to us by these modern test meters. Time moves on and we move with it.

The red insulin balls gradually become more friendly and familiar as we learn not to expect miracles, or be disappointed when stress, infection or weather temporarily disrupt blood sugar levels. Our confidence increases, we make fewer mistakes and we handle them better. We train ourselves to tune in to the song of our own good health.

Synthetic ‘human’ insulin versus natural animal insulin

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IDDT campaigning

Pork and beef insulins available in the UK
Synthetic ‘human’ insulin versus natural animal insulin
Animal insulin – Minister’s letter
Limiting availability of blood glucose test strips


Back to Here to Help

Synthetic ‘human’ insulin versus natural animal insulin

IDDT has campaigned for the continued availability of pork and beef insulins since its formation in 1994 when significant numbers of people experienced adverse effects from synthetic human insulins. The continued availability of animal insulins was threatened which would deny people the insulin they need to remain healthy. The major insulin manufacturers ignored the needs of this significant minority of people with diabetes and in 2007 they discontinued manufacture of animal insulin. However, thanks to a smaller supplier, Wockhardt UK, the UK is one of the very few countries where pork and beef insulins are still available.
By the late 1990s  the major insulin manufacturers introduced insulin analogues and these synthetic insulins also caused some people to have adverse effects, all too often not acknowledged by their doctors and diabetes team.

Below is a summary of the lobbying campaign carried out by IDDT and its members – it’s a record of how we did it!

Click here to read how we lobbied…

IDDT Launch Public Awareness Campaign

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IDDT Launch Public Awareness Campaign

16th March 2009

The Insulin Dependent Diabetes Trust (IDDT) announced today the launch of their latest public awareness campaign, ‘Understanding Your Diabetes.’ This campaign aims to help the general public have a better understanding of the difference between Type 1 and Type 2 diabetes and help those with diabetes make informed choices about their treatment – not just insulin and medication – but how the right treatment can also improve their quality of life.

The 4 key messages in this campaign are that:

  1. Patients should always be involved in decisions about the treatment of their diabetes.
  2. They shouldn’t be afraid to ask about their medicines and the available choices.
  3. If, or when they move to insulin treatment, then they should know that they can choose between animal, human, or analogue insulins.
  4. They should be aware that synthetic human and analogue insulins involve different regimes that often require more frequent daily injections compared with animal insulins. So they need to be able to discuss the choices with their GP to consider how different regimes may affect their lifestyle.

IDDT’s Chair, Jenny Hirst commented; ‘Our members, whether they have Type 1 or Type 2 diabetes, tell us that they need our support and that’s exactly why we set-up IDDT over 15 years ago – to help them manage their condition.’

She continued, ‘People with Type 1 diabetes are tired of being accused – by ill-informed people – that the reason that they have diabetes is because they eat too much sugar, or that they must have been overweight at some stage in their lives. The truth is very different! People with Type 1 diabetes have it through no fault of their own and it is totally unavoidable. In addition, many patients who have Type 2 diabetes also need help to better understand their condition. So we hope that this campaign will help to clarify the differences between the two types of diabetes and help all those who are currently struggling with their management of the disease.’

As part of this awareness campaign the charity has produced a patient information booklet, entitled, ‘Understanding Your Diabetes’ which is available free of charge and explains in detail the differences between Type 1 and Type 2 diabetes.* The booklet is written in plain English and explains the relationship between insulin or medication, diet and exercise. In doing this, it supports people with both types of diabetes by removing some of the harmful myths and misunderstandings. Alongside this booklet the charity will be running a series of advertisements in the medical press and exhibiting at professional conferences to encourage GPs and practice nurses to ‘spread the word’ to their patients.

For further information or copies of the booklet, please contact:

Insulin Dependent Diabetes Trust [IDDT]
PO Box 294

tel: 01604 622837
fax: 01604 622838
e-mail: enquiries@iddtinternational.org
website: www.iddtinternational.org

* For press enquiries, ‘Understanding Your Diabetes,’ please contact:

Veronica Wray

tel: 020 8568 8546
Mob: 07710 624454
e-mail: info@veronicawray.com

Humulin M3 injection pens – KwikPen available

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Withdrawal of Mixtard 30

Novo Nordisk plans to withdraw Mixtard 30
Nearest equivalent insulins to Mixtard 30
Humulin M3 injection pens – KwikPen available
IDDT opposes Mixtard 30 withdrawal

  News Release:

Marketing of insulin – a missed opportunity


Humulin M3 injection pens – KwikPen available

Following the discontinuation of Novo Nordisk’s human Mixtard 30, many people are, or already have been changed to Humulin M3 made by Eli Lilly. This is the nearest equivalent to Mixtard 30. Some people may have experienced difficulties in obtaining the standard pre-loaded injection pens of Humulin M3.

IDDT has contacted Eli Lilly who acknowledge that stocks of the standard pen are low and they are advising doctors and health professionals to prescribe the new pre-loaded KwikPen with Humulin M3. This was due to be introduced in March 2011 but Lilly have already brought it into the UK to meet demand.

Diabetes – Everyday Eating

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Very often, particularly after diagnosis, people feel confused about the advice they are given about healthy eating. They feel insecure about what they are eating and how this may affect their diabetes or they simply do not have enough information about diet. As one gentleman said “I want to be told what I can eat – not what I can’t”.

This booklet includes a 4 week Menu Plan to give people ideas about what they can eat. It is based on the principle of healthy eating and could help weight loss. It also provides an introduction to counting carbohydrates and is a stepping stone to learning more about diet and diabetes.

Diabetes – Everyday Eating

Medication errors in hospitals

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Medication errors in hospitals

A National Diabetes Inpatient Audit [NaDIA] report publishes May 17th 2012 has shown that nearly one in three hospital patients with diabetes are affected by medication errors. This is a small improvement on last year. The audit examined bedside data for 12,800 patients and 6600 patient questionnaires, covering subjects including medication errors and patient harm over a seven day period in October 2011. It involved 11,900 patients in 212 English hospitals and 900 patients in 18 Welsh hospitals.

During the seven day audit period hospitals in England and Wales made at least one medication error in the treatment of 3700 inpatients. 32.4 per cent of patients (3,430) experienced at least one medication error in the previous seven days of their hospital stay.

Patients with errors suffered with:

  • More than double the number of hypos [low blood sugars] compared to people with errors.
  • 65 patients developed ketoacidosis [DKA] during their hospital stay. This worse than last year when the number was 44. DKA occurs when blood glucose levels are consistently high which suggests that insulin treatment was not given for a significant period of time.

Medication errors were recorded under two types – ‘prescriptions error’ and ‘medication management error’.

Prescription errors

  • 20.7% of patients with diabetes experienced a prescription error – an improvement on last year when it was 25.5%.
  • The most common error was failing to sign off information that insulin had been given on the patient’s bedside. This happened to 11.1% of patients – last year it was 12.7%.

Medication management errors

  • 18.4% of patients with diabetes experienced medication management errors – an improvement on last year when it was 19.7%.
  • The most common error was failing to adjust medication appropriately when the patient has a high blood glucose level. This happened to 23.9% of patients – last year it was 27.9%.
  • 17.4% of patients with medication errors had a severe hypoglycaemic attack while in hospital compared to 7.5% without medication errors.

The report can be accessed at www.ic.nhs.uk/nda

In commenting on the report the lead clinician Dr Gerry Rayman made the following points:

  • Training [of health professionals] needs to be mandatory to reduce hypoglycaemia and prevent DKA occurring in hospital for which there is no excuse: its occurrence is negligent and should never happen.
  • Controlling diabetes can be difficult, more so when people are ill and unable to eat and drink. This is why knowledge, experience and skill of diabetes specialist staff are so important. There is no doubt that big improvements in care and patient safety can happen by ensuring that hospitals are adequately staffed wih inpatient diabetes specialist teams.

NHS Diabetes: “Do the course. Save a life.”

Every hospital in England has been sent an information pack designed to encourage NHS hospital staff to complete free online training to avoid insulin errors and remind them that insulin errors are serious. There message is “Do the course. Save a Life.”

Anna Morton, the Director of NHS Diabetes has highlighted that diabetes teams in hospital need to promote the safe use of insulin course to their non-specialist colleagues. She also says that all NHS staff who prescribe, prepare or administer insulin should be appropriately trained to bring down the number of avoidable errors.

More information:


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GM Vs animal insulin

Choices – The Evidence
Evidence from people with diabetes
A little bit of history
Action and duration times of animal and GM ‘human’ insulins
Hypoglycaemia and loss of warnings
‘Dead in Bed Syndrome’
The concerns of patients are justified
Availability of animal insulins in the UK
Changing your insulin
What to do if your consultant refuses to change your insulin
Availability of animal insulin if admitted to hospital
Frequently asked questions
Allergic reactions to insulin



  • GM synthetic ‘human’ insulin causes side effects for some people that largely disappear with a change to natural animal insulin. These problems do not just occur in people that have previously used animal insulin, however this is the group who are able to make comparisons.
  • No large scale, long-term trials comparing GM ‘human’ and animal insulins have ever been carried out. The research that has been carried out has largely been in the laboratory situation and/or using small numbers of people, so the validity of this research is questionable.
  • The link between GM ‘human’ insulin, hypoglycaemia, loss of warning symptoms and unexplained, sudden death or ‘dead in bed syndrome’, has not been satisfactorily explained. However small the number of deaths, any avoidable death is unacceptable and this issue needs further investigation. Equally any increase in frequency or severity of hypoglycaemia is unacceptable.
  • The first research in 1980 using GM ‘human’ insulin, by Professor Harry Keen, involved 17 healthy non-diabetic men and in 1982 ‘human’ insulin was given a licence for general use. This is a remarkably short time for a new drug, especially as ‘human’ insulin was the first ever genetically engineered drug to be used on people.
  • There is no evidence to show that synthetic ‘human’ insulin has any advantages over natural animal insulins. No formal post-marketing research was ever carried out despite the fact that ‘human’ insulin was the first genetically produced drug to ever be used on people. For this reason alone, the experiences of patients using it should have been, and still are, of vital importance in the development and use of other genetically produced drugs.
  • GM ‘human’ insulin has been shown to be more aggressive with a faster action and a higher peak of action than the equivalent porcine or bovine insulins.
  • The Cochrane Review, July 2002 and updated in 2004, comparing ‘human’ and animal insulin showed that there is no evidence that ‘human’ insulin is superior to animal insulin. It also showed that the majority of the research carried out was ‘methodologically poor’ and that many patient-oriented outcomes like health-related quality of life or diabetes complications and mortality rates were never investigated in high quality randomised clinical trials. So the introduction of synthetic ‘human’ insulin was never backed up by sufficient proof of advantages and safety. In the years since its introduction, this proof has never been obtained because the research has not been carried out. View the Cochrane Review

Is Hypoglycaemia Dangerous?

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Is Hypoglycaemia Dangerous?

Hypoglycaemia can affect people’s work, relationships, ability to drive and their quality of life but there are three main aspects to the question of whether it is actually dangerous:

  1. Severe untreated hypoglycaemia leads to coma with or without an accompanying seizure and this can lead to death. A study in the UK analysed the records of 23,752 people with Type 1 diabetes between the ages of 1 and 84 who had been diagnosed before the age of thirty to ensure that they really had Type 1 diabetes. They entered the study between 1972 and 1993 and were followed until 1997. By 1997, 949 people had died and hypoglycaemia was responsible for 18% of deaths in men and 6% of deaths in women.
  2. There is growing evidence that repeated moderate/severe hypoglycaemia can cause a reduction in cognitive function. This is of special concern in children where the brain is still developing. Some research has suggested that repeated hypoglycaemia in children can reduce the IQ by 5 or 6 points which does not sound very much but one researcher suggested that this could mean the difference between getting a university place and not. [See Useful Research item 8 of contents]
  3. Loss of warnings of an impending hypo can be classed as dangerous because it can result in more episodes of hypoglycaemia with all the consequent risks.

It is for all these reasons, and more, that IDDT believes that natural pork and beef insulin must remain available indefinitely. The most common reported adverse reaction to ‘human’ insulin is loss of warnings of hypoglycaemia, which in many people reverses with a change to natural pork or beef insulin. For this sub-group of people it is essential that the choice of animal insulins remains available to ensure that they do not suffer unnecessary and avoidable hypoglycaemia.

The Use of ACE Inhibitors

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The Use of ACE Inhibitors

ACE inhibitors, are drugs normally used for the treatment of high blood pressure. This is a category of drugs called Angio-Converting Enzyme inhibitors – ACE for short. ACE is an enzyme found in our bodies which activates a hormone called angiotensin causing the blood vessels to constrict, so raising blood pressure and putting pressure on the heart. ACE inhibitors prevent the action of angiotensin resulting in a lowering of blood pressure. However, there is evidence that the use of ACE inhibitors in people who start to show small amounts of protein in the urine, helps to reduce the progression to macroalbuminuria. In other words the use of ACE inhibitors has a protective effect on the kidneys, even in people whose blood pressure is normal.

What does the research show?
A meta-analysis [Ann Intern Med 2001 March ; 134[5] 370-9] was published on this subject. This is an analysis of studies to provide better evidence than just looking at individual studies. In this case, the studies were selected on the following basis:

  1. They included at least 10 people with Type 1 diabetes who had microalbuminuria and normal blood pressure.
  2. They had a control group who were not treated with ACE inhibitors [placebo group]
  3. They had follow up results at least a year later.

12 studies were selected with a total of 698 patients. The results showed:

  • The progression to macroalbuminuria was reduced in patients receiving ACE inhibitors.
  • After two years the albumin excretion rate was 50.5% lower in treated patients than in those receiving a placebo [no treatment].
  • For patients with normal blood pressure, Type 1 diabetes and microabluminuria, ACE inhibitors significantly reduced progression to macroalbuminuria and also increased the chances of regression back to normal where no proteins were found in the urine.
  • The beneficial effects of ACE inhibitors were weaker at lower levels of protein excretion.

This has lead to some debate amongst the medical profession about when ACE inhibitors should be prescribed and to whom. While there are differing views on the use of ACE inhibitors to protect the kidneys, it is clear that early detection and early intervention is the way to prevent, treat and even regress problems with protein in the urine. The debate appears to be centred around whether or not people with diabetes should start taking low dose ACE inhibitors before there is any sign of protein in the urine or raised blood pressure to try to prevent the development of microalbuminuria. If people who are at risk of developing kidney disease can be identified, then there appears to be is a case for prescribing ACE inhibitors for these people.

Note: ACE inhibitors can have fairly mild side effects, the common one being an irritating cough. They are not suitable for everyone and so this needs to be discussed with your doctor. They are not recommended for pregnant women.

Charcot Foot

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Diabetic Neuropathy

What is Diabetic Neuropathy?
Neuropathy Affecting The Feet
Advice on Cutting Your Toenails
Symptoms of Neuropathy Affecting Your Feet and Hands
Heel Fissures
Charcot Foot
Wrong Sized Shoes
Neuropathy and Antidepressants
Diabetic Holiday Foot Syndrome
Patient and Family Carer Experience
Diabetes and Hearing Loss May be Due to Neuropathy


Back to Related Health Issues

Charcot Foot

This is a non-ulcerative foot condition that can occur in people with diabetes and is associated with nerve damage [neuropathy]. It is a condition that affects people who have lost their sense of pain in their feet. Pain protects the feet as it warns people that they are doing too much walking, standing or exercising. In Charcot foot the foot changes shape due to destruction of the bones and joints and this is not caused by infection.

However, it is difficult to detect and is often treated as an infection because areas of the foot become red and swollen. It may also be mistaken for cellulitis. Another problem with diagnosis is that the initial X-ray of the foot may appear normal. Sometimes people are alerted to Charcot foot if they have a history of injuries caused by tripping or falling. If the condition goes untreated or is badly managed, then it can have very serious results. Despite difficulties with diagnosis, immediate diagnosis and putting the foot out of action is essential.

The treatment of Charcot foot is continuous foot care education, protective footwear and routine foot care to prevent the formation of ulcers.

InDependent Diabetes Trust