Diabetes
Stress, Anxiety and Depression

Stress
Anxiety
Depression
Depression in Parents
GE insulin, Hypoglycaemia and Depression
Useful Research

 

Stress, Anxiety and Depression

Depression and Diabetes

The prevalence of 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 showed that among a group of people with diabetes, of those whose HbA1c levels averaged less than 9%, only 21% tested positive for depression. By comparison of those with HbA1cs over 9%, 42% tested positive for depression. Other research has shown that people with chronic conditions, including diabetes, are three times more likely to suffer depression than the general population.
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%. While these results show an association between high blood sugars and depression, it remains unclear whether high blood sugars cause the depression or depression causes high blood sugars. [American Diabetes Association Conference 1998]

Research published in 2010 found that:

• people with depression were 17% more likely to develop Type 2 diabetes
• people with diabetes were 29% more likely to have depression compared with people without diabetes
• the risk of diabetes was greater in those with depressed mood, rising to 25% greater in those on antidepressants
• People with diabetes had a greater risk of depression rising to 53% higher among those treated with insulin.

The researchers recommend lifestyle changes to lower the risk of both conditions eg weight management and regular exercise. [Arch Intern Med 2010;170:1884-9]

How do you know if you are depressed?
The signs of depression include the following:

• No longer enjoying or being interested in most activities.
• Feeling tired or lacking energy.
• Being agitated or lethargic.
• Feeling sad or low much of the time.
• Weight gain or weight loss.
• Sleeping too little or too much.
• Difficulty paying attention or making decisions.
• Thinking about death or suicide.

If you have some or all of these symptoms over two weeks or more, then you should see your doctor.

How does depression affect people with diabetes?
An international report has shown 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]
Research using questionnaires has shown that depression in people with both Type 1 and Type 2 diabetes may have the following effects:

• They are less likely to eat the types and amounts of food recommended.
• Less likely to take all their medications.
• Less likely to function well, both physically and mentally.
• Greater absenteeism from work.

[Archives of Internal Medicine, Nov 27, 2000]

The need for diagnosis
Recent estimates suggest that up to three quarters of cases of depression in people with diabetes may go undiagnosed. This may be because of poor detection rates but it could also be that some people with diabetes don’t report their symptoms of depression because they see them as ‘just part of having diabetes’.
Screening for depression [not specifically for people with diabetes] has been recommended by national and international bodies and in the UK, the Department of Health recommends that all GPs use two simple questions to screen for symptoms of depression:

• During the last month, have you been bothered by feeling down, depressed or hopeless?
• During the last month, have you often been bothered by having little interest or pleasure in doing things?

If people answer ‘yes’ to either of these questions, they are given a questionnaire to answer to measure the extent and nature of the symptoms. So if you answer ‘yes’ to the two questions above or you have more mild symptoms, you are not alone and the clear message from research is to seek help from your doctor because there is a good chance that your life will improve.
It is important that similar methods are used in diabetes hospital clinics where many people with Type 1 diabetes receive their treatment.

Treatment
Treatment for depression in people with diabetes has been shown to be effective and has the additional benefits of improving blood sugar control. The evidence suggests that cognitive behaviour therapy and anti-depressant medicines are as effective in people with diabetes as in those without diabetes. One study found that not only did treatment improve blood sugar control but during treatment there was an improvement in mood and weight. As the treatment of depression can improve blood sugar control, it is also likely to reduce the risk of complications but importantly, it can also improve quality of life.
It is also well recognised that exercise helps to reduce depression, so although it may be the last thing that people feel like doing, it is worth increasing the amount of exercise being taken.

Cost of insulin analogues – NHS has wasted £625 million on analogue insulin in the past 10 years

Research published online in BMJ Open has shown that the NHS has spent an extra £625 million over the past 10 years on analogue insulins when the recommended human insulin alternatives, which are considerably cheaper, would probably have been just as effective. During this period, insulin analogues were 47% more expensive than human insulin. The authors base their findings on an analysis from the four UK prescription pricing agencies for the years 2000 to 2009. [Costs were adjusted for inflation and reported at 2010 prices.]

Over the 10 years:

• The NHS spent a total of £2,732 million on insulin with the annual cost rising by 130%, from £156 million to £359 million.
• Prescriptions for analogue insulin accounted for £1,629m [59% of the total]. Human insulin accounted for £1,056m [39% of the total] and animal insulin accounted for £47.2m [2% of the total].
• The annual cost of analogue insulin rose from £18.2 million [12% of the total] to £305 million [85% of the total].
• The cost of human insulin fell from £131 million [84% of the total] to £51 million [14% of the total].

The authors of this study point out:

• If prescribing guidelines recommending human insulin as first choice treatment for Type 2 diabetes had been followed, there would have been considerable financial savings.
• If all patients prescribed insulin analogues had been prescribed human insulin instead, the NHS could have saved itself £625 million [though to be more accurate, it is tax payers’ money that would have been saved].
• If even half of these patients had been changed to human insulin, that still would have been a saving of £300 million.
• Insulin analogues were developed to mimic the action of insulin made by the body but according to the authors, it is not clear if the benefits are sufficient to justify the additional costs as there has been no observable clinical benefit.

Study author, Professor Craig Currie from Cardiff University told Pulse [22.09.22]: ‘While it has been shown that insulin analogues are associated with reduced weight gain, less hypoglycaemia (particularly nocturnal), improved lowering of postprandial glucose and improved dosing schedules, most commentators agree that these benefits are modest in comparison to human insulin. The cost effectiveness of analogues insulin depended on the type of diabetes, the individual patient and the type of synthetic insulin used. For example, rapid-acting insulin analogues in patients with type 1 diabetes are likely to be a cost-effective use of finite healthcare resources.’
To view the paper in full click here:
http://press.psprings.co.uk/Open/september/bmjopen000258.pdf

Facts

• There are over 2.5 million people with diabetes in the UK and 90% have Type 2 diabetes, some of whom take insulin and 10% have Type 1 diabetes.
• Both human and analogue insulins are synthetic and made in a laboratory.
• Pork and beef insulins are natural insulins derived from the pancreases of pigs and cattle. They were the only available insulins until human insulin was marketed in 1982.

NICE Guidelines
The NICE guidelines for treatment of Type 1 diabetes recommend that the experiences and preferences of the insulin user should be taken into account and the type of insulin prescribed should be the one that allows people optimal wellbeing.

NICE guidelines for Type 2 diabetes recommend that human insulin is prescribed as first line treatment. Alternative insulin analogue treatments (such as insulin detemir or insulin glargine) should only be given in particular circumstances. These are:

• if they reduce the number of injections required in a person who needs assistance from a healthcare professional to inject insulin
• if episodes of symptomatic hypoglycaemia restrict the person’s lifestyle and the person would otherwise need twice-daily NPH insulin injections in combination with oral glucose-lowering drugs
• or if the person cannot use the device to inject NPH insulin.

The advice to GPs
Dr Brian Karet, a GPSI in diabetes in Bradford, said the benefits of analogue insulin were ‘marginal’ and so GPs should consider switching patients to human insulin in light of these findings. He said: ‘I think it is essential that we do this. It will certainly save a significant amount. Commissioning groups are already considering costs and benefits, and this is a very obvious one.’  [Pulse, Sept 22nd 2011]

IDDT Comments:
Our first reaction is that at last there has been a dawning of the true facts about insulin analogues! IDDT has written many times over the last few years about the pharmaceutical industry’s marketing techniques when they introduce their latest insulin products.  All too often it is marketing rather than evidence of benefit which accounts for the increasing use of new insulins.

We saw this first with the introduction of human insulin in 1982. For the majority, there was a lack of evidence of benefit of human insulin over animal insulin [Cochrane Systematic Review, 2005]. Sales of human insulin rapidly increased with greater expense as they were significantly more expensive than animal insulin.

In 2008, we wrote about this similar trend with insulin analogues – the marketing kicked in. We reported the findings of two reviews carried out in Germany by the Institute for Quality and Efficiency in Healthcare [IQWiG, 2008] which not only questioned the use of insulin analogues but recommended that they were not funded in Germany unless the price was the same as human insulin.

In 2010, as a result of the Channel 4 programme, we again highlighted all these points and questioned why prescribers and PCTS have not taken notice of the NICE Guidelines on insulin.

This is now in the public domain and receiving considerable publicity. IDDT suggests there are other points to consider.

• Novo Nordisk has already announced their intention to globally discontinue human insulins. Indeed they have already started with the withdrawal of Mixtard 30 at the end of 2010, used by 90,000 people. In the light of the BMJ study, is Novo Nordisk going to revise its plans?
• Rapid-acting analogues are more aggressive and of shorter duration than short-acting human insulins. If people who need a regime of short and long-acting insulin are prescribed analogues, they usually will have pre-meal injections and therefore have to test their blood glucose more often. This is an additional extra cost compared to using twice daily human insulin.
• Perhaps most important of all, the long-term safety of analogue insulins has not been established and research continues. So they have been shown not to be beneficial for the majority, considerably more expensive and their long-term safety is not yet proven.

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

Mixtard 30 Update

Yes, it is almost a year since Novo Nordisk discontinued human Mixtard 30 for commercial reasons. This resulted in 90,000 people having to change from the insulin that suited them. From the calls we receive, there are still people who have not been able to manage their diabetes as well since this change. Most frustrating of all is that Novo Nordisk’s Actraphane, a pre-mix human insulin, is licensed and available in some European countries but it can’t be accessed in the UK because the rules only allow personal importation from countries outside the EU!

We continued to argue our case in the UK but basically received no help or support so we moved to Members of the European Parliament who certainly understood our concerns. Lady Sarah Ludford MEP and Dr Simon Busuttil MEP [Maltese delegation] followed up our concerns.

Dr Busuttil’s correspondence made the following points:

• I have had multiple meetings with Novo Nordisk and on each occasion I have taken the opportunity to bring up your case. Unfortunately to date I have not received a reply that would adequately address the problems you have raised and received no indications from industry that a solution is in sight.
• Novo Nordisk has confirmed that Actraphane is identical to Mixtard 30.
• I would recommend that you take up the matter with the UK Health authorities, as the only solution as I see it would be to revise the UK’s system on personal importation of such medical products.

IDDT’s Trustees believe that we should follow Dr Busuttil’s recommendation and take up the personal importation issues with the UK authorities. This we will be doing in 2012. We realise that we have no way of changing minds on Actraphane but no doubt Novo Nordisk will discontinue other insulins and we need to try to prevent a similar situation arising in the future.

After over a year going through Parliament and 374 amendment generated by the House of Lords, on March 20th MPs cast their final vote and the Health and Social Care Bill was approved by a government majority of 88. On March 27th, it received Royal Assent and will now be known as the Health and Social Care Act (2012).

Different terminology is being used to describe the changes in the NHS that will have to take place – the more positive amongst are calling it restructuring of the NHS while the more negative amongst us are calling the destruction of the NHS. Whichever side of the fence one sits on, it is clear that there are going to be major changes in the NHS with GPs taking control of most of the NHS annual budget of £106 billion, cuts in the number of health bodies and the introduction of more competition into services. All this has to take place at a time of financial cut backs.

Somehow the staff working in the NHS have to be brought together to work in a system  to which all raised serious objections on the basis that patient care will suffer. Those of us who have had to work in systems that go against our beliefs, know this is not going to be an easy task and it will not be surprising if the morale of NHS staff sinks to an all time low.

Possibly the most frightening aspect of the new system is that it is not based on evidence that it will actually work. It strikes me as an odd society that has a great deal of regulation and bureaucracy to ensure that there is evidence of safety and efficacy of prescribed drugs by regulation and bureaucracy and to ensure that research is safely and ethically carried out, yet a change to the whole structure of the NHS is brought in without any real evidence. We are not even being given a reason for the structural changes, certainly not a reason that stands up.

Like it or not, Members of Parliament, our representatives, have made the decisions about our future services. David Cameron and Andrew Lansley may well go down in history but it will not be for the same reasons as Beveridge and Bevan.

Yes, it leaves many of us as patients feeling insecure. Since July 5th 1948 we have had universal healthcare provided free according to need. Is the Health and Social Care Act setting in place a return to an insurance-based system with personal health budgets, year of care funding for long-term conditions and Foundation Trust Hospitals will be able to raise nearly half their funding from private patients? Could we return to the days our parents and grandparents remember, when you didn’t call the doctor because you couldn’t afford the fees? When services can be provided by ‘any qualified provider’, will we even know who is providing the services? Let us hope that this negative approach is ill-founded. Only time will tell…

As patients, we will need to be vigil to ensure that we receive the care and services which will enable us to receive timely, essential treatment to maintain our health.

If you have access to the internet, you can read the NHS Constitution for England, March 2012 by clicking on: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_113613 
Hard copies of the Constitution can be obtained from the Department of Health, telephone 0800 123 1002.

Animal insulins continue to be available – statement from Wockhardt UK

IDDT formed to maintain supplies of animal insulins, not only so that this choice of natural insulin remains available for everyone, but especially for the people who have adverse reactions to the synthetic human and/or analogue insulins. We never forget that this need still exists and we know that many animal insulin users worry about the continued availability of the animal insulin they need. Many are often wrongly told that animal insulins are no longer available. In order to give reassurance to those people who need animal insulins, we have received a statement from the Managing Director of Wockhardt UK.

Click here to read the statement about availability from the Managing Director of Wockhardt

Click here to read: Packaging changes of animal insulins – the statement from Wockhardt UK

Click the images below to see how the packaging has changed for Hypurin Porcine Isophane and Neutral.

 

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
Medical Assessment Forms
Insulin and Driving Taxis
Hypoglycaemia and Driving
Driving and Medicines
Driving and Visual Field Loss

Living with Diabetes

Driving and hypoglycaemia – what are doctors being advised to do?

The Association of British Clinical Diabetologists [ABCD] has recognised that the EU Directive on standards of driving in diabetes will have a significant impact not only on drivers with diabetes but also on the doctors who complete medical reports for the DVLA. The ABCD has clarified their response to the Directive and this basically advises doctors on their actions with their patients on the most important change – hypoglycaemia. [Practical Diabetes Vol. 29 No1] It seems sensible that people with diabetes know what advice their doctors are receiving, so below are the key points in the ABCD recommendations to doctors.

Just a reminder, the changes are:

• If a Group 1 driver [car/motorcycle] has had two or more hypos requiring assistance from another person, day or night, in the previous 12 months, they must inform the DVLA and be advised not to drive.
• If a Group 2 driver [bus/lorry] has one or more hypos in the previous 12 months, they must inform the DVLA and be advised not to drive.

What is a reportable hypo?
The requirement of assistance would include:

• admission to Accident and Emergency,
• treatment by paramedics,
• treatment by a partner/friend with glucagon or glucose because the person with diabetes cannot do it themselves.

It does NOT include another person offering or giving assistance when the person is aware they are hypo and able to take action independently.

The ABCD is therefore advising hospital doctors to take great care to elicit an exact history of each hypo and chart it carefully in the records. It advises primary care teams to consider referral to specialist teams patients who have suffered one severe hypo requiring assistance because a second one could lead to loss of driving licence and loss of job.

What if people do not report their hypos?
While people may not report their hypos to their doctor, reports of hypos may be sent from the ambulance team or A & E to the patient’s GP, In this case, the ABCD advise that it would be ‘sensible to see the patient and inquire about the frequency and severity of hypoglycaemia’. If there have been two severe hypos requiring assistance from another person in the previous 12 months, the doctor MUST inform the patient that they need to notify the DVLA and advise the patient not to drive. The same applies to a Group 2 driver who has had one severe hypo.

What about unconfirmed night hypos?
Doctors may suspect that severe night hypos are happening to people who live on their own but these are not witnessed, because the person lives alone! This would not necessarily be an episode that should be reported, although the doctor may advise the patient to notify the DVLA. Silly though this sounds, people who live on their own and have severe night hypos, may be advantaged as far as reporting to the DVLA is concerned, although of course, not for their own health and wellbeing. If hypo unawareness is suspected, then it is advisable to refer the patient to specialist care.

What about hypo unawareness?
The ABCD suggest that for a Group 1 licence, where a patient’s home monitoring results show blood glucose levels of below 3mmol/L but reports no symptoms, this should be classed as hypoglycaemia unawareness. If hypoglycaemia below 3mmol/L without any awareness is typical of a patient’s hypos, then this may be classed as completely unaware and the patient should report this to the DVLA and be advised not to drive. When blood glucose levels are below 3 and there are no symptoms, cognitive dysfunction during the hypoglycaemia is likely to be present and  there is a risk of severe hypos. People with these types of hypos should be referred to specialist care for a review of their regime. 
Group 2 drivers have to have complete awareness, so any degree of unawareness results in the licence being revoked.

What are a doctor’s responsibilities if a patient continues to drive when they are not fit to do so?
The ABCD says that any doctor who is aware that a patient is not fit to drive, should advise the patient not to do so and to inform the DVLA. If the patient does not notify the DVLA or refuses to do so, under General Medical Council guidelines the doctor is allowed to notify the DVLA. However, it is advised that it is good practice to confirm the conversation in writing to the patient and also inform the patient that their insurance is no longer valid. 

What about people with Type 2 diabetes?
If Type 2 diabetes is treated with metformin, then this does not cause hypos. However, if sulphonylureas are added to the treatment, then they can cause hyoglycaemia? The ABCD say that if everyone treated with sulphonylureas were to be encouraged to test, this would hugely increase the cost of blood monitoring. [IDDT would question whether this is a good enough reason to not test?] It is stated that the greatest risk of hypos on sulphonylureas is in the first 3 months of treatment so ‘it would seem sensible to maintain current practice and only encourage extra testing in peole who are starting treatment, experiencing hypoglycaemia or with reduced awareness’. They also note that the highest risk of hypos in people with Type 2 diabetes prior to starting treatment with insulin is late afternoon.
A Group 2 driver on a sulphonylurea or glinide is required by law o test blood glucose levels at least twice daily and at times relevant to driving.

ABCD recommendations for safe blood glucose levels for driving

• In a person with good hypo awareness, normal blood glucose levels are adequate but ABCD recommend testing before driving and at no longer than 2 hourly intervals while driving.
• In a person with impaired awareness, ABCD recommend not driving without eating if blood glucose is under 7mmol/L although 5mmol/L is probably safe for a drive of under 10 minutes.

Replacement of Disability Living Allowance with Personal Independence Payments

The government intends to replace Disability Living Allowance (DLA) with Personal Independence Payments (PIP). This may affect people with Type 1 and Type 2 diabetes who are in receipt of DLA. The government is running a consultation on these changes. It is important that people submit their views before the closing date on April 30th 2012. For details click here.

The consultation document can be downloaded from www.dwp.gov.uk/consultations/2012

Consultation responses can be emailed to: [email protected]
or sent by post to:

PIP Assessment Development Team
Department for Work & Pensions
2nd Floor Area B
Caxton House
Tothill Street
London
SW1H 9NA

Jubilee Parties

With the Queen’s Jubilee this year there is a range of all types of parties being held to celebrate and no matter what type of party – it means food and drinks to tempt you to over-indulge.

For those with diabetes parties can be a challenge as to what to eat to fit in with their diet. Indeed, some people will avoid any party as they do not want to face temptations on offer.

The diet for the different types of diabetes does vary.

• For those with Type 2 diabetes most people will try to reduce calories by watching the amount of fat they eat as well as avoiding large portion sizes.
• For those with Type 1 diabetes attention to the carbohydrate content of foods plus watching saturated fat plus salt links in with the dietary advice usually given to this group.

For both groups watching that there is not an excess of fatty and sugary items is important. But remember this is a special occasion and do not be too obsessive about things. Enjoy yourself and be active with dancing or any sports involved to help use up the calories, plus assisting in moderating blood glucose levels.

So here are some ideas as to what to eat and drink both, if you are invited to a party or are organising one yourself.

Quite a few of the suggestions are also aimed to be easy on the pocket if you are holding the party yourself plus appeal to all ages. They are all also a bit different from the usual selections.

They are all intended to be easy to make and the sort of thing children can help with.

Garnishes and decorations for foods really give eye appeal and tempt people (especially children) to try what may be an unfamiliar dish.

Ideas for alcohol free drinks are suggested as for people with diabetes alcohol especially on an empty stomach is not advised. Also many people welcome an alcohol free alternative as they are driving.

Suggestions for food

If you are providing the food yourself or choosing from a buffet table here are some ideas:

Starters

• Home made vegetable soup served in cups (often very welcome with the chilly days or evenings), make this from a selection of vegetables with lentils or beans added and made smooth in a liquidiser or with a whisk. Croutons can be added for an extra crunch.
• Melon or grapefruit slices.
• If you buy samosas, onion bahjees, battered items like fish or chicken strips or mini pies – heat them in the oven rather than deep fat fry.

Mains

• A selection of cold roast meats or poultry’
• Salads which are undressed and people can add a dressing such as a bought “light” one or homemade with vinegar or lemon juice or low fat yoghurt with lots of herbs or paprika added.
• Make a selection of salads such as bean salads, salads with new potatoes, pasta, rice and cous cous as well as the more traditional ones with lettuce, tomatoes and cucumber.
• Homemade coleslaw is easy to make and can include other vegetables like grated turnips for variety and use a low fat dressing.
• Mini pizzas – just cut out from a thin pizza base and top with tomato and a sprinkle of cheese plus lots of vegetables or cold meats.
• Jacket potatoes – these can be filled with a home made chilli or baked beans.
• Bread, preferably seeded or granary, but how about making your own sour dough bread or soda bread – both are lovely especially when warm and then do not really need any spread.
• Stuffed peppers or mushrooms – with a stuffing of breadcrumbs or rice mixed with herbs and pine nuts or chopped nuts.
• Baked salmon or shell fish.
• Home made mini burgers, minted lamb shish kebabs, chicken or beef satay.
• Kebabs with a selection of vegetables.
• Instead of sandwiches try filling slices of bread with a savoury spread and rolling up to make pin-wheels.
• Filled wraps and pitta breads make a good alternative to sandwiches
• If you buy sausages and burgers oven bake rather than deep fat frying them.

Desserts

• Fruit salad.
• Trifle made with fruit, low sugar jelly, custard made with skimmed milk.
• Fruit terrine made with say strawberries, apples and blueberries or blackcurrants set in a clear or red jelly to reflect patriotic colours.
• Blancmanges made with skimmed milk.
• Lower fat cakes such as home made tea loaves.
• Mini-scones made with a low fat spread.
• Home made drop scones or griddle cakes with dried fruit in and made with skimmed milk.
• If you buy ready made cakes and pastries serve small pieces and also serve with a selection of fruits.

Nibbles

• Savoury fresh popcorn flavoured with finely grated cheese.
• Nuts and seeds heated in pan and flavoured with chilli sauce.
• Tiny oat biscuits.
• Small dry roasted potatoes.
• For bought snacks choose lower fat crisps and breadsticks.
• Dips can be made from salsas and low fat yoghurts.

Drinks

• Fruit punches made with a selection of fruit and a base of low calorie squash.
• Mixing orange juice with low calorie lemonade gives an easy St Clements type of drink – just decorate with orange and lemon slices.
• Mix low calorie ginger ale with the low calorie lemonade.
• Juices such as cranberry juice can easily be mixed with low calorie lemonade and decorated with berries and lemon slices.

Whatever you decide to do, try and eat things slowly by doing more chatting and passing plates around and generally helping. Ask for smaller portions of the high fat and high sugar items such as gateaux. Do watch the amount of alcohol you take especially if taking insulin as alcohol can reduce blood glucose levels. If possible stick to the lower alcohol drinks or alternate them with the ones containing alcohol.

Have a good time!

If we can be of help at any time or you would like more information about diabetes:

• give us a call on 01604 622837
• email [email protected]
• write to IDDT, Po Box 294, Northampton NN1 4XS

Gluten Free Diets – An Update

By Dr Mabel Blades,  Freelance Dietician and Nutritionist
On 1st January 2012 the rules about making claims as regards which foods are gluten free changed.

Background

A number of people suffer from coeliac disease and while this used to be regarded as a simple food intolerance, it is now regarded as an autoimmune disease where the body’s immune system attacks its own tissues (thus there is a link with Type 1 diabetes). In people with coeliac disease the autoimmune reaction is triggered by gluten, which is the name of the protein found in wheat, rye and barley. Some people with the condition are also sensitive to oats.

Numbers

In the general population about 0.75% of people suffer from Coeliac Disease, but it rises to 2-10% in those with Type 1 diabetes. Therefore the NICE guidelines recommend that all people with Type 1 diabetes are screened for coeliac disease.

What is gluten free?

In the past as long as foods did not contain wheat, rye, barley or any products derived from them they could generally be described as gluten free.
With the realisation of the sensitivity of some to gluten and how little contamination is required to cause a problem, it was decided that only foods which contain no more than 20 parts gluten in a million parts of food can be labelled as gluten free. This legislation came into effect on 1st January 2012. Now the only food which can be described as gluten free is:

• Specially made foods for people with gluten intolerances such as pasta made from rice instead of wheat flour
• Everyday foods such as soup made only from vegetables which would contain less than 20 parts per million

No gluten containing ingredients

To assist people with coeliac disease caterers and food businesses can make a factual statement to let customers know it does not contain any gluten containing ingredients. So look out for this on foods and menus.

Extra information

Additional information on this can be obtained from the Food Standards Agency, http://www.food.gov.uk/ and also Coeliac UK, http://www.coeliac.org.uk/

National Carers Week 18th – 24th June 2012

Most people with diabetes do not need carers but some people have diabetes and other conditions and they may well require a carer. IDDT is supporting National Carers Week by providing useful links which give information on Charities that can offer support to reduce the isolation that many carers experience.

A carer can be someone of any age who provides unpaid support to family or friends who could not manage without this help due to illness, disability, mental ill-health or a substance misuse problem.

Being a carer may mean:

• Facing a life of poverty, isolation, frustration, ill health and depression.
• Many carers give up an income, future employment prospects and pension rights to become a carer.
• Many carers also work outside the home and are trying to juggle jobs with their responsibilities as carers.
• The majority of carers struggle alone and do not know that help is available to them.
• Carers say that access to information, financial support and breaks in caring are vital in helping them manage the impact of caring on their lives.

If you are a carer or know someone that is, these are organisations can offer support and information:

IDDT’s leaflet ‘For Family Carers’ for people living with diabetes
https://www.iddt.org/wp-content/uploads/2009/10/for-family-carers.pdf

Finance and Benefits:

http://www.direct.gov.uk/en/caringforsomeone/moneymatters/carersallowance/index.htm

http://www.carers.org/carers-allowance

http://www.carersuk.org/help-and-advice/help-with-money

Organisations that can help:

Carers Trust
http://www.carers.org

Carers UK
http://www.carersuk.org/

http://www.carersuk.org/help-and-advice

Carers Matter
http://www.carersmatters.co.uk/

Community Care – Care Matters
http://www.communitycare.co.uk/Articles/21/06/2007/104895/essential-information-on-time-for-change-care-matters.htm

The National Carers Strategy is available here:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4006522

Can you help to prioritise research about the prevention, diagnosis and treatment of sight loss and eye conditions?

The Sight Loss and Vision Survey will – for the first time – identify the most pressing unanswered questions from patients, carers and eye health professionals about the prevention, diagnosis and treatment of sight loss and eye conditions. This will ensure that future research can be prioritised according to the needs of patients, carers and eye health professionals.

This exciting initiative will be overseen by The James Lind Alliance, a non-profit making organisation funded by the National Institute for Health Research, ensuring the exercise produces an unbiased result, with equal weighting given to the views of the different participating groups. So whether your interest is personal or professional, whether you are concerned about eye conditions relating to diabetes your opinions will count.

To learn more about this initiative visit www.sightlosspsp.org.uk where you’ll find the online survey, how to download and post/fax a form, answer questions on the phone, or request alternative formats such as Braille or audio. The survey takes less than 10 minutes to complete, so please take this opportunity to change the future of eye research. The survey closes on July 31st 2012.

IDDT is pleased to announce the launch of its new booklet “Type 2 Diabetes – Management and Medication”.

The booklet has been produced to help patients better understand the treatments available and the on-going management of their diabetes. The aim is to help them understand and reduce the risks of developing long-term complications.

Patients really don’t receive enough support from their healthcare professionals and there is a general lack of education about the progressive nature of the disease. This booklet explains about the likely progression of the condition and the fact that patients once diagnosed with Type 2 diabetes within 7 years (on average) need treatment with insulin. The booklet explains the different types of treatment and the ways in which different types of medication work, such as tablets and/or insulin. We also explain how the insulins work, from long-acting to short-acting, and the different ways of administering insulin, from pens to insulin pumps.

Type 2 Diabetes – Management and Medication is available to patients free of charge, but a small postage & packing charge will be made for healthcare professionals requesting multiple copies.

Download an electronic (PDF) copy here –
Type 2 Diabetes – Management and Medication

Or order the printed version via the –
IDDT Leaflets order form

Type 2 Diabetes – Management and Medication

IDDT is pleased to announce the launch of its new booklet “Type 2 Diabetes – Management and Medication”.

The booklet has been produced to help patients better understand the treatments available and the on-going management of their diabetes. The aim is to help them understand and reduce the risks of developing long-term complications.

Patients really don’t receive enough support from their healthcare professionals and there is a general lack of education about the progressive nature of the disease. This booklet explains about the likely progression of the condition and the fact that patients once diagnosed with Type 2 diabetes within 7 years (on average) need treatment with insulin. The booklet explains the different types of treatment and the ways in which different types of medication work, such as tablets and/or insulin. We also explain how the insulins work, from long-acting to short-acting, and the different ways of administering insulin, from pens to insulin pumps.

Type 2 Diabetes – Management and Medication is available to patients free of charge, but a small postage & packing charge will be made for healthcare professionals requesting multiple copies.

Download an electronic (PDF) copy here –
Type 2 Diabetes – Management and Medication

Or order the printed version via the –
IDDT Leaflets order form

Alcohol and diabetes

 

Living with Diabetes

When you drink alcohol, your liver decreases its ability to release glucose so that it can clean the alcohol from your blood. Because glucose production is shut down, hypoglycaemia [low blood sugar] becomes a risk for people with diabetes, particularly if you drink on an empty stomach or shortly after taking insulin or glucose-lowering tablets. It takes two hours for just one ounce of alcohol to metabolise and leave your system so the risk continues long after your glass is empty. Even modest amounts of alcohol can have this effect.

Research carried out at the Royal Bournemouth Hospital [Diabetes Care, July 2005] showed that alcohol has been implicated in up to one fifth of hospital visits for hypoglycaemia, low blood sugars. The researchers investigated the effect of evening alcohol in 16 people with Type 1 diabetes who had normal hypo warnings and who drank alcohol on a regular basis. The participants were evaluated with continuous blood glucose monitoring on two occasions – after taking orange juice and vodka or just orange juice followed by the same meal and same dose of insulin. The participants experienced 1.3 episodes of hypoglycaemia per day during the 24 hours after the alcoholic drink compared to 0.6 episodes after a non-alcoholic drink. The researchers suggest that this research may encourage people to be more ‘proactive’ in adjusting their insulin appropriately if they are drinking alcohol.

Facts about alcohol and diabetes:

• Alcohol lowers blood glucose levels so increases the risk of hypoglycaemia (low blood sugars) not just while drinking but also over the next 24 hours or longer.
• Alcohol impairs judgement, so you may not realise that you are hypo and will not treat it with sugary food. You may also be mistaken for being drunk by others around you and so they will not offer help. Both of these situations could lead to severe hypoglycaemia.
• There may be carbohydrates in the alcoholic we drink may but these do not offset the blood sugar lowering effect of the alcohol, so they should not be counted as part of your overall carbohydrate consumption. (Remember that while Pils is a low sugar lager, it has a higher alcohol content, so it is not a good drink for people with diabetes.)

Having diabetes does not mean that you cannot drink but there are some golden rules that people with diabetes should follow:

• Only drink in moderation – sensible advice whether or not you have diabetes.
• Learn by experience how alcohol affects you – everyone is different.
• Take the appropriate steps to prevent a hypo and if necessary lower your insulin dose at the meal prior to going out for a drink.
• The best time to drink alcohol is with a meal.  If you are not having a meal with your alcohol, then it is a good idea to nibble carbohydrate [eg crisps] throughout the evening.
• Never drink alcohol before a meal.
• Carry out more blood glucose tests to check for hypos for at least the next 24 hours after drinking alcohol.
• Have an extra bedtime snack before going to bed.  Remember that alcohol could lower your blood glucose during the night while you are asleep, resulting in a night hypo.  The alcohol may also make you sleep more soundly so that the hypo warnings may not wake you.

Medicines and Healthcare products Regulatory Agency

The Medicines and Healthcare products Regulatory Agency (MHRA) is today urging those with diabetes using Hypurin Porcine Isophane insulin cartridges to check their medication after a packaging error came to light.

The issue occurred when a carton for cartridges of intermediate acting Hypurin Porcine Isophane Insulin 100 IU/ml got into the production line for the short acting Hypurin Porcine Neutral Insulin 100IU/ml.

One such pack was identified by a pharmacist before it reached the patient and whilst the manufacturer, Wockhardt UK Ltd, believes it is highly unlikely there are any other such packs in the supply chain, patients and pharmacists are being asked to check their cartons.

The issue relates to one batch of Hypurin Porcine Neutral Insulin, with the batch number PL40147, and although it is considered highly unlikely that there are any other rogue packs in the supply chain, the MHRA has issued a drug alert following a precautionary recall by the manufacturer.

Pharmacists and wholesalers are being asked to check stocks of Hypurin Porcine Isophane Insulin and contact Wockhardt immediately if any packs of this insulin, embossed with this batch number, are identified.

Pharmacists are also asked to contact patients who may have stocks of this insulin. Cartons of Hypurin Porcine Neutral Insulin 100 IU/ml with the same lot number are not included in this recall and should not be returned. No other batches of Hypurin insulin are affected.

Gerald Heddell, MHRA Director of Inspection, Enforcement and Standards said: "It is important that patients continue to administer their insulin as required. Patients with any questions or concerns should contact their GP or pharmacist as soon as possible. An investigation has taken place and action has been taken to rectify the issue."

The drug alert can be viewed at:
http://www.mhra.gov.uk/Publications/Safetywarnings/DrugAlerts/CON184737

First ever mandatory care standards to improve the level of care of children and young people with diabetes

Announced in early April 2012, every child and young person with diabetes in England can expect an improvement in their level of care as a landmark funding agreement for paediatric diabetes services comes in to force.

The ‘Best Practice Tariff for Paediatric Diabetes’ sets out 13 mandatory care standardsfor paediatric diabetes service teams to meet. Providers who can prove they meet these levels of care will qualify for greater funding. Local services unable to achieve these standards will be supported to improve but face having their funding withdrawn if unable to reach the required level by April 2013.

The long-term aim is that these changes will lead to improvements in care and outcomes for children and young people with diabetes. In turn this should lead to a reduction in costs, a reduction in emergency admissions to hospital and in a reduction in the long-term preventable complications.

Anna Morton, Director of NHS Diabetes, said: “Outcomes for children with diabetes in this country compare poorly to the rest of Europe. We will show that with a proper funding mechanism and access to expert support, providers can improve, and unacceptable variations in care can be addressed.
“We are encouraging all paediatric providers, particularly those in poor performing areas, to engage with us to ensure our standards are met, and that every child, no matter where they live, receives the care and support they deserve.”

NHS Diabetes is calling on all healthcare professionals involved in the support and care of children and young people with diabetes to join their paediatric diabetes network to ensure sharing of good practice, up-to-date guidance and education tools.

What are the 13 care standards?

1. Every child or young person with diabetes will be cared for by a specialist team of health care professionals (consisting of a doctor, a nurse and a dietician as a minimum) who have specific training in paediatric diabetes.
2. The doctor must be a consultant or speciality doctor with training as detailed by the British Society for Paediatric Endocrinology and Diabetes, the nurse must be a paediatric nurse with training in children’s diabetes as detailed by the Royal College of Nursing and the dietician must be a paediatric dietician with experience and/or training in diabetes. If the doctor is a Specialist Registrar who wants to specialise in paediatric diabetes, they must be supervised by the consultant or speciality doctor.
3. When a new diagnosis of diabetes is made in a child or young person, this must be discussed with a member of the specialist team within 24 hours of the diagnosis. The child or young person and their family must be seen by a senior member of the specialist team on the next working day.
4. The diabetes team should offer a structured education programme at diagnosis and with updates as needed, aimed at the age and understanding of the young person and their family.
5. Every child or young person with diabetes must be offered at least four clinic appointments a year with the doctor and specialist team.
6. The HbA1c (long term blood glucose measurement) must be checked at every clinic visit and the result available in clinic for the appointment. It is recommended that this is checked at least four times a year.
7. Every child or young person with diabetes should be offered an appointment with the dietitian at least once a year.
8. At least eight additional contacts per year (phone calls, e-mails, school visits etc) by members of the team are recommended.
9. Every child or young person with diabetes must have an annual review, as detailed in the NICE guidelines on managing diabetes in children and young people (blood tests every year, plus blood pressure check and screening for eye and kidney problems from age 12).
10. The team should check that the child or young person with diabetes is coping psychologically at least once a year and they should have access to psychology services as needed.
11. The team should provide 24 access to advice on emergency management of diabetes for the family and other health professionals.
12. It is also expected that the team will take part in the National Paediatric Diabetes Audit, attend their local Paediatric Diabetes Network meetings regularly and have a clear policy for transition to adult services.
13. Each team must have a clear policy which should cover what they do to try to help children and young people with high HbA1cs improve their control and what they will do if a child or young person keeps not coming or is not brought to clinic, among other things.

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:
http://www.diabetes.nhs.uk/safe_use_of_insulin/safe_use_of_insulin_elearning_module/

How to donate

You can make a donation to IDDT using the button below, which will open a secure PayPal window. You can make a one-off or regular donation via PayPal or a debit or credit card

How to donate

You can make a donation to IDDT using the button below, which will open a secure PayPal window. You can make a one-off or regular donation via PayPal or a debit or credit card