Related Health Issues

Hypoglycaemia
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
Impotence
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

Related Health Issues

Hypoglycaemia
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
Impotence
Women, Sex and Diabetes
Osteoporosis – Is There A Link with Diabetes?
An experience of the menopause

Osteoporosis – Is There A Link With Diabetes?

What is osteoporosis?

It literally means ‘porous bones’. Our bones are made up of a thick outer shell and a stronger inner mesh of tiny struts of bones and in osteoporosis some of these struts become thin or break. This makes the bone more delicate and likely to break. The most common fractures in people with osteoporosis are wrists, hips and spinal bones. Osteoporosis often goes undetected until a fracture occurs.

Causes of osteoporosis
There are two types of cells in bones that are constantly working – one group of cells build up new bone and the other breaks down old bone. Calcium and phosphate are essential for normal bone formation and up to the mid-20s uses these minerals to enable the bone-building cells work harder to build strength into the skeleton. If calcium and phosphate intake is insufficient or if the body does not absorb enough calcium from the diet, then bone production and tissue may suffer.

As part of the natural aging process, from 40 years onwards the cells that break down bones overtake and bones gradually lose their density.

Who is at risk of osteoporosis?
It is a common problem and in the UK one in two women and one in five men over 50 will break a bone. It is extremely rare in children, young people and pregnant women.

Bone health is largely hereditary but there are factors that can increase the risk of osteoporosis:

• Women who have early menopause or hysterectomy.
• Men with low levels of testosterone.
• People who have broken a bone after only minor injury.
• Medical conditions which make people immobile for a long time.
• The use of certain medications such as steroids and anticonvulsants.
• Medical conditions that affect the absorption of food eg Crohn’s disease, celiac disease or ulcerative colitis.
• Smoking.
• Excessive alcohol intake.
• Women who are underweight or have an eating disorder.

Symptoms
There are no symptoms of osteoporosis in the early stages. In the late stages the symptoms include:

• Fractures of the vertebrae, wrists or hips.
• Low back pain.
• Neck Pain
• Bone pain or tenderness
• Loss of height over time.
• Stooped posture.

If you think you are at risk of osteoporosis
You should discuss this with your GP. You may need a special scan called a dual energy x-ray absorptiometry (DXA), which measures bone density. It is a simple and painless procedure that is recommended for people at high risk. Osteoporosis diagnosed on a bone density scan does not always mean you are at high risk of bone fractures as other factors such as age, have to be taken into account.

Treatment
Treatments focus on slowing down or stopping bone loss, preventing bone fractures by reducing the risks of falls and controlling pains associated with having the condition.

There is a range of drug treatments to reduce the risk of breaking bones which your doctor will discuss.

Note: 21.11.07 A drug to treat osteoarthritis pain has been suspended
The Medicines and Healthcare products Regulatory Agency [MHRA] suspended the sales of Prexige because it can damage the liver. It is used to treat osteoarthritis pain and is in the same class of drugs as Vioxx, withdrawn 3 years ago for causing heart attack and stroke. The MHRA advice is that people who are in good health and benefiting from taking Prexige may continue on it but should see their doctor to discuss alternatives but people taking it who feel unwell should stop taking it immediately and see their doctor as soon as possible.

Lifestyle changes can also help

• Regular exercise that require muscles to pull on bones or help the bones to retain or even gain density eg walking, jogging, yoga, resistance exercises. [Not exercises that increase the risk of falling.]
• Diet should include adequate amounts of calcium, vitamin D and protein. High calcium foods include low-fat milk, yogurt, ice cream and cheese, salmon and sardines (with the bones), and leafy green vegetables.
• Give up unhealthy habits such as smoking and limit alcohol intake.
• Prevent falls by making sure vision is as good as possible, remove hazards around the house, wear good fitting shoes, avoid walking on icy roads alone.

Are There Links Between Osteoporosis and Diabetes?
A review of 16 studies involving over 800,000 people who sustained a total of nearly 140,000 hip fractures has found that having diabetes, especially Type 1 diabetes, makes people more likely to have hip fractures.

The review of 12 studies showed that people with Type 2 diabetes are 70% more likely to fracture their hip and in the review of 6 studies, those with Type 1 over 6 times more likely to do so. The researchers suggest that the cause could be diabetes complications, such as retinopathy, neuropathy, low blood sugars and stroke making people more likely to fall.

A study [J Cell Biochem, Nov 2007] refers to bone loss [which can lead to osteoporosis] as ‘a less well-known complication of Type 1 diabetes’ and that there are differences between bone loss in Type 1 diabetes and age-related bone loss. It suggests that possible contributors to the suppression of bone formation in Type 1 diabetes include: increased marrow adiposity, hyperlipidemia, reduced insulin signaling, hyperglycemia, inflammation, altered adipokine and endocrine factors, increased cell death and altered metabolism.

Another study carried out in Germany [J. Bone Miner Res. Sept 2007 (9)] has shown the trends of longer life expectancy and a lifestyle of low physical activity and high-energy food intake contribute to an increasing incidence of diabetes and osteoporosis. However, people with newly diagnosed Type 1 diabetes may have impaired bone formation due to the absence of the anabolic effects of insulin and amylin, but in people with long-standing Type 1 diabetes, vascular complications may account for low bone mass and increased fracture risk. It is suggested that prevention of fractures caused by osteoporosis in people with Type 1 diabetes may include tight control of blood glucose levels and aggressive prevention and treatment of vascular complications.

People with Type 2 diabetes have an increased fracture risk thought to be caused by increased risk of falling. The research suggests that people with Type 2 diabetes may benefit from early visual assessment, regular exercise to improve muscle strength and balance and specific measures for preventing falls.

Excess body fat may contribute to poor bone health, according to a new study of 115 young women between 18 and 19 years old. The finding adds to the growing list of obesity-related health problems, which already includes an increased risk of heart disease, stroke, cancer, and others.

In the study, researchers conducted three-dimensional bone scans of women with normal body fat (less than 32%) and high body fat (greater than 32%). Women with high body fat had bones that were 8 to 9% weaker than those with normal body fat.

While it’s not known exactly why excess fat is bad for bone health, animal studies have found that obese rats produce more fat cells than bone cells in bone marrow, which may explain the weakening.

The finding could be particularly damaging for obese children, whose bones are still developing. Childhood obesity, researchers said, could have a lasting negative impact on the skeleton.

Warning: Avandia, a drug to treat Type 2 diabetes may cause increased risk of bone fractures.

In March 2007 GlaxoSmithKline [GSK] issued a warning to women and doctors of an increased risk of bone fractures when taking Type 2 diabetes medications containing rosiglitazone – sold under the names of Avandia, Avandamet and Avandaryl. The warning came after GSK reviewed the Diabetes Outcome and Progression Trial [ADOPT] in which 4,360 people with Type 2 diabetes were followed for 4-6 years to compare rosiglitazone medications to metformin and glyburide [sulphonylurea] on their own.

The trial discovered a pattern of fractures in women taking rosiglitazone which occurred in the upper arm, hands and feet. These are not places where osteoporosis in postmenopausal women is commonly seen – it is usually in the hip or spine. Men in the study taking the three types of rosiglitazone did not show a difference in fracture rates. In the US people using any of these medications are being advised to report fractures as an adverse reaction.

It is worth noting that a Cochrane Review of Avandia also found an increased number of bone fractures in women taking the drug. It recommended that if you are a woman, especially if you are this, then you should avoid taking Avandia due to the increased risk of bone fractures. There are other drugs for the treatment of Type 2 diabetes that have not been shown to have this risk.

General information about osteoporosis can be obtained from:

National Osteoporosis Society
Manor Farm
Skinners Hill
Camerton
Bath
BA2 0PJ

helpline: 0845 450 0230
website: www.nos.org.uk

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

NHS Choices: osteoporosis

This section provides up-to-date news and views about treatments, research and latest developments. IDDT’s quarterly Newsletters and Type 2 and You, are available on line here so there’s something for everyone interested in diabetes. These publications also cover personal experiences and discuss ‘hot’ topics in the world of diabetes.

Facts
Pre-conception
Pregnancy
Caesarean Section
Report – Diabetes in Pregnancy: Caring for baby after birth [2007]
Breastfeeding and Weaning
Gestational Diabetes

Facts

From a study carried out in Finland and published in Diabetic Medicine 2002, Vol looking at pregnancy from 22 weeks to one year after birth.

• The rate of congenital abnormalities in babies born to women with diabetes has not changed in recent years.
• The perinatal mortality remains 3-5 times higher in women with diabetes than in non-diabetic women.
• The proportion of perinatal deaths caused by congenital abnormalities has reduced but the post-natal mortality has significantly increased.
• Diabetic mothers of malformed babies were significantly younger than mother of babies that were not malformed.
• Nearly two thirds of the malformed babies were boys.

The study points out that the reduction in prenatal deaths and increase in post-natal deaths could be due to better care during pregnancy. But it is also worth noting that the mortality rate in the general population has also reduced markedly. In England in 1960 it was 32.5 per 1000 total births compared with 7.6 per 1000 births in 1992.

Note: A perinatal death is usually defined as death of the foetus after 28 weeks of pregnancy and the first week of the baby’s life.

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

NHS Choices: pregnancy care planner

From a study carried out in Finland and published in Diabetic Medicine 2002, Vol looking at pregnancy from 22 weeks to one year after birth.

• The rate of congenital abnormalities in babies born to women with diabetes has not changed in recent years.
• The perinatal mortality remains 3-5 times higher in women with diabetes than in non-diabetic women.
• The proportion of perinatal deaths caused by congenital abnormalities has reduced but the post-natal mortality has significantly increased.
• Diabetic mothers of malformed babies were significantly younger than mother of babies that were not malformed.
• Nearly two thirds of the malformed babies were boys.

The study points out that the reduction in prenatal deaths and increase in post-natal deaths could be due to better care during pregnancy. But it is also worth noting that the mortality rate in the general population has also reduced markedly. In England in 1960 it was 32.5 per 1000 total births compared with 7.6 per 1000 births in 1992.

Note: A perinatal death is usually defined as death of the foetus after 28 weeks of pregnancy and the first week of the baby’s life.

Facts
Pre-conception
Pregnancy
Caesarean Section
Report – Diabetes in Pregnancy: Caring for baby after birth [2007]
Breastfeeding and Weaning
Gestational Diabetes

Pre-conception

It has been known for some years that good diabetic control at the time of conception improves the chances of having a healthy baby. Entering the pregnancy with good control increases the chances of a healthy baby because important organs of the foetus develop during the early part of pregnancy – the brain, the spine, the heart, the kidneys and the gastrointestinal system. Malformations associated with diabetes are spina bifida, where the spine does not completely close and heart defects. As these malformations are formed during early pregnancy, getting into better control later in the pregnancy does not change what has already developed. However, it is important to remember that just because a woman is not in good control does not mean that she is bound to have a baby that is affected.

For these reasons, a planned pregnancy with good blood glucose control at the time of conception is the ideal situation although it is estimated that as many as two thirds of pregnancies are unplanned. A planned pregnancy also means that folic acid supplements, which reduce the risk of spina bifida and other defects, can also be taken prior to conception. Many diabetes clinics now offer ‘pre-conception counselling’ for couples intending to have a baby to try to ensure that the mother’s blood glucose control is good at conception and from the outset of the pregnancy.

Checking the safety of insulin and other drugs
It is worth checking at this stage the safety of the insulin you are using and any other drugs. None of the analogues have been tested in pregnant women or those planning pregnancy so any risks to the foetus and/or mother are unknown. Commonly prescribed for people with diabetes are ACE-inhibitors for the treatment of blood pressure and/or to slow down the progression of kidney disease and also statins to reduce cholesterol levels. Both these classes of drugs are potentially toxic for the foetus.

But do women attend pre-conception counselling?
Researchers in Hull [ref1] who carried out a study looking into the use of Humalog during pregnancy were struck by the large number of women in this study who did not have pre-conception counselling despite the fact that this was freely available to them – only 40% took it up.

So they carried out a questionnaire study in 69 women between the ages of 16 and 45 to survey their attitudes and knowledge of maternal diabetes and pregnancy. 18 of the women already had children and the rest didn’t. The results were surprising but according to the researchers are similar to other studies:

• In both women with and without children, a high proportion of women [85%] knew that their diabetes could affect the health of the baby and that good control was important at the time of the conception.
• Of the 18 with children only 44%, less than half, had attended pre-conception counselling before their last pregnancy.
• Only 52% of those without children and 28% of those with children reported the intention to do so before a future pregnancy.

So although the knowledge about the need for pre-conception counselling was there, this knowledge is not acted upon. What is more, the women that had already had one pregnancy were even less likely to seek counselling before a future pregnancy! The researchers point out that teaching and knowledge do not necessarily change behaviour and they suggest that a novel approach is needed if pregnancy outcomes are to be improved and that this should continue throughout the reproductive years.

Just a comment…
It is a shame that the questionnaire did not ask why women don’t attend pre-conception counselling. It is well recognised that pregnant women with diabetes go to great lengths to maintain very tight blood sugars to safeguard the health of the baby and indeed, their own health, so it is surprising that so few women attend. Perhaps the term ‘Pre-conception counselling’ is not one that appeals to people contemplating having a baby, especially young people! The word counselling alone can be off-putting for some people. Straight forward ‘Family Planning’ may be more appealing but a little imagination would produce a better name.
Ref 1 Diab Med 2002, Vol 19:605

Facts
Pre-conception
Pregnancy
Caesarean Section
Report – Diabetes in Pregnancy: Caring for baby after birth [2007]
Breastfeeding and Weaning
Gestational Diabetes

Pregnancy

Blood glucose control throughout pregnancy
Blood sugar control is important throughout pregnancy but for different reasons. In the early stages of pregnancy it is important for the healthy development of the foetus and in the later stages, it is important to avoid hyperglycaemia because of the impact on the baby’s metabolism.

Excess glucose in the mother’s circulation easily passes through the placenta to the baby and it is as if it is eating sweets all the time. This stimulates insulin production in the baby, insulin is a potent growth hormone and so fat is deposited which can result in a large baby which can lead to complications at delivery because the baby will not easily fit through the birth canal. After delivery the baby still produces large amounts of insulin which can result in the new born baby being hypoglycaemic. The hypoglycaemia  can be dealt with by the paediatrician.

The first trimester – the first 3 months
Low blood sugars are more common during the first 3 months of pregnancy because the baby begins to feed off the mother’s glucose stores. In addition to this, the hormones are working hard to create the placenta and this can make it hard to control blood sugars. So it is important to blood test frequently and be prepared for unexpected hypos. Sometimes during this period the symptoms of hypos may change and you may not always recognise them, so it is advisable to warn friends and work colleagues about the signs of hypos. If you don’t already have glucagon for emergencies, then it may be a good idea to discuss this with your doctor. Glucagon is an emergency drug/hormone that is injected if you have a severe hypo and are unconscious and so cannot eat or drink. It works by making the liver release its own stores of glucose.

Morning sickness is common in 70% of pregnant women. It is worse on an empty stomach and some women find that eating a cracker or something similar may help. It may also help to make sure that you have a bedtime snack with protein and carbohydrate. Sometimes eating smaller and more frequent meals helps. If morning sickness is a real problem, you should discuss this with your dietitian. If it is so severe that you are vomiting up to 10 times a day, then you should call your doctor because there is a risk of ketoacidosis [very high blood sugars that are out of control]. 

The doses of insulin you need may change frequently because of the body’s hormone activity during this time. It may also be necessary to change your insulin regime – your meal times and injection times.

The second and third trimesters [4 to 9 months]
During this time insulin requirements usually increase and could be as high as two or three times your normal daily amount. This is because the placenta produces a hormone that makes it more difficult for the insulin to work. So frequent testing and dose adjustments when necessary, are essential. Once the baby is born, insulin requirements quickly drop back to normal.

During this time the doctors will continue to monitor your blood glucose levels, blood pressure and kidney function. Some women with and without diabetes develop high blood pressure and oedema  [fluid retention causing swelling] during the latter part of their pregnancy. If this is left untreated it can lead to pre-eclampsia which puts both mother and baby at risk.

Labour
Many women with diabetes go into labour on their own and delivery is normal but this depends largely on the baby’s size and position. Women with diabetes tend to have bigger babies and so if the baby is large it may have problems moving safely through the birth canal. This is one of the reasons the healthcare team monitor the health and size of the baby very closely. If the baby is large then labour may be induced.

The decision to induce labour is usually taken after 36 weeks and this will depend on the baby’s size, the maturity of its lungs, the health of the placenta and the mother’s health.

If the baby is too large or the health of mother and baby is at risk then a Caesarian section will be carried out. This is much more common in women with diabetes than in women without diabetes.

There is an interesting diabetes and pregnancy case study on the NHS Choices website:

NHS Choices: diabetes and pregnancy real story

Facts
Pre-conception
Pregnancy
Caesarean Section
Report – Diabetes in Pregnancy: Caring for baby after birth [2007]
Breastfeeding and Weaning
Gestational Diabetes

Caesarean Section

Women with diabetes are more likely to give birth by Caesarean section, the main reasons being are that their babies tend to be larger, labour tends not to progress as smoothly and/or if the mother’s safety is at risk. If the mother to be has diabetes complications, this can make vaginal delivery of the baby more dangerous for both mother and baby. However giving birth by Caesarean section has disadvantages:

• Diabetes increases the chances of infection and can slow down wound healing so making surgery such as a Caesarian section more risky.
• Caesarean section means a longer stay in hospital, greater chance of transfusions and a slower recovery.

If a woman has had one Caesarean section does it mean that this will happen with the birth of subsequent children?
A study published in The Journal of Reproductive Medicine [Dec 2000] looking at 127 women most of whom had already given birth by Caesarean showed that only 43.7% of diabetic women that attempted vaginal birth after a Caesarean, succeeded but in women without diabetes 60 – 80% of them had successful vaginal births after a Caesarean. The authors of the study called for more research because they felt unable to conclude that vaginal birth after a Caesarean was safe for women with diabetes.

Techniques for Caesarean sections
Research carried out in Austria, published in the Journal Obstetrics and Gynaecology [January 2003], describes a new technique for Caesarean sections which is less painful and far quicker than current methods, taking about 20 minutes in all. The new method reduces blood loss in the mother by half so cutting the length of the procedure and allowing the mother to recover more quickly.

The newer method means that doctors use a sharp knife to cut the skin but then blunt instruments to gently pull the uterine wall apart and deliver the baby. This compares with sharp dissection used by some doctors. The women need fewer stitches because only three layers need to be stitched compared to between four and seven in other methods.

Professor James Walker of the Royal College of Obstetricians and Gynaecologists reported to the BBC that many aspects of this technique are already in use in Britain as this is ‘good practice’. Perhaps this is a question that mothers-to-be should raise during pregnancy.

Note: One in five births in Britain is now by Caesarean section and the World Health Organisation state that just one in ten births is by Caesarean section.

The National Institute for Clinical Excellence [NICE] has published on Caesarian Section which provides information for pregnant women, their partners and the public. This can be obtained by visiting the NICE website:
www.nice.org.uk/guidance/cg132

Facts
Pre-conception
Pregnancy
Caesarean Section
Report – Diabetes in Pregnancy: Caring for baby after birth [2007]
Breastfeeding and Weaning
Gestational Diabetes

Report – Diabetes in Pregnancy: Caring for baby after birth [2007]

Do babies of diabetic mothers need to be placed in special care units?
This is an issue that has been raised with IDDT as pregnant women with diabetes have been advised that their newborn babies will be babies removed from them and placed in the special baby care unit with some being told that this is a necessary and normal procedure – even in hospitals with a ‘good reputation’. While this could be necessary on health grounds, many diabetic mothers are being separated from their babies for no other reason than hospital convenience or ‘hospital policy’.

The findings of a national inquiry, the Confidential Enquiry into Maternal and Child Health [CEMACH] produced in a report, Diabetes in Pregnancy: Caring for baby after birth [2007], stated that in over half of mothers with Type 1 and Type 2 diabetes their newborn babies are automatically moved to a special care baby unit when there was no specific medical indication for admission and in other cases, because babies were not being kept warm enough. This leads to unnecessary separation of babies from their mothers. The report goes on to confirm that there are many benefits of early interaction between mother and baby and states that hospitals should have policies to enable this to happen.

The author of the report stated: “Babies of mothers with diabetes have more complications and do need careful monitoring, nevertheless in the absence of specific risks or complications, every effort should be made to ensure that these babies can be kept with their mothers safely in order for bonding, temperature control and breast feeding to take place.”

The report also shows that there were a number of barriers to breastfeeding and these were:

• A quarter of babies did not have early feeding on the labour ward.
• Instant formula was given as first feed to two thirds of babies.
• Maternal choice not to breastfeed was the main reason for instant formula feeding on the postnatal ward.
• The first blood glucose test was often performed too early to be informative, with inaccurate methods of testing used and insufficient documentation of management.

The report recommends that:

• Mothers with diabetes to receive advice about the benefits of breastfeeding for their child during the antenatal period.
• Babies to be with their mothers immediately after birth, provided there are no postnatal complications. Early mother-baby contact helps to establish breastfeeding and to regulate the temperature in babies.
• Encouragement of breastfeeding within an hour of birth, but all mothers should be supported in the feeding method of their choice.
• Better guidelines and training for healthcare professionals in the management of babies of mothers with diabetes.

IDDT advice to pregnant women with diabetes
Make sure that you know the hospital system before you are due to have your baby and make it clear that you don’t want to be separated from your newborn baby unless there are medical grounds for doing so.

Facts
Pre-conception
Pregnancy
Caesarean Section
Report – Diabetes in Pregnancy: Caring for baby after birth [2007]
Breastfeeding and Weaning
Gestational Diabetes

Breastfeeding and Weaning

A great deal is published about pregnancy and women with diabetes but what about after the birth? It is difficult to find research that deals with the effects of breast on diabetic mums and the control of their diabetes. There seems to be even less information on how to deal with weaning and advice is usually given on the basis of common sense.

Breast Feeding
A great deal is published about pregnancy and women with diabetes but what about after the birth? It is difficult to find research that deals with the effects of breast feeding on diabetic mums and the control of their diabetes.

There is no reason why women with diabetes should not breast feed like any other mum. Breast milk production uses a lot of glucose/carbohydrate from the mother’s supply so it is important to avoid hypoglycaemia by lowering insulin doses as necessary. According to the Nutritional Subcommittee of Diabetes UK, [Diab Med 20.786-807] the high energy needs of lactation mean that a mother is likely to require an extra 40-50g carbohydrate per day compared with pre-pregnancy amounts. Extra carbohydrate may be required before going to bed while the baby is still having night feeds. However, once breastfeeding stops, insulin doses and carbohydrate intake will need to be changed.

Although only small, a recently published study [Pract Diab Int October 2003, Vol.20 No.8] showed:

• In both breastfeeding and non-breastfeeding mothers with Type 1 diabetes, glucose levels were lower during the first week after delivery.
• Insulin requirements remained lower than before pregnancy throughout the 2 months after the baby is born, whether the mothers were breastfeeding or not.
• Hypoglycaemia does not occur more frequently during or immediately after breastfeeding.

Weaning
There seems to be even less information on how to deal with weaning and advice is usually given on the basis of common sense.

If you have been doing a lot of regular exercise and then you stop your blood sugars would go up unless you either ate less or increased insulin doses. The same applies when milk production ceases when the child is weaned.

Although there is little research on this, the general advice for diabetic mums is that weaning should be done gradually so that adjustments in diet and insulin can be slow and smooth. Natural weaning where the child outgrows his/her need for breastfeeding, is the easiest to allow the mother’s body to adjust. But if there is an active decision to wean the baby, then reducing breastfeeds by no more than one feed per week seems to be the general advice. This enables blood glucose control to be more easily managed.

For copies of IDDT’s leaflet on Pregnancy and Diabetes or IDDT’s Pregnancy Information Pack, contact:
IDDT
PO Box 294
Northampton
NN1 4XS

tel: 01604 622837
e-mail: [email protected] 

Facts
Pre-conception
Pregnancy
Caesarean Section
Report – Diabetes in Pregnancy: Caring for baby after birth [2007]
Breastfeeding and Weaning
Gestational Diabetes

Gestational Diabetes

Gestational diabetes is the type of diabetes that occurs during pregnancy. Like other forms od diabetes, gestational diabetes affects the way the body uses the glucose [sugar] in the blood and as a result the blood sugars rise too high. The glucose in the blood is the body’s main source of energy.

If gestational diabetes is untreated or uncontrolled, it can result in a variety of health problems for both that mother and baby. So it is important that a treatment plan is worked out to keep blood sugars within the normal range. The good news is that controlling blood sugars can help to ensure a healthy pregnancy and a healthy baby.

Signs and Symptoms
Most women do not have any signs or symptoms of gestational diabetes but your healthcare professional will check for gestational diabetes as part of your prenatal care.

When signs and symptoms do occur they include:

• Excessive thirst
• Increased urination.

About 3 to 5% of all pregnant women develop gestational diabetes.

The Causes of Gestational Diabetes
Normal metabolism
Normally during digestion the body breaks down the carbohydrates you eat into simple sugars [glucose] and this glucose is absorbed into the blood and transported around the body by the blood vessel system to provide the energy needed for all our activities. This process cannot take place without insulin.

Insulin is produced in the pancreas, a gland behind the stomach, and helps the glucose to pass into the cells to provide energy and maintains normal levels of glucose in the blood.

 The liver also plays a part in maintaining normal blood glucose levels. When there is more glucose in the cells than your body needs for energy, it is removed from the blood and stored it in the liver as glycogen. It can then be used when necessary, such as at times when you run low on glucose eg if you have missed a meal. In this situation the liver releases glucose into the bloodstream.

The amount of glucose in the blood varies according to several factors – the food eaten, exercise, stress and infections. The relationship between insulin, glucose and the liver makes sure that the blood glucose levels stay within normal limits. This should be 4 to 7mmols/l.

During pregnancy, the placenta, which supplies your baby with nutrients, produces hormones that prevent the insulin from working properly. These hormones include oestrogen, cortisol and human placental lactogen. They are vital for a healthy pregnancy but they also make the cells in your body more resistant to insulin.

As the placenta grows larger in the second and third trimesters, it produces even more of these hormones so further increasing insulin resistance. Normally the pancreas will respond by producing enough extra insulin to overcome this resistance. But sometimes three times as much insulin as normal may be necessary and the pancreas can’t produce enough. When this happens the glucose in the blood cannot be transported into the cells and too much remains in the blood so raising the blood glucose levels above normal and this is gestational diabetes.

Who is at Risk of Developing Gestational Diabetes?
Many women who develop gestational diabetes have no known risk factors and any woman can develop it although some are at greater risks than others. The risks increase with:

Age – Women older than 25 are more likely to develop it.

Family history – If a close family member, such as a parent or sibling, has Type 2 diabetes.

Personal history – If you’ve had it with a previous pregnancy or if you have had an unexplained still birth or a baby weighing more that 9 pounds, you may be screened more closely for gestational diabetes with the next pregnancy.

Weight – Being overweight before the pregnancy makes gestational diabetes more likely but gaining weight during the pregnancy does not cause it.

Race – Women from certain races are more prone to gestational diabetes.

Diagnosis and Screening
Until fairly recently there was no evidence from research that screening for gestational diabetes resulted in fewer childbirth complications and healthier babies but a study in 2005 showed that screening women and treating gestational diabetes aggressively resulted in fewer complications and healthier babies. So screening is usually a routine part of pre-natal care for most mothers. There is some debate amongst doctors about whether women under 25 with no risk factors for gestational diabetes should undergo the test because their risk is low.

Screening usually takes place between 24 and 28 weeks of the pregnancy because the condition can’t be detected until then, although if your doctor thinks that you are at patrticular risk, it may be done earlier.

What is the test?
You will be asked to drink a glucose solution that tastes very sweet and then you are asked to wait for an hour after which a blood sample is taken from a veitnin your arm. This will measure the level of sugar [glucose] in your blood and will tell how efficiently your body deals with sugar.

A blood sugar level of below 7.5mmols/l is usually considered normal in this test but having a blood sugar level above this does not necessarily mean that you have gestational diabetes although it does mean that you will need a further test. For the next test you will be asked to fast overnight, then you will be given another sweet drink with a higher concentration of glucose. This time your blood sugar levels will be monitored every hour for 3 hours and if at least two of these are abnormally high, this confirms the diagnosis of gestational diabetes.

During pregnancy routine urine tests are carried out but these are not sufficiently reliable to diagnose gestational diabetes because the amount of sugar in the urine can vary throughout the day as a result of the food eaten.

Treatment
Controlling your blood sugar is essential to having a healthy baby and avoiding complications during the delivery. Most women are able to do this with lifestyle changes – with diet and exercise, but some made need medication as well. In both cases measuring blood sugar levels is essential because it tells you whether your blood sugars are within the normal range.

Monitoring your blood sugar levels
This might sound difficult at first but once you have learnt how to do it, it is will become routine. You draw a drop of blood from your finger with a special device. This is placed on a test strip which is then put into a blood glucose monitor and this will give you your blood sugar level.

Blood sugar levels fluctuate throughout the day according to what you have eaten and how much exercise you have taken, so your doctor may suggest that you carry out blood sugar tests several times a day to ensure that they stay within healthy limits.

Note: your doctor will measure your blood sugars during labour – if they rise too high, your baby’s will also rise and this will cause the baby to produce insulin which may lead to low blood sugars [hypoglycaemia] after the birth.

Diet
A healthy diet is important for all pregnant women but for those with gestational diabetes, diet is part of the treatment – eating the right kind of food in the correct amounts is one of the best ways to control blood sugar levels.

Generally you should eat more fruit, vegetables and whole grains that are high in nutrition but low in fats and calories with fewer animal products and sweets. However, no one diet is suitable for everyone and you should discuss the diet that is suitable for you with a dietitian.

Exercise
Physical exercise generally lowers blood sugar levels for two reasons:

• It causes sugar [glucose] to be transported to the cells where it is needed for energy and so the blood sugar levels drop.
• It also reduces blood sugar levels by increasing body’s sensitivity to insulin – so your body needs less insulin to transport glucose to your cells.

Exercise is important for all pregnant women as it:

• Helps to prevent some of the discomforts during pregnancy – back pain, muscle cramps, constipation and sleep difficulties.
• It prepares you for labour by increasing muscle strength and the endurance developed by regular exercise reduces the stress on your ligaments and joints during delivery.

Type of exercise suitable for women with gestational diabetes
This should be discussed with your doctor or healthcare professional and then you can decide which activities you enjoy. Safe aerobic activities are a good way to lower blood sugars eg walking, cycling and swimming but ordinary activities such as gardening and housework can also have a similar effect. If you haven’t been active for some time, then you should build up your exercise levels gradually until you are carrying out moderate aerobic exercise on most days.

Stretching and strength training exercises combined with aerobic exercise at the same time everyday is the best combination. Varying your exercise routine and working out with other pregnant women can help you stay motivated.

Medications
Sometimes exercise and diet do not lower your blood sugar levels sufficiently and so medication may be necessary. For many years insulin was the only option for women with gestational diabetes because it does not cross over to the baby through the placenta but more recently the oral drug metformin [glyburide] is used.

Monitoring your Baby

Ultrasound
When you have gestational diabetes your baby’s growth will be closely monitored by ultrasound. Ultrasound uses high-frequency sound waves and computer processing to give pictures of your baby inside the uterus. Ultrasound is less accurate as your baby gets bigger.

Non-stress test or biophysical profile
If you are taking medications for your gestational diabetes your doctor may suggest a non-stress test [NST] or biophysical profile to make sure that your baby is getting enough oxygen and nourishment, especially nearer to the due date. This is a non-invasive test and causes does not cause your baby any stress. It takes about 30 minutes, does not require hospitalisation and is a simple test that checks how often your baby moves and how much the baby’s heart rate increases with this movement.

Length of pregnancy
In most cases doctors try to prevent your pregnancy from going longer than 40 weeks because this may increase the risk of complications. Most women with gestational diabetes deliver healthy babies, labour is not routine and delivery by Caesarian section is necessary in some cases. Gestational diabetes does not affect your ability to breast feed or look after your new baby.

Complications
If you have gestational diabetes, it is understandable that you may worry about the health of your baby and the possibility that it may cause birth defects. However, this is not usually the case because in general birth defects develop during the first 3 months of pregnancy and gestational diabetes does not develop until the second or third trimester so blood sugar levels are normal during the early, critical months. Most women go on to deliver healthy babies, but untreated or uncontrolled blood sugar levels can cause problems for you and your baby.

Complications that may affect your baby
Consistently keeping your blood sugar levels within the normal range can reduce these possible complications.

• Macrosomia is when the baby grows too large because extra glucose crosses the placenta into the baby’s blood. The baby’s pancreas then makes extra insulin to cope with this and the baby grows too large [macrosomia]. Very large babies may have difficulty during delivery and are more likely to sustain birth injuries or be born by Caesarian section.
• Hypoglycaemia [low blood sugar levels] occurs in some babies immediately after birth. This is because the babies are accustomed to receiving large amounts of blood sugar from their mothers and their own insulin production is high. Babies with hypoglycaemia have their blood sugar levels checked regularly after birth through an intravenous drip to prevent the blood sugars dropping too low.
• Respiratory distress syndrome is a condition which makes breathing difficult for the baby. It is more likely to occur in premature babies. It is caused by a lack of certain substances in the lungs that help to prevent the lungs from collapsing when the baby takes a breath. Some babies may need help with their breathing until their lungs become stronger.
• Jaundice is a yellowish colouring of the skin and the whites of the eyes. It occurs because the baby’s liver is not sufficiently mature. New born jaundice may begin within 2 or 3 days after birth but sometimes it does not appear for a week. New born jaundice is not a disease in itself and is not serious but will be monitored by the doctor.
• Shoulder dystocia can occur if the baby is very large and the shoulders are too big to move through the birth canal. In most cases doctors can free the baby but injuries may occur. This is a rare but serious complication of gestational diabetes.
• Stillbirth or death is a rare occurrence and if it occurs it is usually because gestational diabetes is undetected and therefore untreated.

Complications that may affect you
If you have gestational diabetes, then you may be at risk of the following complications:

• Pre-eclampsia is characterised by significant increase in blood pressure and left untreated, it can lead to serious complications for mother and baby, even death. Having gestational diabetes increases the risk of pre-eclampsia.
• Caesarian section may be recommended if your baby is large [macrosomia] but gestational diabetes itself does not mean that a Caesarian section has to be planned.
• Type 2 diabetes is more likely to develop in later life in women who have gestational diabetes, although many cases can be prevented with a healthy lifestyle of a health diet and regular exercise. Up to 40% of women develop Type 2 diabetes within 5 to 10 years after delivery and this risk may be increased in obese women.

Living with Gestational Diabetes
It is not easy living with a condition that can affect the health of your unborn baby and you may find it stressful, especially as you have to carry out regular blood sugar monitoring, follow a healthy diet and take regular exercise. 

Prolonged stress itself can raise blood sugar levels and so it is important to learn as much as you can about your condition – books from the library, talking to other women with the same condition and of course, talking to your doctor, a dietitian, your midwife and a diabetes specialist nurse. They can answer your questions and help you to learn how to manage your blood sugar levels during pregnancy.

After your Baby is Born
You can breast feed and look after your baby. After the birth your blood sugar levels will be checked frequently and then again in 6 weeks. Gestational diabetes usually clears up after the baby is born because when the placenta is removed, the hormones it was producing, which caused your insulin resistance, are also removed.

Once you have had gestational diabetes it is sensible to have your blood sugars tested at least once a year and also to maintain a healthy lifestyle to lessen your chances of developing Type 2 diabetes later in life.

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

NHS Choices: gestational diabetes

Driving and Diabetes
Holidays and Travel Tips
Looking after your Insulin and Injecting Devices
Alcohol and Diabetes
Cultural Eating and Dietary Information

For further information on living with diabetes, including travelling with diabetes, diabetes and footcare, and sport with diabetes, you can also visit the NHS Choices website:

NHS Choices: living with diabetes

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

Vehicles You Can Drive

On January 1st 1998, driving restrictions came into force in the UK to bring the UK in line with the other European countries.
People with insulin-treated diabetes have medically restricted driving licences issued for a maximum of 3 years. Diabetes is NOT specifically singled out – the regulations apply [i] to all conditions which require a medically restricted licence and [ii] to everyone applying for a licence for the first time whether young or old, with a normal licence or a restricted licence.

You ARE able to:

• Drive a car or vehicle up to 3.5 tonnes with a trailer.
• Tow a caravan, boat, horse box or broken-down vehicle.
• Drive a minibus of less than 9 seats.
• If you drive a non-commercial minibus on a voluntary unpaid basis you can apply for a special licence. This is bit complex and you can obtain information from the DVLA Swansea, Fact Sheet INF 28.

Driving a mini-bus
For many people there has always been some confusion over the DVLA regulations for driving a mini-bus.
You may be able to drive a mini-bus if you hold a car licence and follow certain conditions. Your driving licence will tell you what vehicles you can drive.  The DVLA states that you may be able to drive a minibus with up to 16 passenger seats using your current car driving licence as long as it’s not for ‘hire or reward’ – there is no payment from or on behalf of the passengers.

The conditions you must meet:

• you’re 21 or older
• the minibus is used for social purposes by a non-commercial body
• you’ve had your driving licence for at least 2 years
• you meet the Group 2’ medical standards if you’re over 70 – check with your GP if you’re not sure you meet the standards
• you’re driving on a voluntary basis and the minibus is used for social purposes by a non-commercial body
• the maximum weight of the minibus is not more than 3.5 tonnes – or 4.25 tonnes including specialist equipment for disabled passengers, eg a wheelchair ramp
• you’re not towing a trailer.

Minibus permit – if you need to charge running costs

You can apply for a minibus permit if you need to charge passengers, as long as:

• the vehicle can carry between 9 and 16 passengers
• you’re driving it for a voluntary organisation that benefits the community – eg an educational, religious or sports organisation
• the minibus service is only available for members of that organisation – not to the general public
• any charges are to cover running costs and are not for profit

Apply for a minibus permit from your local authority, or contact DVSA (Driving Vehicle Standards Agency).

No blanket ban on driving 3.5 and 7.5 tonnes vehicles or for LGV drivers
There is no longer a blanket ban on driving these vehicles but people will be assessed on a individual basis. This includes the following:

• The applicant needs to satisfy the DVLA that since commencing treatment with insulin ‘he has had sufficient experience in the driving of vehicles to make practicable an assessment of the risk posed by his driving vehicles in those classes.’ The qualifying condition for this purpose was set to require that the applicant has driven at least 4 hours a day 3 days a week during the 12 month period prior to the application.
• Applicants must have had no hypoglycaemia attacks while driving.
• They must undergo an annual examination by a diabetes specialist to enable the DVLA to assess that their diabetes is adequately controlled.
• They must regularly monitor their condition and at least 2 months records will be required.

HGV licence applications process improved by the DVLA (2015)
The Driving and Vehicle Licensing Authority (DVLA) has made some improvements in the way people treated with insulin apply for their annual renewal to drive vehicles over 3.5 tonnes. This is to reduce the unreasonable delays people have been experiencing when renewing their licences.

• The DVLA Drivers Medical Group has increased capacity to assess applications from people with diabetes.
• The application form (D4) is being simplified so that it is easier to complete and will reduce the number of rejected applications.
• The response time will be speeded up for any vocational drivers chasing up the whereabouts of their First Vocational Licence Application with the DVLA Contact Centre.

There are also plans to improve the whole process which includes:

• Updating all DVLA literature to advise drivers not to send in their driving licence when applying for a renewal.
• Changing legislation to allow drivers to apply for their licence 90 days before it is due to expire.
• Recruiting and training more staff and medical professionals.

You can contact the DVLA Contact Centre about Vocational Medical Enquiries on 0300  790 6806

Driving and Diabetes

Driving and the EU law
Driving and hypoglycaemia – what are doctors being advised to do?
Driving Regulations in the UK
Insulin and Driving Taxis
Hypoglycaemia and Driving
Driving warnings in Insulin Products
Driving and Medicines
Driving and Visual Field Loss
Research

 

Living with Diabetes

Medical assessment forms

People with diabetes often have to ask their doctor to fill in forms to independently assess their health and more specifically, their diabetes. The most common form is for driving licence renewal but there are others ones that occur from time to time – for suitability for employment, for insurance policies and for mortgage applications.

in Diabetes Update [Summer 2000], Diabetes UK advised doctors and health professionals about the sort of information that he/she needs to fill in about their patients with diabetes. Perhaps we, as the patients, would also benefit from knowing the sort of information that is going to be provided about us once we have given written consent for this information to be passed on. So here are some of the points that doctors are being advised to make:

General Information

• Type of diabetes, duration and treatment [insulin, tablets, diet only].
• HbA1c results past and present.
• Any episodes of ketoacidosis [very high blood sugars] or severe hyperglycaemia.
• Hypos are a major concern for driving and for some employers.
• Weight, vision [with glasses if worn], blood pressure, lipids and smoking habit.
• Presence of diabetic complications – retinopathy, neuropathy and nephropathy.
• The patient’s involvement in their own care eg their clinic attendance record, knowledge about diabetes etc.
• The impact of diabetes on the ability to work or drive.

Employment

Decisions about the suitability for employment are made on two key points regardless of your diabetes and these are:

• Are you fit to carry out the required tasks within the acceptable risks of the job?
• Will the job itself adversely affect your health? 

If you are treated with insulin and work in potentially hazardous occupations, you should realise that in assessing you for suitability for employment the doctor will be looking to see that:

• You are physically and mentally fit, to non-diabetic standards.
• Your diabetes is stable.
• You have no disabling hypos and no loss of awareness of hypos
• You have no advanced complications, no significant coronary heart disease or any other vascular disease. 

Hypoglycaemia

As we all know hypoglycaemia affects cognitive function and co-ordination and therefore is important for both work and driving. The DVLA requires specific information about hypoglycaemia and so your doctor will want to know from you and from your records, the following information:

• Have you recently had any severe hypos?
• If so, how many have there been in the last 12 months and the last 3 months and have they occurred during the day or the night? 

The fact sheet in Diabetes Update goes on to point out that while severe hypos can occur in anyone with insulin treated diabetes, recurrent severe hypos suggest that there is impaired hypo warnings and that this is a major driving hazard. For this purpose the article defines severe hypoglycaemia as a hypo which requires the help of someone else regardless of whether or not the person with diabetes is conscious or unconscious. It goes on to point out that:

It is inappropriate for people with recent severe hypoglycaemia to drive, to work in dangerous environments or to undertake hazardous tasks and that there should be an interval of perhaps 6 months without a severe hypo.

Loss of hypo warnings

If you have loss of hypo warnings, you should not drive or work in a dangerous situation, because not only could this be dangerous for you but it could also harm others. IDDT has always said that people who have lost or partially lost their warnings do not necessarily know that they have. So what are the signs that loss of hypo warnings may have occurred?

• Frequent severe hypos reduce warnings and even one mild hypo is enough to reduce them.
• If your hypo warnings are sweating, shaking trembling, then you are likely to have sufficient warnings, but if your warnings are confusion, slurred speech and difficulty walking or functioning in other ways, then you are likely to have impaired hypo warnings.
• If your spouse or partner recognises that you are hypo before you do.
• Regular blood glucose levels below 3mmols/l without symptoms.
• A ‘good’ HbA1c result ie within the normal range could mean that there have been hypos that haven’t been recognised – unawareness. 

We have to remember that when a doctor signs forms on our behalf he/she is taking responsibility for saying we are able to carry out the employment tasks or drive a vehicle safely. It is right and proper therefore that all these questions have to be addressed by the doctor and that he/she is not just making life difficult for us!

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

Insulin and Driving Taxis

March 2007

The Department of Transport issued guidance for insulin users who hold licences for driving taxis. Previously, whether or not a taxi driver using insulin was allowed to drive a taxi varied according to local authorities with some having automatic bans. IDDT is aware that some people with Type 2 diabetes have avoided going on to insulin in order to keep their taxi driving licence – not good for their long-term health but understandable when they have a family to support.

The new guidance for England and Wales published in October 2006 recommended that ‘best practice is to apply the C1 standards’. CI licences are issued annually but only after applicants have successfully been through a strict medical assessment. Hopefully local authorities will now follow this guidance and the standards will not vary from one area to another and nor will people whose diabetic control is satisfactory be denied their livelihood. For taxi drivers who do receive an automatic ban, this guidance can be used to argue their case.

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.

Driving and Diabetes

Driving and the EU law
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

Driving warnings in insulin products

In 1998 the driving warnings in insulin product information were reviewed in the UK and Europe and after consultation, the following amendments were made:

Summary of product characteristics in the Data Sheets
"The patient’s ability to concentrate and react may be impaired as a result of hypoglycaemia or hyperglycaemia. This may constitute a risk in situations where their abilities are of special importance (eg driving a car or operating machinery.)

Patients should be advised to take precautions to avoid hypoglycaemia whilst driving, this is particularly important for those who have reduced or absent awareness of the warning signs of hypoglycaemia. The advisability of driving should be considered in these circumstances."

Patient Information Leaflet
"Your ability to concentrate or react may be reduced if you have hypoglycaemia or hyperglycaemia. Please keep these possible problems in mind in all situations where you might put yourself or others at risk (eg driving a car or operating machinery.)

You should contact your doctor about the advisability of driving if you have:

• frequent episodes of hypoglycaemia
• reduced or absent warning signs of hypoglycaemia."

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

Driving and medicines

Facts

• The link between alcohol and road traffic accidents is well established.
• There is increasing evidence that some prescribed medicines and some over-the-counter medicines may also impair driving ability.
• A recent survey has shown that 17% of drivers involved in road traffic accidents were found to have traces of medicines in their blood eg antidepressants and antihistamines.

The commonly used medicines that may impair your ability to drive are those that may cause drowsiness are:

• Some antidepressants
• Strong pain killers eg codeine
• Powerful tranquillisers eg those used for the treatment of some types of mental illness
• Some medicines used to treat epilepsy eg phenobarbitone
• Benzodiazepine tranquillisers used to treat anxiety and insomnia
• Some antihistamines for treatment of hayfever and allergies

Your ability to drive may also be impaired by:

• Eye drops that cause blurred vision.
• Insulin and some oral anti-diabetic medicines that may cause confusion as a result of low blood glucose levels.

How do you know if your medication may impair your ability to drive?

All medicines that may cause drowsiness are labelled with this warning:

"Warning. May cause drowsiness. If affected do not drive or operate machinery."

It is important to note the words ‘if affected’ in this warning as it places the responsibility on you to decide whether or not the side effects of drowsiness are likely to impair your driving ability. In other words, you have been warned, so if you had an accident as a result of being drowsy, then the responsibility rests with you!

If alcohol is taken with some medicines, then this can make the drowsiness worse and so labels may also contain the warning:

"Avoid alcoholic drink."

A clear message:

Always read the information leaflet about any medications you take whether prescribed by your doctor or bought over the counter at your pharmacy. You can obtain further information about your medicine from:

• Your doctor
• Your pharmacist

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

Driving and Visual Field Loss

IDDT’s July 2002 Newsletter drew attention to the DVLA implementing more stringent standards for visual field assessment and driving. This has resulted in greater numbers of people losing their driving licence because of reduced visual fields after laser treatment for retinopathy. IDDT wrote to the DVLA for clarification on this matter.

Jackie Banks had laser treatment for her retinopathy 25 years ago and there was no need for further treatment. She has been classed as fit to drive ever since – that is until these stringent regulations came into effect. She led almost a one-woman campaign for several years which resulted in her retaining her licence, as well as helping many other people to do the same. 

The seriousness of the new regulations was brought home to us when IDDT member Stephen, applied to renew his driving licence as a matter of routine and he visited a DVLA nominated optometrist for a field test. Then like a bolt from the blue, a letter arrived from the DVLA informing him that he could no longer drive because of his visual field loss. Stephen had laser treatment some years ago but his retinopathy was non-progressive and in the opinion of his ophthalmologist, had never interfered with his visual fields to prevent him driving. So what had changed – certainly not the state of Stephen’s eyes, at his last routine check with his ophthalmologist. The answer – the system!

The visual field test

Visual fields are measured on instruments called perimeters and there are two types:

• A manually operated perimeter eg Goldmann using a system on moving lights.
• An automated perimeter that uses static flashing lights and automatically prints out the results. This is widely used because it requires less skill on the part of the operator.

The manually operated Goldmann type is often easier to use for the person being checked and may well give better results. Clearly your results could be different according to which perimeter is used. The results of these tests will influence the renewal of your licence.

DVLA regulations
These are very difficult to interpret, even for qualified people. There are several problems with this system which IDDT raised with the DVLA:

• perimeters were never designed to be a definitive test on which to base vital decisions about whether or not to issue a driving licence.
• The DVLA has commissioned research to look at the best way of testing for visual field defects and driving which will be available in 2-3years time. We have therefore queried the appropriateness of this stringent interpretation of the EU Directive BEFORE the results of the research are known.
• The DVLA perimeter uses a static fixation point ie your eye has to be fixed on a central point while trying to recognise the flashing lights in the peripheral field. Actually no one drives like this, the eyes are moving all the time and therefore minor defects in the peripheral field are not noticed because of the eye movements.

The response from the DVLA:
As simply as I can put it, the DVLA only accept the results of automated perimeters and not the Goldmann. However, where there is some doubt as to the width of the visual field, then they may request a further test on a Goldmann to ‘avoid erroneously refusing or revoking the entitlement’ to drive. However, they also acknowledge that the automated perimeter was recommended as the standard for consistency of quality of testing and accessibility, ie the ability of the tester and the fact that not many optometrists possess a manually operated perimeter. Is this a good enough reason for choosing one particular instrument, the Goldmann, the results of which could affect the lives of so many people?

Application for renewal of driving licence

• In the past, a report from your own ophthalmologist was sufficient information for the DVLA but now people are being requested to attend a DVLA nominated optometrist [optician] for a field test, apparently to speed up the process. The optometrist’s report goes to the DVLA and they make the decision. However, you can choose to have this cheque with your own ohthalmologist instead.
• IDDT is aware that in some cases, the visual field test is not carried out by the optometrist but by an ‘operative’ in the shop and we have reported this to the DVLA. When the future of your licence is at stake, you should try to ensure that the test is carried out by the nominated optometrist, who actually receives the fee for this, and NOT by an unqualified person.
• It is important to note that if you have recently seen your ophthalmologist for your routine visit, then you can request that his/her report is sent to the DVLA and so avoid using the optometrist system. This may be preferable because not only is your history known but hospitals  are more likely to have both types of perimeters. Sound advice would be to try to organise your routine eye check within weeks of your licence being up for renewal. This requires a bit of forward planning but it may be worth it.

So what happened to Stephen?
On receipt of the letter from the DVLA, he immediately went to see his ophthalmologist who was very supportive and confirmed that his visual fields had not deteriorated over the years since his laser treatment. He carried out field tests with BOTH types of perimeters and Stephen appealed against the decision to revoke his licence. Several months later he received his new driving licence. But in the meantime, he had to have taxis to work everyday because he starts early in the morning and he had several months of unnecessary stress and worry to say nothing of the inconvenience and costs. The key points in Stephen’s case was that his retinopathy had remained stable for several years and he had received no further laser treatment. Other people have not been so fortunate. Clearly if there is significant visual field loss, then it is unsafe to drive but if the loss is borderline by the DVLA standards, then it is important to be aware that you do not simply give up.

But it looks as if this situation may improve…
DVLA Expert Consensus Workshop, March 2006

This workshop made various recommendations although it is not clear whether these have been adopted officially but if you are facing this situation it is well worth using them in the meantime. The Workshop recommendations show greater understanding that [a] retinopathy is not always progressive and can stabilise and [b] that some people can learn to adapt to field loss without being unsafe drivers. 

The recommendations state:

• Before having the Esterman field test, you should be given full information on the procedure and appeals system. You should also be familiarised with the Esterman test before taking it and if you fail, you should be offered a repeat test on the same day.
• If you fail the Esterman test you could be offered a Goldmann test [a different instrument].
• If you fail the Goldmann test but you could show that you meet the criteria to be considered an exceptional case, you could be allowed to re-apply and have the chance to demonstrate that you have compensated sufficiently for your field loss by taking an on-road driving assessment. To be classed as an ‘exceptional case’ you would need to supply a medical opinion that your condition has stabilised and that you have learned to compensate sufficiently for your field loss.
• These alternatives should be made available so that people do not have their driving licences removed unnecessarily. However the burden of proof in showing that the retinopathy has stabilised rests with the person and not the DVLA.
• Visual fields should not be re-tested for at least 3 months after laser treatment as vision may be affected immediately after it.
• The current 3 yearly visual field testing may be too frequent for some people where there is evidence of a stable condition and a mechanism would need to be in place to identify the people where this applies.

There is a need for more evidence and further research.

Note: It appears that other EU countries have not adopted the same stringent interpretation of the EU Directive as the UK [what’s new?]. In most EU countries, it is the ophthalmic consultant that tells people whether or not they should be driving following laser treatment.

Driving and Diabetes

Driving and the EU law
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

Research

Alcohol, driving and hypoglycaemia
Alcohol can interfere with all aspects of the normal physiological, cognitive and symptomatic responses to hypoglycaemia. In otherwise healthy individuals, the net effect of alcohol on glucose metabolism is neutral, provided that liver glycogen stores are replete. For insulin treated people, the influence of hypoglycaemia is more relevant.

A study conducted in 1990 found that moderate alcohol consumption of 100-120mg/100ml blood,* markedly reduced awareness of hypoglycaemia and slowed down reaction time. The loss of awareness occurred despite the presence of the usual symptoms such as facial flushing, blurred vision, pounding heart and sweating. The patients felt hypo after alcohol when blood alcohol levels were within the normal range but by contrast, the clinical features of low blood glucose can be mistaken for alcohol intoxication.

Even at very low levels of blood alcohol it is possible that there may be a deleterious effect on cognitive performance which may be aggravated if blood glucose levels fall below the threshold which has been shown to impair cognitive performance. It is therefore better not to take any risks with driving and better not to drink at all if driving.

*Current legislation in the UK provides an upper limit of 80mg/100ml blood.

[Kerr et al, Diabetologia 33: 216-21]

The perception of safe driving ability during hypoglycamia in patients with type 1 diabetes
Hypoglycaemia and its subsequent cognitive impairment may place people with diabetes at risk when driving. This study looks at the factors that influence judgements of safe driving ability during hypoglycaemia.

30 men and 30 women who had an average duration of Type 1 diabetes of 9 years and no complications underwent hypoglycaemia with a stepped insulin clamp. Glucose levels were reduced in stages over 190 minutes to 40mg/dL [2.2mmols/l]. At each point the patients completed a symptom questionnaire and a neuropsychological test, estimated their blood glucose level and reported whether they could drive safely. The study was repeated with another 93 patients later in the year and the results were similar.

The proportion of patients judging that they could drive safely decreased as blood glucose levels went down from 70% at 120mg/dL [6.6mmols/l] to 22% at 40mg/dL [2.2mmols/l]. When blood sugars were between 3.3 and 3.9mmols/l the first group said they would drive 60% of the time and the second group 64% of the time. With a blood sugar of less than 2.2 mmols/l the figures were 38% and 47%.

Men and middle-aged patients were more likely to consider it safe to drive during hypoglycaemia than women and those under 25 years. Those who were symptomatic and those who recognised hypoglycaemia were less likely to report ability to drive during hypoglycaemia. Most patients who were cognitively impaired appeared to recognise this and reported that they could not drive safely at blood glucose levels of 40mg/dL [2.2mmols/l]. Glucose levels less than 70mg/dL [3.9mmols/l] should be treated before driving. This information is as important for middle-aged, experienced drivers as it is for younger inexperienced drivers.

The author is quoted in the Pharmaceutical Journal 28.8.99 "Given the relatively low level of low blood glucose detection, the suggestion that individuals measure their blood glucose levels and raise potentially low blood glucose levels before driving does not seem unreasonable."

Am J Med 1999 Sep; 107(3):246-53