diabetes

LOW BLOOD SUGAR
Hypoglycaemia is when your blood sugar gets too low (below 4 mmols/l). Always keep dextrose tablets or hypo food with you, following this you will require a long acting carbohydrate (see Treating a hypo)

Hypos can be caused by
Missed or late meals, not enough food, too much insulin or tablets, more activity than normal, alcohol, hot weather

Help yourself to prevent hypos
Increase carbohydrates or reduce insulin before exercise. Monitor blood glucose more often. Watch for trends in blood glucose and discuss patterns if worried. Remember the effects of exercise on blood sugar can last several hours. Keep to a steady treatment pattern by taking your medication at the correct times. Eat regular meals and snacks. Drink alcohol in moderation

Symptoms
The symptoms of a hypo will differ between individuals. Similarly, each hypo that you have might not feel exactly like the last one. You may feel:

• weak and wobbly
• shaky
• sweaty
• a tingling in your mouth
• hungry
• confused
• you may have a headache (a headache on waking may mean you have had a hypo during the night, and nightmares can be a symptom of night hypo)
• have a fast or pounding heartbeat
• or have blurred vision
  

Other people around you might notice that you are pale, slurring your words, acting strangely, unusually aggressive, or lacking concentration

Treating a hypo
As soon as you feel as if you maybe going into a hypo, you should stop what you are doing and if at all possible check your blood glucose level. Take some sugar (quick acting carbohydrates) such as: 50ml of Lucozade, a large spoonful of undiluted Ribena, 3-4 teaspoons of sugar, honey, or jam, 5 to 7 glucose/dextrose tablets

If you are away from home you should always carry with you: glucose/dextrose tablets, or Glucogel (a thick sugary gel). If you start to feel better after 5 minutes or so have some long acting carbohydrate, such as a piece of toast, fruit, biscuits, a scone or a cereal bar. This will make sure that your blood sugar doesn’t go down again

If you don’t feel better after 5 minutes, take more sugar/quick acting carbohydrate. It is recommended that you do not drive a vehicle for up to 45 minutes after you start feeling better after a hypo, be aware that the risk of further hypo is increased for the next 24 hours

If you miss the signs
Sometimes it can be hard to catch a hypo at the early stages, and you may need someone to help you to treat it. Tell people that you work with, your family and friends that you have diabetes and may need their help in the future. Let them know where you keep your hypo food too, in case they need to help you. Always carry your ID card or wear an identity bracelet or necklace so that strangers will know what is wrong and what to do

If you are unable to treat yourself but you are conscious
Jam, honey, treacle or Glucogel can be put into the side of your mouth and your cheek rubbed from the outside. If there is any doubt about your ability to swallow, do not put anything in your mouth. Once you are feeling better,you should take a snack. Your Diabetes Specialist Nurse can teach a friend or relative how to deal with the situation. If there is any doubt or you do not respond an ambulance must be called: 999. Ensure friends understand you do not need insulin in this situation

In control
Occasional mild hypos are often a part of having diabetes, but they shouldn’t take over your life. If you are having frequent hypos, speak to your Diabetes Specialist Nurse or your GP. By recognising what causes hypos, you can help to prevent them by planning ahead. It is important to let your Diabetes Specialist Nurse know if you have trouble controlling your blood sugar

HIGH BLOOD SUGAR
Hyperglycaemia is when your blood sugar gets too high. This can be caused by: illness, not enough insulin or a missed dose, less exercise than usual, eating more food than anticipated, or food with more sugar in it than you thought, emotional stress, injecting into lumpy sites

Symptoms may include
Increased thirst, passing a lot of urine, large amounts of sugar and ketones in the urine, loss of appetite, feeling and being sick, lack of energy, blurred eyesight

Managing high blood sugars
Don't panic! It is normal for blood sugars to go up and down during the day. Monitor your blood glucose more frequently. Increase fluid intakes such as water or sugar free drinks. If you have persistently high blood glucose levels check for ketones in your blood or urine, and contact your diabetes team for advice

SICK DAY RULES
If you get a cold, flu, or any other illness, here are a few simple rules you should always remember that may help you with those "sick day rules"

Contact your diabetes clinic or your GP if: you are unsure about what to do, you are vomiting, you don't improve quickly (24hrs), your blood glucose level remains high or, adversely low, you are worrying

Even though illness is not something you can plan in advance, try to be prepared and ask your doctor or diabetes nurse about what to do if you become ill. MOST IMPORTANTLY, NEVER STOP TAKING YOUR INSULIN UNDER ANY CIRCUMSTANCES AND ENSURE YOU HAVE KETONE TESTING EQUIPMENT THAT IS IN DATE

HAEMOGLOBIN A1c TESTING (HbA1c)
As you know, keeping your diabetes in good control is the key to staying healthy. You check your blood glucose levels at different times of the day to make sure your diabetes plan is working. These tests tell you what your blood glucose level is at that moment, which is very helpful. However, your blood glucose levels change a lot over the course of a day. Although self-testing frequently is a good way to manage your diabetes, it ALONE does not give you the whole picture

There is another test that can tell you your average blood glucose for the past 2 to 3 months. This test is called a Haemoglobin A1. You may hear a few different names for this test, including: HbA1c, Glycohaemoglobin, A1C

What is Haemoglobin?
Haemoglobin is a protein inside your red blood cells. It is the part of the red blood cell that carries oxygen from your lungs to the rest of your body. Haemoglobin also carries glucose, because glucose can stick to all kinds of proteins in your body. Once glucose sticks to haemoglobin, it is stuck there for the life of the red blood cell, about 3 or 4 months. The more glucose there is in your blood, the more will end up stuck to the haemoglobin

What does the HbA1c measure?
HbA1c is a measure of how much glucose is stuck to your haemoglobin. Your HbA1c reading tells you and your healthcare team what your average blood glucose level has been for the past 2 or 3 months. If you have lots of glucose in your blood and your average blood glucose has been high for the past few months, then your HbA1c will be high. The HbA1c test allows you to see how good your control has really been. You should talk to your healthcare team about your daily blood glucose tests and your HbA1c

How does my HbA1c reading compare to my daily blood glucose levels?

HbA1c Reading	Average blood glucose level	Your blood glucose control
14%	20 mmol/L	Very poor control, take immediate action to lower
10%	13.9 mmol/L	Poor control, take action to lower
9%	11.6 mmol/L	Poor control, take action to lower
8%	10 mmol/L	Marginal control, take action to lower
7%	8.3 mmol/L	Marginal control, take action to lower
6.5%	7.5 mmol/L	Good control target
6%	6.7 mmol/L	Very good control

This chart is an example of how blood glucose compares to HbA1c. The numbers in this chart are for non-pregnant adults. “Take action” depends on your own plan, and your action steps should be discussed with your healthcare team. Some labs use different ways to test and have a different normal range. Talk to your healthcare team about your results

How can HbA1c testing help me?
An HbA1c higher than 7.4% is a warning sign that your diabetes is out of control. If your haemoglobin HbA1c is high, your healthcare team may change your diabetes plan to help control your blood glucose better. Changes in your plan are expected from time to time and will help bring your HbA1c closer to normal. When your HbA1c is close to normal, you know you are doing all you can to stay healthy

Research shows that good blood glucose control does lower your risk of developing major diabetes related health problems including heart disease, stroke, kidney disease, eye disease, nerve damage, amputations, and circulation problems. By keeping your blood glucose close to normal, you will stop or delay the damage high blood glucose does to blood vessels and nerves. You can prevent the complications of diabetes

Where do I go for an HbA1c test?
Some doctors can do an HbA1 in their office by taking a blood drop from a finger prick. You can wait for the results and discuss them right away. You can also go to the lab for this test but will have to return at a later date to discuss the result with your doctor.

How often should I have an HbA1c test?
The ACE and AACE recommend that anyone with diabetes should have an HbA1c done every 6 months for people at or below the target of 7.4%, and every 3 months for those above7.4% or changing therapy. If you inject insulin, you should have this test done every 3 months. Two major studies have shown the importance of good blood glucose control and the relationship of the HbA1c to diabetes complications:

The first was the Diabetes Control and Complications Trial (DCCT). In this study, patients with type 1 diabetes had an HbA1c every month. This gave the healthcare team useful information to change treatment plans. In this study, patients who had close to normal HbA1c were in better health and had fewer cases of eye disease, kidney disease and nerve damage

The other study was called the United Kingdom Prospective Diabetes Study (UKPDS). This was a study done with patients with type 2 diabetes. People who had good blood glucose control were in better health in this study, too

Both of these studies show that the hard work it takes to control your blood glucose is worth it. Your healthcare team will help you take good care of your blood glucose. They will tell you how often you should have an HbA1c test performed

Source for this section: Bayer Healthcare

GLYCAEMIC INDEX
The Glycaemic Index (GI) is a ranking of carbohydrate foods based on their immediate effect on blood sugar levels. Carbohydrate foods that break down quickly during digestion have a higher GI value because they quickly cause a higher rise in blood sugar. In comparison, carbohydrates that breakdown slowly, release glucose more gradually into the bloodstream and have low GI values

As well as improving your blood sugar levels, diets that contain a greater proportion of lower GI carbohydrates have been shown to be more satisfying, can help with weight loss and improve blood cholesterol levels.
Remember that the glycaemic effect is seen when you compare foods with the same (grammes) of carbohydrate

The most important part of ‘Carbohydrate Counting’ is to calculate the TOTAL amount of carbohydrate in a meal, regardless of type and adjust the insulin dose accordingly. The effect of the glycaemic index is not as obvious when patients are taking fast acting insulin before meals. But, if you find that your blood sugar response is different to that expected, you may want to consider whether the glycaemix index of food eaten was particularly different. For example, you may get a lower blood sugar response after eating a portion of pasta compared to a jacket potato (same grammes of carbohydrate)

The table below shows typical carbohydrate foods and lists them in order of their glycaemic effect with the foods on the right having the lowest GI, i.e. more likely to cause a smaller rise in the blood sugar level

LOW GI RATING [under 55]	MEDIUM GI RATING [55 to 70]	HIGH GI RATING [more than 70]
All bran Apple Apple juice (unsweetened) Apple muffin Apricot (dried) Apricots (dried) Baked beans Banana cake Basmati rice Buckwheat Bulgur Wheat (Burg hut) Butter beans beans Carrots Cherries Chick peas Corn chips (Doritos) Crisps (plain) Custard Fruit  bread/loaf/toast Granary Bread Grapefruit Grapefruit juice (unsweetened) Grapes Green Peas Haricot Beans Kidney beans Kiwi fruit Lentils Milk (full fat or skimmed) Milkshake (low fat) Noodles Noodles Oat based cereal  eg:Oat crunch Oatmeal Biscuits Orange Orange juice Pasta,  spaghetti, fettucine, etc. Peach Pear (canned and fresh) Pineapple juice (unsweetened) Plum Porridge Rye Bread Semi-skimmed & Skimmed milk Soya Beans Spaghetti Special K Sultana Bran Sweet potato Yam Yoghurt (low fat)	Apricots (fresh or canned) Banana Basmati rice Beetroot Boiled New potatoes Couscous Croissant Crumpet Fruit cocktail (canned) Gnocchi Hamburger bun Ice cream (full fat) Macaroni cheese Mango Melon Mini-wheats Muesli Paw paw (papaya) Peach (canned in heavy syrup) Pineapple Pitta bread Raisins Rich Tea or Digestive Ryvita Shredded wheat Sultanas Sweet corn Taco shells Weetabix Wholemeal bread	Bagel Broad beans Cheerios Coco Pops Corn Flakes Cornflakes French fries Gluten free bread Instant Potato Jacket (Baked) potato Long-grain (brown & white) rice Lychees (canned) Mashed potato Morning Coffee Oven Chips Parsnip Puffed crispbread Pumpkin (Squash) Rice (brown cooked) Rice (instant cooked) Rice (steamed white) Rice Krispies Smash (instant mashed potato) Sugar Puffs Swede Water biscuit/cracker Water melon Watermelon White bread White baguette

Source for this section: Royal Bournemouth Hospital

ALCOHOL IMPLICATIONS
For the majority of students alcohol is a routine part of their life at University, and a diagnosis of Diabetes doesn't automatically mean that alcohol is a no go area

DRUG IMPLICATIONS
As most people will realise the use of illegal drugs carries health risks, but patients with diabetes should be aware that the effect of drugs become much more unpredictable, and in some circumstances life-threatening

HEALTHY EATING
You can take a look at the following (general advice) pages on our web site:

WEB SITES
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Note: Novo Nordisk operate an out-of-hours emergency diabetes HELPLINE for people with diabetes, who use their products. Telephone 0845 600 5055

Source for sections unless specified separately: www.leedsstudentmedicalpractice.co.uk