What is Diabetes? Symptoms Where to get Treatment and What to Expect Eating Working Foot care
What is Diabetes?
Symptoms
Where to get Treatment and What to Expect
Eating
Working
Foot care
First things first, Diabetes Mellitus is not a disease that can be caught from others but is a condition that develops over time. It occurs when the pancreas fails to produce enough of the hormone Insulin to control the levels of glucose in the blood. Insulin is like a key, it unlocks the "doors" to cells and allows the sugars from the blood to enter and provided energy. Diabetes is not picky and can occur in anyone anytime regardless of race, sex or background and is said to affect about 2% of the British population.
Diabetes comes in two forms: Type I and Type II
∞ Type I or Insulin Dependent Diabetes Mellitus (IDDM) is where the pancreas produces none of the insulin required to control the glucose levels in the blood, allowing them to rise dangerously high. High glucose levels can lead to life threatening conditions if left untreated for long periods of time.
∞ Type II, Non-Insulin Dependent Diabetes Mellitus (NIDDM) or Maturity Onset Diabetes is where the pancreas fails to produce enough of the insulin required to control the glucose levels in the blood, allowing them to rise and fall in a dangerously uncontrolled way. Again like IDDM the high glucose levels can lead to life threatening conditions if left untreated for long periods of time.
IDDM affects about 25% of all people with diabetes and usually occurs in individuals under 30 years who tend to be underweight. NIDDM generally occurs in individuals over 30 years who tend to be overweight.
It is still not known exactly why the pancreas fails to produce insulin. There has been suggestion that the body makes antibodies that destroy insulin producing cells. (This appears to be supported by the high number of new diabetes sufferers in people with HIV/AIDS.) What is clear however, is that people with IDDM must take insulin injections for the rest of their lives.
The symptoms of diabetes are similar for both types. Type I can develop in a matter of weeks or months in a way that can't be overlooked, whereas Type II develops gradually and the symptoms are often put down to "getting older". When glucose levels rise beyond the normal (hyperglycaemia), excess sugar spills into the urine, giving rise to the first symptoms of diabetes:
∞ Excessive urination: As the body is taking water from other cells to dilute the glucose a sufferer will pass large amounts of urine.
∞ Thirst: Due to the loss of fluid from the urination and glucose dilution.
From my own experience, I found myself consuming over 4 litres of liquid every hour, a few days prior to diagnosis, in an attempt to satisfy my extreme thirst! Like most other sufferers, I hadn't realised I was drinking so much until someone pointed it out to me.
∞ Genital itchiness: Alas sugary urine creates a wonderful environment for fungal infections such as thrush. These infections irritate the skin and cause it to itch .
∞ Tiredness, hunger and weight loss: Because glucose is being lost before it can be converted to energy, the body has to find other sources of energy, so fat and protein stores start to be eaten into. The result is weight loss, despite having a larger than normal appetite.
∞ Visual problems: Unusual visual disturbances and rapid loss of distance sight. In a space of 3 days I was unable to see my computer monitor clearly or from one side of the room to the other when wearing my prescribed glasses. These symptoms tend to appear together or within a few days of each other, especially in IDDM cases. Just because you are a little thirsty of late or are feeling tired does not mean that you have diabetes. So don't panic. If you are unsure or think you may be a sufferer visit your GP and ask to be tested.
Where to get Treatment and What to Expect
Standard of care to expect Hospital or clinic?
In order to achieve the best possible care, the health professionals and the person with diabetes need to co-operate as equal members of a team. It is essential that the patient understands their diabetes well as possible so that they can be an effective member of this team. Below are the British Diabetic Association's (BDA) guidelines on the standard of diabetes care you should expect, which supports the idea of patient education and training alongside the medical treatment of the condition.
When you have just been diagnosed, you should have:
∞ A full medical examination.
∞ A talk with a registered nurse who has a special interest in diabetes. They should explain what diabetes is and be able to advise you on your individual treatment.
∞ A talk with a state registered dietician, who will want to know what you are used to eating and will provided basic advice on what to eat in the future. A follow-up meeting should be arranged for more detailed advice.
∞ A discussion on the implications of diabetes on your job, driving, insurance, prescription charges etc and whether you need to inform DVLA and your insurance company, if you are a driver.
∞ Information about the BDA's services and details of your local BDA group.
∞ Ongoing education about your diabetes and the beneficial effects of exercise, and assessments of your control. You should be able to take a close friend or relative with you to educational sessions if you wish.
If you are treated by insulin:
∞ Frequent sessions for basic instruction in injection technique, looking after insulin and syringes, blood glucose and ketone testing and what the results mean.
∞ Supplies of relevant equipment.
∞ Discussion about hypoglycaemia (hypos), when and why it may happen and how to deal with it.
If you are treated by tablets:
∞ A discussion about the possibility of hypoglycaemia (hypos), when and why it may happen and how to deal with it.
∞ Instruction on blood and urine testing and what the results mean and supplies of relevant equipment.
If you are treated by diet alone:
∞ Instruction on blood and urine testing and what the results mean and supplies of relevant equipment.
Once your diabetes is reasonably controlled you should:
∞ Have access to the diabetes team at regular intervals - annually if necessary. These meetings should give time for discussion as well as assessing diabetes control.
∞ Be able to contact any member of the health care team for specialist advice when you need it.
∞ Have more education sessions as you are ready for them.
∞ Have a formal medical review once a year by a doctor experienced in diabetes.
At this review:
∞ Your weight should be recorded.
∞ Your urine should be tested for the presence of proteins.
∞ Your blood should be tested to measure long term control - The HbA1C (Glycosylated Haemoglobin) Test.
∞ You should discuss control, including your home monitoring results.
∞ Your blood pressure should be checked.
∞ Your vision should be checked and the back of the eyes examined. A photo may be taken of the back of your eyes. If necessary you should be referred to an ophthalmologist.
∞ Your legs and feet should be examined to check your circulation and nerve supply. If necessary you should be referred to a state registered chiropodist.
∞ If you are on insulin, your injection sites should be examined.
∞ You should have the opportunity to discuss how you are coping at home and at work.
Your role:
∞ You are an important member of the care team so it is essential that you understand your own diabetes to enable you to be in control of your condition.
∞ You should ensure you receive the described care from your local diabetes clinic, practice or hospital. If these services are not available to you, you should: contact your GP to discuss the diabetes care available in your area, contact your local Community Health Council, contact the British Diabetic Association or your local DBA branch.
The pro and cons...
Good medical supervision is vital for someone with diabetes if they want to stay fit and healthy. However finding the best care is not always as easy as it sounds. There is probably little to choose between a well organised hospital based clinic and a well organised GP clinic, assuming that the medical and nursing staff at a GP clinic are committed to the care of people with diabetes.
Naturally, not every GP will have a special interest in diabetes and a GP clinic that was set up because it "seems like a good idea", may not offer the best standard of care. On the other hand, a hospital clinic that operates a conveyor belt system with scant regard for individual needs is not to be recommended either.
When making your choice, remember it is very important that the clinic you attend is one which suits you as far as location and appointment times are concerned. You should also feel comfortable with your clinic. One potential advantage of a GP clinic is that you will almost certainly see the same doctor every time you attend.
This is not necessarily true in the hospital clinic, where the Diabetes Specialist may be working with Associate Specialists and Clinical Specialists (GPs with a working interest in and experience of diabetes) as well as their own junior medical staff. However if there is one particular regular doctor whom you'd like to see, it can usually be arranged. The sister in charge or the clinic is probably the best person to ask about this.
Faced with a choice of where to go for your diabetic care you will find that your choice of doctor will play a vital role:
∞ It is very important to see a doctor whom you both like and trust, since good diabetic care is dependent upon co-operation between patient and doctor. Friendly co-operation is much more effective than a relationship which is merely tolerated. ∞ Remember that the partnership between you and your doctor is an equal one the requires input from you as well.
∞ You will get much more out of your doctor if you know something on the subject under discussion. Obtain information on diabetes from reputable sources, such as your diabetic clinic or The British Diabetic Association. Knowing and understanding the issues involved really is half the battle.
∞ To complete the picture look for a doctor who can answer your questions and discuss his advice with you.
Medical Staff - Who will treat you
The hospital based clinic will almost certainly be larger than the GP clinic both in terms of staff and patient number. Members of staff you can expect to meet at a hospital clinic include:
∞ A Laboratory Technician who will take a blood sample.
∞ A Nurse who will weigh you and test your urine sample.
∞ A Doctor who will discuss these results with you to see whether any change in treatment is required. They will also discuss any problems or worries arising from your diabetes treatment and may carry out relevant examinations at this time, on your feet or eyes for instance.
Depending on the individual clinic, you may also meet:
∞ A Diabetes Nurse Specialist. It is their job to help people with diabetes look after themselves by providing information about the condition and by offering practical support. They are able to pay home visits to people with diabetes which, since diabetes is a condition that is mostly managed at home, is a very valuable part of their job. Such a service also helps the elderly and the sick who are unable to get out to the clinic easily.
∞ A Dietician. When you are first diagnosed it is essential to see a dietician, who can explain the sort of food you should eat. You will probably need several sessions with them, and ideally afterwards occasional appointments to review your eating habits.
∞ A Chiropodist. Soon after diagnosis you should see a chiropodist to advise you on good foot care. This is extremely important to prevent problems later on. See my section on foot care.
In most GP clinics you will probably only see:
∞ A Nurse who will check your blood sugar, urine and weight.
∞ A Doctor who will review the results of this previous examination with you. They will suggest a change of treatment if necessary.
Both these members of staff will be available to discuss any worries or problems you have with your diabetes. The nurse will often have particular experience in helping with and non medical problems. Like the Diabetes Nurse Specialist at hte hospital, the Practice Nurse may also be able to visit a patient at home. Obviously your GP will also pay home visits. This is something which a hospital doctor will rarely do. This means the continuity of care may be easier in general practice.
Also worth taking into consideration is that unless the staff at your hospital clinic are a particularly lively and outgoing crew, you will probably find a visit there rather more impersonal than a trip to you local surgery - at least for the first few visits! As times goes by, most people will chalk up enough trips to the clinic (probably two or three a year, depending on the type of treatment you receive) to build up a friendly relationship with the staff. You might feel that in the early days of your diabetes you need familiar surroundings. If you do, seeing your GP, whom you probably know well, is likely to be a good option.
Some people consider that hospital clinics have a great advantage because other services which may be useful to someone with diabetes are available at the same site. Hence instant referral is possible for any problems that occur. On the other hand, GPs who run diabetic clinics should have built up close links with these services and have ready access to specialist advice. So geographical distance from a specialist centre in unlikely to pose any practical problems.
Shared Care
In many areas, GPs may operate a system of "shared care". If your GP operates such a system it means that you will go to the hospital once a year to see a specialist but the rest of the time you will visit your GP clinic. The more experienced GP is less likely to participate in a shared care system, but they will maintain strong links with the hospital specialist for the purpose of discussing difficult problems and keeping themselves up to date.
Making Your Choice
The problem with having a choice is that you have to make a choice. This is much more difficult than just being told to attend a specific clinic. If different services offer individuals specific advantages, but are overall very close, just how do you make your choice of what is best for you?
You could try experiencing the different types of care which are on offer before you make a choice. In order to do this, you firstly need to find out exactly what is on offer in your area.
Every Health Authority will have a diabetic clinic but you may want to know what is on offer from GPs. Start by asking your own GP whether they run a clinic. If the answer is "no", perhaps they know of another local practice that does.
If you draw a blank with this line of enquiry, your Diabetes Specialist will certainly know. All you need do is ring the hospital where they are based and ask for their secretary. Pose your question and arrange a time to ring back the secretary for the answer. Do make sure that your question is clear and unambiguous so that no misunderstandings can occur.
Another way of gaining information is to contact other BDA members. Start with the local branch chairman and secretary - the hospital diabetic clinic will have their names and telephone numbers.
Once you have finished your detective work you may have discovered that your GP does not run a diabetes clinic, but someone esle local does. Under these circumstances you may be asking youself whether it is reasonable to change your doctor. It is not generally advised to change from a GP whom you have known and liked for some time solely because they did not run their own diabetic clinic. But if you wish to change then the choice is entirely yours.
Before you do change it is courteous to let your old GP know why you want to leave thier list. A simple letter is a satisfactory way of doing this. You are then free to take your medical card to your chosen GP's surgery and register there - again you should explain your reasons for changing. Be warned that the new GP does not have to take you own. It is worth checking with them in advance for acceptance. Bear in mind that the relationship between you and your doctor is a very personal one and a doctor whom someone else thinks is wonderful may not turn out to be your cup of tea at all.
If you have diffuclty finding a GP, your local Family Health Service Authority (FHSA) can advise you.
The Deciding Factors
If you decide that you want your treatment to come from a GP clinic but need to change your doctor, it helps to have a clear idea of exactly what you want from your GP and what information you will need to help you decide.
∞ Talk to other people with diabetes.
∞ Visit possible practices to see for yourself what is on offer.
∞ Ask for the practice leaflet which will give details of the doctors, other staff and ther services provided by the practice.
∞ Talk to the diabetic clinic staff and find out how it is run, what liaison there is with the hosptial and other services and how long it has been running.
A long standing clinic will have great experience behind it. A new clinic may have greath enthusiasm and openmindedness. Both have their advantages and may be equally good. Finally, only you can decide which practice you feel most comfortable with.
If you have diabetes, you are prone to foot problems for two reasons.
∞ Diabetes can cause Ischaemia or poor blood circulation. Our bodies need a good supply of blood in order to heal injuries, but if circulation is poor in feet and legs, injuries can take much longer to heal.
∞ Diabetes can cause Neuropathy or nerve damage, to feet and legs leaving numbness and tingling. If you have neuropathy you may not feel pain when you hurt yourself, and will probably continue walking on the injured part. This can result in infections spreading quickly without being noticed.
Usually neuropathy and ischaemia affect people in later life, but everyone must take some precautions. Prevention, in this case, is much better than cure.
Neuropathy and ischaemia are made worse by high blood glucose levels and smoking. So, as always, the low fat, low sugar, high fibre diet, combined with regular exercise is still your best "insurance" policy against future complications.
It is a good idea to have you feet examined regularly by the doctor, diabetes clinic or state registered chiropodist. You, however can play a vital role by checking your feet daily. It is advised to establish a daily foot care routine.
Washing
∞ Wash you feet once a day with soap and warm water. Mild soap is best.
∞ Don't soak your feet for long periods.
∞ Take care to rinse all soap off your feet after washing.
∞ Dry carefully between your toes; aviod rubbing them roughly.
∞ Moisturise dry feet with cream, but not between the toes.
∞ If the skin is too moist, wipe your feet with surgical spirit, especially between toes. Only do this after bathing your feet.
∞ When dry, dust feet with talcum powder.
∞ Change your socks every day.
Look after your nails
∞ Cut your toenails after washing, as they will be softer then. Ask your chiropodist to cut them for you if they are too sore, too tough or you are unable to cut them yourself.
∞ Follow the natural line of your toe when cutting - don't cut them too short.
Things to look out for
∞ A change of colour on any part of your feet.
∞ Any new pain or throbbing either in your feet or toes.
∞ Swelling of your feet or legs.
∞ Any sore places, cracks, corns, blisters or calluses. Moisture weeping from under a toenail may be a sign of a sore under the nail. Using a mirror will help to see your soles more easily.
∞ Your feet need attention if they smell strange, even if they don't hurt.
∞ If you have had a hypo, check your feet carefully, as you may have injured them without noticing.
If you find any of these changes, go to your doctor, diabetes clinic or chiropodist. If they are not available, go directly to the casualty department of your hospital. Even delays of a few hours or days can turn minor problems into serious matters which may be difficult to heal easily.
Be choosy with your shoes
Alongside the care, what you put your feet into is equally as important. Poorly fitting shoes are responsible for the majority of diabetic foot problems. Shoes that do not fit properly can put unwanted pressure on your feet - sometimes even alter their shape.
Flat or low heeled shoes are best for everyday wear. Slippers shouldn't be worn day in, day out, and open toed sandals are best avioded as they leave the toes open to injuries. Adults shouldn't go barefoot. Choose thicker, shock absorbing shoes for long walks, and plastic sandals for the beach. If you want to wear slip-ons or high-heeled fashion styles on special occasions it should not be a problem if you follow these guidelines.
∞ It's very important that you buy a shoe that fits you correctly. Your chiropodist can tell you about shoe shops in your area that will measure and fit your shoes properly. People with neuropathy sometimes find the shape of their foot has altered. Hospitals can provide special insoles and shoes when necessary.
∞ Ask the shop assistant to fit your feet individuallyif you have an odd sized foot.
∞ The shoes should be slightly longer than your longest toe when you are standing, so that toes will be able to move freely when walking - Your foot lengthens when you walk.
∞ Watch out for creases across the shoe when you walk - this could mean the shoes are too tight.
∞ Make sure shoes are not too big or your feet will slide and rub. Lace ups or T bars will support feet and stop them slipping around.
∞ Run your hand inside the shoe to check for ridges or nails that might be uncomfortable. If you have neuropathy you won't feel pain when wearing the shoe.
∞ Get into the habit of shaking out your shoes each day to get rid of stones or grit. Also make sure you check the soles for drawing pins or nails you may have stepped on.
The proper socks are just as important as good shoes
∞ Your socks should be loose fitting - avoid the elasticised kind and garters as they restrict circulation.
∞ 100% cotton or wool socks are the most healthy and comfortable.
∞ Avoid socks with heavy ridsges or darning, which can rub. Turning socks inside out can help.
First Aid
Everyone at some point will either stub a toe, suffer blisters or cut/graze their feet as a part of everyday life. You can treat minor scratches or grazes yourself by cleaning the area with diluted antiseptic and covering with a sterile dressing. Blisters if small should be protected with a dressing, larger ones should be seen by a doctor etc. On no account should you prick/burst a blister. If it should break open, ensure it is clean and cover with a dry sterile dressing. Stubbed toes will usually just swell a little and be bruised for a few days.
Any sore place that hasn't healed within two or three days, which starts to get bigger, oozes or reddens needs a doctor's attention.
You must let the experts treat more serious injuries such as athletes foot, calluses and nail problems. Never treat corns or cut hard skin yourself, even with products from the chemist. These can contain acids which are very harmful to diabetic feet.
The information provided in these pages is purely a guide and is by no means an authority on Diabetes or its treatment. It is primarily based on my personal experiences of the condition and information I have obtained from reputable sources such as The British Diabetic Association. If you would like me to put in a link to your pages, would like to suggest/post additions to any of these pages or just want to drop me a line, E-Mail me.
These pages were conceived, designed & written in raw HTML by Mark Bryant
Copyright © 1998 Mark Bryant
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