Type 1 diabetes in children, adolescents and young adults: how to become an expert on your own diabetes

409 Pages·2004·6.5 MB·English

by  Ragnar Hanas

Type 1
How to
become
an
expert Diabetes
on your
own
diabetes
in children, adolescents and young adults
OCIET YWOIFNANUETHRORS
•ROYSNtehwe GMeendeorifca atlh lR eBe oaodke rforAND•E
AL Award CIN
SOCIETY OF M E DI
Dr Ragnar Hanas
SECOND EDITION
TYPE 1 DIABETES
in Children, Adolescents and Young Adults
How to become an
expert on your own
diabetes
Dr Ragnar Hanas, MD, PhD
Consultant Paediatrician
Second edition
fully revised and updated
CLASS PUBLISHING•LONDON
© Copyright 2004 by Ragnar Hanas, MD, PhD, Uddevalla, Sweden.
All rights reserved.
Ragnar Hanas asserts his rights as set out in sections 77 and 78 of the Copy-
right, Designs and Patents Act 1988 to be identified as the author of this
work wherever it is published commercially and whenever any adaptation of
this work is published or produced including any sound recordings or films
based upon this work.
Illustrations and figures are reproduced with the permission of respective
copyright owner (see page 354).
NOTICE
For dosages and applications mentioned in this book, the reader can be
assured that the author has taken great lengths to ensure that the indica-
tions reflect the standard of knowledge at the time this work was completed.
However, insulin needs and diabetes treatment must be individually tailored
for each and every person with diabetes. Treatment methods and dosages
may change. Advice and recommendations in this book cannot be expected
to be generally applicable in all situations and always need to be supple-
mented with individual assessment by a diabetes team. The author and the
publishers do not accept any legal responsibility or liability for any errors or
omissions, or the use of the material contained herein and the decisions
based on such use. Neither the author nor the publishers will be liable for
direct, indirect, special, incidental or consequential damages arising out of
the use, or inability to use, the contents of this book.
Printing history:
First published by the author, 1998
Second edition 2004, reprinted 2005
The author and publishers welcome feedback from users of this book.
Please contact the publishers:
Class Publishing, Barb House, Barb Mews, London W6 7PA, UK
Telephone: [phone] [International +4420]
Fax: [phone]
E-mail: [email protected]
Visit our website at http://www.class.co.uk
A CIP catalogue record for this book is available from the British Library
ISBN 1 85959 078 0
Designed by David Penfold and Ragnar Hanas
Edited by Richenda Milton-Thompson
Printed and bound in Finland by WS Bookwell, Juva
Contents
Acknowledgements................................................ x 6. High blood glucose levels...................... 26
Preface................................................................... xi Not enough insulin?............................................ 27
How to treat a high blood glucose level............. 27
Foreword by Dr Peter Swift................................... xii Ketoacidosis (diabetic coma)............................. 29
Blurred eyesight and diabetes............................ 30
Foreword by Dr Stuart Brink................................ xiii
7. Regulation of blood glucose ................. 31
1. Introduction.............................................. 1
The liver................................................................ 32
Glucagon.............................................................. 33
2. Getting to grips with diabetes................. 4 Adrenaline............................................................ 37
When you first find out you have diabetes........... 4 Cortisone.............................................................. 37
Very young children................................................ 6 Growth hormone.................................................. 38
Routine check-ups.................................................. 6
Living the life you choose....................................... 7
8. Hypoglycaemia ...................................... 39
Blood glucose levels and symptoms
3. Caring for your own diabetes.................. 8
of hypoglycaemia................................................. 43
Goals for managing diabetes................................ 8 Symptoms of hypoglycaemia when
How can you achieve these goals?....................... 8 the blood glucose level is high........................... 45
Becoming your own expert.................................... 9 Severe hypoglycaemia........................................ 45
Can you take “time off” from diabetes?............ 10 Convulsions.......................................................... 46
Alternative and complementary therapies........ 11 Does severe hypoglycaemia damage the brain? 47
Hypoglycaemia unawareness............................. 48
Rebound phenomenon ...................................... 49
4. Diabetes: some background................. 12
Too little food or too much insulin?.................... 51
Type 1 diabetes................................................... 12 Night time hypoglycaemia................................... 51
Type 2 diabetes................................................... 13 Dawn phenomenon............................................. 54
Other types of diabetes....................................... 14 Somogyi phenomenon........................................ 55
How common is diabetes?................................. 14 Will low blood glucose levels return to normal if the
Can you catch diabetes?..................................... 15 child doesn’t wake up?....................................... 56
Does eating too many sweets cause diabetes? 16 Can you die from hypoglycaemia?...................... 56
Why does the blood glucose level vary, at which
hypoglycaemia is noticed?................................. 57
5. How your body works............................. 17
Insulin................................................................... 18
9. Treating hypoglycaemia......................... 60
Your body doesn’t realize it has diabetes.......... 20
The anatomy of your body.................................. 21 Practical instructions:.......................................... 60
Pancreas.............................................................. 22 Timing and hypoglycaemia.................................. 63
Islets of Langerhans............................................ 23 Helping someone with diabetes who
Cellular metabolism........................................... 24 is not feeling well................................................. 63
A healthy cell........................................................ 24 Glucose................................................................ 64
Starvation............................................................. 24 Fructose............................................................... 65
Diabetes and insulin deficiency......................... 25 Sweets and hypoglycaemia................................ 65
After hypoglycaemia............................................ 66
iii
iv Type 1 Diabetes in Children, Adolescents and Young Adults
Learning to recognize the symptoms Does the meter show the correct value?........... 96
of hypoglycaemia................................................. 67 Continuous glucose monitoring.......................... 97
Children and blood glucose tests........................ 97
Does a high blood glucose level make
10. Insulin treatment................................. 68
you feel ill?............................................................ 98
Regular short-acting insulin................................ 69 Does continuous finger pricking
Intermediate-acting insulin................................. 69 cause loss of feeling?.......................................... 99
Long-acting insulin .............................................. 69 Ketones .............................................................. 99
Intravenous insulin.............................................. 69 Vomiting and ketones....................................... 101
Rapid-acting insulin............................................. 70 Blood ketones................................................... 102
Basal insulin......................................................... 71
New basal insulins............................................... 71
12. The HbA test................................... 104
1c
Pre-mixed insulin ................................................. 72
A larger dose lasts longer.................................... 72 What level should HbA be?........................... 104
1c
Units and insulin concentrations........................ 72 How often should you check your HbA ?....... 107
1c
Twice-daily treatment.......................................... 73 Can my HbA be “too good”?.......................... 108
1c
Three-dose treatment.......................................... 73 HbA when travelling....................................... 108
1c
Multiple injection treatment................................ 73 Is it worth taking tests?.................................... 108
Injections before meals (bolus insulin).............. 73 Fructosamine.................................................... 109
When should you take your premeal dose?....... 75
Insulin pump......................................................... 77
13. Injection technique........................... 110
Can I skip a meal?............................................... 77
Bedtime insulin.................................................... 78 Getting used to injections................................. 110
When should bedtime insulin of NPH Injections for parents........................................ 110
type be taken?..................................................... 78 Taking the pain out of injections ..................... 111
When should the long-acting Where do I inject the insulin?........................... 111
injection be taken?.............................................. 78 Is it necessary to disinfect the skin?............... 116
Mixing insulins ..................................................... 79 Storage of insulin.............................................. 116
Depot effect ......................................................... 79 Syringes............................................................. 117
How accurate is your insulin dose?.................... 80 Injections with syringes..................................... 118
Insulin absorption................................................ 80 Pen injectors...................................................... 118
What happens if a child won’t finish a meal?.... 81 Why aren’t all insulins available for pens?...... 119
What if you forget to take your insulin?.............. 82 Replacing pen needles .................................... 119
What if you take the wrong type of insulin?....... 84 Different pens for day and night time insulin.. 119
Having a lie in at weekends................................ 85 Air in the cartridge or syringe........................... 120
Staying awake all night........................................ 85 Insulin on the pen needle................................. 121
Shift work.............................................................. 86 Used needles and syringes.............................. 121
Birthday parties.................................................... 86
Insulin at school and day nurseries ................... 87
14. Injection equipment.......................... 122
Sleeping away from home................................... 87
Automatic injectors........................................... 122
Jet injectors....................................................... 122
11. Monitoring............................................ 88
Insuflon.............................................................. 122
How many tests should I take?........................... 88
“Good” or “bad” tests?........................................ 91
15. Adjusting insulin doses..................... 127
Diabetes or not?................................................... 91
Are some things forbidden?................................ 91 Starting insulin treatment................................. 127
Urine glucose....................................................... 92 How much does insulin lower the
Renal threshold ................................................... 92 blood glucose level?......................................... 129
Blood glucose...................................................... 94 Temporary changes of insulin dose................. 130
How do I take blood tests?.................................. 94 What about the food you eat?.......................... 131
Borrowing someone else’s Changing the content of the meal to
finger-pricking device........................................... 95 affect blood glucose.......................................... 131
v
Physical exercise or relaxation?....................... 133 Physical exercise............................................... 182
What to do if your blood glucose level is high 133 Using the pump at night only............................ 183
Permanent changes of insulin dose................ 135 Is the pump a nuisance?................................... 183
Keeping good records....................................... 137 Does using a pump cause weight gain?.......... 184
What is the best order for changing the doses? Having a lie in.................................................... 184
(multiple injection treatment)........................... 137 Travel tips........................................................... 184
Low blood glucose levels.................................. 137 Toddlers using pumps....................................... 185
Insulin for evening snack.................................. 137 Pregnancy.......................................................... 185
Bedtime insulin.................................................. 138 Rapid-acting insulin in the pump...................... 185
What should you do next?................................ 141
Blood glucose levels at night............................ 143
17. Side effects of insulin treatment..... 188
Night time hypoglycaemia................................. 145
Insulin for breakfast.......................................... 145 Pain..................................................................... 188
Insulin for lunch and dinner/tea...................... 145 Insulin leakage................................................... 188
Holiday or weekday?......................................... 145 Blocked needles................................................ 188
Exercising or relaxing?...................................... 145 Bruises after injections..................................... 188
Puberty............................................................... 146 Fatty lumps........................................................ 189
Using rapid-acting insulin Redness after injections................................... 189
analogues.......................................................... 148 Insulin antibodies.............................................. 190
Adjusting the dose............................................. 150 Lipoatrophy........................................................ 191
High blood glucose levels................................. 150 Insulin oedema.................................................. 191
Hypoglycaemia................................................... 151
Can you eat the same things as before?......... 153
18. Insulin requirements........................ 192
Exercise.............................................................. 153
Pre-mixed insulin............................................... 154 How much insulin does your body need?........ 192
Switching to rapid-acting analogues................ 154 Puberty and growth........................................... 192
Using long-acting Lantus.................................. 156 Remission (“honeymoon”) phase..................... 193
Insulin adjustments during the Insulin sensitivity and resistance..................... 195
remission phase............................................... 157 Ideal insulin doses?........................................... 198
Hypoglycaemia................................................... 158
Low blood glucose readings............................. 159
19. Nutrition............................................. 200
Hypoglycaemia before a meal.......................... 159
Experiment!........................................................ 159 Absorption of carbohydrates............................. 201
Emptying the stomach...................................... 203
Sugar content in our food................................. 205
16. Insulin pumps................................... 160
Taking fluids with food...................................... 206
Starting the pump............................................. 162 Dietary fats......................................................... 206
The basal rate.................................................... 163 Dietary fibre....................................................... 208
Temporary change of the basal rate................ 165 Glycaemic index................................................. 209
Premeal bolus doses......................................... 166 Milk..................................................................... 210
Change of insertion site.................................... 169 Vegetables......................................................... 210
More frequent home monitoring...................... 171 Potatoes............................................................. 211
Insulin depot with a pump................................ 172 Bread.................................................................. 211
Ketoacidosis (diabetic coma) .......................... 173 Pasta.................................................................. 212
Disconnecting the pump................................... 175 Meat and fish..................................................... 212
Taking a bath or shower................................... 175 Pizza .................................................................. 213
Pump alarm....................................................... 175 Salt..................................................................... 213
“No delivery alarm”........................................... 177 Herbs and spices............................................... 213
Leakage of insulin............................................. 178 Fruit and berries................................................ 213
Air in the tubing................................................. 178 Meal times......................................................... 213
Sick days and fever........................................... 179 Snacks................................................................ 214
Pump removal doses........................................ 179 Can mealtimes be changed?............................ 215
Admission to hospital........................................ 181 Hungry or full?.................................................... 215
vi Type 1 Diabetes in Children, Adolescents and Young Adults
Infant feeding.................................................... 215 Nausea and vomiting........................................ 259
Carbohydrate counting..................................... 216 Gastroenteritis................................................... 261
School................................................................ 219 Wound healing.................................................. 263
Party-time.......................................................... 220 Surgery............................................................... 263
Special “diabetic” food?................................... 220 Drugs that affect blood glucose....................... 264
“Fast food”........................................................ 221 Teeth.................................................................. 264
Food at educational camps.............................. 221 Vaccinations...................................................... 265
Vegetarian and vegan diets............................. 221
Different cultures.............................................. 222
27. Smoking............................................. 266
Passive smoking................................................ 267
20. Sweeteners....................................... 223
Giving up smoking............................................. 267
Sugar free?........................................................ 223 Snuff................................................................... 268
Diet drinks and “light” foods............................ 226
28. Alcohol............................................... 269
21. Sweets, treats and ice cream.......... 227
Alcohol and the liver......................................... 269
How much extra insulin should you take?...... 228 Why is it dangerous to be drunk with
Ice cream........................................................... 229 diabetes?........................................................... 269
Chocolate........................................................... 231 Basic rules......................................................... 270
Weekend sweets............................................... 232 What if you’ve had too much to drink?............ 271
Taking a break from eating sweets................. 233 Can you drink at home?.................................... 271
Potato crisps...................................................... 234
Chewing gum..................................................... 235
29. Illegal drugs....................................... 272
22. Weight control................................... 236
30. Pregnancy and related issues.......... 273
Satisfied or “feeling full”?................................. 236 Pre-pregnancy care........................................... 275
Reducing weight................................................ 237 Caring for the mother........................................ 275
The little extras.................................................. 238 How will the child develop?.............................. 276
High HbA and weight loss............................. 238 Will the child have diabetes?........................... 276
1c
Infertility............................................................. 277
Does the need for insulin change
23. Eating disorders................................ 240
during menstrual periods?............................... 277
Sexuality............................................................. 277
24. Physical exercise............................... 242 Contraceptives.................................................. 278
How do insulin and exercise work together?.. 243 Forgotten to take a pill?.................................... 280
Can the blood glucose level increase Emergency contraception................................. 280
through exercise?............................................. 244
Hypoglycaemia after exercise.......................... 245
31. Social issues...................................... 281
Physical education............................................ 247
Top level competitive sports............................ 248 School................................................................ 281
Keeping fit with diabetes.................................. 251 Day nurseries and child care............................ 283
Camps and skiing trips..................................... 251 Child care allowance......................................... 284
Marathon efforts!.............................................. 251 Adoption............................................................. 284
Anabolic steroids............................................... 252 Choice of job or employment........................... 284
Diving................................................................. 252 Military service.................................................. 285
Licence to drive................................................. 285
Driving and diabetes......................................... 286
25. Stress................................................. 255
Insurance policies............................................. 287
Stress in daily life.............................................. 256 Diabetes ID....................................................... 288
Juvenile Diabetes Research
Foundation International ................................. 289
26. Fever and sick days.......................... 258
vii
Diabetes Associations....................................... 289 35. Lowering the risk of complications.. 314
Diabetes UK....................................................... 289
Diabetes Federation Ireland............................. 290 The Oslo study................................................... 315
The International Diabetes Federation (IDF)... 290 The Stockholm study......................................... 315
International Society for Pediatric and Adolescent The DCCT study.................................................. 315
Diabetes (ISPAD)............................................... 290 The Berlin eye study.......................................... 317
Sponsor families................................................ 290 The Linköping studies....................................... 317
The St. Vincent Declaration.............................. 291 What HbA is it possible to achieve
1c
Diabetes camps and educational holidays..... 291 in a diabetes clinic?........................................... 318
Diabetes and the Internet................................. 293
When does a young person become
36. Research and new developments... 319
an adult?............................................................ 293
New treatments for diabetes.......................... 319
Reimbursed accessories................................... 293
Implantable insulin pumps............................... 319
Blood glucose meters........................................ 320
32. Travel tips.......................................... 294
Glucose sensor.................................................. 320
Vaccinations...................................................... 295 C-peptide ........................................................... 320
Ill while abroad?................................................ 295 Vaccinations....................................................... 320
Diarrhoea problems.......................................... 296 Salicylic acid....................................................... 321
Passing through time zones............................. 297 What causes diabetes?................................... 321
An autoimmune disease................................... 322
Heredity.............................................................. 323
33. Associated diseases......................... 300
Environmental factors....................................... 323
Coeliac disease.................................................. 300 Cows’ milk.......................................................... 324
Thyroid diseases................................................ 300 Climate............................................................... 325
Skin diseases..................................................... 301 AGE.................................................................... 325
Infections........................................................... 301 Blocking the immune process......................... 326
Fungal infections............................................... 302 Immune treatment............................................ 326
Light treatment.................................................. 327
Diazoxide............................................................ 327
34. Complications in blood vessels....... 303
Nicotinamide...................................................... 327
What causes complications?............................ 303 Transplantation................................................ 328
Large blood vessels........................................... 305 Pancreas............................................................ 328
Why are only certain cells damaged by a high blood Islet transplantation.......................................... 329
glucose?............................................................. 305 Engineered cells................................................ 329
Small blood vessels........................................... 306 Other ways of administering insulin................ 329
Complications affecting Nasal spray........................................................ 329
the eyes (retinopathy)...................................... 306 Tablets................................................................ 329
Risks................................................................... 306 Insulin as suppositories.................................... 330
Treatment.......................................................... 307 Inhalation of insulin........................................... 330
Disturbed vision at unstable blood Chemical alteration of the insulin molecule.... 330
glucose levels.................................................... 308
Glasses............................................................... 309
37. Psychology......................................... 331
Contact lenses................................................... 309
Complications affecting The onset of diabetes........................................ 331
the kidneys (nephropathy)............................... 309 Diabetes rules or family rules?......................... 332
Risks................................................................... 309 Making friends with your diabetes................... 334
Treatment.......................................................... 310 Diabetes affects the whole family.................... 335
Complications affecting Being a relative or friend of someone
the nerves (neuropathy)................................... 311 with diabetes..................................................... 336
Risks................................................................... 311 Telling your friends............................................ 337
Treatment.......................................................... 313 How do you change your life style?.................. 337
viii Type 1 Diabetes in Children, Adolescents and Young Adults
Diabetes at different 39. Well-known people with diabetes.... 351
developmental stages..................................... 338
Infants (0-1½years)......................................... 338 Gary Mabbut...................................................... 351
Toddlers (1½-3 years)...................................... 339 Tara Moran........................................................ 351
Pre-school children (3-6 years)....................... 340 Steve Redgrave................................................. 352
Primary school children.................................... 341 Nicole Johnson.................................................. 352
Intermediate level children.............................. 342
Puberty............................................................... 343 Epilogue............................................................. 354
Healthy siblings................................................. 345 Artwork and other credits................................. 354
Divorced families.............................................. 346
Fathers’ involvement........................................ 347 Glossary............................................................. 357
Brittle diabetes.................................................. 347 Units................................................................... 357
Quality of life...................................................... 348 Terms................................................................. 357
References........................................................ 366
38. Needle-phobia................................... 349
Index................................................................... 380
To my children
Mikael, Malin and Marie
You may well feel that there is an overwhelming amount of knowledge
you must take in, but nobody expects you to memorize the entire con-
tents of this book. If you use it as a reference, and read a little at a
time, you will gradually get to grips with the information it contains.