TREATMENT WHAT YOU NEED TO KNOW. Working in partnership with

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1 Type 2 DIABETES TREATMENT food Lifestyle WHAT YOU NEED TO KNOW Working in partnership with

2 PACK SOME PEACE OF MIND... Diabetes UK Insurance Services provides comprehensive travel insurance, covering pre-existing medical conditions, with no upper age limit on single trip policies. What s more, Diabetes UK receives a donation for every policy sold, at no extra cost to you. So what are you waiting for? Choose to protect yourself and your loved ones with the help of Diabetes UK Insurance Services. TRAVEL INSURANCE LIFE ASSURANCE HOME INSURANCE MOTOR INSURANCE RETIREMENT ESTATE PLANNING FUNERAL PLANNING HEALTH CASH PLAN Call for a quote or more information. Quoting: TT2. Alternatively, visit now for more information and a 10% discount off your travel insurance policy. Diabetes UK Insurance Services is a trading name of Heath Lambert Limited which is authorised and regulated by the Financial Services Authority. Registered Office: 9 Alie Street, London E1 8DE. Registered No.: England & Wales. Gallagher Risk & Reward Limited is authorised and regulated by the Financial Services Authority. Registered Office: 9 Alie Street, London, E1 8DE. Registered No England & Wales. Funeral plan is provided by Dignity Pre Arrangement Limited. A company registered in England No.: VAT registered No.: King Edwards Court, King Edwards Square, Sutton Coldfield, West Midlands B73 6AP Telephone No.: Fax No.: Part of Dignity plc. A British company. Registered with the Funeral Planning Authority. Key Retirement Solutions Limited. Registered in England No Registered Office: Harbour House, Portway, Preston, Lancashire, PR2 2PR. Telephone Facsimile Key Retirement Solutions is authorised and regulated by the Financial Services Authority. All benefits payable are subject to BHSF Limited policy terms: Copies available on request. BHSF Limited is authorised and regulated by the Financial Services Authority. SD3890_A/

3 Testing Hypos & hypers Education Eating in Eating out Welcome Welcome to What You Need to Know Type 2 Diabetes. This is an introductory guide for adults who ve recently been diagnosed with Type 2 diabetes. It also serves as a handy refresher for those who have had the condition for some time. Following diagnosis, it s perfectly understandable that you may be experiencing a wide range of emotions. You may feel upset, angry, confused and even guilty. You may be asking yourself the question, Why me? and wondering how you will cope. This guide will answer a lot of your questions and address your doubts and concerns by giving you the facts. It takes you through diabetes care and living your day-to-day life from work and illness, to socialising and travel. It also sheds light on some complications that you need to be aware of and the steps you can take to prevent them. It will also tell you where you need to go for more information. Plus, there s lots of information about how Diabetes UK can support you as you continue to live your life to the full. what s inside... INTRODUCTION 5 Debunking the myths 6 What is diabetes? DIABETES CARE 8 Medications 12 Moving to insulin 14 Testing 18 Hypos & hypers 22 Long-term testing 24 The care to expect 30 Education 31 Health information online FOOD 32 A healthy balance 34 Top tips for eating well 36 Carbohydrates 40 Food labelling 44 Eating in 46 Eating out 50 Alcohol 52 Religious fasting 53 Questions & answers Type 2 diabetes 3

4 Physical activity Pregnancy Work Travel Driving LIVING WITH DIABETES 55 Weight management 60 Calorie swaps 62 Physical activity 66 Accepting diagnosis 68 Telling people 70 Love life 72 Contraception 74 Pregnancy & labour 78 Illness & infections 80 Work & discrimination 82 Travel 84 Festivals 86 Driving 88 Smoking & drugs complications 90 Cardiovascular disease (CVD) 92 Retinopathy 94 Neuropathy 96 Nephropathy FURTHER INFORMATION 98 About Diabetes UK ARTICLES & ADVERTISEMENTS Products and services advertised in this guide are not necessarily recommended by Diabetes UK. Although the utmost care is taken to ensure products and services advertised are accurately represented, it is only possible to thoroughly check specialist diabetes equipment. Please exercise your own discretion about whether or not an item or service advertised is likely to help you personally and, where appropriate, take professional advice from your medical advisor. Please note also that prices are applicable only to British buyers and may vary for overseas purchases. Diabetes UK policy statements are always clearly identified as such. Diabetes UK 2013 A charity registered in England and Wales (no ) and in Scotland (no. SC039136). With thanks to all the contributors and advisors, and the volunteers who participated in photoshoots. 4 Type 2 diabetes 2013

5 debunking the myths INTRODUCTION diabetes my ths Myth: Eating lots of sugar causes diabetes Myth: People with diabetes can t play sport Myth: People with diabetes cannot have sugar Myth: It s not safe to drive if you have diabetes Having diabetes doesn t mean having to have a sugar-free diet. People with diabetes should follow a healthy, balanced diet low in fat, salt and sugar, but they should still be able to enjoy a wide variety of foods, including some with sugar. If people with diabetes are responsible and have good control of their blood glucose levels they are just as safe on the roads as everyone else. Nevertheless, the myth persists that people with diabetes are unsafe to drive. i For more on driving, see p86. Having lots of sugar has no direct effect on your risk of diabetes. Sugary foods are high in calories which can mean taking in more calories (energy) than your body needs, leading to weight gain. This increases the risk of Type 2 diabetes. Myth: People with diabetes should eat diabetic foods People with diabetes are encouraged to exercise as part of a healthy lifestyle. Keeping active can help reduce the risk of complications such as heart disease. Sir Steve Redgrave, Olympic gold medal-winning rower, is an example of someone who has achieved great sporting achievements while living with diabetes. i For more on exercise, see p62. Diabetic labelling tends to be used on sweets, chocolate, biscuits and similar foods that are generally high-calorie and often have lots of fat. Diabetes UK doesn t recommend diabetic foods for people with diabetes because these foods still affect blood glucose levels, are expensive and can cause diarrhoea. If people want to treat themselves occasionally then they should go for the real thing. i For more on food, see p Type 2 diabetes 5

6 Introduction what is diabetes? Type 2 diabetes explained You may hear a lot of different and sometimes conflicting information about diabetes and how it affects people, which can be confusing. It s important to get the right information from a trusted source, so here are some of the facts gullet stomach liver pancreas What is diabetes? Diabetes is a condition where your body can t produce insulin, it doesn t produce enough, or where your insulin doesn t work properly. If you don t have the right amount of insulin, or if your insulin isn t doing its job properly, you can become very ill. What is insulin? It is a hormone that helps your body use the glucose in your blood to give you energy. Insulin is made by an organ called the pancreas, which lies just behind the stomach. It acts as the key that unlocks the body s cells to let glucose in, which is then converted into energy. Where does glucose come from? Glucose enters the bloodstream when we digest carbohydrate from various kinds of food and drink, including starchy foods (such as bread, rice, potatoes), fruit, some dairy products, sugar and other sweet foods. The liver also produces glucose. In people without diabetes, insulin carefully controls the amount of glucose in the blood. What happens in someone with Type 2 diabetes? Type 2 diabetes develops when 6 Type 2 diabetes 2013

7 what is diabetes? INTRODUCTION the pancreas doesn t produce enough insulin or when the insulin it produces doesn t work properly (known as insulin resistance). As a result, glucose remains in the bloodstream and is unable to enter the cells where it can be converted into energy. This is why some people with untreated diabetes often feel tired. The body then gets rid of the excess glucose via the urine. This can make you pass more urine than usual and become dehydrated, which may lead to extreme thirst. What are the symptoms? The symptoms of undiagnosed Type 2 diabetes are the same as those you may experience if your blood glucose levels are higher than normal. These may include: passing urine more often, especially at night increased thirst extreme tiredness genital itching or regular episodes of thrush wounds and cuts that take a long time to heal blurred vision losing weight without trying. What are the risk factors? Although you already have diabetes, you might want to encourage your family and friends to see if they are at risk and to look out for the signs of Type 2 diabetes. The earlier they take action, the sooner they can get the right care. People who are most at risk of Type 2 diabetes are: aged over 40 years old (or over 25 if South Asian) from a Black African, Caribbean or South Asian origin those who have a parent, brother or sister with diabetes overweight women with a waistline bigger than 80cm (31.5in) men with a waistline bigger than 94cm (37in), or 90cm (35in) for South Asian men those who have ever had high blood pressure, a heart attack or a stroke people taking anti-psychotic medication to treat a mental health condition women who have polycystic ovary syndrome or have had gestational diabetes or had a baby weighing more than 4.5kg (9.9lb) known to have pre-diabetes, impaired glucose tolerance or impaired fasting glucose. The more risk factors a person has, the greater their risk of developing Type 2 diabetes. How is Type 2 diabetes treated? There are three main treatments: healthy eating and being physically active, or healthy eating, being physically active and medication, or healthy eating, being active, medication and insulin injections. Your diabetes healthcare team will talk to you about how to manage your diabetes. You may need to make lifestyle changes, such as eating more healthily and being more active, and if necessary losing weight. You may also need to take diabetes medication or have insulin injections or both. Everybody is different and it can sometimes take a while to find out what works best for your diabetes. As Type 2 is progressive, your treatment may need to change over time either the dose or the type of medication. Your doctor or nurse will work with you to find the treatment that s right for you. Some people refer to Type 2 diabetes as mild depending on how it is treated. Type 2 diabetes is not mild, it is a serious medical condition that won t go away, but with the right treatment it shouldn t stop you living a full life. It s important that you understand what you need to do Type 2 diabetes 7

8 Diabetes care MEDICATIONS your medication Alongside a healthy diet and physical activity, medication may also be used to control your diabetes Keeping good control of your blood glucose levels (as well as your blood pressure and blood fats) is the best way of avoiding the long-term complications associated with diabetes. Diabetes medications help to lower blood glucose levels, and they work in a number of different ways (see overleaf). When you are first diagnosed with Type 2 diabetes, your doctor may ask you to look at what you are eating, lose weight if necessary and be more active as a way of getting your blood glucose levels under control. This is because excess weight makes the insulin you are still producing work less effectively. These lifestyle changes work for some people and they are able to control their diabetes as a result. But others find their blood glucose levels stay high or start to rise again despite a period of time where lifestyle changes were controlling their levels. Doctors will then add in some form of medication. This is not used instead of a healthy lifestyle you still need to eat healthily and be physically active. For some people, even this won t be enough; Type 2 diabetes is a progressive condition and more than one type of treatment is likely to be needed over your lifetime. Some people who can initially keep control with one type of medication may, over time, need to change that medication or need to take several different types, or need to take insulin. This doesn t mean they have done anything wrong it s just that the body needs more help to control diabetes and keep complications at bay. Your diabetes healthcare team will help you decide when (and if) your treatment needs to change. Which diabetes medication is best for me? This will depend on your own needs and situation, so you should discuss the types of medication available and the ones best suited to you with your healthcare team. Whichever medication you are prescribed, it will only work if you take it properly and regularly. Make sure your doctor or pharmacist explains how much to take, when to take it and discusses possible side effects with you. Know your medication When you re given your prescription, it is important to know the name of your medication, what dose you should take and when. Diabetes medications are safe drugs but, like all medication, they can have side effects or react with other medicines you are taking. There are several different types of medication, which work in slightly different ways, and can have particular side effects. Ask your doctor, nurse or pharmacist about the medication you re taking. types of medication There are several different groups (or types) of diabetes medication: Biguanides Sulphonylureas Alpha-glucosidase inhibitors Prandial glucose regulators Thiazolidinediones (glitazones) Incretin mimetics DPP-4 inhibitors (gliptins) SGLT2 inhibitors. These groups may contain more than one medication. Most medicines have two different names. One is the generic (proper) name. The other is the brand (trade) name given by the manufacturer. 8 Type 2 diabetes 2013

9 MEDICATIONS diabetes care The important name to remember is the generic name. If you are unsure about whether you have the right medication, check with your pharmacist. If you feel you need more information on your medication(s) speak to your doctor, nurse or pharmacist. The Patient Information Leaflet (PIL) also has more information. This is produced by the manufacturer and is dispensed with your medication. combination medication The aim of any treatment is to keep blood glucose levels as close to normal as possible. As this is individual to each person, the target levels must be agreed between you and your diabetes team. To stay within your range you may need to take a combination of tablets, such as a sulphonylurea and metformin, or a combination of tablets and an injection. Q&A What if I forget to take a tablet or a dose? You need to keep taking your tablets regularly to keep your diabetes under control. But if you do forget a dose, don t double the amount when you come to take your next dose. If it is only an hour or two since your normal time for taking the tablet, just take it as soon as you remember. If it s more than a few hours after, miss the dose out and take the next one at the usual time. If you frequently forget to take your tablets, discuss this with your doctor. It may be possible to simplify your treatment. Do I still need my medications when I m ill and not eating? Yes. If you cannot eat your ordinary meals, try to have some snacks or soup, milk or fruit juice instead. Your doctor may suggest you test your glucose levels at least four times a day and keep a record of your results. If you are being sick and cannot keep anything down, contact your GP or diabetes clinic straight away. Read more about managing your diabetes when you are ill on p78. Side effects All medication has potential side effects and you should check the information leaflet supplied to see which side effects you might experience. Some side effects are just temporary while your body gets used to the treatment. Remember that you are unlikely to experience all side effects that are listed, and you may not experience any at all. If you do, speak to your doctor as there may be another type of diabetes medication you could try instead. Ask your doctor for advice if you notice an adverse change in your symptoms after moving to a new drug or any new side effects you think you have. You can also report unwanted side effects (not already included in the patient information leaflet) using the yellow card scheme, which is used is to collect information from on suspected side effects. Visit call or pick up a card from your GP Type 2 diabetes 9

10 Diabetes care MEDICATIONS Sulphonylureas Different sulphonylureas are available, examples include gliclazide, glipizide and glibenclamide. How they work They stimulate the cells in the pancreas to make more insulin. They also help the insulin to work more effectively. There is a risk of hypoglycaemia (low blood glucose levels). When to take them They are taken once or twice a day, with or shortly before, meals. Prandial glucose regulators Examples include repaglinide and nateglinide. How they work Like the sulphonylureas, these stimulate the cells in the pancreas to make more insulin. However, unlike the sulphonylureas, they work very quickly but only last for a short time. There is also a risk of hypoglycaemia (low blood glucose levels). When to take them They should be taken within half an hour prior to each meal. If you miss a meal, the dose is not required. Biguanides Metformin is the only biguanide used in the UK. How it works Metformin helps stop the liver producing new glucose and enables the body s insulin to carry glucose into muscle and fat cells. It can also aid weight loss. When to take it Metformin is usually used as the first line of treatment, especially for people who are overweight. Metformin is taken two or three times a day, with a meal to help the insulin work at the correct time. It is available as tablets for immediate release (up to three times a day) or prolonged release (usually once a day), and oral solution and powder for immediate release. muscle liver pancreas Thiazolidinediones (glitazones) The only one in this group is pioglitazone. How it works Pioglitazone helps the body to overcome insulin resistance, enabling it to use its own natural insulin more effectively. When to take them Once or twice a day. It s useful for overweight people and helps to prevent heart problems. 10 Type 2 diabetes 2013

11 MEDICATIONS diabetes care Alpha-glucosidase inhibitors There is only one tablet of this type currently used in the UK, called acarbose. How it works It slows down the absorption of starchy foods from the intestine, slowing down the rise in blood glucose after meals. When to take it It should be chewed with the first mouthful of food or swallowed whole with a little liquid immediately before food. stomach kidney (located behind) Incretin mimetics This is a non-insulin medication given by injection, examples include exenatide and liraglutide. How they work They increase levels of hormones called incretins. These hormones help your body produce more insulin as it is needed; reduce the amount of glucose being produced by the liver when it is not needed; reduce the rate at which your stomach digests food and reduce appetite. When to take them There are three types of incretin mimetics. The once-daily version (Victoza) can be given any time, but the twice-daily (Byetta) should be given within 60 minutes of the morning and evening meal not after a meal. There is also a once weekly version called Bydureon. SGLT2 inhibitors The only one in this group is Dapagliflozin. How it works It works by reducing the amount of glucose being absorbed in the kidneys so that it is passed out in the urine, reducing the amount of glucose in your blood. When to take it Once a day. Because of the way it works, your urine will test positive for glucose while you are on this medication. How effective it is depends on your kidney function. There is a risk of genital infections and urinary tract infections. DPP-4 inhibitors (gliptins) Examples in this group include sitagliptin, vildagliptin and saxagliptin. How they work They block the action of the enzyme DPP-4, which destroys the hormone incretin. Incretins help the body produce more insulin when it is needed and reduce levels of glucose being produced by the liver when it is not needed. These hormones are released throughout the day and levels are increased at meal times. When to take them Depending on the type, they are taken once or twice a day with or without food Type 2 diabetes 11

12 Diabetes care Moving to insulin Some people with Type 2 diabetes may find that over time they re taking more than one medication, and that insulin may be an option. It sounds daunting, but with time it will become part of your daily routine treatment changes If the medication you are taking is no longer able to control your diabetes on its own, insulin may be another option. This is because your pancreas is becoming less efficient in producing its own insulin. This often happens after several years on tablets. This problem may be eased by changing to a different type or a higher dose of medication or by taking several different types of medication together. But, if the problem persists, your doctor may recommend insulin instead of, or as well as, the tablets you re taking. In some cases, you might only need insulin temporarily during an operation, for instance, to control blood glucose levels. Similarly, you may be advised to use insulin if you are pregnant or breastfeeding. In these cases, you may be able to go back to your original medication, but, for some, this will no longer be as effective and they ll need to stay on insulin. If you need insulin, it will be explained what you need to do. Coping with starting insulin You may feel like you ve done something wrong or you haven t achieved all that was expected of you, but it s not your fault that you have to take insulin. Diabetes is a progressive condition and over time it is unlikely that the treatment you were first given will continue to work as well. Using insulin just means that your body needs a bit more help to keep you healthy and minimise the risk of developing complications. Most people who change to insulin say that they feel much fitter and wish they had changed earlier. Talk to your diabetes healthcare team if you are worried. Once you ve got over the initial fear of injecting, you will hopefully feel much better. Some of the symptoms of high blood glucose levels you may be experiencing will get better, too, eg you may feel less tired and less thirsty Starting insulin injections Insulin is a protein, so it can t be taken in tablet form otherwise it would be digested in the stomach and wouldn t be able to work. This is why it needs to be injected via a small syringe or pen injector. Your diabetes healthcare team will show you how to inject insulin, work out which insulin is best for you and tell you when you will need to inject. You ve probably been given a pen injector device pens are fairly easy to use and there is a whole range to suit different types of insulin. The needles used are very small because the insulin only needs to be injected under the skin (subcutaneously) not into a muscle or vein. Once injected, it s absorbed into small blood vessels and passes into the bloodstream Starting insulin injections doesn t mean that you ve developed Type 1 diabetes. You still have Type 2 diabetes but it is treated with insulin changing treatment doesn t change your condition. 12 Type 2 diabetes 2013

13 Where to inject There are four main places: Arms* Stomach Stomach Bottom Bottom Thighs Thighs * check with your diabetes healthcare team as arms aren t suitable for everyone. where it gets to work. Most insulin prescribed today is genetically engineered human insulin, which doesn t involve the use of any animal or indeed human products. If you find your injections a little painful or uncomfortable, especially the first few, it may be because you are tense and anxious. But, as your confidence grows, they ll get easier and become second nature. Keep on moving It s vital that you rotate or change injection sites. If you keep injecting into the same site small lumps can build up under the skin. These won t Moving to insulin How to inject 1 Make 2 Eject 3 Choose 4 If 5 Put 6 Inject 7 Release 8 Remember look or feel very nice, and also mean that the insulin doesn t work properly because it s harder to absorb through the lumps. Also, don t inject in the same spot within each site change the spot that you sure your hands and the area you re injecting are clean. two units of insulin into the air to make sure the tip of the needle is filled with insulin (called an air shot ). an area where there is plenty of fatty tissue, eg tops of thighs or the bottom. diabetes care you have been advised to, lift a fold of skin (the lifted skin fold should not be squeezed so tightly that it causes skin blanching or pain) and insert the needle at a 90 angle. With short needles you don t need to pinch up, unless you are very thin. Check with your diabetes healthcare team. the needle in quickly. If you continue to find injections painful, try numbing an area of skin by rubbing a piece of ice on the site for seconds before injecting. the insulin, ensuring the plunger (syringe) or thumb button (pen) is fully pressed down and count to 10 before removing the needle. the skin fold and dispose of the used needle safely. to use a new needle every time. Reusing a needle will make it blunt and can make injecting painful. use each time. By rotating injection sites and spots you can help avoid getting lumps (any that may have occurred will slowly disappear). This also applies if you are prescribed the non-insulin injection Type 2 diabetes 13

14 Diabetes care TESTING time to test Some people with Type 2 diabetes test their blood glucose levels, so what does it involve? It is recommended to prick the side, rather than the middle of your finger You may need to do some form of testing either blood or urine to understand more about how your diabetes is being managed. Whether or not you need to test should be assessed by your diabetes healthcare team; they should talk with you to decide if it s right for you. If you go ahead with testing, your healthcare team should assess how you monitor your blood glucose levels every year (or more often if it s needed) as well as checking that you know what to do with your results. Two ways to test The different ways you can test your blood glucose at home are: Urine testing This involves holding a special strip under a stream of urine for a few seconds and comparing the colour change 14 Type 2 diabetes 2013 on the strip after a set amount of time (check the manufacturer s instructions) with the chart on the strip container. This shows whether there is any glucose in the urine a result of none is the ideal. Urine testing gives a less accurate picture of your blood glucose level than blood testing, but your doctor may still feel that it s suitable for you. It is less accurate because there is usually no glucose in your urine unless your blood glucose levels have been persistently over 10mmol/l. Also, it doesn t give you an indication of what your blood glucose level is at the time you test, because the urine may have been produced several hours before. Urine tests also can t tell you if your blood glucose is too low which is important for people on insulin or certain diabetes medication. Since the amount of glucose in the urine is dependent on a person s kidney function and this varies from person to person, urine tests aren t always reliable and can cause confusion. Blood testing To test your blood glucose, you prick the side (as opposed to the pad) of your finger with a special device and put a drop of blood on a testing strip, which is then read by a blood glucose meter. The strips for meters can only be read by the meter itself. Blood testing gives you an accurate real time picture of your blood glucose levels. It can help you to maintain day-to-day control, find out if you are hypo (hypoglycaemia low blood glucose levels), and also helps to provide information that can be used to prevent long-term

15 TESTING diabetes care complications. Your diabetes healthcare team will teach you how to do the test properly so that you can be sure your results are as accurate as possible and you know how to respond to these results. When to test Your diabetes healthcare team will help you to understand testing and together you will agree how many and what types of tests are best for you. Sometimes you may be advised to do a few tests at different times to get an overall picture of your diabetes control and show where changes in your treatment may be needed. You may also need to test more if you re unwell, driving or doing physical activity. See p78, 86, and 62. Keeping control Good control means keeping your blood glucose levels as near normal as possible. Research has shown Q&A that good control of blood glucose levels as well as blood fats (including cholesterol) and blood pressure greatly reduces the chances of developing the long-term complications of diabetes. Testing and responding to the results appropriately can help you reduce the risk of these complications. If you test your blood, you should agree your individual target blood glucose range with your healthcare team. This usually means between 4 7mmol/l before meals and under 8.5mmol/l two hours after meals. Don t panic if you have the odd result above the upper limit this happens to everyone. If you re testing your urine, you re aiming for a negative result but, again, don t worry if you occasionally get a positive result. Good control also means understanding how your medication, food and activity affects your blood glucose. This will give you the confidence to adjust your My doctor always does a blood test, even though I take my results book with me to check-ups. Doesn t he trust my records? The test that your doctor does measures your overall control for the last few weeks it is not the same test as the ones you do at home. There are different types of this test. The HbA1c test is the most common and gives your average blood glucose level for the previous 8 12 weeks. This, along with the tests you do at home, help your doctor to see how well your treatment is working and to make any changes necessary. See p22 for more on the HbA1c test. How to test blood glucose 1 Wash 2 Make 3 Prick 4 Use 5 Keep your hands rather than using wet wipes (these contain glycerine that could alter the result). sure your hands are warm if they are really cold it s hard to draw blood, and fingerpricking will hurt more. the side of a finger (not the index finger or thumb) don t prick the middle, or too close to a nail, because this can really hurt. a different finger each time and a different part this will hurt less. a diary of your results. This will help your helathcare team suggest adjustments to your treatment, if needed. Try the Diabetes UK smartphone app to keep track. tracker-app 2013 Type 2 diabetes 15

16 Diabetes care TESTING Quote Your target range Target ranges are agreed between you and your diabetes healthcare team. For guidance, the general blood glucose target ranges for people with Type 2 diabetes are: 4 7mmol/l before meals less than 8.5mmol/l two hours after meals. treatment, activity, and what and when you eat, and avoid high or low blood glucose levels. Then you can fit diabetes into your life, rather than planning your life around it. Also, good control means taking the complications of diabetes seriously, doing your best to keep yourself healthy and minimising your risks you need to make sure you are receiving all the essential health checks (see 15 healthcare essentials on p29). Choosing a meter Your diabetes healthcare team will usually provide you with a meter if a decision has been made that blood glucose testing is definitely for you. To monitor your blood glucose levels, not all people will be given a meter. Testing strips for the meter will be prescribed for you, depending on the amount you need. If you are choosing a blood glucose meter, it can be complex as new products come out all the time. Some manufacturers also produce computer software to enable you to look at trends in your levels. However, if you buy your own meter, you may not always get a prescription for testing strips you ll need to speak to your healthcare team about this. The Medical Devices Agency evaluates all blood glucose meters that are available in the UK and ensures that they meet international standards. If you re at all unsure about the most suitable equipment for your needs, contact your healthcare team. They should help you to understand blood glucose monitoring, support you in using a meter that meets your needs and devise a care plan that suits you (see p24). ACTION POINTS If you are testing your blood glucose, ask your diabetes healthcare team what targets you should be aiming for and what you should do about high/low results. Make sure you know how to quality-check your blood glucose meter and how often you should do this. 16 Type 2 diabetes 2013

17 you re not alone with diabetes TESTING become a member Join us today Diabetes UK is the leading charity that cares for, connects with and campaigns on behalf of all people affected by and at risk of diabetes. Over 300,000 supporters are the bedrock of the work we do at Diabetes UK to: Help people manage their diabetes effectively by providing information, advice and support. Campaign with people with diabetes and with healthcare professionals to improve the quality of care across the UK s health services. Fund pioneering research into care, cure and prevention for all types of diabetes. Every supporter makes a difference to the lives of those affected by diabetes. Members also receive balance every two months, with the latest information about living with diabetes. Join today. Call and quote Tesco2 or visit

18 Diabetes care hypos & hypers managing highs & lows People who take certain medications or insulin may be at risk of hypos and once diagnosed you are still at risk of hypers. Understanding them will help you to manage them The key to controlling diabetes is to balance your food, activity and medication. But it s not always easy. When the balance isn t right, you may develop hypoglycaemia (hypo when blood glucose drops too low) or hyperglycaemia (hyper when blood glucose rises too high). Hypos Hypoglycaemia (or hypo) means low blood glucose levels, ie when the blood glucose level drops below 4mmol/l. In people without diabetes, low blood glucose levels trigger the body to stop producing insulin and to release stored glucose to keep the body going. But, in people with diabetes, while this mechanism still works, it s not so effective. Some people with Type 2 diabetes may need tablets or insulin injections to increase the amount of insulin circulating in the bloodstream. Insulin produced in this way can t be switched off so it will continue to work, even though blood glucose is too low. If your Type 2 diabetes is controlled by diet and physical activity alone or by diet and metformin or acarbose tablets, there is no risk of hypos. But if you are treating your diabetes with insulin, sulphonylureas or prandial glucose regulators, you are at risk of hypos (see p8). Explaining what hypos are all about to your friends and loved ones is a good idea Spotting the symptoms Hypos can come on quickly and you will tend to develop symptoms that will indicate that your blood glucose levels are dropping too low. Everyone has different symptoms, but common ones are: feeling hungry trembling or shakiness sweating anxiety or irritability going pale fast pulse or palpitations tingling of the lips blurred vision. Why do hypos happen? There s no hard and fast rule why they happen, and sometimes there s just no obvious cause. But some things that can mean it s more likely include: too much insulin a delayed or missed meal or snack 18 Type 2 diabetes 2013

19 hypos & hypers diabetes care not enough carbohydrate unplanned physical activity (see p62) drinking large quantities of alcohol or drinking alcohol without food (see p50). treating a hypo There are a series of steps to take when treating a hypo: Immediate treatment If you have tested your blood glucose and it is low, or you notice your hypo warnings, take action quickly or it s likely to become more severe, and you may become confused, drowsy or possibly even unconscious or have a fit. Immediately treat with 15 20g of a fast-acting carbohydrate such as: a sugary/non-diet drink glucose tablets sweets, eg Jelly Babies fruit juice glucose gel this can be useful if you re feeling drowsy and someone can help you, but should not be used if you are unconscious (glucose gel is available on prescription if you are treated with insulin). such as: half a sandwich fruit a small bowl of cereal biscuits and milk the next meal, if due. Explaining hypos to others Some people find explaining hypos to family, friends and work colleagues tricky, but it s better to let them know in advance what might happen so that if and when you have a hypo, they can help you deal with it. Explain why they ll sometimes see you eating or drinking sugary things, and tell them what to do if you can t manage on your own. Some people find that they get irritable or stubborn when they go hypo, so you ll need to let people know what to do to get you to eat or drink something. Severe hypos A severe hypo is when you need help from another person to treat it. If a hypo is untreated there is a risk that you may become unconscious. While this is not common, it s important that you know what to do so you can be prepared: Hypo treatments vary, and the quantities vary from person to person. Choose the treatment that works best for you. But avoid food and drinks containing fat (eg chocolate, biscuits, milk). This is because fat delays the absorption of sugar, so won t treat the hypo quickly enough. Retest Check your blood glucose after minutes and, if it s still low, repeat with the same treatment. Follow-on treatment To prevent your blood glucose levels dropping again, you may need to follow with 15 20g of a longer-acting carbohydrate, Hypos & everyday life There are a few things that you need to be aware of: Driving Hypos are most dangerous when you need all your concentration and co-ordination, such as driving a car. Even a mild hypo, because of its effects on the brain, can seriously impair your ability to drive (see p86 for details). Exercise Exercise will generally lower blood glucose levels. If your diabetes is treated with certain tablets or insulin, then you may be at risk of a hypo if you do intense exercise for a period of over an hour. So it s sensible to check your glucose levels before and during the exercise and to keep some fast-acting glucose such as a non-diet drink close by. See p62 for more on physical activity Type 2 diabetes 19

20 Diabetes care hypos & hypers If possible, you should be placed in the recovery position (on your side with your head tilted back) If you have been given a glucagon injection kit (available as GlucaGen HypoKit), someone else can help you by injecting it, but only if the person you are with has been trained to use it. If you don t have a glucagon kit available or you have not recovered within 10 minutes of receiving the glucagon injection, the person you are ACTION POINTS Try to understand the main causes of hypos and hypers and take steps to keep yourself safe. Familiarise yourself with your warning signs and symptoms that a hypo or hyper is taking place and try to have your treatment available at all times. 20 Type 2 diabetes 2013 with should put you in the recovery position and call an ambulance immediately. If you are unable to swallow or are unconscious, you should not be given anything by mouth and ambulance staff should be called straight away. Make sure your family and friends are aware. Always tell your diabetes healthcare team if you have had a severe hypo as your treatment may need to be altered. Hypers At the other end of the scale are hypers (hyperglycaemia), which happen when blood glucose levels go too high. Some of the reasons are: a missed dose of medication too little medication eating too much carbohydrate food over-treating a hypo stress being unwell with an infection. Symptoms include: increased thirst frequent urination top tips 1 Keep 2 If 3 Make Hypos hypo treatments with you at all times. you re having nighttime hypos, test your glucose levels before you go to bed and during the night ask your healthcare team about the time to test. sure you carry some form of ID, an identity card, bracelet or necklace, so that if you ever become unwell or if you are unable to communicate in an emergency, people are aware that you have diabetes and can help. headaches extreme tiredness. Treatment If your blood glucose level is high for just a short time, emergency treatment won t be necessary. But if it stays high you need to take action: Make sure you drink plenty of sugar-free fluids. If you are on insulin, you may need to take extra insulin. If you are feeling unwell, especially if you are vomiting, you must contact your diabetes healthcare team for advice.

21 hypos & hypers diabetes care It s better to let people know in advance what might happen Q&A Should I keep my blood glucose levels high to avoid hypos? No. It can be harmful for you if you try to run your blood glucose levels consistently very high in order to avoid hypos. You may start to feel thirsty, go to the loo a lot and feel tired basically you will feel like you did before you were diagnosed. Long-term high blood glucose levels can lead to complications (see p90 onwards). What are the main reasons for hypos? The most frequent cause is missing or delaying a meal, but occasionally it might be a mistake in your medication dose or unplanned exercise. Stress, or very hot or cold weather, also causes some people to have hypos. If there s a simple explanation for the odd hypo, there s no need to adjust your treatment. It s only if you have frequent hypos at similar times or if you have a severe hypo that you may have to look at what you eat or your medication doses. Speak to your diabetes healthcare team for advice or if you have any concerns. You may also find that it helps to do more blood glucose tests. That way, you ll be able to spot when your levels are likely to drop and take action, without running your levels too high all the time. How do hypos affect my blood glucose levels? After you ve had a hypo, your blood glucose level may actually rise. If you are on insulin don t be tempted to increase your dose. The rise may happen because you felt incredibly hungry during the hypo and ate to correct this. Your levels may also rise because hypos cause the body to mobilise its own glucose stores. Will hypos affect my quality of life? Unfortunately, occasional hypos may happen. But they should not be frequent or severe. If they are, contact your diabetes healthcare team. Try to build a picture of any hypos you have to see if there is a pattern in their occurrence. If there is, you may wish to alter your diabetes treatment with the help of your healthcare team. Why do some people have severe hypos without any warnings? Research suggests that people who keep their diabetes very tightly controlled may have problems in recognising hypo warnings. Research also shows that if you have one severe hypo without warnings, you re more likely to have repeated episodes. And once you ve had one severe hypo, you are at risk of further severe hypos, so you should take particular care. There is also some evidence that people who ve had diabetes for a long while may have lost their hypo warnings. However, they can often regain them by adjusting their diabetes treatment. If you re having problems, talk them through with your diabetes healthcare team. They ll be able to give you individually tailored advice Type 2 diabetes 21

22 Diabetes care long-term testing long-term control You ll be invited for various tests at least once a year to check on your overall health now that you have diabetes. There will be particular targets to aim for Monitoring your health when you have diabetes is crucial to prevent some of the complications associated with the condition. This involves knowing your blood glucose, blood pressure and blood fat levels, and there are targets you should be aiming for. As well as day-to-day blood glucose testing, the HbA1c test (usually done from a fingertip blood test) measures your diabetes control over two to three months. This target and the others are: HbA1c: below 48mmol/mol but 58mmol/l or below for those at risk of severe hypoglycaemia Blood pressure: 130/80mm Hg or less Blood fats: total cholesterol: below 4mmol/l LDL (bad fat): below 2mmol/l HDL (good fat): 1mmol/l or above for men, 1.2mmol/l or above for women triglycerides: 1.7mmol/l or below. Remember, target ranges are individual and your diabetes healthcare team may suggest a different target to you. See p29 for 15 healthcare essentials. For more on complications, see p90. Q&A I have sickle cell anaemia and my doctor has said that he can t do the HbA1c test on me. Why is this? HbA1c measures the amount of glucose that is being carried by the red blood cells in the body. But red blood cells are affected if you are anaemic, or have a condition like sickle cell anaemia or thalassaemia (all of which involve a lack of, or abnormal type of, haemoglobin the oxygen carrying part of the blood). So this means that the test will give a false result. 22 Type 2 diabetes 2013

23 DIABETES NEED TO KNOW? NEED TO TALK? Our CARELINE is staffed by professional counsellors who have extensive knowledge of diabetes. They can provide information about diabetes, take the time to talk things through and explore emotional, social, psychological or practical difficulties you may be experiencing. The telephone service: is available during working hours on all weekdays provides access to a translation service for people who do not want to speak English welcomes calls via Text Relay for people with a hearing impairment offers recorded information on the most popular diabetes-related subjects out of hours. You can contact us directly any time between 9am and 5pm, Monday to Friday. careline@diabetes.org.uk CALL * WRITE TO Diabetes UK Careline, 10 Parkway, London NW1 7AA *The cost of calling 0845 numbers can vary according to the provider. Please check with your own provider for details, particularly about mobile phones as they can cost considerably more than landline calls. Or call and your call will be connected directly to the Careline. A charity registered in England and Wales (215199) and in Scotland (SC039136). Diabetes UK Type 2 diabetes 23

24 Diabetes care THE care to expect YOUR CARE EXPLAINED It takes a team of professionals to provide the best possible diabetes care. Find out who s in your team and what care and services to expect Your diabetes healthcare team is made up of all the healthcare professionals who are involved in your care, but you won t see them all together at the same time. Your diabetes care may be provided in different places depending on your specific needs, but most likely at your GP surgery. It is best to discuss with your GP the roles and responsibilities of those providing your diabetes care. It is important to identify the key members of your diabetes healthcare team and agree the name of the key contact, who you are likely to see most often. You may see some members of your team more often than others and they may change over time. To achieve the best possible diabetes care, it is essential for you to work in partnership with your diabetes healthcare team and use your combined experience and expertise to agree what care and support you need. Remember, the most important person in the team is you because the decisions made will affect you. (See Planning your diabetes care, right). Your healthcare team will have a wealth of experience Planning your diabetes care The partnership between you and your diabetes healthcare team, where you are actively involved in deciding how your diabetes will be managed, is a process called care planning. During your appointments, you should: discuss your concerns and questions with members of your diabetes healthcare team work together to set realistic goals decide how you are going to achieve these goals. Your healthcare team will have The goals you agree during a wealth of your discussions experience will form the basis of your care plan, which is the written summary of what you and your diabetes healthcare team are both going to do to help you to manage your diabetes. A paper copy of your care plan should be given to you by a member of your diabetes healthcare team. If not, ask for one. 24 Type 2 diabetes 2013

25 THE care to expect diabetes care The most important person in your diabetes team is you top tips Appointments What care to expect It is important that you understand your diabetes and the healthcare you can expect so that you are an effective member of your own diabetes healthcare team. There are different stages that your care will go through: When you have just been diagnosed with diabetes, you should: Have a full medical examination and discuss with a member of your diabetes healthcare team any immediate treatment you need; your concerns and unanswered questions; your feelings and reaction to being diagnosed. Receive an explanation of what s on offer for you to learn more about diabetes and keeping well. This includes diabetes education and self-management courses (see p30), as well as other sources of information and support. See a registered dietitian to talk about what you usually eat, how this relates to your condition, and what other information and support will help you manage your food and diabetes. Once you have received initial information and treatment, your ongoing care includes: A yearly formal care planning review with a doctor or nurse experienced in diabetes. This should include a discussion of your test results and examinations, as well as your experiences of living with diabetes and any other concerns, needs or anxieties. Full review every year to check for complications (see the 15 healthcare essentials p29). Before decide what you need to know write down the points you want to raise bring your blood glucose meter and results record with you bring any news features/stories or research that you have any questions about. During listen actively ask questions, give feedback and ask for clarification if you re unsure of anything make notes to help you remember what has been said check you ve covered your list. After review what s been said and agreed make a note of anything you need to do before your next appointment. Regular access to your healthcare team to assess your diabetes control. This could be every four to six months, or as agreed in your care plan. You should have the time to ask questions and to discuss your care. Access to a member of your healthcare team for specific support and advice when you need it. This could be in person or by phone, or text, depending on what is used in your area Type 2 diabetes 25