Health and medical information

NATURAL HISTORY OF TYPE 1 DIABETES: THE EFFECT OF INTENSIVE MANAGEMENT The effect of intensive management was to delay the rate of appearance of microaneurysms in the primary prevention cohort compared with the standard management group. However, the risk reduction was only 27%, and at 5 years of therapy approximately 50% of the intensively managed group had one or more microaneurysms compared with close to 70% of patients in the standard group. By life table analysis over 9 years of follow-up, an estimated 7.9% of patients who received intensive treatment would require laser therapy compared with 30% of those with conventional treatment (risk reduction: 59%; p = 0.001). Thus, although mild background retinopathy progressed in both groups, serious progression of retinopathy and the need for laser therapy was significantly greater in patients randomized to conventional therapy compared with those in the intensive therapy group. This finding provided strong port for intensive glycemic regulation in type 1 diabetes.*27\357\8*

WHAT IS DIABETES?Definition : According to International Expert Committee working under the sponsorship of American Diabetes Association (ADA) 1997, Diabetes mellitus is a group of metabolic disease characterized by hyperglycaemia (high blood glucose) resulting from defects in insulin secretion, action or both. The chronic hyperglycaemia of diabetes is associated with long term damage, dysfunction of various organs specially the eyes, kidneys, nerves, heart and blood vessels.For easy understanding: Diabetes is a state of high blood glucose (blood sugar) due to lack or relative lack of hormone insulin.Whether Blood Glucose or Blood Sugar : So far, you have noticed that I have used the word blood glucose whereas you have heard the doctors, nurses and patients in the clinics talking about ‘Blood sugar’. Scientifically speaking, it is more correct to use glucose since there are many types of sugar of which glucose is just one (the simplest).Fructose, often used as sweetening agent in diabetic food is another sugar which differs from glucose but easily changes into it.Table sugar (sucrose) is a more complicated substance, although it easily changes into glucose in the body. Having said this, one must admit that most doctors talk about blood sugar instead of blood glucose and I shall use the terms ‘blood glucose’ and ‘blood sugar’ interchangeably.Insulin : Insulin is an important polypeptide, anabolic hormone secreted by Beta Cells of pancreatic gland situated in abdomen just behind the stomach. Body fuel (Glucose) and Energy ; Every body needs energy to do work. If we think of the human body, it needs glucose as body fuel while a car needs petrol as fuel and a train engine needs coal as fuel.When we compare a human body with a car, which converts fuel into energy, the car burns petrol to produce energy which turns the wheels, recharges the batteries and keep the inside warm while our bodies burn glucose to power the muscles, heart and brain and keeps the body warm by maintaining a constant body temperature. Both the car and human body*4\329\8*

ON THE G.I. FACTOR The effect of fibre on the G.L factor of a food depends on the type of fibre. Finely ground cereal fibre, such as in wholemeal bread has no effect whatsoever on the rate of starch digestion and subsequent blood sugar response. Similarly, any cereal product made with wholemeal flour will have a G.L factor similar to that of its white counterpart. Breakfast cereals made with wholemeal flours will also tend to have high G.L factors unless there are other influencing factors. Puffed wheat (80) and Weet-Bix™ (69) which are made from well cooked whole wheat grains have high G.L factors.

If the fibre is still intact it can act as a physical barrier to digestion and then the G.I. factor will tend to be lower. This is one of the reasons why legumes have exceptionally low G.L factors (30 to 40). It is also one of the reasons why whole (intact) grains usually have low G.I. factors, although rice is the exception. Many varieties of rice, whether brown or white, have G.L factors over 80.

Viscous fibre Viscous fibre thickens the viscosity or thickness of the mixture in the digestive tract. This slows the passage of food and restricts the movement of enzymes, thereby slowing digestion. The end result is a lower blood sugar response. Legumes contain high levels of viscous fibre, as do oats and psyllium (a seed which is a major ingredient in some breakfast cereals and laxatives). These foods all have low G.I. factors.

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Food is part of our culture and way of life. Our food choices are determined by many factors ranging from religious beliefs to the deliriously sensual role that food plays in our lives. For babies, food has a comforting role to play, beyond meeting the immediate physical need. For adults, food reflects status—we prepare special meals for special occasions and for special guests to show respect or friendship.

It is no wonder that with so many factors influencing our food choices, we tend to overlook the very basic role food plays in the nourishment and growth of our bodies. In a busy lifestyle, it’s easy to see food simply as a solution to overcoming hunger. In other circumstances we focus on the social aspects of food and eat too much.

Australia’s CSIRO Division of Human Nutrition has developed a food model which guides us on the types and amounts of foods we should be eating daily for health. For many reasons our eating habits today fall very short of these recommendations.

Kilojoule-laden foods (sometimes called energy dense foods), such as alcohol, chocolate, chips and confectionery, provide few nutrients for a lot of kilojoules. For this reason they are referred to as ‘indulgences’ and are best limited to no more than one to two serves per day.

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There are a number of devices to make injections of insulin more convenient. One of these is the insulin pen and this works on the same system as the fountain pen for writing: it is shaped rather like a pen, has an internal reservoir or cartridge of insulin which is replaceable and a needle where the pen would normally have a nib. The needle is replaceable as needed, generally after a few days of use and the insulin cartridges hold between 150 and 250 units.

There are insulin cartridges for both long and fast acting insulins and some insulin mixtures. The first of these pens introduced to the market here was designed by Novo Industries and called the Novopen, and some people use the term to refer to all the available pen systems. There are however other types including Insuject by Nordisk. Moreover there are different pens for long acting and for short acting insulin. Thus, Novo pen I is usually used for Actrapid insulin and Novopen II for Protaphane, Ultratard and Actraphane. Insuject is used for Velosulin and Insuject-X used for Insulatard, Mixtard and Initard.

The original intent of the pens was to allow quick acting insulin to be administered conveniently before each meal. This mimics to some extent the way the pancreas releases insulin when we eat. In addition to these three insulin injections, an injection of long or moderately long acting insulin is given at night, usually before bed. This provides a supply of insulin throughout the night and into the next day.

The pen makes it relatively easy to have insulin at lunch time at school or work by carrying the pen in a pocket or bag. It makes it more convenient to accept invitations for meals away from home and gives more flexibility in timing and insulin dosage. Some people vary their dose of quick acting insulin according to their blood glucose level (more if it is very high) and most people vary the dose according to the degree of exercise they expect to have following the injection. A young person would therefore lower the dose if he was going swimming or had a football match. Some people have a little more quick acting insulin if they are at a social occasion and expect to be eating a bit extra.

The ability to vary the dose in this way depends on doing extra blood glucose estimates at times, especially when getting used to the system.

The pre-mixed insulins make it possible for some people to use the pen for twice daily injections. This does have the advantage of convenience but the disadvantage that it is not possible to vary the portions of the fast and slow acting insulins when they are pre-mixed. The insulin manufacturers may develop systems where the proportions of the insulins can be varied. If this happens, it is likely that the pen systems will largely replace the conventional syringes and bottles of insulin.

One disadvantage of the system is that it is not always possible to check that the full dose has been given. Using the syringe, the dose can be checked when it has been drawn into the syringe and it is obvious when the full dose has been given and the syringe has been emptied. With the pen, it is possible for malfunctioning of the pen or for a blocked needle to occur so that some or even all of the dose is not given properly. It is also possible for a young child to make errors. This can be partly overcome by expelling two to four units of insulin into the air to check that the pen is working before administering the insulin dose beneath the skin.

Some people choose to use the four injections a day pen system for convenience. Others do so to get the best possible control of their diabetes. Most people, when they first develop diabetes, prefer to start with one or two injections a day and feel it is best to become familiar with the syringe before trying the pen system, particularly as it does not necessarily lead to better control. Like all gadgets, they can become lost or broken and it is important to have the conventional syringe as a standby.

Adjustment of insulin dose using the pen system

It usually works out that between a third and a half of the total insulin requirements for the day is given as an injection of slow acting insulin at night. The remainder of the total dose is given as three injections of quick acting insulin before each meal, in about equal proportions. These proportions, and the total amount of insulin for the day, depend upon a person’s total insulin requirements, their pattern of response to insulin and their usual meal and activity habits. They would normally be worked out by your doctor.

After a few days, a pattern of response will probably develop and based on blood tests, dose adjustments can be made.

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