Type 1 Diabetes in Children, Adolescents, and Young Adults: How to Become an Expert on Your Own Diabetes (Class Health)

417 Pages·2006·9.66 MB·English

by  Ragnar Hanas

Comments on Type 1 Diabetes from reviewers
“This is far and away the best diabetes resource I have ever come across. It has information you will
not find anywhere else and is well presented and indexed … If you are serious about managing your
child's diabetes to the best of your ability, you cannot afford to do without this book.”
Reviewer from London, featured on the Amazon website
“I have no hesitation in thoroughly recommending this book to adolescents and young people with
Type 1 diabetes, their families, and also to all healthcare professionals involved in their care.”
Professor Martin Silink in Diabetologia
“The information is clear, concise and extremely readable. All imaginable topics are covered from
hypoglycaemia, through pregnancy and on to psychological issues! It is difficult to imagine anyone,
including healthcare professionals, teachers and grandparents, not learning something helpful.”
Practical Diabetes International
“It covers all aspects of living with diabetes and is one of the most useful and comprehensible books
written for the person with diabetes.”
Paediatric Nursing
“Congratulations to Dr Hanas on authoring a very comprehensive and informative book on type 1
diabetes. This is the most complete book on living with type 1 diabetes available and takes the reader
from understanding basic information to the complex.”
Pediatric Diabetes

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
Third edition
fully revised and updated
CLASS PUBLISHING•LONDON
Copyright © 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 Cop-
yright, 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 361).
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 English edition published by the author 1998
Second UK edition 2004, reprinted 2005
Third UK edition 2007.
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 10 1859591531
ISBN 13 9781859591536
Designed by David Penfold and Ragnar Hanas
Edited by Richenda Milton-Thompson
Printed and bound in Finland by WS Bookwell, Juva
Contents
Comments on Type 1 Diabetes from reviewers... i 6. High blood glucose levels...................... 26
Acknowledgements................................................ x Not enough insulin?............................................ 27
How to treat a high blood glucose level............. 27
Preface................................................................... xi Ketoacidosis........................................................ 28
Blurred eyesight and diabetes............................ 30
Foreword by Dr Peter Swift................................... xii
7. Regulation of blood glucose ................. 31
Foreword by Dr Stuart Brink................................ xiii
Counter-regulation............................................... 31
The liver................................................................ 32
1. Introduction.............................................. 1
Glucagon.............................................................. 33
Adrenaline............................................................ 36
2. Getting to grips with diabetes................. 4 Cortisol................................................................. 37
When you first find out you have diabetes........... 4 Growth hormone.................................................. 38
Very young children................................................ 6
Routine check-ups.................................................. 6
8. Hypoglycaemia ...................................... 39
Living the life you choose....................................... 7
Blood glucose levels and symptoms
of hypoglycaemia................................................. 42
3. Caring for your own diabetes.................. 8
Symptoms of hypoglycaemia when
Goals for managing diabetes................................ 8 the blood glucose level is high........................... 44
How can you achieve these goals?....................... 8 Severe hypoglycaemia........................................ 44
Becoming your own expert.................................... 9 Seizures................................................................ 46
Can you take “time off” from diabetes?............ 10 Does severe hypoglycaemia damage the brain? 46
Alternative and complementary therapies........ 11 Hypoglycaemia unawareness............................. 48
Rebound phenomenon....................................... 49
Too little food or too much insulin?.................... 50
4. Diabetes: some background................. 12
Night time hypoglycaemia................................... 51
Type 1 diabetes................................................... 12 Dawn phenomenon............................................. 54
Type 2 diabetes................................................... 13 Somogyi phenomenon........................................ 54
Other types of diabetes....................................... 14 Will low blood glucose levels return to normal if the
How common is diabetes?................................. 14 child doesn’t wake up?....................................... 56
Can you catch diabetes?..................................... 15 Can you die from hypoglycaemia?...................... 56
Does eating too many sweets cause diabetes? 16 Why does awareness of hypoglycaemia occur at
different levels of blood glucose?...................... 57
5. How your body works............................. 17
9. Treating hypoglycaemia......................... 60
Insulin................................................................... 18
Your body doesn’t realize it has diabetes.......... 20 Practical instructions:.......................................... 60
The anatomy of your body.................................. 21 Timing and hypoglycaemia.................................. 63
Pancreas.............................................................. 22 Helping someone with diabetes who
Islets of Langerhans............................................ 23 is not feeling well................................................. 63
Cellular metabolism........................................... 24 Glucose................................................................ 64
A healthy cell........................................................ 24 Fructose............................................................... 64
Starvation............................................................. 24 Sweets and hypoglycaemia................................ 65
Diabetes and insulin deficiency......................... 25 After hypoglycaemia............................................ 66
v
vi 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........................ 98
Does continuous finger pricking
10. Insulin treatment................................. 68
cause loss of feeling?.......................................... 98
Regular short-acting insulin................................ 69 Ketones .............................................................. 99
Intermediate-acting insulin................................. 69 Vomiting and ketones....................................... 101
Long-acting insulin .............................................. 69 Blood ketones................................................... 102
Intravenous insulin.............................................. 69
Rapid-acting insulin............................................. 70
12. The HbA test................................... 105
1c
Basal insulin......................................................... 71
New basal insulins............................................... 71 What level should HbA be?........................... 105
1c
Pre-mixed insulin ................................................. 72 How often should you check your HbA ?....... 108
1c
A larger dose lasts longer.................................... 72 Can my HbA be “too good”?.......................... 109
1c
Units and insulin concentrations........................ 72 HbA when travelling....................................... 109
1c
Twice-daily treatment.......................................... 73 Is it worth taking tests?.................................... 109
Three-dose treatment.......................................... 73 Fructosamine.................................................... 110
Multiple injection treatment................................ 74
Injections before meals (bolus insulin).............. 74
13. Injection technique........................... 111
When should you take your premeal dose?....... 75
Insulin pump......................................................... 77 Getting used to injections................................. 111
Can I skip a meal?............................................... 77 Injections for parents........................................ 111
Bedtime insulin.................................................... 78 Taking the pain out of injections ..................... 112
When should bedtime insulin of NPH Where do I inject the insulin?........................... 112
type be taken?..................................................... 78 Is it necessary to disinfect the skin?............... 117
When should the long-acting Storage of insulin.............................................. 117
injection be taken?.............................................. 78 Syringes............................................................. 118
Mixing insulins ..................................................... 79 Injections with syringes..................................... 119
Depot effect ......................................................... 80 Pen injectors...................................................... 119
How accurate is your insulin dose?.................... 80 Why aren’t all insulins available for pens?...... 120
Insulin absorption................................................ 80 Replacing pen needles .................................... 120
What happens if a child won’t finish a meal?.... 82 Different pens for day and night time insulin.. 121
What if you forget to take your insulin?.............. 83 Air in the cartridge or syringe........................... 121
What if you take the wrong type of insulin?....... 84 Insulin on the pen needle................................. 122
Having a lie in at weekends............................... 85 Used needles and syringes.............................. 122
Staying awake all night........................................ 86
Shift work.............................................................. 86
14. Injection equipment.......................... 123
Birthday parties.................................................... 86
Insulin at school and day nurseries ................... 87 Automatic injectors........................................... 123
Sleeping away from home................................... 87 Jet injectors....................................................... 123
Insuflon.............................................................. 123
11. Monitoring............................................ 88
15. Adjusting insulin doses.................... 128
How many tests should I take?........................... 88
“Good” or “bad” tests?........................................ 90 Starting insulin treatment................................. 128
Diabetes or not?................................................... 91 How much does insulin lower the
Are some things forbidden?................................ 91 blood glucose level?......................................... 131
Urine glucose....................................................... 92 What to do if your blood glucose level is high 133
Renal threshold ................................................... 92 Different ways of adjusting insulin doses........ 135
Blood glucose...................................................... 94 What about the food you eat?.......................... 135
How do I take blood tests?.................................. 94 Changing the content of the meal to
Borrowing someone else’s affect blood glucose.......................................... 136
finger-pricking device........................................... 95 Changing insulin doses.................................... 137
vii
Keeping good records....................................... 139 Having a lie in.................................................... 186
What is the best order for changing the doses? Travel tips........................................................... 187
(multiple injection treatment)........................... 139 Toddlers using pumps....................................... 187
Premeal bolus doses........................................ 140 Pregnancy.......................................................... 187
Insulin for breakfast.......................................... 140 Rapid-acting insulin in the pump...................... 188
Insulin for lunch and dinner/tea...................... 140
Insulin for evening snack.................................. 140
17. Side effects of insulin treatment..... 191
Holiday or weekday?......................................... 141
Physical exercise or relaxation?....................... 141 Pain..................................................................... 191
Using rapid-acting insulin Insulin leakage................................................... 191
analogues.......................................................... 141 Blocked needles................................................ 191
Adjusting the basal insulin................................ 143 Bruises after injections..................................... 191
High blood glucose levels................................. 143 Fatty lumps........................................................ 192
Hypoglycaemia................................................... 144 Redness after injections................................... 193
Exercise.............................................................. 145 Insulin antibodies.............................................. 193
Pre-mixed insulin............................................... 145 Lipoatrophy........................................................ 194
Switching to rapid-acting analogues................ 145 Insulin oedema.................................................. 194
Can you eat the same things as before?......... 148
Bedtime NPH insulin........................................ 149
18. Insulin requirements........................ 195
What should you do next?................................ 152
Blood glucose levels at night............................ 154 How much insulin does your body need?........ 195
Night time hypoglycaemia................................. 154 Puberty and growth........................................... 195
Using the basal analogue Levemir.................. 156 Remission (“honeymoon”) phase..................... 196
Using long-acting Lantus.................................. 156 Insulin sensitivity and resistance..................... 198
Puberty.............................................................. 158 Ideal insulin doses?........................................... 201
Insulin adjustments during
the remission phase......................................... 159
19. Nutrition............................................. 203
Hypoglycaemia................................................... 160
Experiment!........................................................ 161 Absorption of carbohydrates............................. 204
Emptying the stomach...................................... 206
Sugar content in our food................................. 208
16. Insulin pumps................................... 162
Taking fluids with food...................................... 209
Starting the pump............................................. 164 Dietary fats......................................................... 209
The basal rate.................................................... 166 Dietary fibre....................................................... 211
Temporary change of the basal rate................ 167 Glycaemic index................................................. 212
Premeal bolus doses......................................... 168 Milk..................................................................... 213
Change of insertion site.................................... 171 Vegetables......................................................... 213
More frequent home monitoring...................... 173 Potatoes............................................................. 214
Insulin depot with a pump................................ 175 Bread.................................................................. 214
Ketoacidosis ..................................................... 175 Pasta.................................................................. 215
Disconnecting the pump................................... 177 Meat and fish..................................................... 216
Taking a bath or shower................................... 177 Pizza .................................................................. 216
Pump alarm....................................................... 178 Salt..................................................................... 216
Occlusion or blockage alarm............................ 178 Herbs and spices............................................... 217
Leakage of insulin............................................. 180 Fruit and berries................................................ 217
Air in the tubing................................................. 181 Meal times......................................................... 217
Sick days and fever........................................... 181 Snacks................................................................ 217
Pump removal doses........................................ 182 Can mealtimes be changed?............................ 218
Admission to hospital........................................ 184 Hungry or full?.................................................... 218
Physical exercise............................................... 184 Infant feeding..................................................... 219
Using the pump at night only............................ 185 Carbohydrate counting...................................... 220
Is the pump a nuisance?.................................. 186 School................................................................. 223
Does using a pump cause weight gain?.......... 186 Party-time........................................................... 224
viii Type 1 Diabetes in Children, Adolescents and Young Adults
Special “diabetic” food?................................... 224 Drugs that affect blood glucose....................... 270
“Fast food”........................................................ 225 Teeth.................................................................. 270
Food at educational camps.............................. 225 Vaccinations...................................................... 271
Vegetarian and vegan diets............................. 225
Different cultures.............................................. 226
27. Smoking............................................. 272
Passive smoking................................................ 273
20. Sweeteners....................................... 227
Giving up smoking............................................. 273
Sugar free?........................................................ 227 Snuff................................................................... 274
Diet drinks and “light” foods............................ 230
28. Alcohol............................................... 275
21. Sweets, treats and ice cream.......... 231
Alcohol and the liver......................................... 275
How much extra insulin should you take?...... 232 Why is it dangerous to be drunk with
Ice cream........................................................... 234 diabetes?........................................................... 275
Chocolate........................................................... 235 Basic rules......................................................... 276
Weekend sweets............................................... 236 What if you’ve had too much to drink?............ 277
Taking a break from eating sweets................. 237 Can you drink at home?.................................... 277
Potato crisps...................................................... 239
Chewing gum..................................................... 239
29. Illegal drugs....................................... 278
22. Weight control................................... 240
30. Pregnancy and sexual issues........... 280
Satisfied or “feeling full”?................................. 240 Pre-pregnancy care........................................... 282
Reducing weight................................................ 241 Caring for the mother........................................ 282
The little extras.................................................. 242 How will the child develop?.............................. 283
High HbA and weight loss............................. 242 Will the child have diabetes?........................... 283
1c
Infertility............................................................. 284
Does the need for insulin change
23. Eating disorders................................ 244
during menstrual periods?............................... 284
Sexuality............................................................. 284
24. Physical exercise............................... 246 Contraceptives.................................................. 285
How do insulin and exercise work together?.. 247 Forgotten to take a pill?.................................... 287
Can the blood glucose level increase Emergency contraception................................. 287
through exercise?............................................. 249
Hypoglycaemia after exercise.......................... 250
31. Social issues...................................... 288
Physical education............................................ 252
Top level competitive sports............................ 252 School................................................................ 288
Keeping fit with diabetes.................................. 256 Day nurseries and child care............................ 290
Camps and skiing trips..................................... 257 Child care allowance......................................... 291
Anabolic steroids............................................... 258 Adoption............................................................. 291
Diving................................................................. 259 Choice of job or employment........................... 291
Military service.................................................. 292
Licence to drive................................................. 292
25. Stress................................................. 261
Driving and diabetes......................................... 293
Stress in daily life.............................................. 262 Insurance policies............................................. 295
Diabetes ID....................................................... 295
Juvenile Diabetes Research
26. Fever and sick days.......................... 264
Foundation International ................................. 296
Nausea and vomiting........................................ 265 Children with Diabetes...................................... 296
Gastroenteritis.................................................. 267 Diabetes Associations....................................... 296
Wound healing.................................................. 269 Diabetes UK....................................................... 297
Surgery............................................................... 269 Diabetes Federation Ireland............................. 297
ix
The International Diabetes Federation (IDF)... 297 The Stockholm study......................................... 324
International Society for Pediatric and Adolescent The Berlin eye study.......................................... 324
Diabetes (ISPAD)............................................... 297 The Linköping studies....................................... 324
The National Service Framework for Diabetes (NSF) The Hvidøre Study............................................. 325
298
Sponsor families................................................ 298
36. Research and new developments... 326
Diabetes camps and educational holidays..... 298
New treatments for diabetes.......................... 326
Diabetes and the Internet................................. 299
When does a young person become Implantable insulin pumps............................... 326
an adult?............................................................ 300 Blood glucose meters........................................ 326
Reimbursed accessories................................... 300 Glucose sensors................................................ 327
C-peptide ........................................................... 327
Vaccinations....................................................... 327
32. Travel tips.......................................... 301
Salicylic acid....................................................... 328
Vaccinations...................................................... 302 What causes diabetes?................................... 328
Ill while abroad?................................................ 303 An autoimmune disease................................... 328
Diarrhoea problems.......................................... 303 Heredity.............................................................. 330
Passing through time zones............................. 304 Environmental factors....................................... 330
Cows’ milk.......................................................... 331
Climate............................................................... 332
33. Associated diseases......................... 307
AGE.................................................................... 332
Coeliac disease.................................................. 307 Blocking the immune process......................... 333
Thyroid diseases................................................ 307 Immune treatment............................................ 333
Skin diseases..................................................... 308 Light treatment.................................................. 334
Infections........................................................... 308 Diazoxide............................................................ 334
Fungal infections............................................... 309 Nicotinamide...................................................... 334
Transplantation................................................ 335
Pancreas............................................................ 335
34. Complications in blood vessels....... 310
Islet transplantation.......................................... 336
What causes complications?............................ 310 Engineered cells................................................ 336
Large blood vessels........................................... 312 Other ways of administering insulin................ 336
Why are only certain cells damaged by a high blood Nasal spray........................................................ 336
glucose?............................................................. 312 Inhalation of insulin........................................... 336
Small blood vessels........................................... 313 Tablets................................................................ 337
Complications affecting Insulin as suppositories.................................... 337
the eyes (retinopathy)...................................... 314 Chemical alteration of the insulin molecule.... 337
Treatment.......................................................... 314
Disturbed vision at unstable blood
37. Psychology......................................... 338
glucose levels.................................................... 315
Glasses............................................................... 316 The onset of diabetes........................................ 338
Contact lenses................................................... 316 Diabetes rules or family rules?......................... 339
Complications affecting Making friends with your diabetes................... 341
the kidneys (nephropathy)............................... 316 Diabetes affects the whole family.................... 342
Treatment.......................................................... 318 Being a relative or friend of someone
Complications affecting with diabetes..................................................... 343
the nerves (neuropathy)................................... 318 Telling your friends............................................ 344
Treatment.......................................................... 320 How do you change your life style?.................. 344
Other complications......................................... 320 Diabetes at different
developmental stages..................................... 345
Infants (0-1½years).......................................... 345
35. Lowering the risk of complications.. 321
Toddlers (1½-3 years)....................................... 346
The DCCT study................................................. 321 Pre-school children (3-6 years)........................ 347
The Oslo study................................................... 323 Primary school children..................................... 348