Why do people get heart disease? Atherosclerotic heart disease develops early in life when the many factors that cause it have a strong influence. Over many decades doctors and scientists have identified the processes in fine detail and now most of the factors which cause heart disease are well known. Theoretically this type of heart disease might be largely prevented if everyone’s risks were assessed in youth and if all the right things were done throughout the rest of their lives. In practice there has been only a limited development of the ways to screen people for risk early in life, and the resources needed to achieve prevention are just not available. However a great deal is already being done to identify risk factors in healthy people and those with established heart disease. Those who take the necessary action reduce their risk.

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Carbohydrates are controlled carefully by a system of exchanges

We control carbohydrates because they are an immediate source of glucose and if not controlled will lead to varying glucose levels in blood. Carbohydrates are controlled by an exchange system. This system allows you to choose the carbohydrates in the meal but keep the total amount the same.

In the diabetic diet, approximately half the energy (calories or joules) should be provided by carbohydrate. The amount of carbohydrate in the diet is referred to as the number of exchanges, where one exchange is equal to a serving of food that contains 15 grams of carbohydrate.

One exchange of carbohydrate foods equals one exchange of another carbohydrate food and so they are interchangeable. It is very important that the amount of carbohydrate (or number of exchanges) stays as constant as possible each day.

You will be advised on the number of exchanges of carbohydrate for each meal, and the best balance between the various carbohydrate groups.

As the child grows or becomes more physically active, the number of exchanges per day will be gradually increased. When growth stops at the end of puberty and if the child becomes less active at that time, the number of exchanges may be reduced.

Protein and fats are taken in moderation and may be controlled

Careful measurement of protein and fats may be important in older persons with diabetes and those who are over-weight. This is because both protein and particularly fats are a major source of energy as calories or joules.

With young people it may not be important to be so precise in allowances of these foods as a rule. It is however sound nutritional advice that excess fats should be avoided as they may be bad for health. Excess protein in the diet may lead to poor diabetic control. The body does have the ability to convert the excess protein and fats into glucose and also store this energy as body fat.

Refined carbohydrates as high sugar foods should be avoided

There are many foods and drinks which have a high content of sugar. Unfortunately these are often favourite foods of children, but they are not normally suitable in the diet for a person with diabetes as they may lead to high levels of glucose in the blood. They hardly satisfy appetite well and they are not necessary from a nutritional point of view.

There are special occasions however when sugar-containing foods are helpful for a person with diabetes. This is particularly when the blood glucose falls too low or when given before extra activity to prevent hypos. They may also be helpful during illness particularly if there is vomiting when your child may not be able to take the ordinary diet.

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The upper outer surface of the thigh, the upper outer surface of the buttocks, the upper outer surface of the upper arm and the front and lower surface of the abdomen are all suitable places for injection insulin.

It is a good idea to change the site of the injection each day, so that it is not always given at the same spot. If insulin is repeatedly put in the same spot, a lump may develop which can be unsightly, and the insulin may be poorly absorbed. On the whole it is usually best to use the buttocks and thighs in young children. These areas are covered by clothing and possible marks or swellings from injections will not be noticed. Most young children seem scared of the abdomen, but this area is often preferred by older people.

Injection in the arm of young children who have very little fat can lead to unpredictable absorption of insulin, as some of the insulin may be injected into muscle which is close to the skin in slim people. Insulin is absorbed more rapidly from muscle than from fat beneath the skin, especially with exercise.

Methods of injection

How you give the injection

1. Ensure the skin is clean. In hospital it is routine to swab the skin with an alcohol swab; this is important because there is always a possibility of unusual hospital germs. At home, many people also advise cleansing the skin with cotton wool dampened with methylated spirits or an alcohol swab. This is probably not really necessary. If the skin is dirty, soap and water and thorough drying is just as good. It is not possible to sterilize the skin with alcohol swabs or methylated spirits, as most of the germs live deep in the skin.

Perhaps the best advice is; be as clean as possible in giving the injection and don’t expect the skin to be sterile – just clean.

2. Pinch up a fold of skin. Now pick up a broad fold of skin between finger and thumb and hold it firmly. This steadies the skin and makes it easier to inject.

Inject at a steep angle

3. Hold the syringe in the other hand. Now push the needle firmly at a steep angle of about 60-90 degrees through the skin into the tissues beneath it. A firm thrust of the needle is easier and hurts less than a very slow cautious insertion. There is no danger of ‘going too far’.

Draw back on the plunger

4. Let go your hold on the skin and use that hand to support the syringe. With the other hand gently pull back the plunger as if trying to withdraw it. Check that no blood enters the barrel, as this would mean the needle is in a blood vessel. If blood should enter the syringe when you pull back the plunger, immediately pull the needle out and inject into another spot.

Push the plunger in

5. Provided blood does not appear (and it probably never will) push the plunger firmly and steadily in so that all the insulin is injected. Now pull the needle straight out.

A drop of fluid or blood emerging onto the surface of the skin after pulling out may be noticed, but does not matter.

Care with the needle and syringe

Now put the cap back on the needle if you intend to use the syringe a second time and store it carefully. Otherwise dispose of it safely, preferably break off the needle so that it cannot injure anyone. A rigid container such as a plastic juice container is useful.

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Your approach should be one of regarding your child as normal, and helping him to feel that way too.

Do not give special consideration or favours.

Discipline him and punish him when necessary as you would your other children. Be careful and sensible with him when he gets sick with childhood illness, but do not over-treat him or ‘mollycoddle’ him.

Be optimistic – but do not promise a cure

It is right to be optimistic about the future. Diabetes cannot at present be cured, and may cause some problems in later life, but efforts in modern research are enormous and are repeatedly leading to advances in knowledge and treatment. However, do not hold out hope to yourself or your child that he may be able to stop insulin injections. The chances are he will not and constant hoping may lead ultimately to disappointment and frustration.

You will find it helpful to keep yourself informed about what is going on in research. Read articles in diabetes journals attend seminars and meetings for people with diabetes and their families. In this way, you will maintain your optimism as you hear about progress. It will also give encouragement to your family by demonstrating your active interest.

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If a severe hypo occurs, check the following possible causes:

1. Was all the diet taken, and at the right time?

2. Was the dose of insulin measured correctly?

3. Has there been extra physical activity that day leading to the burning up of more glucose in the body?

4. Has there been some digestive upset, perhaps with diarrhea or vomiting, leading to poor absorption of the food?

Check the diet. Check sugar for activity

If any of these factors has been the cause of the reaction, then prevention of further reactions should be possible by attention to the cause. Perhaps a review of the measurement of diet is needed, and a talk with the dietitian may be helpful. If extra activity was the cause, then the child should remember to take more sugar or other carbohydrates next time he has such activity. If it was due to a digestive upset, then substitution of emergency fluid feedings for the usual diet may lead to better absorption.

Does the insulin dose need reducing?

If none of the above factors was present, then it may be the insulin dose needs reduction. Have blood tests been low recently? You should discuss this with your doctor, but at all events a reduction of 2 to 4 units of insulin at a time is usually sufficient.

An occasional mild hypo is not harmful

If you can find no reason at all for the hypo reaction (and this is quite possible) then you may wish to discuss it with your doctor, but an occasional mild reaction does have to be expected and should not be a source of worry.

Just be sure that you and your child give as much attention to the details of the treatment regimen as possible.

Remember also that hypo reactions, though unpleasant and perhaps alarming, are not dangerous if treated promptly. With growth, maturity and experience they should occur less and less and perhaps be entirely preventable.

Glucagon

Glucagon has the opposite effect to insulin; it raises the glucose level in blood. Glucagon is given by injection.

Glucagon is a hormone which, like insulin, is normally produced in the pancreas. It has the opposite effect to insulin however, and it can release glucose from stores in the liver and thus raise the blood glucose level. It can be injected under the skin like insulin with an insulin syringe and needle, or using the syringe provided.

It is therefore a very useful material, as it can be used in children who have a severe hypo reaction if they are unable to take sugar by mouth.

Within 10 to 15 minutes a person with diabetes who has been unconscious or unable to swallow will usually return to consciousness so he can then take sugar by mouth. Parents can give this injection without trouble.

Give sugar after the glucagon

It is important to give sugar by mouth as soon as the child is able to take it, giving it the same way as for any severe insulin reaction.

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Urine test for glucose

Before blood tests became generally accepted as the best method for monitoring day to day control of diabetes, urine tests were used to check the level of sugar in urine as a rough guide to the blood glucose levels.

The basis of this test was that when blood glucose values rose over approximately 10 mmol/1, glucose overflows into the urine where it can be detected. The higher the blood glucose values and the longer the period that they were too high, the more glucose is passed in the urine. Thus a rough estimate of control was based on a concentration of sugar in urine.

Clearly this test was very helpful but not really reliable. It was found that sometimes the blood test and the urine test didn’t agree. A negative urine test moreover tells you that the blood glucose value is not too high but it doesn’t tell you whether it is too low.

Some children find blood tests too painful and prefer urine tests. Sometimes parents find that a urine test is helpful as an extra check before bed to ensure that the blood glucose is high as a reassurance that a hypo is not likely to develop. Sometimes it is useful to have a urine test as a stand-by if the blood glucose meter breaks down. Some physicians find urine glucose tests provide helpful additional information to assess control.

For all these reasons it may be helpful to know about urine tests for glucose, though it is quite possible you won’t use them.

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