Your attitude to a diet

Meals for people with diabetes need not be different from those of the family

Although a diet does involve restrictions on foods and careful measurement, it is important to remember that the meal itself may not really be very different from the ordinary meals the rest of the family are having anyway. It should be just as attractive and your child should enjoy his meals just as much as ever.

Once you are confident about the details and you are used to the measurements, eating out with friends or relatives, or at restaurants, will be no problem.

It is hoped that meal times will not be a battle to get the right foods in (though this can be a problem with any family, with or without diabetes). If he does not like a certain food it may be wiser not to insist that every mouthful is eaten, but rather to substitute something else for any uneaten food. You can consult your food lists to do this.

Your child’s attitude to a diet

Some children resent a diet

Some children take happily to a diet, accepting the restrictions when they are explained, and co-operating with their parents in the regulation of their meals.

Other children resent having these restrictions and badly miss the sweet foods or concentrated carbohydrate foods they are used to having.

All children are occasionally tempted to try something that is forbidden from their diet. Often they will feel guilty about it afterwards, particularly if they understand the need for the restrictions, or sense their parents’ disapproval.

It is not easy to be on a diet

It will be helpful to parents to consider how their child feels about these restrictions. He may feel the diet is a punishment, or he may feel singled out if all the rest of the family can eat differently. In any event, it is a pity to take a moral attitude yourself towards the diet. Some discipline is clearly necessary with the diet, but this will be most successful if tempered with an understanding of the temptations that may confront anyone on a diet.

If adults find it hard to be on a diet, it is not surprising that children do too, particularly if it is the favourite foods that are restricted or excluded.

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Air bubbles

Bubbles in the syringe when drawing up.

You should avoid bubbles in the syringe because they will lead to error in the correct measurement of the dose. Actually a few bubbles of air accidentally injected under the skin are not dangerous.

To get rid of bubbles, with the needle tip below the surface of the insulin, hold the syringe vertical, pointing up, and tap the side gently with your finger, so the bubbles come to the top. Now inject them into the bottle and draw the plunger back again. Repeat if necessary.

If using a mixture of two insulins, and bubbles enter when the second insulin is being withdrawn, you must discard the insulin and start again. This is unlikely to happen unless the tip of the needle is above the surface of the insulin in the bottle.

Air may also enter the syringe if the plunger is allowed to move while transferring the needle from the first to the second bottle of insulin.

Check these points if air has entered the syringe.

Leakage of insulin

Some insulin is ‘lost’ during injection.

If it happens, try to judge how much was lost. If only a small proportion is lost, do nothing, but if blood glucose levels become high during the day, phone your doctor in case a supplementary dose before tea is needed. If a lot is lost, and you are using single insulin (not a mixture) draw up an amount of insulin about half of what you think you lost, and give this. Then watch the blood tests during the day as above. If a mixture is being given it is usually better to give nothing else at the time, but to give a supplement of insulin at night. Contact your doctor or the clinic to discuss this. If you feel almost all the dose was lost, start again, but give a little less in case some did inject. It is always better to give a little less, and then a supplement during the day, than too much and risk a hypoglycemic reaction.

A skin lump

A superficial lump comes up in the skin while injecting. You are not injecting deeply enough. Perhaps you are entering the skin at too shallow an angle and sliding just under the skin. Push the needle in deeper. If this problem recurs, discuss your injection technique with your doctor or nurse.

Redness around the injection site

Occasionally an allergy may develop to the insulin, and this can lead to a rash or merely redness (like an insect bite) where the injection was given.

This may not affect the way the insulin works so that it is not an urgent problem, but if it persists or recurs discuss it with your doctor.

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Most toddlers are demanding, entertaining and exhausting even without diabetes. The development of diabetes adds a new dimension to the care parents have to provide for their child at this age.

This is an age when a child is developing independence with toileting and eating and sleeping. It is a time they want to do things for themselves before they are good at it, and this can cause frustration for a busy mother. Toddlers can make a lot of fuss as they develop independence from babyhood, and they can get angry if they don’t get their own way. It is also a time of high activity but then they become very tired. If they are at a creche or kindergarten or there are elder brothers or sisters, then they will also probably develop many respiratory and other minor infections. These lead to loss of appetite which makes a mother’s life more difficult. All these things happen with any toddler, but they also make it more difficult to care for diabetes.

Don’t expect perfect control of diabetes

How does this all affect diabetes? Most parents of a toddler find that perfect diabetic control is difficult – probably impossible to achieve because of variable activity, variable appetite and occasional infections.

Don’t worry – things improve greatly when they start school and relatively poor control at this age does not seem to have any long-term consequences. Regular visits to physician or diabetic clinic should help in assessing control and reassuring you that your child isn’t adversely affected by the varying blood glucose values.

Mealtimes should be pleasant, not a battle

How do you cope with a diabetic diet when a child has very variable appetite and a strong will of her own? By not being too rigid and not allowing mealtimes to become a battle. Offer the meal, help your child have her meal and enjoy the pleasure of your company at the mealtime, just as you would if she didn’t have diabetes.

If she doesn’t finish the meal in a reasonable time, don’t prolong the agony, but remove the plate and check how much of her carbohydrate exchanges have not been eaten. If it’s just a small amount this probably doesn’t matter – you can always monitor blood glucose values later and check they don’t get too low.

If quite a lot of food is left you could give a drink to replace some of the missed exchanges. Alternatively you may offer something an hour later, particularly if the glucose level becomes low. Don’t spend extra time on the meal because this can develop into a battle of wits, and it’s a fight you probably won’t win without a lot of fuss and bother.

Try not to let your child know you are concerned about the food being eaten; it just raises anxiety and may be used – unconsciously – by your child to gain more of your time and attention.

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Glucagon is prepared as a dry powder

Glucagon is manufactured as a dry powder. It deteriorates quickly after it has been dissolved as a solution, so it is stored as the dry powder, and sterile water is provided to dissolve it when it is needed. Do not mix until it is actually required.

How to dissolve the glucagon

A     Using glucagon hypo kit

1. Remove the cap from the vial. Remove the needle guard.

2. Inject all the sterile water from the syringe into the vial containing the tablet of glucagon. Do not withdraw the needle from the vial.

3. Shake the vial with the needle and syringe still inserted until the glucagon is completely dissolved.

4. Slowly draw the dose up into the syringe keeping the tip of the needle below the level of the glucagon solution.

     Using glucagon supplied with vial of water

1. Remove the protective caps from the rubber stoppers of both vials.

2. Use a 1ml. insulin syringe. Draw back the plunger to the 100 unit mark to fill the syringe with air.

3. Plunge the needle into the bottle of water and inject air into the vial in the same way as you would when drawing up insulin.

4. Draw up all the water into the syringe just as if you were drawing up insulin. Don’t worry about air bubbles – they don’t matter. Don’t worry if you don’t get all the water.

5. Now insert the needle into the vial with the powder of Glucagon and inject all the water into the vial.

6. Remove the needle and mix the powder with the water by inverting the bottle back and forth. Sometimes it is hard to dissolve, and if you leave the needle in the bottle you may lose some of the solution.

7. Put the needle back into the bottle (no need to inject any air) and draw out all the solution. Don’t worry if you miss a bit – the dose doesn’t need to be precise. Get rid of large air bubbles but small ones do not matter. They will cause no harm if injected beneath the skin.

Ñ     Injecting the glucagon

Now inject all of the Glucagon under the skin just like an insulin injection. Inject it anywhere that is convenient and where you inject insulin.

Glucagon may take five to fifteen minutes to work. As soon as your child wakes up a bit, give glucose or sugar or honey by mouth. Glucagon works only temporarily and you should give sugar as soon as possible and repeat this until the blood sugar value rises above 5 mmol/l.

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There are two commonly used test systems available for testing glucose in urine. These are Diastix and Diabur-Test-5000. Both work on the same principle. There is a plastic strip or stick that has a small square of chemical reagents at one end. When this is dipped in urine a reaction occurs between any glucose in the urine and the chemicals on the strip. The reaction takes a short while to develop, and at the end of that time a colour develops in the test square. This colour varies in shade and darkness according to the concentration of glucose in the urine.

By comparison of this colour with a series of colour blocks printed on the container, it is possible to judge how much glucose there is in the urine. This can be recorded either as a percentage or as an actual quantity.

Usually it is sufficient to judge if the test is negative (no glucose in the urine), a small amount or a large amount. A negative test suggests that the blood glucose is below 10 mmol/1. A small amount of glucose in urine suggests that the blood value is slightly raised. A large amount suggests that the blood glucose value could be quite high.

Urine that has been in the bladder for some time consists of urine made by the kidneys over this period. It is possible that the blood glucose value had been high earlier but has fallen to normal or low levels at the end of the period.

This would mean that the mix of urine over this period gives an average of the concentration of glucose in the urine. This could be helpful in assessing control over that period of time, but it is not particularly helpful in telling you what is happening at the time you do the test.

To avoid this problem you may be asked to test a ’second specimen’. This means emptying the bladder and discarding this urine first. Then wait ten to thirty minutes and pass a urine sample again. This is a fresh sample representing urine made by the kidneys over the past ten to thirty minutes. It is sometimes referred to as the ’second specimen’ and is the sample that you test.

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This is the most common reason why you may have elevated cholesterol levels. This is good news because it can be easily corrected. A high intake of fat and cholesterol in the diet is usually blamed for elevated blood cholesterol, but as you will learn, sugar and an excess intake of carbohydrate and trans fats are the real villains. Any excess calories we consume can be converted into cholesterol and triglycerides therefore if you eat too much and become overweight, you raise your risk of heart disease. Changing what you eat is your most powerful weapon against heart disease.

Excess Carbohydrate

Today it is common for most people to eat a lot of carbohydrate. This is found in foods such as grains, cereals, starches and sugar. One reason for this is because we are constantly told to reduce our fat intake; we must eat something else to replace fat, and usually this means eating more carbohydrate. Another reason is because many people are addicted to carbohydrate. Sugar is addictive, and the more we eat it the more we crave it. Carbohydrate rich foods are also quick and convenient. A common diet may consist of toast or cereal for breakfast, a sandwich for lunch, pasta, rice or potatoes for dinner, and biscuits, crackers or other sweets as snacks – not forgetting sugar in tea or coffee throughout the day.

It is true that we need carbohydrate for energy, but most of us are not athletes, and our sedentary lives never allow us to burn off this carbohydrate. Instead it is converted into body fat. It is also true that we are better off consuming complex carbohydrates, meaning it is better to eat wholegrain bread and pasta, and brown rice instead of their white, refined alternatives. However, this still usually results in too much carbohydrate in the diet, which is broken down into glucose.

When we get an excess of glucose into our bloodstream our body converts it into fat. Therefore, a high carbohydrate intake stimulates the production of fatty acids, which are joined together to form triglycerides. A high alcohol intake also raises cholesterol and triglyceride levels. You will learn that triglycerides are a major risk factor for heart disease. We all know that saturated fats are a really bad type of fat for our hearts. In fact not all saturated fats are bad. It is the long chain saturated fatty acids that are bad for our heart because they are sticky, and can therefore clog our arteries. You do not have to eat any fat at all to have high blood levels of these saturated fats because our body makes them out of excess sugar in our diet. These fats can then be converted into cholesterol. So now you know that eating too much sugar, starches and grains can raise your levels of cholesterol and triglycerides, putting you at great risk of heart disease. If you do not burn off this extra fat through physical activity, you will not only appear overweight; fat deposits will accumulate in organs such as your liver, pancreas, heart, kidneys and other organs. Fatty degeneration of organs can occur as a result of excess sugar intake. Fatty liver disease now affects approximately 20% of the population.

Trans Fatty Acids

Some fats are good for our heart, some fats are bad, and some are terrible. Trans fatty acids are the worst kind of fat you could eat. You may have heard of these fats, as they have been receiving a lot of publicity lately. They are believed to greatly increase the risk of heart disease and cancer. For now just briefly, unsaturated fatty acids in their natural state have a cis configuration. This means that at the position of the double bonds between carbon atoms in the fatty acid molecule, both hydrogen atoms attached to the carbons are on the same side of the molecule. In trans fatty acids, the hydrogen atoms attached to the carbons are on opposite sides of the molecule. The word trans means across, or on the other side, so if you were going on a trans Tasman holiday you might be going from Sydney to New Zealand.

The twisting of the unsaturated fatty acid molecule to create a trans fat occurs when the oil is heated to high temperatures, such as during frying and deep frying, and also during the commercial manufacture of vegetable oil and some margarines.

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•     The blighted-ovum problem can be prevented, at least to some extent, by freezing the man’s semen in a deep-freeze in a laboratory. When unfrozen, most of the poor-quality sperms will have been killed off and the couple’s chances of a successful pregnancy greatly increased.

•     Cervical problems can almost all be prevented. Gynecologists should be very cautious and gentle when dilating the cervix to do an abortion or a D&C, using only the smallest dilator they need to. Better management of labour, with the woman in an upright position (sitting, squatting, kneeling or standing) will greatly help reduce cervical trauma during birth.

•     Perhaps the greatest single preventive for cervical problems is the use of a special stitch put in by a gynecologist at about 14 weeks. This holds the cervical canal closed and keeps the baby safely inside. The stitch is removed at about 38 weeks, or earlier if the woman goes into labour before this.

•     Hormone treatments can be given to prevent hormone-deficiency states that cause miscarriages.

•     The surgical correction of uterine abnormalities and the removal of fibroids can prevent miscarriages in some of the women in whom these are a problem.

•     Supportive psychotherapy should be more widely offered to any woman who has had more than one miscarriage because it works in a significant proportion of women.

•     We look in some detail at how to prevent congenital abnormalities in babies on page 294.

•     If any woman has a history of miscarriage or premature labour it makes sense not to have intercourse (or even, probably, orgasms) around the time at which she previously had the miscarriage. If you are worried about a miscarriage, don’t have sex or an orgasm in weeks 10-14 of the pregnancy. There is no evidence that using a vibrator inside the vagina causes miscarriages, but it is probably sensible to steer clear of them around this vulnerable time.

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Spirituality deals with the big questions. But what exactly is spirituality? That’s one of the biggest questions of all.

A review of 250 articles and studies dealing with spirituality revealed that 75 percent defined spirituality as a personal philosophy of meaning, say the creators of a course in health-care spirituality at the University of Tennessee, Knoxville, College of Nursing. But this is only part of the story, reported the course creators.

How does one know if he is being spiritual? Management consultant Dr. Krista Kurth says that spiritually inspired actions share the following six traits.

1.     They are motivated by an internal attitude of love.

2.     They involve giving – or serving others – with no expectation of personal gain. Simple, wholehearted service for others’ sake.

3.     The elements of compassion and humility are present.

4.     The effort involves some degree of difficulty to make because it requires that we transcend our own narrow self-interest.

5.     A conscious, ongoing process of growth and learning must take place in order for us to live more fully and express the spiritual aspects.

6.     The actions involve spiritual practices or other consciously performed rituals that require commitment, discipline, and effort.

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As a physician who has treated hundreds of patients with eating disorders over the past fifteen years, I much prefer the “no-fault” approach to managing eating disorders. Simply put, if you have an eating disorder, or if you are the parent of an anorexic or bulimic child, don’t condemn yourself: You are not to blame.

“Fault” and “blame” are unnecessary-even harmful-concepts. They result in mental roadblocks, such as: “I am sick [or my child is sick] because I am a bad person [or parent]. If I could just snap out of it [or fix the problem], I could make myself [or my child] well.”

Thinking in terms of “fault” is counterproductive. You don’t suffer from an eating disorder because you are “bad” or because you are “not trying hard enough.” On the contrary, I believe you are actually trying very hard to deal with the stresses in your life. Unfortunately, the method you have chosen-starvation or rigid dieting or purging-is just making your problems worse.

People who skip meals to lose weight often succumb to the urge to binge. They wind up eating more than if they had just stuck to the old three-square-meals-a-day formula. Learning to then purge as a way to exert “damage control” over bingeing makes it that much easier to binge in the future, leading to a vicious cycle. Some girls starve themselves as a way of coping with their fears of growing up. The damage starvation does to their bodies may delay their physical and emotional development, but it can’t stop the process of growing older. Rather than helping to overcome the challenges of maturation, an eating disorder can cause physiological havoc that leads to disease, more mental turmoil, and sometimes even death.

Someone on the outside might wonder why people try to cope with their pain through such misguided means as disturbed eating. The answer, I think, is that often they fear their lives will just get worse if they don’t do something-anything. The problem thus arises not from lack of effort but from using the wrong tools. In a time of stress and change, they seek to control one basic element in their lives-food-somehow believing that if they can control their eating habits, they can keep all their other troubles at bay. Attempting to force the body to ignore its inherent biological rules of eating, however, is like believing you’ll always win at gambling in Las Vegas-eventually the “house” always wins.

I conceive of eating disorders as arising, not from some inherent flaw within a person, but from the clash between social values and biological drives that exist within an emotionally vulnerable individual.

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You’ve probably heard that old admonition to think before you speak. Well, Sue McGovern thinks before she eats—and it has helped her maintain a 30-pound weight loss for 20 years.

Sue, a 42-year-old resident of Shillington, Pennsylvania, never paid much attention to her food choices while she was growing up. “It was nothing for me and two or three of my friends to devour a half-gallon of chocolate-almond ice cream and a 12-pack of doughnuts in a sitting,” she says. “We didn’t think of these episodes as binges. They were simply a way of life.”

For Sue, that way of life eventually started showing on the scale. By the time she was ready to enter college, she weighed 175 pounds.

“But because I was tall and in reasonably good shape, I never looked fat—just big,” she recalls. ‘

In college, Sue didn’t have a car, so she traveled everywhere via *i foot, bike, or skateboard. To her pleasant surprise, she began losing © weight without changing her eating habits. She was down to 155 pounds when she graduated.

But once Sue started working full-time, her active lifestyle ground to a halt. “That’s when I realized that I had to make better food choices if I didn’t want to regain the weight that I had lost,” she says. “I read all that I could about good nutrition and healthy eating, and I changed my eating habits accordingly.”

For the first time in her life, Sue began thinking about what she was putting in her mouth. She stopped eating for the sake of eating and instead chose foods with the greatest nutritional value. Red meat, chips, chocolate, and other high-fat, high-calorie foods disappeared from her diet. Grains, vegetables, and tofu became her staples of choice. “I discovered all kinds of healthful foods that I’d never had before,” she said. “I was intrigued by tofu, sprouts, and herbs. And I spent hours picking berries and wild nuts.”

Through a combination of healthier eating habits and daily exercise—jogging was her activity of choice—Sue managed to take off another 10 pounds. Her weight has remained in the range of 140 to 145 pounds for about 20 years.

WINNING ACTION

Ask yourself, “Is this good for me?” Sometimes, our food choices become so ritualized that we never consider what’s in them or how they’re affecting our bodies. The next time you reach for a snack or sit down to your “usual” meal, ask yourself whether the food has any nutritional value. If you’re looking at a plateful of nothing but calories and fat, choose something else. You and your body deserve better.

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