• Smoking of tobacco is now clearly established as a cause of atherosclerosis. Few authorities now dispute the evidence. There are however some interesting dietary aspects: Did you know that smokers tend to eat less fruit and vegetables compared to non-smokers (and thus eat less of the protective anti-oxidant plant compounds)? Did you know that smokers tend to eat more fat and more salt than non-smokers? These characteristics of the smoker’s diet may be caused by a desire to seek stronger food flavours as a consequence of the taste-blunting effect of smoking. While these dietary differences may make the smoker at greater risk of heart disease there is only one piece of advice for anyone who smokes: please stop smoking!

• High blood pressure causes changes in the walls of arteries. The muscle layer (remember an artery is not a rigid pipe, it is a muscular tube, which when healthy can change its size to control the flow of blood) becomes thickened and atherosclerosis is more likely to develop. Treatments for blood pressure have become more effective over the last thirty years, but it is only now becoming clear which types of treatment for blood pressure are also effective at reducing heart disease risk.

• Diabetes is caused by a lack of insulin—either the body does not produce enough or the body ‘demands’ more than normal (because It has become insensitive to insulin). In diabetes some of the chemical (metabolic) processes which take place tend to accelerate atherosclerosis. Diabetes may also result in raised blood fats. The increased risk of heart disease is a major reason why so much effort is put into achieving normal control of blood sugar in diabetic patients, and also why all people with diabetes should be checked for the other risk factors of heart disease.

• High blood cholesterol increases the risk of heart disease. Your blood cholesterol is determined by genetic (inherited) factors— which you cannot change—and lifestyle factors—which you can change. There are some relatively rare conditions in which particularly high blood cholesterol levels occur. People who have inherited these conditions need a thorough ‘work-up’ by a specialist doctor followed by life-long drug treatment. In most people high blood cholesterol is partly determined by their genes, which have ’set’ the cholesterol slightly high and lifestyle factors which push it up more. The most important dietary factor is fat. The Sets prescribed for blood cholesterol lowering are low fat (low saturated fat), high carbohydrate, high fibre diets. Body weight also affects blood cholesterol—in some people being overweight has a significant effect on the levels—attaining a reasonable weight can be helpful. The blood also contains triglycerides, another type of fat which is particularly high after meals. High triglycerides may be linked with increased risk of heart disease in some people.

• Overweight and obese people are more likely to have high blood pressure and to have diabetes. They are also at increased risk of getting heart disease. Some of that increased risk is due to the high blood pressure, and the tendency to diabetes, but there is a separate ‘independent’ effect of the obesity. When increased fatness develops it can be distributed evenly all over the body or it may occur centrally—in and around the abdomen (tummy). This central obesity is particularly strongly associated with the risk of heart disease.

Thus every effort should be made to get body weights nearer to normal – especially if the extra weight is ‘middle-age spread’.

• Exercise has several benefits for the heart. Cardiovascular fitness is improved by regular strenuous exercise and the blood supply to the heart may be ‘improved’. Exercise is also important in maintaining body weight and has effects on metabolism and some factors related to blood dotting. Getting regular exercise is clearly important.

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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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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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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 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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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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