The number of public toilets in England has fallen by 14% in a decade. There are now 15,481 people for each public toilet in England. Let’s hope they all don’t want to go at the same time!
In Scotland the level is 8,500 people per toilet and in Wales it is 6,748.
The shortage is causing people to have to urinate in public, according to the Royal Society of Public Health (RSPH). They say, “Access to a public toilet can be the difference at to whether someone can comfortably leave their house. For others, they can only go out if they deliberately reduce fluid intake.”
Whether councils provide public toilets or not is discretionary. Their funding power has dropped by 26% since 2010 and this has affected spending on public toilets. My comment: In my own area there has been a noticeable drop in activities for young people, libraries, and community hubs for people of all ages matched by increased expenditure on home care for the elderly.
The RSHP wants adequate toilet facilities to be funded centrally. They also want developers to include public toilets when they build non-residential buildings. They say, “We need to give local authorities the resources they need to provide the facilities we all rely on.”
My comment: People who have diabetes or other disabilities can obtain a key to unlock public toilets under the RADAR scheme. These are big blue keys and they cost £7.50. You register for one of them online. Google RADAR. One problem is that there are not that many toilets that are available under the scheme. An App that helps is Where is Public Toilet. This covers most of the world. It’s best to look for available toilets before you leave your home or hotel.Most places that serve food and drink provide toilets and they may let you use their facilities if you pay them, even if you are not a customer.
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Adapted from BMJ 11 October 2025
About half of all patients with diabetes will develop a symmetrical polyneuropathy but several other atypical nerve conditions can also occur.
Treatment induced neuropathy of diabetes is an acute and severely painful small fibre neuropathy that occurs with a steep drop in glycated haemoglobin levels.
Radiculoplexus neuropathies include lumbosacral, cervical, and thoracic forms, in which pain and weight loss are followed by weakness and sensory loss in the distribution of a single anatomical region.
Monophasic cranial neuropathies are caused by non-inflammatory microvascular ischaemia and present acutely followed by slow improvement.
Compressive neuropathies are when nerves are compressed.
There is more chronic inflammatory demyelinating polyneuropathy in patients with diabetes than in the general population, but definitive diagnosis is difficult to ascertain when diabetes is also present.
Diabetes now affects 9.3% of the world’s population, and half of them have typical symmetric neuropathy. Carpal tunnel syndrome affects 20-30% of diabetics. Cranial neuropathies affect 1% of the population which is ten times higher than in the general population. Over a five year period, about 10% of diabetics will get a treatment induced neuropathy. Lumbosacral neuropathy will eventually affect 1% of diabetics. Chronic inflammatory demyelinating neuropathy affects 0.7 to 10.3 people for every 100,000 people. It is the rarest type.
Treatment induced neuropathy is associated with a high rate of damage to the retina and kidney. It is thought that neuronal ischaemia and the release of cytokines damage the small blood vessels to the nerves.
Prior high blood glucose is the main risk factor for this type of neuropathy. Pain, and autonomic symptoms occur such as low blood pressure, gut dysmotility and sexual dysfunction. The usual age of onset is 25 in type one diabetes and 51 in type two diabetes. The faster the rate in improvement in blood sugars, the higher the risk.
The usual presenting problem is pain in the arm or leg within six to eight weeks of rapid blood sugar correction. The pain is usually in the glove and stocking distribution. Unfortunately the pain is often difficult to treat even with modern drugs such as tricyclic antidepressants, SSRIs, gabapentinoids, and sodium channel blockers. The condition and pain usually stablise over three years if the blood sugars can be kept in control and stable. Foot ulceration can become a common problem if the condition becomes recurrent due to blood sugar swings.
Radiculoplexus neuropathy is caused by a vasculitis of affected nerve roots, plexus and individual nerves in the back. Most people have pain. Rapid glycaemic control can be a pre-disposing factor. Leg weakness, foot drop, numbness and autonomic symptoms can occur. It usually stays one sided.
Post surgical inflammatory neuropathy is typically defined as a neuropathy occurring within 30 days of a surgical event. It occurs in non diabetics too, but more often in diabetics.
Multiple mononeuropathies can also occur in diabetics. This tends to affect the lower arm or lower leg.
Figuring out what type of neuropathy is occurring may be done on clinical history and examination, electrodiagnostic testing, MRI scans, blood tests, lumbar puncture, and nerve biopsy.
Most neuropathies require good blood sugar control to improve, may worsen for a period of time before improvement, and may need drug or other treatments and supportive aids such as braces and wheelchairs. Sometimes residual motor deficits such as foot drop can persist long term.
For Facial mononeuropathy a short course of oral steroids starting within 72 hours of onset may improve recovery.
GLP-1 based treatment for diabetes, weight control, and fatty liver disease is rapidly increasing. These agents also rapidly reduce HbA1c levels. A study was done to specifically look at the effects on type two diabetics and polyneuropathy risk on these agents. One group got the weight loss injection and the other got metformin and insulin. Over five years there was no difference in neuropathy diagnoses.
Our individual metabolic response to different foods types may influence our risks of developing diabetes and cardiovascular disease. Californian researchers decided to test 55 members of the general population after they had consumed various carbohydrate foodstuffs to see what the blood sugar response was over time.
Glucose levels typically peaked at about an hour and were highest for rice, potatoes and grapes. They noted that responses varied considerably between individuals however. Eating fibre, protein or fat before the carbohydrate reduced the size of the peak blood sugar compared with eating the carbohydrate on its own. This of course won’t be news to insulin users who need to check their blood sugar regularly.
Longest lasting blood sugar rises over 100 minutes Pasta-Potatoes-Bread-Rice
Shortest lasting blood sugar rises under 100 minutes Berries-Grapes-Beans
What can we make of this?
If you have a low blood sugar, grapes could be a good option if you don’t have juice or glucose tablets. Otherwise keep them for eating after a meal or with cheese.
In terms of diabetes control, both beans and berries are good options because they don’t raise your blood sugars very much and in addition the levels fall quickly too.
Pasta could be a good option if you are undertaking planned prolonged exercise as it raises the blood sugar moderately and lasts the longest in your system.
Rice, potatoes, and bread produce high blood sugar spikes, so if you like eating these, it is preferable to eat them with some sort of fat, and eat them after the protein component of your meal.
An Australian study has shown that people with both type one and type two diabetes are hospitalised for injury more often than the general population.
Most of these injuries happened due to falls.
People using insulin have 60% more chance of being hospitalised for injury. Type two diabetics who take sulphonylureas have also a raised risk.
My comments: These findings tend to indicate that hypoglycaemia is a cause of falls. There could also be other reasons. I recall visiting a woman who had two broken wrists. She had fallen in the street and had fallen off the kerb. I asked why she thought she fell. She said, “I can’t feel my feet.” As a fractured hip in older age is a major reason for losing independence it is important for diabetics to aim for as best blood sugar control as appropriate for them, but also to take care to reduce hypoglycaemia.
No excess prostate cancer has been found in hypogonadal men who were treated with replacement testosterone over 20 months follow up.
A randomised trial of 5,000 men found no difference in genital problems between the treated group and the untreated group.
The incidences of prostate cancer, acute urinary retention, prostatic surgery, and drug treatment for urinary symptoms were all low and no different between the groups.
My comment: This should be reassuring for those men who need to take testosterone for sexual health reasons and also to correct their hormonal status, as testosterone deficiency can be one cause of type two diabetes in older men.
Adapted from BMJ 4 Nov 2023 The Bottom Line: The time to tackle rising type 2 diabetes is T2DaY by Partha Kar consultant in diabetes and endocrinology Portsmouth Hospitals NHS Trust.
England’s 18-40 year olds with type two diabetes now exceed those with type one. In the not too distant past, type two diabetes was associated with middle age rather than youth. Causes for this increase include lifestyle, environmental and societal factors.
About 4% of people with type two diabetes are now under 40 years of age. Worryingly, this rise in type two diabetes is accelerating fastest in the under 40s. It tends to affect people who are socioeconomically deprived, are in minority ethnic groups, and in those with obesity. And the complications are aggressive.
There tends to be a greater risk of the vascular complications of diabetes compared to later onset type two diabetes. There are poorer pregnancy outcomes compared to type one diabetes. If you are diagnosed at the age of 30, you can expect to live 14 fewer years of life. At diagnosis, multi-morbidity is common and even if not present, can develop rapidly.
The 18 to 40 age group are often in education or working. They face transitions from the family home, to university or the workplace. Money tends to be tight. They are considering buying homes or renting. They may pairing off with partners, and they may already have a young family or be planning to start. Increasingly they can’t afford to buy a home, and put off having children till older ages.
There are now about 140,000 young adults with type two diabetes. It is important that the correct diagnosis is made at the outset, and that pregnancy planning and outcomes are prioritised. Dr Shivani Misra from Imperial College London, has published a Type 2 Diabetes in the Young programme that she hopes will be adopted in order to improve the outlook for these young people and their families.
Meanwhile, Government initiatives are needed to reduce socio-economic deprivation, improve healthy food options, improve space for exercise, and improve people’s motivation to look after themselves.
Nature has reported that an AI model called RETFound has been successfully trained to diagnose diabetic retinopathy from eye scans.
1.6 million unlabelled retinopathy pictures were used to teach the computer what a retina looked like. After this it was taught to diagnose specific conditions using a much smaller selection of images. The machine was excellent at diagnosing diabetic retinopathy and progress has also been made in teaching it to diagnose cardiac failure, stroke and Parkinson’s disease.
An analysis of data from 1.5 million people from 19 countries indicates that for every decade that someone is diagnosed with type two diabetes, they will lose 3 to 4 years of life expectancy.
In the USA if you are a 50 year old man, you would be likely to lose 14 years if you had been diagnosed at age 30, 10 years if you were diagnosed age 40 and 6 years if you were diagnosed aged 50, compared to someone who was not diabetic.
My comment: Given that there is a big rise in type 2 diabetes diagnosis in children and young adults, this is pretty concerning. Of course, there are ways to effectively manage the condition and even put it into remission. There are more effective drugs available but cutting out refined carbohydrates and regular exercise are two of the most effective thing that people can do for themselves.
Adapted from Medscape article by Peter Russell 6 Dec 2022
Children with type one diabetes have more school absences than classmates who do not have the condition, but difficulties with blood sugar control were linked to the most absences.
Despite lower attendances many children with type one diabetes achieve good exam grades and go on to higher education. But those with higher HbA1c levels were more likely to get poorer grades and found it harder to get a place at college level.
Cardiff researchers think that children who struggle with their glycaemic control could benefit from more clinical and educational support.
Researchers looked at over a quarter of a million children aged 6 to 18 and over a thousand children with type one diabetes who attended schools and colleges in Wales between 2009 and 2016. Factors such as the child’s household socioeconomic status, neighbourhood deprivation, sex and age were taken into account.
The results showed that type one children were absent for 8.8 sessions per year more than children without diabetes. Those with the best glycaemic control missed 6.7 sessions per year and children with the poorest levels of control missed 14.8 sessions.
Children in the quintile with the best glycaemic control got results 4 grades higher than those without diabetes at the age of 16. However for those in the lowest quintile of HbA1c control attainment was 5 grades lower than their classmates who did not have the condition.
Those with the best glycaemic management were 1.7 times more likely to gain a place in higher education than the general population whereas those in the lowest quintile for glycaemic management were 0.4 times as likely to go onto higher education than those who did not have type one diabetes. In essense those in the highest quintile were almost three times more likely to attend higher education than in the least optimal quintile.
Dr Robert French, one of the researchers was impressed that children with diabetes under adequate control were as likely to progress to higher education as their non diabetic peers even though they lost more school days to diabetes.
Overachievement for children with type one diabetes who effectively managed their glycaemic control could be due to factors unrelated to glucose levels and could reflect socioeconomic conditions, family support and effective self management.
Robert French et al. Educational attainment and childhood onset type one diabetes. Diabetes Care 1 Dec 2022 45(12) 2852-2851.
My comment: I know from my own experience of being a parent of a child with type one diabetes that the formulation of strictly kept routines around blood sugar testing, meals, homework, activity, and sleep made a big difference to my son’s blood sugar control and educational attainment. By my son’s diagnosis it had been already discovered that 9 out of 10 diabetic children had worse school attainment than average for their peers and that high blood sugars affected concentration, mood and memory. It would seem that for most diabetic children the educational gap has been greatly improved in the 20 years since. The overachievement affect is understandable when a child or young adult is given more family support, and this is usually maternal support, during their adolescent years, than is perhaps the case for non diabetic children. The adoption of a low carb diet makes glycaemic control much easier for all diabetics and this is even more important when the hormonal surges of puberty are causing glycaemic uproar, and the need to perform in exams can determine future career paths.
Q: Can you speak to the ability or inability to “cure” T2D? Does it have to do with the loss of the pancreatic beta cells?
A: Yes, it has generally been shown that new-onset type 2 diabetes is easier to “reverse,” meaning that blood glucose levels can be so well managed that it appears diabetes has been cured. Over time, a loss of some insulin-making capacity occurs in people with long-standing T2D, particularly if it has not been well-managed, related both to the impairment of pancreatic β-cell function and the decrease in β-cell mass. (PMID: 27615139)
Q: Isn’t insulin resistance now found to be in T1DM as well?
A: Yes, anyone can develop insulin resistance, and it occurs in at least a third of people with type 1 diabetes as well, although it is not always associated with excess weight gain or overweight. Since people with T1D lack insulin due to the body’s own immune system killing off the pancreatic β-cells, greater resistance increases the total doses of insulin needed (whether injected, pumped, or inhaled). Thus, they have developed characteristics of both types and have “double diabetes.” (PMID: 34530819)
Q: Under lifestyle goals, would you include stress management?
A: Stress management was not assessed in the large multi-center clinical trials on type 2 diabetes prevention, but mental stress can certainly raise blood glucose levels due to the greater release of glucose-raising hormones like cortisol and adrenaline. It certainly would be beneficial to address better ways to manage mental stress as part of lifestyle goals for optimal blood glucose outcomes. (PMID: 29760788)
Q: As each person has their own limitations, how important is it to get a physician clearance and exercise guidelines before working with the client?
A: It really depends on the person’s circumstances. How intense will the planned activities be? Is the person currently sedentary? Has he/she been getting annual checkups to monitor blood glucose management and to check the status of any complications? Does he/she have diabetes-related or other health complications that could be worsened by physical activity? The lower the intensity, the more active an individual has been, and the lower the risk for cardiovascular complications, the less likely medical clearance is absolutely necessary.
The latest ACSM Consensus Statement on activity and T2D will be released in early 2022 in Medicine & Science in Sports & Exercise and states, “For most individuals planning to participate in a low- to moderate-intensity physical activity like brisk walking, no pre-exercise medical evaluation is needed unless symptoms of cardiovascular disease or microvascular complications are present. In adults who are currently sedentary, medical clearance is recommended prior to participation in moderate- to high-intensity physical activity.”
Q: Can flexibility training be used for warmups, or do you recommend it only after the workout?
A: While it is possible to do flexibility training at any point during a workout, joints tend to have a greater range of motion after blood flow to those areas has been increased with a light or short aerobic warmup. It may be prudent to do a quick aerobic warmup, some stretching, the full workout, and then more extensive stretching afterwards for optimal results.
Q: Was there any particular protocol for strength training? sets, reps, periodization? What is considered “intense” resistance work? Would fatigue based off of several sets of moderate intensity be recommended then?
A: That is a tough question, and it depends on who you ask. I have seen a lot of debate over the optimal strength training protocol during the many years I have been in the exercise/fitness world. If people are just starting out with resistance training, they will gain from doing even a minimal amount of training.
Starting out with 1-3 sets of 8 to 10 main exercises that work all of the large muscles groups at a light to moderate intensity is considered appropriate for most older or sedentary adults, many of whom have joint limitations or health issues. Moderate intensity is considered 50%-69% of 1-RM (1 repetition maximum) and vigorous is 70%-85% of 1-RM. Both intensity (fewer reps at a higher intensity) and the number of sets (3-5) or days of training (starting at 2, progressing to 3 nonconsecutive days) can increase over 2 to 3 months. Periodization is usually not undertaken by older adults, but may be appropriate for younger, fitter ones.
Q: Do you have any insight or are aware of any studies that involve high intensity (%1-RM) resistance training and T2DM? Or any studies that compare resistance training volume (Sets x Reps x Load)?
A: Some older studies have determined that glycemic management is improved by supervised high-intensity resistance training in people with type 2 diabetes (PMID 12351469). Others have also found that home-based (and, therefore, unsupervised) resistance training results in a lesser impact on blood glucose levels, likely due to reductions in adherence and exercise training volume and intensity (PMID 15616225).
Q: I’m still confused about glucose response to acute exercise. Which is better if you want to bring down your BG right now? Can you speak to the possibility of increased blood sugars with intense aerobic exercise?
A: Most light-to moderate-intensity aerobic exercise will lower blood glucose levels, assuming that some insulin is present in the body. (People who are very insulin deficient may have a rise in blood glucose from doing any activity.) Any activity that gets up into the intense/vigorous range, even if only during occasional intervals, has the potential to raise blood glucose due to a greater release of glucose-raising hormones during the activity. This is particularly true if the activity is short and intense. In individuals with any type of diabetes, declines in blood glucose during high-intensity interval exercise are smaller than those observed during aerobic exercise.
That said, if someone wants to lower blood glucose right now with exercise, it also depends on the timing of exercise. Doing something light to moderate for at least 10 to 30 minutes is the best bet, particularly after a meal when insulin levels are generally higher. Avoid doing intense aerobic or heavy resistance training as those may have the opposite effect. For early morning exercise, any intensity can potentially raise blood glucose due to higher levels of insulin resistance then and lower circulating levels of insulin in the body.
Q: I had an endocrinologist say that long runs or walks are better, and another one said to do a bit of weights.
A: Which activities someone chooses to do should depend on the goal of the training. Is it increased fitness, lowering blood glucose levels acutely, or gaining strength and improving overall blood glucose management? Long, slow aerobic training does have the benefit of increasing cardiorespiratory fitness and lowering blood glucose levels (in most cases). Resistance training, on the other hand, increases muscular strength and endurance and helps people gain and preserve muscle mass, which is where most carbohydrates are stored in the body. It may not, however, lower blood glucose levels, at least not acutely.
Both have their place in a weekly training regimen. Insulin resistance is lowered for 2 to 72 hours following a bout of aerobic training. Resistance training has more of a long-term impact on insulin action by enhancing carbohydrate storage capacity. The best advice is to do some aerobic training at least every other day and some resistance training at least 2, and preferably 3, nonconsecutive days per week. These activities can be done on the same days or different ones.
