Resilience matters most for young and old when it comes to living with diabetes

Pic thanks to Diabetes UK

The Journal of Health Psychology have recently ran a series of articles showing that a positive attitude towards coping with chronic illness gives a better quality of life.

Adolescent type one diabetics who felt competent in their self- care, were optimistic and had high levels of self- esteem coped better than those who did not share these characteristics.  Low resilience was associated with higher distress, poor quality of life, maladaptive coping strategies and poor glycaemic control.

Older adults of low socioeconomic status who had low resilience had an increased risk of diabetic neuropathy compared to those in the same financial straits but with higher resilience.

As a GP I see some children struggle with diabetes and I know that their poor glycaemic control will have devastating consequences in future years.  Most of these children have parents who are struggling to cope with their lives, regardless of the diabetes, and don’t seem to be able to make the highly structured changes that are necessary to manage the condition really well. To make matters worse they often miss clinic appointments. There are liaison nurses who do house visits and psychologists who try to help. Proper (not current NHS!)dietary advice would help and even meal provision with portioned carb and protein counts would be one way to help these families. After all, meals are made available free to some pensioners and surely this would be cheaper on the long run than dialysis and the dropping out of the job market that early complications often bring.

(Research findings from Jounal of Health Psychology 2015 20,9, 1196-1206 and 1222-8 from Human Givens Volume 22, No 2, 2015.

Bye-Bye Diet Coke

Get thee behind me Satan...
Get thee behind me Satan…

It’s now… ooh, it’s now 10 days since D-Day, otherwise known as the day I kicked the Diet Coke.

As a type 1 diabetic who follows a low-carb diet most of the time (not all of the time, as I’m not perfect and I find the occasional pull of the chocolate/bread temptation too hard to resist), in theory Diet Coke shouldn’t pose a problem. It’s sugar-free and carb-free after all.

But drinking Diet Coke in the quantities that I did (one-and-a-half litres a day) definitely suggests addiction and who wants to be an addict?

Google “giving up diet coke” and you’ll find lots of forums and discussion threads where people discuss their addictions. Other diet drinks are mentioned, but it’s Diet Coke that seems to form the commonality – suggesting that there is indeed something addictive in Diet Coke, even if that is just its psychological pull.

Continue reading “Bye-Bye Diet Coke”

Can your job cause type two diabetes?

A  study of English civil servants has shown that those who earn the least are almost twice as likely to get type two diabetes than those who earn the most.

The ones who earn the least are also over one and a half times more likely to be obese and also one and a half times more likely to pursue an unhealthy lifestyle. This lifestyle includes a group of factors including smoking, drinking excessively, having a poor diet and being physically inactive.

The group comprised of over 7000 adults and equal numbers of men and women and measurements were repeated over an average of 14 years. The authors of the Whitehall II study, do not discuss what the reasons may be for the associations but I can think of a few possibilities.

Healthy food such as meat, fish, eggs, cheese, butter, olive oil, fruit and vegetables cost a lot more than unhealthy food such as sausages, sausage rolls,  bread, pasta, pizza, chips, burgers,  vegetable oil and margarine. As you will know from our book, the cornerstone to preventing weight gain and controlling diabetes is a low carbohydrate diet that is plentiful in protein, vegetables, some fruit and naturally saturated and mono-unsaturated fats.

I’m not sure if the studied civil servants all worked in central London or not. If they did, it would be logical for those who earned more to be able to afford housing nearer their place of work, thereby having to spend less time commuting.

Spending more time travelling to work each day certainly can eat into time that could otherwise be spend on planning meals, shopping and undertaking planned exercise. Being able to have flexible working hours can also help people spend less time commuting and undergo less stress while they do so.

As employees rise higher in the civil service the annual leave time allowed tends to rise as well as the pay. This could also affect the time that could be spent on exercise as well as enjoyable pursuits.  As we know, many exercise options are free, but some are not, and with poor weather outside, exercise plans can slide.  Being able to go to a gym, tennis club or golf course can provide a social outlet as well as an opportunity to exercise. Exercise helps improve mood and relief stress as well as being an opportunity to gain muscle and being able to eat more calories a day and get away with it.

What about smoking and drinking then? Why are these behaviours more common in those who are paid less?

It has been known for a long while that those with less money tend to smoke more.  As for drink, the more affluent can certainly put away plenty of drink too, particularly the more affluent, executive middle class woman, compared to her shop assistant or factory working sister. Greater workplace stress and difficulty with the elusive work/life balance are thought to be factors for the higher earning woman.

What about mental health factors? It has been found that the lower choice someone has about their job role the higher their stress and the greater their chances are of becoming depressed. Perhaps the lower the job status the less autonomy civil servants have at work?  From my work in the police force and the NHS I have seen the opposite scenario as well. I have seen very able people refuse promotion because of the necessity to do a lot of unscheduled extra work and take on responsibility that seems relatively poorly rewarded financially as people rise up the hierarchy.

Television watching also tends to increase the amount of sugary food and drink consumed across all age groups according to a study. Do the more affluent watch less telly? Perhaps having a dining table and using it for family meals can be a factor in reducing our waistlines?

The reasons for the socio-economic differences in the causation of type two diabetes are up for discussion. But also up for discussion is what can we do to lessen the chances of being affected?

Being aware that your job could be putting you are more risk of type two diabetes is a first step. How can you get more control over how you do your job? Can you get flexi-time so as to make home arrangements and commuting less stressful?  Can you eat in a more healthful way? Can you make more time for exercise or incorporate physical activity into your working day? Are those self- soothing habits such as smoking, drinking and watching the telly stealing years from your life?

Sadly it looks like the workplace subsidised canteen and gym perks are becoming less likely rather than more likely. I would not be surprised to see these socio-economic differences between civil servants greatly amplified between people who are unemployed and those workers who are just scraping a living wage compared to  more affluent workers. And where type two diabetes goes so does the increased rates of complications, cardiovascular disease and cancer.

Based on Contribution of modifiable risk factors to social inequalities in type 2 diabetes: prospective Whitehall II cohort study. Silvia Stringhini et all. BMJ Sept 12 and BMJ learning module: The effect of television watching on dietary intake.

Bariatric surgery better than diets for sustained weight loss

Bariatric surgery has been shown to be the most effective treatment for substantial and sustained weight loss with a significant reduction in obesity related conditions and long term mortality according to the National Confidential Enquiry into Patient Outcome and Death 2014. Bariatric surgery operations are likely to become more popular as a result.

Bariatric surgery is particularly helpful for diabetics because it can greatly improve blood sugar control and even induce complete remission of type two diabetes. NICE recommends that those with a body mass index over 30 who have had diabetes for under ten years are considered for the operation. Asians may be considered at even lower BMIs.  Simple observation will demonstrate that there are many more people eligible for these operations than can currently be dealt with on the NHS. Indeed currently just under a third of patients pay for the operations themselves.

There are various types of surgery. Some reduce the area of the stomach like the laparoscopic adjustable band,  and some reduce absorption of nutrients like the sleeve gastrectomy. Some are a mixture of the two like the Roux-en-Y gastric band which is the commonest procedure that also produces the greatest weight loss.

Excess weight loss can be as high as 58% with patients’ weight levelling off after two years. Weight gain can recur and this can be due to not following the diet or a surgical failure than needs adjustment.

Once referred to a bariatric clinic the advantages and disadvantages of the various types of surgery is discussed. Psychological support and dietetic support is given. I recall that a bariatric surgeon told me that people referred to his clinic had very marked self- esteem issues and often defaulted from the clinic.

The short term problems after surgery include wound infections, vomiting, intolerance to pureed meals, problems swallowing and leaks at the staple lines for some operations.

Long term patients will need to continue to restrict calories and take multivitamins.  Acid suppression therapy is often required and patients should avoid non- steroidal anti-inflammatories. Gall stones may occur and may require surgical removal.  Hair loss may occur but is temporary.

After a Roux-en-Y operation calories are restricted to less than a thousand a day.  Patients have to take a protein rich diet so they do not become deficient. Iron supplement are particularly needed by women. Most people require vitamin B12 injections every 3 to 6 months. B vitamins, calcium and vitamin D, and the fat soluble vitamins A, D, E and K may be needed.  Annual checks of full blood count, electrolytes, liver function, glucose, iron, ferritin, vitamin D, B 12, calcium, parathyroid hormone, thiamine, folate and selenium are required.

The good news for diabetic  is that blood sugars often improve a great deal and for many  return to normal. Thus insulin and drug requirements will lessen or even stop.  Blood pressure, lipid problems and obstructive sleep- apnea also improve or resolve.

Women may find that they are able to conceive after bariatric surgery but this is discouraged for about 18 months after surgery because of the rapid weight loss and nutritional deficiencies that are common at this time. There is more risk of pre-term and small for age births in women post- surgery.

It can be seen that should the number of surgeries be increased to anything like what is required to deal with the obesity/diabetes epidemic, that resources for long term follow up of these patients will also need to be improved. Support for General Practitioners  will be needed, particularly as there is not sufficient structured follow up, particularly for those who have had operations out with the NHS and even abroad.

Based on article by Vamshi P Jagadesham and Marion Sloan from Sheffield in British Journal of General Practice August 2014.

Top 10 Countries – Rates of Diabetes

syringeA recent post on looked at the rates of diabetes in other European countries – and the top rate of diabetes prize goes to… Turkey.

Some 14.71 percent of adults in Turkey have diabetes and it is described as one of the top priorities for the Turkish government. The country spends $895 on each person with diabetes.

At number two for diabetes, Portugal spends a lot more ($2,011 per person) on its 13.09 percent problem. But power is delegated to individual regions so it can depend on where you live.

Number three is on the table is Bosnia and Herzegovina, spending $523 per person and with 12.1 percent of people having diabetes. (Montenegro has 12 percent.)

Serbia comes in at number five, with 11.96 percent of its population suffering from diabetes and spending $666 per person. According to the report, high-risk groups are targeted but it is felt that not enough resources are allocated to the issue.

In sixth place is Germany, with an 11.52 percentage of population figure. Germany spends a massive $4,943 per person – one of the highest figures in Europe. However, it is felt that diabetes isn’t a priority on the political agenda in Germany.

Macedonia’s population is affected by diabetes with 11.44 of Macedonians diagnosed with the condition. Funds are limited though, with only $403 spent per person.

Malta spends $2,113 per person and 10.69 percent of the population have diabetes. Most of their prevention methods focus on lifestyle changes, according to the article, with people are encouraged to eat well, exercise more, and give up smoking.

Spain, with 10.58 percent of its population suffering from diabetes, spends $3,090 per person. However, diabetes associations in the country don’t think there’s enough support or resources to make a difference.

Some 10.2 per cent of Cypriots have diabetes and it is estimated that Cyprus spends $2,295 on each person with diabetes. A large-scale prevention plan to be introduced in 2016.

Where, you might ask, is the UK in terms of numbers of people with diabetes – surprisingly, the report says that 6.6 percent of the UK population have diabetes – 43rd place in Europe. According to the American Diabetes Association, in the US some 9.3 percent of the population has diabetes (2012 figures).

Read the full report here.


For help managing your diabetes, Check out our book, The Diabetes Diet. Pic thanks to Melissa Wiese on Flickr

The Etiquette of Diabetes

Do you do blood tests in public?
Do you do blood tests in public?

Do you inject in public? What happens if you are in a meeting and you suddenly experience a hypo (low blood sugar) and what do you say to people when you are invited to their homes for a meal?

These are the questions I have been asking of late, as I have been thinking of diabetic etiquette. My modus operandi for life is “do not make a fuss”. It’s the Brit in me. I shy away from behaviours that draw too much attention and I am not keen on putting people to trouble.

But health is important and being too polite to refuse a piece of cake that a friend has made means you run the risk of high blood sugars and feeling ill, politeness starts to look silly doesn’t it?

Let’s take a look at the different issues that come up when you are living with diabetes and how you can handle them.

So – injections in public.

Continue reading “The Etiquette of Diabetes”

X-Pert Advice for Healthcare Professionals

trudiAre you a healthcare professional who is worried about advising patients to try a low carb/high fat diet?

Hi there, I’m Dr Trudi Deakin, chief executive of the charity X-PERT Health which develops, implements and evaluates structured education for the prevention and management of diabetes.

We strive to keep abreast of the latest research so that healthcare professionals and patients obtain the most up-to-date lifestyle management information. Literature reviews are undertaken on an annual basis and the research papers critically appraised to draw accurate and meaningful conclusions. The following hierarchical system for levels of evidence is used [1]:

Grading of evidence:

  • Ia: systematic review or meta-analysis of RCTs.
  • Ib: at least one RCT.
  • IIa: at least one well-designed controlled study without randomisation.
  • IIb: at least one well-designed quasi-experimental study, such as a cohort study.
  • III: well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case-control studies.
  • IV: expert committee reports, opinions and/or clinical experience of respected authorities.

Grading of recommendations:

  • A: based on hierarchy I evidence.
  • B: based on hierarchy II evidence.
  • C: based on hierarchy III evidence.
  • D: directly based on hierarchy IV evidence.

Continue reading “X-Pert Advice for Healthcare Professionals”