1. Coping with Diabetes

2. Programme 1 7 2 8 3 9 4 10 5 11 6 What to tell the family
School issues 2
Dispelling myths and false beliefs 8
Exercise 3
Acute illness 9
Smoking, alcohol and drugs 4
Nutritional advice 10
Pregnancy 5
Storing insulin 11
Fasting 6
Effects of growth on diabetes

3. What to tell the family

4. At diagnosis First contact is crucial Can achieve the following:
Explain diabetes symptoms
Enroll the family into care of the child
Specifically invite the father and mother
Initial diabetes education
Dispel myths and false beliefs
Family bewildered and shocked
Be supportive, empathic and caring
Answer comprehensively and respectfully
You will very likely be the first contact for many children and families when the diagnosis is suspected or confirmed. This first contact with the family of a child with diabetes is a crucial and critical opportunity to achieve an understanding with them. A number of objectives can be achieved, including explaining diabetes symptoms. Using a diagram can be very useful in this process. It can help to enrol the family into care of the child, to do some initial, simple diabetes education and can help to dispel myths and false beliefs. This is a very important aspect of this initial contact.
The family members are often bewildered and shocked, and do not understand what has happened to their child. Denial, anger, bargaining, confusion, depression and uncertainty often cloud the family’s perception of what is happening to their child. The healthcare should be supportive, empathic and caring but firm in bringing the family into the therapeutic team. Remember to answer questions comprehensively and respectfully

5. Symptoms Explain symptoms and signs Diagrams useful
Demonstrate glucose values and urine dipsticks
Explain mechanism
Insulin deficiency
Unknown cause
Raise questions for future discussion
Explain the symptoms and signs that the child and his/her family have been experiencing. These may include polyuria, nocturia, bed-wetting, polydypsia, weight loss, nausea and vomiting and
abdominal pain. Remember that diagrams are useful for this.
A demonstration of glucose values and urine ketones on a dipstick is useful to make the diagnosis concrete and to expose the family to some of the care issues that they may/will need to perform. In addition, explain the mechanism of the clinical presentation. Include the deficiency of insulin and the unknown cause of the deficiency. Raise questions that may come up for discussion later e.g. the cause of the diabetes, cure of diabetes, prevention of diabetes, etc. Do not shy away from these questions

6. Dispelling myths and false beliefs

7. Myths and false beliefs
Cause of diabetes/ genetics/ environment
Cure for diabetes
Use of alternative medications
Toxicity of insulin
Use of pills for treatment
Infectiousness of diabetes
Many myths and false beliefs exist about type 1 diabetes. Among these are the following.
A cure for diabetes
The belief that there is a cure for diabetes is often part of the ‘bargaining’ stage, as the parents come to terms with their child’s diabetes. Explain that there is no cure for diabetes at present, but that there is always the possibility of a cure being developed within this child’s lifetime.
Use of alternative medications
The use of alternative medications is often proposed as a cure or an alternative way of treating diabetes. These alternatives include traditional African medications, homeopathic medications, etc. Dissuade parents from attempting to use alternative medications without first consulting with the diabetes clinic. On occasion, the use of alternative medications under medical supervision may help to dispel the idea that these alternatives are of any value. Distrust of Western medicine is often an underlying motivation for the use of alternative medications. However, it is important to stress that insulin is indispensable for a child with type 1 diabetes.
Toxicity of insulin
Insulin has been considered by some families to be toxic. This may stem from distrust or experience of acute complications of diabetes (eg severe hypoglycaemia). If insulin has been used for any length of time, point out its benefits eg decreased thirst and urination. Discourage the family from stopping insulin therapy.
Will pills work?
Most people who know someone with diabetes would have encountered someone with type 2 diabetes, and would expect a child newly-diagnosed with type 1 diabetes to be treated with tablets as well. Explain the differences between type 1 and type 2 diabetes. Note that children with type 1 diabetes need insulin to survive. Also note that some people with type 2 diabetes also need insulin to be healthy.
 Can my other children catch diabetes from the affected child?
Some people may believe that diabetes is infectious. Explain the uncertain origin of type 1 diabetes, but be clear that type 1 diabetes in not an infectious disease. Note that some families have more than one child affected by diabetes, but that this is not because it is infectious.
Answer any other questions that may come from the audience about other myths and fallacies that they know about.

8. Acute illness

9. Acute illness Acute illness may cause:
High glucose (hyperglycaemia)
Low glucose (hypoglycaemia)
Ketones
Ketones may occur during, before or after the illness
Children with diabetes do not have more frequent illness
Know how to advise families on management of acute illness
Acute illness (eg infectious, particularly gastrointestinal diseases) can affect blood glucose control. The consequences of acute illness include having high glucose values (hyperglycaemia), or the appearance of ketones, or low blood glucose (hypoglycaemia). Early detection of changes in glucose values, and active management, will prevent these acute complications of diabetes and prevent hospitalisation. Changes in blood glucose values may precede or follow an acute infection.
Children with well-controlled diabetes should not experience more frequent or severe illness or infections than children without diabetes. However, children with poorly-controlled diabetes may experience more infections.
It is important that you know how to advise families on the management of acute illness

10. Management (1) Do not stop insulin delivery
May increase or decrease dose
Need frequent monitoring
Glucose 3-4 hourly
Ketones 1-2 times per day
Admit if:
no home monitoring
it is not getting better despite doing all you can at home
Treat illness
Sugar-free medication
No steroids
Do not stop insulin delivery even though the child is ill. Insulin doses may need to be increased or decreased, based on the blood glucose and food intake, but should not be stopped. If there are no facilities for home monitoring of glucose or ketones, then the child should be taken to a healthcare facility for regular testing. Consider increasing or decreasing doses of insulin.
Increase monitoring of blood glucose to 3-4 hourly (and more frequently if the glucose level fluctuates widely or changes rapidly). Monitor ketones 1-2 times per day.
Evaluate and treat the acute illness. Where possible use sugar-free medications or tablets (as appropriate). If no sugar-free medications are available then use the locally available medications. Avoid steroid use .

11. Management (2) Supportive care
Easily digested food
Adequate fluid intake
Antipyretics (paracetamol)
Consider admission
Adjust insulin doses – never stop insulin
Educate family on management of illness
Provide written guidelines for family
Provide, or ensure that the family is able to provide, appropriate supportive care including:
 1. easily-digested foods when there is a loss of appetite
2. adequate fluid intake. Fever and hyperglycaemia can cause increased fluid losses. Oral rehydration fluid provides both a source of fluid and energy. Treat or prevent vomiting by frequently offering small volumes of fluid to drink
3. treating fever with anti-pyretics (e.g. paracetamol)
4. admitting the child to a healthcare facility if these supportive measures cannot be ensured as an out-patient. consider admission under the following circumstances: very young children with diabetes, parents’ inability to check glucose at home, supportive care cannot be ensured at home, if the acute illness is severe or
if there is persistent ketonuria.
 Adjust insulin doses as required during the acute illness.
Educate the family on management of acute illnesses frequently. Provide written guidelines to families when appropriate

12. Nutritional advice

13. Nutritional advice (1)
Food provides energy for growth and day-to-day functioning
Food intake influenced by
Family functioning
Psychological and emotional factors
Societal factors
Socio-economic factors
Nutritional advise is a very important component of caring for children with diabetes. We had highlighted a few of these issues earlier. Now we shall focus a little on the details of dietary advice that you can give families and children. In an ideal world, dietary issues will be discussed and taught by a dietician or nutrition specialist. However, very often it is you and the main team that has to provide this information. You will be asked frequently about dietary issues.
Food provides energy for growth and for day-to-day functioning. Food intake may be influenced by a number of factors. Family functioning and the role of the child affected by diabetes in the family is one of the factors that has be considered. Psychological and emotional factors influence food intake as do societal and socio-economic factors. Stress, anxiety, trauma and depression may change eating patterns. You have to consider these when giving advise about nutrition. Food and its relation to glucose are key components of self care for people with type 1 diabetes. Food intake must be balanced against insulin; both the type and dose of insulin are important. Monitoring the effects of food and insulin by doing blood glucose testing after meals will help to adapt the food intake and or the insulin dose at that particular meal.

14. Nutritional advice (2)
Food (carbohydrate) intake to be balanced against insulin
Food intake to be balanced against activity
Glucose monitoring used to balance food intake, activity and/or insulin dose

15. General dietary guidelines
Use meal plans rather than a diet
Try not to have do’s and don’ts
Keep plans simple and practical
Use meal plans rather than restrictive diets. It is advisable to talk about meal plans rather than ‘diabetic diets’.
Calorie restriction is an important consideration for obese children with diabetes.
Emphasise simplicity and practicality in discussing meal plans.
Match meal plans with country, regional, ethnic, religious, family styles as much as possible. Allow for individual idiosyncrasies and tastes. Allow flexibility and variety in food selection
Balance financial needs and availability of foods and snacks. In essence, the family will determine the meal plan and you would help to make adjustments to the plan to improve glucose values.

16. Meal plans Depend on local factors
Calorie restriction for obese patients
Allow for individual choice
Allow flexibility and variety in food selection
Balance financial needs and availability of foods and snacks
Depends on what is available locally

17. Food and insulin Balance food and insulin Adapt insulin to suit meal
Different regimens allow change in
Meal plans
Meal frequency
Food
Insulin
The aim of dietary advice for children in this condition is to try and match the insulin given with the food available.
About half of the insulin requirement each day is used to control glucose levels from eating. The other half is needed for the body to function normally, even when the person does not eat at all. If a person is ill and insulin-resistant, the total amount of insulin needed may still be the same as on a normal day, even when the person is not eating.
You may need different insulin regimens for different meal plans. Always try to adapt the insulin regimen to suit the meal plan..
Different regimens may meal increased flexibility on meal plans or may have to be adjusted to the local meal frequency.

18. Food and insulin Twice daily regimen Multiple daily injections
Regular snacks and meals
Risk of hypos is missed meals/snacks
Emphasise regularity and portion sizes at meals
Multiple daily injections
More flexibility
Less short-acting insulin for smaller meals
Need to understand effects of food and insulin on glucose
For example, a twice daily regimen, especially one that uses a fixed ratio, premixed insulin will require a meal plan that has regular snacks and meals. There are risks of hypoglycaemia when meals or snacks are missed. Indicate high insulin in afternoons and the need for regular lunch. In this situation, you should emphasize regularity and portion sizes at meal times.
Multiple daily insulin regimens allow more flexibility in meal times and portion sizes. Higher doses of short acting insulin at meal times meal lower doses of long-acting insulin. Smaller meals can be compensated for with less short-acting insulin at that meal. This regimen would require understanding of effects of food and insulin on glucose values.
There are further examples in the manual

19. Teaching about food Plan for balanced meals Aim for:
50-60% carbohydrates
15-20% protein
<30% fats
Teach food groups and reading food labels
Teach entire family – especially the father and grandparents
Energy requirements change with growth
Plan for a balanced diet. This plan should have an overall breakdown of 50-60% carbohydrates, 15-20% protein & less than 30% fats
Teach parents and young people how to read food labels for the macro-nutrients: carbohydrates, proteins, fats, and the differences between saturated and unsaturated fat sources, to optimise cardiovascular health i.e. a healthy diet.
Involve the entire family in nutrition education as everyone would need to adhere to the dietary changes.
Remember that energy requirement increase with growth

20. Storing insulin

21. Storing insulin Insulin is a ‘fragile’ protein medication
Denatured if frozen or in excessive heat
Stored at 2-8°C
Use before expiry date
Once opened, may last
1 month if not refrigerated
3 months if refrigerated
Storage of insulin is important
Storing insulin is important to ensure that insulin remains effective.
Insulin is a protein and is relatively fragile. It may be denatured if frozen or exposed to excessive heat. Denatured insulin does not work well in reducing blood glucose levels.
Ideally insulin should be kept at between 2-8 degrees Centigrade (36-45 degrees Fahrenheit). IF stored correctly, insulin may last up to 30 months or until the expiry date.
Once opened, a vial of insulin should ideally be used within 3 months. If not refrigerated, a vial of insulin should be used within 1 month of opening.
In practice, many people find that the potency of insulin (its ability to lower glucose levels) starts to deteriorate within 6-8 weeks of opening even with refrigeration, because of the constant change of temperature.

22. Storage of insulin Clinic and home Power refrigeration
Not freezer
Back-up generator
Passive/water refrigeration
Underground
Clay pots
Rotate stock by expiry date
The rules of storage apply to both the home and clinic situation. Store the insulin in a refrigerator, in a section which is not prone to freezing. Do not place in the freezer as freezing denatures insulin more rapidly than heat. Try to keep the temperature constant. It is good to keep a diary of daily temperature inside the refrigerator, taken with a mercury or digital thermometer (not a clinical thermometer). Ensure power supply if the power supply is prone to interruption, particularly for refrigerators in larger clinics and hospitals. Suggestions are made in the manual.
When refrigeration is not available , it may be necessary to find another storage method. Methods include water, underground storage, eartherware pots, etc. Emphasize the best local options. Options are discussed in the manual.
Insulin should be stored by batches and rotated regularly by date of manufacture and date of delivery to the clinic

23. Questions
These are some of the issues that you need to be aware of as you help children and their families to cope with their diabetes. There are more details of these problems in the manual. Your most important role is support and guide families. Take questions

24. novo nordisk changing diabetes - Outro
Changing Diabetes® and the Apis bull logo are registered trademarks of Novo Nordisk A/S 24
novo nordisk changing diabetes - Outro