Page 20 - The SA Journal Diabetes & Vascular Disease Volume 9 No 4 (November 2012)

162 VOLUME 9 NUMBER 4 • NOVEMBER 2012
PATIENTS AS PARTNERS SA JOURNAL OF DIABETES & VASCULAR DISEASE
gain and increased insulin resistance. It’s a vicious circle. The increased
insulin resistance makes the body less responsive to insulin, causing a rise
in blood glucose and hyperglycaemia.
This explains why it is such an uphill struggle for many people with
diabetes to lose weight. To add to this, many are elderly and have ad-
ditional health issues that reduce their mobility, so preventing them from
doing even gentle exercise.
Careful explanation of these issues will help patients understand what
is going on and enable them to discuss and develop strategies to deal
with them. Many patients find it a relief to discover that there are reasons
why they gain weight and find it hard to lose weight. Knowing that insulin
will make them feel hungry makes patients more aware, so that, hope-
fully, they will be able to resist the temptation to nibble. A supportive and
sympathetic approach by the practice nurse will enable them to remain
positive about starting insulin therapy. Indeed, if a patient manages to
improve their glycaemic control without gaining any weight then they
should be congratulated!
EXERCISE AND INSULIN
Exercise is beneficial to health, with or without diabetes. Research
shows that 30 minutes walking each day has several advantages for
health. While people with diabetes should be encouraged to increase
their exercise levels, they also need to be aware of the likely effects on
their blood glucose levels – particularly if they are treated with insulin.
Small, sustainable changes in activity should be encouraged – fre-
quent visits to the gym and taking part in marathons are really not neces-
sary! Using a pedometer is one way to encourage people to do a bit more
exercise. The recommended number of steps is 10 000 a day, but as long
as patients do a bit more than they did before, and exercise within their
own limitations, then there will be health benefits.
Exercise requires energy, therefore extra glucose is needed in the cells,
which means that blood glucose levels will fall more when a patient is
active than if they sat at home in a chair. In my experience, many patients
fail to take account of this and are often bewildered by the resulting ‘see-
sawing’ of their blood glucose levels.
HYPOGLYCAEMIA RISKS
A patient new to insulin needs to be aware of the potential for hypogly-
caemia, as well as understanding what it is, the signs and symptoms, and
the treatment. Reducing the previous dose of insulin and/or eating more
carbohydrate, if exercise levels are expected to be higher than usual, can
avoid hypoglycaemia. However, these measures may not be required if
optimal glycaemic control has not been achieved or if the exercise is very
gentle and for only a short time. Patients should be encouraged to experi-
ment, recording blood glucose levels before and after exercise, enabling
them to understand the effects. They will then appreciate their possible
need for less insulin or more carbohydrate. Avoiding hypoglycaemia and
ensuring the safety of the patient is essential when giving advice.
WHAT FACTORS AFFECT BLOOD GLUCOSE RESULTS?
In my experience, many patients are bewildered by fluctuating blood glucose
results and need help to make sense of them. Broadly speaking, and as-
suming that the patient is well, blood glucose levels are affected by three
things – food intake, or, more specifically, carbohydrate intake – the amount
of available insulin in the body, whether injected or produced by the pancreas
– and, lastly, exercise. Frequently reminding patients of these points should
enable them to consider logically what is happening when they are trying to
understand their blood glucose results. Keeping it simple is the key.
ERRATIC ABSORPTION OF INSULIN
The rate of absorption of insulin will be affected by any increase in blood
flow to the injection site. Therefore, exercise, a hot bath, or hot weather
will all speed up the absorption of insulin, resulting in an increased risk
of hypoglycaemia. Patients using insulin need to be made aware of these
issues to avoid any potential problems.
Injecting into areas of lipohypertrophy will also lead to the erratic ab-
sorption of insulin, potentially affecting glycaemic control and leading
to unexpected hypoglycaemic attacks. Regular examination of injection
sites by the practice nurse and educating patients about how to rotate
injection sites will effectively avoid these problems.
INSULIN TREATMENT AND ILLNESS
Illness puts extra demands on the body, which, in turn, affects home-
ostasis. Homeostasis is the regulation of the body’s systems required
The vicious circle of weight gain with insulin
What three factors affect blood glucose results?
u v wFood Insulin Exercise