Self Care Tips
Laila King's Diabetes Tips
Driving and Diabetes
Driving and Hypoglycaemia Risk
If you are treated with insulin or sulphonylurea drugs (e.g. gliclazide/Diamicron, glimepiride/Amaryl), the main potential danger in driving is the possibility of hypoglycaemia.
In order to avoid hypoglycaemia, you should:
If symptoms of hypoglycaemia occur, you should:
- Stop driving as soon as it is safe to do so.
- Remove the ignition key and move into the passenger seat to avoid any suggestion that you remain in charge of the car.
- Immediately take a glucose drink or glucose tablets and follow this by taking a longer acting carbohydrate, e.g. a cereal bar, fruit, or a small sandwich.
- Not drive for 45 minutes after blood glucose has been corrected. Studies have shown that cognitive function does not recover fully until this time.
Motor Insurance
You will need to inform your motor insurance company when your diabetes is diagnosed and, subsequently, notify them about any changes in your treatment (i.e. going to tablets, starting insulin). This is required whether you are treated with a diet only, tablets, or insulin. An insurance company cannot refuse you insurance or increase your premium unless it has evidence that you are a higher-risk driver. If you encounter any problems, please contact Diabetes UK to get best value motor insurance quotes through them.
Insurance cover
Since the Disability Discrimination Act (1995) came into effect at the end of 1996, insurers can only refuse cover or charge more for cover if they have evidence of increased risk. Most of the evidence available about drivers with diabetes indicates that they are no higher risk than any other driver. As a result of this many insurance companies no longer ask about diabetes when you apply for insurance.
If this happens, it is worth challenging the insurer, especially if your diabetes is well controlled. Diabetes UK or Disability Rights Commission can assist you to get the best possible insurance deal. Diabetes UK services have a motor insurance quote line on Freephone 0800 731 7431. Some insurance companies may not ask you about your health, but you should always tell them about your diabetes.
We recommend that you take at least three quotes when arranging your car insurance and often insurance companies will give a discount for purchasing online. Challenge your insurer if you feel you are being discriminated against because of your diabetes.
If you have an accident
If you have a hypoglycaemic episode at the wheel, you may be charged with driving under the influence of a drug, insulin, driving without due care and attention, or dangerous driving. Therefore, it is essential that you check your blood glucose levels to make sure this does not happen. If you are prosecuted, we recommend that you seek legal advice immediately. If you do have a hypo at the wheel, you should notify the DVLA immediately. If you have lost or have poor warning symptoms of impending hypoglycaemia or have frequent hypos, you should probably not be driving.
Vision Test Requirements
You should be able to read a number plate (7.9cm) at a distance of 20.5 metres. This approximates to an equivalent Snellen Chart corrected acuity of 6/12.
The Driver and Vehicle Licensing Agency (DVLA)
It is your legal responsibility to inform the Driver and Vehicle Licensing Agency (DVLA) of your diagnosis of diabetes, whether it is treated with insulin, or oral hypoglycaemic agents, and fill in the DVLA Medical Fitness to Drive Declaration Form.
The DVLA need not be informed if treatment is with diet alone. Patients treated with insulin will be sent a Diabetic 1 form, which will ask for further details, including the name of the GP or consultant and for consent to approach that doctor directly if necessary.
Insulin and driving is a vitally important topic for legal, professional and safety reasons:
- 1. The law requires all people on insulin therapy who hold a driving license in any form to inform the DVLA in Swansea (Drivers and Vehicle Licensing Agency, Drivers Medical Unit, Longview Road, Swansea SA99 ITU).
- 2. The law also requires that all drivers on insulin therapy must inform their insurance companies about their diabetes treatment.
- 3. Any person who develops disabling hypoglycaemia while driving or who develops other complications, such as poor vision (severe retinopathy) or numbness in feet (neuropathy) must tell the DVLA.
- 4. All doctors completing a Fitness to Drive forms for the DVLA must confirm that their patient understands how to manage driving and diabetes.
3-Year License
For insulin-treated patients, a license for 3 years will normally be issued, which allows you to drive a vehicle up to 3.5 tonnes. When the license expires, you will receive a reminder to renew the license and may also be sent another Diabetic 1 form to complete with more up-to-date information. Renewals will be free of charge.
If you are treated with tablets or diet alone you may be issued with a ‘till 70' license. If you are treated by diet alone you will be issued with a ‘till 70' license. However, you should inform the DVLA if you develop any complications as a result of your diabetes or if you require treatment with insulin. When this license expires, you will need to renew it every one to three years, just like other people in the UK who are over 70 years old. There is a charge for this renewal.
Provisional licenses are restricted to one, two or three years only if your diabetes is treated with insulin.
If you ride a motorcycle, the rules for informing the DVLA are the same as those for a car.
Driving large goods vehicles and passenger carrying vehicles
People whose diabetes is treated by diet alone or diet and tablets are normally allowed to hold LGV and PCV licenses, provided they are otherwise in good health.
People treated with insulin are not allowed to hold these licenses. If you currently hold such a license and start using insulin, you must inform the DVLA and stop driving the vehicle immediately.
NB. The law does not bar insulin users from driving taxis (provided there are less than 9 seats).
If you are on insulin, you can now undergo a medical assessment to apply for C1 entitlement to be added to your standard car license. To qualify for C1 entitlement you must:
- Have had no hypoglycaemic attacks requiring assistance while driving within the last 12 months.
- Regularly monitor your condition by checking your blood glucose levels at least twice daily and at times relevant to driving.
- Arrange to be examined at least once every 12 months by a hospital consultant who specialises in diabetes. On examination, the consultant will be required to see your blood glucose records for the last three months (unless you are new to insulin).
- Have been stabilised on insulin for a period of one month.
When you apply for a C1 license you will be given an application pack, which will contain a medical report (form D4) that must be completed by your doctor. You will have to pay the doctor the fee charged for this examination, which could be up to £100. If you are on insulin and have passed this initial medical examination, the DVLA will then send you a further medical questionnaire (C1EXAM) that must be completed by a hospital consultant who specialises in diabetes.
Your C1 entitlement will be issued for one year and can be renewed on an annual basis, subject to the assessment by your diabetes consultant. You will not have to pay additional license renewal fees until your car entitlement is renewed at age 70 or over.
Do not drive:
- if you have just started to take insulin and your diabetes is not yet properly controlled - your doctor or diabetes specialist nurse will be able to give you more advice on this;
- if you have difficulty in recognising early symptoms of hypoglycaemia;
- if you have any problems with your eyesight that cannot be corrected by glasses; and
- if you have numbness or weakness in your limbs caused by neuropathy (diabetic nerve damage).
You should:
- avoid long or stressful journeys if you are tired;
- test your blood glucose level before driving and regularly during a long drive;
- consult your doctor or diabetes specialist nurse if you have any worries on any of these points; and
- inform the DVLA of your diabetes if you are treated with insulin or tablets.
Women with gestational diabetes treated with insulin
If you develop gestational diabetes and need to commence insulin treatment, you should notify the DVLA immediately. You will normally be allowed to continue with your current driving license but are recommended to stop driving if your control is unstable and especially if you do not have good warning signs of impending hypoglycaemia. You should notify the DVLA six weeks after delivery if you are still on insulin, as your license will then need to be reassessed.
Further information:
Driver and Vehicle Licensing Agency www.dvla.gov.uk/medical.aspx
Telephone:
0870 600 0301 (Medical section)
Guidelines for Diabetes and Ramadan Fasting
Fasting and Feasting with Diabetes
Ramadan, the Holy Month for Muslims, is a time of worship, self-discipline, austerity and charity. During Ramadan there is a change in mealtimes, daily routine, eating special traditional foods and fasting (nothing consumed between dawn and sunset). People who are Muslim and have diabetes can be exempted from fasting. However, if you wish to fast, you need to closely monitor your diet, meal timings and medications to prevent any problems occurring such as low glucose levels.
If you have Type 2 Diabetes and are treated by dietary adjustments alone, there should be no problem with fasting during Ramadan. If you are treated with sulphonylurea tablets, insulin injections, or a combination of the two, you need to discuss how fasting may affect your blood glucose control with your London Diabetes Team, well before Ramadan begins. During the coming years as Ramadan moves into the summer and spring months in the Northern hemisphere, the daylight hours are going to get longer and longer. Hence, fasting will become increasingly risky for people treated for diabetes.
We advise you not to fast if:
- Your diabetes is poorly controlled
- You have a serious diabetic complication such as angina or uncontrolled hypertension
- You are pregnant
- You require daily supervision or care such as the elderly or those with any degree of alertness or comprehension
- You are ill with a condition such as flu
- You have a history of diabetic ketoacidosis or hypo-unawareness (do not recognize low blood glucose levels)
- You have previously had trouble whilst fasting with hypoglycaemia (low blood glucose)
- Divide your food into two meals - Sehri (Suhhur) and Iftar (‘breaking fast' meal at sunset)
- Try to have the meal at Sehri just before dawn and not at midnight, try to spread out your food intake to balance your blood glucose levels
- Try to include more slowly digested foods such as fruit and vegetables, dhal, cereals, basmati rice, chapatti, naan bread and yoghurt in your meals
- Eat carbohydrate (starchy food) at both meals
- Only have small amounts of foods such as ladoo, jelaibi or burfi
- Avoid very fatty fried foods like samosa or pakora
- Avoid using too much salt and use spices instead
- Drink plenty of low calorie or ‘diet' drinks and water
- Break the fast as soon as any signs of dehydration, hypoglycaemia or hyperglycaemia occur
When you fast certain medication can increase your risk of hypoglycaemia; we recommend you test your blood glucose levels more often, for example at least 3 - 4 hourly to make sure your glucose levels do rise too high (more than 10.0 mmol/l or 180mg/dl) or drop too low (less than 4.0 mmol/l or 72mg/dl). If your blood glucose level drops below 4.0mmol/L (72mg/dl) or you have any signs and symptoms of low glucose levels (e.g. sweating, dizziness and shaking) we recommended you break the fast immediately. Treat the low glucose level with 15 grams of a quick acting carbohydrate like 4-5 glucose tablets, sweet drink wait 15 minutes until you feel better then eat a longer acting carbohydrate like bread or fruit to stop the level dropping again.
You may feel tired when fasting during Ramadan, so although it is important that you continue your daily activity and prayer, try to rest at some point in the day, especially in the hours before the break of the fast (Iftar).
Fasting, Diabetes, Diet, Exercise and Medication
If you are taking tablets it is important to follow the guidelines above and consider when to take your medication.
Biguanides e.g. Metformin
If you feel unwell taking these tablets whilst fasting, consider reducing them for Ramadan. If you continue to take them, the largest dose should be taken at Iftar, so they work when you are eating.
Sulphonylureas e.g. Gliclazide, Glipizide, Glimepiride (with or without Metformin)
These tablets can cause your blood glucose to drop too low (hypoglycaemia) when fasting and could make you feel ill. There are new quick acting tablets such as Repaglinide and Nateglinide that might be more suitable to take when fasting. If you are in doubt about what to do with your tablets please contact the London Medical team or your GP for advice.
Thiazlidinediones e.g. Pioglitazone or Rosiglitazone (with other tablets or insulin)
These tablets are usually taken in the morning and may cause low blood glucose levels when fasting, so it is best to take them at Iftar.
Prandial Glucose Regulators e.g. Repaglinide (Prandin, formally know as NovoNorm), (Nateglinide, also known as Starlix)
These tablets can be taken with the meals eaten; you may need to adjust the dose according to the meal size. If you miss a meal do not take the tablet. If you have a big meal you may require a bigger dose than normal.
If you are taking Repaglinide and a long acting insulin like Lantus or Detemir, you need to stop Repaglinide in the middle of the day and possibly halve your morning dose e.g from 2mg to 1mg, from 4mg to 2mg, to avoid having a hypo mid-morning.
Gliptins (DPP-4 Inhibitors)
You may be taking a tablet called Sitagliptin (Januvia) once daily or Vildagliptin (Galvus) once or twice daily. You continue to take these as usual even when fasting. They do not cause hypoglycaemia as they make your pancreas to produce its insulin only when glucose levels are rising.
Byetta
Byetta can be injected just before you eat but no earlier than 60 minutes before your meal. If you are taking Byetta twice a day, try to have two meals and take the Byetta before. Remember not to take Byetta too close together (this could become a problem if you eat very late at night and take your Byetta before your sunrise meal). Some people may prefer to take their first Byetta injection when they break their fast at sunset, and the second dose with the bigger meal near midnight. Leave about six hours between the injections.
Byetta does not cause hypoglycaemia as it makes your pancreas to produce insulin only when glucose levels are rising.
Victoza
Victoza is very easy to take during Ramadan fasting as you can take it at any time of the day - roughly at 24 hourly intervals - with no relation to meal times. Victoza does not cause hypoglycaemia as it makes your pancreas to produce insulin only when glucose levels are rising.
Taking Insulin - with or without tablets
If you are taking insulin, it is important to adjust the dose to avoid glucose readings of less than 4.0mmol/l (72mg/dl), but at the same time to control your glucose levels for the whole 24-hour period. Aim to keep your glucose level within 4.0mmol/l - 8.0mmol/L (72mg/dl - 144mg/dl).
- If you are taking rapid or short acting insulin with meals, continue to take the insulin when you eat
- Adjust the insulin dose to match the size of the meal and continue to take your long acting insulin
- If taking pre-mixed you should have the bigger dose before Iftar in the evening, and possibly a lower dose during the day or switch to rapid-acting insulin
The above suggestions require individual assessment and discussion with your diabetes team. The Diabetes Team at the London Medical are very happy to assist you in preparing for this occasion.
New Years Resolutions for 2010
New Years is a time to come up with resolutions to better your life for the future. Why not use your resolution this year to set goals to better your diabetes management and overall health?
Your diabetes management goals for the New Year should be specific, measurable, action-oriented, realistic and time-limited.
Annual Goals
• See your Diabetes Team 2 - 4 times/year.
• Follow your schedule for checking blood glucose levels.
• Follow exact instructions for every diabetes medications you take.
• Know and keep these numbers in check: HbA1C, blood pressure and cholesterol.
• Get a renal function test and microalbumin test each year.
• Get moving. Any form of physical activity is a step in the right direction.
• Create a well-balanced meal plan with your diabetes educator.
• Have a yearly eye exam.
• See your dentist twice a year.
• Get a flu shot in the fall.
• Always be prepared for a low or high blood glucose reaction - know the warning signs.
Daily Goals
• Check blood glucose X times a day (depending on what your physician suggests).
• Take all diabetes-related medications.
• Examine your feet for cuts and sores.
• Bathe with mild soap and lukewarm water.
• Brush and floss your teeth.
