Taking a headline, and running with it. Pun intended.

obesity, overweight
Moderation is key to a longer, healthier life. Sorry it’s boring.

Today’s award for the most unhelpful headline goes to the subeditors of the BBC with this little gem:

‘Exercise ‘not key to obesity fight’

So what happens is, if they want to say something they should say, they stick it in inverted commas to make it look like they’re not really saying it, when they’re saying it. Along the lines of ‘wasn’t me, guv’nor’. BBC, you must be so proud.

An editorial in the British Journal of Sports Medicine said that it was time to ‘bust the myth’ that exercise had a big effect on obesity. Naturally the reach of the BBC is wider than that of the British Journal of Sports Medicine – and the reach of the headline is far, far wider than the reach of the detail in the story. And that’s why headlines are risky, and need to thought about responsibly. Now we’ll have a situation where people think that the disembodied quote from three experts writing in a periodical they’ll never read is licence for them never to do exercise again.

But let’s look at it. Those experts are right in one sense – our diet is so far out of whack it dwarfs our sedentary lifestyle in how damaging it is to our long-term health. We like junk food, and it’s hard to avoid since it’s so cheap and plentiful. Those who are obese can have a tremendous effect on their weight if they cut their daily calorie intake from that of a pro cyclist down to that of a sedentary person (in some cases a drop in excess of 2000 calories). The other reason they’re right is that in those who are morbidly obese, really effective exercise is impossible. The first gains need to come from curbing intake.

But the key to success remains – a deficit between what calories you need, and what you actually consume. One of the results of exercise is to boost the deficit.

What was also not addressed was the fixation on obesity. I suppose it’s easy to fixate on because it’s so visible – but generally it’s not being fat that kills you, it’s heart disease, or diabetes that leads to complications, or a stroke or whatever. Obesity increases the risk of all of these. Exercise is great at reducing the risk of these. So exercise, whether you use it for calorie busting or not, is a great thing to have in your life.

The problem with obesity is the same as the problem with politics – we get hooked on the extreme – extreme eating, extreme dieting, extreme exercise, extreme left, extreme right. Actually there’s a sweet spot, and it’s at neither end of the spectrum. A reasonable diet and reasonable exercise will have you living healthier for longer. Yes, there are those who feel the need to eat a diet of raw wizardfruit and ground unicorn horn, or whatever’s currently trendy (I lose track); there’ll always fads and extremes – it’s just not where the success is.

Today’s message is just not encouraging. Exercise does work, and it works best when you’re paying attention to diet as well. People who are trying to make changes should be supported and encouraged, not discouraged by being told half the story. Moderation is something we can all do. For some of us, that’s a habit we need to learn – but that’s OK, recognising it is the best place to start.

Journalists: Be responsible

Experts: Stop trying to be extreme to get column inches

Everyone else: Be different, be average.

Santa is not a well man.

He’s been doing the same high-level stressful job for as long as anyone can remember, and now he’s doing it for our children. Yes he gets the best part of a year off, but just how long can he keep going?

I don’t want to appear preachy, but be aware that with his current lifestyle and obligations, Santa is not going to go on forever. Don’t be surprised if one year, you have to deliver all those gifts yourself and pretend it was Santa.

Just look at the evidence:

Ulcers:

  • Job in logistics – renowned for being a sector of decreasing returns, when taking into account tariffs, fuel and duty, and infrastructure
  • High public expectation, huge responsibility = massively unfair level of stress on one person
  • Dealing with animals, and therefore animal welfare people. Do you know the regulations for keeping working reindeer? Nope, neither do I. 
  • Dealing with elves; renowned for being tricky customers, these little chaps are hot on their ethnic minority, disability, and human rights laws. ‘Elf and Safety, mate. 

DVT:

  • Long periods of static position and limited leg room in sleigh. Plus, new sleigh models have a smaller parcel shelf, so smaller parcels may need to be suspended from ‘curry hook’ in passenger foot well.

Metabolic syndrome:

  • The classic combination of increased girth, increased blood pressure, high cholesterol and high glucose. Just look at the diet and lifestyle of this chap.
  • Mince-pies and clotted cream – diet high in sugar and saturated fat – hypercholesterolaemia and hyperglycaemia leading to increased risk of diabetes and cardiovascular events

Cardiovascular disease:

  • Excess fat in diet, being overweight, and not getting sufficient cardiovascular exercise to strengthen heart muscle contribute to risk of cardiovascular disease
  • High blood pressure and stressed lifestyle likely to cause complications.

Gout:

  • Excessive alcohol intake increases concentration of uric acid in blood increasing likelihood of developing gout
  • Obesity, high blood pressure, hypercholesterolaemia and decreased kidney function can all contribute to increased risk of gout

Chronic kidney disease:

  • Developing type 2 diabetes and having prolonged high concentration of glucose in blood over time can damage fine capillaries in kidneys, decreasing kidney function.

Type 2 diabetes:

  • Obesity through high-calorie diet – waist circumference now a risk factor for diabetes – due to increased percentage of body fat, likely increased insulin resistance, leading to over-production of insulin to compensate.
  • Likely impaired fasting glycaemia or early stages of diabetes, as has been overweight for a considerable  time. However, there has been no over-frequent incidence of Santa using people’s toilets, and he usually sticks to ‘just the one’ sherry at each house so unlikely to be experiencing osmotic symptoms of diabetes such as increased thirst or need to wee.
  • Night-time working and long hours have also been connected with developing type 2 diabetes (admittedly in Italian shift-workers) – and this chap must have the weirdest body clock ever.

Erectile dysfunction:

  • Sustained hyperglycaemia leads to damage of penile capillaries. Decreased incidences of nookie with Mrs Christmas may lead to marital problems.

Clinical depression:

  • Well if you had all that lot, there’d be a greater chance of being depressed, right?

 

FoxFit

FoxFit.

With type 2 Diabetes and heart disease on the increase, it’s good to know what the risks the are and how you can protect yourself and your family from these and other health nasties. We even calculate your risk of type 2 diabetes, cardiovascular events and osteoporosis.

FoxFit takes the guesswork out of getting fit. It’s our unique programme geared towards getting people fitter, healthier, and helping people achieve the body they want. It’s a bit like the NHS HealthCheck but better because it’s run by qualified nurses and it’s more thorough. We’re not just interested in your weight, we’re interested in ALL of you. It’s this sort of MOT everyone should have – but it’s only available at Fox Cycling (the NHS HealthCheck is not nearly as comprehensive, nor is it part of an ongoing plan).

Click above link to read more.

What’s the deal with diabetes?

Today Diabetes UK in partnership with Tesco is launching a campaign to raise awareness of the complications of type 2 diabetes. According to the charity only a third of us are aware of what could happen if our type 2 diabetes goes undiagnosed and/or untreated.

What is type 2 diabetes?

A person with type 2 diabetes is still producing insulin, but not enough, either because their pancreas isn’t releasing so much, or because they are becoming resistant to their own insulin, or both.

When we put on weight, our insulin resistance increases as well as blood pressure, and often cholesterol. All of these things can increase our risk of not only developing type 2 diabetes, but also our risk of strokes and heart attacks.

What problems does type 2 diabetes cause?

The increased sugar in your bloodstream can damage small blood vessels, this can cause blindness, chronic kidney disease (where kidney function is substantially decreased), it can also cause a loss of feeling and/or pain in the extremities caused by associated nerve damage. Many men with type 2 diabetes will also suffer from erectile dysfunction (sometimes referred to as ‘impotence’).

How can I protect myself from type 2 diabetes?

  • Diabetes UK has a handy online tool to help calculate your risk of type 2 diabetes. You can find it here:  http://riskscore.diabetes.org.uk/
  • Keeping healthy by eating a varied diet (which will reduce your risk of cancer and heart disease too).
  • Get some cardiovascular exercise (this is the sort that increases your heartrate); this improves your heart health, and burns calories, reducing your weight, your insulin resistance, your cholesterol and your blood pressure. Result!
Studio cycling is a great way to get fast results - and to maintain your fitness.
Studio cycling is a great way to get fast results – and to maintain your fitness.

Treating Severe Hypoglycaemia

Patient is unable to self-treat. If conscious, and able to swallow safely, patient should be given one of the following:

  • 100ml Lucozade
  • 150ml non-diet fizzy drink
  • 200ml smooth orange juice
  • 5-6 dextrose tablets
  • 4 jelly babies
  • 7 jelly beans
  • 2 tubes glucose gel

Repeat as required and stay with patient until recovered.

If patient is unconscious, he should be put in recovery position, glucagon can be injected if trained to do so. Otherwise dial 999 for ambulance.

Symptoms of Diabetes

(Guide only, type 2 diabetes can be asymptomatic for years)

Symptoms Type 1 Diabetes Type 2 Diabetes
Onset Fast (days/weeks) Slow (months/years)
Thirst √ often profound
Polyuria/nocturia
Bedwetting in children  –
Lethargy/tiredness
Mood changes/irritability
Weight loss √++ √+/-
Visual disturbances
Thrush infections (genital)
Recurrent infections (boils/ulcers)
Hunger
Tingling/pain/numbness in extremities
Occasionally abdominal pain
Confusion If advanced √ Especially in the elderly
Incontinence √ Especially in the elderly
Glucosuria May be absent especially in the elderly or if there is a high renal threshold
Ketones in urine or blood May be present (ketoacidosis) Likely to be present

Thanks to Practice Nurse 41 8

Treating Mild Hypoglycaemia

To raise blood glucose, take one of the following:

  • 100ml Lucozade
  • 150ml non-diet fizzy drink
  • 200ml smooth orange juice
  • 5-6 dextrose tablets
  • 4 jelly babies
  • 7 jelly beans
  • 2 tubes glucose gel

If blood glucose is still below 4mmol/l after 10 mins, or if patient doesn’t feel better, repeat one of the above treatments.

When feeling better, eat some starchy food such as a sandwich or a banana, monitoring blood glucose afterwards.

Symptoms of Hyperglycaemia

  • Frequent urination
  • Nocturia
  • Copious urine
  • Unusual bed-wetting
  • Excessive thirst
  • Difficulty concentrating
  • Thrush/genital itching
  • Slow healing wounds
  • Fatigue/lethargy

HbA1c Conversion

HbA1c DCCT (%) 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5
HbA1c IFCC (mmol/mol) 42 48 53 59 64 69 75 80

Type I Diabetes

Type I diabetes occurs when there is a loss of insulin secretion ability due to automimmune destruction of the beta cells in pancreatic tissue. Patients generally present with the symptoms of hyperglycaemia including ketoacidosis.

Type I diabetes is the most common form in young people (affecting aout 0.5% of the population); bringing with it the potential for problems such as retinopathy, neuropathy, nephropathy and vascular disease.

Small amounts of insulin are produced by the pancreas throughout the day to ensure cells have access to glucose, and suppress the release of stored glucose from the liver. During fasting periods, glucagon is released to ensure glucose supplies for brain function.

Carbohydrates are digested in order to provide glucose, which results in the release of insulin titrated to the supply of glucose to use and store glucose in suitable quantities.

Insulin needs to be replaced in type I diabetes patients to ensure 24 hour cover. Boluses may also need to be prescribd to match carbohydrate intake at mealtimes. Often this can be suitably treated with a twice daily insulin if the patient’s daily routine is predictable, for patients whose lifestyle is more varied, titrated insulin may be required perhaps involving a pump or more frequent injections.

Carbohydrate awareness is important for those with type I diabetes because it is carbohydrates that affect blood glucose levels, and therefore patients need to be aware of the carbohydrate values of the foods they consume. This is particularly important for those titrating their insulin.

One of the ways insulin titration is done is through ‘dose adjustment for normal eating’ (DAFNE) which was designed for those with type I diabetes and can contribute to an improved quality of life and satisfaction for patients. Research shows that patients on DAFNE treatment are less likely to be admitted to hospital with ketoacidosis or hypoglycaemia, and also the treatment can make huge cost savings for providers. It consists of a 38 hour training course delivered in a group session based around competency skills. The scheme is successful in promoting understanding of diabetes, awareness of implications regarding diet, and the skills and knowledge required to count carbohydrates and titrate insulin accordingly with the use of DAFNE algorithms.

Symptoms of Diabetes

  • Increased thirst
  • Fatigue, mood swings
  • Urinary frequency
  • Blurred vision
  • Slow wound healing
  • Thrush or genital itching

Symptoms of Hypoglycaemia

Autonomic phase (BM 2.8-4mmol)

  • Sense of hunger
  • Paleness
  • Palpitations
  • Tachycardia
  • Sweating
  • Shaking
  • Anxiety

 Neuroglycopenic stage (BM <2.8mmol)

  • Confusion
  • Struggle to concentrate
  • Behavioural change (anger, aggression)
  • Blurred vision, slurring of speech
  • Seizures
  • Coma

Blood Glucose Testing and Handwashing

Washing hands with water increases the accuracy of blood glucose testing, a Japanese study has found. Cleaning with alcohol swabs did not improve accuracy, however.

Hirose, T. (2011) Glucose monitoring after fruit peeling: pseudohyperglycaemia when neglecting handwashing before fingertip blood sampling. Diabetes Care 34, 3, 596-597

Type 2 Diabetes and Daily Step Count in the Middle Aged

Increases in type 2 diabetes have been linked with reduced physical activity. An Australian study has found that an increased daily step count can reduce BMI, and therefore is related to a greater insulin sensitivity amongst middle-aged adults.

Dwyer, T et al (2011) Association of change in daily step count over five years with insulin sensitivity and adiposity: population based cohort study. British Medical Journal 10.1136/bmj.c7249

Diabetes Glucose Testing when Handwashing Facilities are not Available

A study published by Diabetes Care suggests that where handwashing facilities are not available but hands are socially clean and not contaminated with sugar, discarding the first drop of blood and testing glucose from the second drop may be more accurate. Having clean hands is still the gold standard to avoid contamination of the sample, but if handwashing is not possible, the first drop of blood will yield more inaccurate results than discarding the first drop and testing the second. The study also found that applying external pressure on figures could also affect the accuracy of results.

Diabetes and Omega-3 Fatty Acids

A study has shown that those who have a high intake of omega-3 fatty acids, particularly from fish are at an increased risk of developing type II diabetes.

Douse L. et al. (2011) Dietary Omega-3 fatty acids and fish consumption and type 2 diabetes. American Journal of Clinical Nutrition 93. 1, 143-150

Early Menopause

This is menopause experienced before the age of 45. These patients are more at risk of health conditions associated with the menopause, such as CHS, CVA and osteoporosis if they don’t take HRT.

Early menopause can be caused by a variety of factors such as; viral infections, enzyme deficiencies, chromosome abnormalities such as fragile X syndrome, and Turner’s syndrome. It may also be caused by FSH receptor gene polymorphism and mutation of inhibin B. Other medical factors include hypothyroidism, type I diabetes, Crohn’s disease, SLE, rheumatoid arthritis, Addison’s disease and myasthenia gravis.

There are other factors of a secondary nature which include chemo/radiotherapy, or oophrectomy.

Assessment and diagnoses will require blood tests for FSH, if necessary two weeks apart if there is no calculable cycle, bloods for testosterone, prolactin (to exclude polycystic ovary syndrome) TSH, progesterone (for fertility). Chromosome analysis for fragile X syndrome may be required, also the assessment ought to include a BMI, BP and bone density scan.

Because women with early onset menopause are at greater risk of the associated conditions, it is essential that they are screened initially and also that these checks are made regularly. Patient education regarding reversible risks factors of these conditions is vital.

For early menopause, HRT or a combined contraceptive pill can be prescribed; particularly as contraception still needs to be considered.

Diabetes and Sleep Apnoea

Type II diabetes patients with sleep problems are more likely to develop neuropathy and retinopathy related problems. A Birmingham study found that neuropathy and retinopathy were 30-40% more prevalent in type II diabetic patients with obstructive sleep apnoea. (Diabetic Medicine 2011, 28:supplement 1).

Care of the Diabetic Foot

Diabetes is a condition with far-reaching consequences. As the population ages, more diabetes-related conditions will occur.

Diabetes is the root cause of the majority of non-traumatic limb amputations, and therefore diabetic foot problems need to be treated as an emergency, according to NICE guidelines.

Diabetic foot problems can include neuropathy, charcot arthropathy (or other deformity), gangrene, ulcers, osteomyelitis, peripheral arterial disease, or infection.

For care of diabetic foot problesm, the multidisciplinary team in an acute setting will comprise: tissue viability nurse, diabetologist, relevant surgeon, diabetes specialist nurse, podiatrist, and possibly a physiotherapist. The aim of the MDT is primarily mobilisation.

Patients with diabetes-related foot problems need to be referred to the responsible MDT within 24 hours of admission. this team will then assess and initiate treatment of  the patient’s underlying diabetes, assess and coordinate care for the presenting foot problems, (the assessment is to include a vascular assessment). Infection also needs to be treated immediately; a swab may be taken, but depending on the stage of infection, it is likely that antibiotics are started before results return from the lab. At this point the patient will be assessed with regard to their need for orthotics or other interventions to protect the feet and revent/reduce future problems where possible. The MDT will also begin to consider discharge, so there is a workable plan in place at the right time.

At all stages, the patient must be kept in the loop with discussions and must be a part of the decision-making process. Patient education and empowerment is paramount, as is effective communication with the primary care team taking over care (if necessary).

Sugar and Diabetes

According to Azmina Govindji (Diabetes Wellness News April 2011) the latest advice to those with diabetes is that a diabetic diet is a low sugar diet, rather than a ‘no sugar’ diet. A lifestyle of exercise and good healthy diet is essential for wellbeing, consuming low levels of salt, sugar and saturated fat, and high in fibre.

A small amount of sugar can be combined with low glycaemic carbohydrates (e.g. pasta and pulses) as low glycaemic foods help to stabilise blood glucose, which prevents the blood glucose increasing too rapidly. All patients with diabetes are entitled to help from a dietitian to enable a healthy yet practical plan.