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Hypodrive Mentor Training Program

Driver training for mentors who have learners who are diagnosed with diabetes or are at a high risk of developing diabetes

Welcome to the Hypodrive learner driver mentor program. This session is aimed at providing you with valuable information about Diabetes Mellitus, the types of diabetes, the management and complications and the questions you need to ask prior to driving. And you are all aware of the devastating consequences of how low or high blood glucose levels can impair your learners’ ability to drive safely. I would like this session to be interactive, so please don’t hesitate to ask questions and if you feel that you can’t ask a question during the presentation please slip it on a piece of paper and hand it to one of the presenters.

What is Diabetes Mellitus?

  • A chronic disease characterised by high blood glucose (sugar) levels
  • Occurs when the pancreas is unable to produce enough insulin, or the body becomes resistant to insulin, or both.

(Department of Health and Ageing, 2011)

Diabetes comes from the Greek word siphon, whereby the body acts as a conduit for the excess fluid and Mellitus from the Greek and Latin word honey. Diabetes is not a new disease as it is mentioned in ancient Egyptian era where they had water tasters. These people would taste the urine to check for diabetes. Not a good job to have I am sure. Today it is often simply referred to as diabetes and it is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin (insulin resistance). Blood sugar levels are controlled by insulin, a hormone produced by the pancreas and diabetes occurs when the pancreas is unable to produce enough insulin, or the body becomes resistant to insulin, or both.

Where does the glucose come from?

So where does the glucose in blood stream come from? Glucose comes from our main fuel source- “carbohydrates” and when we consume carbohydrates they are broken down into glucose where it is absorbed into the blood stream. Carbohydrates include all dairy products except for cheese (when cheese is processed the sugar content is removed), legumes, fruit, cereals, pasta, bread, and starchy vegetables, etc. So you might say what can I eat, firstly lets not panic, to start off with there is nothing that you can’t eat, its just a matter of looking at serving sizes. At the same time it is important that we have sufficient carbohydrates each day as it is fuel for our bodies. If you think of our bodies as cars, if we don’t  have sufficient fuel, we don’t function and nor would our car.

What is Insulin?

  • Insulin is hormone made by the pancreas
  • Acts like a key by unlocking the cell door (glucose channels) so that the sugar is moved from the blood stream into the muscles where we use it for energy

(Phillips, 2007, p. 11)

Glucose levels in response to eating

In response to your carbohydrate intake your blood glucose and insulin levels will fluctuate and in a person without diabetes normal blood glucose levels range from 3-8.0mmol/L
Note: Excludes those aged less than 10 years.

Source: National Diabetes Register and AIHW analysis of de-identified NDSS data (data extracted July 2011)

This graph presents the latest statistics for people with type 2 diabetes using insulin. It needs to be noted that not all people with Type 2 diabetes need insulin for treatment and lifestyle modifications such as regular exercise and a healthy diet, along with medication. However some people require  insulin and this can depend how long they have had diabetes and their age. From 2000 to 2009, there were 94,663 males and 77,583 females who began to use insulin to treat their Type 2 diabetes. The average annual rate of new cases over this period was 95 per 100,000 people. This was 108 new cases per 100,000 for males and 82 new cases per 100,000 for females.

Until the age of 85 years, the incidence of insulin-treated Type 2 diabetes increased as people got older. For those aged 10–14 the incidence was 3 per 100,000 people and for the 55–69 year age group it was 238 per 100,000.

http://www.aihw.gov.au/diabetes/incidence/#t3

Diabetes – The Facts

  • Diabetes has reached epidemic proportion in Australia and globally
  • 1.7 million Australians have diabetes
  • 275 diagnosed each day
  • 60 a day in Queensland

(Department of Health and Ageing,, 2011 )

Globally, Diabetes has reached epidemic proportion.  It is estimated that 1.7 million Australians have diabetes and half of these people don’t know that they have it. (type 2 diabetes). Type 2 diabetes continues to be the fastest growing chronic disease.  The 2007-08 Australian National Health Survey estimated that 4% of the population, have diabetes keeping in mind that this this survey relies on self-reported data. These figures have doubled since 1995 and In QLD there are approximately 300,000 people diagnosed with diabetes (Diabetes Australia QLD). It is estimated that two million Australians have pre-diabetes this putting them at risk of developing type 2 diabetes. Diabetes is the sixth leading cause of death in Australia

http://www.aihw.gov.au/publication-detail/?id=10737419311

What’s the concern?

Undetected or poorly controlled diabetes:

  • Increases the risk of heart attack and stroke
  • Can lead to blindness
  • Kidney failure
  • Foot ulcers and amputation
  • Impotence in men
  • Affects driving ability

Healthinsite

Long term complications include:
– heart attacks and strokes: up to four times more likely in people with diabetes
– blindness: retinopathy affects one in six people with diabetes
– kidney damage: three times more common in people with diabetes
– amputations: 15 times more common in people with diabetes

Undetected or poorly controlled diabetes affects driving ability particularly if you are experiencing hyperglycaemia (high blood sugar) or hypoglycaemia (low blood sugar) it also increases the risk of long term complications which has a detrimental affect on your health.

Types of Diabetes

  • Type 1 – 10-15% of the population
  • Type 2 – previously accounts for 80-90% of people diagnosed with diabetes
  • Gestational Diabetes (GDM)

(Bilous & Donnelly, 2010)

Type 1 diabetes is an auto-immune disease in which the body’s immune system destroys the insulin-producing beta cells in the pancreas. This type of diabetes, also known as juvenile-onset or insulin-dependent diabetes, accounts for 10-15% of all people with the disease. It usually develops rapidly and it can appear at any age (predominately in children), although commonly in anyone under 40. It is triggered by environmental factors such as viruses, diet or chemicals in people who are genetically predisposed to the condition. People with type 1 diabetes must inject themselves with insulin several times a day and follow a healthy diet and exercise plan. In other words they have to think like a pancreas.

Type 2 Diabetes: Type 2 diabetes results from a combination of genetic and environmental factors and although there is a strong genetic predisposition, other risk factors include: ethnicity, increasing age, some medications (Steroids),  and in some women, Polycystic ovarian syndrome (PCOS). Type 2 diabetes is a two step model first the body is resistant to insulin produced and over time it becomes deficient.

Gestational diabetes occurs in pregnancy and usually disappears when the baby is born, however, it can increase the risk of type 2 diabetes developing in women. (Diabetes Australia). (Diabetes Australia)

Diagnosis

(Diabetes Management in General Practice 2011/2012)

The diagnosis of type 1 diabetes is usually clear cut as the person presents with weight loss, increased thirst, having to go to the toilet frequently, blurred vision, with or with out vomiting and/or abdominal pain.

On the other hand, the diagnosis of type 2 diabetes is determined by a three-step screening procedure, Firstly the initial risk assessment using a risk assessment tool or risk factors. The risk assessment tool is in your handouts please complete it and if you score high make an appointment to see your GP or feel free to talk to me after this session. Remember in most cases diabetes can be prevented and managed well.

Secondly – your GP will order a fasting blood test, this may also include cholesterol- if fasting 5.5-6.9mmol/L diabetes is uncertain Your GP will order a Oral Glucose Tolerance Test, this requires you to book into a pathology centre, you attend in the fasting state blood is taken and then you have to consume 75gms of glucose, 1 hour blood is taken again and at 2 hours. If fasting is greater than 7mmol/L or greater than or equal to 11.0mmol/L diabetes is likely. Diabetes Management in General Practice 2011/2012 pg.9

Management

  • Healthy Eating
  • Regular Physical activity
  • Blood glucose monitoring
  • Medication and Insulin
  • Regular check ups with health professionals
  • Check daily foot wear
  • Eye checks
  • Dental checks
Living well with diabetes means keeping blood glucose level as close to normal range as possible.(Healthinsite). The biggest problem with diabetes is that elevated BGL’s produce no pain, so people are not inclined to go to the doctor as much as they would if they had an ache that never went away. As a diabetes educator I am continually informing people of  the problems associated with elevated readings but its hard for people to into consideration because they haven’t got a problem with their eyes, feet etc so why should I change. I ask you to think what would you do?? Are you going to make a change that will have an impact on your life or say well when it happens then I will deal with it. Well its your choice but if you change your eating habits to a healthier version even if its one thing you are on the way.  It is important to maintain healthy eating and this will be discussed in the next session, however you should aim for at least 30 minutes of daily physical activity. Start thinking of ways that you can get more physical activity in your day. For example take the stairs instead of the elevator. Use the broom instead of the blower, get up and change the channels on the tv, park the car further from the shop entrance, etc. Additionally it is important to have  regular check ups with health professionals such as regular blood tests, monitoring HbA1C. checking blood pressure, cholesterol levels, and feet.

Ideal Blood Glucose Targets

  • 4-6mmol/L fasting
  • Up to 8mmol/L 2hours post meal
  • 6-7mmol/L at bedtime
  • Always Remember ‘5mmol/L or greater to drive’
So what is your target blood sugar level? Well for starters it  depends on many factors, including whether you have type 1 or type 2 diabetes mellitus, your age, overall health, social support system and personal preferences.

It’s important that people with diabetes stabilise their blood glucose levels. What is termed ‘acceptable’ blood glucose levels can vary slightly but, as a general rule of thumb, fasting blood glucose levels should be less than 6.0 mmol/L, while non-fasting levels should be 4-8 mmol/L. If you plan on driving you should be 5mmol/L or greater before you drive and if you have a history of hypo unawareness you should be 6 or greater to drive.

As mentioned before by keeping your blood glucose as close as possible to normal reduces the risk of long-term complications of diabetes.

Acute Complications of Diabetes

2 complications can occur if diabetic management is not optimal:

  • Hypoglycaemia (hypo)
  • Hyperglycaemia (Hyper)
There are two acute complications of diabetes this meaning that they can occur quickly and at intervals and in most cases they are often preventable.

Hypoglycaemia (meaning low) commonly referred to as Hypo is classified when your blood glucose level falls below 4mmol/L or less with or with out symptoms.

Hyperglycaemia (meaning high) on the other hand is recognised when BGL’s are greater than 15mmol/L.

Hypoglycaemia (hypo’s)

  • Defined as a blood glucose level <4mmol/L with or without symptoms
  • Occurs in the people with diabetes treated with insulin and oral antidiabetic drugs (sulphonlyureas)

(Bilous& Donnelly,2010 )

Symptoms of hypoglycaemia can vary from person to person, as can the severity. Classically, hypoglycaemia is diagnosed by a low blood sugar of 4mmol/L or less and in some instances with or without  symptoms. The brain cannot make its own glucose and is 100% dependent on the rest of the body for its supply. In fact, in order to  function properly, the brain requires 120-140g glucose per day (demonstrate what this is by a food model). In the event that the brain’s requirements increase and/or the demands are not met the glucose level in the blood falls resulting in decreased cognitive function.

So we need to ask who is at risk of a hypo? Firstly people at risk of a hypo are those taking insulin and people who are on certain oral medications for their diabetes. (Mathur, R)

Causes of Hypoglycaemia

  • Insufficient carbohydrates
  • Too much medication
  • Too much physical activity
  • Alcohol, up to 24 hours later
There are several factors that can contribute to a hypo and they can be caused by too much insulin or oral medication, insufficient carbohydrates, a delayed or missed meal or snack, increased physical activity either intentional or unintentional or when alcohol is consumed without eating food or on the other hand too much alcohol is consumed. When people consume alcohol their levels may be elevated to begin with but the liver needs to get rid of the alcohol as it is a toxin so it stops the normal production of glucose to break down the alcohol. People on insulin and some oral medications are at risk of a hypo up to 24 hours after they have consumed it. (Betterhealth channel)

Signs and Symptoms

Sympathetic

  • Headache
  • Hypothermia
  • Visual Disturbances
  • Mental Dullness
  • Confusion
  • Amnesia
  • Seizures
  • Coma

(Bilous& Donnelly, 2010)

The first set of symptoms are called sympathetic (or adrenergic) because they relate to the nervous system’s response to hypoglycaemia and for a majority of people, these symptoms are easily recognisable. The person may experience symptoms such as Hunger, Weakness, Sweating, Tachycardia, Palpitations, Tremor, Nervousness, Irritability, Tingling of mouth and fingers.

Anyone who has experienced an episode of hypoglycaemia describes a sense of urgency to eat, which soon resolves the symptoms. And, that’s exactly the point of these symptoms. They act as warning signs. At this level, the brain still can access circulating blood glucose for fuel. The symptoms provide a person the opportunity to raise blood glucose levels before the brain is affected. (Mathur, R)

http://www.medicinenet.com/hypoglycemia/page2.htm

Signs and Symptoms

Neuroglucopenic

  • Headache
  • Hypothermia
  • Visual Disturbances
  • Mental Dullness
  • Confusion
  • Amnesia
  • Seizures
  • Coma
In the event that the person does not or cannot respond by eating something to raise blood glucose, the levels of glucose continue to drop. Most will progress to neuro-glyco-penic symptoms (the brain is not getting enough glucose). At this point, symptoms progress to confusion, drowsiness, changes in behavior, coma, and seizure. (Mathur, R)
Check BGL 10-15 minutes later to ensure it is rising

If not rising repeat step one

Step 2:

Give a long-acting carbohydrate

e.g: ½ sandwich

Or   2 to 4 dry biscuits

Or   piece of fruit

Or   glass of milk or tub of yoghurt

Always give a long acting or slow release carbohydrate once BGL is on the increase. It is advisable to wear identification stating they have diabetes and whether you have recurrent hypoglycaemia..  Always check blood sugars before they drive a car, operate heavy machinery, or do anything physically taxing. Remember must be 5 or greater to drive and if you have hypo unawareness then you should be 6mmol/L or greater to drive. Always  carry a quick-acting glucose source (such as those mentioned) at all times, and keep the HYPODRIVE HYPO-KIT in your car, the office, and by their bedside. On a final note many people like the idea of treating hypo’s with cake, cookies, or chocolate. However, sugar in the form of complex carbohydrates or sugar combined with fat and protein are much too slowly absorbed to be useful in the acute treatment of hypoglycaemia. Save the chocolate for treats.

Hyperglycaemia

  • Elevated blood glucose level (BGL) >15mmol/L due to a relative or absolute insulin deficiency
  • Symptoms usually occur if BGL is persistently >15mmol/L
  • Diabetic ketoacidosis (DKA) – Type 1
  • Hyperosmolar coma – Type 2
  • Chronic hyperglycaemia = defects in psychomotor tasks, attention, learning and memory

(Bilous & Donnelly, )

Hyperglycaemia refers to an elevated BGL of 15mmol/l or greater. Chronic or continual elevation in BGL’s affects the individual’s ability to function.

The cause of hyperglycaemia should be sought as soon as possible.

Most common causes are not enough medication or missing a dose of medication for the treatment of diabetes, including emotional Stress, pain, some medications such as cortisone, illness such as Infection, changes in food, reduced physical activity or a new diagnosis of Diabetes

Symptoms of Hyper’s

  • Blood sugar levels greater than 15mmol/L
  • Excessive thirst
  • Increased urination
  • Nocturia
  • Fatigue
  • Weight Loss
  • Blurred vision
  • Impaired cognitive function
  • Change in behavior (usually irritable)
Symptoms include blurred vision (The blurred vision is a result of the lens of your eye changing shape which ultimately affects your ability to drive).  (My Dr) Elevated BGL’s also contribute to Change in behavior (usually irritable) and Impaired cognitive function all affecting judgment and  the ability to drive appropriately. It is recommended that you don’t drive until your BGL’s are within range and/or the symptoms of hyper glycaemia have resolved.

Management of hyperglycemia requires

Review of:

-Medication

-Diet

-Physical activity

-Stress

-Infection

Always Remember ‘5 to DRIVE’

References

Assessing Fitness to drive for commercial and private vehicle drivers. http://www.austroads.com.au/images/stories/Assessing_Fitness_to_Drive_Small_Size.pd

fAustralianDemographic Statistics. http://www.oesr.qld.gov.au/products/briefs/aust-demographic-stats/qld-pop-counter.php

Bilous. R & Donnelly, R. 2010.  Handbook of Diabetes. 4thedu. Wiley-Blackwell.

Betterhealth channel.  Diabetes and coma http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Diabetes_and_coma

Diabetes in the Workplace http://www.diabetesvic.org.au/living-with-diabetes/diabetes-in-the-workplace

Glucagon Emergency Kit

http://www.drugs.com/cons/glucagon-emergency-kit.html

Diabetes Australia http://www.diabetesaustralia.com.au/en/Understanding-Diabetes/What-is-Diabetes/

Diabetes Facts http://www.diabetesvic.org.au/health-professionals/diabetes-facts

Driving and Diabetes http://www.diabetesvic.org.au/living-with-diabetes/driving-and-diabetes

Diabetes Management in General Practice, Guidelines for Type 2 Diabetes (2011/2012) p9.

Ian Goodall, Mark Shephardand Jill Tate: Recommended Changes in HbA1c Reporting Units for Australian Laboratories , Positon Statement of the Australasian Association of Clinical Biochemists http://www.aacb.asn.au/admin/?getfile=2802

Health insite – http://www.healthinsite.gov.au/topics/Diabetes

Mathur. R. Hypoglycaemia. http://www.medicinenet.com/hypoglycemia/page2.htm

Department of health and ageing: http://www.health.gov.au/internet/main/publishing.nsf/Content/pq-diabetes

My dr dot.com. Diabetes: monitoring and treating http://www.mydr.com.au/diabetes/diabetes-monitoring-and-treating

Phillips. P. Princeton (2007) Healthworks Blood Glucose. Princeton , Australia

Australian  Institute of Health and Welfare  http://www.aihw.gov.au/publication-detail/?id=10737419311

Australian  Institute of Health and Welfare ,The incidence of insulin –treated type 2 diabetes http://www.aihw.gov.au/diabetes/incidence/#t3

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