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PUBERTY AND GROWTH OF CHILDREN WITH DIABETES: BOYS
As boys develop, changes occur in their body hair, voice and in the size of the penis and testes; wet dreams and morning erections occur which usually precede the ability to have a full erection on stimulation. These developments of manhood do not usually have a dramatic effect upon blood glucose control. What does change is the amount of food you need, and with it the dose of insulin. As you develop your full adult body size you need more and more food, and more insulin to help convert it into body tissue.
This increased fuel demand also affects girls, but to a lesser extent. But do not eat too much. Puppy fat does not just disappear; there is rarely any excuse for getting fat!
The hormonal changes which produce normal body growth are complex and are sensitive to chemical abnormalities in the body and other illnesses. Furthermore, the body has to be able to use all the glucose you gain from digesting your food. If your insulin balance is wrong and the glucose you need for growing is in the blood and cannot get into the tissues you will not grow normally. This can mean you end up much shorter than you should have done. Your body does not wait for your diabetic control to improve. Once you have missed your growth spurt you will stay short. So, eat the right amount for growing tall but not fat and keep your blood glucose levels normal to achieve your full potential.
*52/102/5*

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TAKING COMMAND OF DIABETES: FINDING A JOB AND WORKING
Beat the competition
Diabetes is not a barrier to getting most jobs. In the UK, people with diabetes are not allowed to enter the armed forces, the police force or, if insulin-treated, drive passenger-carrying or large goods vehicles. But the vast majority of trades and professions are open to people with diabetes with the right qualifications. Throughout the world jobs are becoming harder to get and it is therefore important for every young person, whether diabetic or not, to gain as many qualifications as he or she can before competing in the job market. This does not just mean academic qualifications, but generally being able to show that you are an interesting person. I must be realistic and say that if you have diabetes some potential employers may think twice before accepting you. This means that you must make sure that your qualifications for the job are as good as possible and preferably better than those of other competitors.
Applications
Virtually all jobs or opportunities for further training are gained through an application form, with or without curriculum vitae, and an interview. Fill out the application form using a typewriter if you can. Otherwise print neatly. Ensure that the form is meticulously neat and that there are no mistakes. Type your curriculum vitae, having gone over it first with your careers guidance adviser or a senior colleague or friend. At this stage, unless specifically asked about health, do not advertise your diabetes. Some application forms ask for information on disabilities. Max, aged sixteen years, answered this question by saying, ‘I have no disabilities, but I am a diabetic’. If asked, it is better to be honest about your diabetes than to conceal it.
When you are asked to go for an interview, look smart and neat- and conform. This is not the time to wear wild fashions unless, perhaps, you are applying to join a pop group. Do not allow your clothes or appearance to put off people in power (your future employer or head of college). When the subject of health comes up, or at an appropriate time during the interview, explain that you have diabetes but that it is well-controlled and does not interfere with your ability to work. You may have to explain exactly what diabetes is.
Medicals
Many organizations request a routine medical check on prospective members. Remember that the medical officer does not know you and your diabetes. Take your blood glucose diary to show your results (make certain that you know what they mean) and also to indicate that you are taking care of your diabetes. Make sure that you can reel off your precise dose and type of insulin and have your identity badge and emergency glucose to show. This may sound very naive, but it is easy to get rattled in the heat of the moment, so write it all down too. A letter of support from your diabetic adviser may help.
*73/102/5*

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TAKING COMMAND OF DIABETES: DIABETIC CHILD
Parents often worry that their child may later become diabetic if one of them has diabetes. Even though they may have considered this before having a family and decided that the risk was small enough to continue, slight anxiety often remains.
The first point to make is that the sooner diabetes is treated the better. If you suspect that your child may have developed diabetes, do not just watch and worry. Check his or her urine or blood glucose and find out. If your fears are confirmed, go to your own doctor immediately.
But do not become obsessed with checking your child’s urine for glucose. Unless both parents have diabetes, the odds are against your child being diabetic. If insulin-dependent diabetes does develop, it will be obvious very rapidly, because of the associated thirst, profuse urine and weight loss.
And if your child does develop diabetes? ‘Doctor, I feel so guilty. It’s all my fault. I’ve given it to her.’ Yes, your genes did contribute, but other factors, many as yet unknown, triggered the diabetic process. You have also given your child her existence and a great deal more than the tiny fragment of genetic material which went towards her becoming diabetic. Your main job now is to help your child adjust to being a well-controlled diabetic as quickly as possible.
Always bear the following points in mind:
Ђў Diabetic men and women can have happy, healthy children.
Ђў It is important to plan your family.
Ђў Consider the risks of passing on your diabetes to your children.
Ђў Make sure that you are fit enough to go through pregnancy and look after your children afterwards.
Ђў Plan to conceive at a time when your blood glucose is normal and tell your doctor as soon as you suspect that you may be pregnant. Keep your blood glucose normal throughout pregnancy but eat enough for your growing baby.
Ђў Remember that insulin needs fall rapidly after delivery.
Ђў Diabetes is no deterrent to breastfeeding.
Ђў As your children grow up take care of yourself as well as your family.
*72/102/5*

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DIABETES AND IMPOTENCE
One of the myths about diabetes is that all diabetic men are impotent. This is nonsense. Most diabetic men are normally potent but a few develop impotence in later years, and this is more common among men with diabetes than non-diabetics. If you think that you may be impotent, do not bottle your worries up inside you but discuss them with your doctor. He will not be embarrassed or think it odd that you want to discuss your sex life. If you go to a diabetes specialist he will probably also have trained in endocrinology or hormone disorders and be used to discussing such problems.
The impotence associated with diabetes is thought to be due to autonomic neuropathy because the autonomic nervous system is responsible for the increase in blood flow to the penis which causes it to become firm and erect. However, one study showed that two-thirds of diabetic men who were troubled by impotence were having wet dreams or morning erections. If this is the case, impotence during intercourse or masturbation is more likely to be due to psychological factors and may improve with counseling. One of the problems is that the more you worry about whether you are going to have an erection while making love, the more likely you are not to have one. If you and your partner can relax about this aspect of love making and not aim for full intercourse for a few weeks or months, but enjoy each other in different ways, things may improve. Many hospitals have counseling services for people with sexual problems. It is important to share your worries with your partner. She will then be able to help you as well.
But what if you are having no erections at all? The first thing to do is to have a full medical check-up. It may be that there is a non-diabetic hormonal reason for your impotence that can be put right by hormone injections. Your doctor will certainly want to take some blood tests to check this. Many illnesses, including uncontrolled diabetes, are associated with temporary impotence and loss of sexual drive. Full potency may return if the illness is treated and sometimes returns if the blood glucose is brought back under control, although this does not always happen.
If after a lot of tests your doctor tells you that you have impotence due to autonomic neuropathy, do not despair. It may be that you and your partner have the sort of relationship in which the sexual act plays only a small part. It is very important that you discuss things fully with your partner. She may be less upset than you imagine and there are other ways of giving each other pleasure. There are several treatments to help impotence. Injections of papaverine into the penis produce an erection in most cases and you can find the dose which suits you. Rarely this causes a prolonged erection which can be painful. There are several sheath-like devices which produce an erection by inducing a vacuum around the penis. Some men prefer penile implants – unlike the other methods these are permanent. Hormone injections are no use for neuropathic impotence; they simply increase the desire without improving the performance.
*57/102/5*

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CONTRACEPTION FOR PEOPLE WITH DIABETES: DIAPHRAGM AND INTRAUTERINE DEVICE
Diaphragm
The diaphragm or Dutch cap is another barrier method used together with spermicides. For this method to be comfortable and effective the vagina has to be measured by a gynecologist so that the cap fits correctly within the vagina and over the cervix. Most women need a little practice before they can insert the cap, covered in spermicidal cream, easily and comfortably. When the diaphragm is in position it can be left there comfortably for some time. It is necessary to insert additional spermicide into the vagina if more than six hours have elapsed since the previous act of intercourse. This method protects the cervix from sperm. The failure rate is three pregnancies per 100 women per year. A similar device called the cervical cap, which is made from a mould of the woman’s cervix and fits exactly, is being studied in several countries. There is little experience of this device being used by women with diabetes, but there is no reason why it should cause particular problems for them.
Intrauterine device (IUD)
The IUD or coil is inserted into the womb and by a combination of chemical and physical effects it prevents the fertilized egg from implanting there properly. Most gynecologists prefer to give this only to women who have already had a pregnancy. The IUD has a failure rate of two pregnancies per hundred women per year. When it has been inserted by the doctor, it can be left in place and no other contraceptive measures need be taken.
There is a small risk of pelvic infection but there is no evidence that this is greater in diabetic women than in the general population. In rare cases, the infection may be so severe the women become permanently infertile. However, a few years ago, a more practical problem was noticed in diabetic users of the coil in Scotland. A large proportion became pregnant with the coil still inside the uterus. It was found that the coils removed from these women had different chemical deposits from those of non-diabetic women. These unusual chemicals had apparently made the coils ineffective. Newer coils are now available and appear to be as effective in women with diabetes as in non-diabetics.
*59/102/5*

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DIABETES IN PREGNANT WOMEN
Insulin
You will almost certainly have to change to twice-daily insulin injections if you do not already need them, and may need more frequent injections of short-acting insulin during the day. It is usual in the UK to transfer diabetic women taking oral hypoglycemic pills to insulin treatment before pregnancy, because of the potential risk of the pills damaging the developing baby. But do not panic if you find that you have become pregnant while taking oral hypoglycemic drugs. Available reports and animal studies show no definite risk of teratogenicity, or imperfect development of the baby. If you have become pregnant while taking the pills, just change to insulin as soon as you know you are pregnant. You will probably be able to go back to your hypoglycemic pills after delivery.
Some centers have used CSH pumps very successfully before and during pregnancy. Most rely on very close monitoring and frequent insulin injections.
Eat enough
Your baby needs energy to grow. This means that you must increase your intake of food as your pregnancy progresses. Beware the dangerous habit of missing food because your blood glucose is a little high. It is easy for ketones to form during pregnancy and they are not good for developing babies. To keep ketones at bay you need insulin and carbohydrate.
Insulin requirements
Theoretically, if you have some insulin reserve of your own, your insulin need may fall during the first ten weeks of pregnancy. In practice, this is not often obvious and what most pregnant women with diabetes notice is a gradual increase in the insulin need, which is greater than you would expect from your increase in carbohydrate. This is because your body becomes increasingly insulin resistant owing to the hormonal changes of pregnancy. By the end of the ninth month you may be on twice the dose of insulin you were taking when your pregnancy started.
*68/102/5*

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DIABETICS AND CONTRACEPTION

Diabetic girls are capable of having babies as soon as they start having menstrual periods, and diabetic boys can father children once they are able to have an erection and ejaculate. Therefore, it is important that you take as much care to prevent unwanted pregnancies as a non-diabetic person. Methods of contraception are described below. The figures given for failure rates are approximate and apply to couples who are using the method properly. They are calculated as the number of women who become pregnant out of a hundred women using that method for a year. The failure rates are much higher if you include all couples using a particular method, because many people do not follow the instructions carefully.
Rhythm method
This relies on the safe period, the time between menstrual bleeding and ovulation. It works only for women with absolutely regular periods, and even then is not wholly reliable. The rhythm method is not an efficient form of contraception. At least fifteen out of 100 women using it for a year will become pregnant.
If measuring your temperature is used to discover when ovulation has occurred, it is slightly more effective. Then the failure rate is five pregnancies per 100 women a year.
This method is not recommended unless you have very strong religious or moral reasons for avoiding a more effective method.
Withdrawal
This is completely unreliable. The idea is that the man withdraws his penis from the vagina before ejaculation so that no sperm enter the vagina. However, sperm can leak from the penis before full ejaculation takes place. It may also be very difficult for the man to withdraw at the critical moment. Furthermore, you should remember that it is possible for sperm to enter the vagina even without full penetration taking place. If you are indulging in heavy petting and there is any contact between the penis and the female genitalia, you need full contraceptive protection.
Sheath
The simplest form of barrier method is the sheath, condom or French letter. This should be combined with spermicidal pessaries, cream, jelly or foam for greater safety. Used properly it has a failure rate of three pregnancies per 100 women per year. The advantages of this method are that the sheaths and spermicide can be bought in many shops and they are simple to use (read the instructions carefully if you are using them for the first time). The sheath has to be put on the erect penis and some couples find that stopping to put the sheath on interferes with the spontaneity of lovemaking. Some men find the sheath uncomfortable. An advantage of the sheath is that it protects both partners from infections and the cervix from sperm.
*58/102/5*

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DIABETES AND PREGNANCY
Contact your doctor as soon as you suspect that you may be pregnant. Do not wait until you are sure. This means you should see him or her if your period has not appeared within a week of its expected day. Obviously it is more difficult to judge if your periods are irregular. Urine pregnancy tests have become more sensitive in recent years but it may be several weeks before you get a definite positive result. If you still have not had your period, keep checking the pregnancy tests.
A blood test can detect pregnancy much earlier than a urine test as tiny quantities of the hormone human chorionic gonadotrophin produced by the placenta are measured. This test is not available in all hospitals.
Normal glucose levels
Both when you are planning your baby and when you are pregnant, you must have normal blood glucose levels. All your blood glucose tests must be between 4 and 6 mmol/1 (72 and 108 mg/dl). Mild hypoglycemia does not seem to harm the baby but severe hypoglycemia may. Not only must you avoid high blood glucose levels, you must do so without going too low. No one pretends that this is easy. Having a baby is hard work for a diabetic mother. It is harder before pregnancy than when you are pregnant because the hormone changes which then occur act as a buffer to swings of glucose.
It is easier to measure such a small change in blood glucose levels with a meter, if you can borrow or buy one, as the colour changes on strips are very subtle. Pre-pregnant or pregnant diabetics should measure their blood glucose level four times a day before meals, with extra measurements if things do not seem right at other times, for example, after meals or during the night. Most clinics now also use the hemoglobin A1c test to check on the average blood glucose control during pregnancy.
*67/102/5*

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DIABETES AND FAMILY PLANNING
Age at diagnosis of diabetes
A Canadian study suggests that if you were aged under twenty years when your diabetes was diagnosed, your children are approximately twenty to forty times more likely to be diabetic than those of non-diabetic parents. If you were aged between twenty and forty when your diabetes was diagnosed, your children are approximately ten times more likely to be diabetic than those of non-diabetic parents. If you were over forty years old, your children are two or three times more likely to be diabetic. In a British study of newly diagnosed diabetics, 5 per cent of those under fifty years of age; 40 per cent of those between fifty and sixty-nine years and 30 per cent of those over seventy had a first-degree relative that is, a parent, sibling or child, who had diabetes.
Rare conditions
There are various very rare conditions in which diabetes plays a part and which are very strongly inherited. You will almost certainly know if you and other members of your family have a rare inherited condition associated with diabetes. In this case ask your doctor about the way it is inherited and the chances of your children having it.
Future generations
It is worth considering whether you are prepared to risk your child having diabetes and handing the condition on to future generations. The risk of passing on insulin-dependent diabetes may be less than that for non-insulin-requiring diabetes. However, a child with insulin-dependent diabetes may have to give himself injections for most of his or her life, whereas a non-insulin-dependent child may live most of his life free from diabetes. Obviously, we hope that medical advances will make diabetes easier to cope with in years to come.
*64/102/5*

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CONTRACEPTION FOR PEOPLE WITH DIABETES: ABOUT STERILIZATION AND MORE
A couple who have completed their family could consider vasectomy or female sterilization by tying the Fallopian tubes, as alternatives. But do not take that decision lightly. You may want children later -possibly with another partner, and reversal of sterilization is not always easy.
An unwanted pregnancy can be a disaster for all concerned, particularly if the woman has diabetes. Nowadays there is no excuse for unprotected intercourse, and this applies to men as well as women.
As soon as a diabetic girl has a relationship in which she thinks there is any possibility of sexual intercourse she should discuss contraception with her doctor. It is best to talk about contraception to whoever looks after your diabetes, but if this is difficult go to a Family Planning Clinic and make sure that you tell them you have diabetes. In an emergency, buy sheaths and spermicide.
I am often asked which is the best method of contraception for people with diabetes. My usual advice is that a barrier method (sheath or diaphragm with spermicide) properly used is best. However, if a couple find this method difficult or unacceptable they are less likely to use it properly than a couple who have themselves chosen a barrier method. Then, having discussed all the advantages and disadvantages, I suggest the progestogen-only Pill.
The decision about which of these methods to use should be shared between the couple and their doctor. Ultimately you should choose the one you feel that you and your partner will be able to use properly.
You should not forget your family in this discussion. Many young girls are afraid to talk about sex and contraception with their parents. It is always better to be open about things within the family, and most parents are more understanding than you imagine. After all, they have a sexual relationship and have probably experienced the same worries that you are having now.
Always bear the following points in mind:
Ђў People with diabetes can enjoy sexual intercourse as much as anyone else, but do not forget that it uses energy.
Ђў Impotence may trouble diabetic men in later years but it is commonly not due to diabetes and is often temporary. Do not bottle up your worries about this but discuss them with your doctor.
Ђў If you are not planning a family, use contraception. Discuss the method of contraception most appropriate for you and your partner with your doctor before you have intercourse, not afterwards.
*61/102/5*

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DIABETES AND FAMILY PLANNING: BLOOD GLUCOSE CONTROL AND PLANNED PREGNANCY
Blood glucose control
A vitally important factor is your blood glucose balance. For many years, doctors have known that good glucose control during pregnancy ensures that both mother and baby have the best possible chance of remaining healthy. But even with normal blood glucose levels from the first prenatal clinic visit onwards, more babies of diabetic mothers die than do those of non-diabetic mothers. The reason for this has become obvious over the past few years. Most women do not confirm that they are pregnant until the developing baby is several weeks old. The first eight weeks are critical in the development of the baby, because this is when most of the major body systems form. If the mother’s blood glucose level is high at this time, this early development is upset and congenital abnormalities may occur. Some of these may be so severe that their baby does not survive. However, among women with diabetes whose blood glucose level is kept within normal limits from the moment of conception, the difference in their babies’ survival and those of non-diabetic mothers virtually disappears.
Planned pregnancy
But how do I know when the moment of conception is? A diabetic mother-to-be must plan her baby and try to conceive only when her blood glucose levels are normal. Use contraception until you have your glucose balance right. Stopping barrier methods is less likely to cause a disturbance to your periods and your diabetic control than stopping the contraceptive Pill. For this reason, some doctors prefer that diabetic women planning to have a family use barrier methods of contraception. Some hospitals have pre-conception or pre-pregnancy clinics to help diabetic women plan their families. Ask if your hospital has one.
*66/102/5*

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DIABETES AND SEX: PARTNERSHIP
Every close relationship with a member of the opposite sex is a form of partnership, a sharing of experiences and ideas between two people. Some partnerships are short, others may last a lifetime. To start with you may be shy about telling your new partner that you have diabetes for fear that he or she will break off the relationship. But hiding your diabetes may lead to more and more lies and evasions. How do you explain that you have to eat within a certain time? If you are taking insulin, how do you manage to do it secretly? What happens if you have a hypoglycemic attack?
Diana, a seventeen-year-old, met her boyfriend, John, at an ice skating rink. They both enjoyed skating and soon began spending every Tuesday evening together at the rink. One evening Diana had to work late at college and missed her evening meal. She thought that she had made up her carbohydrate intake with crackers and an apple but unfortunately she collapsed with a severe hypoglycemic attack at the side of the rink. John was very frightened when he could not wake her up and the staff at the ice rink called an ambulance which rushed her to the hospital. No one knew that Diana had diabetes, but routine checks in the casualty department showed she had a low blood glucose level and she was soon revived.
John, much relieved, took her home. He was very upset that she had not trusted him enough to tell him about her diabetes- especially because his aunt was diabetic and he would have known what to do if he had realized that Diana was simply hypoglycemic. They are still going out three years later.
Eventually you may both decide that you want to make your partnership permanent. By this time you should certainly have told your partner that you have diabetes and he or she should know what this means to you in practical terms, now and in the future. It is a good idea if your partner learns how to help you check on your diabetes and also about your diet and how to give you your insulin or pills.
Your diabetic adviser will be happy to see your partner with you and explain things if you wish. It is important that you have frank and open discussions about all aspects of your diabetes. It can also be helpful to discuss sex and families at this time.
*55/102/5*

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DIABETES IN WOMEN: DELIVERY
In the old days, diabetic women were admitted to the hospital for months during their pregnancy, their babies were induced several weeks early and caesarian section was commonly performed. This was partly because poor glucose control led to very big babies. Nowadays, many obstetricians experienced in caring for diabetic women allow the pregnancy to come to term and vaginal delivery to take place.
Labour
When you go into labour, careful and continuous monitoring of you and the baby is started. A continuous glucose infusion is run into a vein with a continuous insulin infusion running at the same time. The rates of glucose and insulin infusion are adjusted according to your blood glucose levels. You will be given plenty of glucose because labour, as its name suggests, is hard work and if you do not have enough glucose, ketones will form which may harm the baby.
Do not be alarmed if a pediatrician or neonatologist is there when your baby is delivered. This is a precaution in case the baby has blood glucose problems while it is adjusting to living away from you. These are easily treated. Occasionally, babies of diabetic mothers have early breathing problems and these can be treated too. Sometimes, if there has been a period of poor glucose control during pregnancy, and occasionally even with perfectly controlled mothers, the baby is very large. If this happens you may need a caesarian section and the baby will probably be admitted to the special care baby unit for a few days. Your baby will be back with you as soon as the doctors have made sure that his or her glucose level is normal and the breathing is all right. The baby’s weight will soon level off to match other babies of the same age.
Within a few hours of delivery your insulin requirements will drop dramatically. Therefore it is important that your glucose drip is not taken down until you are eating properly.
Today most diabetic women have healthy babies. If something goes wrong, do not blame yourself. Remember that a very small proportion of non-diabetic women also have babies with congenital problems, for no obvious reason. All you can do is try your best to keep yourself healthy during pregnancy and to keep your blood glucose normal; no one is perfect and no one can do more than her best.
Expert care
By now you will have realized that ensuring that women with diabetes keep well during pregnancy and labour and have healthy babies is a complex business. It is much better to travel a few extra miles to a hospital that has a special clinic for diabetic mothers than to go somewhere closer to home which rarely sees a pregnant woman with diabetes. Your diabetes adviser will know of local diabetic prenatal clinics, and he or she may even share one with an obstetric colleague. If you have difficulties in finding expert care, your diabetic association (the American Diabetic Association – ADA – or the British Diabetic Association – BDA) may be able to tell where your nearest diabetic prenatal clinic is. Home deliveries are out of the question for the diabetic mother-to-be.
*69/102/5*

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CHILDREN AND YOUNG PEOPLE WITH DIABETES: COLLEGE OR UNIVERSITY
Anna developed diabetes when she was eighteen years old, just three months before she was due to start at a university about a hundred miles from her home town. She had brilliant examination grades and a promising career lay ahead of her. When the time came to start university she refused to go. She said that she knew she would not be able to cope with her diabetes at the university. No amount of explanation and assurance could persuade her otherwise. She allowed her diabetes to destroy her future.
Anna’s story is sadly not unique. For her, the combination of leaving home and coping with the practicalities of diabetes became overwhelming. But of course, the problem can easily be solved with a little common sense and care. I saw many diabetic students in Oxford thoroughly enjoying the academic and not-so-academic side of university life. Their diabetes is simply part of their everyday routine, rarely intruding on what they want to do.
Leaving home
For someone with diabetes, leaving home means moving away not only from your family but also from the doctors and other people who have been helping you to look after your diabetes, maybe since you were a child. Of course you can still see them during vacations, but what happens if you need help in term time? Most students register with the college doctor or with a local family doctor to cover them during term time. You can still your own family doctor when you are at home. Most towns have a diabetic clinic. Ask your diabetic clinic doctor to contact the clinic in your college town and ask if the doctor there will keep an eye on you.
Of course, if you are moving to a new town permanently, your records will be transferred to your new family doctor and diabetic clinic. You will soon get used to the new team. Remember that different areas may do things a little differently. There is often more than one way of coping with a diabetic problem and there are several views on most aspects of care.
Always bear these points in mind:
Ђў A diabetic pupil should not miss classes because of his or her diabetes.
Ђў Control should be good enough for concentration in class as well as for homework and studying for exams. All diabetic pupils must be able to perform at their best during exams.
Ђў All the student’s teachers should know about his or her diabetes and what to do about hypoglycemia.
Ђў There is no reason why diabetics should not go on school trips.
Ђў You should gradually take over the responsibility for your diabetes from your parents – and parents should start letting go.
Ђў Feel free to go out with your friends and try new foods and new experiences. But use a little common sense; your parents were teenagers once and their advice is worth listening to.
Ђў Drink alcohol in moderation if you want to but eat something with it.
Ђў Do not smoke.
Ђў Remember that as soon as diabetic girls have started menstruating and diabetic boys have erections, they are capable of creating children.
Ђў If you leave home make sure that you arrange for a new family doctor and diabetic adviser to take over your care.
Ђў Talk about your worries to your parents or to your doctor. Do not let your diabetes get you down. Go out and enjoy life.
*54/102/5*

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CONTRACEPTION FOR PEOPLE WITH DIABETES: ORAL CONTRACEPTIVE PILL
The oral contraceptive pill, taken according to instructions, is the most effective way of preventing conception. The side-effects of the Pill are greater than those of other methods of contraception, but the failure rate is less than one pregnancy per hundred women per year.
However, diabetic women need to weigh the risks to their health of taking this hormone preparation. The Pill affects both glucose and fat metabolism. Both the oestrogen and the progestogen component can increase the body’s intolerance to glucose. The increased insulin resistance may theoretically put the blood glucose level up in a treated diabetic. In practice this does not usually cause any problems because the dose of insulin can be adjusted. However, it may mean that a diet-treated diabetic finds it hard to control her glucose levels by diet alone. Oestrogens also increase the blood fats, triglycerides and cholesterol but progestogens do not. The Pill can cause high blood pressure (which may occur in people with diabetes anyway) and it is associated with blood clotting (thrombosis) problems, most commonly in the deep veins of the calf (called deep vein thrombosis). Atherosclerosis or hardening of the arteries may also develop or get worse and cause heart attacks or strokes. The risk of a heart attack or stroke through taking the Pill is probably greater in diabetics than in non-diabetics.
The risks of side-effects are greater in women over thirty-five years old, and much greater in women who smoke. These problems are related to the amounts of the two contraceptive hormones in the Pill. Nowadays, most Pills have a low oestrogen component and some contain progestogen only. Diabetic women, who decide with their doctor that they want to use the Pill, should certainly use a low-oestrogen one. Many doctors feel that the progestogen-only Pill is the most sensible choice.
*60/102/5*

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DIABETES: QUESTIONS ABOUT FAMILY PLANNING
Will you be able to look after your child?
Nowadays, most people with diabetes can look forward to a long and happy life. It is no longer unusual to meet people who have been on insulin for over fifty years and who have little trouble with their diabetes. However, some people with diabetes develop complications of the disease, and a very few are unfortunate enough to have severe complications such as heart disease or kidney disease at a time when they want to start a family. If this applies to you, you must face the fact that you may not be fit enough to help your children to grow up. This places an additional burden on your partner. If you and your partner are in this difficult situation, it is important to have some frank discussions with your doctor.
Am I fit enough to have a baby?
No woman planning a family should smoke, drink a lot of alcohol or be too fat. Before you become pregnant, ask your doctor to check that you are immune to German measles (rubella) because it can cause severe damage to your baby if you catch it during the early months of pregnancy. If you are not immune your doctor can arrange for you to be vaccinated against rubella. As a person with diabetes you also need to know whether you have any complications of diabetes, such as high blood pressure or retinopathy, which may worsen during pregnancy; while if you have severe complications, you must consider the risk to your health if you become pregnant. Your doctor will advise you about this.
*65/102/5*

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SEX IN RELATIONSHIPS FOR PEOPLE WITH DIABETES: INTERCOURSE

Most people start to discover the pleasurable feelings of sexual excitement by exploring their own bodies. As you grow up you learn both to give and to receive sexual pleasure in close relationships with members of the opposite sex. Sexual contact may be confined to kissing and cuddling or may extend to full sexual intercourse. Sexual attraction may be a major reason for getting together or be only a small factor in your partnership. Whatever importance you give it within your relationship, remember that it is a shared experience and that you should both pay as much attention to giving pleasure as to receiving it. People with diabetes can gain as much pleasure from the sexual aspects of a relationship as anyone else.
Sexual intercourse is a pleasurable and important part of a close relationship for men and women. This applies to people with or without diabetes. The act of intercourse itself is a form of exercise and often happens at a time when you would usually be resting. If you are having intercourse regularly at night you may need to increase your bedtime snack or reduce your evening insulin, especially if you tend to have low glucose levels during the night. If you are an insulin-treated diabetic you should keep some glucose tablets under the pillow or beside the bed so that you can eat them quickly should you feel hypoglycemic, for whatever reason. If you have intercourse at other times, perhaps unexpectedly, and you know that it will bring your glucose down, eat some food or a couple of glucose tablets immediately afterwards. An unexpected hypoglycemic attack can spoil a beautiful relationship!
Sometimes, before your diabetes is controlled, or at times of poor glucose control, you may not feel much like sex because you are just not very fit. Indeed, you may feel below par generally and need as much sleep as you can get. You may be snappy or irritable with the people you love. As your glucose levels return towards normal, your energy levels should improve, and this includes your sexual energy and desire for intercourse. If your glucose is high you may not be a very relaxing person to share a bed with because the increased urine output makes you get up to pass urine during the night and you have to keep drinking because you are thirsty. Also, if you have soreness in the genital area from thrush, you may find intercourse uncomfortable. The accompanying discharge may be unattractive for your partner too.
*56/102/5*

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PUBERTY AND GROWTH OF CHILDREN WITH DIABETES: GIRLS
As a rule, girls develop sexually at an earlier age than boys. Their breasts start to swell and the nipples and surrounding ring of tissue develop an adult shape. Hair grows over the pubic area and under the arms and menstrual periods start. For many diabetic women, period times are no different from any other part of the month, but for about a third, the build up to a period means a change in blood glucose control. Some women find that their insulin dose increases greatly before periods and suddenly falls after the bleeding starts. A few find that their control is unchanged until they start to bleed. Then they suddenly start going hypoglycemic and need much less insulin for one or two days. Few girls have completely regular periods to start with and if you tend to have a rise in blood glucose around period time, you may find your glucose going up and down as your periods come and go. The only thing you have to do is make sure that you are on a flexible insulin pattern, for example, a very long-acting insulin with as many short-acting injections as you need, or twice daily short-acting and medium-acting insulins, and adjust things day-by-day. You may find that your moods go up and down too. It is not uncommon to feel grumpy or depressed before a period, and some women have fluid retention as well.
It is important to remember that you are capable of having babies as soon as your first period starts. The myth that all diabetic women are sterile is completely untrue, as several surprised diabetic mothers have found!
*51/102/5*

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BDA (BRITISH DIABETIC ASSOCIATION) / OB (OUTWARD BOUND) MOUNTAIN COURSE: ROPES COURSES
All OB centers have a ropes course strung in the trees. Low obstacles are difficult, high ones easy. We run safety ropes over the high obstacles and the students clip themselves into these, moving from one safety rope to another without ever being undipped altogether. Some of the obstacles are terrifying. It is difficult for a person with diabetes to decide whether the pounding heart, sweating and trembling is caused by fear or hypoglycemia. This is because the same hormones that produce the symptoms of hypoglycemia-adrenaline (epinephrine) and noradrenalin (norepinephrine) – are released by fear. The ropes course requires coordination and concentration and is not the place to have a hypoglycemic attack. As with rock climbing, everyone eats one or two glucose tablets before starting on the ropes and wears a bum bag all the time.
Danny, a sixteen-year-old on insulin, who is a little absent-minded, was having difficulty on the 50-foot-long Burma rope bridge strung 20 feet in the air across the course.
Halfway across he said, in a rather small voice, ‘I think I need some glucose.’
‘Well, have some then!’ I replied from below.
He pointed to the base of a tree 20 feet down where his bum bag was lying! I had to climb a tree in a hurry and meet him with some glucose.
As with other activities, the signs of hypoglycemia are poor coordination, difficulty in doing something, or long periods of indecision. The main rule is not to move on and unclip from the safety rope you are on until your blood glucose level has been restored.
*99/102/5*

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DIABETES IN WOMEN: AFTER DELIVERY
For all new mothers the weeks after delivery are ones of mixed feelings – the joy of your new baby; the sleepless nights; the worries about getting it right if this is your first child; the responsibilities of parenthood; and maybe a sense of anticlimax too. This can be especially acute in a diabetic mother. During pregnancy you have had very frequent clinic appointments and a lot of people have been deeply concerned about your general health and your diabetes. When you leave the hospital and your postnatal check-ups finish you may feel suddenly left alone. This is a time when husbands can be very supportive.
Breastfeeding
Diabetes is no deterrent to breastfeeding. You will continue to need plenty to eat while you are feeding your baby. Peggy, who comes to my clinic and has had three babies since becoming diabetic, thinks that she increases her diet by about 40 g carbohydrate a day while she is breastfeeding.
Your insulin requirements will have dropped after delivery and it may take a little while to get your insulin and diet right. It is important that you do not have hypoglycemic attacks while you are holding your new baby in your arms and so it is better to run a little higher than you did during pregnancy to be sure that this does not happen. Aim for 6 or 7 mmol/1 (108 or 126 mg/dl) rather than 4 mmol/1 (72 mg/dl). When you stop breastfeeding, your dietary requirements may be reduced a little, although you may not notice any difference as you will have been weaning your baby gradually.
*70/102/5*