APPENDIX A Dietary guidelines for elderly

diabetic patients

FOOD ALLOWED

The following foods contain little or no sugar, but protein foods such as meat, fish, eggs and poultry contain both fat and energy and therefore should be eaten in moderation.

Meat

Poultry Fish Fats

Eggs Cheese

Fruit

Vegetables

Lean meat, mince, stew, beef, lamb, pork, ham, liver, kidney, cooked or tinned meats. Choose leaner varieties where possible. Chicken, turkey, duck. Fresh or frozen, tinned, smoked. Butter, margarine, ghee; lard, dripping, oil. Use these sparingly. Fry only occasionally. Use those containing less fat e.g. cottage cheese, edam, gouda, low fat Cheddar and Cheshire, crowdie, camembert. Several portions of any seasonal fresh fruit daily, including apples, bananas, fresh guava, grapefruit, pear, peach, pineapple, oranges, fresh lychees. Fresh, frozen, raw or pickled (without sugar) Asparagus, artichoke, aubergine, beansprouts,

110 Appendix A

Soups Beverages

Seasonings

Sweeteners

broccoli, brussel sprouts, cabbage, carrots, cauli­flower, celery, chinese leaves, chillies, courgette (zucchini, squash) cucumber, fennel, green beans, leeks, lettuce, marrow, mushrooms, mus­tard, cress, onions, okra, peas (not processed), peppers, radish, root ginger, spinach, spring onions, swede, tomato, turnip, watercress, vine leaves. Thin vegetable soup, consomme. Tea, coffee, water, soda-water, sugar-free squashes, low-calorie drinks, lemon juice, Bovril, Oxo, Marmite and stock cubes. Salt, pepper, herbs, spices, curry powder, garlic, mustard, tumeric, chilli powder, ground ginger, coriander, oregano, paprika, saffron, tamarind. Food essences and colourings. Gelatine Saccharine and aspartame sweeteners.

FOODS TO BE AVOIDED

The following foods contain rapidly absorbed sugars and therefore should be avoided.

Sugar, dextrose, glucose, glucose drinks, glucose sweets, sherberts, Jam, marmalade, honey, treacle, syrup, lemon curd, mincemeat,

marZipan, Turkish delight, sweets, chocolate, peppermints, chewing gum, chocolate biscuits, sweet biscuits, buns, cakes, pies and pastries, shortbread, lemonade,

fruit squashes, fizzy drinks, milk shake syrups

or powder, bottled sauces, sweet chutneys, tinned fruit in

syrup, sweetened

condensed milk, sugar coated

breakfast cereals.

Foods which contain carbohydrate 111

FOODS WHICH CONTAIN CARBOHYDRATE

Foods in italics are high in fibre or low in fat and are therefore recommended. Carbohydrate-containing foods should be taken regularly at t:ach meal.

Bread

Biscuits

Cereals

Pasta

Legumes Vegetables

Milk and yoghurt

Fruit

Soups

Miscellaneous

Bread, rolls, baps, croissants, pitta bread, bagel, wholemeal bread and rolls, whole­meal pitta bread, chapatis. Plain biscuits, e.g. digestive biscuits bran biscuits, wholemeal crackers and crisp breads, oatcakes, rich tea biscuits, cream crackers, crisp breads and water biscuits, plain matzo crackers, plain scones, currant buns (not sugar coated). Cornflour, custard, sago, tapioca, barley, white semolina, rice, wholemeal semo­lina, flour, wholemeal flour, Rice crispies, cornflakes, Special K, all bran, Shredded Wheat, Weetabix, puffed wheat, bran­flakes, unsweetened muesli, porridge. Spaghetti, macaroni, noodles, choose wholemeal varieties. Peas, beans, lentils (dhal). Sweetcorn, yam, Chinese mushrooms, plantain, potatoes (boiled, baked in jacket, mashed, chipped, potato crisps). Fresh, skimmed or semi-skimmed low-fat yoghurt, fruit flavoured yoghurt, un­sweetened fruit yoghurt. Canned in its own juice (see foods allowed) natural fruit juice, jelly, ice­cream Lentil, pea soup, vegetable or Scotch broth. Black pudding, sausage, haggis, fish fingers, samosas, sausage rolls, pies, pastry, pakora (bhaji), pickled vegetables in vinegar (no sugar added).

112 Appendix A

FOOD EXCHANGES LIST FOR ELDERLY DIABETIC PATIENTS

The following list of foods contain 10 g carbohydrate i.e. 1 exchange. It represents only a small part of the exchange lists available for diabetics.

Food

Wholemeal bread or white bread Digestive biscuits Branflakeslcornflakes Muesli unsweetened Chapati Brown or white rice Plantain - green, raw Potato

boiled jacket roast

Sweet potato - raw, peeled Apple - with skin Apricots - fresh Banana Guavas - fresh Mango - fresh Orange - fresh Pawpaw - fresh Milk

fresh, whole semi -skimmed

Yoghurt - plain and diet Sausages - grilled Scones

Handy Measure

V2 large slice or 1 small

1 large 3 heaped tablespoons 2 level tablespoons 1 very thin saucer size 2 level tablespoons 1 small slice

1 small 1 medium Vz medium 1 small slice 1 small 4 medium 1 small 1 V3large 1 medium V6large

1 glass (200 ml) 1 glass (200 ml) 1 small carton 2 average sized 1 small

APPENDIX B Ten basic instructions for

patIents

1. Take regular exercise, it helps diabetic control; 2. If possible adopt a regular eating pattern; 3. If you become more thirsty have your blood glucose

checked; 4. If vomiting occurs seek medical advice without delay; 5. Act quickly when you notice the initial symptoms of

hypoglycaemia; 6. Report frequent hypo glycaemia. Diabetes can be con­

trolled without this; 7. If you take insulin, always carry glucose tablets or sweets

and an ID card; 8. Never stop insulin; 9. Look after your feet carefully, if you can't manage, get

someone to do it for you; 10. Never be frightened or embarrassed to ask for help: better

safe than sorry.

British Geriatrics Society, 1 St Andrew's Place, Regents Park, London, NW14LB, UK

American Geriatrics Society, 770 Lexington Avenue, Suite 400, New York, NY 10021, USA

APPENDIX C Useful addresses

Australian Association of Gerontology, The Science Centre, 35--43 Clarence St, Sydney 2000, Australia New Zealand Geriatric Society, 48 Hood Street, Dunedin, New Zealand British Diabetic Association, 10 Queen Anne St, London, W1M OBD, UK

American Diabetic Association, 1660 Duke St, Alexandria, VA 22314, USA

Chest Heart and Stroke Association, Tavistock House North, T avistock Square, London, WC1W 9JE, UK

116 Appendix C

Scottish National Federation For the Welfare of the Blind, 8 St Leonard's Bank, Perth, PH2 8EB, UK

Talking Newspaper Association of the United Kingdom, 68a High St, Heathfield, East Sussex, TN2l 8JB, UK

Centre for Policy on Ageing, Nuffield Lodge Stucho, Regents Park, London, NW14RS, UK

British Association for Services to the Elderly, 3 Keele Farmhouse, Keele, Newcastle-under-Lyme, ST5 lAX, UK

British Society for Research on Ageing, Geigy Unit for Research in Ageing, Department of Geriatric Medicine, University Hospital of South Manchester, Manchester, M20 8LR, UK

Age Concern Scotland, 33 Castle Street, Edinburgh, EH2 3DN UK

Age Concern England, 60 Pitcairn Road, Mitcham, Surrey, CR4 3LL, UK

Diabetes Australia, QBE Building 33-35 Ainslie Avenue, Canberra ACT, PO Box 944, Civic Square ACT 2608, Australia

Irish Diabetic Association, 82-83 Lower Gardiner Street, Dublin 1, Eire

Canadian Diabetes Association, 78 Bond Street, Toronto, Ontario M5B 2J8 Canada

New Zealand Diabetes Association, 4 Coquet Street, PO Box 54, Oamaru, New Zealand

Medic Alert Foundation, 11113 Clifton Terrace, London N4 3JP, UK

Useful addresses 117

Pharmaceutical comranies who provide useful practical educationa literature

Servier Laboratories Ltd, Fulmer Hall, Windmill Road, Fulmer, Slough, SL3 6HH, UK

Sterling-Winthrop Research Laboratories, Onslow Street, Guildford, Surrey, GU14YS, UK

Eli Lilly and Company Ltd, City Wall House, Basing View, Basingstoke, Hampshire, RG212LA, UK

118 Appendix C

Becton Dickinson UK Ltd, Diabetes Health Care Division, Between Towns Road, Cowley, Oxford, OX4 3L Y, UK

Nordisk-UK, Nordisk House, Garland Court, Garland Road, East Grinstead, RH19 IDN, UK

BCL, Boehringer Corporation (London) Ltd, Boehringer Mannheim House, Bell Lane, Lewes, East Sussex, BN71LG, UK

Ames Division, Miles Ltd, PO Box 37, Stoke Court, Stoke Poges, Slough, SL2 4LY, UK

Novo Laboratories Ltd, Ringway House, Bell Road, Doneshill East, Basingstoke, Hampshire, RG24 OQB, UK

Suppliers of equipment (injection devices, monitoring equipment etc)

Hypoguard (UK) Ltd, Dock Lane, Woodbridge, Suffolk, IP12 IPE, UK

Owen Mumford Ltd, Brookhill, Woodstock, Oxon OX7 1 TU, UK

Contacta, TVM (Manchester) Ltd, 9 Bloom Street, Salford, Lancashire, UK

APPENDIX D Further reading

This appendix gives the reader some source material from which to gain some more detailed knowledge. When a chapter does not have detailed further reading then information can be gleaned from the more general texts listed under the heading of general background reading.

GENERAL BACKGROUND READING

Krall, L. P. (ed.) (1988) World Book of Diabetes in Practice (Vol. 3) Elsevier, Amsterdam.

Ireland, J. T., Thomson, W. S. T. and Williamson, J. (1980) Diabetes Today, HM & M Publishers, Aylesbury.

Shaw, M. W. (ed.) (1984), The Challenge of Ageing, Churchill Livingstone, Edinburgh.

Brocklehurst, J. c. (ed.) (1985) Textbook of Geriatric Medi­cine and Gerontology, 3rd ed, Churchill Livingstone, Edinburgh.

Ellenburg, M. and Rifkin, H. (eds) (1983) Diabetes Mellitus, 3rd ed, Medical Examination Publishing, New York.

Practical Diabetes, Journal for The Diabetes Care Team, The Newbourne Group; Home and Law Publishing Ltd, Hamp­stead Rd, London NW1 7QQ.

120 Appendix D

Pathy, M. S. J. (ed.) (1985) The Principles and Practice of Geriatric Medicine, John Wiley, Chichester.

Diabetes Care, The Journal of Clinical and Applied Research and Education, American Diabetes Association, Alexandria Va., USA.

Bloom, A. and Ireland, J. (eds) (1980) A Colour Atlas of Diabetes, Wolfe Medical Publications Ltd, London.

Care of the Elderly, The Newbourne Group; Home and Law Publishing Ltd, Hampstead Road, London NW1 7QQ.

CHAPTERS 1 AND 2

Mann, J. L., Pyorala, K. and Teuscher, A. (1983) Diabetes in Epidemiological Perspective, Churchill Livingstone, Edinburgh.

Levin, M. E. (1982) Diabetes: the geriatric difference, Geri­atrics, 37(12) 41--45.

Hindson, D. A. (1984) Diagnosis and treatment of diabetes mellitus in Drug Treatment in the Elderly (ed. R. E. Vestal) Adis Health Science Press, Sydney.

CHAPTER 3

Knight, P. V. and Kesson, C. M. (1986) Educating the elderly diabetic, Diabetic Medicine 3(2) 170-173.

AssaI, J. P. and Pernet, A. (1982) Education as part of therapy in (eds) L. P. Krall and K. G. M. M. Abertii, World Book of Diabetes in Practice, Excerpta Medica, Amsterdam.

Baksi, A. K., Hide, D. and Giles, G. (eds) (1984) Diabetes Education, John Wiley, Chichester.

AssaI, J. P., Alivisatos, J. G. and Halimi, D. (eds) (1988) The

Further reading 121

Teaching Letter, Diabetes Education Study Group of The European Association for the Study of Diabetes, Artem, 27 Rue du Pont 92200 Neuilly-Sur-Seine, France.

CHAPTER 4

Thomas, B. (ed.) (1988) Manual of Dietetic Practice, British Dietetic Association, Blackwell Scientific, Oxford.

Krause, M. V. and Mahon, L. K. (1984) Food, Nutrition and Diet Therapy, 7th ed, Saunders, Philadelphia.

Tarr, S. P., Wenlock, R. W. and Buss, D. H. (1985) Immigrant Foods, Second Supplement to McCance and Widdowson's Composition of Food, HMSO, London.

CHAPTER 5

Knight, P. V. (1987) The choice of oral hypoglycaemic agent for the elderly in Advanced Geriatric Medicine 6, (eds F. I. Caird and J. G. Evans) P. S. G. Wright, Bristol pp.151-154.

Knight, P. V., Semple, C. G. and Kesson, C. M. (1986) The use of Metformin in the elderly patient Journal of Clinical and Experimental Gerontology, 8(1,2) 51-58.

CHAPTER 7

Martin, B. J., Knight, P. V., Kesson, C. M., O'Donnell, J. R. and Young, R. E. (1984) Glycosylated haemoglobin: its value in screening for diabetes mellitus in the elderly. Journal of Clinical and Experimental Gerontology, 6(2) 87-94.

122 Appendix D

CHAPTER 8

Connor, H. M., Boulton, A. J. M. and Ward,J. D. (eds) (1986) The Foot in Diabetes, John Wiley, Chichester ..

Faris, I. (1983) Management of the Diabetic Foot, Churchill Livingstone, Edinburgh.

CHAPTER 9

Scott, P. J. W. and Caird, F. I. (1986) Drug-Induced Diseases in the Elderly, Elsevier, Amsterdam, pp. 37-44 and 155-156.

Chen, M. S., Hindson, D. A. and Vestal, R. E. (1987) Hypoglycaemic agents and the treatment of Diabetes Mellitus in the elderly, in Clinical Pharmacology in the Elderly, (ed. C. Swift) Dekker, New York, pp. 581-628.

CHAPTER 11

Caird, F. I. (1980) Management of Diabetes and Its Compli­cations in Metabolic and Nutritional Disorders in the Elderly, (eds A. N. Exton-Smith and F. I. Caird) Wright, Bristol, pp.161-179.

Kennedy, H. and Caird, F. I. (1986) Diabetic retinopathy in The Eye and its Disorders in the Elderly, (eds J. Williamson and F. I. Caird) Wright, Bristol, pp. 101-110.

CHAPTER 13

Kinson, J. and Natrass, M. (1984) Caring for The Diabetic Patient, Churchill Livingstone, Edinburgh.

Acidosis, lactic 39, 93 Addison's disease 78 Addresses, useful Appendix C Alcohol 33 Allergy, to insulin 46 Amputation 56,62,84,89 Amyotrophy 87 Anaemia, haemolytic 12 Ankle jerks 87 Antibodies, islet cells 7 Atheroma 26 Autonomic neuropathy 57,

76,88

Beta blockers 67 Biguanides 39 Blood glucose

age effect 11 control 42 GTT12 hyperglycaemia 10, 70 in intercurrent illness 92 monitoring 52

Brain, in hypoglycaemia 76

Callous 60

INDEX

Carbohydrate complex 31 exchange system 30 GTT12 hypoglycaemia 45,80 in intercurrent illnesses 93

Cataract 10, 84 Chiropody 56, 105 Clinic

diabetic 20, 104 eye 85 GP105

Coma hyperglycaemia 10 hypoglycaemia 76 HONK 72

Control assessment 12 blood testing 51 calorie 31 complications 84 diet 26 glycosylated haemoglobin

53 insulin therapy 42-44 metabolic 19 urine testing 51

124 Index

Coronary artery disease 27,86,89

Corticosteroids, diabetogenic effect 7, 18, 66

Death coronary artery disease 86 hypoglycaemia 75

Dementia hypo glycaemia 75 senile 17

Diagnosis autonomic neuropathy 88 diabetes 6, 10, 11 HONK 73

Diarrhoea diabetic 88 Diet

carbohydrate 31 content Appendix I fat content 27 for the elderly 30 general features 26 guidelines 32 high fibre 27 hyperglycaemia 73 in intercurrent illness 93

Fasting glucose 6, 11 Fat dietary 27 Feet

chiropody 56,105 examination 53 heat trauma 57 neuropathy 87 problems 56 vascular disease 88

Foot Care general 56

specialist nurse 102 ulcers 60

Fibre, high fibre diet 30,32

Gangrene 56,89 Glucagon 79 Glucose

GTT11 polyuria 10 profile 52 renal threshold 51 tolerance 8 treatment of hypoglycaemia

45 Glycogen 79 Glycosuria 10, 19

amyotrophy 87 home monitoring 51 hyperglycaemia 70

Growth Hormone hypoglycaemia 78 intercurrent illness 92

Glycosylated haemoglobin 11, 12,53

Headache, in hypoglycaemia 76, 79

Hepatic function biguanides 39 glucose production 39 sulphonylurea 37

Home Monitoring 51,53 Hyperglycaemia 10,51,67,

70-75,92 Hyperosmolar coma HONK

72 Hypertension, beta blockers

67 Hypo, see hypoglycaemia

Hypoglycaemia education 99 general 75-81 insulin therapy 45 masked by drugs 67 nocturnal 38, 76 sulphonylureas 37 urine testing 51

Hypotension hyperglycaemia 10 postural 68, 88

Infection feet 56, 60 fungal 10 hyperglycaemia 72, 92 peripheral vascular disease

57 urinary tract 71

Insulin absorption 46 allergy 46 antagonistic hormones 92 beta blockers 67 difficulties with therapy 100 dose 44 drug failure 38 hyperglycaemia 73 hypoglycaemia 45, 75 initial injections 99 insensitivity 8 resistance 72 sources 42 sulphonylureas 37 therapy 42 types 43

Ischaemia 56 major foot problems 62 vascular disease 89

Index 125

Ketoacidosis 71, 73, 92 Ketones 10 Kidney

disease 86 drug excretion 38

Lactic acidosis Metformin 39 intercurrent illness 93

Laser photocoagulation 85 Lipoatrophy 46 Lipohypertrophy 46 Low renal threshold 51

Maculopathy 85 Mini-clinic 21,106 Monilial infection see Infec-

tion, fungal Monitoring diabetes 49-53,

93,96,102 Mortality

hyperglycaemia 74 hyperosmolar coma 73 Metformin 39 vascular disease 88

Muscle wasting in amyotrophy 87

Nephropathy see renal disease Neurological disorders 87-8 Neuropathy

autonomic 87 in bowel and bladder problems 88 in foot problems 56-7 in hypoglycaemia 76 in postural hypotension 68,88

126 Index

Neuropathy-cant'd motor 87

in foot problems 56-7 sensory 87

in foot problems 56-7, 60,62

Neuroglycopoenia 76 NIDDM (non-insulin depen­

dent diabetes mellitus) 6-8,50,70,71,97,104

Nocturia 71 Nurse Specialist 95-102

Obesity aetiology of diabetes 7 dietary treatment 28-30 hyperglycaemia 74

Ocular complications 84-6 Oedema

cerebral 79 feet 57 kidney disease 86

Oral hypoglycaemic agents 35-40

aetiology of hypoglycaemia 78

biguanide therapy 39-40 dosages 36 failures 38 intercurrent illness 92 management of hypergly-

caemia 74 sulphonylurea therapy 37-8

Osmotic diuresis 70 Overdose

insulin 77 sulphonylurea 78

Pathology, multiple 18

Peripheral vascular disease 19, 88

beta-blockers 67 foot problems 56,60'

Photocoagulation-laser 85 Plaster cast 61 Polypharmacy 18 Polyuria 10, 70, 71 Postural hypotension 68, 88 Prevalence of

complications 50, 89 diabetes mellitus 6 poor nutritional intake 26 tuberculosis 90

Prevention of coma during illness 92 complications 10,44,50,96 foot lesions 58 hypoglycaemia 45,79,97

Primary drug failure 38 Prognosis in amyotrophy 87 Proteinuria 51,86 Proliferative retinopathy 84 Pruritus vulvae 10

Reactive hyperglycaemia 76 Renal complications 51, 53,

86 Renal threshold for glucose 51 Retinopathy 10, 84-86 Retinal camera 85

Screening for complications 53,85 diabetes mellitus 12

Secondary causes of diabetes 6 Secondary drug failure 38 Shared care 21, 103-107

Skin feet 57,60 sepsis 10, 13

Smoking 19,59,89 Steroids see corticosteroids Stroke 11, 74, 88

see also cerebrovascular disease

Sulphonylurea agents 37-9 doses 36 hypoglycaemia 37, 76, 78 illness 92, 93 interaction with other drugs

67, 78 mode of action 37 overdose 78 renal function and 38 side effects 37 weight and 74

Surgery feet 59 insulin and 43

Thirst 10, 71, 72 Thiazide diuretics 6, 11,66 Trauma

feet and 57,87,89 insulin and 43

Tuberculosis 90

Ulcers, feet 10, 60-62, 89 Urinalysis see urine testing

Index 127

Urinary frequency 71 incontinence 71 tract infection 71, 73,88

Urine testing 11, 51, 71,102 glucose 11,51,93 ketones 51, 72 protein 86

Vascular disease 10, 13,56, 88-9

Video cassettes-educational 22 Viral infections and IDDM 7 Vision/visual acuity, dimin-

ished 13, 17,45,59,66, 77,85,86,102

Visual aids 17 Visual changes at diagnosis 84 Vitreous haemorrhage 84 Vomiting 93

Weight, ideal 28 Weight, loss

biguanides and 39 dietary therapy 28-9 drug failures and 38 guar gum and 40 symptoms of 8,10, 75

X-ray chest 90 feet 60