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BDA (BRITISH DIABETIC ASSOCIATION) / OB (OUTWARD BOUND) MOUNTAIN COURSE: NIGHT EXERCISES AND ORIENTEERING
Night exercises
Most of us sleep at night. This means that we are not used to needing energy then. If you are running through a forest or building a bridge in the dark, you need lots to eat, perhaps a triple evening snack, and less evening insulin, perhaps 25 per cent less short-acting insulin.
The night exercises on the BDA/OB courses are very exciting and involve complicated problem solving and team work, for example, to rescue the damsel from the bandit chief in his stronghold in the forest. Teams have to stick together and everyone carries glucose. Staff uses radios to keep in touch and track groups in the dark to ensure that everyone is accounted for. An extra snack is always available in the vehicle and back at base.
Orienteering
Map reading with pinpoint accuracy and speed are needed for orienteering. The object is to find markers on the mountain-side with clippers attached.
When you find the marker you clip your record sheet to it to prove that you have found it. We usually run this as a team event, with at least two students in each team, and more for younger groups. Because the fastest team to find all the markers is the winner, there is a tendency for students to ignore warning symptoms of hypoglycemia deliberately so as not to hold the others in the group back. Then they have a bad hypoglycemic attack on the mountain. The rule is, have large snacks before orienteering and take plenty to eat in the bum bags.
Staff usually monitors the progress of the teams from high vantage points. The most important one is the long stop at the end of the course, because at Eskdale poor navigators could end up on top of Scafell Pike (the highest mountain in England) if they were to get lost on the orienteering trail!
*100/102/5*

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BDA (BRITISH DIABETIC ASSOCIATION) / OB (OUTWARD BOUND) MOUNTAIN COURSE: ROCK SPORTS AND HYPOGLYCEMIA
Rock sports
I once read in a textbook that people with diabetes should not go rock climbing. There is no reason why you should not enjoy rock sports provided you obey the safety rules. Rock climbers should use safety ropes and climbing belts or harnesses and learn to climb with a properly trained instructor. All equipment should be of a high standard and well maintained. Diabetic climbers should ensure that their blood glucose is at least 7 mmol/1 (126 mg/dl) before starting a climb and eat a couple of glucose (dextrose) tablets immediately before climbing. They should have glucose tablets on their person where they can be reached easily with one hand and where they will not fall out. Your glucose will be no use if it is lying on the grass 60 feet below you! We use ski bags or bum bags with zippers to carry glucose for all activities on BDA/OB courses that are not on or in water.
Hypoglycemia
Signs of hypoglycemia are unusual slowness, great difficulty finding hand or footholds or uncharacteristic irritation or fear. Sometimes it may lead to the diabetic climber becoming crag fast, when he is unable to move up or down. If any of these signs appear, the person controlling the safety rope (the belayer) should stop the rope (that is, fix it so that it cannot move) and insist that the climber has some glucose. If necessary, someone may need to go to the climber’s assistance. Because of this, a diabetic should not go climbing in a group of fewer than three people.
*95/102/5*

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BDA (BRITISH DIABETIC ASSOCIATION) / OB (OUTWARD BOUND) MOUNTAIN COURSE: ABSEILING
Abseiling is another exciting rock sport. Used by rock climbers as a means of getting down a cliff or crag, it has now gained popularity among outdoor centers as an activity that can be enjoyed on its own. It is a controlled way of descending using a rope or rope and harness.
One of the most popular trips on some of the BDA/OB courses is the 170-foot abseil down the sheer walls of an old slate quarry. A double abseil rope should be used so that if one rope shears there is a back-up. This is fed through a friction device, of which there are several types, and there is a separate safety rope. The abseiler controls the rate of descent by altering the angle of the abseil rope through the friction device. If he or she were to become unconscious and let go of the rope, gravity would take over and the descent would become virtually a free fall. A separately controlled safety rope protects the abseiler from this risk. The safety rope should always be attached to a climbing belt and at least a sit harness. Some instructors recommend a full body or alpine harness.
The feeling of triumph when you reach the top of a climb or the exhilaration of abseiling has to be experienced to be believed. So far, most of the students on BDA/OB courses have tried both, and many have chosen to tackle more difficult routes later in their courses.
I have only two reservations about climbing for people with diabetes. First, there can be no unroped or solo climbing. Not long ago I heard of an experienced diabetic climber who fell and died while climbing alone. My second reservation is over lead climbing, in which the climber seeks out the route protected by a safety rope from below. He or she clips the rope through runners put in as he climbs. If he falls from above his last runner he descends twice that distance before being checked by the safety rope and his safety depends on good, secure runners. This may mean a 20-foot fall if he is 10 feet above his last runner. The second climber is protected by a rope from above and the distance he falls is determined by the slack on the rope and the small amount if stretches (which should be only a few feet). Your diabetes must be very well-controlled, with good warning of hypoglycemic attacks, and you must be a good climber, to lead.
*96/102/5*

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BDA/OB MOUNTAIN COURSE: MORNING ROUTINE
Many OB centers start the day with a jog and swim before breakfast. While this is no problem for people being treated by diet alone or pills, it is more difficult for those on insulin. When should you take the insulin? When and what should you eat? The main risk is of hypoglycemia in the water when the run has used up your available energy. However, you do not want to eat something and then run on a full stomach. You also need some insulin to allow your muscles to use the energy you have just eaten. But if you have your insulin immediately before too small a snack you may go hypoglycemic. This is more likely to occur if you have taken the insulin in your leg because exercise will increase the blood supply to this region and the insulin will be absorbed more rapidly.
The solution varies with the individual. If you tend to wake up low or normal, have milk and biscuits or crackers and go for the jog and swim. Take your insulin on your return and then have breakfast. If you wake up with medium glucose levels, your insulin is probably running out, but practical experience suggests that you can manage a short jog and swim on a smaller snack, such as one biscuit or cracker, or possibly none. Take your insulin on your return. If you wake up high, your evening insulin has been used up. If you exercise, you run the risk of ketosis. You should have your insulin and a more substantial snack before you exercise, and try to sort out your evening food and insulin for next time.
If you are only jogging and not leaping into cold water at the end of the run, you can keep your glucose level a little lower because you are not at risk of drowning if you go hypoglycemic. However, you may be at risk of being knocked down in the road if you are running in town.
*94/102/5*

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BDA/OB MOUNTAIN COURSE: INSULIN AND FOOD
The BDA/OB mountain course is based at the OB centre in Eskdale with expeditions out into the mountains. Each day starts with a run and a dip into the tarn, followed by showers and breakfast. Sometimes the morning is spent on one activity, the afternoon on another, but some activities take one or two days. Further exercises fill the evenings, BDA staff lives in the same accommodation as the students and share in all the activities.
When we started these courses no one knew what insulin reduction and food increase would be appropriate. Over the past ten years the participants and I have learned several lessons about insulin dose reduction and food increase. First, it is best to make the main insulin reduction and food increase on the first day of the course. This may mean that a few people have their blood glucose running a little high on the second day, but most have no problems. Second, the reduction in insulin dose needs to be greater than you would expect. Nowadays I advise students to reduce their insulin dose by 15 to 20 per cent of the pre-course level and by 30 to 50 per cent if they are prone to hypoglycemic attacks at home. Experience has taught us that students who have ever had a hypoglycemic eposide without warning or which they have been unable treat themselves they are at higher risk of hypoglycemia than other people with diabetes. People on oral hypoglycemic pills should reduce their pills by a third to a half, or if they are taking a very small dose, stop it altogether. At the same time I suggest that they double their snacks or increase their daily carbohydrate intake by about 50 g a day and gradually increase this during the course.
*93/102/5*

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DIABETES OUTWARD BOUND: BLOOD GLUCOSE LEVELS, FUEL FOR EXERCISE, INSULIN AND SAFETY
Blood glucose levels
In order to prevent hypoglycemic attacks we needed to know what was happening to every participant’s blood glucose level. We taught all the participants who were not already checking their blood glucose how to do so and what the results meant. I decided that to be safe I would ask all the participants to run their blood glucose levels higher than is normally acceptable. We aimed for 10 mmol/1 (180 mg/dl) rather than 4 mmol/1 (72 mg/dl) to allow for rapid falls in glucose during exercise.
Fuel for exercise
We increased everyone’s diet by doubling the carbohydrate in ail snacks right from the beginning, and then gradually increasing the main meals throughout the course. I was astonished by the amount the students needed to eat, and so were they. Some of them doubled their total daily carbohydrate intake and still had blood glucose levels of 7-10 mmol/1 (126-180 mg/dl). We used normally forbidden foods, such as chocolate and sweet biscuits or cookies, to provide rapidly absorbed energy during exercise, and glucose tablets immediately before anything potentially dangerous, such as climbing.
Insulin
One of our problems was that no one knew by how much the insulin dose needed to be reduced on such a constantly energetic course. On the first course, I suggested reducing the insulin by a few units on the first day, and if the blood glucose levels were under 7 mmol/1 (126 mg/dl) or hypoglycemic attacks occurred, I reduced it further. The participants and I were all surprised by the final insulin reductions. The body very rapidly becomes sensitized to insulin with regular strenuous exercise.
Safety
We did all we could to prevent attacks occurring. But what about the unexpected severe one that might cause unconsciousness? Safety standards are high at all OB centers. Safety ropes are used for climbing and life-jackets on the water. Activities are supervised by highly trained and experienced instructors. We used one simple rule to assess all activities – if the student suddenly becomes unconscious will he still be safe? We found that existing safety standards at the OB centers already covered this. We decided that students should not do solo activities and we ensured that all instructors and students were taught how to deal with a hypoglycemic attack, even a severe one. All activities were accompanied by OB instructors and BDA staff, if necessary linked to base by radio. Finally, I made sure that all the students carried glucose and glucagon all the time, that all instructors and BDA staff carried solid and liquid glucose, glucagon and blood testing kit on their persons all the time, and that comprehensive medical supplies including intravenous fluids were readily available at base and in camp. Full first aid kits also went out with all groups away from base.
*92/102/5*

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DIABETES OUTWARD BOUND
In 1981, the British Diabetic Association (BDA) and the Outward Bound (OB) Trust together established the first Outward Bound course for insulin-treated diabetic teenagers. At that time, some people said it was impossible for diabetics to complete such an energetic course and that activities such as climbing and abseiling were too dangerous for anyone taking insulin. Paul, aged sixteen years, who came on the eighth BDA/ OB mountain course, told me that he had been banned from his canoeing club when he became diabetic. Yes, the eighth course. The first group of sixteen diabetics proved that they were as capable of completing an OB course as any group of non-diabetic teenagers. Since 1981, there have been over twenty-five BDA/OB courses for people with diabetes ranging in age from fourteen to sixty-four years, and on all forms of treatment. In 1991 we had our ten year reunion.
Most of the participants on these courses do not realize that, long before they arrive, a great deal of planning has gone on behind the scenes. Before the first course a dietitian and I went up to the OB centre at Eskdale in the Lake District to discuss the activities with the course director. It all sounded rather alarming to us, but right from the beginning I had decided that the BDA group was going to try all the activities of an ordinary course. If we were going to do it, we were going to do it properly. I copied down a list of the planned activities and exactly what they entailed, and noted the daily timetable. Then I took it home and thought very hard.
The aim was for all participants to enjoy and complete the course successfully without their diabetes getting in their way, but without losing control of their blood glucose. How could I ensure that the participants would be as safe as humanly possible? What was the worst that could happen? It all seemed to boil down to one major hazard – hypoglycemia. We needed to protect the participants from the risk of going hypoglycemic and falling off something, falling into water, getting confused, getting lost or getting injured. If someone with diabetes is exercising hard, he or she is more likely to become hypoglycemic. Furthermore, we would be spending our time in a mountainous area, several hours from the nearest telephone and at least twenty miles (thirty-two kilometers) from the nearest hospital.
The first step was to ensure that the applicants for the course were in reasonable control of their diabetes. An OB course is not the place to try to sort out someone with grossly uncontrolled diabetes. I later learned that application forms rarely give you as much information as you need on the applicant’s degree of control, and that some of the participants may be in a dreadful muddle with themselves and their diabetes.
Everyone with diabetes is different and everyone responds individually to treatment and different situations. Warning signs of hypoglycemic attacks are different. It was therefore very important that all the helpers on the BDA and OB teams got to know all the students as soon as possible. I had a talk with every participant on arrival, and discussed his or her diabetes, general health and any worries about the course.
*91/102/5*

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EXERCISES FOR DIABETICS WITH SPECIAL PROBLEMS: LEGS AND EYES
Legs
Atherosclerosis of the large blood vessels of the legs may cause pain in your calves (and sometimes thighs or buttocks) when you walk. This is called intermittent claudication. I cannot ever remember seeing someone with intermittent claudication who did not smoke. As I said before, people with diabetes do not smoke.
If your legs hurt, you do not want to walk, but with this condition it is important that you do. While you keep exercising the legs, collateral vessels will open up to bypass the blocked and narrowed ones and improve the circulation. Walking is one of the best exercises to help intermittent claudication. Set yourself a target distance to walk and add a few yards to it every day. You will find that you have to stop less and less frequently to let your legs recover.
Exercises at home can help too. Hold on to the back of a firm chair and raise yourself up and down on your toes several times. Sit down and lift your legs up and down off the floor. Then lift them straight up in front of you and make circles with your toes, rotating your feet at the ankles. Go to the bottom of the stairs or find a firm stool to put near your chair and do a few step ups. Start gently at first and then do more of each exercise and move more quickly.
Eyes
If you have proliferative retinopathy you should not exercise until your ophthalmologist says you can. Vigorous exercise could cause new vessels to bleed.
*89/102/5*

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TAKING COMMAND OF DIABETES: EXERCISE FOR THE NOT-SO-YOUNG
Whatever your age, you can benefit from a little exercise. For mature people not used to sport, walking is good exercise, with the benefits of fresh air and a changing view to keep you from getting bored. Try a short walk every day. Early morning stretching and flexing of your arms and legs, like a cat when it wakes up, helps to keep you supple. There are many exercise programmes that give you specific exercises to follow. The general rule is to do it gradually and not to do anything that hurts.
Always bear the following points in mind:
? Exercise is good for people with diabetes. It increases your glucose utilization and your insulin sensitivity.
? Eat more and take fewer pills or less insulin when you exercise.
? Take the type of exercise you enjoy and that you can manage safely. Do not pretend to yourself that you are fit when you are not. Grade your exercise.
? If you have complications of diabetes, ask your doctor about exercise. It may help your condition.
? You are never too old to exercise; and if you exercise regularly it will make you feel good and keep you fit.
*90/102/5*

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TYPES OF EXERCISE FOR PEOPLE WITH DIABETES
Sprinting
This is an example of the ‘quick burst’ type of exercise. Sprinting is not the type of exercise for the unfit older amateur to choose. You need a lot of energy in a very short time. This can be provided beforehand by rapidly absorbed carbohydrate, such as a glucose drink. More rapidly absorbed and some slowly absorbed carbohydrate will be needed afterwards. A small insulin reduction may be necessary.
Marathon running
This is an example of endurance exercise. A marathon runner builds up to a distance of many miles by gradually increasing training runs over a long period of time.
If you take up this type of running you need to consider how far you usually run and at what time of day, and reduce your insulin accordingly. You will need slowly absorbed carbohydrate food and some instant energy before you start. The instant energy, for example in the form of slightly salted glucose drinks, will need to be repeated at frequent intervals along the track, probably every one or two miles, to top up your energy and fluid supplies. After the race you will have to take more rapidly absorbed and plenty of slowly absorbed carbohydrate to counteract late falls in glucose.
Water sports
There is no reason why people with diabetes should not go swimming. Swimming exercises the whole body. If you go to a pool regularly you can increase the number of lengths or widths that you swim gradually, so it is a good exercise for the older diabetic.
The risk is that the exercise will make you hypoglycemic and that you will become unconscious and drown, but this is preventable. First, never swim alone and do not go out of your depth if the person with you is not capable of rescuing you from deeper water (in any case, it is better to choose a companion who can swim). Second, immediately before entering the water, you must ensure that you have eaten enough to fuel your swim, but not overfilled your stomach. Eat a high fibre meal about one to two hours before swimming and have some rapidly absorbed carbohydrate, such as glucose, just before you enter the water. Carry glucose with you in the water; hard-boiled candies can be knotted into a plastic bag pinned to your bathing suit. Hypostop glucose gel comes in a small polythene bottle which is water-resistant and can be carried in a pocket in your bathing suit. If you are in the water for a long time, have a snack halfway through.
People with diabetes are prone to cramp, and this may be reduced by drinking bitter lemon or tonic, both of which contain quinine. The possibility of cramp is another reason why you should not swim alone. Do not allow yourself to get chilled; cold and hypoglycemia do not mix.
If you have not been swimming before, or not recently, check your blood glucose level before and after swimming to see what effect this exercise has had on you.
Swimming in the sea is more hazardous. It can be done by diabetics, but you must take all the precautions described above and remember the added dangers. Never go far from land out of your depth, especially where there are big waves or unknown currents.
*84/102/5*

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SKIING AS AN EXERCISE FOR PEOPLE WITH DIABETES
Skiing courses are now offered to people with diabetes in several countries including Britain, the USA and Norway. Like any other form of exercise it is important to start gradually and learn how the activity affects you and your diabetes. This may be difficult if you have only a week on the slopes in which to learn to ski and to cope with the weather, new food and everything else. If you can, practice on a dry ski slope first so that you have learned the basic moves before you leave home.
Good, well-fitting equipment is very important. It is vital that your boots are comfortable, because any soreness may spoil your holiday and rubs and blisters may take a long time to heal. Take your time choosing your footwear and do not be hurried into a bad decision. Remember that you usually get what you pay for; it may be worth paying a little more for comfort. Cold is one hazard, especially if you have poor circulation. I even saw two diabetics with frostbite in Oxford one winter. So wear proper ski gloves and make sure your feet are kept warm, particularly if you are doing a lot of standing around in very cold conditions. Your ski equipment shop will advise you on the best type of socks to wear inside your boots.
Another problem is glare from the sun and snow. Many skiers suffer from sun-burnt faces so do not forget to put sunscreen on your face, and wear a pair of protective goggles to save you from snow blindness.
Although the beginners’ slopes may be near the hotel, as you progress you will be going farther and farther up the mountain and you may spend the whole day away from base. It is important that you have enough food not only to last for expected meals and snacks but to cope with unexpected delays. Your food should include plenty of rapidly absorbed glucose. The bum bag or ski bag comes in handy here and will not impede your skiing. Take your insulin and syringes or pen with you too, but do not allow the insulin to freeze.
If you have an accident it is vital that you do not become hypoglycemic and cold. You should eat some glucose if you feel hypoglycemic and have to wait in the snow to be rescued, even if you are going to need an anesthetic to set a broken leg. When the doctor arrives, tell him what you have eaten, when and why.
What about the apres ski? You have earned it and need to replace all the calories and carbohydrate the skiing has used up. Take alcohol in moderation though, because it may prevent your body from reorganizing its glucose stores after all your exercise. If you spend the evenings at a disco, remember to take an extra snack and insulin with you.
*85/102/5*

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EXERCISE FOR PEOPLE WITH DIABETES: WINTER MOUNTAIN WALKING,
TENNIS AND SQUASH

Winter mountain walking
In winter conditions all mountains are dangerous and require special skill and expertise. The pretty view of the snow-capped mountains reflected in the lake in the chocolate box picture conceals glass-slippery ice, snow-covered holes and gullies, treacherous snow slopes and avalanches, and was produced by a blizzard which may well recur. This also applies a few yards from the ski slopes, so beware the temptation to take a stroll off the beaten track. Take local advice about walking. If it is snowy enough to ski you will almost certainly need proper winter walking equipment with ice axes and crampons, and these cannot be used unless you have been trained to handle them properly.
Remember that walking in snow warmed by the sun is extremely hard work and uses enormous amounts of energy. If you are setting off on foot, get up very early so as to complete most of your walk (especially the uphill bit) before the snow has softened. Having said all this, I think the mountains are beautiful in winter and well worth exploring. My comments apply to people with and without diabetes and non-diabetics alike. Those with diabetes can derive as much enjoyment from winter walking as anyone else.
Tennis and squash
Tennis and squash are good sports to take up if you travel because many cities have squash and tennis courts and the equipment is not bulky to carry. They present no particular problems if you have diabetes. Squash has increasingly become a game for professional people and businessmen, and it is being taken up by more mature people. It is a demanding and exciting game and requires a high level of fitness. As with all other sports, start training gradually and do not place sudden and unexpected demands on your body. Practice on your own to start with and build up to full matches. Squash is not an appropriate game for people who have heart trouble.
*86/102/5*

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EXERCISE FOR PEOPLE WITH DIABETES: SPORTS COURSES AND TEAM SPORTS
Sports courses or vacations
Many vacations, however, include sporting activities. If you go on one of these to learn sailing or improve your tennis, for example, you will need to reduce your insulin or pills and increase your food intake during the relatively short periods of intensified exercise. The effect of greater insulin sensitivity will become increasingly obvious.
Team sports
There are people with insulin-treated diabetes in many well-known sports teams, for example, in football, swimming and hockey. They have a duty not only to themselves to perform well but also to their team, county or country. At this level of sport, you will be training regularly and exercise will be part of your daily routine. Each diabetic player must work out for himself how much to eat before a match and what to eat at half-time. Important matches may also cause you stress, which may increase or decrease your insulin need. Added to this is the effect of travel before and after the match. Your diabetic preparations should be included in your pre-match ritual.
*87/102/5*

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DIABETES: EXERCISES FOR PEOPLE WITH SPECIAL PROBLEMS
Heart disease
People with diabetes are at greater risk of heart trouble than non-diabetics. If you have angina or have had a heart attack, do not assume that you will never be able to exercise again and that you must lead the life of an invalid. The right sort of exercise will help your heart. The first thing to do is to find out from your doctor exactly what has happened to your heart. Then ask what sort of exercise you can do safely.
Heart attack
If you have had a heart attack you will probably be told to rest in bed for the first few days, then be allowed to sit out of bed, and within a couple of weeks be walking increasing distances on flat surfaces, in the hospital or at home. After this the usual advice is to do a little more each day, on flat surfaces to start with, then up stairs and inclines, gradually increasing the speed and length of your walks.
Some cardiologists ask people who have had a heart attack to do a gentle exercise test on a treadmill within a few weeks of the attack to see how the heart behaves under supervised exercise and to assess the need for further treatment. Increasingly, hospitals are running training sessions in the gymnasium for people who have recovered from an attack.
Angina
Angina is nearly always brought on by exertion and this may stop you from exercising at all. Nowadays, with a wide range of medication to choose from and the option, where appropriate, of coronary artery bypass surgery, people with angina need not spend the whole time resting. In fact, this is definitely not good for them. Get yourself thoroughly tested by your doctor or a cardiologist, take your recommended treatment and then ask about gently increasing the amount you do each day. Your doctor will be able to show you how to count your pulse and what the maximum rate should be when you exercise. It may be possible to get back to normal with the right treatment.
One class of drugs used to treat angina, the beta-blockers sometimes make your muscles feel very tired. This is especially likely with non-selective beta-blockers, so a change to a selective one may help. Other drugs, the nitrates, make your blood vessels dilate. Nitrates come in many forms, including pills that can be taken under the tongue, or skin patches. If you inject your insulin into your arm and stick your nitrate skin patch on that arm you may find that your insulin is absorbed very rapidly. It would then obviously be better to alter the site where you put the patch.
*88/102/5*

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DIABETES AND EXERCISE: BODY GLUCOSE STORES, DANGER OF EXERCISES
Reorganization of body glucose stores
After each bout of exercise the body reorganizes its glucose stores. The muscles start to build up glycogen again. The waste products of exercise are cleared from the blood stream. Obviously, hypoglycemia can occur during exercise because glucose is used to produce energy. However, it can also occur during reorganization of glucose stores. This sort of hypoglycemic attack can take place several hours after you have finished exercising. It may happen at night, even after you have eaten a large meal. You may find you need extra carbohydrate before, during and after strenuous exercise.
These changes in your body’s metabolism mean that if you start a regular exercise programme you will need to eat more (unless you are trying to lose weight) and take less insulin or fewer oral hypoglycemic pills. The amount by which the food should be increased and insulin decreased varies for each person and each activity. If you continue a regular exercise pattern for months, your diet and insulin dose will stabilize. You will need to protect yourself against hypoglycemic attacks during and after exercise.
Can exercise be dangerous for diabetics?
Yes, under some circumstances: You should not exercise hard when you are showing moderate or heavy ketones in the urine. You should not exercise when you are hypoglycemic, but wait until you have corrected this. While exercising keep your heart rate within the training zone for your age.
The level of exercise you choose is also important. If you are young and relatively fit, a few hours’ very energetic exercise will do little damage. If you are over forty, overweight, unfit and suffer from angina, a game of squash could kill you. Do not rush in, but take it gradually. Exercise regularly (three times a week is often recommended) and gradually increase the length and amount you do at each session.
*83/102/5*

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EXERCISE FOR PEOPLE WITH DIABETES: WHAT HAPPENS WHEN YOU EXERCISE
Exercise is good for anyone with diabetes. It helps keep your weight down, increases your sensitivity to insulin, tones your muscles, encourages your circulation, helps your heart and makes you feel good. You can Tine tune’ your blood glucose by balancing food, treatment and exercise. Regular sensible exercise is an excellent means of relaxation and often a source of good companionship.
Glucose
The main source of energy for exercising muscles is glucose. It is constantly circulating in the blood stream ready to be taken up by the cells. Approximately half of this glucose is converted into energy immediately, one-fifth is stored as glycogen in the liver and a quarter is stored as glycogen in the muscles. Glucose cannot enter any cells without insulin. Insulin is also essential for glucose to be converted into glycogen stores in the muscles. As the muscles work, the glycogen is broken down to provide glucose for energy. As the muscle glycogen is used up, more glucose is taken from the blood stream to provide more energy. The liver releases glucose from its glycogen stores to meet the increased energy need. At the same time, fat and protein are also used to provide energy. If insulin is not available, or if the liver glycogen stores are exhausted, the exercising muscle has to rely entirely on fat and protein breakdown for energy once it has used up all its glycogen stores. Excess insulin stops the release of glucose from the liver stores.
Insulin sensitivity
As exercise continues, the body, and the muscles in particular, become more sensitive to the action of insulin. This means that a given dose of insulin helps more glucose to be used by the body. In practical terms, it means that someone with diabetes who starts a regular exercise training programme needs fewer oral hypoglycemic pills or less insulin a day to control his or her blood glucose, even if the body weight stays the same. This increase in insulin sensitivity happens both to diabetics and non-diabetics. It appears rapidly and disappears equally rapidly when you stop exercising regularly.
*82/102/5*

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DIABETES AND JOB: ALCOHOL FLUSHING AND STRESS. FINDING A JOB AND WORKING

Alcohol flushing
Alcohol may produce another problem for people on pill treatment. About 60 per cent of those on chlorpropamide develop facial flushing within half an hour of drinking alcohol. For a few people this reaction can be very distressing with a feeling of severe burning in the face, and sometimes all over the body, nausea, wheezing and faintness. Whether you get this alcohol flushing depends to some extent on the dose of chlorpropamide you are taking and when you last took it. It is less likely to happen with other sulphonylurea drugs, such as glibenclamide, and the simple solution if you have this problem is to change your pills. About 6 per cent of the population is born with the tendency to flush with alcohol. So, if you are a born alcohol flusher, you will either have to put up with it or stop drinking.
Stress
Stress is by no means limited to business people. There is little scientific evidence that stress causes diabetes. However, many people with diabetes find that their blood glucose level goes up at times of stress.
Martin, forty-eight years old, works in a car factory. He is also a union shop steward. Normally, his diabetes is well-controlled, but one afternoon he came into clinic with a glucose level of 20 mmol/1 (360 mg/dl). He had just had a furious argument with his fellow shop stewards who wanted to call the men out on strike over an issue with which he disagreed. He told me later that it took two days for his glucose levels to come down after this incident.
Finding a job and working
? Diabetes is not a barrier to getting most jobs.
? Make sure that your qualifications are as good as or better than any non-diabetic competitor.
? When applying for jobs be honest.
? Tell your friends and colleagues about your diabetes. There is no need to be ashamed or embarrassed about it.
? Consider your work pattern when organizing your diet and diabetes treatment. A little forward planning can make life easier. Ensure that you arrange for a new family doctor and diabetes adviser if you leave home.
*81/102/5*

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DIABETES AND JOB: ABOUT FLUCTUATING GLUCOSE LEVELS, PILLS AND DIET
Controlling fluctuating glucose levels
The first rule is not to keep altering your insulin dose. It takes several days for the effect of a change in a long-acting insulin dose to become apparent. Furthermore, if you change two types of insulin at once it may be hard to judge the effect, especially if you are also altering your food intake. To start with, make sure that you do not go hypoglycemic, so run a little on the high side. Then take each part of the day in turn and bring the blood glucose levels down towards normal by adjusting your food intake. Try adjusting your insulin only when food adjustments have failed. This process may take two or three weeks so a little patience is needed. If things start going badly awry do not struggle on but ask for help. It may be that you would be better on another insulin regimen.
Pills or diet alone
Much of what has been said above also applies to people on oral hypoglycemic treatment. In general, people treated with pills or diets alone have less dramatic swings in blood glucose level than those taking insulin. Nevertheless, good glucose balance is as important. The need to adjust energy input to balance output is the same whatever form of treatment you are using. The dose or the timing of pills may need to be altered, for example, as I described for shift work. Hypoglycemia is less common among people on pills and may catch you unawares when a heavier workload precipitates your first attack.
*78/102/5*

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DIABETES AND BUSINESS: BUSINESSMAN OR WOMAN
In the tough world of business it is important that your diabetes does not dull your competitive edge. Indeed, in some business deals, a badly timed hypoglycemic attack could lose millions! It is also important that controlling your diabetes does not interfere with your work. Therefore you must strike a balance between the time and effort needed to maintain good glucose control and the interference to your lifestyle that these efforts can cause; not forgetting the immediate and long-term damage that poor glucose control can cause.
Gadgets
If you are well off financially, you may be able to afford the aids that can make diabetic life easier and more comfortable. These include blood glucose measuring meters or biosensors. But money does not buy personal expertise, and there have been problems with people who have bought themselves CSII pumps without adequate backup and failed to learn how to use them properly.
Meetings
The life of the typical businessman includes frequent meetings, large dinners with alcohol, long-distance travel and much stress. While many businessmen do not live like this all the time, most will encounter some of these facets at one time or other.
Meetings rarely begin or finish on time. They are periods of physical inactivity, when you are usually trapped in a smoke-filled room. Yet it is important not to fall asleep or to leave the room as your opponents will use the opportunity to their advantage, while your friends will promptly volunteer you for some thankless task. In your briefcase you should include something to eat that is unobtrusive, your emergency glucose, your blood testing kit and your insulin (this is where a preloaded syringe, Novopen, BD-Lilly pen or Pur-in pen is helpful). If you have enough to eat and your insulin, you can sit out any meeting that is overrunning without worrying about your diabetes.
Obviously it is preferable not to have to check your blood glucose level or to give insulin during a meeting, but both can be done surreptitiously if essential, and if you are among friends aware of your diabetes it should not matter. I once saw a very eminent physician with diabetes give an injection of insulin while sitting on a platform chairing a meeting of several hundred people. I doubt if many of those present noticed him slip his preloaded syringe out of his pocket and inject the insulin because it was done in seconds. The easiest site is the abdomen. Just undo the lower buttons on your shirt and inject the insulin. Injecting through tights or trousers is possible but not very hygienic, and is not to be recommended.
As a general principle, it is better to inject insulin quickly in public than to retreat into a lavatory and acquire an infected injection site. This also removes the unfortunate suspicion that the man slipping quietly into the lavatory with a syringe is a junkie.
*79/102/5*

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DIABETES AND BUSINESS: MEALS AND ALCOHOL
Meals
Business dinners are traditionally high in sugar, fat and alcohol. However, any reasonable restaurant should be able to offer alternatives that fit in with a diabetic diet. A grilled steak with potatoes and salad followed by fresh fruit and bread and cheese is one possibility available in most cities. If in doubt as to the contents of a tempting dish, ask the waiter or the chef.
Alcohol
People with diabetes do not have to become teetotal, but alcohol can upset glucose balance in several ways. First, it is a source of calories and must be considered as part of the day’s calorie input. Second, and more important, it reduces the amount of glucose released into the circulation by the liver. This means that there is a risk of hypoglycemia after drinking alcohol. After a heavy night’s drinking, alcohol is likely to be circulating in the blood the next morning. In practical terms, this means that a person with diabetes, particularly if insulin-treated, who has some alcohol in the evening may become hypoglycemic on the way home, that night or the next morning. Always have something to eat with an alcoholic drink.
Tony is forty-two years old, on twice-daily insulin injections and works in a sports shop. He drank one and a half pints of ?sugar-free’ beer after work. On his way home he was stopped by the police while driving erratically and was promptly treated as a drunk driver because his breath smelled of alcohol and he was confused and aggressive. A breath test was negative but he was taken to the police station because of his behaviour. Unfortunately, he did not bother to carry a diabetic card and no one realized that he was diabetic.
Later that night Tony was found unconscious in the cells. When he was transferred to the hospital, a blood check revealed that his glucose was 1 mmol/1 (18 mg/dl). He was revived with an intravenous glucose injection.
Tony could not believe that as little as one and a half pints of beer could have had such a severe effect on his glucose level. One of the things he did not know was that ’sugar-free’ beer has less carbohydrate in it because the brewing process is taken further. The excess carbohydrate is converted into more alcohol. Also, when someone has had nothing to eat, even a small amount of alcohol can induce hypoglycemia.
*80/102/5*