Type 2 Diabetes Workbook for Children and Young People

Patient Information Leaflet

What is Type 2 Diabetes?

Diabetes is a serious life-long health condition that means that the amount of glucose (sugar) in the blood is too high because the body cannot use it properly. Our bodies convert food, especially starch (e.g., in potato) and sugar (e.g., in chocolate) into glucose after eating. The body needs these foods as glucose is the fuel that gives our bodies energy.
In type 2 diabetes people develop resistance to a hormone called insulin that is produced by the pancreas, which means the insulin can no longer do its job properly. Insulin’s role is to allow glucose to enter the cells in our body to make energy. In type 2 diabetes, the insulin does not work as it did before and the glucose remains in the blood stream, instead of entering the cells.

It is common to feel tired because of the body no longer making as much energy. The body will try to get rid of the glucose in the blood stream and this will pass out in the urine and often people need to pee more often than usual, which also makes them feel thirsty.

The key (the insulin) is unable to unlock the padlock on the door to the cell properly – usually because the lock is just not working properly.

Some people are more susceptible to developing type 2 diabetes and this is true of people of Asian origin. Carrying too much weight also increases the probability of getting type 2 diabetes.

Too much glucose in the blood causes problems in the small blood vessels in the body, including in the areas of the kidneys, the eyes and it also affects the nerves.

Type 2 Diabetes is quite rare in young people under the age of 18 years and when diagnosed at this age, type 2 diabetes is much more serious than in older people, partly because it means living with the condition for a longer period, but also because of the more aggressive nature of the disease at this age. Blood glucose levels may also have been high for some time before diabetes was detected. In young people, the probability of needing to take insulin injections is greater.

Health complications linked to type 2 diabetes are likely to develop at a young age and much more quickly than in older adults.

Why do people get Type 2 diabetes?

• Genetics and family history can play a significant part
• More common in people of South Asian, African and African-Caribbean descent.
• Being overweight or obese with increased fat tissue can lead to higher level of insulin resistance.

Why is blood glucose high in type 2 diabetes?

• Impaired insulin production in the pancreas
• Insulin resistance – impaired insulin action

Warning signs of type 2 diabetes?

You may have had warning signs of developing type 2 diabetes. These may include the following:
1. Going to the toilet to pass urine a lot
2. Thirsty
3. Tired
4. Noticed dark patches of skin on your neck, armpits, groin or fingers
5. Noticed an increase in your waist measurement
6. Noticed an increase in your weight
7. May ‘Snore’
8. May have not noticed any signs

Aims

• Healthy/active lifestyle for mental and physical well-being
• Reduce or maintain weight to achieve a healthy BMI
• Maintain normal blood glucose levels
•  Prevent associated problems and future complications

Medications

Metformin
Metformin hydrochloride
Brand names: Glucophage®, Metsol®
Metformin is usually the first medication recommended in young people to manage blood glucose levels.
Metformin is a tablet that will help to control your blood glucose levels without causing hypos.
The usual starting dose is 500mg twice a day with meals, but this can be doubled if blood glucose levels are not reducing enough. The maximum dose is 1000mg twice a day (total 2000mg).

When you first start taking this tablet it may upset your stomach for the first few days, it is important that you keep taking the tablet as the symptoms should improve. If you do feel unwell, please get in touch so we can help you.
If you find the tablet is too big to swallow and you have difficulties taking it, it can be crushed. Pill crushers are available from your pharmacy but also a mortar and pestle can be used. The powder will not dissolve in water but can be mixed with foods such as yoghurt and eaten.
If you have been prescribed Metformin Slow Release (SR) this cannot be crushed as it affects the way, it works.
Although your pharmacist may tell you not to take medication at mealtimes, because it reduces the effectiveness, Metformin SHOULD be taken at mealtimes because this reduces the side-effects (e.g., upset tummy, diarrhoea).

Why is it important for my child to take this medication?

Your child has been prescribed metformin because their diabetes is not fully controlled, even when eating a strict diet. Metformin should help to control your child’s blood sugar levels, in combination with a controlled diet.
What is Metformin available as?
• Tablets: 500 mg, 850 mg
• Liquid medicine: 500 mg in 5 mL
• Oral powder: 500 mg per sachet, 1g per sachet; these contain aspartame
When should I give Metformin?
• Metformin is usually given once each day with or straight after a meal. This is usually in the morning.

• If your child needs a higher dose of metformin, they may need to take it two – three times each day, with or straight after a meal. Ideally these times are six hours apart. Give the medicine at about the same time each day so that this becomes part of your child’s daily routine, which will help you to remember.

How much should I give?

Your doctor will work out the amount of metformin (the dose) that is right for your child. The dose will be shown on the medicine label.
Your doctor may suggest that your child has a low dose to start with. They may then increase the dose as your child gets used to the medicine and depending on how your child responds to it.
It is important that you follow your doctor’s instructions about how much to give.

When should the Metformin start working?

Metformin should start working straight away, although you may not see any difference in your child.

Insulin

If blood glucose levels do not normalise with Metformin, the next treatment in young people is insulin. This is because other medications are only licensed for use in those who are 18 years or over.
There are two types of insulin:
• Background insulin (usually Lantus)
• Quick acting or mealtime insulin (usually Novorapid)

Glucagon-Like-Peptide-1 (GLP-1)

Glucagon-Like-Peptide-1 (GLP-1) e.g., Victoza, Byetta, Bydureon, Lyxumia)
These medications imitate the GLP-1 that is made in the body naturally. They are given as an injection either once a day or once a week. They help to control your blood glucose levels by encouraging your body to make more insulin. They can also help to manage your weight because they slow down the rate at which the stomach empties, keeping that full feeling for longer.
It is possible that this may be discussed with you in clinic by the doctors.

Blood glucose monitoring

You will be shown how to use a blood glucose meter. The one given is the Accu-chek Instant meter.
If you are on insulin with meals (Novorapid/Fiasp)
You will need to check blood glucose levels more often so that we can get your doses right. Check your levels:
• On waking
• Before each meal
• Before going to bed
• If you don’t feel well and think you may be high or low

Why Check?

• It puts you in charge of your diabetes, giving you immediate feedback on how your treatment plan is working.
• It can help with necessary lifestyle and treatment choices
• It can help monitor for symptoms of hypo or hyperglycaemia
• It allows you to view patterns of high or low blood glucose levels
• Please let us know if your blood glucose levels are above 14mmol/l. You should check your blood ketones if your blood glucose levels are high.

What are ketones?

Ketones are formed when the body cannot use the glucose in the bloodstream, because there is not enough insulin present, or the insulin is not working properly. In this case, the body breaks down fat to produce ketones, which the body can use as an alternative source of fuel to glucose but if the levels rise, they can be very acidic and dangerous for the body.
Ketones should be checked if glucose 14mmol/l or above lasting 90 minutes or more or glucose above 18mmol/l and unwell.
Advise us immediately if you also have ketones of or greater than 0.6mmol/l.
Dehydration is a very serious problem in type 2 diabetes when high blood glucose levels arise.
DO NOT IGNORE HIGH BLOOD GLUCOSE LEVELS. IT CAN BE VERY DANGEROUS.

Sick Day Rules

Advice for vomiting/unwell
If you already have access to glucose monitoring, increase the frequency of checking your glucose every 2 to 4 hours. Ensure you:
• Stay hydrated: drink at least ½ cup (100mls) of water (you can also drink any other sugar free drink) every hour.
• Do not fast: maintain carbohydrate intake
• If you are unable to eat or drink or are vomiting, replace meals with sugary fluids or ice cream
• Never stop insulin: you may have to adjust the dose
You may need to stop taking some medications during the period you are unwell (see below for specific advice). If you are worried about other symptoms not related to your diabetes, please seek medical advice from your paediatric diabetes team or the Childrens ward. Seek medical attention if you are unable to control your glucose levels (persistently over 18mmol/L) or unable to stay hydrated due to vomiting.

If you are taking tablets or non-insulin injectable medications for diabetes, you may find that because of reduced appetite or inability to eat your usual meals, these tablets may cause low sugars. Some of the tablets (oral hypoglycaemic agents) will need to be stopped during the period you are unwell and this may cause your blood sugar to go up.
Increase the frequency of glucose monitoring to 2 – 4 hourly .
If you are taking any of the following diabetes medications you need to stop them when you are sick:
• Metformin – dehydration can make it more likely that you will develop a serious side effect called lactic acidosis
• Sulfonylureas – if you are unable to eat or drink, it will be more likely that you develop low blood glucose (hypos). Examples: names ending with ‘ide’ such as gliclazide, glibencamide, glipizide. If you are eating and drinking normally and blood sugars are high continue to take Sulfonylureas.
• GLP-1 analogues –dehydration can make it more likely that you will develop a serious side effect. Examples: names ending with ‘tide’ such as exenatide, dulaglutide, liraglutide, lixisenatide and semaglutide.
• SGLT2 inhibitors – dehydration can make it more likely that you will develop a serious side effect called ketoacidosis. Examples: names ending with ‘flozin’ such as canagliflozin, dapagliflozin, empagliflozin and ertugliflozin
Restart when you are well (normally after 24 to 48 hours of eating and drinking normally). When you restart your medicine, just take them as normal.

Low blood glucose levels (Hypoglycaemia)
Hypoglycaemia or “a hypo” will only normally happen if you are on insulin. If you have a blood glucose level of less than 4mmol/l, you will need to give yourself glucose to bring the level back up above 4mmol/l. We recommend you check your blood glucose again after 15 minutes to make sure it has come up above 4mmol/l after treatment.
Dextrose tablets or Lucozade are the best way of raising your blood glucose levels when you are hypo. You are going to need 4-5 Lift tablets, 1 Lift Juice OR around 200ml Lucozade. If your blood glucose levels do not come up above 4mmol/l after 15 minutes, you may need to increase the amount of hypo treatment you use. Discuss this with your diabetes team.
If you are not eating within an hour of treating your hypo, you will need a small, healthy snack such as a piece of fruit to keep you going until your next meal.

What do we check in clinic?

HbA1c or Glycated Haemoglobin
Haemoglobin is a protein in red blood cells. Glucose becomes attached to this protein as it flows through the blood. The more glucose that is in the bloodstream on a regular basis, the more will become attached and the higher the HbA1C level. We would like this level to be as close to 48mmol/mol (6.5%) as possible. Keeping the HbA1C at this level means that the damage caused to the small blood vessels is much less than when the level is higher.
Blood vessels carry blood from your heart to your organs such as your kidneys, some of which are very small. These organs perform vital tasks in your body and a good blood supply is needed both to take vital nutrients and to clear waste products. Too much glucose in the blood vessels causes damage to the lining of these blood vessels and may eventually slow down the blood flow, which will cause damage in turn to the organs.

HbA1c Chart
The chart below gives you an idea of whether your diabetes management is on track, and you are making sure you’re doing everything you can to reduce your risk of health issues in the future.

Diet and Nutrition

Stage 1
It is important for the whole family to support the family member with type 2 diabetes. Choose an approach to dietary change that suits you as a family. This may initially include:
• Eating together as a family to make it a social occasion
• Choosing to drink water or no added sugar/diet drinks
• Keeping unhealthy snacks out of the cupboards at home
• Limiting spending on snack foods outside the home
• Looking at portion sizes served
• Choosing healthier products based on reading the labels when shopping
N.B. There is no need to buy any products labelled specially for diabetics as they are often more expensive and may contain sweeteners such as sorbitol, which are not calorie free and may have a laxative effect.
Stage 2
Taking further steps to make dietary changes means thinking about approaches to losing weight that might appeal to you – you have probably read about different diets and approaches to losing weight such as:
• General healthy eating – reducing portion sizes, aiming to have more wholegrains, more fruit and vegetables etc.
• The low carbohydrate diet – reducing portions of carbohydrate and increasing fat and protein in the diet
• Group approaches – e.g., Weight Watchers/Slimming World etc to have input and support on a regular basis with a structured eating plan
• The vegetarian diet – meals based around vegetables, beans, pulses and nuts
•The very low-calorie diet – involving meal replacements in the form of drinks and bars.

Meal Planning
Meal planning is important as it helps us to shop only for the foods that we need to prepare the meals we have decided on.
This approach helps save money, waste and reduces the amount we are able to over-eat.
The Eatwell Guide
The Eatwell Guide promotes a balanced and varied intake to improve health, and this will also keep your glucose levels in target more of the time.

Nutrients

Vitamin B12

Levels can sometimes be low in people who have type 2 diabetes, so it is particularly important to make sure you include some dairy foods in your diet. If you do not, please discuss this with us as we may recommend a supplement.
It is especially important if you are vegetarian to get your protein, iron, zinc and vitamin B12 from sources other than meat. Choose from the foods listed below:
• Soya based foods including tofu
• Beans, lentils and chickpeas
• Seeds, nuts and nut butters (like peanut butter)
If you eat these foods in combination with cereal foods (such as wholemeal bread, rice, pasta) these will provide you with proteins that are equivalent to those found in meat. Some vegetarians still eat eggs, milk and fish. These provide a more complete form of protein equivalent, similar to that in meat.
B vitamins can be obtained by eating fortified breakfast cereals, soya foods and yeast extracts (such as marmite or vegemite).
Vitamin D
The Scientific Advisory Committee for Nutrition (SACN) published a report in 2016 in which it recommends that everyone, in the UK, over the age of 4 years takes a vitamins D supplement of 10 μg/d (400 IU/d), throughout the year.
At particular risk of vitamin D deficiency are those of Asian origin due to darker pigmentation and in women, skin being covered.

Those with a higher BMI, with diabetes and who are not physically active, or smoke are also more likely to have lower vitamin D levels (SACN 2016).
Having low vitamin D levels can cause you to feel low in mood.

Sugar Substitutes

There are many alternatives to sugar, some natural, and some artificially manufactured. It is important to know:
• Which contain carbohydrate and affect your blood glucose levels, and those that do not.
• All food additives have an E number, but this does not tell you whether it is natural, or if it will affect your blood glucose level
Sweeteners with no carbohydrate that will not affect your blood glucose level:
All artificial sweeteners available in the UK have been approved for use, in recommended amounts by the Food Standards Agency (FSA), following rigorous testing. They should be used in very small quantities as they are many hundred times sweeter than sugar. The following sugar substitutes are carbohydrate free, and have a negligible effect on blood glucose, so don’t need carbohydrate counting:
• Aspartame E951(Canderel), Saccharin E954 (Hermesetas), Acesulfame K E950 (Hermesetas Gold- also contains Aspartame), Cyclamate (Hermesetas liquid), Sucralose E955 (Splenda),
• Stevia E960 – a natural, calorie free sweetener (from the Stevia plant)

Sweeteners that will have a small affect on your blood glucose level:
Erythritol E968 (Truvia), Isomalt (E953), Maltitol (E965), Mannitol (E421), Sorbitol (E420) and Xylitol (E967) are low in carbohydrate but are not free. They all have a possible laxative effect and therefore we do not recommend using them.

N.B. Sugar free gum
Contains Xylitol in very small amounts and is recommended by dentists. This gum often contains sweeteners such as Xylitol, which comes from
Page
19
birch wood has shown promising results in studies looking at reducing dental caries.

Sugar alternatives that will affect your blood glucose level:
Honey, maple syrup, coconut/palm or date sugar, molasses, rice/corn/agave syrup all contain the same amount of carbohydrate as sugar does, therefore all need to be carbohydrate counted. Some break down into glucose more slowly than regular sugar (sucrose) but still require the same amount of insulin.
Fructose
Fructose powder is not low carbohydrate and is not recommended as it may have a laxative effect. Agave and corn syrup are also high in fructose. High amounts of processed fructose in the diet are not healthy. Three-four pieces of fruit a day is fine, however.
For further information on artificial sweeteners see the NHS website:
http://www.nhs.uk/Livewell/Goodfood/Pages/the-truth-about-artificial-sweeteners.aspx

What is carbohydrate and why is it important?

Carbohydrate is the main nutrient in food that provides energy for the body so you can breathe, walk, run, play football and dance. Carbohydrate is broken down into glucose by the digestive system and enters the blood stream. Carbohydrate is both starch (in rice, bread etc) and sugar (fruit, milk, added sugar). Glucose is needed in the body’s cells (muscles, organs) to produce energy, but in type 2 diabetes, the body struggles to transport glucose from the blood into the cells.

How much carbohydrate do I need?

Everybody needs carbohydrate for energy, but lower carbohydrate diets have been shown to be useful for managing blood glucose levels in type 2 diabetes.

To provide your body with a consistent supply of energy it’s best to spread carbohydrate as equally as possible throughout the day. This is not possible every day and would be very boring if followed prescriptively, however, a structure to your normal eating would help your energy levels and blood glucose control.
Your average daily carbohydrate requirement calculated with your Dietitian is:
Daily carbohydrate: _______ g to _______g
Main meals carbohydrate: _______g to _______g
Making it balanced

If you would like to look at reducing your carbohydrate portions further and choose a medium-low carbohydrate diet, discuss this with your dietitian.

Glycaemic Index

Individual foods and meals affect blood glucose levels in different ways. Some foods cause a sharp rise, whilst others produce a slow, gentle rise. A gentle rise is easier for your body to manage when you have type 2 diabetes and also helps to keep you feeling full for longer, which is useful for weight management.
Glycaemic Index (GI) is a way to rank foods based on how quickly a food will raise blood glucose:
• Foods with a high GI ≥70 raise blood glucose quickly.
• Foods with a low GI ≤55 raise blood glucose slowly.
• Foods with a medium GI (56-69) are still good choices
Low GI foods produce a slower and less pronounced rise in blood glucose levels. It will benefit your blood glucose if you have at least one low GI food at each meal. If you have a low GI meal, the benefit will last until after the next meal.
If high GI foods are mixed with lower GI foods e.g., Coco Pops and Bran flakes, the effect on blood glucose will also be reduced.

What else can affects GI?

If a food contains little or no carbohydrate, it does not have a GI value e.g., avocado, meat, fish, eggs, cheese and most alcoholic drinks.
Most fruit and vegetables are low GI, and it is therefore recommended to include a variety of these in your diet. Including vegetables or salad at main meals will help to make sure the overall GI of the meal is low.
When making food choices, think about the fat and sugar content. Some foods with a low or medium GI will have a high calorie (energy) value e.g., croissant, chocolate, crisps, ice cream, nuts and dried fruit. Keeping the portion size of these small will benefit your health.
Fat and protein in foods slows down how fast carbohydrates leave the stomach. For example, eggs on toast would have a lower GI compared to toast with jam. Having a good protein food at main meals will help balance your blood glucose control.
Fibre also affects how fast carbohydrates will break down into sugar. Wholegrain bread will be a better choice than white bread.
Less processed foods are harder to digest and have a lower GI than very processed foods. – It’s always best to have a piece of fruit compared with fruit juice for example.
Adding vinegar or lemon/lime juice into salad dressings at a meal will reduce the GI of the meal.

Why do we eat?

We don’t always eat because we are hungry. Some other reasons why people eat at other times are listed here. You may find that you also have other reasons. It might help to write down how you are feeling when you eat to work out whether there are triggers for your eating that could be avoided by changing behaviour.
Emotional or comfort eating – when we are feeling low in mood or upset, we often think that eating can help to make us feel better, but this is going to be a temporary fix so finding other ways to deal with these emotions will help in the longer term.
Boredom eating – finding a distraction or something else to do could help, especially if it’s an activity or sport.
Stress eating – studying for an exam or getting worried about a situation can cause us to indulge, sometimes without us being aware we are doing it. Exercise can be a good way to deal with stress as it can lead to the release of endorphins that help combat the stress and improve our mood.
Social eating – joining in can seem important to be accepted by people and sometimes our friends and relatives put a lot of pressure on us to eat, especially if they have made a lot of effort to prepare our favourite foods. Practising ways to manage social situations by politely saying you are not hungry or asking to take food home.

Change

It is important, when we set ourselves goals to make change in our lives that we keep these goals realistic so we can do them fairly easily. We can also have a think about how we might measure the goals so you know when you’ve reached them and can recognize your achievements in some way and also set new ones if we want to.
If you’re not sure where to start, you can talk through your current routine and meals with the dietitian. They can make suggestions about what could make your lifestyle healthier. It is then important that you decide which (if any) of these suggestions you’d like to take on board. If none of the ideas appeal to you, you could have a chat with your siblings, friends, parents, teachers, mentor or religious leader – anyone who might help you to think things through and make up your mind.

Physical activity and exercise

Being physically active is one of the most important things for your health, and to help manage your blood glucose level.
The benefits are:
• Helps your body to stay sensitive to insulin.
• Keeps the cardiovascular system (heart and lungs) healthy.
• Promotes a positive frame of mind.
The current government recommendations to get the full benefit are:
1. Sixty minutes of moderate activity every day, activities such as walking and playground activities.
2. Three times a week enjoying vigorous activities that strengthens muscles and bones, such as fast running and team sports.
3. All children should minimise the amount of time being inactive for extended periods, such as sitting watching TV and playing video games.

Tips on increasing physical activity.
• Always take the stairs
• Cycle or walk to shops
• Get off the bus one stop earlier and walk the rest of the way
• Take up an activity you enjoy

Sleep and health

Getting enough quality sleep is one of the most important things you can do to look after your overall health. Getting the right amount of quality sleep is essential for:
Promoting growth
Looking after your heart
Keeping a healthy weight
Keeping your immune system healthy
Improving attention span
Improving learning
How many hours sleep do you get per night?
Compare your hours with the recommended amount on the next page and see if more sleep will benefit your health.
Top tips for quality sleep
Set an individualised bed and wake time to ensure you get the recommended amount of sleep:
Sleep time:
Wake time:

Have a consistent bedtime routine:

• Turn TV, mobile phone, electric devices and computer games off 2 hours before bedtime.
• Dim the lights and do calm activities such as reading.
• No computerized equipment in the bedroom
• Bedroom temperature not too high, keep at 65-70 degrees.
• Take a family approach to good sleep habits by mum, dad and siblings also getting the recommended amount of sleep.

Food and activity diary

In order to create an individualised nutrition plan please complete a food diary for 5 days before your appointment being as specific as possible:
• Remember to include all food and drinks including any snacks, spread/butter, type of milk full fat/semi skimmed/1%skimmed milk
• Describe foods as accurately as you can in handy measures (tablespoons, teaspoons, slices) or in weight (g/oz or ml/oz)
• State method of cooking e.g., grilled, baked, fried
• If possible, give recipe for homemade items or rough quantities
• Brand names are helpful to include, if available

If you have any questions, or if there is anything you do not understand, please contact the Russells Hall Hospital switchboard number on 01384 456111 and ask for the relevant department who issued this leaflet.

If you have any feedback on this patient information leaflet please email dgft.patient.information@nhs.net

This leaflet can be made available in large print, audio version and in other languages, please call 0800 073 0510.

Originator Birmingham Women’s and Childrens Hospital. Date reviewed: November 2023. Next review due: August 2026. Version: 1. DGH ref: DGH/PIL/00158.