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|01 Human physiology at Manchester Medical School - 1974. Married & did 18 month Dietetics Diploma, Hollings College. Shortage of dietitians. |
|02 Dietitians had been nurses or caterers. Still catering, but medical advancement - attracted me. For diabetics, restricted carbohydrates fitted round twice-daily injections.|
|03 10 gram carbohydrate exchanges. Fats & salads free. Children`s allowance dependent on age - Adult`s varied slightly according to job.|
|04 “Carbohydrate Countdown” booklet (See Extras). Never questioned counting until met patients. Nothing sweet allowed. Could buy fructose. Fat disregarded. |
When training, new 10 gram exchanges had replaced Lawrence diet.
|05 During training, saw few children with diabetes – ‘delicate` – only beginning to attend ordinary schools. |
Started work,1979, Withington Hospital. Saw diabetic adults admitted for other things. Meals measured by kitchen. Moved to teaching hospital with children`s ward. Saw newly-diagnosed.
|06 Children educated on ward, 7-10 days. Then seen in outpatients. |
All literature for adults. Visited children on wards – no sugar, extra protein or fat if hungry.
|07 Adults mostly Type 2 – weight control, no blood-testing, no disposable syringes - 1979-83. (Some parents bought disposables for children.) Blood-testing complicated. Occasional Type 1 adult, developing complications. Huge clinics…|
|08 …like now. Foot & mobility problems. Most didn`t see dietitian. |
Hard for overweight - no food content information. Weight Watchers reduced calories. Sympathy - prognosis poor.
|09 Left to have son. Then part-time - dietetic service for North West BUPA hospitals. Moved to Bristol, 1985 – BUPA, locums at Bristol Royal Infirmary, research. Antenatal work with diabetics – good outcomes. Moved to Midlands, 1989.|
|10 Part-time in diabetic clinic, Birmingham Children`s Hospital. Locums in Solihull & worked in registry office – one stillbirth due to diabetes.|
|11 Children`s Hospital offered home care. Most not hospitalised. Still used exchanges after 1990, but moving to healthy eating.|
|12 Diagosis devastating. Family memories of reduced life expectancy & complications. We said children could have long lives. Now in mainstream schools – we visited. Less information before internet – most for adults. We created own - still addressed to adults.|
|13 Main changes in 1990s: Move to healthy eating – vague – so I kept track of carbohydrate. First blood testing machines. Awareness re fibre. Couldn`t vary food much because tied to 2 injections. Encouraged to replace fat with carbohydrate…|
|14 …before hadn`t bothered re fat. Awareness of heart disease & lipids. Avoided fast carbohydrates & fat, but enough carbohydrates for growth. Retained pre-diagnosis diet if not overweight, avoiding sweets…|
|15 …& specialist products. Fed to appetite – sometimes adjusted insulin. |
Specialist products lost favour - high fat, expensive, sorbitol laxative.
|16 Drinks with new sweeteners available to general public. |
‘Healthy eating` doesn`t address quantity. We tried to address quality & quantity. Now emphasis on carbohydrate counting…
|17 …but not return to past - new emphasis on glycaemic index.|
|18 Focussed on healthy eating - but some foods lift blood sugars more quickly. More insulins . Introduced basal bolus - didn`t count carbohydrate. After 2000, long-acting insulins plus short-acting with meals - people could eat what liked, count carbohydrate & adjust insulin.|
|19 When growing, need for insulin to match greater carbohydrate. Children slow to change to more injections. Now newly-diagnosed begin on multiple injections. Carbohydrate-counting essential: need for maths worrying…|
|20 …give set doses to some, but reduces benefit. DAFNE courses for adults – some eat unhealthily & adjust insulin; some eat healthily & benefit from flexibility. New insulins may change management, but currently need to count carbohydrate.|
|21 Adjust advice for Asian diet. More overweight children with Type 2. Stress this isn`t ‘mild` diabetes.|
|22 Type 1 doubled since 1990. In 1990, no Type 2s – now 5%. More diabetes combined with coeliac disease & secondary to other conditions. |
|23 Type 1 still misdiagnosed by GPs. Children do well at sports – more normal life than 1990. 30 years ago, girls advised against pregnancy. |
At DAFNE course saw different ways people have managed. Current management better for children, though must visit schools to advise on multiple injections.
|24 NHS can`t afford much home visiting. Poor attendance at outpatients. Families need to be more responsible.|
|25 Home visits have pros & cons. Less home visiting might mean more school visiting & group sessions in holidays. |
|26 Not many new babies, but many under one. Help with breast-feeding, weaning, ‘terrible twos`. Will start multiple injections, but I worry re future effect of ‘no food, no injections`…|
|27 …even with twice-daily – wanted them to have insulin before food. |
Next issues at school – sweets, erratic exercise. Parents encouraged to treat all children same. Early adolescence hard – balancing independence/dependence.
|28 Teens difficult - social life etc. Diabetes affects attitude to food. Multiple injections should help. Leaving home or starting work difficult. If well-adjusted & grown, we`ve succeeded. When I began, didn`t grow well, have full job opportunities, or expect children.|
|29 Trials showed control avoids complications. Clearer aims – HbA1c. More monitoring & screening. Better insulins & delivery. Can`t avoid concern re carbohydrate.|