Diabetes during life's big moments

To Talk to any bride during the month before her wedding-if you dare. Anyone who's gotten married recently knows well the stress that can be part of preparing for what should be a most joyous occasion juggling questions for caterers, musicians, and seamstresses; managing family dynamics so everyone feels involved and included; and riding a roller coaster of emotions during a time when everyone tells you just how happy you should be. Now add diabetes care into the mix of what the bride or groom needs to manage.

Where does this ongoing demand fall amid the million other tasks to be attended to?

Even when life is at its most normal, caring for our diabetes can sometimes seem like taking on a second career: We have to plan out schedules in advance and allot time for taking shots or medicines, monitoring blood glucose levels, choosing and preparing healthy foods, exercising, and seeing the doctor, diabetes educator, dietitian, and sometimes other health-care specialists regularly. When we step back to consider all we do to take care of our health, it's hard to understand how we manage to find the time to do it all.

When major events surface in our lives-such as weddings, Bar or Bat Mitzvahs, graduations, special birthdays or anniversaries, or the loss of a loved one-taking care of diabetes can seem like just one task too many. There are so many other things to think about. So whether we are the center of attention or just a guest at a big event, taking care of diabetes can take a back seat to the event itself.

But the reality for people with diabetes is that unless we attend to our health needs during these special times, all of the work we've put into making an occasion joyful and meaningful could be for naught. Our diabetes doesn't take a vacation, even when we stand up in front of family and friends for our graduation. It doesn't take a vacation at the christening of a new child. Even in times of deepest grief, our diabetes is there, demanding our attention.

If you have an important event coming up in your life, though, don't despair. By anticipating the possible challenges connected to your special occasion, you can create a plan to manage your diabetes and still be fully present-emotionally, physically, and spiritually-at your celebration.

Recognizing the stress

The happiest moments of our lives can also be some of the most stress full moments, and the stress typically starts before the event has even taken place. Dorothy Cohen, who has Type 2 diabetes, remembers when her children were planning a huge fiftieth wedding anniversary party for her and her husband. "I am a very shy, private person and I kept insisting the children keep the party small or don't do it. They wanted to include everyone my husband and I had ever known, from his old Army friends to our neighbors and everyone in between. I was so nervous the day of the party, I left the house without my medication and we had to drive 40 minutes back to the house to get it," she recalls. Although Dorothy says that in the end she was able to enjoy the party, the anticipation of the event nearly derailed her diabetes management regimen.

It is critical for people with diabetes to know that stress can interfere with tight blood glucose control. Stress causes the release of "fight or flight" hormones into the bloodstream. These hormones prepare the body for action by releasing stored glucose from the liver, which in turn causes blood glucose levels to go up. So whether your stress comes from planning a party or, like Dorothy, worrying about it, stress could be affecting your blood glucose control.

Psychologist Bret Boyer, who has Type 1 diabetes and uses an insulin pump, works with people on mental health issues and diabetes. Dr. Boyer explains that there are different kinds of stress that can affect people leading up to and during major life moments. One type is the insidious kind of stress that builds up in response to everyday occurrences. "This kind of stress comes from a lot of little hassles throughout the day," he says. "Alone, they're not so bad, but when lots of little things go wrong, it takes a cumulative effect on your nervous system."

Newlywed Jane Robinson experienced this sort of commutative stress when she was planning her wedding. "My fiancé and I lived on opposite coasts and were planning our wedding and looking for jobs so that we could both be living in the same city by the time we got married. I don't think I realized how every little detail I was trying to manage was adding up to a whole lot of stress," she says. In retrospect, the stress and anxiety in Jane's life were probably affecting her diabetes control. "My HbAIc results [a measure of average blood glucose level over the previous two to three months] from those nine months were much higher than my usual ones, and my endocrinologist kept asking me what was going on. I hadn't changed my eating, insulin, or exercise, and I just couldn't pinpoint what was happening. Feeling like my blood sugar was out of control just made me feel more on edge," she says.

If either Jane or her endocrinologist had recognized that she was under a lot of stress because of all the changes that were occurring in her life, they could have talked over some ways to deal with it-such as setting aside a few minutes to relax each day, asking family members or close friends to help with wedding arrangements, or identifying a supportive friend with whom she could talk about her feelings on a regular basis.

This might have helped more than what they tried-namely, increasing her insulin doses to bring down her HbA1c because her blood glucose levels continued to fluctuate according to her emotions, and she sometimes ended up with low blood glucose. The good news is that after her wedding and honeymoon, Jane was able to get back to the kind of blood glucose control she desired.

Besides the commutative stress of lots of little hassles, another kind of stress that Dr. Boyer describes is the stress that comes with experiencing the event itself. "There you are, at your big moment, and it's important to realize that a number of emotions may be happening. Stress is not only when bad things happen. Stress occurs when things go differently in our lives and we need to respond to the change," he explains. During times of transition, there is often a loss as well as a gain. "Change is very hard for people, even when we think of a change as a `good' change. When someone gets married, he may be very excited and ready to move ahead with this partner, but he may also be feeling some grief about not being single and independent anymore," Dr. Boyer explains. Sometimes it is hard to acknowledge the difficult emotions, such as sadness and grief, that come up during times that are "supposed to be" happy, and that can increase the feeling of being stressed.

The strong emotions that come with important personal events not to mention the changes in your daily routine that these events usually cause-can make controlling your blood glucose more difficult, but not impossible. "You need to find a way to balance your self management and integrate it into your big day," says Dr. Boyer. "Too often, people fall into one of two camps: Either they think it's a holiday so they ignore their diabetes, or they focus so much on controlling their blood glucose that they take themselves out of participating the joyousness of the day."

Striking a balance between, and diabetes care can be a challenge under the best of circumstances. How do you do it on may be the busiest, most stress or seemingly most important day, your life?

Creating a plan for control

The more you plan ahead, the more you will be able to relax enjoy yourself in the moment, before your big event takes plan think through the day's activity and how you will fit in your do better management routine. Without a schedule for the day (a possibly for several days leading to the event) and note when you will perform diabetes tasks such monitoring your blood glucose exercising, and doing your d foot check. By actually spelling "check blood glucose" or "inject insulin and eat," you are give yourself a concrete reminder details that could otherwise be highly overlooked in the whirlwind last-minute preparations or t excitement of the occasion. And writing out everything you into to accomplish, you may see that you're taking on too much a should consider scaling back your plans or delegating some tasks someone else-before you get stressed out.

One of the items that shouldn’t be eliminated from your to-do list, however, is putting together a diabetes supply kit for the day of t event. You will need all of the items you usually need on an ordinary day; such as your meter, strips, lancets; insulin, if you use it, an syringes or pens and pen needle other medicines; alcohol pads skin sanitizer in case you can't g to a sink to wash your hands; glucose tablets or gel; and possibly small snack such as an energy bar.

Another thing to think about in advance is who will carry your supply kit. If you will be carrying it, how will you do it? Will you carry a purse? Wear a fanny pack? Does your outfit have big enough pockets to hold everything? What if you get hot and take off a layer? If someone else will be carrying it, who? How will you be sure that person stays near you? What special instructions do you need to give that person?

Jim Wilson learned the value of planning ahead the hard way at Iris high school graduation when he was not prepared with glucose tablets. "We had to walk almost a mile from the school to the stadium where the graduation took place, and I could feel myself get ting low while we were walking. I had taken off my jacket back at the school when we put our robes on and left my glucose tablets in my jacket pocket. I was feeling so lightheaded by the time we sat down I thought I might pass out. I had to walk off the field and find my Mom, who always has a backup supply with her, "Jim says. "The whole thing was really embarrassing."

When you are a guest

As a guest at a special event, you get to relax and enjoy the celebration without worrying about being in the spotlight or attending to the responsibilities of being a host. Of course, it also means that you probably won't be privy to certain information that can be important to people with diabetes, such as what time dinner will be served and what kinds of food to expect. How important that type of information is depends in part on how you treat your diabetes.

For people using an insulin pump these may not be big issues since the pump continuously infuses a basal, or background, amount of insulin, and larger amounts, or boluses, are given when a person eats. If a meal is delayed, the bolus is simply not given until the meal takes place. The bolus dose can be tailored to the amount of carbohydrate in the snack or meal.

People who use a combination of insulin glargine (brand name Lantus) and one of the rapid-acting insulins, aspart (NovoLog) or lispro (Humalog), also have some flexibility with mealtimes and food choices. The long-acting glargine supplies a peak less basal insulin much like that provided by an insulin pump or a normal pancreas. The rapid-acting insulins, meanwhile, have an onset of approximately 15 minutes and an effective duration of about three to four hours. They should be injected within 15 minutes of starting a meal, and the dose can be adjusted based on how much carbohydrate will be cater. If a meal is delayed, the injection of lispro or aspart is delayed as well.

People who use Regular insulin, NPH, Lente, or Ultralente will probably require more specific information about meal timing and content. These insulins have a "peak action time" during which they lower blood glucose most effectively. If a person's meals and insulin injections are not matched carefully, low blood glucose, or hypoglycemia, can result. It's a good idea to talk to your health-care provider about adjusting doses, injection times, and mealtimes if you use one of these insulins.

People who take a sulfonylurea (glimepiride, glipizide, glyburide) may also need more specific information about mealtime and content to achieve optimum blood glucose control. Because these medicines stimulate the pancreas to release insulin, hypoglycemia can be a problem if meals are not taken at regular intervals.

If you feel that additional information about the day's activities could help you manage your diabetes effectively, don't hesitate to get in touch with the event's host ahead of time and ask about what you need to know. He may not be able to tell you the exact mealtime, but he should be able to give you a ballpark range. Just remember to be sensitive-you don't want to call a bride or groom the day before the wedding. Call a few weeks in advance of the occasion if possible.

When the event rolls around, have your diabetes supplies and your action plan in hand. Decide in advance when you will check your blood glucose level or do other tasks, and be sure to wear a watch. (Setting your watch alarm or a cell phone alarm if you have one may be prudent in case you get distracted.) Planning out a diabetes care schedule for an event ahead of time allows you to devote less time to thinking about your diabetes at the event and more time to socializing and having fun.
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