Combe down surgery


Diabetes is a lifelong condition where your own body’s ability to produce sufficient insulin to regulate
the amount of sugar in your blood is impaired. It is often associated with the body being unable to
make maximum use of the insulin that is around (Insulin resistance). Having high blood sugar
(Glucose) levels for prolonged periods is associated with problems with the eyes, kidneys, the
circulation and nerve supply to the feet, and makes diabetics more susceptible to heart attacks and
We can help you keep your blood sugar levels within acceptable limits by dietary advice, tablets and
occasionally Insulin. A 1% reduction in your blood sugar levels can reduce your chances of developing
the complications of diabetes by 35%.
There is now also very good evidence that keeping your blood pressure and blood fats (Cholesterol)
normal, has a further benefit in preventing the complications of diabetes. Exercise is also important in
your general wellbeing and keeping your weight down.
Clinic Organisation
In order to monitor your blood sugar levels, check your blood pressure and urine regularly and detect
any complications early, we like to see all the people in the practice with Diabetes at least twice a year.
We hold diabetic clinics on Thursday afternoons. You will see Liz Fare, the Diabetic nurse twice a year
and Dr Batterham once a year if you have any other significant health problems.
All the appointments for the diabetic clinics will be sent to you, and you will be asked to see the nurse
a fortnight before for a blood test & urine test (please bring the first urine sample of the day with you,
to this appointment) so we have all your up to date results when we see you in the clinic and are
therefore able to asses your diabetes fully. For most of the blood test appointments you will need to be
fasted, i.e. water only from the night before.
If you have to cancel your clinic appointment please let Sue Copperman at the surgery know (who sorts
out the appointments) so she is able to arrange a further appointment.
The Diabetic clinic is run by Dr Imogen Batterham and Sr Liz Fare. If you have problems with your
diabetes during surgery hours please contact Dr Batterham or Liz Fare at the surgery. If you have
problems out of hours please phone 03000339933 for Bath Emergency Medical Services, the on call
doctors’ number.
Once a year you will be sent an appointment by the retinal screening service at the RUH to have your
eyes photographed & screened to ant diabetic changes to your eyes. This operates independently of the
surgery. If you need to cancel or change any appointments please contact them directly on 824115.
Monitoring your own Diabetes
We can only guide and advise you about your diabetes. It is important that you look after your own
diabetes and we will obviously help you with this through the diabetes clinic and general appointments.
We have developed computer print outs of all your diabetes results for you to keep that you will be
given once a year. These are for your benefit to remind you when your next clinic and what your blood
pressure, HbA1c etc is relative to what it should be. This will allow you to keep an eye on things
yourself and help you appreciate what areas need to be improved.
Monitoring blood sugar
There are two ways we can monitor what your blood sugar levels are up to: -
 Finger prick test or BM. This is the test you can do at home. It tells you what your blood sugar is at that moment. This will obviously vary throughout the day. It should be checked just before
food or 2 hours after food
. For good sugar control almost all your blood sugars should be
below 9. If your diabetes is stable i.e your sugar levels are not going up & down too much, and
you are not taking insulin, it is not necessary to check your sugars regularly but can be useful if
you are feeling unwell.
 Sheets for recording your blood sugars are available on the Website.  HbA1c that is the blood test we check prior to your clinic appointment. This checks what your blood sugar has been on average during the 6 weeks prior to the blood test. It is not the same units as your finger prick test & should be below 53. It is also possible to check the amount of sugar in the urine. This is not a reliable test as the urine is
produced over several hours. However for some people with early diabetes this is appropriate as a
guide. For good sugar control you should ideally have no sugar in your urine.
Most people diagnosed with late onset or type 2 diabetes are still producing quite a lot of insulin but
not enough to keep the blood sugar levels low enough. However the natural progression of diabetes is
that less insulin is produced over time. Therefore at diagnosis most people can control their sugar
levels by diet alone. With time however we may need to add tablets one by one and sometimes Insulin.
The tablets either squeeze more insulin from the pancreas e.g. Gliclazide, or help the body use the
insulin more effectively, e.g. Metformin and glitazones.
If you are overweight the best thing you can do for your diabetes is to lose weight. People who are
overweight often have a significant amount of insulin resistance, i.e. they produce a lot of insulin but
the tissues are unable to use it. With weight loss the body’s ability to use the insulin hugely improves.
Indeed a 10% weight loss is associated with a 35% reduction in the incidence of diabetes related
deaths. Well worth considering! Slimming World and Weight Watchers basically follow a diabetic
With sugar, cholesterol and blood pressure control you may well end up taking quite a lot of
medication. The important thing to remember about looking after your diabetes is that if all these
aspects are well controlled the chances of you developing all the complications is hugely reduced. If
you are overweight, reducing your weight will reduce the need for medication. If you are very
overweight your diabetes may disappear with weight loss alone. Losing weight will also improve your
blood pressure.
The Diabetic diet
The diabetic diet is central in keeping your blood sugars satisfactory and Liz will discuss it at length
with you and give you further information to read. It is essentially a low sugar, low fat diet.
A few points to remember are:
 Low fat products are not necessarily low sugar, e.g. yoghurts.  Any product can be called low fat with only 25% less fat than full fat products, i.e. still lots of  Virtually fat free is OK but watch for sugar content.  Unsweetened natural orange or any fruit juice is full of natural sugar (3 pieces of fruit a day is  Food specifically sold as diabetic food is expensive and usually not necessary.  Virtually all ice cream is full of sugar and fat. Weight watchers brand is low fat, low sugar and  Check all the labels of pre packed food. If sugar, glucose, sucrose or fructose are in the top 3 ingredients, the product is not suitable for diabetics. A lot of cereals are an exception to this as they contain predominantly the cereal ingredient (e.g. Cornflakes, Rice krispies and Weetabix). There is a very informative web page on the diabetes UK website which gives a very
comprehensive guide to food shopping for diabetes.

There are several long-term complications of diabetes. The chance of you developing any of these can
be considerably reduced if you look after yourself and your diabetes well from the time your diabetes is
diagnosed. If you leave it until you develop a problem some of the damage will already have been
done. The complications are as follows and the means of prevention discussed:-

The kidneys can be affected in diabetes. Very early changes in the kidneys can be detected by testing
for minute quantities of protein in the urine. We check for this yearly (by sending the urine you bring to
your blood test appointment to the lab). If protein is detected we can prevent deterioration of your
kidneys by keeping a close eye on your blood pressure and giving you medication if required.
Eyes (Retinopathy)
Diabetes can cause damage to the blood vessels at the back of the eye, resulting in new blood vessels
forming, and other blood vessels bleeding. This can damage your eyesight.
If these changes are detected early, referral to an eye specialist for laser treatment can prevent the
problem getting worse. Therefore we keep a yearly check on the back of your eyes. This is done by
photographing the back of your eyes at the surgery; an eye specialist then looks at the photographs. To
achieve the best photographs we like to put drops in your eyes to dilate the pupil, this may make your
eyesight a bit blurred for up to 2 hours, and because of this we recommend you do not drive to your
appointments for this.
Diabetic eye problems can be prevented by good blood sugar control.
The photographs do not check for glaucoma and general eyesight, you need to attend your
Optician for this.

People with diabetes are prone to developing problems with the circulation and nerve supply to the
feet. It is therefore perfectly possible to have sores on your feet which you are unable to feel, and
therefore unaware of, which then take months to heal because of the poor circulation.
We therefore recommend that you keep a close eye on your feet and try and pre-empt any problems.
The things to look out for are:-
 Areas of hard skin.  Verrucas.  Bunions.  Athlete’s foot.  Dry & cracked skin (Lots of moisturiser like E 45 cream)  Corns.  Ingrown toenails.
Careful attention should also be taken when cutting toenails if you have any doubt in your abilities then
ask the Podiatrist to cut them for you.
We also encourage you to have any shoes properly fitted and not walk around barefoot. If you are at all
concerned contact one of us at the surgery or arrange a chiropody appointment and don’t leave it too
long. Podiatry is available through St Martin’s Hospital. If you do not already attend for Podiatry then
please ask to be referred.
Heart disease and strokes
Angina, heart attacks and strokes are more common in people with diabetes. Again you can reduce the
risk of developing any of these by looking after yourself and your diabetes. This is not only associated
with high sugar levels but also high blood pressure and cholesterol levels. Hence it is as important to
have a low fat diet as it is to avoid sugar.

Impotence is much more common in people with diabetes; occasionally this is caused by medication
and is reversible on stopping the appropriate medication. More often it is just the diabetes. We would
hope that if this were a problem to you, you would feel able to discuss it with any of the doctors or
nurses at the surgery.
This looks like a list of frightening prospects and life ahead. However we cannot emphasize enough the
importance of looking after yourself and your diabetes, as all these problems are much less common
with good diabetic care and management.

Diabetes UK

Diabetes UK is based in London. Members receive regular magazines, which give useful advice about
all aspects of diabetes.
Diabetes UK also produces recipe books, advice about insurance policies favourable to diabetics, and
offer discount on blood testing meters, which sadly are not available on prescription. (The lancets and
test strips are).
The address is: -10 Queen Anne Street,
London. WIM OBD
Telephone: 020 7323 1531
Fax: 020 7637 3544
Web site:
Local education sessions
The Bath and North East Somerset Primary Care Trust provide excellent education sessions for
recently diagnosed diabetics. These sessions will cover all the aspects discussed in this leaflet but in
more detail. We strongly recommend you attend these sessions. If you are interested then please
contact Dr Batterham or Liz Fare and we will ask the PCT to send you details.

The PCT also run sessions to update your diabetic diet. These are called ‘conversation map’

Local Diabetes website

The Royal united hospital has a very good website which will give you more information.

You are entitled to free prescriptions if you are on tablets or Insulin. If your diabetes is controlled by
diet alone this is sadly not the case. You will need a form from your pharmacist to fill in to claim for
free prescriptions.
Most items are available on prescription, including blood-testing strips but the monitoring machines
are not. You can buy the machines from any chemist.
Prescriptions can be ordered on line via our website
Remember we need 48 hours to process the prescriptions.
Flu and Pneumonia Vaccines
As a diabetic we strongly recommend that you have these vaccinations. The Flu vaccine is yearly &
the pneumonia once in a lifetime. The reason for this is that as a diabetic you are more likely to pick up
infections and if you do have an infection it will upset your diabetic control and you might be very
unwell. We give these vaccinations each Autumn.

If you are taking tablets or Insulin for your diabetes you are obliged to let the DVLC and your car
insurance company know that you have diabetes. This does not normally prevent you from driving.
Diabetics on insulin may be unable to hold an HGV or PSV licence. Although this is not set in stone as
it once was. More details are available on


As a diabetic your arteries get harder earlier than a non-diabetic. This risk is made considerably greater
by smoking. It is therefore very strongly recommended that if you are diabetic you do not smoke. If
you would like help stopping smoking Jules, one of the nurses at the surgery will be able to help you.
If you are concerned about the care of your diabetes whilst on holiday then please discuss it with Liz
beforehand. This may be particularly relevant if you are crossing time zones. We have a separate
information sheet discussing problems whilst travelling. Any of the nurses or Doctors can give you a
copy of this.

If you are contemplating trying to conceive, it is vitally important your control is as good as possible
before conception. This is a very specialist field and we would refer you to the hospital diabetic
specialist before you become pregnant to ensure you have the best possible outcome from the
pregnancy with regard to both you & the baby. Diabetes UK have some useful information on this

Although we photograph your eyes yearly, this is only to check the back (Retina) of the eye. We do not
check to see if you need glasses or for glaucoma. It is therefore important you attend your opticians
regularly. Eyesight is often affected by high blood sugars. Therefore do not get expensive new glasses
until your diabetes is well controlled.


When you are unwell your blood sugar levels commonly go up. It is therefore important to continue
your medication despite eating less. Diarrhoea and sickness is an exception when sugar levels
sometimes go down, you should however continue your medication and check your blood sugar levels
more often. If in any doubt please contact Dr Batterham or Liz at the surgery.
Servicing glucose testing machines

If you feel your glucose monitoring machine is not working correctly or you are unsure of how to use
it, Rita in Lloyds pharmacy in Combe Down, is able to calibrate your machine and advise you on how
to use it correctly.
If you have any questions or concerns then Dr Batterham or Liz would be happy to answer them. A
telephone call may be all that is required. We are obviously happy to see you between diabetic clinics
if you have any concerns.
Medic alert bracelets & necklaces
These are available from The Medicalert foundation tel ; 0800 581420 and
enable you to carry brief medical details with you at all times.
June 2012
This information sheet is available our websitewhich will make all the
links easier to access.


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