Driving and Diabetes

By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NPPossessing a driver’s license is a rite of passage in our society.
A driver’s license is seen as a gateway to independence and is a necessity for survival in many instances since many places in the US don’t have adequate public transportation. Driving is such a huge part of our lives, but there are instances when the ability to drive competently is also at issue. The American Diabetes Association (ADA) published a Position Statement on Diabetes and Driving in the 2014 Clinical Practice Recommendations. I would like to summarize the key points of this Position to provide an overview to help both people with diabetes and their health care providers have the best information about driving with diabetes.

The process for identifying drivers with diabetes varies from state to state, depending on what type of vehicle the driver needs to be licensed for. In some states, questions such as “Do you have any medical condition that may interfere with the safe operation of a motor vehicle?” are asked at the initial application for license. These questions may then prompt the need for further medical evaluation. There is no need for a medical examination just because the driver has diabetes. Most often a medical evaluation would be requested when there has been a documented episode of hypoglycemia while driving. Visit the ADA Website for more information on specific rules for each state.

Drivers with diabetes that are commercial drivers in interstate commerce have different rules and follow a set of uniform federal regulations. ALL drivers are subject to an examination every 2 years to update the driver’s ongoing general fitness. Drivers with diabetes managed with diet, exercise, and oral medications do not have any further requirements. Drivers who use insulin often require a more detailed medical evaluation so an exemption to drive and medical certification can be granted. Drivers for commercial motor vehicles, such as school bus drivers and vehicles that transport passengers or hazardous materials are subjected to more strict evaluations that differ state to state.

There are many factors to consider when caring for the driver with diabetes. I want to be clear: a diagnosis of diabetes or the use of oral medications or insulin does not mean that driving ability is compromised. The ADA has determined that the single most significant factor associated with collisions for drivers with diabetes appears to be a recent history of severe hypoglycemia regardless of diabetes type or treatment. The ADA Workgroup on Hypoglycemia defines severe hypoglycemia as an event that disrupts cognitive motor function and requires the assistance of another person to treat the hypoglycemic event.

The plan of assessment and care of the driver with diabetes needs to be individualized. It is important to not only review hypoglycemia awareness, but to also review the other conditions that could interfere with safe driving. These conditions may include decreased visual acuity due to retinopathy or cataracts, neuropathy that diminishes the sensation of the right foot, or sleep apnea which can result in daytime sleepiness. Drivers that have had a hypoglycemic event will need much closer evaluation and education. The driver may need re-education to address issues with mealtimes and dosing of medications (or medications may need to be adjusted altogether), further education about hypoglycemia awareness, and the best methods of treating low blood sugars. Drivers who have had episodes with severe hypoglycemia may also need to perform additional glucometer testing.

People driving for long distances should have a good supply of glucose tablets easily available in the glove compartment or in the console. A supply of snacks such as packages of cheese and peanut butter crackers or nuts should also be stored in the front of the car with the driver and checked before each trip. Drivers who feel hypoglycemia occurring while driving should pull off the road immediately, put on their blinkers, and treat with a fast acting carbohydrate. Do not resume driving until blood sugar values are normalized.

Finally, I advise that all of my patients with diabetes have a medical ID with them at all times. Symptoms of hypoglycemia may appear as if driving under the influence of alcohol or drugs, which can lead to losing precious treatment time if there is an incident where you are unable to identify yourself as having diabetes.  First responders are trained to look for things like a bracelet or necklace, or a card in the wallet.


Fasting and Diabetes – is it safe?

By Erika Chan
Dietetic Intern

This month, over 1.5 billion Muslims will be practicing the holiday known as Ramadan. Ramadan occurs during the 9th month of the Islamic lunar calendar. This year, the religious holiday started on Saturday, June 28, 2014 and will continue until the evening of Monday, July 28, 2014. The holiday is dedicated to purifying the soul, focusing attention on God, and practicing self-sacrifice and discipline – which includes fasting from sunrise until sundown throughout the religious holiday.

If you have diabetes, Ramadan requires balancing your religious obligations with practices that will keep your body healthy and happy. You can rest assured that there is a safe way to observe this holy holiday even with diabetes, but you should be vigilant and educated on how to keep your blood sugars under control.

First, it is important to know that while most Muslims practice strict adherence to fasting during Ramadan, fasting is not required. The Quran does not recommend fasting if it could harm ones’ health– particularly for those who are sick, pregnant, or elderly. Therefore, those with poorly controlled diabetes should not fast if it puts their health at risk. However, diabetes can be safely managed while fasting. You should continue to take your medications during Ramadan, but depending on blood sugar levels, timing or dosage may require modification.

As those with diabetes know, eating consistent carbohydrates and timing of medication are important to keeping blood sugars regulated. Fasting, however, can deregulate this system and cause dangerous effects including dehydration and hypoglycemia throughout the day. Furthermore, the large influx of food when breaking the fast at sundown can cause hyperglycemia in diabetics.

For these reasons, it is important to routinely check blood sugars (which does not count as breaking your fast) and monitor your physical symptoms to avoid dehydration and hypoglycemia. Hypoglycemia is technically defined as glucose levels below 70mg/dl, and can cause dizziness, lightheadedness, hunger, and disorientation. This state should be treated immediately with small amounts of food, juice, or a glucose tab to restore normal blood sugars. If this condition occurs, there are options to avoid re-occurrence, and you should contact your medical provider to alter medications or discuss other acceptable ways of breaking the fast if necessary.

Conversely, when breaking your fast you should be cautious about consuming too many carbohydrates at one time, which can cause hyperglycemia. As usual, try to keep carbohydrate amounts close to normal goals (when not fasting), and eat adequate amounts of protein and vegetables to help blunt possible spikes in blood sugar. Furthermore, it is important to start the day with a hearty meal of complex carbohydrates and protein to slow digestion and provide fullness and adequate fuel throughout the day.

Just as Ramadan is a time for self-reflection, if you are managing diabetes it is important to be in tune with your body and its physical symptoms. While it is certainly possible to manage diabetes while fasting during Ramadan, each person’s body will react differently.  It is important to contact your health care provider to discuss ways to coordinate diabetes management with your religious practices ahead of time in order to keep both your body and mind healthy and well.

(Post reviewed by Melanie Pearsall, RD, CDE, MGH Revere HealthCare Center)

(Summer) Safety First

By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen W

Summer has arrived in a fashion that will be hard to forget. That’s what life in New England is all about:  blink and the weather will change.  I really love summer, weather and all. It’s a time where I slow down the daily pace, enjoy the long hours of daylight, and remember being a kid where my only responsibility was reading the 7 books required from the Boston Latin School Summer Reading List. Well, adulthood has a few more responsibilities and I want to give you some pointers that will hopefully keep this summer healthy and happy for you and yours. 

 Managing your Diabetes can get a little tricky with the advent of heat and humidity, so a little pre-planning can help ensure you’re able to enjoy this magical season completely.  Remember, extreme heat can lead to heat exhaustion and heat stroke, both of which can be serious medical conditions requiring urgent medical attention.  Symptoms of heat exhaustion include dizziness, extreme sweating, muscle cramps, and clammy skin. This is best treated with cool fluids in a cool location and close monitoring of your glucose levels. Heat stroke is much more serious and characterized by a dangerous rise in your body temperature along with decreased ability to perspire. This potentially life threatening condition always requires urgent medical attention. 

  • It’s so important to stay well hydrated. The best choices are water and sugar free liquids.  Caffeinated beverages can actually cause dehydration so drink those sparingly. It’s also a good idea to use caution when drinking alcohol. Small amounts of diluted sports drink may be necessary if you’re exercising in the heat. It’s best to develop a plan with your health care provider to determine if you need additional fluids.
  • Exercise is important to maintain all year round, but extra caution is required with the heat, humidity, and bright sun. Outdoor exercise is best done before and after the high sun and heat of the day. However, with very hot temperatures and elevated heat indexes, outdoor exercise may need to be postponed. Indoor activity should be done in air conditioned facilities.  If you don’t have access to a gym you can try walking around the mall, or up and down all of the aisles of the store while doing your food shopping.
  • The sun isn’t always your friend. ALWAYS wear sunscreen during any outside activity, not just when you’re at the beach. The sun’s rays are strong and present, even when the sky is hazy, and you have to protect your skin. It’s also important to use the sunscreen correctly. Dermatologists recommend using a shot glass worth of lotion for the whole body. Reapplication is needed every 3 hours or so, especially after swimming or sweating. Another way to help to protect you from the sun and heat is to wear a wide brimmed hat and light colored, light weight loose clothes that will help to deflect the sun.
  • Your blood sugar control may be affected by the heat. Your appetite may fall off or you may be eating those special treats of summer: corn on the cob, potato salad, and lots of berries. All these things are fine in moderation, but may make your blood sugars a little erratic. You also have to be really careful about your supplies and medications. Your glucometer, test strips, oral medications, and insulin are all extremely heat and sunlight sensitive. Prolonged exposure to extremes of weather will cause malfunction and possible inactivation of your medications. This could be life threatening. Always store these things in moderate temperatures and use a well insulated gel pack for travel or any weather related storage. NEVER use a freeze pack for your insulin: it will freeze, not cool, your insulin and it will be deactivated.
  • NO bare feet. EVER. Good foot care is always in season. Always wear socks when doing heavy exercise, walking, and hiking as they will help to absorb moisture and protect the skin from breaking down. Change your socks frequently if they get too sweaty and always make sure your shoes fit well. Wear closed toe shoes with outdoor work like lawn mowing or painting to provide extra protection in the event of an accident. I ask all my patients, regardless of their medical conditions, to always wear water shoes or beach shoes when at the beach, in the ocean, and even poolside. It is very common to get a cut or abrasion from debris in the water or on the shoreline and this could be very serious for anyone, and especially so for people with Diabetes.  Avoid flip flops as the rubber piece that separates the toes can cause friction and lead to skin breakdown.

I hope that this list will help you and your families have a wonderful summer.  Now if you’ll excuse me, I have to go and start working on my self-appointed summer reading list.  Happy summer to all!



Winter Safety Tips

By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen W

The calendar tells us that winter begins December 21st. I’ve lived in New England all my life and am used to winter beginning anytime around Halloween, so this year I feel like I’ve already received the best Christmas gift ever…fall weather in December!  Alas, the reality is starting to set in and winter preparations are needed. Winter safety is very important for all of us, but presents challenges for people living with Diabetes. It’s better to think about these challenges now when the ground is bare and the thermostat above freezing.  I’ve listed below a few common issues that may occur and could become serious problems if not identified and dealt with sooner rather than later.

Foot protection:

Daily foot care is one of the most important principles of good Diabetes management. The first place to start is with your boots.  Make sure your shoes fit well—poorly fitting shoes (too big, too small, and too narrow) can lead to skin breakdown, blister formation, and possible infection. You also need to keep your feet warm and dry.  Leaving wet socks on can cause serious problems such as lacerations and blisters that could develop into dangerous infections.  Even waterproof shoes have their limits, so always throw an extra pair of socks in your bag or your desk drawer.  Here’s a tip:  When shopping for boots, try them on with heavier socks (since we usually wear thicker socks in the winter).

Traveling & Commuting:

Foul weather can really disrupt your daily commute to work— as well as long distance travel for work or pleasure— which can impact your schedule when you’re trying to regulate your blood sugars. If you’re commuting on public transportation, trains may be delayed or you may have to walk unexpected distances. When driving, there may be road closures, detours that take you far from your destination, traffic jams, or totally impassable roads. It’s a good idea to carry some extra snacks, water, and glucose tabs with you to prepare for unexpected situations. Severe weather or unsafe road conditions may make it too dangerous to get out of the car to open the trunk for your provisions, so keep some snacks in the backseat at all times and always have a stash of glucose tablets or gel readily accessible in the glove compartment. Take a survey of the trunk and pack it with a sturdy shovel, ice melt, jumper cables, and blankets. Also, make sure you have a working flashlight, extra batteries, flares, a cell phone charger, and a first aid kit. Take your car in for winter maintenance in the fall and always double check that you have enough wiper fluid and antifreeze (try to keep your gas tank full also). I think a great gift to give or receive is AAA membership, so consider that your tip for last minute Christmas shopping!

Frostbite & Hypothermia:

It’s important to stay as warm and dry as you can during inclement weather to prevent frostbite and hypothermia—two very serious cold weather complications.

Frostbite is an injury to the body caused by freezing. In areas affected by frostbite, loss of feeling and color can occur. The early signs include redness or pain to an area of skin—both of which indicate it’s time to protect that area immediately and get out of the cold if possible. The skin may also turn grayish yellow in color and/or feel waxy or numb. Frostbite most often affects the nose, ears, cheeks, chin, fingers, or toes and can cause permanent damage.  Severe cases can lead to amputation. The risk of frostbite is increased in people with reduced blood circulation, Diabetes, and neuropathy and also may affect people who are not dressed properly for extremely cold temperatures.

Hypothermia is an abnormally low body temperature that may occur when you’re exposed to cold temperatures for a prolonged period of time, especially if you are underdressed or very wet from precipitation. The body begins to lose heat faster than it can be produced. Prolonged exposure to cold will eventually use up your body’s stored energy; if the body temperature gets too low the brain starts to slow down.  Warning signs of hypothermia include shivering, exhaustion, confusion and slurred speech—not unlike some symptoms of hypoglycemia. It’s important to be sure your blood sugar is at a safe value, and then try to get as warm and dry as possible and get medical attention as soon as you can.


There are a couple more things to keep in mind. Any of these situations that I have mentioned could cause you to have hypoglycemia:

  • Winter is also the time for illness. Getting a flu vaccine, washing your hands, and getting plenty of rest are the most important steps you can take to good health.
  • Remember home safety, too.  Make sure your heating system is in good working order and you have household carbon monoxide (CO), monitors. If you have a fireplace or woodstove be sure that they are vented properly to avoid fire or CO poisoning.

The most important thing to remember is to try to be prepared…then go out any enjoy all that winter in New England has to offer…the good and the bad.


Summer Fun

sandcastle on the beachThe grill has been pulled out of hibernation and pressed into service for the first of many backyard BBQs.  Kids, reveling in their freedom from books and classrooms, chase after the ice cream truck as it makes its afternoon rounds through the neighborhood.  Yup, summer has arrived; time to hit the beach, drive with the windows open and spend time with friends and family on vacation or weekend getaway.  The start of summer is brimming with anticipation and potential for fun outdoor activities, but there are a few things to consider as you enjoy these fun and carefree days.

The first and most important thing to remember is it can get HOT!  This may sound like stating the obvious but it’s very easy to underestimate the effect hot weather has on our bodies.  High heat and humidity make it difficult for the body to cool itself properly, a risk factor for developing a heat-related illness like heat exhaustion.  Warmer weather can also affect blood glucose levels, so you may find you need to test more often as the weather heats up.  You’ll also want to protect your testing supplies and medications (including insulin) from extreme temperatures—never leave them in a hot car or trunk when traveling—and out of direct sunlight.

Dehydration also becomes a concern when the temperature rises.  We lose a lot of fluid through sweating, so stay hydrated by drinking plenty of water throughout the day (stay away from caffeinated beverages and alcohol, though).  Also, try to limit outdoor activities during the hottest part of the day.  Exercising somewhere with air conditioning is best on hot days, but if you prefer exercising outdoors go out either in the early morning or in the evening when it’s a bit cooler.

Beaches and pools are popular summertime destinations.  But while you’re cooling off by the water, it’s still important to keep your feet protected from sharp rocks, shells and other debris.  Wear a comfortable pair of beach shoes while walking and avoid crossing hot sand or pavement with bare feet.  And always, whether you’re at the beach or in your own back yard, wear sunscreen!  Sunburns can raise blood sugar, and blistered or peeling skin can potentially become infected.  Keep your skin protected from sunburn (as well as other harmful effects of sun) by applying sunscreen that has an SPF of 30 to any exposed skin before going outside (including face, neck and tops of feet) and reapply throughout the day, especially after spending time in the water.

Hope everyone has a safe and happy summer!

(Information reviewed by MGH Diabetes Center)