Dr. Ben-Zur recommends that you read this regarding deep vein thrombosisWhat Is Deep Vein Thrombosis?
Deep vein thrombosis (throm-BO-sis), or DVT, is a blood clot that forms in a vein deep in the body. Blood clots occur when blood thickens and clumps together.
Most deep vein blood clots occur in the lower leg or thigh. They also can occur in other parts of the body.
A blood clot in a deep vein can break off and travel through the bloodstream. The loose clot is called an embolus. When the clot travels to the lungs and blocks blood flow, the condition is called pulmonary embolism (PULL-mun-ary EM-bo-lizm), or PE.
PE is a very serious condition. It can damage the lungs and other organs in the body and cause death.
Blood clots in the thigh are more likely to break off and cause PE than blood clots in the lower leg or other parts of the body.
Blood clots also can form in the veins closer to the skin’s surface. However, these clots won’t break off and cause PE.
Blood clots can form in your body’s deep veins when:
- Damage occurs to a vein’s inner lining. This damage may result from injuries caused by physical, chemical, and biological factors. Such factors include surgery, serious injury, inflammation, or an immune response.
- Blood flow is sluggish or slow. Lack of motion can cause sluggish or slowed blood flow. This may occur after surgery, if you’re ill and in bed for a long time, or if you’re traveling for a long time.
- Your blood is thicker or more likely to clot than usual. Certain inherited conditions (such as factor V Leiden) increase blood’s tendency to clot. This also is true of treatment with hormone replacement therapy or birth control pills.
Many factors increase your risk for deep vein thrombosis (DVT). They include:
- A history of DVT.
- Disorders or factors that make your blood thicker or more likely to clot than normal. Certain inherited blood disorders (such as factor V Leiden) will do this. This also is true of treatment with hormone replacement therapy or using birth control pills.
- Injury to a deep vein from surgery, a broken bone, or other trauma.
- Slow blood flow in a deep vein from lack of movement. This may occur after surgery, if you’re ill and in bed for a long time, or if you’re traveling for a long time.
- Pregnancy and the first 6 weeks after giving birth.
- Recent or ongoing treatment for cancer.
- A central venous catheter. This is a tube placed in vein to allow easy access to the bloodstream for medical treatment.
- Being older than 60 (although DVT can occur in any age group).
- Being overweight or obese.
Your risk for DVT increases if you have more than one of the risk factors listed above.What Are the Signs and Symptoms of Deep Vein Thrombosis?
The signs and symptoms of deep vein thrombosis (DVT) may be related to DVT itself or to pulmonary embolism (PE). See your doctor right away if you have symptoms of either. Both DVT and PE can cause serious, possibly life-threatening complications if not treated.Deep Vein Thrombosis
Only about half of the people with DVT have symptoms. These symptoms occur in the leg affected by the deep vein clot. They include:
- Swelling of the leg or along a vein in the leg
- Pain or tenderness in the leg, which you may feel only when standing or walking
- Increased warmth in the area of the leg that’s swollen or in pain
- Red or discolored skin on the leg
Some people don’t know they have DVT until they have signs or symptoms of PE. Symptoms of PE include:
- Unexplained shortness of breath
- Pain with deep breathing
- Coughing up blood
Rapid breathing and a fast heart rate also may be signs of PE.How Is Deep Vein Thrombosis Diagnosed?
Your doctor will diagnose deep vein thrombosis (DVT) based on your medical history, a physical exam, and the results from tests. He or she will identify your risk factors and rule out other causes for your symptoms.Medical History
To learn about your medical history, your doctor may ask about:
- Your overall health
- Any prescription medicines you’re taking
- Any recent surgeries or injuries you’ve had
- Whether you’ve been treated for cancer
During the physical exam, your doctor will check your legs for signs of DVT. He or she also will check your blood pressure and your heart and lungs.Diagnostic Tests
You may need one or more tests to find out whether you have DVT. The most common tests used to diagnose DVT are:
- Ultrasound. This is the most common test for diagnosing deep vein blood clots. It uses sound waves to create pictures of blood flowing through the arteries and veins in the affected leg.
- A D-dimer test. This test measures a substance in the blood that’s released when a blood clot dissolves. If the test shows high levels of the substance, you may have a deep vein blood clot. If your test is normal and you have few risk factors, DVT isn’t likely.
- Venography (ve-NOG-ra-fee). This test is used if ultrasound doesn’t provide a clear diagnosis. Dye is injected into a vein, and then an x ray is taken of the leg. The dye makes the vein visible on the x ray. The x ray will show whether blood flow is slow in the vein. This may indicate a blood clot.
Other less common tests used to diagnose DVT include magnetic resonance imaging (MRI) and computed tomography (CT) scanning. These tests provide pictures of the inside of the body.
You may need blood tests to check whether you have an inherited blood clotting disorder that can cause DVT. You may have this type of disorder if you have repeated blood clots that can’t be linked to another cause, or if you develop a blood clot in an unusual location, such as a vein in the liver, kidney, or brain.
If your doctor thinks that you have pulmonary embolism (PE), he or she may order extra tests, such as a ventilation perfusion scan (V/Q scan). The V/Q scan uses a radioactive material to show how well oxygen and blood are flowing to all areas of the lungs.
Goals of Treatment
The main goals of treating deep vein thrombosis (DVT) are to:
- Stop the blood clot from getting bigger
- Prevent the blood clot from breaking off and moving to your lungs
- Reduce your chance of having another blood clot
Medicines are used to prevent and treat DVT.Anticoagulants
Anticoagulants (AN-te-ko-AG-u-lants) are the most common medicines for treating DVT. They’re also known as blood thinners.
These medicines decrease your blood’s ability to clot. They also stop existing blood clots from getting bigger. However, blood thinners can’t break up blood clots that have already formed. (The body dissolves most blood clots with time.)
Blood thinners can be taken as either a pill, an injection under the skin, or through a needle or tube inserted into a vein (called intravenous, or IV, injection).
Warfarin and heparin are two blood thinners used to treat DVT. Warfarin is given in pill form. (Coumadin® is a common brand name for warfarin.) Heparin is given as an injection or through an IV tube. There are different types of heparin. Your doctor will discuss the options with you.
Your doctor may treat you with both heparin and warfarin at the same time. Heparin acts quickly. Warfarin takes 2 to 3 days before it starts to work. Once the warfarin starts to work, the heparin is stopped.
Pregnant women usually are treated with heparin only, because warfarin is dangerous during pregnancy.
Treatment for DVT with blood thinners usually lasts from 3 to 6 months. The following situations may change the length of treatment.
- If your blood clot occurred after a short-term risk (for example, surgery), your treatment time may be shorter.
- If you’ve had blood clots before, your treatment time may last longer.
- If you have certain other illnesses, such as cancer, you may need to take blood thinners for as long as you have the illness.
The most common side effect of blood thinners is bleeding. This happens if the medicine thins your blood too much. This side effect can be life threatening.
Sometimes, the bleeding is internal (inside your body). People treated with blood thinners usually receive regular blood tests to measure their blood’s ability to clot. These blood tests are called PT and PTT tests.
These tests also help your doctor make sure you’re taking the right amount of medicine. Call your doctor right away if you have easy bruising or bleeding. This may be a sign that your medicines have thinned your blood too much.
These medicines interfere with the blood clotting process. They’re used to treat blood clots in patients who can’t take heparin.Thrombolytics
These medicines are given to quickly dissolve a blood clot. They’re used to treat large blood clots that cause severe symptoms.
Because thrombolytics can cause sudden bleeding, they’re used only in life-threatening situations.
Vena Cava Filter
A vena cava filter is used if you can’t take blood thinners or if you’re taking blood thinners and still developing blood clots.
The filter is inserted inside a large vein called the vena cava. The filter catches blood clots that break off in a vein before they move to the lungs. This prevents pulmonary embolism. However, it doesn’t stop new blood clots from forming.
These stockings can reduce the swelling that may occur after a blood clot has developed in your leg. Graduated compression stockings are worn on the legs from the arch of the foot to just above or below the knee.
These stockings are tight at the ankle and become looser as they go up the leg. This creates gentle pressure up the leg. The pressure keeps blood from pooling and clotting.
These stockings should be worn for at least a year after DVT is diagnosed.
You can take steps to prevent deep vein thrombosis (DVT).
If you’re at risk for DVT or pulmonary embolism (PE), you can help prevent the condition by:
- Seeing your doctor for regular checkups.
- Taking all medicines your doctor prescribes.
- Getting out of bed and moving around as soon as possible after surgery or illness. This lowers your chance of developing a blood clot.
- Exercising your lower leg muscles during long trips. This helps prevent a blood clot from forming.
If you’ve had DVT or PE before, you can help prevent future blood clots by following the above steps and:
- Taking all medicines your doctor prescribes to prevent or treat blood clots
- Following up with your doctor for tests and treatment
- Using compression stockings as your doctor directs to prevent swelling in your legs from DVT
Contact your doctor at once if you have any signs or symptoms of DVT or PE. For more information, see “What Are the Signs and Symptoms of Deep Vein Thrombosis?”Travel Tips
Your risk of developing DVT while traveling is small. The risk increases if the travel time is longer than 4 hours, or if you have other risk factors for DVT.
During long trips, it may help to:
- Walk up and down the aisles of the bus, train, or airplane. If traveling by car, stop about every hour and walk around.
- Move your legs and flex and stretch your feet to encourage blood flow in your calves.
- Wear loose and comfortable clothing.
- Drink plenty of fluids and avoid alcohol.
If you’re at increased risk for DVT, your doctor may recommend wearing compression stockings during travel or taking a blood-thinning medicine before traveling.Living With Deep Vein Thrombosis
If you’ve had a deep vein blood clot, you’re at greater risk for another one. During treatment and after, it’s important to:
- Take steps to prevent deep vein thrombosis (DVT). (See “How Can Deep Vein Thrombosis Be Prevented?”)
- Check your legs for signs and symptoms of DVT. These include swollen areas, pain or tenderness, increased warmth in swollen or painful areas, or red or discolored skin on the legs.
- Contact your doctor right away if you have signs and symptoms of DVT.
Medicines that thin your blood and prevent blood clots are used to treat DVT. These medicines can thin your blood too much and cause bleeding (sometimes inside the body). This side effect can be life threatening.
Bleeding may occur in the digestive system or the brain. Signs and symptoms of bleeding in the digestive system include:
- Bright red vomit or vomit that looks like coffee grounds
- Bright red blood in your stools or black, tarry stools
- Pain in your abdomen
Signs and symptoms of bleeding in the brain include:
- Severe pain in your head
- Sudden changes in your vision
- Sudden loss of movement in your arms or legs
- Memory loss or confusion
If you have any of these signs or symptoms, get treatment right away.
You also should seek treatment right away if you have a lot of bleeding after a fall or injury. This could be a sign that your DVT medicines have thinned your blood too much.
Talk to your doctor before taking any medicines other than your DVT medicines. This includes over-the-counter medicines. Aspirin, for example, also can thin your blood. Taking two medicines that thin your blood may raise your risk for bleeding.
Ask your doctor about how your diet affects these medicines. Foods that contain vitamin K can change how warfarin (a blood-thinning medicine used to treat DVT) works. Vitamin K is found in green, leafy vegetables and some oils, like canola and soybean oil. Your doctor can help you plan a balanced and healthy diet.
Discuss with your doctor whether drinking alcohol will interfere with your medicines. Your doctor can tell you what amount of alcohol is safe for you.
- Deep vein thrombosis (DVT) is a blood clot that forms in a vein deep in the body. Most deep vein blood clots occur in the lower leg or thigh. They also can occur in other parts of the body.
- A blood clot in a deep vein can break off, travel through the bloodstream to the lungs, and block blood flow. This condition is called pulmonary embolism (PE). PE is a very serious condition that can cause death.
- Blood clots can form in your body’s deep veins when:
- Damage occurs to a vein’s inner lining
- Blood flow is sluggish or slow
- Your blood is thicker or more likely to clot than usual
- Many factors increase your risk for DVT. People who have had DVT before or have more than one risk factor are at increased risk for the condition.
- Only about half the people with DVT have symptoms. These symptoms occur in the leg affected by the deep vein clot. They include swelling of the leg or along a vein in the leg, pain or tenderness in the leg, increased warmth in the area of the leg that’s swollen or in pain, and red or discolored skin on the leg.
- Other symptoms may relate to PE. These may include unexplained shortness of breath, pain with deep breathing, and coughing up blood.
- Your doctor will diagnose DVT based on your medical history, a physical exam, and the results from tests. He or she will identify your risk factors and rule out other causes for your symptoms.
- DVT is treated with medicines that thin the blood, interfere with the blood clotting process, and dissolve blood clots. Other treatments include filters to catch blood clots and compression stockings that prevent blood from pooling and clotting.
- You can take steps to prevent DVT. See your doctor regularly. Follow your treatment plan as your doctor prescribes, stay active if possible, and exercise your lower leg muscles during long trips.
- Contact your doctor at once if you have any symptoms of DVT or PE
- This information is for you only.
- Always follow your healthcare provider’s instructions for taking medicines or other changes.
- Ask your provider about nonprescription medicines and supplements before you take them.
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The term “diabetes mellitus” refers to a group of diseases that affect how your body uses blood glucose, commonly called blood sugar. Glucose is vital to your health because it’s the main source of energy for the cells that make up your muscles and tissues. It’s your body’s main source of fuel.
If you have diabetes, no matter what type, it means you have too much glucose in your blood, although the reasons may differ. Too much glucose can lead to serious health problems.
Chronic diabetes conditions include type 1 diabetes and type 2 diabetes. Potentially reversible diabetes conditions include prediabetes — when your blood sugar levels are higher than normal, but not high enough to be classified as diabetes — and gestational diabetes, which occurs during pregnancy.
Diabetes symptoms vary somewhat, depending on what type of diabetes you have. If you have prediabetes or gestational diabetes, you may not experience symptoms. Or you might experience some or all of the symptoms of type 1 and type 2 diabetes:
- Increased thirst
- Frequent urination
- Extreme hunger
- Unexplained weight loss
- Blurred vision
- Slow-healing sores
- Frequent infections, such as gum or skin infections and vaginal or bladder infections
Although type 1 diabetes can develop at any age, it typically appears during childhood or adolescence. Type 2 diabetes, the most common type, can develop at any age and is often preventable.
When to see a doctor
- If you suspect you may have diabetes. If you notice any possible diabetes symptoms, contact your doctor. The earlier the condition is diagnosed, the sooner treatment can begin.
- If you’ve already been diagnosed with diabetes. If you’ve been diagnosed with diabetes, you’ll need close medical follow-up until your blood sugar levels stabilize.
To understand diabetes, first you must understand how glucose is normally processed in the body.
How glucose normally works
Glucose is a main source of energy for the cells that make up your muscles and other tissues. Glucose comes from two major sources: the food you eat and your liver. During digestion, sugar is absorbed into the bloodstream. Normally, sugar then enters cells with the help of insulin.
The hormone insulin comes from the pancreas, a gland located just behind the stomach. When you eat, your pancreas secretes insulin into your bloodstream. As insulin circulates, it acts like a key by unlocking microscopic doors that allow sugar to enter your cells. Insulin lowers the amount of sugar in your bloodstream. As your blood sugar level drops, so does the secretion of insulin from your pancreas.
Your liver acts as a glucose storage and manufacturing center. When you haven’t eaten in a while, for example, your liver releases stored glucose to keep your glucose level within a normal range.
Causes of type 1 diabetes
In type 1 diabetes, your immune system — which normally fights harmful bacteria or viruses — attacks and destroys the insulin-producing cells in the pancreas. This leaves you with little or no insulin. Instead of being transported into your cells, sugar builds up in your bloodstream.
Causes of prediabetes and type 2 diabetes
In prediabetes — which can lead to type 2 diabetes — and in type 2 diabetes, your cells become resistant to the action of insulin, and your pancreas is unable to make enough insulin to overcome this resistance. Instead of moving into your cells, sugar builds up in your bloodstream. Exactly why this happens is uncertain, although excess fat — especially abdominal fat — and inactivity seem to be important factors.
Causes of gestational diabetes
During pregnancy, the placenta produces hormones to sustain your pregnancy. These hormones make your cells more resistant to insulin. As your placenta grows larger in the second and third trimesters, it secretes more of these hormones — making it even harder for insulin to do its job.
Normally, your pancreas responds by producing enough extra insulin to overcome this resistance. But sometimes your pancreas can’t keep up. When this happens, too little glucose gets into your cells and too much stays in your blood. This is gestational diabetes.
Risk factors for diabetes depend on the type of diabetes.
Risk factors for type 1 diabetes
Although the exact cause of type 1 diabetes is unknown, family history may play a role. Your risk of developing type 1 diabetes increases if you have a parent or sibling who has type 1 diabetes. Other factors have been proposed, as well, such as exposure to a viral illness.
Risk factors for prediabetes and type 2 diabetes
Researchers don’t fully understand why some people develop prediabetes and type 2 diabetes and others don’t. It’s clear that certain factors increase the risk, however, including:
- Weight. The more fatty tissue you have, the more resistant your cells become to insulin.
- Inactivity. The less active you are, the greater your risk. Physical activity helps you control your weight, uses up glucose as energy and makes your cells more sensitive to insulin.
- Family history. Your risk increases if a parent or sibling has type 2 diabetes.
- Race. Although it’s unclear why, people of certain races — including blacks, Hispanics, American Indians and Asian-Americans — are at higher risk.
- Age. Your risk increases as you get older, especially after age 45. Often, that’s because you tend to exercise less, lose muscle mass and gain weight as you age. But type 2 diabetes is increasing dramatically among children, adolescents and younger adults.
- Gestational diabetes. If you developed gestational diabetes when you were pregnant, your risk of developing prediabetes and type 2 diabetes later increases. If you gave birth to a baby weighing more than 9 pounds (4 kilograms), you’re also at risk of type 2 diabetes.
- Polycystic ovary syndrome. For women, having polycystic ovary syndrome — a common condition characterized by irregular menstrual periods, excess hair growth and obesity — increases the risk of diabetes.
Other conditions associated with diabetes include:
- High blood pressure
- High levels of low-density lipoprotein (LDL), or “bad,” cholesterol
- Low levels of high-density lipoprotein (HDL), or “good,” cholesterol
- High levels of triglycerides, another fat in the blood
When these conditions — high blood pressure, high blood sugar and abnormal blood fats — occur together with obesity, they are associated with resistance to insulin.
Risk factors for gestational diabetes
Any pregnant woman can develop gestational diabetes, but some women are at greater risk than are others. Risk factors for gestational diabetes include:
- Age. Women older than age 25 are at increased risk.
- Family or personal history. Your risk increases if you have prediabetes — a precursor to type 2 diabetes — or if a close family member, such as a parent or sibling, has type 2 diabetes. You’re also at greater risk if you had gestational diabetes during a previous pregnancy, if you delivered a very large baby or if you had an unexplained stillbirth.
- Weight. Being overweight before pregnancy increases your risk.
- Race. For reasons that aren’t clear, women who are black, Hispanic, American Indian or Asian are more likely to develop gestational diabetes.
Diabetes complications vary depending on the type of diabetes you have.
Complications of type 1 and type 2 diabetes
Short-term complications of type 1 and type 2 diabetes require immediate care. Left untreated, these conditions can cause seizures and a state of unconsciousness (coma).
- High blood sugar (hyperglycemia). Your blood sugar level can rise for many reasons, including eating too much, being sick or not taking enough glucose-lowering medication.
- Increased ketones in your urine (diabetic ketoacidosis). If your cells are starved for energy, your body may begin to break down fat. This produces potentially toxic acids known as ketones.
- Low blood sugar (hypoglycemia). If your blood sugar level drops below your target range, it’s known as low blood sugar. Your blood sugar level can drop for many reasons, including skipping a meal and getting more physical activity than normal. However, low blood sugar is most likely if you take glucose-lowering medications that promote the secretion of insulin or if you’re receiving insulin therapy.
Long-term complications of diabetes develop gradually. The earlier you develop diabetes — and the less controlled your blood sugar — the higher the risk of complications. Eventually, diabetes complications may be disabling or even life-threatening.
- Cardiovascular disease. Diabetes dramatically increases the risk of various cardiovascular problems, including coronary artery disease with chest pain (angina), heart attack, stroke and narrowing of arteries (atherosclerosis). If you have diabetes, you are twice as likely to have heart disease or stroke.
- Nerve damage (neuropathy). Excess sugar can injure the walls of the tiny blood vessels (capillaries) that nourish your nerves, especially in the legs. This can cause tingling, numbness, burning or pain that usually begins at the tips of the toes or fingers and over a period of months or years gradually spreads upward. Left untreated, you could lose all sense of feeling in the affected limbs. Damage to the nerves related to digestion can cause problems with nausea, vomiting, diarrhea or constipation. For men, it may lead to problems with erectile dysfunction.
- Kidney damage (nephropathy). The kidneys contain millions of tiny blood vessel clusters (glomeruli) that filter waste from your blood. Diabetes can damage this delicate filtering system. Severe damage can lead to kidney failure or irreversible end-stage kidney disease, requiring dialysis or a kidney transplant.
- Eye damage. Diabetes can damage the blood vessels of the retina (diabetic retinopathy), potentially leading to blindness.
- Foot damage. Nerve damage in the feet or poor blood flow to the feet increases the risk of various foot complications. Left untreated, cuts and blisters can become serious infections. Severe damage might require toe, foot or even leg amputation.
- Skin and mouth conditions. Diabetes may leave you more susceptible to skin problems, including bacterial infections, fungal infections and itching. Gum infections also may be a concern, especially if you have a history of poor dental hygiene.
- Bone and joint problems. Diabetes may put you at risk of bone and joint problems such as osteoporosis.
Complications of gestational diabetes
Most women who have gestational diabetes deliver healthy babies. However, untreated or uncontrolled blood sugar levels can cause problems for you and your baby.
Complications in your baby can occur as a result of gestational diabetes:
- Excess growth. Extra glucose can cross the placenta, which triggers your baby’s pancreas to make extra insulin. This can cause your baby to grow too large (macrosomia). Very large babies are more likely to become wedged in the birth canal, sustain birth injuries or require a C-section birth.
- Low blood sugar. Sometimes babies of mothers with gestational diabetes develop low blood sugar (hypoglycemia) shortly after birth because their own insulin production is high. Prompt feedings and sometimes an intravenous glucose solution can return the baby’s blood sugar level to normal.
- Respiratory distress syndrome. If your baby is delivered early, respiratory distress syndrome — a condition that makes breathing difficult — is possible. Babies who have respiratory distress syndrome may need help breathing until their lungs become stronger.
- Jaundice. This yellowish discoloration of the skin and the whites of the eyes may occur if a baby’s liver isn’t mature enough to break down a substance called bilirubin, which normally forms when the body recycles old or damaged red blood cells. Although jaundice usually isn’t a cause for concern, careful monitoring is important.
- Type 2 diabetes later in life. Babies of mothers who have gestational diabetes have a higher risk of developing obesity and type 2 diabetes later in life.
- Death. Rarely, untreated gestational diabetes results in a baby’s death either before or shortly after birth.
Complications in you can also occur as a result of gestational diabetes:
- Preeclampsia. This condition is characterized by high blood pressure and excess protein in the urine. Left untreated, preeclampsia can lead to serious or even life-threatening complications for both mother and baby.
- Subsequent gestational diabetes. Once you’ve had gestational diabetes in one pregnancy, you’re more likely to have it again with the next pregnancy. You’re also more likely to develop diabetes — typically type 2 diabetes — as you get older.
Complications of prediabetes
Prediabetes may develop into type 2 diabetes.
Preparing for your appointment
You’re likely to start by first seeing your family doctor or a general practitioner. However, in some cases when you call to set up an appointment, you may be referred immediately to an endocrinologist, who specializes in diabetes, among other disorders.
Because appointments can be brief, and because there’s often a lot of ground to cover, it’s a good idea to be well prepared for your appointment. Here’s some information to help you get ready for your appointment, and what to expect from your doctor.
What you can do
- Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there’s anything you need to do in advance. This might include restricting your diet, such as for a fasting blood sugar test.
- Write down any symptoms you’re experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
- Write down key personal information, including any major stresses or recent life changes. If you’re monitoring your glucose values at home, bring a record of the glucose results, detailing the dates and times of testing.
- Make a list of all medications, as well as any vitamins or supplements, that you’re taking.
- Record your family medical history. In particular, note any relatives who have had diabetes, heart attacks or strokes.
- Take a family member or friend along, if possible. Sometimes it can be difficult to soak up all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
- Write down questions to ask your doctor. Be clear about aspects of your diabetes management that you need clarification on.
- Be aware if you need any prescription refills. Your doctor can renew your prescriptions while you’re there.
Your time with your doctor is limited, so preparing a list of questions will help you make the most of your time together. List your questions from most important to least important in case time runs out. For diabetes, some basic questions to ask your doctor include:
- Are the symptoms I’m experiencing now related to my diabetes or another condition?
- What kinds of tests do I need to best manage my diabetes?
- What else can I do to protect my health?
- What are other options to manage my diabetes?
- I have these other health conditions. How can I best manage them together?
- Are there any restrictions that I need to follow?
- Should I see another specialist?
- Is there a generic alternative to the medicine you’re prescribing me?
- Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?
In addition to the questions that you’ve prepared to ask your doctor, don’t hesitate to ask questions during your appointment at any time that you don’t understand something.
What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:
- When did you first begin experiencing symptoms that concerned you about the possibility that you have diabetes?
- Have your symptoms been continuous, or occasional?
- How severe are your symptoms?
- Is there a family history of preeclampsia or diabetes?
Tests and diagnosis
Tests for type 1 and type 2 diabetes
In June 2009, an international committee composed of experts from the American Diabetes Association, the European Association for the Study of Diabetes and the International Diabetes Federation recommended that type 1 and type 2 diabetes testing include the:
- Glycated hemoglobin (A1C) test. This blood test indicates your average blood sugar level for the past two to three months. It works by measuring the percentage of blood sugar attached to hemoglobin, the oxygen-carrying protein in red blood cells. The higher your blood sugar levels, the more hemoglobin you’ll have with sugar attached. An A1C level of 6.5 percent or higher on two separate tests indicates you have diabetes.
If the A1C test isn’t available, or if you have certain conditions that can make the A1C test inaccurate — such as if you’re pregnant or have an uncommon form of hemoglobin (known as a hemoglobin variant) — your doctor may use the following tests to diagnose diabetes:
- Random blood sugar test. A blood sample will be taken at a random time. Regardless of when you last ate, a random blood sugar level of 200 milligrams per deciliter (mg/dL) — 11.1 millimoles per liter (mmol/L) — or higher suggests diabetes.
- Fasting blood sugar test. A blood sample will be taken after an overnight fast. A fasting blood sugar level between 70 and 99 mg/dL (3.9 and 5.5 mmol/L) is normal. If it’s 126 mg/dL (7 mmol/L) or higher on two separate tests, you’ll be diagnosed with diabetes.
Tests for gestational diabetes
Screening for gestational diabetes is a routine part of prenatal care. Most health care providers recommend a blood test known as a glucose challenge test between the 24th and 28th weeks of pregnancy — or earlier if you’re at particularly high risk of gestational diabetes.
You’ll begin the glucose challenge test by drinking a syrupy glucose solution. One hour later, you’ll have a blood test to measure your blood sugar level. A blood sugar level above 140 mg/dL (7.8 mmol/L) usually indicates gestational diabetes, but you’ll likely need a second test to confirm the diagnosis.
For the follow-up test, you’ll be asked to fast overnight. Then you’ll drink another sweet solution — this one containing a higher concentration of glucose — and your blood sugar level will be checked every hour for a period of three hours.
Tests for prediabetes
The American College of Endocrinology suggests prediabetes testing for anyone who has a family history of type 2 diabetes and for those who are obese or have metabolic syndrome. Women with a personal history of gestational diabetes also should be tested.
The primary test to screen for prediabetes is the:
- Glycated hemoglobin (A1C) test. This blood test indicates your average blood sugar level for the past two to three months. It works by measuring the percentage of blood sugar attached to hemoglobin, the oxygen-carrying protein in red blood cells. The higher your blood sugar levels, the more hemoglobin you’ll have with sugar attached. An A1C level between 6 and 6.5 percent suggests you have prediabetes.
If the A1C test isn’t available, or if you have certain conditions that can make the A1C test inaccurate — such as if you’re pregnant or have an uncommon form of hemoglobin (known as a hemoglobin variant) — your doctor may use the following tests to diagnose diabetes:
- Fasting blood sugar test. A blood sample will be taken after an overnight fast. A blood sugar level from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) is considered prediabetes.
- Oral glucose tolerance test. A blood sample will be taken after you fast for at least eight hours or overnight. Then you’ll drink a sugary solution, and your blood sugar level will be measured again after two hours. A blood sugar level less than 140 mg/dL (7.8 mmol/L) is normal. A blood sugar level from 140 to 199 mg/dL (7.8 to 11 mmol/L) is considered prediabetes. This is sometimes referred to as impaired glucose tolerance (IGT). A blood sugar level of 200 mg/dL (11.1 mmol/L) or higher may indicate diabetes.
Treatments and drugs
Depending on what type of diabetes you have, blood sugar monitoring, insulin and oral medications may play a role in your treatment. A pancreas transplant may be an option for select people.
But no matter what type of diabetes you have, maintaining a healthy diet, exercising and keeping a healthy weight are all keys to managing your diabetes.
Treatments for all types of diabetes
An important part of managing all types of diabetes includes maintaining a healthy weight through a healthy diet and exercise plan:
- Healthy eating. Contrary to popular perception, there’s no diabetes diet. You won’t be restricted to boring, bland foods. Instead, you’ll need plenty of fruits, vegetables and whole grains — foods that are high in nutrition and low in fat and calories — and fewer animal products and sweets. In fact, it’s the best eating plan for the entire family. Even sugary foods are OK once in a while, as long as they’re included in your meal plan.
Yet understanding what and how much to eat can be a challenge. A registered dietitian can help you create a meal plan that fits your health goals, food preferences and lifestyle. Once you’ve covered the basics, remember the importance of consistency. To keep your blood sugar on an even keel, try to eat the same amount of food with the same proportion of carbohydrates, proteins and fats at the same time every day.
- Physical activity. Everyone needs regular aerobic exercise, and people who have diabetes are no exception. Exercise lowers your blood sugar level by transporting sugar to your cells, where it’s used for energy. Exercise also increases your sensitivity to insulin, which means your body needs less insulin to transport sugar to your cells. Get your doctor’s OK to exercise. Then choose activities you enjoy, such as walking, swimming or biking. What’s most important is making physical activity part of your daily routine. Aim for at least 30 minutes or more of aerobic exercise most days of the week. If you haven’t been active for a while, start slowly and build up gradually.
Treatments for type 1 and type 2 diabetes
Treatment for type 1 and type 2 diabetes primarily involves monitoring of your blood sugar along with insulin, other diabetes medications or both.
- Monitoring your blood sugar. Depending on your treatment plan, you may check and record your blood sugar level several times a week to several times a day. Careful monitoring is the only way to make sure that your blood sugar level remains within your target range.
Even if you eat on a rigid schedule, the amount of sugar in your blood can change unpredictably. With help from your diabetes treatment team, you’ll learn how your blood sugar level changes in response to things like food, physical activity, medications, illness, alcohol, stress and — for women — fluctuations in hormone levels.
In addition to daily blood sugar monitoring, your doctor may recommend regular A1C testing to measure your average blood sugar level for the past two to three months. Compared with repeated daily blood sugar tests, A1C testing better indicates how well your diabetes treatment plan is working overall. An elevated A1C level may signal the need for a change in your insulin regimen or meal plan. Your target A1C goal may vary depending on your age and various other factors. However, for most people, the American Diabetes Association recommends an A1C of below 7 percent. Ask your doctor what your A1C target is.
- Insulin. Anyone who has type 1 diabetes needs insulin therapy to survive. Some people with type 2 diabetes need insulin, as well. Because stomach enzymes interfere with insulin taken by mouth, oral insulin isn’t an option for lowering blood sugar. Often, insulin is injected using a fine needle and syringe or an insulin pen — a device that looks like an ink pen, except the cartridge is filled with insulin.
An insulin pump also may be an option. The pump is a device about the size of a cell phone worn on the outside of your body. A tube connects the reservoir of insulin to a catheter that’s inserted under the skin of your abdomen. The pump is programmed to dispense specific amounts of insulin automatically. It can be adjusted to deliver more or less insulin depending on meals, activity level and blood sugar level.
Many types of insulin are available, including rapid-acting insulin, long-acting insulin and intermediate options. Depending on your needs, your doctor may prescribe a mixture of insulin types to use throughout the day and night.
- Oral or other medications. Sometimes other oral or injected medications are prescribed as well. Some diabetes medications stimulate your pancreas to produce and release more insulin. Others inhibit the production and release of glucose from your liver, which means you need less insulin to transport sugar into your cells. Still others block the action of stomach enzymes that break down carbohydrates or make your tissues more sensitive to insulin. Your doctor might prescribe low-dose aspirin therapy to help prevent cardiovascular disease.
- Transplantation. In some people who have type 1 diabetes, a pancreas transplant may be an option. Other types of transplants are being studied as well. With a successful pancreas transplant, you would no longer need insulin therapy. But pancreas transplants aren’t always successful — and the procedure poses serious risks. You’d need a lifetime of potent immune-suppressing drugs to prevent organ rejection. These drugs can have serious side effects, including a high risk of infection, organ injury and cancer. Because the side effects can be more dangerous than the diabetes, pancreas transplants are usually reserved for people whose diabetes can’t be controlled or those who have serious complications.
Treatment for gestational diabetes
Controlling your blood sugar level is essential to keeping your baby healthy and avoiding complications during delivery. In addition to maintaining a healthy diet and exercising, your treatment plan may include monitoring your blood sugar and, in some cases, using insulin.
Your health care provider will also monitor your blood sugar level during labor. If your blood sugar rises, your baby may release high levels of insulin — which can lead to low blood sugar right after birth.
Treatment for prediabetes
If you have prediabetes, healthy lifestyle choices can help you bring your blood sugar level back to normal or at least keep it from rising toward the levels seen in type 2 diabetes. Maintaining a healthy weight through exercise and healthy eating can help.
Sometimes medications — such as the oral diabetes drugs metformin (Glucophage) and acarbose (Precose) — also are an option if you’re at high risk of diabetes. This includes if your prediabetes is worsening or you have cardiovascular disease, fatty liver disease or polycystic ovary syndrome.
In other cases, medications to control cholesterol — statins, in particular — and high blood pressure medications are needed. Your doctor might prescribe low-dose aspirin therapy to help prevent cardiovascular disease. Healthy lifestyle choices remain key, however
Lifestyle and home remedies
Diabetes is a serious disease. Following your diabetes treatment plan takes round-the-clock commitment. But your efforts are worthwhile. Careful management of diabetes can reduce your risk of serious — even life-threatening — complications.
Lifestyle for all diabetes
No matter what type of diabetes you have:
- Make a commitment to managing your diabetes. Learn all you can about diabetes. Make healthy eating and physical activity part of your daily routine. Establish a relationship with a diabetes educator, and ask your diabetes treatment team for help when you need it.
- Take care of your teeth. Diabetes may leave you prone to gum infections. Brush and floss your teeth at least twice a day. And if you have type 1 or type 2 diabetes, schedule dental exams at least twice a year. Consult your dentist right away if your gums bleed or look red or swollen.
Lifestyle for type 1 and type 2 diabetes
In addition, if you have type 1 or type 2 diabetes:
- Identify yourself. Wear a tag or bracelet that says you have diabetes. Keep a glucagon kit nearby in case of a low blood sugar emergency — and make sure your friends and loved ones know how to use it.
- Schedule a yearly physical and regular eye exams. Your regular diabetes checkups aren’t meant to replace yearly physicals or routine eye exams. During the physical, your doctor will look for any diabetes-related complications, as well as screen for other medical problems. Your eye care specialist will check for signs of retinal damage, cataracts and glaucoma.
- Keep your immunizations up-to-date. High blood sugar can weaken your immune system. Get a flu shot every year, and get a tetanus booster shot every 10 years. Your doctor may recommend the pneumonia vaccine or other immunizations as well.
- Pay attention to your feet. Wash your feet daily in lukewarm water. Dry them gently, especially between the toes. Moisturize with lotion, but not between the toes. Check your feet every day for blisters, cuts, sores, redness or swelling. Consult your doctor if you have a sore or other foot problem that doesn’t start to heal within a few days.
- Keep your blood pressure and cholesterol under control. Eating healthy foods and exercising regularly can go a long way toward controlling high blood pressure and cholesterol. Medication may be needed, too.
- If you smoke or use other types of tobacco, ask your doctor to help you quit. Smoking increases your risk of various diabetes complications, including heart attack, stroke, nerve damage and kidney disease. In fact, smokers who have diabetes are three times more likely to die of cardiovascular disease than are nonsmokers who have diabetes, according to the American Diabetes Association. Talk to your doctor about ways to stop smoking or to stop using other types of tobacco.
- If you drink alcohol, do so responsibly. Alcohol can cause either high or low blood sugar, depending on how much you drink and if you eat at the same time. If you choose to drink, do so only in moderation and always with a meal. Remember to include the calories from any alcohol you drink in your daily calorie count.
- Take stress seriously. If you’re stressed, it’s easy to abandon your usual diabetes management routine. The hormones your body may produce in response to prolonged stress may prevent insulin from working properly, which only makes matters worse. To take control, set limits. Prioritize your tasks. Learn relaxation techniques. Get plenty of sleep.
Above all, stay positive. The good habits you adopt today can help you enjoy an active, healthy life with diabetes.
Type 1 diabetes can’t be prevented. However, the same healthy lifestyle choices that help treat prediabetes, type 2 diabetes and gestational diabetes can help prevent them.
- Eat healthy foods. Choose foods low in fat and calories. Focus on fruits, vegetables and whole grains. Strive for variety to prevent boredom.
- Get more physical activity. Aim for 30 minutes of moderate physical activity a day. Take a brisk daily walk. Ride your bike. Swim laps. If you can’t fit in a long workout, break it up into smaller sessions spread throughout the day.
- Lose excess pounds. If you’re overweight, losing even 5 percent of your body weight — for example, 10 pounds (4.5 kilograms) if you weigh 200 pounds (90.7 kilograms) — can reduce the risk of diabetes. To keep your weight in a healthy range, focus on permanent changes to your eating and exercise habits. Motivate yourself by remembering the benefits of losing weight, such as a healthier heart, more energy and improved self-esteem.
Sometimes medication is an option as well. Oral diabetes drugs such as metformin (Glucophage) and rosiglitazone (Avandia) may reduce the risk of type 2 diabetes — but healthy lifestyle choices remain essential.Remember this article is for your information only. Dr. Ben-Zur recommends consulting your physician prior to making any changes in your diet, exercise or medical program.
Diabetes is a chronic (lifelong) disease marked by high levels of sugar in the blood.Causes
Insulin is a hormone produced by the pancreas to control blood sugar. Diabetes can be caused by too little insulin, resistance to insulin, or both.
To understand diabetes, it is important to first understand the normal process by which food is broken down and used by the body for energy. Several things happen when food is digested:
- A sugar called glucose enters the bloodstream. Glucose is a source of fuel for the body.
- An organ called the pancreas makes insulin. The role of insulin is to move glucose from the bloodstream into muscle, fat, and liver cells, where it can be used as fuel.
People with diabetes have high blood sugar. This is because:
- Their pancreas does not make enough insulin
- Their muscle, fat, and liver cells do not respond to insulin normally
- Both of the above
There are three major types of diabetes:
- Type 1 diabetes is usually diagnosed in childhood. Many patients are diagnosed when they are older than age 20. In this disease, the body makes little or no insulin. Daily injections of insulin are needed. The exact cause is unknown. Genetics, viruses, and autoimmune problems may play a role.
- Type 2 diabetes is far more common than type 1. It makes up most of diabetes cases. It usually occurs in adulthood, but young people are increasingly being diagnosed with this disease. The pancreas does not make enough insulin to keep blood glucose levels normal, often because the body does not respond well to insulin. Many people with type 2 diabetes do not know they have it, although it is a serious condition. Type 2 diabetes is becoming more common due to increasing obesity and failure to exercise.
- Gestational diabetes is high blood glucose that develops at any time during pregnancy in a woman who does not have diabetes. Women who have gestational diabetes are at high risk of type 2 diabetes and cardiovascular disease later in life.
Diabetes affects more than 20 million Americans. Over 40 million Americans have prediabetes (early type 2 diabetes).
There are many risk factors for type 2 diabetes, including:
- Age over 45 years
- A parent, brother, or sister with diabetes
- Gestational diabetes or delivering a baby weighing more than 9 pounds
- Heart disease
- High blood cholesterol level
- Not getting enough exercise
- Polycystic ovary disease (in women)
- Previous impaired glucose tolerance
- Some ethnic groups (particularly African Americans, Native Americans, Asians, Pacific Islanders, and Hispanic Americans)
High blood levels of glucose can cause several problems, including:
- Blurry vision
- Excessive thirst
- Frequent urination
- Weight loss
However, because type 2 diabetes develops slowly, some people with high blood sugar experience no symptoms at all.
Symptoms of type 1 diabetes:
- Increased thirst
- Increased urination
- Weight loss in spite of increased appetite
Patients with type 1 diabetes usually develop symptoms over a short period of time. The condition is often diagnosed in an emergency setting.
Symptoms of type 2 diabetes:
- Blurred vision
- Increased appetite
- Increased thirst
- Increased urination
A urine analysis may be used to look for glucose and ketones from the breakdown of fat. However, a urine test alone does not diagnose diabetes.
The following blood tests are used to diagnose diabetes:
- Fasting blood glucose level — diabetes is diagnosed if higher than 126 mg/dL on two occasions. Levels between 100 and 126 mg/dL are referred to as impaired fasting glucose or prediabetes. These levels are considered to be risk factors for type 2 diabetes and its complications.
- Oral glucose tolerance test — diabetes is diagnosed if glucose level is higher than 200 mg/dL after 2 hours. (This test is used more for type 2 diabetes.)
- Random (non-fasting) blood glucose level — diabetes is suspected if higher than 200 mg/dL and accompanied by the classic diabetes symptoms of increased thirst, urination, and fatigue. (This test must be confirmed with a fasting blood glucose test.)
Persons with diabetes need to have their hemoglobin A1c (HbA1c) level checked every 3 – 6 months. The HbA1c is a measure of average blood glucose during the previous 2 – 3 months. It is a very helpful way to determine how well treatment is working.Treatment
The immediate goals are to treat diabetic ketoacidosis and high blood glucose levels. Because type 1 diabetes can start suddenly and have severe symptoms, people who are newly diagnosed may need to go to the hospital.
The long-term goals of treatment are to:
- Prolong life
- Reduce symptoms
- Prevent diabetes-related complications such as blindness, heart disease, kidney failure, and amputation of limbs
These goals are accomplished through:
- Blood pressure and cholesterol control
- Careful self testing of blood glucose levels
- Foot care
- Meal planning and weight control
- Medication or insulin use
There is no cure for diabetes. Treatment involves medicines, diet, and exercise to control blood sugar and prevent symptoms.
If you have diabetes, your doctor may tell you to regularly check your blood sugar levels at home. There are a number of devices available, and they use only a drop of blood. Self-monitoring tells you how well diet, medication, and exercise are working together to control your diabetes. It can help your doctor prevent complications.
The American Diabetes Association recommends keeping blood sugar levels in the range of:
- 80 – 120 mg/dL before meals
- 100 – 140 mg/dL at bedtime
Your doctor may adjust this depending on your circumstances.
WHAT TO EAT
You should work closely with your health care provider to learn how much fat, protein, and carbohydrates you need in your diet. A registered dietician can help you plan your dietary needs.
People with type 1 diabetes should eat at about the same times each day and try to be consistent with the types of food they choose. This helps to prevent blood sugar from becoming extremely high or low.
People with type 2 diabetes should follow a well-balanced and low-fat diet.
HOW TO TAKE MEDICATION
Medications to treat diabetes include insulin and glucose-lowering pills called oral hypoglycemic drugs.
People with type 1 diabetes cannot make their own insulin. They need daily insulin injections. Insulin does not come in pill form. Injections are generally needed one to four times per day. Some people use an insulin pump. It is worn at all times and delivers a steady flow of insulin throughout the day. Other people may use inhaled insulin.
Unlike type 1 diabetes, type 2 diabetes may respond to treatment with exercise, diet, and medicines taken by mouth. There are several types of medicines used to lower blood glucose in type 2 diabetes.
Medications may be switched to insulin during pregnancy and while breastfeeding.
Gestational diabetes may be treated with exercise and changes in diet.
Regular exercise is especially important for people with diabetes. It helps with blood sugar control, weight loss, and high blood pressure. People with diabetes who exercise are less likely to experience a heart attack or stroke than those who do not exercise regularly.
Here are some exercise considerations:
- Always check with your doctor before starting a new exercise program.
- Ask your doctor or nurse if you have the right footwear.
- Choose an enjoyable physical activity that is appropriate for your current fitness level.
- Exercise every day, and at the same time of day, if possible.
- Monitor blood glucose levels before and after exercise.
- Carry food that contains a fast-acting carbohydrate in case you become hypoglycemic during or after exercise.
- Carry a diabetes identification card and a cell phone in case of emergency.
- Drink extra fluids that do not contain sugar before, during, and after exercise.
You may need to change your diet or medication dose if you change your exercise intensity or duration to keep blood sugar levels from going too high or low.
People with diabetes are more likely to have foot problems. Diabetes can damage blood vessels and nerves and decrease the body’s ability to fight infection. You may not notice a foot injury until an infection develops. Death of skin and other tissue can occur.
If left untreated, the affected foot may need to be amputated. Diabetes is the most common condition leading to amputations.
To prevent injury to the feet, check and care for your feet every day.
With good blood glucose and blood pressure control, many of the complications of diabetes can be prevented.
Studies have shown that strict control of blood sugar, cholesterol, and blood pressure levels in persons with diabetes helps reduce the risk of kidney disease, eye disease, nervous system disease, heart attack, and stroke.
Emergency complications include:
- Diabetic hyperglycemic hyperosmolar coma
- Diabetic ketoacidosis
Long-term complications include:
- Coronary artery disease
- Diabetic nephropathy
- Diabetic neuropathy
- Diabetic retinopathy
- Erection problems
- Infections of the skin, female urinary tract, and urinary tract
- Peripheral vascular disease
Go to the emergency room or call the local emergency number (such as 911) if you have symptoms of ketoacidosis:
- Abdominal pain
- Deep and rapid breathing
- Increased thirst and urination
- Loss of consciousness
- Sweet-smelling breath
Go to the emergency room or call the local emergency number (such as 911) if you have symptoms of extremely low blood sugar (hypoglycemic coma or severe insulin reaction):
- Convulsions or unconsciousness
- Double vision
- Lack of coordination
Maintaining an ideal body weight and an active lifestyle may prevent type 2 diabetes.
Currently there is no way to prevent type 1 diabetes.
There is no effective screening test for type 1 diabetes in people who don’t have symptoms.
Screening for type 2 diabetes and people with no symptoms is recommended for:
- Overweight children who have other risk factors for diabetes starting at age 10 and repeating every 2 years
- Overweight adults (BMI greater than 25) who have other risk factors
- Adults over 45, repeated every 3 years
To prevent complications of diabetes, visit your health care provider or diabetes educator at least four times a year. Talk about any problems you are having.
Regularly have the following tests:
- Have your blood pressure checked every year (blood pressure goals should be 130/80 mm/Hg or lower).
- Have your glycosylated hemoglobin (HbA1c) checked every 6 months if your diabetes is well controlled, otherwise every 3 months.
- Have your cholesterol and triglyceride levels checked yearly (aim for LDL levels below 100 mg/dL).
- Get yearly tests to make sure your kidneys are working well (microalbuminuria and serum creatinine).
- Visit your ophthalmologist (preferably one who specializes in diabetic retinopathy) at least once a year, or more often if you have signs of diabetic retinopathy.
- See the dentist every 6 months for a thorough dental cleaning and exam. Make sure your dentist and hygienist know that you have diabetes.
- Make sure your health care provider inspects your feet at each visit.
Stay up-to-date with all of your vaccinations and get a flu shot every year in the fall.
This article is for your information only. Always consult your physician prior to making any changes in your diet, exercise or medical program.
Mosca L, Banka CL, Benjamin EJ, et al. Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women: 2007 Update. Circulation. 2007; Published online before print February 19, 2007.
Smith SC Jr, Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute. Circulation. 2006 May 16;113(19):2363-72. Erratum in: Circulation. 2006 Jun 6;113(22):e847.
Morrow DA, Gersh BJ. Chronic coronary artery disease. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia, Pa: Saunders Elsevier;2007: chap 54.
Boden WE, O’rourke RA, Teo KK, et al. Optimal Medical Therapy with or without PCI for Stable Coronary Disease. N Engl J Med. 2007 Mar 26; [Epub ahead of print].
U.S. Preventive Services Task Force. Aspirin for the prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement.Ann Intern Med. 2009;150:396-404.
Diabetes mellitus is a chronic disease caused by the inability of the pancreas to produce insulin or to use the insulin produced in the proper way. Diabetes is the 7th leading cause of death among Americans; over 15 million Americans suffer from one form or another of this disease.Description of Diabetes
After a meal, a portion of the food a person eats is broken down into sugar (glucose). The sugar then passes into the bloodstream and to the body’s cells via a hormone (called insulin) that is produced by the pancreas.
Normally, the pancreas produces the right amount of insulin to accommodate the quantity of sugar. However, if the person has diabetes, either the pancreas produces little or no insulin or the cells do not respond normally to the insulin. Sugar builds up in the blood, overflows into the urine and then passes from the body unused. Over time, high blood sugar levels can damage:
- eyes – leading to diabetic retinopathy and possible blindness
- blood vessels – increasing risk of heart attack, stroke and peripheral artery obstruction
- nerves – leading to diabetic neuropathy, foot sores and possible amputation, possible paralysis of the stomach, chronic diarrhea
- kidneys – leading to kidney failure
Diabetes has also been linked to impotence and digestive problems. It is important to note that controlling blood pressure and blood glucose levels, plus regular screenings and check-ups, can help reduce risks of these complications.
There are two main types of diabetes, Type I and Type II:
Type I diabetes or insulin-dependent diabetes (formerly called juvenile-onset diabetes, because it tends to affect persons before the age of 20) affects about 10 percent of people with diabetes. With this type of diabetes, the pancreas makes almost no insulin.
Type II diabetes or non-insulin-dependent diabetes. This was previously called “adult-onset diabetes” because in the past it was usually discovered after age 40. However, with increasing levels of obesity and sedentary lifestyle, this disease is now being found more and more in adolescents – and sometimes even in children under 10 – and the term “adult onset” is no longer used.
Type II diabetes comprises about 90 percent of all cases of diabetes. With this type of diabetes, either the pancreas produces a reduced amount of insulin, the cells do not respond to the insulin, or both.
There are three less common types of diabetes called gestational diabetes, secondary diabetes and impaired glucose tolerance (IGT):
Gestational diabetes occurs during pregnancy and causes a higher than normal glucose level reading.
Secondary diabetes is caused by damage to the pancreas from chemicals, certain medications, diseases of the pancreas (such as cancer) or other glands.
Impaired glucose tolerance (IGT) is a condition in which the person’s glucose levels are higher than normal.
The cause of Type I diabetes is genetically based, coupled with an abnormal immune response.
The cause of Type II diabetes is unknown. Medical experts believe that Type II diabetes has a genetic component, but that other factors also put people at risk for the disease. These factors include:
- sedentary lifestyle
- obesity (weighing 20 percent above a healthy body weight)
- advanced age
- unhealthy diet
- family history of diabetes
- improper functioning of the pancreas
- minority race (higher risk in Black, Hispanic, American Indian, westernized Asian and native Hawaiian populations)
- medication (cortisone and some high blood pressure drugs)
- women having given birth to a baby weighing more than 9 lbs.
- previously diagnosed gestational diabetes
- previously diagnosed IGT
Usually, the symptoms of Type I diabetes are obvious. That is not true for Type II. Many people with Type II do not discover they have diabetes until they are treated for a complication such as heart disease, blood vessel disease (atherosclerosis), stroke, blindness, skin ulcers, kidney problems, nerve trouble or impotence.
The warning signs and symptoms for both types are:
Type I: Frequent urination, increased thirst, extreme hunger, unexplained weight loss, extreme fatigue, blurred vision, irritability, nausea and vomiting.
Type II: Any Type I symptom, plus: unexplained weight gain, pain, cramping, tingling or numbness in your feet, unusual drowsiness, frequent vaginal or skin infections, dry, itchy skin and slow healing sores.
Note: If a person is experiencing these symptoms, they should see a doctor immediately.
Besides a complete history and physical examination, the doctors will perform a battery of laboratory tests. There are numerous tests available to diagnose diabetes, such as a urine test, blood test, glucose-tolerance test, fasting blood sugar and the glycohemoglobin (HbA1c) test.
A urine sample will be tested for glucose and ketones (acids that collect in the blood and urine when the body uses fat instead of glucose for energy).
A blood test is used to measure the amount of glucose in the bloodstream.
A glucose-tolerance test checks the body’s ability to process glucose. During this test, sugar levels in the blood and urine are monitored for three hours after drinking a large dose of sugar solution.
The fasting blood sugar test involves fasting overnight and blood being drawn the next morning.
The glycohemoglobin test reflects an average of all blood sugar levels for the preceding two months.
A landmark study, the 10-year, multi-center Diabetes Control and Complications Trial (DCCT), has now shown that intensifying diabetes management with stricter control of blood sugar levels can reduce long-term complications.
The results of DCCT are extraordinary in that they prove that tight control of glucose levels can in fact dramatically slow the onset and progression of diabetic complications in both Type I and Type II diabetes. Additionally, researchers have found strict attention to diet and exercise also helps in the management of diabetes.
Management of Type I Diabetes
Virtually everyone with Type I diabetes (and more than one in three people with Type II) must inject insulin to make up for their deficiency. Until recently, insulin came only from the pancreases of cows and pigs (with pork insulin more closely duplicating human insulin). While beef, pork and beef/pork combinations are still widely used, there are now two types of “human” insulin available: semisynthetic (made by converting pork insulin to a form identical to human) and recombinant (made by using genetic engineering). All insulin helps glucose levels remain near normal (about 70 to 120 mg/dl).
Different types of insulin work for different periods of time. The numbers shown below are only averages. The onset (how long it takes to reach the bloodstream to begin lowering the blood sugar), peaking (how long it takes to reach maximum strength) and duration (how long it continues to lower the blood sugar) of insulin activity can vary from person to person and even from day to day in the same person.
Rapid or Regular Activity: Onset is within half an hour and activity peaks during a 2 to 5 hour period. It remains in the bloodstream for about 8 to 16 hours. These fast-acting, short-lasting insulins are useful in special cases: accidents, minor surgery or illnesses, which cause the diabetes to go out of control or whenever insulin requirements change rapidly for any reason. These are also being used more and more in combination with a long-acting insulin or alone (prior to meals and at bedtime).
Semilente: A special type of short-acting insulin that takes 1 to 2 hours for onset, peaks 3 to 8 hours after injection and lasts 10 to 16 hours.
Intermediate-Acting: Reaching the bloodstream 90 minutes after injection, intermediate-acting insulin peaks 4 to 12 hours later and lasts in the blood for about 24 hours. There are two varieties of this type of insulin: Lente (called L) and NPH (called N).
Long-Acting: These insulins, which take 4 to 6 hours for onset, are at maximum strength 14 to 24 hours after injection, lasting 36 hours in the bloodstream. Long-acting insulin is referred to as U (for Ultralente).
Please be aware of the following problems that exist with insulin intake:
- Hypoglycemia (low blood sugar) is sometimes called an insulin reaction or insulin shock. It can occur suddenly in people using insulin if too little food is eaten, if a meal is delayed or in the case of extreme exercise. Symptoms include feeling cold, clammy, nervous, shaky, weak or hungry, and some people become pale, have headaches or act strangely.
- Hyperglycemia (high blood sugar) occurs when too much food is eaten or not enough insulin is taken. The warning signs are large amounts of sugar in the urine and blood, frequent urination, great thirst and nausea.
- Ketoacidosis (in its most severe form – diabetic coma) develops when insulin and blood sugar are so out of balance that ketones accumulate in the blood. Symptoms include high blood sugar or ketones in the urine, dry mouth, great thirst, loss of appetite, excessive urination, dry and flushed skin, labored breathing, fruity-smelling breath and possible vomiting, abdominal pain and unconsciousness.
In addition to daily injections of insulin, regular physical activity and a controlled diet are essential. The American Diabetes Association (ADA) recommends the following daily dietary guidelines:
- Up to 70 percent of all calories should be obtained from carbohydrates and unsaturated fats. These carbohydrates should be mainly complex carbohydrates and naturally occurring sugars (simular to those in milk and fruits). Examples of unsaturated fats are vegetable oils and margarine.
- Between 10 and 20 percent of calories should be obtained from protein.
- Less than 10 percent of all calories should be obtained from fat. Saturated fats are found in animal products and in some vegetable oils (such as coconut, palm, and palm-kernel oils).
- Eat 30 to 35 grams of fiber.
- Eat no more than 300 mg of cholesterol.
For Type I diabetes, the meal plan should be tailored to the person’s individual needs and is likely to include three meals and two or three snacks a day. A person with diabetes must eat these meals and snacks at set times each day to properly balance insulin.
Management of Type II Diabetes
The ADA recommends diet (see ADA guidelines stated above) and regular physical activity as the first line of treatment for Type II diabetes. If normal glycemic levels are not achieved within three (3) months, drug treatment is recommended.
Currently there are four (4) classes of prescription drugs available for the treatment of Type II diabetes:
- Sulfonylureas (Diabinese, Dymelor, PresTab, Orinase, Tolinase, Micronase, DiaBeta, Glynase, Glucotrol, Glucotrol XL and Amaryl), which stimulate the pancreas to release more insulin.
- Biguanides (Glucophage and Metformin), which keep the liver from releasing too much glucose.
- Alpha-glucoside inhibitors (Precose), which slow the digestion of some carbohydrates.
- Thiazolidinediones, which control glucose levels by making muscles more sensitive to insulin and reduce the amount of glucose that the liver produces.
Clinical trials suggest that oral antidiabetic agents – particularly the new noninsulin secretagogues (including Troglitazone and Metformin, which act on the liver and skeletal muscle) – may be useful in delaying or preventing development of Type II diabetes. Both agents, acting primarily by different mechanisms of action, also have demonstrated potential beneficial effects on serum lipid profiles.
Although these oral medications work in different ways, they can be combined to work more effectively to manage Type II diabetes. When these combinations of oral treatments are no longer effective (for about 60 percent of people with Type II diabetes), the doctor will start a regimen of insulin alone or in combination with an oral medication.
There is no foolproof way to prevent diabetes, but steps can be taken to improve the chances of avoiding it:
- Exercise. Studies of both men and women have shown that vigorous exercise, even if done only once a week, has a protective effect against diabetes. Exercise not only promotes weight loss but lowers blood sugar as well.
- Lose weight. There is evidence that both men and women who gain weight in adulthood increase their risk of diabetes. A study conducted at Harvard showed that adult women who gained 11 to 17 pounds since the age of 18 doubled their risk of diabetes; those who gained between 18 and 24 pounds almost tripled their risk. Fact: 90 percent of diabetics are overweight.
- Diet. The use of a diet low in calories and in saturated fat is an ideal strategy for preventing Type II diabetes. (See the ADA guidelines stated in the TREATMENT section).
- Stop smoking. Smoking is especially dangerous for people with diabetes who are at risk for heart and blood vessel diseases.
- Use alcohol in moderation. Moderation for men means no more than two drinks a day; for women, one drink is the limit. Choose drinks that are low in alcohol and sugar such as dry wines and light beers. If you use mixers, try to select one that is sugar free, such as diet drinks, club soda, seltzer or water. If you take diabetic pills or insulin, alcohol can drop blood glucose levels too far. Have the drink with a meal or snack.
How often does the blood sugar need to be checked?
What are the best monitoring techniques for this?
How do you measure glucose levels?
What type of insulin or insulins will you be prescribing?
Who would help in learning about and giving injections?
Do you have a dietitian you could recommend?
How much can exercise and diet control the diabetes?
Is there information available or assistance on planning a regular exercise program?
What is important for family members to learn also?
How do you recognize a diabetic reaction and when should a doctor be notified?
What are the signs and symptoms of insulin deficit and excess?
What measure should be taken for either condition?
Are there any other signs or symptoms that need to be reported to the doctor?
When traveling, is an adjustment in the insulin dose needed?
Can OTC medications be taken?
If so, what is the medication and what are the side effects?
(Women) Should there be a concern about taking menopause-based medicine with insulin?
** Remember this article is for your information only. Dr. Ben-Zur recommends consulting your physician prior to making any changes in your diet, exercise or medical program.
© 2009 nhlbi.nih.gov/health/dci
Diabetes mellitus (DM) is a set of related diseases in which the body cannot regulate the amount of sugar (specifically, glucose) in the blood.
Glucose in the blood gives you energy to perform daily activities, walk briskly, run for a bus, ride your bike, take an aerobic exercise class, and perform your day-to-day chores.
- From the foods you eat, glucose in the blood is produced by the liver (an organ on the right side of the abdomen near your stomach).
- In a healthy person, the blood glucose level is regulated by several hormones, including insulin. Insulin is produced by the pancreas, a small organ between the stomach and liver. The pancreas secretes other important enzymes that help to digest food.
- Insulin allows glucose to move from the blood into liver, muscle, and fat cells, where it is used for fuel.
- People with diabetes either do not produce enough insulin (type 1 diabetes) or cannot use insulin properly (type 2 diabetes), or both (which occurs with several forms of diabetes).
- In diabetes, glucose in the blood cannot move into cells, so it stays in the blood. This not only harms the cells that need the glucose for fuel, but also harms certain organs and tissues exposed to the high glucose levels.
Type 1 diabetes: The body stops producing insulin or produces too little insulin to regulate blood glucose level.
- Type 1 diabetes comprises about 10% of total cases of diabetes in the United States.
- Type 1 diabetes is typically recognized in childhood or adolescence. It used to be known as juvenile-onset diabetes or insulin-dependent diabetes mellitus.
- Type 1 diabetes can occur in an older individual due to destruction of pancreas by alcohol, disease, or removal by surgery. It also results from progressive failure of the pancreatic beta cells, which produce insulin.
- People with type 1 diabetes require daily insulin treatment to sustain life.
Type 2 diabetes: The pancreas secretes insulin, but the body is partially or completely unable to use the insulin. This is sometimes referred to as insulin resistance. The body tries to overcome this resistance by secreting more and more insulin. People with insulin resistance develop type 2 diabetes when they do not continue to secrete enough insulin to cope with the higher demands.
- At least 90% of patients with diabetes have type 2 diabetes.
- Type 2 diabetes is typically recognized in adulthood, usually after age 45 years. It used to be called adult-onset diabetes mellitus, or non-insulin-dependent diabetes mellitus. These names are no longer used because type 2 diabetes does occur in younger people, and some people with type 2 diabetes need to use insulin.
- Type 2 diabetes is usually controlled with diet, weight loss, exercise, and oral medications. More than half of all people with type 2 diabetes require insulin to control their blood sugar levels at some point in the course of their illness.
Gestational diabetes is a form of diabetes that occurs during the second half of pregnancy.
- Although gestational diabetes typically goes away after delivery of the baby. Women who have gestational diabetes are more likely than other women to develop type 2 diabetes later in life.
- Women with gestational diabetes are more likely to have large babies.
Metabolic syndrome(also referred to as syndrome X) is a set of abnormalities in which insulin-resistant diabetes (type 2 diabetes) is almost always present along with hypertension, high fat levels in the blood (increased serum lipids, predominant elevation of LDL cholesterol, decreased HDL cholesterol, and elevated triglycerides), central obesity, and abnormalities in blood clotting and inflammatory responses. A high rate of cardiovascular disease is associated with the metabolic syndrome.
Pre-diabetes is a common condition related to diabetes. In people with pre-diabetes, the blood sugar level is higher than normal but not high enough to be considered diabetic.
- Pre-diabetes increases your risk of developing type 2 diabetes and of heart disease or stroke.
- Pre-diabetes can typically be reversed without insulin or medication by losing a modest amount of weight and increasing your physical activity. This weight loss can prevent, or at least delay, the onset of type 2 diabetes.
- An international expert committee of the American Diabetes Association redefined the criteria for pre-diabetes, lowering the blood sugar level cut-off point for pre-diabetes. Approximately 20% more adults are now believed to have this condition and may develop diabetes within 10 years if they do not exercise or maintain a healthy weight.
About 17 million Americans (6.2% of adults in North America) are believed to have diabetes. About one third of diabetic adults do not know they have diabetes.
- About 1 million new cases occur each year, and diabetes is the direct or indirect cause of at least 200,000 deaths each year.
- The incidence of diabetes is increasing rapidly. This increase is due to many factors, but the most significant are the increasing incidence of obesity and the prevalence of sedentary lifestyles.
Complications of diabetes
Both forms of diabetes ultimately lead to high blood sugar levels, a condition called hyperglycemia. Over a long period of time, hyperglycemia damages the retina of the eye, the kidneys, the nerves, and the blood vessels.
- Damage to the retina from diabetes (diabetic retinopathy) is a leading cause of blindness.
- Damage to the kidneys from diabetes (diabetic nephropathy) is a leading cause of kidney failure.
- Damage to the nerves from diabetes (diabetic neuropathy) is a leading cause of foot wounds and ulcers, which frequently lead to foot and leg amputations.
- Damage to the nerves in the autonomic nervous system can lead to paralysis of the stomach (gastroparesis), chronic diarrhea, and an inability to control heart rate and blood pressure during postural changes.
- Diabetes accelerates atherosclerosis, (the formation of fatty plaques inside the arteries), which can lead to blockages or a clot (thrombus). Such changes can then lead to heart attack, stroke, and decreased circulation in the arms and legs (peripheral vascular disease).
- Diabetes predisposes people to high blood pressure and high cholesterol and triglyceride levels. These conditions independently and together with hyperglycemia increase the risk of heart disease, kidney disease, and other blood vessel complications.
In the short run, diabetes can contribute to a number of acute (short-lived) medical problems.
- Many infections are associated with diabetes, and infections are frequently more dangerous in someone with diabetes because the body’s normal ability to fight infections is impaired. To compound the problem, infections may worsen glucose control, which further delays recovery from infection.
- Hypoglycemia, or low blood sugar, occurs from time to time in most people with diabetes. It results from taking too much diabetes medication or insulin (sometimes called an insulin reaction), missing a meal, doing more exercise than usual, drinking too much alcohol, or taking certain medications for other conditions. It is very important to recognize hypoglycemia and be prepared to treat it at all times. Headache, feeling dizzy, poor concentration, tremors of hands, and sweating are common symptoms of hypoglycemia. You can faint or have a seizure if blood sugar level gets too low.
- Diabetic ketoacidosis is a serious condition in which uncontrolled hyperglycemia (usually due to complete lack of insulin or a relative deficiency of insulin) over time creates a buildup in the blood of acidic waste products called ketones. High levels of ketones can be very harmful. This typically happens to people with type 1 diabetes who do not have good blood glucose control. Diabetic ketoacidosis can be precipitated by infection, stress, trauma, missing medications like insulin, or medical emergencies like stroke and heart attack.
- Hyperosmolar hyperglycemic nonketotic syndrome is a serious condition in which the blood sugar level gets very high. The body tries to get rid of the excess blood sugar by eliminating it in the urine. This increases the amount of urine significantly and often leads to dehydration so severe that it can cause seizures, coma, and even death. This syndrome typically occurs in people with type 2 diabetes who are not controlling their blood sugar levels, who have become dehydrated, or who have stress, injury, stroke, or are taking certain medications, like steroids.
Type 1 diabetes: Type 1 diabetes is believed to be an autoimmune disease. The body’s immune system attacks the cells in the pancreas that produce insulin.
- A predisposition to develop type 1 diabetes may run in families, but genetic causes (a postitive family history) is much more common for type 2 diabetes.
- Environmental factors, including common unavoidable viral infections, may also contribute.
- Type 1 diabetes is most common in people of non-Hispanic, Northern European descent (especially Finland and Sardinia), followed by African Americans, and Hispanic Americans. It is relatively rare in those of Asian descent.
- Type 1 diabetes is slightly more common in men than in women.
Type 2 diabetes: Type 2 diabetes has strong genetic links, meaning that type 2 diabetes tends to run in families. Several genes have been identified and more are under study which may relate to the causes of type 2 diabetes. Risk factors for developing type 2 diabetes include the following:
- High blood pressure
- High blood triglyceride (fat) levels
- Gestational diabetes or giving birth to a baby weighing more than 9 pounds
- High-fat diet
- High alcohol intake
- Sedentary lifestyle
- Obesity or being overweight
- Ethnicity, particularly when a close relative had type 2 diabetes or gestational diabetes: certain groups, such as African Americans, Native Americans, Hispanic Americans, and Japanese Americans, have a greater risk of developing type 2 diabetes than non-Hispanic whites.
- Aging: Increasing age is a significant risk factor for type 2 diabetes. Risk begins to rise significantly at about age 45 years, and rises considerably after age 65 years.
Symptoms of type 1 diabetes are often dramatic and come on very suddenly.
- Type 1 diabetes is usually recognized in childhood or early adolescence, often in association with an illness (such as a virus or urinary tract infection) or injury.
- The extra stress can cause diabetic ketoacidosis.
- Symptoms of ketoacidosis include nausea and vomiting. Dehydration and often-serious disturbances in blood levels of potassium follow.
- Without treatment, ketoacidosis can lead to coma and death.
Symptoms of type 2 diabetes are often subtle and may be attributed to aging or obesity.
- A person may have type 2 diabetes for many years without knowing it.
- People with type 2 diabetes can develop hyperglycemic hyperosmolar nonketotic syndrome.
- Type 2 diabetes can be precipitated by steroids and stress.
- If not properly treated, type 2 diabetes can lead to complications like blindness, kidney failure, heart disease, and nerve damage.
Common symptoms of both major types of diabetes:
- Fatigue: In diabetes, the body is inefficient and sometimes unable to use glucose for fuel. The body switches over to metabolizing fat, partially or completely, as a fuel source. This process requires the body to use more energy. The end result is feeling fatigued or constantly tired.
- Unexplained weight loss: People with diabetes are unable to process many of the calories in the foods they eat. Thus, they may lose weight even though they eat an apparently appropriate or even excessive amount of food. Losing sugar and water in the urine and the accompanying dehydration also contributes to weight loss.
- Excessive thirst (polydipsia): A person with diabetes develops high blood sugar levels, which overwhelms the kidney’s ability to reabsorb the sugar as the blood is filtered to make urine. Excessive urine is made as the kidney spills the excess sugar. The body tries to counteract this by sending a signal to the brain to dilute the blood, which translates into thirst. The body encourages more water consumption to dilute the high blood sugar back to normal levels and to compensate for the water lost by excessive urination.
- Excessive urination (polyuria): Another way the body tries to get rid of the extra sugar in the blood is to excrete it in the urine. This can also lead to dehydration because excreting the sugar carries a large amount of water out of the body along with it.
- Excessive eating (polyphagia): If the body is able, it will secrete more insulin in order to try to deal with the excessive blood sugar levels. Moreover, the body is resistant to the action of insulin in type 2 diabetes. One of the functions of insulin is to stimulate hunger. Therefore, higher insulin levels lead to increased hunger and eating. Despite increased caloric intake, the person may gain very little weight and may even lose weight.
- Poor wound healing: High blood sugar levels prevent white blood cells, which are important in defending the body against bacteria and also in cleaning up dead tissue and cells, from functioning normally. When these cells do not function properly, wounds take much longer to heal and become infected more frequently. Also, long-standing diabetes is associated with thickening of blood vessels, which prevents good circulation including the delivery of enough oxygen and other nutrients to body tissues.
- Infections: Certain infection syndromes, such as frequent yeast infections of the genitals, skin infections, and frequent urinary tract infections, may result from suppression of the immune system by diabetes and by the presence of glucose in the tissues, which allows bacteria to grow well. They can also be an indicator of poor blood sugar control in a person known to have diabetes.
- Altered mental status: Agitation, unexplained irritability, inattention, extreme lethargy, or confusion can all be signs of very high blood sugar, ketoacidosis, hyperosmolar hyperglycemia nonketotic syndrome, or hypoglycemia (low sugar). Thus, any of these merit the immediate attention of a medical professional. Call your health care provider or 911.
- Blurry vision: Blurry vision is not specific for diabetes but is frequently present with high blood sugar levels.
When to Seek Medical Care
If you someone you know are not known to have diabetes but are having any symptoms that suggest diabetes or concern you in any way, make an appointment to see a healthcare provider as soon as possible. When you make the appointment, tell the operator that you are concerned about diabetes. He or she may make arrangements for blood sugar testing before the appointment.
If the patient is known to have diabetes, call a healthcare provider right away if any of the following apply:
- The patient is experiencing diabetes symptoms. This may mean that your blood sugar level is not being controlled despite treatment.
- The patient’s blood sugar levels, when tested, are consistently high (more than 200 mg/dL). Persistently high blood sugar levels are the root cause of all of the complications of diabetes.
- The patient’s blood sugar level is often low (less than 60 mg/dL). This may mean that management strategy is too aggressive. It also may be a sign of infection or other stress on the system such as kidney failure, liver failure, adrenal gland failure, or the concomitant use of certain medications.
- The patient has an injury to the foot or leg, no matter how minor. Even the tiniest cut or blister can become very serious in a person with diabetes. Early diagnosis and treatment of problems with the feet and lower extremities, along with regular diabetic foot care, are critical in preserving the function of the legs and preventing amputation.
- The patient has a low-grade fever (less than 101.5°F). Fever is a sign of infection. In patients with diabetes, many common infections can potentially be more dangerous for them than for other people. Note any symptoms, such as painful urination, redness or swelling of the skin, abdominal pain, chest pain, or cough, that may indicate where the infection is located.
- The patient is nauseated or vomiting but can keep liquids down. The healthcare provider may adjust medications while the patient is sick and will probably recommend an urgent office visit or a visit to the emergency department. Persistent nausea and vomiting can be a sign of diabetic ketoacidosis, a potentially life-threatening condition, as well as several other serious illnesses.
- The patient has a small sore (ulcer) on the foot or leg. Any non-healing sore or ulcer on the feet or legs of someone with diabetes needs to be seen by a medical professional right away. A sore less than 1 inch across, not draining pus, and not exposing deep tissue or bone can safely be evaluated in a healthcare provider’s office as long as the patient does not have fever and their blood sugar levels are in control.
When you call a healthcare provider, tell the operator that you or someone you know has diabetes and are concerned.
- The patient will probably be referred to a nurse who will ask questions and make a recommendation about what to do.
- Be prepared for this conversation. Have a list of medications, medical problems, allergies to medicines, and a blood sugar diary handy by the phone.
- The nurse may need any or all of this information to decide both the urgency of the patient’s condition and how best to recommend treatment for the problem.
The following situations can become 911 medical emergencies and warrant an immediate visit to a hospital emergency department.
- The person with a severe diabetic complication may travel to the emergency department by car or ambulance.
- A companion should go along to speak for the person if the person is not able to speak for himself or herself with the emergency care provider.
- Bring a list of medical problems, medications, allergies to medications, and the blood sugar diary to the emergency department. This information will help the emergency care provider diagnose the problem and treat it appropriately.
The following are signs and symptoms of diabetic complications that warrant emergency care.
- Altered mental status: Lethargy, agitation, forgetfulness, or just strange behavior can be a sign of very low or very high blood sugar levels.
- If the person is a known diabetic, try giving him or her some fruit juice (about 6 ounces) or cake icing if the person is awake enough to swallow normally without choking. Avoid giving things such as hard candy that can lodge in the throat. The healthcare provider can prescribe glucose wafers or gels that melt under the tongue.
- If the person does not wake up and behave normally within about 15 minutes, call 911.
- If the person is not a known diabetic, these symptoms can be signs of stroke, drug intoxication, alcohol intoxication, oxygen starvation, and other serious medical conditions. Call 911 immediately.
- Nausea or vomiting: If the patient is known to have diabetes and cannot keep food, medications, or fluids down at all, they may have diabetic ketoacidosis, hyperosmolar hyperglycemic nonketotic syndrome, or another complication of diabetes.
- If the patient has not already taken the latest insulin dose or oral diabetes medicine, do not take it without talking to a medical professional.
- If the patient already has low blood sugar levels, taking additional insulin or medication will drive the blood sugar level down even further, possibly to dangerous levels.
- Fever of more than 101.5°F: If the primary healthcare provider cannot see the patient right away, seek emergency care for a high fever if they are diabetic. Note any other symptoms such as cough, painful urination, abdominal pain, or chest pain.
- High blood sugar level: If the patient’s blood sugar level is more than 400 mg/dL, and the primary healthcare provider cannot see them right away. Very high blood sugar levels can be a sign of diabetic ketoacidosis or hyperosmolar hyperglycemic nonketotic syndrome, depending on the type of diabetes you have. Both of these conditions can be fatal if not treated promptly.
- Large sores or ulcers on the feet or legs: If the patient has diabetes, a non-healing sore larger than 1 inch in diameter can be a sign of a potentially limb-threatening infection.
- Other signs and symptoms that merit immediate care are exposed bone or deep tissue in the wound, large areas of surrounding redness and warmth, swelling, and severe pain in the foot or leg.
- If left untreated, such a sore may ultimately require amputation of the limb.
- Cuts or lacerations: Any cut penetrating all the layers of skin, especially on the legs, is a potential danger to a person with diabetes. Proper wound care, although important to anyone’s recovery, is especially important in diabetics to assure good wound healing.
- Chest pain: If the patient is diabetic, take very seriously any pain in the chest, particularly in the middle or on the left side, and seek medical attention immediately.
- People with diabetes are more likely than non-diabetic people to have a heart attack, with or without experiencing chest pain.
- Irregular heartbeats and unexplained shortness of breath may also be signs of heart attack.
- Severe abdominal pain: Depending on the location, this can be a sign of heart attack, abdominal aortic aneurysm (widening of the large artery in the abdomen), diabetic ketoacidosis, or interrupted blood flow to the bowels.
- All of these are more common in people with diabetes than in the general population and are potentially life-threatening.
- Those with diabetes also get other common causes of severe abdominal pain such as appendicitis, perforated ulcer, inflammation and infection of the gallbladder, kidney stones, and bowel obstruction.
- Severe pain anywhere in the body is a signal for timely medical attention.
Exams and Tests
Doctors use special tests in diagnosing diabetes and also in monitoring blood sugar level control in known diabetics.
If the patient is having symptoms but are not known to have diabetes, evaluation should always begin with a thorough medical interview and physical examination. The healthcare provider will about symptoms, risk factors for diabetes, past medical problems, current medications, allergies to medications, family history of diabetes or other medical problems such as high cholesterol or heart disease, and personal habits and lifestyle.
A number of laboratory tests are available to confirm the diagnosis of diabetes.
Finger stick blood glucose: This is a rapid screening test that may be performed anywhere, including community-based screening programs.
- A fingerstick blood glucose test is not as accurate as testing the patient’s blood in the laboratory but is easy to perform, and the result is available right away.
- The test involves sticking the patient’s finger for a blood sample, which is then placed on a strip. The strip goes into a machine that reads the blood sugar level. These machines are only accurate to within about 10% of true actual laboratory values.
- Fingerstick blood glucose values may be inaccurate at very high or very low levels, so this test is only a preliminary screening study. This is the way most people with diabetes monitor their blood sugar levels at home.
Fasting plasma glucose: The patient will be asked to eat or drink nothing for 8 hours before having blood drawn (usually first thing in the morning). If the blood glucose level is greater than or equal to 126 mg/dL without eating anything, they probably have diabetes.
- If the result is abnormal, the fasting plasma glucose test may be repeated on a different day to confirm the result, or the patient may undergo an oral glucose tolerance test or a glycosylated hemoglobin test (often called “hemoglobin A1c”) as a confirmatory test.
- If fasting plasma glucose level is greater than 100 but less than 126 mg/dL, then the patient has what is called impaired fasting glucose, or IFG. This is considered to be pre-diabetes. The patient does not have diabetes, but they are at high risk of developing diabetes in the near future.
Oral glucose tolerance test: This test involves drawing blood for a fasting plasma glucose test, then drawing blood for a second test at two hours after drinking a very sweet drink containing 75 grams of sugar.
- If the blood sugar level after the sugar drink is greater than or equal to 200 mg/dL, the patient has diabetes.
- If the blood glucose level is between 140 and 199, then the patient has impaired glucose tolerance (IGT), which is also a pre-diabetic condition.
Glycosylated hemoglobin or hemoglobin A1c: This test is a measurement of how high blood sugar levels have been over about the last 120 days (the average life-span of the red blood cells on which the test is based).
- Excess blood glucose hooks on to the hemoglobin in red blood cells and stays there for the life of the red blood cell.
- The percentage of hemoglobin that has had excess blood sugar attached to it can be measured in the blood. The test involves having a small amount of blood drawn.
- A hemoglobin A1c test is the best measurement of blood sugar control in people known to have diabetes. A hemoglobin A1c result of 7% or less indicates good glucose control. A result of 8% or greater indicates that blood sugar levels are too high for too much of the time.
- The hemoglobin A1c test is less reliable to diagnose diabetes than for follow-up care. Still, a hemoglobin A1c result greater than 6.1% is highly suggestive of diabetes. Generally, a confirmatory test would be needed before diagnosing diabetes.
- The hemoglobin A1c test is generally measured about every three to six months for people with known diabetes, although it may be done more frequently for people who are having difficulty achieving and maintaining good blood sugar control.
- This test is not used for people who do not have diabetes or are not at increased risk of diabetes.
- Normal values may vary from laboratory to laboratory, although an effort is under way to standardize how measurements are performed.
Diagnosing complications of diabetes
If you or someone you know has diabetes, the patient should be checked regularly for early signs of diabetic complications. The healthcare provider can do some of these checks; for others, the patient should be referred to a specialist.
- The patient should have their eyes checked at least once a year by an eye specialist (ophthalmologist) to screen for diabetic retinopathy, a leading cause of blindness.
- The patient’s urine should be checked for protein (microalbumin) on a regular basis, at least one to two times per year. Protein in the urine is an early sign of diabetic nephropathy, a leading cause of kidney failure.
- Sensation in the legs should be checked regularly using a tuning fork or a monofilament device. Diabetic neuropathy is a leading cause in diabetic lower extremity ulcers, which frequently lead to amputation of the feet or legs.
- The healthcare provider should check the feet and lower legs at every visit for cuts, scrapes, blisters, or other lesions that could become infected.
- The patient should be screened regularly for conditions that may contribute to heart disease, such as high blood pressure and high cholesterol.
Self-Care at Home
If you or someone you know has diabetes, they would be wise to make healthful lifestyle choices in diet, exercise, and other health habits. These will help to improve glycemic (blood sugar) control and prevent or minimize complications of diabetes.
Diet: A healthy diet is key to controlling blood sugar levels and preventing diabetes complications.
- If the patient is obese and has had difficulty losing weight on their own, talk to a healthcare provider. He or she can recommend a dietitian or a weight modification program to help the patient reach a goal.
- Eat a consistent, well-balanced diet that is high in fiber, low in saturated fat, and low in concentrated sweets.
- A consistent diet that includes roughly the same number of calories at about the same times of day helps the healthcare provider prescribe the correct dose of medication or insulin.
- It will also help to keep blood sugar at a relatively even level and avoid excessively low or high blood sugar levels, which can be dangerous and even life-threatening.
Exercise: Regular exercise, in any form, can help reduce the risk of developing diabetes. Activity can also reduce the risk of developing complications of diabetes such as heart disease, stroke, kidney failure, blindness, and leg ulcers.
- As little as 20 minutes of walking three times a week has a proven beneficial effect. Any exercise is beneficial; no matter how light or how long, some exercise is better than no exercise.
- If the patient has complications of diabetes (eye, kidney, or nerve problems), they may be limited both in type of exercise and amount of exercise they can safely do without worsening their condition. Consult with your health care provider before starting any exercise program.
Alcohol use: Moderate or eliminate consumption of alcohol. Try to have no more than seven alcoholic drinks in a week and never more than two or three in an evening. One drink is considered 1.5 ounces of liquor, 6 ounces of wine, or 12 ounces of beer. Excessive alcohol use is a known risk factor for type 2 diabetes. Alcohol consumption can cause low or high blood sugar levels, nerve pain called neuritis, and increase in triglycerides, which is a type of fat in our blood.
Smoking: If the patient has diabetes, and you smoke cigarettes or use any other form of tobacco, they are raising the risks markedly for nearly all of the complications of diabetes. Smoking damages blood vessels and contributes to heart disease, stroke, and poor circulation in the limbs. If someone needs help quitting, talk to a healthcare provider.
Self-monitored blood glucose: Check blood sugar levels frequently, at least before meals and at bedtime, and record the results in a logbook.
- This log should also include insulin or oral medication doses and times, when and what the patient ate, when and for how long they exercised, and any significant events of the day such as high or low blood sugar levels and how they treated the problem.
- Better equipment now available makes testing blood sugar levels less painful and less complicated than ever. A daily blood sugar diary is invaluable to the healthcare provider in seeing how the patient is responding to medications, diet, and exercise in the treatment of diabetes.
- Medicare now pays for diabetic testing supplies, as do many private insurers and Medicaid.
The treatment of diabetes is highly individualized, depending on the type of diabetes, whether the patient has other active medical problems, whether the patient has complications of diabetes, and age and general health of the patient at time of diagnosis.
- A healthcare provider will set goals for lifestyle changes, blood sugar control, and treatment.
- Together, the patient and the healthcare provider will devise a plan to help meet those goals.
Education about diabetes and its treatment is essential in all types of diabetes.
- When the patient is first diagnosed with diabetes, the diabetes care team will spend a lot of time with the patient, teaching them about their condition, treatment, and everything they need to know to care for themselves on a daily basis.
- The diabetes care team includes the healthcare provider and his or her staff. It may include specialists in foot care, neurology, kidney diseases, and eye diseases. A professional dietitian and a diabetes educator also may be part of the team.
The healthcare team will see you at appropriate intervals to monitor your progress with your goals.
Type 1 diabetes
Treatment of diabetes almost always involves the daily injection of insulin, usually a combination of short-acting insulin [for example, lispro (Humalog) or aspart (NovoLog)] and a longer acting insulin [for example, NPH, Lente, glargine (Lantus), detemir, or ultralente].
- Insulin must be given as an injection. If taken by mouth, insulin would be destroyed in the stomach before it could get into the blood where it is needed.
- Most people with type 1 diabetes give these injections to themselves. Even if someone else usually gives the patient injections, it is important that the patient knows how to do it in case the other person is unavailable.
- A trained professional will show the patient how to store and inject the insulin. Usually this is a nurse who works with the healthcare provider or a diabetes educator.
- Insulin is usually given in two or three injections per day, generally around mealtimes. Dosage is individualized and is tailored to the patient’s specific needs by the healthcare provider. Longer acting insulins are typically administered one or two times per day.
- Some people have their insulin administered by continuous infusion pumps to provide adequate blood glucose control. Supplemental mealtime insulin is programmed into the pump by the individual as recommended by his or her healthcare provider.
- It is very important to eat if the patient has taken insulin, as the insulin will lower blood sugar regardless of whether they have eaten. If insulin is taken without eating, the result may be hypoglycemia. This is called an insulin reaction.
- There is an adjustment period while the patient learns how insulin affects them, and how to time meals and exercise with insulin injections to keep blood sugar level as even as possible.
- Keeping accurate records of blood sugar levels and insulin dosages is crucial for the patient’s diabetes management.
- Eating a consistent, healthy diet appropriate for the patient’s size and weight is essential in controlling blood sugar level.
Type 2 diabetes
Depending on how elevated the patient’s blood sugar and glycosylated hemoglobin (HbA1c) are at the time of diagnosis, they may be given a chance to lower blood sugar level without medication.
- The best way to do this is to lose weight if obese and begin an exercise program.
- This will generally be tried for three to six months, then blood sugar and glycosylated hemoglobin will be rechecked. If they remain high, the patient will be started on an oral medication, usually a sulfonylurea or biguanide [metformin Glucophage)], to help control blood sugar level.
- Even if the patient is on medication, it is still important to eat a healthy diet, lose weight if they are overweight, and engage in moderate physical activity as often as possible.
- The healthcare provider will monitor the patient’s progress on medication very carefully at first. It is important to get just the right dose of the right medication to get the blood sugar level in the recommended range with the fewest side effects.
- The doctor may decide to combine two types of medications to get blood sugar level under control.
- Gradually, even people with type 2 diabetes may require insulin injections to control their blood sugar levels.
- It is becoming more common for people with type 2 diabetes to take a combination of oral medication and insulin injections to control blood sugar levels.
Many different types of medications are available to help lower blood sugar levels in type 2 diabetes. Each type works in a different way. It is very common to combine two or more types to get the best effect with fewest side effects.
- Sulfonylureas: These drugs stimulate the pancreas to make more insulin.
- Biguanides: These agents decrease the amount of glucose produced by the liver.
- Alpha-glucosidase inhibitors: These agents slow absorption of the starches one eats. This slows down glucose production.
- Thiazolidinediones: These agents increase sensitivity to insulin.
- Meglitinides: These agents stimulate the pancreas to make more insulin.
- D-phenylalanine derivatives: These agents stimulate the pancreas to produce more insulin more quickly.
- Amylin synthetic derivatives: Amylin is a naturally occurring hormone secreted by the pancreas along with insulin. An amylin derivative, such as pramlintide (Symlin), is indicated when blood sugar control is not achieved despite optimal insulin therapy. Pramlintide is administered as a subcutaneous injection along with insulin and helps achieve lower blood sugar levels after meals, helps reduce fluctuation of blood sugar levels throughout the day, and improves hemoglobin A1C levels.
- Incretin mimetics: Incretin mimetics promote insulin secretion by the pancreas and mimic other blood sugar level lowering actions that naturally occur in the body. Exenatide (Byetta) is the first incretin mimetic agent approved in the United States. It is indicated for diabetes mellitus type 2 in addition to metformin or a sulfonylurea when these agents have not attained blood sugar level control alone.
- Insulins: Human insulin is the only type of insulin available in the United States; it is less likely to cause allergic reactions than animal-derived varieties of insulin. The type of insulin chosen to customize treatment for an individual is based on the goal of providing optimal blood sugar control. Different types of insulin are available and categorized according to their times of action onset and duration. Commercially prepared mixtures of some insulins may also be used to provide constant (basal) control and immediate control.
- Rapid-acting insulins
- Regular insulin (Humulin R, Novolin R)
- Insulin lispro (Humalog)
- Insulin aspart (Novolog)
- Insulin glulisine (Apidra)
- Prompt insulin zinc (Semilente, slightly slower acting)
- Intermediate-acting insulins
- Isophane insulin, neutral protamine Hagedorn (NPH) (Humulin N, Novolin N)
- Insulin zinc (Lente)
- Long-acting insulins
- Extended insulin zinc insulin (Ultralente)
- Insulin glargine (Lantus)
- Insulin detemir (Levemir)
- Follow the healthcare provider’s treatment recommendations. Keep records of blood sugar levels as often as recommended by the healthcare provider, including the times the levels were checked, when and how much insulin or medication was taken, when and what was eaten, and when and for how long the patient exercised. Call the healthcare provider if the patient has any problems with their treatment or symptoms that suggest poor glucose control.
- Attend diabetes education classes at the local hospital. The more educated the patient and their family are about the disease, the better they are likely to do.
- Regular visits to the primary healthcare provider
- If the patient takes insulin, they should see the healthcare provider about every three months or more often. For other diabetics, every three to six months is generally adequate, unless they are having problems.
- Recognize low blood sugar levels and know how to treat them
- The patient and their family should be taught how to recognize the signs and symptoms of low blood sugar levels. The patient should have a clear plan for treating low blood sugar levels and know when to call 911. Mild symptoms include confusion and sweating, moreover, these symptoms can progress to lethargy, agitation (sometimes with violent, jerking motions), or even seizures.
We do not yet know of a way to prevent type 1 diabetes. Type 2 diabetes, however, can be prevented in some cases.
- Control weight to normal or near-normal levels by eating a healthy low-fat, high-fiber diet.
- Regular exercise is crucial to the prevention of type 2 diabetes.
- Keep alcohol consumption low.
- Quit smoking.
- If you have high blood fat levels (such as high cholesterol) or high blood pressure, take your medication as directed.
- Lifestyle modification and/or certain medications can be used in people with prediabetes to prevent progression to diabetes. Pre-diabetes can be diagnosed by checking fasting glucose and two hours after ingesting 75 grams of glucose.
If you or someone you know already have diabetes, your focus should be on preventing the complications, which can cause serious disabilities such as blindness, kidney failure requiring dialysis, amputation, or even death.
- Tight glucose control: The single best thing the patient can do is to keep their blood sugar level within the suggested range every day. The only way to do this is through a combination of regular blood sugar checks, a balanced diet low in simple sugars and fat and high in complex carbohydrates and fiber, and appropriate medical treatment. Please consult a nutritionist or check with the doctor with questions in regard to diet.
- Quit smoking
- Maintain a healthy weight
- Increase physical activity levels. Aim for moderately vigorous physical activity for at least 30 minutes every day.
- Drink an adequate amount of water and avoid taking too much salt.
- The skin should be taken care of; keep it supple and hydrated to avoid sores and cracks that can become severely infected.
- Brush and floss the teeth every day. See a dentist regularly to prevent gum disease.
- The feet should be washed and examined daily, looking for small cuts, sores, or blisters that may cause problems later. The toenails should be filed rather than cut to avoid damaging the surrounding skin. A specialist in foot care (podiatrist) may be necessary to help care for the feet.
Diabetes is a leading cause of death in all industrialized nations. Overall, the risk of premature death of people with diabetes is twice that of people who do not have diabetes. Prognosis depends on the type of diabetes, degree of blood sugar control, and development of complications.
Type 1 diabetes
About 15% of people with type 1 diabetes die before age 40 years, which is about 20 times the rate of that age group in the general population.
- The most common causes of death in type 1 diabetes are diabetic ketoacidosis, kidney failure, and heart disease.
- The good news is that prognosis can be improved with good blood sugar control. Maintaining tight blood sugar control has been proven to prevent, slow the progression of, and even improve established complications of type 1 diabetes.
Type 2 diabetes
The life expectancy of people who are diagnosed with type 2 diabetes in their 40s decreases by 5-10 years because of the disease.
- Heart disease is the leading cause of death for people with type 2 diabetes.
- Excellent glycemic control, tight blood pressure control, and keeping the “bad” cholesterol (LDL) level at the recommended level of <100 mg/dL (or lower, particularly if other risk factors for cardiovascular disease are present) and the “good” (HDL) cholesterol as high as possible. Use of aspirin when indicated can prevent, slow the progression of, and improve established complications in diabetes.
This article is for your information only. Always consult your physician prior to making any changes in your diet, exercise or medical program.
American Association of Diabetes Educator
Diabetes is a serious problem that costs our entire planet. Most people don’t realize that it is not only the world’s 4th leading cause of death, diabetes is increasing daily and now affects an estimated 246 million people globally.
There are three main types of diabetes. Type 1 diabetes, usually diagnosed in children and adolescents, occurs when the pancreas is unable to produce insulin. Insulin is a hormone that ensures body energy needs are met. Approximately 10 per cent of people with diabetes have type 1 diabetes.
The remaining 90 per cent have type 2 diabetes, which occurs when the pancreas does not produce enough insulin or when the body does not effectively use the insulin that is produced. Type 2 diabetes usually develops in adulthood, although increasing numbers of children in high-risk populations are being diagnosed.
A third type of diabetes, gestational diabetes, is a temporary condition that occurs during pregnancy. It affects approximately 3.7 per cent of all pregnancies (in the non-Aboriginal population) and 8 – 18 per cent of all pregnancies (in the Aboriginal population), and involves an increased risk of developing diabetes for both mother and child.Is diabetes serious?
If left untreated or improperly managed, diabetes can result in a variety of complications, including:
- Heart disease
- Kidney disease
- Eye disease
- Problems with erection (impotence)
- Nerve damage
The first step in preventing or delaying the onset of these complications is recognizing the risk factors, as well as signs and symptoms of diabetes.What are the risk factors for diabetes?
If you are aged 40 or over, you are at risk for type 2 diabetes and should be tested at least every three years. If any of the following risks factors apply, you should be tested earlier and/or more often.
- A member of a high-risk group (Aboriginal, Hispanic, Asian, South Asian or African descent)
- Overweight (especially if you carry most of your weight around your middle)
- A parent, brother or sister with diabetes
- Health complications that are associated with diabetes
- Given birth to a baby that weighed more than 4 kg (9 lb)
- Had gestational diabetes (diabetes during pregnancy)
- Impaired glucose tolerance or impaired fasting glucose
- High blood pressure
- High cholesterol or other fats in the blood
- Been diagnosed with polycystic ovary syndrome, acanthosis nigricans (darkened patches of skin), or schizophrenia
Signs and symptoms of diabetes include the following:
- Unusual thirst
- Frequent urination
- Weight change (gain or loss)
- Extreme fatigue or lack of energy
- Blurred vision
- Frequent or recurring infections
- Cuts and bruises that are slow to heal
- Tingling or numbness in the hands or feet
- Trouble getting or maintaining an erection
It is important to recognize, however, that many people who have type 2 diabetes may display no symptoms.Can you prevent diabetes?
Scientists believe that lifestyle changes can help prevent or delay the onset of type 2 diabetes. A healthy meal plan, weight control and physical activity are important prevention steps.How is diabetes treated?
People with diabetes can expect to live active, independent and vital lives if they make a lifelong commitment to careful diabetes management, which includes the following:
- Education: Diabetes education is an important first step. All people with diabetes need to be informed about their condition.
- Physical Activity: Regular physical activity helps your body lower blood glucose levels, promotes weight loss, reduces stress and enhances overall fitness.
- Nutrition: What, when and how much you eat all play an important role in regulating blood glucose levels.
- Weight Management: Maintaining a healthy weight is especially important in the management of type 2 diabetes.
- Medication: Type 1 diabetes is always treated with insulin. Type 2 diabetes is managed through physical activity and meal planning and may require medications and/or insulin to assist your body in making or using insulin more effectively.
- Lifestyle Management: Learning to reduce stress levels in day-to-day life can help people with diabetes better manage their disease.
- Blood Pressure: High blood pressure can lead to eye disease, heart disease, stroke and kidney disease, so people with diabetes should try to maintain a blood pressure level at or below 130/80. To do this, you may need to change your eating and physical activity habits and/or take medication.
- This information is for you only.
- Always follow your healthcare provider’s instructions for taking medicines. Do not miss any doses, do not take less medicine, and do not stop taking medicine without talking to your provider first. It can be dangerous to suddenly stop taking blood pressure medicine. Also, do not increase your dosage of any medicine without first talking with your provider.
- Ask your healthcare provider or pharmacist for information about the drugs you are taking.
- Ask your provider about nonprescription medicines and supplements before you take them.
Becker RC, Meade TW, Berger PB, Ezekowitz M, O’Connor CM, Vorchheimer DA, et al. The primary and secondary prevention of coronary artery disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun;133(6 Suppl):776S-814S.
Dr. Ben-Zur recommends that you read this article about HypoglycemiaWhat is hypoglycemia?
Hypoglycemia, also called low blood glucose or low blood sugar, occurs when blood glucose drops below normal levels. Glucose, an important source of energy for the body, comes from food. Carbohydrates are the main dietary source of glucose. Rice, potatoes, bread, tortillas, cereal, milk, fruit, and sweets are all carbohydrate-rich foods.
After a meal, glucose is absorbed into the bloodstream and carried to the body’s cells. Insulin, a hormone made by the pancreas, helps the cells use glucose for energy. If a person takes in more glucose than the body needs at the time, the body stores the extra glucose in the liver and muscles in a form called glycogen. The body can use glycogen for energy between meals. Extra glucose can also be changed to fat and stored in fat cells. Fat can also be used for energy.
When blood glucose begins to fall, glucagon—another hormone made by the pancreas—signals the liver to break down glycogen and release glucose into the bloodstream. Blood glucose will then rise toward a normal level. In some people with diabetes, this glucagon response to hypoglycemia is impaired and other hormones such as epinephrine, also called adrenaline, may raise the blood glucose level. But with diabetes treated with insulin or pills that increase insulin production, glucose levels can’t easily return to the normal range.
Hypoglycemia can happen suddenly. It is usually mild and can be treated quickly and easily by eating or drinking a small amount of glucose-rich food. If left untreated, hypoglycemia can get worse and cause confusion, clumsiness, or fainting. Severe hypoglycemia can lead to seizures, coma, and even death.
In adults and children older than 10 years, hypoglycemia is uncommon except as a side effect of diabetes treatment. Hypoglycemia can also result, however, from other medications or diseases, hormone or enzyme deficiencies, or tumors.What are the symptoms of hypoglycemia?
Hypoglycemia causes symptoms such as
- dizziness or light-headedness
- difficulty speaking
Hypoglycemia can also happen during sleep. Some signs of hypoglycemia during sleep include
- crying out or having nightmares
- finding pajamas or sheets damp from perspiration
- feeling tired, irritable, or confused after waking up
Hypoglycemia can occur as a side effect of some diabetes medications, including insulin and oral diabetes medications—pills—that increase insulin production, such as
- chlorpropamide (Diabinese)
- glimepiride (Amaryl)
- glipizide (Glucotrol, Glucotrol XL)
- glyburide (DiaBeta, Glynase, Micronase)
- nateglinide (Starlix)
- repaglinide (Prandin)
- sitagliptin (Januvia)
Certain combination pills can also cause hypoglycemia, including
- glipizide + metformin (Metaglip)
- glyburide + metformin (Glucovance)
- pioglitazone + glimepiride (Duetact)
- rosiglitazone + glimepiride (Avandaryl)
- sitagliptin + metformin (Janumet)
Other types of diabetes pills, when taken alone, do not cause hypoglycemia. Examples of these medications are
- acarbose (Precose)
- metformin (Glucophage)
- miglitol (Glyset)
- pioglitazone (Actos)
- rosiglitazone (Avandia)
However, taking these pills along with other diabetes medications—insulin, pills that increase insulin production, or both—increases the risk of hypoglycemia.
In addition, use of the following injectable medications can cause hypoglycemia:
- Pramlintide (Symlin), which is used along with insulin
- Exenatide (Byetta), which can cause hypoglycemia when used in combination with chlorpropamide, glimepiride, glipizide, glyburide, tolazamide, and tolbutamide
In people on insulin or pills that increase insulin production, low blood glucose can be due to
- meals or snacks that are too small, delayed, or skipped
- increased physical activity
- alcoholic beverages
Diabetes treatment plans are designed to match the dose and timing of medication to a person’s usual schedule of meals and activities. Mismatches could result in hypoglycemia. For example, taking a dose of insulin—or other medication that increases insulin levels—but then skipping a meal could result in hypoglycemia.
To help prevent hypoglycemia, people with diabetes should always consider the following:
- Their diabetes medications. A health care provider can explain which diabetes medications can cause hypoglycemia and explain how and when to take medications. For good diabetes management, people with diabetes should take diabetes medications in the recommended doses at the recommended times. In some cases, health care providers may suggest that patients learn how to adjust medications to match changes in their schedule or routine.
- Their meal plan. A registered dietitian can help design a meal plan that fits one’s personal preferences and lifestyle. Following one’s meal plan is important for managing diabetes. People with diabetes should eat regular meals, have enough food at each meal, and try not to skip meals or snacks. Snacks are particularly important for some people before going to sleep or exercising. Some snacks may be more effective than others in preventing hypoglycemia overnight. The dietitian can make recommendations for snacks.
- Their daily activity. To help prevent hypoglycemia caused by physical activity, health care providers may advise
- checking blood glucose before sports, exercise, or other physical activity and having a snack if the level is below 100 milligrams per deciliter (mg/dL)
- adjusting medication before physical activity
- checking blood glucose at regular intervals during extended periods of physical activity and having snacks as needed
- checking blood glucose periodically after physical activity
- Their use of alcoholic beverages. Drinking alcoholic beverages, especially on an empty stomach, can cause hypoglycemia, even a day or two later. Heavy drinking can be particularly dangerous for people taking insulin or medications that increase insulin production. Alcoholic beverages should always be consumed with a snack or meal at the same time. A health care provider can suggest how to safely include alcohol in a meal plan.
- Their diabetes management plan. Intensive diabetes management—keeping blood glucose as close to the normal range as possible to prevent long-term complications—can increase the risk of hypoglycemia. Those whose goal is tight control should talk with a health care provider about ways to prevent hypoglycemia and how best to treat it if it occurs.
People who take diabetes medications should ask their doctor or health care provider
- whether their diabetes medications could cause hypoglycemia
- when they should take their diabetes medications
- how much medication they should take
- whether they should keep taking their diabetes medications when they are sick
- whether they should adjust their medications before physical activity
- whether they should adjust their medications if they skip a meal
Signs and symptoms of hypoglycemia vary from person to person. People with diabetes should get to know their signs and symptoms and describe them to their friends and family so they can help if needed. School staff should be told how to recognize a child’s signs and symptoms of hypoglycemia and how to treat it.
People who experience hypoglycemia several times in a week should call their health care provider. They may need a change in their treatment plan: less medication or a different medication, a new schedule for insulin or medication, a different meal plan, or a new physical activity plan.Prompt Treatment for Hypoglycemia
When people think their blood glucose is too low, they should check the blood glucose level of a blood sample using a meter. If the level is below 70 mg/dL, one of these quick-fix foods should be consumed right away to raise blood glucose:
- 3 or 4 glucose tablets
- 1 serving of glucose gel—the amount equal to 15 grams of carbohydrate
- 1/2 cup, or 4 ounces, of any fruit juice
- 1/2 cup, or 4 ounces, of a regular—not diet—soft drink
- 1 cup, or 8 ounces, of milk
- 5 or 6 pieces of hard candy
- 1 tablespoon of sugar or honey
Recommended amounts may be less for small children. The child’s doctor can advise about the right amount to give a child.
The next step is to recheck blood glucose in 15 minutes to make sure it is 70 mg/dL or above. If it’s still too low, another serving of a quick-fix food should be eaten. These steps should be repeated until the blood glucose level is 70 mg/dL or above. If the next meal is an hour or more away, a snack should be eaten once the quick-fix foods have raised the blood glucose level to 70 mg/dL or above.For People Who Take Acarbose (Precose) or Miglitol (Glyset)
People who take either of these diabetes medications should know that only pure glucose, also called dextrose—available in tablet or gel form—will raise their blood glucose level during a low blood glucose episode. Other quick-fix foods and drinks won’t raise the level quickly enough because acarbose and miglitol slow the digestion of other forms of carbohydrateHelp from Others for Severe Hypoglycemia
Severe hypoglycemia—very low blood glucose—can cause a person to pass out and can even be life threatening. Severe hypoglycemia is more likely to occur in people with type 1 diabetes. People should ask a health care provider what to do about severe hypoglycemia. Another person can help someone who has passed out by giving an injection of glucagon. Glucagon will rapidly bring the blood glucose level back to normal and help the person regain consciousness. A health care provider can prescribe a glucagon emergency kit. Family, friends, or coworkers—the people who will be around the person at risk of hypoglycemia—can learn how to give a glucagon injection and when to call 911 or get medical help.Physical Activity and Blood Glucose Levels
Physical activity has many benefits for people with diabetes, including lowering blood glucose levels. However, physical activity can make levels too low and can cause hypoglycemia up to 24 hours afterward. A health care provider can advise about checking the blood glucose level before exercise. For those who take insulin or one of the oral medications that increase insulin production, the health care provider may suggest having a snack if the glucose level is below 100 mg/dL or adjusting medication doses before physical activity to help avoid hypoglycemia. A snack can prevent hypoglycemia. The health care provider may suggest extra blood glucose checks, especially after strenuous exercise.Hypoglycemia When Driving
Hypoglycemia is particularly dangerous if it happens to someone who is driving. People with hypoglycemia may have trouble concentrating or seeing clearly behind the wheel and may not be able to react quickly to road hazards or to the actions of other drivers. To prevent problems, people at risk for hypoglycemia should check their blood glucose level before driving. During longer trips, they should check their blood glucose level frequently and eat snacks as needed to keep the level at 70 mg/dL or above. If necessary, they should stop for treatment and then make sure their blood glucose level is 70 mg/dL or above before starting to drive again.Hypoglycemia Unawareness
Some people with diabetes do not have early warning signs of low blood glucose, a condition called hypoglycemia unawareness. This condition occurs most often in people with type 1 diabetes, but it can also occur in people with type 2 diabetes. People with hypoglycemia unawareness may need to check their blood glucose level more often so they know when hypoglycemia is about to occur. They also may need a change in their medications, meal plan, or physical activity routine.
Hypoglycemia unawareness develops when frequent episodes of hypoglycemia lead to changes in how the body reacts to low blood glucose levels. The body stops releasing the hormone epinephrine and other stress hormones when blood glucose drops too low. The loss of the body’s ability to release stress hormones after repeated episodes of hypoglycemia is called hypoglycemia-associated autonomic failure, or HAAF.
Epinephrine causes early warning symptoms of hypoglycemia such as shakiness, sweating, anxiety, and hunger. Without the release of epinephrine and the symptoms it causes, a person may not realize that hypoglycemia is occurring and may not take action to treat it. A vicious cycle can occur in which frequent hypoglycemia leads to hypoglycemia unawareness and HAAF, which in turn leads to even more severe and dangerous hypoglycemia. Studies have shown that preventing hypoglycemia for a period as short as several weeks can sometimes break this cycle and restore awareness of symptoms. Health care providers may therefore advise people who have had severe hypoglycemia to aim for higher-than-usual blood glucose targets for short-term periods.Being Prepared for Hypoglycemia
People who use insulin or take an oral diabetes medication that can cause low blood glucose should always be prepared to prevent and treat low blood glucose by
- learning what can trigger low blood glucose levels
- having their blood glucose meter available to test glucose levels; frequent testing may be critical for those with hypoglycemia unawareness, particularly before driving a car or engaging in any hazardous activity
- always having several servings of quick-fix foods or drinks handy
- wearing a medical identification bracelet or necklace
- planning what to do if they develop severe hypoglycemia
- telling their family, friends, and coworkers about the symptoms of hypoglycemia and how they can help if needed
|Normal and Target Blood Glucose Ranges|
|Normal Blood Glucose Levels in People Who Do Not Have Diabetes|
|Upon waking—fasting||70 to 99 mg/dL|
|After meals||70 to 140 mg/dL|
|Target Blood Glucose Levels in People Who Have Diabetes|
|Before meals||70 to 130 mg/dL|
|1 to 2 hours after the start of a meal||below 180 mg/dL|
For people with diabetes, a blood glucose level below 70 mg/dL is considered hypoglycemia.Hypoglycemia in People Who Do Not Have Diabetes
Two types of hypoglycemia can occur in people who do not have diabetes:
- Reactive hypoglycemia, also called postprandial hypoglycemia, occurs within 4 hours after meals.
- Fasting hypoglycemia, also called postabsorptive hypoglycemia, is often related to an underlying disease.
Symptoms of both reactive and fasting hypoglycemia are similar to diabetes-related hypoglycemia. Symptoms may include hunger, sweating, shakiness, dizziness, light-headedness, sleepiness, confusion, difficulty speaking, anxiety, and weakness.
To find the cause of a patient’s hypoglycemia, the doctor will use laboratory tests to measure blood glucose, insulin, and other chemicals that play a part in the body’s use of energy.Reactive Hypoglycemia
To diagnose reactive hypoglycemia, the doctor may
- ask about signs and symptoms
- test blood glucose while the patient is having symptoms by taking a blood sample from the arm and sending it to a laboratory for analysis*
- check to see whether the symptoms ease after the patient’s blood glucose returns to 70 mg/dL or above after eating or drinking
A blood glucose level below 70 mg/dL at the time of symptoms and relief after eating will confirm the diagnosis. The oral glucose tolerance test is no longer used to diagnose reactive hypoglycemia because experts now know the test can actually trigger hypoglycemic symptoms.
Causes and Treatment
The causes of most cases of reactive hypoglycemia are still open to debate. Some researchers suggest that certain people may be more sensitive to the body’s normal release of the hormone epinephrine, which causes many of the symptoms of hypoglycemia. Others believe deficiencies in glucagon secretion might lead to reactive hypoglycemia.
A few causes of reactive hypoglycemia are certain, but they are uncommon. Gastric—or stomach—surgery can cause reactive hypoglycemia because of the rapid passage of food into the small intestine. Rare enzyme deficiencies diagnosed early in life, such as hereditary fructose intolerance, also may cause reactive hypoglycemia.
To relieve reactive hypoglycemia, some health professionals recommend
- eating small meals and snacks about every 3 hours
- being physically active
- eating a variety of foods, including meat, poultry, fish, or nonmeat sources of protein; starchy foods such as whole-grain bread, rice, and potatoes; fruits; vegetables; and dairy products
- eating foods high in fiber
- avoiding or limiting foods high in sugar, especially on an empty stomach
The doctor can refer patients to a registered dietitian for personalized meal planning advice. Although some health professionals recommend a diet high in protein and low in carbohydrates, studies have not proven the effectiveness of this kind of diet to treat reactive hypoglycemia.Fasting Hypoglycemia
Fasting hypoglycemia is diagnosed from a blood sample that shows a blood glucose level below 50 mg/dL after an overnight fast, between meals, or after physical activity.
Causes and Treatment
Causes of fasting hypoglycemia include certain medications, alcoholic beverages, critical illnesses, hormonal deficiencies, some kinds of tumors, and certain conditions occurring in infancy and childhood.
Medications. Medications, including some used to treat diabetes, are the most common cause of hypoglycemia. Other medications that can cause hypoglycemia include
- salicylates, including aspirin, when taken in large doses
- sulfa medications, which are used to treat bacterial infections
- pentamidine, which treats a serious kind of pneumonia
- quinine, which is used to treat malaria
If using any of these medications causes a person’s blood glucose level to fall, the doctor may advise stopping the medication or changing the dose.
Alcoholic beverages. Drinking alcoholic beverages, especially binge drinking, can cause hypoglycemia. The body’s breakdown of alcohol interferes with the liver’s efforts to raise blood glucose. Hypoglycemia caused by excessive drinking can be serious and even fatal.
Critical illnesses. Some illnesses that affect the liver, heart, or kidneys can cause hypoglycemia. Sepsis, which is an overwhelming infection, and starvation are other causes of hypoglycemia. In these cases, treating the illness or other underlying cause will correct the hypoglycemia.
Hormonal deficiencies. Hormonal deficiencies may cause hypoglycemia in very young children, but rarely in adults. Shortages of cortisol, growth hormone, glucagon, or epinephrine can lead to fasting hypoglycemia. Laboratory tests for hormone levels will determine a diagnosis and treatment. Hormone replacement therapy may be advised.
Tumors. Insulinomas are insulin-producing tumors in the pancreas. Insulinomas can cause hypoglycemia by raising insulin levels too high in relation to the blood glucose level. These tumors are rare and do not normally spread to other parts of the body. Laboratory tests can pinpoint the exact cause. Treatment involves both short-term steps to correct the hypoglycemia and medical or surgical measures to remove the tumor.
Conditions occurring in infancy and childhood. Children rarely develop hypoglycemia. If they do, causes may include the following:
- Brief intolerance to fasting, often during an illness that disturbs regular eating patterns. Children usually outgrow this tendency by age 10.
- Hyperinsulinism, which is the overproduction of insulin. This condition can result in temporary hypoglycemia in newborns, which is common in infants of mothers with diabetes. Persistent hyperinsulinism in infants or children is a complex disorder that requires prompt evaluation and treatment by a specialist.
- Enzyme deficiencies that affect carbohydrate metabolism. These deficiencies can interfere with the body’s ability to process natural sugars, such as fructose and galactose, glycogen, or other metabolites.
- Hormonal deficiencies such as lack of pituitary or adrenal hormones.
*A personal blood glucose monitor cannot be used to diagnose reactive hypoglycemia.Points to Remember
- When people with diabetes think their blood glucose level is low, they should check it and treat the problem right away.
- To treat hypoglycemia, people should have a serving of a quick-fix food, wait 15 minutes, and check their blood glucose again. They should repeat the treatment until their blood glucose is 70 mg/dL or above.
- People at risk for hypoglycemia should keep quick-fix foods in the car, at work—anywhere they spend time.
- People at risk for hypoglycemia should be careful when driving. They should check their blood glucose frequently and snack as needed to keep their level 70 mg/dL or above.
- In reactive hypoglycemia, symptoms occur within 4 hours of eating. People with reactive hypoglycemia are usually advised to follow a healthy eating plan recommended by a registered dietitian.
- Fasting hypoglycemia can be caused by certain medications, critical illnesses, hereditary enzyme or hormonal deficiencies, and some kinds of tumors. Treatment targets the underlying problem.
This article is for your information only. Dr Ben-Zur recommends consulting your physician prior to making any changes in your diet, exercise or medical program.
Source: American Diabetes Association. Standards of Medical Care in Diabetes—2008. Diabetes Care. 2008;31:S12–S54.
What is diabetes? What causes diabetes?
Diabetes (diabetes mellitus) is classed as a metabolism disorder. Metabolism refers to the way our bodies use digested food for energy and growth. Most of what we eat is broken down into glucose. Glucose is a form of sugar in the blood – it is the principal source of fuel for our bodies.
When our food is digested the glucose makes its way into our bloodstream. Our cells use the glucose for energy and growth. However, glucose cannot enter our cells without insulin being present – insulin makes it possible for our cells to take in the glucose.
Insulin is a hormone that is produced by the pancreas. After eating, the pancreas automatically releases an adequate quantity of insulin to move the glucose present in our blood into the cells, and lowers the blood sugar level.
A person with diabetes has a condition in which the quantity of glucose in the blood is too elevated (hyperglycemia). This is because the body either does not produce enough insulin, produces no insulin, or has cells that do not respond properly to the insulin the pancreas produces. This results in too much glucose building up in the blood. This excess blood glucose eventually passes out of the body in urine. So, even though the blood has plenty of glucose, the cells are not getting it for their essential energy and growth requirements.
Diabetes comes from Greek, and it means a siphon. Aretus the Cappadocian, a Greek physician during the second century A.D., named the condition diabainein. He described patients who were passing too much water (polyuria) – like a siphon. The word became “diabetes” from the English adoption of the Medieval Latin diabetes.
In 1675 Thomas Willis added mellitus to the term, although it is commonly referred to simply as diabetes. Mel in Latin means honey; the urine and blood of people with diabetes has excess glucose, and glucose is sweet like honey. Diabetes mellitus could literally mean “siphoning off sweet water”.
In ancient China people observed that ants would be attracted to some people’s urine, because it was sweet. The term “Sweet Urine Disease” was coined.There are three main types of diabetes:
Diabetes Type 1 – You produce no insulin at all.
Diabetes Type 2 – You don’t produce enough insulin, or your insulin is not working properly.
Gestational Diabetes – You develop diabetes just during your pregnancy.
(World Health Organization)
Diabetes Types 1 & 2 are chronic medical conditions – this means that they are persistent and perpetual. Gestational Diabetes usually resolves itself after the birth of the child.Treatment is effective and important
All types of diabetes are treatable, but Type 1 and Type 2 diabetes last a lifetime; there is no known cure. The patient receives regular insulin, which became medically available in 1921. The treatment for a patient with Type 1 is mainly injected insulin, plus some dietary and exercise adherence.
Patients with Type 2 are usually treated with tablets, exercise and a special diet, but sometimes insulin injections are also required.
If diabetes is not adequately controlled the patient has a significantly higher risk of developing complications, such as hypoglycemia, ketoacidosis, and nonketotic hypersosmolar coma. Longer term complications could be cardiovascular disease, retinal damage, chronic kidney failure, nerve damage, poor healing of wounds, gangrene on the feet which may lead to amputation, and erectile dysfunction.
People can often have diabetes and be completely unaware. The main reason for this is that the symptoms, when seen on their own, seem harmless. However, the earlier diabetes is diagnosed the greater the chances are that serious complications, which can result from having diabetes, can be avoided.
Here is a list of the most common diabetes symptoms:
- Frequent urination
Have you been going to the bathroom to urinate more often recently? Do you notice that you spend most of the day going to the toilet? When there is too much glucose (sugar) in your blood you will urinate more often. If your insulin is ineffective, or not there at all, your kidneys cannot filter the glucose back into the blood. The kidneys will take water from your blood in order to dilute the glucose – which in turn fills up your bladder.
- Disproportionate thirst
If you are urinating more than usual, you will need to replace that lost liquid. You will be drinking more than usual. Have you been drinking more than usual lately?
- Intense hunger
As the insulin in your blood is not working properly, or is not there at all, and your cells are not getting their energy, your body may react by trying to find more energy – food. You will become hungry.
- Weight gain
This might be the result of the above symptom (intense hunger).
- Unusual weight loss
This is more common among people with Diabetes Type 1. As your body is not making insulin it will seek out another energy source (the cells aren’t getting glucose). Muscle tissue and fat will be broken down for energy. As Type 1 is of a more sudden onset and Type 2 is much more gradual, weight loss is more noticeable with Type 1.
- Increased fatigue
If your insulin is not working properly, or is not there at all, glucose will not be entering your cells and providing them with energy. This will make you feel tired and listless.
Irritability can be due to your lack of energy.
- Blurred vision
This can be caused by tissue being pulled from your eye lenses. This affects your eyes’ ability to focus. With proper treatment this can be treated. There are severe cases where blindness or prolonged vision problems can occur.
- Cuts and bruises don’t heal properly or quickly
Do you find cuts and bruises take a much longer time than usual to heal? When there is more sugar (glucose) in your body, its ability to heal can be undermined.
- More skin and/or yeast infections
When there is more sugar in your body, its ability to recover from infections is affected. Women with diabetes find it especially difficult to recover from bladder and vaginal infections.
- Itchy skin
A feeling of itchiness on your skin is sometimes a symptom of diabetes.
- Gums are red and/or swollen – Gums pull away from teeth
If your gums are tender, red and/or swollen this could be a sign of diabetes. Your teeth could become loose as the gums pull away from them.
- Frequent gum disease/infection
As well as the previous gum symptoms, you may experience more frequent gum disease and/or gum infections.
- Sexual dysfunction among men
If you are over 50 and experience frequent or constant sexual dysfunction (erectile dysfunction), it could be a symptom of diabetes.
- Numbness or tingling, especially in your feet and hands
If there is too much sugar in your body your nerves could become damaged, as could the tiny blood vessels that feed those nerves. You may experience tingling and/or numbness in your hands and feet.
Diabetes can often be detected by carrying out a urine test, which finds out whether excess glucose is present. This is normally backed up by a blood test, which measures blood glucose levels and can confirm if the cause of your symptoms is diabetes.
If you are worried that you may have some of the above symptoms, you are recommended to talk to your Doctor or a qualified health professional.Type 1 diabetes
Type 1 diabetes is an autoimmune disease – the person’s body has destroyed his/her own insulin-producing beta cells in the pancreas.
People with Diabetes Type 1 are unable to produce insulin. Most patients with Diabetes Type 1 developed the condition before the age of 40. Approximately 15% of all people with diabetes have Type 1.
Type 1 diabetes is fatal unless the patient regularly takes exogenous insulin. Some patients have had their beta cells replaced through a pancreas transplant and have managed to produce their own insulin again.
Type 1 diabetes is also known as juvenile diabetes or childhood diabetes. Although a large number of diabetes Type 1 patients become so during childhood, it can also develop after the age of 18. Developing Type 1 after the age of 40 is extremely rare.
Type 1, unlike Type 2, is not preventable. The majorities of people who develop Type 1 are of normal weight and are otherwise healthy during onset. Exercise and diet cannot reverse Type 1. Quite simply, the person has lost his/her insulin-producing beta cells. Several clinical trials have attempted to find ways of preventing or slowing down the progress of Type 1, but so far with no proven success.
A C-peptide assay is a lab test that can tell whether somebody has Type 1 or Type 2. As external insulin has no C-peptide a lack of it would indicate Type 1. The test is only effective when ALL the endogenous insulin has left the body – this can take several months.
A person with Type one will have to watch what he/she eats. Foods that are low in fat, salt and have no or very little added sugar are ideal. He/she should consume foods that have complex carbohydrates, rather than fast carbohydrates, as well as fruits and vegetables. A diet that controls the person’s blood sugar level as well as his/her blood pressure and cholesterol levels will help achieve the best possible health. Portion size is also important in order to maintain a healthy bodyweight.
Meal planning needs to be consistent so that the food and insulin can work together to control blood glucose levels. According to the Mayo Clinic there is no ‘diabetes diet’.
The Clinic says you do not need to restrict yourself to boring bland foods. Rather you should, as mentioned above, consume plenty of fruits, vegetables and whole grains – foods that are highly nutritious, low in fat, and low in calories. Even sugary foods are acceptable now and again if you include them in your food plan.
If you have Type 1 you should seek the help of a registered dietitian. A dietitian can help you create a food plan that suits you. Most dietitians agree that you should aim to consume the same quantity of food, with equal portions of carbs, proteins and fats at the same time each day. Complications – the bad news and the good news
A person with Type 1 has a two to four times higher risk of developing heart disease, stroke, high blood pressure, blindness, kidney failure, gum disease and nerve damage, compared to a person who does not have any type of diabetes.
A person with Type 1 is more likely to have poor blood circulation through his/her legs and feet. If left untreated the problem may become such that a foot has to be amputated. A person with Type 1 will likely go into a coma if untreated.
The good news is that treatment is available and it is effective and can help prevent these complications from happening.
Keep your blood pressure under 130/80 mm Hg.
Keep your cholesterol level below 180 mg.
Check your feet every day for signs of infection.
Get your eyes checked once a year.
Get your dentist to check your teeth and gums twice a year.
Before starting exercise make sure your doctor tells you it is OK. Try to make physical activity part of your daily life. You should try to do at least 30 minutes of exercise or physical activity each day. Physical activity or exercise means aerobic exercise.
If you have not done any exercise for a while, start gently and build up gradually. Physical activity helps lower your blood sugar. Remember that exercise is good for everybody, not just people with Type 1.
The benefits are enormous for your physical and mental health. You will become stronger, fitter, your sleep will improve as will your skin tone – and after some time you will look great!
Exercise will help your circulation – helping to make sure your lower legs and feet are healthy.
Remember to check your blood sugar level more frequently during your first few weeks of exercise so that you may adapt your meal plans and/or insulin doses accordingly. Remember that a person with Type 1 has to manually adjust his/her insulin doses – the body will not respond automatically.
“Gary Hall won an Olympic gold medal in swimming.
He had Type 1 diabetes.”
A person with diabetes type 2 either:
- Does not produce enough insulin. Or
- Suffers from ‘insulin resistance’. This means that the insulin is not working properly.
The majority of people with Type 2 have developed the condition because they are overweight. Type 2 generally appears later on in life, compared to Type 1. Type 2 is the most common form of diabetes.
In the case of insulin resistance, the body is producing the insulin, but insulin sensitivity is reduced and it does not do the job as well as it should do. The glucose is not entering the body’s cells properly, causing two problems:
- A build-up of glucose in the blood.
- The cells are not getting the glucose they need for energy and growth.
In the early stages of Type 2 insulin sensitivity is the main abnormality – also there are elevated levels of insulin in the blood. There are medications which can improve insulin sensitivity and reduce glucose production by the liver.
As the disease progresses the production of insulin is undermined and the patient will often need to be given replacement insulin.
“Excess abdominal fat is much more likely to bring on Type 2 Diabetes than excess fat under your skin”
Many experts say that central obesity – fat concentrated around the waist in relation to abdominal organs – may make individuals more predisposed to develop Type 2 diabetes.
Central obesity does not include subcutaneous fat – fat under the skin. The fat around your waist – abdominal fat – secretes a group of hormones called adipokines. It is thought that adipokines may impair glucose tolerance.
The majority of people who develop diabetes Type 2 were overweight during the onset, while 55% of all Type 2 patients were obese during onset.
“Sometimes all the patient needs is to do more exercise,
lose weight and eat fewer carbs”
It is not uncommon for people to achieve long-term satisfactory glucose control by doing more exercise, bringing down their bodyweight and cutting down on their dietary intake of carbohydrates.
However, despite these measures, the tendency towards insulin resistance will continue, so the patient must persist with his/her increased physical activity, monitored diet and bodyweight.
If the diabetes mellitus continues the patient will usually be prescribed orally administered anti-diabetic drugs. As a person with Type 2 does produce his/her own insulin, a combination of oral medicines will usually improve insulin production, regulate the release of glucose by the liver, and treat insulin resistance to some extent.
If the beta cells become further impaired the patient will eventually need insulin therapy in order to regulate glucose levels.
Age and ethnicity. The older you are the higher your risk is, especially if you are over 40 (for white people), and over 25 (for black, South Asian and some minority groups). It has been found in the UK that black people and people of South Asian origin have five times the risk of developing Type 2 compared to white people.
Diabetes in the family. If you have a relative who has/had diabetes your risk might be greater. The risk increases if the relative is a close one – if your father or mother has/had diabetes your risk might be greater than if your uncle has/had it.
Bodyweight (and inactivity combined with bodyweight). Four-fifths of people who have Type 2 became so because they were overweight. The more overweight a person is the higher his/her risk will be. The highest risk is for a person who is overweight and physically inactive. In other words, if you are very overweight and do not do any exercise your risk is greatest.
Cardiovascular problems and stroke. A person who has had a stroke runs a higher risk of developing Type 2. This is also the case for people who suffer from hypertension (high blood pressure), or have had a heart attack. Any diagnosis of a problem with circulation indicates a higher risk of developing Type 2.
Gestational Diabetes. A woman who became temporarily diabetic during pregnancy – gestational diabetes – runs a higher risk of developing Type 2 later on. Women who give birth to a large baby may run a higher risk, too.
Impaired fasting glycaemia (IFG) – Impaired glucose tolerance (IGT). A person who has been diagnosed as having impaired fasting glycaemia or impaired glucose tolerance and does not have diabetes runs a significantly higher risk of eventually developing Type 2. People with IFG or IGT have higher than normal levels of glucose in their blood. In order to prevent diabetes it is crucial that you eat healthily, keep an eye on your weight and do exercise.
Severe mental health problems. It has been found that people with severe mental health problems are more likely to develop Type 2.
A long time ago
Before insulin was discovered in 1921 Diabetes Type 1 was a fatal disease – most patients would die within a few years of onset. Things have changed a great deal since then.
You can lead a normal life
If you have Type 1 and follow a healthy eating plan, do adequate exercise, and take insulin, you can lead a normal life.Balance insulin intake with food and lifestyle
The quantity of insulin intake must be closely linked to how much food you consume, as well as when you eat. Your daily activities will also have a bearing on when and how much insulin you take.Checking your blood glucose levels
A person with diabetes has to have his/her blood glucose levels checked periodically. There is a blood test called the A1C which tells you what your average blood glucose levels were over a two-to-three month period.
Type 2 patients need to eat healthily, be physically active, and test their blood glucose. They may also need to take oral medication, and/or insulin to control blood glucose levels.
Prevent developing cardiovascular disease
As the risk of cardiovascular disease is much higher for a diabetic, it is crucial that blood pressure and cholesterol levels are monitored regularly.
Healthy eating, doing exercise, keeping your weight down will all contribute towards good cardiovascular health – some patients will need oral medication for this.Stop smoking!
As smoking might have a serious effect on the cardiovascular health the patient should stop smoking.A health care provider
A health care professional (HCP) will help the patient learn how to manage his/her diabetes. The HCP will also monitor the diabetes control. It is important that you know what to do and that a professional is helping and monitoring the management of your diabetes.
In most countries the GP (general practitioner, primary care physician, family doctor) provides this regular care. There are also diabetitians, endocrinologists, cardiologists, nurses, internists, pediatricians, dietitians, podiatrists, ophthalmologists, optometrists, sports specialists and many others.
If a diabetes patient is pregnant she should see an obstetrician who specializes in diabetes (gestational diabetes). There are pediatricians who specialize in caring for the infants of diabetic mothers.
The main aim of diabetes management is to keep the following under control:
- Blood glucose levels
- Blood pressure
- Cholesterol levels
The patient will need to make sure his/her blood glucose levels do not fluctuate too much.
Hypoglycemia – low blood glucose – can have a bad effect on the patient. Hypoglycemia can cause:
- Palpitations, Tachycardia
- Feeling hot, sweating
- Feeling cold
- Abdominal discomfort
- Numbness, pins and needles
- Depression, moodiness
- Apathy, Tiredness, Fatigue, Daydreaming
- Bad coordination, slurred speech
Hyperglycemia – when blood glucose is too high – can also have a bad effect on the patient. Hyperglycemia can cause:
- Polyphagia – frequently hungry
- Polydipsia – frequently very thirsty
- Polyuria – frequent urination
- Blurred vision
- Extreme tiredness
- Weight loss
- Cuts and scrapes will heal slowly and badly
- Dry mouth
- Dry or itchy skin
- Erectile dysfunction (impotence)
- Recurrent infections
- Kussmaul hyperventilation: deep and rapid breathing
- Cardiac arrhythmia
Monitoring your own glucose is done with a Glucose Meter. Self-monitoring is often called SMBG (self-monitoring of blood glucose). Glucose meters today are small, battery-operated devices.A sample of blood
When you want to test for glucose with a glucose meter you need to place a small sample of your blood on a test strip. Your skin is pricked with a lancet – like a very fast pin-prick.
These test strips are disposable. You then place the strip in the monitor. The strips are coated with glucose dehydrogenase or hexokinase that combines with glucose in blood.
The blood is usually taken from a finger, but some meters allow the use of other parts of the body to supply the blood sample.
The meter tells you how much glucose is present in your blood. How meters do this may vary. With some meters a measurement of the amount of electricity that passes through your blood sample is measured, while others measure the degree of reflection of light. The glucose level is displayed as a number. In the case of this picture (below right) the person’s glucose level is low. Many of the new meters can store a series of test results, while others can be connected to your personal computer to store results, which you can also print out.How to choose a glucose meter
According to the FDA there are 25 different meters on the market. They are not all the same. You should bear the following in mind when choosing one:
- Testing speed
- Memory (ability to store results)
The newer models have automatic timing, error codes and signals, barcode readers to help with calibration. Some have spoken instructions for people who are visually impaired.Using your meter
Frequency of meter usage varies significantly from patient-to-patient. It is important that you adhere to the instructions given to you from your health care provider. Every person with diabetes should be self-monitoring his/her blood glucose – this is especially so for people who are taking insulin.
According to the American Diabetes Association (ADA), patients with Type 1 should self-monitor blood glucose at least three times per day.
The ADA says that women with gestational diabetes (diabetes during pregnancy) should self-test twice a day.
There is no general recommendation from the ADA regarding frequency of self-testing for Type 2 patients.
Most patients who do have to self-test will generally have to do so before meals, a couple of hours after meals, at bedtime, 3.a.m., and whenever signs or symptoms are felt.
When a patient changes medication testing should be carried out more frequently.
If you have an unusual illness or sudden stress, you should test more frequently.
As meters work in different ways you should get training from a diabetes educator.Using a glucose meter – instructions
- Wash your hands with warm water and soap. Dry completely. You could also dab or wipe the area with alcohol and then dry completely.
- Use the lancet to prick your fingertip.
- Hold your hand down. Hold your finger at the same time until you see a small droplet of blood appear.
- Place the blood on the test strip.
- Follow the instructions for placing the test strip and using your meter.
- Keep a record of your result.
Many regulatory authorities, such as the FDA, require that meters and test strips come with instructions. It is important that you become familiar with these instructions, which should be included in the User Manual. Some meters give out an error code if something is wrong. Checking the User Manual will tell you what the error code means.
In many countries the User Manual will have a toll free number. If you call and cannot get through call your health care provider or your local emergency room. Check out the website of the manufacturer. The FDA advises patients to visit the manufacturer’s website regularly for any updates or issues.
Three things will have a major impact on your blood glucose and blood lipids (cholesterol, triglycerides) levels
- What you eat
- How much you eat
- When you eat
By selecting the right types of foods, as well as appropriate quantities you can significantly improve your ability to control your blood glucose and blood lipids.What does healthy eating mean?
Healthy eating most certainly does not mean you will go hungry and have to spend much of your life desperately trying to resist temptation. You can still consume the food you like. All it means is that you will have to be much more aware of how much carbohydrate, fat and protein you consume each time you eat. You just have to get the balance right.Carbohydrates
Carbohydrates are most abundantly found in fruit, vegetables, yoghurt, sweets, pasta and bread.
Our body needs carbohydrates; we cannot live without them. When consumed, our bodies turn the carbohydrate into blood glucose – glucose is needed by our cells for energy and growth.
If you consume the same amount of carbohydrates each time you eat – especially if those times are at the same time each day – you will be well on your way towards controlling your blood glucose.
It is important that you do not skip meals, no matter what your blood glucose readings indicate. All you will achieve by skipping meals is a more aggressive fluctuation in your blood glucose levels – something you want to try to avoid.
If your consumption of glucose can follow a regular pattern, it will be easier for you to balance food with your medicine(s) and physical activity with optimum blood glucose control.
A varied and moderated diet is ideal if you want to enjoy good health. Your carbohydrate intake should consist of a variety of grains, fruits and vegetables. They have plenty of fiber – fiber helps control blood glucose.
Remember that brown rice has more fiber than white rice; whole-grain breads have the most fiber. If you are cooking or baking, opt for whole-wheat or whole grain flours. Include pulses, such as beans; they are a great source of fiber. Dark green leafy vegetables and dark yellow ones have a slower release of carbohydrates than most other vegetables.
According to the Mayo Clinic, your daily intake of calories should consist of:
- Carbohydrates 45% to 65%
- Proteins 15% to 20%
- Fats 20% to 35%
If you adhere to your meal plan for portion sizes and eating times you should eat the same mix of carbohydrates, proteins and fats each day. Your blood sugar control will be ideal, as will your weight. The more you vary from your food plan, the Mayo Clinic informs, the more your blood glucose will fluctuate.The rewards will be worth it
The ideal eating pattern for a person with diabetes is not really any different from what a non-diabetic person would do if he/she aimed for optimum health and fitness. However, the diabetes patient has the added incentive of trying to prevent complications from developing, such as cardiovascular disease, kidney problems, vision problems and leg and feet sores.
Foods on offer for a diabetes patient are extensive and varied. You will be able to plan a wide range of tasty and interesting meals.The food pyramid
When you talk to your health care professional, diabetes educator or dietician, they will probably mention the Food Pyramid.
At the base there are foods rich in carbohydrates, such as grains, then there are fruit and vegetables.
Above are meat, fish, milk and cheese; which are rich in protein. At the top are the fatty foods.
Almost all diabetes and medical associations say that you should eat more from the groups at the bottom of the pyramid, and less from those at the top.
It is vital that you talk to an expert about your eating plan. It needs to be tailored according to your weight, age, which medications you are taking and how physically active you are (and, if so, when during the day you are likely to be the most active).
Not all carbohydrates are the same. The Glycemic Index (GI) describes what effect certain foods can have on our blood glucose levels. A high GI tends to cause more blood glucose fluctuations than a low one. Ask your dietician.How is diabetes managed? – physical activity, exercise
Physical activity Is crucial for a person with diabetes
- it helps control your blood glucose
- it helps keep your weight down
- it helps keep your blood pressure down
- it helps raise your HDL (High-density lipoprotein), good cholesterol levels
- it helps lower your LDL (Low-density lipoprotein), bad cholesterol levels
These five benefits have a DIRECT bearing on how successfully you manage your diabetes. Exercise also has other general health benefits – you sleep better, your mental state improves, etc.How much exercise should you do?
Most experts say you should do exercise on at least five days of each week. Each session should be of moderate-intensity and should not last less than thirty minutes. The following activities could be classed as of moderate-intensity:
- fast walking
- cycling 5-9mph (level terrain, perhaps some slight hills)
- mowing the lawn
- You should experience some increase in your breathing rate
- There should be an increase in your heart rate
- A Borg Scale perceived exertion of 11 to 14
- You should burn 3.5 to 7 calories per minute
- You should reach a METs of 3 to 6
MET stands for Metabolic Equivalent. An MET of 1 is when you are sitting down doing nothing. If you walk slowly your MET may rise to 2 or 2.5. If you walk normally it will go up to 3, while a brisk walk may bring it to 5. If a wild gorilla suddenly appeared in the street and started chasing you your desperate sprint would shoot your MET right up to about 8 or even perhaps 9.Beginners be careful!
If you have not done exercise for a long time you will need to start with a little light exercise and build up slowly over time. Each week add a little more time to each session and/or increase the intensity.
Remember regular exercise is what matters. 5 days of 30 minutes each is great. One day per week at 150 minutes is not.
You must talk to your health care provider about an exercise plan. He/she may want to check you over before you start. Certain exercises are not ideal for patients who suffer from high blood pressure, eye and/or foot problems.
Strength training is also good
The Centers for Disease Control and Prevention (CDC) says that strength training exercises are good because they help you build muscle. Strength training usually involves using weights.Join a gym
There are many gyms today whose staff are experienced and qualified to receive and train people for various illnesses and conditions. In North America, Western Europe, Japan and Australasia gyms receive doctors’ referrals – doctors send them to specific gyms as part of their therapy.
Having somebody there to help you along, occasionally to push you along, can be a great motivator – especially for beginners who may view the whole experience with apprehension.
Gyms are all-weather; they have equipment which gives you immediate feedback on how well you are doing – your speed, heart rate, calories burnt per minute/hour, your progress, etc.
Numerous people prefer gyms because it gives them a feeling of doing something with others. Do not be afraid of joining one. They are generally welcoming and members will not be concerned about what you look like or how unfit you may be – they are there for their health, just like you.
Hypoglycemia is sometimes called insulin reaction. It is when your blood glucose is too low. Even though you may do all you can to manage your diabetes, hypoglycemia can happen, and it can and must be treated before it gets worse.
If you remember to check your blood glucose when your doctor tells you to, your chances of experiencing hypoglycemia are much lower. Also, a low blood glucose result will tell you that you need to treat it.
If you feel the symptoms of hypoglycemia you should check your blood glucose. If the reading tells you that your blood glucose is low, you should treat it immediately.
The American Diabetes Association (ADA) says that if you feel a hypoglycemic reaction but cannot check your blood glucose it is better to treat the reaction than to wait till you can check.
You need to raise your blood glucose. The fastest way to do this is to eat some form of sugar. The ADA advises:
- Take 3 glucose tablets (easily bought)
- 1/2 a cup of fruit juice
- 5 to 6 pieces of hard candy (UK ‘sweets’)
You should ask your dietitian or health care professional for more advice on what you could eat to treat hypoglycemia.
Make sure you always carry at least one type of sugar with you so that you are prepared.Check blood glucose, treat It and wait 20 minutes
After you have checked your blood glucose and treated the hypoglycemia wait between 15 to 20 minutes and check your blood glucose again. If your blood glucose is still low repeat the whole process – eat some glucose, wait about 15-20 minutes and check your blood glucose again.
Remember to stick to your eating times – your regular meals and snacks are vital for keeping your blood glucose levels as stable as possible. Hypoglycemia can affect all the organs in your body, especially your brain.
Hypoglycemia, if not treated quickly gets worse rapidly and the patient will soon pass out.
A patient who passes out because of hypoglycemia will need immediate treatment – probably a glucagon injection, or an emergency visit to a hospital.
Glucagon is injected, just like insulin is. However, glucagon raises blood glucose.
You should ask your doctor to make sure you have some.
It is possible, and not very unusual, for a person to pass out and never have noticed they had been suffering from hypoglycemia. This is known as hypoglycemia unawareness. The patient’s blood glucose drops and he/she is not aware of it.
Hypoglycemia unawareness is more common among patients who have lived with diabetes for a long time, those with nerve damage (neuropathy), patients on medication for hypertension (high blood pressure) and those on tight glucose control.
- Tingling sensation around the mouth
- Lightheadedness, dizziness
- Trembling, shakiness
- Pallid skin (you go pale)
- Irritability, moodiness, you might become tearful
- Seizure (you have a fit, spasm)
- Absent mindedness
- Strong desire to eat
Hyperglycemia is when your blood glucose is too high; it is the opposite of hypoglycemia. Hyperglycemia needs to be treated immediately as it is a major cause of complications among people with diabetes.
Hyperglycemia happens when there is no insulin in the blood, not enough insulin in the blood, or the insulin in the blood is not working properly.
The main reason for hyperglycemia for a patient who is being treated for diabetes type 1 is that he/she has not given himself enough insulin. For a type 2 diabetic it could be the same reason, but also his/her insulin is less effective than it should be.
For a patient with diabetes, overeating can bring on hyperglycemia, as can too little exercise on a given day. Mental stress can also bring it on. Remember that your body’s supply of insulin is determined by how much you give yourself, and when. For a person who does not have diabetes his/her body will respond automatically with appropriate quantities of insulin.
- High blood glucose
- High levels of sugar in the urine
- Very hungry, hungry often (polyphagia)
- Excessive thirst, frequent thirst (polydipsia)
- Excessive and frequent urination (polyuria)
- Blurred vision – Weight loss
- Wounds and cuts heal poorly
- Dry mouth
- Cardiac arrhythmia
- Deep and rapid breathing (kussmaul hyperventilation)
- Impotence (erectile dysfunction)
- Itchy and/or dry skin
Your doctor will tell you what your glucose levels should be and how often you should check it. If you stick to good diabetes management practices your chances of experiencing hyperglycemia are significantly reduced.Ketoacidosis
As soon as you detect hyperglycemia, treat it immediately. People who experience hyperglycemia and do not treat it run a significantly high risk of going into diabetic coma (ketoacidosis).
Ketoacidosis happens when there is not enough insulin in your blood. Remember that without the insulin your cells cannot get the vital fuel (energy) they need. Your body starts breaking down fats to get its energy. This process of breaking down fats produces ketones – waste products. Large amounts of ketones are bad for you. Excess ketones in your blood will result in frequent urination as your body tries to eliminate it. However, it eventually becomes a losing battle, with the build up of ketones happening faster than their elimination through urination.
- your breath smells fruity
- nausea and sometimes vomiting
- your mouth is extremely dry
- you are short of breath
The American Diabetes Association says exercising can help lower blood glucose levels. If your blood glucose is above 240mg/dl. Check your urine for ketones and do not exercise if there are ketones present as this will raise your blood glucose levels even more!
Reducing your food intake will also help lower your blood glucose. It is important that you stick to your meal plan, which should be worked out with a dietitian or health care professional.
Ask your doctor for the best way to lower blood glucose levels.
If none of the measures mentioned above manages to lower your blood glucose it is possible that your medication may have to be re-scheduled. Your insulin and medication doses may need to be altered, as might their timing (when you have them).
Remember that good diabetes management helps reduce the incidence of hyperglycemia. Learn to detect hyperglycemia quickly so that you can treat it early on.
You cannot take insulin as a pill. If you did, the moment it got to your stomach it would be digested and would never get into your bloodstream.
You have to inject insulin into the fat just under your skin – from there it will get to your bloodstream.
There are many types of insulin. According to the American Diabetes Association (ADA) there are over 20 types of insulin in the American market. They work in different ways, they are made differently, and they vary in price.
Insulin is most commonly made in laboratories today. It can also come from animals, mainly pigs.
This type of human insulin starts to work within five minutes of being injected and peaks after about one hour. It continues to be active for 2 to 4 hours. Examples of rapid-acting insulin are lispro marketed by Eli Lilly, insulin aspart marketed by Novo Nordisk, or insulin glulisine marketed by sanofi-aventis.Short-acting insulin
Also known as Regular (acting) insulin. This type of human insulin reaches your bloodstream approximately 30 minutes after you inject it, and peaks from 2 to 3 hours after injection. It is effective for 3 to 6 hours.
This human insulin takes from 2 to 4 hours to reach the bloodstream after injection. It peaks at 4 to 12 hours. It is effective for approximately 12 to 18 hours.Long-acting insulin
This insulin gets into your bloodstream about 6 to 10 hours after you inject it. It is effective for 20 to 24 hours. This type of insulin is also known as ultralente.Pre-mixed insulin
Some patients have to mix two different types of insulin. If they find that difficult they can have the insulin pre-mixed. This is especially useful for people who are visually impaired.Allergic reaction to insulin additives
The insulin a diabetic takes has additives to keep it free of bacteria and to tweak its time of action. Some patients may have an allergic reaction to some additives found in intermediate and long-acting insulins – however, this is very rare.
Diabetes treatment – insulin pump
Insulin pumps are mostly used by people with Diabetes Type 1. However, more and more people with Type 2 are starting to use them.
Users say that the pump allows them to get the treatment to adapt to them, instead of the other way round as is the case with insulin injections.
An Insulin Pump really can help you maintain your blood glucose levels with specific parameters.
The pump delivers short (rapid) acting insulin, around the clock, through a catheter placed under your skin. It separates your insulin dosage into the basal rate and the bolus dose.Basal insulin
This is your normal level of blood insulin when you have not eaten or when you are asleep. Basal insulin is delivered constantly throughout the day and night. It is possible to set the pump so that amounts vary, depending on what time of day and night it is.Bolus (extra)
When you eat your blood will need more insulin. You press buttons on the insulin pump which will give you a bolus – additional insulin. The bolus covers your increased insulin requirement because you have consumed carbohydrate.
If your blood glucose is too high you can take a bolus to bring it back down again.
Most people simply attach the pump to their belt or waistband using a clip or case. You can also keep it in your pocket.
If you are wearing a dress you could attach it to your arm or leg under your clothes.
When sleeping many people place the pump next to them on the bed, place it under the pillow or attach it to their clothing.
Pump manufacturers say the pump is very rugged and will withstand being dropped on the floor or the occasional soaking. However, you should try to avoid that from happening.
- No more injections
- The pump is more accurate
- They improve A1C
- Blood glucose levels fluctuate less badly
- Easier diabetes management
- More leeway on your eating times
- More leeway on what you eat
- You can exercise without eating loads of carbs
This information is only for you. Always follow your healthcare provider’s instructions for taking medicines. Do not miss any doses, do not take less medicine, and do not stop taking medicine without talking to your provider first. It can be dangerous to suddenly stop taking blood pressure medicine. Also, do not increase your dosage of any medicine without first talking with your provider.
- Ask your healthcare provider or pharmacist for information about the drugs you are taking.
- Ask your provider about nonprescription medicines and supplements before you take them.
Diabetes in African Americans?
Today, diabetes mellitus is one of the most serious health challenges facing the more than 30 million African Americans. The following statistics illustrate the magnitude of this disease among African Americans.
- In 1993, 1.3 million African Americans were known to have diabetes. This is almost three times the number of African Americans who were diagnosed with diabetes in 1963. The actual number of African Americans who have diabetes is probably more than twice the number diagnosed because previous research indicates that for every African American diagnosed with diabetes there is at least one undiagnosed case.
- For every white American who gets diabetes, 1.6 African Americans get diabetes.
- One in four black women, 55 years of age or older, has diabetes. (Among African Americans, women are more likely to
- Twenty-five percent of blacks between the ages of 65 and 74 have diabetes.
- African Americans with diabetes are more likely to develop diabetes complications and experience greater disability from the complications than white Americans with diabetes.
How Many African Americans Have Diabetes?
National Health Interview Surveys (NHIS) conducted between 1963 and 1990 show that African Americans have a rising prevalence of diabetes. (Prevalence is the percentage of cases in a population.) Most African Americans with diabetes have Type 2, or noninsulin-dependent diabetes. Type 2 diabetes usually develops after age 40. However, in high-risk populations, susceptible people may develop it at a younger age. A small number of African Americans have Type I or insulin-dependent diabetes, which usually develops before age 20.
NHIS conducted from 1991 to 1992 indicate higher rates of diabetes among African Americans than among white Americans. At age 45 or older, the prevalence of diabetes is 1.4 to 2.3 times as frequent in blacks as in whites. The greatest difference seen in NHIS was among people aged 65 to 74. Figure 1 details these 1991-92 NHIS statistics. Statistics collected in 1993 indicate that in this age group, 17.4 percent of black Americans had diagnosed diabetes, compared to 9.5 percent of white Americans.Juvenile Onset Type 1 Diabetes Mellitus?
What is it?
Type 1 diabetes is a complex disorder caused by the body’s inability to produce insulin. Insulin is a hormone manufactured and secreted by the pancreas. Specifically, it is produced by cells called beta cells, which are located in a region of the pancreas called the islets of Langerhans. Insulin is essential for the cells of your body to metabolize glucose properly and function normally.
Type 1 diabetes accounts for only 5 percent to 10 percent of all cases of diabetes. The other forms are type 2 diabes and gestational diabetes. Type 1 diabetes has also been known as insulin-dependent mellitus (IDDM), juvenile onset diabetes mellitus, ketosis-prone diabetes mellitus and immune-mediated diabetes. It usually begins in childhood or adolescence, but is a lifelong disease, since there is no cure. However, effective treatment allows most people with type 1 diabetes to live long lives.
Type 1 diabetes is an autoimmune disease that affects 0.3% of the world’s population. It is caused by autoaggressive T cells that infiltrate the pancreas and eventually destroy the insulin-producing B-islet cells. This results in an increase in glucose levels, which are normally kept in check by insulin. Autoimmune diabetes usually affects young people, who are then dependent on an artificial source of insulin for life. The identity of the self proteins in the pancreatic islets that target the cells for autoimmune destruction has long been debated. Yoon, et al, report a real breakthrough in understanding the etiology of type 1 diabetes. They showed that a single self protein expressed by B-islet cells, glutamic acid, decarboxylase (GAD), controls the development of diabetes in the nonobese mouse diabetic (NOD) mouse (a good animal model of human type 1 diabetes.
Type 1 diabetes has a prevalence rate of approximately 8% in African-Americans.Type 2 Diabetes
What Risk Factors Increase the Chance of Developing Type 2 Diabetes?
The frequency of diabetes in black adults is influenced by the same risk factors that are associated with Type 2 diabetes in other populations. Three categories of risk factors increase the chance of developing Type 2 diabetes in African Americans. The first is genetics, which includes inherited traits and group ancestry. The second is medical risk factors, including impaired glucose tolerance, hyperinsulinemia and insulin resistance, and obesity. The third is lifestyle risk factors, including physical activity.Genetic Risk Factors
Researchers suggest that African Americans and recent African immigrants to America have inherited a “thrifty gene” from their African ancestors. Years ago, this gene enabled Africans, during “feast and famine” cycles, to use food energy more efficiently when food was scarce. Today, with fewer “feast and famine” cycles, the thrifty gene that developed for survival may instead make weight control more difficult. This genetic predisposition, along with impaired glucose tolerance (IGT), often occurs together with the genetic tendency toward high blood pressure.
African-American ancestry is also an important predictor of the development of diabetes. To understand how rates of diabetes vary among African Americans, it is important to look at the historical origins of black populations in America. Genetic predisposition to diabetes is based, in part, on a person’s lineage. The African-American population formed from a genetic ad-mixture across African ethnic groups and with other racial groups, primarily European and North American Caucasian.
Impaired Glucose Tolerance (IGT)
People with IGT have higher-than-normal blood glucose levels but not high enough to be diagnosed as diabetes. Some argue that IGT is actually an early stage of diabetes. African-American men and women differ in their development of IGT. As black men grow older, they develop IGT at about the same rates as white American men and women. African-American women, who have higher rates of diabetes risk factors, convert more rapidly from IGT to overt diabetes than black men and white women and men.
Hyperinsulinemia and Inssulin Resistance
Higher-than-normal levels of fasting insulin, or hyperinsulinemia, are associated with an increased risk of developing Type 2 diabetes. It is known that hyperinsulinemia often predates diabetes by several years. One study showed a higher rate of hyperinsulinemia in African-American adolescents in comparison to white American adolescents. To date, insufficient information is available on the relationship between insulin resistance or hyperinsutinemia and the development of Type 2 diabetes in African Americans.
Obesity is a major medical risk factor for diabetes in African Americans. The National Health and Nutrition Survey (NHANESII), conducted between 1976 and 1980, showed substantially higher rates of obesity in African Americans aged 20 to 74 years of age who had diabetes, compared to those who did not have diabetes. NHANESII also showed higher rates of obesity among African-American women and men than white Americans without diabetes. (See figure 2.)
Some recent evidence shows that the degree to which obesity is a risk factor for diabetes may depend on the location of the excess weight. Truncal, or upper body obesity, is a greater risk factor for Type 2 diabetes, compared to excess weight carried below the waist. One study showed that African Americans have a greater tendency to develop upper-body obesity, which increases their risk of Type 2.
Although African Americans have higher rates of obesity, researchers do not believe that obesity alone accounts for their higher prevalence of diabetes. Even when compared to white Americans with the same levels of obesity, age, and socioeconomic status, African Americans still have higher rates of diabetes. Other factors, yet to be understood, appear to be at work.Lifestyle Risk Factors
Physical activity is a strong protective factor against Type 2 diabetes. Researchers suspect that a lack of exercise is one factor contributing to the unusually high rates of diabetes in older African-American women.
How Does Diabetes Affect African-American Young People?
African-American children have lower rates of Type 1 diabetes than white American children. The prevalence of Type 1 diabetes in white American children aged 15 and younger is nearly twice as high as in African-American children of the same age.
Researchers tend to agree that genetics probably makes Type 1 diabetes more common among children with European ancestry. In fact, African-American children with some European ancestry have slightly higher prevalence of Type I diabetes. T’his incidence is also influenced by environmental and lifestyle factors.
How Does Diabetes Affect African-American Women During Pregnancy?
Gestational diabetes, which develops in about 2 to 5 percent of all pregnant women, usually resolves after childbirth. Several studies have shown that African-American women have a higher rate of gestational diabetes. An Illinois study showed an 80 percent higher incidence of gestational diabetes in African Americans compared with white women. Once a woman has had gestational diabetes, she has an increased risk of developing gestational diabetes in future pregnancies. In addition, experts estimate that about half of women with gestational diabetes regardless of race develop Type 2 diabetes within 20 years of the pregnancy.
How Do Diabetes Complications Affect African Americans?
Compared to white Americans, African Americans experience higher rates of three diabetes complications – blindness, kidney failure, and amputations. They also experience greater disability from these complications. Some factors that influence the frequency of these complications, such as delay in diagnosis and treatment of diabetes, denial of diabetes, abnormal blood lipids, high blood pressure, and cigarette smoking, can be influenced by proper diabetes management.Kidney Failure
African Americans experience kidney failure, also called end-stage renal disease (ESRD), from 2.5 to 5.5 times more often than white Americans. Interestingly though, hypertension, not diabetes, is the leading cause of kidney failure in black Americans. Hypertension accounts for almost 38 percent of ESRD cases in African Americans, whereas diabetes causes 32.5 percent. In spite of their high rates of the disease, African Americans have better survival rates from kidney failure than white Americans.Visual Impairment
The frequency of severe visual impairment is 40 percent higher in African Americans with diabetes than in white Americans. Blindness caused by diabetic retinopathy is twice as common in blacks as in whites. Compared to white women, black women are three times more likely to become blind from diabetes. African-American men have a 30 percent higher rate of blindness from diabetes than white American men. Diabetic retinopathy may occur more frequently in black Americans than whites because of their higher rate of hypertension.Amputations
African Americans undergo more diabetes-related lower-extremity amputations than white or Hispanic Americans. One study of 1990 U.S. hospital discharge figures showed amputation rates for African Americans with diabetes were 19 percent higher than for white Americans. In a 1991 California study, however, African Americans were 72 percent more likely to have diabetes-related amputations than white Americans, and 117 percent more likely than Hispanic Americans.
Does Diabetes Cause Excess Deaths in African Americans?
Diabetes was an uncommon cause of death among African Americans at the turn of the century. By 1993, however, according to the Centers for Disease Control and Prevention’s National Center for Health Statistics, death certificates listed diabetes as the fifth leading cause of death for African Americans aged 45 to 64, and the third leading cause of death for those aged 65 and older in 1990. Diabetes is more dangerous for African-American women, for whom it was the third leading cause of death for all ages in 1990.
Diabetes death rates may actually be higher than these studies show for two reasons. First, diabetes might not have been diagnosed. Second, many doctors do not list diabetes as a cause of death, even when the person was known to have diabetes.
# Remember this article is for your information only. Dr. Ben-Zur recommends consulting your physician prior to making any changes in your diet, exercise or medical program.
Becker RC, Meade TW, Berger PB, Ezekowitz M, O’Connor CM, Vorchheimer DA, et al. The primary and secondary prevention of coronary artery disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun;133(6 Suppl):776S-814S
Contrary to what you may have heard, there is no ” diabetes diet,” per se — and that’s good news! The foods recommended for a diabetes diet to control blood glucose (or sugar) are good for those with diabetes — and everyone else. This means that you and your family can eat the same healthy foods at mealtime. However, for people with diabetes, the total amounts of carbohydrates consumed each day must be monitored carefully. Of the different components ofnutrition — carbohydrates, fats, and proteins — carbohydrates have the greatest influence on blood sugar levels. Most people with diabetes also have to monitor total fat consumption and protein intake, too.
To keep your blood sugar levels in check, you need to make healthy food choices, exercise regularly, and take the medicines your health care provider prescribes. A dietitian can provide in-depth nutrition education to help you develop a personalized meal plan that fits your lifestyle and activity level, and meets your medical needs.
Learn the ABCs of a Diabetes Diet
The goal of nutrition for people with diabetes is to attain the ABCs of diabetes. The A stands for the A1c or hemoglobin A1c test, which measures average blood sugar over the previous 3 months. B is for blood pressure, and C is for cholesterol. People with diabetes should attain as near as normal blood glucose control (HbA1c), blood pressure, and healthy cholesterol level.
Alcohol and Diabetes
Use discretion when drinking alcohol on a diabetes diet. Alcohol is processed in the body very similarly to the way fat is processed, and alcohol provides almost as many calories as fat. If you choose to drink alcohol, only drink it occasionally and when your blood sugar level is well-controlled. It’s a good idea to check with your doctor to be sure drinking alcohol is acceptable.
Diabetes and Glycemic Index
For years, researchers have tried to determine what causes blood sugar levels after meals to soar too high in those with diabetes. Potential culprits have included sugar, carbohydrates, and starches, among other foods. The glycemic index is a ranking that attempts to measure the influence that each particular food has on blood sugar levels. It takes into account the type of carbohydrate in a meal and its effect on blood sugars.
Foods that are low on the glycemic index appear to have less of an impact on blood sugar levels after meals. People who eat a lot of low glycemic index foods tend to have lower total body fat levels. High glycemic index foods generally make blood sugar levels higher. People who eat a lot of high glycemic index foods often have higher levels of body fat, as measured by the body mass index (BMI).
Talk to your doctor, a registered dietitian, or a diabetes educator and ask if the glycemic index might work to help gain better control of your blood sugar levels.
The glycemic load takes into account the effect of the amount of carbohydrates in a meal. Both the type of carbohydrate and the amount have an effect on blood sugars
Eating Right on a Diabetes Diet
If you have diabetes, it’s important to eat right every day to keep your blood sugar levels even and stay healthy. Here’s some easy tips:
- Be sure to eat a wide variety of foods. Having a colorful plate is the best way to ensure that you are eating plenty of fruits, vegetables, meats, and other forms of protein such as nuts, dairy products, and grains/cereals.
- Eat the right amount of calories to maintain a healthy weight.
- Choose foods high in fiber such as whole grain breads, fruit, and cereal. They contain important vitamins and minerals. You need 25 to 35 grams of fiber per day. Studies suggest that people with type 2 diabetes who eat a high fiber diet can improve their blood sugar and cholesterol levels. Similar results have been suggested in some studies in people with type 1 diabetes.
Serving Sizes and Diabetes
Be sure to eat only the amount of food in your diabetes meal plan. Excess calories result in excess fat and excess weight. In people with type 2 diabetes, excess body fat means less sensitivity to insulin. Weight loss in overweight and obese people with type 2 diabetes helps improve blood sugars and reduces those risk factors which lead to heart disease. Your dietitian can help you determine the appropriate serving sizes you need, depending on if you need to maintain your weight, gain weight, or lose weight, and if you have high or low blood sugar levels.
- In women with gestational diabetes, it’s important to eat multiple meals and snacks per day as recommended.
- Do not skip meals.
- Eat meals and snacks at regular times every day. If you are taking a diabetes medicine, eat your meals and take your medicine at the same times each day.
Note: If you are taking some of the newer diabetes medicines, some of these tips may not apply to you; ask your health care provider the tips you should follow.
The Sweet Truth about Food and Diabetes
You might have heard that, as a person with diabetes, you shouldn’t have any table sugar. While some health care providers continue to promote this, many — realizing that the average person lives in the real world and will probably indulge in a bit of sugar every now and then — have adopted a more forgiving view. Most experts now say that small amounts of sugar are fine, as long as they are part of an overall healthy meal plan. Table sugars do not raise your blood sugar any more than similar amounts of calories from starches, which is found in many foods that we consume. It is important to remember that sugar is just one type of carbohydrate.
When eating sugar, keep these tips in mind:
- Read food labels. Learn how to determine how much sugar or carbohydrates are in the foods that you eat.
- Substitute, don’t add. When you eat a sugary food, such as cookies, cakes, or candies, substitute them for another carbohydrate or starch (for example, potatoes) that you would have eaten that day. Make sure that you account for this in your carbohydrate budget for the day. If it is added to your meal for the day, then remember to adjust your insulin dose for the added carbohydrates so you can continue to maintain glucose control as much as possible. In other words, readjust your medications if you do add sugars to you meals.
- Sugary foods can be fattening. Many foods that have a lot of table sugar are very high in calories and fat. If you are watching your weight (and many people with diabetes must), you need to eat these foods in moderation!
- Check your blood sugar after eating sugary foods and talk to your health care provider about how to adjust your insulin if needed when eating sugars.
- Ultimately, the total grams of carbohydrates — rather than what the source of the sugar is — is what needs to be accounted for in the nutritional management of the person with diabetes.
Diabetes Diet Myths
Before you start a diabetes diet, get the facts. So many people believe that having diabetes means you must avoid sugar and carbohydrates at all cost, load up on protein, and prepare “special” diabetic meals apart from the family’s meals. Wrong! Most individuals with diabetes can continue to enjoy their favorite foods, including desserts, as long as they monitor the calories, carbs, and other key dietary components and keep a regular check on their blood glucose levels.
Get the facts and start enjoying the foods you love on a diabetes diet.
Diabetes Diet Q&A
What Is the TLC Diet for Diabetes?
People with diabetes who have abnormal cholesterol levels will likely be placed on a diet known as a “TLC” diet. The TLC diet will help reduce the intake of cholesterol-raising nutrients. As part of this diet you may be asked to lose weight and increase physical activity levels — all of these are components that will help lower bad LDL cholesterol. Looking at food labels will help you become more knowledgeable about your intake of fats and cholesterol.
Specifically, the TLC diet calls for the following:
- Total fat consumption should be 25%-35% or less of total calories eaten per day.
- Saturated fats should be less than 7% of total calories eaten in a day.
- Polyunsaturated fats (from liquid vegetable oils and margarines low in trans fats) should be up to 10% of the total calories per day consumed.
- Monounsaturated fats (derived from vegetable sources like plant oils and nuts) should be up to 20% of total calories per day eaten.
- Carbohydrates should be 50%-60% of total calories per day eaten
- We should eat 20-30 grams of fiber per day. These can be derived from oats, barley, psyllium, and beans.
- The amounts of protein in the diet should equal about 15%-20% of total calories eaten per day.
- Cholesterol content of the diet should be less than 200 milligrams per day.
How Much Fat Is Acceptable on a Diabetes Diet?
People with diabetes have higher than normal risk for heart disease, stroke, and disease of the small blood vessels in the body. Controlling blood pressure and limiting the amount of fats in the diet will help reduce the risk of these complications.
Limiting the amounts of saturated fats, increasing the amount of regular exercise, and receiving medical treatment can lower bad LDL cholesterol. This has been repeatedly shown in medical studies to help people with diabetes reduce their risk of heart disease and reduce the risk of death if a heart attack does occurs in a diabetic person.
Can I Use Artificial Sweeteners on a Diabetes Diet?
Artificial sweeteners can be added to a variety of foods and beverages without adding more carbohydrates to your diabetes diet. Using non-caloric artificial sweeteners instead of sugar also greatly reduces calories in your favorite foods.
Can I Use Artificial Sweeteners on a Diabetes Diet? continued…
Keep in mind that foods with artificial sweeteners are not necessarily ‘no’ carbohydrates foods. Many have carbohydrates; therefore, you must read the food labels to determine the gram amounts per serving that these have in order to take into account the effect that these carbohydrates have on your glycemic control. Foods labeled with artificial sweeteners can affect your blood sugars.
As long as you are aware of the content of carbohydrates you can adjust your meal or medication to maintain blood glucose control. Sugar free means no sugar has been added, but you must remember these foods still contain carbohydrates which does affect your blood sugars.
Examples of artificial sweeteners you can use include:
- Other non-nutritive sweeteners
Pregnant or breastfeeding women should avoid saccharine, and people who suffer from phenylketonuria should not use aspartame. People with phenylketonuria are unable to metabolize phenylalanine, an amino acid that’s a common part of many proteins.
Some artificial sweeteners — such as xylitol, mannitol, and sorbitol — have some calories and do slightly increase blood sugar levels.
The American Diabetes Association cautions that eating too much of any artificial sweetener can cause gas and diarrhea.
**Remember this article is for your information only. Always consult your physician prior to making any changes in your diet, exercise or medical program.