People's Health Daily

Type 1 Diabetes

2012-10-17T19:18:00.000-07:00

Type 1 diabetes accounts for 5 to 10 percent of all diagnosed cases of diabetes, but is the leading cause of diabetes in children of all ages. Type 1 diabetes accounts for almost all diabetes in children less than 10 years of age. Type 1 diabetes is an autoimmune disease in which the immune system destroys the insulin-producing beta cells of the pancreas that help regulate blood glucose levels. Onset. Type 1 diabetes mostly has an acute onset, with children and adolescents usually able to pinpoint when symptoms began. Onset can occur at any age, but it most often occurs in children and young adults. Children and adolescents may present with ketoacidosis as the first indication of type 1 diabetes. Others may have post-meal hyperglycemia, or modest fasting hyperglycemia that rapidly progresses to severe hyperglycemia and/or ketoacidosis in the presence of infection or other stress.

Symptoms. The immunologic process that leads to type 1 diabetes can begin years before the symptoms of type 1 diabetes develop. Symptoms become apparent when most of the beta-cell population is destroyed and usually develop over a short period of time. Early symptoms, which are mainly due to hyperglycemia, include increased thirst and urination, constant hunger, weight loss, and blurred vision. Children also may feel very tired. The immunologic process that leads to type 1 diabetes can begin years before the symptoms of type 1 diabetes develop. Symptoms become apparent when most of the beta-cell population is destroyed and usually develop over a short period of time. Early symptoms, which are mainly due to hyperglycemia, include increased thirst and urination, constant hunger, weight loss, and blurred vision. Children also may feel very tired.

Risk Factors. A combination of genetic and environmental factors put people at increased risk for type 1 diabetes. Researchers are working to identify these factors so that targeted treatments can be designed to stop the autoimmune process that destroys the pancreatic beta-cells.

Co-morbidities. Children with type 1 diabetes are at risk for the long-term complications of diabetes. Autoimmune diseases such as celiac disease and autoimmune thyroiditis are also associated with type 1 diabetes.

Management. The basic elements of type 1 diabetes management are insulin administration (either by injection or insulin pump), nutrition management, physical activity, blood glucose testing, the avoidance of severe hypoglycemia, and the avoidance of prolonged hyperglycemia or DKA. Algorithms are used for insulin dosing based on blood glucose level and food intake.

Diabetes in Children and Adolescents

2012-10-17T18:55:00.001-07:00

Overview of Diabetes in Children and Adolescents
Diabetes mellitus is a group of diseases characterized by high levels of glucose in the blood resulting from defects in insulin production, insulin action, or both. Diabetes is associated with serious complications and premature death, but timely diagnosis and treatment of diabetes can prevent or delay the onset of long-term complications (damage to the cardiovascular system, kidneys, eyes, nerves, blood vessels, skin, gums, and teeth). New management strategies are helping children with diabetes live long and healthy lives. Type 1 diabetes in U.S. children and adolescents is increasing (1) and more new cases of type 2 diabetes are being reported in young people. The American Diabetes Association provides helpful guidance in consensus statements for managing children with type 1 diabetes (2) and type 2 diabetes (3). To update primary care providers and their staff about this evolving area of diabetes care, the NDEP has developed this overview of current statistics and care recommendations.

Statistics

Diabetes is one of the most common diseases in school-aged children. According to the 2011 National Diabetes Fact Sheet, about 215,000 young people in the US under age 20 had diabetes in 2010. This represents 0.26 percent of all people in this age group. (4) Based on data from 2002 to 2005, the SEARCH for Diabetes in Youth study reported that approximately 15,600 US youth less than 20 years of age were diagnosed annually with type 1 diabetes, while 3,600 were newly diagnosed with type 2 diabetes. (5) Type 2 diabetes was rare in children younger than 10 years of age, regardless of race or ethnicity. In youth aged 10 to 19 years, type 2 diabetes became increasingly common, especially in minority populations such as American Indians, African Americans, Hispanic/Latinos, Asians and Pacific Islanders. Among non-Hispanic white youth aged 10 to19 years, the rate of new cases was higher for type 1 than for type 2 diabetes. For Asian/Pacific Islander and American Indian youth aged 10–19 years, the opposite was true—the rate of new cases was greater for type 2 than for type 1 diabetes. Among non-Hispanic black and Hispanic youth aged 10 to19 years, the rates of new cases of type 1 and type 2 diabetes were similar. (5)

Clinical Preventive Services for Normal-Risk Adults

2012-10-16T18:26:00.000-07:00

Immunization

Tetanus-Diptheria (Td): every 10 Years, 18 years and older.

Varicella (VZV): Susceptible only two doses, 18 years and older.

Measles, Mumps, Rubella (MMR): Women of childbearing age-One dose, 18-50 years.

Pneumococcal: One dose, 65 years and older.

Influenza: Yearly, 50 years and older.

Chemoprevention

Discuss aspirin to prevent cardiovascular events:

Men: Periodically, 40 years and older.

Women: Periodically, 50 years and older.

Discuss breast cancer chemoprevention with women at high risk.

Counseling Calcium Intake: Women, periodically 18 years and older.

Folic Acid: Women of childbearing age, 18-50 years. Tobacco cessation, drug and alcohol use, STDs and HIV, nutrition and physical activity, sun exposure, oral health, injury prevention and poly-pharmacy: Periodically, >18 years. Upper age limits should be individualized for each patient.

Weight

Normal body mass index (weight (kg)/height (sq. meters) for Indian Americans is <23

Waist circumference <90 cm or 36 inches (men); <80 cm or 32 inches (women)

Clinical Preventive Services for Normal-Risk Adults

2012-10-15T18:24:00.001-07:00

Screening

Blood Pressure, Height and Weight: Periodically, 18 years and older.

Cholesterol:

Men, Every 5 years (and more frequently if at risk or abnormal), 35 years and older.

Women, Every 5 years (and more frequently if at risk or abnormal), 45 years and older.

Diabetes: Periodically, adults with hypertension or hyperlipidemia.

Pap Smear: Women, Every 1 to 3 Years, 18-65 years.

Mammography: Every 1 to 2 Years, 40 years and older.

Colorectal cancer:Periodically, 50 years and older with Stool Guiac &/or sigmoidoscopy colonoscopy.

Osteoporosis: Women, routinely, >65 years old or >60 years at risk for fractures.

Alcohol Use: Periodically 18 years and older.

Vision and Hearing: Periodically, 65 years and older

PSA Screening: In Men periodically

Some other factors that can affect Health!

2012-10-14T18:23:00.000-07:00

Include at least 20 gms. of fiber everday. Whole grains, beans & vegetables are rich sources

Many 'fast' foods are high in fat, salt and/or sugar. Limit or avoid frequent use of such foods

If you have high blood pressure, restrict the use of salt, salty foods like regular chips and pickles

Talk to your physician about your multi-vitamin and multi-mineral supplements.

Have a routine check-up blood lipid levels.

DIABETES CAN BE MANAGED! TAKE CONTROL! YOU CAN DO IT!

Foods from different sources can be combined to make up a balanced meal. Your personal meal plan should be designed to suit your lifestyle. Your meal plan will suggest servings of each food group at every meal. The different food groups and examples of one serving in each food group are as follows: (Please note that values are approximate)

1. GRAINS/BEANS/STARCHY VEGETABLES (without added fats or oils) (ex. Rice flour, Beans/Legumes)
2. MEAT & MEAT ALTERNATIVES-VERY LEAN (ex. Chicken Turkey, Tuna in water)
3. MEAT & MEAT ALTERNATIVES-MEDIUM FAT (ex. Egg, Fried Fish)
4. MEAT & MEAT ALTERNATIVES-HIGH FAT (ex. Peanut Butter, Regular cheese)
5. VEGETABLES (no fat added) (ex. Cabbage Cauliflower, White radish)
6. FRUITS (ex. Banana, Mango, Canned fruits, Apple, Orange)
7. MILK AND MILK PRODUCTS (ex. Whole/skimmed/low fat milk)
8. FATS AND OILS (ex. cooking oil, nuts or seeds)

Methods of preparing and cooking

2012-10-12T17:15:00.002-07:00

Methods of preparing and cooking

Sprouting legumes increases nutritional value. It can be fun sprouting different legumes!

Steam vegetables with little water Do not drain the cooking water from rice or vegetables

Limit or avoid highly processed foods or high-fat, salty fast" foods

Try to eat small, frequent meals at regular times

Drink plenty of water/liquids

6-8 glasses is the usually recommended amount. Plain water is the best. Avoid excessive use of caffeinated drinks life coffee, tea and caffeine containing drinks.

Use alcohol only after talking to your physician.

What Can I Eat To Manage My Diabetes?

2012-10-11T23:02:00.000-07:00

Diabetes is a condition where your body is not able to make enough insulin onr the insulin is not being used properly. Insulin enables your body to get energy from glucose – the sugar broken down from the foods you eat. A poor balance between insulin and blood glucose levels can result in high glucose (hyper-glycemia) or low blood glucose (hypoglycemia ) levels in your blood. Maintaining blood glucose levels around acceptable levels is important and research has shown that it can help prevent complications in your eyes, kidneys, blood vessels and more. Under your physicians guidance, diabetes and blood glucose levels are managed with Medical Nutrition Therapy, an individualized meal plan, exercise and medications as needed. The foods you eat, total calories, activity and body weight are some of the factors that can affect blood levels. Foods that contain carbohydates can raise blood glucose levels. Fats and protein can also affect weight, if eaten in excess. Keep a daily log of your meals and blood glucose levels to better understand fluctuations. Include a daily exercise plan into your regimen (after talking to your physician). Become familiar with food labels and ingredients. Your Dietitian can help you with this.

My doctor says I don’t need to see a specialist for my diabetes. How do I know if my doctor is right?

2012-07-08T18:10:00.000-07:00

At the time of writing, there are estimated to be about

16 million adults in the United States who are aware that they have diabetes. There are, however, only about

4000 certified adult diabetes specialists in clinical practice and not all of these are in full-time practice. Some, perhaps one in four, do not see patients with diabetes at all. This translates to one diabetes specialist for every 5000 people with diabetes.

The average diabetes specialist carries a clinic census of several hundred active patients, each of whom he or she sees from two to several times per year. From these statistics, it is clear that the vast majority of people with diabetes will not be able to consult a specialist. However, not all people with diabetes need specialist input, and those who do will usually not require it for the majority of the course of the disease, especially in the case of type 2 diabetes. Much of the education necessary to effectively manage diabetes, especially that centering on glucose monitoring and diet and nutrition, is accessible by referral directly from your family doctor. Given its frequency, many family doc- tors see a considerable number of patients with dia- betes and are competent in its routine management. They also generally make effective judgments as to when specialist consultation is advisable.

Some of the circumstances in which consultation with a diabetes specialist is often advisable

How does the sugar in fruit drinks differ from the sugar in sodas?

2012-07-08T18:06:00.001-07:00

The sugar in fruit juices is predominantly fructose, which is a disaccharide, meaning that it contains two molecules of glucose joined together and must be bro- ken down to glucose in order to be absorbed, which may cause a delayed or muted effect on the blood sugar. Fruit juices will also contain a moderate amount of some vitamins and minerals. Sodas do not contain significant amounts of vitamins or minerals. The sugar in regular non-diet sodas is glucose, which is very readily absorbed and sweeter tasting. The amount of sugar in a standard 12-ounce can of regular soda is equivalent to about 9 teaspoons of table sugar (which is neither glucose nor fructose, but sucrose, another disaccharide) and therefore provides a large amount of calories, which can raise the blood sugar level very quickly. This is helpful if a low blood sugar reaction is being treated, but not a recommended part of the dia- betic diet, as it causes a very sharp rise in blood glucose to levels above those recommended. This rise is hard to prevent with either pills or insulin, without giving doses that will later lead to low blood sugar levels.

I have heard that depression is more common in people with diabetes. Is this true?

2012-06-22T19:38:00.000-07:00

Yes, it is true that people with diabetes (and with other long-term illnesses) can experience higher rates

of depression. This can be due to factors relating to the diabetes itself, or it can be unrelated. There is no convincing evidence that the actual blood sugar level itself is reliably predictive of mood, even in those with a tendency to depression. The severity of the diabetes and its complications, as well as its impact upon a person’s lifestyle and aspirations, can be an important predictor of depression. For some the impact may be major and for others much less so, even though the degree of severity of the diabetes is the same. It is important to remember that the vast majority of people in our society with treated dia- betes (more than 15 million in the United States alone) are able to adjust to the disorder and have happy, productive, and rewarding lives. Some have even achieved astonishing things in all walks of life. Examples include the gold medal winning Olympic swimmer Gary Hall, the NBA basketball player Adam Morrison, and the actresses Halle Berry and Mary Tyler Moore and Supreme Court Justice Sonia Sotomayor, all of whom have lived with diabetes while achieving great success. If you are experiencing unusual degrees of sadness, reduced enthusiasm or interest in life, or excessive stress that you perceive is related to your diabetes, your doctor or certified diabetes educator may be able to help you to identify resources that can help you cope. Some of these resources are discussed in Ques- tion 82. Many certified diabetes educators (CDEs) are trained to provide such psychosocial support. If you are truly suffering from depression, your dia- betes may or may not be an underlying cause, even though it may seem that way. Your doctor or CDE will help you to identify whether expert professional psychological or psychiatric consultation is needed.

How will my diabetes affect my work? Are there any jobs I cannot do?

2012-06-22T19:21:00.001-07:00

Whether your diabetes will affect your work depends upon the nature of your diabetes and the nature of your work. Thus, the impact can be almost negligible to highly significant and life-changing. People with early or well-controlled type 2 diabetes, especially if they are not taking medications known to cause hypoglycemia, should be able to perform satisfactorily in almost any type of work that they wish to do. In situations in which personal or public endangerment is a possibility (e.g., transportation and heavy equipment operation) glucose monitoring should be performed periodically, especially when feeling unwell, as high blood sugars can be associ- ated with impaired mental functioning and increase the risk of dehydration and dizziness or drowsiness. If you have type 1 diabetes or insulin-requiring type 2 diabetes, or have type 2 diabetes but are taking pills known to cause low blood sugar then the performance of cer- tain occupations which could potentially endanger yourself or others places a special burden of care and attention upon you. With regards to motor transporta- tion, motor vehicle departments have regulations, which may vary from state to state, as to licensure requirements. They may involve, for example, produc- ing records from the memory of a glucose monitor to show that you have checked your blood sugar at regu- lar intervals prior to and during driving and have had no significant low blood sugar readings while doing so. With regard to flying, there are federal regulations and states may have additional requirements. If you are considering a military career and have diabetes, you will have to inform your recruiter, who will advise you of your eligibility.

A number of occupations are not covered by specific regulations, but you will generally be held to the standard of reasonable behavior if you cause harm to people or property wholly or in part as a result of your diabetes. If you did not know what a reasonable person might be expected to know, or act on the knowledge that you have as a reasonable person might be expected to act, you could be judged to have recklessly endangered the lives of others or negli- gently damaged the property of others and could be subject to legal penalties. If in doubt, therefore, dis- cuss your diabetes with your doctor and your employer and seek advice from experts on regulations that might apply to you.

How can I avoid getting bruises or swellings on my stomach from my insulin shots?

2012-06-22T19:14:00.000-07:00

Bruises and swellings on the stomach (or more accu- rately the abdominal wall) due to insulin are caused by two distinct mechanisms and are not usually variations of the same thing. However, occasionally a bruise will be severe enough so as to cause an actual swelling.

Bruising is due to leakage of blood from small vessels penetrated at the time of the insulin injection. Some people are more likely to bruise than others, including the elderly and those on anticoagulant or antiplatelet medications (blood thinners) such as warfarin, heparin, clopidogrel, ticlopidine, and others. Some people on routine doses of aspirin for protection from stroke and heart attack will note an increased tendency to bruise with their insulin injections, while others do not. Injection tools or technique may also play a role. Those with relatively small amounts of body fat on their abdominal walls (or thighs or arms if you use them) need to be sure to lift and gently pinch the skin and insert the needle at an angle in the middle of the pinched tissue. Injecting the needle directly and to the hilt may lead to an inadvertent injection into the mus- cle. This will change the pattern of action of the insulin and lead to a bruise or sometimes a painful bleed into the muscle itself. Some types of needle are more prone to cause bruising in some individuals than others. If you bruise easily, use the smallest diameter (gauge) of needle you can find. Remember that the higher number of gauge means a smaller diameter. Swellings, especially if they are chronic, are often due to a property of the insulin itself. Insulin is one of the hormones responsible for growth and maintenance of our tissues including muscle protein and fat stores. If insulin is injected repeatedly in the same area, addi- tional fat can become laid down in that spot. This takes on the appearance of a painless fatty mound (lipohypertrophy), which can be somewhat disfigur- ing. Fortunately, these fatty mounds will disperse if the insulin is no longer injected there, although it may take several weeks or months to remodel. To avoid these, the insulin injection sites should be rotated. Keeping a simple map of your abdominal wall, divided into a grid of 20 or 30 boxes and checking off a box after you have used it, will allow you to avoid using the same spot repeatedly within a 3- or 4-week period. Rarely, the opposite of lipohypertrophy may occur, i.e., loss of body fat in a localized or more generalized way. This is known as lipoatrophy. This is sometimes pre- ceded by a viral infection, but more often the underly- ing cause cannot be identified.

Red or itchy areas at the site of injection may indicate an allergic reaction to the insulin or a component of it. This is quite rare with modern insulins, but will neces- sitate a process known as desensitization, which needs to be performed under the supervision of a specialist. Larger red or discharging swellings, which are shiny and tender, indicate an abscess due to infection and you should seek medical attention promptly.

Is there a link between lack of sleep or disturbed sleep and my blood sugars?

2012-06-13T18:46:00.000-07:00

There certainly can be. Studies have shown that sleep deprivation can have a negative effect on several aspects of metabolism, including blood sugar, blood pressure, and even cholesterol levels. Blood sugars can be increased by the stress of lack of sleep. What constitutes an adequate amount of sleep varies among individuals, so what may be a metabolic stress for one may not be so for another. The elevation in blood sugars will not nec- essarily occur upon awakening, but can occur anytime due to elevated levels of stress hormones throughout the day. Stress hormones tend to push the blood sugar level up. Sometimes sev- eral days of deprived sleep are necessary to have a measurable effect on the blood sugars.

Several other factors are worth noting. If the lack of sleep is associated with restless behavior (e.g., tossing and turning or arising and pacing), the increased physi- cal activity may actually lower the blood sugars. A con- dition known as obstructive sleep apnea, or OSA, can occur in people with obesity and type 2 diabetes. This can cause frequent awakening at night, with daytime sleepiness and napping. The net amount of sleep may be more or less than normal in people with OSA. Gen- erally, a bed partner will notice snoring and a disturbed breathing pattern. This condition is treatable and sometimes constitutes medical justification for surgical intervention to control obesity. You should inform your doctor if you suspect you have this problem. Finally, shortened sleep tends to be associated with weight gain, so that restoration of a satisfactory sleep pattern can actually aid in efforts to reduce weight, which will generally help to control blood sugars.

How does stress affect my blood sugars?

2012-06-13T18:38:00.001-07:00

Stress is a broad term that can have a number of meanings. For the purposes of this question, only emo- tional stress will be discussed. Emotional stress (whether its source is personal, professional, psycho- logical, or social) can affect the blood sugar in a num-

ber of ways. The most frequent manifestation of stress

is the result of the rise in the circulating level of stress hormones in the blood. The stress hormones, such as epinephrine or adrenaline and cortisol, release stored glucose into the blood, thus raising sugar levels. They also make the tissues resistant to insulin. The result is a rise in blood sugar levels, which often leads to a need for more insulin or other medication.

Stress can also affect blood sugar levels by its effect on eating behavior. When under stress, eating habits often change. This change may be predictable in a given

Stress can also

affect blood sugar levels by its

effect on eating behavior.

individual but is quite unpredictable in different indi- viduals. It can vary from eating less and losing weight, to eating more or eating at different times, such as dur- ing the night. This can significantly alter one’s pattern of blood sugar readings. Also, significant amounts of stress often interrupt established patterns of exercise and leisure sports, which can cause blood sugars to rise.

Furthermore, a person’s adherence to a prescribed medical regimen often suffers during times of stress. The manage- ment of one’s diabetes can consume a considerable amount of a person’s time and attention and be a stress in itself. For this reason, people often reduce their frequency of glucose monitoring and sometimes the number of pre- scribed pills or injections that they actually take. Occa- sionally, this can have serious short-term consequences, but of significant concern is that people under prolonged stress who do not pay close attention to the management of their diabetes open themselves up to an increased risk of the serious long-term complications discussed in Part4. Therefore, if you are a person with diabetes under stress, it is wise to focus on addressing and relieving that stress in the interests of your long-term health.

How accurate are glucose monitors?

2012-06-13T18:25:00.003-07:00

Glucose monitors are quite accurate in that any given reading on the same sample of blood should only vary by a few percentage points (i.e., 5–10). In order to obtain approval from the Food and Drug Administra- tion, such medical devices have to show that they are

both precise and accurate. This means that they will

obtain a similar result under similar conditions and that the result will be close to the real true value, as best as we are able to ascertain it, i.e., according to the accepted gold standard, which is glucose measured in the labora- tory. Furthermore, when such a device is compared to the gold standard measurement in clinical trials, a spec- ified number of readings have to fall very close to the readings obtained by the gold standard device. This value is more than 95%. The rules for approval of such devices have been published by the FDA and can be viewed at http://www.fda.gov/cdrh/oivd/guidance/

1171.pdf. Although users are often surprised by the variation in results that they will see upon obtaining a reading within a very short space of time from a prior reading, it has to be acknowledged that the variation is seldom such that a different course of action would be taken. For example, insulin would be given or not given or a low blood sugar level would be treated or not treated. Actual numerical accuracy tends to be less when the glucose level is very low. However, since such a low value should always be treated, the accuracy of the actual reported number is not critical.

When a surprising glucose value that does not fit with the expected circumstances is obtained, it is always prudent to recheck that reading, on either the same or a different monitor. Also, it is advisable to check that the monitor is functioning well, by checking the low battery indicator, assuring that the correct coding has been entered and that the test strips are within date and inserted properly. Sometimes, variation in tech- nique by the user accounts, at least partially, for varia- tion in the result obtained. This can include liquid on the puncture site, contamination with glucose, exces- sive squeezing of the finger, and sweating.

Should I get one of the new continuous glucose monitors?

2012-06-07T20:55:00.001-07:00

There are now three types of continuous glucose mon- itors available. They all transmit glucose results wire- lessly from a small sensor placed just beneath the skin via a transmitter whose signal is received by the mon- itor placed anywhere from 5 to 10 feet away. Results are sent from every minute to every 5 minutes and the trend of the readings can be shown on graphs. One, the Medtronic Realtime System®, can transmit the results into the same unit that is used as the insulin pump. However, even though the same unit acts as both mon- itor and pump, it is still necessary for the wearer to pro- gram and set the amount of insulin to be delivered. Studies have shown that the additional information provided by the frequently delivered values and the graphed trends reduces high and low glucose events in the wearer by about half. It is important to note that all the current continuous glucose monitors are approved only for use with and alongside conventional glucose meters. This means that before acting on the informa- tion the continuous monitor provides, you should verify it by obtaining a reading with your regular monitor. Also, the two technologies provide similar but slightly different information. The conventional monitor mea- sures blood glucose from the blood droplet resulting from the finger prick. The continuous meter does not use blood. Instead, it measures the glucose level in the fluid bathing the tissue under the skin. This is in fact derived from the blood plasma itself, but it takes several minutes to adjust to reflect the blood level. The avail- able continuous meters need to be calibrated twice daily (Medtronic Guardian®, Dexcom 7®) with a conven- tional fingerstick reading, although the newer Abbott Freestyle Navigator® needs only four calibration readings.

The decision as to whether to get one of these monitors depends on the value to the wearer of knowing his or her readings on a minute-by-minute basis. For people early in the course of diabetes, on oral medications, and in good control, they are probably not necessary. For peo- ple on insulin, with a history of low and high readings, especially if they are hard to predict or explain, the information provided by continuous glucose sensing may be very valuable. However, approval for insurance coverage is often limited to specific circumstances, such as the frequent occurrence of very high or low blood sugars that cannot otherwise be prevented.

features are important to different individuals, depending on their needs. Probably the best way to answer this question is to discuss some of the available features. Size is one of the first that springs to mind. Monitors have been getting ever

What is the best kind of glucose monitor?

2012-06-07T20:51:00.000-07:00

Since insulin became available, probably nothing has more revolutionized the day-to-day management of diabetes, especially type 1 diabetes, than the arrival of the capillary glucose monitor. So successful has this technology been that this is a difficult question to

answer specifically because there are up to 20

approved glucose monitors for use at any one time, with new or updated models appearing frequently. Also, different features are important to different individuals, depending on their needs. Probably the best way to answer this question is to discuss some of the available features. Size is one of the first that springs to mind. Monitors have been getting ever smaller since they first appeared more than 30 years ago. It is now possible to get a monitor that is about the same size as a standard lipstick (e.g., One Touch Ultra-Mini®) and is yet highly functional. Memory size is not as important as it might at first seem. A memory of about 100 readings is probably sufficient, although almost every monitor now has more. There is limited practical usefulness of going back too far, since treatment decisions should be based on recent information, rather than distant data. Sample size is sometimes important and most available meters now use much smaller blood samples than was previously the case. Microsample meters such as some Freestyle® and One Touch® models use samples less than 1/50th the size of an actual droplet of blood. Many monitors will permit sampling from sites other than the finger- tip, such as the forearm (most) and palm, which is useful for those with sensitive fingers or for people who are heavily involved in manual or delicate work. The speed of obtaining the reading is now usually around 5 seconds after the blood sample is applied, although some models (such as the Prestige IQ®) can take up to 50 seconds. This is much shorter than models in the early days, which could take from 1 to 2 minutes. Most meters can now be linked by cable, Bluetooth, or broadband to a computer and their contents are downloadable, including to the Internet. Some meters have multistrip cassettes that dispense between 10 and 20 test strips, such as the Accuchek Compact Plus®, for added convenience. Other features include the ability to display results graphically (e.g., One Touch Ultrasmart®), to func- tion at high altitude (e.g., Advocate Duo®), and to speak the results for those with limited vision (e.g., Prodigy Duo®). The features of 10 available glucose

Table 11 Features of 10 Available Capillary Glucose Monitors

Name Vol Site Time Mem DL Other
One Touch Ultra 2 One Touch Ultrasmart One Touch Ultramini Accuchek Compact+ Accuchek Advantage Advance Microdraw Freestyle Flash Advocate Duo Prodigy Duo Prestige IQ	1.0 1.0 1.0 1.5 4.0 1.5 0.3 0.7 0.6 4.0	F, A F, A F, A F, A F F, P F, A F, A F, A F	5 5 5 5 26 15 7 7 6 50	500 3000 50 300 480 250 250 450 450 365	+ + − +IR + + +IN + + +	Graphs 1.2 oz Drum, no code To 10,742 ft Talks, 5 oz WB/plasma

Vol: Sample vol in _L; F=finger; A=arm; P=palm; Time=time to results in seconds; Mem=mem- ory capacity; DL=downloadable; IR=infrared; WB=whole blood.

monitors are shown in Table 11 and an example of a typical data printout can be seen in Figure 6.

Finally, those with longstanding or complicated diabetes might want to consider the option of continuous glucose monitoring, which is discussed in Question 60. However, bear in mind that you will still require a conventional capillary glucose monitor.

Figure 6 Example of a data printout from contemporary glucose monitor.

What tests should my doctor be doing on a regular basis to monitor my diabetes?

2012-06-07T20:43:00.000-07:00

Some of the tests that your doctor will perform to monitor your diabetes and the status of any of its chronic complications The main things that interest your doctor are monitoring the control of your blood sugar, the control of your cholesterol and blood pressure, and the presence or progress of any long-term complications of your diabetes and to check for the presence or absence of other related con- ditions. Tests in this context can refer to clinical examination, such as checking the condition of your feet and testing the sensation, laboratory blood tests, and special tests, as indicated, such as scans or other images. Many of these your doctor can do himself

Table 10 Items That May Be Checked Regularly in Persons with Diabetes Monitoring Tool

Glucose control HbA1c, fructosamine, CBGs, eAG Lipids Fasting lipid panel ± special lipid tests

Blood pressure BP cuff measurements

Large vessel health EKG, carotid IMT

Small vessel health

Feet Inspection, microfilament, capillary refill, ABIs

Kidneys Serum creatinine, estimated CCr, MACR Eyes Retinal imaging, dilated eye exam Peripheral nerves Monofilament, NCV testing, touch and

vibration perception, proprioception*

Autonomic nerves Postural BP, pulse, RR variation

Abbreviations: HbA1c: hemoglobin A1c; CBGs: capillary (fingerstick) blood glucoses; eAG: estimated average glucose; BP: blood pressure; EKG (ECG): electrocardiogram; IMT: intimal-medial thickness by ultrasound; ABIs: ankle- brachial indices; CCr: creatinine clearance; MACR: microalbumen-to-creati- nine ratio; NCV: nerve conduction velocity; RR: R-wave to R-wave (on EKG).

*Position sense.

and others may require referral to another specialist. A

detailed eye examination is an example of the latter.

What is the target level for my blood sugar?

2012-06-06T17:08:00.000-07:00

The target level for your blood sugar depends on who you are and on the other circumstances of your health. Various authoritative expert bodies have published blood sugar targets to aim at before and 2 hours after meals at various stages of life, including for children, adults, pregnant women, and the elderly. The various

recommendations differ in certain respects, but are gen- erally similar and those of the American Diabetes Association and the American Association of Clinical Endocrinologists are shown in Table 8. Wherever pos- sible, otherwise healthy individuals with diabetes should aim to achieve blood sugar levels that are as close to normal as possible, as long as these can be reached with- out side effects that are either distressing or dangerous. This is a matter of judgment between you and your physician. The target levels for blood sugar can either be described by blood sugar levels themselves or in overall terms, according to the Hemoglobin A1c

Table 8 Blood Sugar and A1c Targets for Diabetes

Time ADA (mg/dl) AACE (mg/dl)
Fasting 2 hours after eating A1c	70–130 Less than 180 Less than 7.0% and as close to 6% as is safely achievable; less than 8% in young children, the elderly, and those at high risk of hypoglycemia	Less than 110 Less than 140 Less than 6.5%

Source: Data from ADA: American Diabetes Association; AACE: American

Association of Clinical Endocrinologists..

(HbA1c or A1c), which is an average measure of blood sugar over the prior 3–4 months, approxi- mately. For all people with diabetes, but especially those who do not need to perform frequent self- monitoring of blood sugar or who are unable to do so, the HbA1c is a very helpful measure and the American Diabetes Association recommends that it is performed at least twice per year. Recently, it has been recommended that the HbA1c should be reported in terms of the estimated average blood glucose (eAG) to which it corresponds, which may be more meaningful to most persons with diabetes.

How often do I need to check my blood sugar?

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How often you need to check your blood sugar depends upon how the information that blood sugar testing provides will be used. All too often, people with diabetes are instructed to test their blood sugar frequently and yet neither they nor their physician or other caregivers make significant use of the informa- tion. Generally, when treatment (such as the amount of insulin to be taken before the next meal) is not being adjusted immediately or even day to day, there is little justification for very frequent testing. Except for people who cannot or will not test, all people with diabetes should be prepared to check their blood sugar frequently when they are sick, under severe physical stress, or taking medications that are known to markedly affect the blood sugar level, such as steroids. Examples of possible glucose monitoring schedules for various circumstances are shown in Table 7.

Type of Diabetes Testing Strategy
Type 1, 2, or GDM on intermit- tent insulin 2 to 4 times daily	Before meals, bedtime, occ. after meals, & during night
Type 1 or 2 on continuous insulin infusion (pump)	Before meals, bedtime, sometimes after meals, & during night
Type 2 on oral antidiabetic pills (OADs)	Before breakfast and supper alternating with before lunch and bedtime, 3 days/week
Type 2 or GDM on lifestyle intervention	As for type 2 on OADs, 1 to 3 days/week
All types, when sick or unstable	As needed to intervene effectively, q2-hours if needed

Many patients start on pills but end up on insulin. Why do pills tend to fail in the end and do they all fail at the same rate?

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Pills for type 2 diabetes tend to fail after a period of time because the severity of the diabetes tends to progress. Diabetes is a disorder associated with aging, reduction in physical activity, and increasing body weight. Since all of these things tend to progress with time, it is not surprising that the severity of the dia- betes tends to progress and the response to pills that were previously effective tends to be diminished. Not only this, but there appears to be a normal aging- related decline in the ability of the pancreas to make insulin that is steeper in those with diabetes. Since one is presently unable to prevent this or prevent aging from occurring, the only factors that are con- trollable to prevent progression of the diabetes are weight and exercise, and these are notoriously diffi- cult to manage with consistent success. Therefore, it is not surprising that many people with type 2 diabetes tend to require more and higher doses of pills over time and that many eventually fail to be controlled on pills alone.

The pills do not all tend to fail at the same rate. The sulfonylurea drugs and metformintend to fail at a rate of about 5% of patients who were previously controlled on them per year. Thus, after 10 years, half of the patients tak- ing these drugs initially successfully will no longer be controlled on them. However, there is encouraging news from some of the newer types of pills for dia- betes. It appears as if the medications of the TZD class and possibly the DPP-IV inhibitor class (see Ques- tions 41 and 52 for a description) may actually modify the course of the diabetes itself and slow its progres- sion. The TZD type of drugs acts to improve the body’s response to the insulin it produces, while the DPP-IV inhibitor class may act to restore the health of the insulin-producing cells of the pancreas. Whether these types of drugs are able to achieve these improvements in a long-term manner, such that patients on them will not require insulin or other drugs by injection at all, remains to be shown by long-term studies.

Are there any medications prescribed for other conditions that can improve or worsen my diabetes?

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Yes, there are a number of medications used to treat other conditions that can affect your blood sugar con- trol. Most of these effects are small, but can be quite dramatic, such as the effect of certain types of steroid medications. Examples of various drugs and how they can affect your blood sugar are shown in Table 5.

Medication

Antiretroviral drugs (some)

Antidepressants (some)

Carvedilol

Estrogen

Etanercept

Losartan

Niacin

Octreotide

Pentamidine

Pentoxifylline

Pseudoephedrine

Ramipril

Steroids

Thiazides

Use

HIV/AIDS

Depression

Blood pressure

BCP, menopause

RA, SLE, psoriasis

Blood pressure

Cholesterol

Various

Infection

Arterial disease

Colds & allergies

Blood pressure

Inflammation

Blood pressure

Do any traditional or nonprescription remedies for diabetes really help control blood sugar? If so, which ones do you recommend?

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There are a number of nonprescription remedies that are known to be effective at lowering blood sugar. In fact, one of the most frequently used and established treatments for diabetes, metformin, was derived from the traditional knowledge that the leaves of the French lilac plant reversed the symptoms of diabetes in some patients. This fact had been known to Europeans for more than 200 years before its eventual isolation and chemical modifi- cation to the medication that we now use. Other non- prescription remedies that have been found to be effective to varying degrees include cinnamon (it appears that the cinnamon stick itself must be used rather than powdered cinnamon alone), the herb gymnema sylvestre (gurmarbooti, gurmar), raw walnuts, bitter melon, and some compounds of the metals chromium and zinc. The beneficial effects of these are generally mild and can be more effective in some people with diabetes than in others, as is also the case for prescription medications. There is generally little down side to trying some of these supplements, as long as the glucose level is carefully monitored and conventional medications are also taken if they are needed. Since these remedies are not labeled or approved by the Food and Drug Administration for this use, there is no specific standardization for their formulation, which can therefore vary widely between manufacturers. Sometimes, exaggerated claims may be made for their effectiveness while at the same time a disclaimer is offered acknowledging that such com- pounds are not intended to diagnose or treat any disease!

I am on insulin for my diabetes and I am overweight. If I lose weight, will I be able to stop the insulin shots?

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Encouragingly, the answer is yes. It is often a pleasant surprise to learn that you do not have to lose a dramatic amount of weight for this to occur. Even a loss of between 5% and 10% in your weight can have remark- able benefits on your blood sugars. Some patients often experience a significant reduction in the amount of insulin they need after only a modest weight reduction. Lowering the insulin dosage helps to control appetite and further helps efforts at weight reduction. Lowering the insulin dosage reduces appetite by reducing the likelihood of hypoglycemia, which must be treated by food intake, thus limiting the success of weight loss efforts. Unfortunately, even with such an incentive, the majority of people with diabetes who start insulin will need to remain on it, due to the difficulty of achieving n>then some additional (supplemental) insulin can be taken to bring it down. The best approach can vary among different patients and your doctor or diabetes educator will have a recommenda- tion for a supplemental scale that may be right for you
and sustaining successful weight reduction and also to the fact that the body’s own insulin production may by now be quite deficient. Available approved medications for weight reduction are also sel- dom helpful long term, due to limiting side effects and lack of effectiveness. However, patients who have undergone bariatric surgery are often able to achieve sustained weight loss and discontinue insulin for the medium to long term. This approach is being increasingly used for people with severe degrees of obesity and serious health problems related to it, including diabetes

I am afraid that I might forget I have taken my insulin and take it twice, or mistakenly take my long-acting dose for my short-acting and vice versa. What should I do if this happens?

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If you think you have taken your insulin twice or taken more or less than you need at that particular point in time, you should not panic, but follow a plan designedto ensure that you do not experience serious consequences from this. First of all, it is surprising how often taking too much insulin does not actually lead to a seriously low level of blood glucose. Having said that, a careful response is needed if you suspect that you have taken too much insulin. In the case of too little insulin, it is often sufficient to monitor the glucose carefully about every couple of hours is generally suf- ficient to detect any problems and address them and be sure to take the right amount at the next scheduled dosage. A brief exposure to high glucose is usually not harmful (unless it is a repetitive event) and the glucose may take 24 hours or so to settle back to its usual pat- tern. If the reduced dosage is noted quickly, such as before eating the upcoming meal, then the remaining amount can be given. If the meal is underway already, then a slightly smaller meal or subsequent snack can be eaten. If the problem is noted later and the blood sugar is very high, then some additional (supplemental) insulin can be taken to bring it down.

The best approach can vary among different patients and your doctor or diabetes educator will have a recommendation for a supplemental scale that may be right for you in these circumstances. of hours and a snack should be kept with you until you feel comfortable that the danger of a serious low blood sugar has passed. You should probably not drive, work at heights, or operate heavy or dangerous machinery during this time. Many people with insulin-requiring diabetes keep a kit containing a syringe of glucagon, a hormone that counteracts the effects of insulin. If the blood sugar falls rapidly and oral glucose, sugar, or a snack is ineffective, glucagon can be given and will usually reverse the falling glucose within a few min- utes. Your doctor can prescribe such a kit for you to keep on hand if you feel it is necessary and reassuring. If you recall that you have taken your insulin twice or taken too much fairly soon after having already done so, then you can take some additional carbohydrate at the meal or a larger-than-usual snack between meals. next scheduled dosage.

A brief exposure to high glucose is usually not harmful (unless it is a repetitive event) and the glucose may take 24 hours or so to settle back to its usual pat- tern. If the reduced dosage is noted quickly, such as before eating the upcoming meal, then the remaining amount can be given. If the meal is underway already, then a slightly smaller meal or subsequent snack can be eaten. If the problem is noted later and the blood sugar is very high, then some additional (supplemental) insulin can be taken to bring it down. The best approach can vary among different patients and your doctor or diabetes educator will have a recommenda- tion for a supplemental scale that may be right for you