Diabetes

he Diagnosis of Diabetes Is Made By A Physician Or Primary Care Provider.

Diabetes is a chronic (long-lasting) health condition that affects how your body turns food into energy.

Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body’s cells for use as energy. People who diagnosed with diabetes the body does not produce or properly use insulin. Insulin is a hormone that is needed to convert sugar, starches and other food into energy needed for everyday life. Over time, that can cause serious health problems, such as heart disease, kidney disease and vision loss.

The cause of diabetes remains unknown, although both genetic and environmental factors such as obesity and lack of exercise appear to play a role. There are 34.2 million people, or 10.5% of the U.S. population, have diabetes. An estimated 26.8 million people - or 10.2% of the population - had diagnosed diabetes. Approximately 7.3 million people have diabetes but have not yet been diagnosed (Centers For Disease Control And Prevention, 2020).

To determine whether of not a patient has pre-diabetes or diabetes, doctors and other health care providers conduct a Fasting Plasma Glucose Test (FPG) or an Oral Glucose Tolerance Test (OGTT). Either test can be used to diagnose pre-diabetes or diabetes.

With the FPG test, a fasting blood glucose level between 100 and 125mg/dl signals pre-diabetes. A person with a fasting blood glucose level above 126mg/dl or higher has diabetes.

In the OGTT test, a person’s blood glucose level is measured after a fast and two hours after drinking a glucose-rich beverage. If the two-hour blood glucose level is between 140 and 199 mg/dl, the person tested has pre-diabetes. If the two-hour blood glucose level is 200 mg/dl or higher, the person tested has diabetes.

Types of Diabetes

Type 1 diabetes is usually diagnosed in children and young adults and was previously known as juvenile diabetes. In type 1 diabetes, the body produces little or not insulin. Insulin is a hormone that is needed to convert sugars and starches into simple sugar called glucose, which can then be turned into energy needed for daily life. Type 1 diabetes develops over weeks or months. The most common symptom is fatigue. The body can’t use what you eat for energy because it doesn’t have enough insulin. High blood sugar (hyperglycemia) develops as a result, which can be very damaging to the body if it’s not controlled.

Symptoms

If you have any of the following diabetes symptoms, see your doctor about getting your blood sugar tested:

• Urinate (pee) a lot, often at night.

• Are very thirsty.

• Lose weight without trying.

• Are very hungry.

• Have blurry vision.

• Have numb or tingling hands or feet.

• Feel very tired.

• Have very dry skin.

• Have sores that heal slowly.

• Have more infections than usual.

• Dry skin and mucous membranes in your mouth and nose.

• Shakiness

• Mood changes or irritability

How is Type 1 Diabetes Diagnosed?

• Blood Tests: Normal sugar (glucose) level is 70-126 mg/dl. Fasting blood glucose level above 126 mg/dl is indicative of diabetes.

• Urine Test: Urine should not have any glucose.

• Hemoglobin A1C (HbA1c): Glycosylated hemoglobin test measures your average blood sugar over the past three months.

• Diabetes is seen in HbA1c levels higher than 6.5%.

• Eye Exam: Your healthcare provider looks for eye damage.

Steps to manage your Blood Glucose Control To Meet Target Goals.

1. Diet is an important part of every diabetes control plan. Eating a healthy diet will help control blood sugar and maintain a healthy weight.

To maintain a healthy diet:

• See a dietician to get a meal plan just for you. This will include carbohydrate counting.

• Eat balanced meals and snacks at regular time intervals each day.

• Stick to your meal plan to avoid rapid changes in your blood sugar-it will also prevent long term problems. Try to eat the same time every day.

• Stay away from foods high in sugar, saturated fat, and cholesterol.

• Don’t drink alcohol or caffeine. Alcohol, when mixed with medications such as insulin may cause severe low blood sugar. Caffeine and insulin may increase blood sugar levels

2. Inject Insulin As Directed By Your Doctor Or Primary Care Provider.

Inject as instructed, including the type and amount of insulin prescribed by your doctor or primary care provider. Injected insulin works like the insulin our bodies make, so it will be needed in all type 1 diabetics to control blood sugar, and in type 2 diabetics in some instances as well.

When taking insulin:

• Never skip an insulin shot.

• Take your insulin at the same time each day to prevent high and low blood sugar levels.

• Tell your health provider about other medical problems before taking other medicine.

3. Physical Activity can help lower your blood sugar. Obtain an exercise program from your doctor or primary care provider. Exercise regularly daily and start a balanced program of exercise and rest.

• Aerobic exercise helps control your blood sugar. You can walk, run, cycle, or swim. All are good choices.

• Too much exercise however can cause low blood sugar. If you are planning strenuous exercise, eat an additional carbohydrate snack to avoid the drop in blood sugar.

• Don’t exercise when you know your blood sugar is low.

• Don’t inject insulin into the area you’ll be exercising for example in your thigh area if you are planning a bike ride in a few hours.

• Wear comfortable shoes and examine your feet before and after exercise.

• Check your blood sugar before and after physical activity (or exercise).

Tips to prevent sudden blood sugar changes:

• Check your blood sugar at home regularly and keep a daily record-remember to bring this with you for appointments with your doctor or primary care provider.

• Always carry a medical identification tag or bracelet-It should list diabetes and medications.

• Carry sugar pills or hard candy to help with unexpected low blood sugar (hypoglycemic) events.

• Speak with your doctor or primary care provider about a regular exercise program. A balanced exercise program of exercise and rest helps keep your blood sugar stable.

• Lose weight if needed. Follow your exercise and nutritional program.

• Check your skin daily-notify your doctor or primary care provider if if you notice a wound that does not heal.

• Take care of your feet. Diabetes can reduce blood flow to your feet. You may not feel heat, cold or pain. You could hurt yourself and not know it. Even an in grown toenail or blister can lead to a serious infection. Wash your feet daily, ear well fitted shoes, and do not walk in bare feet.

• Complete regular annual checkups including HbA1c, Blood Pressure, Cholesterol Lipid Panel, Creatinine and a Microalbumin (Measures how well your kidneys are working), Foot Exam, Dilated Eye Exam, Dental Exam. If the Influenza Vaccine is available, please obtain it.

Type 2 Diabetes

Type 2 diabetes is the most common form of diabetes. In type 2 diabetes, the body does not produce enough insulin, or it cannot properly use the insulin the body makes. Insulin is necessary for the body to be able to use glucose for energy. When you eat food, the body breaks down all of the sugars and starches into glucose, which is the basic fuel for the cells in the body. Insulin takes the sugar from the body blood into the cells. When glucose builds up in the blood instead of going into the cells, it can cause two problems:

• Right away, your cells may be starved for energy.

• Over time, high blood glucose levels may lead to other complications in the eyes, kidneys, nerves, or heart.

• Finding out you have diabetes can be scary. Type 2 diabetes is serious, but people with diabetes can live long, healthy, happy lives.

While diabetes occurs in people of all ages and races, some groups have a higher risk for developing type 2 diabetes than others. Type 2 diabetes is more common in African Americans, Latinos, Native Americans, Asian Americans/Pacific Islanders as well as the aged population.

Factors the following may increase your risk for diabetes include:

• Family history of diabetes

• Obesity

• Physical or emotional stress

• Pregnancy

• Certain medications

• Giving birth to babies that weighed over nine (9) pounds.

• Age-over 40

Follow the steps for Managing your Blood Glucose Control and Tips to Prevent Sudden Blood Sugar Changes discussed above.

Gestational Diabetes

Pregnant women who have never had diabetes before, but who have high blood sugar (glucose) levels during pregnancy are said to have gestational diabetes. Gestational diabetes affects 2% to 10% of all pregnant women, of which about 50% will go on to develop type 2 diabetes (Center’s for Disease Control and Prevention, 2020). We don’t know what causes gestational diabetes, but we do know some clues. The placenta supports the baby as it grows. Hormones from the placenta help the baby to develop. But these hormones also block the action of the mother’s insulin in her body. This problem is called insulin resistance. Insulin resistance makes it hard for the mother’s body to use in insulin. She may need up to three times as much insulin.

Gestational Diabetes.

Gestational diabetes starts when your body is not able to make and use all the insulin it needs for pregnancy. Without enough insulin, glucose cannot leave the blood and be changed to energy. Glucose builds up in the blood in high levels. This is called hyperglycemia.

How gestational diabetes can affect your body

Gestational diabetes affects the mother in late pregnancy, after the baby’s body has been formed, yet the baby still grows. Because of this, gestational diabetes does not cause the kinds of birth defects sometimes seen in babies whose mothers had diabetes before pregnancy.

However, untreated, or poorly controlled gestational diabetes can hurt your baby. When you have gestational diabetes, your pancreas works overtime to produce insulin, but the insulin does not lower your blood glucose levels. Although insulin does not cross the placenta, glucose and other nutrients do, so extra glucose goes through the placenta, giving the baby high blood glucose levels. This causes the baby’s pancreas to make extra insulin to get rid of the blood glucose. Since the baby is getting more energy than it needs to grow and develop, the extra energy is stored as fat.

This can lead to macrosomia, or a baby that is significantly larger than normal. Babies with macrosomia face health problems of their own, including damage to their shoulders during birth. Because of the extra insulin made by the baby’s pancreas, newborns may have very low blood levels at birth and are also at higher risk for breathing problems. Other complications include miscarriage, birth defects and congenital heart disease with high levels of HbA1c during the first ten weeks of pregnancy. Babies with excess insulin become children who are at risk for obesity and adults who are at risk for type 2 diabetes.

Treating gestational diabetes

Gestational diabetes can hurt you and your baby, treatment needs to start quickly. Treatment for gestational diabetes aims to keep blood glucose levels equal to those of pregnant women who do not have gestational diabetes. Treatment for gestational diabetes always includes special meal plans and scheduled physical activity. It may also include daily blood glucose testing and insulin injections. You will need help from your doctor or primary care provider, nurse educator, and other members of your health care team so that your treatment for gestational diabetes can be changed as needed.

For you as the mother-to-be, treatment for gestational diabetes helps lower the risk of a cesarean section birth that very large babies may require. Sticking with your treatment for gestational will give you a healthy pregnancy and birth and may help your baby to avoid future poor health.

Gestational diabetes: Looking ahead

Gestational diabetes usually goes away after pregnancy. But once you’ve had gestational diabetes, your chances are 2 in 3 that it will return in future pregnancies. In a few women, however, pregnancy uncovers type 1 or type 2 diabetes. It is hard to tell whether these women have gestational diabetes or have stated showing their diabetes during pregnancy. These women will need to continue diabetes treatment after pregnancy.

Many women who have gestational diabetes go on to develop type two diabetes years later. There seems to be a link between the tendency to have gestational diabetes and type 2 diabetes.

Gestational diabetes: Looking ahead.

Gestational diabetes and type 2 diabetes both involve insulin resistance. Certain basic lifestyle changes may help prevent diabetes after gestational diabetes.

• Losing weight: Are you more than 20% over your ideal body weight? Losing a few pounds can help you avoid developing type 2 diabetes.

• Making healthy food choices: Follow simple daily guidelines, like eating a variety of foods including fresh fruits and vegetables, limiting fat intake to 30% or less daily calories, and watching your portion size. Healthy eating habits can go a long way in preventing diabetes and other health problems.

• Exercise: Regular exercise allows your body to use glucose without extra insulin. This helps combat insulin resistance and is what makes exercise helpful to people with diabetes. Never start an exercise program without the approval of your doctor or primary care provider first.

Diabetes Conditions

Hypoglycemia

Hypoglycemia, (low blood glucose or insulin reaction) can happen even during those times when you’re doing all you can to manage your diabetes. However, it can be caused by taking too much insulin or diabetes medication, skipping meals or being more active than usual. Although many times you can’t prevent hypoglycemia (low blood glucose) from happening, it can be treated before it gets worse. For this reason, it’s important to know what hypoglycemia is, what the symptoms of hypoglycemia are, and how to treat hypoglycemia.

What are the symptoms of hypoglycemia?

The symptoms of hypoglycemia include:

• Shakiness

• Dizziness

• Sweating

• Hunger

• Headache

• Pale skin color

• Sudden moodiness or behavior changes, such as crying for no apparent reason.

• Clumsy or jerky movements

• Seizure

• Difficulty paying attention or confusion.

• Tingling sensations around the mouth

• Nervousness

• Heart palpations

How do you treat hypoglycemia?

The quickest way to raise your blood glucose and treat hypoglycemia is with some form of sugar, such a 4 glucose tablets (you may purchase glucose tablets at the drug store) ½ cup of fruit juice, or 5-6 pieces of hard candy.

Once you’ve checked your blood glucose and treated your hypoglycemia, wait 15 or 20 minutes and check your blood again. If your blood glucose is still low and your symptoms of hypoglycemia don’t go away, repeat the treatment. After you feel better be sure to eat your regular meals and snacks as planned to keep your blood glucose levels up.

How do you treat hypoglycemia?

It’s important to treat hypoglycemia quickly because hypoglycemia can get worse and you could pass out. If you pass you, you will need IMMEDIATE TREATMENT such as an injection of glucagon or emergency treatment in a hospital.

Glucagon raises blood glucose. It is injected like insulin. Ask your doctor or primary care provider to prescribe it for you and tell you how to use it. You need to tell people around you (such as family members and co-workers) how and when to inject glucagon should you ever need it.

If glucagon is not available, you should be taken to the nearest emergency room for treatment for low blood glucose. If you need immediate medical assistance or an ambulance, someone should call the emergency number in your area (911) for help. It’s a good idea to post emergency numbers by the telephone.

Hyperglycemia

You have diabetes, which means you must deal with some of the problems that go along with having the disease. One of those problems is hyperglycemia. Hyperglycemia happens from time to time to all people who have diabetes.

Hyperglycemia can be a serious problem if you don’t treat it. Hyperglycemia is a major cause of many of the complications that happen to people who have diabetes. Blindness, kidney disease, nerve vessel disease, foot complications and skin changes to name a few.

Hyperglycemia is the technical term for high blood glucose (sugar). High blood sugar happens when the body has too little, or not enough, insulin or with the body can’t use insulin properly.

Hyperglycemia

Several things can cause hyperglycemia. For example, if you have type 1 diabetes, your body may not have given yourself enough insulin. If you have type 2 diabetes, your body may have enough insulin, but it is not as effective as it should be.

The problem could be that you ate more than planned or exercised less than planned. The stress of an illness, such as a cold or flu, could also be the cause. Other stresses, such as family conflicts or school or dating problems, could also cause hyperglycemia.

What are the symptoms of hyperglycemia?

The signs and symptoms include high blood glucose, high levels of sugar in the urine, frequent urination, increased thirst, dry mouth, blurry vision, and fatigue.

Part of managing your diabetes is checking your blood glucose often. Ask your doctor how often you should check and what your blood glucose levels should be. Checking your blood and then treating high blood glucose early will help you avoid the other symptoms of hyperglycemia.

It’s important to treat hyperglycemia as soon as you detect it. If you fail to treat hyperglycemia, a condition called Ketoacidosis (Diabetic Coma) could occur. Ketoacidosis develops when your body doesn’t have enough insulin. Without insulin, your body can’t use glucose for fuel. So, your body breaks down fats to use for energy.

When your body breaks down fats, waste products called ketones are produced. Your body cannot tolerate large amounts of ketones and will try to get rid of them thorough the urine. Unfortunately, the body cannot release all the ketones and they build up in the blood. This can lead to Ketoacidosis.

Hyperglycemia symptoms include:

• Shortness of breath

• Breath that smells fruity

• Nausea and vomiting

• Dry Mouth

• Fatigue

Treatment For Hyperglycemia

Often, you can lower your blood glucose level by exercising. However, if your blood glucose is above 240mg/dl, check your urine for ketones. If you have ketones, do NOT exercise.

Exercising when ketones are present may make your blood glucose level go even higher. You’ll need to work with your doctor or primary care provider to find the safest way for you to lower your blood glucose level.

Cutting down on the amount of food you eat might also help. Work with your dietitian to make changes in your meal plan. If exercise and changes in your diet don’t work, your doctor or primary care provider may change the amount of your medication or insulin or possibly the timing of when you take it.

Ketoacidosis

Ketoacidosis (key-toe-ass-i-DOE-sis) is a serious condition that can lead to a diabetic coma (passing out for a ling time) or even death. Ketoacidosis may happen to people with type 1 diabetes.

Ketoacidosis occurs rarely in people with type 2 diabetes. But some people-especially older people-with type 2 diabetes may experience a different serious condition. It’s called hyperosmolar nonketotic coma.

Ketoacidosis

Ketoacidosis means dangerously high levels of ketones. Ketones are acids that build up in the blood. They appear in the urine when your body does not have enough insulin. Ketones can poison the body. They are a warning sign that your diabetes is out of control or that you are getting sick.

Treatment for Ketoacidosis usually takes place in the hospital.

What are the warning signs of Ketoacidosis?

Ketoacidosis usually develops slowly. But when vomiting occurs, this life-threatening condition can develop in a few hours.

The first symptoms are:

• Thirst or a very dry mouth

• Frequent urination

• High blood glucose (sugar) levels

• High levels of ketones in the urine

Next, other symptoms appear:

• Constantly feeling tired

• Dry or flushed skin

• Nausea, vomiting, or abdominal pain (Vomiting can be caused by many illnesses not just Ketoacidosis. If vomiting continues for more than 2 hours, contact your doctor or primary healthcare provider).

• A hard time breathing, short deep breaths (Call 911 Immediately)

• Fruity odor on breath

• A hard time paying attention or confusion.

Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)

Hyperosmolar Hyperglycemic Nonketotic Syndrome or HHNK, is a serious condition most frequently seen in older people. HHNS can happen to people with either type 1 or type 2 diabetes, but it occurs more often in people with type 2 diabetes. HHNS is usually brought on by something else, such as an illness or infection.

In HHNS, blood sugar levels rise, and your body tries to get rid of the excess sugar by passing it into your urine. You make lots of at first, and you have to go to the bathroom more often. Later you may not have to go to the bathroom as often, and your urine becomes very dark. Also, you may be very thirsty. Even if you are not thirsty, you need to drink liquids. If you don’t drink enough liquids at this point, you can get dehydrated.

If HHNS continues, the severe dehydration will lead to seizures, coma and eventually death. HHNS may take days or even weeks to develop. Know the warning signs of HHNS.

What are the warning signs of HHNS?

• Blood sugar level over 600 mg/dl

• Dry, parched mouth

• Extreme thirst (this may gradually disappear)

• Warm, dry skin that does not sweat.

• High fever (over 101 degrees Fahrenheit for example)

• Sleepiness or confusion

• Loss of vision

• Hallucinations (seeing or hearing things that are not there)

• Weakness on one side of the body (Call 911 immediately)

• If you have any of these symptoms, call 911.

How to avoid HHNS

The best way to avoid HHNS is to check your blood sugar regularly. Many people check their blood sugar several times a day, such as before or after meals. Talk with your doctor or primary care provider about when to check your blood sugar and what does it mean. Speak to your doctor or primary care provider about your target blood sugar range and when to call if your blood sugars are too high, or too low and not in your target range. When you are sick, you will check your blood sugar more often, and drink a glass of liquid (alcohol-free and caffeine-free) every hour. Work with your team to develop your own sick day plan.

Blood Glucose Monitoring Tests

People with diabetes work to keep their blood sugar (glucose) as close to normal as possible. Keeping your blood glucose in your target range can help prevent or delay the start of diabetes complications such as nerve, eye, kidney, and blood vessel damage.

When you learned you had diabetes, you and your health care team worked out a diabetes care plan. The plan provides a balance of the food you eat with your exercise and, possibly, diabetes pills or insulin. You can do two types of checks to help you keep track of how your plan is working. These are blood glucose checks and urine ketone checks.

Blood glucose monitoring is the main tool you have to check your diabetes control. This check tells you your blood glucose level at any one point in time. Keeping a log of your results is vital. When you bring this record to your health care provider, you have a good picture of your body’s response to your diabetes care plan. Blood glucose checks let you see what works and what doesn’t. This allows you and your doctor, dietitian, or nurse educator to make needed changes.

How Blood Glucose Checks Work

You stick your finger with a special needle, called a lancet, to get a drop of blood. With some meters, you can also use your forearm, thigh, or fleshy part of your hand. There are spring-loaded lancing devices that make sticking yourself less painful. Before using the lancing device, wash your hands or the site you choose with soap and water for 20 seconds. If you use your fingertip, stick the side of your fingertip by your fingernail to avoid having sore spots on the frequently used part of your finger.

Glucose Meters

Blood glucose meters are small, computerized machines that “read” your blood glucose. In all types of meters, your blood glucose level shows up as a number on a screen (like that on your pocket calculator). Be sure your doctor or nurse educator shows you the correct way to use your meter. With all the advances in blood glucose meters, use of a meter is better than visual checking.

Consider the following when deciding on a meter:

• What meter does your doctor or primary care provider suggest? They may have meters that they use often and know best.

• What will it cost? Some insurance companies will only pay for a certain meter. Call your insurance company before you purchase a meter and supplies. If your insurance company does not pay for blood glucose checking supplies, rebates are often available toward the purchase of your meter. You still have to consider the cost of the matching strips and lancets. Shop around.

• How easy is the meter to use? Methods vary. Some have fewer steps than others.

• How simple is the meter to maintain? Is it easy to clean? How is the meter calibrated? (set correctly for the batch of strips you are using)?

Meter Accuracy

Experts testing meters in the lab setting found them accurate and precise. That’s the good news. The bad: meter mistakes most often come from the person doing the blood checks. For good results, you must do each step correctly. Here are other things that can cause your meter to give a poor reading:

• Dirty meter

• Meter or strip that’s not at room temperature.

• An outdated test strip.

• Meter not calibrated (set up) for the current box of test strips.

• Blood drop too small

Record your glucose monitoring.

When you finish the blood glucose check, write down your results and use them to see how food, activity and stress affect your blood glucose. Take a close look at your blood glucose record to see if your level is too high or too low several days in a row at about the same time. If the same thing keeps happening, it might be time to change your plan. Work with your doctor, primary care provider, and nurse educator to learn what your results mean for you. This takes time.

Keep in mind that blood glucose results often trigger strong feelings. Blood glucose numbers can leave you upset, confused, angry or down. It’s easy to use the numbers to judge yourself. Remind yourself that your blood glucose level is a way to track how well your diabetes care plan is working for you. It is not a judgment of you as a person. The results may show you need a change in your diabetes care plan.

Checking for Ketones

You may need to check your urine for ketones once in a while. Ketone in the urine is a sign that your body is using fat for energy instead of using glucose because not enough insulin is available to use glucose for energy. Ketones in the urine is more common in type 1 diabetes.

Urine tests are simple, but to get good results, you have to follow directions carefully. Check to be sure that the strip is not outdated. Read the insert that comes with your strips. Go over the correct way to check your ketone strip with your doctor, primary care provider or nurse.

Here’s how most urine test go:

• Get a sample of your urine in a clean container.

• Place the strip in the sample (you can also pass the strip through the urine stream).

• Gently shake excess urine off the strip.

• Wait for the strip pad to change color. The directions will tell you how long to wait.

• Compare the strip pad to the color chart on the strip bottle, this gives you a range of the amount of ketones in your urine.

• Record your results.

What do your results mean? Small or trace amounts of ketones may mean that ketone buildup is starting. You should test again in a few hours. Moderate or large amounts are a danger sign. They upset the chemical balance of your blood and can poison the body. Never exercise when your urine checks show moderate or large amounts of ketones and your blood glucose is high. These are signs that your diabetes is out of control. Talk to your doctor at once if your urine results show moderate to large amounts of ketones.

Keeping track of your results and related events is important. Your log gives you the data you and your doctor or primary care provider need to adjust your diabetes care plan.

When to Test

Ask your doctor, primary care provider or nurse when to check for ketones. You may be advised to check for ketones when:

• You blood glucose is more than 300 mg/dl.

• You feel nauseated, are vomiting, or have abdominal pain.

• You feel tired all the time.

• You are thirsty or have a very dry mouth.

• Your skin is flushed.

• You have a hard time breathing (Call 911) or your breath smell “fruity”.

• You feel confused or “in a fog”.

These can be signs of high ketone levels that need your doctor or primary care provider’s help.

Complications of Diabetes

Kidney Disease (nephropathy)

Kidneys are remarkable organs. Inside them are millions of tiny blood vessels that act as filters. Their job is to remove waste products from the blood.

Sometimes this filtering system breaks down. Diabetes can damage the kidneys and cause them to fail. Failing kidneys lose their ability to filter out waste products, resulting in kidney disease.

When our bodies digest the protein we eat, the process creates waste products. In the kidneys, millions of tiny blood vessels (capillaries) with even tinier holes in them act as filters. As blood flows through the blood vessels, small molecules such as waste products squeeze through the holes. These waste products become part of the urine. Useful substances, such as protein and red blood cells, are too big to pass through the holes in the filter and stay in the blood.

Kidney Disease (nephropathy)

Diabetes can damage this system. High levels of blood sugar make the kidneys filter too much blood. All this extra work is hard on the filters. After many years, they start to leak. Useful protein is lost in the urine. Having small amounts of protein in the urine is called macroalbuminuria. When kidney disease is caught (during macroalbuminuria) several treatments may keep kidney disease from getting worse. Having larger amounts of protein in the urine is called macroalbuminuria. When kidney disease is caught later (during macroalbuminuria), end-stage renal disease, or ESRD, usually follows.

In time, the stress of overwork causes the kidneys to lose their filtering ability. Waste products then start to build up in the blood.

Finally, the kidneys fail. This failure, ESRD, is very serious. A person with ESRD needs to have a kidney transplant or to have the blood filtered by machine (dialysis).

Not everyone with diabetes develops kidney disease. Factors that can influence kidney disease development include genetics, blood sugar control, and blood pressure.

The better a person keeps diabetes and blood pressure under control, the lower the chance of getting kidney disease.

Symptoms and diagnosis of kidney disease

The kidneys work hard to make up for the failing capillaries, so kidney disease produces no symptoms until almost all function is gone. Also, the symptoms of kidney disease are not specific. The first symptom of kidney disease is often fluid buildup. Other symptoms of kidney disease include loss of sleep, poor appetite, upset stomach, weakness, and difficulty concentrating. It is vital to see a doctor or primary care provider regularly. The doctor can check your blood pressure, urine, (for protein) blood (for waste products) and organs for other complications of diabetes.

Kidney Disease Prevention

Diabetic kidney disease can be prevented by keeping blood sugar in your target range. Research has shown that tight blood sugar control reduces the risk of microalbuminuria by one third. In people who already have microalbuminuria, the risk of progressing to macroalbuminuria was cut in half. Other studies have suggested that tight control can reverse microalbuminuria.

Treatments for kidney disease

Important treatments for kidney disease are tight control of blood glucose and blood pressure. Blood pressure has a dramatic effect on the rate at which the disease progresses. Even a mild rise in blood pressure can quickly make kidney disease worsen. Four ways to lower your blood pressure are losing weight, eating less salt, avoiding alcohol and tobacco, and getting regular exercise.

When these methods fail, certain medicines may be able to lower blood pressure. There are several kinds of blood pressure drugs. Not all are equally good for people with diabetes. Some raise blood sugar levels or mask some of the symptoms of low blood sugar. Doctors usually prefer people with diabetes to take blood pressure drugs called ACE inhibitors.

ACE inhibitors are recommended foremost people with diabetes, high blood pressure and kidney disease. Recent studies suggest that ACE inhibitors, which include captopril and enalapril, slow kidney disease in addition to lowering blood pressure. In fact, these drugs are helpful even in people who do not have high blood pressure.

Another treatment some doctors and primary care providers use with macroalbuminuria is a low-protein diet can decrease protein loss in the urine and increase protein levels in the blood. Never start a low protein diet without talking to your doctor or primary care provider.

Once the kidneys fail, dialysis is necessary. The person must choose whether to continue with dialysis or to get a kidney transplant. This choice should be made as a team effort. The team should include the doctor and diabetes educator, a nephrologist, a kidney transplant surgeon, a social worker, and a psychologist.

Kidney Transplantation

Diabetes sometimes damages kidneys so badly that they no longer work, When the kidneys fail, the person needs a way to replace their function, which is to clean the blood. One option is kidney transplantation. For more information on kidney transplantation visit http://www.diabetes.org/types-1-diabetes/kidney-trnasplants.jsp

Dialysis

Dialysis is a way of cleaning the blood with an artificial kidney. Dialysis is the more common form of kidney-replacement therapy. There are two types of dialysis: hemodialysis and peritoneal dialysis.

No matter which type is chosen, the person undergoing dialysis needs to work closely with the health care team to keep diabetes under control.

Hemodialysis

In hemodialysis, an artificial kidney removes waste from the blood. A surgeon must first create an “access,” a place where blood can easily be taken from the body and sent to the artificial kidney for cleaning. The access, usually in the forearm, can be made from the patient’s own blood vessels or from a piece of implanted tubing. The access is inside the body and cannot be seen from the outside. Usually, this surgery is done 2 to 3 months before dialysis starts so the body has time to heal.

Hemodialysis must be done 2 to 3 days per week, and lasts 3 to 5 hours each time. Blood travels through the artificial kidney, where waste products are filtered out and the clean blood returns to the body. Only about ½ cup of blood is out of your body at one time.

Usually, hemodialysis is done in a clinic, with many people receiving dialysis at the same time. Hemodialysis can also be done at home, but it requires a partner, such as a relative or friend, and special training.

Hemodialysis

Hemodialysis is not perfect for everyone. During treatments, people can have high or low blood pressure, and upset stomach or muscle cramps. A special diet is needed to stay healthy. Other problems can develop over time, such as nerve problems, anemia, bone disease, poor nutrition, problems with infection, problems with access, and difficulty regulating insulin doses. Sometimes, these complications are the result of diabetes, not of hemodialysis.

Peritoneal dialysis

Another form of dialysis is called peritoneal dialysis. The lining inside of your abdomen (the peritoneum) becomes the filter. A soft plastic tube is put into the abdomen by a surgeon. When the body heals, cleansing fluid (dialysate) is put into the abdomen through this tube. Waste products in the bloodstream pass through the peritoneum into the dialysate, along with the waste products is drained off.

The two main types of peritoneal dialysis are continuous ambulatory peritoneal dialysis (CAPD) and continuous cycling peritoneal dialysis (CCPD). People perform CAPD themselves by attaching a plastic bag filled with cleansing fluid to the tube in the abdomen and raising it to shoulder level. This causes the fluid to run into the abdomen. The bag is then unhooked or rolled up around the waist. In several hours, the fluid is drained out and thrown away. A fresh bag of fluid is then put into the abdomen to begin cleansing again. This is called an “exchange” and takes about 30-45 minutes. It is done 4 or 5 times a day. Between exchanges, the person can move around and perform daily activities.

In CCPD, a machine puts the cleansing fluid into the abdomen and drains it automatically. This is usually done at night.

CAPD and CCPD may be better treatments than hemodialysis for some people. With daily dialysis, the body does not build up too much fluid. This reduces the stress on the heart and blood vessels. A person can eat a more normal diet and have more time for work and travel.

Peritoneal dialysis

Peritoneal dialysis is not for everyone, however. A person must be able to see well and do each step correctly to prevent infection in the abdomen. Anemia, bone disease, and poor nutrition can occur, just like in hemodialysis.

Eye Disease

People with diabetes do have a higher risk of blindness than people without diabetes.

But most people who have diabetes have nothing more than minor eye disorders. You can keep minor problems minor, and if you do develop a major problem, there are treatments that often work well if you begin them right away.

To understand what happens in eye disorders, it helps to understand how the eye works. The eye is a ball covered with a tough outer membrane. The covering in front is clear and curved. This curved area is the cornea, which focuses light while protecting the eye.

After light passes through the cornea, it travels through a space called the anterior chamber (which is filled with a protective fluid called the aqueous humor), through the pupil (which is a hole in the iris, the colored part of the eye), and then through a lens that performs more focusing. Finally, light passes through another fluid-filled chamber in the center of the eye (the vitreous humor) and strikes the back of the eye, the retina.

Like the film in a camera, the retina records the images focused on it. But unlike film, the retina also converts those images into electrical signals, which the brain receives and decodes.

One part of the retina is specialized for seeing fine detail. This tina area of extra sharp vision is called the macula.

Blood vessels in and behind the retina nourish the macula. The smallest of these blood vessels are capillaries.

Glaucoma

People with diabetes are 40% more likely to suffer from glaucoma than people without diabetes. The longer someone has had diabetes the more common glaucoma occurs. Risk also increases with age.

Glaucoma occurs when pressure builds up in the eye. In most cases, the pressure causes drainage of the aqueous humor to slow down so that it builds up in the anterior chamber. The pressure pinches the blood vessels that carry blood to the retina and optic nerve. Vision is gradually lost because the retina and nerve are damaged.

There are several treatments for glaucoma. Some use drugs to reduce pressure in the eye, while others involve surgery.

Cataracts

Many people without diabetes get cataracts but people with diabetes are 60% more likely to develop this eye condition. People with diabetes also tend to get cataracts at a younger age and have them progress faster. With cataracts, the eye’s clear lens clouds, blocking light,

To help deal with mild cataracts, you may need to wear sunglasses more often and use glare-control lenses in your glasses. For cataracts that interfere greatly with vision, doctors usually remove the lens of the eye. Sometimes the patient gets a new transplanted lens. In people with diabetes, retinopathy can get worse after removal of the lens, and glaucoma may start to develop.

Retinopathy

Diabetic retinopathy is a general term for all disorders of the retina caused by diabetes. There are two major types of retinopathy: non-proliferative and proliferative.

Eye Disease

Non-proliferative retinopathy is the most common form of retinopathy. In non-proliferative retinopathy, capillaries in the back of the eye balloon and form pouches. Non-proliferative retinopathy can move through three stages (mild, moderate, and severe), as more and more blood vessels become blocked. Although retinopathy does not usually cause vision loss at this stage, the capillary walls may lose their ability to control the passage of substances between the blood and the retina. Fluid can leak into the part of the eye where focusing occurs, the macula. When the macula swells with fluid, a condition called macula edema, vision blurs and can be lost entirely. Although non-proliferative retinopathy usually does not require treatment, macular edema must be treated, but fortunately treatment is usually effective at stopping and sometimes reversing vision loss.

In some people retinopathy progresses after several years to a more serious form called proliferative retinopathy. In this form, the blood vessels are so damaged they close off. In response, new blood vessels start growing in the retina. These new vessels are weak and can leak blood, blocking vision a condition called vitreous hemorrhage. The new blood vessels can also cause scar tissue to grow. After the scar tissue shrinks, it can distort the retina or pull it out of place. This is called retinal detachment.

Your retina can be badly damaged before your notice any change in vision. Most people with non-proliferative retinopathy have no symptoms. Even with proliferative retinopathy, the more dangerous form, people sometimes have no symptoms until it is too late to treat them. For this reason, you should have your eyes examined regularly by an eye care professional.

People who keep their blood sugar levels closer to normal are less likely to have retinopathy or have milder forms.

Nerve Vessel Disease

Nerves send messages to and from your brain about pain, temperature, and touch. They tell your muscles when and how you move. They also control body systems that digest food and pass urine. About half of all people with diabetes have some form of nerve damage. It is more common in those who have had the disease for a number of years. Nerve damage from diabetes is called diabetic neuropathy, and it can lead many kinds of problems.

The are two common types of nerve damage. The first is sensorimotor neuropathy also known as peripheral neuropathy. This can cause tingling, pain, numbness, or weakness in your feet and hands.

The second is called autonomic neuropathy. This type can lead to:

• Digestive problems such as feeling full, nausea, vomiting, diarrhea, or constipation.

• Problems with how well your bladder works.

• Problems having sex.

• Dizziness or faintness

• Loss of typical signs of a heart attack

• Loss of the warning signs of low blood

• Increased or decreased sweating

• Changes in how your eyes react to light and dark

People with diabetes can also have what is called focal neuropathy. In this kind of nerve damage, a nerve or a group of nerves is affected, causing sudden weakness or pain. It can lead to double vision, a paralysis on one side of the face called Bell’s palsy, or pain in the front of the thigh or other parts of the body.

Nerve Vessel Disease

People with diabetes also are a risk for compressed nerves. Something in the body presses against a nerve preventing it from sending a signal. Carpal tunnel syndrome is a common cause of numbness and tingling in the fingers and can lead to muscle pain and weakness as well. Nerve damage can be hard to diagnose because its symptoms can be caused by other conditions. Symptoms can be very mild. Knowing the symptoms to look for and reporting them to your health care team can help. Make a list your symptoms or use the checklists in this brochure. Your doctor will give you an exam and a number of tests to check for nerve damage.

Foot Complications

People with diabetes can develop many different foot problems. Even ordinary problems can get worse and lead to serious complication. Foot problems most often happen when there is nerve damage, also called neuropathy, which results in loss of feeling in your feet. Poor blood flow or changes in the shape of your feet or toes may cause problems.

Although it can hurt, diabetic nerve damage can also lessen your ability to feel pain, heat, and cold. Loss of feeling often means you may not feel a foot injury. You could have a tack in your shoe and walk on it all day without knowing. You could get a blister and not feel it. You might not notice a foot injury until the skin breaks down and becomes infected.

Nerve damage can also lead to changes in the shape of feet and toes. Ask your health care provider about special therapeutic shoes, rather than forcing deformed feet and toes deformed feet and toes into regular shoes.

Skin Changes

Diabetes can cause changes in the skin oof your foot. At times your foot may become very dry. The skin may peel and crack. The problem is that the nerves that control oil and moisture in your foot no longer work.

After bathing, dry your feet and seal in the remaining moisture with a thin coat of plain petroleum jelly, (Vaseline) an unscented hand cream, or such other products.

Do not put oils or creams between your toes. The extra moisture can lead to infection. Also, don’t soak your feet-that can dry your skin.

Calluses

Calluses occur more often and build up faster on the feet of people with diabetes. This is because there are high-pressure areas under the foot. Too much callus may mean that you will need therapeutic shoes and inserts.

Calluses, if not trimmed, get very thick, break down and turn into ulcers. (open sores). Never try to cut calluses or corns yourself-this can lead to ulcers and infection. Let your health care provider cut your calluses. Also, do not try to remove calluses and corns with chemical agents. These products can burn your skin.

Using a pumice stone every day will help keep calluses under control. It is best to use the pumice stone on wet skin. Put on lotion right after you use the pumice stone.

Foot Ulcers

Ulcers occur most often of the ball of the foot or the bottom of the big toe. Ulcers on the sides of the foot are usually due to poorly fitting shoes. Remember, even though some ulcers do not hurt, every ulcer should be seen by your doctor or primary care provider right away. Neglecting ulcers can result in infections which in turn can lead to loss of a limb.

What your health care provider will do varies with your ulcer. Your health care provider may take x-rays of your foot to make sure the bone is not infected. The health care provider may clean out any dead and infected tissue. You may need to go to the hospital for this. Also, the health care provider may culture the wound to find out what type of infection you have, and which antibiotic will work best.

Keeping off your feet is very important. Walking on an ulcer can make it get larger and force the infection deeper into your foot. Your health care provider may put a special shoe, brace, or cast on your foot to protect it.

If your ulcer is not healing and the circulation is poor, your health care provider may need to refer you to a vascular surgeon. Good diabetes control is important. High blood glucose levels make it hard to fight infection.

After the foot ulcer heals, treat your foot carefully. Scar tissue under the healed wound will break down easily. You may need to wear special shoes after the ulcer is healed to protect this area and prevent the ulcer from returning.

Poor Circulation

Poor circulation (blood flow) can make your foot less able to fight infection and heal. Diabetes causes blood vessels of the foot and leg to narrow and harden. You can control some of the things that cause poor blood flow. Don’t smoke-smoking make arteries harden faster. Also, follow your health care provider’s advice for keeping your blood pressure and cholesterol under control.

If your feet are cold, you may be tempted to warm them. Unfortunately, if your feet cannot feel heat, it is easy for you to burn them with hot water bottles, or heating pads. The best way to help cold feet is to wear socks.

Some people feel pain in their calves when walking fast, up a hill, or on a hard surface. This condition is called intermittent claudication. Stopping to rest for a few moments should end the pain. If you have these symptoms, you must stop smoking. Work with your doctor or primary care provider to get started on a walking program. Some people can be helped with medication to improve.

Poor Circulation

Circulation. Exercise is good for poor circulation. It stimulates blood flow in the legs and feet. Walk in sturdy, good-fitting, comfortable shoes. Don’t walk when you have open sores.

Amputation

People with diabetes are far more likely to have a foot or leg amputated than other people. The problem? Many people with diabetes have artery disease, which reduces blood flow to the feet. Also, many people with diabetes have nerve disease, which reduces sensation. Together, these problems make it easy to get ulcers and infections that may lead to amputation. Most amputations are preventable with regular care and proper footwear.

One of the biggest threats to your feet is smoking. Smoking affects small blood vessels. It can cause decreased blood flow to the feet and make wounds heal slowly. A lot of people with diabetes who need amputations are smokers.

Skin Complications

Some of these problems are skin conditions anyone can have, but people with diabetes get more easily. These include bacterial infections, fungal infections and itching.

Bacterial Infections

Several kinds of bacterial infections occur in people with diabetes. One common is styes. These are infections of the glands of the eyelids. Another kind are boils, or infections of the hair follicles. Carbuncles are deep infections of the skin and the tissue underneath. Infections can also occur around the nails.

Inflamed tissues are usually hot, swollen, red, and painful. Several different organisms can cause infections. The most common ones are the Staphylococcus bacteria, also called staph.

Once, bacterial infections were life threatening, especially for people with diabetes. Today, death is rare, thanks to antibiotics and better methods of blood sugar control.

But even today, people with diabetes have more bacterial infections than other people do. Doctors believe people with diabetes can reduce their chances of these infections by practicing good skin hygiene.

Fungal Infections

The culprit in fungal infections of people is often Candida albicans. This yeast-like fungus can create itchy rashes of moist, red areas surrounded by tiny blisters and scales. These infections often occur in warm, moist folds of the skin. Problem areas are under the breast around the nails, between fingers and toes, in the corners of the mouth, under the foreskin (in circumcised men), and in the armpits and groin.

Common fungal infections include jock itch, athlete’s foot, ringworm (a ring-shaped itchy patch) and vaginal infection that causes itching.

Itching

Localized itching is often caused by diabetes. It can be caused by a yeast infection, dry skin, or poor circulation. When poor is the cause of itching, the itchiest areas may be the lower parts of the legs.

You may be able to treat itching yourself. Limit how often you bathe, particularly when the humidity is low. Use mild soap with moisturizer and apply skin cream after bathing.

Diabetic Dermopathy

Diabetes can cause changes in the small blood vessels. These changes can cause skin problems called diabetic dermopathy.

Dermopathy often looks like light brown, scaly patches. These patches may be oval or circular. This disorder most often occurs on the front of both legs. But the legs may not be affected to the same degree, these patches do not hurt, open up, or itch. Dermopathy is harmless. You do not need to be treated.

Necrobiosis Lipoidica Diabeticorum

Another disease that may be caused by changes in the blood vessels is necrobiosis lipoidica diabeticorum (NLD). NLD is similar to diabetic dermopathy. The difference is that the sports are fewer but larger and deeper.

NLD often starts as a dull, red, raised area. After a while, it looks like a shiny scar with a violet border. The blood vessels under the skin may become easier to see. Sometimes NLD is itchy and painful.

NLD is a rare condition. Adult women are the most likely to get it. As long as the sores do not break open, you do not need to have it treated. But if you get open sores see your doctor or primary care provider for treatment.

Atherosclerosis

Thickening of the arteries, atherosclerosis, can affect the skin of the legs. People with diabetes tend to get atherosclerosis at younger ages than other people do. As atherosclerosis narrows the blood vessels, the skin changes. It becomes hairless, thin, cool, and shiny. The toes become cold. Toenails thicken and discolor. And exercise causes pain in the calf muscles because the muscles are not getting enough oxygen.

Because blood carries the infection-fighting white cells, affected legs heal slowly when the skin is injured. Even minor scraps can result in open sores that heal slowly.

Atherosclerosis

People with neuropathy are more likely to suffer foot injuries. These occur because the person does not feel pain, heat, cold, or pressure as well. The person can have an injured foot and not know about it. The wound goes uncared for, and so infections develop easily. Atherosclerosis can make things worse. The reduced blood flow can cause the infection to become severe.

Allergic Reactions

Allergic skin reactions can occur in response to medicines, such as insulin or diabetes pills. You should see your doctor if you think you are having a reaction to medicine. Be on the lookout for rashes, depressions, or bumps at the site where you inject insulin.

Diabetic Blisters (Bullosis Diabeticorum)

Rarely, people with diabetes erupt in blisters. Diabetic blisters can occur on the backs of fingers, hands, toes, legs, and buttocks.

These sores look like burn blisters. They sometimes are large. But they are painless and have no redness around them. They heal by themselves, usually without scars, in about three weeks. They often occur in people who have diabetic neuropathy. The only treatment is to bring blood sugar levels under control.

Eruptive Xanthomatosis

Eruptive Xanthomathosis is another condition caused by diabetes that’s out of control. It consists of a firm, yellow, pea-like enlargements in the skin. Each bump has a red halo and may itch. This condition occurs most often on the backs of hands, feet, arms, legs, and buttocks.

The disorder usually occurs in young men with type 1 diabetes. The person often has high levels of cholesterol and fat in the blood. Like diabetic blisters, these bumps disappear when diabetes control is restored.

Digital Sclerosis

Sometimes, people with diabetes develop tight, thick, waxy skin on the backs of their hands. Sometimes skin on the toes and forehead also becomes thick. The finger joint become stiff and can no longer move the way they should. Rarely, knees, ankles or elbows also get stiff.

This condition happens to about one third of people who have type 1 diabetes. The only treatment is to bring blood sugar levels under control.

Disseminated Granuloma Annulare

In disseminated granuloma annulare, the person has sharply defined ring-shaped raised areas on the skin. These rashes occur most often on parts of the body far from the trunk (for example, the fingers or ears). But sometimes the raised areas occur on the trunk. They can be red, red-brown, or skin-colored.

Acanthosis Nigricans

Acanthosis nigricans is a condition in which tan or brown raised areas appear on the sides of the neck, armpits, and groin. Sometimes they also occur on the hands, elbows, and knees. Acanthosis nigricans usually strikes people who are very overweight. The best treatment is to lose weight. Some creams can help the spots look better.

Gastroparesis

Gastroparesis is a disorder affecting people with both type 1 and type 2 diabetes, where the stomach takes too long to empty its contents. It happens when nerves to the stomach are damaged or stop working. The vagus nerve controls the movement of food through the digestive tract. If the vagus nerve is damaged, the muscles of the stomach and intestines do not work normally, and the movement of food is slowed or stopped.

Just as with other types of neuropathy, diabetes can damage the vagus nerve if blood glucose levels remain high over a long period of time. High blood glucose causes chemical changes in the nerves and damages the blood vessels that carry oxygen and nutrients to the nerves.

Just as with other types of neuropathy, diabetes can damage the vagus nerve if blood glucose levels remain high over a long period of time. High blood glucose causes chemical changes in nerves and damages the blood vessels that carry oxygen and nutrients to the nerves.

Signs and symptoms of Gastroparesis (delayed gastric emptying) are:

• Heartburn

• Nausea

• Vomiting of undigested food

• Weight loss

• Abdominal bloating

• Erratic blood glucose (sugar) levels

• Lack of appetite

• Gastroesophageal reflux

• Spasms of the stomach wall

Since food is absorbed more slowly in gastroparesis, it is important to work closely with your healthcare provider and dietitian to make changes in your diabetes management plan as needed.

Depression

Feeling down once in a while is normal. But some people feel a sadness that just won’t go away. Life seems hopeless. Feeling this way most of the day for two weeks or more is a sign of serious depression. At any given time, most people with diabetes do not have depression. But studies show that people with diabetes have a greater risk of depression than people without diabetes. There are no easy answers about why this is true.

The stress of daily diabetes management can build. You may feel alone or set apart from your friends and family because of the extra work.

If you face diabetes complications such as nerve damage, or if you are having trouble keeping your blood sugar levels where you’d like, you may feel like you’re losing control of your diabetes. Even tension between you and your doctor may make you feel frustrated and sad.

Just like denial, depression can get you into a vicious cycle. It can block good diabetes self-care. If you are depressed and have no energy, chances are you will find such tasks as regular blood sugar testing too much. If you feel so anxious that you can’t think straight, it will be hard to keep up with a good diet. You may not feel like eating at all. Of course, this will affect your blood sugar levels.

Poor diabetes control can also cause symptoms that look like depression. Low or high sugars for example, can make you feel tired or anxious. Low blood sugar during the night can interrupt you sleep and make it more difficult back asleep or wake up in the morning. If physical problems are not the cause of your depression, then additional help is needed.

Spotting depression is the first step. Getting help is the second. If you have been feeling really sad, blue, or down in the dumps, check for these symptoms:

• Loss for pleasure: You no longer take interest in doing things you used to enjoy.

• Change in sleep patterns: You have trouble falling asleep, you wake often during the night, or you want to sleep more than usual, including the day.

• Change in appetite: You eat more or less than you used tom resulting in a quick weight gain or weight loss

• Trouble concentrating: You can’t watch a TV program or read an article because thoughts or feelings get in the way.

• Loss of energy: You feel tired all the time.

• Nervousness: You always feel so anxious you can’t sit still

• Guilt: You feel you “never do anything right” and worry that you are a burden to others.

• Morning sadness: You feel worse in the morning than you do the rest of the day.

• Suicidal thoughts: You feel you want to die or are think about ways to hurt yourself.

If you have three or more of these symptoms, or if you have just one or two but have been feeling low for tow weeks or more, it’s time to get help.

Diabetes Management

Nutrition

What you eat is one of the most important aspects of managing diabetes. Don’t fight against good nutrition. Find tips and ideas to make healthful eating a part of your busy lifestyle. Along with exercise and medications, nutrition is important for good diabetes control. By eating well-balanced meals in the correct amounts, you can learn to thrive with diabetes.

To manage diabetes while still enjoying starchy foods follow these tips:

• For the plate method, limit starches to ¼ of your plate. This is about ½ cup 1 cup of a starchy food or 2 slices of bread.

• For Carbohydrate counters, stick to about 45-60 Grams of total carbohydrate per meal (including fruits and dairy too).

• Choose whole grain starches starchy vegetables and legumes inside of refined carbohydrates.

Carbohydrates and Diabetes

Understanding the effect of carbohydrate on blood glucose levels is key to managing diabetes. The carbohydrate in food makes blood glucose levels go up.

The key to keeping blood glucose levels at your goal is to balance the food you eat with your physical activity and any pills or insulin you take. If you eat more carbohydrate than usual, you can expect your blood glucose levels to be higher than usual. Likewise, it you eat less, you can expect your blood glucose levels to be lower.

Finding the balance for yourself is important so you can feel your best, do the things you enjoy, and lower your risk of diabetes complications.

There are three main types of carbohydrate in food. They are starch, sugar, and dietary fiber. Starch and sugar both raise blood glucose levels so including both types in your meal plan is essential. Foods that contain carbohydrate are:

• Beans and legumes

• Grains and starchy vegetables

• Fruit

• Dairy products like milk and yogurt

• Sweets and snack foods like chips

Meal planning for diabetes is more than just cutting back on starch or sugar. There are many options that people with diabetes use to help them plan their meals. Having diabetes doesn’t have to mean eating the same foods day after day. By choosing the right meal planning tool for you, you’ll be able to try new foods and enjoy your favorites. You may want to try them all or use a combination to find out which you like the most.

Plate Method

It’s simple! Include more non-starchy vegetables and smaller portions of everything else. No special tools and nothing to count or read. Learn more on the plate method at: http://www.diabetes.org/food-nutrition-lifestyle/nutrition/meal-planning/create-your-plate.jsp

Counting Carbohydrates

Carbohydrate-containing foods raise blood glucose levels. By keeping track of how many carbohydrates you eat and setting a limit for your maximum amount to eat, you can help to keep your blood glucose levels on track.

Carbohydrates and Diabetes

Glycemic Index

The amount and type of carbohydrate affects blood glucose levels. Choose most of your foods with a lower Glycemic response as a way to fine tune your Carb counting. Read more at: http://www.diabetes.org/food-nutrition-lifestyle/nurtrition/meal-planning/glycemic-index-and-diabetes.jsp

Fats and Diabetes

Carbohydrate gets all of the attention in diabetes management. How much total fat you eat depends on many factors depends on many factors but more important than total fat is the type fat you eat. There are “healthy fats” and “unhealthy fats.”

To lower your risk of heart disease, try to eat less of the unhealthy fats-saturated and trans-fat. At the same time, you can protect your heart by eating the healthy fats- monosaturated, polyunsaturated and omega-3 fats.

It is true that all fat is high in calories so it is important to watch portion sizes as well. As you are cutting back on the sources of saturated fats and trans fats, you’ll want to substitute the healthy fats in their place. Instead of 1 cheese stick for an afternoon snack have 12 almonds. The calories are about the same, but you will have improved your heart health with that single change.

Saturated Fats

Why should you eat less saturated fats? Because saturated fat raises blood cholesterol levels. High blood cholesterol is a risk factor for heart disease. People with diabetes are at high risk for heart disease and limiting your saturated fat can help lower your risk of having a heart attack or stroke.

Foods containing saturate fat include:

• High-fat dairy products such as full-fat cheese, cream, ice cream, whole milk 2% milk and sour cream.

• High -fat meats like regular ground beef, bologna, hot dogs, sausage, bacon, and spareribs

• Lard

• Butter

• Fatback and salt pork

• Cream Sauces

• Gravy made with meat drippings

• Chocolate

• Palm oil and palm kernel oil

• Poultry (Chicken and turkey) skin

One of the important diabetes nutrition guidelines is to eat less than 7% of calories from saturated fat. For most people eating, this is about 15 grams of saturated fat per day. That is not much when you consider just one ounce of cheese can have 8 grams of saturated fat. Many adults, especially women or sedentary men, may need less. To find out a specific goal for you, talk with your health care provider or dietitian.

Saturated fat grams are listed on the label under total fat. As a general rule, compare foods with less saturated fat. Foods with 1 gram or less saturated fat per serving are considered low in saturated fat.

Trans Fat.

Like Saturated fat, trans fat tends to increase blood cholesterol levels. Trans fat is actually worse for you than saturated fat, and for a heart-healthy diet, you want to eat as little trans fat as possible by avoiding all foods that contain it.

Trans fats are produced when liquid oil is made into a solid fat. This process is called hydrogenation. Trans fats act like saturated fats and can raise your cholesterol level. Trans fats are listed on the label, making it easier to identify these Unless there is at least 0.5 grams or more of trans fat in a food, the label can claim 0 grams. If you want to avoid as much trans fat as possible, you must read the ingredient list on food labels. Look for words like hydrogenated oil or partially hydrogenated oil. Select foods that either do not contain hydrogenated oil or where liquid oil is listed first in the ingredient list. Sources of trans fat include:

• Processed foods like snacks (crackers and chips) and baked goods (muffins, cookies, cakes) with hydrogenated oil or partially hydrogenated oil.

• Stick margarines.

• Shortening

• Some fast-food items such as french fries.

Cholesterol

Your body makes some of the cholesterol in your blood. The rest comes from foods you eat. Foods from animals are sources of dietary cholesterol. Cholesterol from the food you eat may increase your blood cholesterol, so it’s a good idea to eat less than 200mg per day. Cholesterol is required on the label if the food contains it. Sources of cholesterol include:

• High-fat dairy products (whole or 2% milk, cream, ice cream, full-fat cheese)

• Egg yolks

• Liver and other organ meats

• High-fat meat and poultry skin

• Monounsaturated Fat

Monounsaturated fats are called “good or healthy” fats because they can lower your bad (LDL) cholesterol. Sources of monounsaturated fat include:

• Avocado

• Canola oil

• Nuts like almonds, cashews, pecans and peanuts.Olive oil and olives

• Sesame seeds

The American Diabetes Association (ADA) recommends eating more monounsaturated fats than saturated or trans fats in your diet. To include more monounsaturated fats, try to substitute olive oil or canola oil instead of butter, margarine or shortening when cooking. Sprinkling a few nuts or sesame seeds on a salad is an easy way to eat more monounsaturated fats. But be careful. Nuts and oils are high in calories, like all fats. If you are trying to lose or maintain your weight, you want to eat small portions of these foods. For example, 6 almonds or 4 pecan halves contain the same number of calories as one teaspoon of oil or butter. Work with your dietitian to include healthy fats into your meal plan without increasing your total calories. Monounsaturated fats are not required on the label. Some foods do list them-particularly if they are a good source.

Polyunsaturated Fat

Polyunsaturated fats are also “healthy” fats. ADA recommends that you include these in your diet as well as monounsaturated fats. Sources of polyunsaturated fats are:

• Corn oil

• Cottonseed oil

• Safflower oil

• Soybean oil

• Sunflower oil

• Walnuts

• Pumpkin or sunflower seeds

• Soft (tub) margarine

• Mayonnaise

• Salad dressings

• Omega-3 Fatty Acids

Omega-3 fatty acids help prevent clogging of the arteries. Some types of fish are high in omega-3 fatty acids. ADA recommends eating non-fried fish 2 or 3 times a week. Sources include:

• Albacore tuna

• Herring

• Mackerel

• Rainbow trout

• Sardines

• Salmon

Some plant foods are also sources of omega-3 fatty acids. Sources include:

• Tofu and other soybean products

• Walnuts

• Flaxseed and flaxseed oil

• Canola oil

Medications

Insulin

Inside the pancreas, beta cells make the hormone insulin. With each meal, beta cells release insulin to help the body use or store the blood glucose it gets from food. In people with type 1 diabetes, the pancreas no longer makes insulin. The beta cells have been destroyed and they need insulin shots to use glucose from meals.

People with type 2 diabetes make insulin, but their bodies don’t respond well to it. Some people with type 2 diabetes need diabetes pills or insulin shots to help their bodies use glucose for energy.

Insulin cannot be taken as a pill. The insulin would be broken down during digestion just like protein in food. Insulin must be injected into the fat under your skin for it to get into your blood.

There are different types of insulin for many different situations and lifestyles. These insulins differ in price and how they are made, and by how they work in the body. Insulin is made n labs to be identical to human insulin.

Types of Insulin

Rapid-acting insulin, such as insulin lispro (Eli Lilly), insulin aspart (Novo Nordisk), or insulin glulisine (Sanofi-Aventis), begin to work about 5 minutes after injection, peak in about 1 hour and continue to work for 2 to 4 hours.

Regular or Short-acting insulin (human) usually reaches the bloodstream within 30 minutes, peaks anywhere from 2 to 3 hours after injection, and is effective for approximately 3 to 6 hours.

Intermediate-acting insulin (human) generally reaches the bloodstream about 2 to 4 hours after injection, peaks 4 to 12 hours later and is effective for about 12 to 18 hours.

Long-acting insulin (ultralente) reaches the bloodstream 6 to 10 hours after injection and is usually effective for 20-24 hours. There are also two long-acting insulin analogues, glargine and detemir. They both tend to lower glucose levels fairly evenly over a 24-hour period with less of a peak of action than ultralente.

Premixed insulin can be helpful for people who have trouble drawing up insulin out of two bottles and reading the correct directions and dosages. It is also useful for those who have poor eyesight or dexterity and is a convenience for people whose diabetes has been stabilized on this combination.

Inhaled Insulin: In 2015 an inhaled insulin product, Affreza is a rapid-acting inhaled insulin that is administered before every meal and can be used by both type 1 and type 2 diabetics. It must be used in combination with an injectable, long-lasting insulin. It begins working within 12-15 minutes, peaks by30 minutes, and lasts about 180 minutes.

Characteristics of Insulin

The three characteristics of the four types of insulin are onset, peak time, and duration.

• Onset is the length of time before insulin reaches the bloodstream and begins lowering blood glucose.

• Peak time is the time during which insulin is at maximum strength in terms of lowering blood glucose.

• Duration is how insulin continues to lower blood glucose.

Insulin Routines

With the help of your health care team, you can find an insulin routine that will keep your blood glucose near normal, help you feel good, and fit your lifestyle. People diagnosed with type 1 diabetes usually start wit two injections of insulin per day of two different types of insulin, and generally progress to three or four injections per day. The types of insulin used depend on the blood glucose levels. Studies have shown that three or four injections of insulin a day give the best glucose control and can prevent or delay the eye, kidney, and nerve damage caused by diabetes.

Most people with type 2 diabetes many need one injection per day without any diabetes pills. Some may need a single injection of insulin in the evening (at supper or bedtime) along wit diabetes pills. Sometimes diabetes pills stop working, and people with type 2 diabetes will start with two injections per day of two different types of insulin. They may progress to three or four injections of insulin per day.

Insulin Delivery

Many people who take insulin use a syringe. Other choices are insulin pens and pump therapy. Some insulin pens contain a cartridge of insulin that is inserted into the pen and some already filled with insulin and are discarded after all the insulin has been used. The insulin dose is dialed on the pen, and the insulin is injected through a needle, much like using a syringe. Cartridges and prefilled insulin pens only contain one type of insulin. Two injections must be given with an insulin pen if using two types of insulin.

Fine Tuning Your Blood Glucose

Many factors affect your blood glucose levels. These include:

• What you eat

• How much and when you exercise.

• Where you inject insulin

• When you take your insulin injections

• Stress and illness

Self-Monitoring

Checking your blood glucose and looking over results can help you understand how exercise, an exciting event, or different foods affect your blood glucose level. You can use it to predict and avoid low or high blood glucose levels. You can also use this information to make decisions about your insulin dose, food, and activity.

Site Rotation

The place on your body where you inject insulin affects your blood glucose level. Insulin enters the blood at different speeds when injected at different sites. Insulin shots work fastest when given in the abdomen. Insulin arrives in the blood a little more slowly from the upper arms and even more slowly from the thighs and buttocks. Injecting insulin in the same general area (for example, your abdomen) will give you the best results from your insulin. This is because the insulin will reach the blood with about the same speed with each insulin shot.

Timing

Insulin shots are most effective when you take them so that insulin goes to work when glucose from your food starts to enter your blood. For example, regular insulin works best if you take it 30 minutes before you eat.

Too much or not enough insulin

High morning blood glucose levels before breakfast can be a puzzle. If you haven’t eaten, why did your blood glucose level go There are two common reasons for high blood glucose levels. One relates to hormones that are released in the early part of sleep (called the Dawn Phenomenon). The other is from taking too little insulin in the evening. To see which one is the cause, set your alarm to self-monitor around 2 or 3 a.m. for several nights and discuss the result with your doctor or primary care provider.

Other Injectables

Amylin Analogue

Pramlintide (brand name Symlin) is a synthetic form of the hormone Amylin, which is produced along with insulin by the beta cells in the pancreas. Amylin, insulin, and another hormone, glucagon work in an interrelated fashion to maintain normal blood glucose levels.

Pramlintide injections taken with meals have been shown to modestly improve A1C levels without causing increased hypoglycemia or weight gain and even promoting modest weight loss. The primary side effect is nausea, which tends to improve over time and as an individual patient determines his or her optimal dose.

Because of differences in chemistry, Pramlintide cannot be combined in the same vial or syringe with insulin and must be injected separately. Pramlintide has been approved for people with type 1 diabetes who are not achieving their goal A1C levels and for people with type 2 diabetes who are using insulin and are not achieving their A1C goals.

GLP-1 Receptor Agonists

These medications stimulate insulin production, while decreasing the liver’s production of glucose. They may suppress appetite and help with weight loss. They cause nausea, which can get better over time. Examples include albiglutide (Tanzem), dulaglutide (Trulicity), and liraglutide (Victoza).

Oral Diabetes Medications

In people with diabetes, blood glucose levels are too high. These high levels occur because glucose remains in the blood rather than entering cells, where it belongs. But for glucose to pass into a cell, insulin must be present and the cell must be “hungry” for glucose.

People with type 1 diabetes don’t make insulin. For them, insulin shots are the only way to keep blood glucose levels down.

People with type 2 diabetes tend to have two problems: they don’t make quite enough insulin and cells of their bodies don’t seem to take in glucose as eagerly as they should.

Sulfonylureas

Sulfonylureas stimulate the beta cells of the pancreas to release more insulin. Sulfonylurea drugs have been in use since the 1950s. Chlorpropamide (brand name Diabinese) is the only first-generation sulfonylurea still in use today. The second generation sulfonylureas are used in smaller doses than the first-generation drugs. There are three second-generation drugs: glipizide (brand names Glucotrol and Glucotrol XL), glyburide (Micronase, Glynase, and Diabeta), and glimepiride (Amaryl). These drugs are generally taken on to two times a day, before meals. All sulfonylurea drugs have similar effects on blood glucose levels, but they differ in side effects, how often they are taken, and interactions with other drugs.

Meglitinides

Meglitinides are drugs that also stimulate the beta cells to release insulin. Repaglinide (brand name Prandin) and nateglinide (Starlix) are meglitinides. They are taken before each of the three meals.

Because sulfonylureas and meglitinides stimulate the release of insulin, it is possible to have hypoglycemia (low blood glucose levels).

You should know that alcohol and some diabetes pills may not mix. Occasionally, chlorpropamide, and other sulfonylureas, can interact with alcohol to cause vomiting, flushing, or sickness. Ask your doctor if you are concerned about any of these side effects.

Biguanides

Metformin (brand name Glucophage) is a biguanide. Biguanides lower blood glucose levels primarily by decreasing the amount of glucose produced by the liver. Metformin also helps to lower blood glucose levels by making muscle tissue.

Biguanides

Sensitive to insulin so glucose can be absorbed. It is usually taken two times a day. A side effect of Metformin may be diarrhea, but this is improved when the drug is taken with food. Adequate dietary intake of vitamin B12 is also needed, as metformin can cause vitamin B12 deficiency.

Thiazolidinediones

Rosiglitazone (Avandia) and pioglitazone (ACTOS) are a group of drugs called Thiazolidinediones. These drugs help insulin work better in the muscle and fat and also reduce glucose production in the liver.

DPP- Inhibitors

A new class of medications called DDP-4 inhibitors help improve A1C without causing hypoglycemia. They work by preventing the breakdown of a naturally occurring compound in the body, GLP-1. GLP-1 reduces blood glucose levels in the body but is broke down very quickly, so it does not work well when injected as a drug itself. By interfering in the process that breaks down GLP-1, DD-4 inhibitors allow it to remain active in the body longer, lowering blood glucose levels only when they are elevated. DDP-4 inhibitors so not tend to cause weight gain and tend to have a neutral or positive effect on cholesterol levels. Examples include sitagliptin (Januvia), saxagliptin (Onglyza), linagliptin (Tradjenta), and alogliptin (Nesina).

Alpha-glucosidase inhibitors

Acarbose (brand name Precose) and meglitol (Glyset) are alpha-glucosidase inhibitors. These drugs help the body to lower blood glucose levels by blocking the breakdown of starches, such as bread, potatoes, and pasta in the intestine. They also slow the breakdown of some sugars, such as table sugar. Their action slows the rise in blood glucose levels after a meal. They should be taken with the first bite of a meal. These drugs may have side effects, including gas and diarrhea.

Oral Combination therapy

Because the drugs listed above act in different ways to lower blood glucose levels, they may be used together. For example, a biguanide and a sulfonylu5rea may be used together. Many combinations can be used. Though taking more than one drug can be more costly and increase the risk of side effects, combining oral medications can improve blood glucose control when taking only a single pill does not have the desired effects. Switching from one single pill together is not as effective as adding another type of diabetes medicine.

Can diabetes pills help me?

Only people with type 2 diabetes can use pills to manage their diabetes. These pills work best when used with meal planning and exercise. This way you have three therapies working together to lower you blood glucose levels.

Diabetes pills don’t work for everyone. Although most people find that their blood glucose levels go down when they begin taking pills, their blood glucose levels may not go near the normal range. Diabetes pills may stop working overtime, so oral combination therapy or insulin may be needed to control your diabetes.

What are the chances that diabetes pills will work for you? Your chances are low if you had diabetes for more than 10 years or already take more than 20 units of insulin each day. On the other hand, your chances are good if you developed diabetes recently or have needed little or not insulin to keep you blood glucose levels near normal.

Also, if you plan to become pregnant, you will need to control your diabetes with diet and exercise or with insulin. It is not safe for pregnant women to take oral diabetes medications.

There is not “best” pill or treatment for type 2 diabetes. You may need to try more than one type of pill, combination of pills, or pills plus insulin.

References

American Diabetes Association. (2021). Retrieved from http://www.daibetes.org

American Diabetes Association. 14. Management of diabetes in pregnancy: Standards of Medical Care in Diabetes—2021. Diabetes Care 2021;44(Suppl. 1):S200–S210

American Diabetes Association. (2021). Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2020. Diabetes Care 2020;43(Suppl. 1):S98–S110

Centers for Disease Control and Prevention. (2020) Diabetes statistic report. Retrieved from https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf

Insulin Site Injection [Digital Image]. Retrieved from http://www.lantus.com/using-lanus/choosing-an-injection-site

Novo Nordisk. (2020). Take 5 to care for yourself. Cornerstones 4 Care. Retrieved from https://www.cornerstones4care.com/

Plate Method [Digital Image]. Retrieved from https://www.cdc.gov/diabetes/managing/eat-well/meal-plan-method.html