Ideal Body Weight

To determine your ideal body weight, use the following formula Men 106 pounds for the first 5 feet and add 6 pounds for every additional inch over 5 feet. Women 100 pounds for the first 5 feet and add 5 pounds for every additional inch over 5 feet. If you are large-framed you can add 10 percent to the calculated weight. For example, if you are a male who is 5 feet 8 inches tall, your ideal body weight is 106 + 48 154 pounds. If you are large-framed, you might weigh as much as 169 pounds.

Adolescence

Adolescence, when there are physical changes of puberty as well as cognitive and emotional changes, brings some new challenges to managing diabetes. Early adolescence ages twelve to fifteen Puberty increases the insulin needs, so your child's medical team will make adjustments of the insulin dose. At this age, the child will do his or her own blood glucose monitoring and injections. You may need to negotiate with your child as to how much supervision is appropriate. It is a good idea to talk to...

Your Diet for Type 2 Diabetes

People with type 2 diabetes are frequently overweight, so advice about nutrition is directed not only at controlling carbohydrate intake, but also at limiting calories. (I discuss caloric restriction and weight loss in Chapter 10.) If you have type 2 diabetes, there are several reasons why you still need to estimate the carbohydrate content of your food Limiting the carbohydrate intake and substituting some of the calories with monounsaturated fats can help reduce your triglyceride levels and...

Glucagon Injection

Injection of glucagon causes release of glucose from glycogen stores in the liver. If you are on insulin, keep an emergency glucagon kit at home and at work. Family members and colleagues at work should be educated about low glucose reactions and trained to inject glucagon in case you become very confused or lose consciousness due to hypoglycemia. You do not want to find out after the event that no one knew where the glucagon was kept and no one felt comfortable giving an injection. A glucagon...

Rimonabant Acomplia

Rimonabant is an antagonist that is, it prevents the CB1 receptor from being stimulated and reduces appetite. Over a one-year period, patients on 20 mg of rimonabant had an eleven-pound weight loss, and when followed for a second year maintained the weight loss, whereas those who came off the drug regained the weight. The main side effects were nausea, anxiety, and depression. About 40 percent of the subjects did not complete the trial. It is too early to say how useful this medication will be...

Setting Up a Support Network

When you are diagnosed with a chronic illness like diabetes, you may go through a period of grief because of the loss of good health. The diagnosis can be overwhelming there is a lot of information that you need to grasp you have to learn about carbohydrates, calories, exercise, weight management, and checking blood glucose levels. You may need to take oral medications or inject insulin. You may also have some or all of these questions What impact will this have on my family How will it affect...

Education

After diagnosis, you will meet with a diabetes educator and a nutritionist. The diabetes educator will Teach you how to monitor glucose levels and keep a blood glucose log, as well as how to inject insulin or exenatide if your doctor prescribes them. Explain symptoms and treatment of hypoglycemia if you are going to take medication that could cause low glucose reactions. Teach you about the carbohydrate content of food Discuss weight-reducing strategies if this is indicated (see Chapter 10) In...

Diabetes Medications 101

Let me make a few general comments about diabetes medications before I discuss them in detail in the following sections. Medicines for diabetes are only one component of the treatment of diabetes. To be successful in controlling the diabetes, you also need to consider other aspects of diabetes care, such as diet and exercise. Whether a specific medicine is suitable for you depends on The type of diabetes you have The other medical problems you may have, which can prevent the use of certain...

Trans Fatty Acids Trans Fats

Trans fats are harmful because they increase the risk of heart disease. They are produced when vegetable oils are converted into semisolid fats such as margarine and vegetable shortening. They are also known as partially hydrogenated vegetable oils. There are some naturally produced trans fats in dairy products, but most of the trans fats in our diet are man-made. Manufacturers put them in food products to increase the product shelf life for example, crackers stay crispy longer. The problem is...

Chapter

Effects of repeated hypoglycemia on cognitive function a psy-chometrically validated reanalysis of the Diabetes Control and Complications Trial data. Diabetes Care 1999 Aug 22 (8) 1273-77. Briscoe VJ, Davis SN. Hypoglycemia in type 1 and type 2 diabetes. Physiology, Pathophysiology, and Management Clinical Diabetes 2006 24 115-21. de Galan BE, Schouwenberg BJ, Tack CJ, Smits P. Pathophysiology and management of recurrent hypoglycaemia and hypoglycaemia unawareness in...

Chromium

When rats are given a diet deficient in chromium, they have higher glucose levels. Similarly, humans who are on intravenous nutrition (total parenteral nutrition), if they are not given chromium supplements, have higher glucose levels and insulin resistance. It has not been shown that people with diabetes have chromium deficiency, but when chromium picolinate has been given to people with diabetes, a number of studies have shown a benefit. For example, in a study published in the journal...

Increase Exercise Physical Activity

Physical activity alone is not very effective in causing weight loss you may lose only 2 to 3 percent of your excess weight. Physical activity will, however, let you keep off the weight that you lose with a reduced-calorie diet. So introduce physical activity into your day, such as taking stairs instead of elevators, walking up escalators, and parking the car farther away from your destination so you walk more. Participate in moderate physical activity (defined as burning more than 300 kcals...

Info

*Another way of thinking about ratios is to keep the denominators unchanged at 15 for carbohydrates and 50 at correction and change the numerator. Thus if you give 0.5 units for 15 grams carbohydrate, the correction will be 0.5 units for 50 mg dl glucose over target. If you give 1 unit for 15 grams carbohydrate, the correction will be 1 unit for 50 mg dl glucose over target. If you give enough insulin, everyone can reach these targets, but at the expense of lots of hypoglycemic reactions. The...

Nutrition

Nutrition has always played a central role in the treatment of diabetes. Before the discovery of insulin, people with type 1 diabetes could be kept alive for a few months by severely restricting carbohydrate intake and eating mostly fats and protein (a ketogenic diet). After the discovery of insulin in 1921, patients were able to eat more carbohydrates. However, the lack of home glucose monitoring and fast-acting insulins meant that there still were significant dietary restrictions. People with...

Type 2 Diabetes in Children

The number of children that have type 2 diabetes is on the rise. Accurate numbers about how many children have this condition are hard to obtain, because the disease may have been present for a while before it is diagnosed. Anywhere between 8 to 46 percent of children with diabetes referred to pediatric centers have type 2 diabetes. The increase in childhood obesity is likely to be the main factor driving this increased incidence of type 2 diabetes. Your child might be diagnosed with diabetes...

Diabetic Eye Disease

Diabetic eye disease includes three conditions diabetic retinopathy, cataracts, and glaucoma. At the back of the eye on the retina are tiny blood vessels that nourish the nerves of the eye. High glucose levels or high blood pressure can injure the cells lining these blood vessels (retinopathy). The earliest visible abnormalities are pinhead red dots next to the blood vessels that may come and go these are called microaneurysms or dot hemorrhages. Further injury then causes leakage of blood and...

Rosiglitazone And Pioglitazone

These medications are also called thiazolidinediones, TZDs, or glitazones. How They Work These are insulin sensitizers they work by making the tissues more sensitive to the effects of insulin (see Table 6-4). Table 6-4 Oral Diabetes Medicines That Work by Making Tissues More Sensitive to Insulin Generic Drug Name (Brand Name in Parentheses) 2 to 8 mg once a day (or in 2 divided doses) They usually take a few days to work, so you should not expect glucose levels to fall for at least a week or...

Nutritionist

Having regular consultations with a nutritionist is important for both type 1 and type 2 diabetes patients. The nutritionist will assess your nutritional needs if you need to lose weight, she will help you to devise a reduced-calorie diet. She will also teach you about foods that raise blood glucose levels and how to count the amount of carbohydrates in your diet. If you have complications of diabetes, she may provide information about foods that are high in fats, cholesterol, protein,...

Optimizing Your Bolus Insulin Dose

Once you are satisfied with your basal glucose control, you can look at the bolus insulin. Before you can do this, you have to know how to count carbohydrates (see Chapter 8). The way you assess your bolus ratio for carbohydrates is to eat your usual meal and give the calculated dose of insulin. Then check your blood glucose after the meal and find out how high it goes you are trying to keep it below 180 mg dl. Check three times, and if the glucose goes much higher than 180 consistently, you...

Newly Diagnosed Type 1 Diabetes

When you are first diagnosed with type 1 diabetes, you will meet your diabetes management team, which consists of your physician, the diabetes educator, and the nutritionist. The physician will answer your questions about diabetes and recommend an initial insulin regimen. The nutritionist will teach you about carbohydrate counting, give you a carbohydrate exchange book (the ADA publishes a good one), and explain how to read food labels. She will also describe how to have a balanced diet and...

Blood Pressure

It is particularly important to measure a child's blood pressure if there is a family history of high blood pressure. Children's blood pressures vary depending on age, sex, and height. If the blood pressure is high on repeated measurements, the pediatrician may do further investigations (including blood tests and looking at the kidney blood vessels using ultrasound). If there is no other abnormality that is responsible for the elevated blood pressure, then the child is treated. A...

Public Schools and Diabetes Training

In the United States, the schools or day care centers that receive public funds are legally required to provide training to school staff on treating diabetes. The ADA has literature for teachers and child-care providers. Your health-care team can also help ensure that the staff members at your child's school are adequately trained. The degree of supervision by the staff of the school will vary with your child's age and abilities. may limit insulin use in order to lose weight. This leads to poor...

Glucagon

Convert glucose to glycogen and make triglycerides Figure 1-3 Summary of Effects of Glucagon on Liver and Fat Cells Promote glycogen breakdown and release of glucose into the blood. Make new glucose from precursors. Break down triglycerides and release fatty acids and glycerol into the blood. then you have diabetes and no further testing is necessary. If your glucose level is less than 200 mg dl, then additional tests may be necessary, as described in the next section on screening for diabetes....

Using An Insulin Pump

An insulin pump is a device the size of a pager. It contains a syringe or reservoir filled with a fast-acting insulin, a battery-powered syringe plunger, and a small computer to control the insulin delivery. The syringe is attached to tubing, which in turn is attached to a small plastic tube (cannula) inserted under the skin (see Figure 6-1). The pump can be programmed to put tiny drops of insulin into the subcutane- ous tissues every three to ten minutes day and night this is the basal...

Educating Yourself

Unlike many other chronic illnesses, diabetes requires significant decision making on a daily basis. I tell my patients that the most important aspect of diabetes care is not what I tell them to do when they see me in my office, but what they do at home. The process of learning how to take care of your diabetes is referred to as diabetes self-management education (DSME). There are many different ways in which you can obtain the skills and information necessary to take good care of your...

Stacking Insulin and Overaggressive Treatment of High Glucose Levels

Some people with diabetes do not like their glucose levels to be high, and they treat every high glucose level aggressively. These individuals who stack their insulin that is, give another dose of insulin before the first injection has had its full action can leave themselves open to hypoglycemia. A common mistake is to give insulin before a meal and then check the glucose level again an hour or two later and give additional insulin without realizing that the premeal insulin is still getting...

The Cure for Type 1 Diabetes

A pancreas transplant will cure type 1 diabetes. So why doesn't everyone with type 1 diabetes get a pancreas transplant There are two reasons. First, there are only a limited number of donor pancreata available a few thousand whereas there are about a million people with type 1 diabetes. Second, people who get an organ transplant have to be on medicines to prevent the body's immune system from attacking and rejecting the organ. These immunosuppressive medicines have serious side effects, such...

Gestational Diabetes

During pregnancy, women are screened for diabetes at twenty-four to twenty-eight weeks, or at the very first visit if they are at very high risk of diabetes as indicated by the following risk factors There are family members with diabetes. Her ethnic background is a group that is particularly susceptible to diabetes. She has polycystic ovarian syndrome. She had diabetes with a previous pregnancy or delivered a baby weighing more than nine pounds. There are two tests that can determine whether a...

Endocrinologist

An endocrinologist is a physician who specializes in treatment of the diseases of endocrine glands, including diabetes. In 1999 there were just over four thousand practicing endocrinologists in the United States, and there are about 18 million people with diabetes, so only a very small number of people with diabetes will ever see an endocrinologist. You should think about having an endocrinologist review your diabetes care if Despite your and your medical team's best efforts you are not able to...

Institutional Aspects of Diabetes

Elderly people living in board and care and nursing facilities may have additional challenges regarding their diabetes management. They may have to rely on caregiv-ers to check their glucose levels and administer their diabetes medications. They may not have control over their meals. The staff may have limited understanding of diabetes management because type 2 diabetes is so much more common, people tend not to remember that older individuals can have type 1 diabetes. These type 1 patients may...

Diabetes And Problems With Skin And Nails

There are a number of skin and nail problems that are more commonly seen in people with diabetes. These include the following Fungal infections of the skin (athlete's foot) and nails (onychomycosis), which require treatment with antifungal medicines. Acanthosis nigricans, a darkening of the skin at the back of the neck and under the armpit. The skin has a velvety feel. This condition occurs in people with type 2 diabetes who are very insulin resistant. It does not require any treatment....

Aerobic Exercise Cardiorespiratory Endurance

During aerobic exercise, there is sustained physical activity. The heart rate and breathing rate increase to supply additional oxygen and fuel to the muscles. Walking, bicycling, jogging, swimming, and racquet sports are examples of aerobic exercise. The American College of Sports Medicine defines moderate exercise as 55 to 69 percent of maximal heart rate hard (or higher intensity) exercise as 70 to 89 percent of maximal heart rate and very hard exercise as 90 percent of the maximal heart rate...

Other Types Of Diabetes

There are less common forms of diabetes in which there is a specific cause for the beta cell failure or problems with insulin function. Some of these conditions are extremely rare, so I discuss only the more common ones in the following sections. Maturity onset diabetes of the young (MODY) refers to diabetes that occurs in childhood or adolescence (before age twenty-five) and is inherited in an autosomal dominant fashion that is, if you have the condition, half of your children are also likely...

Using Continuous Glucose Monitoring Systems

With conventional home blood glucose monitors, depending on how many times you prick your finger, you may check your glucose levels anywhere from one to twelve times per day. New kinds of monitoring systems, called continuous glucose monitoring systems, are now available that measure glucose levels every few minutes throughout the day and night. These systems enable you to review your glucose levels overnight while you are asleep and also trend glucose changes following food, insulin...

Low Carbohydrate Diets

Several studies have compared the Atkins type of low-carbohydrate diet with a low-fat diet, and these studies have found that at six months, people on the low- carbohydrate, high-protein diet had indeed lost more weight than the people on the low-fat diets, but by twelve months both groups had lost the same amount of weight. A significant proportion of subjects in both groups dropped out of the study by one year (up to 50 percent in some studies). Since the studies were for one year only, it is...

Certified Diabetes Educator

The certified diabetes educator (CDE) will educate you about the kind of diabetes you have and your medication options. She will educate you about the importance of controlling glucose, lipids, and blood pressure to prevent complications and about the effects of exercise and emotions on glucose control. She will also show you how to use glucose monitors, how to treat high and low glucose levels, and how to exercise safely. If you are on insulin, she will teach you how to inject insulin and how...

Adjust the Insulin Dose

Before exercise, adjust the bolus or basal insulin, or both, in anticipation of the exercise. A bolus of a fast-acting insulin analog lasts for about four hours, and the peak is at about one to one and a half hours. If you exercise within two hours, you will need to cut back on the premeal bolus (to 50 to 75 percent of your usual dose). Making an adjustment in basal insulin dosing is easier if you are on an insulin pump. If you are planning for exercise of long duration (longer than ninety...

Getting Diagnosed

People may be diagnosed with type 2 diabetes in a number of different ways Due to symptoms of high glucose levels thirst, blurred vision, and weight loss Sometimes the glucose levels are so high that the patient may have severe dehydration and confusion or coma (hyperosmolar coma) Infections bladder, vaginal, or penile yeast infection may indicate diabetes Long-term complications of diabetes such as a foot ulcer may also indicate diabetes

Sitagliptin How It Works

Sitagliptin inhibits an enzyme (called dipeptidyl protease IV, DPP IV) and so prolongs the action of the hormone glucagon-like polypeptide 1 (GLP-1) that is released from the intestine in response to food. (See Table 6-6.) The prolonged activity of the released GLP-1 lowers glucose levels by three different means It stimulates the release of insulin from beta cells. It inhibits glucagon release from alpha cells. It slows down stomach emptying. Table 6-6 Oral Diabetes Medicine That Prolongs the...

What to Do if You Get Sick and Are on Insulin

Do not stop your insulin depending on the severity of the illness you may need the same or more insulin. If you have type 1 diabetes and you stop the insulin, you will go into DKA (see Chapter 3). If you are on a basal-bolus insulin regimen, take the same amount of the long-acting insulin as you normally do. If you are on a pump, keep the basal rates the same. Cover your carbohydrates with insulin in the usual way. If you have vomiting and you are not sure if you will keep the food down, you...

Sibutramine Meridia

This medication works in the brain to reduce appetite by its effect on nerve terminals that release serotonin and noradrenaline. Its side effects include insomnia, dry mouth, and increased heart rate and blood pressure. The usual starting dose is 10 mg once a day, increased to 15 mg at four weeks if the weight loss is less than four pounds. In a two-year study, people taking sibutramine were better able to keep off their weight than those taking placebo (43 percent versus 16 percent). There is...

Optimizing Your Basal Insulin Dose

Ideally, if your basal insulin (insulin glargine, detemir, NPH, or pump basal) dose is correct, then even if you did not eat and had your normal activity, your glucose levels will stay in the normal range. This is usually not true in practice, and there is always some drift in your glucose levels. This is because of the day-to-day variability in the absorption of the injected insulin and the way the body responds to the insulin. Your goal is to minimize the upward and downward drift of your...

Choosing Your Infusion

The infusion set is the tiny plastic tube or cannula that you insert into the subcutaneous tissue. There are many different infusion sets available, and your pump edu cator will work with you to choose a set that will work best for you. There are some pump sets that have a cannula (plastic tubing) angled at 30 to 45 degrees, and some sets with a straight cannula (90 degrees). Most are made of Teflon, but there are some that are made of metal. The angled sets are more reliable than the straight...

Diabetes and Pregnancy

Diabetes complicates about 8 percent of pregnancies each year. About 75 percent of these diabetic pregnancies are gestational diabetes that is, the woman is diagnosed as having diabetes during the pregnancy. Of the remaining, 23 percent involve preexisting type 2 diabetes and about 1 to 2 percent involves preexisting type 1 diabetes. The issues surrounding preexisting diabetes are slightly different from those faced by women who first develop diabetes during pregnancy. Women who have diabetes...

Insulin Preparations Available in the United States

Regular insulin Insulin lispro (Humalog) Insulin aspart (Novolog) Insulin glulisine (Apidra) 70 percent NPH 30 percent regular (70 30 insulin) 50 percent NPH 50 percent regular (50 50 insulin) 75 percent NPL 25 percent insulin lispro (Humalog Mix 75 25) 50 percent NPL 50 percent insulin lispro (Humalog Mix 50 50) 70 percent insulin aspart protamine 30 percent insulin aspart (Novolog Mix 70 30) Exubera (1 mg and 3 mg blister packets of powdered regular insulin)

Established Type 1 Diabetes

Currently, there is no way of preventing the decline in insulin secretion that occurs with time in those with type 1 diabetes. The honeymoon period can last only a few weeks, or it can last for more than a year or two. Generally speaking, children and young adults tend to have shorter honeymoons, whereas older individuals can maintain insulin secretion for several years. There are, however, many exceptions to this observation. As your insulin secretion declines, you will need more insulin to...

Gestational Diabetes And Risk For Type 2 Nongestational Diabetes

If you have gestational diabetes, your risk of developing type 2 diabetes in the future is 5 to 50 percent. Therefore, you should have a two-hour 75-gram oral glucose tolerance test (OGTT) six to ten weeks after delivery. With tight glucose control and careful management of diabetes complications, women with diabetes can have healthy babies Optimal glucose control before conception and early in pregnancy reduces the risk of fetal malformations. Later in pregnancy, tight glucose control reduces...

How Diabetes Impacts Diseases of Aging

Elderly people with long-standing diabetes are more likely to have kidney disease, nerve damage, and circulation problems such as heart disease and stroke. They are less able to walk, do housework, prepare meals, and manage money when compared to age-matched individuals who do not have diabetes. Women with diabetes become disabled at approximately twice the rate of women without diabetes, and they have an increased risk of falls and hip fractures. Long-standing diabetes can affect bone quality,...

If You Take Oral Medicines

In most cases you can take your usual medicines the day before the procedure, but none on the day of the procedure, and then restart them when you start eating. If you are on metformin and you need a procedure where you get a special x-ray with contrast dye, you may be asked to stop your metformin for a couple of days until a serum creatine confirms that your kidneys are not affected by the contrast dye. When you stop metformin, your glucose levels may run high, and your doctor may ask you to...

Other Treatments

Your doctor will check your lipid profile and start you on medications to lower your LDL cholesterol below 100 mg dl (optimally around 70 mg dl) and triglycerides below 150 mg dl. Your blood pressure should be consistently below 130 80, and if you are above this level, your doctor will start you on blood pressure medicines usually an ACE inhibitor. You may also be prescribed a low-dose aspirin tablet daily. Your doctor will also screen and treat for complications of diabetes as outlined in...

Podiatrist

If you have evidence for diabetic nerve damage and or significant circulatory problems, you should visit a podiatrist who has an interest and expertise in treating diabetes. If you have diabetic nerve damage or circulation problems, the podiatrist will treat calluses and fungal infections, cut nails, and prescribe orthotic supports or custom shoes as necessary. The podiatrist will also teach you how to look after your feet so that you do not injure them. If you have absolutely normal feet (like...

Setting Up Your Insulin Pump

Once your pump is approved, the manufacturer will ship it to your house. A pump educator from the manufacturer (also paid for by the manufacturer) will come to your house and explain the features of the pump and how to program it. He will also show you how to fill a reservoir without getting bubbles and how to prime the tubing. An inch of bubble in your tubing is equivalent to half a unit of insulin. Thus, having bubbles in your tubing can reduce the amount of insulin you are getting and can...

Nutrition in Type 1 Diabetes

Most people with type 1 diabetes are of normal body weight, and they usually do not need to be on a calorie-restricted diet. They also do not tend to have the cholesterol abnormalities that are commonly seen in patients with type 2 diabetes. The American Diabetes Association recommends that an adult should obtain 45 to 65 percent of the total daily kilocalories in the form of carbohydrates 25 to 35 percent of the total daily kilocalories in the form of fat (of which less than 7 percent are from...

Glossary

Acanthosis nigricans Dark velvety skin usually seen at the back of the neck or under armpit that is a sign of insulin resistance Addison's disease Autoimmune damage to adrenal gland that results in deficiency of the stress hormone cortisol alpha cells Cells in the islets of Langerhans in the pancreas that make glucagon angina Pain in the chest, usually experienced during exercise, because of narrowing of the blood vessels that supply blood to the muscles of the heart angiotensin converting...

Of Diabetes Genes and Environment

Diabetes occurs as an interaction between the genes that you inherit and the environment in which you live. In type 1 diabetes, we know a fair bit about the genes, but relatively little about how environmental factors impact the disease. In contrast, for type 2 diabetes, the genetic causes are largely unknown, but we know that obesity and lack of exercise are important environmental risk factors. In the United States, there are approximately 1 million people with type 1 diabetes, and about...

Panax Quinquefolius American Ginseng

Several small studies reported an improvement in fasting glucose and HbA1c with 3 grams of American ginseng. The studies are of limited duration (eight weeks). Reported side effects of American ginseng include insomnia, high blood pressure, and anxiety. The ADA review found that there was inadequate evidence to support use of herbal medicine or mineral supplements in the treatment of diabetes. If you decide to use them, buy your supplements from reputable suppliers those with USP (United States...

Monitoring Lipids Cholesterol Levels

Heart disease is a risk factor in people with diabetes, especially if you have type 2 diabetes, long-standing type 1 diabetes, or complications from type 1 diabetes. In type 2 diabetes, the risk of heart attack is increased twofold. This is the same frequency as nondiabetic individuals who have already had a previous heart attack. Under these circumstances, your LDL cholesterol should be below 100 mg dl ideally around 70 mg dl. Have your lipid levels checked annually by your physician, and more...

What About Alcohol

Should you count the carbohydrates in the alcohol you drink When you drink alcohol, it is metabolized (that is, broken down) by the liver, and there is less glucose production while the alcohol is being broken down. In people with diabetes who are on insulin, this can cause hypoglycemic reactions. It is therefore important that you drink alcohol with a meal rather than on an empty stomach. The recommended amount of alcohol is the same as for people without diabetes two drinks for men and one...

Testing For Autoimmune Diseases

I mentioned in Chapter 3 that people with type 1 diabetes are at risk for other autoimmune diseases, especially thyroid disease and celiac disease. When your child is diagnosed with type 1 diabetes, he should also be screened for autoimmune thyroid disease. His doctor will do these thyroid tests at intervals or if there is a problem with your child's growth, because low thyroid hormone levels can slow down growth. In celiac disease, eating foods containing gluten (that is, those derived from...

Toddlers Ages One to Three

With toddlers, it is best to establish a schedule with food and insulin injections. This can be challenging, especially with a child who refuses to eat or is a picky eater. Hypoglycemia is the biggest concern with this age group, and often it is best managed by giving insulin after a meal. Other steps that you can take include the following Establish a routine for checking glucose and injections. Use a glucose meter that requires the smallest blood sample and gives quick results. Test glucose...

Managing Diabetes Supplies

Take adequate supplies for your diabetes management when you travel. In fact, take twice the amount of diabetes medication and supplies that you will normally need. If you are on an insulin pump (see Chapter 6), take some basal insulin such as insulin glargine and syringes in case you have a pump failure. Keep the insulin cool by packing it in an insulated bag with refrigerated gel packs, or use Frio packs (see friouk.com index.php). Also take glucose tablets, gels, and snacks for treatment of...

Diabetes Management on the Airplane

If food will not be served on your flight, take food and fast-acting carbohydrate with you. If it is a long flight with a meal (and keep in mind that in-flight meals are rare these days), it is not necessary to order a special meal on the plane, but it is a good idea to have some food with you (two to three snacks) in case the meal is delayed. Inject your insulin dose after your meal arrives. Since the pressure in an airplane is different than the pressure on the ground, do not inject air into...

Nervous System Complications

Nerve damage to the feet can stop you from recognizing injury, and as a result you can develop calluses, foot ulcers, or even a Charcot's foot (see Chapter 3). If you have significant peripheral neuropathy, you should avoid pounding the pavement and try non-weight-bearing exercises such as swimming, rowing, and cycling instead. When you buy athletic footwear, choose shoes with cushioned midsoles and socks that wick away moisture. Autonomic neuropathy can dull the classic warning signs of...

Exercise and Type 2 Diabetes

If you have type 2 diabetes and you are on insulin, you will face issues similar to those of a person with type 1 diabetes (see the tips and advice in the preceding section), except that generally, your glucose levels will be more stable. This is principally because most patients with type 2 diabetes still have functioning beta cells in their pancreas, with a significant contribution of their own insulin. If you take oral diabetes medications, you cannot assume that your health will be fine...

Artificial Sweeteners

Used in moderation, table sugar (sucrose) can be a part of your diet. However, if you are having problems with glucose control or you are trying to limit your carbohydrate intake (for weight loss or lowering triglycerides), reducing the amount of sugar you eat may be important to you. If this is the case, you have the option of using sweeteners that do not raise blood glucose levels. Aspartame (NutraSweet) consists of two major amino acids, aspartic acid and phenylalanine, which combine to...

Effect On Intellectual Function

Do repeated low glucose levels affect intellectual function Research studies that looked at this topic have not given clear answers. Part of the problem is that many subjects who have severe hypoglycemic reactions also have other complications from the diabetes that could impact intellectual function. What is reassuring is that in the DCCT (a big research study of type 1 diabetes), severe hypoglycemic episodes did not result in decreased intellectual function over eighteen years of follow-up....

Lack of Glucagon Response

In new onset diabetes, glucagon levels rise in response to a falling glucose level, and this is the most important factor preventing a further fall in the glucose level. People with diabetes longer than five years lose this glucagon response. As a result, these individuals are at a significant disadvantage in protecting themselves against falling glucose levels. People who have diabetes because of pancreatitis or pancreatic surgery also lack glucagon and so are at increased risk for...

Failure to Adjust for Exercise

In Chapter 9, I explain why people with diabetes, especially type 1 diabetes, can find glucose control with exercise particularly challenging. Hypoglycemia can occur during or even several hours after exercise, and so glucose levels need to be monitored and food and insulin adjusted. Failure to do this can lead to hypoglycemia. Unexpected exercise can also be a challenge I remember seeing a sixty-eight-year-old woman with type 1 diabetes in my office, and during her visit the fire alarm went...

Overestimation of Carbohydrate Intake

One of the most common reasons for recurrent hypoglycemia is injecting too much insulin or taking too much oral medication for the amount of carbohydrates ingested. You may overestimate the amount of carbohydrate in the food or eat less than planned, or you may be delayed in eating after taking the insulin or medicine. For example, a number of times, I have had patients inject a dose of insulin in the car before they went to a restaurant. At the restaurant, the food did not come at the expected...

What Should My Glucose Levels Be

In people without diabetes, glucose values can be in the 60 to 70 mg dl range or even lower with prolonged fasting. The problem with diabetes is that if you are taking medicines that can cause hypoglycemia, like insulin and sulfonylureas, a glucose level around 60 is of concern because it could go down even further. The ADA defines a glucose level of 70 mg dl or less as hypoglycemia, even if you feel fine and show no symptoms. Thus, if you are on medicines that can cause hypoglycemia, you...

Pramlintide How It Works

Pramlintide limits the glucose rise after meals by slowing stomach emptying and lowering the postmeal glucagon levels. (See Table 6-7.) It also causes modest weight loss two to four pounds on average. When beta cells release insulin, they also release another protein called islet amyloid polypeptide (IAPP or amylin). The normal function of IAPP is not well understood, but it may have a role in appetite regulation. Pramlintide is a modified form of IAPP. It is approved for use by people with...

Understanding Home Monitoring

Blood glucose monitoring at home is an important part of diabetes management and serves a number of purposes. First, monitoring at home makes it easier to detect low blood glucose reactions, because you cannot rely on how you feel to detect low glucose levels. When aiming for the glucose targets mentioned in Table 5-1, many people with diabetes develop hypoglycemic unawareness (see Chapter 7), meaning they can have glucose levels in the 40s and 50s and still feel quite fine. For this reason,

Monitoring Glucose Levels

Causes Ventilator Dyssynchrony

When you have diabetes, your glucose levels fluctuate much more than those of people without diabetes. In people without diabetes, fasting glucose levels in the morning are usually between 60 and 100 mg dl. Before each meal, the levels are below 100 mg dl. The peak values one to two hours after a meal are in the 120s and usually stay below 140, even after a meal rich in carbohydrates. With current therapies, it is difficult to achieve normal glucose levels when you have diabetes. Even when...

Preventing Hypoglycemia

As you aim to get HbA1c levels (see Chapter 5) close to normal, the risk of hypoglycemia goes up. You can take the following measures to limit the risk Set realistic targets aim to keep premeal glucose levels between 90 and 130 rather than at 80. Also, if you have recently had a severe hypoglycemic reaction, then for about six weeks aim to keep your glucose around 150. This will help you recover your ability to sense hypoglycemia to some degree. Learn to count carbohydrates and adjust insulin...

Treating Hypoglycemia

Treating hypoglycemia is fairly straightforward eat or drink any food that has a lot of glucose and is easily absorbed. Sources of glucose include glucose tablets and gels that you can buy at your pharmacy. Fruit juice and nonfat milk are also good sources. Foods with a lot of fat such as chocolate are not as good because the fat will delay the absorption of the glucose. Fructose does not raise the blood glucose, but most foods that have fructose, such as honey and fruits, also have a lot of...

Adjusting Your Insulin for Time Changes

The body's sensitivity to insulin varies throughout the day and night. You are most insulin sensitive early in the night and most resistant early in the morning. These changes in insulin sensitivity are due to the daily fluctuations in the levels of hormones, particularly cortisol. The internal body clock that regulates these hormones gets cues from environmental light and temperature. When you go to a different time zone, the body clock and the hormones reset to the new light-dark cycle. This...

Working with Small Insulin Doses

Giving the small doses of insulin can be challenging. Eli Lilly and Novo Nordisk make pens that will deliver in half units, but the minimum dose is 1 unit. Becton, Dickinson and Company makes an ultrafine short-needle insulin syringe with half-unit markings. You can also ask your pharmacy to dilute the insulin. Eli Lilly makes a diluent for NPH, regular, and Humalog insulin. Similarly, Novo Nordisk makes a diluent for Novolin regular, and this can also be used for NovoLog. For U50 insulin, the...

The Dex Com Medtronic and Abbott Systems

The DexCom, Medtronic MiniMed, and Abbott Pharmaceutical (not yet available) systems all work in a similar way. The sensor is a tiny flexible probe that you insert under the skin in the same way you insert an insulin pump infusion set can-nula (see Chapter 6). The sensor measures the glucose concentration in the tissue fluid every five minutes for about three to seven days before it needs replacing. All the systems have software available to download the data into your computer. These systems...

Driving and Hypoglycemia

Some of the medicines used to treat diabetes (insulin, sulfonylureas, repaglinide, and nateglinide) can cause hypoglycemia, which can affect reflexes and judgment. In addition, long-term diabetes complications, especially vision problems and neuropathy, may interfere with driving ability. There have been a number of research studies that have looked at the impact of diabetes on car accidents. Generally speaking, the impact appears to be modest if it exists at all. It does seem that the risk for...

Salt and Potassium

High blood pressure occurs frequently in people with type 2 diabetes and with diabetic kidney disease. Reducing your salt intake can help lower the blood pressure. You can reduce the amount of salt in your diet by Avoiding or reducing intake of foods with high salt content such as canned foods, pickled vegetables, soy sauce, teriyaki sauce, and tomato sauce. Cooking with less salt. Instead, use herbs, spices, and lemon juice for flavoring. Another element that you might need to think about in...