LIVING WELL WITH DIABETES requires both good medical care and effective self-management. In this chapter we will help you learn about the disease and what you do to manage it.
Diabetes is a disease that makes it difficult for the body to turn food into energy. To understand diabetes, it is helpful to know a little about the digestion process, the function of the pancreas and insulin, and how these relate to diabetes (see Figure 18.1.)
Some of the food we eat (sugar, starch, and other carbohydrates) is broken down in the digestion process into a simple sugar called glucose. Glucose is absorbed into the bloodstream from your stomach, causing the level of blood glucose (also known as blood sugar) to rise. For the cells of your body to use the glucose as fuel, it needs the help of insulin. Insulin is a hormone produced by the pancreas, a small gland located below and behind your stomach. Insulin helps the blood glucose get from the bloodstream into the cells. Once inside the cells, the glucose is burned to give your body energy.
Figure 18.1 The Digestion Process
Glucose in the body can be compared to the gasoline in a car; each is a fuel and a source of energy. Gasoline alone, however, is not enough to make the car move. We also need a key to start the motor, which allows the gasoline to be converted into energy. Like the car, our bodies also need a key that enables us to use glucose as energy. Insulin is this key; it opens the door to allow the glucose to pass from the bloodstream into the cells, where it produces energy for the body.
For people with diabetes, insulin is not able to carry out this function for one of two reasons. The pancreas may not produce enough insulin (this is called Type 1 diabetes), or the insulin that is produced cannot be used efficiently by the body (Type 2 diabetes). In either case the unabsorbed glucose remains in the bloodstream (see Table 18.1). The result is high blood glucose. When the kidneys filter the blood, excess glucose spills out in the urine. This causes two of the symptoms of diabetes: frequent urination and large amounts of sugar in the urine. This is how diabetes got its name, officially diabetes mellitus. The Greek word diabetes means “to pass through,” and the Latin word mellitus means “sugar” or “honey.”
The exact cause of diabetes is not known. Type 1 diabetes, which requires insulin as medication, usually starts in childhood; it is an autoimmune disease in which the body’s immune system may damage the pancreatic cells that produce insulin.
Type 2 diabetes is sometimes called adult-onset diabetes. However, we are seeing more and more teens and even children developing Type 2 diabetes. Type 2 diabetes does not seem to be an autoimmune disease. Rather, it tends to run in families and may start as a result of other factors. These include being overweight, lack of exercise, eating, and other lifestyle habits or some other illness. It is more common among people who are overweight. Excess body fat does not allow the body to make proper use of insulin. Insulin is produced, but the body is resistant to it. This resistance prevents the body from moving the glucose from the blood into the cells of the body efficiently. Glucose builds up in the blood because the body cannot use it. Fortunately, we know some ways to prevent this type of diabetes, as will be discussed shortly.
Table 18.1 Overview of Type 1 and Type 2 Diabetes
The important difference between the two types of diabetes is that Type 1 requires a daily supplement of insulin, whereas the majority of people with Type 2 may not initially need extra insulin to control the disease. However, if blood glucose levels cannot be well controlled with diet, exercise, and oral medications, supplementary insulin can be tremendously helpful in Type 2 diabetes.
Diabetes is usually diagnosed and monitored with blood tests. Monitoring is done by a combination of home testing of blood glucose (see page 289) and laboratory testing of hemoglobin A1C. The A1C measures your average blood glucose over the past 2 to 3 months. This laboratory test helps you understand how well you are able to keep your diabetes under control. A1C results range from about 4 to about 16. It is also the test your doctor uses to monitor your diabetes and how well your treatment program is working to control your diabetes. For people with diabetes, the usual aim is to keep the A1C below 7 (though some doctors recommend a slightly higher goal for patients, especially those over 65 and with other health conditions).
How Do I Know If I Have Diabetes?
Some people with diabetes have no symptoms, while others may have some or all of the following:
Extreme tiredness
Extreme thirst
Frequent urination, especially at night
Blurry vision or a change in vision
Increased hunger
Unintentional weight loss
Sores or cuts that heal slowly
Numbness or tingling in the feet
Frequent infections of skin, gums, bladder, or vagina (yeast infections)
Recently the results of the A1C are sometimes reported as a calculated eAG (estimated average glucose) blood test. The eAG is easier for some people to understand in that it is reported in the same units and ranges as your daily blood glucose monitoring. It is recommended that you have an A1C at least every year, and more often if you are adjusting your treatment plan.
High blood sugar over months and years can lead to serious complications. For most people, the higher the blood glucose level, the higher the chance of complications.
Although extremely high blood sugar levels can cause loss of consciousness and even death, most complications are related to damage done to blood vessels and nerves throughout the body. This can lead to heart disease and stroke, kidney damage, loss of vision, pain and loss of feeling in the feet, and slow healing of infections and wounds.
Fortunately, you can greatly reduce or delay such complications through healthy eating, exercise, weight control, controlling blood pressure and cholesterol, taking certain medications, and not smoking.
Type 2 diabetes is a growing epidemic. Like most chronic disease, diabetes does not happen overnight. Instead it happens slowly over time. There are many people who have a condition known as prediabetes. This means that their blood sugar levels are higher than normal but not high enough to be diagnosed as diabetes. Prediabetes is an early warning sign. But the good news is that maintaining a healthy weight and being physically active can often reverse prediabetes and delay or prevent the development of Type 2 diabetes.
Some of the risks for diabetes, such as having a brother, sister, or parent with diabetes, cannot be changed. But most of the risks can be reduced by healthy eating, regular exercise, and weight control. Sometimes just losing 5 or 10 pounds can stop or slow the development of diabetes.
If you are at risk for diabetes, talk with your health professional. Knowing early about diabetes can help you prevent complications. It’s worse to have diabetes and not know it.
Successful diabetes management includes maintaining blood sugar in a safe range, detecting early problems, and taking action to prevent complications. This involves working closely with your doctor and health care team and practicing effective self-management, which includes all of the following:
Monitoring your blood glucose
Observing symptoms and knowing what to do
Following a healthy eating plan
Engaging in regular physical activity
Managing stress and emotions
Dealing with sick days, infections, and other illnesses
Using prescribed medications in a safe and effective way
Getting necessary tests, exams, and immunizations
Management of diabetes is aimed at keeping blood glucose in a safe range. The only way to tell if blood glucose is in a safe range is to monitor it. Monitoring is not a treatment. It is a tool you can use to find out how you are doing and make any needed day-to-day changes in diet and exercise, as well as changes in your medications, as recommended by your health care team.
There are two ways to monitor blood glucose levels:
A1C and estimated average glucose (eAG) tests. These are in fact the same blood test, but the results can be reported in two different ways. The test is ordered by your doctor and done in a laboratory; it shows your average blood glucose levels over approximately 3 months (see page 288).
Home blood glucose monitoring. This consists of a series of blood glucose tests you can do at home using a small drop of blood, glucose strips, and a home glucose meter. The meter is about the size of a cellphone and can be taken with you anywhere. The meter is easy to use. You can check your blood sugar at home, at work, or anywhere else. Be sure to get instructions on how to monitor your blood sugar and what equipment you will need. In this way you will ensure accurate results. It is especially helpful to have a doctor, nurse, pharmacist, or diabetes educator observe your technique and give you tips.
Because blood sugar levels change often throughout the day and night, you will want to learn how your eating, exercise, medications, stress, illness, and infections all affect your blood sugar. Monitoring can help with this. Checking your own blood sugars gives you and your doctor more flexibility in making decisions about how to control your blood sugar levels. Checking your blood glucose may also help you evaluate and take action if your blood sugar is too high or too low (see page 298).
How often you check your blood glucose depends on how you and your health care team are going to use the information. Remember, monitoring is not a treatment. It is used to give you information so that you can make needed changes. You may want to monitor several times a day or perhaps once a week. If you are using insulin more than once a day or are using an insulin pump, you should monitor at least three times per day. You should monitor anytime you want to know how you are doing with your self-management plan. There are a few times when it is especially important to monitor, including these:
When you start a new medication
When you change the dose of a medication
Anytime you think you might have low or high blood sugar
Days when you are sick
The important thing about monitoring is that the information is for you.
When you monitor your own blood sugar, it is important to know your blood sugar targets. Talk with your doctor about your personal targets. For many people, the blood sugar targets are as follows:
Before a meal, including in the morning after fasting: 70 to 130 mg/dL
2 hours after a meal: less than 180 mg/dL
Remember that your doctor may recommend slightly different targets for you.
We suggest that you conduct an experiment. On two days, one a weekday and one a weekend day, monitor your blood glucose five times: first thing in the morning before eating, before a meal, 2 hours after a meal, before exercising, and again after exercising. We know that this is a lot of finger sticks, but you have to do this only once, and you will learn a lot. You can plot your blood sugars on the accompanying chart.
If there are things about these numbers you do not understand or if you want help to figure out what these numbers mean, talk with your health care provider or diabetes educator.
Blood sugar naturally rises and falls during the course of the day. It is usually lowest in the morning when you wake up and highest an hour or two after you eat.
Your target range is likely from a low of about 70 first thing in the morning to a high of 180 after meals. Do not be concerned if your blood sugar fluctuates within this target range.
Use the following table to plot your blood glucose profile. Then ask yourself the questions below it.
My Daily Glucose Results
Day 1
Day 2
Questions to Ask Yourself
Was your blood sugar within the recommended range?
Are any of your numbers under or over your recommended target?
Do you notice any daily pattern?
Are there times during the day that your glucose is lower than target range?
Are there specific times during the day that your glucose is higher than target range?
Can you think of any reasons why your blood glucose acted as it did?
What is important is that your blood sugars be about the same each day in relationship to the same activities (for example, an hour or two after meals or after exercising).
You may also be instructed by your doctor or diabetes educator on how to check your urine at home for ketones if your blood sugars tend to be high. Ketones 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.
If you have been managing your diabetes, (eating well, exercising, and taking your medication) and your early morning reading is almost always high, you should talk to your doctor. You may go to bed with your blood sugars in a target range, but then find that the levels jump up in the morning. This is known as the “dawn effect” or “dawn phenomenon.” Blood sugars may rise a few hours before getting up in the morning in response to release of hormones and extra glucose from the liver. To prevent or correct high blood sugar levels in the morning, your doctor may, based on the results of blood testing throughout the night, recommend not eating carbohydrates close to bedtime, adjusting your dosage of medication or insulin, or switching to a different medication.
Although it is important to know how you feel when your blood glucose is very low or high, this is not a reliable way to manage diabetes. First, many people do not have symptoms until their blood sugar is already very high or low. Some people with diabetes are unaware of any symptoms they may have during periods of high or low blood sugars. This makes it very difficult to stay within their appropriate blood glucose range. Second, many of the symptoms are the same for both high and low blood sugar. Without knowing the actual blood glucose level, one does not know what to do. The only way for you to know about your blood glucose on a day-to-day basis is to monitor it.
The goal of diabetes management is to keep blood sugars in a target range. Sometimes your blood glucose may get too high (hyperglycemia) or too low (hypoglycemia). The causes of hyperglycemia and hypoglycemia include the following:
Too little or too much medication or insulin
Eating at irregular hours or missing or skipping meals
Having too little or too much food (especially carbohydrates)
Increased or decreased physical activity
Having an illnesses, infection, or surgery
Emotional stress
It is critically important that you learn to recognize the symptoms, take self-care corrective action, and know when and how to seek medical assistance (see Table 18.2 on page 294–295).
We recommend that people with diabetes wear an emergency bracelet or carry an emergency card in their wallet (or both). The emergency card should also have information about the medications you are taking, your doctor’s contact information, and an emergency contact person’s name and number. We also recommend that you always carry a “remedy food” or fast-acting carbohydrate source with you to quickly manage a low blood sugar.
Healthy eating is the core of diabetes self-management. You are the only one who can manage your blood sugar. The good news is that this is not as hard as it might seem. Small changes in your eating can make important differences in your blood glucose levels and how you feel. Let’s start with some reassurance. You do not have to go hungry. You do not need special foods. You can still eat the foods you like. Healthy eating for diabetes is healthy eating for your whole family. In Chapter 11 there is information about healthy eating. Here we will give the important basics for people with diabetes. If you have diabetes, you need to be more careful than other people about when, how much, and what types of foods you eat. This is because the type of food, the timing of when you eat, and the amount you eat all effect your blood sugar.
All food affects blood sugar. However, carbohydrates (carbs) are the nutrients that do the most to determine blood sugar levels. Your job is to monitor your carbs, especially refined carbohydrates like sugar. You can do this by learning about the carbohydrate content in different foods, eating healthy foods with fewer carbs, watching your portion size, and knowing the number of carbs in a portion. We discuss all of these in Chapter 11.
Choose vegetables, fruits, and whole grains. These foods give you good nutrients, energy, and fiber, fewer calories, and less fat. Limit high-carbohydrate snacks, such as candy, cakes, cookies, sodas, and ice cream. These raise your blood glucose and add fats and calories without giving you healthful nutrients. We are not saying you can’t ever have the foods you love. You just need to limit these foods. Think about having 45 to 60 grams of carbs to spend at each meal If you spend 40 grams of these carbs on cake, consider limiting your other carbs for this meal. Remember, moderation is the key to successful management of blood glucose.
Planning meals when you have diabetes may sound complicated. To help you out, here’s a simple tip for healthy eating. Try the plate method to plan your meals (see Figure 18.2). For each meal, half your plate should be non-starchy vegetables (spinach, broccoli) and fruit, a fourth of your plate should be some lean protein (fish, meat, beans, etc.), and the last fourth can be a starch such as potatoes, whole-grain bread, or rice. Note that this plate is a little different from the one in Figure 11.1 in Chapter 11 for people who do not have diabetes.
Figure 18.2 The Diabetes Plate
Table 18.2 Hyperglycemia and Hypoglycemia*
Here is one final suggestion. Most people would benefit from smaller portions. A portion may be smaller than you think. For example, a portion of rice or pasta containing 15 grams of carbohydrate is ⅓ cup. This does not mean you cannot have more than a portion. It means you need to keep your total grams of carbs per meal between 45 and 60. You can learn about portion sizes and the carbohydrate content of common foods in Chapter 11.
It is generally better to eat smaller meals every 4 to 5 hours during the day. Be sure not to skip breakfast. This is when your body most needs fuel as you have not eaten for a long time.
To learn more about managing your eating plan, we recommend that you spend some time with a certified diabetes educator. This is a person who has been specially trained to teach diabetes management. A registered dietitian (RD) can also help you tailor your eating plan to your lifestyle. Some additional resources are listed at the end of this chapter.
Regular exercise, along with healthy eating, is a core element of controlling blood glucose levels and improving health for everyone with diabetes. However, people who are taking medication to control diabetes should discuss any change in exercise habits with their doctor, dietitian, or health educator because changes in activity levels often require changes in medication and eating schedules.
Exercise is beneficial for people with diabetes in several ways. Mild to moderate aerobic exercise decreases the need for insulin and helps control blood glucose levels by increasing the sensitivity of body cells to insulin and lowering blood glucose levels both during and after exercise. This type of regular exercise is also essential for losing weight and reducing cardiovascular risk factors such as high levels of blood lipids (cholesterol and triglycerides) and high blood pressure.
The exercise program recommended for people with diabetes is generally the same as the conditioning program described in Chapter 7. Mild to moderate aerobic exercise for approximately 30 minutes at a time performed as part of a general conditioning program is a safe and effective way to help control diabetes and stay healthy. Most people with diabetes should aim for at least 150 minutes a week. If you would like to do more exercise—for example, if you wish to run a marathon—check with your health care team, as you may need to make adjustments to your eating or medications (or both).
Additional considerations for people with diabetes are to begin an exercise program only when your diabetes is well under control, keep in touch with your doctor to make changes in medication and diet if needed, and coordinate eating, medication, and exercise to avoid hypoglycemia (low blood sugar). It is often helpful to check your blood sugar levels before and after exercise so that you develop a sense of how your body responds to exercise. If you do not take insulin, plan to be active within an hour after eating your meals or snacks to prevent low blood sugar. If you have Type 1 diabetes and your blood sugar is less than 100 mg/dL before exercising, eat 15 to 30 grams of carbohydrate before you start exercising unless advised otherwise by your health care team. Stop exercising right away if you are dizzy, have shortness of breath, feel sick to your stomach, or are in pain. Drink extra fluids before, during, and after exercise. If you have problems with sensation in your feet or poor circulation, be sure to check your feet regularly and protect yourself from blisters and abrasions. It is especially important to inspect your feet and practice good skin and nail hygiene regularly. Shoe inserts can be tailored to help protect the soles of the feet.
For more information on how to develop and maintain an exercise program, see Chapter 7.
After learning that you have diabetes or if you develop diabetes-related complications, you may be feeling angry, scared, or depressed. These feelings are normal, understandable, and manageable. For people with diabetes, stress and emotions such as anger, fear, frustration, and depression can raise blood sugar levels. For this reason, it is important to learn effective ways to deal with these feelings. Hiding or ignoring your feelings is not healthy. You will find lots of tools for dealing with stress and negative emotions in Chapters 4 and 5.
People with diabetes, like all people, sometimes get sick. When you get an infection, a cold, or the flu, your blood sugar tends to go up. How your body uses food and diabetes medicines changes. For this reason, it is important to plan for sick days and to know what to do and when to seek help. The following points should be included in your plan.
Have a family member or friend who is able to help you when needed. This person should know what to do, when to call the doctor, or when to take you to the emergency department.
Have plenty of both sweetened and unsweetened or sugarless (or sugar-free) liquids on hand.
Have a thermometer at home and know how to use it.
Have your emergency medical information on hand (including doctor’s number and list of medications and dosages).
Be sure to ask your health care providers under what circumstances you should call them. (Some general guidelines are provided below.)
Take your usual dose of insulin or pills unless you have a special “sick-day plan,” you are vomiting, or your health care team tells you otherwise.
Test your blood sugar two to four times a day. If your blood sugar is over 300 mg/dL, test every 3 to 4 hours. Write down the results and time.
If you take insulin and your blood sugar is above 300 mg/dL, test your urine for ketones. Record whether you have small, moderate, or large amounts.
Watch for symptoms of hypoglycemia or hyperglycemia (see pages 294–295).
Track how much fluid you drink. To prevent dehydration, try to sip at least 8 ounces (1 cup) of fluids every hour while awake. If your blood sugar is over 240 mg/dL, use sugar-free drinks such as broth, tea, or water. If your blood sugar is low, eat or drink ½ to 1 cup of a sugared liquid (fruit juice or regular soft drink).
Check your temperature twice a day and record it.
Keep eating if possible. Small frequent meals or snacks can help.
Keep in touch. Tell a family member or friend how you are feeling and have the person check in with you frequently.
If your blood sugar is less than 60mg/dL two times in one day
If your blood sugar is over 300 mg/dL for 8 hours or your blood sugars are much higher than they usually are
If your temperature rises above 101°F (38.3°C) or if it stays above 100°F (37.8°C) for more than 2 days
If you vomit or have diarrhea for more than 24 hours
If you are not able to drink liquids or eat food or keep down medications for more than 8 hours
If you have a small level of ketones in your urine as indicated on the test strips
If you experience deep or troubled breathing, an extremely dry mouth, or a fruity odor to your breath
If you have been sick longer than expected and are not getting better
You are not feeling well and are unsure what you should do to care for yourself
If your blood sugar is over 500 mg/dL
If you find moderate to large amounts of ketones in your urine
When you call your health care professional, be prepared. Have the following information: your type of diabetes, your blood sugar level (if you know it), your temperature, if you have ketones in your urine, your symptoms, the medications you are taking, and what you have done to treat your symptoms.
In addition to healthy eating and exercising, most people with diabetes benefit from medications. These help keep blood sugar, blood pressure, and cholesterol levels in the target ranges. Although they can be helpful, many people do not like taking medications. For some of us, not taking medications is a point of pride. We might want to manage our conditions naturally. In some cases it is possible to manage without medications. However, most people with diabetes, if they are going to maintain blood glucose control and prevent complications, need to take one or more medications. Medications can help prevent such complications as heart attack, stroke, kidney disease, and early death. Unfortunately, you cannot wait to see what happens before you decide to take medications to reduce your risks. Once diabetes complications have appeared, they usually cannot be reversed.
Your doctor will recommend medications based on your type of diabetes, how well your blood sugar is controlled, and your other medical conditions.
Insulin for Type 1 diabetes. Insulin is required throughout your life because your body does not produce insulin.
Medications for Type 2 diabetes. There are several types of pills that can be used separately or in combination to help control your blood sugar. Oral or injected insulin is also a safe and effective choice for many people with Type 2 diabetes.
In addition to using medications to control blood sugar, studies have shown that certain other medications can reduce the risk of developing diabetes complications. Because of their protective benefit, these medications are recommended even if your blood pressure and cholesterol are in the target ranges. Depending on your age and medical conditions, common types of preventive medications may include the following:
Aspirin. Low-dose aspirin (81 mg) reduces risk for heart attack and stroke by decreasing the chance of a sudden blockage in an artery.
ACE inhibitors or ARBs. These specialized medications to control blood pressure protect your kidneys and reduce the chance of having a heart attack or stroke.
Statins. These decrease inflammation and lower cholesterol, reducing the chance of a heart attack or stroke.
Talk with your doctor if you are not taking these additional preventive medicines to find out whether you should be taking them.
Some people with Type 2 diabetes can manage their blood glucose without insulin or other diabetes medications by controlling their exercise, diet, and weight, sometimes losing only 10 to 15 pounds (4–6 kg). The rule of thumb is that a weight loss of 7% will help bring blood glucose into a healthy range. This means 14 pounds if you weight 200 pounds. However, along with diet and exercise, most patients with Type 2 diabetes will need the help of oral medications or insulin to safely control their blood sugar and help prevent complications. The medications do not take the place of healthy eating and regular physical activity. Table 18.3 lists the most common medications currently used to treat diabetes.
Insulin is used to treat everyone with Type 1 diabetes and for many people with Type 2 diabetes. It is used to replace the insulin that is not produced or is inadequately utilized by the body. Using insulin injections is now one of the safest and most effective ways to control blood glucose and prevent complications. Research now supports using insulin earlier in the treatment of Type 2 diabetes if blood sugar levels are quite high, if oral medications do not control blood sugar, or if you experience side effects from oral medications. Some patients are initially fearful of using insulin, but once started, they find that the injections are rather easy and nearly painless (usually causing less discomfort than the finger stick required to check blood sugar). In addition, controlling blood sugar levels is often much easier with the use of insulin. Remember, using insulin is a good thing and a wise decision if recommended by your doctor.
Table 18.3 Common Medications Used for Diabetes
There are several types of insulin, depending on how fast and how long they work. It is important that you know the type of insulin you are taking, the company that makes it, the dose (number of units you are taking), and when to take it (before a meal or snack or soon after taking the first bite of your food). Also make sure that the insulin you are taking has not passed its expiration date. If you feel that you could benefit from learning more about the use of insulin, talk with your doctor or diabetes educator. Your doctor may also work out with you a written plan for how to adjust your insulin dose (“sliding scale”) based on your daily home blood glucose measurements. Some patients with diabetes may also benefit from the use of the newer insulin pumps. You will also find a list of resources at the end of this chapter.
If you do need medications, you should know when to take them and never skip a dose. Most of these drugs are taken once or twice a day, usually right before meals. Check with your doctor before stopping or changing your medicines, even if you don’t feel well. When traveling, always keep your medications with you, not in your luggage.
Other medications, including over-the-counter medications and some natural remedies and dietary supplements, can sometimes interact with diabetes medications. Therefore, it is important that your doctor and pharmacist know all the medications you are taking, including prescription and nonprescription drugs and any vitamins, minerals, supplements, herbals, and natural medicines used.
Here is one last piece of advice about medications. If you start a new drug and experience side effects, be sure to tell your health care team right away. A change in medicine or in the dosage of the current medicine may clear up some side effects.
Diabetes can cause other problems in the body. These can often be delayed and sometimes avoided by maintaining good blood glucose control. Remember that most complications are directly related to this control. The following are the most common complications of diabetes:
Heart disease and stroke. It may surprise you that heart disease and stroke are the biggest killers of people with diabetes. High blood sugar levels can harden and block the arteries. The good news is that there are many things you can do to help reduce these potential problems.
Nerve damage. Diabetes can cause damage to nerves (neuropathy), resulting in a burning or tingling sensation, numbness, or severe pain, especially in the feet and hands. Nerve damage can also lead to sexual problems such as erection problems in men and vaginal dryness in women. Nerve damage can also lead to problems with digestion and urination.
Kidney damage. Diabetes can damage the blood vessels in the kidney, especially when the blood pressure is high, causing kidney failure. The first sign may be detected by a test for small amounts of protein in the urine.
Vision problems. Blurred vision can occur when high blood sugar levels temporarily cause the lens in the eye to swell. More serious and permanent damage to the blood vessels in the retina in the back of the eye (retinopathy) can lead to poor vision or even blindness.
Infections. Diabetes can decrease immune function and reduce blood flow, which can lead to slower healing and more frequent infections of the skin, feet, lungs, and other parts of the body.
Gum disease. People with diabetes have a greater risk for gum (periodontal) disease and infection. That’s why it is important to discuss your diabetes with your dentist and to get regular dental checkups.
Here’s a handy checklist to make sure you are doing the things and getting the care that will help significantly prevent or delay these and other complications of diabetes. They may even save your life!
Maintain safe blood glucose levels. A healthy diet, regular exercise, a healthy weight, and (if needed) medications are the keys to controlling blood sugar levels and preventing complications.
Control your blood pressure. The target blood pressure reading for people with diabetes are usually 130/80 or less (or as recommended by your doctor). Lower blood pressure means less stress on your heart and blood vessels, eyes, and kidneys. To prevent complications of diabetes, controlling blood pressure can be as important as controlling blood glucose levels.
Control your blood cholesterol. LDL (“bad”) cholesterol, rather than total cholesterol, is the measure that is usually monitored for people with diabetes. The target level for people with diabetes is 100 or less (and some studies suggest an even lower target level of 70; check with your doctor). Remember that taking a statin medication may further reduce the risk of heart attack and stroke even if your cholesterol level is low without the statin.
Protect your kidneys. Along with regular testing, taking an ACE inhibitor or ARB medication can help lower blood pressure as well as protect your kidneys.
Get regular checkups, exams, and immunizations.
• Have an A1C test at least once a year.
• Have kidney function tests at least once a year.
• Have cholesterol and lipid tests at least once a year.
• Have eye exams (including inspection of the retina at the back of your eyeball) every 1 to 2 years (or as recommended by your doctor), and report any changes in vision to your doctor. This retinal exam is different from a test by an optometrist, who checks your vision to see if you need glasses or corrective lenses.
• Remind your health care provider to check your feet at each visit or at least once a year. One way to do this is to always take off your shoes and socks in the examining room. (See below for other tips about foot care.)
• Have your blood pressure checked at every visit (or as recommended by your provider) and keep track of the numbers.
• Have a flu shot every year and a pneumonia vaccination at least once (may need to be repeated after age 65).
• Have a dental exam once a year or as recommended by your provider; floss and brush your teeth at least once a day.
Check out your feet. When you have diabetes, your feet need extra care and attention. Diabetes can damage the nerve endings and blood vessels in your feet, making you less likely to notice when your feet are injured. Diabetes also limits your body’s ability to fight infection and get blood to areas that need it. If you get a minor foot injury, it could become an ulcer or a serious infection.
• Examine your feet every day. You or someone else should look between the toes and on the tops and bottoms of the feet for cuts, cracks, sores, corns, calluses, blisters, ingrown toenails, extreme dryness, bruises, redness, swelling, or pus.
• Wash your feet every day. Use warm (not hot) water. Check the water temperature with your wrist or another part of your body, not your feet, and dry thoroughly, especially between the toes. Do not soak your feet.
• Cut your toenails straight across. If you can’t safely trim your toenails yourself, ask a family member to do it or get professional help. Also, do not clean under your toenails or remove skin with sharp objects. (Many senior centers have a day or two a month when a professional comes in to cut toenails.)
• If your feet are dry, rub on a mild lotion before bed. Do not put lotion between your toes. Avoid lotions that contain alcohol or other ingredients that end in -ol, as these tend to dry out the skin.
• Wear comfortable shoes and socks (never go barefoot except when bathing or in bed). Your shoes should support, protect, and cover your feet. If your feet sweat, use powder. Before putting on shoes, check inside for rough places or any sharp objects such as tacks or nails on the sole of the shoe. Break in new shoes gradually. Avoid socks with tight, elastic tops.
• To avoid “hot spots,” do not wear the same shoes two days in a row. If you have any problems with your feet, change your shoes in the middle of the day.
• Have your doctor or other clinician check your feet at each office visit.
• Always get early treatment for foot problems. A minor irritation can lead to a major problem.
Take these additional precautions.
• Be sure to tell your health care provider if you are taking aspirin (81 mg tablet) to lessen your risk of heart attacks and stroke.
• Do not smoke, or if you do smoke, take steps to quit.
• In general, it is a good idea to avoid alcohol. For the person with diabetes, alcohol can cause a sudden and drastic drop in blood glucose, and it adds calories that can lead to weight gain. If you do drink, make sure you have some food with it to avoid a low blood sugar reaction, which can happen if you have alcohol on an empty stomach.
• Protect your skin. Don’t get sunburned, and keep your skin clean.
• Wear a MedicAlert necklace or bracelet, and carry with you a list of all your medications.
• At every visit and if you are hospitalized or go to the emergency department, remind the doctor and nurse that you have diabetes.
Most complications of diabetes can be prevented, delayed, and treated. You have an important role. Let us quickly review what you must do:
Maintain your blood glucose level within your normal range.
Be aware of your body and symptoms.
Report changes early. Time is important.
Make sure you get regular checkups, exams, tests, and immunizations.
To become a good diabetes self-manager, there is lots to learn. Putting all of this into action is sometimes difficult. Set personal goals to control your diabetes, review them regularly, and revise them as needed. Be sure to talk to your doctor or diabetes educator about your questions, problems, and concerns. Find other information and resources in your community. Take a diabetes education program. Consider joining a diabetes support group either in your community or online. Some resources are listed at the end of this chapter.
American Diabetes Association. A Field Guide to Type 2 Diabetes: The Essential Resource from the Diabetes Experts. Alexandria, Va.: American Diabetes Association, 2004.
American Diabetes Association. Complete Guide to Diabetes, 5th ed. Alexandria, Va.: American Diabetes Association, 2011.
Arsham, Gary, and Ernest Lowe. Diabetes: A Guide to Living Well, 4th ed. Alexandria, Va.: American Diabetes Association, 2004.
Beaser, Richard S., and Amy P. Campbell. The Joslin Guide to Diabetes: A Program for Managing Your Treatment. New York: Simon & Schuster, 2005.
Bierman, June, Virginia Valentine, and Barbara Toohey. Diabetes: The New Type 2: Your Complete Handbook to Living Healthfully with Diabetes Type 2. New York: Tarcher, 2008.
Polonsky, William H. Diabetes Burnout: What to Do When You Can’t Take It Anymore. Alexandria, Va.: American Diabetes Association, 1999.
Raymond, Mike. The Human Side of Diabetes. Chicago: Noble Press, 1992.
Schade, David S., Patrick J. Boyle, and Mark R. Burge. 101 Tips for Staying Healthy with Diabetes and Avoiding Complications. Alexandria, Va.: American Diabetes Association, 1996.
Walker, Rosemary, and Jill Rodgers. Diabetes: A Practical Guide to Managing Your Health. New York: DK, 2005.
American Diabetes Association (ADA), 1660 Duke Street, P.O. Box 25757, Alexandria, VA 22313; (888) DIABETES: http://www.diabetes.org/. The ADA publishes a bimonthly magazine called Diabetes Forecast. It is filled with practical tips on diabetes care and relates personal experiences of people with diabetes.
International Diabetes Center, 4959 Excelsior Boulevard, Minneapolis, MN 55416: http://www.Idcdiabetes.org/. The center offers a variety of inexpensive pamphlets, booklets, and slide sets dealing with various facets of diabetes care.
Joslin Diabetes Foundation, One Joslin Place, Boston, MA 02215; http://www.joslin.harvard.edu/. This world-famous facility has separate divisions for research, education, and youth. Its efforts involve all facets of diabetes management and research. It is one of eight Diabetes Research and Training Centers designated by the National Institutes of Health.
National Diabetes Education Program, http://www.ndep.nih.gov/. On this site you will find a wide variety of materials to help you self-manage your diabetes.
National Diabetes Information Clearinghouse, 7910 Woodmont Avenue, Suite 1811, Bethesda, MD 10014; http://diabetes.niddk.nih.gov/. This organization publishes a list of nutrition information related to diabetes management.
