Glucose Tolerance Test - GTT

Alternative names
Oral glucose tolerance test

Definition

The glucose tolerance test is a laboratory method to check how the body breaks down (metabolizes) blood sugar.

How the test is performed

Glucose is the sugar that the body uses for energy. Patients with untreated diabetes have high blood glucose levels. Glucose tolerance tests are one of the tools used to diagnose diabetes.

The most common glucose tolerance test is the oral glucose tolerance test (OGTT). You can not eat or drink anything after midnight before the test. For the test, you will be asked to drink a liquid containing a certain amount of glucose. Your blood will be taken before you do this, and again every 30 to 60 minutes after you drink the solution. The test takes up to 3 hours.

Blood glucose levels above normal limits at the times measured can be used to diagnose type 2 diabetes or gestational diabetes (high blood glucose during pregnancy). Insulin levels may also be measured. (Insulin is the hormone produced by the pancreas that moves glucose from the bloodstream into cells.)

The intravenous glucose tolerance test (IGTT) is not often used. In this test, glucose is injected into your vein for 3 minutes. Blood insulin levels are measured before the injection, and again at 1 and 3 minutes after the injection. This test may predict the development of type 1 diabetes in some patients.

How to prepare for the test

Make sure you eat normally for several days before the test.

Do not eat or drink anything for 12 hours prior to the test. You can not eat during the test.

Ask your health care provider if you are using medications that can interfere with the test results.

How the test will feel

When the needle is inserted to draw blood, some people feel moderate pain, while others feel only a prick or stinging sensation. Afterward, there may be some throbbing.

Why the test is performed

The oral glucose tolerance test is used to screen pregnant women for gestational diabetes between 24 and 28 weeks of pregnancy. It may also be used to in cases where the disease is suspected, despite a normal fasting blood glucose.

Normal Values

Normal blood values for a 75-gram oral glucose tolerance test used to check for type 2 diabetes:

* Fasting: 60 to 100 mg/dL
* 1 hour: less than 200 mg/dL
* 2 hours: less than 140 mg/dL. Between 140-200 mg/dL is considered impaired glucose tolerance or pre-diabetes. This group is at increased risk for developing diabetes. Greater than 200 mg/dL is diagnostic of diabetes mellitus

Normal blood values for a 50-gram oral glucose tolerance test used to screen for gestational diabetes:

* 1 hour: less than 140 mg/dL

Normal blood values for 100-gram oral glucose tolerance test used to screen for gestational diabetes:

* Fasting: less than 95 mg/dL
* 1 hour: less than 180 mg/dL
* 2 hour: less than 155 mg/dL
* 3 hour: less than 140 mg/dL

Note: mg/dL = milligrams per deciliter

What abnormal results mean

Greater than normal levels of glucose may mean you have diabetes or gestational diabetes.

However, high glucose levels may be related to another medical problem (for example, Cushing syndrome).

What the risks are

The risks of drawing blood from a vein include:

* Excessive bleeding
* Fainting or feeling lightheaded
* Hematoma (blood accumulating under the skin)
* Infection (a slight risk any time the skin is broken)
* Multiple punctures to locate veins

Veins and arteries vary in size from one patient to another and from one side of the body to the other. Obtaining a blood sample from some people may be more difficult than from others.

Special considerations

Interfering factors:

* Acute stress (for example, from surgery or an infection)
* Vigorous exercise

Several drugs may cause glucose intolerance, including:

* Thiazide diuretics (for example, hydrochlorothiazide)
* Beta-blockers (for example, propranolol)
* Oral contraceptives (birth control pills)
* Corticosteroids (for example, prednisone)
* Certain psychiatric medications

Before having the test, let your health care provider know if you are taking any of these medications.

Gestational diabetes - Diabetes in pregnancy

Diabetes can develop during pregnancy in a woman who hasn't previously had the condition. This is called gestational diabetes, which affects two to three per cent of pregnant women. If it is not properly controlled, it can lead to problems for the mother or her baby.

What is gestational diabetes?

Gestational diabetes develops in women during pregnancy because the mother's body is not able to produce enough insulin. Insulin is a hormone that enables the body to break down sugar (glucose) to be used as energy. Without sufficient insulin the amount of sugar in the blood rises.

High blood sugar levels in the mother's body are passed through the placenta to the developing baby. This can cause health problems.

Gestational diabetes usually begins in the second half of pregnancy, and goes away after the baby is born. This makes it different to the more common forms of diabetes which, once they occur, are permanent.

What causes gestational diabetes?

The cause of gestational diabetes is unknown. It is thought that the hormones produced during pregnancy may block the action of insulin. Gestational diabetes can happen if the mother's body can't produce enough extra insulin to counteract this blocking effect.

Risk factors

Although there is no clear reason why some women get gestational diabetes, women are more at risk if they:

• have a family history of type II (adult-onset) diabetes
• are over the age of 35
• are obese
• have previously given birth to a large baby
• have previously given birth to a baby born with an abnormality
• have previously had a stillbirth late in pregnancy

Symptoms

In most women, gestational diabetes causes no symptoms. Some women do get symptoms of high blood sugar, such as increased thirst, increased need to pass water and increased hunger, although these are also common later on in pregnancy anyway.

The effects of gestational diabetes

Effects on the fetus during pregnancy

• Having high blood sugar can cause the baby to grow larger, which can make delivery difficult and potentially cause injuries to both mother and baby during birth. In some cases a caesarean section is necessary.

Effects on the baby after birth

• The baby may have low blood sugar (hypoglycaemia) after birth. This is because the baby's pancreas makes extra insulin in response to the mother's high blood sugar levels. Shortly after birth, the baby may continue to make extra insulin even though high levels of blood sugar are no longer present. After a pregnancy affected by gestational diabetes, the newborn baby's blood sugar level is checked regularly. Sometimes babies are given an early feed of a sugar (glucose) solution through a drip (fed directly into a vein) to correct low blood sugar.
• It is more likely that the newborn baby will develop jaundice (yellowing of the skin and whites of the eyes). This is not serious and usually fades over a few weeks, without the need for medical treatment.
• There is an increased risk that the baby will be born with congenital problems, such as a heart defect. Sometimes, infants can be born with respiratory distress syndrome, in which the baby has problems breathing because his or her lungs have not matured as normal. This usually clears up with time.
• There is also a slightly higher chance of stillbirth or death as a newborn, but if detected and the glucose levels well managed, death is rare.
• There may be an increased risk of the baby developing type II diabetes or being overweight later in life.

Effects on the mother

Gestational diabetes is not an immediate threat to the woman's health. Most women with gestational diabetes whose blood sugar levels stay within the safe range deliver their babies without complications. However, in some women it can result in high blood pressure.

Women who get gestational diabetes are more likely to develop gestational diabetes in future pregnancies, and are at a higher risk of developing type II diabetes later in life.

Diagnosing gestational diabetes

Urine is routinely tested for sugar throughout pregnancy, and high blood sugar, if present, is usually detected between 24 and 28 weeks of pregnancy.

The only way to confirm gestational diabetes is with a glucose tolerance test, which needs to be carried out after eight hours without food. The woman is given a solution of glucose to drink, and then blood samples are taken and analysed at different intervals to see how the body deals with the glucose over time.

If a doctor believes a woman is likely to develop gestational diabetes, this test may be carried out earlier than 24-28 weeks. Any woman whose medical history means she's at a greater risk of diabetes, or is concerned about any symptoms should see her GP.

Treatment

Self-help

The most important part of treatment is to control blood sugar levels. For many women, this means regular testing of blood sugar (glucose) levels, a carefully planned diet and regular exercise.

Home glucose testing kits are available from chemists. These usually involve taking a tiny blood sample with a pinprick device. The blood is put onto a strip and inserted into a glucose measuring device, which gives the blood glucose level.

Doctors usually advise blood glucose testing once a week, although for some women this may need to be more often. Glucose needs to be measured in the morning before breakfast and again two hours after breakfast. Some women may also need to test levels in the mid-afternoon.

A doctor or dietician can give advice about what and how much to eat. A meal plan will probably consist of a variety of foods including plenty of starchy fillers such as bread, pasta, rice and potatoes, and at least five portions of fruit and vegetables each day.

It's important to limit consumption of sugary foods like cakes, biscuits and soft drinks. A diet that is low in fat is also desirable. This can be acheived by avoiding full-fat dairy products such as butter and cream, and limiting fatty meat, pies, sausages and burgers. Grilling, steaming or microwaving food rather than frying or roasting means less fat is added during cooking.

Gentle, regular exercise such as walking can help reduce blood sugar levels and promote a sense of well-being. A doctor or midwife can advise about suitable exercise during pregnancy.

Medicines

Despite making the above lifestyle changes, a few women's blood sugar levels remain too high, and they may need daily injections of insulin. The extra insulin will not cross the placenta and will not affect the baby. Any woman who needs to take insulin will be taught how to take it by her doctor or nurse.

It is possible to have too much insulin and this can cause low blood sugar (hypoglycaemia). Common symptoms of this are weakness, shaking, hunger and sweating. For people taking insulin, it is a good idea to keep a snack handy at all times in case low blood sugar develops.

After the birth

In almost every case, gestational diabetes disappears on its own after delivery. To be sure, doctors may check the mother's blood sugar levels a few times after the birth.

Prevention

To help reduce the risk of getting gestational diabetes, women should make healthy lifestyle choices, such as eating a balanced diet, taking regular exercise and maintaining the correct weight for their height

Diabetes Diagnosis -Tests

Introduction - Diabetes Diagnosis -Tests

Blood and urine tests help show if your diabetes treatment is working and can alert your doctor to early signs of diabetes complications, such as kidney disease.

Glycated hemoglobin test

A glycated hemoglobin test, also called a glycosylated hemoglobin test or hemoglobin A1C test, reflects your average blood sugar level for the two- to three-month period before the test. Your doctor uses it to determine how well you're managing your blood sugar.

How the test is done

A lab technician takes a sample of blood from a vein in your arm and sends the blood sample to a lab for analysis.

Recommended results

Normal ranges often vary among laboratories. The American Diabetes Association (ADA) recommends that your glycated hemoglobin level be 7 percent or less.

How often to have the test

How often you have this test depends on the type of diabetes you have and how well you're managing your blood sugar. If your blood sugar is consistently within your doctor's recommended target range, the ADA recommends that you have this test twice each year. If you start a new diabetes medication regimen or have trouble keeping your blood sugar within target range, the ADA recommends that you have this test four times each year.

Serum creatinine test

This test measures the level of creatinine in your blood. Creatinine is a chemical waste product that's produced when you use your muscles. If your kidneys aren't functioning properly, they aren't able to remove as much creatinine from your blood.

How the test is done

A lab technician takes a sample of blood from a vein in your arm and sends the blood sample to a lab for analysis.

Recommended results

The normal ranges are:

* Women. 0.7 to 1.2 milligrams per deciliter (mg/dL)
* Men. 0.9 to 1.4 mg/dL

How often to have the test

People with diabetes typically have this lab test at least once each year.

Urine microalbumin test

A urine microalbumin test assesses the health of your kidneys by screening for protein leakage into your urine. If your kidneys become damaged, waste products normally filtered out by your kidneys remain in your blood, and protein (albumin) that should remain in your blood leaks into your urine.

How the test is done

When you visit your doctor, you provide a fresh urine sample. The urine is sent to a laboratory for analysis, or a technician in your doctor's office performs the test using a chemically treated test strip. In addition, your doctor may ask you to collect all of your urine in a container over a 24-hour period and bring it in to be assessed.

Recommended results

Results of the urine microalbumin test are measured as milligrams (mg) of protein leakage. Typically, here's what your results will mean:

* Less than 30 mg is normal.
* 30 to 299 mg indicates early-stage kidney disease (microalbuminuria).
* 300 mg or more indicates advanced kidney disease (macroalbuminuria).

Without appropriate treatment, your kidneys are likely to fail within a few years of developing macroalbuminuria.

How often to have the test

The frequency of urine microalbumin testing depends on your individual situation. In general, you have the test yearly after your diagnosis, but you may need it more often if your levels are high. Talk with your health care team about how often you need the test.

Lipids test

A lipids test measures the level of fats (lipids) in your blood. A rising level of certain blood fats can alert your doctor to an increased risk of blood vessel damage. The test measures the level of two such substances, which increase your heart disease risk: low-density lipoprotein (LDL), the "bad" cholesterol, and triglycerides. The test also determines your level of high-density lipoprotein (HDL), the "good" cholesterol, which protects against heart disease.

How the test is done

A lab technician takes a sample of blood from a vein in your arm and sends the blood sample to a lab for analysis.

Recommended results

Optimal levels are:

* LDL: Less than 100 milligrams per deciliter (mg/dL)
* HDL: Greater than 40 mg/dL if you're a man or greater than 50 mg/dL if you're a woman
* Triglycerides: Less than 150 mg/dL

How often to have the test

The ADA recommends that you have this test at least once each year and more often if your levels aren't normal or you're taking lipid-lowering medication.

Diabetic Diet

Popular misconceptions about nutrition and diabetes include the idea that a "diabetic diet" is a "sugar free diet"; or that refined sugar is "bad" and "natural sweeteners" are "good". Can "non-sugar" foods be eaten in any amounts? Can a person with diabetes "cheat" every once in a while? What IS a "diabetic diet"? Because so many questions and misunderstandings exist, it is important for a person with diabetes to be able to understand the fundamentals of nutrition, one of several essential elements of successful diabetes management.

There is actually no such thing as a single "diabetic diet". The diet that a person with diabetes follows to help manage his or her blood sugar levels is based on the same nutrition principles that any healthy person, with or without diabetes, should follow for good health. When a person with diabetes sees a Registered Dietitian for nutrition counseling, the goal is to create a nutrition plan. This will help the person manage his or her blood sugar levels, reduce the risk of heart disease and other diet-related conditions, maintain a healthy weight, as well as meet the person’s nutritional, lifestyle, social, and cultural needs.

The energy that we get from foods, measured in calories, comes from three types of nutrients: fats, proteins, and carbohydrates. Any food that provides calories will raise blood sugar. When foods are digested, they are broken down into the body’s basic fuel-- glucose, a type of sugar. The glucose is absorbed by the bloodstream, and is then known as blood glucose or blood sugar. In a person without diabetes, insulin is released by the pancreas after a meal or snack to allow the glucose in the blood to get into the body’s cells, where it is burned for energy. This brings the level of glucose in the blood back down to the normal range. If insulin is not produced or is not working properly, the glucose can not enter the cells to be used, and it builds up in the bloodstream. This results in high blood sugar, and this condition is known as diabetes.

Although all foods that provide calories are converted into glucose by the body, certain nutrients have a more direct effect on the blood’s glucose level. Fats in foods are eventually digested and converted into glucose, but this can take up to 6 to 8 or more hours after a meal, and the release of glucose into the blood is v e r y s l o w ... Protein in foods (such as meats, poultry, fish, eggs, soy and other beans, and milk) takes about 3 to 4 hours after a meal to "show up" as blood glucose.

Carbohydrates, on the other hand, take only about half an hour to an hour after a meal to be turned into blood glucose. The word "carbohydrate" actually means "sugars and starches." Chemically, a starchy food is just a "chain" of glucose molecules. In fact, if a starchy food like a soda cracker is held in the mouth for a few minutes, it will start to taste sweet as the digestive enzymes in the saliva begin to break the starch down into its glucose parts.

Any food that is high in any type of carbohydrate will raise blood glucose levels soon after a meal. Whether a food contains one ounce of sugar (natural or refined) or one ounce of starch, it will raise blood glucose the same amount, because the total amount of CARBOHYDRATE is the same. Although a glass of fruit juice and the same amount of sugary soda may seem like a "good" versus "bad" choice, each will raise blood glucose about the same amount. This information regarding the amount of carbohydrate in different foods is the center of a nutrition management tool for people with diabetes called Carbohydrate Counting. Foods high in carbohydrates include starches such as rice, pasta, breads, cereals, and similar foods; fruits and juices; vegetables; milk and milk products; and anything made with added sugars, such as candies, cookies, cakes, and pies.

The goal of a diabetes nutrition plan is to provide a mixture of fats, carbohydrates, and proteins at each meal at an appropriate calorie level to both provide essential nutrients as well as create an even release of glucose into the blood from meal to meal and from day to day. A Registered Dietitian assesses the nutritional needs of a person with diabetes and calculates the amounts of fat, protein, carbohydrate, and total calories needed per day, and then converts this information into recommendations for amounts and types of foods to include in the daily diet. The total number of meals and snacks and their timing throughout the day can differ for each person, based on his or her nutritional needs, lifestyle, and the action and timing of medications.

Overall, a nutrition plan for a person with diabetes includes 10 to 20 percent of calories from protein, no more than 30 percent of calories from fats (with no more than 10 percent from saturated fats), and the remaining 50 to 60 percent from carbohydrates. Carbohydrate foods that contain dietary fiber are encouraged, as a high fiber diet has been associated with decreased risks of colon and other cancers. For people with high blood cholesterol levels, lower total fat and saturated fat contents may be recommended. Sodium intake of no more than 3000 mg per day is suggested; for people with high blood pressure, sodium should be limited to 2400 mg per day or as advised by a physician.

One "diabetic diet" definitely does not fit all. In fact, ANY food can fit into the diet of someone with diabetes, with the help and guidance of a Registered Dietitian. Managing blood glucose levels does not have to mean giving up favorite foods, sweets, or restaurants and fast foods. Each person with diabetes has very different nutritional and personal needs, making ongoing assessment and counseling with a Registered Dietitian an essential element of successful diabetes management.

Oral Diabetes Medicines

Why did my doctor prescribe oral diabetes medicine for me?
If you have type 2 diabetes, your body's tissues do not get enough insulin. This results in high blood sugar levels. Some people who have type 2 diabetes don't make enough insulin. Other people make enough insulin but their bodies are not able to use it properly.

Some people who have type 2 diabetes need to take insulin in shots to help control their blood sugar levels. Most take pills by mouth (oral medicine) to help control their diabetes. Some people take insulin and oral medicines.


What are some common oral diabetes medicines?There are 5 types of oral diabetes medicines. Your doctor will decide which type of medicine is right for you.

Sulfonylureas help your body make more insulin. These are the most common type of oral diabetes medicine. Some examples of sulfonylureas include acetohexamide (brand name: Dymelor), chlorpropamide (brand name: Diabinese), glipizide (brand name: Glucotrol) and glyburide (brand names: DiaBeta, Glynase, Micronase).

Metformin (brand name: Glucophage) helps control blood sugar in a couple of ways. It helps your body use insulin better. It also helps your body make less sugar and reduces the amount of sugar your body absorbs from food. It almost never causes hypoglycemia (low blood sugar).

Meglitinides help your body make more insulin. Examples include nateglinide (brand name: Starlix) and repaglinide (brand name: Prandin). These pills are usually taken with meals.

Thiazolidinediones help your body use insulin better. They also help your body make less sugar. There are 2 thiazolidinediones: pioglitazone (brand name: Actos) and rosiglitazone (brand name: Avandia).

Alpha-glucosidase inhibitors help your body absorb sugar more slowly to keep your blood sugar lower. This type of medicine is taken every time you eat a meal. There are 2 alphaglucosidase inhibitors: acarbose (brand name: Precose) and miglitol (brand name: Glyset).

Sometimes two kinds of medicines are given together. For example, glyburide combined with metformin (brand name: Glucovance), glipizide combined with metformin (brand name: Metaglip) and rosiglitazone combined with metformin (brand name: Avandamet).

Do these medicines have any side effects?
Like most medicines, these drugs can cause side effects. Your doctor may want to see you or want you to have tests (like liver tests) to check for problems. However, the side effects usually are not severe and are not common. Side effects of oral diabetes medicines may include the following:

Nausea and vomiting
Diarrhea
Gas and bloating
Decreased appetite
Headache and/or muscle aches
Flu- or cold-like symptoms
Talk to your doctor about any side effects you may be having.

Will a diabetic drug interact with my other medicines?
If you take 2 or more drugs at the same time, how the drug works can change. When this happens, the risk of side effects increases. This is called a "drug-drug interaction." Vitamins and herbal supplements can affect the way your body processes drugs too.

Drug-drug interactions can be dangerous. Be certain that your doctor knows all of the over-the-counter and prescription medicines, vitamins and herbal supplements that you are taking. Also, talk to your doctor before you take any new over-the-counter or prescription medicine or use a vitamin or herbal supplement.

Certain foods or drinks can also keep your medicine from working the way it should or make side effects worse. This is called a "drug-food interaction." For example, if you’re taking an oral diabetes medicine, drinking alcohol can increase your risk of low blood sugar.

Know the signs

People who have diabetes need to know the signs of hyperglycemia (high blood sugar ) and hypoglycemia (low blood sugar). Make sure your family members, friends and coworkers know how to help you in an emergency situation.

Signs of low blood sugar:
Shakiness
Drowsiness
Cold sweats and pale, cool skin
Headache
Confusion
Fast heartbeat
Extreme hunger
Diarrhea or gas

Exercising more than usual can sometimes cause low blood sugar. Keep candy, juice or glucose tablets on hand to treat low blood sugar. Call your doctor if your symptoms become severe or bothersome.

Signs of high blood sugar:
Increased hunger
Increased thirst
Increased urination

Eating more than you usually do, forgetting to take your diabetes medicine, or taking another medicine that you don't usually take can all cause high blood sugar. Call your doctor if any of the above symptoms become severe.

Herbs and Vitamins for Diabetes

Herbs and Vitamins for Diabetes

Diabetes is characterized by higher than normal blood sugar or blood glucose levels in the body. While a certain amount of glucose is necessary for proper cell nutrition, abnormally high glucose levels can be harmful to your health and can lead to serious complications.

Glucose needed for proper cell metabolism is found in the food we eat and is also produced by the liver and muscles. However, without the aid of insulin produced by the pancreas, glucose is not able to enter the cells. Consequently, if insulin levels are too low or the insulin doesn't work properly, glucose is not able to enter the cells, remains in the blood, and increases blood levels of glucose that lead to diabetes.

There are three primary types of diabetes.

Type 1 diabetes, formerly known as juvenile diabetes or insulin-dependent diabetes, is commonly diagnosed in adolescents, teenagers, or young adults. In type 1 diabetes, the pancreas is unable to make insulin because the body's immune system has attacked and destroyed the pancreas cell responsible for insulin production. Traditional treatments for type 1 diabetes includes taking insulin shots or using an insulin pump, making dietary changes, exercise, taking aspirin daily, and strictly controlling blood pressure and cholesterol.

Type 2 diabetes, formerly known as adult-onset diabetes or non-insulin-dependent diabetes, is by far the most common form of diabetes in the world. People can develop type 2 diabetes at any time during their life even during early childhood. In type 2 diabetes, the pancreas is unable to produce enough insulin and the fat, muscle, or liver cells do not use it properly. Obesity can drastically increase the probability of developing type 2 diabetes. Traditional treatments for type 2 diabetes include using doctor prescribed diabetes medications, dietary changes, regular exercise, taking aspirin daily, and controlling blood pressure and cholesterol.

Gestational Diabetes

While not as common as type 1 or type 2, gestational diabetes can develop during the late stages of pregnancy. Although this form of diabetes usually goes away after the baby is born, a woman who has had gestational diabetes is more likely to develop type 2 diabetes later in life. Gestational diabetes is caused by the increased hormone levels during pregnancy or from a shortage of insulin in the body during pregnancy.

People with diabetes have a high risk of contracting a number of ancillary health conditions including heart disease and atherosclerosis. In addition, those with diabetes have a higher mortality rate if they also have high homocysteine levels.

Vitamin supplements that may help diabetics


Alpha lipoic acid (improve insulin sensitivity and symptoms of diabetic neuropathy)


Brewer's yeast (providing approximately 60 mcg of chromium per tablespoon)


Chromium (improve glucose tolerance in type 1 and 2 diabetes


Evening primrose oil (improve nerve function and relieve pain of diabetic neuropathy)


Fiber (may control blood sugar levels as well as oral diabetes drugs)


Glucomannan (absorption of dietary sugar)


Magnesium (for magnesium deficiency)


Other vitamin supplements with possible effects.


Multivitamin and Mineral Supplements (reduce the risk of infection if used regularly)


Vitamin E (may improve glucose tolerance)


Vitamin B6 (improve symptoms of diabetic neuropathy)


Vitamin B12 (reduces nerve damage caused by diabetes)


Vitamin B1 (may help reduce blood sugar levels)


Biotin (needed to process glucose)


Coenzyme Q10 (protect against effects of diabetes-induced depletion)


L-carnitine (reduces cholesterol and triglycerides)


Niacinamide (useful in the very early stages of type 1 diabetes)


Zinc (lower blood sugar in type 1 diabetes)


Vitamin D (needed to maintain adequate blood levels of insulin)


Inositol (needed for normal nerve function)


Taurine (restore blood taurine to normal levels in type 1 diabetes)


Fish oil (improves glucose tolerance, high triglycerides, and cholesterol levels)


Manganese (for manganese deficiency)


Herbal supplements that may help diabetics


Cayenne (topical application can relieve symptoms of diabetic neuropathy)


Psyllium (improve control of blood glucose and cholesterol)


Fenugreek


Other herbs with possible effects.


Asian/Korean ginseng (improve blood sugar control and energy type 2 diabetes)


Gymnema (stimulate production of insulin in people with type 2 diabetes)


Aloe vera (reduce the amount of drug glibenclamide required to manage blood sugar)


Bitter melon (improve blood-sugar control in people with type 2 diabetes)


Bilberry (lower risk of some diabetic complications - cataracts and retinopathy)

Gastroparesis and Diabetes

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 nerves and damages the blood vessels that carry oxygen and nutrients to the nerves.

Signs and Symptoms

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

heartburn
nausea
vomiting of undigested food
an early feeling of fullness when eating
weight loss
abdominal bloating
erratic blood glucose (sugar) levels
lack of appetite
gastroesophageal reflux
spasms of the stomach wall
These symptoms may be mild or severe, depending on the person.

Complications of Gastroparesis



Gastroparesis can make diabetes worse by making it more difficult to manage blood glucose. When food that has been delayed in the stomach finally enters the small intestine and is absorbed, blood glucose levels rise.

If food stays too long in the stomach, it can cause problems like bacterial overgrowth because the food has fermented. Also, the food can harden into solid masses called bezoars that may cause nausea, vomiting, and obstruction in the stomach. Bezoars can be dangerous if they block the passage of food into the small intestine.


Diagnosis



The diagnosis of gastroparesis is confirmed through one or more of the following tests.

Barium X-ray

After fasting for 12 hours, you will drink a thick liquid containing barium, which covers the inside of the stomach, making it show up on the X-ray. Normally, the stomach will be empty of all food after 12 hours of fasting. If the X-ray shows food in the stomach, gastroparesis is likely. If the X-ray shows an empty stomach, but the doctor still suspects that you have delayed emptying, you may need to repeat the test another day. On any one day, a person with gastroparesis may digest a meal normally, giving a falsely normal test result. If you have diabetes, your doctor may have special instructions about fasting.

Barium Beefsteak Meal

You will eat a meal that contains barium, which allows the doctor to watch your stomach as it digests the meal. The amount of time it takes for the barium meal to be digested and leave the stomach gives the doctor an idea of how well the stomach is working. This test can help find emptying problems that do not show up on the liquid barium X-ray. In fact, people who have diabetes-related gastroparesis often digest fluid normally, so the barium beefsteak meal can be more useful.

Radioisotope Gastric-Emptying Scan

You will eat food that contains a radioisotope, a slightly radioactive substance that will show up on the scan. The dose of radiation from the radioisotope is small and not dangerous. After eating, you will lie under a machine that detects the radioisotope and shows an image of the food in the stomach and how quickly it leaves the stomach. Gastroparesis is diagnosed if more than half of the food remains in the stomach after two hours.

Gastric Manometry

This test measures electrical and muscular activity in the stomach. The doctor passes a thin tube down the throat into the stomach. The tube contains a wire that takes measurements of the stomach's electrical and muscular activity as it digests liquids and solid food. The measurements show how the stomach is working and whether there is any delay in digestion.

Blood tests

The doctor may also order laboratory tests to check blood counts and to measure chemical and electrolyte levels.

To rule out causes of gastroparesis other than diabetes, the doctor may do an upper endoscopy or an ultrasound.

Upper Endoscopy

After giving you a sedative, the doctor passes a long, thin tube called an endoscope through the mouth and gently guides it down the esophagus into the stomach. Through the endoscope, the doctor can look at the lining of the stomach to check for any abnormalities.

Ultrasound

To rule out gallbladder disease or pancreatitis as a source of the problem, you may have an ultrasound test, which uses harmless sound waves to outline and define the shape of the gallbladder and pancreas.

Treatment



The most important treatment goal for diabetes-related gastroparesis is to manage your blood glucose levels as well as possible. Treatments include insulin, oral medications, changes in what and when you eat, and, in severe cases, feeding tubes and intravenous feeding.

Insulin for blood glucose control

If you have gastroparesis, your food is being absorbed more slowly and at unpredictable times. To better manage blood glucose, you may need to

take insulin more often
take your insulin after you eat instead of before
check your blood glucose levels frequently after you eat and administer insulin whenever necessary
Your doctor will give you specific instructions based on your particular needs.

Medication

Several drugs are used to treat gastroparesis. Your doctor may try different drugs or combinations of drugs to find the most effective treatment.

Meal and Food Changes

Changing your eating habits can help control gastroparesis. Your doctor or dietitian will give you specific instructions, but you may be asked to eat six small meals a day instead of three large ones. If less food enters the stomach each time you eat, it may not become overly full. Or the doctor or dietitian may suggest that you try several liquid meals a day until your blood glucose levels are stable and the gastroparesis has improved. Liquid meals provide all the nutrients found in solid foods, but can pass through the stomach more easily and quickly.

The doctor may also recommend that you avoid high-fat and high-fiber foods. Fat naturally slows digestion -- a problem you do not need if you have gastroparesis -- and fiber is difficult to digest. Some high-fiber foods like oranges and broccoli contain material that cannot be digested. Avoid these foods because the indigestible part will remain in the stomach too long and possibly form bezoars.

Feeding Tube

If other approaches do not work, you may need surgery to insert a feeding tube. The tube, called a jejunostomy tube, is inserted through the skin on your abdomen into the small intestine. The feeding tube allows you to put nutrients directly into the small intestine, bypassing the stomach altogether. You will receive special liquid food to use with the tube. A jejunostomy is particularly useful when gastroparesis prevents the nutrients and medication necessary to regulate blood glucose levels from reaching the bloodstream. By avoiding the source of the problem (the stomach) and putting nutrients and medication directly into the small intestine, you ensure that these products are digested and delivered to your bloodstream quickly. A jejunostomy tube can be temporary and is used only if necessary when gastroparesis is severe.

It is important to note that in most cases treatment does not cure gastroparesis -- it is usually a chronic condition. Treatment helps you manage gastroparesis, so that you can be as healthy and comfortable as possible.

Diabetes and Men's Sexual Health

Sex is an important part of life and relationships. But diabetes can affect a man’s sex life. Some men with diabetes have impotence, also called erectile dysfunction or ED. ED is when a man can no longer have or keep an erection. Over time, blood vessels and nerves in the penis can become damaged. This can lead to ED. If you have ED, there is hope. There are ways to treat ED. ED is not a normal part of getting older, and it doesn’t happen to all men who have diabetes. ED can also be caused by other conditions, such as prostate or bladder surgery. Talk with your health care team about new therapies.

If you have ED or some other sexual problem, it’s normal to feel embarrassed or upset. You may blame yourself or your partner. Some men feel guilty and angry. Others feel like there’s no hope. These feelings can make it hard to talk openly with your partner or your doctor. But talking about ED means you’re a step closer to getting help.


In Search of Answers

Today, there are many ways to treat ED and more are on the way. If one thing doesn’t work, something else might.

Here are some options:

Taking pills to treat ED


Putting medicine called prostaglandins (prahs-ta-GLAND-ins) into your penis


Using a vacuum tube and pump that you put over your penis. The pump creates a vacuum in the tube. The vacuum draws blood into the penis. A band is placed around the base of the penis so you keep the erection after you take off the vacuum tube


Having surgery to put a device in the penis. Surgery can also fix blood vessels so more blood will flow to the penis


Certain medicines, such as some pills for high blood pressure or depression, may cause ED. Pills for stomach ulcers or heartburn also may cause it. Ask your doctor if ED is a side effect of any of your medicines. There may be other pills you can take. Remember, talk with your doctor or diabetes educator before trying any treatment for ED or before stopping any of your medicines.

It’s not easy to accept that you have ED. And it can be even harder to talk about it, especially with your partner. Even if your doctor doesn’t ask about ED, talk about it if you’re having problems. Talking about ED is the only way to learn about treatments and get help.


Family Ties

Diabetes doesn’t affect your ability to become a father. But you and your partner might have questions about starting a family. Talk with your health care team if you have questions or concerns.

Here are some tips:

Not every man with diabetes gets ED
ED is not the end of your sex life
You can get help. There are several treatment options
Talk with your partner and your doctor or diabetes educator to get help


Depression and Anxiety

Diabetes raises your risk for depression. Depression is a medical condition that’s more serious than just feeling a little sad. Depression can lead to ED, and ED can cause men to feel depressed. People with diabetes sometimes feel they have a lot to worry about. They worry about their health, their future, and all the other stresses in their life. For some men, having sexual problems once in a while makes them worry about developing ED all the time. Lots of worry, also called an anxiety disorder, can lead to ED. Talk with your health care team if you have these feelings. Medicine or counseling can help with both depression and anxiety disorder

Your Body's Well Being

Make it a priority to take good care of your body. The time you spend now on eye care, foot care and skin care, as well as your heart health and oral health, could delay or prevent the onset of dangerous diabetes complications later in life. In addition, one of the best things you can do for your body is to stop smoking.

Heart Disease and Stroke
People with diabetes have extra reason to be mindful of heart and blood vessel disease. Diabetes carries an increased risk for heart attack, stroke, and complications related to poor circulation.

Skin Care
As many as one-third of people with diabetes will have a skin disorder caused or affected by diabetes at some time in their lives. In fact, such problems are sometimes the first sign that a person has diabetes. Luckily, most skin conditions can be prevented or easily treated if caught early.

Foot Care
People with diabetes can develop many different foot problems. Foot problems most often happen when there is nerve damage in the feet or when blood flow is poor. Learn how to protect your feet by following some basic guidelines.

Eye Care
Diabetes can cause eye problems and may lead to blindness. People with diabetes do have a higher risk of blindness than people without diabetes. Early detection and treatment of eye problems can save your sight.

Oral Health & Hygiene
If you have diabetes, you are at a higher risk for gum disease and other mouth-related problems. Learn more about maintaining good dental health.

Smoking
Kicking the smoking habit is hard, but worth the work. Tobacco has many bad health effects, particularly for people with diabetes. No matter how long you've smoked, your health will improve when you quit.

Alcohol
Alcohol is everywhere: at family gatherings, at cookouts, after the company softball game, and at parties. One very common question is "What would you like to drink?" If you have diabetes, what do you say?

Stress
Stress results when something causes your body to behave as if it were under attack. Sources of stress can be physical, like injury or illness. Or they can be mental, like problems in your marriage, job, health, or finances.

Insulin Routines

Insulin Therapy

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 with two injections of insulin per day of two different types of insulin and generally progress to three or four injections per day of insulin of different types. The types of insulin used depend on their blood glucose levels. Studies have shown that three or four injections of insulin a day give the best blood glucose control and can prevent or delay the eye, kidney, and nerve damage caused by diabetes.

Most people with type 2 diabetes may 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 with 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 come 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 your insulin


when you take your insulin injections


illness


stress



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.

Don't inject the insulin in exactly the same place each time, but move around the same area. Each mealtime injection of insulin should be given in the same general area for best results. For example, giving your before-breakfast insulin injection in the abdomen and your before-supper insulin injection in the leg each day give more similar blood glucose results. If you inject insulin near the same place each time, hard lumps or extra fatty deposits may develop. Both of these problems are unsightly and make the insulin action less reliable. Ask your health care provider if you aren't sure where to inject your insulin.




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 up? There are two common reasons for high before-breakfast 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 results with your health care provider.

The Basics of 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 after injection, 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 to 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.


Characteristics of Insulin



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

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



All insulins come dissolved or suspended in liquids. However, the solutions have different strengths. The most commonly used strength in the United States today is U-100. That means it has 100 units of insulin per milliliter of fluid. U40, which has 40 units of insulin per milliliter of fluid, is not used in the U.S., but is still used in Europe and in Latin America. If you're traveling outside of the U.S., be certain to match your insulin strength with the correct size syringe.

Insulin Additives



All insulins have added ingredients. These prevent bacteria from growing and help maintain a neutral balance between acids and bases. In addition, intermediate and long-acting insulins also contain ingredients that prolong their actions. In some rare cases, the additives can bring on an allergic reaction.

Animal Insulins



For many years, the insulin used by people with diabetes was produced from the pancreases of pigs and cows. Synthetic human insulin derived from genetically engineered bacteria first became available in the 1980s, and now all insulin available in the United States is manufactured in a laboratory. Although the development of synthetic human insulin was a boon for most people, especially those who were allergic to the animal insulins, a few people find that they can manage their diabetes better using animal insulins.

About Insulin and other drugs

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 the protein in food. Insulin must be injected into the fat under your skin for it to get into your blood.

There are many different insulins for many different situations and lifestyles and there are more than 20 types of insulin sold in the United States. These insulins differ in how they are made, how they work in the body, and price. Insulin is made in labs to be identical to human insulin or it comes from animals (pigs). Future availability of animal insulin is uncertain.

HBA1C Test for Diabetes

Because you have diabetes, you and your doctor, diabetes educator, and other members of your health care team work to keep your blood glucose (sugar) at ideal levels. There are two powerful reasons to work for effective blood sugar control:

You will feel better.You may prevent or delay the start of diabetes complications such as nerve, eye, kidney, and blood vessel damage.
One way to keep track of your blood sugar changes is by checking your blood sugar at home. These tests tell you what your blood sugar level is at any one time.

But suppose you want to know how you've done overall. There's a test that can help. An A1C (also known as glycated hemoglobin or HbA1c) test gives you a picture of your average blood glucose control for the past 2 to 3 months. The results give you a good idea of how well your diabetes treatment plan is working.

In some ways, the A1C test is like a baseball player's season batting average. Both A1C and the batting average tell you about a person's overall success. Neither a single day's blood test results nor a single game's batting record gives the same big picture.

How HbA1C Works
You know from the name that the test measures something called A1C. You may wonder what it has to do with your blood sugar control. Hemoglobin is found inside red blood cells. Its job is to carry oxygen from the lungs to all the cells of the body. Hemoglobin, like all proteins, links up with sugars such as glucose.

You know that when you have uncontrolled diabetes you have too much sugar in your bloodstream. This extra glucose enters your red blood cells and links up (or glycates) with molecules of hemoglobin. The more excess glucose in your blood, the more hemoglobin gets glycated. It is possible to measure the percentage of A1C in the blood. The result is an overview of your average blood glucose control for the past few months.

Thanks for the Memories
How does the A1C test look backward? Suppose your blood sugar was high last week. What happened? More glucose hooked up (glycated) with your hemoglobin. This week, your blood glucose is back under control. Still, your red blood cells carry the 'memory' of last week's high blood glucose in the form of more A1C.

This record changes as old red blood cells in your body die and new red blood cells (with fresh hemoglobin) replace them. The amount of A1C in your blood reflects blood sugar control for the past 120 days, or the lifespan of a red blood cell.

In a person who does not have diabetes, about 5% of all hemoglobin is glycated. For someone with diabetes and high blood glucose levels, the A1C level is higher than normal. How high the A1C level rises depends on what the average blood glucose level was during the past weeks and months. Levels can range from normal to as high as 25% if diabetes is badly out of control for a long time.

You should have had your A1C level measured when your diabetes was diagnosed or when treatment for diabetes was started. To watch your overall glucose control, your doctor should measure your A1C level at least twice a year. This is the minimum. There are times when you need to have your A1C level tested about every 3 months. If you change diabetes treatment, such as start a new medicine, or if you are not meeting your blood glucose goals, you and your doctor will want to keep a closer eye on your control.

How Does It Help Diabetes Control?
How can your A1C test results help your control?
Here are two examples.

Bob D., 49 years old, has type 2 diabetes. For the past seven years, he and his doctor have worked to control his blood sugar levels with diet and diabetes pills. Recently, Bob's control has been getting worse. His doctor said that Bob might have to start insulin shots. But first, they agreed that Bob would try an exercise program to improve control.

That was three months ago. Bob stuck to his exercise plan. Last week, when the doctor checked Bob's blood sugar, it was near the normal range. But the doctor knew a single blood test only showed Bob's control at that time. It didn't say much about Bob's overall blood sugar control.

The doctor sent a sample of Bob's blood to the lab for an A1C test. The test results would tell how well Bob's blood sugar had been controlled, on average, for the past few months. The A1C test showed that Bob's control had improved. With the A1C results, Bob and the doctor had proof that the exercise program was working. The test results also helped Bob know that he could make a difference in his blood sugar control.

The A1C test can also help someone with type 1 diabetes. Nine-year-old Lisa J. and her parents were proud that she could do her own insulin shots and urine tests. Her doctor advised her to begin a routine of two shots a day and to check her blood sugar as well.

Lisa kept records of all her test results. Most were close to the ideal range. But at her next checkup, the doctor checked her blood and found her blood sugar level was high. The doctor sent a sample of Lisa's blood for an A1C test. The results showed that Lisa's blood glucose control had in fact been poor for the last few months.

Lisa's doctor asked Lisa to do a blood sugar check. To the doctor's surprise, Lisa turned on the timer of her meter before pricking her finger and putting the blood drop on the test strip. The doctor explained to Lisa and her parents that the way Lisa was testing was probably causing the blood sugar test errors.

With time and more accurate blood sugar results, Lisa and her parents got better at using her results to keep food, insulin, and exercise in balance. At later checkups, her blood sugar records and the A1C test results showed good news about her control.


A1C tests can help:

Confirm self-testing results or blood test results by the doctor

Judge whether a treatment plan is working Show you how healthy choices can make a difference in diabetes control.
Test Limit


Although the A1C test is an important tool, it can't replace daily self-testing of blood glucose. A1C tests don't measure your day-to-day control. You can't adjust your insulin on the basis of your A1C tests. That's why your blood sugar checks and your log results are so important to staying in effective control.

It is important to know that different labs measure A1C levels in different ways. If you sent one sample of your blood to four different labs, you might get back four different test results.

For example, an 8 at one lab might mean that blood glucose levels have been in the near-normal range. At a second lab, a 9 might be a sign that, on average, blood glucose was high. This doesn't mean that any of the results are wrong. It does mean that what your results say depends on the way the lab does the test.

Talk to your doctor about your A1C test results. Know that if you change doctors or your doctor changes labs, your test numbers may need to be "read" differently.

The A1C test alone is not enough to measure good blood sugar control. But it is good resource to use along with your daily blood sugar checks, to work for the best possible control.

Tight Diabetes Control

Keeping your blood glucose levels as close to normal as possible can be a lifesaver. Tight control can prevent or slow the progress of many complications of diabetes, giving you extra years of healthy, active life.

But tight control is not for everyone and it involves hard work.

By the Numbers


Good control means getting as close to a normal (nondiabetic) blood glucose level as you safely can. Ideally, this means levels between 90 and 130 mg/dl before meals, and less than 180 two hours after starting a meal, with a glycated hemoglobin level less than 7 percent. The target number for glycated hemoglobin will vary depending on the type of test your doctor's laboratory uses.

In real life, you should set your goals with your doctor. Keeping a normal level all the time is not practical. And it's not needed to get results. Every bit you lower your blood glucose level helps to prevent complications.

What Tight Control Does


No one knows why high glucose levels cause complications in people with diabetes. But keeping glucose levels as low as possible prevents or slows some complications.

The Diabetes Control and Complications Trial (DCCT) proved it. Researchers followed 1,441 people with diabetes for several years. Half of the people continued standard diabetes treatment. The other half followed an intensive-control program. Those on intensive control kept their blood glucose levels lower than those on standard treatment, although the average level was still above normal. The results? In the tight-control group, compared with the standard-treatment group,

Diabetic eye disease started in only one-quarter as many people.


Kidney disease started in only half as many people.


Nerve disease started in only one-third as many people.


Far fewer people who already had early forms of these three complications got worse.

Living With Tight Control


To get tight control, you must pay more attention to your diet and exercise. You must measure your blood glucose levels more often. And, if you take insulin, you must change how much you use and your injection schedule.

In intensive therapy, you provide yourself with a low level of insulin at all times and take extra insulin when you eat. This pattern mimics the release of insulin from the normal pancreas.

There are two ways to get more natural levels of insulin: multiple daily injection therapy and an insulin pump. Both are good methods. Your choice should depend on which best fits your lifestyle.

In multiple daily injection therapy, you take three or more insulin shots per day. Usually, you take a shot of short-acting or Regular insulin before each meal and a shot of intermediate- or long-acting insulin at bedtime.

With an insulin pump, you wear a tiny pump that releases insulin into your body through a plastic tube. Usually, it gives you a constant small dose of Regular insulin. You also have the pump release extra insulin when you need it, such as before a meal.

With either method, you must test your blood glucose levels several times a day. You need to test before each shot or extra dose of insulin to know how many units to take and how long before eating to take it. Also, you may want to test 2-3 hours after eating to make sure you took enough insulin. You must adjust your insulin dose for how much you plan to eat and how active you expect to be.

You do not need to figure these things out on your own. Whatever method you choose, your health care team (your doctor, dietitian, diabetes educator, and other health care professionals) should spend a lot of time teaching you about it. Your team will help you make guidelines for how much insulin to take and when. You will also come up with guidelines for eating and exercising. These guidelines may change several times as you test them out.

You shouldn't try tight control on your own. A good health care team is a must. Choose a doctor who understands diabetes well or is willing to learn for your sake. Your doctor should have ties with other health professionals you need, such as dietitians and a mental health worker. If you live in a small town, look at your options carefully. You may be better off driving to a city to see a specialist.

How to Keep Going and Going


Starting a program of tight control is exciting. But it can also be overwhelming. How do you keep from running out of energy?

One way is to start slowly. For example, you might start by checking your blood glucose more times each day. Get used to that first. Then start multiple daily injections. Once you're used to those, add your new exercise program and make the changes in your diet.

If you are newly diagnosed with diabetes, look honestly at yourself. Are you still angry and depressed that you have diabetes? If so, you already have a big challenge facing you. You may want to wait to try tight control until after you've come to terms with the changes in your life.

Keep your goals realistic. No matter how hard you try, your blood glucose readings will not be perfect every time. If they are often too high or too low, you should talk to your doctor about whether your plan needs to be adjusted. But if "wrong" levels happen only sometimes, that's life. With practice, you will become more skilled at choosing the right insulin doses for various situations.

If you need to, take a breather from the new routine. Having some time off may make it easier to stick to your plan when you start again.

Pluses and Minuses


One big reason to try tight control is to prevent complications later. But tight control has effects you can enjoy right now. You will probably feel better and have more energy. Also, because you adjust your insulin dose to your life, and not the other way around, you have more freedom. You can vary your activities more. And you're not locked into having your meals at the same time each day.

Tight control is especially good for pregnant women. It can reduce the risk of birth defects in the baby.

But the DCCT found two major problems with tight control.

First, people had three times as many low blood glucose reactions (hypoglycemia). You will need to be alert to the symptoms of hypoglycemia so that you can treat yourself quickly. Also, you should always check your blood glucose levels before you drive.

If you often have low blood glucose reactions when you try tight control, talk to your doctor. You may need to ease up on your goals or go back on standard therapy for a while.

Second, people on tight control gained more weight than people on standard insulin treatment. The average in the DCCT was 10 pounds. If you are concerned about putting on pounds, work with your dietitian and doctor to devise a meal and exercise plan to prevent it.

You should also consider the cost. You will need to see your health care team more often. Pumps cost about $5000, and pump supplies run $60 to $80 a month. Multiple injection therapy is much cheaper. But you will still use more supplies, like test strips and syringes, than before.

Tight Control and Type 2 Diabetes


The DCCT studied only people with type 1 diabetes. But doctors believe that tight control can also prevent complications in people with type 2 diabetes.

Most people with type 2 diabetes do not take insulin. You may be wondering how you can achieve tight control without it.

One way is to lose weight. Shedding excess pounds may bring your glucose levels down to normal. The key to losing weight and keeping it off is changing your behavior so that you eat less and exercise more. Your doctor should work with you to find an eating and exercise plan you can stick to.

Even if you don't need to lose weight, exercise is helpful in controlling your blood glucose levels. It makes your cells take glucose out of the blood.

You will need to check your blood glucose regularly. You should decide with your doctor how often. Once a day or even once a week may be enough for some people with type 2 diabetes.

If exercise and good eating habits are not enough to keep your glucose under control, you doctor may prescribe pills. And if these don't work, you may need to take insulin.

People with type 2 diabetes should talk to their doctors before starting tight control.

Tight Control Is Not for Everyone


Tight control is not safe for everyone with diabetes.

Children should not be put on a program of tight control. Having enough glucose in the blood is vital to brain development. Some doctors say that tight control should wait until a child reaches 13; others say after the age of 7 is okay.

Elderly people probably should not go on tight control. Hypoglycemia can cause strokes and heart attacks in older people. Also, the major goal of tight control is to prevent complications many years later. Tight control is most worthwhile for healthy people who can expect to live at least 10 more years.

Some people who already have complications should not be on tight control. For example, people with end-stage kidney disease or severe vision loss probably should not try it. Their complications are probably too far along to be helped. Some people who have coronary artery disease or vascular disease should not try tight control. People who have hypoglycemia unawareness probably should not go on tight control

Checking Your Blood Glucose

People with diabetes work to keep their blood sugar (glucose) as near 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 aims to balance the foods you eat with your exercise and, possibly, diabetes pills or insulin. You can do two types of checks to help keep track of how your plan is working. These are blood glucose checks and urine ketone checks.

Blood Glucose Monitoring 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 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.

Here is a table that lists blood glucose ranges for adults with diabetes:


Glycemic control

A1C
<7.0%

Preprandial plasma glucose (before a meal)
90–130 mg/dl (5.0–7.2 mmol/l)

Postprandial plasma glucose (after a meal)
<180 mg/dl (<10.0 mmol/l)

Blood pressure
<130/80 mmHg

Lipids


LDL
<100 mg/dl (<2.6 mmol/l)

Triglycerides
<150 mg/dl (<1.7 mmol/l)

HDL
>40 mg/dl (>1.1 mmol/l)


Who Should Check?

Experts feel that anyone with diabetes can benefit from checking their blood glucose. The American Diabetes Association recommends blood glucose checks if you have diabetes and are:

taking insulin or diabetes pills on intensive insulin therapy pregnant having a hard time controlling your blood glucose levels having severe low blood glucose levels or ketones from high blood glucose levels having low blood glucose levels without the usual warning signs


Urine Checks

Urine checks for glucose are not as accurate as blood glucose checks. Urine testing for glucose should not be done unless blood testing is impossible.

A urine check for ketones is another matter. This check is important when your diabetes is out of control or when you are sick. You can find moderate or large amounts of ketones in urine when your body is burning fat instead of glucose for fuel. This happens when there is too little insulin at work. Everyone with diabetes needs to know how to check their urine for ketones.

How Blood 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 site you chose with soap and water. 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.

Checking With a Blood Glucose Meter



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.

How to Pick a Meter

There are many meters to choose from. Some meters are made for those with poor eyesight. Others come with memory so you can store your results in the meter itself. The American Diabetes Association does not endorse any products or recommend one meter over another. If you plan to buy a meter, here are some questions to think about:

What meter does your doctor or diabetes educator 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 ask how to get 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)?

Are meters accurate?

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 need to do each step correctly. Here are other things that can cause your meter to give a poor reading:

a dirty meter

a meter or strip that's not at room temperature

an outdated test strip

a meter not calibrated (set up for) the current box of test strips

a blood drop that is too small
Ask your health care team to check your skills at least once a year. Error can creep in over time.

Logging Your Results

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 or diabetes educator to learn what your results mean for you. This takes time. Ask your doctor or nurse if you should report results out of a certain range at once by phone.

Keep in mind that blood glucose results often trigger strong feelings. Blood glucose numbers can leave you upset, confused, frustrated, 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. It is not a judgment of you as a person. The results may show you need a change in your diabetes plan.

Checking for Ketones

You may need to check your urine for ketones once in a while. 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. 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 with your doctor or nurse.

Here's how most urine tests 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 glucoser is high. These are signs that your diabetes is out of control. Talk to your doctor at once if your urine results show moderate or large amounts of ketones.

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


When to Test

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

your blood glucose is more than 300 mg/dl

you feel nauseated, are vomiting, or have abdominal pain

you are sick (for example, with a cold or flu)

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 your breath smells "fruity"

you feel confused or "in a fog"

These can be signs of high ketone levels that need your doctor's help.

Managing Your Blood Glucose

Keeping your blood sugar (glucose) as close to normal as possible helps you feel better and reduces the risk of long-term complications of diabetes.

Checking Your Blood Glucose
People with diabetes work to keep their blood glucose as near 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.

Tight Diabetes Control
Keeping your blood glucose levels as close to normal as possible can be a lifesaver. Tight control means getting as close to a normal (nondiabetic) blood glucose level as you safely can.

A1C Test
An A1C test gives you a picture of your average blood glucose control for the past 2 to 3 months. The results give you a good idea of how well your diabetes treatment plan is working.

Ketoacidosis

Ketoacidosis (key-toe-ass-i-DOE-sis) is a serious condition that can lead to diabetic coma (passing out for a long 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 (hi-per-oz-MOE-lar non- key-TOT-ick KO-ma).

Ketocidosis means dangerously high levels of ketones. Ketones are acids that build up in the blood. They appear in the urine when your body doesn't 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. But you can help prevent ketoacidosis by learning the warning signs and checking your urine and blood regularly.

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 health care provider.)
A hard time breathing (short, deep breaths)
Fruity odor on breath
A hard time paying attention, or confusion


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Ketoacidosis is dangerous and serious. If you have any of the above symptoms, contact your health care provider IMMEDIATELY, or go to the nearest emergency room of your local hospital.
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How do you know if you have large amounts of ketones?



A simple urine test can detect ketones. You use a test strip, like a blood testing strip. Ask your health care provider when and how you should test for ketones. Many experts advise to check your urine for ketones when your blood glucose is more than 240 mg/dl.

When you are ill (when you have a cold or the flu, for example), check for ketones every 4 to 6 hours. And check every 4 to 6 hours when your blood glucose is more than 240 mg/dl.

Also, check for ketones when you have any symptoms of ketoacidosis.

What if you find higher-than-normal levels of ketones?



If your health care provider has not told you what levels of ketones are dangerous, then call when you find moderate amounts after more than one test. Often, your health care provider can tell you what to do over the phone.

Call your health care provider at once if:

Your urine tests show large ketones
Your urine tests show large ketones and your blood glucose level is high
You have vomited more than twice in four hours and your urine tests show high ketones
Do NOT exercise when your urine tests show ketones and your blood glucose is high. High levels of ketones and high blood glucose levles can mean your diabetes is out of control. Check with your health care provider about how to handle this situation.

What causes ketoacidosis?



Ketones mean your body is burning fat to get energy. Moderate or large amounts of ketones in your urine are dangerous. They upset the chemical balance of the blood.

Commonly, the flu, a cold, or other infections may sometimes bring on ketoacidosis.

Here are three basic reasons for moderate or large amounts of ketones:

Not getting enough insulin. Maybe you did not inject enough insulin. Or your body could need more insulin than usual because of illness. If there is not enough insulin, your body begins to break down body fat for energy.


Not enough food. When people are sick, they often do not feel like eating. Then, high ketones may result. High ketones may also occur when someone misses a meal.


An insulin reaction (low blood glucose). When blood glucose levels fall too low, the body must use fat to get energy. If testing shows high ketones in the morning, the person may have had an insulin reaction while asleep

Hyperglycemia

You have diabetes, which means you have to 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. For this reason, it's important to know what hyperglycemia is, what its symptoms are, and how to treat it.

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

A number of things can cause hyperglycemia. For example, if you have type 1 diabetes, you 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, and increased thirst.

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 through the urine. Unfortunately, the body cannot release all the ketones and they build up in your blood. This can lead to ketoacidosis.

Ketoacidosis is life-threatening and needs immediate treatment. Symptoms include:

shortness of breath


breath that smells fruity


nausea and vomiting


a very dry mouth

Talk to your doctor about how to handle this condition
How do you treat hyperglycemia?



Often, you can lower your blood glucose level by exercising. However, if your blood glucose is above 240 mg/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 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 may change the amount of your medication or insulin or possibly the timing of when you take it.

How do you prevent hyperglycemia?



Your best bet is to practice good diabetes management. The trick is learning to detect and treat hyperglycemia early -- before it can get worse

Hyperglycemia

You have diabetes, which means you have to 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. For this reason, it's important to know what hyperglycemia is, what its symptoms are, and how to treat it.

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

A number of things can cause hyperglycemia. For example, if you have type 1 diabetes, you 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, and increased thirst.

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 through the urine. Unfortunately, the body cannot release all the ketones and they build up in your blood. This can lead to ketoacidosis.

Ketoacidosis is life-threatening and needs immediate treatment. Symptoms include:

shortness of breath


breath that smells fruity


nausea and vomiting


a very dry mouth

Talk to your doctor about how to handle this condition
How do you treat hyperglycemia?



Often, you can lower your blood glucose level by exercising. However, if your blood glucose is above 240 mg/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 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 may change the amount of your medication or insulin or possibly the timing of when you take it.

How do you prevent hyperglycemia?



Your best bet is to practice good diabetes management. The trick is learning to detect and treat hyperglycemia early -- before it can get worse

Hypoglycemia

Part of living with diabetes is learning to cope with some of the problems that go along with having the disease. Hypoglycemia or low blood glucose (sugar) is one of those problems. Hypoglycemia happens from time to time to everyone who has diabetes.

Hypoglycemia, sometimes called an insulin reaction, can happen even during those times when you're doing all you can to manage your diabetes. So, although many times you can't prevent it from happening, hypoglycemia (low blood glucose) can be treated before it gets worse. For this reason, it's important to know what hypoglycemia is, what 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
How do you know when your blood glucose is low?


Part of managing diabetes is checking blood glucose often. Ask your doctor how often you should check and what your blood glucose levels should be. The results from checking your blood will tell you when your blood glucose is low and that you need to treat it.

You should check your blood glucose level according to the schedule you work out with your doctor. More importantly though, you should check your blood whenever you feel low blood glucose coming on. After you check and see that your blood glucose level is low, you should treat hypoglycemia quickly.

If you feel a reaction coming on but cannot check, it's best to treat the reaction rather than wait. Remember this simple rule: When in doubt, treat.

How do you treat hypoglycemia?



The quickest way to raise your blood glucose and treat hypoglycemia is with some form of sugar, such as 3 glucose tablets (you can buy these at the drug store), 1/2 cup of fruit juice, or 5-6 pieces of hard candy.

Ask your health care professional or dietitian to list foods that you can use to treat low blood glucose. And then, be sure you always have at least one type of sugar with you.

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 level up.

It's important to treat hypoglycemia quickly because hypoglycemia can get worse and you could pass out. If you pass out, 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 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 (such as 911) for help. It's a good idea to post emergency numbers by the telephone.

If you pass out from hypoglycemia, people should:

NOT inject insulin.
NOT give you food or fluids.
NOT put their hands in your mouth.
Inject glucagon.
Call for emergency help.

How do you prevent low blood glucose?



Good diabetes control is the best way we know to prevent hypoglycemia. The trick is to learn to recognize the symptoms of hypoglycemia. This way, you can treat hypoglycemia before it gets worse.

Hypoglycemia Unawareness



Some people have no symptoms of hypoglycemia. They may lose consciousness without ever knowing their blood glucose levels were dropping. This problem is called hypoglycemia unawareness.

Hypoglycemia unawareness tends to happen to people who have had diabetes for many years. Hypoglycemia unawareness does not happen to everyone. It is more likely in people who have neuropathy (nerve damage), people on tight glucose control, and people who take certain heart or high blood pressure medicines.

As the years go by, many people continue to have symptoms of hypoglycemia, but the symptoms change. In this case, someone may not recognize a reaction because it feels different.

These changes are good reason to check your blood glucose often, and to alert your friends and family to your symptoms of hypoglycemia. Treat low or dropping sugar levels even if you feel fine. And tell your team if your blood glucose ever drops below 50 mg/dl without any symptoms