By Laura Hieronymus, M.S.Ed., A.P.R.N., B.C.-A.D.M., C.D.E., and Gregory Hood, M.D.
“If one does not know to which port one is sailing, no wind is favorable.”
—Seneca the Elder
Diabetes is a chronic condition, meaning that once you are diagnosed, it’s there to stay. While this idea can be daunting and even overwhelming at times, the good news is that with regular medical care and optimal blood glucose control, you can live a long, healthy life. With the proper training in diabetes self-management, you will become the navigator of your daily care, while your physician and other health-care professionals act as both the compass that helps guide you in the right direction and the crew that helps to troubleshoot any changes in course.
Charting the course
When you choose a destination, a map can be the most useful tool to help get you there. In diabetes management, guidelines for care that are based on both research studies and practical experience act like a map for health-care professionals to help them provide the safest, most effective plan for their patients with diabetes. Every year, the American Diabetes Association (ADA) publishes a supplement to the medical journal Diabetes Care that includes updated “Standards of Medical Care in Diabetes.” While this publication is written for health-care professionals, you should also be aware of these standards so that you can work with your diabetes care team in using them to chart the course toward your optimal diabetes health.
All adults 45 years of age and over should be screened for diabetes, and if the results are normal, the screening test should be repeated every three years. However, people who have additional risk factors for diabetes may need to be tested at a younger age, more frequently, or both. These risk factors include being overweight, having a first-degree relative with diabetes (a parent, child, or sibling), having high blood pressure or abnormal blood lipid (cholesterol and triglyceride) levels, having had gestational diabetes (diabetes that occurs during pregnancy) or having delivered a baby that weighed more than nine pounds, as well as being a member of an ethnic group that has a high rate of diabetes.
A fasting plasma glucose test is the preferred method for diagnosing diabetes in most people, although a different test is preferred for women who are pregnant. It is necessary to fast for at least eight hours before having blood drawn for this test to get an accurate result. A fasting plasma glucose level of 126 mg/dl or higher, with a repeat test with similar results on a different day, confirms the diagnosis.
Other acceptable criteria for a diagnosis of diabetes include a combination of symptoms of diabetes (see “Symptoms of Diabetes”) and a casual (nonfasting) plasma glucose level of 200 mg/dl or higher. Again, it is recommended that the blood test be repeated to confirm diagnosis.
A third test, called the oral glucose tolerance test, can also be used to diagnose diabetes. In this test, a person’s fasting plasma glucose level is measured before he drinks a solution that contains a specific amount of glucose. Subsequent blood tests are then done one, two, and usually three hours after the glucose solution is consumed. A plasma glucose level of 200 mg/dl or greater at the two-hour mark indicates diabetes. The oral glucose tolerance test is not routinely used to diagnose either Type 1 or Type 2 diabetes. However, it is sometimes used in diagnosing impaired glucose tolerance, which indicates prediabetes, a strong risk factor for developing diabetes, and the oral glucose tolerance test should be used to diagnose gestational diabetes.
A complete medical evaluation is necessary to diagnose the type of diabetes a person has, to determine whether complications of diabetes are already present at diagnosis, and to decide on treatment methods and a plan for ongoing diabetes care. If you have a history of diabetes and are visiting a physician for the first time, you should have a complete physical exam as well as a discussion about your current blood glucose control, the presence of any diabetes complications, and your ongoing diabetes care needs. (For a list of features that should be checked by your health-care provider, see “Monitoring for Control and Complications.”)
The best care for diabetes management involves a team approach. Typical team members include (but aren’t necessarily limited to) physicians (whose coproviders may include nurse practitioners or physician assistants), nurses, dietitians, pharmacists, and mental health professionals, all of whom should have experience working with people with diabetes. It’s best if your team members can work together to offer you the most up-to-date diabetes management plan possible.
Blood glucose control
The primary goal of diabetes management is optimal blood glucose control, since the complications of diabetes are directly linked to high blood glucose levels. Learning how to monitor your blood glucose levels and learning what the results mean are therefore essential parts of your diabetes treatment plan. Self-monitoring of blood glucose helps you and your diabetes care team evaluate your overall blood glucose control and review the trends and patterns of your blood glucose levels during the course of the day.
General recommendations for how often you should monitor may vary with the type of diabetes you have, your treatment plan, and the extent to which your health insurance plan will reimburse you for monitoring supplies. Insulin users, especially those who take insulin multiple times a day, should monitor their blood glucose levels three times or more daily. People with Type 2 diabetes who use insulin less frequently, use other diabetes medicines, or manage their diabetes with meal-planning and physical activity alone should monitor their blood glucose levels as recommended by their diabetes care team to keep tabs on their level of blood glucose control. (To get a sense of what you’re aiming for, see “Blood Glucose Targets.”)
If you are meeting your blood glucose target levels, you should have a glycosylated hemoglobin (HbA1c) test at least twice a year. The HbA1c test is a blood test that gives a measure of your diabetes control over the preceding two to three months. If you have had a recent change in your diabetes treatment plan, or if your blood glucose levels are regularly outside of the recommended ranges, you should have an HbA1c test every three months. (To see how HbA1c test results correlate with blood glucose monitoring results, see “What Does My HbA1c Mean?”)
Tools for management
When it comes to diabetes self-management, knowledge is the best tool you can have. Knowing the steps you can take and the contingencies you should plan for will help keep you healthy and keep the sailing smooth.
Nutrition. When you have diabetes, it is important to understand the relationship between food and blood glucose control. All people with diabetes should see a registered dietitian, preferably one with expertise in diabetes. You and your dietitian should discuss and customize a meal plan for you, taking your health and your personal goals into consideration. Your dietitian can show you how to monitor the effects of the foods you eat on your blood glucose levels.
If you are interested in losing weight, a dietitian can provide suggestions that will help you do so in a safe, nutritionally sound manner while still focusing on blood glucose control to prevent the complications of diabetes. If you have high blood pressure or abnormal blood lipid levels, which are common among people with diabetes, your meal plan should address those issues as well. If you have any diabetes complications, the dietitian may also recommend some changes in your meal plan that can help slow their progression.
Keep in mind that as you age, your body and your diabetes treatment needs change, so your nutrition status and caloric needs will need to be reevaluated. Periodic follow-up visits with the dietitian are key to maintaining your diabetes health.
Diabetes education. In addition to covering your medical visits, most health plans, including Medicare, provide some coverage for diabetes self-management education and training. All people with diabetes should receive diabetes education from a diabetes educator, preferably at an American Diabetes Association–recognized education service, which must meet a set of national standards. Certified diabetes educators (C.D.E.‘s) are health-care professionals, such as doctors, nurses, dietitians, pharmacists, exercise physiologists, and social workers, who specialize in the care and treatment of people with diabetes. They can help you learn how to stay healthy with diabetes.
Diabetes education can take place in group or individual sessions. Initially, the educator should cover topics such as what diabetes is; tools for managing the condition, including meal planning, physical activity, diabetes drugs, blood glucose monitoring, and common lab tests that should be done periodically; potential complications related to diabetes; and coping skills. Special training is also available for women with diabetes who are planning to become pregnant or are currently pregnant.
Individualized training that considers your age, career, and culture as well as your medical status can be essential to your success in managing diabetes. Diabetes education should encourage you to set goals to achieve behavior change as well as address your specific needs. If you feel your individual needs have not been addressed, let your educator know what areas you need help with.
Physical activity. The benefits of physical activity for people with diabetes include improvement in blood glucose levels, weight control, and, when moderate-to-intense aerobic physical activity is done regularly, reduction of cardiovascular disease risk. Research has also shown that resistance training exercises (such as weight lifting) can be helpful in the management of Type 2 diabetes (though lifting heavy weights may not be appropriate for people with certain diabetes complications).
See your doctor for a physical exam before starting an exercise program, especially if you haven’t been active for a while. Your physician may recommend a graded exercise test with electrocardiogram (ECG) monitoring to evaluate the effect of physical activity on your heart.
While physical activity can have a positive effect on blood glucose control, there are times when it should be avoided. If you have Type 1 diabetes and your blood glucose levels are above 250 mg/dl and you detect ketones in your urine, or if your blood glucose levels are above 300 mg/dl (even if there are no ketones in your urine), you should not exercise until your blood glucose levels have been brought into your target range. If your blood glucose level is less than 100 mg/dl and you use insulin or a drug that stimulates the pancreas to release more insulin (such as glyburide, glipizide, or glimepiride), you should have a carbohydrate-containing food or beverage to raise your blood glucose level before you exercise. Your diabetes care team can help you determine a safe way to include physical activity in your diabetes care plan.
Mental health care. The day-to-day necessity of dealing with a chronic illness can add stress and strain to one’s life, and your diabetes care team should address these issues with you. If you’re having trouble coping, they may recommend that you see a psychologist (or other mental health care professional) to talk about issues such as your attitude toward having diabetes, your expectations for managing the condition, your general and health-related quality of life, and the financial, social, and emotional resources at your disposal. If needed, including a mental health professional in your diabetes care team is recommended, because emotional well-being is an important part of your personal diabetes management.
Sick-day plan. Physical stressors, such as illness, trauma, or surgery, can disrupt your blood glucose control, leading to very high blood glucose levels. This, in turn, can trigger serious conditions such as diabetic ketoacidosis (in which poisonous acids called ketones build up in the blood) or nonketotic hyperosmolar state (in which high blood glucose levels cause severe dehydration). You and your diabetes care team should determine a sick-day plan in advance that spells out what to do if one of these stressors occurs. Your sick-day plan may call for more frequent blood glucose monitoring, monitoring of ketones in the blood or urine, and ongoing communication with your physician to help you manage your diabetes during an illness. Should you need to be admitted to the hospital for any reason, ask that a member of your diabetes care team be consulted regarding your treatment to ensure that you maintain the best possible blood glucose control. Keeping your blood glucose levels as close as possible to their target ranges while you are in the hospital can reduce your chance of developing further illness or infection during your stay.
Hypoglycemia plan. Knowing how to deal with hypoglycemia (low blood glucose) is important for people for people whose diabetes treatment plans include insulin or diabetes drugs that increase the body’s own production of insulin, such as glyburide, glipizide, or glimepiride. Learn to identify your particular signs and symptoms of hypoglycemia, which may include weakness, shakiness, a sweaty or clammy feeling, fast heart rate, confusion, dizziness, changes in vision and lack of coordination. Treatment to raise blood glucose is usually called for in adults with diabetes if blood glucose levels fall below 70 mg/dl. Usually, 15–20 grams of pure glucose (the amount found in 3–5 glucose tablets) is the recommended treatment, although any form of carbohydrate in the appropriate amount is acceptable. Using a food with added fat (such as a chocolate bar) however, is not recommended to treat hypoglycemia because fat may slow the body’s absorption of the carbohydrate.
Your diabetes care team will recommend that you check your blood glucose 15 minutes after treatment to assure that your blood glucose level has returned to the recommended range. If it hasn’t, treating again is generally recommended. Your physician may also prescribe a glucagon emergency kit if you are at risk for severe hypoglycemia. When a person develops severe hypoglycemia, he may lose consciousness and be unable to treat himself. Glucagon is a hormone that causes the liver to release glucose into the bloodstream, raising blood glucose levels. It must be injected and should be given by someone, such as a family member, friend, or coworker, who has been trained to administer it.
Immunizations. Influenza and pneumonia are especially dangerous in people with chronic medical conditions such as diabetes. Therefore, all people with diabetes who are at least six months old should receive a yearly influenza vaccine (flu shot). Your physician may ask you some questions to confirm that the vaccine will be safe for you. For example, the vaccine is usually not given to people who are allergic to eggs or egg products.
At least one lifetime pneumonia vaccine is also recommended for adults with diabetes. In some cases, the vaccine needs to be repeated. Check with your diabetes care team for specific recommendations regarding a pneumonia vaccine for you.
Preventing cardiovascular disease
Cardiovascular disease is the cause of death in at least 65% of adults with diabetes. Type 2 diabetes is an independent risk factor for macrovascular disease (disease of the large blood vessels, including the heart’s blood vessels), and cardiovascular complications may already be present when diabetes is diagnosed.
Risk factors for cardiovascular disease include dyslipidemia (abnormal levels of blood lipids such as cholesterol and triglycerides), high blood pressure, smoking, a family history of developing heart disease at an early age, and the presence of the protein albumin in the urine.
You can lower your risk of cardiovascular disease by controlling your cholesterol, triglyceride, and blood pressure levels with diet, exercise, and drug therapy if necessary; by stopping smoking if you smoke; and by taking aspirin if your physician recommends it.
Lipid management. Abnormal lipid, or blood fat, levels contribute to higher rates of cardiovascular disease, particularly in people who have Type 2 diabetes. You and your physician should discuss lifestyle measures you can take, such as following an eating plan that focuses on reduction of saturated fat, dietary cholesterol, and trans fat intake as well as weight loss (if necessary); increased physical activity; and, if you smoke, smoking cessation. These measures can help lower low-density lipoprotein (LDL, or “bad”) cholesterol, raise high-density lipoprotein (HDL, or “good”) cholesterol, and lower triglycerides (see “Target Lipid Levels for Adults With Diabetes”). Keeping blood glucose levels close to the normal range can also improve lipid levels, particularly high triglyceride levels.
If you do not meet your goals with lifestyle changes alone, your physician will likely recommend drug therapy. The first priority is to lower LDL cholesterol to a target level of less than 100 mg/dl, and a class of drugs called statins is the first choice for this job (except during pregnancy). If you already have cardiovascular disease, a reduction in LDL to a level of less than 70 mg/dl is an option that is widely recommended to stave off cardiovascular events. Lipid levels are usually measured once a year in people with diabetes, although they may be measured more or less often depending on a person’s cardiovascular risk.
Controlling high blood pressure. High blood pressure, defined as blood pressure greater than or equal to 140/90 mm Hg, affects the majority of people with diabetes. In people with Type 1 diabetes, it is often the result of underlying nephropathy (kidney disease). In people with Type 2 diabetes, high blood pressure contributes to high rates of cardiovascular disease.
Because high blood pressure is so common and can do a lot of damage to your internal organs, your blood pressure should be measured at every routine diabetes visit. If your systolic blood pressure (the top number) is greater than or equal to 130 mm Hg or your diastolic blood pressure (the bottom number) is greater than or equal to 80 mm Hg, you will need to take steps to lower these values. You should also have your blood pressure measured again on another day to confirm that it is elevated.
The goal for blood pressure for adults with diabetes is less than 130/80 mm Hg. If your blood pressure exceeds this level, your diabetes care team will likely recommend that you reduce your sodium intake and increase your intake of fruits, vegetables, and low-fat dairy products; avoid excessive alcohol consumption; increase your level of physical activity; and make an effort to lose weight if you’re overweight.
You may also be prescribed blood-pressure–lowering drugs if lifestyle measures don’t produce the desired change or if your blood pressure is higher than a certain cutoff. People with a systolic blood pressure of 130–139 mm Hg or a diastolic blood pressure of 80–89 mm Hg are usually advised to start with lifestyle and behavior changes alone, and if target blood pressure levels are not reached in three months, to begin drug therapy. People with a systolic blood pressure greater than 140 mm Hg or a diastolic blood pressure 90 mm Hg or higher are usually advised to start blood-pressure–lowering drug therapy right away, in addition to lifestyle and behavior changes.
Taking care to lower blood pressure gradually to avoid any complications is a goal for elderly people. If medicine is necessary, your physician will likely prescribe either an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB). It is not uncommon for two or three different drugs to be used to reach blood pressure goals. It is important to be aware that ACE and ARB therapy, as well as some other antihypertensive drugs, should not be used during pregnancy.
Smoking cessation. Cigarette smoking contributes to one of every five deaths in the United States and is the leading avoidable cause of premature death. Smoking is related to the early development of cardiovascular disease as well as the microvascular complications of diabetes (such as eye and kidney disease). If you are a smoker, you and your physician should discuss a plan for quitting. Counseling or other forms of treatment should be a routine part of your diabetes care.
Aspirin therapy. If you are over 40 years old, your physician will recommend aspirin therapy to prevent cardiovascular events, including stroke and heart attack, unless there is a reason for you not to use it. Research has shown reductions of 20% in strokes and 30% in heart attacks with aspirin therapy. Although doses of 75 to 325 mg a day have been studied, there is no evidence to support a specific dose, so using the lowest possible dose may help reduce side effects.
Everyone with diabetes should consider aspirin therapy except those under the age of 21 because of an increased risk of a rare but potentially deadly disorder called Reye syndrome, which is associated with viral infection and aspirin use in this age group. The beneficial effects of aspirin therapy have also not been studied in people younger than 30.
Preventing other complications
Retinopathy (diabetic eye disease) is the leading cause of new cases of blindness in adults under age 65. Uncontrolled blood glucose levels damage small blood vessels in the eye, weakening the blood vessel walls and allowing fluid or blood to leak into the retina, the light-sensitive part of the eye that sends visual signals to the brain. The presence of retinopathy is strongly related to how long a person has had diabetes. In people with Type 1 diabetes, retinopathy rarely appears before the fifth year of having the condition; however, the risk for retinopathy is greater for people with Type 1 than for those with Type 2 diabetes.
High blood pressure and nephropathy (kidney disease) are also associated with an increased risk of retinopathy. The risk for retinopathy can be reduced with control of blood glucose and blood pressure levels.
The following are the current recommendations for adults with diabetes regarding eye examinations:
Nephropathy is the most common cause of kidney failure in the United States and the greatest threat to life in adults with Type 1 diabetes. One-third of people with Type 1 diabetes develop kidney disease within 15 years of diagnosis. Diabetes damages the small blood vessels in the kidneys, impairing their ability to remove impurities from the blood. People with severe kidney damage must have a kidney transplant or rely on dialysis to filter waste from their blood.
Intensive diabetes management with the goal of achieving near-normal blood glucose levels has been shown to reduce the risk and slow the progression of kidney disease in people with Type 1 and Type 2 diabetes. Optimal control of blood pressure is another recommendation to reduce risk for nephropathy. It is essential that people with diabetes undergo an annual test for the presence of microalbuminuria (the spilling of small amounts of the protein albumin into the urine, which indicates kidney damage). This should be done in everyone who has had Type 1 diabetes for five years or more and in everyone with Type 2 diabetes starting at diagnosis. Testing for microalbuminuria should also occur during pregnancy.
If microalbuminuria is detected, optimal blood glucose control, as well as controlling blood pressure using either angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) can slow the progression to kidney damage. In this situation, your dietitian will recommend restricting protein intake to about 10% of calories daily, or 0.8 grams per kilogram of body weight per day (the current adult recommended dietary allowance for protein), which may also slow the decline of kidney function. If a person has nephropathy, early detection and treatment can improve his quality of life and delay or prevent the need for dialysis and renal transplantation.
Neuropathy (diabetic nerve disease) is one of the most common and most challenging complications of diabetes. Elevated blood glucose levels can cause damage to the peripheral nervous system (peripheral neuropathy), which affects the sensory nerves that reach the arms, legs, hands, and feet. Neuropathy is a major contributing factor in foot and leg amputations among people with diabetes. Damage can also be done to the autonomic nerves (autonomic neuropathy), which control blood pressure, heart rate, digestion, and sexual function, as well as other internal organ processes. Studies have shown that intensive control of blood glucose can reduce the development and progression of nerve damage in Type 1 and Type 2 diabetes by as much as 60%.
Although most neuropathies are detected based on symptoms, your physician should screen you annually for peripheral neuropathy with tests such as those for sensation (feeling); pressure, temperature, and vibration perception; and reflexes. Your physician should also check your feet at each diabetes visit to assess any potential problems. While there have been several advances in therapies to treat neuropathy, there is no known direct treatment for the underlying causes of neuropathy at this time (though stabilizing blood glucose levels is an important first step). Treatment of peripheral neuropathy currently focuses on pain management. Your diabetes educator should give you guidelines for foot care to help prevent any injury and infection to your feet and legs due to loss of sensation from peripheral neuropathy. Treatment of autonomic neuropathy also focuses on relief of symptoms and is based on each individual’s condition.
With the ADA’s standards of care serving as a map to guide you, you can control your diabetes destiny. The sailing may not always be smooth, but if you stay on course with self-care, optimal blood glucose control, continuing diabetes education, and regular visits to and communication with your diabetes care providers, good health and prevention of diabetes-related complications can be your charted destination.
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