Cholesterol and Diabetes

What Is Cholesterol?

Cholesterol is a type of lipid (or fat) that, among other important functions, builds cell membranes in the body. While some cholesterol is obtained through diet, the body synthesizes most of it.

Low-density lipoprotein (LDL), or “bad cholesterol,” can increase the risk of heart attacks, diabetes and other health problems. High-density lipoprotein (HDL) is often called “good cholesterol” because it helps move cholesterol out of the bloodstream. Triglycerides are a type of fat that can signal risks of a heart attack or a stroke. Too much “bad cholesterol” in the bloodstream increases the risk of cardiovascular disease. People with diabetes often have high levels of “bad cholesterol” and low levels of “good cholesterol.”

How Is Cholesterol Tested — and How Often?

Cholesterol testing is usually combined with other tests, such as triglyceride testing, to develop an overall “lipoprotein profile.” It is important to fast for eight to 12 hours before the test, after which blood will be drawn and analyzed. A person with heart disease or diabetes should ideally have an LDL cholesterol level below 100 mg/dL (milligrams per deciliter). For those with no known risk factors for cardiovascular disease, it should be less than 160 mg/dL. HDL cholesterol should be more than 40 mg/dL, while triglycerides should be less than 150 mg/dL.

In general, cholesterol testing as a screening tool is recommended every five years, according to The American Academy of Family Physicians. More frequent cholesterol checks may be required for those with risk factors (such as diabetes) for heart disease.

What Is the Treatment for Cholesterol Problems?

Lifestyle changes can go a long way in helping to control cholesterol levels. The American Diabetes Association recommends these tips:

• Eating less saturated fat, which is found in fatty meats, chicken skin, non-skim milk, ice cream, cheese and many snacks
• Eating foods high in fats that help to lower cholesterol levels, such as fish, olive oil and nuts
• Eating foods high in fiber, such as oatmeal, fruit, vegetables, dried beans and peas
• Exercising and maintaining a healthy weight
• Not smoking

There are also medications that lower “bad” cholesterol (LDL) and increase “good” cholesterol (HDL). Some researchers believe that, as a protective measure, people over the age of 40 who have diabetes should take statins (drugs that help lower cholesterol), even if their cholesterol levels are normal. People with diabetes should talk to their health care providers about the best treatment.

_Sources:

_{"Can Statin Medications Help Reduce Effects of Heart Attacks?" Diabetes.org. 2006. American Diabetes Association. 27 Sep 2007 .}

_{"Treating High Cholesterol in People with Diabetes." Diabetes.org. 2006. American Diabetes Association. 27 Sep 2007 .}

_{"Triglycerides." American Heart Association. American Heart Association. 27 Sep 2007. .}

“The Heart of Diabetes.” American Heart Association. American Heart Association. 27 Sep 2007. http://www.s2mw.com/heartofdiabetes/cholesterol.html

Holiday Eating and Type 2 Diabetes

The Challenge:

The holidays are here, and with their arrival comes a virtual onslaught of sugary-, high-calorie temptation. Thanksgiving Day can feel like the start of a horse race. The starter pistol fires, and off we go, racing through an obstacle course of side dishes, gravies, sauces, pies, cookies, and candy.

Rounding the bend into Christmas, it can feel like the very air is filled with sugar. Everywhere we turn, someone is holding a tray of fresh-baked treats, and asking us, "Want one? Take two, they're small."

How can you keep your blood glucose levels out of the stratosphere and stay on your eating plan?

Pick and Choose When You Indulge:

Think about all the holiday foods that may be coming your way via work, friends, family and parties. If you can prepare for days when temptations will running be high, you can consciously choose not to indulge on the days when nothing special is going on. Save your calories for the celebrations. Write down your "splurge days" on a calendar. If you have too many "splurge days," you might want to indulge at only one event a week, and make healthy choices the rest of the time.

Beware of Free-Roaming Calories:

The free mini-chocolate bars that some department stores hand out. The random box of candy canes that sits by the coffee pot at work. The free samples at the grocery store. These are calories that don't need to be eaten. Walk right by.

Dodge the Guilt:

Someone who spent all night making intricate gingerbread cut-outs from an heirloom family recipe is not going to take no for an answer when they offer you one. And refusal can seem like an insult. And you may feel bad about that, so you eat the cookie. What to do?

Compliment the cookies and the cookie baker, and remark about the attention to detail, the craftsmanship, the artistic vision, the dedication and love that must have gone into each and every cookie. Then, take one. And walk away. Wrap it in a napkin and give it to the first person you see.

Watch Out for That Extra Helping of Family Guilt:

Family guilt is a phenomenon all it's own. It is the guilt with the potential to haunt you long past the holidays, because your family knows where you live. You can try to say, "No, thank you," but that's usually not successful. You can also try to say, "Make mine a small piece," but that never works either.

Diversion is a good tactic to follow here. Offer to help pass the goody around. Serve everyone else, but forget to serve yourself. Go pour a cup of coffee. By the time you return, everybody else will be finished and the treat will be a fading culinary memory on everybody's lips but yours. Or, postpone the inevitable. Remark about how full you are right now, and might you have your helping later? In the fun and festivity of the family gathering, no one will ever notice that you never came back for that helping.

Be the Master of Your Mouth

When all is said and done, nothing can go into our mouths unless we put it there. We really do have control. We don't have to eat everything that's handed to us. Make a deal with yourself. Set rules to follow. Manage the flow of Christmas cookies by planning to have one cookie every night after dinner for dessert. Realize that the holiday season only consists of two or three actual days. Indulge only on those days, and continue with your good weight loss goals and strategies all of the days in between.

Focus on the Fun, Not the Food:

The holidays aren't just about food. They're about friends and family, too. Use the season to spend time catching up with loved ones, enjoying things like community events, caroling, sledding, and shopping. Bring the focus away from eating and celebrate the people in your life at this time of year.

Bring Your Own Goodies:

Going to a party? Invited to a holiday get-together? Offer to bring something for the table. Make a vegetable or fruit platter, or a low calorie treat. At least there will be one thing there that won't lead you astray.

Step up the Exercise:

It will help burn off those accidental encounters with goodies that sometimes happen to the best of dieters. Exercise will also get you moving, keep you focused on your goals, and give you a welcome break from being surrounded by treats. Exercise is also a great way to lower blood glucose levels. Exercise can be your secret weapon.

Keep Your Eye on the Prize:

Remind yourself daily why you want to be a healthy weight. Check your blood sugar more often to make sure you're staying in your target range. Enjoy the holidays without regret. With strategy, foresight and a plan of action, you'll come through the season in good health for the coming year.

Exercise and Diabetes: How Much Is Enough?

Exercise is an effective way to improve the body's ability to use insulin and help control blood sugar levels -- important goals for people with diabetes. But how much exercise does it take to achieve these benefits?

Starting a Diabetes Exercise Program

Anyone who has diabetes should get the OK for a new exercise program from his or her diabetes care team. Topics to discuss include what activity level is appropriate and what (if any) special precautions to take, based on the type of diabetes, medications, current fitness state, complications, glucose levels and other factors.

How Often to Exercise

Researchers have discovered that when a muscle is exercised, it draws glucose out of the bloodstream for fuel, helping control levels of sugar in the blood. This effect continues not just during exercise, but for 24 to 72 hours afterward.

For this reason, experts recommend people with diabetes exercise at least five days per week, if not every day. This ensures that the muscles draw sugar from the bloodstream continuously.

How Long to Exercise

While science hasn't produced a definitive answer to how much time is enough for people with diabetes to exercise, here are some useful observations:

• Many studies of diabetes and exercise have looked at the benefits of walking (or, in some cases, biking or jogging) for about 30 minutes per session. This amount has been found to be quite effective at controlling blood sugar.
• A group of Italian researchers followed a large number of people with diabetes for two years. The results of their study, published in 2005 in Diabetes Care, found that people who got 38 minutes of exercise per day saw significant blood sugar benefits. Those who got about 83 minutes per day did even better.

So what does all of this mean for people with diabetes? It means that 30 minutes of moderate physical activity -- like brisk walking five to seven days per week -- is a great goal for people trying to control blood sugar. If people with diabetes can extend any or all of those sessions to 45 to 60 minutes or more, they'll get additional benefits, including a better chance of losing weight.

Starting a Diabetes Exercise Program

There's no need to start off immediately with 30 to 60 minutes of exercise daily. Anyone who hasn't exercised in a while or isn't in good shape should start off slowly to avoid injuries or discouragement.

It is important to begin with only as much exercise as is comfortable, even if it's just five or 10 minutes. A minute or two should be added to each session and -- within a few weeks -- the exercise should last for a continuous 20 minutes to half an hour.

Diabetes Exercise Alternatives

Any physical activity that engages the large muscles and elevates breathing -- known as aerobic exercise -- will benefit someone with diabetes.

Activities like mowing the lawn, doing housework, dancing, pushing a stroller or walking nine holes on the golf course are just as effective as more focused fitness-oriented activities.

Results to Expect From a Diabetes Exercise Program

Someone who has diabetes, is overweight and is just starting up an exercise program will probably lose weight. Even if they don't, though, studies have shown that exercise helps control blood sugar regardless of weight loss.

Most people find that regular exercise gives them more energy; reduces some aches, pains and other minor health problems; helps improve sleeping and can even boost mood.

Diabetes, Exercise and Blood Sugar Levels

Exercise also affects blood sugar levels. How much? Everybody's situation is different. Heath care providers usually recommend that people with diabetes take and record their blood glucose levels before and after exercise so that the timing of exercise, medication and meals can be adjusted if necessary.

As exercise sessions increase in length, the risk of hypoglycemia -- a condition in which blood sugar drops dangerously low -- increases. People with diabetes should be sure to discuss this with members of their diabetes care teams.

Some people with prediabetes or type 2 diabetes are able to control their blood sugar levels solely through their exercise programs.

_Sources:

_{Di Loreto, Chiara. "Make Your Diabetic Patients Walk: Long-term impact of different amounts of physical activity on type 2 diabetes." Diabetes Care 28(2005): 1295-1302.}

_{"Diet and Exercise: The Keys to Success with Diabetes." The Cleveland Clinic Health Information Center. 7 Sep 2007 The Cleveland Clinic Foundation .}

_{"Physical Activity/Exercise and Diabetes." Diabetes Care. 2002. American Diabetes Association. 3 Sep 2007 .}

"What I Need to Know About Physical Activity and Diabetes." National Diabetes Information Clearinghouse. June 2004. National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health. 3 Sep 2007 .

What Is Brittle Diabetes?

Brittle diabetes, also called labile diabetes, is a term used to describe uncontrolled type 1 diabetes. People with brittle diabetes frequently experience large swings in blood sugar (glucose) levels. These cause either hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar), which is more common and sometimes extreme.

Other Conditions Related to Brittle Diabetes

Brittle diabetes can be caused by gastrointestinal absorption problems, including delayed stomach emptying (gastroperesis), drug interactions, problems with insulin absorption, or hormonal malfunction.

People who have severely low blood sugar levels may also have problems with their thyroid (hypothyroidism) and adrenal glands (adrenal insufficiency). Treatment of these conditions often leads to the resolution of brittle diabetes.

Gastroperesis can affect relative absorption rates of food, glucose and insulin into the bloodstream. The problem can be a side effect of damage to the nerves that control internal organs. This is a condition that sometimes occurs in people with diabetes. Medications such as Reglan (metoclopramide) do help to encourage more normal stomach emptying. Studies have found, though, that treating gastroperesis does not lead to improvements in overall control of the diabetes or its related complications.

Psychological problems, including depression and stress, are also often associated with brittle diabetes.

Difference between Brittle and Stable Diabetes

The blood sugar levels of people with stable diabetes may fluctuate occasionally. However, these fluctuations are not frequent and -- unlike brittle diabetes -- do not impact the ability to carry out regular activities of daily living.

Brittle Diabetes and the Family

The person with brittle diabetes is frequently hospitalized, misses work and often has to contend with psychological problems. All of these factors place additional emotional and financial stress on family members.

How Often Does Brittle Diabetes Occur?

Brittle diabetes is relatively rare. Less than 1 of people who have insulin-dependent diabetes patients experience brittle diabetes. However, those who do are often troubled by frequent medical problems and hospital admissions. Overall, three in 1,000 (0.3 of) people with type 1 diabetes will develop brittle diabetes.

Who Gets Brittle Diabetes and Why

People with psychological problems, such as stress and depression, are at highest risk of experiencing brittle diabetes. In some cases, these psychological problems lead them to neglect self-care for their diabetes. For example, they may stop maintaining a healthy diet or may not manage their blood sugar). As blood sugar control wanes, metabolic imbalances further complicate and often worsen the underlying psychological problems, causing a repetitive cycle of brittle diabetes.

One small study documented that people with brittle diabetes have a greater hormonal response to stress than those whose diabetes is not brittle. This psychological-hormonal connection may influence the development of brittle diabetes.

Brittle diabetes is more common in young women, with overweight women more likely to be affected. Most people with brittle diabetes tend to be between the ages of 15 and 30.

Treatment for Brittle Diabetes

Identifying and correcting the underlying issues, whether physiologic or psychological, is essential to treating brittle diabetes. Blood tests can help to determine the cause of glucose instability. If blood glucose responds normally to diabetes drugs in a controlled environment (such as in a hospitalized patient), then one should look for environmental, psychological or behavioral causes.

While there may be a physiological explanation for brittle diabetes, that's only one of the potential behavioral/environmental explanations, and diagnosing a psychological cause of brittle diabetes can often be a lengthy and challenging process.

If the cause is determined to be psychological, treatment may involve exploring and trying to lessen the stress of the person's situation. It is helpful to consult a psychology professional in evaluating and treating these patients. Psychotherapy has proven to be effective in treating brittle diabetes.

Patients with brittle diabetes may sometimes need to be transferred to a different diabetes care team or center for a fresh start managing their diabetes. Switching to a specialty diabetes center can sometimes help to break the cycle of brittle diabetes.

Treating brittle diabetes sometimes requires a prolonged hospital stay of a few weeks with intensive monitoring of food, glucose and insulin.

People whose brittle diabetes is caused primarily by physical, rather than psychological, factors may benefit from a continuous insulin pump to control glucose levels precisely.

Selected patients with severe degrees of brittle diabetes may consider isolated islet transplant or pancreas transplant. While promising, transplantation remains a relatively new therapy and carries significant risks, including those associated with anti-rejection immunosuppressive therapy. Therefore, only people who have exhausted all other means of glucose management should consider transplantation.

The most important component of treating brittle diabetes is close supervision by the patient's diabetes care team to treat underlying causes, ensuring that the patient receives and understands all necessary education, and supporting the patient and family on the path to effective diabetes management.

_Sources:

_{Bertuzzi, F, A Secchi, and V Di Carlo. "Islet Transplantation in Type 1 Diabetic Patients." Transplantation Proceedings 36(2004): 603-4.}

_{Dutour A, V Boiteau, F Dadoun, A Feissel, C Atlan, and C Oliver. "Hormonal Response to Stress in Brittle Diabetes" Psychoneuroendorinology 21(1996): 525-43.}

_{Lehmann R, RA Honegger, C Feinle, M Fried, GA Spinas, and W Schwizer. "Glucose Control is Not Improved by Accelerating Gastric Emptying in Patients with Type 1 Diabetes Mellitus and Gastroperesis. A Pilot Study with Cisapride as a Model Drug." Experimental and Clinical Endocrinology and Diabetes 111(2003): 255-61.}

_{McCulloch, David K. "The Patient with Brittle Diabetes Mellitus." UpToDate.com. 2007. UpToDate. 18 Sep 2007}

_{Stacher, G, G Schernthaner, M Francesconi, HP Kopp, H Bergmann, G Stacher-Janotta, and U Weber. "Cisapride Versus Placebo for 8 Weeks on Glycemic Control and Gastric Emptying in Insulin-Dependent Diabetes: A Double Bind Cross-Over Trial." Journal of Clinical Endocrinology and Metabolism 84(1999): 2357-62.}

_{Vantyghem, MC and M Press. "Management Strategies for Brittle Diabetes." Annales d’Endocrinologie 67(2006): 287-96.}

Medications for Diabetes

How Can Medications Help Manage Diabetes?

A healthy lifestyle is the most important tool for fighting diabetes. Adopting healthy habits -- a nutritious diet, regular exercise and no smoking or excessive alcohol use -- will help prevent diabetes-related complications.

But for many who have been diagnosed with diabetes, healthy habits can’t do it all. Medications are also required to help manage the disease and its associated effects. Diabetics require anywhere from zero to six or more medications.

Management of blood sugar is of particular concern, and medications are usually required to achieve control. Maintaining good cardiovascular health, particularly controlling blood pressure and cholesterol, may also require medication.

Medications for Blood Sugar Control

Several classes of so-called antidiabetic medications are available to help control blood sugar. These include insulin, sulfonylureas, meglitinides, biguanides, thiazolidinediones and alpha-glucosidase inhibitors. Many different brand-name medications exist for each class of medication. People with diabetes may have to take one or more of these medications, with or without insulin, to control blood sugar levels.

Medications for Blood Pressure Control

Lowering blood pressure is one of the important steps that people with diabetes can take to protect their health. Several kinds of medications are available to help control blood pressure. The categories of blood pressure medicines include angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, diuretics and calcium channel blockers.

As with medications that control blood sugar levels, many brand-name medications are available in each class of blood pressure medication. It may be necessary to take one or more of these medications to help reach a targeted blood pressure of 130/80 mmHg or lower, as is recommended for all people with diabetes.

Is a Daily Aspirin Helpful?

Aspirin can be helpful to prevent cardiovascular events such as a heart attack or stroke. Aspirin does not directly impact blood sugar control in people with diabetes, but health care providers may recommend a daily aspirin to help protect against cardiovascular problems.

Medications for Cholesterol Control

Good cholesterol control, along with blood pressure control and a daily aspirin, can also help to protect against cardiovascular problems, including heart attack and stroke. Health care providers may recommend a medication called a statin, for which there are many brand-name options, or other medications to help lower cholesterol.

Will Diabetes Medications Work With Other Medications?

Many people with diabetes have other diseases that may require prescription medications. They may also use over-the-counter remedies for pain, congestion or other problems. It is possible to take other medications with diabetic medications, but doses may need to be adjusted.

It is important for a person with diabetes to inform their health care providers of all prescription and over-the-counter medications he or she is taking. This will allow the diabetes care team to determine whether any other medications must be adjusted before starting a regimen of diabetes medications.

In addition, it is important to tell all health care providers when any adjustments have been made to a medication regimen, such as adding or deleting a medication or adjusting the time or strength of a dose. People with diabetes should also always check with their doctor before taking any over-the-counter medications, herbs or other supplements.

Where to Go to Find Help

Sorting out the complicated information about diabetes medications is not easy, but help is available. Professional organizations, such as the American Diabetes Association and the American Heart Association, provide a wealth of patient educational materials on the Internet and in print. In addition, the National Diabetes Information Clearinghouse is an excellent resource for patient information.

Many hospitals and endocrinology practices have diabetes support groups with various educational and discussion opportunities. People with diabetes should ask their local health care provider or diabetes care team for information on resources and options in the community.

_Sources:

_{McCulloch, David K. "Glycemic Control in Type 2 Diabetes Mellitus: Initial Treatment." UpToDate.com 2007. UpToDate. 9 Sept. 2007 (subscription)}

_{McCulloch, David K. "Glycemic Control in Type 2 Diabetes Mellitus: Persistent Hyperglycemic and Long-Term Therapy." UpToDate.com. 2007. UpToDate. 9 Sept. 2007 (subscription)}

McCulloch, David K. "Overview of Medical Care in Adults with Diabetes Mellitus.” UpToDate.com. 2007. UpToDate. 9 Sept. 2007 (subscription)

Diabetes and Pregnancy

Most major organ systems are formed in the growing fetus during the first seven weeks after conception. This phase -- when some women do not know that they are pregnant -- is widely considered the most critical time of development in the entire human lifespan. The early weeks of pregnancy are especially critical for women with diabetes.

The extra precautions described here mainly apply to women with diabetes who become pregnant, rather than women who develop gestational diabetes during pregnancy. During pregnancy, gestational diabetes does not carry the same risk of maternal complications as type 1 or type 2 diabetes.

How Should Women With Diabetes Prepare for Pregnancy?

Women with diabetes should have a complete physical examination before becoming pregnant. As part of the examination, they should provide their doctors with a complete medical history, including duration and type of diabetes, medications and supplements taken, and any history of diabetic complications, such as neuropathy, nephropathy, retinopathy and cardiac problems.

It is also important for women with diabetes to plan ahead and maintain excellent blood sugar control before conceiving, as high blood sugar levels during the first trimester can lead to miscarriage or congenital anomalies, which are abnormal changes during fetal development in the uterus.

Before becoming pregnant, women with diabetes should also have their kidney function tested. Although pregnancy does not worsen diabetic nephropathy (kidney disease), pregnant women with advanced kidney disease are more prone to high blood pressure, which can affect nearly all body systems and ultimately endanger the fetus.

What Special Care or Tests Are Required for Pregnant Women With Diabetes?

Pregnant women with diabetes need to carefully monitor eye care, including a full retinal examination before, during and after pregnancy, as diabetic retinopathy (damage to the retina’s blood vessels) can worsen during pregnancy. This complication occurs particularly in women who have poor blood glucose (sugar) control.

During pregnancy, women should measure their blood glucose several times daily: before and after meals, at bedtime, and at night if there is a concern about nighttime hypoglycemia (low blood sugar). The American Diabetes Association recommends pre-meal glucose measurements of 80 to 110 mg/dL (milligrams per deciliter) and post-meal glucose measurements below 155 mg/dL.

If a pregnant women with diabetes has a blood glucose measurement around 180 mg/dL, her urine should be checked for ketones (acids) to rule out ketoacidosis, which can sometimes cause a miscarriage. Ketoacidosis occurs when the body lacks insulin.

Why Is Managing Blood Sugar Especially Important for Pregnant Women With Diabetes?

In a 1989 study, women with a prepregnancy A1C value (a blood test that measures glucose levels) that was greater than 9.3% had the highest risk of miscarriages and birth to babies born with congenital anomalies. Studies have indicated that A1C values of up to 6% (with 5% being considered normal) carry the same risk of miscarriage and fetal anomalies as a nondiabetic pregnancy.

Women with higher than normal blood sugar levels, whether they have gestational, type 1 or type 2 diabetes, also tend to have larger babies. This leads to a greater risk of injuries of the shoulder and brachial plexus (the nerves connecting the spine with the arm and shoulder) to the infant during childbirth.

Poorly controlled diabetes is also associated with pre-eclampsia (high blood pressure) and premature delivery.

There is very little information about the effect of hyperglycemia (high blood sugar) on long-term development of the fetus.

Are There Diabetes Medications That Should be Avoided During Pregnancy?

Women with type 2 diabetes who take oral medications for blood sugar control should switch to using insulin before becoming pregnant and throughout pregnancy. While some oral antidiabetic medications have been studied and were found to be safe in pregnancy, insulin is the best and safest method for controlling blood sugar throughout pregnancy.

Many blood pressure medications can be dangerous for the fetus; therefore, usually these medications should be stopped before pregnancy if blood pressure can be maintained below 130/80 mmHg with dietary salt control alone. If blood pressure medications are absolutely necessary, women may have to be switched to a new medication prior to pregnancy. In particular, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are excellent for blood pressure control in nonpregnant women with diabetes; however, these are not safe when used by a woman who is diabetic and pregnant. Similarly, cholesterol-lowering medications should also be stopped during pregnancy.

How are Diet and Exercise Managed for Pregnant Women With Diabetes?

Nutrition is vitally important for pregnant women with type 1 and type 2 diabetes. In general, pregnant and nursing women with diabetes should ingest 15 to 17 calories per pound of body weight daily, although this may vary from person to person and should be discussed with the diabetes care team before, during, and after pregnancy and nursing.

Important nutritional concerns in type 1 diabetes include consistent day-to-day food intake and consumption of a bedtime snack, and adjusting insulin according to activity and food content to prevent high or low blood sugar levels to carefully treat hyperglycemia and hypoglycemia, respectively.

Nutrition is the most important means of blood glucose control in type 2 diabetes. Pregnant women with type 2 diabetes should talk with their diabetes care providers, and ideally a diabetes nutritionist, to determine their goals for daily calories, carbohydrates, nutritional balance in foods, and timing of eating throughout the day.

Exercise is beneficial for pregnant women with type 2 diabetes, as it helps improve the body’s response to insulin. Women with type 1 diabetes who exercised prior to pregnancy can probably continue to exercise during pregnancy. However, women with type 1 diabetes who are not accustomed to exercise are more prone to hypoglycemia with exercise during pregnancy; for this reason, these women are not advised to begin an exercise regimen when pregnant.

_Sources:

_{Delahanty, Linda M. and David K. McCulloch. "Nutritional Considerations in Type 1 Diabetes Mellitus." UpToDate.com 2007. UpToDate. 18 Sept. 2007 (subscription) .}

_{Delahanty, Linda M. and David K. McCulloch. "Nutritional Considerations in Type 2 Diabetes Mellitus." UpToDate.com 2007. UpToDate. 18 Sept. 2007 (subscription) .}

_{Greene, M.F., J.W. Hare, J.P. Cloherty, B.R. Benacerraf, and J.S. Soeldner. "First Trimester Hemoglobin A1 and Risk for Major Malformation and Spontaneous Abortion in Diabetic Pregnancy." Teratology 39(1989): 225-31.}

_{Jovanovic, Lois. "Glycemic Control in Women with Type 1 and Type 2 Diabetes Mellitus During Pregnancy." UpToDate.com 2007. UpToDate. 18 Sept. 2007 (subscription) .}

_{Jovanovic, Lois. "Prepregnancy Counseling and Evaluation of Women with Diabetes Mellitus." UpToDate.com 2007. UpToDate. 16 Sept. 2007 (subscription) .}

"Preconception Care of Women with Diabetes." Diabetes Care 27(Suppl 1)(2004): 76 S. 18 Sept. 2007 .

Insulin: Who Needs It and Who Doesnt?

People with type 1 diabetes require supplemental insulin because their bodies can no longer produce insulin themselves. However, type 2 diabetes is different. Less than one third of those with type 2 diabetes take insulin. The CDC puts the number at about 28%. Some experts have long believed that more patients with type 2 diabetes should be on insulin to reach their glycemic (blood glucose) and lipid (cholesterol) targets.

When diagnosed with type 2 diabetes, many people wonder if -- or when -- they will need insulin. Some patients fear injections or believe that insulin, however delivered, represents a personal failure, so they resist taking the drug, even when they need it. That’s not wise. Whether or not a patient with type 2 diabetes needs insulin is based on individual circumstances. The first step? Knowing the facts.

Does Everyone with Diabetes Need Insulin?

Type 1 and type 2 diabetes are conditions in which the body lacks a normal supply of insulin to remove glucose from the blood. This creates two problems: high blood glucose levels and a lack of stored glucose, the body’s major fuel source.

The difference between type 1 and type 2 diabetes lies in the cause of this condition. Beta cells, found in the pancreas, produce the body’s insulin. In type 1 diabetes, most of those beta cells have been destroyed, limiting the supply of insulin. As a result, individuals with type 1 diabetes must take insulin to control their blood glucose levels.

In type 2 diabetes, the pancreas may still produce insulin, but it either produces insufficient amounts or the body resists the insulin itself. Diet, exercise and various oral medications can help the body use its self-produced insulin more efficiently. Here’s the catch: Type 2 diabetes is a progressive disease, meaning the insulin-producing beta cells deteriorate over time. Eventually, actual insulin therapy (in the form of injections) may become necessary.

Insulin Treatment: What Are the Options?

There are more than 20 types of insulin sold in the United States. These products differ in how they are made, how they work in the body and how much they cost. Using any insulin requires attention to at least three variables: onset (the time before the insulin begins to act), peak (the point at which insulin is most effective) and duration (how long the insulin is effective in the body).

Based on the goals and structure of a patient’s management plan, a health care professional may prescribe rapid-, intermediate- or long-acting insulin. Among these categories, insulin onset can begin as soon as 10 to 15 minutes or as long as six hours after injection. Insulin can remain effective for up to 24 hours. Some people who have trouble dosing for themselves use a pre-mixed product of different types of insulin.

Using Insulin

Different delivery options are also available. Traditional insulin therapy uses injections, either via syringes or insulin pens. These pens can be easier to use than syringes and look very much like writing pens. Frequency and dosing depend on glucose levels and the type of insulin prescribed.

Patients can also use insulin pumps or inhaled insulin. A pump provides a continuous delivery of rapid-acting insulin through a catheter under the skin. The constant flow delivered by the pump is called the basal rate. At mealtimes, or at other times when patients want to take insulin to cover snacks or to “correct” blood glucose levels, the user programs the pump to deliver an additional dose, called a bolus. A newer product, inhaled insulin, is a short-acting substance inhaled before meals or snacks. It eliminates injections, at least for short-acting insulin, but it’s not as precise as injections. The long-term health risks, if any, are unknown.

When Will a Patient Progress from Oral Medications to Insulin?

Some people can control type 2 diabetes with a well-balanced diet and regular exercise. However, persistently high blood glucose levels probably reflect the need for pharmacological treatment. Traditionally, type 2 patients have begun treatment with an oral medication, but this has begun to change in recent years. Today, if someone’s A1c level (a test that measures average blood glucose over the last few months) is over 7%, his or her health care professional may actually start insulin immediately.

As type 2 diabetes progresses, the pancreatic beta cells gradually lose their ability to produce insulin. Eventually, the patient requires supplemental insulin to manage the disease. The speed at which diabetes progresses — that is, the rate at which beta cell function declines — depends on many factors, including the patient’s weight, genetics, diet and activity level.

It is important for patients to stay in close contact with their health care professionals. According to many experts, if an A1c level is over 7%, that is a sign that the patient should go on insulin.

Worries about Taking Insulin

Feeling nervous or uncomfortable about starting insulin is very common, but these concerns should not deter a patient. If used properly, insulin is a life-promoting drug. If the drug makes patients skittish, they should talk to their health care team or ask their health care professional for help finding a support group.

_Sources:

_{Mayfield, M.D., M.P.H., Jennifer and Russell D. White, M.D. "Insulin Therapy for Type 2 Diabetes: Rescue, Augmentation, and Replacement of Beta-Cell Function." American Family Physician 1 Aug. 2004. 489-500. 10 Sep. 2007.}

_{Walsh, P.A., C.D.E., John. "Will Inhaled Insulin Really Take Your Breath Away?" The Diabetes Mall. 2007. Diabetes Services Inc. 10 Sep. 2007. .}

"National Diabetes Fact Sheet." Diabetes & Me. 09 June 2005. Centers for Disease Control and Prevention. 10 Sep. 2007. .