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. .

For Diabetics, Honesty is the Best Policy

People who lie to their health care providers do so for many reasons. Some patients lie so they’ll appear to be “good” patients. Some lie to avoid being judged. Some lie because they don’t want to admit a bad habit to themselves, let alone to their health care providers. Regardless of their motive, diabetics sometime forget that honesty and health go hand in hand.

Individuals with diabetes are expected to become experts in self-care. They need to learn about -- and put into practice -- healthy meal planning and counting carbohydrates, blood testing, exercising and medicine taking. They also have target goals for blood sugar levels, amounts of exercise, caloric intake and more. With so many things to balance, it’s easy for something to slip their minds.

Why Patients Lie

Between visits, many individuals with diabetes may have forgotten a few times to test their blood sugar levels. They may have slipped up and had a couple of high-calorie meals. Maybe they didn’t exercise as much as they had planned.

Do they come clean? Or do they tell a few white lies to make it appear they’re doing a better job than they actually are with their diabetes management? After all, what’s the big deal? Their health care providers won’t care or even find out. Right?

Wrong. The results of their hemoglobin A1c tests will show what their average blood sugar levels actually have been over the past two to three months, so fudging their self-monitored blood sugar readings or being misleading about their adherence to their diet and exercise routines won’t work. Plus, any changes in regimen will be based on falsehoods and prove useless or even dangerous.

The Importance of Good Communication

Telling the complete truth can be a daunting task if diabetics have experienced negative reactions from either their diabetes care teams or their loved ones. Maybe they’ve had health care providers who have placed blame on them, instead of looking at ways to make things better. Perhaps partners or friends have wondered why they can’t work harder or do better.

Dr. Barbara Anderson, senior psychologist at the Diabetes Care Center at Texas Children’s Hospital and professor of pediatrics, Baylor College of Medicine, has seen this happen over and over. “Encouraging and positive communications by clinicians is one way to achieve honesty in the patient/physician relationship,” she says. “If we want patients to be honest, it’s got to have noticeable positive benefits for them.”

Anderson says it’s vital for people to have health care teams they can work with. “Find a physician who is honest and will treat you as a whole person,” she says. “Make sure they are up-to-date in the field. Look for a team that says, ‘we are going to work with you as your coach.’ Ninety-nine percent of diabetes treatment is self-care and one of the biggest mistakes physicians and all of us make with patients is to over-simplify the burden of diabetes self-care.”

“Some physicians expect patients to be honest about blood sugar logs,” she says. “Then they draw huge circles in red pen around all the high numbers that the patient has recorded, and the judgmental comments and blaming start.”

Sandra Krafsig, a certified diabetes educator at Marlborough Hospital in Massachusetts, agrees. “The log book is not a report card,” she says. “It’s a tool to help pick out trends, trouble areas that we can work on together to balance glucose and meals.”

In order for the log book to be a successful tool, it needs to be accurate so the observed trends reflect reality.

The Positive Benefits of Honesty

Difficulties in self-managing diabetes are often due to issues with treatment plans. If patients are honest, their health care providers will be able to analyze their successes and failures in terms of their treatment plans. They can then figure out how to adjust the plans to allow for greater success in the future.

Together, people with diabetes and their health care providers can figure out what might have led to any high readings, how they can be avoided and whether changes in their treatment plans are needed.

Those who haven’t followed their exercise programs need to let their health care professionals know that, too. They should try to explain why they haven’t been compliant. If their routines were too difficult or too boring, new exercise plans can be created that might be more successful.

If they are taking other medications or over-the-counter drugs and don’t let their health care providers know, they run the risk of having other drugs prescribed that could interact badly with the ones they haven’t mentioned.

Diabetes is a juggling act. When people with diabetes are honest with their health care teams about how they are managing their self-care, they provide the necessary information for creating more effective treatment plans.

_Sources:

_{Anderson, Barbara J. Telephone interview. 29 Aug. 2007.}

_{Johnson, Carla. "Lying to Doctor Can Mean Health Risks." Washington Post. 16 Feb 2007. 1 Sep 2007 .}

_{Krafsig, Sandra. E-mail interview. 29 Aug. 2007.}

_{Penckofer, Sue. Telephone interview. 29 Aug. 2007.}

Yeast Infections With Diabetes

How Do Yeast Infections Occur?

Candida, or yeast, often lives on the human body as part of the body’s normal bacteria and organisms. When a change occurs, such as a shift in the body’s acidity from infection, condom use, antibiotics or diabetes, the balance of organisms is disrupted. Candida cells multiply unchecked, resulting in a yeast infection.

Why Are Women With Diabetes Prone to Vaginal Yeast Infections?

While most women will experience at least one yeast infection during the course of their lives, those with diabetes are especially susceptible. Yeast cells that normally live in the vagina are kept in careful check by the minimal available nutrients in the acidic environment of the vagina. In women with diabetes, vaginal secretions contain more glucose, or sugar, due to higher amounts of glucose in the blood. Yeast cells are nourished by this excess glucose, causing them to multiply and become a yeast infection. Also, hyperglycemia interferes with the immune functions that help prevent yeast infections. Yeast infections in women with diabetes can mean that blood glucose levels are not well-controlled or that an infection is brewing in another part of the body.

What Are the Symptoms of a Vaginal Yeast Infection?

Yeast infections often cause itching or discomfort around the vagina, white secretions resembling cottage cheese, foul odor and pain with urination or sexual intercourse. Some women, however, do not notice any symptoms with a vaginal yeast infection. Yeast infections can also occur in other locations, such as moist areas of the feet or skin folds, a dialysis access site or the mouth (thrush). Any yeast infection can cause discomfort and possibly result in a more serious infection.

How Is a Yeast Infection Diagnosed?

An examination is done if symptoms are due to a yeast infection and not another source, such as a bacterial infection or sexually transmitted disease. A microscope may be used to look at a cell sample to confirm the presence of yeast. Occasionally, further laboratory tests may be needed in order to confirm a yeast infection.

How Can a Yeast Infection Affect Diabetes?

The presence of yeast in the vagina or other areas blocks the body’s natural defense mechanisms against infection. When a woman with diabetes has a yeast infection, she is more likely to get other infections as well. This is because the combination of yeast and high blood sugar inhibits the body’s ability to fight off other bacteria and viruses. Any infection in a person with diabetes poses a risk because blood sugars may be much higher or lower than normal while the body tries to fight infection.

What Are the Treatment Options?

Antifungal medications, available over the counter and by prescription, effectively treat yeast infections in people with diabetes. A health care professional should be consulted before starting any new medications because oral antifungals can interact with regular medications. Some people may prefer to use a vaginal medication. Experts suggest that yeast infections occurring in women with diabetes may require up to two weeks of treatment. Other topical or oral antifungal agents, such as nystatin, are available by prescription to treat yeast infections in areas other than the vagina.

The most important thing to remember when treating a yeast infection, especially for people with diabetes, is for them to take the full amount of medication recommended by their health care providers. When medications are stopped early, because the person feels better, the infection can return and be even stronger than before.

What Questions Should Be Asked?

Once a diagnosis is confirmed, women should ask their health care providers for treatment recommendations. For example, whether they should use a vaginal cream or if oral medications would help. People who experience four or more yeast infections per year should ask their health care providers to check that their diabetes is under control and not causing the yeast infections because of overly high blood sugar.

_Sources:

_{"Vaginal Yeast Infections: Transmission." Health and Science Topics. 29 Aug 2006. National Institute of Allergy and Infectious Diseases. 30 Aug 2007 .}

_{Weintrob, Amy C., Sexton, Daniel J. “Susceptibility to infections in persons with diabetes mellitus.” UpToDate Online (4 Aug 2006). UpToDate 30 Aug 2007 (subscription)}

_{Sobel, Jack D. “Candida vulvovaginitis.” UpToDate Online (11May 2007). UpToDate 30 Aug 2007 (subscription)}

_{Kauffman, Carol A. “Overview of candida infections.” UpToDate Online (6 March 2007). UpToDate 30 Aug 2007 (subscription) < topickey="fung_inf/10432&selectedTitle="96~4125&source="search_result">}

_{Kauffman,Carol A. "Treatment of oropharyngeal and esophageal candidiasis." UpToDate. CD-ROM.15.2 ed.UpToDate,2007.}

Eating Disorders in Teens with Type 1 Diabetes

_{Eating disorders affect approximately 10 percent of American adolescents and young adults. These disorders can range from full-blown anorexia and/or bulimia to patterns of disordered eating such as binging, excessive exercise, or other methods of controlling calorie intake.}

• _{Identifying Anorexia Nervosa}
• _{Symptoms of Bulimia Nervosa}
• _{Eating Disorder Triggers}

_{Results of a study conducted at the University of Toronto and the Hospital for Sick Children showed that eating disorders are twice as likely to occur in teenage girls with type 1 diabetes than in girls who do not have diabetes.}

_{Teens with Type 1 sometimes exhibit another symptom of disordered eating that is unique to diabetes: deliberately changing their insulin dose to achieve weight control or weight loss. Manipulating doses of insulin has been shown to be a popular approach to weight loss among some teens with Type 1 diabetes.}

_{During the time of diagnosis of Type 1, or before good metabolic control is achieved, kids usually experience weight loss. Sometimes teens think this a good thing, especially girls who live with constant peer pressure to be thin. When insulin therapy is begun there is most likely some weight gain, especially as metabolic control is gained. Some teens don't like the additional weight gain, especially if it is noticed and commented on by their peers. Shortchanging or skipping their insulin dose seems like an easy fix, because not taking enough insulin brings on hyperglycemia which causes excessive urination and weight loss.}

_{This is very dangerous in many ways. Teens who use insulin dose manipulation to achieve weight loss suffer serious consequences to their health:}

• _{Higher A1c levels due to poor metabolic control.}
• _{Early onset of diabetes complications, especially retinopathy. In fact, the highest percentage of teens with detectable damage were the ones with the most severe eating disorders, 86 percent had evidence of retina damage, compared with 24 percent for teens who did not have eating disorders.}
• _{Hypoglycemia due to not eating or not eating enough.}
• _{Diabetic ketoacidosis (DKA), brought on by deliberately short-changing the insulin dose or skipping doses altogether.}
• _{What is Diabetic Ketoacidosis?}

_{Warning Signs of Possible Eating Disorder}

_{Sometimes it's hard to tell when there is disordered eating or intentional insulin manipulation going on. Eating disorders are very secretive in nature and teens will attempt to hide it from their families and friends. Signs include:}

• _{Poor metabolic control despite the appearance of compliance.}
• _{Look for signs of hyperglycemia -- excessive urination, excessive thirst, unusually high blood sugars, and/or fatigue.}
• _{Signs of hypoglycemia, such as shakiness, irritability, confusion, sweatiness, anxiety, and fainting.}
• _{Preoccupation with self-image, weight, or food intake.}
• _{Moodiness, irritability, anxiety or depression, being overly critical of appearance, self-hatred.}

_{What Can Parents Do?}

• _{Be aware that your teen may be defensive or deny that there's a problem.}
• _{Call your teen's healthcare provider if you suspect an eating disorder of any kind.}
• _{Seek referrals for therapists and/or treatment centers who are experienced with eating disorders and diabetes. An endocrinologist may be a good source of information.}

_{Early treatment is important because the longer an eating disorder continues, the harder it is to treat. Also, for kids with diabetes, the longer they are not in good metabolic control, the more long-term damage they might suffer from the complications of uncontrolled blood glucose.}

_Sources:

_{Daneman MB, BCh, FRCPC, Denis and Rodin MD, FRCPC, Gary, Jones PhD, Jennifer, Colton MD, Patricia, Rydall MSc, Anne, Maharaj PhD, Sherry, and Olmsted PhD, Marion. "Eating Disorders in Adolescent Girls and Young Adult Women with Type 1 Diabetes." Diabetes Spectrum 2002 15:83-105. 07 Feb. 2007.}

_{Jones, Jennifer, Margaret L. Lawson, Denis Daneman, and Marion P. Olmsted, Gary Rodin. "Eating disorders in adolescent females with and without type 1 diabetes: cross sectional study." British Medical Journal 10 Jun 2000 320:1563-1566. 07 Feb 2007.}

_{Barrett, Janet. "Weight Woes & Dieting Disasters." Juvenile Diabetes Research Foundation International. 2007. JDRF. 7 Feb 2007}

_{"Eating Disorders." KidsHealth for Parents. 2005. Nemours Foundation. 7 Feb 2007.}

Cardiovascular Exercise and Diabetes

Cardiovascular, or cardio, training involves exercise in which a person’s heart rate increases to a higher than normal rate. This type of workout, also called aerobic exercise, can be especially beneficial for people with diabetes because it can help burn extra glucose in the body and also decrease resistance to insulin.

A good cardio exercise routine has many positive health effects, such as:

• Improving muscle strength
• Reducing body fat
• Increasing energy levels
• Lowering blood pressure
• Increasing the level of good cholesterol
• Decreasing the risk of coronary artery disease
• Strengthening the heart
• Improving control of blood sugar levels
• Improving circulation

The most important aspect of a cardio routine can also be the most difficult to achieve, that is, regularity. The maximum benefits of cardio training are realized when someone exercises on most days of the week. This is because the effects of the exercise aren’t permanent, although they are accumulative. For instance, research from Duke University suggests that when the exercise is done regularly for the long term, then it can significantly help the body process blood sugar levels, but if the exercise is only done once, then the effects only last for approximately one day.

Concerns for People with Diabetes

As always, people with diabetes should keep their healthcare providers well informed of anything that can affect their health. Exercise, especially, falls into this category. Talk to your doctor about what kind of exercise is best for you, and be sure to discuss any questions or concerns that arise as your exercise program progresses.

People with diabetes need to pay particular attention to their feet during exercise. The American Diabetes Association suggests using silica gel or air midsoles as well as polyester or cotton-polyester socks to prevent blisters and keep the feet dry.

A Cardio Training Program

A cardio training program aims to increase breathing capacity and improve overall health. Cardio work gets the heart beating faster, is rhythmic, and involves the large muscle groups, such as those in the legs. Generally, the program will start at a certain level, and then it will increase gradually as endurance is built.

Many types of physical activity can be categorized as cardio exercise, including:

• Jogging or running
• Walking or hiking
• Bicycling
• Using a stair step or elliptical machine
• Cross-country skiing
• Rowing
• Dancing
• Swimming

How a person structures his or her exercise program will depend on individual variables related to overall health and current fitness level. Because people with diabetes often have complicated health concerns, it’s very important to talk with a doctor or healthcare provider before beginning a cardio training regimen.

Many cardio exercise programs will specify how often, how long, and how hard a person should exercise. Often the workout will involve short periods of intense activity, followed by periods of lower-intensity exercise. A healthcare team can help determine the best workout for an individual. Personal trainers are also helpful for setting up a program, and many gyms provide this service.

Achieving and maintaining a higher-than-normal heart rate is the basic goal of a cardiovascular workout. Different people have different “target” heart rates and will want to maintain those rates for different lengths of time. Heart-rate monitors can help determine measurements, or there are other ways to tell when an optimal exercise level has been reached. A doctor or healthcare provider can help with these determinations.

Elements of a Cardio Workout

There are four phases to an aerobic workout:

Phase 1: Warm up (5-10 minutes): The goal is to get the heart rate up to about 50 to 60% of the target rate.

Phase 2: Stretching (5-10 minutes): Stretching the muscles helps avoid injury and prepares them for more rigorous activity.

Phase 3: Activity (30-40 minutes): This is the main exercise. Times will vary depending on fitness level.

Phase 4: Cool down (5-10 minutes): The period during which the heart rate gradually resumes its normal level.

At Home or in a Gym?

Once the doctor gives the OK to begin cardio training, it’s time to explore different exercise options. It might be easier to begin at a gym where the staff can explain cardio exercise machines and help develop a program that it suitable for an individual’s needs.

When joining a gym, ask some questions first. Find out whether the staff is certified by the American College of Sports Medicine. Ask what experience they have in working with clients who have diabetes. Also, see if the gym offers a trial membership. Many gyms offer a free day or a free week or more to try out their facility.

For some people, however, it will be just as easy to work alone. Jogging and walking are good individual aerobic exercises. Exercising with a partner can help if motivation begins to fade.

Getting More Information

The best place to get more information about cardio workouts is by talking to your healthcare team. Ask them what kind of exercise and at what intensity would be best for your individual needs.

People new to aerobic activity might find it helpful to take a look at About.com’s “Cardio for Beginners” or consider working with a personal trainer or physical therapist at first. These professionals can help you learn the basic principles of the activity, determine and monitor your target heart rate, and develop an overall plan.

_Sources:

_{“Aerobic Exercise: What 30 Minutes a Day Can Do.” MayoClinic.com 2007. Mayo Foundation for Medical Education and Research. 8 Oct. 2007 .}

_{American Diabetes Association. “Physical Activity/Exercise and Diabetes.” Diabetes Care 27(2004): S58-S62. 8 Oct. 2007 .}

_{“Cardio for Beginners.” About.com. 19 July 2007. About.com. 6 Nov. 2007.}

_{Duke University. “Intensive Exercise Improves Body's Ability To Process Blood Sugars.” Dukenews.duke.edu. 14 Feb. 2002. Duke University Office of News & Communications. 6 Nov. 2007. .}

_{“How Does Physical Exercise Help Cure Diabetes.” Ygoy.com 27 June 2007. Ygoy.Inc. 6 Nov. 2007. .}

_{Kelley G.A. and K.S. Kelley. “Effects of Aerobic Exercise on Lipids and Lipoproteins in Adults With Type 2 Diabetes: a Meta-Analysis of Randomized-Controlled Trials.” Public Health 121(2007): 643-55. 8 Oct. 2007 (abstract) .}

_{Lam, Michael. “Secret 3 - Cardiovascular Training Exercises.” DrLam.com 2005. An Insider’s Guide to Natural Medicine. 8 Oct. 2007 .}

_{Mayo Clinic Staff. “Diabetes Management: How Lifestyle, Daily Routine Affect Blood Sugar.” MayoClinic.com. 21 June 2007. Mayo Foundation for Medical Education and Research. 6 Nov. 2007. .}

_{Sandstedt, Kristina. “Seated Exercise Series: Chair Aerobics.” DiabetesInControl.com (2003). Diabetes in Control. 8 Oct. 2007 .}

_{Tackett, Chad. “Cardiovascular Exercise Principles & Guidelines: Part One. (2005) The Fitness Jumpsite. 7 Oct. 2007 .}

Taylor, J.D. “The Impact of a Supervised Strength and Aerobic Training Program on Muscular Strength and Aerobic Capacity in Individuals With Type 2 Diabetes.” 8 Oct. 2007 J Strength Cond Res. 21(2007): 824-830. (abstract) .

Everything You Need to Know about Insulin

Insulin is a hormone that helps move glucose from out of our blood and into our cells so that we can use the glucose for energy. The glucose comes from most of the food that we eat.

In type 1 diabetes, the pancreas no longer releases insulin, so the glucose keeps circulating in the blood with no way out. People who are type 1 have to inject insulin several times a day, just to survive.

Some people with type 2 may also need insulin, due to a reduced insulin response from their pancreas or because they are insulin resistant.

• Diabetes and Insulin
• Insulin: Who Needs It and Who Doesn't?

Managing diabetes is a balancing act between insulin and blood glucose. Finding the right amount of insulin to keep blood glucose levels as close to normal as possible is the key to good control.

• Adjusting Your Insulin
• Insulin Action Reference Chart
• Insulin Rotation Site FAQs

Starting insulin can be nervewracking. Many people are apprehensive about injecting. When kids are diagnosed, many parents are afraid of hurting their child at first. It may take a while to become comfortable with injecting.

• How to Give an Insulin Injection
• Parents, Kids and Diabetes

Insulin pumps have been available for about the last 20 years. They can provide greater flexibility and tighter control of blood glucose than injection can. They give a basal rate of insulin continuously while allowing boluses of insulin during times when you need it.

Walking and Diabetes

Walking is one of the most popular and widely recommended forms of physical activity for people with diabetes. It’s easy, relaxing and can be done practically anywhere. Most important, it’s highly effective at controlling blood glucose levels. Still, there are important things for people with diabetes to consider before taking off.

The Benefits of Walking

By walking every day, for 30 minutes to an hour, diabetics can reap the following benefits:

• Improved glucose control. Exercise helps muscles absorb blood sugar, preventing it from building up in the bloodstream. This effect can last for hours or even days, but it’s not permanent. That’s why walking regularly is essential for continued blood glucose control.
• Better cardiovascular fitness. Because people with diabetes are at increased risk for heart disease, this is an important benefit.
• Weight control. Regular walking burns calories; this can help control weight, which in turn can reduce health risks.

Getting the Go-ahead from a Health Care Provider

First, it’s important for a diabetic to get the OK from a health care provider for any new exercise program to make sure that the patient is fit enough to increase his or her activity levels. A health care specialist can also inform the patient of special precautions to take based on what type of diabetes he or she has. Other factors to consider include medications being taken, one’s current fitness state, glucose levels and other factors.

Walking and Diabetic Foot Care

Foot health is particularly important for anyone with diabetes, so the input of a podiatrist may be especially useful if you're considering a walking program. Blisters, abrasions and breaks in the skin of the feet are often hard to detect since foot numbness is one symptom of diabetes. These injuries are slow to heal and prone to infection, since another symptom of diabetes is reduced blood flow in the small blood vessels of the extremities. A podiatrist or other health care specialist can recommend alternative forms of exercise if a foot condition makes walking difficult.

The Importance of Shoes

It’s not necessary to spend a lot of money on walking shoes, but there are a few things to keep in mind:

• The shoes need to fit comfortably, with plenty of room in the toe area. They should not rub at the heel. Some walking shoes include an extra pair of eyelets close to your ankle. Lacing these may help prevent heel friction.
• Walking shoes are different from running shoes. Walking shoes have flatter, broader soles, which help improve balance.
• The staff at a “walking store,” an increasingly popular type of specialty retailer, is usually well trained at fitting walking shoes.
• Don’t forget socks. Cotton socks can bunch and retain moisture. Check out newer synthetic fabrics, such as CoolMax and Dri-Fit, that wick moisture away from the skin.

Starting a Walking Program

Now that the preliminaries are out of the way, it’s time to get started.

• Begin slowly and easily. Walking just 5 or 10 minutes on the first day is perfectly acceptable if that’s all you can accomplish. The important thing is to not get injured or sore, which could end a walking campaign at the starting line.
• Add 5 or 10 minutes per week. As one continues to improve, aim for 45 minutes to an hour, five to seven days per week. That’s an ideal amount of time for blood glucose maintenance. However, health benefits begin to accrue at just 30 minutes per day.
• Break it up. Several 10- to 15-minute sessions are just as effective as one longer walk.
• Count your steps. During the last few years, pedometers -- small devices that clip to the belt to count steps -- have become popular. They can help track total steps taken on daily walks, or all day long. Recording walking totals can be motivating.
• Find a place to walk. If one’s neighborhood is unsafe, limit walking to daytime, walk in groups or try a nearby school track, community center or shopping mall.

Special Considerations

• Always wear a diabetes ID bracelet and carry glucose pills, hard candy or sweet snacks in case blood sugar drops.
• Follow a doctor’s orders regarding when to check blood glucose levels. Diabetics may need to take readings before, after and perhaps even during their exercise routine.
• Be sure to do a foot check after each walking session and check for cuts, abrasions and blisters.

Walking with Others

It’s often valuable to have a friend join you on walks to help stay motivated, especially through busy periods, bad weather and holidays, when it’s tempting to slack off. In many communities, there are a variety of walking groups -- mall-walkers, stroller-walkers, hikers, race-walkers and groups formed by neighborhoods, religious groups and social clubs.

Check community center bulletin boards, neighborhood newsletters or postings at health clubs to find a local walking group. Enter the phrase “walking clubs” and the name of your city or town into an Internet search engine, and many other options will likely present themselves.

Sources:

"Diabetes and Exercise: When to Monitor Your Blood Sugar." 23 Feb. 2007. MayoClinic. Com. 03 Feb. 2007. Mayo Foundation for Medical Education and Research. 9 Sep. 2007. .

American Diabetes Association. "Physical Activity/Exercise and Diabetes." Diabetes Care. 27.1 Jan. 2004. S58-62. 5 Sept. 2007. .

"What I Need to Know About Physical Activity and Exercise." National Diabetes Information Clearinghouse. June 2004. National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health. 9 Sep. 2007. .

“Diet and Exercise: The Keys to Success with Diabetes.” The Cleveland Clinic Health Information Center. 18 July 2003. Cleveland Clinic Foundation. 9 Sep. 2007.

Diabetes - A Complicated Disease

Diabetes is a chronic disease with many complications. Short-term and long-term complications, as well as co-existing diseases, are a constant threat. Both type 1 and type 2 diabetes may develop the same complications, but symptoms of the complications in people with type 2 may be the first signs of diabetes.

Short-term complications are the day-to-day problems that can attack without warning, such as hypoglycemia and hyperglycemia. Diabetic ketoacidosis and hyper-osmolar syndrome are emergency situations that require immediate care.

Read about short-term complications:

• Hypoglycemia
• Hyperglcemia
• Diabetic Ketoacidosis (DKA)
• Hyperglycemic Hyperosmolar Nonketotic Coma (HHNKC)
• When to go to the ER - Diabetic Emergencies

Diabetes is a chronic illness with no cure, and it is progressive. Long-term complications are the result of damage that can occur over a period of years.

Long-term complications:

• Nephropathy - Kidney Disease in Diabetes
• Neuropathy and Diabetes
• Retinopathy and Diabetes

Diabetes can affect other aspects of the body as well. Besides cardiovascular diseases and associated conditions, it can also wreak havoc with emotions and alter quality of life.

Conditions Associated with Diabetes:

• Erectile Dysfunction and Diabetes
• Depression and Diabetes
• Heart Disease and Diabetes
• Stroke and Diabetes
• High Blood Pressure and Diabetes

Complications are a fact of life when you have diabetes, but knowing what you are up against is half the battle.

Heart Disease and Diabetes

Heart disease is any disorder that makes the heart function differently than it should. Heart disease is one of the most common complications of diabetes.

Why Heart Disease Is Common in People With Diabetes

People with diabetes tend to have more “bad” (LDL) cholesterol and less “good” (HDL) cholesterol. HDL cholesterol helps move bad cholesterol from the bloodstream to the liver. Over time, excess LDL cholesterol in the bloodstream is deposited inside blood vessels, where it sticks to the walls of the vessels and interferes with blood flow.

If the vessels leading to the heart become clogged, this can lead to a heart attack. If vessels leading to the legs become clogged, peripheral arterial disease (PAD) can result.

In addition to cholesterol levels, diabetes itself can bring about significant cardiac health risk, due in part to changes in the blood vessels produced by hyperglycemia, changes in blood coagulation properties, and changes in the plaques that form in the blood vessels of diabetics.

Minimizing Your Risks for Heart Disease

People with diabetes are two to four times more likely to have a stroke or heart attack than those without the disease. They are also at a higher risk for PAD. However, this doesn’t mean heart disease is inevitable. A great deal can be done to help minimize the risks.

Research has shown that making certain healthy lifestyle changes can reduce the risk of heart disease. Eating a heart-healthy diet, achieving an optimal weight and sticking to a daily exercise routine all help.

In addition, several studies have found that keeping blood sugar levels within a target range is vital. According to researchers at the Johns Hopkins Bloomberg School of Public Health, for each percentage point increase in A1c levels, the risk of heart disease increases by 14%. Anyone with diabetes should make sure to check blood sugar levels regularly. A health care provider can help set an ideal target range for blood sugar levels.

Symptoms of Heart Disease

Chest pain is a common heart attack symptom. Since diabetes can impact the nerves, some people with diabetes have heart attacks without experiencing any pain whatsoever. These so-called silent heart attacks are not usually diagnosed until a routine medical exam.

Anyone who has experienced a silent heart attack is at greater risk for another, more serious heart attack and should be closely monitored by a cardiologist.

In addition to chest pain, heart attack symptoms can include:

• Discomfort or pain in the back, arms, neck or stomach
• Shortness of breath
• Sweating or lightheadedness
• Nausea or indigestion
• Extreme weakness or anxiety

If any of these symptoms lasts for more than five minutes, the Cleveland Clinic suggests getting emergency treatment immediately.

Peripheral arterial disease may also reveal no symptoms, particularly in someone who has diabetic neuropathy, a condition that affects the nerves, making it difficult to feel sensation. A doctor may order an ankle-brachial index to diagnose PAD, or check the pulses in the feet and legs to see if circulation is impaired.

Some symptoms of PAD include:

• Painful cramps in the thigh, calves or hips during such exercise as walking or stair climbing
• Persistent leg pain that continues even after exercise is stopped
• Wounds on feet that are slow to heal or don’t heal
• Gangrene
• A much lower temperature in the affected foot or leg compared to rest of body

Because heart disease can be without symptoms until something major occurs, it’s essential to minimize the risk factors.

_Sources:

_{“Heart Attack Symptoms.” The Cleveland Clinic Heart and Vascular Institute. (Sep. 2006). The Cleveland Clinic. 7 Sep 2007. .}

_{"Diabetes and cardiovascular disease: Lifestyle changes and medication can improve your health." Mayo Clinic. 05 May 2005. CNN. 8 Sep 2007}

_{Van der Horst, Iwan C.C., M.W.N Nijsten, M. Vogelzang, and F. Zijlstra. “Persistent hyperglycemia is an independent predictor of outcome in acute myocardial infarction.” (2007) Cardiovascular Diabetology. 6:2. 7 Sep 2007. .}

_{Selvin, Elizabeth, S. Marinopoulos, G. Berkenblit, T. Rami, F. L. Brancati, N. R. Powe, and S. H. Golden. “Meta-Analysis: Glycosylated Hemoglobin and Cardiovascular Disease in Diabetes Mellitus.” Annals of Internal Medicine. (2004). 141: 421 – 31.}

_{“Know the Warning Signs of a Heart Attack.” Diabetes.org. 5 Sep 2007. American Diabetes Association. <>.}

What is Prediabetes?

Over 41 million adult Americans between the ages of 40 to 74 have pre-diabetes. If you are diagnosed with prediabetes, it means that the cells in your body are becoming resistant to insulin and your blood glucose levels are higher than normal, although not high enough to qualify as type 2 diabetes.

What is the impact of diabetes?

Over time, diabetes can lead to blindness, kidney failure, and nerve damage. These types of damage are the result of damage to small vessels, referred to as microvascular disease. Diabetes is also an important factor in accelerating the hardening and narrowing of the arteries (atherosclerosis), leading to strokes, coronary heart disease, and other large blood vessel diseases. This is referred to as macrovascular disease. Diabetes affects approximately 17 million people (about 8% of the population) in the United States. In addition, an estimated additional 12 million people in the United States have diabetes and don't even know it.

From an economic perspective, the total annual cost of diabetes in 1997 was estimated to be 98 billion dollars in the United States. The per capita cost resulting from diabetes in 1997 amounted to $10,071.00; while healthcare costs for people without diabetes incurred a per capita cost of $2,699.00. During this same year, 13.9 million days of hospital stay were attributed to diabetes, while 30.3 million physician office visits were diabetes related. Remember, these numbers reflect only the population in the United States. Globally, the statistics are staggering.

Diabetes is the third leading cause of death in the United States after heart disease and cancer.

What is diabetes?

Diabetes mellitus is a group of metabolic diseases characterized by high blood sugar (glucose) levels, that result from defects in insulin secretion, or action, or both. Diabetes mellitus, commonly referred to as diabetes (as it will be in this article) was first identified as a disease associated with "sweet urine," and excessive muscle loss in the ancient world. Elevated levels of blood glucose (hyperglycemia) lead to spillage of glucose into the urine, hence the term sweet urine.

Normally, blood glucose levels are tightly controlled by insulin, a hormone produced by the pancreas. Insulin lowers the blood glucose level. When the blood glucose elevates (for example, after eating food), insulin is released from the pancreas to normalize the glucose level. In patients with diabetes, the absence or insufficient production of insulin causes hyperglycemia. Diabetes is a chronic medical condition, meaning that although it can be controlled, it lasts a lifetime.