Diabetes

Wednesday, October 25, 2006

Introduction
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Your doctor says you have diabetes. This guide will help you learn how to take care of your diabetes and how to prevent some of the serious problems that diabetes can cause. This guide was written with help from people like you, people who have diabetes and wanted more information about it. I hope Your Guide to Diabetes: Type 1 and Type 2 will answer many of your questions. You may want to share this information with your family and friends so they too will understand more about diabetes and how they can help you live a healthy life. And remember, you can always ask your health care team any questions you might have

To view information on another digestive disease, click on Digestive Diseases Library.

Digestive Diseases Library
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Diabetes
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Diabetes means your blood glucose (often called blood sugar) is too high. Your blood always has some glucose in it because your body needs glucose for energy to keep you going. But too much glucose in the blood isn't good for your health
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How do you get high blood glucose?
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Glucose comes from the food you eat and is also made in your liver and muscles. Your blood carries the glucose to all the cells in your body. Insulin is a chemical (a hormone) made by the pancreas. The pancreas releases insulin into the blood. Insulin helps the glucose from food get into your cells. If your body doesn’t make enough insulin, or if the insulin doesn’t work the way it should, glucose can’t get into your cells. It stays in your blood instead. Your blood glucose level then gets too high, causing pre-diabetes or diabetes.
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What is pre-diabetes?

Pre-diabetes is a condition in which blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes. People with pre-diabetes are at increased risk for developing type 2 diabetes and for heart disease and stroke. The good news is, if you have pre-diabetes, you can reduce your risk of getting diabetes. With modest weight loss and moderate physical activity, you can delay or prevent type 2 diabetes and even return to normal glucose levels
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Pre-Diabetes
Before people develop type 2 diabetes, they almost always have "pre-diabetes" -- blood glucose levels that are higher than normal but not yet high enough to be diagnosed as diabetes. There are 54 million people in the United States who have pre-diabetes. Recent research has shown that some long-term damage to the body, especially the heart and circulatory system, may already be occurring during pre-diabetes.

Research has also shown that if you take action to manage your blood glucose when you have pre-diabetes, you can delay or prevent type 2 diabetes from ever developing. Together with the National Institute of Diabetes and Digestive and Kidney Diseases, the American Diabetes Association published a Position Statement on "The Prevention or Delay of Type 2 Diabetes" to help guide health care professionals in treating their patients with pre-diabetes.
There is a lot you can do yourself to know your risks for pre-diabetes and to take action to prevent diabetes if you have, or are at risk for, pre-diabetes. The American Diabetes Association has a wealth of resources for people with diabetes. People with pre-diabetes can expect to benefit from much of the same advice for good nutrition and physical activity. The links on this page are cornerstones of successful management of pre-diabetes.

How to Tell if You Have Pre-Diabetes
Learn how you may be at risk for pre-diabetes.

How to Prevent Pre-Diabetes
Pre-diabetes is a serious medical condition that can be treated.

The good news is that the recently completed Diabetes Prevention Program study conclusively showed that people with pre-diabetes can prevent the development of type 2 diabetes by making changes in their diet and increasing their level of physical activity.

Frequently Asked Questions about Pre-Diabetes
How do I know if I have pre-diabetes? What is the treatment for pre-diabetes? Learn the answers to these questions and more in this section.

Common Concerns
In this section, learn more about common concerns that people with diabetes face every day. These include what happens when you're sick, and when you travel, should you get a flu/pneumonia shot, and dealing with feelings like anger and depression.

Diabetes Learning Center
It's essential for people with diabetes to take care of themselves. To help you take the first steps toward better diabetes care, we have created the Diabetes Learning Center, an area for people who are newly diagnosed with diabetes, or those needing basic information.

The signs of diabetes are:

being very thirsty
urinating often
feeling very hungry or tired
losing weight without trying
having sores that heal slowly
having dry, itchy skin
losing the feeling in your feet or having tingling in your feet
having blurry eyesight

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You may have had one or more of these signs before you found out you had diabetes. Or you may have had no signs at all. A blood test to check your glucose levels will show if you have pre-diabetes or diabetes
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What kind of diabetes do you have?
People can get diabetes at any age. There are three main kinds:

Type 1 diabetes, formerly called juvenile diabetes or insulin-dependent diabetes, is usually first diagnosed in children, teenagers, or young adults. With this form of diabetes, the beta cells of the pancreas no longer make insulin because the body’s immune system has attacked and destroyed them. Treatment for type 1 diabetes includes taking insulin, making wise food choices, being physically active, taking aspirin daily (for some), and controlling blood pressure and cholesterol
Type 2 diabetes, formerly called adult-onset diabetes or noninsulin-dependent diabetes, is the most common form of diabetes. People can develop type 2 diabetes at any age—even during childhood. This form of diabetes usually begins with insulin resistance, a condition in which fat, muscle, and liver cells do not use insulin properly. At first, the pancreas keeps up with the added demand by producing more insulin. In time, however, it loses the ability to secrete enough insulin in response to meals. Being overweight and inactive increases the chances of developing type 2 diabetes. Treatment includes using diabetes medicines, making wise food choices, being physically active, taking aspirin daily, and controlling blood pressure and cholesterol.Some women develop gestational diabetes during the late stages of pregnancy. Although this form of diabetes usually goes away after the baby is born, a woman who has had it is more likely to develop type 2 diabetes later in life
Gestational diabetes is caused by the hormones of pregnancy or a shortage of insulin....

This guide is for people who have either type 1 diabetes or type 2 diabetes.
Why do you need to take care of your diabetes?After many years, diabetes can lead to serious problems with your eyes, kidneys, nerves, and gums and teeth. But the most serious problem caused by diabetes is heart disease. When you have diabetes, you are more than twice as likely as people without diabetes to have heart disease or a stroke.
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If you have diabetes, your risk of a heart attack is the same as someone who has already had a heart attack. Both women and men with diabetes are at risk. You may not even have the typical signs of a heart attack.
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You can reduce your risk of developing heart disease by controlling your blood pressure and blood fat levels. If you smoke, talk with your doctor about quitting. Remember that every step toward your goals helps!
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Later in this guide, we'll tell you how you can try to prevent or delay long-term problems. The best way to take care of your health is to work with your health care team to keep your blood glucose, blood pressure, and cholesterol in your target range.What's a desirable blood glucose level?...Everyone's blood has some glucose in it. In people who don't have diabetes, the normal range is about 70 to 120. Blood glucose goes up after eating but 1 or 2 hours later returns to the normal range....Ask your health care team when you should check your blood glucose with a meter. Talk about whether the blood glucose targets listed below are best for you. Then write in your own targets. Blood glucose targets for most people with diabetes:
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Levels...... My target levels My Actual Levels
Before meals=... 90 to 130............____ to ____............
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Levels 1 or 2 hrs.
after a meal=.....less than 180......less than ____..........
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It may be hard to reach your target range all of the time. But the closer you get to your goal, the more you will reduce your risk of diabetes-related problems and the better you will feel. Every step helps.
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Do four things every day to lower high blood glucose:
.... 1. Follow your meal plan
.... 2. Be physically active
.... 3. Take your diabetes medicine
.... 4. Check your blood glucose
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Experts say most people with diabetes should try to keep their blood glucose level as close as possible to the level of someone who doesn't have diabetes. The closer to normal your blood glucose is, the lower your chances are of developing serious health problems.Check with your doctor about the right range for you
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Your health care team will help you learn how to reach your target blood glucose range.
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Your main health care providers are your
... 1. doctor;
... 2. nurse;
... 3. diabetes educator; and
... 4. dietitian.
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When you see your health care provider, ask lots of questions. Before you leave, be sure you understand everything you need to know about taking care of your diabetes.
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A diabetes educator is a health care worker who teaches people how to manage their diabetes. Your educator may be a nurse, a dietitian, or other kind of health care worker
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A dietitian is someone who's specially trained to help people plan their meals.
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Follow Your Meal PlanPeople with diabetes should have their own meal plan. Ask your doctor to give you the name of a dietitian who can work with you to develop a meal plan. Your dietitian can help you plan meals that include foods that you and your family like to eat and that are good for you too. Ask your dietitian to include foods that are heart-healthy to reduce your risk of heart disease.
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Your diabetes meal plan will include breads, cereals, rice, and grains; fruits and vegetables; meat and meat substitutes; dairy products; and fats. People with diabetes don’t need to eat special foods. The foods on your meal plan are good for everyone in your family! Making wise food choices will help you:

reach and stay at a weight that's good for your body;
keep your blood glucose, blood pressure, and cholesterol under control; and
prevent heart and blood vessel disease

Diabetes can start at any age.
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ACTION STEPS
If you use insulin
Follow your meal plan.
Don't skip meals, especially if you've already taken your insulin, because your blood glucose may go too low.
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ACTION STEPS
If you DON'T use insulin

Follow your meal plan.
Don't skip meals, especially if you take diabetes medicine, because your blood glucose may go too low.
It may be better to eat several small meals during the day instead of one or two big meals. ...

Be Physically Active
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Physical activity is good for your diabetes. Walking, swimming, dancing, riding a bicycle, playing baseball, and bowling are all good ways to be active. You can even get exercise when you clean house or work in your garden. Physical activity is especially good for people with diabetes because:
... 1. physical activity helps keep weight down
... 2. physical activity helps insulin work better to lower blood glucose
... 3. physical activity is good for your heart and lungs
... 4. physical activity gives you more energy
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Before you begin exercising, talk with your doctor. Your doctor may check your heart and your feet to be sure you have no special problems. If you have high blood pressure or eye problems, some exercises like weightlifting may not be safe. Your health care team can help you find safe exercises
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Try to be active almost every day for a total of about 30 minutes. If you haven't been very active lately, begin slowly. Start with 5 to 10 minutes, and then add more time. Or exercise for 10 minutes, three times a day.
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If your blood glucose is less than 100 to 120, have a snack before you exercise.
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Being active helps you feel better. When you exercise, carry glucose tablets or a carbohydrate snack with you in case you get hypoglycemia. Wear or carry an identification tag or card saying that you have diabetes.
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ACTION STEPS
If you use insulin

See your doctor before starting a physical activity program.
Check your blood glucose before, during, and after exercising.
Don't exercise when your blood glucose is over 240 or if you have ketones in your urine.
Don’t exercise right before you go to sleep because it could cause hypoglycemia during the night.

ACTION STEPS
If you don't use insulin
See your doctor before starting a physical activity program.
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Take Your Diabetes Medicine Every Day
Insulin and diabetes pills are the two kinds of medicines used to lower blood glucose.
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If You Use Insulin
You need insulin if your body has stopped making insulin or if it doesn't make enough. Everyone with type 1 diabetes needs insulin, and many people with type 2 diabetes do too. Some women with gestational diabetes also need to take insulin.
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You may need insulin to control your blood glucose. There are five ways to take insulin:
Taking shots, also called injections. You’ll use a needle attached to a syringe—a hollow tube with a plunger—that you fill with a dose of insulin. Some people use an insulin pen, a pen-like device with a needle and a cartridge of insulin.

Using an insulin pump. A pump is a small device, worn on a belt or in a pocket, that holds insulin. The pump connects to a small plastic tube and a very small needle. The needle is inserted under the skin and stays in for several days.
Using an insulin jet injector. This device sends a fine spray of insulin through the skin with high-pressure air instead of a needle.
Using an insulin infuser. A small tube is inserted just beneath the skin and remains in place for several days. Insulin is injected into the end of the tube instead of through the skin.
Using inhaled insulin. You’ll use a special device to breathe in powdered insulin through the mouth.
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If You Take Diabetes Pills

If your body makes insulin, but the insulin doesn't lower your blood glucose, you may need diabetes pills. Some pills are taken once a day, and others are taken more often. Ask your health care team when you should take your pills.

Be sure to tell your doctor if your pills make you feel sick or if you have any other problems. Remember, diabetes pills don’t lower blood glucose by themselves. You'll still want to follow a meal plan and be active to help lower your blood glucose.

Sometimes, people who take diabetes pills may need insulin for a while. If you get sick or have surgery, the diabetes pills may no longer work to lower your blood glucose.

You may be able to stop taking diabetes pills if you lose weight. (Always check with your doctor before you stop taking your diabetes pills.) Losing 10 or 15 pounds can sometimes help you reach your target blood glucose level.

If You Don't Use Insulin or Take Diabetes Pills

Many people with type 2 diabetes don't need insulin or diabetes pills. They can take care of their diabetes by using a meal plan and exercising regularly.

Many people with type 2 diabetes take pills to help keep blood glucose in their target range.

Check Your Blood Glucose as Recommended

You'll want to know how well you're taking care of your diabetes. The best way to find out is to check your blood to see how much glucose is in it. If your blood has too much or too little glucose, you may need a change in your meal plan, exercise plan, or medicine.

Ask your doctor how often you should check your blood glucose. Some people check their blood glucose once a day. Others do it three or four times a day. You may check before and after eating, before bed, and sometimes in the middle of the night.

Your doctor or diabetes educator will show you how to check your blood using a blood glucose meter. Your health insurance or Medicare may pay for the supplies and equipment you need. Checking your blood glucose will help you see if your diabetes treatment plan is working.

Take Other Tests for your Diabetes:

Urine Tests

Tests for Your Diabetes

You may need to check your urine if you're sick or if your blood glucose is over 240. A urine test will tell you if you have ketones in your urine. Your body makes ketones when there isn't enough insulin in your blood. Ketones can make you very sick. Call your doctor right away if you find moderate or large amounts of ketones, along with high blood glucose levels, when you do a urine test. You may have a serious condition called ketoacidosis. If it isn't treated, it can cause death. Signs of ketoacidosis are vomiting, weakness, fast breathing, and a sweet smell on the breath. Ketoacidosis is more likely to develop in people with type 1 diabetes. You can buy strips for testing ketones at a drug store. Your doctor or diabetes educator will show you how to use them.

The A1C Test

Another test for blood glucose, the A1C, also called the hemoglobin A1C test, shows what your overall blood glucose was for the past 3 months. It shows how much glucose is sticking to your red blood cells. The doctor does this test to see what your blood glucose is most of the time. Have this test done at least twice a year. Ask your doctor what your A1C test showed. A result of under 7 usually means that your diabetes treatment is working well and your blood glucose is under control. If your A1C is 8 or above, your blood glucose may be too high. You’ll then have a greater risk of having diabetes problems, like kidney damage. You may need a change in your meal plan, physical activity plan, or diabetes medicine.A1C Results Target for most people under 7.

Time to change my diabetes care plan is when my A1C Results are 8 or above. Talk with your doctor about what your target should be. Even if your A1C is higher than your target, remember that every step toward your goal helps reduce your risk of diabetes problems.

Keep Daily Records

Write down the results of your blood glucose checks every day. You may also want to write down what you ate, how you felt, and whether you exercised.

By keeping daily records of your blood glucose checks, you can tell how well you're taking care of your diabetes. Show your blood glucose records to your health care team. They can use your records to see whether you need changes in your diabetes medicines or your meal plan. If you don't know what your results mean, ask your health care team.

Things to write down every day in your record book are:

results of your blood glucose checks
your diabetes medicines: times and amounts taken
if your blood glucose was very low
if you ate more or less food than you usually do
if you were sick
if you found ketones in your urine
what kind of physical activity you did and for how long

ACTION STEPS

If you use insulin

Keep a daily record of:

your blood glucose numbers
the times of the day you took your insulin
the amount and type of insulin you took
whether you had ketones in your urine.

ACTION STEPS

If you DON'T use insulin

Keep a daily record of

your blood glucose numbers
the times of the day you took your diabetes pills
the foods you ate including: amounts, time of day, snacks
your physical activity.

printer-friendly version of sample record page

printer-friendly version of blank record page

When Your Blood Glucose Is Too High or Too Low

Sometimes, no matter how hard you try to keep your blood glucose in your target range, it's too high or too low. Blood glucose that's too high or too low can make you very sick. Here's how to handle these emergencies.

What You Need to Know About Hyperglycemia

If your blood glucose stays over 180, it may be too high. High blood glucose means you don’t have enough insulin in your body. High blood glucose, or “hyperglycemia,” can happen if you miss taking your diabetes medicine, eat too much, or don’t get enough exercise. Sometimes, the medicines you take for other problems cause high blood glucose. Be sure to tell your doctor about other medicines you take.

Having an infection, being sick, or under stress can also make your blood glucose too high. That's why it's very important to check your blood glucose and keep taking your insulin or diabetes pills when you're sick.

If you're very thirsty and tired, have blurry vision, and have to go to the bathroom often, your blood glucose may be too high. Very high blood glucose may also make you feel sick to your stomach.If your blood glucose is high much of the time, or if you have symptoms of high blood glucose, call your doctor. You may need a change in your insulin or diabetes pills, or a change in your meal plan.

What You Need to Know About Hypoglycemia

Hypoglycemia happens if your blood glucose drops too low. It can come on fast. It's caused by taking too much diabetes medicine, missing a meal, delaying a meal, exercising more than usual, or drinking alcoholic beverages. Sometimes, medicines you take for other health problems can cause blood glucose to drop.

Hypoglycemia can make you feel weak, confused, irritable, hungry, or tired. You may sweat a lot or get a headache. You may feel shaky. If your blood glucose drops lower, you could pass out or have a seizure

If you have any of these symptoms, check your blood glucose. If the level is 70 or below, have one of the following right away:

2 or 3 glucose tablets
1/2 cup (4 ounces) of any fruit juice
a piece of fruit or a small box of raisins
1 cup (8 ounces) of milk
1/2 cup (4 ounces) of a regular (not diet) soft drink
5 or 6 pieces of hard candy
1 or 2 teaspoons of sugar or honey

When your blood glucose is too low, do these steps:

Have one of these "quick fix" foods listed above.
After 15 minutes, check your blood glucose again to make sure your level is 70 or above.
Repeat these steps as needed.
Once your blood glucose is stable, if it will be at least an hour before your next meal, have a snack.

How to protect yourself if you blood glucose has dropped too low:

If you take insulin or a diabetes pill that can cause hypoglycemia, always carry food for emergencies.
It's a good idea also to wear a medical identification bracelet or necklace.
If you take insulin, keep a glucagon kit at home and at a few other places where you go often. Glucagon is given as an injection with a syringe and quickly raises blood glucose.
Show your family, friends, and co-workers how to give you a glucagon injection if you pass out because of hypoglycemia.

You can prevent hypoglycemia by:

eating regular meals,
taking your diabetes medicine,
and checking your blood glucose often. Checking will tell you whether your glucose level is going down. You can then take steps, like drinking fruit juice, to raise your blood glucose.

When you have hypoglycemia, have a snack to bring your blood glucose back to normal.

ACTION STEPS

If you use insulin

Tell your doctor if you have hypoglycemia often, especially at the same time of the day or night several times in a row.
Tell your doctor if you've passed out from hypoglycemia.
Ask your doctor about glucagon. Glucagon is a medicine that raises blood glucose.
If you pass out from hypoglycemia, someone should call 911 and give you a glucagon shot.

ACTION STEPS

If you DON'T use insulin

Tell your doctor if you have hypoglycemia often, especially at the same time of the day or night several times in a row.
Be sure to tell your doctor about other medicines you are taking.
Some diabetes pills can cause hypoglycemia. Ask your doctor whether your pills can cause hypoglycemia.

Why Taking Care of Your Diabetes Is Important

Taking care of your diabetes every day will help keep your blood glucose in your target range and help prevent other health problems that diabetes can cause over the years. This part of the guide describes those problems. You are told these things, not to scare you, but to help you understand what you can do to keep them from happening.

Do what you can every day to keep your blood glucose in the range that's best for you.
Follow your meal plan every day.
Be physically active every day.
Take your diabetes medicine every day.
Check your blood glucose as recommended.

Diabetes and Your Heart and Blood Vessels
The biggest problem for people with diabetes is heart and blood vessel disease. Heart and blood vessel disease can lead to heart attacks and strokes. It also causes poor blood flow (circulation) in the legs and feet.

To check for heart and blood vessel disease, your health care team will do some tests.

At least once a year, have a blood test to see how much cholesterol is in your blood.
Your health care provider should take your blood pressure at every visit.
Your provider may also check the circulation in your legs, feet, and neck.

The best way to prevent heart and blood vessel disease is to take good care of yourself and your diabetes.

Eat foods that are low in fat and salt.
Keep your blood glucose on track.
Know your A1C. The target for most people is under 7.
If you smoke, quit.
Be physically active.
Lose weight if you need to.
Ask your health care team whether you should take an aspirin every day.
Keep your blood pressure on track. The target for most people is under 130/80. If needed, take medicine to control your blood pressure.
Keep your cholesterol level on track. The target for LDL cholesterol for most people is under 100. If needed, take medicine to control your blood fat levels.

What's a desirable blood pressure level?
Blood pressure levels tell how hard your blood is pushing against the walls of your blood vessels. Your pressure is given as two numbers: The first is the pressure as your heart beats and the second is the pressure as your heart relaxes. If your blood pressure is higher than your target, talk with your health care team about changing your meal plan, exercising, or taking medicine.
Blood Pressure ResultsTarget for most people with diabetes

under 130/80 ......My last result..............................____________

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...................................... My target............................. ____________

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What are desirable blood fat levels?

Cholesterol, a fat found in the body, appears in different forms. If your LDL cholesterol ("bad" cholesterol) is 100 or above, you are at increased risk of heart disease and may need treatment. A high level of total cholesterol also means a greater risk of heart disease. But HDL cholesterol ("good" cholesterol) protects you from heart disease, so the higher it is, the better. It's best to keep triglyceride (another type of fat) levels under 150. All of these target numbers are important for preventing heart disease.

Target Blood Fat Levels for People With Diabetes

Total cholesterol under 200.My last result_____My target ..... _____

LDL cholesterol under 100..My last result_____My target ..... _____

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HDL cholesterolabove 40 (men)My last result _____

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My target ...... _____above 50 (women)

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My last result _____

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My target ...... _____

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Triglycerides under 150

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My last result _____

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My target ...... _____

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Diabetes and Your Eyes

Have your eyes checked once a year. You could have eye problems that you haven't noticed yet. It is important to catch eye problems early when they can be treated. Treating eye problems early can help prevent blindness.
High blood glucose can make the blood vessels in the eyes bleed. This bleeding can lead to blindness. You can help prevent eye damage by keeping your blood glucose as close to normal as possible. If your eyes are already damaged, an eye doctor may be able to save your sight with laser treatments or surgery.
The best way to prevent eye disease is to have a yearly eye exam. In this exam, the eye doctor puts drops in your eyes to dilate your pupils. When the pupils are dilated, or big, the doctor can see into the back of the eye. This is called a dilated eye exam and it doesn’t hurt. If you've never had this kind of eye exam before, you should have one now, even if you haven't had any trouble with your eyes. Be sure to tell your eye doctor that you have diabetes.

Here are some tips for taking care of your eyes:

For adults and adolescents (10 years old and older) with type 1 diabetes: Have your eyes examined within 3 to 5 years of being diagnosed with diabetes. Then have an exam every year.
For people with type 2 diabetes: Have an eye exam every year.
For women planning to have a baby: Have an eye exam before becoming pregnant.
If you smoke, quit.
Keep your blood glucose and blood pressure as close to normal as possible.
Tell your eye doctor right away if you have any problems like blurry vision or seeing dark spots, flashing lights, or rings around lights.
See your eye doctor for an eye exam with dilated pupils every year.
Early treatment of eye problems can help save your sight.
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Diabetes and Your Kidneys

Your kidneys help clean waste products from your blood. They also work to keep the right balance of salt and fluid in your body.

Too much glucose in your blood is very hard on your kidneys. After a number of years, high blood glucose can cause the kidneys to stop working. This condition is called kidney failure. If your kidneys stop working, you'll need dialysis (using a machine or special fluids to clean your blood) or a kidney transplant.

Make sure you have the following tests at least once a year to make sure your kidneys are working well:

a urine test for protein, called the microalbumin test
a blood test for creatinine
Some types of blood pressure medicines can help prevent kidney damage. Ask your doctor whether these medicines could help you.

You can also help prevent kidney problems by doing the following:

Take your medicine if you have high blood pressure.
Ask your doctor or your dietitian whether you should eat less protein (meat, poultry, cheese, milk, fish, and eggs).
See your doctor right away if you get a bladder or kidney infection. Signs of bladder or kidney infections are cloudy or bloody urine, pain or burning when you urinate, and having to urinate often or in a hurry. Back pain, chills, and fever are also signs of kidney infection.
Keep your blood glucose and blood pressure as close to normal as possible.
If you smoke, quit.

Diabetes and Your Nerves

Over time, high blood glucose can harm the nerves in your body. Nerve damage can cause you to lose the feeling in your feet or to have painful, burning feet. It can also cause pain in your legs, arms, or hands or cause problems with eating, going to the bathroom, or having sex.

Nerve damage can happen slowly. You may not even realize you have nerve problems. Your doctor should check your nerves at least once a year. Part of this exam should include tests to check your sense of feeling and the pulses in your feet.
Tell the doctor about any problems with your feet, legs, hands, or arms. This might be Peripheral Neuropathy. Also, tell the doctor if you have trouble digesting food, going to the bathroom, or having sex, or if you feel dizzy sometimes.
Nerve damage to the feet can lead to amputations. You may not feel pain from injuries or sore spots on your feet. If you have poor circulation because of blood vessel problems in your legs, the sores on your feet can't heal and might become infected. If the infection isn't treated, it could lead to amputation.
Ask your doctor whether you already have nerve damage in your feet. If you do, it is especially important to take good care of your feet. To help prevent complications from nerve damage, check your feet every day.

Here are some ways to take care of your nerves:

Keep your blood glucose and blood pressure as close to normal as possible.
Limit the amount of alcohol you drink.
Check your feet every day.
If you smoke, quit.

Foot Care Tips:
You can do a lot to prevent problems with your feet. Keeping your blood glucose in your target range and taking care of your feet can help protect them.

Check your bare feet every day. Look for cuts, sores, bumps, or red spots. Use a mirror or ask a family member for help if you have trouble seeing the bottoms of your feet.
Wash your feet in warm—not hot—water every day, but don't soak them. Use mild soap.
Dry your feet with a soft towel, and dry carefully between your toes.
After washing your feet, cover them with lotion before putting your shoes and socks on.
Don't put lotion or cream between your toes.
File your toenails straight across with an emery board. Don't leave sharp edges that could cut the next toe.
Don't try to cut calluses or corns off with a razor blade or knife, and don't use wart removers on your feet. If you have warts or painful corns or calluses, see a podiatrist, a doctor who treats foot problems.
Wear thick, soft socks.
Don't wear mended stockings or stockings with holes or seams that might rub against your feet.
Check your shoes before you put them on to be sure they have no sharp edges or objects in them.
Wear shoes that fit well and let your toes move. Break new shoes in slowly. Don't wear flip-flops, shoes with pointed toes, or plastic shoes. Never go barefoot.
Wear socks if your feet get cold at night. Don't use heating pads or hot water bottles on your feet.
Have your doctor check your feet at every visit. Take your shoes and socks off when you go into the examining room. This will remind the doctor to check your feet.
See a podiatrist for help if you can't take care of your feet yourself.

Peripheral Neuropathy

If you are found to have Peripheral Neuropathy, there are medications to help you with the pain from this disease. One such medication is Lycra.

About Lycra:

LYRICA is not for everyone. Some of the most common side effects of LYRICA are:

dizziness and sleepiness,
dry mouth,
swelling of hands and feet,
blurry vision,
weight gain, and
trouble concentrating.

You may have a higher chance of swelling or gaining weight if you are also taking certain diabetes medicines. And, if you drink alcohol or take medicines that make you sleepy, you may feel more sleepy when you start LYRICA.

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You should not drive a car or work with machines until you know how LYRICA affects you. Tell your doctor about any changes in your eyesight, muscle pain along with a fever or tired feeling, or skin sores due to diabetes. Also tell your doctor if you are planning to father a child. Tell your doctor if you are pregnant, plan to become pregnant, or are breast-feeding. If you have had a drug or alcohol problem, you may be more likely to misuse LYRICA. You should talk with your doctor before you stop taking LYRICA, or any other prescription medication.
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PATIENT INFORMATION (LEER- i- kah) Read the Patient Information that comes with LYRICA before you start taking it and each time you get a refill. There may be new information.

This information does not take the place of talking with your doctor about your condition or treatment. If you have any questions about LYRICA, ask your doctor or pharmacist.

What is the most important information I should know about LYRICA?
1. LYRICA may cause dizziness and sleepiness.

Do not drive a car, work with machines, or do other dangerous activities until you know how LYRICA affects how alert you are. Ask your doctor when it is okay to do these activities.

2. LYRICA may cause problems with your eyesight, including blurry vision.

Call your doctor if you have any changes in your eyesight.

What is LYRICA?
LYRICA is a prescription medicine used in adults, 18 years andolder, to treat:

pain from damaged nerves (neuropathic pain) that happens with diabetes,
pain from damaged nerves (neuropathic pain) that follows healing of shingles (a painful rash that comes after a herpes zoster infection)
partial seizures when taken together with other seizure medicines

Pain From Damaged Nerves (neuropathic pain)

Diabetes and shingles can damage your nerves.
Pain from damaged nerves may feel:

.........1. sharp,

.........2. burning,

..........3. tingling,

..........4. shooting, or

..........5. numb.

If you have peripheral neuropathy due to diabetes, the pain can be in your:

..........1. arms,

..........2. hands,

..........3. fingers,

..........4. legs,

..........5. feet, or

..........6. toes.

If you have shingles, the pain is in the area of your rash.
You may experience this kind of pain even with a very light touch.

LYRICA can help relieve the pain. Some people taking LYRICA had less pain by the end of the first week of LYRICA therapy. LYRICA may not work for everyone. LYRICA has not been studied for nerve pain in children under 18 years of age.

Partial Seizures

Partial seizures start in one part of the brain. A seizure can make you fearful, confused, or just feel “funny”. You may smell strange smells. A seizure may cause your arm or leg to jerk or shake. It canspread to other parts of your brain, make you pass out, and causeyour whole body to start jerking.

...
LYRICA can lower the number of seizures for people who are already taking seizure medicine.

...

LYRICA has not been studied for partial seizures in children under 18 years of age.
...

Who Should Not Take LYRICA?Do not take LYRICA if you are allergic to any of its ingredients. The active ingredient is pregabalin. See the end of this information for a complete list of ingredients in LYRICA.
What should I tell my doctor before taking LYRICA?

Tell your doctor about all your medical conditions, including if you:

• have any kidney problems or get kidney dialysis
• have heart problems including heart failure
• have a bleeding problem or a low blood platelet count
• are pregnant or plan to become pregnant. It is not known if LYRICA may harm your unborn baby. You and your doctor will have to decide if LYRICA is right for you while you are pregnant.
• are breastfeeding. It is not known if LYRICA passes into breast milk and if it can harm your baby. You and your doctor should decide whether you should take LYRICA or breastfeed, but not both.
• Tell your doctor about all the medicines you take includingprescription or non- prescription medicines, vitamins or herbalsupplements. LYRICA and other medicines may affect each other.

Especially tell your doctor if you take:

• rosiglitazone (Avandia®) or pioglitazone (Actos®) for diabetes. You may have a higher chance of weight gain or swelling if these medicines are taken with LYRICA. See "What are the possible side effects of LYRICA."
• any narcotic pain medicine (such as oxycodone), tranquilizersor medicines for anxiety (such as lorazepam). You may have a higher chance for dizziness and sleepiness if these medicines are taken with LYRICA. See "What is the most important information I should know about LYRICA?"
• any medicines that make you sleepy

Know all the medicines you take. Keep a list of them with you toshow your doctor and pharmacist each time you get a new medicine.

Tell your doctor if you plan to father a child. Animal studies showed that pregabalin, the active ingredient in LYRICA, made male animals less fertile. Also, in animal studies, birth defects occurred in the offspring of male animals who were treated with pregabalin. It is not known if these effects would happen in people.

How should I take LYRICA?

Take LYRICA exactly as prescribed. Your doctor may adjust your dose during treatment. Do not change your dose without talking to your doctor.
Do not stop taking LYRICA suddenly without talking to your doctor. If you stop taking LYRICA suddenly, you may have headaches, nausea, diarrhea or trouble sleeping. Talk with your doctor about how to slowly stop LYRICA.
LYRICA is usually taken 2 or 3 times a day, depending on your medical condition. Your doctor will tell you how much LYRICA to take and when to take it. Take LYRICA at the same times each day.
LYRICA may be taken with or without food.
If you miss a dose by a few hours, take it as soon as you remember. If it is close to your next dose, just take LYRICA at your next regular time. Do not take two doses at the same time.
If you take too much LYRICA, call your doctor or poison control center or go to the nearest emergency room right away.

What Should I Avoid While Taking LYRICA?

Do not drive a car, work with machines, or do other dangerous activities until you know how LYRICA affects how alert you are. See "What is the most important information I should know about LYRICA?"
Do not drink alcohol while taking LYRICA. LYRICA and alcohol can affect each other and increase side effects such as sleepiness and dizziness. This can be dangerous.
Do not take other medicines without talking to your doctor. Other medicines include prescription and non-prescription medicines, vitamins, and herbal supplements. LYRICA and other medicines may affect each other and increase the side effects of sleepiness and dizziness. Be especially careful about medicines that make you sleepy (such as sleeping pills, anxiety medicines, tranquilizers and some antihistamines, pain relievers and seizure medicines).

What are the possible side effects of LYRICA? LYRICA may cause side effects including:

dizziness and sleepiness. See "What is the most important information I should know about LYRICA?"
eyesight problems. See "What is the most important information I should know about LYRICA?"
weight gain and swelling of the hands and feet (edema). Weight gain may affect the management of diabetes. Weight gain and swelling can also be a serious problem for people with heart problems.
unexplained muscle problems, such as muscle pain, soreness, or weakness. If you develop these symptoms, especially if you also feel sick and have a fever, tell your doctor right away.
The most common side effects of LYRICA are:

..........• dizziness

..........• blurry vision

..........• weight gain

..........• sleepiness

..........• trouble concentrating

..........• swelling of hands and feet

..........• dry mouth
...

LYRICA caused skin sores in animals. Although skin sores were not seen in studies in people, if you have diabetes, you should pay extra attention to your skin while taking LYRICA and tell your doctor of any sores or skin problems.

LYRICA may cause some people to feel “high.” Tell your doctor, if you have abused prescription medicines, street drugs, or alcohol in the past.

Tell your doctor about any side effect that bothers you or that doesnot go away. These are not all the side effects of LYRICA. For more information, ask your doctor or pharmacist.

How should I store LYRICA?

Store LYRICA at room temperature, 59 to 86º F (15 to 30º C)in its original package.
Safely throw away LYRICA that is out of date or no longer needed.
Keep LYRICA and all medicines out of the reach of children.

General information about LYRICA

Medicines are sometimes prescribed for conditions other than those listed in patient information leaflets. Do not use LYRICA for a condition for which it was not prescribed. Do not give LYRICA to other people, even if they have the same symptoms you have. It may harm them.

This information summarizes the most important information about LYRICA. If you would like more information, talk with your doctor. You can ask your doctor or pharmacist for information about LYRICA that is written for health professionals.

You can also visit the LYRICA website at:

www.LYRICA.com

or call 1- 866- 4LYRICA.

What are the ingredients In LYRICA?

Active ingredient: pregabalin
Inactive ingredients:

..........1. lactose monohydrate,

..........2. cornstarch,

..........3. talc;

Capsule shell:

..........1. gelatin and

..........2. titanium dioxide;

Orange capsule shell:

..........1. red iron oxide;

White capsule shell:

..........1. sodium lauryl sulfate,

..........2. colloidal silicon dioxide. Colloidal silicon dioxide is a manufacturing aid that may or may not be present in the capsule shells.

Imprinting ink:

..........1. shellac,

..........2. black iron oxide,

..........3. propylene glycol,

..........4. potassium hydroxide.

...
PARKE -DAVISDiv of PFIZER Inc

New York, NY 10017

LAB-0299-2.0

Avandia is a registered trademark of GlaxoSmithKline. Actos is a registered trademark of Takeda Chemicals Industries,Ltd. and used under license by Takeda Pharmaceuticals of America,Inc. and Eli Lilly and Co.

Diabetes and Your Gums and Teeth

Diabetes can lead to infections in your gums and the bones that hold your teeth in place. Like all infections, gum infections can cause blood glucose to rise. Without treatment, teeth may become loose and fall out.

Help prevent damage to your gums and teeth by doing the following:

See your dentist twice a year. Tell your dentist that you have diabetes.
Brush and floss your teeth at least twice a day.
If you smoke, quit.
Keep your blood glucose as close to normal as possible.

Keeping your blood glucose in your target range, brushing and flossing your teeth every day, and having regular dental checkups are the best ways to prevent gum and teeth problems when you have diabetes.

Taking Care of Your Diabetes at SpecialTimes

Diabetes is part of your life. It's very important to take care of it when you're sick, when you're at school or work, when you travel, or when you're pregnant or thinking about having a baby. Here are some tips to help you take care of your diabetes at these times.
I. When You're Sick
Take good care of yourself when you have a cold, the flu, an infection, or other illnesses. Being sick can raise your blood glucose. When you're sick, do the following:

Check your blood glucose every 4 hours. Write down the results.Keep taking your insulin and your diabetes pills. Even if you can't keep food down, you still need your diabetes medicine. Ask your doctor or diabetes educator whether to change the amount of insulin or pills you take.
Drink at least a cup (8 ounces) of water or other calorie-free, caffeine-free liquid every hour while you're awake.
If you can't eat your usual food, try drinking juice or eating crackers, popsicles, or soup.
If you can't eat at all, drink clear liquids such as ginger ale. Eat or drink something with sugar in it if you have trouble keeping food down.
..

II. Test your urine for ketones if

your blood glucose is over 240
you can't keep food or liquids down

III. Call your health care provider right away if

your blood glucose has been over 240 for longer than a day
you have moderate to large amounts of ketones in your urine
you feel sleepier than usual
you have trouble breathing
you can't think clearly
you throw up more than once
you've had diarrhea for more than 6 hours
..

ACTION STEPS

If you use insulin

Take your insulin, even if you've been throwing up.
Ask your doctor about how to adjust your insulin dose, based on your blood glucose test results.

..
ACTION STEPS

If you DON'T use insulin

Take your diabetes pills, even if you've been throwing up.
When You're at School or WorkTake care of your diabetes when you're at school or at work:
..a. Follow your meal plan.
..b. Take your medicine and check your blood glucose as usual.
..c. Tell your teachers, friends, or close co-workers about the signs of hypoglycemia. You may need their help if your blood glucose drops too low.
..d. Keep snacks nearby and carry some with you at all times to treat hypoglycemia.
..e. Tell your company nurse or school nurse that you have diabetes.
..

When You're Away From HomeTaking care of your diabetes, even on vacation, is very important.

Here are some tips:

Follow your meal plan as much as possible when you eat out. Always carry a snack with you in case you have to wait to be served.
Limit your drinking of beer, wine, or other alcoholic beverages. Ask your diabetes educator how much alcohol you can safely drink. Eat something when you drink.
If you're taking a long trip by car, check your blood glucose before driving. Stop and check your blood glucose every 2 hours. Always carry snacks like fruit, crackers, juice, or soda in the car in case your blood glucose drops too low.
Ask ahead of time for a diabetes meal if you're traveling by plane. Most airlines serve special meals for people with health needs. Carry food (like crackers or fruit) with you in case meals are late.
Carry your medicines (insulin and diabetes pills) and your blood testing supplies with you. Never put them in your checked luggage.
Ask your health care team how to adjust your medicines, especially your insulin, if you're traveling across time zones.
Take comfortable, well-fitting shoes on vacation. You'll probably be walking more than usual, so you should take extra care of your feet.
If you're going to be away for a long time, ask your doctor for a written prescription for your diabetes medicine and the name of a doctor in the place you're going to visit.
Don't count on buying extra supplies when you're traveling, especially if you're going to another country. Different countries use different kinds of insulin and pills.
When traveling by plane, find out if and when a meal will be served. Then decide when to take your insulin shot or diabetes pills. You may need to bring your own food for the trip.

ACTION STEPS

If you use insulin

When you travel, take a special insulated bags to carry your insulin and to keep it from freezing or getting too hot.
Bring extra supplies for taking insulin and testing your blood glucose in case of loss or breakage.
Ask your doctor for a letter saying that you have diabetes and need to carry supplies for taking insulin and testing blood glucose.
..

When You're Planning a Pregnancy

Planning ahead is very important if you want to have a baby. High blood glucose can be harmful to both a mother and her unborn baby. Even before you become pregnant, your blood glucose should be close to the normal range. Keeping blood glucose near normal before and during pregnancy helps protect both mother and baby.

..
Your insulin needs may change when you're pregnant. Your doctor may want you to take more insulin and check your blood glucose more often. If you take diabetes pills, you'll take insulin instead when you're pregnant.

..
If you plan to have a baby, do the following:

Work with your health care team to get your blood glucose as close to the normal range as possible.
See a doctor who has experience in taking care of pregnant women with diabetes.
Have your eyes and kidneys checked. Pregnancy can make eye and kidney problems worse.
Don't smoke, drink alcohol, or use harmful drugs.
Follow the meal plan you get from your dietitian or diabetes educator to make sure you and your unborn baby have a healthy diet.
If you're already pregnant, see your doctor right away. It's not too late to bring your blood glucose close to normal so that you'll stay healthy during the rest of your pregnancy.
..

Where to Get More Help With Your Diabetes

People Who Can Help You:

Your doctor. He or she may be your doctor at the clinic where you go for health care, your family doctor, or someone who has special training in caring for people with diabetes. A doctor with that kind of special training is called an endocrinologist or diabetologist. You'll talk with your doctor about what kind of medicine you need and how much you should take. You'll also agree on a target blood glucose range and blood pressure and cholesterol targets. Your doctor will do tests to be sure that your blood glucose, blood pressure, and cholesterol are staying on track and that you're staying healthy. Ask your doctor if you should take aspirin every day to help prevent heart disease.
Your diabetes educator. A diabetes educator may be a nurse, a dietitian, or another kind of health care worker. Diabetes educators teach you about meal planning, diabetes medicines, physical activity, how to check your blood glucose, and how to fit diabetes care into your everyday life. Don't be shy about asking your doctor or diabetes educator about the information in this guide. Ask questions if you don't understand something. After all, it's your health!Your family and friends. Taking care of your diabetes is a daily job. You may need help or support from your family or friends. You may want to bring a family member or close friend with you when you visit your doctor or diabetes educator. Taking good care of your diabetes can be a family affair!
A counselor or mental health worker. You might feel sad about having diabetes or get tired of taking care of yourself. Or you might be having problems because of work, school, or family. If diabetes makes you feel sad or angry, or if you have other problems that make you feel bad, you can talk to a counselor or mental health worker. Your doctor or diabetes educator can help you find a counselor if you need one.

Organizations That Can Help You :

to find a diabetes educator near you, call the American Association of Diabetes Educators toll-free at 1–800–832–6874, or look on the Internet at http://www.diabeteseducator.org/ and click on “Find an Educator.”
to find a dietitian near you, call the American Dietetic Association toll-free at 1–800–366–1655, or look on the Internet at http://www.eatright.org/ and click on "Find a Dietitian."

To find programs about diabetes or for additional information, contact:

American Diabetes Association
1701 North Beauregard Street
Alexandria, VA 22311
Phone: 1–800–342–2383
Internet: http://www.diabetes.org/
Juvenile Diabetes Research Foundation International
120 Wall Street19th Floor
New York, NY 10005
Phone: 1–800–533–2873
Internet: http://www.jdrf.org/
..

Both these organizations have magazines and other information for people with diabetes.They also have local groups in many places where you can meet other people who have diabetes.

To get more information about taking care of diabetes, contact:

National Diabetes Information Clearinghouse
1 Information Way
Bethesda, MD 20892–3560
Phone: 1–800–860–8747
Fax: 703–738–4929
Email: ndic@info.niddk.nih.gov
Internet: http://www.diabetes.niddk.nih.gov/
National Diabetes Education Program
1 Diabetes Way
Bethesda, MD 20892–3600
Phone: 1–800–438–5383
Fax: 703–738–4929
Internet: http://www.ndep.nih.gov/
National Diabetes Information Clearinghouse
1 Information Way
Bethesda, MD 20892–3560
Email: ndic@info.niddk.nih.gov
..

Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scientists and outside experts.
..

This publication is not copyrighted. The Clearinghouse encourages users of this publication to duplicate and distribute as many copies as desired.
..

Scientific Studies Have Proven:

Gymnema Sylvestre is perhaps the most powerful herbal agent for improving blood sugar control. Human studies have demonstrated that Gymnema Sylvestre has therapeutic value for both type 1 and type 2 diabetics. In a study involving type 1 diabetics, average insulin requirements dropped by almost 30%. In another study of type 2 diabetics, A1c levels were reduced from 12 – 8.5%.
Studies have shown that Cinnamon Extract increases glucose metabolism. All three of the research groups that took Cinnamon Extract had significant reductions in blood sugar, ranging from 18 to 29%. The results of this study were published in the December 2003 issue of Diabetes Care.
There have been more than 20 clinical studies on Chromium supplementation in diabetes. The results of these studies have shown that Chromium lowers fasting blood sugar, improves glucose tolerance and lowers insulin levels. At least 90% of Americans have a serious Chromium shortage

...
Talk with your doctor about the use of these three supplements in order to help control your diabetes. If your doctor agrees, check with your pharmacist to find a supplement that contains all three!

To view information on another digestive disease, click on Digestive Diseases Library.

Digestive Diseases Library
..

Tuesday, October 24, 2006

Hypoglycemia

Hypoglycemia, also called low blood sugar, occurs when your blood glucose (blood sugar) level drops too low to provide enough energy for your body's activities. In adults or children older than 10 years, hypoglycemia is uncommon except as a side effect of diabetes treatment, but it can result from other medications or diseases, hormone or enzyme deficiencies, or tumors.

Glucose, a form of sugar, is an important fuel for your body. Carbohydrates are the main dietary sources of glucose. Rice, potatoes, bread, tortillas, cereal, milk, fruit, and sweets are all carbohydrate-rich foods.

After a meal, glucose molecules are absorbed into your bloodstream and carried to the cells, where they are used for energy. Insulin, a hormone produced by your pancreas, helps glucose enter cells. If you take in more glucose than your body needs at the time, your body stores the extra glucose in your liver and muscles in a form called glycogen. Your body can use the stored glucose whenever it is needed for energy between meals. Extra glucose can also be converted to fat and stored in fat cells.

When blood glucose begins to fall, glucagon, another hormone produced by the pancreas, signals the liver to break down glycogen and release glucose, causing blood glucose levels to rise toward a normal level. If you have diabetes, this glucagon response to hypoglycemia may be impaired, making it harder for your glucose levels to return to the normal range.

Symptoms of hypoglycemia include

hunger
nervousness and shakiness
perspiration
dizziness or light-headedness
sleepiness
confusion
difficulty speaking
feeling anxious or weak

...Hypoglycemia can also happen while you are sleeping. You might:

cry out or have nightmares
find that your pajamas or sheets are damp from perspiration
feel tired, irritable, or confused when you wake up

Hypoglycemia: As a Side Effect of Diabetes Medications
Hypoglycemia can occur in people with diabetes who take certain medications to keep their blood glucose levels in control. Usually hypoglycemia is mild and can easily be treated by eating or drinking something with carbohydrate. But left untreated, hypoglycemia can lead to loss of consciousness. Although hypoglycemia can happen suddenly, it can usually be treated quickly, bringing your blood glucose level back to normal.

Causes of Hypoglycemia
In people taking certain blood-glucose lowering medications, blood glucose can fall too low for a number of reasons:

meals or snacks that are too small, delayed, or skipped
excessive doses of insulin or some diabetes medications, including sulfonylureas and meglitinides (Alpha-glucosidase inhibitors, biguanides, and thiazolidinediones alone should not cause hypoglycemia but can when used with other diabetes medicines.)
increased activity or exercise
excessive drinking of alcohol

Prevention
Your diabetes treatment plan is designed to match your medication dosage and schedule to your usual meals and activities. If you take insulin but then skip a meal, the insulin will still lower your blood glucose, but it will not find the food it is designed to break down. This mismatch might result in hypoglycemia.

To help prevent hypoglycemia, you should keep in mind several things:

Your diabetes medications. Some medications can cause hypoglycemia. Ask your health care provider if yours can. Also, always take medications and insulin in the recommended doses and at the recommended times.
What to Ask Your Doctor About Your Diabetes Medications:

............1. Could my diabetes medication cause hypoglycemia?
............2. When should I take my diabetes medication?
............3. How much should I take?
............4. Should I keep taking my diabetes medication if I am sick?
............5. Should I adjust my medication before exercise?

Your meal plan. Meet with a registered dietitian and agree on a meal plan that fits your preferences and lifestyle. Do your best to follow this meal plan most of the time. Eat regular meals, have enough food at each meal, and try not to skip meals or snacks.
Your daily activity. Talk to your health care team about whether you should have a snack or adjust your medication before sports or exercise. If you know that you will be more active than usual or will be doing something that is not part of your normal routine—shoveling snow, for example—consider having a snack first.
Alcoholic beverages. Drinking, especially on an empty stomach, can cause hypoglycemia, even a day or two later. If you drink an alcoholic beverage, always have a snack or meal at the same time.
Your diabetes management plan. Intensive diabetes management—keeping your blood glucose as close to the normal range as possible to prevent long-term complications—can increase the risk of hypoglycemia. If your goal is tight control, talk to your health care team about ways to prevent hypoglycemia and how best to treat it if it does occur.

Normal blood glucose levels in people who do not have diabetes (mg/dl)

Upon waking (fasting) 70 to 110
After meals 70 to 140

Target blood glucose levels in people who have diabetes

Before meals 90 to 130
1 to 2 hours after the start of a meal less than 180

Below target range: Hypoglycemia (low blood glucose) 70 or below

Treatment
If you think your blood glucose is too low, use a blood glucose meter to check your level. If it is 70 mg/dL or below, have one of these "quick fix" foods right away to raise your blood glucose:

2 or 3 glucose tablets
1/2 cup (4 ounces) of any fruit juice
1/2 cup (4 ounces) of a regular (not diet) soft drink
1 cup (8 ounces) of milk
5 or 6 pieces of hard candy
1 or 2 teaspoons of sugar or honey

After 15 minutes, check your blood glucose again to make sure that it is no longer too low. If it is still too low, have another serving. Repeat these steps until your blood glucose is at least 70. Then, if it will be an hour or more before your next meal, have a snack.

If you take insulin or a diabetes medication that can cause hypoglycemia, always carry one of the quick-fix foods with you. Wearing a medical identification bracelet or necklace is also a good idea.

Exercise can also cause hypoglycemia. Check your blood glucose before you exercise.

Severe hypoglycemia can cause you to lose consciousness. In these extreme cases when you lose consciousness and cannot eat, glucagon can be injected to quickly raise your blood glucose level. Ask your health care provider if having a glucagon kit at home and at work is appropriate for you. This is particularly important if you have type 1 diabetes. Your family, friends, and co-workers will need to be taught how to give you a glucagon injection in an emergency.

Prevention of hypoglycemia while you are driving a vehicle is especially important. Checking blood glucose frequently and snacking as needed to keep your blood glucose above 70 mg/dL will help prevent accidents.

Hypoglycemia and Diabetes: Doing Your Part
Signs and symptoms of hypoglycemia can vary from person to person. Get to know your own signs and describe them to your friends and family so they will be able to help you. If your child has diabetes, tell school staff about hypoglycemia and how to treat it.

If you experience hypoglycemia several times a week, call your health care provider. You may need a change in your treatment plan: less medication or a different medication, a new schedule for your insulin shots or medication, a different meal plan, or a new exercise plan.

Hypoglycemia in People Who Do Not Have Diabetes
Two types of hypoglycemia can occur in people who do not have diabetes:

reactive (postprandial, or after meals) and fasting (postabsorptive). Reactive hypoglycemia is not usually related to any underlying disease; fasting hypoglycemia often is related to underlying disease.

Symptoms
Symptoms of both types resemble the symptoms that people with diabetes and hypoglycemia experience:

hunger,
nervousness,
perspiration,
shakiness,
dizziness,
light-headedness,
sleepiness,
confusion,
difficulty speaking, and
feeling anxious or weak.

If you are diagnosed with hypoglycemia, your doctor will try to find the cause by using laboratory tests to measure blood glucose, insulin, and other chemicals that play a part in the body's use of energy.

Reactive Hypoglycemia

In reactive hypoglycemia, symptoms appear within 4 hours after you eat a meal.

Diagnosis
To diagnose reactive hypoglycemia, your doctor may

ask you about signs and symptoms
test your blood glucose while you are having symptoms (The doctor will take a blood sample from your arm and send it to a laboratory for analysis. A personal blood glucose monitor cannot be used to diagnose reactive hypoglycemia.)
check to see whether your symptoms ease after your blood glucose returns to 70 or above (after eating or drinking)
A blood glucose level of less than 70 mg/dL at the time of symptoms and relief after eating will confirm the diagnosis.
The oral glucose tolerance test is no longer used to diagnose hypoglycemia; experts now know that the test can actually trigger hypoglycemic symptoms.

Causes and Treatment of Reactive Hypoglycemia

The causes of most cases of reactive hypoglycemia are still open to debate:

Some researchers suggest that certain people may be more sensitive to the body's normal release of the hormone epinephrine, which causes many of the symptoms of hypoglycemia. Others believe that deficiencies in glucagon secretion might lead to hypoglycemia.

A few causes of reactive hypoglycemia are certain, but they are uncommon.
.....1. Gastric (stomach) surgery, for instance, can cause hypoglycemia because of the rapid passage of food into the small intestine.
.....2. Also, rare enzyme deficiencies diagnosed early in life, such as hereditary fructose intolerance, may cause reactive hypoglycemia.

Treatment of Reactive Hypoglycemia

To relieve reactive hypoglycemia, some health professionals recommend taking the following steps:

eat small meals and snacks about every 3 hours
exercise regularly
eat a variety of foods, including meat, poultry, fish, or nonmeat sources of protein; starchy foods such as whole-grain bread, rice, and potatoes; fruits; vegetables; and dairy products
choose high-fiber foods
avoid or limit foods high in sugar, especially on an empty stomach
Your doctor can refer you to a registered dietitian for personalized meal planning advice.
Although some health professionals recommend a diet high in protein and low in carbohydrates, studies have not proven the effectiveness of this kind of diet for reactive hypoglycemia.

Fasting Hypoglycemia
Diagnosis
Fasting hypoglycemia is diagnosed from a blood sample that shows a blood glucose level of less than 50 mg/dL after an overnight fast, between meals, or after exercise.

Causes and Treatment
Causes include: certain medications, alcohol, critical illnesses, hormonal deficiencies, some kinds of tumors, and certain conditions occurring in infancy and childhood.

Medications
Medications, including some used to treat diabetes, are the most common cause of hypoglycemia. Other medications that can cause hypoglycemia include

salicylates, including aspirin, when taken in large doses
sulfa medicines, which are used to treat infections
pentamidine, which treats a very serious kind of pneumonia
quinine, which is used to treat malaria

If using any of these medications causes your blood glucose to drop, your doctor may advise you to stop using the drug or change the dosage.

Alcohol
Drinking, especially binge drinking, can cause hypoglycemia because your body's breakdown of alcohol interferes with your liver's efforts to raise blood glucose. Hypoglycemia caused by excessive drinking can be very serious and even fatal.

Critical Illnesses
Some illnesses that affect the liver, heart, or kidneys can cause hypoglycemia. Sepsis (overwhelming infection) and starvation are other causes of hypoglycemia. In these cases, treatment targets the underlying cause.

Hormonal Deficiencies
Hormonal deficiencies may cause hypoglycemia in very young children, but usually not in adults. Shortages of cortisol, growth hormone, glucagon, or epinephrine can lead to fasting hypoglycemia. Laboratory tests for hormone levels will determine a diagnosis and treatment. Hormone replacement therapy may be advised.

Tumors
Insulinomas, insulin-producing tumors, can cause hypoglycemia by raising your insulin levels too high in relation to your blood glucose level. These tumors are very rare and do not normally spread to other parts of the body. Laboratory tests can pinpoint the exact cause. Treatment involves both short-term steps to correct the hypoglycemia and medical or surgical measures to remove the tumor.

Conditions Occurring in Infancy and Childhood
Children rarely develop hypoglycemia. If they do, causes may include:

Brief intolerance to fasting, often in conjunction with an illness that disturbs regular eating patterns. Children usually outgrow this tendency by age 10.
Hyperinsulinism, which is the excessive production of insulin. This condition can result in transient neonatal hypoglycemia, which is common in infants of mothers with diabetes. Persistent hyperinsulinism in infants or children is a complex disorder that requires prompt evaluation and treatment by a specialist.
Enzyme deficiencies that affect carbohydrate metabolism. These deficiencies can interfere with the body's ability to process natural sugars, such as fructose and galactose, glycogen, or other metabolites.
Hormonal deficiencies such as lack of pituitary or adrenal hormones.

Hope Through Research
The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) was established by Congress in 1950 as one of the National Institutes of Health under the U.S. Department of Health and Human Services. The NIDDK conducts and supports research in diabetes, glucose metabolism, and related conditions. Researchers supported by NIDDK are investigating topics such as:

What are the causes of hypoglycemia?
Can islet cell transplantation eliminate hypoglycemia?
Can laparoscopy (a surgical procedure) be used to find and remove insulinomas (insulin-producing tumors)?
Do new frequent-glucose-monitoring devices help prevent hypoglycemia?
Why do repeated episodes of hypoglycemia lead to loss of awareness of hypoglycemia symptoms?

A complete listing of clinical research studies can be found at http://ClinicalTrials.gov on the Internet.

Points to Remember:

Diabetes-Related Hypoglycemia:

If you think your blood glucose is low, check it and treat the problem right away.
To treat hypoglycemia, have a serving of a quick-fix food, wait 15 minutes, and check your blood glucose. Repeat the treatment until your blood glucose is above 70.
Keep quick-fix foods in the car, at work—anywhere you spend time.
Be careful when you are driving. Check your blood glucose frequently and snack as needed to keep your level above 70 mg/dL.

Hypoglycemia Unrelated to Diabetes

In reactive hypoglycemia, symptoms occur within 4 hours of eating. People with this condition are usually advised to follow a healthy eating plan recommended by a registered dietitian.

Fasting hypoglycemia can be caused by certain medications, critical illnesses, hereditary enzyme or hormonal deficiencies, and some kinds of tumors. Treatment targets the underlying problem.

For More Information

American Diabetes Association
National Service Center
1701 North Beauregard Street
Alexandria, VA 22311
Phone: 1–800–232–3472
Fax: 703–549–6995
Email: customerservice@diabetes.org
Internet: www.diabetes.org
Juvenile Diabetes Research Foundation International
120 Wall Street
19th Floor
New York, NY 10005–4001
Phone: 1–800–533–2873 or 212–785–9500
Fax: 212–785–9595
Email: info@jdrf.org
Internet: www.jdrf.org

--------------------------------------------------------------------------------

National Diabetes Information Clearinghouse
1 Information Way
Bethesda, MD 20892–3560
Email: ndic@info.niddk.nih.gov

The National Diabetes Information Clearinghouse (NDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health under the U.S. Department of Health and Human Services. Established in 1978, the Clearinghouse provides information about diabetes to people with diabetes and to their families, health care professionals, and the public. The NDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about diabetes.

Publications produced by the clearinghouse are carefully reviewed by both NIDDK scientists and outside experts. This publication was reviewed by Catherine L. Martin, M.S., R.N., C.D.E., University of Michigan Health System, Ann Arbor, MI; and Neil H. White, M.D., C.D.E., Department of Pediatrics, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, MO.

This publication is not copyrighted. The Clearinghouse encourages users of this publication to duplicate and distribute as many copies as desired.

To view information on another digestive disease, click on Digestive Diseases Library.

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Monday, October 23, 2006

Diabetic ketoacidosis
From Wikipedia, the free encyclopedia

Diabetic ketoacidosis (DKA) is a life-threatening complication in patients with untreated diabetes mellitus (chronic high blood sugar or hyperglycemia). Near complete deficiency of insulin and elevated levels of certain stress hormones combine to cause DKA. DKA is more common among Type I diabetics, but may also occur in Type II diabetics generally when physiologically stressed, such as during an infection. Patients with new, undiagnosed Type I diabetes frequently present to hospitals with DKA. DKA can also occur in a known diabetic who fails to take prescribed insulin. DKA was a major cause of death in Type I diabetics before insulin injections were available; untreated DKA has a high mortality rate.

Biochemical mechanism
DKA is characterized by hyperglycemia, acidosis, and high levels of circulating ketone bodies. The pathogenesis of DKA is mainly due to acidosis. Excessive production of ketone bodies lowers the pH of the blood; a blood pH below 6.7 is incompatible with life. Onset of DKA may be fairly rapid, often within 24 hours.

A key component of DKA is that there is no or very little circulating insulin so it occurs mainly (but not exclusively) in type 1 diabetes (because type 1 diabetes is characterized by a lack of insulin production in the pancreas). It is much less common in type 2 diabetes because the latter is closely related to cell insensitivity to insulin, not shortage or absence of insulin. Some type 2 diabetics have lost their own insulin production and must take external insulin; they have some susceptibility to DKA.

Although glucagon plays a role as an antagonistic hormone to insulin when there are low blood glucose levels, mainly by stimulating the process of glycogenolysis in hepatocytes (liver cells), insulin is the much more important hormone with more widespread effects throughout the body. Its presence or absence can by itself regulate most of DKA's pathological effects; notably, it has a short half-life in the blood of only a few minutes (typically about six), so little time is needed between cessation of insulin release internally and the reduction of insulin levels in the blood.
Most cells in the body are sensitive to one or more of insulin's effects; the main exception being erythrocytes, neurons, hepatocytes, some intestinal tissue, and pancreatic beta-cells which do not require insulin to absorb glucose from the blood. The difference is due to different glucose transporter (GLUT) proteins. Most cells contain only GLUT-4 proteins which move to the cell surface membrane when stimulated by a second messenger cascade initiated by insulin, thus enabling uptake of glucose. Conversely, when insulin concentrations are low, these transporters dissociate from the cell membrane and so prevent uptake of glucose.
Other effects of insulin include stimulation of the formation of glycogen from glucose and inhibition of glycogenolysis; stimulation of fatty acid (FA) production from stored lipids and inhibition of FA release into the blood; stimulation of FA uptake and storage; inhibition of protein catabolism and of gluconeogenesis, in which glucose is synthesized (mostly from some amino acid types, released by protein catabolism). A lack of insulin therefore has significant effects, all of which contribute to increasing blood glucose levels, to increased fat metabolism and protein degradation. Fat metabolism is one of the underlying causes of DKA.

Muscle wasting
Muscle wasting occurs primarily due to the lack of inhibition of protein catabolism; insulin inhibits the breakdown of proteins and, since muscle tissue is protein, a lack of insulin encourages muscle wasting, releasing amino acids both to produce glucose (by gluconeogenesis) and for the synthesis of ATP via partial respiration of the remaining amino acids.
In those suffering from starvation, blood glucose concentrations are low due to both low consumption of carbohydrates and because most of the glucose available is being used as a source of energy by tissues unable to use most other sources of energy, such as neurons in the brain. Since insulin lowers blood glucose levels, the normal bodily mechanism here is to prevent insulin secretion, thus leading to similar fat and protein catabolic effects as in type 1 diabetes. Thus the muscle wastage visible in those suffering from starvation also occurs in type 1 diabetics, normally resulting in weight loss.

Ketone body production
Despite possibly high circulating levels of plasma glucose, the liver will act as though the body is starving if insulin levels are low. In starvation situations, the liver produces another form of fuel: ketone bodies. Ketogenesis, that is fat metabolic processing (beginning with lipolysis), makes ketone bodies as intermediate products in the metabolic sequence as fatty acids (formerly attached to a glycerol backbone in triglycerides) are processed. The ketone bodies beta-hydroxybutyrate and acetoacetate enter the bloodstream and are usable as fuel for some organs such as the brain, though the brain still requires a substantial proportion of glucose to function. If large quantities of ketone bodies are produced, the metabolic imbalance known as ketosis may develop, though this condition is not necessarily harmful. The positive charge of ketone bodies causes decreased blood pH. An extreme excess of ketones can cause ketoacidosis.
In starvation conditions, the liver also uses the glycerol produced from triglyceride metabolism to make glucose for the brain, but there is not nearly enough glycerol to meet the body's glucose needs.

Brain
Normally, ketone bodies are produced in minuscule quantities, feeding only part of the energy needs of the heart and brain. In DKA, the body enters a starving state. Eventually, neurons (and so the brain) switch from using glucose as a primary fuel source to using ketone bodies.
As a result, the bloodstream is filled with an increasing amount of glucose that it cannot use (as the liver continues gluconeogenesis and exporting the glucose so made). This significantly increases its osmolality. At the same time, massive amounts of ketone bodies are produced, which, in addition to increasing the osmolar load of the blood, are acidic. As a result, the pH of the blood begins to move downward towards an acidotic state. The normal pH of human blood is 7.35-7.45, in acidosis the pH dips below 7.35. Very severe acidosis may be as low as 6.9-7.1. The acidic shift in the blood is significant because the proteins (i.e. body tissues, enzymes, etc.) in the body can be permanently denatured by a pH that is either too high or too low, thereby leading to widespread tissue damage and functional deficits, organ failure, and eventually death.
Glucose begins to spill into the urine as the proteins responsible for reclaiming it from urine (the SGLT family) reach maximum capacity (the renal threshold for glucose). As glucose is excreted in the urine, it takes a great deal of body water with it, resulting in dehydration. Dehydration further concentrates the blood and worsens the increased osmolality of the blood. Severe dehydration forces water out of cells and into the bloodstream to keep vital organs perfused. This shift of intracellular water into the bloodstream occurs at a cost as the cells themselves need the water to complete chemical reactions that allow the cells to function.

Symptoms and Signs

Sluggish, extreme tiredness.
Extreme thirst, despite large fluid intake.
Constant urination
Fruity smell to breath, similar to nail polish remover or peardrops.
Hyperventilation, at first rapid and shallow, then progressively deeper and less rapid.
Extreme weight-loss.
Oral Thrush may be present, or/ yeast infections that fail to go away, this is because the normal fungal/flora present in oral cavity/cervix in women, the balance is upset and bacterial began to feast on the high sugar from urine output/ dry mouth from extreme thirst.
Muscle wasting.
Agitation / Irritation / Aggression / Confusion

Labs
A high anion gap indicates that there is loss of HCO3- without increase in Cl-.
When acetoacetic acid and beta-hydroxybutyric acid dissociate, they will produce an H+ anion that will be immediately neutralized by bicarbonate. This will cause loss of bicarbonate which will increase anion gap

During treatment, a drop in HCO3- is compensated for by an increase in Cl- from IV fluids. This is also known as hyperchloremic acidosis. The effect causes anion gap to return to normal despite the persistence of the metabolic acidosis. At presentation, both types of acidosis may be present and the elevation in the anion gap will be less than expected for the degree of depression in the bicarbonate level.

Serum potassium concentration is often elevated at presentation as insulin deficiency result in potassium movement out of the cells into the extracellular fluid. Insulin therapy lowers the potassium concentration and may cause severe hypokalemia, particularly in patients with a normal or low serum potassium concentration at presentation.

Late signs
At this point, DKA is life-threatening and medical attention should be sought immediately.

Emesis (vomiting), although this is not always a sign of late-stage ketoacidosis, and can occur both in early-stage ketoacidosis and in non-ketoacidic hyperglycaemia.
Confusion.
Abdominal pain.
Loss of appetite.
Flu-like symptoms.
Lethargy and apathy.
Extreme weakness.
Kussmaul breathing ("air hunger"). A type of hyperventilaion where patients breathe very deeply at a normal or reduced rate. This is a sign of severe acidosis.
Unconsciousness (diabetic coma) after prolonged DKA. At this stage, speedy medical attention is imperative.

Complications
People with diabetic ketoacidosis need close and frequent monitoring for complications. Surprisingly, the most common complications of DKA are related to the treatment:

Hypokalemia and often, potassium depletion
Cerebral edema [1]
Hyperglycemia
Ketoacidemia[citation needed]
Fluid and electrolyte depletion [2]
Aspiration
Unrecognized renal tubular necrosis[citation needed]
Pulmonary edema [3]
Myocardial Infarction

Treatment
Treatment consists of hydration to lower the osmolality of the blood, replacement of lost electrolytes, insulin to force glucose and potassium into the cells, and eventually glucose simultaneously with insulin in order to correct other metabolic abnormalities, such as lowered blood potassium (hypokalemia) and elevated ketone levels. Many patients require admission to a step-down unit or an intensive care unit (ICU) so that vital signs, urine output, and blood tests can be monitored frequently. Brain edema is not rare, and so this may suggest intensive monitoring as well. In patients with severe alteration of mental status, intubation and mechanical ventilation may be required. Survival is dependent on how badly-deranged the metabolism is at presentation to a hospital, but the process is only occasionally fatal.
DKA occurs more commonly in type 1 diabetes because insulin deficiency is most severe, though it can occur in type 2 diabetes. In about a quarter of young people who develop type 1 diabetes, insulin deficiency and hyperglycemia lead to ketoacidosis before the disease is recognized and treated. This can occur at the onset of type 2 diabetes as well, especially in young people. In a person known to have diabetes and being adequately treated, DKA usually results from omission of insulin, mismanagement of acute gastroenteritis, the flu, or the development of a serious new health problem (e.g., bacterial infection, myocardial infarction).

Insulin deficiency switches many aspects of metabolic balance in a catabolic direction. The liver becomes a net producer of glucose by way of gluconeogenesis (from protein) and glycogenolysis (from glycogen, though this source is usually exhausted within hours). Fat in adipose tissue is reduced to triglycerides and fatty acids by lipolysis. Muscle is degraded to release amino acids for gluconeogenesis. The rise of fatty acid levels is accompanied by increasing levels of ketone bodies (acetone, acetoacetate and beta-hydroxybutyrate; only one, acetone, is chemically a ketone -- the name is an historical accident). As ketosis worsens, it produces a metabolic acidosis, with anorexia, abdominal distress, and eventually vomiting. The rising level of glucose increases the volume of urine produced by the kidneys (an osmolar diuresis). The high volume of urination (polyuria) also produces increased losses of electrolytes, especially sodium, potassium, chloride, phosphate, and magnesium. Reduced fluid intake from vomiting combined with amplified urination produce dehydration. As the metabolic acidosis worsens, it induces obvious hyperventilation (termed Kussmaul respiration). Kussmaul's respirations are the body's attempt to remove carbon dioxide from the blood that would otherwise form carbonic acid and further worsen the ketoacidosis.

On presentation to hospital, patients in DKA are typically suffering dehydration and breathing both fast and deeply. Abdominal pain is common and may be severe. Consciousness level is typically normal until late in the process, when obtundation (dulled or reduced level of alertness or consciousness) may progress to coma. Dehydration can become severe enough to cause shock. Laboratory tests typically show hyperglycemia, metabolic acidosis, normal or elevated potassium, and severe ketosis. Many other tests can be affected.

At this point the patient is urgently in need of intravenous fluids. The basic principles of DKA treatment are:

Rapid restoration of adequate circulation and perfusion with isotonic intravenous fluids
Gradual rehydration and restoration of depleted electrolytes (especially sodium and potassium), even if serum levels appear adequate
Insulin to reverse ketosis and lower glucose levels
Careful monitoring to detect and treat complications

Treatment usually results in full recovery, though death can result from inadequate treatment or a variety of complications, such as cerebral edema (occurs mainly in children).

Management: refer to DKA flowchart in http://www.aafp.org/afp/990800ap/455.html

Diabetic ketoaddosis (DKA) is a result of severe insulin insufficiency. It occurs
in type I diabetics and may be the presenting manifestation. Precipitating factors of DKA includeinsufficient or interrupted insulin therapy, infection, emotional stress, and excessive alcohol ingestion. presentation preceded by polyuria and polydipsia dehydration and sweeting• anorexia, nausea, vomiting, fatigue • abdominal pain (especially in children)
• Kussmaul’s respirations (fruity rapid deep breathing) pathophysiology in DKA.  Lack of insulin causes the liver to turn fat into ketone bodies, a fuel mainly used by the brain.  Elevated levels of ketone bodies in the blood decrease the blood's pH, leading to most of the symptoms of DKA.  Elevated levels of ketone bodies sever Abdominal pain & decrease the blood's pH.  electrolyte disturbance with hyperkalemia decreased level of consciousness that may progress to coma.  Ketoacidosis with electrolyt disturbance ,dyhydration & sever abdominal pain are severe enough to cause hypotension, shock, and death. Diagnosis of DKA 1-Elevated blood glucose, increased serum levels of keton bodies, & metabolic acidosis (low serum bicarbonate and low blood pH), 2- increased anion gap [sodium - (bicarbonate + chloride)]. Mangment Prompt proper treatment of DKA is managed with insulin, fluids, and electrolyte replacement. insulin• initial bolus of 5-10 U (or 0.1 U/kg) IV in adults • followed by continuous infusion at 5-10 U (or 0.1 U/kg) per hour Hyperosmolar nonketotic coma (HONK) is a syndrome that occurs predominantly in patients with type II diabetes and is characterized by severe hyperglycemia in the absence of significant ketosis. CAUSES  Elderly diabetics. With Infections, strokes, use of phenytoin, steroids, immunosuppressant agents, and diuretics are other precipitating factors.  HONK can occur after therapeutic procedures such as peritoneal or hemodialysis, tube-feeding of high-protein formulas, and high-carbohydrate infusion. The pathophysiology profound dehydration resulting from a sustained hyperglycemic diuresis. Theclinical findings are weakness, polyuria, polydipsia, lethargy, confusion, convulsions, and coma. The diagnosis of HONK is suggested by elevated blood glucose (1,000 mg/dl), extremely high serum osmolality BUN (prerenal azotemia) and mild metabolic acidosis (bicarbonate around 20 mEq/L) is also seen without ketosis. management of HONK involves fluid and electrolyte replacement as well as insulin. ❏ cerebral edema may result if osmolality is treated aggressively ,,overall mortality high >50%

References

^ Diabetic ketoacidosis. Diabetic ketoacidosis. Mayo Foundation for Medical Education and Research (2006). Retrieved on 2007-06-15.
^ Diabetic Coma > Diabetic ketoacidosis. Diabetic ketoacidosis. Armenian Medical Network (2006). Retrieved on 2007-06-15.
^ Diabetic ketoacidosis complications. Diabetic ketoacidosis. The Diabetes Monitor (2007).

Retrieved on 2007-06-15.
Retrieved from "http://en.wikipedia.org/wiki/Diabetic_ketoacidosis"

Categories: Diabetes

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Tuesday, October 03, 2006

Glycemic index
From Wikipedia, the free encyclopedia

For a look at the Glycemic Index, and to find out which foods are low, medium or high on the index, go to:
Glycemic Index:
http://www.glycemicindex.com/

The Glycemic index (also glycaemic index) or GI is a measure of the effects of carbohydrates on blood glucose levels. Carbohydrates that break down rapidly during digestion releasing glucose rapidly into the bloodstream have a high GI; carbohydrates that break down slowly, releasing glucose gradually into the bloodstream, have a low GI. For most people, foods with a low GI have significant health benefits. The concept was developed by Dr. David J. Jenkins and colleagues [1] in 1980–1981 at the University of Toronto in their research to find out which foods were best for people with diabetes.

A lower glycemic index suggests slower rates of digestion and absorption of the sugars and starches in the foods and may also indicate greater extraction from the liver and periphery of the products of carbohydrate digestion. A lower glycemic response is often thought to equate to a lower insulin demand, better long-term blood glucose control and a reduction in blood lipids. The insulin index may therefore also be useful as it provides a direct measure of the insulin response to a food.

The glycemic index of a food is defined by the area under the two hour blood glucose response curve (AUC) following the ingestion of a fixed portion of carbohydrate (usually 50 g). The AUC of the test food is divided by the AUC of the standard (either glucose or white bread, giving two different definitions) and multiplied by 100.

The effect on blood glucose from a high versus low glycemic index carbohydrate

The average GI value is calculated from data collected in 10 human subjects. Both the standard and test food must contain an equal amount of available carbohydrate. The result gives a relative ranking for each tested food.[2]

The current validated methods use glucose as the reference food, giving it a glycemic index value of 100 by definition. This has the advantages that it is universal and it results in maximum GI values of approximately 100. White bread can also be used as a reference food, giving a different set of GI values (if white bread = 100, then glucose ≈ 140). For people whose staple carbohydrate source is white bread, this has the advantage of conveying directly whether replacement of the dietary staple with a different food would result in faster or slower blood glucose response. The disadvantages with this system are that the reference food is not well-defined, and the GI scale is culture dependent.

Glycemic index of foods
GI values can be interpreted intuitively as percentages on an absolute scale and are commonly interpreted as follows:

Classification
GI range
Examples

Low GI
55 or lessmost fruit and vegetables (except potatoes, watermelon), grainy breads, pasta, legumes/pulses, milk, products extremely low in carbohydrates (fish, eggs, meat, nuts,oils)
Medium GI
56 - 69
wheat bread, whole wheat products in general, brown rice, basmati rice, orange sweet potato, table sugar
High GI
70 - 99
corn flakes, baked potato, some white rices (eg. jasmine), croissant, white bread, candy
100
straight glucose

A low GI food will release glucose more slowly and steadily. A high GI food causes a more rapid rise in blood glucose levels and is suitable for energy recovery after endurance exercise or for a person with diabetes experiencing hypoglycemia.

The glycemic effect of foods depends on a number of factors such as the type of starch (amylose vs. amylopectin), physical entrapment of the starch molecules within the food, fat and protein content of the food and organic acids or their salts in the meal — adding vinegar for example, will lower the GI. The presence of fat or soluble dietary fibre can slow the gastric emptying rate thus lowering the GI. Unrefined breads with higher amounts of fiber generally have a lower GI value than white breads.[3] Many brown breads, however, are treated with enzymes to soften the crust, which makes the starch more accessible. This raises the GI, with some brown breads even having GI values over 100.

While adding butter or oil will lower the GI of meal, the GI ranking does not change. That is, with or without additions, there is still a higher blood glucose curve after white bread than after a low GI bread such as pumpernickel.

The glycemic index can only be applied to foods with a reasonable carbohydrate content, as the test relies on subjects consuming enough of the test food to yield about 50 g of available carbohydrate. Many fruits and vegetables (but not potatoes) contain very little carbohydrate per serving, or have very low GI values. This also applies to carrots, which were originally and incorrectly reported as having a high GI.[4] Alcoholic beverages have been reported to have low GI values, but it should be noted that beer has a moderate GI. Recent studies have shown that the consumption of an alcoholic drink prior to a meal reduces the GI of the meal by approximately 15%.[5]

Many modern diets rely on the Glycemic Index, including the South Beach Diet, Transitions by Market America and NutriSystem Nourish Diet [6].

Disease prevention
Several lines of recent scientific evidence have shown that individuals who followed a low GI diet over many years were at a significantly lower risk for developing both type 2 diabetes and coronary heart disease than others. High blood glucose levels or repeated glycemic "spikes" following a meal may promote these diseases by increasing oxidative damage to the vasculature and also by the direct increase in insulin levels. [7] In the past, postprandial hyperglycemia has been considered a risk factor mainly associated with diabetes. However, more recent evidence shows that it also presents an increased risk for atherosclerosis in the non-diabetic population.[8]

Conversely, there are regions such as Peru and Asia where people eat high-glycemic index foods such as potatoes and high GI rices, but without a high level of obesity or diabetes[citation needed]. The high consumption of legumes in South America and fresh fruit and vegetables in Asia likely lowers the glycemic effect in these individuals. The mixing of high and low GI carbohydrates produces moderate GI values.

A study from the University of Sydney in Australia suggests that having a breakfast of white bread and sugar-rich cereals, over time, may make a person susceptible to diabetes, heart disease, and even cancer.[1]

The glycemic index is supported by leading international health organisations including the American Diabetes Association.[9]

Weight control
(This section does not cite any references or sources) Recent animal research provides compelling evidence that high GI carbohydrate is associated with increased risk of obesity. In human trials, it is typically difficult to separate the effects from GI and other potentially confounding factors such as fibre content, palatability, and compliance. In one study (Pawlak et al, 2004), male rats were split into high and low GI groups over 18 weeks while mean bodyweight was maintained. Rats fed the high GI diet were 71% fatter and had 8% less lean body mass than the low GI group. Postmeal glycemia and insulin levels were significantly higher and plasma triglycerides were threefold greater in the high GI fed rats. Furthermore, pancreatic islet cells suffered "severely disorganised architecture and extensive fibrosis". The evidence in this study showed that continued consumption of high glycemic index carbohydrates would likely have led to the development of severe metabolic abnormalities.

Endurance athletes
Endurance athletes such as ultra-marathoners and Ironman triathletes have become increasingly aware of the glycemic index of foods taken before and during training and competition. In the hours before a competition athletes may consume foods with a lower GI value so that energy is released more slowly.

Criticism
The glycemic index has been criticised for the following reasons:
GI takes into account only the resulting glucose in blood chemistry, with no consideration of the effect of other sugars, particularly fructose. An example is Coca-Cola. While already having a medium GI rating, Coca-Cola actually contains even more sugar than is otherwise being accounted for by the GI, as it contains HFCS 55, meaning that for each serving, the 55% fructose is not being accounted for. High levels of fructose cause the same blood sugar spike as a similar amount of glucose[citation needed]. While fructose does not produce the large insulin response of glucose [2], it can cause its own set of health problems, due to an increase in plasma lipids. [3]
The GI does not take into consideration other factors besides glycemic response, such as insulin response, which can be more appropriate in representing the effects from some food contents other than carbohydrates.

A person's glycemic response varies (not the GI) depending on the kind of food, its ripeness, the length of time it was stored, how it was cooked, and its variety (white potatoes are a notable example, ranging from moderate to very high GI even within the same variety [4]).

The GI of a food varies from person to person and even in a single individual from day to day, depending on blood glucose levels, insulin resistance, and other factors.

The GI of a mixed meal is very difficult to predict. For example, fats and proteins can make a meal sit in the stomach longer, which reduces a food's GI.
This criticism can be addressed by taking the Glycemic load into account.

See also

Glycemic load
Diabetic diet
Insulin index about: "Insulemic response" (i.e. the amount of insulin in the bloodstream) to food rather than "glycemic response" (the amount of glucose in the bloodstream).

References

^ DJ Jenkins et al (1981). "Glycemic index of foods: a physiological basis for carbohydrate exchange." Am J Clin Nutr 34; 362-366
^ Brouns et al (2005). "Glycaemic index methodology." Nutrition Research Reviews 18; 145-171
^ http://www.norden.org/pub/velfaerd/livsmedel/uk/TN2005589.pdf Nordic Council of Ministers: Glycemic Index, TemaNord2005:589, Copenhagen 2005.
^ Brand-Miller et al (2005). The Low GI Diet Revolution: The Definitive Science-based Weight Loss Plan. Marlowe & Company. New York, NY
^ Brand-Miller, in press
^ Nutrisystem
^ Temelkova-Kurktschiev et al (2000). "Postchallenge plasma glucose and glycemic spikes are more strongly associated with atherosclerosis than fasting glucose or HbA1c level." Diabetes Care 2000 Dec;23(12):1830-4
^ Balkau et al (1998) "High blood glucose concentration is a risk factor for mortality in middle-aged nondiabetic men. 20-year follow-up in the Whitehall Study, the Paris Prospective Study, and the Helsinki Policemen Study." Diabetes Care 1998 Mar;21(3):360-7
^ Sheard et al (2004). "Dietary carbohydrate (amount and type) in the prevention and management of diabetes: a statement by the american diabetes association." Diabetes Care;27(9):2266-71
DJ Jenkins et al (1981). "Glycemic index of foods: a physiological basis for carbohydrate exchange." Am J Clin Nutr 34; 362-366
Pawlak et al (2004). "Effects of dietary glycaemic index on adiposity, glucose homoeostasis, and plasma lipids in animals." Lancet 28;364(9436):778-85

External links

The external links in this article may not follow Wikipedia's content policies or guidelines.Please improve this article by removing excessive or inappropriate external links.
Glycemic Index and GI Database University of Sydney
Gl News University of Sydney
"International table of glycemic index and glycemic load values: 2002" American Journal of Clinical Nutrition
Michel Montignac: Glycemic Index
"GI of International Foods"
Glycemic Index - Metabolic Syndrome How GI can help metabolic syndrome, weight loss, diabetes and cardiovascular disease.
Glycemic Index Updates Glycemic Index Updates
GI Diet: The GI Girls Times Online
Retrieved from "http://en.wikipedia.org/wiki/Glycemic_index"
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