Standards of CARE But what is good care

Standards of CARE But what is good care? What You Should Expect From Your Health Care Providers

Providers When you have diabetes, it is important that you get good medical care. Now that it's clear that high blood sugar (glucose) levels play a role in many complications, your doctor's skill is more vital than ever. Good care helps you live a full life with as few complications as possible. But what is good care? The American Diabetes Association provides standards of medical care for people with diabetes. These guidelines give the most up-to-date information on taking care of your diabetes. Also, the guidelines let you know what to expect from your doctor and health care team.

The Team Approach You should be receiving your diabetes care from a team put together by your doctor. Diabetes is complicated. Your doctor alone cannot be an expert in every area. For this reason, your diabetes care team may include an eye doctor, nurses, and a dietitian. Depending on what complications you have, your doctor may send you to other specialists as well, such as a foot doctor.

o-high levels of sugar in the blood are a feature of all forms of diabetes. The main goal of diabetes treatment is to bring sugar levels down to as close to normal as is safely possible. How far down? Suggested goals are 80–120 milligrams per deciliter (mg/dl) before meals and 100–140 mg/dl at bedtime. Your doctor may set different targets for you, depending on other factors, such as how often you have low blood sugar reactions. Most aspects of your treatment plan—measuring your sugar levels, taking diabetes pills or insulin shots, exercising, losing weight, planning meals—are aimed at helping you reach your target sugar level. High sugar levels can affect many parts of the body. They can lead to eye, nerve, and kidney diseases. High sugar levels also make it easier to get infections. They can blur your vision or make you feel tired or thirsty all the time. People with diabetes also are more likely to develop other health problems, including high blood pressure, high cholesterol and fat levels, and heart disease. As you can see, keeping your sugar levels under control is vital to your future health and happiness. Your team can advise you on ways to reach this goal. But much rests on your shoulders. For this reason, your treatment team should spend a lot of time teaching you about diabetes and how to make diabetes care part of your life. The First Visit Your first visit to a doctor who will treat your diabetes should have four parts. 1) The doctor should take a medical history (ask questions about your life, complications, and previous diabetes treatment plan). 2) The doctor should give you a complete physical examination. 3) The doctor should run tests on your blood and urine to find out your blood sugar level, your glycated hemoglobin level (a measure of average blood glucose levels over the past 2–3 months), your cholesterol and fat levels, and your urine protein level. Your age, complications, and symptoms dictate which other laboratory tests your doctor does. 4) Your health care team should work with you to make a plan for managing your diabetes. This checklist will help you make sure your health care team is thorough at your first visit. They should • measure your height and weight • measure your blood pressure • look in your eyes, ask you about any problems you have seeing, and refer you to an eye doctor for a dilated eye exam • look in your mouth, and ask about your dental health • feel your neck to check your thyroid gland, and do tests if necessary • feel your abdomen to check your liver and other organs • take your pulse • look at your hands and fingers • listen to your heart and lungs through a stethoscope • look at your bare feet, and check the sensation and pulses in your feet • check your skin, especially the places where you inject insulin • test your reflexes • take blood and urine samples for tests • ask how and when you were diagnosed with diabetes • ask for results of laboratory tests you had in the past • ask about your eating habits and weight history • ask about your current diabetes treatment plan • ask how often and how hard you exercise • ask about times you've had ketoacidosis as well as low blood sugar reactions • ask about infections you've had • ask what complications you've had and what treat-ments you've received for them • ask what medicines you are taking • ask about factors that make you more likely to get heart disease, such as smoking, high blood pressure, eating and exercise habits, cholesterol levels, and family history • ask what other medical problems you've had • ask who else in your family has diabetes • ask about problems you may have had while pregnant Putting together a diabetes care plan is an important part of your first visit. Your diabetes care plan will not be the same as everyone else's. To work well, the plan must be adapted to your own life. For example, it needs to take account of your work or school schedule, how active you are, what and when you like to eat, your cultural background, and other medical problems you have. You need to be involved in devising your diabetes care plan. Otherwise, it's unlikely that the plan will fit into your life or that you will understand what you need to do. Is your diabetes care plan complete? If so, it should include • a list of goals (both short term and long term) • a list of the medicines that you will use to control your diabetes • advice from a dietitian on eating • a list of changes you have agreed to make in your life, such as getting more exercise or stopping smoking • teaching sessions for you and your family on how and when to measure your blood sugar levels and urine ketones, how to keep records of these, and how to treat low blood sugar reactions • a plan for seeing an eye doctor • a plan for seeing a foot doctor, if you need to • a plan for seeing other specialists, if you need to • instructions on when to come back and when you should call • a birth-control and prepreg-nancy plan • a plan for caring for your teeth and seeing the dentist • a plan for sick days Future Visits How often you should return to your diabetes doctor depends on many things. If you take insulin for your diabetes or if you're having trouble controlling your sugar levels, you should see your doctor at least 4 times a year. Otherwise, you should see your doctor 2–4 times a year. You may need to visit your doctor more often if you have complications or if you are starting a new medicine or insulin program. Your doctor will advise you about when to return. He or she should also tell you other times to call or come back. For example, your doctor may want you to call if you've had nausea or vomiting that make you unable to eat or if you've had a fever for more than a day. You will need to stay in touch with your doctor by phone every week or even every day if you are making big changes in your diabetes care plan. When you return, expect the doctor and other members of your health care team to give you a physical examination, take a medical history, run laboratory tests, and fine-tune your treatment program. These later visits are not as in-depth as your first visit, although you should get a complete physical examination once a year. Also, your doctor may order new tests, do other examinations, or refer you to a specialist depending on test results and your needs. This checklist will help you make sure your health care team does a good job at your follow-up visits. They should • ask about times you've had high or low blood sugar levels • ask to see your blood sugar records • ask what adjustments you've made to your diabetes care plan • ask what problems you've had in following your diabetes care plan • ask about symptoms that might indicate you are getting a diabetes complication • ask what other illnesses you had since your last visit • ask what medicines you are taking now • ask if your life has changed in any way • measure your weight and blood pressure • look in your eyes • look at your feet • take blood for glycated hemoglobin measurement • once a year, take a urine sample to look for protein and take blood for cholesterol and blood fat tests • review your treatment plan to measure your progress in meeting goals and see where you are having problems Children and Teenagers Standards of care for children are somewhat different. Children whose diabetes is not well controlled sometimes are slow to grow and mature. So the doctor should measure height at every visit, not just the first. And the doctor should check the progress of sexual maturation. The types of laboratory tests the doctor does also can differ, because children are not at risk for certain complications. The diabetes care plan must take children's needs into account. Children need enough nourishment to grow properly. It's important to prevent low blood sugar reactions, which can easily happen to children when they are too young to know the warning signs of a reaction. The dietitian may recommend more snacks and different foods than for adults to help with these special needs. Also, children tend to get more illnesses than adults. Parents need instructions about sick days and when to call. Treatment plans need to be adapted for teens as well. The busy schedules of many teenagers can make it hard for them to stick to their diabetes meal plan. For these reasons, children with their parents and teenagers should meet with a dietitian each year to review their meal plans and work out problems.

The Goal To

All About Insulin The ins and outs of the hormone you need What Is Insulin? Inside the pancreas, beta cells make the hormone insulin. With each meal, beta cells release insulin to help the body use or store the glucose it gets from food. In people with type 1 diabetes, the pancreas no longer makes insulin. The beta cells have been destroyed. They need insulin shots to use glucose from meals. People with type 2 diabetes make insulin, but their bodies don't respond well to it. Some people with type 2 diabetes need diabetes pills or insulin shots to help their bodies use glucose for energy. Insulin cannot be taken as a pill. It would be broken down during digestion just like the protein in food. Insulin must be injected into the fat under your skin for it to get into your blood. There are more than 20 types of insulin sold in the United States. These insulins differ in how they are made, how they work in the body, and price. Insulin comes from animals (pigs or cows) or is made in labs to be identical to human insulin. There are four types of insulin, based on • how soon the insulin starts working (onset) • when it works the hardest (peak time) • how long it lasts in your body (duration). However, each person responds to insulin in his or her own way. That is why onset, peak time, and duration are given as ranges. Rapid-acting insulin (Lispro) reaches the blood within 15 minutes after injection. It peaks 30 to 90 minutes later and may last as long as 5 hours. Short-acting (regular) insulin usually reaches the blood within 30 minutes after injection. It peaks 2 to 4 hours later and stays in the blood for about 4 to 8 hours. Intermediate-acting (NPH and lente) insulins reach the blood 2 to 6 hours after injection. They peak 4 to 14 hours later and stay in the blood for about 14 to 20 hours. Long-acting (ultralente) insulin takes 6 to 14 hours to start working. It has no peak or a very small peak 10 to 16 hours after injection. It stays in the blood between 20 and 24 hours. Some insulins come mixed together. For example, you can buy regular and NPH insulins already mixed in one bottle. They make it easier to inject two kinds of insulin at the same time. However, you can't adjust the amount of one insulin without also changing how much you get of the other insulin. Strength. Insulins come dissolved in liquids at different strengths. Most people use U-100 insulin. This means it has 100 units of insulin per milliliter (ml) of fluid. Be sure that the syringe you use matches the insulin strength. U-100 insulin needs a U-100 syringe. In Europe and Latin America, U-40 insulin is also used. If you're outside the United States, be certain to match your insulin strength with the correct size syringe. Additives. All insulins have added ingredients to keep them fresh and help them work better. Intermediate- and long-acting insulins also have ingredients to make them act longer. Today's insulins are very pure. Allergic reactions are rare. Storage and safety. Using cold insulin can make your shot more painful. You can keep the bottle of insulin you are currently using at room temperature or warm the bottle by gently rolling it between your hands before you fill the syringe. If you buy more than one bottle of insulin at a time, store the extra bottles in the refrigerator until you start to use them. Never store insulin at very cold (under 36 degrees Fahrenheit) or very hot (over 86 degrees Fahrenheit) temperatures. Extreme temperatures destroy insulin. Do not put your insulin in the freezer or in direct sunlight. Insulin may lose some potency if the bottle has been opened for more than 30 days. Look at the bottle closely to make sure the insulin looks normal. If you use regular, it should be perfectly clear—no floating pieces or color. If you use NPH or lente, it should be cloudy, with no floating pieces or crystals on the bottle. Do not use insulin past the expiration date.

Insulin Therapy With the help of your health care team, you can find an insulin routine that will keep your blood sugar near normal, help you feel good, and fit your lifestyle. People diagnosed with type 1 diabetes usually start with two injections of insulin per day of two different types of insulin. People with type 1 diabetes generally progress to three or four injections per day of insulin of different types. The types of insulin used depend on their blood sugar levels. Studies have shown that three or four injections a day give the best blood sugar control and can prevent or delay the eye, kidney, and nerve damage caused by diabetes. Most people with type 2 diabetes may need one injection per day without any diabetes pills. Some may need a single injection of insulin in the evening (at supper or bedtime) along with diabetes pills. Sometimes diabetes pills stop working, and people with type 2 diabetes will start with two injections per day of two different types of insulin. They may progress to three or four injections per day. Insulin Delivery Many people who take insulin use a syringe. Other choices are insulin pens and pump therapy. Some insulin pens contain a cartridge of insulin that is inserted into the pen. Some pens come already filled with insulin and are discarded after all the insulin has been used. The insulin dose is dialed on the pen, and the insulin is injected through a needle, much like using a syringe. Cartridges and prefilled pens only contain one type of insulin. Two injections must be given with an insulin pen if using two types of insulin.

Fine-Tuning Your Blood Sugar Many factors affect your blood sugar levels. These include: • what you eat • how much and when you exercise • where you inject your insulin • when you take your injections • illness • stress Self-monitoring. Checking your blood sugar and looking over results can help you understand how exercise, an exciting event, or different foods affect your blood sugar level. You can use it to predict and avoid low or high blood sugar levels. You can also use this information to make decisions about your insulin dose, food, and activity. Site rotation. The place on your body where you inject insulin affects your blood sugar level. Insulin enters the blood at different speeds when injected at different sites. Insulin shots work fastest when given in the abdomen. Insulin arrives in the blood a little more slowly from the upper arms and even more slowly from the thighs and buttocks. Injecting insulin in the same general area (for example, your abdomen) will give you the best results from your insulin. This is because the insulin will reach the blood with about the same speed with each shot. Don't inject in exactly the same place each time but move around the same area. Each meal-time injection of insulin should be given in the same general area for best results. For example, giving your before-breakfast injection in the abdomen and your before-supper injection in the leg each day give more similar blood sugar results. If you inject near the same place each time, hard lumps or extra fatty deposits may develop. Both of these problems are unsightly and make the insulin action less reliable. Ask your health care provider if you aren't sure where to inject your insulin. Timing. Insulin shots are most effective when you take them so that insulin goes to work when glucose from your food starts to enter your blood. For example, regular insulin works best if you take it 30 minutes before you eat. Too much or not enough insulin? High morning blood sugar levels before breakfast can be a puzzle. If you haven't eaten, why did your blood sugar level go up? There are two common reasons for high before-breakfast blood sugar levels. One relates to hormones that are released in the early part of sleep (called the Dawn Phenomenon). The other is from taking too little insulin in the evening. To see which one is the cause, set your alarm to self-monitor around 2 or 3 a.m. for several nights and discuss the results with your health care provider.

Injection Technique and Syringe Reuse Many people safely reuse their syringes. However, if you are ill, have open wounds on your hands, or have poor resistance to infection, you should not risk syringe reuse. Syringe makers will not guarantee the sterility of syringes that are reused. Keep the needle clean by keeping it capped when you're not using it. Cleaning it with alcohol removes the coating that helps the needle slide into the skin easily. Never let the needle touch anything but clean skin and the top of the insulin bottle. Most important, never let anyone use a syringe you've already used, and don't use anyone else's syringe. Reusing syringes may help you cut costs, avoid buying large supplies of syringes, and reduce waste. However, talk with your doctor or nurse before you begin reusing. They can help you decide whether reuse would be a safe choice for you. Syringe Disposal It's time to dispose of a syringe when the needle is dull or bent or if it has come in contact with anything other than clean skin. Your syringe is medical waste. If you can do it safely, clip the needles off the syringes. When you remove the needle, no one can use the syringe. It's best to buy a device that clips, catches, and contains the needle. Do not use scissors to clip off needles—the flying needle could hurt someone or become lost. If you don't destroy your needles, recap them. Place the needle or entire syringe in an opaque (not clear) heavy-duty plastic bottle with a screw cap or a plastic or metal box that closes firmly. Do not use a container that will allow the needle to break through or recycle your syringe container. Your area may have rules for getting rid of medical waste such as used syringes. Ask your refuse company or city or county waste authority what method meets their rules. When traveling, bring your used syringes home. Pack them in a heavy-duty holder, such as a hard plastic pencil box, for transport. Other related materials: For additional information on diabetes, visit the American Diabetes Association Book Store or follow the hyperlinks to view our Complete Guide to Diabetes, The Uncomplicated Guide to Diabetes Complications, and 101 Medication Tips for People with Diabetes.

ORAL DIABETES MEDICATIONS Pills to treat type 2 diabetes The first treatment for type 2 diabetes is often meal planning for blood glucose (sugar) control, weight loss, and exercising. But sometimes these measures are not enough to bring blood sugar down near the normal range. The next step is taking a medicine that lowers blood sugar levels. There are two kinds of medicines: oral medications (pills) and insulin shots. Diabetes pills are not insulin. How They Work In people with diabetes, blood sugar levels are too high. These high levels occur because glucose remains in the blood rather than entering cells, where it belongs. But for glucose to pass into a cell, insulin must be present, and the cell must be "hungry" for glucose. People with type 1 diabetes don't make insulin. For them, insulin shots are the only way to keep blood sugar levels down. People with type 2 diabetes tend to have two problems. They don't make quite enough insulin, and the cells of their bodies don't seem to take in glucose as eagerly as they should. All diabetes pills sold today in the US are members of three classes of drugs. They work in different ways to lower blood sugar. The first class of drugs stimulates the beta cells to release more insulin. 1. Sulfonylurea drugs have been in use since the 1950s. Chlorpropamide (brand name Diabinese) is the only first-generation sulfonylurea still in use today. The second generation sulfonylureas are used in smaller doses than the first-generation drugs. There are three second-generation drugs: glipizide (brand names Glucotrol and Glucotrol XL), glyburide (Micronase, Glynase, and Diabeta), and glimepiride (Amaryl). These drugs are generally taken one to two times a day, before meals. All sulfonylurea drugs have similar effects on blood sugar levels, but they differ in side effects, how often they are taken, and interactions with other drugs. 2. Repaglinide (brand name Prandin) is presently the only meglitinide. It is taken before each of three meals. Because this class of drugs stimulates the release of insulin, it is possible to have hypoglycemia (low blood sugar). You should know that alcohol and some diabetes pills may not mix. Occasionally, chlorpropamide, and more rarely other sulfonylureas, can interact with alcohol to cause vomiting and flushing—or even to make you very sick. Ask your doctor if you are concerned about this effect. The second class of diabetes drugs sensitizes the body to the insulin that is already present. 1. Metformin (brand name Glucophage) is a biguanide. It lowers blood sugar by helping insulin work better, mostly in the liver. It is usually taken two times a day. A side effect of metformin may be diarrhea, but this is improved when the drug is taken with food. 2. The glitazones, rosiglitazone (Avandia), and pioglitazone (Actose), form a group of drugs called thiazolidinediones. They help insulin work better in the muscle and fat. Glitazones are taken once or twice a day with food. Although effective in lowering blood glucose levels, glitazones can have a rare but serious effect on the liver. For this reason, your doctor will perform blood tests regularly to monitor the health of your liver. The third class of oral drugs slows or blocks the breakdown of starches and certain sugars. Acarbose (brand name Precose) and meglitol (Glyset) are alpha-glucosidase inhibitors. They help the body to lower blood sugar by blocking the breakdown of starches, such as bread, potatoes, and pasta. They also slow the breakdown of some sugars, such as table sugar. Their action slows the rise in blood sugar levels after a meal. They should be taken with the first bite of a meal. These drugs may have side effects, including gas and diarrhea. Oral Combination Therapy Because the drugs listed above act in different ways to lower blood sugar, they may be used together. For example, a biguanide and a sulfonylurea may be used together. Many combinations can be used. However, it is more costly when more drugs are used. The risk of side effects also increases. Switching to another pill is usually less effective than adding another type of diabetes medicine. Can Diabetes Pills Help Me? Only people with type 2 diabetes can use pills for their diabetes. These pills work best when used with meal planning and exercise. This way you have three therapies working together to lower your blood sugar. Diabetes pills don't work for everyone. Although most people find that their blood sugar levels go down when they begin taking pills, their blood sugar may not go near the normal range. What are the chances that diabetes pills will work for you? Your chances are low if you have had diabetes for more than 10 years or already take more than 20 units of insulin each day. On the other hand, your chances are good if you developed diabetes recently or have needed little or no insulin to keep your blood sugar near normal. You should also know that diabetes pills sometimes stop working after a few months or years. The cause is often unknown. This doesn't mean your diabetes is worse. Switching to another pill doesn't work as well as adding another type of diabetes medicine. Even if diabetes pills do bring your blood sugar near the normal range, you may still need to take insulin if you have a severe infection or need surgery. Pills may not be able to control blood sugar during these stressful times, when blood sugar levels shoot up. Also, if you plan to become pregnant, you will need to switch to insulin until the baby is born. There is no "best" pill or treatment for type 2 diabetes. You may need to try more than one type of pill, combination of pills, or pills plus insulin.

. What About Insulin? Although it is a common practice to try pills before insulin, you may start on insulin, based on several factors. These factors include: • how long you have had diabetes • how high your blood sugar level is • what other medicines you take • your overall health Because diabetes pills seem to help the body use insulin better, some people take them along with insulin shots. The idea behind this "combination" therapy is to try to help insulin work better.

Using Diabetes Pills Wisely In general, these pills are safe and work well. But like any other drug, they must be used with care. All diabetes pills can interact with other medicines. Because of the chance of drug interactions, you need to tell your doctor about all medicines you are taking. While you're taking diabetes pills, you should check with your doctor before starting anything new—even over-the-counter items. Any sulfonylurea or meglitinide can cause blood sugar levels to drop too low (hypoglycemia). Metformin or the glitazones rarely cause hypoglycemia unless taken with insulin stimulators (sulfonylureas or repaglinide) or insulin injections. Acarbose or meglitol, taken as prescribed, does not cause hypoglycemia. However, hypoglycemia can occur when acarbose or meglitol is taken in combination with other oral diabetes medications. This reaction must be treated with glucose gels or tablets or milk, because sucrose (table sugar) will not be broken down fast enough to treat hypoglycemia.

The Cost of Care Costs vary widely among the different pills. Even the same drug can vary in price from store to store. Call around to find the best price for the one you take. Generic versions of some sulfonylureas are available. These cost less than the brand-name products and in general are reliable. To save you more money, ask your doctor to prescribe the largest tablet strength suitable for the dose you need. One 500-mg tablet, for example, often costs much less than two 250-mg tablets. Diabetes pills aren't perfect, but they can help to lower blood sugar levels for many people with type 2 diabetes. Keeping your blood sugar close to normal will help to reduce your risks for the long-term complications in the future, and help you feel your best today. Other related materials: For more information on diabetes, visit American Diabetes Association

Book Store or follow the hyperlinks to our related books. Complete Guide to Diabetes and 101 Medication Tips for People with Diabetes.

Hypoglycemia, Low Blood Sugar What is Hypoglycemia? (Low Blood Sugar) · Part of living with diabetes is learning to cope with some of the problems that go along with having the disease. Hypoglycemia is one of those problems. Hypoglycemia happens from time to time to everyone who has diabetes. · Hypoglycemia can happen even during those times when you're doing all you can to control your diabetes. So, although many times you can't prevent it from happening, hypoglycemia can be treated before it gets worse. For this reason, it's important to know what hypoglycemia is, what its symptoms are, and how to treat it. · What Are The Symptoms Of Hypoglycemia? 1. The symptoms include: 2. Shakiness. 3. Dizziness. 4. Sweating. 5. Hunger. 6. Headache. 7. Pale skin color. 8. Sudden moodiness or behavior changes, such as crying for no apparent reason. 9. Clumsy or jerky movements. 10. Difficulty paying attention, or confusion. 11. Tingling sensations around the mouth. How do you know when your blood sugar is low? · Part of keeping diabetes in control is testing blood sugar often. · Ask your doctor how often you should test and what your blood sugar levels should be. The results from testing your blood will tell you when your blood sugar is low and that you need to treat it. · You should test your blood sugar level according to the schedule you work out with your doctor. More importantly, though, you should test your blood whenever you feel an insulin reaction coming on. After you test and see that your blood sugar level is low, you should treat this condition quickly. · If you feel a reaction coming on but cannot test, it's best to treat the reaction rather than wait. Remember this simple rule: When in doubt, treat. How Do You Treat Hypoglycemia? · The quickest way to raise your blood sugar is with some form of sugar, such as 3 glucose tablets (you can buy these at the drug store), 1/2 cup of fruit juice, or 5-6 pieces of hard candy. · Ask your health care professional or dietitian to list foods that you can use to treat an insulin reaction. And then, be sure you always have at least one type of sugar with you. · Once you've tested your blood and treated your reaction, wait 15 or 20 minutes and test your blood again. If your blood sugar is still low and your symptoms don't go away, repeat the treatment. After you feel better, be sure to eat your regular meals and snacks as planned to keep your blood sugar level up. · It's important to treat hypoglycemia quickly because it can get worse and you could pass out. If you pass out, you will need IMMEDIATE treatment, such as an injection of glucagon or emergency treatment in a hospital. · Glucagon raises blood sugar. It is injected like insulin. Ask your doctor to prescribe it for you and tell you how to use it. You need to tell people around you (such as family members and co-workers) how and when to inject glucagon should you ever need it. · If glucagon is not available, you should be taken to the nearest emergency room for treatment. If you need immediate medical assistance or an ambulance, someone should call the emergency number in your area (such as 911) for help. It's a good idea to post emergency numbers by the telephone. If you pass out, people should: 1. NOT inject insulin. 2. NOT give you food or fluids. 3. NOT put their hands in your mouth. 4. Inject glucagon. 5. Call for emergency help. How do you prevent hypoglycemia? · Good diabetes control is the best way we know to prevent hypoglycemia. The trick is to learn to recognize the symptoms of an insulin reaction. This way, you can treat low blood sugar before it gets worse.

Hyperglycemia, High Blood Sugar What is Hyperglycemia? (High Blood Sugar) · You have diabetes, which means you have to deal with some of the problems that go along with having the disease. One of those problems is hyperglycemia. Hyperglycemia happens from time to time to all people who have diabetes. · Hyperglycemia can be a serious problem if you don't treat it. · Hyperglycemia is a major cause of many of the complications that happen to people who have diabetes. For this reason, it's important to know what hyperglycemia is, what its symptoms are, and how to treat it. What Is Hyperglycemia? · Hyperglycemia is the technical term for high blood sugar. High blood sugar happens when the body has too little, or not enough, insulin or when the body can't use insulin properly. · A number of things can cause hyperglycemia. For example, if you have type 1 diabetes, you may not have given yourself enough insulin. If you have type 2 diabetes, your body may have enough insulin, but it is not as effective as it should be. · The problem could be that you ate more than planned or exercised less than planned. The stress of an illness, such as a cold or flu, could also be the cause. Other stresses, such as family conflicts or school or dating problems, could also cause hyperglycemia. What Are The Symptoms Of Hyperglycemia? · The signs and symptoms include: high blood sugar, high levels of sugar in the urine, frequent urination, and increased thirst. How Do You Know When Your Blood Sugar Is High? · Part of keeping your diabetes in control is testing your blood sugar often. Ask your doctor how often you should test and what your blood sugar levels should be. Testing your blood and then treating high blood sugar early will help you avoid the other symptoms of hyperglycemia. · It's important to treat hyperglycemia as soon as you detect it. If you fail to treat hyperglycemia, a condition called ketoacidosis (diabetic coma) could occur. Ketoacidosis develops when your body doesn't have enough insulin. Without insulin, your body can't use glucose for fuel. So, your body breaks down fats to use for energy. · When your body breaks down fats, waste products called ketones are produced. Your body cannot tolerate large amounts of ketones and will try to get rid of them through the urine. · Unfortunately, the body cannot release all the ketones and they build up in your blood. This can lead to ketoacidosis. · Ketoacidosis is life-threatening and needs immediate treatment. Symptoms include: shortness of breath, breath that smells fruity, nausea and vomiting, and a very dry mouth. Talk to your doctor about how to handle this condition. How Do You Treat Hyperglycemia? · Often, you can lower your blood sugar level by exercising. However, if your blood sugar is above 240 mg/dl, check your urine for ketones. If you have ketones, do NOT exercise. · Exercising when ketones are present may make your blood-sugar level go even higher. You'll need to work with your doctor to find the safest way for you to lower your blood sugar level. · Cutting down on the amount of food you eat might also help. Work with your dietitian to make changes in your meal plan. If exercise and changes in your diet don't work, your doctor may change the amount of your medication or insulin or possibly the timing of when you take it. How Do You Prevent Hyperglycemia? · Your best bet is to practice good diabetes control. The trick is learning to detect and treat hyperglycemia early -- before it can get worse.

Ketoacidosis What Is Ketoacidosis? Ketoacidosis (key-toe-ass-i-DOE-sis) is a serious condition that can lead to diabetic coma (passing out for a long time) or even death. Ketoacidosis may happen to people with type 1 diabetes. Ketoacidosis does not occur in people with type 2 diabetes. But some people -- especially older people -- with type 2 diabetes may experience aa different serious condition. It's called hyperosmolar nonketotic coma (hi-per-oz-MOE-lar non- key-TOT-ick KO-ma). This pamphlet is not about this condition. Ketocidosis means dangerously high levels of ketones. Ketones are acids that build up in the blood. They appear in the urine when your body doesn't have enough insulin. Ketones can poison the body. They are a warning sign that your diabetes is out of control or that you are getting sick. Treatment for ketoacidosis usually takes place in the hospital. But you can help prevent ketoacidosis by learning the warning signs and testing your urine and blood regularly. What Are The Warning Signs Of Ketoacidosis? Ketoacidosis usually develops slowly. But when vomiting occurs, this life-threatening condition can develop in a few hours. The first symptoms are: 1. Thirst or a very dry mouth. 2. Frequent urination. 3. High blood-sugar levels. 4. High levels of ketones in the urine. Next, other symptoms appear: 1. Constantly feeling tired. 2. Dry or flushed skin. 3. Nausea, vomiting, or abdominal pain (Vomiting can be caused by many illnesses, not just ketoacidosis. If vomiting continues for more than 2 hours, contact your health care practitioner.) 4. A hard time breathing (short, deep breaths). 5. Fruity odor on breath. 6. A hard time paying attention, or confusion. Ketoacidosis is dangerous and serious. If you have any of the above symptoms, contact your health care practitioner IMMEDIATELY, or go to the nearest emergency room of your local hospital. How Do You Know If You Have Large Amounts Of Ketones? A simple urine test can detect ketones. You use a test strip, like a blood-testing strip. Ask your health care practitioner when and how you should test for ketones. Many experts advise to check your urine for ketones when your blood sugar is more than 240 mg/dl. When you are ill (when you have a cold or the flu, for example), test for ketones every 4 to 6 hours. And test every 4 to 6 hours when your blood sugar is more than 240 mg/dl. Also, test for ketones when you have any symptoms of ketoacidosis. What If You Find Higher-Than-Normal Levels Of Ketones? If your health care practitioner has not told you what levels of ketones are dangerous, then call when you find moderate amounts after more than one test. Often, your health care practitioner can tell you what to do over the phone. Call your health care practitioner at once if: 1. Your urine tests show large ketones. 2. Your urine tests show large ketones and your blood-sugar level is high. 3. You have vomited more than twice in 4 hours and your urine tests show high ketones. Do NOT exercise when your urine tests show ketones and your blood sugar is high. High levels of ketones and high blood sugars can mean your diabetes is out of control. Check with your health care practitioner about how to handle this situation. What Causes Ketoacidosis? Ketones mean your body is burning fat to get energy. Moderate or large amounts of ketones in your urine are dangerous. They upset the chemical balance of the blood. Commonly, the flu, a cold, or other infections may sometimes bring on ketoacidosis. Here are three basic reasons for moderate or large amounts of ketones: 1. Not getting enough insulin. Maybe you did not inject enough insulin. Or your body could need more insulin than usual because of illness. If there is not enough insulin, your body begins to break down body fat for energy. 2. Not enough food. When people are sick, they often do not feel like eating. Then, high ketones may result. High ketones may also occur when someone misses a meal. 3. An insulin reaction (low blood sugar). When blood-sugar levels fall too low, the body must use fat to get energy. If testing shows high ketones in the morning, the person may have had an insulin reaction while asleep.

Tight Diabetes Control Keeping your blood glucose levels as close to normal as possible can be a lifesaver. Tight control can prevent or slow the progress of many complications of diabetes, giving you extra years of healthy, active life. But tight control is not for everyone and it involves hard work. By the Numbers · Tight control means getting as close to a normal (nondiabetic) blood glucose level as you safely can. Ideally, this means levels between 70 and 120 mg/dl before meals and less than 180 mg/dl after meals, with a glycated hemoglobin level less than 7 percent. · (The target number for glycated hemoglobin will vary depending on the type of test your doctor's laboratory uses.) · In real life, you should set your goals with your doctor. Keeping a normal level all the time is not practical. And it's not needed to get results. Every bit you lower your blood glucose level helps to prevent complications. What Tight Control Does · No one knows why high glucose levels cause complications in people with diabetes. But keeping glucose levels as low as possible prevents or slows some complications. · The Diabetes Control and Complications Trial (DCCT) proved it. Researchers followed 1,441 people with diabetes for several years. Half of the people continued standard diabetes treatment. The other half followed an intensive-control program. · Those on intensive control kept their blood glucose levels lower than those on standard treatment although the average level was still above normal. The results? Compared with the standard-treatment group, in the tight-control group: 1. Diabetic eye disease started in only one-quarter as many people. 2. Kidney disease started in only half as many people. 3. Nerve disease started in only one-third as many people. 4. Far fewer people who already had early forms of these three complications got worse. Living With Tight Control · To get tight control, you must pay more attention to your diet and exercise. You must measure your blood glucose levels more often. And, if you take insulin, you must change how much you use and when you use it. · In intensive therapy, you provide yourself with a low level of insulin at all times and take extra insulin when you eat. This pattern mimics the release of insulin from the normal pancreas. · There are two ways to get more natural levels of insulin: multiple daily injection therapy and an insulin pump. Both are good methods. Your choice should depend on which fits into your life better. · In multiple daily injection therapy, you take three or more insulin shots per day. Usually, you take a shot of short-acting or Regular insulin before each meal and a shot of intermediate- or long-acting insulin at bedtime. · With an insulin pump, you wear a tiny pump that releases insulin into your body through a plastic tube. Usually, it gives you a constant small dose of Regular insulin. You also have the pump release extra insulin when you need it, such as before a meal. · With either method, you must test your blood glucose levels several times a day. You need to test before each shot or extra dose of insulin to know how many units to take and how long before eating to take them. · Also, you may want to test two or three hours after eating to make sure you took enough insulin. You must adjust your insulin dose for how much you plan to eat and how active you expect to be. · You do not need to figure these things out on your own. Whatever method you choose, your health care team (your doctor, dietitian, diabetes educator, and other health care professionals) should spend a lot of time teaching you about it. · Your doctor may even put you in the hospital for a few days. Your team will help you make guidelines for how much insulin to take and when. You will also come up with guidelines for eating and exercising. All these guidelines will change several times as you test them out. · You shouldn't try tight control on your own. A good health care team is a must. Choose a doctor who understands diabetes well or is willing to learn for your sake. · Your doctor should have ties with other health professionals you need, such as a dietitian and a mental health worker. If you live in a small town, look at your options carefully. You may be better off driving to a city to see a specialist. How to Keep Going and Going and Going · Starting a program of tight control is exciting. But it can also be overwhelming. How do you keep from running out of energy? · One way is to start slowly. For example, you might start by testing your blood glucose more times each day. Get used to that first. Then start multiple daily injections. Once you're used to those, then add on your new exercise program and make the changes in your diet. · If you are newly diagnosed with diabetes, look honestly at yourself. Are you still angry and depressed that you have diabetes? · If so, you already have a big challenge facing you. You may want to wait to try tight control until after you've come to terms with the changes in your life. · Keep your goals realistic. No matter how hard you try, your blood glucose readings will not be perfect every time. If they are often too high or too low, you should talk to your doctor about whether your plan needs to be adjusted. But if "wrong" levels happen only sometimes, that's life. · With practice, you will become more skilled at choosing the right insulin doses for various situations. · If you need to, take a breather from the new routine. Having some time off may make it easier to stick to your plan when you start again. Pluses and Minuses · One big reason to try tight control is to prevent complications later. But tight control has effects you can enjoy right now. You will probably feel better and have more energy. · Also, because you adjust your insulin dose to your life, and not the other way around, you have more freedom. You can vary your activities more. And you're not locked into having your meals at the same time each day. · Tight control is especially good for pregnant women. It can reduce the risk of birth defects in the baby. But the DCCT found two major problems with tight control. 1. First, people had three times as many low blood glucose reactions (hypoglycemia). You will need to be alert to the symptoms of hypoglycemia so that you can treat yourself quickly. Also, you should always test your blood glucose levels before you drive. § If you often have low blood glucose reactions when you try tight control, talk to your doctor. You may need to ease up on your goals or go back on standard therapy for a while. 2. Second, people on tight control gained more weight than people on standard insulin treatment. The average in the DCCT was 10 pounds. § If you are concerned about putting on pounds, work with your dietitian and doctor to devise a meal and exercise plan to prevent it. § You should also consider the cost. You will need to see your health care team more often. Pumps cost about $4500, and pump supplies run $60 to $80 a month. Multiple injection therapy is much cheaper. But you will still use more supplies, like test strips and syringes, than before. Tight Control and Type 2 Diabetes · The DCCT studied only people with type 1 diabetes. But doctors believe that tight control can also prevent complications in people with type 2 diabetes. · Most people with type 2 diabetes do not take insulin. You may be wondering how you can achieve tight control without it. · One way is to lose weight. Shedding excess pounds may bring your glucose levels down to normal. The key to losing weight and keeping it off is changing your behavior so that you eat less and exercise more. Your doctor should work with you to find an eating and exercise plan you can stick to. · Even if you don't need to lose weight, exercise is helpful in controlling your blood glucose levels. It makes your cells take glucose out of the blood. · You will need to test your blood glucose regularly. You should decide with your doctor how often. Once a day or even once a week may be enough for some people with type 2 diabetes. · If exercise and good eating habits are not enough to keep your glucose under control, you doctor may prescribe pills. And if these don't work, you may need to take insulin. · People with type 2 diabetes should talk to their doctors before starting tight control. Tight Control Is Not for Everyone Tight control is not safe for everyone with diabetes. · Children should not be put on a program of tight control. Having enough glucose in the blood is vital to brain development. Some doctors say that tight control should wait until a child reaches 13; others say after the age of 7 is okay. · Elderly people probably should not go on tight control. Hypoglycemia can cause strokes and heart attacks in older people. Also, the major goal of tight control is to prevent complications many years later. Tight control is most worthwhile for healthy people who can expect to live at least 10 more years. · Some people who already have complications should not be on tight control. For example, people with end-stage kidney disease or severe vision loss probably should not try it. Their complications are probably too far along to be helped. · Some people who have coronary artery disease or vascular disease should not try tight control. · People who often have low blood glucose reactions probably should not go on tight control.

DIABETES SELF-TESTING Simple tests you do yourself can help you care for your diabetes and feel better. All people with diabetes have to work to keep the amount of glucose (sugar) in their blood as near to normal as possible. This is called being in control. You want diabetes control because you will feel better. Also, keeping blood sugar levels near the normal range can help prevent or delay the start of such diabetes side effects as nerve, eye, kidney, and blood vessel damage. When you learned you had diabetes, you and your health care team worked out a diabetes care plan. The plan aims to balance the foods you eat with your exercise and, possibly, diabetes pills or insulin. You can do two types of tests to help keep track of how your plan is working. These are blood glucose tests and urine ketone tests.

Blood Sugar Monitoring Tests Blood sugar monitoring is the main tool you have to check your diabetes control. This test tells you your blood sugar level at any one time. Keeping a log of your results is vital. When you bring this record to your health care provider, you have a good picture of your body's response to your diabetes care plan. Blood sugar checks let you see what works and what doesn't. This allows you and your doctor, dietitian, or nurse educator to make needed changes.

Who Should Test? Experts feel that anyone with diabetes can benefit from self-monitoring of blood sugar. The American Diabetes Association recommends blood glucose testing if you have diabetes and are: • taking insulin or diabetes pills • on intensive insulin therapy • pregnant • having a hard time controlling your blood sugar levels • having severe low blood sugar levels or ketones from high blood sugar levels • having low blood sugar levels without the usual warning signs Urine Tests Urine tests for sugar are not as accurate as blood tests. Urine testing for sugar should not be done unless blood testing is impossible. A urine test for ketones is another matter. This is an easy test that is very important when your diabetes is out of control or when you are sick. You can find moderate or large amounts of ketones in urine when your body is burning fat instead of glucose for fuel. This happens when there is too little insulin at work. Everyone with diabetes needs to know how to test their urine for ketones. How Blood Tests Work You prick your finger with a special needle, called a lancet, to get a drop of blood. There are spring-loaded lancing devices that make sticking your finger less painful. Before sticking your finger, wash your hands with soap and water. Prick the side of your finger by your fingernail to avoid having sore spots on the parts of your finger you use the most. Blood glucose meters are small computerized machines that "read" your blood sugar. In all types of meters, your blood sugar level shows up as a number on a screen (like that on your pocket calculator). Be sure your doctor or nurse educator shows you the correct way to use your meter. With all the advances in blood sugar meters, use of a meter is better than visual checking. How to Pick a Meter There are many meters to choose from. Some meters are made for those with poor eyesight. Others come with memory so you can store your test results in the meter itself. The American Diabetes Association does not endorse any products or recommend one meter over another. If you plan to buy a meter, here are some questions to think about: • What meter does your doctor or diabetes educator suggest? They may have meters that they use often and know best. • What will it cost? Don't assume that your health insurance will cover the cost of a meter. Also consider the cost of testing supplies, such as test strips, when you think about which meter to buy. Once you choose a meter, you'll also have to buy the matching test strips. Shop around. Rebates are often offered. • How easy is the meter to use? Methods vary. Some have fewer steps than others. • How simple is the meter to maintain? Is it easy to clean? How is the meter calibrated (set correctly for the batch of test strips you are using)?

Are Meters Accurate? Experts testing meters in the lab setting found them accurate and precise. That's the good news. The bad: meter mistakes most often come from the person doing the blood checks. For good results you need to do each step correctly. But there is an easy way to check your skill. Bring your meter to your doctor's office. Do a blood sugar check minutes before or after your blood is drawn from your vein. Compare your results with the doctor's blood results. Your meter results should not be off by more than 10 or 15 percent. Here are other things that can cause your meter to give a poor reading: • a dirty meter • a meter that's not at room temperature • an outdated test strip • a meter not calibrated (set up for) the current box of test strips • a blood drop that is too small Ask your health care team to check your testing skills at least once a year. Error can creep in over time.

Logging Your Results When you finish the blood sugar check, write down your results. There is more to testing than finding out a number. That's why keeping a log of your results and related events (like exercise, unusual excitement, and special meals) is so important. You and your doctor or diabetes educator can use your records to learn what your test results mean for you. This takes time. Ask your doctor or nurse if you should report test results out of a certain range at once by phone. Keep in mind that blood sugar results often trigger strong feelings. Blood sugar numbers can leave you upset, confused, frustrated, angry, or down. It's easy to use the numbers to judge yourself. Remind yourself that your blood sugar level is a way to track how well your diabetes care plan is working. It is not a judgment of you as a person. The results may show you need a change in your diabetes plan.

Checking for Ketones You may need to check your urine for ketones once in a while. Ketones build up in your blood and then "spill" over into your urine. It is much more common for ketones to build up if you have type 1 diabetes than type 2 diabetes. Urine tests are simple, but to get good results, you have to follow directions carefully. Check to be sure that the test strip is not outdated. Read the insert that comes with your test strips. Go over the correct way to test with your doctor or nurse. Here's how most urine tests go: 1) Get a sample of your urine in a clean container. 2) Place the test strip in the sample (you can also pass the strip through the urine stream). 3) Gently shake excess urine off the strip. 4) Wait for the test strip pad to change color. The directions will tell you how long to wait. 5) Compare the strip pad to the color chart on the test strip bottle. This gives you a range of the amount of ketones in your urine. 6) Record your results. What do your test results mean? Small or trace amounts of ketones may mean that ketone buildup is starting. You should test again in a few hours. Moderate or large amounts are a danger sign. They upset the chemical balance of your blood and can poison the body. Never exercise when your urine tests show moderate or large amounts of ketones and your blood sugar is high. These are signs that your diabetes is out of control. Talk to your doctor at once if your urine tests show moderate or large amounts of ketones. Keeping track of your results and related events is important. Your log gives you the data you and your doctor and diabetes educator need to adjust your diabetes care plan.

When to Test Ask your doctor or nurse when you should check for ketones. You may be advised to test for ketones when: •your blood glucose is more than 300 mg/dl •you feel nauseated, are vomiting, or have abdominal pain • you are sick (for example, with a cold or flu) • you feel tired all the time • you are thirsty or have a very dry mouth • your skin is flushed • you have a hard time breathing • your breath smells "fruity" • you feel confused or "in a fog" These can be signs of high ketone levels that need your doctor's help. Other related materials: For more information on blood glucose and urine ketone testing, see the following books: Click here to view the American Diabetes Association Complete Guide to Diabetes or 101 Tips for Improving your Blood Sugar.