S U T T E R H E A LT H D I S E A S E M A N A G E M E N T

Diabetes Type 2
Basics
Special thanks goes to the Sutter Health Disease Management Education Work
Group for the development of this publication and to both the Sutter Health Disease
Management Steering Committee and Sutter Health affiliated physicians who provided
content review. This booklet is not intended as a substitute for professional medical care.

Education Work Group Members:

Ruth Barnard, RD, CDE (SGMF)
Helen Chaknova, RN, MSN (MPHS)
Amy Fox, RD, CDE (SMF)
Ramona M. Fries, MS, RN, CDE (SMCS)
Lorri Holzberg, MA, RD, CDE (CMG)
Diane Lesnick, MPH, RD, CDE (PAMF)
Claudia Parker Lutz, MPH, RD, CDE (NCH)
Teri McAllister, RN, BS (SHSS)
Karen Mulder, Pharm.D. (SHSS)
Cindy Rudolph, RN, CDE (MPHS)
Mindy Schwartz, CNS, MSN, CDE (CPMC)
Savannah Shyne, MPH (CPMC)
Kim Vagt, MS, RD, CDE (SAH)

AD Hoc Members:
Carrie Nagy-Marsh, RN, (SHSSR)

Additional review by:

Kimberly Buss, M.D.
Sallie Adams, M.D.
Meg Durbin, M.D.
Cheryl Phillips, M.D., Medical Director
Sutter Health Disease Management
Steering Committee
Dear Patient:
Whether you have diabetes, pre-diabetes or high blood glucose (sugar) – or you simply want to learn more
about diabetes – this booklet is for you. Inside, you will find a wealth of information about the basics of
diabetes care and many tools to help you manage this condition. As you read, keep in mind that diabetes is
a complex disease. The knowledge and skills you need for diabetes self management will take time to learn.
Now is the time to get started.

Good News
• You have been diagnosed. You can get your blood glucose under control.
• You are not alone. Your physician or diabetes care team will be here to help.
Research has shown that:
- people in good control of their diabetes can live long, healthy lives.
- it is possible to prevent, minimize or delay complications of diabetes
• A variety of effective treatments for diabetes are now available, and more are on the horizon.

Challenges
• Diabetes is a lifelong condition with a variety of challenges along the way.
• Adjusting to a new diagnosis of diabetes is personal and it may take time.
• Different people have different emotions. Some people feel scared or worried. Others become angry or
deny that they have diabetes. Sadness or depression can also set in. All of these emotions are normal,
but can be hard to work through alone. If you find that emotions keep you from enjoying life or taking
necessary actions to stay healthy, talk to your physician and/or your diabetes care team.
• Coming to accept that you have diabetes will enable you to learn more, build support and to make adjust-
ments in your life for better health and glucose control.

Note: This booklet was specifically developed with an emphasis on type 2 diabetes and its related condition of prediabetes.
If you or a loved one has type 1 or gestational diabetes, your medical management and blood glucose control strategies
will be somewhat different. Still, it is important for you to learn self management skills and some of the information in
this booklet may be useful. Be sure to discuss any diabetes management questions, lifestyle information or diet/exercise
changes you plan to make with your physician and diabetes care team.
Table of Contents
About Diabetes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
An Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Types of Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Basic Skills of Self Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Good Nutrition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Self Monitoring of Blood Glucose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Physical Activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Problem Solving Diabetes Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Low Blood Glucose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
High Blood Glucose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Managing Sick Days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Risk Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
An Ounce of Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Heart Disease Risk Reduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Foot Infection Risk Reduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Dental Disease Risk Reduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Eye, Nerve and Kidney Protection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Sexual Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Diabetes and Pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Living Well with Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Stress Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Learning How to Change Habits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Chart A: Getting the Very Best Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Chart B: Blood Glucose Record Keeping Log . . . . . . . . . . . . . . . . . . . . . . . 30

Diabetes Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Diabetes Medications. . . . . . . . . . . . . . . . . . . . . . . . . Located in back pocket

4 DIABETES BASICS
Diabetes is…
• Common • Controllable • Manageable
How to Stay Healthy with Diabetes
Diabetes is the word used to describe consistently
high blood glucose (sugar) levels in the body. It is
not one disease with an identified cause and single
cure. Rather, there are a number of reasons why high
blood glucose can develop.
No matter what the cause of diabetes is, the goals
of its medical treatment and your self-management
skill development are always the same:
• Maintain blood glucose levels as close to normal
levels as possible
• Minimize the risk of developing complications of
diabetes
• Live a healthy, full and active life with positive
outlook and support
All of these areas work together to
help you stay healthy.
Learning to Live Well with Diabetes
Finding out that you have diabetes or pre-diabetes
can be very unsettling. You may have been feeling
tired or unwell before the disease was diagnosed,
and now you must face the fact that you have a
chronic disease. This is never easy, but you are
going to need to learn how to take care of yourself
in new ways. Many diseases today can be treated
with a simple medication and, usually, the only
self-care skills required of you is to take your medi-
cation on time.
Diabetes self care is different. In fact, the correct
terminology is “diabetes self management” because
diabetes requires that you play an active role in
your healthcare. Your physician or diabetes care
team members (diabetes educator, nurse educator,
dietitian, pharmacist, podiatrist, etc) will all be
advising you to change something: the way you eat,
how you exercise, your weight and your morning
routines – all at the same time!
Yes! It can be overwhelming. But look at the big
picture. The goal is your well-being and good health.
Stay connected with your diabetes care team, ask
questions and explore the many diabetes resources
available. Overtime, you will learn what you need to
learn, develop skills, build confidence and success-
fully adjust to new lifestyle routines that help you
stay healthy.
 INTRODUCTION 5

10 Ways to Adjust to A New Diagnosis of Diabetes

1. Talk to your family and friends, and let them know what is going on. They may be anxious and worried
about you themselves, and want to know what they can do to help. Accept this help, when possible.
2. Set reasonable, achievable goals for yourself when you take on a new challenge. For example, work on
losing five pounds this month instead of thirty. Begin exercise training by walking around the block three
times a week, instead of running 3 miles a day. Start with small steps and work toward your goals to build
your confidence.
3. Don’t feel guilty if you slip up on occasion. Learn from your slips. Adjust your goals as needed, and then
move forward again. Stay at it.
4. When you reach a goal, congratulate yourself on doing a good job. You want to be in control of your diabe-
tes. Don’t let it control you!
5. Don’t think about all the things you “should” do. If you were to try to do everything at once, you might
easily become overwhelmed and never actually do anything. Focus your thoughts on what to do today.
6. If you are having a problem keeping up with your self management program, let your physician or diabe-
tes care team know. Together, you can modify your goals to make them more attainable.
7. Think positively, and try not to feel sorry for yourself. Many people of all ages have successfully dealt with
diabetes. You can, too. The worst thing you can do is to deny there is a problem with your body’s blood
glucose control, because denial stalls action. There is so much you can be doing to prevent problems. As
they say, “Just do it!”
8. Don’t worry about what other people will think. Many people don’t understand diabetes. This is your
chance to show them that this is a condition that can be controlled.
9. Having diabetes isn’t the end of the world. It’s a new stage of your life. And, it is up to you to
take charge.
10. Your actions will make a big difference! The information on the following pages will help guide
you to success.
6 ABOUT DIABETES
About Diabetes
An Overview
Diabetes is a medical condition of consistently high
blood glucose levels. The health consequences of
poorly controlled diabetes over time are serious
and can be life-threatening. But diabetes can be
controlled.
It requires lifelong medical care and self-management
to keep blood glucose within a healthy range and to
protect against complications that can result from
poor control.
What is diabetes?
Diabetes is diagnosed when a person’s blood glucose
levels rise significantly above the normal range and
stay high.
The reasons for high blood glucose are:
• the body cannot make enough insulin to
meet demand
• the body cannot properly use the insulin it
does make
• the body cannot make enough insulin nor
use it properly
What is insulin?
Insulin is a hormone produced by an organ of the
body called the pancreas. Without insulin, life
threatening chemical imbalances in the body would
develop.
• Insulin helps the body use glucose (sugar) as a
fuel to produce energy.
• It works as a key that signals muscle and fat cells
to unlock their “doors’; this allows glucose to
leave the blood and enter the cells.
• Inside of these cells, glucose is burned (metabo-
lized) as fuel or stored.
What is glucose?
Glucose is a small sugar that is an essential fuel for
human life. Under normal conditions, it is the only
fuel used by the brain and nerve cells. It is also a
primary fuel for muscles and other body systems.
• Glucose is obtained or made from most of the
foods we eat, especially carbohydrate rich foods
like grains, fruit, milk and sugar sweeteners.
• Glucose can be used immediately as fuel or
stored as glycogen for later use. It can also be
converted into fat if too much fuel has entered
the body at one time.
• Glucose travels from one part of the body to
another via the bloodstream. Blood always has
glucose traveling through it.
• Blood glucose level refers to the amount of glu-
cose in your bloodstream at any given time, and
there is a range that is considered “normal” or
healthy. Problems can develop when the blood
glucose level is too high or too low.
Types of Diabetes
Diabetes is an all-too-common disease, and more
people develop it everyday. No one is immune, but
some are at higher risk than others due to lifestyle,
family history or genetic background.
• Today, approximately 20 million Americans have
diabetes.
• One out of three Americans with diabetes does
not know they have it.
• Unless changes are made in diet and activity
patterns of our youth, it is predicted that 1 in
3 people born since the year 2000 will develop
diabetes within their lifetime.
A person’s risk of developing diabetes increases if
they are:
• Overweight
• Consistently overeating
• Physically inactive
• Over age 45
• African American, Latino/Hispanic, American
Indian, Native Alaskan, Asian or Pan-Asian
• A person whose parent, grandparent, brother or
sister has diabetes

• A woman who has a history of gestational
diabetes or of delivering a baby weighing
over nine pounds
• A person whose mother had diabetes during
pregnancy
What are the different types of diabetes?
There are several types of diabetes because there are
different reasons why high blood glucose develops.
Each type has an underlying explanation and a set
of treatment strategies. The common condition for
all types of diabetes, however, is high blood glucose.
The common goal is blood glucose control.
Type 1 diabetes
Type 1 diabetes develops because, for unknown rea-
sons, the body’s immune system destroys beta cells
in the pancreas. These cells make insulin. People
with type 1 diabetes require lifelong insulin use.
• Symptoms of type 1 diabetes usually come on
suddenly and blood glucose is typically very
high (above 500 mg/dl) when this disease is first
diagnosed.
• Common symptoms of very high blood glucose
include fatigue, unexplained weight loss, in-
creased thirst, urination and hunger.
• Type 1 diabetes can occur at any age but is
most commonly diagnosed in children and
adolescents.
Type 2 diabetes
Type 2 diabetes is a progressive disease. It generally
takes several years to develop high blood glucose
as the body’s cells gradually lose their ability to
respond well to insulin. This condition is more
likely to develop as a person gets older, gains excess
weight and/or lives an inactive lifestyle.
• Insulin resistance develops over time as cells
become less responsive to insulin.
• Initially, beta cells of the pancreas can make more
insulin to overcome insulin resistance. Blood
glucose levels can remain normal during early
phases of insulin resistance.
TYPES OF DIABETES 7
• Over time, beta cells tire out and can no longer
make enough insulin. As insulin production by
the pancreas falls, blood glucose levels begin
to rise.
• Symptoms of rising blood glucose levels develop
slowly. These may include fatigue, thirst, more
frequent urination, increased hunger, slow
wound healing, more infections and/or blurred
vision. Some people never experience or notice
any symptoms.
• Type 2 diabetes can occur at any age. In the past,
it was called “adult diabetes,” because it occurred
mainly in adults. Today, insulin resistance, pre-dia-
betes and type 2 diabetes are also being discovered
in children and adolescence because of poor diets,
inactivity and unhealthy weight gain.
Pre-diabetes
Sometimes called “Impaired Glucose Tolerance” or
“Impaired Fasting Glucose”, pre-diabetes is an ear-
lier stage of the progressive condition that can lead
to type 2 diabetes.
• Pre-diabetes is diagnosed when blood glucose
levels are higher than normal, but not high
enough to be diagnosed as diabetes.
• People with pre-diabetes have increased risk of
developing type 2 diabetes in the future.
Gestational diabetes
When diabetes is diagnosed during pregnancy, it
is called gestational diabetes (GDM). Hormones of
pregnancy naturally increase insulin resistance and,
for some women, high blood glucose develops. High
blood glucose is not healthy for either the mother
or her fetus, so medical and lifestyle management is
required.
• The risk of developing high blood glucose during
pregnancy is higher for older mothers, over-
weight women and those with a family history or
genetic tendency toward type 2 diabetes.
• In most cases, blood glucose levels return to
normal after delivery. This is not always true,
however, and postnatal visits that include glucose
checks for several months are important.
8 BASIC SKILLS OF SELF MANAGEMENT
• Women who have had gestational diabetes are
more likely to develop type 2 diabetes later in
life. Exercise, a healthy diet and weight control
may offer protection.
• Children whose mothers had diabetes during
pregnancy are also at higher risk of developing
type 2 diabetes during their lifetime. An active
lifestyle, healthy diet and weight control may
offer protection.
How is diabetes diagnosed?
Diabetes is diagnosed by measuring the amount
of glucose in a person’s blood and comparing this
blood glucose level to the criteria (numbers) set by
national standards. There are several tests that can be
used to make a diagnosis.
Common laboratory blood glucose tests include:
• Fasting blood glucose (FBG) – this measurement
is taken after going without food for at least 8
hours. A blood glucose of 126 mg/dl or greater
on two occasions may be diagnosed as diabetes.
• Random blood glucose (RBG) – this measure-
ment is taken regardless of when you last ate. A
blood glucose of 200 mg/dl or greater may indi-
cate diabetes. Further testing is usually necessary.
• Oral glucose tolerance test (OGTT) – this mea-
surement is taken after drinking a beverage with
75 grams of glucose. A blood glucose reading of
200 mg/dl or greater after this drink may indicate
diabetes. A different type of OGTT is also done to
test for gestational diabetes.

Basic Skills of Self Management
Good Nutrition
Diabetes and Meal Planning
Learning what is good to eat, when to eat and how
much to eat can help you feel good, meet your blood
glucose targets and reach your healthy weight goals.
What should I eat?
Begin with the basics: eat a healthy balance of
wholesome foods. Include a variety of foods in your
diet each day so that your body gets the compete
nutrition it needs. You do not need special foods.
In fact, the foods that are good for you are good for
everyone. Plan your diet to include:
Carbohydrate Rich Foods
Carbohydrate rich foods increase blood glucose
more than other foods, but it is still important to eat
them to maintain good health. Don’t totally cut them
out of your diet. Just learn to make healthier choices
and eat reasonable portions.
The main types of carbohydrate rich foods are:
Grain foods, such as breads, cereal, pasta, noodles,
rice, crackers, and tortillas. Your healthiest choices
would be those made from whole grain, rather than
refined flours.
Starchy vegetables, such as potatoes, sweet potatoes,
winter squash, corn, and dried beans. When eaten as
a vegetable, all of these would be great choices.
Fruit, including whole fruit, dried fruit and fruit
juices. Your best choices would be whole, fresh fruit
or unsweetened canned or frozen fruit. If you like
dried fruit, eat small portions. It is usually best to
avoid fruit juices, or take small portions.
Milk and yogurt. The healthiest choices in this cat-
egory are fat free or very low fat (1%). Read labels to
avoid products with extra sugar added.
Sugars and Sweets, including syrup, honey, candy,
regular sodas and soft drinks, ice cream, cookies,
donuts, cake and pie, to name a few. The best advise?
Limit to small amounts.
GOOD NUTRITION 9
Non-Starchy Vegetables
Although non-starchy vegetables – such as lettuce,
broccoli, cucumber, carrots and tomatoes – contain
some carbohydrates, they have little to no effect on
blood glucose. Healthy advice: eat plenty of them!
Protein Rich Foods
Protein rich foods – like meats, fish, poultry, eggs or
cheese – do not contain carbohydrate, unless flour or
sauce has been added in a recipe. The healthiest se-
lections in this food group are fish, chicken or turkey
(without skin), lean trimmed meats, tofu, low-fat or
nonfat cheeses.
Oils and Fats
Oils derived from plant foods are, as a rule, much
healthier to eat than animal fats. Fish oil is an excep-
tion. Still, all fats and oils have a lot of calories, so
watch the portions if you are working to keep your
weight down. Healthy selections include olive oil,
canola oil, avocado, seeds, nuts, peanut butter, oil
based salad dressing, soft margarine with no trans
fat, and low-fat mayonnaise
Menu Planning Tips
Your body will turn most of the carbohydrate
(“CARB”) you eat into sugar to provide you with
energy. Carbohydrate rich foods are an important
part of your meal plan. But eating too many carbo-
hydrates at one meal or snack can raise your blood
glucose too high. Here are some meal planning
strategies that can help you succeed at meeting you
blood glucose targets.
• Instead of avoiding carbohydrate altogether, eat
2 to 4 servings of carbohydrate rich foods at each
meal. This is a rough estimate, because individual
needs vary. But it is a good place to begin.
Why? If you eat too few carbohydrates, your body may
not get the glucose energy it needs to maintain good
health and your blood glucose levels can fall too low.
10 BASIC SKILLS OF SELF MANAGEMENT
• Replace regular sodas, sweetened drinks and
fruit juices with water, mineral water, sugar-free
sodas or other liquids with very little or zero
carbohydrates.
Why? Sugar rich beverages concentrate carbohydrate
in liquid form. These can rapidly raise blood glucose
and do not signal the brain to recognize fullness as
readily as solid food does.
• Use sugar substitutes in coffee, on cereal, and
on other food you would previously have used
sugar, honey or syrup as a sweetener.
Why? Sugar substitutes do not add carbohydrate to
the meal.
• Eat fewer foods that have sugar as a main ingre-
dient, such as cookies, cakes, pastries and can-
dies. If you want a small dessert, such as a cup
of ice cream or a few small cookies, occasionally
substitute them for one of your other carbohy-
drate choices.
Why? These foods add a lot of carbohydrate yet they
are low in nutritional value. Try to save your carbohy-
drate food budget for healthier foods.
• Limit your intake of fats, especially fats from
animal sources such as cream, butter, fatty meats
and regular fat cheese.
Why? Most animal fats are highly saturated and will
increase your risk of blood vessel narrowing from
cholesterol, organ damage from reduced blood flow and
heart disease.
When should I eat?
As far as meal timing goes, the best strategy is to
eat 3 meals per day and, if meal times are far apart
or blood glucose dips between meals, plan strategic
snacks. If you skip meals or delay meals for long
periods of time, you may be at risk of a dangerous
low blood glucose event or “hypoglycemia”. Many
people who skip meals find they have a tendency
to overeat later. This offers no advantage for weight
control and may in fact cause more problems with
overall weight management.
That is why it is important to:
• Spread your food into reasonable portions
throughout the day. It is usually best to go no
longer than four or five hours without eating.
• If you are taking a diabetes medication or insulin,
it is even more important to avoid skipping or
delaying your meals and snacks. This helps pro-
tect you from a low blood glucose event.
• If you exercise or have more physical activity on
a given day than usual, plan a little extra carbo-
hydrate food to be eaten before and/or after the
exercise. This may mean planning an extra snack
time. See the section on exercise for more information.
How much should I eat?
Eating small-to-moderate portions and a variety of
healthy foods several times throughout the day can
help keep your energy levels more stable and will
control blood glucose levels far better than the “feast
vs. famine” style of eating that often is practiced by
Americans. While this booklet cannot advise you of
the best meal size and distribution for you, here are a
few guidelines to help you get started.
• The amount of calories and carbohydrates recom-
mended for you will depend on your weight,
weight goals, height, age, activity level and medi-
cations.
• One serving or portion of a carbohydrate food
is counted as 15 grams of carbohydrate. (see the
food label on page 12 for more information)
• Most people with diabetes do well with 30-60
grams of carbohydrate (2-to-4 carbohydrate rich
food servings/portions) at each meal, plus one or
more snacks containing about 15 grams of carbo-
hydrate (1 serving) each.
Remember, this is just a general guideline. Indi-
vidual needs vary.
Ask your physician and/or diabetes care team for a referral
to a Registered Dietitian for more individual guidance.
 GOOD NUTRITION 11

The Plate Method

The Plate Method is a good way to help you get
started with mealtime carbohydrate management.
As the diagram demonstrates, this method sug-
gests that half of your plate be filled with non-
starchy vegetables, one fourth with meat or other
protein rich foods, and one fourth of the plate
contains starchy vegetables and/or grains. In
addition, one serving of fruit and a cup of milk or
yogurt will complete a balanced meal.

Milk
8oz. serving

Fruit
1 small piece or
1/2 cup serving

Meat/protein
1/4 of plate
Non-starchy vegetables
1/2 of plate

Starch/bread
1/4 of plate
12 BASIC SKILLS OF SELF MANAGEMENT

Understanding Food Labels for Diabetes Management

The two most important pieces of information for your carbohydrate controlled diet are the:
1. Serving Size (measure and weight in grams)
2. Total Carbohydrate (weight in grams)

N u t r i t i o n Facts
Serving Size 1 cup (228g)
Servings Per Container 2
Amount Per Serving
Calories 90 Calories from Fat 30
% Daily Value*
Total Fat 3g 5%
Saturated Fat 0g 0%
Transfat 0 g 0%
Cholesterol 0mg 0%
Sodium 300mg 13%
Total Carbohydrate 13g 4%
Dietary Fiber 3g 12%
Sugars 3g
Protein 3g
Vitamin A 80% • Vitamin C 60%
Calcium 4% • Iron 4%
* Percent Daily Values are based on a 2,000 calorie diet. Your daily
values may be higher or lower depending on your calorie needs:
First:
Check Serving Size
The serving size for this food is one cup. Here, the
total serving size weighs 228 grams.
There are two servings or two cups in this container.
Second:
Check Total Carbohydrate Content
The Total Carbohydrate tells how much of the food
is carbohydrate, based on one serving.
Fiber is included in the total carbohydrate grams.
Sugar is also included in the total carbohydrate
amount. This value shows the total amount of both
natural and added sugars.
What is missing? Starch! Starch is part of the total
carbohydrate, but it is not listed separately. That is
why total carbohydrate must be considered, not
just sugar.

Calories: 2,000 2,500

Total Fat Less than 65g 80g
Sat Fat Less than 20g 25g
Cholesterol Less than 300mg 300mg
Sodium Less than 2,400mg 2,400mg
Total Carbohydrate 300g 375g
Dietary Fiber 25g 30g
Talk with your dietitian about the specifics of label
reading to help you understand how to include
healthy amounts of carbohydrate, fiber and fats in
your diet or if you have been advised to reduce your
intake of sodium or cholesterol.

Developed and Approved by: Mary Ellen Di Paola RD, CDE, Rozane Gee RD, MS, CDE, Sabine Anna Haake, RD, Mary Pasquali RD, MS, CNSD,
Dayna Ramlan RN, CDE, Sharon Urbiztondo RD, CNSD, Holley Wysong RD, CDE. Date: 9/01. Last Updated: 6/03

Produced by: Cathy Camenga, RN, MS, Adrienne Paolini, RN, BSN, OT, Sheri Salamone, Randi Kofsky, Jane Binger, RN, EdD, Bruce Smith,
Center for Patient and Community Education, California Pacific Medical Center, San Francisco, CA.

© 2001 - 2003 California Pacific Medical Center

Funded by: A generous donation from the Mr. and Mrs. Arthur A. Ciocca Foundation.
 SELF MONITORING OF BLOOD GLUCOSE 13

Self Monitoring of
Blood Glucose
Testing your own blood glucose levels between
doctor visits is highly recommended. Your blood
glucose readings give you feedback, and allow you,
your doctor and diabetes care team to see how the
combination of food, stress, physical activity and
medications are affecting you.
Blood glucose meters are now small and portable.
There are a variety of meter styles. Your diabetes
care team can help you select one and teach you how
to use it. Ask your physician or diabetes care team
when and how often to check your blood glucose.
How do I check my blood glucose?
• Prepare your meter and get your testing
supplies ready.
• Wash your hands with soap and water, then dry
before each finger stick. Don’t routinely use alco-
hol because it dries your skin over time.
• Prick the side of your finger (not the tip or pad)
with the lancet or use an alternate site as
instructed.
• Place the blood droplet you obtain on the test
strip you have loaded into your meter. Follow the
instructions that came with your glucose meter
for specific testing information.
What are the blood glucose targets for people with
diabetes?
The targets recommended by the American Diabetes
Association (ADA) are listed below. Your personal glu-
cose targets may be different, so it is important to talk
with your physician or diabetes care team about these.
ADA Blood Glucose Targets
• Before meals: 90 to 130 mg/dl
• One to two hours after the start of a meal:
less than 180 mg/dl
When should I call my health care provider?
You should call your physician to report blood glu-
cose results if:
• Your blood glucose is higher than 300 mg/dl
more than twice in one week
• You are taking diabetes medication or insulin,
and your blood glucose drops below 70 mg/dl
Getting an A1C Check
The A1C check is a blood test that gives information
about your average blood glucose levels over the past
two to three months. To stay current, an A1C check is
typically done every three to six months. To minimize
the risk of diabetes complications, you want to keep
your A1C test results under 7 percent. An A1C will
improve as blood glucose control improves.

• Keep a record of your results, including dates

and time.
• Take your blood glucose meter and blood test
results to every clinic visit.

How can I be sure my test results will be accurate?

• Always check that none of your supplies have
expired before testing
• If required, check that your meter is properly
coded for your test strips
• Perform quality control tests on your meter
routinely
14 BASIC SKILLS OF SELF MANAGEMENT
Physical Activity
A physically active lifestyle really helps keep blood
glucose in good control. As muscles contract for
exercise, physical work or a brisk walk with
a friend, they are using glucose at a faster
rate than they would use it at rest.
There are two important pieces of
advice for almost everyone with dia-
betes: “just do it” and “follow your
doctor’s advice.”
Why is physical activity important
for people with diabetes?
Here’s what physical activity can do
for you:
• Lower your blood glucose, blood
pressure, cholesterol and triglyceride
(blood fats) levels
• Lower your risk for heart disease and stroke
• Help you manage stress
• Help insulin work better
• Help you manage your weight
• Help you feel better
I have not been very active lately and I want to
increase my physical activity level, what should I
do first?
Before starting or significantly advancing any exer-
cise program, check with your physician or diabetes
care team.
• You may need to have several tests done before
your doctor advises you on the best exercise
types, frequency and challenge level for you.
• Be safe; start any new exercise program slowly
and build gradually.
What kinds of physical activities should I include?
There are 3 main types of exercise. Each has health
benefits and all should be included, unless you have
another health condition that prohibits it.
Aerobic Exercise
Aerobic exercise burns both glucose and fats as fuel;
it strengthens heart and lungs; and it has great ben-
efits for weight control.
• Good examples include brisk walking, swimming
and dancing.
• An exercise session that last 30-60 minutes a day,
performed at least five days a week, is a good
aerobic workout goal for most people.
• If you have not been very active recently, start out
with 5 or 10 minutes of gentle aerobic exercise
at least 5 times each week. Gradually add more
time to each exercise session until you meet your
workout goal.
• Or split up your activity for the day by taking
10-minute brisk walks about 1 to 2 hours after
each meal. Don’t work out immediately after
eating a meal, however, as this can be stressful
for your heart.
Strength Training
Strength training exercises benefit glucose manage-
ment because they burn glucose as fuel; help build
muscle size (larger, toned muscles can both burn and
store more glucose); and, when done properly, they
help protect us from injury by improving overall
body balance.
• Always check with your physician before
starting a serious or challenging
strength training program. Lifting
too much weight can cause dan-
gerous elevations in blood
pressure, and cause seri-
ous injury.
• Lifting light weights with-
out straining two or three
times per week is generally safe for most people
who want to begin strength training.
• Proper technique for weight lifting is important,
and a consultation with a physical therapist, exer-
cise physiologist or personal trainer is a good idea.
Flexibility Exercises
Flexibility exercises are basically stretches that are
best performed when muscles are warmed up first.
Stretching does not burn much glucose, but it does
protect muscles from injury that can result from exer-
cise and/or tight muscles resulting from inactivity.
• Stretch three to seven days a week, preferably with
warm muscles. Hold each stretch for 15-60 seconds.
Do three to five repetitions for each stretch.
Yoga is an excellent form of activity that incorporates
flexibility training, muscle strengthening and
breathing.

How much water should I drink before and during
exercise?
• General advice is to drink 12 – 16 ounces of water
over the course of an hour before beginning a
strenuous or long exercise session.
• Drink another 3 to 4 ounces of cool water every
15 to 20 minutes during your exercise session.
• Drink another cup or two of water after you have
cooled down from your exercise.
• You will likely need more water on very
warm days.
You will experience benefits from exercise even if your
activities are not strenuous!
Important Safety Guidelines for Your
Exercise
Follow these general guidelines to protect yourself
from sports injury:
• Wear properly fitting shoes with good support
and absorbent, soft socks.
• Carry or stay near drinking water so that you can
stay well hydrated.
• Start new exercise slowly, and gradually
increase the length of your exercise sessions
over several weeks.
• Follow your doctor’s advice for how hard your
workouts should be.
• Warm up with easy movement for 5 -10 minutes
at the beginning of each exercise session.
• Cool down by gradually slowing the pace at the
end of each exercise session.
• Gently stretch the muscles you worked after each
exercise session.
ALWAYS follow these guidelines if you take diabetes
medication (insulin or pills) because exercise may
lower your blood glucose more than you expect:
• Check your blood glucose before and after
exercising.
• Carry some form of quick acting sugar with you
(such as hard candy, raisins, glucose tablets or
glucose gel) in case your blood glucose drops
during or after an exercise session.
PHYSICAL ACTIVITY 15
• Wear a medical bracelet or other diabetes
identification tag.
Don’t take chances with your heart. Stop
activity immediately and call 911 if you
experience any of the following symptoms:
• Tightness or pain in your chest, arms,
ears, jaws or teeth
• Severe shortness of breath
• Heart palpitations or dizziness
In addition to exercise sessions, try to stay active
throughout the day. Being active helps you burn
calories, condition muscles and control glucose better.
Place a check mark next to the things you’d like to try:
• Walk instead of drive whenever possible.
• Take the stairs instead of the elevator.
• Work in the garden, rake leaves or wash the car.
• Play with the kids.
• Carry things upstairs in two trips instead of one.
• Park at the far end of the shopping center park-
ing lot and walk to the store.
• Sit less, move more.
Tips to Create a More Active Lifestyle
• Make a list of several activities you enjoy that are
physical.
• Plan time to enjoy these activities each week, and
vary them.
• Make activity more fun by planning together
with friends or family.
• Include indoor activities on your list, as rainy or
hot day alternatives.
• Record your progress, problem-solve your barri-
ers and reward yourself in meaningful ways
for success.
16 P R O B L E M S O LV I N G D I A B E T E S C O N T R O L

Problem Solving Diabetes Control

Low Blood Glucose What can make blood glucose fall into the Low
Blood Glucose range?
What is low blood glucose? • Delaying the time to eat, or missing a meal or
Low blood glucose, or “hypoglycemia,” is a term snack altogether
that is used when your blood glucose level drops • A smaller meal or snack than usual, especially
below 70 mg/dl. The lower your glucose falls, the one with less carbohydrate
more serious it can be. Low blood glucose must be
treated immediately when it occurs, because letting • More physical activity than usual: exercise, work
it continue will usually make it much worse. or play
• Taking more diabetes medication than you need
Know the Warning Signs of
• Side effects from other medications you may
Low Blood Glucose
be taking
Early warning signs • Drinking alcoholic beverages, especially on an
• Sweating • Cold clammy skin empty stomach
• Shakiness • Crankiness
What should I do if I have low blood glucose?
• Nervousness • Hunger
There is a standard set of steps to follow to bring
• Weakness • Rapid heartbeat
your blood glucose level up quickly, without causing
• Dizziness • Lightheadedness it to climb too much, too fast.
• Headache
1. Test your blood glucose, if possible. (If this is not
possible, but you are having symptoms, begin
Late warning signs
the Rapid Treatment Steps for Low Blood Glucose
• Tingling around the mouth immediately.)
• Mental dullness
2. Depending on your results, follow these treat-
• Altered level of consciousness ment guidelines:
• Changes in vision
Rapid Treatment: If the result of your test is 70
• Seeing spots in front of your eyes mg/dl or below, and/or if you have late warning
• Personality change signs of low blood glucose, start the Rapid Treat-
ment Steps for Low Blood Glucose immediately to
Can I get these symptoms even if my blood glucose quickly bring your blood glucose level back up to
isn’t low? a safer range.
It is possible. Signs of low blood glucose can come
on when your blood glucose level is falling rapidly
due to exercise, medication or a combination of
both… even if your blood glucose level has not yet
fallen below 70 mg/dl. No matter. The symptoms
come on because rapid change in blood glucose can
be stressful to the body. Follow the same guidelines
that are advised in the Rapid Treatment Steps for Low
Blood Glucose to slow down the change in your blood
glucose rate.

Rapid Treatment Steps for
Low Blood Glucose
Step 1: Eat or drink 1 of the sugar items in this
list right away:
• 3 to 4 glucose tablets
• 1 packet of glucose gel
• 1/2 cup (4 ounces) of fruit juice
• 1/2 cup (4 ounces) of a regular (not diet)
soft drink
• 1 cup fat-free or 1% milk
• 5 to 7 pieces of hard candy
• 1 tablespoon of sugar or honey
Step 2: Wait 15 minutes, then recheck your
blood glucose. If it is still below 70,
have one more serving of a sugar item
above. Try to get your blood glucose
between 70 - 100 mg/dl before
moving on to Step 3.
Step 3: Eat a snack with one or two
carbohydrate foods, plus protein
or little fat to keep your blood glucose
level from dropping again soon. If it is
close to mealtime, just eat your normally
scheduled meal without the extra snack.
Protective Treatment: If your blood test result is
between 70 and 100 mg/dl and/or if you have
any of the early warning signs of low blood glu-
cose described above, eat a snack that includes 15
grams of carbohydrate.
I have heard that people can pass out when they
have low blood glucose. What does that mean?
If a person’s blood glucose level falls very low, they
can eventually lose consciousness and pass out, This
is a serious medical emergency called Severe Hypo-
glycemia. It is usually the result of a severe insulin
reaction.
LOW BLOOD GLUCOSE 17
Risk of Severe Hypoglycemia increase when:
• drinking alcohol and not eating while taking
diabetic medication or insulin
• doing extreme exercise while on a very restrictive
diet and taking diabetic medication or insulin
Immediate emergency treatment is required:
• Call 911
• Give Glucagon
What is Glucagon?
Glucagon is an emergency drug given by injection
to raise blood glucose levels. It is given in case of
a severe reaction to insulin or if someone becomes
unconscious due to low blood glucose levels. Ask
your physician or diabetes care team if you should
have glucagon on hand in case of emergency. If the
answer is “yes”, you will need instruction to under-
stand it yourself, and you will need to teach a family
member or friend how to give it to you.
Glucagon is available by prescription only. It comes
in a kit or in a box. If you use a kit, follow the in-
structions that come with it.
What should I do about frequent low blood
glucose?
Having frequent low blood glucose reactions is not
good because, the more often they occur, the less
you will feel the next one coming on in its early
stages. It is important to keep a record of the times
you have low blood glucose and note any possible
causes. Discuss these episodes with your physician
or diabetes care team. Your treatment plan may need
to be adjusted in order to prevent frequent low blood
glucose events.
How do I prevent low blood glucose episodes?
• Don’t skip or delay meals.
• Take your medications as directed.
• Test your blood glucose regularly as directed by
your physician or diabetes care team.
18 P R O B L E M S O LV I N G D I A B E T E S C O N T R O L
• Test your blood glucose before and after exercise
and physical activity.
• If you drink alcohol, only have it with a meal or
snack that includes carbohydrate. And, do not
drink more than one to two drinks per day.
Low Blood Glucose and Driving
Protect yourself and others by choosing to drive only
when your blood glucose is in a safe range.
• Check your blood glucose before driving.
• Do not drive if your blood glucose is below 70
mg/dl or if you have any symptoms of low blood
glucose. Treat your low blood glucose first before
you start your car trip.
• When driving or traveling, always carry your
blood glucose meter and glucose tablets with you.
High Blood Glucose
What is high blood glucose?
High blood glucose, or “hyperglycemia,” is a term
that is used when your blood glucose level is consis-
tently above your target range. It is important that
you, your doctor and diabetes care team problem
solve the reason for high blood glucose so that it can
be treated. Letting blood glucose levels remain high
will increase the risk of complications sooner and
later. When blood glucose levels are very high (above
300), dehydration and illness can develop quickly.
Know the Signs and Symptoms of
High Blood Glucose:
• Extreme thirst
• Frequent urination
• Blurred vision
• Dry skin
• Hunger
• Drowsiness
• Slow healing of wounds
Note: You can have high blood glucose
without showing any symptoms!
What can make blood glucose rise and
stay high?
• Eating too much food, especially too much
carbohydrate
• Sedentary lifestyle; Inactivity
• Excessive weight gain
• Less diabetes medication than what is needed
• Not taking diabetes medication as directed
• Side effects of other medications you may
be taking
• Infection, injury or illness, such as cold or flu
• Stress
What should I do if my blood glucose is too high?
It is important to identify the reasons for consistent
high blood glucose together with your diabetes
care team so that the most effective treatments for
you can be prescribed.
• Keep a record of the times you have high blood
glucose and note any possible causes. Discuss
these episodes with your physician or diabetes
care team. Your treatment plan may need to be
adjusted.
• Drink plenty of zero calorie beverages (e.g., wa-
ter, sugar free soda).
Call your physician or diabetes care team if:
• your blood glucose level is above 300 mg/dl and
you are ill or
• your blood glucose level is above 300 mg/dl
more than twice in one week, or
• you have symptoms of high blood glucose.

Managing Sick Days
When you are sick, the physical stress on your body
from the illness can cause your blood glucose to rise.
At these times, it may be harder to keep your blood
glucose in your target range. Be prepared. Before
your next cold, flu or other illness, work with your
physician or diabetes care team to create an action
plan. Your plan should include:
• An extra week’s supply of insulin, diabetes pills
and test strips
• Sugar-free cough medication and non-aspirin
pain relievers
• Thermometer
• A log book to record your blood glucose levels,
symptoms and any instructions you receive from
your physician or diabetes care team
• Someone you can call to check in on you
When to call your physician or diabetes
care team
• If you have blood sugar levels greater than
300 mg/dl for 24 hours or under 70 mg/dl for
three readings in a row. Follow guidelines to treat
low blood glucose.
• If you have vomiting or diarrhea for more than
six hours or cannot keep fluids down.
• If you have a fever of 101° F or higher for more
than 24 hours.
• If you have a dry mouth, increased thirst, de-
creased urination and dry flushed skin.
How often should I test my blood glucose when I
am sick?
• Check your blood glucose levels every four
hours, or more often as needed, and record the
results in your log book.
• Check your temperature every four hours and
record it in your log book.
M A N A G I N G S I C K D AY S 19
What should I drink and eat during my illness?
• Take your diabetes medication or insulin as
directed.
• Drink sugar-free fluids to stay hydrated (at least
8 ounces per hour). These may include water, diet
soft drinks, sugar-free Kool-Aid, Crystal Light,
decaffeinated tea or broth. Avoid coffee and caf-
feinated drinks, since they can disrupt your sleep,
upset your stomach and increase urine produc-
tion (fluid losses increase).
• Eat the meals at the times you normally would, as
much as possible. If you can only tolerate a little at
a time, eat more frequently by adding snacks.
• If your blood glucose is in the normal range or
only slightly elevated (200 mg/dl or less) and
you cannot tolerate regular foods, try eating a
food that gives you 15 grams of carbohydrates
every one to two hours. Examples include:
1/2 cup low-fat ice cream
1/2 cup soft pudding
1/2 cup yogurt
1/2 cup cooked cereal
1/4 cup sherbet
1 tbsp. honey
1/2 cup regular Jell-O
1/2 cup regular soda
1 cup of cream soup (thinned)
1/2 cup fruit juice
1/2 twin popsicle
• If your blood glucose level is greater than 250
mg/dl, take only the sugar free liquids men-
tioned above.
• If you cannot eat or drink anything, or you are
not able to keep food or liquids down for more
than 6 hours, call your physician.
• Be sure you read and follow the guidelines: When
to call your physician or diabetes care team.
20 RISK REDUCTION
Risk Reduction
An Ounce of Prevention
People with diabetes lead full and active lives but it
is also true that serious complications can develop
overtime, especially when diabetes is not kept in
good control. These health problems include:
• Heart and blood vessel diseases (cardiovascular
disease)
• Eye disease (retinopathy)
• Kidney disease (nephropathy)
• Nerve disease (neuropathy)
• Foot problems, such as dry, cracked skin, foot
ulcers and amputation
The best way to avoid, minimize or delay complica-
tions associated with diabetes is to keep your blood
glucose, blood pressure and cholesterol under con-
trol. It also helps to have regular checkups so your
physician or diabetes care team can detect and treat
any problems early.
Heart Disease Risk Reduction
Heart disease is the number one health problem linked
to diabetes. The ABC’s of Diabetes summarizes the key
tests that must be done regularly to be sure your risk
factors for heart disease are being well controlled.
ABC’s of Diabetes Care
A is for A1C (pronounced A-one-C). Your A1C check
tells you what your average blood glucose level has
been for the most recent two-to-three months before
the test is done. It is the blood check “with a memory.”
To know where you stand in overall glucose control,
you should have your A1C checked about every three
to six months. A1C goal: less than 7 percent
B is for blood pressure. When your blood pressure
is high, your heart has to work harder. High blood
pressure also causes organ damage, and puts you
at higher risk for eye, kidney and heart problems.
Controlling blood pressure is as important as
controlling blood glucose levels to prevent these
complications from developing. Blood pressure
goal: less than 130/80
C is for cholesterol. Your cholesterol numbers tell
you about the amount of fat carried in your blood.
There are 3 measures that are studied. HDL (“good”)
is a cholesterol molecule that helps protect your
heart. LDL (“bad”) is a cholesterol molecule that will
increase fat and cholesterol build up in your blood
vessels, leading to heart disease. Triglycerides are a
kind of fat, and high amounts of this in your blood
also increases your risk of heart attack and stroke.
The ADA recommends the following
cholesterol goals for most people
with diabetes:
Total cholesterol Below 200 mg/dl
LDL cholesterol Below 100 mg/dl
Below 70 mg/dl for people
who also have heart and
blood vessel disease
HDL cholesterol Above 40 mg/dl (men)
Above 50 mg/dl (women)
Triglycerides Below 150 mg/dl
Most of the day-to-day care of your diabetes is up to
you. If your regular blood tests show that you are not
reaching the ABC goals set for heart disease protec-
tion, talk to your physician or diabetes care team.
You may need an addition or adjustment in your
medication or diet plan to reach these goals. They are
important.
Heart and Blood Vessel Disease
Diabetes increases your risk of stroke, heart disease
and heart attack. Be sure you and your family know
the warning signs of these emergencies.
What is a heart attack?
A heart attack occurs when the blood vessels supply-
ing your heart become partially or totally blocked by
fat and cholesterol deposits. Any blockage will reduce
or cut off the blood supply that provides your heart
with the oxygen and nutrients it needs to keep beating.

Heart Attack Warning Signs
• Chest pain or discomfort
• Pain or discomfort in your arms, back, jaw or neck
• Shortness of breath
• Sweating
• Dizziness or light-headedness
• Indigestion or nausea
• Weakness or fatigue
Become familiar with these warning signs, and call
911 right away if they occur.
What is a stroke?
A stroke (sometimes called a brain attack) occurs
when the blood supply to part of your brain is inter-
rupted and damage to the brain tissue occurs. The
most common cause is a blocked blood vessel. Stroke
can cause a number of problems, including loss of
muscular strength or control, paralysis, difficulty
thinking or speaking, and emotional problems.
Stroke Warning Signs
• Weakness or numbness on one side of your body
• Sudden confusion or trouble understanding
• Trouble talking
• Dizziness, loss of balance or trouble walking
• Trouble seeing out of both eyes or double vision
• Severe headache
If you experience any of the above warning signs,
call 911 immediately. Very prompt medical attention
can help prevent permanent brain damage.
HEART DISEASE RISK REDUCTION 21
What can I do to keep my heart and blood vessels
healthy?
Most importantly, keep your blood glucose, blood
pressure and cholesterol levels under control by
working with your physician and diabetes care team.
This may require medication, in addition to these
healthy lifestyle choices you can make:
• Eat healthy foods. Eat fresh, whole fruits and a
good variety of vegetables, along with low-fat
dairy foods, whole grains, fish, poultry and nuts.
Eat very little saturated fat and zero trans fats. Ask
a dietitian for help creating a healthy meal plan.
• Limit the amount of sodium (salt, salty foods)
you eat.
• If you are overweight, work on weight loss by
eating less and getting in more physical activity
than you do now.
• Become more active. Physical activity, even
something as simple as walking, can help you
manage your blood glucose, blood pressure and
cholesterol levels better, and reduce stress.
• If you smoke, get help to quit. This is very
important.
• Take your medications as directed.
• Ask your physician or diabetes care team if you
should take aspirin. This may help to reduce your
risk of heart attack and stroke.
The Dangers of Smoking
Why is smoking especially harmful for
people with diabetes?
Smoking damages the blood vessels
throughout the body. If you have diabetes
and you smoke, your risk of heart attack,
heart disease, stroke and peripheral arterial
disease (damage to the blood vessels in your
feet and legs) dramatically increases.
Ask your physician or diabetes care team for a personal plan
to help you quit smoking and other available resources.
22 RISK REDUCTION
Foot Infection Risk Reduction
Foot infections occur more often in people with
diabetes, and they are much harder to treat. High
glucose levels, over time, can cause nerve damage
and reduce blood flow to the feet and toes. Nerve
damage often results in pain, tingling and numbness
in the feet. Poor circulation can lead to poor wound
healing. In combination, poor blood flow and nerve
damage means that a simple injury, such as a blister,
that has not been caught early, can develop into a
serious infection very quickly. So, what’s the solu-
tion? Daily foot care habits:
What can I do to take care of my feet?
• Trim your toenails straight across and file the
edges. Rounded edges help prevent ingrown
toenails.
• Choose socks that won’t irritate your feet, such as
seamless socks or those with flat or soft seams.
• Wear comfortable, well fitting shoes.
• Before you put on shoes, feel inside them to make
sure there are no pebbles or rough edges that
might hurt your feet.
• Protect your feet all the time by wearing shoes or
slippers, even around the house or at the beach.
• Have your physician or diabetes care team check
your feet at each visit and do a complete foot
exam once a year.
Daily Foot Care Instructions
• Wash your feet with warm (not hot) water and
soap, then dry completely.
• If your skin is dry, apply lotion that does not con-
tain perfume. DO NOT put the lotion between
your toes.
• Examine the tops, bottoms and sides of your feet,
as well as between your toes. Use a mirror to help
you see the bottoms and sides of your feet, or
have a family member assist you.
• Check for sores, cuts, bruises and ingrown toe-
nails, daily.
• If you do find a foot injury, call your physician or
diabetes care team. Don’t try to take care of foot
problems yourself.
Dental
Disease Risk
Reduction
Diabetes increases the
risk of dental prob-
lems, including gum
disease that can lead to serious infections. Take any
signs of early infection seriously, and if your gums
bleed or are red, see your dentist.
What should I do to protect my teeth?
• Keep your blood glucose in your target range.
• See your dentist twice a year.
• Brush at least twice a day with a soft brush and
floss daily.
Eye, Nerve and Kidney Protection
Eye Disease (Diabetic Retinopathy)
High blood glucose can damage the tiny blood vessels
in your eyes. This damage can cause vision problems
and even lead to blindness. High blood pressure with
high glucose increases the risk of eye disease.
Fortunately, the progression of eye disease can be
slowed or stopped if it is found early. Only a trained
eye doctor can detect early changes to the blood
vessels in your eyes, and regular eyes exams are an
important part of your diabetes care.
What can I do to prevent or delay eye problems?
• Keep your blood glucose and blood pressure
within target ranges.
• Have a dilated eye exam every year in addition to
a vision check.
• Be sure your eye doctor knows that you have
diabetes.

Kidney Disease (Diabetic Nephropathy)
Kidney disease can occur because high blood glucose
damages the tiny blood vessels in your kidneys.
High blood pressure in combination with high glu-
cose can make kidney disease worse.
What can I do to prevent or delay kidney problems?
• Keep your blood glucose and blood pressure
within target ranges.
• Have regular medical checkups. Be sure this
includes a urine test to check for microalbumin/
creatinine ratio once a year. This test looks for
protein in your urine and can be an early sign
that your kidneys are under stress.
• Along with good blood glucose and blood pres-
sure control, early treatment with common blood
pressure medications can slow the progression of
kidney disease.
• A high protein diet is NOT recommended if you
have early signs of kidney disease, and limiting
salt is also important. You may want to meet with
your diabetes care dietitian to be sure your diet
provides a good balance of carbohydrate, protein
and healthy fats.
Nerve Disease (Diabetic Neuropathy)
High blood glucose can also damage nerve cells over
time. Nerve damage leads to loss of feeling, especial-
ly in the toes and feet, but it can happen anywhere
on the body. A blister from poorly fitting shoes, for
example, may not be noticed until it is severe. Or,
sunburn might not be felt until the skin is severely
injured. Pain or tingling sensations for no reason
might also develop as a result of nerve damage.
Nerve problems can also affect inner organs, causing
diarrhea, bladder infections, sweating (especially
after eating), dry skin, light-headedness and loss of
balance. If you experience any of these problems,
talk to your physician or diabetes care team.
DIABETES AND PREGNANCY 23
Sexual Health
Will diabetes affect my sex life?
Diabetes doesn’t have to ruin your sex life but nerves
that control sexual organs and blood vessels that
keep them healthy can be damaged. In order to
maintain the health of these organs, you will need to
control your ABC’s: blood glucose, blood pressure
and cholesterol levels. Work with your physician or
diabetes care team to prevent or reduce any potential
problems.
What problems might women experience?
For women, vaginal and urinary tract infections
are most common. They tend to occur when blood
glucose levels are high. Some women with diabetes
also experience vaginal dryness and pain during
sex. These problems can be treated with estrogen or
lubricant. If you have these or other sexual concerns,
talk with your physician or diabetes care team.
What problems might men experience?
For men with diabetes, erectile dysfunction (ED) is
the most commonly reported sexual health problem.
The best way to avoid ED is to keep your blood
glucose, blood pressure and cholesterol levels under
control. Other causes of ED include alcohol use,
certain prescription drugs, nerve or blood vessel
damage, low male hormone levels, stress and de-
pression. If you are experiencing ED or have other
sexual concerns, talk with your physician or diabetes
care team.
24 LIVING WELL WITH DIABETES
Diabetes and Pregnancy
What can I do to have a healthy pregnancy?
Most women with diabetes have healthy babies, but
it takes planning and attention. If you are thinking
about trying to get pregnant, begin now by telling
your doctor and diabetes care team, and start work-
ing to get your blood glucose in excellent control. For
women with diabetes, excellent blood glucose con-
trol for several months before trying to get pregnant
is urged. A balanced, nutrient rich diet and regular
exercise is also important to prepare for a healthy
pregnancy.
Get in to see your obstetrician before you get preg-
nant or very soon once the pregnancy has started,
because high blood glucose can cause harm in early
development. By keeping your blood glucose close
to normal, you give your baby the best chance for a
healthy start.
Later in pregnancy, you will find that blood glucose
levels become harder to control. This is because hor-
mones of late pregnancy increase insulin resistance.
At the same time, you need to eat to support your
energy and the baby’s growth, without gaining too
much weight, too fast. Excellent blood glucose con-
trol is very important during this time of pregnancy,
because your high glucose requires the baby to make
too much of its own insulin. Blood pressure control
is also important. The balance is tricky, and to have
a healthy pregnancy, you and the baby will need to
be closely monitored by your obstetrician, diabetes
specialist physician and diabetes care team.
Throughout the pregnancy, your medications are
carefully reviewed. If you are taking diabetes pills
now, you may need to switch to insulin once you
are pregnant. Your other medications will need to be
reviewed for safety as well. Work closely with your
physician or diabetes care team to ensure you have
as safe and healthy a pregnancy as possible.
If you don’t want to become pregnant or if you are
not ready because your blood glucose is not yet con-
trolled, use an effective method of birth control. An
unplanned pregnancy can hurt you and your baby.
Ask your physician or diabetes care team which
birth control method would be best for you.

Living Well with Diabetes
Living well with diabetes is a challenge. It is also a
choice. It is many small choices you make every day.
The fact is that no one can make these choices except
you. But we are here to help: to help you get control
of your diabetes and to support your learning. The
formula for living well with diabetes is to become
very skilled at managing your condition and to take
charge as the lead player on your diabetes care team.
Opportunity lies ahead.
Key diabetes management skills and strategies:
• Select a healthy, balanced diet.
• Follow a general plan for how much and
when to eat.
• Engage in physical activity every day.
• Work to maintain a healthy weight for you.
• Practice good dental and skin hygiene, daily
foot care and keep your routine health care
appointments.
• Take your medications as directed; learn the
basics about how they work, possible side effects,
and what to do in case you miss a dose.
• Track and record your progress. Monitor your
blood glucose and keep track of your A1C, blood
pressure and cholesterol levels.
• Learn all you can about diabetes. Read, ask many
questions and attend diabetes education programs.
• Learn strategies to help you manage stress in
healthy ways. Seek out support when you need it.
Stress Management
Stress is a natural reaction to challenge and threat,
and everyone will experience it at some times in life.
Stress is a good thing, a powerful motivator, in small
doses. But too much stress, for too long will cause
your blood pressure, heart rate, blood glucose and
cholesterol levels to go up. The effect: Stress makes it
more difficult to manage diabetes.
STRESS MANAGEMENT 25
Learning skills and strategies to manage stress can be
really help keep diabetes under control. If you think
stress is getting in the way of your diabetes manage-
ment success, talk to your physician and diabetes
care team about resources for stress management
training in your area.
10 Strategies to Better Manage Stress
1. Learn how to set manageable goals:
2. Focus your energy on the parts of your life
that are truly important.
3. Walk or find other ways to be physically
active each and every day.
4. Share your thoughts and emotions. Talk
with family and your friends; write in a
journal or draft a letter.
5. Consider joining a support group or, if
needed, meet with a professional.
6. Keep building your skills and knowledge.
Read. Attend diabetes classes and support
groups.
7. Eat on time, stay hydrated, choose healthy
foods, try not to over eat.
8. Learn to relax and calm yourself. Stretch
slowly and breathe deeply.
9. Do what you love and have fun at it: dance,
swim, read a good book, listen to your
favorite music, take time for a hobby, see a
play or movie.
10. Seek out and spend time with people who
are positive, enjoy life and who make you
feel good. Find and keep your sense of
humor.
26 LIVING WELL WITH DIABETES
Learning How to Change Habits
No book that advises change would be complete
without talking about habits. A one-time change is
usually easy but, in order to make change permanent,
old habits and routines must be changed. Changing
habits is much harder, but possible. First, you need to
decide that change is worth the effort. In the case of
diabetes, the benefits of good control are evident and
your changes will really pay off. So, how do you get
started and stick with it? Here are some important
tools that can help you reach your goals.
Succeeding at Change
• Write it down. Putting intentions on paper can
help you think things through, work out the bugs
in your plan and commit.
• State your objectives. What do you need to
achieve? For example, “I want to lose 50 pounds”
or “I want a good exercise program.” might be
your objectives. Write this down.
• Set realistic and achievable goals. If your goals
aim too high, you can set yourself up for failure.
If you set your goals too low, you might not make
much effort. Write goals you want to work on
and believe you can achieve.
• Break your goals into smaller, specific action
steps with time frames. A time frame keeps you
focused, but make it reasonable. What can you
achieve today, this week or this month?
• Don’t give up! Remember it takes time to build
new habits; try to be patient. Change is a process,
and requires problem solving along the way. Ask
your physician and diabetes educators to help
you choose the important goals to work on first,
if you are not sure.
 LEARNING HOW TO CHANGE HABITS 27

Answer the questions below to help you reach your goals.

Here’s my objective:

Example: I will increase my physical activity.
Example B: I will improve my diet, eat less fat and more vegetables.

Here’s what I’ll do:

Example: I will walk 10 minutes a day five times a week and increase the time by five minutes each week.
Example B: I will bring my lunch to work at least three days a week instead of eating fast food or eating out.

Here’s when I’ll do it:

Example: I’ll walk after breakfast.
Example: I will bring lunch on Monday, Tuesday and Thursday.

Here’s what I need to get ready:

Example: I’ll need comfortable walking shoes.
Example: I’ll get a lunch box and keep healthy foods (fruit, lean meats or non-fat cheese, whole grain
bread, vegetables) on hand.

This might get in the way of my plan:

Example: If it’s raining, I won’t be able to walk outside.
Example: I did not shop ahead of time.

If that happens, I’ll do this instead:

Example: I’ll go to the recreation center or mall and walk around inside.
Example: I’ll order a small deli sandwich on whole grain bread with a side salad and piece of fruit.

Here’s when I’ll start:

Example: I’ll start my walks this coming Monday.
Example: I’ll plan lunch meals and buy food this weekend for next week.
28 LIVING WELL WITH DIABETES

10 Ways to Maintain New Habits

1. Plan ahead and set up your environment so it is easier to stick with your new habit. Example: Stock up
on vegetables and fruit instead of high-fat snacks.
2. Think through your schedule and routine. Where can you find time for your new habit or your routine?
Example: If you prefer to walk in the morning before work, get up a little earlier so you’ll have time.
3. Focus on the benefits of your new habit. Example: you have more energy on the days that you are
physically active.
4. Think ahead. Example: What are the roadblocks that might come up and how can I get around them.
5. Ask for support from family, friends, your physician or diabetes care team. Example: Ask a family mem-
ber to watch the kids while you go for a walk.
6. Don’t dwell on slips; move on. Example: If you sometimes slip up and go back to your old habit, don’t
despair. Start fresh tomorrow.
7. Monitor your progress. Example: Keep track of your efforts by writing down what you are doing, your
successes and your challenges.
8. Vary your routine; keep it interesting. Example: If you get tired of walking around your neighborhood,
walk inside the shopping mall or at a local park instead.
9. Find meaningful rewards for your success at sticking with your plan.
10. Remember: It takes time to make new habits, but your patience and persistence will pay off in the
long run!
 DIABETES RESOURCES 29

Chart A: Getting the Very Best Care

Every 3-6 months at Primary Care Physician Visit:

ADA* ACCE** My My Result My Result

What to Do Target Target Target Date Date

Review blood glucoses

before meals 90–130 mg/dl 110 mg/dl

2 hours after meal < 180 mg/dl 140 mg/dl

Blood pressure < 130/80 mmHg

Check need for aspirin

Complete foot exam

Review meal plan

Review activity level

Check weight

Review Smoking Status

Discuss questions or concerns

Dental checkups

A1C < 7% 6.5%

Physical exam

Total Cholesterol < 200 mg/dl

LDL cholesterol < 100 mg/dl

HDL cholesterol (men) > 40 mg/dl

HDL cholesterol (women) > 50 mg/dl

Triglycerides < 150 mg/dl

Dilated eye exam

Microalbumin/Creatinine ratio

Flu shot

Pneumonia vaccine (1x)

*ADA = American Diabetes Association

**ACCE = American College of Clinical Endocrinologists
30 LIVING WELL WITH DIABETES

Chart B: Blood Glucose Record Keeping Log

Breakfast Lunch Dinner

Day Pre Post Pre Post Pre Post Bedtime Other Comments

1
2
3
4
5
6
7
8
9
10
11
12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31
 DIABETES RESOURCES 31

Diabetes Resources
Many sites have materials available in English
and Spanish.

American Diabetes Association

www.diabetes.org

American Dietetic Association

www.eatright.org

American Heart Association - Diabetes

www.americanheart.org

Centers for Disease Control and Prevention (CDC)

National Center for Chronic Disease Prevention
and Health Promotion
www.cdc.gov/diabetes
1-877-232-3422

Joslin Diabetes Center

www.joslin.harvard.edu/education/beginnerguide.html

National Institutes of Health

National Diabetes Education Program (NDEP)
www.ndep.nih.gov

National Institute of Diabetes and Digestive and

Kidney Diseases (NIDDK)
www.niddk.nih.gov
1-800-860-8747 or (301) 654-3327

Weight-Control Information Network (WIN)

http://win.niddk.nih.gov/index.htm
1-877-946-4627 or (202) 828-1025

Nutrition and Food Information

www.dietfacts.com
www.calorieking.com

WebMD
www.webmd.com
Notes:
Diabetes Medications
2 D I A B E T E S M E D I C AT I O N S
Diabetes Medications
There are a variety of medications used to help keep
blood glucose levels in control and minimize the risk
of developing complications. Diabetes medications
are selected based on the type of diabetes diagnosed.
They are often changed or adjusted to maintain good
blood glucose control over time.
Oral Medications for Type 2
Diabetes
Why do I need medication?
Over time, a healthy diet and regular exercise alone
may not be enough to keep your diabetes under
control. You may need one or more medications to
maintain healthier blood glucose levels.
You may not like the idea of taking medications,
but newer diabetes medications have proven very
effective at improving blood glucose control. Adding
a medication to your diabetes management plan can
help you to:
• Feel better, and have more energy to be active
and enjoy life
• Eat a little more naturally without worrying
about the effect of small amounts of carbohydrate
on your blood glucose level
• Lower your risk of diabetes complications, such
as stroke, heart attack, kidney damage, blindness
and serious foot infections
How do I take my medication?
There are several types of oral medications used to
treat diabetes. Each works in a different way, has a
site of action in the body and specific guidelines for
its proper use. If you are one of many people who
need more than one type of medication, be sure you
understand the guidelines for each of the medica-
tions you take.
Here is an overview with general guidelines for oral
diabetes medications:
• It is important to know what time to take each
medication and what to do if you miss a dose.
• Medications need to be taken about the same
time every day to get the best effect.
• All medications work best and side effects are
minimized when they are taken as directed by
your physician or diabetes care team.
• Most oral diabetes medications work throughout
the day and are not targeted to help control glu-
cose at one specific meal.
• In contrast, these four medications do help
control glucose at mealtimes: Prandin, Starlix,
Acarbose and Miglitol.
How can I remember to take my medication?
If you are new to medications, this may take some
effort. Having to take different medications every
day can get confusing. Here are some ideas that may
help you to remember:
• Try using a pill organizer with a compartment for
each day of the week.
• Link your pill-taking routine to something else
that is routine in your day. For example, take
your morning medication right after you brush
your teeth or with breakfast.
• Use a chart or calendar to check off when you’ve
taken your medications.
 O R A L M E D I C AT I O N S F O R T Y P E 2 D I A B E T E S 3

What should I do if I forget to take my medication?
Instructions for a missed dose of medication will
depend on the medication.
Ask your physician or diabetes care team what to do
if you miss a dose of any medication you take, and
make a note of these instructions.
Will the medications have any side effects?
All medications have a chance of causing side effects,
even aspirin. If you notice any changes in the way
you feel when you take medication, such as head-
aches or nausea, talk to your physician or diabetes
care team. This may be an indication that your medi-
cations need to be adjusted.

ORAL DIABETES MEDICATIONS

The following table summarizes oral medications used for diabetes control.

These medications help the pancreas make more insulin

Sulfonylureas
• Most sulfonylureas work up to 12 hours. Extended release versions work up to 24 hours.
• Usually taken once or twice a day before meals.
• Possible side effects include low blood glucose and weight gain.
• Drug reaches its greatest effect two to six hours after taking a dose.
Examples:
Glyburide (Micronase, Glynase, DiaBeta) Glimepiride (Amaryl)
Glipizide (Glucotrol, Glucotrol XL)

Meglitinides
• Meglitinides are short-acting and only work up to four hours.
• Must be taken before each meal. Do not take if you skip a meal.
• Possible side effects include low blood glucose.
Examples:
Repaglinide (Prandin) Nateglinide (Starlix)
4 D I A B E T E S M E D I C AT I O N S

This medication reduces the amount of glucose release by the liver

Biguanides
• Most biguanides work for 4 to 12 hours. Extended release versions work up to 24 hours.
• Usually taken one to three times a day with meals.
• Possible side effects include temporary stomach discomfort, nausea and diarrhea. If symptoms
persist, contact your physician or diabetes care team.
• When used alone, rarely causes weight gain or low blood glucose. Low blood glucose may occur
when taken with other diabetes medications.
Examples:
Metformin (Glucophage) Metformin Long-Acting (Glucophage XR)

These medications help muscle and fat cells respond to your own insulin
Thiazolidinediones (TZDs)
• May take four to six weeks to see effects on blood glucose after starting this medication.
• Take once or twice a day as directed by your physician or diabetes care team. May be taken with or
without food.
• Possible side effects include weight gain and fluid retention. Low blood glucose may occur when
taken with other diabetes medications.
• May reduce effectiveness of birth control medications.
• May worsen heart conditions, especially heart failure.
Examples:
Pioglitazone (Actos) Rosiglitazone (Avandia)
 ote: Recent reports suggest a possible increased risk of heart attack
N
or heart related death. FDA analysis of all the data is ongoing. Please
discuss with your clinician.

These medications slow digestion of starches into sugar in the intestines

Alpha-Glucosidase Inhibitors
• Works for up to four hours.
• Take this medication with first bite of each meal.
• Possible side effects include bloating, gas and diarrhea.
Examples:
Acarbose (Precose) Miglitol (Glyset)
 OVER THE COUNTER 5

This medication increases release of insulin from the pancreas and decreases glucose
production by the liver
DPP-4 Inhibitors
• Take this medicine with or without food.
Example:
Sitagliptin (Januvia)

These medications are combinations of 2 diabetes medications otherwise available in

single tablet form. They are combined for patient convenience
Examples:
Glyburide/Metformin (Glucovance) Avandia/Glimepiride (Avandaryl)
Glipizide/Metformin (Metaglip) Actos/Metformin (ActosPlus Met)
Avandia/Metformin (Avandamet)

Over the Counter May Raise Blood Glucose:

• Decongestants/cold remedies
Are there other medications that may affect my
blood glucose? • Cough drops and syrups with sugar
Yes, many, so be sure to discuss all the medications • Niacin in high doses
you are taking with your physician or diabetes care • Corticosteroids (prednisone)
team. This includes over-the-counter medications, vi-
tamins and herbal supplements. If you are taking other • Asthma and allergy medications
medications that raise or lower your blood glucose, • Estrogens and birth control pills
you may need more frequent blood glucose monitor-
• Diuretics (water pills)
ing or to have your diabetes care plan adjusted.
• HIV medications
The following table gives a few examples of over-
the-counter and prescription medications that may May Lower Blood Glucose:
affect your blood glucose levels.
• Nicotine patches
• Some blood pressure medications, such as beta-
blockers, may raise or lower blood glucose and
make it difficult to recognize signs of low blood
glucose.
• Alcohol
6 D I A B E T E S M E D I C AT I O N S

Can I use herbs or dietary supplements? How do I use insulin?

That depends! Dietary supplements and herbal
products may affect your blood glucose or compli-
cate diabetes management.
Be sure to discuss any herbal products or dietary
supplements you are taking or considering taking
with your physician or diabetes care team.
First, there are some important terms and concepts
you need to know:
Onset: Insulin onset is the time when the insulin action
kicks in and it starts working to lower blood glucose.
Peak: Insulin peak is the time when the insulin action
reaches its maximum ability to lower blood glucose.

Injectable Medications for Duration: Insulin duration is the length of time

insulin action lasts and it is still working to lower
Type 2 Diabetes – Insulins blood glucose.
Insulin is a hormone produced by the beta cells of
Insulin Dosing
the pancreas. Insulin plays a critical role in glucose
metabolism (fuel utilization) and blood glucose Based on your blood glucose patterns, daily routines,
control in your body. In short, diabetes is a condition diet, exercise and other concerns, you and your
that develops when insulin is in short supply or physician or diabetes care team will determine the
when it is not being used efficiently by the body. best type(s), frequency and doses of insulin for you
to control blood glucose.
Will I need to use insulin?
Perhaps. Diabetes is a progressive illness. Over time, Insulin Injections
the pancreas may not keep up with the insulin de- Generally, the abdomen is the best site for injecting
mands of the body. This is not due to a lack of trying insulin; however, the outer side of the upper arm,
but, rather, it is the natural course of their disease thigh and buttocks can also be used. Insulin is in-
process. jected into the fatty tissue beneath the skin (subcuta-
neous tissue). It is important to change the site where
During times of increased stress or illness, insulin is you inject your insulin. Never inject in the same site
often necessary. two times in a row.
Depending on the situation, insulin may be started
while oral diabetes medications are still being taken.
Or, insulin may be started alone.
Transitioning to insulin is common for people who
have had type 2 diabetes for many years. It is often a
very positive move that helps people more effective-
ly control their blood glucose and adds protection
against complications.

Does insulin come in a pill?

No, that is not possible because acid in the stomach
destroys insulin.
Insulin is currently given by injection. Recently,
an inhaled insulin has also become available. New
methods are being researched all the time.
 I N J E C TA B L E M E D I C AT I O N S F O R T Y P E 2 D I A B E T E S – I N S U L I N S 7

Insulin Action and Timing*

The following chart summarizes types of insulin available
with the onset, peak and duration of their insulin action.
Examples include:
Onset Peak Duration
Types of Insulin (hours) (hours) (hours)

Rapid-Acting
Insulin lispro (Humalog®) 0.2-0.5 0.5-1.5 3-4

Insulin aspart (NovoLog®) 0.2-0.5 1-3 3-5

Insulin glulisine (Apidra™) 0.2-0.5 0.5-1.5 3-4

Short-Acting
Insulin regular 0.5-1 2-4 6-8
(Humulin® R, Novolin® R)

Intermediate-Acting
Insulin NPH 1-2 6-12 18-24
(Humulin® N, Novolin® N)

Long-Acting
Insulin detemir (Levemir®) 3-4 6-8 6-23

Insulin glargine (Lantus®) 3-4 none 24

Combinations
Novolog® Mix 70/30 0.2-0.5 1-4 18-24

Humalog® Mix 75/25™ 0.2-0.5 2-12 18-24

Humulin, Novolin® 70/30 0.5 2-12 18-24

*Insulin action can also vary depending on your level of physical activity,
injection site and other factors.
8 D I A B E T E S M E D I C AT I O N S

Drawing Up Insulin
Step 1 Step 4
Wash your hands and test your blood sugar. Turn the vial upside down and withdraw the
amount of insulin you need. Check for air bubbles in
the syringe. Remove the air bubbles by tapping on
the side of the syringe and recheck that you have the
correct dose.

Step 2
Check that you have the correct vial of insulin and
know what dose you need. Remove the cover on the
vial and clean the top of the vial with alcohol.

Step 3 into the skin. Once the needle is in place, press the
Check that you have the correct syringe. Remove the
top from the needle and pull back on the plunger.
Draw the same amount of air into the syringe as you
will need for your dose of insulin. Insert the needle
into the vial of insulin and inject the air into the vial.
Leave the needle in the vial.
Step 5
Holding the needle at a 90° angle relative to the
surface of your injection site, push firmly but gently
plunger fully down to inject all the insulin in the
syringe. Once the insulin has been delivered, pull
the needle straight up and out of your skin. Properly
dispose of the needle and syringe.
 I N J E C TA B L E M E D I C AT I O N S F O R T Y P E 2 D I A B E T E S – I N S U L I N S 9
Side Effects of Insulin
The most common side effect of insulin is low blood
glucose (hypoglycemia or low blood sugar). It is also
the most potentially serious. It is very important for
you to know how to prevent, recognize and quickly
treat low blood glucose. For more detail, refer to section
titled “Low Blood Glucose” in the Problem Solving chap-
ter of this booklet.
Tips for Safe Insulin Use
Know your insulin.
For each type of insulin you use, you need to know:
• Its type – long acting, intermediate acting, short
acting or rapid acting
• Its action – when it starts to work (onset), when
it has its greatest effect (peak) and how long it
works (duration)
• Whether it is a clear or cloudy solution
Store your insulin safely.
• Check the expiration date. Never use insulin that
has expired!
• Keep insulin in the refrigerator before opening.
• Label the insulin with the date it is opened.
• Once opened, refer to package insert for your
insulin storage guidelines. Guidelines may vary
for different types of insulin.
• Do not expose insulin to very warm temperatures
or direct sunlight. Never freeze insulin. Never
leave insulin in your car or leave it in your
handbag. (Insulated carrying cases are available
to keep insulin cool and protected for trips away
from home.)
Mixing insulins
• Do not mix either of the long acting insulins,
detemir (Levemir®) or glargine (Lantus®), with
any other insulin.
• If you take two other types of insulin, you may be
able to mix them in the same syringe, but doing
so may significantly change the insulin action.
Ask your physician or diabetes care team if and
how you can safely mix your insulin.
Insulin Delivery Systems
Subcutaneous Insulin
Insulin delivery systems include a container of
insulin (vial or cartridge); a device to measure and
deliver the insulin dose (pen, syringe, pump); and a
needle or catheter to be placed under the skin.
• Insulin vials and syringes with needles: available
in different sizes
• Insulin pens and pen needles
• Insulin pumps
Insurance coverage for these products will vary. Check
with your physician, diabetes care team or pharmacy if
you are interested in any of these products.
Inhaled Insulin
Inhaled insulin (Exubera) has recently become avail-
able. It generally works to lower blood glucose the
same way as subcutaneous insulin, but the insulin
delivery system is very different. This insulin
is stored in very small foil packs. The packs are
crushed to release insulin into the delivery chamber,
where it is mixed with a fine mist. The insulin mist is
then inhaled, held for several seconds in the lungs,
and released by exhaling.
10 D I A B E T E S M E D I C AT I O N S
Inhaled insulin can cause seriously low blood glu-
cose just like other forms of insulin and, if you are
using it, you need to monitor your blood glucose fre-
quently to stay in good control and protect yourself.
There are differences in the timing of insulin action
compared to other insulins:
• The onset of action with Exubera is rapid (5-20
minutes), making it similar to that of the rapid
acting insulins (Humalog, Novolog and Apidra)
listed in the previous table.
• The duration of insulin action is longer (six to
eight hours), however, making it more similar to
regular insulin in this regard.
Also, there are unique guidelines and precautions.
Inhaled insulin should not be used by:
• Smokers, including anyone who has stopped
smoking within the last six months or anyone
who resumes smoking
• People with lung disease (asthma, COPD, etc.)
• People with a respiratory illness, unless moni-
tored closely
Lung testing is required before starting inhaled insu-
lin therapy and periodically thereafter.
Other Injectable Medications
for Diabetes
Exenatide (Byetta)
Helps the pancreas make more insulin when blood
glucose is high and reduces the amount of glucose
made by the liver
• Recommended for use in patients with type 2
diabetes who are already receiving metformin,
a sulfonylurea, a TZD or a combination and still
have poor blood glucose control.
• Dose: 5-10 mcg injected twice daily up to 60 min-
utes before morning and evening meal.
• Reduces glucose made by the liver.
• Lowers blood glucose after meals.
• Usually doesn’t cause hypoglycemia
• Decreases appetite and can help with weight loss.
• Most common side effect is nausea.
Pramlintide (Symlin)
Reduces amount of glucose made by the liver
• Lowers blood glucose after meals.
• Decreases appetite and can help with weight loss.
• When used with insulin, the two drugs together
may increase the risk of low blood glucose. Blood
glucose levels should be monitored regularly.
• Most common side effect in the beginning is nau-
sea which usually decreases over time.
Disposal of Medical Waste
Needles and lancets (also known as “sharps”) are
considered medical waste. If these items are not dis-
posed of properly, they could injure people.
Each county in the state of California has its own policy
concerning medical waste disposal. The following are
recommendations for safely disposing of used needles.
Local Household Hazardous Waste Program
Call your local household hazardous waste agency
and ask if they collect needles (sharps) at their collec-
tion facilities or on household hazardous waste days.
Some do; others do not.
As a last resort, needles can be placed into a strong
plastic container with a tight cap or lid, such as a
plastic bleach jug or plastic liquid detergent bottle.
Seal the container with strong tape and place the
container in the garbage. Be sure that this container
is not placed in a recycling bin.
Clinical Integration
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