http://www.diabetes.

org/

A.D.A
 create a meal plan
works with your schedule
keeps your weight on track
improves your blood glucose, blood
pressure, and cholesterol numbers.
 Carbohydrate Counting

How Much Carb?

A place to start is at about 45-60 grams of
carbohydrate at a meal.
What Foods Have Carbohydrate?
starchy foods like bread, cereal, rice, and crackers
fruit and juice
milk and yogurt
dried beans like pinto beans and soy products like
veggie burgers
starchy vegetables like potatoes and corn
sweets and snack foods like sodas, juice drinks, cake,
cookies, candy, and chips
Non-starchy vegetables have a little bit of
carbohydrate but in general are very low.
 How Much Carbohydrate is in These Foods?
15 grams of carbohydrate in:
1 small piece of fresh fruit (4 oz)
1/2 cup of canned or frozen fruit
1 slice of bread (1 oz) or 1 (6 inch) tortilla
1/2 cup of oatmeal
1/3 cup of pasta or rice
4-6 crackers
1/2 English muffin or hamburger bun
1/2 cup of black beans or starchy vegetable
1/4 of a large baked potato (3 oz)
2/3 cup of plain fat-free yogurt or sweetened with sugar
substitutes
2 small cookies
2 inch square brownie or cake without frosting
1/2 cup ice cream or sherbet
1 Tbsp syrup, jam, jelly, sugar or honey
2 Tbsp light syrup
6 chicken nuggets
1/2 cup of casserole
1 cup of soup
1/4 serving of a medium french fry
 Protein and Fat
Always include a source of protein and fat to balance out your
meal.
Using Food Labels
Look at the serving size. All the information on the label is
about this serving of food. If you will be eating a larger
serving, then you will need to double or triple the
information on the label.
Look at the grams of total carbohydrate.
Total carbohydrate on the label includes sugar, starch, and
fiber.
Know the amount of carb you can eat, figure out the portion
size to match.
If you are trying to lose weight, look at the calories.
Comparing products can be helpful to find those lower in
calories per serving.
To cut risk of heart disease and stroke, look at saturated
and trans fats. Look for products with the lowest amount of
saturated and trans fats per serving.
For people with high blood pressure, look at the sodium.
Look for foods with less sodium.
 Glycemic Index and Diabetes
What is the glycemic index?
measures how a carbohydrate-containing food raises
blood glucose.
Foods are ranked based on how they compare to a
reference food either glucose or white bread.
A food with a high GI raises blood glucose more than
a food with a medium or low GI.
Examples of carbohydrate-containing foods with a low
GI include
dried beans and legumes (like kidney beans and lentils),
all non-starchy vegetables and some starchy vegetables,
most fruit,
many whole grain breads and cereals (like barley, whole
wheat bread, rye bread, and all-bran cereal).
Meats and fats dont have a GI because they do not
contain carbohydrate.
 What affects the GI of a food?
Fat and fiber tend to lower the GI of a food. As a
general rule, the more cooked or processed a food,
the higher the GI; however, this is not always true.
Below are a few specific examples of other factors
that can affect the GI of a food:
Ripeness and storage time the more ripe a fruit or
vegetable is, the higher the GI
Processing juice has a higher GI than whole fruit; mashed
potato has a higher GI than a whole baked potato, stone
ground whole wheat bread has a lower GI than whole wheat
bread.
Cooking method: how long a food is cooked (al dente pasta
has a lower GI than soft-cooked pasta)
Variety: converted long-grain white rice has a lower GI than
brown rice but short-grain white rice has a higher GI than
brown rice.
 Other things to consider if using the GI:
The GI value represents the type of carbohydrate in a food
but says nothing about the amount of carbohydrate typically
eaten. Portion sizes are still relevant for managing blood
glucose and for losing or maintaining weight.
The GI of a food is different when eaten alone than it is when
combined with other foods. When eating a high GI food, you
can combine it with other low GI foods to balance out the
effect on blood glucose levels.
Many nutritious foods have a higher GI than foods with little
nutritional value. For example, oatmeal has a higher GI than
chocolate. Use of the GI needs to be balanced with basic
nutrition principles of variety for healthful foods and
moderation of foods with few nutrients.
 Create Your Plate
Using your dinner plate, put a line down the middle of the
plate.
Then on one side, cut it again so you will have 3 sections
on your plate.
Fill the largest section with non-starchy vegetables such as:
spinach, carrots, lettuce, greens, cabbage, bok choy
green beans, broccoli, cauliflower, tomatoes,
vegetable juice, salsa, onion, cucumber, beets, okra,
mushrooms, peppers, turnip
Now in one of the small sections, put starchy foods such as:
whole grain breads, such as whole wheat or rye
whole grain, high-fiber cereal
cooked cereal such as oatmeal, grits, hominy, or cream of wheat
rice, pasta, dal, tortillas
cooked beans and peas, such as pinto beans or black-eyed peas
potatoes, green peas, corn, lima beans, sweet potatoes, winter
squash
low-fat crackers and snack chips, pretzels, and fat-free popcorn
 And then on the other small section, put your meat or
meat substitutes such as:
chicken or turkey without the skin
fish such as tuna, salmon, cod, or catfish
other seafood such as shrimp, clams, oysters, crab, or mussels
lean cuts of beef and pork such as sirloin or pork loin
tofu, eggs, low-fat cheese
Add an 8 oz glass of non-fat or low-fat milk. If you dont
drink milk, you can add another small serving of carb
such as a 6 oz. container of light yogurt or a small roll.
And a piece of fruit or a 1/2 cup fruit salad and you have your
meal planned. Examples are fresh, frozen, or canned in juice or
frozen in light syrup or fresh fruit.
 Snacks
Snacks with less than 5 grams of About 10-20 grams of carbohydrate
carbohydrate cup almonds or other nuts
3 celery sticks + 1 Tablespoon of peanut cup dried fruit and nut mix
butter 1 cup chicken noodle, tomato (made with water), or
5 baby carrots vegetable soup
5 cherry tomatoes + 1 Tablespoon ranch 1 small apple or orange
1 hard-boiled egg 3 cups light popcorn
1 cup cucumber slices + 1 Tablespoon 1/3 cup hummus + 1 cup raw fresh cut veggies
ranch dressing (green peppers, carrots, broccoli, cucumber, celery,
cup of fresh blueberries cauliflower or a combination of these)
1 cup of salad greens, 1/2 cup of diced cup cottage cheese + cup canned or fresh fruit
cucumber, and with vinegar and oil
1 frozen sugar-free popsicle 1 cheese quesadilla (made with one 6-inch corn or
1 cup of light popcorn whole wheat tortilla + 1 oz shredded cheese) +
2 saltine crackers cup salsa
10 gold-fish crackers 2 rice cakes (with a 4-inch diameter) + 1
16 green olives Tablespoon peanut butter
cup sugar-free gelatin 5 whole wheat crackers (or oz) + 1 piece of string
1 piece of string cheese stick cheese
2 Tablespoons pumpkin or sesame seeds turkey sandwich (1 slice whole wheat bread + 2
of a whole avocado (~4 g.) oz turkey + mustard)
cup tuna salad + 4 saltines
About 30 grams of carbohydrate (good to eat before exercise)
peanut butter sandwich (1 slice whole wheat bread + 1 Tablespoon peanut butter) + 1 cup milk
6 oz light yogurt + cup berries (blueberries, blackberries, raspberries, or a combination of these)
1 English muffin + 1 teaspoon low-fat tub margarine
3/4 cup whole grain, ready-to-eat cereal + cup fat-free milk
1 medium banana + 1 Tablespoon peanut butter
 Alcohol
If you choose to drink alcohol, limit the amount and have
it with food. Talk with your health care team about
whether alcohol is safe for you.
Women should drink 1 or fewer alcoholic beverages a
day (1 alcoholic drink equals a 12 oz beer, 5 oz glass of
wine, or 1 oz distilled spirits (vodka, whiskey, gin,
etc.).
Men should drink 2 or fewer alcoholic drinks a day.
If you drink alcohol at least several times a week, make
sure your doctor knows this before he/she prescribes a
diabetes pill.
 Carbohydrates
Starch
Starchy vegetables like peas, corn, lima beans, and potatoes
Dried beans, lentils, and peas such as pinto beans, kidney beans, black eyed
peas, and split peas
Grains like oats, barley, and rice. (The majority of grain products in the US are
made from wheat flour. These include pasta, bread, and crackers but the variety
is expanding to include other grains as well.)
The grain group can be broken down even further into whole grain or refined
grain.
A grain, let's take wheat for example, contains three parts:
bran
germ
endosperm
The bran is the outer hard shell of the grain. It is the part of the grain that
provides the most fiber and most of the B vitamins and minerals.
The germ is the next layer and is packed with nutrients including essential fatty
acids and vitamin E.
The endosperm is the soft part in the center of the grain. It contains the starch.
Whole grain means that the entire grain kernel is in the food.
If you eat a whole grain food, it contains the bran, germ, and endosperm so you
get all of the nutrients that whole grains have to offer. If you eat a refined grain
food, it contains only the endosperm or the starchy part so you miss out on a lot
of vitamins and minerals. Because whole grains contain the entire grain, they are
much more nutritious than refined grains.
 Sugar
Sugar is another type of carbohydrate. You may also hear sugar
referred to as simple or fast-acting carbohydrate. There are two
main types of sugar:
naturally occurring sugars such as those in milk or fruit
added sugars such as those added during processing such as
fruit canned in heavy syrup or sugar added to make a cookie
On the nutrition facts label, the number of sugar grams includes
both added and natural sugars.
There are many different names for sugar. Examples of common
names are table sugar, brown sugar, molasses, honey, beet
sugar, cane sugar, confectioner's sugar, powdered sugar, raw
sugar, turbinado, maple syrup, high-fructose corn syrup, agave
nectar, and sugar cane syrup.
You may also see table sugar listed by its chemical name,
sucrose. Fruit sugar is also known as fructose and the sugar in
milk is called lactose. You can recognize other sugars on labels
because their chemical names also end in "-ose." For example
glucose (also called dextrose), fructose (also called levulose),
lactose, and maltose.
 Fiber
Fiber comes from plant foods so there is no fiber in animal products such as milk, eggs, meat, poultry, and
fish.
Fiber is the indigestible part of plant foods, including fruits, vegetables, whole grains, nuts, and legumes.
When you consume dietary fiber, most of it passes through the intestines and is not digested.
For good health, adults need to try to eat 25 to 30 grams of fiber each day. Most Americans do not consume
nearly enough fiber in their diet, so while it is wise to aim for this goal, any increase in fiber in your diet can be
beneficial. Most of us only get about what is recommended.
Fiber contributes to digestive health, helps to keep you regular and helps to make you feel full and satisfied
after eating. Additional health benefits, of a diet high in fiber such as a reduction in cholesterol levels
have been suggested by some so may be an additional benefit.
Good sources of dietary fiber include:
Beans and legumes. Think black beans, kidney beans, pintos, chick peas (garbanzos), white beans, and
lentils.
Fruits and vegetables, especially those with edible skin (for example, apples, corn and beans) and those with
edible seeds (for example, berries).
Whole grains such as:
Whole wheat pasta
Whole grain cereals (Look for those with three grams of dietary fiber or more per serving, including those
made from whole wheat, wheat bran, and oats.)
Whole grain breads (To be a good source of fiber, one slice of bread should have at least three grams of fiber.
Another good indication: look for breads where the first ingredient is a whole grain. For example, whole
whe+at or oats.) Many grain products now have "double fiber" with extra fiber added.
Nuts try different kinds. Peanuts, walnuts and almonds are a good source of fiber and healthy fat, but
watch portion sizes, because they also contain a lot of calories in a small amount.
In general, an excellent source of fiber contains five grams or more per serving, while a good source of fiber
contains 2.5 - 4.9 grams per serving.
It is best to get your fiber from food rather than taking a supplement. In addition to the fiber, these foods have
a wealth of nutrition, containing many important vitamins and minerals. In fact, they may contain nutrients that
haven't even been discovered yet!
It is also important that you increase your fiber intake gradually, to prevent stomach irritation, and that you
increase your intake of water and other liquids, to prevent constipation.
Because fiber is not digested like other carbohydrates, for carbohydrate counting purposes, if a serving of a
food contains more than or equal to 5 grams of dietary fiber, you can subtract half the grams of dietary fiber
from the total carbohydrate serving of that food.
 Diabetes Superfoods
Beans
Whether you prefer kidney, pinto, navy or black beans, you cant find better
nutrition than that provided by beans. They are very high in fiber giving you
about 1/3 of your daily requirement in just a cup and are also good
sources of magnesium, and potassium.
They are considered starchy vegetables but a cup provides as much
protein as an ounce of meat without the saturated fat. To save time you can
use canned beans, but be sure to drain and rinse them to get rid of as much
sodium as possible.
Dark Green Leafy Vegetables
Spinach, collards, kale these powerhouse foods are so low in calories and
carbohydrates, you cant eat too much.
Citrus Fruit
Grapefruit, oranges, lemons and limes. Pick your favorites and get part of
your daily dose of soluble fiber and vitamin C.
Sweet Potatoes
A starchy vegetable packed full of vitamin A and fiber. Try in place of regular
potatoes for a lower GI alternative.
Berries
Which are your favorites: blueberries, strawberries or another variety?
Regardless, they are all packed with antioxidants, vitamins and fiber. Make
a parfait alternating the fruit with light, non-fat yogurt for a new favorite
dessert.
 Tomatoes
An old standby where everyone can find a favorite. The good news is that no matter
how you like your tomatoes, pureed, raw, or in a sauce, youre eating vital nutrients
like vitamin C, iron, vitamin E.
Fish High in Omega-3 Fatty Acids
Salmon is a favorite in this category. Stay away from the breaded and deep fat fried
variety... they dont count in your goal of 6-9 ounces of fish per week.
Whole Grains
Its the germ and bran of the whole grain youre after. It contains all the nutrients a
grain product has to offer. When you purchase processed grains like bread made
from enriched wheat flour, you dont get these. A few more of the nutrients these
foods offer are magnesium, chromium, omega 3 fatty acids and folate.
Pearled barley and oatmeal are a source of fiber and potassium.
Nuts
An ounce of nuts can go a long way in providing key healthy fats along with hunger
management. Other benefits are a dose of magnesium and fiber.
Some nuts and seeds, such as walnuts and flax seeds, also contain omega-3 fatty
acids.
Fat-free Milk and Yogurt
Everyone knows dairy can help build strong bones and teeth. In addition to calcium,
many fortified dairy products are a good source of vitamin D. More research is
emerging on the connection between vitamin D and good health.
Some of the above list can be tough on the budget depending on the season and
where you live. Look for lower cost options such as fruit and vegetables in season or
frozen or canned fish.
Foods that every budget can live with year round are beans and rolled oats or barley
that you cook from scratch.
 Fruits
The best choices of fruit are any that are fresh, frozen or canned without added
sugars.
General tips
Choose canned fruits in juice or light syrup
Dried fruit and fruit juice are also nutritious choices, but the portion sizes are small so
they may not be as filling as other choices.
Tips
For Carb counters
A small piece of whole fruit or about cup of frozen or canned fruit has about 15
grams of carbohydrate. Servings for most fresh berries and melons are from - 1
cup. Fruit juice can range from 1/3 -1/2 cup for 15 grams of carbohydrate. Only 2
tablespoons of dried fruit like raisins or dried cherries contains 15 grams of
carbohydrate so be cautious with your portion sizes! Fruit can be eaten in exchange
for other carbohydrates in your meal plan such as starches, grains, or dairy.
For Plate Method
If using the plate method, having a small piece of whole fruit or a cup of fruit salad
for dessert is a great compliment to the non-starchy vegetables, small portion of
starch and protein foods that are on your plate.
For using the Glycemic Index
Most fruits have a low glycemic index because of their fructose and fiber content.
Melons and pineapple have medium GI values as do some dried fruits such as dates,
raisins, and sweetened cranberries. Overall, fruit is encouraged when using the
glycemic index to guide food choicesso enjoy.
 Common Fruits
The following is a list Grapes
of common fruits: Honeydew melon
Apples Kiwi
Applesauce Mango
Apricots Nectarine
Banana Orange
Blackberries Papaya
Blueberries Peaches
Cantaloupe Pears
Cherries Pineapple
Dates Plums
Dried fruit Raspberries
Figs Strawberries
Fruit cocktail Tangerines
Grapefruit Watermelon
 Dairy
Low-fat Milk and Yogurt
Including sources of dairy products in your diet is an easy way to get calcium and high-quality
protein. Many dairy products, like no sugar added, fat-free yogurt, can be eaten as a dessert
with only about 15 grams of carbohydrate and 100 calories per 6 oz container.
What are the best choices?
The best choices of dairy products are:
Fat-free or low-fat (1% milk)
Plain non-fat yogurt
non-fat light yogurt without added sugar
unflavored soy milk
If you are lactose intolerant, you may want to try fortified soy milk as a source of calcium and
vitamin D.
General tips:
Each 1 cup serving of milk or 2/3 cup serving of yogurt has about 12 grams of carbohydrate and
8 grams of protein.
If you are trying to switch to lower fat dairly products, take the time to get used to the taste and
texture difference. For example, first change from whole milk to 2%. Then to 1% or non-fat milk.
Switching from whole to 1% milk will save you 70 calories and 4 grams of saturated fat in every
serving!
Tips for Carb Counters
1 cup of milk or yogurt is equal to 1 small piece of fruit or 1 slice of bread
Tips for the Plate Method
Your meal plan calls for 8 ounces of milk. If you dont drink milk, you can substitute another
carbohydrate containing food like a piece of fruit or a small dinner roll.
Tips for using the Glycemic Index
Milk has a low glycemic index so choose lower-fat dairy products to fit into your meals.
 Non-starchy Vegetables

What are the best choices?

The best choices are fresh, frozen and canned vegetables and vegetable
juices without added sodium, fat or sugar.
General tips:
If using canned or frozen vegetables, look for ones that say low sodium or
no salt added on the label.
As a general rule, frozen or canned vegetables in sauces are higher in
both fat and sodium.
If using canned vegetables with sodium, drain the vegetables and rinse
with water then warm in fresh water. This will cut back on how much
sodium is left on the vegetables.
For good health, try to eat at least 3-5 servings of vegetables a day. This is
a minimum and more is better! A serving of vegetables is:
cup of cooked vegetables or vegetable juice
1 cup of raw vegetables
 Common Non-starchy Vegetables
The following is a list of common non-
starchy vegetables: Hearts of palm
Amaranth or Chinese spinach Jicama
Artichoke Kohlrabi
Artichoke hearts Leeks
Asparagus Mushrooms
Baby corn Okra
Bamboo shoots Onions
Beans (green, wax, Italian) Pea pods
Bean sprouts Peppers
Beets Radishes
Broccoli Rutabaga
Brussels sprouts Salad greens (chicory, endive, escarole, lettuce,
Cabbage (green, bok choy, Chinese) romaine, spinach, arugula, radicchio,
Carrots watercress)
Cauliflower Sprouts
Celery Squash (cushaw, summer, crookneck, zucchini)
Chayote Sugar snap peas
Coleslaw (packaged, no dressing) Swiss chard
Cucumber Tomato
Daikon Turnips
Eggplant Water chestnuts
Greens (collard, kale, mustard, turnip) Yard-long beans
 Artificial Sweeteners
Curb Your Cravings
Foods and drinks that use artificial sweeteners are another option
that may help curb your cravings for something sweet.
Sometimes artificial sweeteners are also called low-calorie
sweeteners, sugar substitutes, or non-nutritive sweeteners. They
can be used to sweeten food and drinks for less calories and
carbohydrate when they replace sugar.
However, many foods containing artificial sweeteners still have
calories and carbs, so be sure to check the nutrition facts label.
Their sweetening power is at least 100 times more intense than
regular sugar, so only a small amount is needed when you use
these sugar substitutes.
Also, with the exception of aspartame, all of the sweeteners listed
below cannot be broken down by the body. They pass through our
systems without being digested so they provide no extra calories.
 FDA Approved
There are five artificial sweeteners that have been tested and
approved by the U.S. Food and Drug Administration (FDA):
acesulfame potassium (also called acesulfame K)
aspartame
saccharin
sucralose
neotame
These sweeteners are used by food companies to make diet drinks,
baked goods, frozen desserts, candy, light yogurt, and chewing
gum. You can buy them to use as table top sweeteners. Add them to
coffee, tea, or sprinkle them on top of fruit. Some are also available
in granular versions which can be used in cooking and baking.
Whats The Deal With Stevia?
Stevia (sometimes called Rebaudioside A or rebiana) is now
generally recognized as safe (GRAS) by the FDA as a food additive
and table top sweetener. When something is generally recognized
as safe by the FDA, it means that experts have agreed that it is safe
for use by the public in appropriate amounts.
Stevia is several hundred times sweeter than sugar. It comes from
the sweetest part of the stevia plant and is an ingredient in many
foods that you can buy at the store.
 Brand Names
Sweetener Name Found in
Stores
Acesulfame
Sunett
Cutting Calories and Potassium
CarbohydrateArtificial Sweet One
sweeteners have no
Aspartame Nutrasweet
carbohydrates and do not
increase blood glucose Equal
levels. Neotame N/A
In the past, there was some Saccharin Sweet N Low
concern that low-calorie
sweeteners caused cancer Sweet Twin
and other health conditions. Sugar Twin
However, numerous studies Sucralose Splenda
have shown that they do not
and several sweeteners Stevia/Rebaudiosid
A Sweet Leaf
have been permitted for e
use. Sun Crystals
Steviva
Truvia
PureVia
 Top 10 Benefits of Being Active
Improve blood glucose management. Activity makes your body more sensitive to
the insulin you make. Activity also burns glucose (calories). Both actions lower
blood glucose.
Lower blood pressure. Activity helps your heart pump stronger and slower.
Improve blood fats. Exercise can raise good cholesterol (HDL) and lower bad
cholesterol (LDL) and triglycerides. These changes are heart healthy.
Take less insulin or diabetes pills. Activity can lower blood glucose and weight.
Both of these may lower how much insulin or diabetes pills you need to take.
Lose weight and keep it off. Activity burns calories. If you burn enough calories,
you'll trim a few pounds. Stay active and you'll keep the weight off.
Lower risk for other health problems. Reduce your risk of a heart attack or stroke,
some cancers, and bone loss.
Gain more energy and sleep better. You'll get better sleep in less time and have
more energy, too.
Reduce stress, anxiety, and depression. Work out or walk off daily stress.
Build stronger bones and muscles. Weight-bearing activities, such as walking,
make bones stronger. Strength-training activities, such as lifting light weights (or
even cans of beans), make muscles strong.
Be more flexible. Move easier when you are active.
 Types of Exercise
Aerobic Exercise
Aerobic exercise increases your heart rate, works your muscles, and raises your
breathing rate. For most people, it's best to aim for a total of about 30 minutes a day,
at least 5 days a week. If you haven't been very active recently, you can start out with
5 or 10 minutes a day. Increase your activity sessions by a few minutes each week.
If your schedule doesn't allow for 30 minutes straight of exercise throughout the day,
you can break it up into no less than 10-minute spurts to get the same health
benefits. For example, you might take a brisk 10-minute walk after each meal.
If you're trying to lose weight, you may want to exercise more than 30 minutes a day.
Here are some examples of aerobic exercise:
Take a brisk walk (outside or inside on a treadmill)
Go dancing
Take a low-impact aerobics class
Swim or do water aerobic exercises
Try ice-skating or roller-skating
Play tennis
Ride your bicycle outside
Stationary bicycle indoors
 Strength Training
Strength training, done 2-3 times a week, helps build strong bones and
muscles. It makes everyday chores like carrying groceries easier for you.
With more muscle, you burn more calories, even at rest. Strength training
can also help to prevent weight gain. Here are some ways to do it:
Join a class to do strength training with weights, elastic bands, or plastic
tubes
Lift light weights at home
Try calisthenics
Flexibility Exercises
Flexibility exercises, also called stretching, help keep your joints flexible and
reduce your chance of injury during other activities. Gentle stretching for 5
to 10 minutes helps your body warm up and get ready for aerobic activities
such as walking or swimming. Your health care team can provide
information on how to stretch. Improve your flexibility by:
Taking an aerobics or fitness classes that includes stretching
Doing yoga or Pilates
Stretching on your own before and after exercising
 Light-Intensity Moderate-Intensity High-Intensity
One minute burns 3.5 One minute burns 3.5 One minute burns
calories. 30 minutes to 7 calories. 30 more than 7 calories.
burns 105 calories.
minutes burns 105 to 30 minutes burns
Walking slowly
210 calories. more than 210
Golf, powered cart
-Walking briskly calories.
Slow treading in the
swimming pool -Golf, pulling or -Race walking,
Light gardening or carrying clubs jogging or running
pruning -Swimming, -Swimming laps
Bicycling, very light recreational -Mowing lawn,
effort -Mowing lawn, power handmower
Dusting or vaccuming motor -Tennis, singles
Gentle stretching -Tennis, doubles -Bicycling more than
-Bicycling (or using a 10 mph, or on steep
stationay bike) 5 to 9 uphill terrain
mph, level terrain, or -Moving or pushing
with a few hills furniture
-Scrubbing floors or -Circuit training
washing windows
-Weight lifting,
machines or free
weights
 Eye Complications
You may have heard that diabetes causes eye problems and may lead to blindness.
People with diabetes do have a higher risk of blindness than people without diabetes.
But most people who have diabetes have nothing more than minor eye disorders.
With regular checkups, you can keep minor problems minor. And if you do develop a
major problem, there are treatments that often work well if you begin them right away.
Eye Insight
To understand what happens in eye disorders, it helps to understand how the eye
works. The eye is a ball covered with a tough outer membrane. The covering in front
is clear and curved. This curved area is the cornea, which focuses light while
protecting the eye.
After light passes through the cornea, it travels through a space called the anterior
chamber (which is filled with a protective fluid called the aqueous humor), through the
pupil (which is a hole in the iris, the colored part of the eye), and then through a lens
that performs more focusing. Finally, light passes through another fluid-filled chamber
in the center of the eye (the vitreous) and strikes the back of the eye, the retina.
Like the film in a camera, the retina records the images focused on it. But unlike film,
the retina also converts those images into electrical signals, which the brain receives
and decodes.
One part of the retina is specialized for seeing fine detail. This tiny area of extra-
sharp vision is called the macula.
Blood vessels in and behind the retina nourish the macula. The smallest of these
blood vessels are the capillaries.
 Glaucoma
People with diabetes are 40% more likely to suffer from glaucoma than
people without diabetes. The longer someone has had diabetes, the more
common glaucoma is. Risk also increases with age.
Glaucoma occurs when pressure builds up in the eye. In most cases, the
pressure causes drainage of the aqueous humor to slow down so that it
builds up in the anterior chamber. The pressure pinches the blood vessels
that carry blood to the retina and optic nerve. Vision is gradually lost
because the retina and nerve are damaged.
There are several treatments for glaucoma. Some use drugs to reduce
pressure in the eye, while others involve surgery.
Cataracts
Many people without diabetes get cataracts, but people with diabetes are
60% more likely to develop this eye condition. People with diabetes also
tend to get cataracts at a younger age and have them progress faster. With
cataracts, the eye's clear lens clouds, blocking light.
To help deal with mild cataracts, you may need to wear sunglasses more
often and use glare-control lenses in your glasses. For cataracts that
interfere greatly with vision, doctors usually remove the lens of the eye.
Sometimes the patient gets a new transplanted lens. In people with
diabetes, retinopathy can get worse after removal of the lens, and glaucoma
may start to develop.
 Retinopathy
Diabetic retinopathy is a general term for all disorders of the retina caused by
diabetes. There are two major types of retinopathy: nonproliferative and proliferative.
Nonproliferative retinopathy
In nonproliferative retinopathy, the most common form of retinopathy, capillaries in the
back of the eye balloon and form pouches. Nonproliferative retinopathy can move
through three stages (mild, moderate, and severe), as more and more blood vessels
become blocked.
Although retinopathy does not usually cause vision loss at this stage, the capillary
walls may lose their ability to control the passage of substances between the blood
and the retina. Fluid can leak into the part of the eye where focusing occurs, the
macula. When the macula swells with fluid, a condition called macula edema, vision
blurs and can be lost entirely. Although nonproliferative retinopathy usually does not
require treatment, macular edema must be treated, but fortunately treatment is
usually effective at stopping and sometimes reversing vision loss.
Proliferative retinopathy
In some people, retinopathy progresses after several years to a more serious form
called proliferative retinopathy. In this form, the blood vessels are so damaged they
close off. In response, new blood vessels start growing in the retina. These new
vessels are weak and can leak blood, blocking vision, which is a condition called
vitreous hemorrhage. The new blood vessels can also cause scar tissue to grow.
After the scar tissue shrinks, it can distort the retina or pull it out of place, a condition
called retinal detachment.
Your retina can be badly damaged before you notice any change in vision. Most
people with nonproliferative retinopathy have no symptoms. Even with proliferative
retinopathy, the more dangerous form, people sometimes have no symptoms until it
is too late to treat them. For this reason, you should have your eyes examined
regularly by an eye care professional.
 Am I at risk for retinopathy?
Several factors influence whether you get retinopathy:
blood sugar control
blood pressure levels
how long you have had diabetes
genes
The longer you've had diabetes, the more likely you are to have retinopathy. Almost everyone with type 1
diabetes will eventually have nonproliferative retinopathy. And most people with type 2 diabetes will also
get it. But the retinopathy that destroys vision, proliferative retinopathy, is far less common.
People who keep their blood sugar levels closer to normal are less likely to have retinopathy or to have
milder forms.
How is it treated?
Huge strides have been made in the treatment of diabetic retinopathy. Treatments such as scatter
photocoagulation, focal photocoagulation, and vitrectomy prevent blindness in most people. The sooner
retinopathy is diagnosed, the more likely these treatments will be successful. The best results occur when
sight is still normal.
In photocoagulation, the eye care professional makes tiny burns on the retina with a special laser. These
burns seal the blood vessels and stop them from growing and leaking.
In scatter photocoagulation (also called panretinal photocoagulation), the eye care professional makes
hundreds of burns in a polka-dot pattern on two or more occasions. Scatter photocoagulation reduces the
risk of blindness from vitreous hemorrhage or detachment of the retina, but it only works before bleeding or
detachment has progressed very far. This treatment is also used for some kinds of glaucoma.
Side effects of scatter photocoagulation are usually minor. They include several days of blurred vision after
each treatment and possible loss of side (peripheral) vision.
In focal photocoagulation, the eye care professional aims the laser precisely at leaking blood vessels in the
macula. This procedure does not cure blurry vision caused by macular edema. But it does keep it from
getting worse.
When the retina has already detached or a lot of blood has leaked into the eye, photocoagulation is no
longer useful. The next option is vitrectomy, which is surgery to remove scar tissue and cloudy fluid from
inside the eye. The earlier the operation occurs, the more likely it is to be successful. When the goal of the
operation is to remove blood from the eye, it usually works. Reattaching a retina to the eye is much harder
and works in only about half the cases.
 Foot Complications
People with diabetes can develop many different foot problems. Even ordinary problems can get
worse and lead to serious complications. Foot problems most often happen when there is nerve
damage, also called neuropathy, which results in loss of feeling in your feet. Poor blood flow or
changes in the shape of your feet or toes may also cause problems.
Neuropathy
Although it can hurt, diabetic nerve damage can also lessen your ability to feel pain, heat, and cold.
Loss of feeling often means you may not feel a foot injury. You could have a tack or stone in your shoe
and walk on it all day without knowing. You could get a blister and not feel it. You might not notice a
foot injury until the skin breaks down and becomes infected.
Nerve damage can also lead to changes in the shape of your feet and toes. Ask your health care
provider about special therapeutic shoes, rather than forcing deformed feet and toes into regular
shoes.
Skin Changes
Diabetes can cause changes in the skin of your foot. At times your foot may become very dry. The
skin may peel and crack. The problem is that the nerves that control the oil and moisture in your foot
no longer work.
After bathing, dry your feet and seal in the remaining moisture with a thin coat of plain petroleum jelly,
an unscented hand cream, or other such products.
Do not put oils or creams between your toes. The extra moisture can lead to infection. Also, don't soak
your feet that can dry your skin.
Calluses
Calluses occur more often and build up faster on the feet of people with diabetes. This is because
there are high-pressure areas under the foot. Too much callus may mean that you will need
therapeutic shoes and inserts.
Calluses, if not trimmed, get very thick, break down, and turn into ulcers (open sores). Never try to cut
calluses or corns yourself - this can lead to ulcers and infection. Let your health care provider cut your
calluses. Also, do not try to remove calluses and corns with chemical agents. These products can
burn your skin.
Using a pumice stone every day will help keep calluses under control. It is best to use the pumice
stone on wet skin. Put on lotion right after you use the pumice stone.
 Foot Ulcers
Ulcers occur most often on the ball of the foot or on the bottom of the big toe. Ulcers on the sides of
the foot are usually due to poorly fitting shoes. Remember, even though some ulcers do not hurt,
every ulcer should be seen by your health care provider right away. Neglecting ulcers can result in
infections, which in turn can lead to loss of a limb.
What your health care provider will do varies with your ulcer. Your health care provider may take x-
rays of your foot to make sure the bone is not infected. The health care provider may clean out any
dead and infected tissue. You may need to go into the hospital for this. Also, the health care provider
may culture the wound to find out what type of infection you have, and which antibiotic will work best.
Keeping off your feet is very important. Walking on an ulcer can make it get larger and force the
infection deeper into your foot. Your health care provider may put a special shoe, brace, or cast on
your foot to protect it.
If your ulcer is not healing and your circulation is poor, your health care provider may need to refer
you to a vascular surgeon. Good diabetes control is important. High blood glucose levels make it hard
to fight infecton.
After the foot ulcer heals, treat your foot carefully. Scar tissue under the healed wound will break down
easily. You may need to wear special shoes after the ulcer is healed to protect this area and to prevent
the ulcer from returning.
Poor Circulation
Poor circulation (blood flow) can make your foot less able to fight infection and to heal. Diabetes
causes blood vessels of the foot and leg to narrow and harden. You can control some of the things
that cause poor blood flow. Don't smoke; smoking makes arteries harden faster. Also, follow your
health care provider's advice for keeping your blood pressure and cholesterol under control.
If your feet are cold, you may be tempted to warm them. Unfortunately, if your feet cannot feel heat, it
is easy for you to burn them with hot water, hot water bottles, or heating pads. The best way to help
cold feet is to wear warm socks.
Some people feel pain in their calves when walking fast, up a hill, or on a hard surface. This condition
is called intermittent claudication. Stopping to rest for a few moments should end the pain. If you have
these symptoms, you must stop smoking. Work with your health care provider to get started on a
walking program. Some people can be helped with medication to improve circulation.
Exercise is good for poor circulation. It stimulates blood flow in the legs and feet. Walk in sturdy, good-
fitting, comfortable shoes, but don't walk when you have open sores.
 Amputation
People with diabetes are far more likely to have a foot or leg
amputated than other people. The problem? Many people with
diabetes have artery disease, which reduces blood flow to the feet.
Also, many people with diabetes have nerve disease, which reduces
sensation. Together, these problems make it easy to get ulcers and
infections that may lead to amputation. Most amputations are
preventable with regular care and proper footware.
For these reasons, take good care of your feet and see your health
care provider right away about foot problems. Ask about prescription
shoes that are covered by Medicare and other insurance. Always
follow your health care provider's advice when caring for ulcers or
other foot problems.
One of the biggest threats to your feet is smoking. Smoking affects
small blood vessels. It can cause decreased blood flow to the feet
and make wounds heal slowly. A lot of people with diabetes who
need amputations are smokers.
 Skin Complications
Diabetes can affect every part of the body, including the skin. As many as 33 percent of
people with diabetes will have a skin disorder caused or affected by diabetes at some time
in their lives. In fact, such problems are sometimes the first sign that a person has
diabetes. Luckily, most skin conditions can be prevented or easily treated if caught early.
Some of these problems are skin conditions anyone can have, but people with diabetes
get more easily. These include bacterial infections, fungal infections, and itching. Other
skin problems happen mostly or only to people with diabetes. These include diabetic
dermopathy, necrobiosis lipoidica diabeticorum, diabetic blisters, and eruptive
xanthomatosis. You may also be interested in our book, Uncomplicated Guide To
Diabetes' Complications, 3rd Edition.
General Skin Conditions
Bacterial Infections
Several kinds of bacterial infections occur in people with diabetes:
Styes (infections of the glands of the eyelid)
Boils
Folliculitis (infections of the hair follicles)
Carbuncles (deep infections of the skin and the tissue underneath)
Infections around the nails
Inflamed tissues are usually hot, swollen, red, and painful. Several different organisms can
cause infections, the most commong being Staphylococcus bacteria, also called staph.
Once, bacterial infections were life threatening, especially for people with diabetes. Today,
death is rare, thanks to antibiotics and better methods of blood sugar control.
But even today, people with diabetes have more bacterial infections than other people do.
Doctors believe people with diabetes can reduce their chances of these infections by
practicing good skin care.
If you think you have a bacterial infection, see your doctor.
 Fungal Infections
The culprit in fungal infections of people with diabetes is often
Candida albicans. This yeast-like fungus can create itchy rashes of
moist, red areas surrounded by tiny blisters and scales. These
infections often occur in warm, moist folds of the skin. Problem
areas are under the breasts, around the nails, between fingers and
toes, in the corners of the mouth, under the foreskin (in
uncircumcised men), and in the armpits and groin.
Common fungal infections include jock itch, athlete's foot, ringworm
(a ring-shaped itchy patch), and vaginal infection that causes itching.
If you think you have a yeast or fungal infection, call your doctor. You
will need a prescription medicine to cure it.
Itching
Localized itching is often caused by diabetes. It can be caused by a
yeast infection, dry skin, or poor circulation. When poor circulation is
the cause of itching, the itchiest areas may be the lower parts of the
legs.
You may be able to treat itching yourself. Limit how often you bathe,
particularly when the humidity is low. Use mild soap with moisturizer
and apply skin cream after bathing.
 Diabetes-Related Skin Conditions
Diabetic Dermopathy
Diabetes can cause changes in the small blood vessels. These changes can
cause skin problems called diabetic dermopathy.
Dermopathy often looks like light brown, scaly patches. These patches may be
oval or circular. Some people mistake them for age spots. This disorder most
often occurs on the front of both legs. But the legs may not be affected to the
same degree. The patches do not hurt, open up, or itch.
Dermopathy is harmless and doesn't need to be treated.

Necrobiosis Lipoidica Diabeticorum

Another disease that may be caused by changes in the blood vessels is
necrobiosis lipoidica diabeticorum (NLD). NLD causes spots similar to diabetic
dermopathy, but they are fewer, larger, and deeper.
NLD often starts as a dull, red, raised area. After a while, it looks like a shiny
scar with a violet border. The blood vessels under the skin may become easier
to see. Sometimes NLD is itchy and painful. Sometimes the spots crack open.
NLD is a rare condition. Adult women are the most likely to get it. As long as the
sores do not break open, you do not need to have it treated. But if you get open
sores, see your doctor for treatment.
 Atherosclerosis
Atherosclerosis is a thickening of the arteries that can affect the skin on the legs.
People with diabetes tend to get atherosclerosis at younger ages than other people
do.
As atherosclerosis narrows the blood vessels, the skin changes. It becomes hairless,
thin, cool, and shiny. The toes become cold. Toenails thicken and discolor. And
exercise causes pain in the calf muscles because the muscles are not getting enough
oxygen.
Because blood carries the infection-fighting white cells, affected legs heal slowly
when the skin in injured. Even minor scrapes can result in open sores that heal
slowly.
People with neuropathy are more likely to suffer foot injuries. These occur because
the person does not feel pain, heat, cold, or pressure as well. The person can have
an injured foot and not know about it. The wound goes uncared for, and so infections
develop easily. Atherosclerosis can make things worse. The reduced blood flow can
cause the infection to become severe.
Allergic Reactions
Allergic skin reactions can occur in response to medicines, such as insulin or
diabetes pills. You should see your doctor if you think you are having a reaction to a
medicine. Be on the lookout for rashes, depressions, or bumps at the sites where you
inject insulin.
Diabetic Blisters (Bullosis Diabeticorum)
Rarely, people with diabetes erupt in blisters. Diabetic blisters can occur on the backs
of fingers, hands, toes, feet, and sometimes, on legs or forearms. These sores look
like burn blisters and often occur in people who have diabetic neuropathy. They are
sometimes large, but they are painless and have no redness around them. They heal
by themselves, usually without scars, in about three weeks. The only treatment is to
bring blood sugar levels under control.
 Eruptive Xanthomatosis
Eruptive xanthomatosis is another condition caused by diabetes that's out of control. It
consists of firm, yellow, pea-like enlargements in the skin. Each bump has a red halo and
may itch. This condition occurs most often on the backs of hands, feet, arms, legs, and
buttocks.
The disorder usually occurs in young men with type 1 diabetes. The person often has high
levels of cholesterol and fat in the blood. Like diabetic blisters, these bumps disappear
when diabetes control is restored.

Digital Sclerosis
Sometimes, people with diabetes develop tight, thick, waxy skin on the backs of their
hands. Sometimes skin on the toes and forehead also becomes thick. The finger joints
become stiff and can no longer move the way they should. Rarely, knees, ankles, or elbows
also get stiff.
This condition happens to about one third of people who have type 1 diabetes. The only
treatment is to bring blood sugar levels under control.

Disseminated Granuloma Annulare

In disseminated granuloma annulare, the person has sharply defined ring- or arc-shaped
raised areas on the skin. These rashes occur most often on parts of the body far from the
trunk (for example, the fingers or ears). But sometimes the raised areas occur on the trunk.
They can be red, red-brown, or skin-colored.
See your doctor if you get rashes like this. There are drugs that can help clear up this
condition.
Acanthosis Nigricans
Acanthosis nigricans is a condition in which tan or brown raised areas appear on the sides
of the neck, armpits, and groin. Sometimes they also occur on the hands, elbows, and
knees.
Acanthosis nigricans usually strikes people who are very overweight. The best treatment is
to lose weight. Some creams can help the spots look better.
 ABCs of Heart Disease
Keeping your ABCs in check can also help you lower your risk for
heart disease and stoke. The ABCs are an easy way to remember
some of the most important health issues related to diabetes. As a
man with diabetes, it's important to stay informed about related
health complications, take a look at the ABCs, and speak with your
healthcare provider to see if these issues are affecting you.

A is for A1C
Your A1C reflects your average blood glucose level for the two to
three month period before the test. Your healthcare provider uses it
to determine how well you are managing your blood sugar. A goal of
less than 7 percent is desirable, which corresponds to an average
blood glucose level of 150 mg/dL.
B is blood pressure
Men with diabetes should aim for a blood pressure level below
130/80 mm Hg. You should monitor blood pressure at each routine
diabetes visit.
 C is for cholesterol (lipids)
A complete cholesterol test, referred to as a lipid panel or lipid
profile, includes the measurement of four types of fats (lipids) in your
blood, low-density lipoprotein (LDL), high-density lipoprotein (HDL)
cholesterol, total cholesterol and triglycerides. LDL is sometimes
called the "bad"cholesterol. Too much of it in your blood causes the
accumulation of fatty deposits (plaques) in your arteries
(atherosclerosis), which reduces blood flow. HDL is sometimes
called the "good"cholesterol because it helps carry away LDL
cholesterol, thus keeping arteries open and blood flowing more
freely. Total cholesterol is the sum of your blood's cholesterol
content. Triglycerides are another type of fat in the blood. When you
eat, your body converts any calories it doesn't need to use right
away into triglycerides, which are stored in fat cells and released
later for energy.
Note: Now you know your ABCs. Speak with your healthcare
provider about ways to keep your ABCs in control.
 High Blood Pressure
(Hypertension)
As many as 2 out of 3 adults with diabetes have high blood pressure.
Because of the risks of high blood pressure to people with diabetes, the American
Diabetes Association and the National Institutes of Health recommend a lower blood
pressure target than the general public (less than 130/80 mmHg).
Blood pressure can be controlled with lifestyle changes, such as diet and exercise, and
medication.
An important part of taking care of yourself is keeping your blood pressure under control.
High blood pressure also called hypertension raises your risk for heart attack, stroke,
eye problems, and kidney disease. As many as 2 out of 3 adults with diabetes have high
blood pressure. Having your blood pressure checked regularly and taking action to reach
your blood pressure target can prevent or delay diabetes problems.
What is high blood pressure?
Blood pressure is the force of blood flow inside your blood vessels. When your health care
team checks your blood pressure, they record two numbers, such as 130/80 mmHg. You'll
hear them say this as "one-thirty over eighty." Both numbers are important:
The first number is the pressure as your heart beats and pushes blood through the blood
vessels. Health care providers call this the "systolic" pressure.
The second number is the pressure when the vessels relax between heartbeats. It's called
the "diastolic" pressure.
When your blood moves through your vessels with too much force, you have high blood
pressure. Your heart has to work harder when blood pressure is high, and your risk for
diabetes problems goes up. High blood pressure is a problem that won't go away without
treatment.
 What is the recommended target for blood pressure?
Both diabetes and high blood pressure increases your risk of heart
attack, stroke, and eye and kidney disease. Because of this, people
with diabetes have a lower blood pressure target than the general
public. The American Diabetes Association (ADA) and the National
Institutes of Health recommend a target blood pressure of less than
130/80 mmHg for people with diabetes. When you keep your blood
pressure below 130/80 mmHg, you'll be lowering your risk for
diabetes problems.
How do I know if I have high blood pressure?
High blood pressure is a silent problem you won't know you have
it unless your health care provider checks your blood pressure. The
ADA recommends that you have your blood pressure checked at
every office visit, or at least 2 to 4 times a year.
How is it treated?
Both lifestyle changes and medication help control blood pressure.
Treatment differs from one person to the next. Work with your health
care provider to find a treatment that's right for you.
 Lifestyle changes
Lifestyle changes can help control your blood pressure as well as your blood
glucose and blood lipids (cholesterol) levels. From the steps below, decide
which steps you would be willing to try. If you need more information about
how to make these changes, talk with your health care team.

Make Wise Food Choices

Eat a serving of fruit at each meal.
Eat one or two servings of vegetables at lunch and at dinner.
Switch to low-fat or fat-free dairy products (such as low-fat cheese and skim
milk).
Eat whole-grain breads (such as whole-wheat bread) and cereals.
Eat nuts or peanut butter sometimes.
Choose lean meats and meat substitutes (such as chicken without the skin,
fish, lean beef, such as flank steak or chuck roast, boiled ham, or pork
tenderloin).
Cook using low-fat methods such as baking, roasting, broiling, or grilling.
Add little or no salt to your food at the table and during cooking.
Try herbs and spices instead of salt.
Check food labels and choose foods with less than 400 mg of sodium per
serving.

Lose Weight or Take Steps to Prevent Weight Gain

Cut down on calories and fat.
Try to be more physically active.
 Be Physically Active
Check with your doctor to find out which activities will be
safe for you. Try to do a total of about 30 minutes of
aerobic exercise, such as brisk walking, most days of the
week. If you're just starting out, start with 5 minutes a
day and gradually add more time.
Be Careful With Alcohol
Talk with your health care team about whether it's wise to
drink alcoholic beverages. If and when you drink
alcoholic beverages, limit yourself to one serving a day
(for women) or two servings a day (for men).
Quit Smoking
Talk with your health care team about methods that can
help.
 Medication
Several types of medication are available. Not everyone takes the same blood
pressure medication, and many people take more than one kind. Which ones
you take will depend on your blood pressure readings and other factors, such as
cost.
ACE inhibitors
These medications lower blood pressure by keeping your blood vessels relaxed.
ACE inhibitors prevent a hormone called angiotensin from forming in your body
and narrowing your blood vessels. These medications also help protect your
kidneys and reduce your risk of heart attack and stroke.
ARBs
These medications keep the blood vessels open and relaxed to help lower blood
pressure. Like ACE inhibitors, ARBs protect your kidneys.
Beta blockers
These medications help lower blood pressure and relax your heart by allowing it
to beat slower and less forcefully. Beta blockers help prevent heart attack and
stroke.
Calcium channel blockers
These medications help the blood vessels relax by keeping calcium out of your
blood vessels and heart.
Diuretics
These medications, sometimes called "water pills," help rid your body of extra
water and sodium through urine.
Are there potential side effects?
Some blood pressure medications produce side effects. Always talk to your
health care team if you think your medication is causing a problem. Your health
care team may be able to substitute another medication.
 Mental Health

Anger
Anger can start at diagnosis with the question, "Why me?" You may
dwell on how unfair diabetes is: "I'm so angry at this disease! I don't
want to treat it. I hate it!"
Denial
Denial is that voice inside repeating: "Not me." Most people go
through denial when they are first diagnosed with diabetes. "I don't
believe it. There must be some mistake," they say.
Depression
Feeling down once in a while is normal. But some people feel a
sadness that just won't go away. Life seems hopeless. Feeling this
way most of the day for two weeks or more is a sign of serious
depression.
 Diabetes and Hearing Loss
Diabetes and hearing loss are two of Americas most widespread health concerns.
Nearly 26 million people in the U.S. have diabetes, and an estimated 34.5 million
have some type of hearing loss.
The numbers are similar is there a link?
Yes, says the National Institute of Health (NIH). In fact, the NIH has found that
hearing loss is twice as common in people with diabetes as it is in those who dont
have the disease. Also, of the 79 million adults thought to have pre-diabetes, the rate
of hearing loss is 30% higher than in those with normal blood sugar.
How does diabetes contribute to hearing loss?
Hearing depends on small blood vessels and nerves in the inner ear. Researchers
believe that, over time, high blood glucose levels can damage these vessels and
nerves, diminishing the ability to hear.
I dont think I have any problem with my hearing.
Are you sure? For most people, hearing loss happens over time. The symptoms can
be hard to notice. Quite often, family members and friends notice hearing loss before
the person experiencing it.
Your doctor may not always screen for hearing loss during a physical. Even if your
doctor does check for hearing loss, you may still pass the screening test in a quiet
exam room. Common signs of hearing loss include:
Frequently asking others to repeat themselves
Trouble following conversations that involve more than two people
Thinking that others are mumbling
Problems hearing in noisy places such as busy restaurants
Trouble hearing the voices of women and small children
Turning up the TV or radio volume too loud for others who are nearby
 Im not even 65 how could my hearing be bad already?
Most people with hearing loss are younger than 65. Hearing problems can even
happen in children.
What should I do if I suspect a hearing loss?
Talk to your primary care doctor. You may then want to seek help from hearing
specialist like: an audiologist, a licensed hearing aid dispenser or a doctor who
specializes in hearing problems. From a full hearing exam, youll learn more
about your hearing loss. You will also be told what can be done to treat it.
What can be done to treat a hearing loss?
Sometimes the problem is just an earwax build-up and the patient is referred to
a doctor to remove the wax. Treatment will depend on the type of hearing loss.
The most common type of hearing loss is called sensorineural hearing loss,
This is the kind usually found with diabetes. It cannot usually be cured.
However, most cases of sensorineural hearing loss can be treated with hearing
aids.
How can I be sure that hearing aids will help?
Hearing aids have changed a lot in the past few years. Instead of making all
sounds louder, like the old kind, newer hearing aids are better at making what
you want to hear more clear. These hearing aids also have special features.
They may have automatic volume control and can reduce background noise.
But I dont want to be seen wearing hearing aids.
Hearing aids are getting smaller and smaller. It is unlikely anyone will notice
when you are wearing them. The truth is, people are more likely to notice your
hearing loss. People who dont treat their hearing problems can become
depressed and try to avoid their friends. On the other hand, studies show that
people who wear hearing aids often have a better quality of life.
 Diabetes and Oral Health Problems
The more severe form of gum disease is called periodontitis.
When you reach this stage, your gums begin to pull away
from your teeth. Pockets form between your teeth and
gums. These fill with germs and pus, and deepen. When
this happens, you may need gum surgery to save your
teeth. If nothing is done, the infection goes on to destroy the
bone around your teeth. The teeth may start to move or get
loose. Your teeth may fall out or need to be pulled.
Is There an Association Between Gum Disease and
Diabetes?
For the nearly 24 million Americans that have diabetes,
many may be surprised to learn about an unexpected
complication associated with this condition. Research shows
that there is an increased prevalence of gum disease
among those with diabetes, adding serious gum disease to
the list of other complications associated with diabetes, such
as heart disease, stroke and kidney disease.
 Is There a Two-Way Street?
Emerging research also suggests that the relationship between serious gum
disease and diabetes is two-way. Not only are people with diabetes more
susceptible to serious gum disease, but serious gum disease may have the
potential to affect blood glucose control and contribute to the progression of
diabetes. Research suggests that people with diabetes are at higher risk for
oral health problems, such as gingivitis (an early stage of gum disease) and
periodontitis (serious gum disease). People with diabetes are at an
increased risk for serious gum disease because they are generally more
susceptible to bacterial infection, and have a decreased ability to fight
bacteria that invade the gums.
The Surgeon General's Report on Oral Health states that good oral health is
integral to general health. So be sure to brush and floss properly and see
your dentist for regular checkups.
If I Have Diabetes, am I at Risk for Dental Problems?
If your blood glucose levels are poorly controlled, you are more likely to
develop serious gum disease and lose more teeth than non-diabetics. Like
all infections, serious gum disease may be a factor in causing blood sugar
to rise and may make diabetes harder to control.
Other oral problems associated to diabetes include: thrush, an infection
caused by fungus that grows in the mouth, and dry mouth which can cause
soreness, ulcers, infections and cavities.
 How Can I Help Prevent Dental Problems Associated
with Diabetes?
First and foremost, control your blood glucose level.
Then, take good care of your teeth and gums, along with
regular checkups every six months. To control thrush, a
fungal infection, maintain good diabetic control, avoid
smoking and, if you wear them, remove and clean
dentures daily. Good blood glucose control can also help
prevent or relieve dry mouth caused by diabetes.
What Can I Expect at My Checkup? Should I Tell My
Dental Professional About My Diabetes?
People with diabetes have special needs and your
dentist and hygienist are equipped to meet those needs -
with your help. Keep your dentist and hygienist informed
of any changes in your condition and any medication you
might be taking. Postpone any non-emergency dental
procedures if your blood sugar is not in good control.
 Gastroparesis
Gastroparesis is a type of neuropathy (nerve damage) in which food
is delayed from leaving the stomach.
This nerve damage can be caused by long periods of high blood
sugar.
Delayed digestion makes the management of diabetes more difficult.
It can be treated with insulin management, drugs, diet, or in severe
cases, a feeding tube.
Gastroparesis is a disorder affecting people with both type 1 and
type 2 diabetes in which the stomach takes too long to empty its
contents (delayed gastric emptying). The vagus nerve controls the
movement of food through the digestive tract. If the vagus nerve is
damaged or stops working, the muscles of the stomach and
intestines do not work normally, and the movement of food is slowed
or stopped.
Just as with other types of neuropathy, diabetes can damage the
vagus nerve if blood glucose levels remain high over a long period
of time. High blood glucose causes chemical changes in nerves and
damages the blood vessels that carry oxygen and nutrients to the
nerves.
 What are the symptoms?
Signs and symptoms of gastroparesis include the following:
Heartburn
Nausea
Vomiting of undigested food
Early feeling of fullness when eating
Weight loss
Abdominal bloating
Erratic blood glucose (sugar) levels
Lack of appetite
Gastroesophageal reflux
Spasms of the stomach wall
These symptoms may be mild or severe, depending on the person.
What are the complications?
Gastroparesis can make diabetes worse by making it more difficult
to manage blood glucose. When food that has been delayed in the
stomach finally enters the small intestine and is absorbed, blood
glucose levels rise.
If food stays too long in the stomach, it can cause problems like
bacterial overgrowth because the food has fermented. Also, the food
can harden into solid masses called bezoars that may cause
nausea, vomiting, and obstruction in the stomach. Bezoars can be
dangerous if they block the passage of food into the small intestine.
 How is it diagnosed?
The diagnosis of gastroparesis is confirmed through one or more of the
following tests:
Barium X-ray
After fasting for 12 hours, you will drink a thick liquid containing barium,
which covers the inside of the stomach, making it show up on the X-ray.
Normally, the stomach will be empty of all food after 12 hours of fasting. If
the X-ray shows food in the stomach, gastroparesis is likely. If the X-ray
shows an empty stomach, but the doctor still suspects that you have
delayed emptying, you may need to repeat the test another day. On any one
day, a person with gastroparesis may digest a meal normally, giving a
falsely normal test result. If you have diabetes, your doctor may have
special instructions about fasting.
Barium Beefsteak Meal
You will eat a meal that contains barium, which allows the doctor to watch
your stomach as it digests the meal. The amount of time it takes for the
barium meal to be digested and leave the stomach gives the doctor an idea
of how well the stomach is working. This test can help find emptying
problems that do not show up on the liquid barium X-ray. In fact, people who
have diabetes-related gastroparesis often digest fluid normally, so the
barium beefsteak meal can be more useful.
 Radioisotope Gastric-Emptying Scan
You will eat food that contains a radioisotope, a slightly radioactive
substance that will show up on the scan. The dose of radiation from the
radioisotope is small and not dangerous. After eating, you will lie under a
machine that detects the radioisotope and shows an image of the food in
the stomach and how quickly it leaves the stomach. Gastroparesis is
diagnosed if more than half of the food remains in the stomach after two
hours.
Gastric Manometry
This test measures electrical and muscular activity in the stomach. The
doctor passes a thin tube down the throat into the stomach. The tube
contains a wire that takes measurements of the stomach's electrical and
muscular activity as it digests liquids and solid food. The measurements
show how the stomach is working and whether there is any delay in
digestion.
Blood tests
The doctor may also order laboratory tests to check blood counts and to
measure chemical and electrolyte levels.
 To rule out causes of gastroparesis other than diabetes,
the doctor may do an upper endoscopy or an ultrasound.
Upper Endoscopy
After giving you a sedative, the doctor passes a long,
thin tube called an endoscope through the mouth and
gently guides it down the esophagus into the stomach.
Through the endoscope, the doctor can look at the lining
of the stomach to check for any abnormalities.
Ultrasound
To rule out gallbladder disease or pancreatitis as a
source of the problem, you may have an ultrasound test,
which uses harmless sound waves to outline and define
the shape of the gallbladder and pancreas.
 How is it treated?
The most important treatment goal for diabetes-related gastroparesis is to manage
your blood glucose levels as well as possible. Treatments include insulin, oral
medications, changes in what and when you eat, and, in severe cases, feeding tubes
and intravenous feeding.
Insulin for blood glucose control
If you have gastroparesis, your food is being absorbed more slowly and at
unpredictable times. To better manage blood glucose, you may need to try the
following:
Take insulin more often
Take your insulin after you eat instead of before
Check your blood glucose levels frequently after you eat and administer insulin
whenever necessary
Your doctor will give you specific instructions based on your particular needs.
Medication
Several drugs are used to treat gastroparesis. Your doctor may try different drugs or
combinations of drugs to find the most effective treatment.
 Meal and Food Changes
Changing your eating habits can help control gastroparesis. Your doctor or dietitian
will give you specific instructions, but you may be asked to eat six small meals a day
instead of three large ones. If less food enters the stomach each time you eat, it may
not become overly full. Or the doctor or dietitian may suggest that you try several
liquid meals a day until your blood glucose levels are stable and the gastroparesis
has improved. Liquid meals provide all the nutrients found in solid foods, but can
pass through the stomach more easily and quickly.
The doctor may also recommend that you avoid high-fat and high-fiber foods. Fat
naturally slows digestion something you don't need if you have gastroparesis
and fiber is difficult to digest. Some high-fiber foods like oranges and broccoli contain
material that cannot be digested. Avoid these foods because the indigestible part will
remain in the stomach too long and possibly form bezoars.
Feeding Tube
If other approaches do not work, you may need surgery to insert a feeding tube. The
tube, called a jejunostomy tube, is inserted through the skin on your abdomen into
the small intestine. The feeding tube allows you to put nutrients directly into the small
intestine, bypassing the stomach altogether. You will receive special liquid food to
use with the tube. A jejunostomy is particularly useful when gastroparesis prevents
the nutrients and medication necessary to regulate blood glucose levels from
reaching the bloodstream.
By avoiding the source of the problem (the stomach) and putting nutrients and
medication directly into the small intestine, you ensure that these products are
digested and delivered to your bloodstream quickly. A jejunostomy tube can be
temporary and is used only if necessary when gastroparesis is severe.
It is important to note that in most cases treatment does not cure gastroparesis it
is usually a chronic condition. Treatment helps you manage gastroparesis, so that
you can be as healthy and comfortable as possible.
 Ketoacidosis (DKA)
Ketones are produced when your body starts burning fat for energy instead
of glucose.
Dangerously high levels of ketones can lead to diabetic coma or death.
Know the warning signs and check urine for ketones, especially when sick.
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. When your cells
don't get the glucose they need for energy, your body begins to burn fat for
energy, which produces ketones. Ketones are acids that build up in the
blood and appear in the urine when your body doesn't have enough insulin.
They are a warning sign that your diabetes is out of control or that you are
getting sick. High levels of ketones can poison the body. When levels get
too high, you can develop diabetic ketoacidosis, or DKA.
Ketoacidosis may happen to anyone with diabetes, though it is rare in
people with type 2. Some older people with type 2 diabetes may experience
a different serious condition called hyperosmolar nonketotic coma (hi-per-
oz-MOE-lar non- key-TOT-ick KO-ma) in which the body tries to get rid of
excess sugar by passing it into the urine.
Treatment for ketoacidosis usually takes place in the hospital. But you can
help prevent ketoacidosis by learning the warning signs and checking 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. Early
symptoms include the following:
Thirst or a very dry mouth
Frequent urination
High blood glucose (sugar) levels
High levels of ketones in the urine
Then, other symptoms appear:
Constantly feeling tired
Dry or flushed skin
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
provider.)
A hard time breathing (short, deep breaths)
Fruity odor on breath
A hard time paying attention, or confusion
 Ketoacidosis is dangerous and serious. If you have any of the above
symptoms, contact your health care provider IMMEDIATELY, or go to the
nearest emergency room of your local hospital.
How do I check for ketones?
You can detect ketones with a simple urine test using a test strip, similar to a
blood testing strip. Ask your health care provider when and how you should
test for ketones. Many experts advise to check your urine for ketones when
your blood glucose is more than 240 mg/dl.
When you are ill (when you have a cold or the flu, for example), check for
ketones every 4 to 6 hours. And check every 4 to 6 hours when your blood
glucose is more than 240 mg/dl.
Also, check for ketones when you have any symptoms of ketoacidosis.
What if I find higher-than-normal levels of ketones?
If your health care provider 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 provider can tell you what to do over the phone.
Call your health care provider at once if you experience the following
conditions:
Your urine tests show high levels of ketones.
Your urine tests show high levels of ketones and your blood glucose level is
high.
Your urine tests show high levels of ketones and you have vomited more than
twice in four hours.
Do NOT exercise when your urine tests show ketones and your blood
glucose is high. High levels of ketones and high blood glucose levels can
mean your diabetes is out of control. Check with your health care provider
about how to handle this situation.
 What causes ketoacidosis?
Here are three basic reasons for moderate or large
amounts of ketones:
Not enough insulin
Maybe you did not inject enough insulin. Or your body
could need more insulin than usual because of illness.
Not enough food
When you're sick, you often don't feel like eating,
sometimes resulting in high ketone levels. High levels
may also occur when you miss a meal.
Insulin reaction (low blood glucose)
If testing shows high ketone levels in the morning, you
may have had an insulin reaction while asleep.
 Neuropathy (Nerve Damage)

Nerve damage from diabetes is called diabetic neuropathy (new-

ROP-uh-thee). About half of all people with diabetes have some
form of nerve damage. It is more common in those who have had
the disease for a number of years and can lead to many kinds of
problems.
Over time excess blood glucose can injure the walls of tiny blood
vessels that nourish your nerves, especially in the legs. Nerves send
messages to and from your brain about pain, temperature and
touch. They tell your muscles when and how to move. They also
control body systems that digest food and pass urine.
If you keep your blood glucose levels on target, you may help
prevent or delay nerve damage. If you already have nerve damage,
this will help prevent or delay further damage. There are also other
treatments that can help.
 Peripheral Neuropathy
Tingling
My feet tingle.
I feel "pins and needles" in my feet.
Pain or increased sensitivity
I have burning, stabbing or shooting pains in my feet.
My feet are very sensitive to touch. For example, sometimes it hurts to have
the bed covers touch my feet.
Sometimes I feel like I have socks or gloves on when I don't.
My feet hurt at night.
My feet and hands get very cold or very hot.
Numbness or weakness
My feet are numb and feel dead.
I don't feel pain in my feet, even when I have blisters or injuries.
I can't feel my feet when I'm walking.
The muscles in my feet and legs are weak.
I'm unsteady when I stand or walk.
I have trouble feeling heat or cold in my feet or hands.
Other
It seems like the muscles and bones in my feet have changed shape.
I have open sores (also called ulcers) on my feet and legs. These sores
heal very slowly.
 Diagnosis
Foot exams. Your health care provider should look at your feet at
each office visit to check for injuries, sores, blisters or other
problems. As a reminder, take off your shoes and socks when you're
in the exam room.
Have a complete foot exam once a year. If you already have foot
problems, have your feet checked more often. A complete foot exam
includes a check of the skin on your feet, your foot muscles and
bones, and your blood flow. Your provider will also check for
numbness in your feet by touching your foot with a monofilament. It
looks like a stiff piece of nylon fishing line or a bristle in a hairbrush.
Other ways to check your nerves include using a tuning fork. It may
be touched to your foot to see if you can feel it moving.
Nerve conduction studies and electromyography (EMG). If the
doctor thinks you might have nerve damage, you may have tests
that look at how well the nerves in your arms and legs are working.
Nerve conduction studies check the speed with which nerves send
messages. An EMG checks how your nerves and muscles work
together.
 Treatment
To treat nerve damage, you will need to keep your blood
glucose levels in your target range, manage your pain
and protect your feet. Many people get depressed when
they have nerve damage and may need medication for
depression as well as counseling.
Medications. Medications to relieve pain and reduce
burning, numbness and tingling are available. Some of
these are known for their use in other conditions but they
still seem to help those with nerve damage. Choices
include medications also used for:
seizure prevention
depression
pain
Speak with your doctor to find out what treatments are
best for you.
 Autonomic Neuropathy
Autonomic neuropathy affects the autonomic nerves, which control
the bladder, intestinal tract, and genitals, among other organs.
Paralysis of the bladder is a common symptom of this type of
neuropathy. When this happens, the nerves of the bladder no longer
respond normally to pressure as the bladder fills with urine. As a
result, urine stays in the bladder, leading to urinary tract infections.
Autonomic neuropathy can also cause erectile dysfunction
(ED) when it affects the nerves that control erection with sexual
arousal. However, sexual desire does not usually decrease.
Diarrhea can occur when the nerves that control the small intestine
are damaged. The diarrhea occurs most often at night. Constipation
is another common result of damage to nerves in the intestines.
Sometimes, the stomach is affected. It loses the ability to move food
through the digestive system, causing vomiting and bloating. This
condition, called gastroparesis, can change how fast the body
absorbs food. It can make it hard to match insulin doses to food
portions.
Scientists do not know the precise cause of autonomic neuropathy
and are looking for better treatments for his type of neuropathy.
 Symptoms
This type of nerve damage affects the nerves in your body that control your
body systems. It affects your digestive system, urinary tract, sex organs,
heart and blood vessels, sweat glands, and eyes. Look at the list below and
make a note about any symptoms you have. Bring this list to your next
office visit.
About my digestive system
I get indigestion or heartburn.
I get nauseous and I vomit undigested food.
It seems like food sits in my stomach instead of being digested.
I feel bloated after I eat.
My stomach feels full, even after I eat only a small amount.
I have diarrhea.
I have lost control of my bowels.
I get constipated.
My blood glucose levels are hard to predict. I never know if I'll have high or
low blood glucose after eating.
About my urinary tract
I have had bladder control problems, such as urinating very often or not
often enough, feeling like I need to urinate when I don't, or leaking urine.
I don't feel the need to urinate, even when my bladder is full.
I have lost control of my bladder.
I have frequent bladder infections.
 About my sex organs
(For men) When I have sex, I have trouble getting or keeping an erection.
(For women) When I have sex, I have problems with orgasms, feeling
aroused, or I have vaginal dryness.
About my heart and blood vessels
I get dizzy if I stand up too quickly.
I have fainted after getting up or changing my position.
I have fainted suddenly for no reason.
At rest, my heart beats too fast.
I had a heart attack but I didn't have the typical warning signs such as chest
pain.
About my body's warning system for low blood glucose levels
(hypoglycemia)
I used to get nervous and shaky when my blood glucose was getting too
low, but I no longer have those warning signals.
About my sweat glands
I sweat a lot, especially at night or while I'm eating.
I no longer sweat, even when I'm too hot.
The skin on my feet is very dry.
About my eyes
It's hard for my eyes to adjust when I go from a dark place into a bright
place or when driving at night.
 Diagnosis
To diagnose this kind of nerve damage, you will need a
physical exam and special tests as well. For example, an
ultrasound test uses sound waves to check on your
bladder. Stomach problems can be found using x-rays
and other tests. Reporting your symptoms plays a big
part in making a diagnosis.
Treatment
There are a number of treatments for damage to nerves
that control body systems. For example, a dietitian can
help you plan meals if you have nausea or feel full after
eating a small amount. Some medications can speed
digestion and reduce diarrhea. Problems with erections
can be treated with medications or devices.
 Additional Types of Neuropathy

Charcot's Joint
Charcot's Joint, also called neuropathic arthropathy, occurs when a joint
breaks down because of a problem with the nerves. This type of neuropathy
most often occurs in the foot.
In a typical case of Charcot's Joint, the foot has lost most sensation. The
person no longer can feel pain in the foot and loses the ability to sense the
position of the joint. Also, the muscles lose their ability to support the joint
properly. The foot then becomes unstable, and walking just makes it worse.
An injury, such as a twisted ankle, may make things even worse. Joints
grind on bone. The result is inflammation, which leads to further instability
and then dislocation. Finally, the bone structure of the foot collapses.
Eventually, the foot heals on its own, but because of the breakdown of the
bone, it heals into a deformed foot.
People at risk for Charcot's Joint are those who already have neuropathy.
They should be aware of symptoms such as swelling, redness, heat, strong
pulse, and insensitivity of the foot. Early treatment can stop bone
destruction and aid healing.
 Cranial Neuropathy
Cranial neuropathy affects the 12 pairs of nerves
that are connected with the brain and control
sight, eye movement, hearing, and taste.
Most often, cranial neuropathy affects the nerves
that control the eye muscles. The neuropathy
begins with pain on one side of the face near the
affected eye. Later, the eye muscle becomes
paralyzed. Double vision results. Symptoms of
this type of neuropathy usually get better or go
away within 2 or 3 months.
 Compression Mononeuropathy
Compression mononeuropathy occurs when a single nerve is
damaged. It is a fairly common type of neuropathy. There seem to
be two kinds of damage. In the first, nerves are squashed at places
where they must pass through a tight tunnel or over a lump of bone.
Nerves of people with diabetes are more prone to compression
injury. The second kind of damage arises when blood vessel
disease caused by diabetes restricts blood flow to a part of the
nerve.
Carpal tunnel syndrome is probably the most common compression
mononeuropathy. It occurs when the median nerve of the forearm is
compressed at the wrist. Symptoms of this type of neuropathy
include numbness, swelling, or prickling in the fingers with or without
pain when driving a car, knitting, or resting at night. Simply hanging
your arm by your side usually stops the pain within a few minutes. If
the symptoms are severe, an operation can give complete relief
from pain.
 Femoral Neuropathy
Femoral neuropathy occurs most often in people with type 2
diabetes. A pain may develop in the front of one thigh. Muscle
weakness follows, and the affected muscles waste away. A different
kind of neuropathy that also affects the legs is called diabetic
amyotrophy. In this case, weakness occurs on both sides of the
body, but there is no pain. Doctors do not understand why it occurs,
but blood vessel disease may be the cause.
Focal Neuropathy
Focal Neuropathy affects a nerve or group of nerves causing
sudden weakness or pain. It can lead to double vision, a paralysis
on one side of the face called Bell's palsy, or a pain in the front of
the thigh or other parts of the body.
Thoracic/Lumbar Radiculopathy
Thoracic or lumbar radiculopath is another common
mononeuropathy. It is like femoral neuropathy, except that it occurs
in the torso. It affects a band of the chest or abdominal wall on one
or both sides. It seems to occur more often in people with type 2
diabetes. Again, people with this neuropathy get better with time.
Unilateral Foot Drop
Unilateral foot drop is when the foot can't be picked up. It occurs
from damage to the peroneal nerve of the leg by compression or
vessel disease. Foot drop can improve.
 Steps to Prevent or Delay Nerve Damage
There's a lot you can do to prevent or delay nerve damage. And, if you already have diabetic
neuropathy (nerve damage), these steps can prevent or delay further damage and may lessen
your symptoms.
Keep your blood glucose levels in your target range.
Meal planning, physical activity and medications, if needed, all can help you reach your target
range. There are two ways to keep track of your blood glucose levels:
Use a blood glucose meter to help you make decisions about day-to-day care.
Get an A1C test (a lab test) at least twice a year to find out your average blood glucose for the
past 2 to 3 months.
Checking your blood glucose levels will tell you whether your diabetes care plan is working or
whether changes are needed.
Report symptoms of diabetic neuropathy.
If you have problems, get treatment right away. Early treatment can help prevent more
problems later on. For example, if you take care of a foot infection early, it can help prevent
amputation.
Take good care of your feet. Check your feet every day. If you no longer can feel pain in your
feet, you might not notice a foot injury. Instead, use your eyes to look for problems. Use a
mirror to see the bottoms of your feet. Use your hands to feel for hot or cold spots, bumps or
dry skin. Look for sores, cuts or breaks in the skin. Also check for corns, calluses, blisters, red
areas, swelling, ingrown toenails and toenail infections. If it's hard for you to see or reach your
feet, get help from a family member or foot doctor.
Protect your feet. If your feet are dry, use a lotion on your skin but not between your toes.
Wear shoes and socks that fit well and wear them all the time. Use warm water to wash your
feet, and dry them carefully afterward.
Get special shoes if needed. If you have foot problems, Medicare may pay for shoes. Ask your
health care team about it.
Be careful with exercising. Some physical activities are not safe for people with neuropathy.
Talk with a diabetes clinical exercise expert who can guide you.
 Hyperosmolar Hyperglycemic
Nonketotic Syndrome (HHNS)
Hyperosmolar Hyperglycemic Nonketotic Syndrome, or HHNS, is a
serious condition most frequently seen in older persons. HHNS can
happen to people with either type 1 or type 2 diabetes, but it occurs
more often in people with type 2. HHNS is usually brought on by
something else, such as an illness or infection.
In HHNS, blood sugar levels rise, and your body tries to get rid of
the excess sugar by passing it into your urine. You make lots of
urine at first, and you have to go to the bathroom more often. Later
you may not have to go to the bathroom as often, and your urine
becomes very dark. Also, you may be very thirsty. Even if you are
not thirsty, you need to drink liquids. If you don't drink enough liquids
at this point, you can get dehydrated.
If HHNS continues, the severe dehydration will lead to seizures,
coma and eventually death. HHNS may take days or even weeks to
develop. Know the warning signs of HHNS.
 What are the warning signs?
Blood sugar level over 600 mg/dl
Dry, parched mouth
Extreme thirst (although this may gradually disappear)
Warm, dry skin that does not sweat
High fever (over 101 degrees Fahrenheit, for example)
Sleepiness or confusion
Loss of vision
Hallucinations (seeing or hearing things that are not there)
Weakness on one side of the body
If you have any of these symptoms, call someone on your health
care team.
 How can I avoid it?
The best way to avoid HHNS is to check your blood sugar regularly.
Many people check their blood sugar several times a day, such as
before or after meals. Talk with your health care team about when to
check and what the numbers mean. You should also talk with your
health care team about your target blood sugar range and when to
call if your blood sugars are too high, or too low and not in your
target range. When you are sick, you will check your blood sugar
more often, and drink a glass of liquid (alcohol-free and caffeine-
free) every hour. Work with your team to develop your own sick day
plan.
Related information
Another condition to watch signs for is ketoacidosis, which means
dangerously high levels of ketones, or acids, that build up in the
blood. Ketones appear in the urine when your body doesn't have
enough insulin, and can poison the body.
 Kidney Disease (Nephropathy)
High blood sugar can overwork the kidneys, causing them to stop working
properly.
When diagnosed early, kidney disease can be slowed with treatment.
When diagnosed later, kidney failure usually results.
Once kidneys fail, replacement therapy via dialysis or transplant is necessary.
Kidneys are remarkable organs. Inside them are millions of tiny blood vessels that
act as filters. Their job is to remove waste products from the blood.
Sometimes this filtering system breaks down. Diabetes can damage the kidneys
and cause them to fail. Failing kidneys lose their ability to filter out waste products,
resulting in kidney disease.
How does diabetes cause kidney disease?
When our bodies digest the protein we eat, the process creates waste products.
In the kidneys, millions of tiny blood vessels (capillaries) with even tinier holes in
them act as filters. As blood flows through the blood vessels, small molecules
such as waste products squeeze through the holes. These waste products
become part of the urine. Useful substances, such as protein and red blood cells,
are too big to pass through the holes in the filter and stay in the blood.
Diabetes can damage this system. High levels of blood sugar make the kidneys
filter too much blood. All this extra work is hard on the filters. After many years,
they start to leak and useful protein is lost in the urine. Having small amounts of
protein in the urine is called microalbuminuria.
When kidney disease is diagnosed early, (during microalbuminuria), several
treatments may keep kidney disease from getting worse. Having larger amounts
of protein in the urine is called macroalbuminuria. When kidney disease is caught
later (during macroalbuminuria), end-stage renal disease, or ESRD, usually
follows.
 In time, the stress of overwork causes the kidneys to lose their filtering ability.
Waste products then start to build up in the blood. Finally, the kidneys fail. This
failure, ESRD, is very serious. A person with ESRD needs to have a kidney
transplant or to have the blood filtered by machine (dialysis).
Who gets kidney disease?
Not everyone with diabetes develops kidney disease. Factors that can
influence kidney disease development include genetics, blood sugar control,
and blood pressure.
The better a person keeps diabetes and blood pressure under control, the
lower the chance of getting kidney disease.
What are the symptoms?
The kidneys work hard to make up for the failing capillaries so kidney disease
produces no symptoms until almost all function is gone. Also, the symptoms of
kidney disease are not specific. The first symptom of kidney disease is often
fluid buildup. Other symptoms of kidney disease include loss of sleep, poor
appetite, upset stomach, weakness, and difficulty concentrating.
It is vital to see a doctor regularly. The doctor can check blood pressure, urine
(for protein), blood (for waste products), and organs for other complications of
diabetes.
How can I prevent it?
Diabetic kidney disease can be prevented by keeping blood sugar in your
target range. Research has shown that tight blood sugar control reduces the
risk of microalbuminuria by one third. In people who already had
microalbuminuria, the risk of progressing to macroalbuminuria was cut in half.
Other studies have suggested that tight control can reverse microalbuminuria.
 Treatments for kidney disease
Self-care
Important treatments for kidney disease are tight control of blood glucose
and blood pressure. Blood pressure has a dramatic effect on the rate at
which the disease progresses. Even a mild rise in blood pressure can
quickly make kidney disease worsen. Four ways to lower your blood
pressure are losing weight, eating less salt, avoiding alcohol and tobacco,
and getting regular exercise.
Drugs
When these methods fail, certain medicines may be able to lower blood
pressure. There are several kinds of blood pressure drugs, however, not all
are equally good for people with diabetes. Some raise blood sugar levels or
mask some of the symptoms of low blood sugar. Doctors usually prefer
people with diabetes to take blood pressure drugs called ACE inhibitors.
ACE inhibitors are recommended for most people with diabetes, high blood
pressure, and kidney disease. Recent studies suggest that ACE inhibitors,
which include captopril and enalapril, slow kidney disease in addition to
lowering blood pressure. In fact, these drugs are helpful even in people who
do not have high blood pressure.
 Diet
Another treatment some doctors use with
macroalbuminuria is a low-protein diet. Protein seems to
increase how hard the kidneys must work. A low-protein
diet can decrease protein loss in the urine and increase
protein levels in the blood. Never start a low-protein diet
without talking to your health care team.
Kidney Failure
Once kidneys fail, dialysis is necessary. The person must
choose whether to continue with dialysis or to get a
kidney transplant. This choice should be made as a team
effort. The team should include the doctor and diabetes
educator, a nephrologist (kidney doctor), a kidney
transplant surgeon, a social worker, and a psychologist.
Peripheral Arterial Disease (PAD)

PAD increases the risk of heart attack and stroke.

Many people don't recognize the warning signs or get the treatment they
need.
PAD can be treated with physical activity, medication, and surgery.
What is peripheral arterial disease?
Peripheral arterial disease, also called PAD, occurs when blood vessels in
the legs are narrowed or blocked by fatty deposits and blood flow to your
feet and legs decreases. If you have PAD, you have an increased risk for
heart attack and stroke. An estimated 1 out of every 3 people with diabetes
over the age of 50 have this condition. However, many of those with
warning signs don't realize that they have PAD and therefore don't get
treatment.

What does diabetes have to do with PAD?

If you have diabetes, you're much more likely to have PAD, a heart attack,
or a stroke. But you can cut your chances of having those problems by
taking special care of your blood vessels.
 How do I know whether I'm at high risk for PAD?
Just having diabetes puts you at risk, but your risk is even greater under the
following conditions:

Smoking
High blood pressure
Abnormal blood cholesterol levels
Overweight
Not physically active
Over age 50
History of heart disease, or you've have had a heart attack or a stroke
Family history of heart disease, heart attacks, or strokes
You can't change your age or your family history, but taking care of your
diabetes and the conditions that come with it can lower your chances of
having PAD.
What are the warning signs of PAD?
Many people with diabetes and PAD do not have any symptoms. Some
people may experience mild leg pain or trouble walking and believe that it's
just a sign of getting older. Others may have the following symptoms:

Leg pain, particularly when walking or exercising, which disappears after a

few minutes of rest
Numbness, tingling, or coldness in the lower legs or feet
Sores or infections on your feet or legs that heal slowly
 How is PAD diagnosed?
The ankle brachial index (ABI) is one test used to diagnose PAD.
This test compares the blood pressure in your ankle to the blood
pressure in your arm. If the blood pressure in the lower part of your
leg is lower than the pressure in your arm, you may have PAD. An
expert panel brought together by the American Diabetes Association
recommends that people with diabetes over the age of 50 have an
ABI to test for PAD. People with diabetes younger than 50 may
benefit from testing if they have other PAD risk factors.

These other tests can also be used to diagnosis PAD:

Angiogram (AN-gee-oh-gram): a test in which dye is injected into the
blood vessels using a catheter and X rays are taken to show
whether arteries are narrowed or blocked.
Ultrasound: a test using sound waves to produce images of the
blood vessels on a viewing screen.
MRI (magnetic resonance imaging): a test using special scanning
techniques to detect blockages within blood vessels.
 How is PAD treated?
People with PAD are at very high risk for heart attacks and stroke, so it is
very important to manage cardiovascular risk factors. Here are some steps
you can take:
Quit smoking. Your health care provider can help you.
Aim for an A1C below 7%. The A1C test measures your average blood
glucose (sugar) over the past 2 to 3 months.
Lower your blood pressure to less than 130/80 mmHg.
Get your LDL cholesterol below 100 mg/dl.
Talk to your health care provider about taking aspirin or other antiplatelet
medicines. These medicines have been shown to reduce heart attacks and
strokes in people with PAD.
Studies have found that exercise, such as walking, can be used both to
treat PAD and to prevent it. Medications may help relieve symptoms.
In some cases, surgical procedures are used to treat PAD:
Angioplasty, also called balloon angioplasty: a procedure in which a small
tube with a balloon attached is inserted and threaded into an artery; then
the balloon is inflated, opening the narrowed artery. A wire tube, called a
stent, may be left in place to help keep the artery open.
Artery bypass graft: a procedure in which a blood vessel is taken from
another part of the body and is attached to bypass a blocked artery
 Stroke

2 out of 3 people with diabetes die from stroke or heart disease.

Maintaining target levels for blood glucose, blood pressure, and
cholesterol increase your chances for prevention.
If you have warning signs of a stroke, call 911 right away.
What is a stroke?
A stroke, sometimes called a "brain attack", occurs when blood
supply to part of your brain is interrupted and brain tissue is
damaged. The most common cause is a blocked blood vessel.
Stroke can cause physical problems such as paralysis, problems
with thinking or speaking, and emotional problems.
What does diabetes have to do with strokes?
If you have diabetes, you're much more likely to have a stroke, heart
disease, or a heart attack. In fact, 2 out of 3 people with diabetes die
from stroke or heart disease. But you can cut your chances of
having these problems by taking special care of your heart and
blood vessels.
 How do I know whether I'm at high risk for a stroke?
Just having diabetes puts you at risk, but your risk is even greater
under the following conditions:
High blood pressure
Abnormal blood cholesterol levels
Smoking
History of stroke or a transient ischemic attack (TIA), also called a
mini-stroke
Family history of stroke or TIAs
You can't change your family history, but taking care of your
diabetes and the conditions that come with it can lower your
chances of having a stroke.
How can I lower my risk of having a stroke?
You can lower your risk by keeping your blood glucose (sugar),
blood pressure, and cholesterol on target with meal planning,
physical activity, and medication. Quitting smoking is important too.
Every step you take will help. The closer your numbers are to your
targets, the better your chances of preventing a stroke.
 What are the warning signs of a stroke?
Typical warning signs of a stroke develop suddenly and can include:
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 one or both eyes
Double vision
Severe headache
Sometimes one or more of these warning signs occur but then
disappear. That condition, called a TIA, occurs when blood flow is
temporarily blocked. It means you may be at risk for a future stroke.
If you have warning signs of a stroke, call 911 right away. Getting
treatment can help prevent permanent damage to your brain. It's
wise to review the symptoms of a stroke with family and friends and
to tell them about the importance of calling 911.
 How is a stroke diagnosed?
A number of tests may be done if a stroke is suspected:
Your doctor will examine you to check for any changes in body
function. For example, the doctor can check your ability to move
your arms and legs. The doctor also will check brain functions such
as your ability to read or to describe a picture.
A CT (CAT scan) or MRI (magnetic resonance imaging) uses special
scanning techniques to provide images of the brain. An ultrasound
examination can show problems in the carotid (ca-RAH-tid) arteries,
which carry blood from the heart to the brain.
A cerebral (seh-REEB-rahl) arteriogram is a test in which a catheter
is inserted into an artery and positioned in the neck. Dye is injected
and X rays show whether arteries are narrowed or blocked.
What are the treatments for stroke?
Treatment you need right away
"Clot-busting" drugs must be given within hours after a stroke to
minimize damage. That's why it's important to call 911 if you're
having symptoms.
 Surgical treatments you may need
Several options for surgical treatment of blocked blood vessels are
available. These include the following:
Carotid artery surgery, also called carotid endarterectomy (en-dar-
teh-REK-teh-mee) is used to remove buildups of fat inside the artery
and to restore blood flow to the brain.
Carotid stenting is a procedure used to remove a blockage in a
blood vessel to the brain. A small tube with a balloon attached is
threaded into the narrowed or blocked blood vessel. Then the
balloon is inflated, opening the narrowed artery. A wire tube, or stent,
may be left in place to help keep the artery open
Other treatments
Treatment following a stroke includes rehabilitation therapies to
restore function or help people relearn skills. Physical, occupational,
and speech therapy may be included, as well as psychological
counseling. Steps to prevent future problems should include
smoking cessation, meal planning, physical activity, and medications
to manage blood glucose, blood pressure, and cholesterol levels.
 Stress
Stress can be physical or mental.
It can complicate diabetes by distracting you from proper
care or affecting blood glucose levels directly.
Learning to relax and making lifestyle changes can help
reduce mental stress.
Stress results when something causes your body to behave
as if it were under attack. Sources of stress can be physical,
like injury or illness. Or they can be mental, like problems in
your marriage, job, health, or finances.
When stress occurs, the body prepares to take action. This
preparation is called the fight-or-flight response. In the fight-
or-flight response, levels of many hormones shoot up. Their
net effect is to make a lot of stored energy glucose and
fat available to cells. These cells are then primed to help
the body get away from danger.
In people who have diabetes, the fight-or-flight response
does not work well. Insulin is not always able to let the extra
energy into the cells, so glucose piles up in the blood.
 How Stress Affects Diabetes
Many sources of stress are long-term threats. For example, it can
take many months to recover from surgery. Stress hormones that
are designed to deal with short-term danger stay turned on for a
long time. As a result, long-term stress can cause long-term high
blood glucose levels.
Many long-term sources of stress are mental. Your mind sometimes
reacts to a harmless event as if it were a real threat. Like physical
stress, mental stress can be short term: from taking a test to getting
stuck in a traffic jam. It can also be long term: from working for a
demanding boss to taking care of an aging parent. With mental
stress, the body pumps out hormones to no avail. Neither fighting
nor fleeing is any help when the "enemy" is your own mind.
In people with diabetes, stress can alter blood glucose levels in two
ways:
People under stress may not take good care of themselves. They
may drink more alcohol or exercise less. They may forget, or not
have time, to check their glucose levels or plan good meals.
Stress hormones may also alter blood glucose levels directly.
 Scientists have studied the effects of stress on glucose levels in
animals and people. Diabetic mice under physical or mental stress
have elevated glucose levels. The effects in people with type 1
diabetes are more mixed. While most people's glucose levels go up
with mental stress, others' glucose levels can go down. In people
with type 2 diabetes, mental stress often raises blood glucose levels.
Physical stress, such as illness or injury, causes higher blood
glucose levels in people with either type of diabetes.
It's easy to find out whether mental stress affects your glucose
control. Before checking your glucose levels, write down a number
rating your mental stress level on a scale of 1 to 10. Then write
down your glucose level next to it. After a week or two, look for a
pattern. Drawing a graph may help you see trends better. Do high
stress levels often occur with high glucose levels, and low stress
levels with low glucose levels? If so, stress may affect your glucose
control.
 Reducing Mental Stress
Making changes
You may be able to get rid of some stresses of life. If traffic upsets
you, for example, maybe you can find a new route to work or leave
home early enough to miss the traffic jams. If your job drives you
crazy, apply for a transfer if you can, or possibly discuss with your
boss how to improve things. As a last resort, you can look for
another job. If you are at odds with a friend or relative, you can
make the first move to patch things up. For such problems, stress
may be a sign that something needs to change.
There are other ways to fight stress as well:
Start an exercise program or join a sports team.
Take dance lessons or join a dancing club.
Start a new hobby or learn a new craft.
Volunteer at a hospital or charity.
 Coping Style
Something else that affects people's responses to stress
is coping style. Coping style is how a person deals with
stress. For example, some people have a problem-
solving attitude. They say to themselves, "What can I do
about this problem?" They try to change their situation to
get rid of the stress.
Other people talk themselves into accepting the problem
as okay. They say to themselves, "This problem really
isn't so bad after all."
These two methods of coping are usually helpful. People
who use them tend to have less blood glucose elevation
in response to mental stress.
 Learning to Relax
For some people with diabetes, controlling stress with relaxation therapy seems
to help, though it is more likely to help people with type 2 diabetes than people
with type 1 diabetes. This difference makes sense. Stress blocks the body from
releasing insulin in people with type 2 diabetes, so cutting stress may be more
helpful for these people. People with type 1 diabetes don't make insulin, so
stress reduction doesn't have this effect. Some people with type 2 diabetes may
also be more sensitive to some of the stress hormones. Relaxing can help by
blunting this sensitivity.
There are many ways to help yourself relax:
Breathing exercises
Sit or lie down and uncross your legs and arms. Take in a deep breath. Then
push out as much air as you can. Breathe in and out again, this time relaxing
your muscles on purpose while breathing out. Keep breathing and relaxing for 5
to 20 minutes at a time. Do the breathing exercises at least once a day.
Progressive relaxation therapy
In this technique, which you can learn in a clinic or from an audio tape, you
tense muscles, then relax them.
Exercise
Another way to relax your body is by moving it through a wide range of motion.
Three ways to loosen up through movement are circling, stretching, and shaking
parts of your body. To make this exercise more fun, move with music.
Replace bad thoughts with good ones
Each time you notice a bad thought, purposefully think of something that makes
you happy or proud. Or memorize a poem, prayer, or quote and use it to replace
a bad thought.
Whatever method you choose to relax, practice it. Just as it takes weeks or
months of practice to learn a new sport, it takes practice to learn relaxation.
 Dealing with Diabetes-Related Stress
Some sources of stress are never going to go away, no matter what
you do. Having diabetes is one of those. Still, there are ways to
reduce the stresses of living with diabetes. Support groups can help.
Knowing other people in the same situation helps you feel less
alone. You can also learn other people's hints for coping with
problems. Making friends in a support group can lighten the burden
of diabetes-related stresses.
Dealing directly with diabetes care issues can also help. Think about
the aspects of life with diabetes that are the most stressful for you. It
might be taking your medication, or checking your blood glucose
levels regularly, or exercising, or eating as you should.
If you need help with any of these issues, ask a member of your
diabetes team for a referral. Sometimes stress can be so severe that
you feel overwhelmed. Then, counseling or psychotherapy might
help. Talking with a therapist may help you come to grips with your
problems. You may learn new ways of coping or new ways of
changing your behavior.
 Pregnant Women
You have the good fortune to live when you do. Health care providers no
longer discourage women with diabetes from becoming pregnant. Women
who manage their diabetes well during pregnancy can have a relatively
normal pregnancy and give birth to a healthy baby.
We now know that the key to a healthy pregnancy for a woman with
diabetes is keeping blood glucose (sugar) in the target rangeboth before
she is pregnant and during her pregnancy. If you have type 1 or type 2
diabetes before getting pregnant; maintaining blood glucose levels and A1C
close to normal just before and during the first trimester (the first three
months) is critical to the proper development of the child while in the
mother's womb. If blood glucose levels are kept near normal from the time
of conception, the risk of birth defects in your baby can be greatly reduced
to no higher than that of a woman without diabetes.
Along with managing blood glucose levels before and during pregnancy,
you need a diabetes treatment plan that keeps meals, exercise, and insulin
in balance. This plan will change as you get further into your pregnancy. You
will also need to check your blood glucose often and keep a record of your
results. With your blood glucose in the target range and good medical care,
your chances of a trouble-free pregnancy and a healthy baby are almost as
good as they are for a woman without diabetes.
 Target blood glucose goals before
getting pregnant

Premeal (before eating): 60-119 mg/dl

1 hour after meals: 100-149 mg/dl
Your health care provider may have you
use goals such as these, but check with
your own team about your specific goals.
 Related Conditions

Hemochromatosis
Hemochromatosis is a single-gene disease that
causes iron accumulation in the tissues of the
body.
Diabetes is a primary complication if
hemochromatosis, sometimes referred to as
"bronze diabetes," goes untreated.
It's fairly common, but often goes undiagnosed
and untreated.
It's treated effectively with frequent phlebotomy
(blood letting).
 What is it?
Hereditary hemochromatosis is the most common single-gene
disease in Western populations, affecting 1 out of every 200-300
people. Yet it is almost unheard of by the general public, and many
health professionals are insufficiently aware of it. Because the
disorder can cause diabetes via damage to the pancreas, it is
something that deserves greater recognition in the American
Diabetes Association community.
Hereditary hemochromatosis is the most common of several "iron
overload" diseases, which are characterized by an excess
accumulation of iron in the body. In the case of hemochromatosis, a
single gene mutation causes extra iron to be absorbed from food in
the intestine, and the body lacks an efficient means of excreting the
excess iron it takes in. Over time, this iron accumulates in the
tissues of the body, most notably the pancreas, the liver, and the
heart. The extra iron builds up in the organs and damages them.
Without treatment, the disease can cause these organs to fail,
leading to diabetes, cirrhosis, and heart disease. In many patients,
the buildup of iron eventually becomes so excessive that it visibly
shows up in the skin, turning it a dark gray or bronze color. In fact,
hemochromatosis is sometimes referred to as "bronze diabetes"
because of the appearance of some patients when they are
diagnosed.
 How common is it?
As many as 1 in 200 Americans are believed to carry both copies of the
gene for hemochromatosis, and it is estimated that about half of them will
eventually develop complications. That puts it roughly on a par with type 1
diabetes for prevalence. Like type 2 diabetes, it is severely underdiagnosed.
What are the symptoms?
Symptoms include the following and tend to occur in men between the ages
of 30 and 50 and in women over age 50 with joint pain being the most
common:
Joint pain
Fatigue
Lack of energy
Abdominal pain
Loss of sex drive
Symptoms typically seen with diabetes and heart disease
How is it diagnosed?
Blood tests (a transferrin saturation test or a serum ferritin test) can
determine whether the amount of iron stored in the body is too high. It is
also possible to test directly for the defective gene. Despite its prevalence
and the availability of simple tests for it, hemochromatosis is often
undiagnosed and untreated. The initial symptoms can be diverse and vague
and can mimic the symptoms of many other diseases. Also, doctors may
focus on the conditions caused by hemochromatosis arthritis, liver
disease, heart disease, or diabetes rather than on the underlying iron
overload.
 What causes it?
Hemochromatosis is caused by a defect in a gene called HFE, which helps
regulate the amount of iron absorbed from food. A person who inherits the
defective gene from both parents (someone who is homozygous) may
develop hemochromatosis. Studies indicate that virtually everyone who is
homozygous for the HFE defect develops increased iron levels, with about
half of them developing complications as a result. People who inherit the
defective gene from only one parent (someone who is heterozygous) are
carriers for the disease but usually do not develop it, although they may
have slightly increased iron levels.
The Founder Effect: An Interesting Genetic Story
Hereditary hemochromatosis represents a striking example of the "founder
effect," which describes a genetic disease that arises from a mutation in just
one or a few individuals. In the case of hemochromatosis, it is believed that
a single individual in Europe, 60 to 70 generations ago, was the sole origin
of most of the hemochromatosis seen in the world today. A chance mutation
in the HFE gene in this individual was passed on, and because the
defective gene didn't cause any problems in people through child-bearing
age (and may have conferred some benefit in times of nutritional deficit),
there was no negative selection to stop it from being passed on. Because of
its origin, hemochromatosis today most often affects Caucasians of
Northern European descent, although other ethnic groups can be affected
by other iron overload diseases.
 Men versus Women
Although both men and women can inherit the hemochromatosis gene, men are
much more likely to be diagnosed with the effects of hemochromatosis than women,
and men also tend to develop problems from the excess iron at a younger age. The
most likely explanation for the difference: menstruation and childbirth. Because
women regularly lose a significant amount of blood every month until menopause, as
well as during childbirth, they consequently lose a significant amount of iron
associated with that blood. For women who are homozygous for hemochromatosis,
the blood loss appears to be just enough to keep the hemochromatosis asymptomatic
until well after menopause.
How is it treated?
Once it is diagnosed, it is managed extremely effectively via frequent phlebotomy
(blood letting)
That difference between men and women in the progression of hemochromatosis is a
clue to the simple, straightforward treatment for hemochromatosis: phlebotomy, or
blood-letting. When first diagnosed, people with hemochromatosis are put on an
intensive schedule of phlebotomy to bring their iron levels down. They must give a
pint of blood once or twice a week, often for many months. Measures of blood iron
levels are monitored, and when they are finally in the normal range, the patient is put
on a maintenance schedule of giving a pint of blood at greater intervals, usually every
2 or 3 months. Unlike diabetes, hemochromatosis is virtually cured through its
treatment, with patients remaining completely asymptomatic as long as iron levels are
monitored and maintained in the normal range.
If treatment begins before any organs are damaged, associated conditions such
as liver disease, heart disease, arthritis, and diabetes can be prevented. The
outlook for people who already have these conditions at diagnosis depends on the
degree of organ damage. For example, treating hemochromatosis can stop the
progression of liver disease in its early stages, which means a normal life expectancy.
However, if cirrhosis has developed, the person's risk of developing liver cancer
increases, even if iron stores are reduced to normal levels. People with diabetes
resulting from pancreatic damage usually see an improvement if not a reversal of
their diabetes, depending on how much damage has occurred.
 Where does the blood go?
The American Red Cross, which controls about 45% of the nation's blood
supply, does not currently accept donations from people with known
hemochromatosis. Everyone agrees that the blood is safe and of high
quality. There is no risk of passing on a genetic disease through blood
transfusions. But the Red Cross has a long-standing policy that potential
donors are not allowed to receive direct compensation for their donation
(beyond the usual orange juice and cookie). Because people with
hemochromatosis would otherwise have to pay for their therapeutic
phlebotomies, they would in effect be getting something of value for being
able to donate for free. Thus the Red Cross has ruled that such donations
violate their policy.
FDA regulations do permit hemochromotosis patients to donate blood, but
with some special restrictions on how the blood is marked and how the
blood banks operate. As a consequence, few blood blanks in the US
currently accept blood from people with hemochromatosis, and most of the
blood given as a result of therapeutic phlebotomy is discarded. (People with
hemochromatosis who wish to donate blood should check to see if any
blood banks in their area will accept their donations.) This is not true in
other countries, which have generally removed any restrictions on this
blood. The American Medical Association and many other groups have
advocated for removal of restrictions for the acceptance of blood donations
from people with hemochromatosis.
 Agent Orange
Studies have shown that dioxin, a contaminant in the Agent Orange
herbicide, can cause a variety of illnesses in laboratory animals.
In 2000, the VA added type 2 diabetes to the list of "presumptive diseases
associated with herbicide exposure."
Vietnam veterans can get exams and medical treatment for Agent Orange-
related illnesses.
Vietnam veterans with type 2 diabetes are eligible for disability
compensation from the Department of Veterans Affairs (VA) based on their
presumed exposure to Agent Orange or other herbicides. In 2000, the VA
added type 2 diabetes to the list of "presumptive diseases associated with
herbicide exposure." That action followed a report from the National
Academy of Sciences that found "limited/suggestive" evidence of an
association between the chemicals used in herbicides during the Vietnam
War, such as Agent Orange, and type 2 diabetes.
The evidence of a link between exposure to Agent Orange (or dioxin, the
problematic contaminant in Agent Orange) and diabetes is modest. Most of
the association between Agent Orange and diabetes comes from studies of
people who lived near or worked at manufacturing plants that produced
large quantities of Agent Orange dioxin. In those cases, there appears to be
some relationship between Agent Orange exposure and increased insulin
resistance, the precursor to type 2 diabetes. In general the exposure that
Vietnam veterans had to Agent Orange was much less than in the
populations studied by scientists. Still, the VA has added diabetes to the list
of conditions for which Vietnam veterans are eligible for disability
compensation.
 What is Agent Orange and what is dioxin?
Agent Orange was a herbicide used in Vietnam to kill unwanted plants and to remove
leaves from trees which otherwise provided cover for the enemy. In the 1970s some
veterans became concerned that exposure to Agent Orange might cause delayed health
effects. The concern about Agent Orange focuses not on the active ingredient, an
herbicide with little or no effect on animals, but on a trace contaminant in the herbicide,
dioxin. Studies have shown that dioxin and dioxin-like compounds (DLCs) can cause a
variety of illnesses in laboratory animals. More recent studies have suggested that the
chemical may be related to a number of types of cancer and other disorders.
In 1978, the Veterans Administration set up the Agent Orange Registry health
examination program for Vietnam veterans who were concerned about the possible
long-term medical effects of exposure to Agent Orange. Vietnam veterans who are
interested in participating in this Agent Orange program should contact the nearest VA
medical center for an examination.
Veterans who participate in the Agent Orange examination program are asked a series
of questions about their possible exposure to herbicides or Agent Orange in Vietnam. A
medical history is taken, a physical examination is performed, and there is a series of
basic laboratory tests. If medically required, consultations with other health specialists
are scheduled. However, no special Agent Orange tests are offered since there is no
test to show if any individual veteran's medical problem was caused by Agent Orange or
other herbicides used in Vietnam. There are tests that show body dioxin levels, but such
tests are not done by the VA because there is a serious question about their value to
veterans. The VA simply makes a presumption of Agent Orange exposure for Vietnam
veterans.
In its 1994 report on Agent Orange, the National Academy of Sciences (NAS) concluded
that individual dioxin levels in Vietnam veterans are usually not meaningful because of
background exposures to dioxin, poorly understood variations among individuals in
dioxin metabolism, relatively large measurement errors, and exposure to herbicides that
did not contain dioxin.
 Benefits of the Agent Orange examination

The veteran is informed of the results of the Agent Orange examination during a
personal interview and gets a follow-up letter further describing the findings. Each
veteran is given the opportunity to ask for an explanation and advice. Where
medically necessary, a follow-up examination or additional laboratory tests are
scheduled. The examination and tests sometime reveal previously undetected
medical problems. These discoveries permit veterans to get prompt treatment for
their illnesses. Some veterans feel they are in good health, but are worried that
exposure to Agent Orange and other substances may have caused some hidden
illness. The knowledge that a complete medical examination does not show any
problems can be reassuring or helpful to Registry participants. All examination and
test results are kept in the veteran's permanent medical record. These data are
entered into the VA Agent Orange Registry.
Vietnam veterans can get medical treatment for Agent Orange-related illnesses.
Under Section 102, Public Law 104-262, the Veterans' Health Care Eligibility Reform
Act of 1996, the VA shall furnish hospital care and medical services, and may furnish
nursing home care to veterans exposed to herbicides in Vietnam. There are some
restrictions. The VA cannot provide such care for 1) a disability which VA determines
did not result from exposure to Agent Orange, or 2) a disease which the NAS has
determined that there is "limited/suggestive" evidence of no association between
occurrence of the disease and exposure to a herbicide agent.
The VA pays disability compensation to Vietnam veterans with injuries or illnesses
incurred in or aggravated by their military service. Veterans do not have to prove that
Agent Orange caused their medical problems to be eligible for compensation. Rather,
the VA must determine that the disability is "service-connected." A Veterans Services
Representative, at a VA medical center or regional office, can explain the
compensation program in greater detail and assist veterans who need help in
applying.
 Frozen Shoulder
Frozen shoulder is a condition where progressively worse pain and stiffness
in the joint causes immobility of the shoulder.
Diabetes is a risk factor for frozen shoulder, but doctors are still researching
the relationship.
Physical therapy, though painful, is generally recommended.
A body in motion tends to stay in motion, and a body at rest tends to stay at
rest. Such is the case with your shoulder and a condition called adhesive
capsulitis. Adhesive capsulitis is more commonly known as frozen shoulder,
and with good reason: It can render your shoulder so stiff, it's almost
impossible to button your shirt that is, if you aren't in too much pain to get
dressed in the first place.
Frozen shoulder usually begins innocently enough. Your shoulder is
bothering you, so you don't use it. Sure, there's something to be said for
resting an overused joint after a weekend softball tournament. But if you've
injured your shoulder or are suffering from chronic shoulder pain and you
don't use your shoulder for a long time, your joint will stiffen up.
From there, it becomes a vicious cycle. If your joint begins to stiffen up, it's
more difficult and more painful to use your shoulder. So you use your
shoulder even less. Your shoulder gets more and more stiff, and eventually,
the lining of the joint gets stiff. Once that happens, you won't be able to
move your shoulder much, even if you want to. It simply won't budge past a
certain point because of pain and stiffness.
 In general, frozen shoulder can come on after an injury to your
shoulder or a bout with another musculo-skeletal condition such as
tendonitis or bursitis. It can also develop after a stroke. Quite often
its cause can't be pinpointed. Nonetheless, any condition that
causes you to refrain from moving your arm and using your shoulder
joint can put you at risk for developing frozen shoulder.
Diabetes is also a risk factor for frozen shoulder, although precisely
why that's so is a subject the medical community is still researching.
One theory involves collagen, one of the building blocks of
ligaments and tendons. Collagen is a major part of the ligaments
that hold the bones together in a joint. Glucose (sugar) molecules
attach to collagen. In people with diabetes, the theory goes, this can
contribute to abnormal deposits of collagen in the cartilage and
tendons of the shoulder. The buildup then causes the affected
shoulder to stiffen up.
Overall, frozen shoulder affects about 20 percent of people with
diabetes, compared with 5 percent of people without diabetes.
Other risk factors are gender and age. Women are more likely to
develop frozen shoulder than men, and frozen shoulder occurs most
frequently in people between the ages of 40 and 60. It usually
affects only one shoulder at a time, and for reasons unknown, the
non-dominant shoulder is affected most often.
 A Lengthy Condition
Frozen shoulder has several stages. First, there is the painful stage.
There is a general ache in the shoulder, and your muscles might
spasm. The pain may be worse at night. This stage can last
anywhere from a few weeks to eight months.
The next stage usually isn't as painful, but the shoulder does
become more stiff. This is when the ligaments shorten and do not
stretch, causing you to lose mobility in your shoulder. This
"stiffening" stage can last from two to six months.
Third is the recovery stage. Like the stiffening stage, this stage
generally is not as painful as the first stage. The ligaments start to
stretch and, gradually, your shoulder and arm regain some or most
of their natural movement. However, recovery may come in fits and
starts, with a bout of pain before each step along the way as the
lining of the joint stretches out. The recovery stage can last from one
to nine months.
So, if left to run its course, frozen shoulder can last from eight
months to 17 months or more. Some cases have lasted as long as
two years.
 The Importance Of Early Treatment
Some doctors concentrate on pain relief during the first stage, but others, like Lori B.
Siegel, MD, chief of the division of rheumatology and associate professor of medicine
at Finch University of Health Sciences/Chicago Medical School in North Chicago, Ill.,
opt for a more aggressive approach. Siegel says keeping the shoulder moving, to
work the stiffness out of the ligaments and tendons so adhesions can't form, is the
way to go.
"If we catch it early, it might be possible to work through it with physical therapy, even
if there's some pain," she says. "But once you enter the middle stage, there's already
been some stiffness and that makes it tougher to work through."
She notes that in the middle stage, treatment can go beyond physical therapy and
exercise and include shots of saline or cortisone to help you regain shoulder mobility
and loosen up the stiff joint.
Most experts agree that physical therapy should be the first treatment attempted for
frozen shoulder. But such therapy, during which a therapist stretches and moves your
shoulder, along with daily home exercise, may not appear to make much sense,
especially if your shoulder hurts. After all, pain is an indication that something is
wrong, and it could be a sign of inflammation. Why move your shoulder if there is
pain and inflammation?
Because lack of use and motion is what leads to stiffness.
"Inflammation should be taken into consideration by your physical therapist, but
unless the shoulder is severely inflamed, you would want physical therapy" says
Michael Mueller, PT, PhD, associate professor at the Washington University School
of Medicine in St. Louis, MO. Anti-inflammatory drugs like ibuprofen can help bring
mild to moderate inflammation down to the point where you are able to start therapy.
After that, it's a matter of how much you hurt.
"The gauge is how much pain you are in," he says. "Your physical therapist should
work with you to see what you can tolerate." But if you cannot do physical therapy
because of pain, you should see your doctor for medication or shots.
 How Early Is Early Enough?
How long should you wait before coming to the conclusion that this isn't "weekend
warrior" pain and it's time to go to the doctor?
That depends on what your symptoms are, says Rachel Peterson Kim, MD, staff
rheumatologist at the Scripps Clinic in La Jolla, CA. "If it's a mild nagging pain, you
can try rest, ice, and anti-inflammatory drugs such as ibuprofen for a week or two,"
she says. "But if you suddenly can't move it at all, or there's a lot of pain, see a
doctor."
If you've lost any mobility in your shoulder, it's time to see a doctor as well, says
Mueller. He suggests a simple test.
Lie on the floor or on your bed. Bring your arm up and over like you are doing a
backstroke. You should almost be able to touch the floor or bed with the back of your
hand. Of course, if you can actually touch it, that's great, but as long as you can
come within a few inches, that's fine. If not, you've lost some range of motion in your
shoulder and you should talk to your doctor about it.
When you go to your doctor, provide as much information as you can, and don't be
afraid to ask questions or repeat yourself. The shoulder is vulnerable to many
different conditions and injuries, and your doctor will need as much information as
possible to give you a correct diagnosis. It's not unheard of for a doctor to mistake
frozen shoulder for other conditions, particularly a torn rotator cuff.
"There are lots of different reasons for shoulder pain, and some doctors will think of
torn rotator cuffs because that is another important condition and part of so many
other problems," says Mueller. So don't be afraid to ask your doctor why he or she
has come to a diagnosis any diagnosis.
 If your doctor confirms frozen shoulder, take his or her advice about exercise
seriously and act immediately, says Kim. "Patients should definitely be doing physical
therapy or exercises at home, in addition to their physical therapy, and they should
follow up with their doctors if there is no improvement," Kim says.
She adds that this is especially important for people with diabetes because they are
less likely than others to have a complete recovery, even with therapy. According to
Kim, permanent loss of as much as 50 percent of shoulder mobility can occur among
people with diabetes. (In the general population, any permanent decrease of range of
motion is usually negligible.) That's why it's so important to stack the odds in our
favor.
"We don't know why people with diabetes have a greater risk of incomplete recovery,"
she says. "No one has really looked at it yet. Is it their blood sugars? Are they less
active? I don't think there's a good answer for it yet."
Siegel adds that it's important not to ignore any signs that the condition is getting
worse. "It's easy to 'cheat' with the shoulder," she says. "A lot of people compensate
for it by bending in other ways or relying on other muscles, but that can lead to other
chronic pain syndromes. It's really a quality-of-life issue."
And if there's no improvement? If it's not getting worse, but it's not getting better
either, then it's time to consider more aggressive treatments, including surgery.
Your doctor may give you general anesthesia and then, while you are completely out
and unable to feel pain, manipulate your arm to loosen the joint. Surgery is the last
resort and should be approached with great caution because the condition usually
improves on its own over time.
The bottom line is, if you've had a traumatic injury to one of your shoulders, like a fall
or a blow, or you suddenly experience intense shoulder pain or a loss of mobility,
even for no apparent reason, get to a doctor. Then learn everything you can about all
of the treatment options available.
 Insulin Storage and Syringe
Safety
Store your current bottle of insulin at room
temperature to avoid painful injections, but
keep extra supplies in the refrigerator.
Syringes can be reused safely, but it must
done carefully to avoid contamination.
Dispose of syringes in containers that
prevent the needles from causing harm
and check medical waste requirements for
your area
 Insulin Storage
Although manufacturers recommend storing your insulin in the refrigerator,
injecting cold insulin can sometimes make the injection more painful. To
avoid this, many providers suggest storing the bottle of insulin you are using
at room temperature. Insulin kept at room temperature will last
approximately 1 month. Remember though, if you buy more than one bottle
at a time to save money, store the extra bottles in the refrigerator. Then,
take out the bottle ahead of time so it is ready for your next injection.
Here are some other tips for storing insulin:
Do not store your insulin near extreme heat or extreme cold.
Never store insulin in the freezer, direct sunlight, or in the glove
compartment of a car.
Check the expiration date before using, and don't use any insulin beyond its
expiration date.
Examine the bottle closely to make sure the insulin looks normal before you
draw the insulin into the syringe.
If you use regular, check for particles or discoloration of the insulin. If you
use NPH or lente, check for "frosting" or crystals in the insulin on the inside
of the bottle or for small particles or clumps in the insulin. If you find any of
these in your insulin, do not use it, and return the unopened bottle to the
pharmacy for an exchange and/or refund.
 Syringe Reuse
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 it would be a safe
choice for you. If you are ill, have open wounds on your
hands, or have poor resistance to infection, you should
not risk insulin syringe reuse. Syringe makers will not
guarantee the sterility of syringes that are reused.
Here are some tips to keep in mind when reusing
syringes:
Keep the needle clean by keeping it capped when you're
not using it.
Never let the needle touch anything but clean skin and
the top of the insulin bottle.
Never let anyone use a syringe you've already used, and
don't use anyone else's syringe.
Cleaning it with alcohol removes the coating that helps
the needle slide into the skin easily.
 Syringe Disposal
It's time to dispose of an insulin syringe when the needle is
dull or bent or has come in contact with anything other than
clean skin.
If you can do it safely, clip the needles off the syringes so no
one can use them. 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, and do not 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. The
CDC has more information about safe needle disposal in your
area.
When traveling, bring your used syringes home. Pack them in
a heavy-duty holder, such as a hard plastic pencil box, for
transport.
 Other Injectable Medications

Pramlintide
Pramlintide (brand name Symlin) is a synthetic form of the hormone
amylin, which is produced along with insulin by the beta cells in the
pancreas. Amylin, insulin, and another hormone, glucagon, work in
an interrelated fashion to maintain normal blood glucose levels.
Pramlintide injections taken with meals have been shown to
modestly improve A1C levels without causing increased
hypoglycemia or weight gain and even promote modest weight loss.
The primary side effect is nausea, which tends to improve over time
and as an individual patient determines his or her optimal dose.
Because of differences in chemistry, pramlintide cannot be
combined in the same vial or syringe with insulin and must be
injected separately. Pramlintide has been approved for people with
type 1 diabetes who are not achieving their goal A1C levels and for
people with type 2 diabetes who are using insulin and are not
achieving their A1C goals.
 Exenatide
Exenatide (brand name Byetta) is the first in a new class of drugs for the
treatment of type 2 diabetes called incretin mimetics. Exenatide is a
synthetic version of exendin-4, a naturally-occurring hormone that was first
isolated from the saliva of the lizard known as a Gila monster.
Exenatide works to lower blood glucose levels primarily by increasing
insulin secretion. Because it only has this effect in the presence of elevated
blood glucose levels, it does not tend to increase the risk of hypoglycemia
on its own, although hypoglycemia can occur if taken in conjunction with a
sulfonylurea. The primary side effect is nausea, which tends to improve over
time.
Like pramlintide, exenatide is injected with meals and, as with pramlintide,
patients using exenatide have generally experienced modest weight loss as
well as improved glycemic control. Exenatide has been approved for use by
people with type 2 diabetes who have not achieved their target A1C levels
using metformin, a sulfonylurea, or a combination of metformin and a
sulfonylurea.
 Aspirin

Daily low-dose aspirin can significantly

lower risk of heart attack.
It's not safe for everyone and can cause
irritation of the stomach lining.
Check with your doctor to determine
whether it's safe and how much to take.