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Diabetes Care Corner

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1. Are you trying to lose weight?
Nearly 9 out of 10 people newly diagnosed with type 2 diabetes are overweight. If you are someone who fights the weight battle, losing some weight could help you better manage your diabetes and help reduce the risk for other serious conditions.

Recommendation: We realize that losing weight and keeping it off is a real challenge for most people. That is why it is important to begin a weight loss program with the help of your entire health care team, including a dietitian, if possible. Dieticians can help you find ways to decrease calories while continuing to consume the foods you enjoy, which aids in keeping off that lost weight. Before beginning a weight loss program you should consider the following:

  • Setting a realistic weight loss goal make sure to set a start time during a calm period in your life. For example, don't begin at the holidays.
  • Keeping a record of what you eat and when use this to make small changes in your eating habits.
  • Avoiding that fad diet changing your eating habits is the only way to lose the weight and keep it off.
  • Making healthy food choices instead of potato chips for a snack, choose fruit or nuts.
  • Becoming more active make sure to check with your physician before beginning any exercise program

Discussion: There are many benefits to losing weight. As you get ready to lose weight, make a list of how losing a few pounds will benefit you personally. Stick your list on the refrigerator or bathroom mirror as a reminder. Here are just a few benefits listed on the American Diabetes Association website:

  • Lower blood glucose if your blood glucose is higher than normal.
  • Lower blood pressure if your blood pressure is higher than normal.
  • Improve your blood fats if they are not in a healthy range.
  • Lighten the stress on your hips, knees, ankles, and feet.
  • Move around easier and breathe easier.
  • Have more energy.
  • Play more with your children or grandchildren.

2. What is your usual blood pressure reading?
Approximately 2 out of 3 adults with diabetes have high blood pressure, also known as hypertension. Keeping this pressure under control can help to prevent complications of diabetes.

Recommendation: Your physician should monitor your blood pressure at every visit; however, regular monitoring with a home blood pressure kit may be beneficial. The American Diabetes Association and the National Institutes of Health recommend a target blood pressure of <130/80mmHg for people with diabetes. If blood pressure is consistently >130/80mmHg, consult with a physician.

Discussion: High blood pressure increases the risk for heart attack, stroke, eye problems, and kidney disease. Both lifestyle modifications and medications can help to lower high blood pressure. Some lifestyle modifications include:

  • Making smart food choices (ask your physician to recommend a dietician or nutritionist)
  • Losing weight, if overweight, or preventing weight gain
  • Exercising (make sure to consult a physician before beginning any exercise routine) Quit smoking
  • Watching alcohol intake (if you drink, limit to 1 serving a day for women and 2 servings for men)

If these lifestyle changes don't decrease your blood pressure to the target level, your physician may choose to add a blood pressure lowering medication to your daily regimen.

3. Do you keep track of your blood glucose levels at home?
People with diabetes should check their blood glucose levels at a variety of times during the day to give themselves a good overall picture of their control.

Recommendation: Make sure to write down your results. You can use them to see how food, activity/exercise, and/or stress affect your blood glucose levels. Make sure to look for patterns -- similar results over and over. If your readings are not within your target range several times a week, please talk to your physician.

Discussion: Keeping your blood glucose within range the majority of time can help decrease the risk of developing complications of diabetes. Your physician should have set target range with you. It is important to remember that blood glucose levels fall in and out of range all day, every day, for everybody. Keep track of your levels and evaluate what effects them and how.

4. Do you know your A1C reading?
Knowing your A1C (also known as glycated hemoglobin or HbA1c) reading is very important. An A1C test gives you a picture of your average blood glucose control for the past 2 to 3 months. The results give you and your physician a good idea of how well your current diabetes treatment plan is working.

Recommendation: You should see physician for A1C test every 3-6 months. If your A1C is not well-controlled (>7%) or if you have had recent changes in your diabetes therapy, then you should test every 3 months. If you are well-controlled (<7%), then you should test every 6 months.

Medication Consideration: Review any medications with your pharmacist and/or physician. If there has been a recent change in therapy, a new A1C test may be needed.

5. What are your cholesterol levels?
Knowing your cholesterol levels is very important for people with diabetes. People with diabetes have an increased risk for heart disease.

Recommendation: Make sure your physician is checking your cholesterol levels annually. If your LDL is greater than 100mg/dL, you should consider starting lifestyle modifications if you haven't yet done so.

Medication Consideration: Review your current medication therapy with your pharmacist or physician. Make sure to include how and when you take all of your medications and any products you take that are over the counter.

6. Do you exercise regularly?
Regular exercise not only burns more calories but actually allows your body to use the insulin it makes for effectively, both of which help to lower blood glucose (sugar) levels. It also reduces the risk of other health conditions such as heart attack, stroke, some cancers, and bone loss. Exercise can also help to build stronger bones and muscles, gain more energy, and is a great way to relieve stress.

Recommendation: Building up to 30 minutes of daily physical activity. This can be as easy as taking a walk on your lunch break or choosing the stairs over the elevator a few times a day. Even everyday tasks such as walking, gardening, yard work, and house cleaning count towards that 30 minute goal. Make sure to consult with your physician for a complete medical evaluation prior to beginning any exercise program.

Precautions: As always, be sure to consult with your physician before beginning any exercise program. Additionally, because exercise can fluctuate blood sugar levels, it is advised to check your blood glucose levels both before and after exercise to avoid levels that are too low. It is also advised to carry glucose tablets along during exercise.

7. Do you have a sick day plan?
When a person gets sick it causes their body to be under stress. In response to the increased stress, your body releases hormones that help it fight your illness. However, the hormones that your body releases can raise your blood sugar levels and interfere with the effectiveness of your insulin, resulting in higher than normal blood sugar levels.

The importance of having a sick day plan is to avoid unnecessary complications. Patients should continue to take all their diabetes medications, check their glucose levels frequently (every 4-6 hours), check for ketones in their urine (type 1 every 4 hours or when blood glucose levels are >250mg/dL; type 2 if blood glucose levels are >300mg/dL), and to drink additional fluids every 1-2 hours (if eating, drink non-caloric fluids; if not eating, drink calorie-containing fluids).

The best time for you to think through a sick day plan is when you are feeling well. Patients should develop a sick day plan with their physician or diabetes educator and stock their sick day kit before they need to use it. It is good to determine, with the help of your physician and/or diabetes educator, when you need to contact a healthcare professional, how often you should measure your blood sugar and urine ketones, what medication to take, and what you should eat and when.

Potential Recommendation: In addition to your written sick day plan information, you may want to stock your sick day kit with appropriate single ingredient products, sugar-free/low sugar products, fluid replacements, and blood glucose/ketone check charts so that you can be prepared. If you feel you need an over the counter medication to treat your symptoms, be sure to check with your doctor or pharmacist for appropriate choices that will not further affect your blood glucose levels and help relieve your symptom

8. Do you take an aspirin daily?

The American Heart Association estimates that approximately two-thirds to three-fourths of deaths among those with diabetes are caused by heart disease or stroke. Studies have shown that daily aspirin therapy is effective in preventing cardiovascular (CV) events, including heart disease and stroke. Individuals with diabetes are considered at high risk for the occurrence of CV events. A common cause of heart disease and stroke in those with diabetes is the hardening of the arteries. This hardening is caused by build up in the blood vessels, which may break away and cause blood clots and block the vessels leading to major organs. Aspirin has the ability to inhibit blood clot formation. Aspirin works by stopping prostaglandins in the body. Prostaglandins are responsible for triggering blood cells, called platelets, to clump together and form blood clots.

Recommendation: Although studies have shown differences among men and women relative to the primary preventative effects of low dose aspirin therapy (i.e. decreased risk of first heart attack in men and decreased risk of ischemic stroke in women) a low dose enteric coated aspirin may be used as primary prevention of heart disease and stroke in diabetes patients. It is important to discuss with your doctor whether daily aspirin therapy is a good choice for you. Your doctor will be able to discuss the risks and benefits associated with aspirin use.

The American Heart Association has issued the following recommendations for aspirin therapy based on an individual's level of risk. You may access a CV risk assessment test at www.americanheart.org to determine what category you fall into.

  • High Risk (10-year risk of 20% or greater): aspirin therapy should be used unless not appropriate
  • Moderate Risk (10-year risk of 10%-19%): aspirin therapy should be considered as long as the benefits are greater than the risks
  • Lower Risk (10-year risk less than 10%): routine use of aspirin is not recommended

There are other ways to prevent heart disease and stroke, which may be used with aspirin therapy. They include:

  • Keeping blood sugar levels as normal as possible and within the range your physician has recommended
  • Controlling blood pressure in the target range for patients with diabetes of less than or equal to 130/80
  • Keeping cholesterol under control
  • If overweight, work to lose weight appropriately
  • Incorporate moderate exercise into routine regularly after talking with your physician
  • If you smoke, quit smoking
  • Maintain a diet low in fat and salt

Medication Considerations: It is important to discuss with your doctor whether or not daily aspirin therapy is appropriate for you, based on benefits outweighing potential risks. The main risks of aspirin therapy are an increase of stomach ulcers and increased abdominal and intestinal bleeding. Those that should not take aspirin include:

  • Pregnant women
  • Those about to undergo surgery
  • Those that drink moderate to heavy amounts of alcohol
  • Those with ulcers or any bleeding problems
  • Those taking regular doses of other pain medications, such as Motrin
  • Those with allergies to aspirin

9. Did you get your flu shot yet?
Getting the flu can be dangerous for anyone. However, it can be especially dangerous for someone with diabetes or other chronic health conditions. Diabetes can weaken the immune system and make a person more susceptible to severe cases of the flu. People with diabetes are three times more likely to die from influenza than a person without diabetes. If a person with diabetes still develops the flu after having the vaccine, it will still help decrease lower respiratory tract involvement and secondary complications. It should also help to reduce the risk of hospitalization and death. Some symptoms of the flu include fever, headache, fatigue, sore throat, stuffy nose and stomach symptoms.

Recommendation: Every person with diabetes that is 6 months of age or older should get a flu shot every year. It is not guaranteed to be 100% effective, but it does make it harder to catch the flu within 6 months of the injection. It is also recommended that the people you spend the most time with get a flu shot as well.

The best time to get a flu shot is the beginning of September or October. It will take about two weeks to take effect. The following people should NOT receive a flu shot:

  • People who have a severe allergy (anaphylactic hypersensitivity) to eggs. (Vaccination may still be considered in high-risk people, but only after an appropriate allergy evaluation and desensitization.)
  • People who have had a severe reaction to an influenza vaccination in the past. (Vaccination may still be considered in high-risk people, but only after an appropriate allergy evaluation and desensitization.)
  • Children less than 6 months of age.
  • People with a moderate-to-severe acute febrile illness. (These people may be vaccinated once their symptoms have lessened. Minor illnesses are not a contraindication to vaccination.)

In addition to the flu shot, a patient with diabetes should also receive a pneumococcal vaccine at least once. This vaccine is recommended to anyone with diabetes over 2 years of age. This vaccine shot is about 60% effective in preventing the most serious bacterial infections. Patients older than 64 should be revaccinated if they received the pneumococcal vaccine before age 65 and more than 5 years ago.

Medication Consideration: If you still end up getting the flu you should contact your physician. Also, if you are in need of any over-the-counter medications to help with symptoms, you should check with your pharmacist to see what is compatible with your medication history. This is also a great time to check your 'Sick Day' kit and make sure all of your medications are in date. In addition, check with your physician on instructions on how to handle your sugar levels in the event of a sickness and what OTC medications are appropriate for you.

10. Do you have the resources to plan healthy meals?
While eating a balanced diet is important for everyone, it is even more critical for someone with diabetes. A properly balanced meal plan can help to control blood sugar levels, blood pressure, cholesterol, and weight. For those with diabetes, a healthy diet must be combined with proper insulin and oral medications as well as exercise in order to achieve desired results. The Diabetes Food Pyramid can be a useful tool for developing healthy meal plans. Unlike the USDA Food Guide Pyramid, which separates foods by type, the Diabetes Food Pyramid separates foods into six groups based on carbohydrate and protein content. While the pyramid serves as a guideline for a proper diet, the exact number of servings differs from person to person, depending on individual goals, lifestyle, caloric and nutrition needs, and food preferences.

Recommendation: Determining the types and amounts of foods that are best for you can be a very difficult task. One option may be to consult with your doctor or a registered dietician who can help you to determine the most appropriate meal plan. Some tips to help you begin to formulate a healthy meal plan include:

  • Eat a wide range of foods to get a balanced intake of carbohydrates, proteins, fats, vitamins, and minerals
  • Eat smaller portions and learn the best serving size for you
  • Do not skip meals, especially on "sick days"
  • Eat the same amount of food each day
  • Limit the consumption of alcohol
  • Limit intake of foods and drinks that are high in sugar (soft drinks, juices, cookies, candy)
  • Eat more foods that are rich in fiber (whole grain breads, fresh fruits and vegetables)

In addition to following a healthy meal plan, regular exercise is a vital for blood glucose control, maintaining a healthy weight, and improving overall health. Exercise can also help to keep your bones strong, improve insulin sensitivity, and reduce cardiovascular risk factors. Your physician and dietician can assist you with the development of an exercise plan that is appropriate for you.

Discussion: The types of foods consumed are very important in maintaining proper blood sugar levels. For example, carbohydrates break down into sugars in your blood to be used as energy and also stored. Diabetes creates a problem in the transport of blood sugars to their proper storage area. Choosing the best type and amount of carbohydrates for your diet will help to maintain your goal blood sugar levels. Salts (sodium) can contribute to elevated blood pressure, and patients with diabetes are at an increased risk for elevated blood pressure, or hypertension. Soft drinks and many canned foods contain a large amount of sodium. Salt substitutes, low-salt diets, and avoiding canned foods and soft drinks can help to reduce this risk. Fiber helps to control cholesterol and blood sugar levels as well as relieving constipation. Protein is extremely important for the body to grow and maintain energy. Lean meats and low-fat dairy products can be a great choice of protein to help maintain proper cholesterol and blood sugar levels. Fats can lead to an increase in cholesterol, but they are also an important energy source. While fats can not be entirely eliminated from a healthy diet, avoiding saturated fats may help to decrease the risk of increased cholesterol.

11. Do you check your feet daily?
People with diabetes can develop many different foot problems. Even simple foot troubles can worsen and lead to serious complications. Foot problems happen most often when there is nerve damage (neuropathy) which can cause a loss of feeling in your feet. Diabetes can also cause the blood vessels of the foot and leg to narrow and harden resulting in poor circulation (blood flow). Poor blood flow can decrease your foots ability to fight infection and heal. For this reason, proper foot care is very important to help prevent injuries.

Recommendation: Check your feet every day and schedule a yearly comprehensive foot exam by a podiatrist. Make sure to look for cuts, blisters, swelling or any other changes to your feet on a daily basis. Call your physician or podiatrist immediately if any changes are noted. Wear properly fitting shoes. Ask your physician about prescription shoes that may be covered by Medicare and other insurance. Make sure to NEVER go barefoot and avoid putting lotion between your toes!

Medication Consideration: Talk to your doctor of pharmacist concerning your current medications regimen and make sure none of the products you are taking could decrease the blood flow to your legs and feet.

12. Has your blood glucose (sugar) level ever dropped too low?
It is important to understand what low blood sugar, or hypoglycemia, is. Recognizing the signs and symptoms associated with hypoglycemia and how to treat you or someone else, is vital .Hypoglycemia usually occurs when blood glucose levels fall below 60-70 mg/dL. Some signs and symptoms that may present when blood glucose levels are low include:-shakiness-headache-sweating-pale skin color-fatigue-clumsy or jerky movements-rapid heart beat-difficulty paying attention or confusion-dizziness-seizure- hunger.

Recommendation: It is important to treat hypoglycemia to prevent it from getting worse, and to prevent yourself from passing out. The first step in treatment is to eat 15grams of a quick-acting sugar, (i.e. glucose tablets/gel, fruit juice, or hard candy). Blood glucose levels should then be checked in 15-20 minutes. Upon next check, if levels are still less than 70 mg/dL, eat another 15 grams of quick-acting sugar. These steps should be repeated until normal blood glucose levels are reached. Normal range is 80-120mg/dl. If the next meal is more than 2 hours away, a protein (i.e. peanut butter sandwich) should be added to the above treatment. Adding a protein will help prevent repeat episodes from occurring. Proteins and fats slow the breakdown of carbohydrates,therefore decreasing the likelihood of hypoglycemia. If an individual is experiencing hypoglycemic episodes throughout the night, a bedtime snack consisting of a starch, protein, and fat can help.

Medication Considerations: If you are taking an alpha glucosidase inhibitor, such as Precose (acarbose) or Glyset (miglitol), you MUST use glucose (glucose tablets/gel), fructose (100% fruit juice), or lactose (milk) products to treat hypoglycemia. Alphaglucosidase inhibitors work by inhibiting the breakdown of sucrose, a sugar, therefore candy and soda are NOT effective treatment options.

13. When was your last comprehensive eye exam?
Diabetes is the leading cause of blindness in adults aged 20-74 years.

Recommendation: A dilated eye exam should be completed annually by an optometrist or ophthalmologist.

Discussion: Uncontrolled blood glucose levels may lead to cataracts, glaucoma, and most importantly, changes in the blood vessels of the eye. Blood vessels may leak and become fragile, or abnormal new vessels may grow on the surface of the retina. This condition is called retinopathy and can cause changes to the vision and eventually lead to vision loss. Diabetic retinopathy is the leading cause of blindness in the United States. Those with untreated diabetes are said to be 25 times more at risk for blindness than the general population and the longer a person has diabetes, the greater the risk of developing diabetic retinopathy. That is why it is important to maintain tight blood glucose control to prevent diabetic retinopathy. The good news is that good blood glucose control, proper eye care and treatment when needed may greatly reduce the risk of severe vision problems.

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