Managing Type 2 Diabetes
Updated on 11/13/2008
Everyone who has diabetes should be seen at least once every six months by an endocrinologist or a diabetologist and periodically by other members of a treatment team, including a diabetes educator and a dietitian, who will help develop a meal plan. Ideally, you should also consult an exercise physiologist about a physical activity plan and perhaps a social worker, psychologist, or other mental health professional for help with the stresses of living with a chronic disease. It's extremely important to see an ophthalmologist annually, so any eye problems can be treated before they become serious.
This section contains information about:
- Diabetes burnout
- Diabetes complications
- Physical activity and exercise
- Guidelines for days when you're sick
- Pregnancy
- Problems that may arise
- Travel
Diabetes burnout is a common patient reaction to the overwhelming, demanding, and frustrating burden of self-care: You know that reasonable care is important for your health, but you don't have the motivation to continue to be vigilant when it seems that blood glucose fluctuations are inevitable anyway.
How to get back on track?
- Remember that success depends upon having realistic, practical, and achievable goals. Define one action you could take to start to improve your situation—preferably a fairly easy action that makes success likely.
- If a specific obstacle keeps getting in your way, try to define it concretely. When, where, and why does the problem occur? Consider changing your behavior or your environment, either to make handling the issue easier or to avoid it.
- Consider: Are there other people who could help you? Moral support at home, at work, and in social situations can make a big difference. Decide what kind of support you need, and ask.
- Understand that strong negative feelings about diabetes are normal. Talking with family, friends, health professionals, and other people with diabetes about your feelings can help you to better tolerate them and react in constructive rather than self-destructive ways.
- Keep your eye on the rewards of good care, not the consequences of failure. Fears about complications may motivate you for a short time, but in the long run most people either dismiss their fears or become paralyzed by them. Rather, focus on how great you've felt when you've managed the disease well.
Developing complications from diabetes is not inevitable. The nationwide Diabetes Control and Complications Trial, completed in the mid-1990s, showed conclusively that people with type 1 diabetes could reduce their risk of complications by as much as 50 percent if they kept their blood glucose level as close to normal as possible. The United Kingdom Prospective Diabetes Study found similar results for people with type 2 diabetes.
What's the target for blood glucose control in someone with diabetes? Ideally, an A1C test, which indicates how well your blood glucose levels have been controlled over the past two months or so, should produce a reading of below 7. If your results are hovering nearer to 8 or even higher, it's time for a change in your treatment plan. Check with your healthcare provider to see what your target A1C is.
The A1C test is an average of your blood glucose levels, so frequent fluctuations between too high and too low can result in a misleading reading. Therefore, it's also important that you routinely measure your blood glucose levels at home. In general, plasma blood glucose results that are over 180 mg/dl two hours after eating or above 140 mg/dl before eating are considered high. If your blood glucose remains high for three days or more, an adjustment in your treatment plan may be required to prevent complications.
This section has more information on:
Chronically high blood-glucose levels can cause nerve damage, or neuropathy. This often results in pain in the extremities—the legs and feet, for example. Over time, the pain can subside and be replaced by numbness, as nerve damage becomes nerve-cell death.
When the damaged nerves influence how well your stomach and intestines clear food through your system, a condition called gastroparesis develops; symptoms can include abdominal discomfort, nausea, vomiting, and bloating. Nerve damage in other areas of the body might mean incomplete emptying of the bladder, incontinence, or sexual dysfunction. Damage to nerves that regulate blood flow and blood pressure can cause significant drops in blood pressure—and lightheadedness or fainting—when you sit or stand.
If you begin to show signs of neuropathy, the most important thing you can do is try to prevent further damage by making sure your blood glucose is under control. Sometimes, improving blood glucose control can lessen symptoms of neuropathy over time, even as it's helping to prevent further damage. Nerves do not grow back, however. Once pain is replaced with numbness—a sign the nerves are dead—the numbness will not go away.
This section contains information on managing the pain of neuropathy
Managing the pain of neuropathy
People with neuropathy often find the discomfort very difficult to tolerate. Some patients find relief by keeping blood glucose as closely controlled as possible, engaging in regular physical activity, and keeping their weight under control. Doctors may suggest aspirin, acetaminophen (Tylenol), or drugs containing ibuprofen. Using these non-narcotic pain relievers consistently throughout the day—rather than waiting until nighttime when symptoms can become more severe—seems to help if pain is the major symptom. Narcotic painkillers are not very effective and can be addictive.
One of the most commonly used and effective medications is gabapentin (Neurontin), which has relatively few side effects. A topical cream (capsaicin) may help relieve the pain of neuropathy by blocking nerve signals. An analgesic ointment such as Ben Gay may also help.
Clinicians have found that certain antidepressants seem to be effective at helping patients tune out their pain. Antidepressants can take several weeks to work, so patients should wait a month before deciding whether a drug is helpful or not.
Some patients have experienced success with other forms of pain management—biofeedback, meditation, hypnosis, and acupuncture, for example.
Some people with diabetes may experience sexual problems, because out-of-control blood glucose levels can lead to blood vessel and nerve damage that hampers performance and enjoyment. While this is more frequently seen in older men who have had diabetes for years, many medical experts believe that women with diabetes experience sexual difficulties as a result of complications of the disease.
Other factors can cause or exacerbate sexual dysfunction, including self-consciousness and fear of failure. If you are experiencing impotence or sexual dysfunction, it's important to see your doctor for an accurate diagnosis of your condition. People who experience sexual difficulties can lead more enjoyable, fulfilling sex lives by learning about causes, treatment options, and how to discuss their feelings and needs with a doctor and partner.
People with diabetes are at greater risk of developing cardiovascular disease, or problems with the heart and blood vessels, for two reasons. First, high blood glucose levels thicken the walls of the blood vessels and make them less elastic. Second, people with diabetes tend to have higher fat levels in their blood. These fats, or lipids, clog and narrow the blood vessels. Any blood vessel in your body can become narrow and clogged, and this can lead to a heart attack, stroke, angina (chest pain), or painful legs. Women with diabetes have the same degree of risk as men for having a heart attack or stroke.
Here are ways you can reduce your risk of heart disease and circulation problems:
- If you smoke, stop.
- Lose weight if you are overweight.
- Keep your blood pressure in the proper range.
- Be physically active.
- Keep your blood fats and cholesterol levels in a healthy range.
- Keep your blood glucose under control.
Diabetes can damage the nerves and narrow the blood vessels of the feet, causing a lack of feeling and poor circulation—and breaks in the skin that can lead to infection. You might not experience pain, for example, if you step on a pebble or develop a blister. But your legs may hurt when you walk, and any cuts may heal slowly. Your feet may get red when you're walking or white when propped up on a chair.
You can lower your chances of developing foot problems by treating your feet gently:
- Wash your feet in warm, soapy water every day. To avoid drying out your skin and getting cracks, don't soak your feet or use hot water, and choose mild soap. Towel off carefully, including between the toes.
- Apply lotion but not between the toes. Put talcum powder on your feet if they sweat.
- Check every day for dry skin, cracks, or cuts, and inform your doctor if you find cuts that are not healing. If you cannot easily inspect your feet, use a mirror or ask for help.
- File your toenails with an emery board, rounding the edges. Do not use scissors. Get assistance if you do not see clearly.
- See a doctor to determine the best treatment for corns and calluses. Never cut them.
- See a foot doctor regularly if you have poor circulation, nerve damage, or thick toenails.
Physical activity and exercise
Physical activity is a key part of your management plan. Regular physical activity offers everyone a payoff, and it provides the added benefit for a person with diabetes of aiding blood glucose control. All physical activity counts—you don't have to go to a gym. Dancing, walking, taking the stairs—such activities can provide the desired benefits. Being active works on diabetes in the following ways:
- Physical activity can lower the level of blood glucose and improve the body's ability to use glucose. With regular exercise, the amount of insulin needed decreases.
- Physical activity can also help reverse the resistance to insulin that occurs as a result of being overweight. There is an increase in the number of insulin receptors, improving the body's ability to use insulin.
- Physical activity decreases the risk of heart problems, a major health concern of people with diabetes.
- Exercise can reduce the body's level of low-density lipoprotein (LDL), or bad cholesterol, which forms plaque that obstructs blood vessels. It also raises levels of good cholesterol, high-density lipoprotein (HDL), which is protective against heart disease. Regular physical activity has been shown to improve blood pressure, too.
Someone with type 2 diabetes may be able to control his or her blood glucose with regular physical activity combined with a meal plan. This section has information on:
- Starting an exercise program
- High blood glucose after physical activity
- Low blood glucose after physical activity
- Unplanned exercise
Before beginning an exercise program, get your doctor's clearance. A medical OK is absolutely imperative if you are 35 or older and/or have had diabetes for 10 years or more. Your blood glucose must be adequately controlled at the outset to produce the desired results.
An exercise program should be individually tailored and designed to complement your lifestyle. Many factors—such as the time of day you exercise and the type and duration of your exercise—will determine whether adjustments should be made in your medications or your meal plan. Discuss your exercise program with your exercise physiologist to determine the type of adjustments you need to make. Start your program gradually, and set realistic goals.
Some tips on exercise:
- If you are over 35, you may need a stress test before beginning to exercise regularly.
- Test your blood glucose before and after exercise.
- Do not exercise if your blood glucose is over 250 mg/dl and there are ketones in your urine. If no ketones are present, do not exercise if blood glucose is 400 mg/dl or more.
- If your blood glucose is more than 300, use extreme caution and check your blood glucose 10 to 15 minutes after starting exercise to be sure it is dropping.
- Plan exercise to prevent low blood glucose reactions. That means you should exercise 1 to 1½ hours after eating, check blood glucose before and after exercise, always carry a carbohydrate snack with you (glucose tablets, juice, etc.), and drink plenty of fluids.
High blood glucose after physical activity
When you exercise, your muscles need added glucose as a source of energy. In response to the demand from your exercising muscles, your liver pours an extra supply into your bloodstream. Remember, however, that the glucose can't be used by your muscles without the help of insulin to "unlock the door" to muscle cells; if the insulin available isn't sufficient, your blood glucose levels can actually increase right after exercise.
To avoid problems:
- Check your blood glucose before exercising. Do not exercise if the reading is over 250 mg/dl and you have ketones.
- If your blood glucose is more than 300, use extreme caution and check your blood glucose 10 to 15 minutes after starting exercise to be sure it is dropping.
- If the reading is 400 or more and no ketones are present, do not exercise.
Low blood glucose after physical activity
A common cause of low blood glucose is too much physical activity without compensating for it. In fact, moderate to intense exercise may cause your blood glucose to drop for the next 24 hours. This post-exercise hypoglycemia is often referred to as the "lag effect" of exercise.
When you exercise, the body uses two sources of fuel to generate energy: glucose and free fatty acids—or fat. The glucose, stored in the body in a form called glycogen, comes from the blood, the liver, and the muscles. During the first 15 minutes of exercise, most of the glycogen is drawn from the bloodstream or the muscles. After 15 minutes of exercise, the body is fueled more by glycogen stored in the liver, and, after 30 minutes of exercise, by the free fatty acids.
The body will replace its depleted glycogen stores, but this process may take four to six hours, or even 12 to 24 hours when the physical activity has been intense. During this period, a person with diabetes is at higher risk for hypoglycemia—though there are precautions that can prevent it:
- Check your blood glucose before exercising to make sure your blood glucose is sufficient. If necessary, eat an appropriate snack.
- Avoid late-evening exercise. Exercise should be completed two hours before bedtime.
- Avoid alcohol before and immediately after exercise.
- Avoid hot tubs, saunas, and steam rooms directly after exercise; otherwise, your heart rate will remain elevated longer, and your blood glucose may continue to drop.
- Check with your doctor about the length, intensity, and duration of your planned exercise program.
- Check your blood glucose immediately after exercise to determine if you need to snack or perhaps decrease insulin at the next meal. This can help to prevent low blood glucose from occurring hours after exercise.
What should you do if you find your blood glucose is less than 100 mg/dl immediately after exercise?
- Follow post-exercise snack guidelines. If you are not scheduled for a snack or a meal for 30 to 60 minutes after exercise, 15 grams of carbohydrate should be sufficient to prevent low blood glucose. If no meal or snack is scheduled for more than one hour, take 15 grams of carbohydrate and 7 to 8 grams of protein.
- Increase carbohydrate intake before exercise.
- Decrease the dose of active insulin for the next exercise session.
- Consider decreasing the insulin dosage following exercise.
- If your blood glucose at bedtime is less than 120 mg/dl, double your bedtime snack, or—if possible—decrease your bedtime insulin dose.
Sometimes exercise or physical exertion occurs spontaneously, so preparation isn't possible. You may need extra carbohydrate (or an adjustment in your medication, or both) at these times to make sure you have sufficient energy. A number of factors will determine what you need:
- Snacks may be necessary for exercise beginning two hours or more after your last meal.
- You may need a snack if you exercise for an hour or more.
- Long-duration or all-day activities may require both a snack adjustment and an insulin or medication adjustment.
- If you are attempting to lose weight, adjust your insulin or medication rather than eating extra food.
Guidelines for days when you're sick
When people with diabetes are sick with a cold or the flu, or are vomiting, or recovering from surgery, their blood glucose will often be higher than usual—even if they are eating less food. This is because insulin is often less effective during an illness or after an injury. Talk to your healthcare provider about how to manage your disease when you're not feeling well. In general, the following "sick day" steps should be taken to keep blood glucose under control:
- Take your usual diabetes medication even if you can't eat normally, unless your healthcare provider instructs you differently. In some cases, additional medication is required.
- Check your blood glucose every three to four hours, including during the night. Have someone do it for you if you are too sick to do it yourself.
- Check for ketones if your plasma blood glucose is 250 mg/dl or higher, unless otherwise instructed by your healthcare team.
- Write down the results of your blood glucose and ketone checks, and have them ready if you need to call your healthcare provider.
- Drink plenty of fluids—about 6 to 8 ounces every hour you are awake. If you are able to eat your meals, drink fluids that are sugar free and caffeine free. If you are unable to eat, alternate sugar-free fluids one hour with fluids containing sugar the next. Include liquids with salt, too, such as bouillon or clear soup.
- Rest. Stay warm.
- Call your healthcare provider if: you are vomiting or have diarrhea for more than two hours; you have a fever; your blood glucose values remain above 250 mg/dl for at least two checks or do not decrease with extra insulin (whether or not you have ketones); you have stomach pains that won't go away.
It's eminently possible for a woman with diabetes to have an uncomplicated pregnancy and a healthy baby these days—as long as she is vigilant about controlling her blood glucose levels. Glucose levels that are too high put both mother's and baby's well-being at risk.
You'll want to use birth control to prevent an unplanned pregnancy; your goal is to conceive after your blood glucose levels have been well controlled for several months. During the earliest weeks of fetal growth, the risk of birth defects is heightened if blood glucose levels are not in control.
During pregnancy, your dietary needs and your insulin needs are bound to change as your body does. It'll be even more vital than usual to get good medical care and nutritional guidance.
Sometimes your blood glucose may become high even when you are feeling well and taking good care of yourself. Your blood glucose may also become too low, in which case you may have an insulin reaction.
This section contains information on:
- Hyperglycemia (high blood glucose)
- Hypoglycemia (low blood glucose)
- Hyperosmolar hyperglycemic state (HHS)
People who do not have diabetes typically have blood glucose levels that run under 126 mg/dl, measured two hours after eating. Your physician will define for you what your target blood glucose should be—identifying a target as close to normal as possible that you can safely achieve given your overall medical health. Be sure to ask your healthcare provider what he or she thinks is a safe target for you for blood glucose before and after meals.
In general, high blood glucose, also called hyperglycemia, is reached when the level is 160 mg/dl or when it is above your individual target. If your blood glucose is high for long periods, you run an increased risk of complications over the long term: eye disease, kidney disease, heart attacks, and strokes, to name a few. High blood glucose can pose health problems in the short term as well. Your treatment plan may need adjustment if your blood glucose stays over 180 mg/dl for three days in a row.
Symptoms of high blood glucose include increased thirst, increased urination, dry mouth or skin, tiredness or fatigue, blurred vision, more frequent infections, slow-healing cuts and sores, and unexplained weight loss.
High blood glucose can be caused by too much food; too little physical activity; poorly calibrated treatment; or illness, infection, injury, or surgery.
What should you do if you have hyperglycemia?
- Be sure to drink plenty of water or noncaloric, caffeine-free fluids.
- Follow your diabetes treatment plan.
- If you take diabetes pills, take the prescribed amount at the correct time, and if you take insulin, talk to your healthcare provider about adjusting it.
- If your blood glucose is 250 mg/dl or greater and you are on insulin, check your urine for ketones. If they are present, call your healthcare team.
- Ask yourself what may have caused the high blood glucose, and take action to correct it. Ask your healthcare team if you are not sure what to do.
- Call your healthcare provider if your blood glucose is over 180 mg/dl for three days in a row and you're not sure what to do.
Low blood glucose, or hypoglycemia, is one of the most common problems associated with insulin treatment, but it can also happen to people with diabetes who are taking pills. In general, hypoglycemia is defined as a blood glucose level below 70 mg/dl (if your meter tests whole blood) or 80 mg/dl or lower (if, like most new meters, yours tests plasma), or below 90 mg/dl if you have symptoms. Be sure to ask your healthcare team what would be considered a low blood glucose requiring treatment.
Hypoglycemia is usually unpleasant, with the most common symptoms being shakiness and sweatiness and having one's heart pound. The most common reasons for hypoglycemia are too much insulin, too little food, or too much activity. A less common but occasional cause is drinking alcoholic beverages. Most hypoglycemia, if quickly and appropriately treated, is more of an inconvenience than a cause for alarm.
However, severe hypoglycemia can cause mental confusion, antagonistic behaviors, unconsciousness, and seizures. The biggest danger is not the condition itself but what may happen as a result: a motor vehicle accident caused by passing out at the wheel or swerving into oncoming traffic, or a tumble down stairs, for example. In rare cases, seizures can result in brain damage.
To avoid problems with hypoglycemia:
- Recognize the symptoms, which are specific to each individual and may change over time. If you have symptoms, test immediately if possible to see if your blood glucose is low.
- Understand the interaction between food intake, treatment, and physical activity so you can anticipate when hypoglycemia is a risk.
- Always carry carbohydrate. Don't overdo it: The most common error is to overtreat low blood glucose.
- Check blood glucose levels again in 15 minutes, and repeat treatment if symptoms persist or blood glucose levels have not risen to your target level or above.
- Check blood glucose levels before driving if you think you may be low—and stop the car immediately if you're already underway. Treat immediately with the appropriate amount of fast-acting carbohydrate. Check blood glucose levels again in 15 minutes, and do not start driving again until you're no longer hypoglycemic.
Hyperosmolar hyperglycemic state
Some people develop very high blood glucose and become quite ill without also developing ketones. This illness is called hyperosmolar hyperglycemic state and is not very common. It may be caused by several factors (including an infection, some medications, or poor self-care) and is marked by severe dehydration.
Call the doctor if your blood glucose is 250 mg/dl or higher for more than two readings and you:
- Are urinating more frequently than usual
- Are excessively thirsty
- Feel ill
- Have a fever
- Feel sick to your stomach or are throwing up
- Experience confusion or vision impairment
Vacations are a good thing for everyone—as long as you don't take a vacation from watching your health. When you are preparing for a trip:
- Ask your doctor for a green light.
- Get a letter from your doctor saying you have diabetes. You may need it if you are ever challenged for having syringes and medications with you.
- Get prescriptions for syringes and medicines. You will need them if you lose your supply.
- If you will be traveling across time zones, check with your medical team to find out what that will mean to your insulin intake and eating schedules.
- Ask your doctor for names of other physicians along your route.
- Get any necessary shots a month before you travel.
- When you pack, carry medical necessities (plus extras) and snacks in a small travel bag—and then, when you travel, keep it with you at all times.
- Take along all the syringes that will be needed during your trip. Pack alcohol to wipe off the tops of insulin bottles. Take a glucagon kit and your monitor and strips to check your blood for glucose. Bring foot-care supplies.
- Store insulin so that it is neither too cold (below 35 degrees) nor too hot (above 90 degrees).
On the road:
- Carry a card that says you have diabetes. It should include your name, address, and phone number; your doctor's name and phone number; and the kind and dosages of all medications you take. Wear a bracelet or necklace with the same information on it.
- Do not skip meals or snacks. Keep food with you to treat an insulin reaction. Pull off the road if you have a reaction while driving.
- Check your blood glucose more often. Match the amount of food you eat and your medication dose with your activity. You will need more food for walking, swimming, or skiing than for sitting in movie theaters. Follow your meal plan and exercise program when traveling.
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