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Type 1 Diabetes Managing overview 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 or refine 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 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 just 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?
Complications of Diabetes (Type 1) 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 keep their blood glucose level as close to normal as possible. The recent 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. The hemoglobin A1C test is an average of your blood glucose levels, so a weakness is that 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:
Neuropathy 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 first thing you can do is to 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 People with neuropathy often find the discomfort very difficult to tolerate. Some patients find relief by keeping blood glucose as closely controlled as possible, experiencing regular physical activity, and keeping their weight under control. Doctors may suggest aspirin, acetaminophen (Tylenol), or drugs containing ibuprofen. Using these nonnarcotic 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. Sexual dysfunction Some people with diabetes 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 particularly true 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. Heart disease 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, angina (heart pain), stroke, or painful legs. Women with diabetes are just as likely as men to have a heart attack or stroke. There's no certain way to avoid heart disease and circulation problems. But there are things to do to cut your risk:
Foot care Over time, 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. 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:
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:
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Starting an exercise program Before beginning an exercise program, get your doctor's clearance. A medical OK is absolutely imperative if you are 35 or older 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 or the type and duration of your exercise--will determine whether adjustments should be made in your insulin dose or your meal plan. Discuss your exercise program with your exercise physiologist to determine the type of adjustments you need to make. Some tips on exercise:
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 insulin available isn't sufficient, your blood glucose levels can actually increase right after exercise. To avoid problems:
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:
What should you do if you find your blood lucose is less than 100 mg/dl immediately after exercise?
Unplanned exercise Sometimes exercise or physical exertion occurs spontaneously, so that preparation isn't possible. You may need extra carbohydrate (or an insulin adjustment, or both) at these times to make sure you have the sufficient energy. A number of factors will determine what you need:
Guidelines for days when you are 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:
Call your healthcare provider if:
Pregnancy 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 willing to be 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 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 and 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. Problems that may arise Sometimes your blood glucose may become high even when you are feeling well and taking good care of yourself. When that happens and ketones are present, you may become very sick with an illness called "DKA," or "diabetic ketoacidosis." 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) 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 of time, 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 exercise or physical activity; poorly calibrated treatment; or illness, infection, injury, or surgery. What should you do if you have hyperglycemia?
Hypoglycemia (low blood glucose) Low blood glucose, or hypoglycemia, is one of the most common problems associated with insulin treatment. 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, it 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 for you. 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. Another cause is drinking alcoholic beverages. Most hypoglycemia, if quickly and appropriately treated, it 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 the stairs, for example. In rare cases, seizures can result in brain damage. To avoid problems with hypoglycemia:
Diabetic ketoacidosis (DKA) When the body cannot use sugar for energy, it uses stored fat. Acids known as ketones may build up in the blood and spill into the urine when fat is burned for energy; when blood sugar is also high, a life-threatening medical emergency called diabetic ketoacidosis, or DKA, can result. You may develop DKA quickly if you are sick, so it's important to check your blood every four hours when you have an illness or infection. You may also get DKA slowly, however. Check for ketones whenever your blood sugar is 250 or above. More information is available at Testing for ketones. If you are getting DKA, you may:
Hyperosmolar hyperglycemic state (HHS) Some people develop very high blood glucose and become very ill without also developing ketones. This type of illness, which is more common in type 2 diabetes but can occur in people with type 1, is called hyperosmolar hyperglycemic state. 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:
Travel Travel is fine--as long as you don't take a vacation from watching your health. When you are preparing for a trip:
On the road:
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