Quick Reference Guide To Diabetes For Health Care Providers: Michigan Diabetes Outreach Network

Michigan Diabetes Outreach Network QUICK REFERENCE GUIDE TO DIABETES FOR HEALTH CARE PROVIDERS Table of Contents
Chapter 1: Chapter 2: Chapter 3: Chapter 4: Chapter 5: Chapter 6: Chapter 7: Chapter 8: Chapter 9: Chapter 10: Chapter 11: Chapter 12: Chapter 13: Chapter 14: Chapter 15: Chapter 16: Chapter 17: Chapter 18: Chapter 19: Screening and Diagnosis of Diabetes Diabetes Standards of Care: Prevention of Complications Nutrition and Diabetes Physical Activity and Diabetes Oral Pharmacological Treatment of Type 2 Diabetes
Insulin and Other Drugs Used in the Treatment of Type 2 Diabetes
Insulin and Type 1 Diabetes Insulin Regimens and Other Drugs Used in the Treatment of Type 1 Diabetes Education Concerns of Insulin Insulin Pumps: What, When, Who and How Self-Monitoring of Blood Glucose (SMBG) Gestational Diabetes Mellitus (GDM) Diabetes and Hypertension Lipid Management in Diabetes Sick Day Management Special Issues: Behavior Change Special Issues: Concerns of Children Acute Complications of Diabetes Chronic Complications of Diabetes
This resource may be printed and copies may be made as needed. Revised June 2006 Paula Ackerman, MS, RD, CDE; Robin Williams, MA, RD, CDE; Julie Walters, RD, CDE; Carolyn Jennings, RD, CDE; Cathy Francke, RD, CDE; Veronica Evans, RN; Kathy Knapp, RN, CDE; Emily Lambright, RN
QUICK REFERENCE GUIDE TO DIABETES FOR HEALTH CARE PROVIDERS

A special project of the Michigan Diabetes Outreach Network
Chapter 1
Screening and Diagnosis of Diabetes

Criteria for screening adults for type 2 diabetes or pre-diabetes:
All adults over 45 years of age, especially those with a BMI > 25 o If blood glucose normal and no risk factors present, retest in 3 years Testing should be considered in younger adults or be carried out more frequently in individuals who are overweight (BMI > 25) and who have additional risk factors such as: o Physically inactive most of the time o Parent or sibling with diabetes o Member of a high risk ethnic group (African American, Latino, Asian American, Native American, or Pacific Islanders) o Hypertensive (> 140/90 mmHg) o HDL-cholesterol < 35 mg/dl o Fasting triglycerides > 250 mg/dl o History of vascular disease o Woman with history of gestational diabetes or delivery of baby weighing more than 9 lbs. o Diagnosis of polycystic ovary syndrome o Previously diagnosed with impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) o Presence of other clinical conditions associated with insulin resistance (i.e. acanthosis nigricans).
Screening should be carried out within a health care setting versus a community setting where there is absence of follow-up care.
Criteria for screening type 2 diabetes in children:

Overweight (classified by any of the following) o BMI >85th percentile for age and sex o Weight for height > 85th percentile o Weight > 120% ideal for height Plus any two of the following risk factors: o Parent or sibling with type 2 diabetes o Member of a high risk ethnic group (African American, Latino, Asian American, Native American, or Pacific Islander) o Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, or polycystic ovary syndrome)
Screening (fasting plasma glucose preferred) should be done at age 10 or at the onset of puberty and repeated every 2 years.
Diabetes and Pre-diabetes Diagnosis:

There are three methods of diagnosing diabetes and each must be confirmed on a subsequent day by any of the following methods:
1.
Symptoms of diabetes (polyuria, polydipsia and unexplained weight loss) plus a casual plasma glucose > 200 mg/dl. (Casual: any time of the day without regard to time of last meal). This is the most common method for diagnosing type 1 diabetes
2. Fasting plasma glucose (Fasting: no caloric intake for at least 8 hours). Preferred method for type 2 diabetes and pre-diabetes 3. 2 hour postprandial plasma glucose during an oral glucose tolerance test using 75 gram glucose load. Diagnostic Criteria Fasting Plasma Glucose < 100 mg/dl 100-125 mg/dl > 126 mg/dl 2 hours post prandial < 140 mg/dl 140 199 mg/dl > 200 mg/dl
Normal Pre-diabetes Diabetes
Gestational Diabetes Mellitus (GDM) Screening and Diagnosis:

At first prenatal visit, assess risk. If woman is at high risk for GDM (i.e. marked obesity, a personal history of GDM, glucosuria or a strong family history of diabetes), she should be tested as soon as possible. High-risk women found not to have GDM on initial screen and average risk women should be tested between 24 and 28 weeks of gestation. Either of the following approaches should be used: o One-step approach: A 100 gm oral glucose tolerance test (OGTT). Two or more abnormal plasma glucose values during this test is diagnostic of GDM (see below) Diagnostic Criteria for the 100 g OGTT Time Venous plasma glucose (hours) value (mg/di) 0 > 95 1 > 180 2 > 155 3 > 140 o Two-step approach: Measure plasma or serum glucose concentration 1 hour after a 50-gram oral glucose challenge test (GCT). If the glucose threshold value is > 140 mg/dl, perform a 100 OGTT (see diagnostic criteria above). When the two-step approach is used, a glucose threshold value greater than 140 identifies approximately 80 % of women with GDM, and the result is further increased to 90% by using a threshold of 130 mg/dl.
References: American Diabetes Association (2006). Clinical Practice Recommendations. Diabetes Care, Vol 29 (1).

A special project of the Michigan Diabetes Outreach Network Chapter 2
Diabetes Standards of Care: Prevention of Complications

To Do At Every Visit:
Check blood pressure (adult target <130/80). Measure weight. Review self-monitored blood glucose (SMBG) values, and assess clients ability to use data for pattern management. Review/adjust medications. Look for symptoms associated with diabetes-related complications. Assess physical activity, lifestyle changes, and self-management skills. Consider referral for medical nutrition therapy, diabetes self-management education, and/or psychosocial assessment if needed. Counsel on smoking cessation, if indicated. Recommend regular use of low dose aspirin therapy for the prevention of CVD, unless contraindicated. Visually inspect feet. (The practice of foot exams at every office visit has been shown to reduce the rate of amputations by 50%).
Twice a year:

1
A1C (quarterly if client is not meeting goals). Refer for dental exam.
Annually:
Lipid profile (every 2 years if normal).1 Serum creatinine and calculated GFR in adults2; urinalysis for protein, ketones, sediment, and if negative for protein microalbumin.3 Refer for dilated eye exam by ophthalmologist or specially trained optometrist4 (if normal, an eye exam may be advised every 2-3 years). Comprehensive foot exam, including monofilament testing Influenza vaccination.
2 3 4 2 3 4
For children with type 1 who are over age 12: at diagnosis, once blood glucose is under control. If normal, then every 5 years until age 18 (then annually). Children with type 2: at diagnosis when blood glucose is under control. If normal, repeat every 2 years. Check creatinine in children if proteinuria is present For type1: only after they have had diabetes for at least 5 years. For type 1: within 3-5 years of onset of diabetes, then annually
Lifetime:
Pneumococcal vaccination (usually only once, repeat if over 65 or immunocompromised and last vaccination was more than 5 years ago).
Diabetes Self-Management Education for Persons with Diabetes

Client and family education, following the National Standards for Diabetes Self-Management Education. Individualized nutrition plan and instructions, ideally with a registered dietitian. Self-monitoring instructions and guidelines. Medication review (including prescription, non-prescription and herbal). Recommendations for lifestyle changes (meal planning, physical activity, smoking cessation). Establishment of short and long term goals. Podiatry consultation, or specialized services, if needed. Dental hygiene. Referral for dilated eye exam. Women of childbearing age-discussion of need for optimal blood glucose control prior to conception and family planning. Agreement on continuing support, follow-up, and return appointments. Instructions on when to contact the health care team.
References:
American Diabetes Association (2006). Clinical Practice Recommendations. Diabetes Care, Vol 29 (1). The National Diabetes Education Program Publication No. NDEP-12.

Chapter 3
Nutrition and Diabetes

Meal plans for persons with diabetes can vary dramatically based on lipid levels, glucose control, weight loss goals, insulin use, activity habits and other health concerns. The majority of persons with diabetes are overweight, and it has been discovered that even a small amount of weight loss (10-20 pounds or 5-9 kg) can greatly assist with glycemic control, even if the person does not attain a desirable body weight. For most individuals, therapeutic lifestyle change (TLC) is the best strategy for weight loss. TLC involves a reduction in calorie intake combined with an increase in physical activity.
In General, Persons with Diabetes...

Do not need any special diet foods (Some of the reduced calorie items can be useful). Benefit from eating on a regular basis (every 4-5 hours). Benefit from eating consistent amounts of carbohydrates (from fruit, milk, bread/starch, and sweets) at meals. Benefit from eating high fiber foods (dried beans, fruits, vegetables and whole grains) everyday. Can eat foods that are good for the whole family. Benefit from decreasing portion sizes, if weight is a concern. Benefit from limiting alcohol and if drinking, only drinking with meals. Benefit from eating a wide variety of foods. Need to limit the amount of saturated fat and hydrogenated or trans fat consumed - found in animal products such as cheese, hamburger, bacon, butter, as well as processed snack foods, shortening and other fats which are solid at room temperature.
Regular meetings with a registered dietitian are recommended to help persons with diabetes develop a meal plan that works for them.
Sugar and Diabetes

Most persons with diabetes can also include some sugar in their meal plan. Sugar containing foods must be substituted for some of the other carbohydrate (bread and starches, fruits, vegetables or milk) at a meal. Also, if the product is high in fat, less fat should be added to the rest of the meal.
Fat Intake and Diabetes

Because individuals with diabetes have an increased risk of heart disease, it is recommended they follow the guidelines from the National Cholesterol Education Program for fat intake. These guidelines recommend a total fat intake of 25-35% of calories, with < 7% from saturated fat. Fat intake from trans fat should be minimal. When substituted for saturated fats, monounsaturated fats can decrease LDL cholesterol and triglyceride levels without decreasing HDL levels. Monounsaturated fats are found in most nuts, olive oil, canola oil, peanut butter and avocados.
Sugar-free Products
Not all sugar-free products are reduced calorie items. If it contains aspartame, saccharin, acesulfame K, or sucralose, the calorie and carbohydrate content may be lower than the regular product, and it may be useful for the person with diabetes. If the item is sweetened with fruit juice, honey, fructose, sugar alcohol (e.g. sorbitol), molasses or any other sugar replacement product, it may not be a calorie or carbohydrate-reduced product! There is no real benefit to using these products in place of sugar-sweetened products.
Additional Help for the Overweight Client

Determine if your client is truly ready to lose weight. Are they intending to make changes within the next six months to lose weight? If no, client may need to explore in more detail the benefits of weight loss. Set reasonable goals. A 10-15% weight loss is generally achievable. Do they have a problem with binge eating or bulimia? An eating disorder clinic or specially trained counselor may be needed. A good understanding of nutrition is necessary--a registered dietitian can help. Mild caloric restrictions are easier to adapt to (250-500 calorie deficit.) Surgical intervention or medication may be options for some obese persons. Regular physical activity is key in helping maintain weight loss.
Many nutrition handouts are available through the Diabetes Outreach Networks (go to www.diabetesinmichigan.org).
References:
American Diabetes Association (2006). Clinical Practice Recommendations. Diabetes Care, Vol 29 (1).

Chapter 4
Physical Activity and Diabetes

Benefits of Regular Physical Activity for Persons with Diabetes
Reduces the risk of Coronary Artery Disease o Decreases plasma cholesterol, triglycerides and LDL-cholesterol o Increases HDL-cholesterol, especially when coupled with weight loss Assists with blood pressure control Improves insulin sensitivity Reduces hyperinsulinemia Reduces body fat and may assist with weight loss Increases muscle mass Improves quality of life/self-esteem Can reduce stress
For those with type 2 diabetes, regular activity may also:

Reduce A1C levels Decrease or eliminate the need for insulin or oral agents Improve insulin sensitivity Help achieve and maintain desirable body weight
For those with type 1 diabetes:

Regular physical activity has not been shown to consistently improve blood glucose control (unless coupled with food and insulin adjustments). Exercise-induced hypoglycemia is common due to accelerated absorption of insulin and increased insulin sensitivity. One of the most common times for hypoglycemia is 6-12 hours after the activity.
Risks of Physical Activity in Persons with Diabetes

1. Hypoglycemia (for those treated with insulin and insulin secretagogues, such as sulfonylureas, meglitinide or nateglinide or combination drugs containing these)
Exercise induced hypoglycemia Monitor blood glucose levels before and after activity. If on insulin: Assure insulin is injected into subcutaneous fat layer Be aware that the risk of hypoglycemia is greatest when insulin is peaking. Try to avoid activity when insulin is peaking, if practical. Lower insulin dose that is peaking during the activity. May start with a 30-50% reduction. Carbohydrate replacement may be needed if activity is unplanned or during activities of long duration. Post-exercise, late-onset hypoglycemia (occurs 4 or more hours after activity and is more common in those with type 1 diabetes) Monitor blood glucose levels frequently during the post-activity period Pre-activity snacks (15-30 minutes prior to the activity) can reduce hypoglycemia when activity is less than 45 minutes in duration. May need carbohydrate replacement during the post-activity period. Activity prior to bedtime may cause nocturnal hypoglycemia. If on insulin, decrease insulin that is peaking during the post-activity period. Frequency Each hour Each hour
Carbohydrate Replacement for Physical Activity Intensity Duration Carbohydrate Needed Mild-moderate < 30 minutes None Moderate 30 60 minutes 15 grams High > 1 hour 30 50 grams
2. Hyperglycemia (after very strenuous, high-intensity activities) Check ketones when blood glucose is greater than 300 mg/dl (type 1) or 400 mg/dl (type 2) (Joslin). o If moderate to large ketones are present, activity may worsen blood glucose levels. Delay activity until ketones are absent. o If no ketones are present, activity may help lower blood glucose. Begin activity and check glucose after 15 minutes. If blood glucose is higher, stop the activity. For those with type 1 diabetes, diabetic ketoacidosis (DKA) may result if activity begins when blood glucose is elevated and/or ketones are present. Medical treatment is necessary.
3. Dehydration Adequate fluid is needed before, during and after being active. (Fluid should be calorie free and caffeine-free, water is ideal.) 4. Exacerbation of cardiovascular disease, such as: Presence of silent heart disease (arrhythmia, cardiac dysfunction) Excessive increases in blood pressure with activity Angina Myocardial infarction Sudden death 5. Worsening of chronic complications with inappropriate activities. Retinopathy: Avoid strenuous, high intensity activities, heavy weight lifting, scuba diving, activities that require the head to be lower than the waist, jarring activities (jogging or racquetball) and competitive sports. Walking, swimming, stationary cycling and best. Peripheral Vascular Disease (PVD): Non-weight bearing activities are best. Walking is helpful for those with intermittent claudication. Severe PVD is an absolute contraindication for a walking program. Peripheral Neuropathy: Avoid weight-bearing activities and jogging. Be cautious of over stretching. Well fitting shoes are crucial. Daily range-ofmotion activities, cycling and swimming are best. Autonomic Neuropathy: Avoid strenuous, high intensity activities and being active in temperature extremes. Recumbent cycling and water aerobics are best. Nephropathy: Low-intensity aerobic activities are best (walking, swimming, cycling). Exercise tolerance is generally diminished. Hypertension: Avoid heavy lifting, straining and excessive arm movements (especially over the head, which can cause dramatic elevations in blood pressure for some).
Physical Activity Recommendations

Type 2 diabetes: 30 60 minutes daily up to 5 times a week. Type 1 diabetes: all levels of activity can be performed by those without complications and are in good glycemic control. For the older adult: 30-40 minutes 5-6 times a week. For weight loss: at least 60 minutes most days of the week.
Activity Sessions
Warm-up: Each activity session should begin with a couple of minutes of light activity, followed by stretching. Activity: Aerobic activity (e.g. walking, swimming or biking). Depending on fitness level, the activity session can last from 5-60 minutes. Most need to start out with a short activity period and add 1-2 minutes every 1-2 weeks. The person should be able to talk during the activity and feel that they are working 'somewhat hard'. Activity sessions may be split into 2 or more sessions per day. For example, a 30 minute daily activity could be broken down into three 10 minute sessions. Cool-down: Slow down the pace for a couple of minutes. End with more stretching.
Safety Tips
1. To prevent hypoglycemia: o Carry a rapidly absorbed carbohydrate source o Monitor blood glucose regularly Wear or carry diabetes identification To prevent injury: o Use proper equipment and shoes o Include a warm-up and cool-down period o Avoid activity in extreme temperatures (hot, humid or freezing) o Stop activity if pain, light-headedness or shortness of breath occurs. To avoid dehydration: o Drink plenty of fluids
2. 3.
4.
A graded stress test may be necessary to evaluate the safety of some activities for people with diabetes. A graded activity test is recommended if one or more of the following are true: Older than 35 Older than 25 years and o has had type 2 diabetes for more than 10 years o has had type 1 diabetes for more than 15 years Other heart disease risk factors present (smoking, high cholesterol, high blood pressure, etc) Presence of microvascular disease (proliferative retinopathy or nephropathy, including microalbuminuria) Peripheral vascular disease Autonomic neuropathy
References: American Diabetes Association (2006). Clinical Practice
Recommendations. Diabetes Care, Vol 29 (1).

Chapter 5
Oral Pharmacological Treatment of Type 2 Diabetes

Pharmacological therapy is recommended after 4-12 weeks if an individualized meal plan, activity, and weight loss trial (if needed) have failed to control blood glucose (BG). If the BG remains above 126 mg/dl fasting and over 200 mg/dl 1-2 hours postprandial, pharmacological treatment should be initiated. Those with extremely high blood glucose and symptoms such as polyuria, and polydipsia, may need insulin to be started immediately. Insulin may be needed for a short period of time or indefinitely. A review and alteration of the other medications one is taking may help to control blood glucose; hyperglycemia may result from nicotinic acid, thiazide diuretics (large doses), beta blockers, Indocin, Dilantin, corticosteroids and fertility agents. There are currently 6 classifications of oral therapy for type 2 diabetes Sulfonylureas Benzoic Acid Derivatives D-Phenylalanine Derivatives Biguanides Thiazolidinediones Alpha Glucosidase Inhibitors Medication Failures After 5 years, approximately 50% of patients will require medication adjustments. Combination therapies can be tried before discontinuing the failed drug (i.e. add metformin if person has failed with sulfonylurea to control BG). If combination therapy fails to control BG, insulin or other injectible medication is the next line of treatment - see Chapter 6 Insulin and Other Drugs in the Treatment of Type 2 Diabetes.
Sulfonylureas
Primary Function: Stimulate the pancreas to make more insulin. Over time, the bodys ability to make insulin may lessen. If this happens, these drugs lose their ability to control blood glucose. Agent 1st Generation Tolbutamide (Orinase) Tolazamide (Tolinase) Chlorpropamide (Diabenese) 2nd Generation Glyburide (DiaBeta, Micronase) Glyburide (Glynase) Glipizide (Glucotrol) Glipizide (Glucotrol XL) Glimepiride (Amaryl) Typical Dosage 0.25-2.0 g/day (divided) 100-1000 mg/day (divided) 100-500 mg bid 1.25 2.5 mg bid 0.75 12.0 mg/day 2.5 20.0 mg bid 2.5 10 mg bid 1-8 mg/day Max dosage 3 g/day 1000 mg/day 750 mg/day 29 mg/day 20 mg/day 40 mg/day 20 mg/day 8 mg/day
Dosing Start at lowest possible dose and increase every 1-2 weeks until glucose control or maximum dose Is reached. Renal insufficiency may require dose reduction. There is no benefit to using two sulfonylureas (i.e. Diabeta and Glucotrol) together. Fasting plasma glucose (FPG) 126-200 mg/dl may respond to monotherapy along with dietary management. FPG greater than 200 mg/dl may need 2 agents or insulin. If sulfonylurea alone fails to control blood glucose, combination therapy or insulin may be used to achieve blood glucose control. Side Effects Skin rashes Hypoglycemia GI (5%) Weight gain Hepatic changes (rare) Hyperinsulinemia Disulfiram like reaction with alcohol (1st generation only) Contraindications Allergy to sulfa drugs Type 1 diabetes Serious illness/severe infection Pregnancy and lactation Surgery or trauma Diabetic Ketoacidosis (DKA) Severe renal or hepatic disease Elderly, debilitated or malnourished persons Candidates for Initial Use: Type 2 diabetes, no dyslipidemia, not overweight, and FPG > 20 mg/dl above target
Benzoic Acid Derivative Repaglinide (Prandin)

Primary Function: Enhances insulin secretion. Is a short-acting agent. The amount of repaglinide-induced insulin release depends on the blood glucose level. Insulin release diminishes as the glucose level declines. Precautions Has the potential to cause hypoglycemia, but to a lesser extent than sulfonylureas. May be taken with decreased kidney function. Longer half-life may be found with antifungals, erythromycin and clarithormycin. Accelerated repaglinide metabolism and shortened drug effect may be found with use of rifampin, phenobarbital, carbamazepine, and troglitazone. Dosing Is available in 0.5 mg, 1 mg and 2 mg dosage units. Maximum dose is 16 mg per day. Initial dose for clients not previously treated with BG lowering agents: 0.5 mg/meal Initial dose for clients previously treated with BG lowering agents or A1C > 8%: 1-2mg/meal. Take with meals. Number of daily doses is determined by the number of meals eaten. If a meal is skipped, the dose is skipped; if a meal is added, a dose is added for that meal. Side Effects Hypoglycemia (16-31%) GI (4%) Upper respiratory infections Contraindications Type 1 diabetes Pregnancy and lactation Diabetic Ketoacidosis
Back pain Headache
Impaired hepatic function Back pain Headache
Candidates for Initial Use: Type 2 diabetes, no dyslipidemia, with or without renal failure, not overweight, and FPG > 20 mg/dl above target
D-Phenylalanine Derivative Nateglinide (Starlix)

Primary Function: Stimulates insulin secretion when needed (postprandial), then allows insulin concentrations to return to baseline. Precautions Is very rapid-acting. Not recommended for combination with a sulfonylurea or Prandin. Dosing Is available in 60 mg and 120 mg tablets. Typical dose: 120 mg taken just before meals. (60 mg tid can be used for those near their A1C goal) Take with meals. Number of daily doses is determined by the number of meals eaten. If a meal is skipped, the dose is skipped; if a meal is added, a dose is added for that meal. Side Effects Hypoglycemia (2.4%) Dizziness (3.6%) Weight gain of < 1 kg Contraindications Type 1 diabetes Pregnancy and lactation Diabetic Ketoacidosis Candidates for Initial Use: Type 2 diabetes with the ability to produce insulin, significant postprandial hyperglycemia not controlled by nutrition therapy and exercise.
_________________________________________________________ Alpha Glucosidase Inhibitors Acarbose (Precose) and Miglitol (Glyset)

Primary Function: Lowers postprandial BG by delaying carbohydrate digestion and slows absorption.
Benefits Does not cause hypoglycemia. Can decrease postprandial blood glucose by about 50 mg/dl and A1c by approximately 0.5-1%. Precautions Generally will not be effective in the treatment of significant fasting hyperglycemia. If hypoglycemic reactions occur, oral glucose (not sucrose) must be used for treatment. Should not be used if the client is using any rapid-acting insulin {lispro (Humalog), aspart (Novolog) or glulisine (Apidra)}. Their mechanisms of action are similar. Should not be used with metformin--severe GI side effects may occur. Check serum transaminase level every 3 months during the first year and then periodically. If elevated, discontinue acarbose. (Liver abnormalities do not seem to be a concern with miglitol.) Dosing and Administration Both are available in 25 mg, 50 mg and 100 mg tablets. Given with the first few bites of major meals. Precose: starting dose 25 mg qd (to decrease side effects), add second dose after 2 weeks and third dose after an additional 2 weeks. Increase to 50 mg tid for 4-8 weeks . Maximum dose for those under 60 kg : 50 mg tid Maximum dose for those 60 kg and over: 100 mg tid Glyset: starting dose of 25 mg tid for 4-8 weeks, then 50 mg tid for 3 months. Increase to 100 mg tid if tolerated and needed. Maximum dose: 100 mg tid May be used alone or in combination therapy Side Effects Most common: GI (abdominal pain, diarrhea, flatulence) Increased serum AST or ALT (Acarbose doses > 200 mg tid) Contraindications Safety not tested for pregnancy or lactation Chronic intestinal problems or diseases present (inflammatory bowel disease, colonic ulceration, obstructive bowel disease and gastroparesis). severe liver and renal disease (creatinine > 2.0). Candidates for Initial Use: Type 2 diabetes, dyslipidemia, obesity, and significant postprandial hyperglycemia
Biguanides Metformin (Glucophage, Glucophage XR)

Primary Function: Decreases glucose output from the liver. Does not stimulate insulin release. Benefits Controls BG without causing hypoglycemia or weight gain in most people. A 2-5 kg weight loss is typical. Studies show a decrease in triglycerides (16%), LDL-cholesterol (8%) and total cholesterol (5%); along with an increase in HDL-cholesterol (2%). Precautions Educate client to immediately report symptoms associated with lactic acidosis (severe weakness, cold, labored breathing, stomach pain, light headed or irregular heart rate). Evaluate kidney and liver (LFT) before initiating metformin. Test creatinine and LFTs every 6-12 months while on metformin therapy.
Dosing Metformin (Glucophage) is available in 500 mg and 850 mg dosage units. Glucophage XR is available in a 500 mg dosage unit. Start at 500 mg per day or 500 mg bid (XR: 500 mg with evening meal) Increase by 500 mg per day every 2 weeks (1 week for XR) up to a maximum effective dose of 2000 mg. (Usual dose 1500-2000 mg per day split into two or three doses - 850 mg tablet in the AM and another in the PM.) Fasting plasma glucose 126-200 mg/dl may respond to monotherapy along with dietary management. Fasting plasma glucose 200-275 mg/dl may respond to a combination therapy or insulin. Side Effects Common: GI (abdominal bloating, nausea, cramping, diarrhea, feeling of fullness) Minor effects: agitation, headache, metallic taste Rare: lactic acidosis, reduction of B12 levels
Contraindications Type 1 diabetes. Pregnancy and lactation. Acute or chronic of lactic acidosis. Hepatic dysfunction Renal dysfunction with serum creatinine >1.5 mg/dl for men and >1.4 mg/dl for women. Over age 80 History of alcoholism or binge drinking Metformin should be temporarily discontinued in any situation that predisposes the individual to acute renal dysfunction including: o Cardiac collapse o Acute myocardial infarctions o Acute exacerbated congestive heart disease. o Use of iodinated contrast media (withhold 48 hours before and after test)
Candidates for Initial Use: Type 2 diabetes, dyslipidemia, obesity or genetic factors favoring insulin resistance and FPG > 20 mg/dl above target
_________________________________________________________ Thiazolidinediones Pioglitizone (Actos) and Roisglitizone (Avandia)

Primary Function: Decreases insulin resistance and increases glucose uptake in muscle and adipose tissue. Benefits Useful in those with renal dysfunction or other conditions in which metformin is contraindicated. Generally well tolerated. Precautions Liver toxicity was been reported with the use of Rezulin. It was withdrawn from the U.S. market on 3/21/00. Liver function tests should occur with Actos and Avandia. Check serum transaminase levels (ALT) prior to starting therapy, every 2 months during the first year, and then periodically.
Do not use if ALT exceeds 2.5 X upper limit of normal or if active liver disease is present. If ALT exceeds 3 X upper limit of normal during treatment, recheck as soon as possible. Discontinue drug if ALT remains > 3 X upper limit of normal. Check liver function immediately if signs of hepatic dysfunction occur (nausea, vomiting, abdominal pain, fatigue, anorexia)
Dosing Actos Approved for monotherapy or in combination with sulfonylurea, metformin or insulin Available in 15 mg, 30 mg and 45 mg tablets. Initial starting dose in monotherapy or combination therapy is 15 mg or 30 mg once daily, taken without regard to meal. Maximum dose is 45 mg once per day If used with insulin, insulin may need to be decreased by 10-25% if patient reports hypoglycemia. Sulfonylurea dose may need to be lowered if hypoglycemia occurs. Some studies showed a 5-26% decrease in triglycerides and a 6-13% increase in HDL-cholesterol. Dosing - Avandia Approved for monotherapy or for use with sulfonylurea, metformin or insulin Avandia is available in 2 mg, 4 mg and 8 mg tablets. Usual starting dose is 2 mg/day - single dose or divided into 2 doses/day. Max dose 8 mg/day. 4 mg bid is more effective than 8 mg once a day. Studies show small increases in HDL-cholesterol and LDL-cholesterol. Side Effects Increased hepatic enzymes Weight gain Plasma volume expansion Edema May make oral contraceptive less effective Contraindications Pregnancy or lactation Children Hepatic dysfunction NYHA Class III or IV Heart Failure Pre menopausal anovulatory women with insulin resistance. Candidates for Initial Use: Type 2 diabetes, obesity or genetic factors favoring insulin resistance and FPG > 20 mg/dl above target
Combination Therapy
Candidates for Combination Therapy: When other therapies reach maximum doses and target BG levels not met (FPG > 140 mg/dl, postprandial BG > 180 mg/dl, A1C > 7-8%).
Glucovance (glyburide/metformin)
Available in 1.25/250 mg, 2.5/500 mg and 5/500 mg dosage units Side effects similar to those noted for glyburide and metformin. Contraindicated in those populations not indicated for use of gyburide and metformin.
Metaglip (glipizide/metformin)
Available in 2.5/250 mg and 2.5/500 mg dosage units Side effects similar to those noted for glipizide and metformin. Contraindicated in those populations not indicated for use of glipizide and metformin.
AvandaMet (Avandia/metformin)
Available in 1/500 mg, 2/500 mg and 4/500 mg dosage units Side effects similar to those noted for rosiglitazone (Avandia) and metformin. Contraindicated in those populations not indicated by use of rosiglitazone (Avandia) and metformin.
ACTOplus Met (Actos/metformin)

Available in 15/500 mg or 15/850 mg dosage units. Side effects similar to those noted for pioglitazone (Actos) and metformin. Contraindicated in those populations not indicated by use of pioglitazone (Actos) and metformin.
Avandaryl (Avandia/Amaryl)
Available in 4/1 mg, 4/2 mg and 4/4 mg dosage units. Side effects similar to those noted for rosiglitazone (Avandia) and glimepiride (Amaryl).
Contraindicated in those populations not indicated by use of rosiglitazone (Avandia) and glimepiride (Amaryl).

Chapter 6
Insulin and Other Drugs Used in the Treatment of Type 2 Diabetes

Insulin
Insulin is used in type 2 diabetes when blood glucose (BG) levels exceed 126 mg/dl fasting or exceed 200 mg/dl postprandial after trying meal planning, activity, and weight loss. Some may need to be started on insulin immediately, especially if they have unexplained weight loss and severe hyperglycemia.
Hyperinsulinemia
The theoretical disadvantage of hyperinsulinemia from using insulin injections does not outweigh the proven benefits of glycemic control.
Starting insulin
Lean patients: 15 units NPH or Lente per day Obese patients: 20-30 units of NPH or Lente per day
Doses can be increased 2-5 units every 3-4 days, depending on blood glucose levels. Some may need over 100 units of insulin per day to control blood glucose.
Adjunct Therapies for Type 2 Diabetes

Exanatide (Byetta) was released for use in 2005 and is used in addition to insulin and/or analogs to assist in gaining better control of blood glucose levels. Pramlintide acetate (Symlin) is a synthetic analog of human amylin. Amylin is a hormone also made and secreted by the beta cells, and therefore lacking in persons with type 1 diabetes. In those without diabetes, it is secreted along with insulin to control post-prandial blood glucose levels. Its anti-hyperglycemic effects include: Slowing gastric emptying
Suppressing glucagon release, resulting in less glucose release from the liver. Regulation of food intake due to modulation of appetite.
Pramlintide acetate is administered by subcutaneous injection prior to meals to mimic normal levels. Injection technique is the same as that for insulin. It cannot be mixed with insulin and may require pre-meal insulin be reduced to prevent hypoglycemia. Side effects may include nausea, vomiting, dizziness, indigestion, stomach pain, decreased appetite and fatigue. Its use is contraindicated in those with gastroparesis, hypoglycemia unawareness, women who are pregnant or breastfeeding and children. Vials in use can be stored at room temperature (less than 77F) for 28 days and then discarded. Vials not in use should be stored in the refrigerator and discarded after the expiration date.

Chapter 7
Insulin and Type 1 Diabetes

Some insulin must be available at all times for persons with type 1 diabetes. Insulin doses may be reduced but usually should never be completely eliminated; to do so can be life threatening.
Starting Insulin Doses

Start Dosage (u/kg/day) 0.2 - 1.0 0.3 - 1.5 0.3 - 1.2 Eventual Dosage (u/kg/day) 0.5 - 1.0 0.8 - 1.5 0.8 - 1.2
Prior to puberty Pubertal Post pubertal
Initial dose is higher if: Obese Long duration of symptoms Extreme hyperglycemia Recent illness Just post-DKA episode Mid-late pubertal
Insulin dose is lower if: Thin No co-morbid illnesses Minimal hyperglycemia No DKA, minimal ketones Early pubertal Minimal symptoms of diabetes
(wt. loss, polydipsia, polyphagia)
Additional Information: Generally 0.5-1 unit per kg body wt. (adolescents often need closer to 1 unit per kg) Insulin dose should mimic the normal physiologic insulin secretion and take into account the persons lifestyle. Long-acting insulin and insulin analogs can be used to provide basal insulin needs, coupled with rapid or short-acting insulin to cover food intake and for correction of hyperglycemia. Total Daily Dose: ~50-65% is basal ~35-50% is bolus (meal coverage) Infants and small children may only need NPH in the AM and evening or may need insulin diluted.
Pre-dinner NPH can be delayed until bedtime to prevent nocturnal hypoglycemia or
counteract the "Dawn Phenomenon". A "honeymoon phase" may occur within a few weeks after diagnosis and last for several months to 2 years. During this time, insulin needs are reduced to about 0.1-0.3 units per kg and only one injection per day may be required. Insulin should be reduced when child leaves the pubertal phase, otherwise obesity and unexplained hypoglycemia can result.
Activity
Adjustments in food intake or insulin dose are often needed for activity (see Chapter 4 Physical Activity and Diabetes)
Adjustment of Insulin (Twice - Daily Insulin Regimens)

Problems should occur 3 days in a row before changes are initiated. Fasting hyperglycemia: Check 3 AM blood glucose. If it is >70 mg/dl, o Increase evening NPH by 10% or o Changing NPH dose from pre-supper to pre-bed (may lower risk of nocturnal hypoglycemia and eliminate the need for a bedtime snack) Fasting hypoglycemia (and low 3 AM blood glucose): Reduce evening NPH by 15%, and possibly move NPH to bedtime if 3 AM is still low. Elevated midmorning or pre-lunch blood glucose: Increase AM rapidacting insulin by 10%. Pre-lunch blood glucose <70 mg/dl: If using short-acting insulin, change to rapid-acting. If still low, reduce AM rapid-acting insulin by 15%. Pre-supper blood glucose higher than desired: Increase AM NPH by 10%. Elevated evening blood glucose (>180 mg/dl after supper and pre-bed over 120 mg/dl after bedtime snack for 3 days): Increase pre-supper Rapid insulin by 10%. Also, make certain that the insulin injection is given 30 minutes before meal if using short-acting insulin. Rapid-acting insulin can be given at the time of eating typically 15 minutes before eating. Rapid-acting insulin can also be given after the meal if the amount of consumption cannot be predicted (e.g. picky eaters). It may also be useful to check technique and injection sites used. The exact amount of change needed will vary from person to person.
Intensive Therapy
Research shows that keeping blood glucose levels as close to normal as possible resulted in the development of significantly fewer complications. Intensive therapy generally involves making adjustments in insulin doses (via multiple insulin injections or use of an insulin pump) to accommodate activity, food intake and pre and post-meal blood glucose levels. However, it can be risky for extremely young children and infants because of the risk of permanent damage from hypoglycemic events. See Chapter 8 for sample insulin regimens. References: American Diabetes Association (2006). Clinical Practice Recommendations. Diabetes Care, Vol 29 (1).

Chapter 8
Insulin Regimens and Other Drugs Used in the Treatment of Type 1 Diabetes
Standard Insulin Regimens
There are many different insulin protocols in use. These are just six commonly used methods of delivering insulin.
One injection of long-acting insulin used in conjunction with oral meds or alone in type 2 diabetes. This helps reduce the livers release of glucose overnight.
Conventional Therapy
Can be premixed, but doing so will reduce flexibility of doses.
Can be premixed, but doing so will reduce flexibility of doses.
Intensive Therapy
Intermediate-acting insulin moved to bedtime (HS) to reduce nocturnal hypoglycemia and/or reduce fasting hyperglycemia.
Comparison of Rapid Acting Insulin Analogs and Short Acting Insulin

Can generally make a 1:1 substitution (rapid for short) Rapid associated with lower postprandial blood glucose, and quicker correction of hyperglycemia Fewer hypoglycemic episodes with rapid; Faster recovery from hypoglycemia with rapid High fat meals or gastroparesis short may be best choice High carbohydrate meals rapid more effective to lower postprandial blood glucose (BG) excursions Decreased need for between meal snacks when using rapid Rapid can be given immediately after the meal when food intake is not predictable. May need more basal insulin when using rapid versus short Rapid may be superior for: o insulin pump use o those using long-acting for basal and rapid before meals and snacks
Adjunct Therapies for Type 1 Diabetes

Pramlintide acetate was released for use in 2005 and is used in addition to insulin and/or analogs to assist in gaining better control of blood glucose levels. Pramlintide acetate (Symlin) is a synthetic analog of human amylin. Amylin is a hormone also made and secreted by the beta cells, and therefore lacking in persons with type 1 diabetes. In those without diabetes, it is secreted along with insulin to control post-prandial blood glucose levels. Its anti-hyperglycemic effects include: Slowing gastric emptying Suppressing glucagon release, resulting in less glucose release from the liver. Regulation of food intake due to modulation of appetite. Pramlintide acetate is administered by subcutaneous injection prior to meals to mimic normal levels. Injection technique is the same as that for insulin. It cannot be mixed with insulin and may require pre-meal insulin be reduced to prevent hypoglycemia. Side effects may include nausea, vomiting, dizziness, indigestion, stomach pain, decreased appetite and fatigue. Its use is contraindicated in those with gastroparesis, hypoglycemia unawareness, women who are pregnant or breastfeeding and children. Vials in use can be stored at room temperature (less than 77F) for 28 days and then discarded. Vials not in use should be stored in the refrigerator and discarded after the expiration date.

Chapter 9
Education Concerns of Insulin

Mixing Insulin
Glargine and detemir should not be mixed with other insulins Regular, Lispro, Aspart, Glulisine and NPH can be mixed - some premixed insulins are available for those unable to mix insulin for themselves. Glulisine mixed with NPH must be injected immediately after mixing Always draw up Regular or rapid-acting insulin first when mixing insulins. Insulin mixed at home should generally be administered immediately after mixing.
Storage of Insulin
In general, insulin vials in use can be stored at room temperature (59-86F) for 1 month. Back stock should be kept refrigerated but never frozen. - Some analogs recommend <77F, check package insert See manufacturer guidelines for cartridges, pre-filled pens. Avoid freezing temperatures and temperatures above 86 degrees. Insulin should not be left in cars or checked in airline baggage.
Do not use Insulin if:

Sediment is present. Clumping or frosting is apparent. Clear insulin is cloudy or discolored. It is beyond the expiration date. Stored improperly.
Injecting Insulin
Sites to use in descending order of absorption: abdomen, upper arm, anteriolateral thigh, and buttocks. Give injections in different areas, abdomen may be used for most injections, but rotations around abdominal area must occur. Do not inject within a 2" radius of umbilicus. Inject into subcutaneous tissue. 90 degree injection angle works for most. Children and very thing adults may need to use a shorter syringe length or 45 degree angle. Massaging injection site is usually not recommended.
Avoid injecting into an area that will soon be used in an activity or one that has just been used as absorption is increased. Avoid injecting immediately before using sauna, hot tub, or hot shower as temperature may increase absorption speed of insulin.
Insulin and Insulin Analogs

Onset (hours) 0.25 - 0.5 < 0.5 0.25 Peak (hours) 0.5 - 4 1 -3 0.5 1.5 Duration (hours) 46 35 3-5 When to administer 0 -15 min before meals* 0 -15 min before meals* 0 -15 min before meals* 30-45 minutes before meals Before am & pm meals or before am meal & at HS am or HS Do NOT mix Once or twice daily Before breakfast & dinner Before breakfast & dinner Before breakfast & dinner Before breakfast & dinner Before breakfast & dinner
Type of Insulin (Trade Name) Rapid Acting Lispro (Humalog) Aspart (Novolog) Glulisine (Apidra) Short Acting (Regular) Humulin R, Novolin R Intermediate Acting NPH, Humulin N, Novolin N Long Acting Glargine (Lantus) Detemir (Levemir) Combinations Humulin 50/50 Humulin 70/30 Novolin 70/30 Humalog Mix 75/25 Novolog Mix 70/30
Appearance Clear Clear Clear
Clear
-1
2-3
6-8
Cloudy
2-4
6 10
14 18
Clear Clear
1 ~1
No peak No peak
Up to 24 Up to 24
Cloudy Cloudy Cloudy Cloudy Cloudy
-1 -1 < <
2 - 5 1 - 16 2 12 1 6 14
14 18 14 18 Up to 24 ~ 22 Up to 24
The action time of any insulin may vary in different individuals or at different times in the same individual. Variables include size of dose, injection site, physical activity and body temperature. References: American Diabetes Association (2006). Clinical Practice Recommendations. Diabetes Care, Vol 29 (1). Core Curriculum for Diabetes Educators, Diabetes Management Therapies 5th Edition. AADE. 2003.
Product labeling information

Chapter 10
Insulin Pumps: What, When, Who, and How

Continuous subcutaneous insulin infusion (CSII) therapy, also known as insulin pump therapy, has been commercially available for more than 20 years. Recently, insulin pump use has greatly increased. The pumps now available have many important safety, memory, and calculation features that make using a pump much easier than in the past.
Indications for Use
Inability to normalize blood glucose on current insulin regimen. (Elevated A1C) Severe hypoglycemia Hypoglycemia unawareness Client preference/need for normalizing lifestyle Recurrent hospitalizations Preconception and pregnancy Gastroparesis Dawn Phenomenon Symogi effect.
How it works:
The pump is approximately the size of a pager and must be worn 24 hours a day. A syringe, holding up to 300 units of insulin, is connected to tubing which is connected to an infusion site where the insulin is deposited subcutaneously. There are two basic delivery rates. Basal rate: Delivers insulin continuously (every few minutes) in tiny amounts at various rates individual to each patient. Basal rates are determined first and usually require more frequent monitoring when pump therapy is first initiated. Once established basal rates seldom change except in children as they grow and develop, illness, exercise, etc Bolus rate: Boluses are delivered by the pump user to correct elevated blood glucose levels or to cover food intake. This is a larger amount of insulin and can be given all at once or over a period of time. Infusion sets come in many types with different cannula lengths and must be changed by the person with diabetes every 48-72 hours.
Criteria for screening adults and children with diabetes for possible pump use:
Willing to monitor and record blood glucose a minimum of 4 times per day Responsible Willing and able to learn how to count carbohydrates. (Some math skills needed for person with diabetes or their caregiver) Willing to commit to medical follow-up. Able to or can learn to problem solve. Preferably currently using MDI and able to adjust insulin to meet changes in lifestyle.
Benefits
Improved glucose control (Lower A1C). Delivers insulin in a more physiological manner. o Both the basal and bolus doses can be adjusted in > 0.05 increments depending on the brand of pump. Normalization of lifestyle. o Pump users have more flexibility in eating, sleeping, exercising, etc. Less frequent and less severe hypoglycemia. Predictable absorption Programmable delivery Uses only rapid or short acting insulin. o Aspart and Glulisine are both approved by the FDA for use in pumps. o Lispro, although not FDA approved for use in pumps, has been deemed appropriate for use by the American Diabetes Association (ADA). Pump companies have 24/7 customer support lines.
Risks
The greatest risk associated with pump therapy is ketoacidosis. Because the pumps use only rapid or short acting insulin, delivery must be constant. If the infusion line becomes occluded or the pump runs out of insulin, blood glucose and ketones can quickly rise. Testing blood glucose levels 4 times per day enables the person to detect possible problems early enough to intervene and prevent severe DKA. o Person should always have syringes and vials of insulin available in case of pump malfunction. Skin infections and reactions to the tape may occur at the insertion site. Changing the site every 2-3 days, and using proper insertion technique diminishes the occurrence of infection. Hypoglycemia is always a risk for anyone who takes insulin. Those on pump therapy have been shown to have a decrease in hypoglycemic events.
American Diabetes Association (2006). Clinical Practice Recommendations. Diabetes Care, Vol 29 (1).
References:

Chapter 11
Self Monitoring of Blood Glucose (SMBG)

Self-monitoring of blood glucose (SMBG) allows persons with diabetes to evaluate their individual response to therapy and assess whether glycemic targets are being met. Results of SMBG can be useful in preventing hypoglycemia and adjusting medications, medical nutrition therapy (MNT) and physical activity. The frequency and timing of SMBG should be determined by individual needs and goals of each person with diabetes. SMBG should be carried out three or more times daily in those with type 1 diabetes, pregnant women using insulin and those on multiple insulin injections. For those using less frequent insulin injections or oral agents or MNT alone, SMBG is useful in achieving glycemic goals. Postprandial glucose may be targeted if A1C goals are not met despite reaching preprandial glucose goals. Persons with diabetes should be routinely evaluated to assess their technique and ability to use data to adjust therapy.
Another test of glycemic control is the A1C test, which measures the average blood glucose control over the past 2-3 months. See table below for the correlation between A1C level and mean plasma glucose. A1C 6% 7% 8% 9% 10% 11% 12% Mean Plasma Glucose 135 mg/dl 170 mg/dl 205 mg/dl 240 mg/dl 275 mg/dl 310 mg/dl 345 mg/dl
A1C is the primary target for glycemic control and should be checked routinely in all persons with diabetes: at least two times a year in those with stable glycemic control.
quarterly in those whose therapy has changed or who are not meeting glycemic goals.
Blood glucose and A1C goals must be individualized based on age, ability to recognize hypoglycemia, history of hypoglycemia and self-management capabilities. This is especially important for children, adolescents, pregnant women and older adults. More stringent goals (A1C <6%) may further reduce complications at the cost of increased risk of hypoglycemia, especially in those with type 1 diabetes. Less stringent goals are be indicated in those with severe or frequent hypoglycemia. See table below for target blood glucose and A1C goals for persons with diabetes. Target Glycemic Goals for Persons with Diabetes Under age 6* Age 6-12* Age 13-19* Adults * Before meals Peak post meal 2 hours post meal Bedtime A1C 100 180 mg/dl --110 200 mg/dl 7.5 8.5% < 180 mg/dl --100 180 mg/dl < 8% 90 130 mg/dl --90 150 mg/dl < 7.5 % 90 130 mg/dl < 180 mg/dl ----< 7.0 %
Adults** < 110 mg/dl --< 140 mg/dl --< 6.5 %
* American Diabetes Association ** American Association of Clinical Endocrinologists
References: American Diabetes Association (2006). Clinical Practice Recommendations. Diabetes Care, Vol 29 (1). American Association of Clinical Endocrinologist (AACE). Medical Guidelines for the Management of Diabetes Mellitus, Endocr Pract. 2002;8 (Suppl 1).

Chapter 12
Gestational Diabetes Mellitus (GDM)

Risk assessment should be identified at the first prenatal visit. Women who meet all of the following criteria are considered low risk: under the age of 25, are of normal weight, have no family history of diabetes, have no history of abnormal glucose tolerance, have no history of poor obstetric outcome, and not members of a high risk ethnic group. No screening is required for those at low risk of developing GDM. Women who are at high risk of developing diabetes (marked obesity, prenatal history of GDM, glycosuria, strong family history of diabetes) should be tested immediately, and retested at 24-28 weeks, if necessary. All others should be screened at 24-28 weeks of pregnancy.
Diagnostic Tests
Random 50 gram, 1 hour glucose challenge Glucose >200 mg/dl, diagnosis of gestational diabetes is made. If >140 mg/dl: administer 100 gram glucose, 3 hour oral glucose tolerance test (3 days unrestricted carbohydrate diet of at least 150 grams per day, followed by 8-14 hour overnight fast).
Three hour, 100 gram glucose oral glucose tolerance test (after an 8-14 hour fast) Diagnosis of gestational diabetes is made when 2 or more values from this test are: o > 95 mg/dl at fasting o > 180 mg/dl at 1 hour o > 155 mg/dl at 2 hours o > 140 mg/dl at 3 hours If only 1 out of 3 values is abnormal, retest at 32 weeks.
Nutritional Intervention
All women should meet with a registered dietitian for assistance with meal planning, with calories sufficient for adequate weight gain. Carbohydrates should be based on the effect on the blood glucose and spaced throughout the day into 3 meals and 2-4 snacks. Carbohydrates can be limited to 35-40% of total calories, and are generally less well tolerated in the morning. A moderate restriction of no more than 30-45 grams at breakfast is usually recommended, with monitoring of blood glucose response. Non-nutritive sweeteners are generally safe in pregnancy. Supplementation with folic acid (400 ug per day) is recommended for all women before and during pregnancy.
Monitoring
Weight gain (usually about 1-2 pounds per week for the second and third trimesters). Recommend at least 15 pounds for the obese, and up to 40 pounds for the underweight. AM urine ketones - if present, may need additional carbohydrate calories before bed or may need shorter period to time between evening snack and breakfast. Food intake and blood glucose levels - fasting, before meals, and 1-2 hours after meals.
Meal plan is adjusted based on weight gain, AM ketones, and blood glucose levels.
Blood Glucose Goals (plasma values)

ADA* ACOG** Fasting <105 mg/dl < 95 mg/dl Pre-meal --60-105 mg/dl 1 hour postprandial <155 mg/dl 130-140 mg/dl 2 hour postprandial <130 mg/dl < 120 mg/dl * American Diabetes Association ** American College of Obstetricians and Gynecologists
Insulin Administration
Generally started if nutritional therapy fails to keep blood glucose <105 mg/dl fasting or <130 mg/dl 2-hour postprandial. Starting doses for gestational diabetes, in third trimester: 0.7 units/kg/day, give 2/3 in the morning as 2/3 NPH, 1/3 R (some use 70/30). Give the other 1/3 in the evening as 2/3 NPH and 1/3 R. Obese: 0.8-1 unit per kg per day in at least 2 doses per day Fasting hyperglycemia: may treat with HS dose of 10 units NPH
Oral hypoglycemic agents and insulin analogs are not approved for use in gestational diabetes at this time.
Activity and Pregnancy

Activity may help with glycemic control. If active prior to pregnancy, a woman with gestational diabetes can usually continue being active. Heart rate should not exceed 140 beats per minute. Activities of less than 15-20 minutes may be indicated. Moderate, regular activity, especially after meals may have a positive impact on blood glucose levels.
Breast Feeding
Should be strongly encouraged for as long as possible. May help with weight loss postpartum and reduce the risk of future diabetes.
Diabetes after Delivery

Most women return to normal blood glucose following delivery. An estimated 40-60% of women with gestational diabetes eventually develop diabetes as they age o risk of developing diabetes can be minimized if women engage in regular physical activities and maintain desirable body weight. A 2 hour oral glucose tolerance test with 75 grams of glucose is recommended at the first 6-8 week postpartum visit.
References: American Diabetes Association (2006). Clinical Practice Recommendations. Diabetes Care, Vol 29 (1). Jovanovic, L (Ed) (2000). Medical Management of Pregnancy Complication Diabetes, 3rd Ed. Alexandria, VA: American Diabetes Association.

Chapter 13
Diabetes and Hypertension

Hypertension (HTN) is twice as common in persons with diabetes compared to the general population. For persons with diabetes, HTN contributes to the development and progression of chronic complications, such as retinopathy, chronic kidney disease and peripheral vascular disease. Achieving and maintaining normal blood pressure levels can also minimize the risk of developing these complications. Controlling HTN begins with detection and diagnosis. Health care professionals are strongly encouraged to check blood pressure at each visit. Following proper blood pressure monitoring technique is essential to obtain accurate blood pressure readings.
Diagnosis, Classification and Treatment of Blood Pressure

Blood Pressure Classification Normal Systolic Diastoic BP BP mmHg mmHg < 120 and < 80 No Risk Factors*, No TCD/CCD** Lifestyle Changes Lifestyle Changes (up to 12 months) Lifestyle Changes + Drug Therapy Lifestyle Changes + Drug Therapy At least one risk factor (not DM) No TOD/CCD** Lifestyle Changes Lifestyle Changes (up to 6 months) Lifestyle Changes + Drug Therapy Lifestyle Changes + Drug Therapy TOD/CCD** and/or diabetes (with or without risk factors) Lifestyle Changes Lifestyle Changes + Drug Therapy (if SBP > 130 and DBP > 80) Lifestyle Changes + Drug Therapy Lifestyle Changes + Drug Therapy
Prehypertension 120139 or 8089 Stage 1 Hypertension Stage 2 & 3 Hypertension 140159 or 9099 > 160 or > 100
If systolic and diastolic BP fall into two separate categories, use the higher category status. *Cardiovascular Risk Factors = hypertension, cigarette smoking, obesity (BMI > 30), physical inactivity, dyslipidemia, diabetes, microalbuminuria, age (over 55 for men; over 65 for women), family history of premature cardiovascular disease (men under age 55 or women under age 65). **TOD/CCD = Target Organ Damage and Clinical Cardiovascular Disease. TOD includes left ventricular hypertrophy, angina, prior myocardial infarction, prior coronary revascularization, heart failure, stroke or transient ischemic attack, chronic kidney disease, peripheral arterial disease or retinopathy.
According to the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) and the American Diabetes Association, the goal of treating hypertension is to achieve and maintain blood pressure less than 130/80 mmHg for persons with diabetes or chronic kidney disease. Most persons with high blood pressure, especially those over age 50, will reach their diastolic BP goal when the systolic BP is at goal. Therefore, the primary focus of therapy should be to achieve the systolic BP goal.
Nonpharmacological Treatment
Modification Weight Reduction DASH Eating Plan Dietary Sodium Restriction Physical Activity Moderation of Alcohol Consumption Recommendation Maintain normal body weight: Body Mass Index (BMI) of 18.5-24.9 Adopt a diet rich in fruits, vegetables and low-fat dairy products with reduced total & saturated fat. See DASH handout at end of guideline. Reduce daily sodium to less than 2400 mg. Eat more fresh, unsalted foods Use herbs and spices to season foods Choose foods with <5% Daily Value for sodium Regular aerobic physical activity (brisk walking) at least 30 minutes per day most days of the week. Limit alcohol intake to 2 drinks per day (men) or 1 drink per day (women) 1 drink = 12 oz beer, 5 oz wine and 1 oz liquor Average SBP Reduction 5-20 mmHg per 10 kg weight loss 8-14 mmHg 2-8 mmHg
4-9 mmHg 2-4 mmHg
Pharmacological Treatment
More than 2/3 of those with diabetes and HTN will require two or more different medications to achieve the goal BP of less than 130/80 mmHg. See below for evidencebased recommendations for the pharmacological treatment of diabetes and HTN. Condition Type 1 or 2 diabetes with NO cardiovascular risk factors or proteinuria Type 1 diabetes with any degree of albuminuria Type 2 diabetes and microalbuminuria Type 2 diabetes and macroalbuminuria, nephropathy or renal insufficiency Those over age 55 with cardiovascular risk factors (history of cardiovascular disease, smoking, dyslipidemia, overweight) Those with recent myocardial infarction (MI) Those with microalbuminuria or overt nephropathy in which ACE Inhibitors or ARBs are not tolerated Recommended drug therapy ACE inhibitor or ARB Thiazide Diuretic (shown to reduce risk of stroke and cardiovascular events) ACE inhibitor (shown to delay the progression of nephroathy) ACE inhibitor or ARB (shown to delay the progression to macroalbuminuria) ARB should be strongly considered ACE Inhibitor should be considered (to reduce the risk of cardiovascular events) Beta blocker should be added to current treatment (to reduce mortality) Non-Dihydropyridine CalciumChannel Blocker should be considered.
Commonly Used Oral Antihypertensive Medications

Class Thiazide Diuretics ACE Inhibitors ARBs Beta Blockers Dihydropyridine Calcium-Channel Blockers Nondihydropyridine Calcium-Channel Blockers Alpha 1 Blockers Drug (Trade Name) hydrochlorothiazide (Microzide, HydroDIURIL) indapamide (Lozol) benazepril (Lotensin) lisinopril (Prinivil, Zestril) enalapril (Vasotec) quinapril (Accupril) fosinopril (Monopril) ramipril (Altace) candesartan (Atacand) losartan (Cozaar) irbesartan (Avapro) valsartan (Diovan) atenolol (Tenormin) metoprolol (Lopressor) nadolol (Corgard) metoprolol extended release (Toprol XL) amlodipine (Norvasc) nifedipine long-acting felodipine (Plendil) (Adalat CC, Procardia XL) Diltiazem extended release (Cardizem CD, Dilacor XR, Tiazac) diltiazem extended release (Cardizem LA) verapamil immediate release (Calan, Isoptin) verapamil long acting (Calan SR, Isoptin SR) verapamil (Coer, Covera HS, Verelan PM) doxazosin (Cardura) terazosin (Hytrin) prazosin (Minipress)
Summary
The treatment of HTN involves considerable knowledge of the recommended lifestyle changes and medications. Because high blood pressure is often asymptomatic, lifestyle changes can be difficult to maintain. Since medications may be expensive and may have unpleasant side effects, some stop treating their high blood pressure with unfortunate results. Health care providers should explore these issues and involve the physician, as needed, to help persons with diabetes achieve their blood pressure goal. The keys are to treat hypertension aggressively and to keep blood glucose under good control to minimize the possibility of developing or exacerbating complications. For more information on Diabetes and Hypertension, check out the Diabetes and Hypertension independent study module at www.diabetesinmichigan.org. Click on independent study modules.
References: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure, NIH Publication No. 03-5231, National High Blood Pressure Education Program, May 2003. American Diabetes Association. Position Statement: Treatment of Hypertension in Adults with Diabetes. Practical Diabetology, March 2003. Wylie-Rosett J. Hypertension and Diabetes: Clinical Synergy and Challenges. On the Cutting Edge, 2004: Vol 25 (4): 4-8.
DASH Eating Plan

Food Group
1600 Calories
Servings based on:

2000 Calories 3100 Calories
Examples Serving Sizes
Comments
Grains/Grain products Vegetables Fruits
6 per day 34 per day 4 per day
7-8 per day
Low-fat or fat-free dairy products Lean meats, poultry and fish Nuts, seeds and dried beans Fats and oils
23 per day 1-2 per day 3 per week 2 per day
Sweets
12-13 per day 1 slice bread Choose whole grains. On the food label, look - 1 cup ready-to-eat cereal for whole wheat flour as first ingredient and at cup cooked rice, pasta, cereal least 2 grams fiber per serving. 45 per day 6 per day 1 cup raw leafy vegetables Choose variety of vegetables. cup cooked vegetable Rich sources of potassium, magnesium and 6 oz vegetable juice fiber. 4 5 per day 6 per day 1 medium fruit Choose variety of fruits. cup dried fruit Good source of potassium, magnesium and cup fresh, frozen or canned fruit fiber. 4 oz fruit juice 2 3 per day 34 per day 8 oz 1%, % or skim milk Major source of calcium and protein. 6-8 oz yogurt Choose low-fat and fat-free dairy products. 1 oz cheese 2 per day 2-3 per day 3 oz cooked lean meat, skinless Choose lean and trim away visible fats. Bake, poultry or fish boil, roast, broil versus frying 45 per week 1 per day 1/3 cup or 1 oz nuts Rich source of energy, magnesium, potassium, 1 Tbsp or oz seeds protein and fiber. cup cooked dried beans 2 3 per day 4 per day 1 tsp soft tub margarine High in calories. Limit portions. 1 Tbsp low-fat mayonnaise Limit saturated fats (solid at room 2 Tbsp light salad dressing temperature). 1 tsp vegetable oil Best oils: canola, olive 5 per week 2 per day 1 Tbsp sugar, jam or jelly Sweets should be low in fat oz jelly beans 8 oz lemonade Source: http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/index.htm
How to Lower Calories on the Dash Eating Plan

To increase fruits
Eat a medium apple instead of 4 shortbread cookies (save 80 calories). Eat cup dried fruit instead of a 2 oz bag of pork rinds (save 230 calories).
To increase vegetables:
Have a hamburger thats 3 oz meat instead of 6 oz. Add cup of carrots and cup spinach. (save 200 calories) Instead of 5 oz chicken, have a stir-fry with 2 oz chicken and 1 cup raw vegetables. Use a small amount of vegetable oil. (save 50 calories). Add fresh or frozen vegetables to soups, pastas or rice.
To increase low-fat or fat-free dairy products:

Drink skim milk instead of 2% milk (save 30 calories per cup) or whole milk (save 60 calories per cup). Have cup low-fat frozen yogurt instead of 1 oz chocolate bar (save 110 calories).
Other calorie saving tips:
Tips for reducing salt

Eat more fresh, unsalted foods. Avoid adding salt to homemade foods. Use spices for flavoring. Read food labels and look for: foods with < 5% of Daily Value for sodium snack foods or salad dressings with < 200 mg of sodium per serving sides (soups, rice, pasta, potatoes) with < 350 mg of sodium per serving frozen meals or fast foods with < 800 mg of sodium.
Use low-fat or fat-free condiments. Use half the amount of regular vegetable oil, soft or liquid margarine or salad dressing. Eat smaller portions, cutting back gradually. Check the food labels to compare fat content in packaged foods (low-fat and fat-free does not always mean lower in calories). Limit foods with lots of added sugar (pies, sweetened yogurts, candy bars, ice cream, sherbet, regular soft drinks and fruit drinks) Eat fruits canned in their own juice. Snack on fruit, vegetable sticks or unbuttered, unsalted popcorn. Drink water or club soda.
The DASH (Dietary Approaches to Stop Hypertension) Study was a National Institutes of Health research project. Following the DASH Eating Plan lowered blood pressure levels in those with normal and elevated blood pressure levels without reducing sodium or using drugs.

Chapter 14
Lipid Management in Diabetes

Lipid abnormalities are common in persons with diabetes (up to 70% of type 2 have lipid disorders). Some problems can be resolved through blood glucose control. Others will require dietary or pharmacological intervention.
Desirable Lipid Levels (fasting)

Cholesterol (mg/dl) <200 <200 LDL-cholesterol (mg/dl) <100 <100 HDL-cholesterol (mg/dl) >40 (men) > 50 (women) >35 Triglycerides (mg/dl) <150 <150
Adults Children
Testing (Fasting Lipid Profile)

Adults: At diagnosis and every year Children with type 1 diabetes (over age 12): Screen at diagnosis, but after glycemic control is achieved. If initial screening is normal, repeat screening every 5 years. If levels are abnormal, follow-up in 3 months and again at 6 months to assess effectiveness of treatment. Children with type 1 diabetes (under age 12): There is no need to screen in absence of parental history of dyslipidemia or early coronary disease. If levels are abnormal, follow-up in 3 months and again at 6 months to assess effectiveness of treatment. Children with type 2 diabetes: Screen at diagnosis, regardless of age, but after glycemic control is achieved. If levels are normal, repeat screening every 2 years.
Type 1
Blood glucose control will often help correct dyslipidemia. Check thyroid function.
Type 2
Most common type of dyslipidemia: high triglycerides with low HDL. Usually have smaller, denser, more atherogenic LDL-particles Obesity exacerbates dyslipidemia. If no evidence of macrovascular disease; weight loss, increased activity, limiting alcohol, and controlling glucose can help.
Lifestyle Therapies for Dyslipidemia

1. Improved BG control Most beneficial for those with type 1 diabetes Will help with hypertriglyceridemia May decrease LDL-cholesterol up to 15% 2. Fat restriction Saturated fat : < 10% of total calories (may need < 7% or total calories) Trans fats : minimal intake Dietary cholesterol: < 200 mg/day 3. Increase fiber Soluble fiber: 10-25 grams/day Plant stanols/sterols: 2 grams/day 4. Modest weight loss Will lead to decrease in triglyceride levels, increased HDL-cholesterol levels, and a modest lowering of LDL-cholesterol. 5. Increased physical activity Will lead to decrease in triglyceride levels, increased HDL-cholesterol levels, and a modest lowering of LDL-cholesterol. 6. Smoking cessation Will lead to improvements in lipid profile.
Treatment of Diabetic Dyslipidemia in Adults (order of priorities)

1. LDL-cholesterol lowering 1st Choice: HMG CoA Reductase Inhibitors (statins) 2nd Choice: Bile Acid Binding Resins (resins) or Fibric Acid Derivatives (fibrates) 2. HDL-cholesterol raising
1st Choice: behavioral interventions (see above) 2nd Choice: Nicotinic acid (with caution due to BG raising) or fibrates
3. Triglyceride lowering 1st priority: BG control 1st Choice: fibrates Statins are moderately effective in those with elevated LDL also. 4. Combined hyperlipidemia 1st Choice: Lifestyle intervention plus a statin 2nd Choice:Lifestyle intervention plus a fibrate 3rd Choice: Lifestyle intervention plus a resin and a fibrate OR lifestyle intervention plus a statin and nicotinic acid (must monitor BG carefully)
Treatment of Diabetic Dyslipidemia in Children

1. Lifestyle intervention (see above) for LDL-cholesterol of 100-129 mg/dl 2. Consider pharmacological intervention for LDL cholesterol 130-159 mg/dl Maximize lifestyle intervention Base decision on complete CVD risk profile, including assessment of blood pressure, family history and smoking status. 3. Pharmacological intervention for LDL cholesterol 160 mg/dl Bile acid sequestrants (resins) are often recommended as first choice in this age group. Statins can be used with caution. Initiate at lowest available dose and increase based on LDL levels and side effects, and monitor LFTs. Statins should be discontinued if there is complaint of significant muscle pain or soreness. 4. Elevated triglycerides Maximize lifestyle intervention If levels > 1000 mg/dl, treatment is necessary. Consider fibrate. Fish oil supplementation with omega-3 fatty acids may help lower triglycerides that are not responding to medication. Resources: American Diabetes Association (2006). Clinical Practice Recommendations. Diabetes Care. Vol 29 (1). American Diabetes Association (2003). Management of Dyslipidemia in Children and Adolescents with Diabetes. Diabetes Care 26:2194-2197.

Chapter 15
Sick Day Management

Knowing how to manage illness is important for persons with diabetes in order to avoid hospitalization.
Sick Day Guidelines

Always take insulin or diabetes medication (often extra insulin is required). o Less insulin may be needed if person is vomiting or has diarrhea. o Omission of insulin is a common cause of ketosis. Test blood glucose frequently. All persons with diabetes should test their blood glucose at home when ill, even if they do not monitor regularly. o For those with type 1, check every 4 hours o For those with type 2, check 2-4 times a day. Record blood glucose (BG) and response to treatment. Share with the healthcare provider. Test for urine ketones every 4 hours (type 1 diabetes). Hypoglycemia is rare, yet may occur with nausea and vomiting of short duration without fever. Over the counter (OTC) and prescription medicines, along with herbal therapies, can contribute to hyperglycemia and hypoglycemia. Record weight changes (loss may signal dehydration) and breathing difficulties. Try to eat usual amount of carbohydrate. o If having difficulty eating, eat or drink 15 grams of carbohydrate every hour or 45-50 grams of carbohydrate every 3-4 hours. o Soft food or liquids may be easier to consume (see below). Drink extra water or sugar-free, caffeine-free fluids (8 oz every hour when awake).
Foods for Sick Day Management (~15 grams carbohydrate each)

(4 oz) cup juice 1cup (8 oz) sports drink (Gatorade, Powerade) cup (4 oz) regular pop cup regular gelatin cup sugar-free pudding cup ice cream 1 cup (8 oz) milk cup unsweetened applesauce 1 cup soup 6 saltine crackers twin popsicle 6 oz light yogurt 1 slice toast 3 squares graham crackers - 1 cup cold cereal cup hot cereal 1/3 cup rice 1/3 cup pasta
cup frozen yogurt
cup sherbet
cup mashed potatoes
Nausea/Vomiting
Blood glucose: over 250 mg/dl 180-250 mg/dl under 180 mg/dl Action Drink calorie-free, caffeine-free liquids in place of meal. Drink/eat 15 grams of carbohydrate in place of meal. Also, probably need additional liquid from water or calorie-free caffeine source. Try to drink or eat usual mealtime carbohydrate amount. If vomiting occurs after insulin administration, may need to sip sugar water every 20-30 minutes to maintain BG levels between 100-180 mg/dl. May require hospitalization.
under 100 mg/dl and vomiting persists
Adjusting Insulin for Illness (no nausea/vomiting)

Continue usual dose of intermediate-acting (NPH) or long-acting insulin (Lantus) Supplemental doses of rapid-acting (Humalog, Novolog) or short-acting (Regular) insulin may be needed due to elevated BG levels or the presence of large or persistent ketones. o Rapid-acting or short-acting insulin may be given every 1-4 hours. o Dose is dependent on severity of illness. o During most illnesses, 10% of total daily insulin dose can be safely given as a supplemental dose. o If BG is greater than 300 mg/dl with large ketones, 20% of total daily dose can be given as a supplemental dose. Adjustments need to be individualized for each person. If hyperglycemia persists, additional doses of rapid or short-acting insulin may be needed throughout the day.
When to Call Physician

Fever greater than 100 degrees for 24 hours Persistent hyperglycemia (BG over 300 mg/dl) Persistent diarrhea (more than 8 hours) Vomiting and unable to take fluids for over 4 hours Sick longer then 24 hours Severe abdominal pain (more common in type 1) Difficulty breathing (more common in type 1) Moderate to large ketones (more common in type 1) Other unexplained symptoms (if in doubt, contact your health care provider)
Preventing Illness
Get influenza vaccination yearly. Get pneumococcal vaccination. If receive first dose prior to age 65, give another single re-vaccination after age 65 (if 5 or more years have lapsed since the previous dose). Practice good hygiene and hand washing. Eat a healthful diet. Get plenty of rest. Stay hydrated. Don't smoke.

Chapter 16
Special Issues: Behavior Change

How to Help Your Clients Change Their Behavior
Determine what your client wants to change: If client does not want to alter health threatening behavior, assist them with determining personal benefits of changing. Those who desire change may need help with: o Setting goals (i.e. maintain fasting blood glucose between 80 and 120 mg/dl) o Breaking goal into easy to follow steps. For example to achieve blood glucose goals they could: Meet with a dietitian for assistance with meal planning. Start walking 10 minutes, 3x per week. Join a diabetes support group Continue learning about diabetes o Knowing how to problem solve (How will you maintain healthy habits when you go on vacation?) o Developing a support system (and dealing with people who may undermine success) o Managing stress (Uncontrolled stress often causes a person to return to unhealthy behavior) o Developing behavioral change strategies (such as eating only in the kitchen)
References: American Diabetes Association (2006). Clinical Practice Recommendations. Diabetes Care. Supplement. Vol 29.

Chapter 17
Special Issues: Concerns of Children

Parents and children need to accomplish ordinary tasks in each development stage of childhood. The main job of a child is to grow.
Parent Roles
Forcing a child to eat and withholding food does not work. Set regular meal and snack times for your child. You are responsible for selecting the foods offered and determining snack and meal times. Everyone in the family can and should eat the same foods. Children with diabetes do not need special foods. Some of the sugar-free items (sugar-free soda, gelatin or pudding) may be helpful if your child needs less carbohydrate at a snack or meal. Set a good example. Eat what you want your children to eat. Provide your child with support and show interest in your child's diabetes care. Provide your child with more snacks (or less insulin) if activity level goes up. If a child won't eat and extra carbohydrate is needed, have some options available (examples: juice, regular soda, crackers). Be aware of behavior changes (crying, irritability) that may signal a low blood glucose level. Always be prepared (glucagon kit, extra carbohydrate sources, insulin, testing supplies, etc).
Children with diabetes...

Need to eat when hungry. Need to grow and develop. Need to have insulin and diet therapy adjusted to fit their lifestyles. Need to take gradual charge of their diabetes with parental support. Need to be able to do the things other children do. May benefit from attending summer camp for children with diabetes.
Type 2 Diabetes in Youth

While children with or at risk for type 2 diabetes may be overweight, most of the above guidelines are still applicable. Type 2 diabetes in youth can be greatly modified by lifestyle changes. It is important for the whole family to be supportive, focusing on eating well and increasing physical activity. This way everyone can be healthier. Teach children to tune in to their body signals, so they can learn to eat when physically hungry and stop before they are too full. Avoid using food as a reward Eat regular meals and snacks. Dont forget to eat breakfast! Aim for 5 a day (fruit and vegetable servings). Reduce or eliminate sweetened drinks. Have water instead. Move more. Sit less. Limit screen time to a maximum of 2 hours a day. Realize some overweight children may do well to just maintain their weight until they can grow into it. Let your child know he or she is accepted unconditionally, whatever his or her weight.
References: Healthy Kids Healthy Weight: Tips for Families with Kids of all Shapes and Sizes; Michigan Department of Community Health, Michigan Department of Education: www.mihealthtools.org/schools The Surgeon Generals Call to Action to Prevent and Decrease Overweight and Obesity: Overweight in Children and Adolescents: http://www.surgeongeneral.gov/topics/obesity/

Chapter 18
Acute Complications of Diabetes:

Hypoglycemia and Hyperglycemia
Hypoglycemia is often defined as plasma blood glucose levels lower than approximately 72 mg/dl. Hypoglycemic episodes can vary greatly in severity of symptoms. Signs/ Symptoms Causes Mild: sweating, trembling, difficulty concentrating, lightheadedness, lack of coordination Severe: inability to self-treat due to mental confusion, lethargy or unconsciousness. Too much diabetes meds/insulin Too much activity Not eating enough carbohydrate Drinking too much alcohol Advancing age and poor nutrition Mild hypoglycemia: 15/15 rule 1. Check blood glucose (BG) If BG is 50-69: give 15 grams carbohydrate If BG is <50: give 30 grams carbohydrate 2. Wait 15 minutes and recheck BG If BG < 70, repeat step 1 If BG > 70, monitor for signs/symptoms of low BG. (May need to eat an additional snack if next meal is more than 1 hour away). Severe hypoglycemia: 1. If able to swallow without risk of aspiration, offer juice or non-diet soft drink or place glucose gel, honey, syrup or jelly inside the persons cheek. 2. If unable to swallow without risk of aspiration: give glucagon injection. Recommended doses are: older children and adults: 1 mg children under age 5: 0.5 mg infants: 0.25 mg
Treatment
Examples of 15 grams of carbohydrate include 3 glucose tablets, 8 Lifesavers, 2 Tbsp raisins, 4 oz non-diet soft drinks, 4 oz fruit juice or 8 oz nonfat milk. It is best to avoid food high in fat content as they may slow gastric emptying and absorption of carbohydrate, taking longer to raise blood glucose levels.
Hyperglycemia Signs/ Symptoms Increased thirst, increased urination, excessive hunger, blurred vision, weight loss (related to lack of insulin). Weakness, lethargy, malaise and headache. Nausea, vomiting, fruity breath, and abdominal pain (related to ketosis). Difficulty breathing (related to the metabolic acidosis). Not enough diabetes meds/insulin or physical activity Eating too much carbohydrate Stress Fluids (caffeine free and carbohydrate/calorie free) Check ketones Insulin to correct hyperglycemia for some
Causes Treatment
Prolonged hyperglycemia can lead to diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), both of which are life threatening. DKA is a complication that results from the lack of insulin and is most frequently seen in those with type 1 diabetes. It is characterized by hyperglycemia, ketosis, acidosis, dehydration and electrolyte imbalance. HHS is most frequently seen in older adults with type 2 diabetes. It is similar to DKA except that insulin deficiency is not as prevalent. It is characterized by severe hyperglycemia, absence of significant ketones, profound dehydration and mental status changes.
Comparison of DKA and HHS Features

Feature Age Duration of symptoms Plasma BG level Sodium concentration Bicarbonate concentration Ketone bodies Arterial pH Serum osmolality Prognosis Priorities of Treatment DKA Under 40 years of age Less than 2 days < 600 mg/dl Normal or low Low 4+ Low < 320 mOsm/kg 3-10% mortality 1. Provide insulin 2. Correct fluid/electrolyte imbalances HHS Over 60 years of age More than 5 days > 600 mg/dl Normal or high Normal Less than 2+ Normal >320 mOsm/kg 10-20% mortality 1. Fluid/electrolyte replacement 2. Adequate insulin
References: Franz MJ et al. (2003). A Core Curriculum for Diabetes Educators, 5th Ed., Diabetes Complications. American Association of Diabetes Educators, Chicago.

Chapter 19
Chronic Complications of Diabetes

Chronic complications of diabetes include cardiovascular disease, neuropathy, nephropathy, retinopathy, periodontal disease, as well as complications from flu and pneumonia. Research Studies Striving for optimal glycemic control is the cornerstone in the prevention of diabetes complications. The Diabetes Control and Complications Trial (DCCT) compared intensive vs. conventional control in persons with type 1 diabetes. Intensive diabetes care reduced the risk of: Retinopathy 76% Neuropathy 60% Nephropathy 50% and Cardiovascular disease 35%. Most participants were then enrolled in the Epidemiology of Diabetes Interventions and Complications (EDIC), an 8 year observation study. It showed further risk reduction in: Heart and blood vessel disease by 42% Heart attack, stroke, or heart and blood vessel disease-related death by 57%. Similarly, the United Kingdom Prospective Diabetes Study (UKPDS) showed that improved blood glucose control in those with type 2 diabetes reduced risk of: Retinopathy by 21% Nephropathy by 33%. The UKPDS also showed that improved blood pressure control reduced incidence of stroke and microvascular complications. However, in light of recommended treatment goals, only: 37% of adults with diagnosed diabetes achieved an A1C of <7% 36% had a blood pressure <130/80 mmHg 48% had a cholesterol <200 mg/dl 7.3% met all three above goals.
Cardiovascular Disease (CVD), the number one killer in those with diabetes, includes coronary artery disease, myocardial infarction, peripheral vascular disease and cerebral vascular disease. Risk factors for CVD include duration of diabetes, age, genetics, race and gender, along with modifiable risk factors listed in the table below. Guidelines for Reducing Risk of CVD Goal Blood Pressure Check at every medical visit Optimal: < 120/80 mmHg Minimal goal: < 130/80 mmHg Take medications as prescribed Cigarette Smoking Advise not to smoke Smoking cessation counseling for those who smoke Diabetes Strive for near normal blood glucose levels Monitor blood glucose levels regularly Take medications as prescribed Diet Limit saturated fats to <7% of total calories Limit dietary cholesterol to < 200 mg Limit intake of trans fatty acids DASH Diet (See chapter 13 Hypertension and Diabetes) Lipids Check lipid profile at least once a year LDL cholesterol < 100 mg/dl HDL cholesterol > 40 mg/dl (men); > 50 mg/dl (women) Triglycerides < 150 mg/dl Non-HDL cholesterol* < 130 mg/dl Take medications as prescribed Physical Activity 30 minutes of moderate-intensity activity on most (preferably all) days of the week Weight BMI of 18.5-24.9 management Waist circumference: < 35 (women); < 40 (men) Antiplatlet agents Consider low dose aspirin in those over age 40 Consider other antiplatlet agent if contraindication to aspirin * Current NCEP/ATP III guidelines suggest that "non-HDL cholesterol" (total cholesterol minus HDL) be utilized in those with triglycerides 200 mg/dl.
Lower Extremity Complications and Neuropathies Diabetic neuropathy involves acute nerve abnormalities, followed by more chronic nerve damage, atrophy and loss. Up to 70% of persons with diabetes have nerve damage, which can lead to lower limb amputation. Common foot problems associated with diabetes include circulation, structural and neuropathic issues. An annual comprehensive foot exam including a 5.07 monofilament test is recommended to screen for neuropathy. Suggested sites for monofilament testing are shown below.
Persons with diabetes should be taught to examine their feet daily and report changes to their health care provider, including redness, swelling, ulcers, temperature change or structural changes. Reducing risk for lower extremity complications includes smoking cessation, controlling blood lipids, blood pressure and blood glucose, weight management and being physically active. Autonomic neuropathy affects blood flow, perspiration and skin hydration. This can lead to dry, cracking skin and calluses. It may also impair ones ability to fight infection. Autonomic neuropathy can also affect other body systems: Genitourinary: problems with bladder, erectile dysfunction. Gastrointestinal: gastroparesis, diarrhea, constipation Cardiovascular: orthostatic hypotension, silent heart attack Impaired insulin counter-regulation: hypoglycemia unawareness Sudomotor: abnormal sweating Pupillary: difficulty seeing in the dark.
Nephropathy Diabetic nephropathy occurs in 20-40% of those with diabetes. Risk factors are listed below. Non-modifiable risk factors Duration of diabetes Family history of hypertension or diabetic nephropathy Race (higher in African American, Hispanic and Native Americans) Gender (men higher than women) Modifiable risk factors Hypertension Hyperglycemia Dyslipidemia Smoking
A family history of high blood pressure and/or the presence of hypertension increase the risk to develop kidney disease and hypertension speeds the progress of kidney disease when it already exists. Guidelines for reducing ones risk of Kidney Disease Goal Blood Pressure Check at every medical visit Optimal: < 120/80 mmHg Minimal goal: < 130/80 mmHg Take medications as prescribed Cigarette Smoking Advise not to smoke Smoking cessation counseling for those who smoke Diabetes Strive for near normal blood glucose levels Monitor blood glucose levels regularly Take medications as prescribed Diet Avoid a high protein diet. Limiting protein to 0.8 g/kg if any evidence of chronic kidney disease. DASH Diet (See chapter 13 Hypertension and Diabetes) Lipids Check lipid profile at least once a year LDL cholesterol < 100 mg/dl HDL cholesterol > 40 mg/dl (men); > 50 mg/dl (women) Triglycerides < 150 mg/dl Non-HDL cholesterol* < 130 Take medications as prescribed Lab Testing Microalbumin: < 30 ug/mg Type 1: within 5 years of diagnosis, then annually Type 2: at diagnosis, then annually Serum Creatinine and Calculated GFR*: annually Weight BMI of 18.5-24.9 management Waist circumference: < 35 (women); < 40 (men) * For GFR calculator: go to www.nkdep.nih.gov/professionals/gfr_calculators/
Retinopathy Diabetes is the leading cause of blindness in the US among those aged 20-74. Eye disease is 25 times more common among persons with diabetes than the general population. Listed below are common eye problems in persons with diabetes. Cataracts (clouding of the lens of the eye) Glaucoma (group of eye diseases that damage the optic nerve) Retinopathy (microvascular disease of the retina) Functional losses Blurry vision Reduced night vision Problems with glare Fading of colors None in early stages Loss of peripheral vision Difficulty with night or low vision None in early stages Later: blurry vision, floaters, flashing lights, sudden vision loss Treatment Surgery to replace the lens Lower eye pressure (eye drops or surgery) Dependent on severity Prevention BG control Annual eye exam Annual eyeball pressure check
Annual dilated eye exam Strive for optimal blood pressure, lipid and glycemic control Smoking cessation
Periodontal Disease Periodontal disease is the most common oral complication of diabetes. It is more prevalent in those with poorly controlled diabetes. Prevention of periodontal disease involves striving for optimal glycemic control, good oral hygiene (regular brushing and flossing of teeth) and follow-up every 6 months with a dental professional. Flu and Pneumonia Influenza and pneumonia are common, preventable infectious diseases associated with high mortality and morbidity in those with chronic diseases. Vaccination guidelines are listed below. Influenza: annual to all with diabetes 6 months of age. Pneumonia: one lifetime vaccine for adults with diabetes. A one-time revaccination is recommended for those >65 years of age previously immunized when they were <65 years of age if the vaccine was administered >5 years ago. References: Franz MJ et al. (2003). A Core Curriculum for Diabetes Educators, 5th Ed., Diabetes Complications. American Association of Diabetes Educators, Chicago. Saydah SH, Fradkin J, Cowie CC: Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. JAMA 291:335342, 2004. American Diabetes Association (2006). Clinical Practice Recommendations. Diabetes Care. Supplement. Vol 29.

Quick Reference Guide To Diabetes For Health Care Providers: Michigan Diabetes Outreach Network

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Michigan Diabetes Outreach Network QUICK REFERENCE GUIDE TO DIABETES FOR HEALTH CARE PROVIDERS Table of Contents

QUICK REFERENCE GUIDE TO DIABETES FOR HEALTH CARE PROVIDERS

Screening and Diagnosis of Diabetes

Criteria for screening type 2 diabetes in children:

Diabetes and Pre-diabetes Diagnosis:

Normal Pre-diabetes Diabetes

Gestational Diabetes Mellitus (GDM) Screening and Diagnosis:

QUICK REFERENCE GUIDE TO DIABETES FOR HEALTH CARE PROVIDERS

Diabetes Standards of Care: Prevention of Complications

Diabetes Self-Management Education for Persons with Diabetes

QUICK REFERENCE GUIDE TO DIABETES FOR HEALTH CARE PROVIDERS

Nutrition and Diabetes

In General, Persons with Diabetes...

Sugar and Diabetes

Fat Intake and Diabetes

Additional Help for the Overweight Client

QUICK REFERENCE GUIDE TO DIABETES FOR HEALTH CARE PROVIDERS

Physical Activity and Diabetes

For those with type 2 diabetes, regular activity may also:

For those with type 1 diabetes:

Risks of Physical Activity in Persons with Diabetes

Physical Activity Recommendations

References: American Diabetes Association (2006). Clinical Practice

Recommendations. Diabetes Care, Vol 29 (1).

QUICK REFERENCE GUIDE TO DIABETES FOR HEALTH CARE PROVIDERS

Oral Pharmacological Treatment of Type 2 Diabetes

Benzoic Acid Derivative Repaglinide (Prandin)

Back pain Headache

Impaired hepatic function Back pain Headache

D-Phenylalanine Derivative Nateglinide (Starlix)

_________________________________________________________ Alpha Glucosidase Inhibitors Acarbose (Precose) and Miglitol (Glyset)

Biguanides Metformin (Glucophage, Glucophage XR)

_________________________________________________________ Thiazolidinediones Pioglitizone (Actos) and Roisglitizone (Avandia)

ACTOplus Met (Actos/metformin)

QUICK REFERENCE GUIDE TO DIABETES FOR HEALTH CARE PROVIDERS

Insulin and Other Drugs Used in the Treatment of Type 2 Diabetes

Adjunct Therapies for Type 2 Diabetes

QUICK REFERENCE GUIDE TO DIABETES FOR HEALTH CARE PROVIDERS

Insulin and Type 1 Diabetes

Starting Insulin Doses

Prior to puberty Pubertal Post pubertal

Pre-dinner NPH can be delayed until bedtime to prevent nocturnal hypoglycemia or

Adjustment of Insulin (Twice - Daily Insulin Regimens)

QUICK REFERENCE GUIDE TO DIABETES FOR HEALTH CARE PROVIDERS

Can be premixed, but doing so will reduce flexibility of doses.

Can be premixed, but doing so will reduce flexibility of doses.

Comparison of Rapid Acting Insulin Analogs and Short Acting Insulin

Adjunct Therapies for Type 1 Diabetes

QUICK REFERENCE GUIDE TO DIABETES FOR HEALTH CARE PROVIDERS

Education Concerns of Insulin

Do not use Insulin if:

Insulin and Insulin Analogs

Appearance Clear Clear Clear

Cloudy Cloudy Cloudy Cloudy Cloudy

Product labeling information

QUICK REFERENCE GUIDE TO DIABETES FOR HEALTH CARE PROVIDERS

Insulin Pumps: What, When, Who, and How

Indications for Use

QUICK REFERENCE GUIDE TO DIABETES FOR HEALTH CARE PROVIDERS

Self Monitoring of Blood Glucose (SMBG)

Adults** < 110 mg/dl --< 140 mg/dl --< 6.5 %

* American Diabetes Association ** American Association of Clinical Endocrinologists

QUICK REFERENCE GUIDE TO DIABETES FOR HEALTH CARE PROVIDERS