Diabetes Management

Your guide to UNDERSTANDING

DIABETES

MANAGEMENT

a book about:

TYPE 1 AND TYPE 2 DIABETES

Diabetes Doctor__________________________

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Registered Dietitian ______________________

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Eye Doctor______________________________

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Foot Doctor ____________________________

Phone no. __________________

Pharmacy ______________________________

Phone no. __________________

Social Worker __________________________

Phone no. __________________

Home Healthcare ________________________

Phone no. __________________

Hospital ________________________________

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Other Healthcare Provider __________________

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Other Healthcare Provider __________________

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Other Healthcare Provider __________________

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© 2020/21, Hospital Educators Resource Catalogue, Inc. dba HERC PUBLISHING Photocopying or duplication of any kind is prohibited.

The purpose of this book is to provide information on diabetes care. The content is not intended to be used in place of professional medical care. Readers are advised to consult a physician or trained medical personnel when diagnosis or treatment is needed.

Order number 15-7

THIS BOOK IS FOR YOU CONTENTS

You may have just learned that you have diabetes or you may be at risk for developing diabetes. If so, you may feel a little overwhelmed. This book will help you understand how to manage your condition.

If you have had diabetes for a while and you have had a change in health, or if you are coping with changes in your treatment plan, this book will help you take care of yourself.

You may be concerned about your health or frightened about the future. If your feelings are getting in the way of managing your diabetes, or if you feel sad or depressed, talk to your diabetes educator or your other healthcare providers.

Sharing your feelings will help you work through them.

There is no cure for diabetes, but with the help of your healthcare providers, you can keep up with changes in treatment and manage your diabetes for a lifetime.

When you have finished reading this book, share it with your loved ones so that they, too, can understand how your diabetes can be managed.

What is diabetes

4

Pre-diabetes

5

Type 1 diabetes

6

Type 2 diabetes

6

Gestational diabetes

8

Managing diabetes

11

Monitoring blood sugar 13 Exercise

19

Your meal plan

22

Counting carbs

23

Food lists

26

Snack ideas

31

Added sugar

32

Sweeteners

32

Fiber

33

Sodium

34

Alcohol

34

Portion control

35

Weight loss

36

Eating out

38

Oral medication

39

Injectable medications

41

Insulin

42

Low blood sugar

51

High blood sugar

53

Ketoacidosis

54

Sick day guidelines

56

Complications

58

Smoking

63

Travel

66

Stress management

67

Problem solving

69

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WHAT IS DIABETES? Understanding diabetes will help you work with your healthcare team and understand your treatment program.

When you have diabetes, the food you eat cannot be used for energy because your body is not making enough insulin OR the insulin you have is not working the way it should. Insulin is a hormone made in the pancreas, an organ that lies behind the stomach.

Here’s how insulin normally works: Most food is broken down into a form of sugar called glucose. Glucose or sugar is the body’s main source of energy. Within 5 to 15 minutes of eating, sugar enters the bloodstream. As sugar enters the bloodstream, blood sugar levels rise. Special cells in the pancreas called beta cells detect the rising blood sugar levels. These cells respond by sending insulin into the bloodstream.

Insulin helps sugar leave the bloodstream and enter the cells. It does this by attaching to receptor sites on the surface of cells where it helps sugar move from the outside of the cell to the inside of the cell. The receptor sites act like doors. To understand how insulin works, think of a cell as a house with many locked doors. Insulin is the key that unlocks the doors and lets sugar leave the bloodstream and enter the cells. After sugar enters the body’s cells, the cells can use it for energy or store it for use later on.

Here’s what happens when you have diabetes: Your pancreas makes little or no insulin OR the insulin you have is not working the way it should. Either way, sugar cannot enter your body’s cells. Instead of entering the cells, it stays trapped in the bloodstream, raising the amount of sugar in your blood to abnormally high levels.

Cell

Your kidneys get rid of some of the extra sugar by filtering it from your blood and removing it from your body through your urine. But your blood sugar is still too high.

Receptor site

4

Because your body is not getting the sugar it needs, you are likely to feel tired. You may urinate more often than usual, you may be very thirsty or you may lose weight even though you are eating the way you normally do. These are all signs of diabetes.

See page 10 for information on the signs of diabetes.

Bloodstream

Receptor site Sugar (glucose) Insulin

PRE-DIABETES The term pre-diabetes identifies people who have blood sugar levels that are higher than normal, but not high enough to be diagnosed with diabetes. Prediabetes is sometimes called metabolic syndrome. People with this syndrome are at a higher risk for developing diabetes, heart disease and stroke.

You are more likely to develop pre-diabetes or metabolic syndrome if you have three or more of these risk factors: • fasting blood sugar between 100 - 125 mg/dL • blood pressure greater than or equal to 140/90 • triglyceride levels of 150 mg/dL or more • low HDL (good cholesterol) –– men less than 40 mg/dL; women less than 50 mg/dL • a waist measurement (at the belly button) –– men greater than 40 inches; women greater than 35 inches • physical inactivity –– less than 30 minutes per day • being overweight • family history of diabetes, heart disease or high blood pressure • non-caucasian background • history of gestational diabetes • other conditions associated with insulin resistance or metabolic syndrome

When people with pre-diabetes make lifestyle changes they may reduce or delay their chances of developing diabetes. Lifestyle changes include: • Losing weight if you are overweight. Lose 5 to 7% of your current weight. For example if you weigh 200 pounds, 5% is 10 pounds; 7% is 14 pounds.

• Increasing your activity to 150 minutes per week. Do some type of activity for 30 minutes a day or 15 minutes twice a day 5 to 7 days a week.

Maintaining these lifestyle changes can decrease your risk of developing Type 2 diabetes, heart disease and high blood pressure.

Blood tests

Normal Range

Pre-diabetes

Diabetes

Fasting plasma glucose test –– taken after an 8 hour fast

less than 100 mg/dL

100 - 125 mg/dL

126 mg/dL or greater on 2 separate occasions

75 gram oral glucose less than 140 mg/dL tolerance test taken after after 2 hours drinking glucose - after an 8 hour fast

between 140 - 199 mg/dL after 2 hours

200 mg/dL or after 2 hours

A1c test

5.7 - 6.4%

6.5% or higher

less than 5.7%

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TYPE 1 DIABETES With Type 1 diabetes, the body makes little or no insulin on its own. People with Type 1 diabetes need insulin shots (injections) each day.

Type 1 diabetes often occurs in children or adolescents, but adults can develop it as well. About 5 to 10 percent of all people with diabetes have Type 1 diabetes.

While the exact cause of Type 1 diabetes is not clearly understood, it is believed that: • There may be a history of diabetes in the family.

• There may be an environmental factor involved, which is not completely understood.

• The body’s immune system may mistakenly destroy the beta cells in the pancreas which produce insulin.

TYPE 2 DIABETES With Type 2 diabetes, the pancreas may make insulin but the body does not use the insulin properly. About 90-95% of all people with diabetes have Type 2 diabetes.

Many people who develop Type 2 diabetes may have a family member who has had Type 2 diabetes.

The symptoms may come on suddenly, but Type 1 diabetes develops over a long period of time.

Another factor in the development of Type 2 diabetes is weight gain.

Often as little as 10 to 15 pounds can affect the receptor sites on the surface of the body’s cells. The receptor sites affect how insulin is used in the body.

Excess weight gain, especially in the abdominal (belly) region, can cause insulin resistance.

No matter which type of diabetes you have, your goal is to control your blood sugar.

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MORE ABOUT TYPE 2 DIABETES As your blood sugar rises, your blood pressure and blood lipids (fats in the blood, such as cholesterol) begin to increase. When blood pressure and blood lipids increase, your blood vessels may be affected. High amounts of lipids in the bloodstream can cause fatty deposits to build up inside the blood vessel walls. High blood pressure can damage the blood vessel walls. Over time, high blood pressure and high blood lipids can cause a heart attack or stroke to occur.

Have your healthcare provider check your cholesterol levels and your blood pressure at least once a year. If your cholesterol levels or your blood pressure is high, your doctor may recommend lifestyle changes and, in some cases, medication to keep these levels within a healthy range. Your doctor also may want you to take an oral diabetes medication (pill) or insulin to control your blood sugar.

You may have developed Type 2 diabetes when you gained those first 15 pounds, but it is not too late to get it under control. No matter how long you have had diabetes, making lifestyle changes will help improve blood sugar control.

Type 2 diabetes tends to occur in adults who: • are over 45 years of age • have a family history of Type 2 diabetes • are overweight • are physically inactive (exercise less than 30 minutes a day) • belong to a high-risk ethnic or racial group (such as Native-American, African-American, Hispanic, Asian-American and Pacific Islander) • women who have had gestational diabetes

Type 2 diabetes in children and teens:

Type 2 diabetes used to be called “adult onset” diabetes because it was most likely to develop in adults. However, today children and teens are developing Type 2 diabetes. Experts don’t fully understand why some children develop Type 2 diabetes and others don’t, but they believe these risk factors may be partly responsible for the growing number of youth with Type 2 diabetes.

• Being overweight. The more body fat a child has, the more resistant the cells become to insulin.

• Being inactive. Being inactive puts a child at risk for developing Type 2 diabetes. Regular physical activity helps with weight loss and causes the cells to be more responsive to insulin.

• Family history. Children with parents, siblings or other family members with Type 2 diabetes have a higher risk of developing it.

• Ethnicity. Native American, African American, Hispanic and Asian American children are at a higher risk for developing Type 2 diabetes.

• Gender. Girls are more likely to develop Type 2 diabetes than boys.

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G E S TA T I O N A L D I A B E T E S Gestational diabetes is a form of Type 2 diabetes that occurs during pregnancy. Like other forms of diabetes, gestational diabetes affects the way the body uses sugar.

When you are pregnant, the placenta produces more of certain hormones which help the body prepare for delivery. While hormones are needed during pregnancy, they can block the receptor sites on the surface of the cells so that insulin cannot help sugar enter the cells where it can be used for energy. As a result, the amount of sugar in the blood rises to abnormally high levels.

You and your baby are connected through the umbilical cord. The nutrition you take in goes directly to your baby through this cord. If your blood sugar is high, the baby’s blood sugar will be high. The baby will store this extra sugar as fat, and the chances of having a large baby (weighing more than 9 pounds) greatly increase. Delivering a large baby is difficult for mother and baby and there can be complications for your baby.

Testing for gestational diabetes The American Diabetes Association recommends that all pregnant women get tested for gestational diabetes during the 24th and 28th week of pregnancy. Beginning at about the 24th week, your placenta is producing large amounts of the hormones that block the insulin receptor sites.

Expectant mothers who are over the age of 35 years, are overweight or have a family history of diabetes may be tested in the first or second trimester. The test involves drinking a high glucose liquid –– then having a blood sugar test in one hour. If your blood sugar is 140 mg/dL or higher, you may be asked to take a second test to confirm the results.

You are at risk for developing gestational diabetes if you: • are over 25 years old • have a family history of Type 2 diabetes –– especially if your parents or siblings have Type 2 diabetes • have had gestational diabetes in a previous pregnancy • were overweight before your pregnancy • are a member of a high-risk group (African-American, Native American,

8

South or East Asian or Pacific Islander)

T R E AT M E N T F O R G E S TAT I O N A L D I A B E T E S Treatment for gestational diabetes involves making healthy choices.

Your healthcare provider and your diabetes educator will develop a treatment plan that will help you control your blood sugar. Here are some of the ways you can help: • Check your blood sugar 2 to 4 times a day. Keep records of your blood sugar and bring them along when you see your healthcare providers.

• Follow a healthy meal plan that includes 3 meals and 3 snacks each day.

It is a good idea to work with a Certified Diabeted Care and Education Specialist (CDCES) to learn how to limit the amount of carbohydrates you are eating as a way to control your blood sugar.

• Exercise daily (with your healthcare provider’s approval). Ask your healthcare provider what types of exercises are best for you. Low-impact activities, such as walking or swimming, are often recommended. Try to exercise at least 30 minutes each day.

• Take diabetes medications (if needed). If eating healthfully and exercising regularly do not lower your blood sugar enough, you may need to take oral diabetes medications (pills) or insulin.

• Stay at a healthy weight. Your healthcare provider will monitor your weight and discuss a healthy weight range with you.

Once your baby is born, your blood sugar should return to normal.

The American Diabetes Association recommends that women who have had gestational diabetes be screened 4 to 12 weeks after the birth of the baby with an oral glucose tolerance test. Women who have had gestational diabetes should be screened at least every 3 years for diabetes or pre-diabetes.

Women who have had gestational diabetes in one pregnancy have a greater chance of developing it in another pregnancy. They are also at a higher risk for developing Type 2 diabetes within the next 20 years. Maintaining a healthy weight, eating a healthy diet and exercising regularly will reduce your risk of developing Type 2 diabetes in the future.

The American Diabetes Association recommends that pregnant women with Type 1 or Type 2 diabetes take a low dose of aspirin starting at the end of the first trimester to lower the risk of pre-eclampsia. Pre-eclampsia happens when a woman has high blood pressure and protein in the urine during pregnancy. Before taking aspirin, discuss this with your healthcare provider.

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SIGNS OF DIABETES When you feel the signs of diabetes, your body is trying to tell you that something is wrong. Pay attention to your body. If you have the signs of diabetes, see your healthcare provider right away.

• Going to the bathroom often –– Your body is trying to get rid of the extra sugar by flushing it out of your body through your urine.

• Thirsty all of the time –– You may be thirsty for cold, sweet things. You have all the sugar you need in your blood, but your body cannot use it, so it makes you feel as though you need to take in more.

• Feel very tired and weak –– Since you don’t have enough insulin or the insulin you have is not working the way it should, sugar cannot enter your cells. Therefore, you do not have the fuel you need for energy. You feel tired all of the time, especially after any type of activity.

• Have an increase in appetite –– Your body feels like it is starving because sugar cannot get into the cells. You feel hungry, especially for sugary foods.

• Have unexplained weight loss –– Since your body cannot use the sugar in your blood for energy, it uses your body’s fat for energy. People with Type 1 diabetes may lose a lot of weight (such as 20 pounds in 2 weeks). People with Type 2 diabetes may lose a smaller amount of weight.

• Blurred vision –– High blood sugar can affect the fluid in your eyes and change the shape of your eyeballs. This is a symptom, not a sign of damage to your eyes. When your blood sugar levels decrease, your vision will improve. Improvement in your vision may take 4-6 weeks.

• Sores that are slow to heal –– Because your blood sugar is high, you may heal slower. The high amount of sugar in your blood feeds the growth of bacteria, so it is easier to get an infection in a sore or cut.

• Bladder and/or vaginal infections –– When your blood sugar is high, you urinate more often and your urine is very high in sugar. It is easy for bacteria to grow in dark, moist areas, such as your urinary tract, and cause infections.

• Feel irritable, moody or depressed –– Your body is going through a lot of changes. You don’t have any energy.

You may have trouble concentrating.

Everything is bothering you and you just don’t feel good.

When your blood sugar levels return to the recommended range, these symptoms will slowly go away.

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MANAGING DIABETES Whether you have Type 1, Type 2 or gestational diabetes, many of the management goals are the same.

People with Type 1 diabetes will always be on insulin.

Since their bodies do not make any insulin at all, they are dependent on insulin injections (shots).

People with Type 2 diabetes may need to make lifestyle changes to control their blood sugar levels. They also may need to take oral diabetes medication (pills) or insulin (along with making lifestyle changes) to control their diabetes.

Diabetes management involves: • Monitoring your blood sugar levels. Checking your blood sugar daily is the best way to know how well your diabetes is being managed. Your healthcare provider will tell you how often to check your blood sugar.

• Following a meal plan. Eating 3 meals a day –– about 4 to 5 hours apart –– gives your body fuel throughout the day. Do not overeat at any one time.

Have a small snack between meals if you need to.

• Exercising regularly (with your doctor’s approval). Regular exercise helps your body use the sugar in your blood. Your goal is to exercise 150 minutes each week. You should gradually work up to this goal.

• Maintaining a healthy weight. Being overweight puts you at risk for developing Type 2 diabetes and developing complications from diabetes.

Losing weight can help open the receptor sites on the surface of your cells, which helps sugar enter your cells and lowers the amount of sugar in your blood.

• Taking medication if needed. Sometimes your body needs help. Taking medication does not mean that you have failed. It means your body is changing and cannot make as much insulin as it once did or as much as you need. The most important thing to remember is that you need to do what you have to do to control your blood sugar.

11

Y O U R T R E AT M E N T P L A N Your healthcare team will provide you with the education and support you need to control your diabetes. If you have questions or if you need more information, contact them. No one can do this alone. Work closely with the members of your healthcare team. Call on them whenever you need help.

Your healthcare team is likely to include: • doctors • nurse practitioners • physician assistants • dietitians • nurses • exercise specialists

• pharmacists • physical therapists • ophthalmologists (eye doctors) • podiatrists (foot doctors) • counselors

Any of these healthcare professionals can be a Certified Diabetes Care and Education Specialist (CDCES). A CDCES has passed a national exam and has a great deal of experience and knowledge in diabetes education.

A CDCES often works in a doctor’s office, a hospital, a pharmacy or an outpatient clinic.

It’s comforting to know that a team of experts is ready and able to help you at any time. But remember, you are the person who must be responsible for the day-to-day management of your diabetes.

Assistance from your healthcare team and a positive attitude on your part can help you deal more successfully with your diabetes.

As you read this book, think about what you can change or improve to help you manage your diabetes.

Your treatment Your treatment is likely to involve: • monitoring (checking) your blood sugar • exercising regularly • following a diabetes meal plan • controlling your weight • taking medications (if needed) • managing stress 12

MONITORING YOUR BLOOD SUGAR Your healthcare provider will want you to check your blood sugar at home. This is called self blood glucose monitoring. It is important to check your blood sugar so that you know whether your diabetes treatment plan is working. If you take oral diabetes medication (pills), injectables or insulin, checking your blood sugar tells your healthcare provider if you need more or less medication. Checking your blood sugar also lets you make changes in your treatment that will keep your blood sugar as close to normal as possible.

Checking your blood sugar will tell you: • what your blood sugar level is at the moment • how food, exercise, medications, stress or illness is affecting your blood sugar • if you have high or low blood sugar There are two ways to check your blood sugar: • checking with the finger-stick method • checking with a continuous glucose monitoring system The finger-stick method involves pricking your finger for a drop of blood and placing the blood on or next to a test strip. The test strip is inserted into a device called a blood glucose meter. The meter reads the strip and shows your blood sugar levels through a display window. Every person with diabetes will start out checking their blood sugar by pricking a finger and using a blood glucose meter.

Every blood glucose meter is a little different. Make sure you know how to use your meter so that you will get accurate numbers.

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M O N ITO R IN G YO U R BL O O D S U G AR Here are some things you should do before you get started: • Contact your insurance company. Ask what type of blood glucose meter is covered by your policy. Also ask which glucose meter and test strips have the lowest co-pay. Find out which pharmacy or mail order company you should use. This information can help you save money on supplies.

• Clean the area you will use to get a sample of blood with soap and water and pat it dry or use an alcohol swab. Using friction helps to clean the area. For example, don’t just wipe off your finger to clean it. In order to thoroughly clean your finger, rub it a few times with soap and water. If there is any kind of sugar on your finger and you use that area for your sample, you will get a false high blood sugar reading.

Most healthcare providers recommend taking blood samples from your finger tip or the side of your finger. Other testing sites (such as your hands, forearms or thighs) may be used, but blood sugar readings are more reliable when samples are taken from the fingers, especially when blood sugar levels are changing.

• Every lancing device has different depth settings. Use the lowest setting that still allows you to get a drop of blood.

• Know where the blood should be placed on the test strip. The instructions on some strips will tell you to place blood on the side of the strip. Others will tell you to place the blood on the end of the strip.

• If you get an unexpected high or low blood sugar reading, wash the area again and retest. If, after thoroughly cleaning the area and taking another blood sample your blood sugar is still high, follow the guidelines given to you by your doctor or diabetes educator for treating high blood sugar.

Drink extra water. Recheck your blood sugar in 2 hours to be sure it is coming down. If it is not coming down, call your doctor right away.

• Write down your blood sugar numbers or call the customer service number on the back of the glucose meter to learn how to download your blood sugar levels. Show your blood sugar records to your healthcare provider.

You may be asked to check your blood sugar once or twice a day or a few times a week, OR you may be asked to check your blood sugar before a meal and again 2 hours after a meal. How often you check depends on your blood sugar levels and how much information your healthcare provider needs.

14

USING A CGMS Another way to check your blood sugar is with a continuous glucose monitoring system also called a CGMS. A CGMS continuously records blood sugar levels throughout the day and night. You can see this information at any time. A CGMS shows you what your blood sugar is at the exact time it is taken and it shows changes in blood sugar levels over a few hours or days.

This device helps you identify trends, such as whether your blood sugar drops significantly after an exercise class. These trends allow you to adjust your medications, food and exercise to keep your blood sugar within the recommended range.

A CGMS records blood sugar levels and stores them. You can download this information and review it with your healthcare provider so that, together, you can make informed decisions about your diabetes management.

Some CGMS have alarms that allow you to set a range that you want your blood sugar to be in most of the time. If your blood sugar goes below or above this range, the CGMS will send a signal so that you can make changes that will keep your blood sugar within the recommended range.

Many CGMS can send an alert to a smartphone to tell you or others that your blood sugar is not within the recommended range.

How does a CGMS work?

A CGMS measures blood sugar levels within the fluid that surrounds the cells below the skin. The CGMS is made up of a sensor, a transmitter and a monitor, which is sometimes called a receiver. The sensor is the part of the device that senses blood sugar levels within the fluid.

The sensor sends the blood sugar reading to the transmitter. The transmitter then sends the information to a monitor.

Your blood sugar reading shows up on a display screen on the monitor. The monitor is a separate hand held device. Many CGMS devices allow you to scan your blood sugar using a smartphone.

15

TYPES OF CGM SYSTEMS Here are three different types of CGM systems available. Your healthcare provider will help you decide which type of equipment is right for you.

1. CGMS has an external sensor (placed on the skin) usually on your arm. You can scan the monitor over the sensor to check your blood sugar. This sensor cannot communicate with an insulin pump. Your blood sugar reading can be sent to a smartphone. The sensor may need to be replaced every 7 to 14 days.

2. CGMS has a sensor that may be placed on your abdomen or your arm. It can communicate with an insulin pump. It lets you check your blood sugar and it also allows you to give more insulin if you need it or it can suspend your pump.

While your pump is suspended, it will not deliver insulin until you resume the pump. The sensor may need to be replaced every 7 to 14 days.

3. CGMS sensor is implanted under the skin on your arm by your healthcare provider. The sensor is left in place for 90 days. A removable and rechargeable transmitter is placed over the sensor. It sends the information to the monitor.

A CGM System can: • show your blood sugar in real time any time of the day or night • track your blood sugar 24 hours a day • show you trends in real time so that you can react to a high or low blood sugar reading before it becomes serious • allow you to review blood sugar readings over days and weeks to help improve your diabetes management

Safety You may need to remove your CGM sensor if you are having an MRI scan, a CT scan or diathermy treatment. Be sure to check the sensor to make sure that it is attached correctly so that it is providing accurate blood sugar readings. If the sensor is bumped or if the adhesive becomes lose, it may not function properly. Ask your health care provider if there are other safety precautions you should follow.

The people who benefit most are those who check the CGMS often and use the information to make informed decisions about their care. If your healthcare provider prescribes a CGMS for you, make the most of the information you collect. Work closely with your healthcare provider to keep your blood sugar within the recommended range.

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YO U R BLO O D SU G AR G O ALS Controlling diabetes means keeping your blood sugar as close to normal as possible. According to the American Diabetes Association, a normal fasting blood sugar for a person who does not have diabetes is less than 100 mg/dL. To get a fasting blood sugar reading, you cannot eat or drink for at least 8 hours before the test.

Your target blood sugar range A target blood sugar range is a range that people with diabetes should try to achieve. Your healthcare team will determine the target blood sugar range that is right for you. The American Diabetes Association recommends a target blood sugar range of 80 to 130 mg/dL before meals.

Your healthcare provider may ask you to check your blood sugar 2 hours after a meal. When you eat, it is normal for your blood sugar to go up.

Here are the American Diabetes Association’s recommendations for many non-pregnant adults with diabetes:

Timing of bloods sugar check

ADA recommendations

blood sugar before meals

80 to 130 mg/dL

blood sugar 1 to 2 hours after the beginning of a meal

less than 180 mg/dL

A low blood sugar is defined as less than 70 mg/dL. At this level many people start to feel the symptoms of low blood sugar.

A blood sugar of 150 mg/dL is considered high. Research shows that the complications of diabetes may occur when blood sugar levels are over 150 mg/dL for a long time. Generally, a long time may be about 5 years.

A healthy blood sugar range may be different for people who do not feel the symptoms of low blood sugar; people with serious medical problems; elderly people or very young people (under the age of puberty) and women who are pregnant.

17

KEEPING BLOOD SUGAR RECORDS Changes in food, work or exercise can affect your diabetes. Illness or stress can cause your blood sugar to go up. Changes in your daily routines can affect your blood sugar as well. Keeping a written record of your blood sugar will help you know if you need to change an oral medication. Most glucose meters and CGMS allow you to send your blood sugar readings to your healthcare provider. You also may be able to print a copy of your blood sugar readings and give it to your healthcare provider.

Record your blood sugar levels, what time of day you checked your blood sugar, what time of day you ate, how many carbohydrates you ate and how much medication you took at the time you checked your blood sugar. Give this information to your health care provider. If you skipped medication or took less than the normal amount, make a note with an explanation. This information allows you and your healthcare provider to discuss what you should do next time a similar situation arises.

Blood sugar control - A1c Test A single blood sugar test shows your blood sugar level at the exact time it is taken. Since your blood sugar can vary over the course of a day, a single blood glucose test is not the best way to check for overall control. An A1c test reflects the average glucose over the past 3 months. This blood test lets your healthcare provider see how well your diabetes is controlled over a period of time. An A1c test shows an estimated Average Glucose (eAG).

The target A1c for many non-pregnant adults is 7%. A less stringent A1c of 8% may be right for some people. Discuss your goals with your healthcare provider.

A1c %

Estimated Average Glucose (eAG)

5% 6% 7% 8% 9% 10% 11% 12%

97 126 154 183 212 240 269 298

American Diabetes Association A1c Ranges

18

Normal Range

Pre-diabetes Range

Diabetes Range

less than 5.7%

5.7% to 6.4%

6.5% or higher

EXERCISE Exercise helps lower your blood sugar in two ways. First, regular exercise can help you shed unwanted pounds, which can bring your blood sugar levels down. Second, exercise at the right level can make your body more sensitive to insulin, which can lead to a drop in blood sugar levels.

The best things you can do to control your diabetes are to lose weight (if you are overweight) and to exercise on a regular basis.

Try to do some sort of physical activity every day. Talk to your healthcare provider before you begin any type of exercise, especially if you have heart disease, a family history of heart disease, high blood pressure or if you are over 35 years of age.

If you have numbness in your feet or legs, do not run, jog or walk long distances without talking to your healthcare provider. If your feet are numb, you can easily step on a rock or an unlevel area and fall.

If you have any type of eye disease, talk with your healthcare provider before you start a strenuous exercise program or anything that involves weight lifting.

Start out slowly and gradually increase your pace and the amount of time you exercise. Warm up and cool down by doing some gentle stretching exercises before and after your exercise session.

Here are some common questions and answers that may help you get started: Where do I find the time to exercise?

You have to decide how important exercise is to you.

Do you value being healthy? Ask yourself, “How well do I want to live and how long do I want to live well.” Everyone with diabetes has to make a choice about how much to exercise, what to eat and how much he/she is willing to do to control diabetes. Will you choose to live long and well? As we age we lose strength and our endurance levels decrease. Exercise helps us maintain our strength, increases our endurance and improves our quality of life.

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MORE ABOUT EXERCISE How do I start a safe exercise program?

Talk to your healthcare provider about getting started. Ask what types of exercises are right for you. Start slowly and gradually increase your pace and the amount of time you exercise. Warm up your muscles before you start with slow, gentle stretching exercises.

Walking is often suggested as a good way to get started. If your doctor says it is OK for you to walk, start with 5 minutes twice a day or the amount of time you can exercise without overdoing it. If you get to a point where exercise is causing pain or discomfort, stop increasing the amount of time you exercise. Begin increasing your time again when your exercise sessions become easier to do. Always work within your body’s limits.

If you are not able to walk, chair exercises may be suggested.

Many libraries or bookstores have tapes or CDs you can use to do your exercises. The effect of exercise on lowering your blood sugar can be seen up to 24 hours after your exercise session.

How much exercise should I do to benefit from the activity?

When you exercise your body uses sugar for energy. After about 20 minutes of activity, your body begins to use fat for fuel. If you want to burn sugar you have to exercise for at least 20 minutes. If you want to lose weight, you have to exercise for more than 20 minutes.

What time of day is the best time to exercise?

Generally, earlier in the day is better. The earlier in the day you exercise, the more blood sugar you use throughout the day. If you exercise at night, there is an increased risk of having low blood sugar when you are asleep, especially if you are on insulin or if you take diabetes pills to lower your blood sugar. Always check your blood sugar before you go to sleep.

If you cannot exercise in the morning, exercise when you can. Be sure to eat a snack before you go to bed if your blood sugar is low. The key is to move around as much as possible, for example: • You can walk around the baseball field when you take your child to practice.

• You can walk in the mall or a large store when you shop or look around.

• You can walk for 10 minutes over your lunch break.

• You can walk up and down the stairs instead of using the elevator.

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EXERCISE GUIDELINES When you exercise, here are some things to remember: • Check your blood sugar before and after you exercise. Exercise can lower your blood sugar for 12 to 24 hours after your exercise session. Watch for signs of low blood sugar. When you first start an exercise program, the chance of having low blood sugar is higher than when your body gets used to a regular exercise schedule.

• If your blood sugar is above 250 mg/dL, do not do any type of vigorous exercise. Vigorous exercise during a time when your blood sugar is high can actually cause your blood sugar to increase even more. Try to figure out why your blood sugar is high. Bring your blood sugar back down to your target range before doing any vigorous activities.

• If your blood sugar is below 100 mg/dL and you will be exercising at a moderate to high intensity, eat a light snack which contains about 15 grams of carbohydrate before you exercise. This will help prevent you from having low blood sugar while you exercise.

• Do not do any strenuous exercise if you are ill. Your body is stressed because you are sick and your blood sugar is likely to be high. Strenuous exercise can raise your blood sugar even more.

• Do not inject a fast or rapid-acting insulin into an area of your body that you will use when you exercise. For example, if you are going to be biking, avoid using your legs as an injection site.

• Stop exercising and contact your healthcare provider you have any of these symptoms: – discomfort in your chest, neck, jaw or arms – dizziness, fainting or nausea – short-term changes in your vision – shortness of breath • Take along a source of carbohydrate in case of low blood sugar. Carry glucose tablets, Lifesavers® or hard candy that you can eat quickly if you have symptoms of low blood sugar.

• Wear well-fitting athletic shoes. Your shoes should have good support and fit your feet. Wear socks without holes or tears. Check your feet for red spots or blisters after you exercise.

• Wear medical identification. Carry a cell phone in case you need help.

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YOUR MEAL PLAN Learning how to eat well is an essential part of managing diabetes. The right foods can help you maintain a healthy weight and keep your blood sugar at a steady level. Eating well is the key to taking control of your diabetes and avoiding diabetesrelated health problems. Begin with these guidelines: • Eat 3 balanced meals a day.

Although there are some general guidelines, there is no universal nutrition plan that every person with diabetes should follow.

• Eat meals 4 to 5 hours apart.

• Do not skip meals.

• Eat small snacks between meals if you need them.

Meal plans should be tailored to each person’s individual needs. Working closely with a certified diabetes care and education specialist (CDCES) will help you develop a meal plan that is right for you.

• Eat a variety of foods.

• Eat plenty of non-starchy vegetables, fruits, lean protein and whole grain foods.

• Limit foods that are high in saturated fat.

• Minimize foods containing added sugar and refined grains.

• Choose whole foods rather than highly processed foods.

Whole foods are foods that are unprocessed and unrefined, or processed and refined as little as possible.

• Drink an 8 ounce glass of water 6 to 8 times a day.

If your diabetes educator suggests using the “Plate” guidelines, these tips will help you plan your meals:

Water

• Put non-starchy vegetables on half of your plate.

Dairy

Fruit

• Divide the other side of your plate into two sections.

In one section, put lean protein foods. In the other section put whole-grain foods and starchy foods.

Use a 9 inch plate.

Lean

• Add one serving of fruit or one serving of a low-fat, 1% or fat-free dairy food. You may add both if your meal plan allows for both foods.

protein Non-starchy

foods

vegetables

• Choose healthy fats in small amounts.

Whole-grain foods &

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• Drink water with your meal.

starchy

• You may add a low-calorie, sugar-free drink, such as coffee or sugar-free tea if you want to do so.

foods

food

C A R B O H Y D R AT E F O O D S Carbohydrates affect blood sugar the most. They are the body’s main source of energy. People with diabetes are often asked to count how many grams of carbohydrate they eat per meal.

Your goal is to eat about the same amount of carbohydrates (carbs) at each meal. Keeping your carbohydrates at a consistent level will help you control your blood sugar levels.

Examples of carbohydrate choices are: • grains • breads, cereals • pasta, rice • starchy vegetables • dried beans, lentils • fruit, fruit juices • milk, yogurt and other dairy foods • sweets, such as sugary foods and drinks About 90 to 100 percent of the carbohydrates you eat enter your bloodstream within a couple of hours after you eat them.

C O U N T I N G C A R B O H Y D R AT E S The total number of carbohydrates you should eat at a meal or a snack is based on your weight, age and activities. A dietitian or a Certified Diabetes Care and Education Specialist can help you decide the number of carbohydrates you need each day.

When you count carbohydrates, you keep track of foods that contain carbohydrates.

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W H AT I S A C H O I C E O R S E R V I N G ?

A carbohydrate choice or serving is equal to 15 grams of carbohydrate. By looking at the nutrition facts portion of a food label you can determine how many carb choices there are in the food. If you count carbs, the nutrition facts on the label will tell you how many grams of carbohydrate are in a serving of food.

The following pages contain lists (or examples) of carbohydrates.

Each food listed also has a serving size. Here are examples of serving sizes.

1 carbohydrate choice (15 grams of carbohydrate)

2 carbohydrate choices (30 grams of carbohydrate)

3 carbohydrate choices (45 grams of carbohydrate)

1 slice of bread

2 slices of bread

2 slices of bread and 1 cup of yogurt

1/3 cup cooked pasta

2/3 cup cooked pasta

1 cup cooked pasta

1 small piece of fruit

1 large piece of fruit

1 1/2 cups flaked cereal and 1 cup of milk

Below is a general guide for planning a balanced meal. Your dietitian will work with you to develop a meal plan that meets your individual needs.

Inactive women Women

Inactive men

Men

Carbohydrate per meal

30-45 grams

45-60 grams

45-60 grams

60-75 grams

(2-3 carb choices)

(3-4 carb choices)

(3-4 carb choices)

(4-5 carb choices)

Protein per meal

2 oz.

2-3 oz.

2-3 oz.

3-4 oz.

Servings added Fat per meal

1

1-2

1-2

2-3

Calories per day

1200-1400

1500-1800

1500-1800

2000-2400

Carbohydrate per day

150 gm

200 gm

200 gm

300 gm

(14 grams) (5 grams)

(14-21 grams) (5-10 grams)

(14-21 grams) (5-10 grams)

(10-15 grams)

The amount of carbohydrates per day listed here should be distributed (eaten) evenly throughout the day.

Inactive means less than 30 minutes of exercise per day.

Active means greater than 30 minutes of exercise per day.

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(21-28 grams)

READING LABELS Nutrition Facts label makes it easier for you to make healthy choices.

SERVING SIZE / SERVINGS PER CONTAINER Pay close attention to the serving size to determine how much you can eat based on your meal plan.

CALORIES Calories on the food label are figured per serving. In this food, if you ate both servings, you would count this food as 460 calories.

TOTAL FAT AND SATURATED FAT You should have no more than 50 to 60 grams of total fat per day. No more than 10% of of your total daily calories should come from saturated fat. If you have heart disease or if you are trying to lower your LDL cholesterol, you may be advised to reduce your saturated fat to no more than 5 to 6% of your total daily calories.

TRANS FAT Trans fat is more harmful for your heart and blood vessels than saturated fat. Avoid foods which contain trans fat.

SODIUM Most people should eat less than 2,300 milligrams of sodium a day.

Your healthcare providers may have more specific guidelines depending on your health and special needs. Follow your healthcare provider’s guidelines concerning your sodium intake.

TOTAL CARBOHYDRATE Check the total carbohydrate in 1 serving. Controlling your carbohydrates is the key to improving your blood sugar levels.

SUGARS Sugars are part of the total carbohydrate. Count total grams of carbohydrate rather than just the amount of sugar the food contains.

Knowing how much sugar is in 1 serving will tell you how fast the food will raise your blood sugar.

ADDED SUGARS Added sugars refer to sugars and syrups that are added to foods and beverages whern they are processed or prepared. Added sugars do not include naturally occurring sugars such as those found in fruit.

You should keep added sugars to less than 10% of the total calories you eat each day.

FIBER Fiber contains carbohydrates. Women should eat 28 grams of fiber per day; men should eat 38 grams of fiber per day. If the food contains more than 5 grams of fiber, you may be able to subtract the amount of fiber from the total grams of carbohydrate. Some people may be instructed NOT to subtract fiber from the total grams of carbohydrates. Ask your diabetes educator or your dietitian for advice on this.

Nutrition Facts 8 servings per container Serving size 2/3 cup (55g) Amount per serving

Calories

230 % Daily Value*

Total Fat 8g

10% 5%

Saturated Fat 1g Trans Fat 0g

Cholesterol 0mg Sodium 160mg Total Carbohydrate 37g

0% 7% 13% 14%

Dietary Fiber 4g Total Sugars 12g Includes 10g Added Sugars

20%

Protein 3g 10% 15% 45% 6%

Vitamin D 2mcg Calcium 200mg Iron 8mg Potassium 235mg

* The % Daily Value (DV) tells you how much a nutrient in a serving of food contributes to a daily diet. 2,000 calories a day is used for general nutrition advice.

Carb. choices Carb. grams 1. . . . . . . . . . . . . . . . . . . 11 – 20 1-1/2 . . . . . . . . . . . . . . . 21 – 25 2 . . . . . . . . . . . . . . . . . . 26 – 35 2-1/2 . . . . . . . . . . . . . . . 36 – 40 3 . . . . . . . . . . . . . . . . . . 41 – 50 3-1/2 . . . . . . . . . . . . . . . 51 – 55 4 . . . . . . . . . . . . . . . . . . 56 – 65 4-1/2 . . . . . . . . . . . . . . . 66 – 70 5 . . . . . . . . . . . . . . . . . . 71 – 80

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C A R B O H Y D R AT E C H O I C E S S TA R C H (1 choice = 15 grams of carbohydrate and 80 calories) Bread White or wheat bread Cornbread Bagel, large (4 oz.)

English muffin French toast Hamburger or hotdog bun Muffin, low-fat Pita pocket - 6 inch Pancake, from mix - 4 inch Tortilla, corn or flour - 6 inch Waffle, 4 l/2 inch

1 slice (1 oz.)

2” square 1/4 1/2 (1 oz.)

1 slice 1/2 (1 oz.)

1 small 1/2 1 1 1

Crackers and snacks Animal crackers Graham crackers Pretzels Saltine-type crackers Popcorn, no fat added

8 3 squares 3/4 oz.

6 3 cups

Starchy vegetables Baked beans 1/3 cup Corn, canned 1/2 cup Peas, green 1/2 cup Mixed, frozen 1/2 cup Beans, dried 1/2 cup (pinto, navy, kidney, lima, etc.)

Cereal Bran cereal Corn flakes Granola, low-fat Hot (cooked) cereal, like Cream of Wheat Oatmeal - old fashioned Oatmeal - regular instant Puffed cereal Raisin bran Sugar frosted cereal

1/2 cup 1/2 cup 1 package 1 1/2 cup 1/3 cup 1/2 cup

Pasta and grains Pasta, cooked Rice, white (cooked) Rice, brown (cooked)

1/3 cup 1/3 cup 1/3 cup

Starchy vegetables Parsnips Potato, baked or boiled Potato, mashed or hash browns Squash (acorn, butternut, winter) Sweet potato Yam French fries Steak fries

1/2 cup 1/2 cup 1/2 cup 1/2 cup 1/2 cup 1/2 cup 10 6

1/2 cup 3/4 cup 1/4 cup

FRUIT (1 choice = 15 grams of carbohydrate and 60 calories) Apple, unpeeled Banana - 4 inch Blueberries, blackberries Canned fruit, unsweetened Cantaloupe (cubed) Figs Grapefruit Grapes or cherries Honeydew melon (cubed) Orange

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1 small 1 3/4 cup 1/2 cup 1 cup 1 large (3 oz.)

1/2 large (6 oz.)

12 to 15 1 cup 1 small (6 oz.)

Plums Raisins Raspberries Strawberries, fresh Watermelon (cubed)

2 small (5 oz.)

2 Tbsp.

1 cup 1 1/4 cup 1 cup

Fruit juice Apple, orange Grapefruit, pineapple Grape, peach, pear, prune Cranberry juice, reduced cal.

Diet V-8 Splash®

1/2 cup (4 oz.)

1/2 cup (4 oz.)

1/3 cup (3 oz.)

1 cup (8 oz.)

5 cups

MILK (1 choice = 12-15 grams of carbohydrate and 90 to 150 calories) Whole, 1% or 2% milk Skim or lowfat milk Yogurt, fruit-flavored, light

Yogurt, fruit-flavored, nonfat or low-fat, artificially sweetened 1 cup Buttermilk, nonfat or low-fat 1 cup

1 cup 1 cup 1 cup

O T H E R C A R B O H Y D R AT E C H O I C E S These foods can fit into your meal plan, but the serving sizes are smaller and they lack important vitamins and minerals. (1 choice = 15 grams of carbohydrate) Brownie, unfrosted - 2-inch square Cake, no icing - 2-inch square Casserole Chocolate syrup Cocoa mix, sugar-free, reduced cal.

Cookie, with cream filling Cookie, sugar-free Frozen yogurt, nonfat or low-fat Frozen yogurt, fat-free, sugar-free Frozen fruit juice bars, 100% juice Gatorade® G-2 Gatorade® Gelatin, regular Gingersnaps Granola bar

1 1 piece 1/2 cup 2 Tbsp.

3 Tbsp.

2 small 3 small 1/3 cup 1/2 cup 1 bar 1 cup 2 cups 1/2 cup 3 1 bar

Ice cream, regular or light Jam, jelly, honey, syrup Jelly beans LifeSavers® Pudding, no sugar, made w/skim milk Pie, pumpkin or custard Pizza, thin crust Potato chips Tortilla chips Salad dressing, fat-free Sherbet or sorbet Soup (most kinds) Spaghetti sauce V-8® or tomato juice

1/2 cup 1 Tbsp.

9 8 1/2 cup 1/16 of pie 1 slice 12-18 chips 9-13 chips 1/4 cup 1/4 cup 1 cup 1/2 cup 1-1/2 cups

N O N - S TA R C H Y V E G E TA B L E S (1 choice = 5 grams of carbohydrate and 25 calories) A choice or serving is 1/2 cup of cooked vegetables or 1 cup of raw vegetables. You should eat 3 to 5 servings of vegetables a day. A serving of vegetables at meal or snack time does not have to be counted in your meal plan.

Artichokes Asparagus Beans (green, wax) Bean sprouts Beets Broccoli Brussel sprouts Cabbage

Carrots Cauliflower Celery Collard Greens Cucumbers Eggplant Green onions Jicama

Kohlrabi Leeks Mushrooms Okra Onions Pea pods Peppers Radishes

Salad greens, lettuce Spinach Tomatoes Turnips Water chestnuts Yellow squash Zucchini

Since these vegetables are high in nutrients and lower in calories they do not affect your blood sugar as much as starchy vegetables, such as corn and peas.

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PROTEIN Protein provides nutrients for building cells, tissue, bones and muscles. A serving of protein is 1 ounce. Two to 3 ounces of protein are usually suggested at each meal. Your dietitian will tell you how much protein to eat. Meat servings are based on cooked meats with fat and bone removed. Meat can have a lot of fat - a serving may contain 3 to 8 grams of fat. When possible, buy lean meats and low-fat or fat-free cheeses and other foods.

The thumb to the first joint is about 1 ounce

The palm of a woman’s hand is about 3 ounces

A deck of cards is about 3 ounces

M E AT A N D M E AT S U B S T I T U T E S ( P R O T E I N ) (1 choice = 0 gms of carbohydrate, 7 gms of protein, and 3-8 gms of fat and 50-100 calories)

Meat (1 ounce portion) Beef Chicken Fish Lamb Pork Wild game *Canned tuna *Hot dogs

Meat substitutes Turkey Veal Seafood Shellfish Shrimp Crab *Beef jerky *Deli/lunch meats

Cottage cheese Cheese Egg Nuts Peanut butter Tofu

Greek-style yogurt

1/4 cup 1 oz.

1 1/4 cup 1 Tbsp.

1/2 cup 1/2 cup

(non-fat plain)

F AT C H O I C E S (1 choice = 0 gms of carbohydrate, 5 gms of fat and 45 calories) Oil (canola, olive, peanut, etc.)

1 tsp.

Margarine, reduced-fat 1 Tbsp.

Mayonnaise 1 tsp.

Mayonnaise, reduced-fat 1 Tbsp.

Salad dressing, reduced-fat 2 Tbsp.

Cream cheese 1 Tbsp.

Cream cheese, reduced-fat 2 Tbsp.

Cheese sauce 2 Tbsp. *Olives, black or green 1 oz. *Bacon (0.3 oz size slice) Medium slice

Butter Almond butter Hazelnut butter Cream, half and half Nuts: almonds, cashews, walnuts Peanuts Peanut butter Seeds: sunflower, pumpkin, flax Sour cream Sour cream, reduced-fat

1 tsp.

1 Tbsp.

1 Tbsp.

2 Tbsp.

1/4 c. (6 nuts) 1/4 c. (10 nuts) 1 Tbsp.

1/4 c. (1 oz.)

2 Tbsp.

3 Tbsp.

Fats are the most concentrated source of calories. Your body needs some fat. It is only when you eat too much fat or the wrong kind of fat that it becomes a problem.

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*These foods are high in sodium and should be eaten sparingly

M O R E A B O U T F AT Unsaturated fats mainly come from plants. They can be monounsaturated or polyunsaturated. Polyunsaturated and monounsaturated fats are high in total fat and have as many calories as saturated fat. However, choosing an unsaturated fat is a healthier option than choosing a saturated fat or a trans fat.

Ask your dietitian about including these fats in your diet.

Omega-3 fatty acids are fats which seem to positively influence a number of factors related to protection from cardiovascular disease. Your dietitian may suggest that you add or eat more foods which contain Omega-3 fats.

Saturated fats are found mainly in foods that come from animals. Eating too much saturated fat can lead to high cholesterol. Having high cholesterol increases your risk of heart disease (heart attack or stroke). Limit or avoid saturated fats.

Trans fats also can increase your risk of cardiovascular disease. Trans fats may be found in commercially baked goods, stick margarine, and vegetable shortening, and they are often used to fry foods. Trans fats are even more harmful for your heart and blood vessels than saturated fats. Avoid foods which contain trans fats.

To reduce the fat in your meals:

•

Choose lean meat. Avoid high-fat meats such as luncheon meats. Limit high-fat choices to 3 times (or less) a week.

• Trim fat from meat and remove skin from poultry before

cooking. Bake, broil, grill, or steam foods instead of frying.

• Include low-fat or nonfat foods in your meal plan. Use

fat-free or low-fat cheese and yogurt rather than the regular versions. Replace regular salad dressings with low-fat or nonfat dressings.

• When cooking, try to use vegetable oils (3/4 cup of liquid oil may be used in place of 1 cup of solid shortening). Examples of vegetable oils are olive oil, canola oil, and peanut oil.

E X A M P L E S O F F AT S

■ Polyunsaturated fats corn oil, safflower oil sesame oil, soybean oil sunflower oil, walnuts & seeds ■ Monounsaturated fats avocados canola, olive & peanut oil most nuts ■ Omega-3 fats fish oil, flax oil, canola oil fish, such as herring, mackerel, salmon, anchovies, oysters, sardines English walnuts, butternuts, soybeans flax seed (ground) No more than 25 to 35% of your total daily calories should come from fat.

■ Saturated fats bacon butter & lard sausage (all kinds) polish dogs & hot dogs luncheon meats solid shortening potato & corn chips cream & sour cream ice cream chocolate fat in red meat poultry skin cocoa butter coconut & palm oil regular cheese whole-milk dairy products fried foods ■ Trans fats baked goods fried foods solid shortening French fries doughnuts & cookies stick margarine

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FREE FOODS Any food or drink that contains less than 5 grams of carbohydrate per serving can be counted as a “free food.” Foods listed with a serving size, but less than 5 grams of carbohydrate, should be limited to 3 servings a day. These foods must be spread throughout the day. If you eat all 3 servings at one time, you will have to count the food as a carbohydrate serving. Here are some examples of free foods:

FAT-FREE OR REDUCED-FAT Cream cheese, fat-free Cocoa powder, unsweetened Non-dairy creamer (liquid) Non-dairy creamer (powder) Mayonnaise, fat-free Mayonnaise, reduced-fat Miracle Whip®, fat-free Miracle Whip®, reduced-fat Margarine, fat-free Margarine, reduced-fat Salad dressing, fat-free Whipped topping (like Cool Whip®) Salsa Sour cream, fat-free or low-fat Yogurt, fat-free

SEASONINGS Garlic Herbs (basil, oregano, rosemary, thyme, etc.)

Lemon juice Lime juice Pimento Spices Flavoring extracts Cooking wine Cooking spray Vinegar

1 Tbsp.

1 Tbsp.

1 Tbsp.

2 tsp.

1 Tbsp.

1 tsp.

1 Tbsp.

1 tsp.

4 Tbsp.

1 tsp.

1 Tbsp.

2 Tbsp.

1/4 cup 1 Tbsp.

2 Tbsp.

BEVERAGES (DRINKS) Carbonated water Club soda Coffee (without sugar) Diet soda Kool-aid® (sugar-free) Mineral water Tang® (sugar-free) Tea (without sugar) Sugar-free drink mixes Crystal Lite®

CONDIMENTS Barbecue sauce Butter Buds® Catsup Chili sauce Cocktail sauce Dill pickle - large Horseradish Molly McButter® Mrs. Dash® Mustard Picante sauce Soy sauce Steak sauce Taco sauce Worcestershire sauce

1 Tbsp.

3 tsp.

1 Tbsp.

1 Tbsp.

1 Tbsp.

1 1/2 3 Tbsp.

2 tsp.

1 tsp.

1 Tbsp.

2 Tbsp.

1 Tbsp.

1 Tbsp.

1 Tbsp.

1 Tbsp.

SUGAR-FREE OR LOW-SUGAR Sugar-free hard candy 1 piece Sugar-free gelatin Sugar-free popsicles Sugar-free gum Sugar-free jam or jelly 1 Tbsp.

Jam or jelly, low-sugar 2 Tbsp.

Sugar-free syrup 1/4 cup Sugar substitutes, like Equal® (aspartame) Sweet’n Low, Sugar Twin (saccharin) Splenda®, Sweet One (acesulfame K) Truvia (Stevia-based sugar substitute) TM

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SNACK IDEAS OTHER SNACKS IDEAS

You can satisfy your cravings and follow your meal plan with these snack ideas. Since the amounts may vary depending on the brands and size of the food item, check the nutrition facts label for the amount of carbohydrates the food contains.

These snacks contain 15 grams of carbohydrates with protein: • 1/2 of an English muffin with 1 Tbsp. peanut butter • 1/2 of a sandwich (1 slice of bread) with 1 Tbsp. peanut butter, or 1 oz. cheese or meat • 2 slices of lite bread with 1 Tbsp. peanut butter, or 1 oz. cheese or meat • 3 graham cracker squares with 1 Tbsp. of peanut butter • 1/2 c. of regular or sugar-free ice cream with peanuts • 1/2 c. of lite canned fruit with 1/4 c. of low-fat cottage cheese ® • 1/2 c. of sugar-free pudding with Cool Whip • 5 vanilla wafers with 1 Tbsp. peanut butter • 6 oz. lite yogurt These snacks contain 30 grams of carbohydrates with protein: • 3/4 c. unsweetened ready-to-eat cereal with 1 c. of skim or 1% milk • Whole sandwich with 2 slices of bread with 1 Tbsp. peanut butter, or 1 oz. cheese or meat • 9 to 13 tortilla chips with 1 oz. cheese sauce and/or meat • 8 animal crackers with 1 c. of skim or 1% milk • two 6-oz. lite yogurts • 1/2 c. oatmeal with 1 c. of skim or 1% milk These low-carbohydrates snacks are not calorie-free: • • • • • •

Mozzarella string cheese Hard-boiled egg Celery with peanut butter or low-fat cream cheese 1/4 to 1/2 c. of walnuts, almonds or pecans 10 pitted jumbo black olives Non-starchy raw vegetables

With every snack you eat, be sure to read the food label for the exact amount of carbohydrates per serving. Carefully check the serving size. If you have any questions, contact your healthcare provider or your diabetes educator.

These snacks contain 15 grams of carbohydrate: ■ JUICY 1-1/2 c. vegetable or tomato juice 5 c. diet V-8 Splash 1 small orange or apple 1 c. watermelon 1-1/4 c. fresh strawberries 3/4 c. fresh peaches or pineapple 1 c. honeydew 1 medium kiwi 1/2 c. canned fruit in lite juice 2 c. Gatorade G-2 ®

®

■ SALTY 10-12 baked chips 8 regular pretzels 12 mini pretzels Crackers: 45 Goldfish 40 Ritz Bits 27 Cheez-Its 19 Cheese Nips , reduced-fat 24 Cheese Nips , regular 12 Wheat Thins 3 Triscuits , reduced-fat 5 Triscuits , regular ®

®

®

®

®

®

® ®

■ CRUNCHY Raw vegetables with 1/4 c. hummus or 1/4 c. salad dressing 1 c. trail mix with seeds 1 low-fat granola bar 9-13 tortilla chips with 1/4 c. salsa 3 cups popcorn, no salt 16 Teddy Grahams 100 Calorie Snack Pack ■ SMOOTH 1/2 medium banana 1/2 c. sugar-free pudding 1/2 c. unsweetened applesauce 6 oz. Lite yogurt 1/2 c. frozen yogurt, sugar-free 1 fudge bar, sugar-free

3 1

ADDED SUGARS Added sugars refer to sugars and syrups, such as white, brown or raw sugar, honey and high-fructose corn syrup, that are added to foods and beverages when they are processed. Added sugars do not include naturally occurring sugars such as those found in fruits.

When sugar is added to foods and beverages, it adds calories without adding any nutrients. Eating and drinking foods with added sugar makes it harder for you to get the nutrients you need, stay within your calorie limit and control your blood sugar. Too much sugar also can lead to obesity and high cholesterol –– risk factors for developing cardiovascular disease.

The US Department of Health and Human Services recommends that we keep added sugar to less than 10% of the total calories we eat each day. Added sugars appear on the Nutrition Facts Label on food products. If the food does not have a Nutrition Facts Label, check the ingredients for added sugar. Look for words that mean that the product has added sugar, such as: • brown sugar & raw sugar • corn sweetener • corn syrup & malt syrup • dextrose & lactose • fructose & high-fructose • glucose, sucrose, trehalose & maltose • honey • invert sugar & turbinado sugar • molasses

A RT IFI CI AL S WEE TENERS The most common artificial sweeteners are aspartame, saccharin, sucralose, acesulfame K and stevia. They are much sweeter than regular sugar, so less of the product is needed to sweeten foods. Artificial sweeteners contain no sugar and few, if any, calories.

They will not affect your blood sugar. When used in cooking, they may cause food to taste bitter. Read the label before you cook with these products.

SUGAR ALCOHOL Sugar alcohol is another type of artificial sweetener that contains about half the calories and carbohydrates as sugar. Common sugar alcohols include maltitol, mannitol, sorbitol and xylitol. Sugar alcohols may be found in many foods labeled “sugar free”, such as candy, cookies, gum and soft drinks. For some people, even a small amount of sugar alcohol can cause gas, bloating and diarrhea. Talk to your diabetes educator about including foods with sugar alcohols in your meal plan.

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FIBER Fiber is the part of food that is not digested. Fiber helps you feel full longer. Fiber also helps lower blood cholesterol levels. Fiber may be soluble or insoluble. Soluble fiber helps lower blood sugar by taking longer to digest, especially after meals. Insoluble fiber is able to retain large amounts of water.

It increases stool volume, makes stool pass easily through the intestinal tract and helps prevent or treat constipation.

Experts recommend that women get 28 grams of fiber per day; men should get 38 grams of fiber per day.

To increase the amount of fiber you eat: • Increase your intake of whole grains. One of the best ways to increase your intake of whole grains is to choose 100% whole grain foods. Choose foods which list whole grains, such as whole wheat or whole oats, as the first ingredient. Half of the total grains you eat each day should be whole grains.

• Eat whole fruits instead of drinking fruit juices.

• Replace white rice, white bread and white pasta with brown rice and wholegrain bread. Eat whole-grain cereals and whole-grain or whole-wheat pasta.

• Snack on raw vegetables instead of chips and crackers.

• Eat more beans. Examples of beans are black, kidney, pinto and lima beans.

These beans contain both soluble and insoluble fiber.

Examples of soluble fiber:

Examples of insoluble fiber:

dried beans, peas, lentils high fiber cereals whole-grain breads oats, rye, chia, barley citrus fruits berries plums broccoli carrots Jerusalem artichokes onions potatoes sweet potatoes

bran whole-grain foods nuts seeds cauliflower celery green beans zucchini

3 3

SODIUM (SALT) Sodium is found naturally in many foods, however, most of sodium we eat is added to our foods during the processing or preparing of the foods. Sodium is found in higher amounts in table salt, seasonings and most foods eaten away from home.

Eating too much sodium can cause your body to hold fluids, which can lead to high blood pressure. Most people should eat less than 2,300 mgs. of sodium a day.

People who have specific health problems may be advised to eat less sodium. Ask your healthcare provider how much sodium you should have each day.

Limit or avoid high sodium foods, such as: boxed & frozen convenience foods canned beans & refried beans canned vegetables & vegetable juices canned fish, hot dogs, ham, sausage snack foods (crackers, chips)

salted nuts & seeds canned soups & broth canned tomatoes & tomato sauce most condiments garlic, onion, celery, seasoning salt & MSG

ALCOHOL The American Diabetes Association says that alcohol can be part of your meal plan ONLY IF your blood sugar is in good control. Drinking alcohol can make controlling your blood sugar difficult. You may forget to check your blood sugar or forget to take your medication. Alcohol may increase your appetite and cause overeating which can lead to high blood sugar, especially if you forget to take your medication. Alcohol also may dull your senses and you may not recognize the signs of low blood sugar and treat it quickly enough.

Drinking alcohol is especially a concern if you drink on an empty stomach, if your blood sugar is already low, if you over or under eat while you drink or if you take insulin or certain diabetes pills. Never drink alcohol if you are pregnant or if you have medical problems, such as neuropathy (nerve damage), pancreatitis (inflammation of the pancreas), high triglycerides or a history of alcohol abuse.

If your doctor says you can have alcohol once in a while, women should have no more than 1 drink a day; men should have no more than 2 drinks a day. Always have a meal before you drink alcohol.

Avoid sweet drinks or drinks that are made with regular soda pop or fruit juice.

One serving of alcohol is: • 4 ounces of dry wine (one small glass) • 12 ounces of lite beer • 1 1/2 ounces of hard liquor mixed with water or a sugar-free drink

3 4

PORTION CONTROL When you are trying to eat healthy it is important to keep track of how much you are eating. It is very easy to mis-judge portion sizes. You can eat too many calories and carbohydrates simply by not paying attention to the size of your portions.

Knowing how much food to eat is just as important as knowing what kind of food to eat.

Being able to identify portion sizes will help you balance the amount of food you eat. At first you will need to measure your serving sizes so that you know what 1/2 cup of cereal or 1 tablespoon of peanut butter looks like.

Food should always be measured after it is cooked and the fat and bones are removed. When measuring liquids, try measuring how much water will fill the glass you usually use at home. Most glasses are 12 to 16 ounces. A serving size of milk is 8 ounces. Once you see what your glass looks like with 8 ounces of liquid, you will know how much liquid to pour into your glass.

When you go out to eat, knowing how much to eat and what a portion size looks like will help you correct the portion size on your plate. You can ask for a box and put the extra amount in a box to take home, or you can split a meal with a friend.

1 to 2 oz. is what a 1 c. is equal to a fist cupped hand can hold

1 tsp. is about the size of a thumb tip

3 oz. of cooked chicken is the size of a deck of cards

Other portion size guides: • 1/2 cup is the size of a tennis ball • 1/4 cup is the size of a golf ball • 2 tablespoons is the size of a ping pong ball

Never eat from a box, sack or container. Put food on a plate or in a bowl so you can see how much you are eating. Put the correct portion size of snack foods in a plastic bag so that you do not overeat. (Non-starchy vegetables make great snacks.

Fresh fruit can satisfy a craving for something sweet.)

It’s easy to take “a little extra” or eat “a couple of bites” of something, but it all adds up. Extra carbohydrates raise your blood sugar. Extra calories increase your weight.

Stay committed to your meal plan. Rather than giving up your plan because you overate at one or two meals, learn from your mistakes. Everyone has a slip now and then. Forgive yourself and try again. You are worth the effort!

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WEIGHT LOSS If you are overweight, losing weight will help your body make better use of insulin. For some people, losing 10 to 15 pounds improves how the body uses insulin and helps achieve normal blood sugar levels.

It’s easy to talk about losing weight, but losing the extra pounds and keeping them off can be tough. Here are some guidelines that can help: • Take a couple of days and write down everything you eat. Write down everything, including the handful of nuts you ate as you walked through the kitchen. Then total the calories and carbohydrates. You are likely to be surprised.

Take a look at how you can cut back. How many calories were in the lemonade you had with your lunch? Did you have to get the large size serving? Now that you know how many calories and carbohydrates you are eating, cut back by 300 to 500 calories a day. You will lose one pound a week by doing this. As you cut back on carbohydrates, watch for signs of low blood sugar.

• Get into the habit of writing down everything you eat and drink each day or log onto a free app. There are many free apps that will look up the number of calories and carbohydrates in any food served at home or at a restaurant.

Most of us are not aware of the mindless eating that we do. Being honest with yourself and recording the amount of food you actually eat and the amount of liquid you drink will help you start losing weight. Awareness leads to control.

• Read labels. Look at the serving size and the number of calories that are in a serving. Often the serving sizes are much smaller than the amount you are likely to eat. By looking at the serving size and the calories, you can make the decision to leave the food alone or make a healthier food choice.

• Gradually change your food choices to include more fruits and vegetables. Eat colorful foods instead of white foods such as white potatoes and white rice. Eat fresh fruit instead of drinking fruit juice.

Fresh fruits are full of vitamins, minerals and fiber and they contain no added sugars.

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MORE ABOUT WEIGHT LOSS • Control your portions. One way to control the size of your portions is to eat off a smaller plate. If you are using a 12 inch dinner plate, change to a 9 inch salad plate. You can still eat what you enjoy –– you will just eat less of it. If you are using a 9 inch plate, fill it to within 1/2 inch of the rim. Use a regular dinner spoon instead of a larger spoon when you serve the food. This will help you serve up a smaller helping.

• Leave the food on the stove and measure out the proper portion sizes.

Don’t go back for second helpings.

• When you feel hungry, drink water. Sometimes hunger is a sign of dehydration. Drinking water may help you feel less hungry and more satisfied.

• Look for low-fat, low-sugar cookbooks that will help you prepare healthy meals. Bake, broil, grill or steam foods.

• Combine regular exercise with changes in your diet.

When you cut back on portions and increase your activity level, low blood sugar may occur. Talk to your healthcare team about making some changes that will help you prevent low blood sugar. Always watch for signs of low blood sugar and be prepared to treat it quickly.

• Plan for slips. It is not realistic to think that you can reach a weight loss goal by eating perfectly all of the time or avoiding temptation every day of your life. Expect to reach your goal, but plan for those times when you get off track.

Planning in this way will help you succeed and stay positive.

Believe you can, because you can!

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EATING OUT T I P S O N E AT I N G O U T

■ Order meats that are

baked, grilled or roasted (without fat), poached, or steamed.

■ Choose sandwiches

made with lean unbreaded chicken, turkey or roast beef. (Avoid high-fat, high-sodium sauces, regular cheese, or mayonnaise).

■ Avoid using high-fat

dressings, eggs, cheese or real bacon bits on your salad. Instead, choose fresh fruits and vegetables.

■ Order a salad. Ask for

the dressing on the side.

■ Ask for a taco salad

without the tortilla bowl, chips or sour cream.

■ Ask for fresh, raw, or

steamed vegetables without butter or sauce instead of french fries or fried or breaded vegetables.

■ If you are eating Asian

food, order steamed dishes such as vegetables.

■ If you are eating Mexi-

can food, order fajitas with vegetables, beef or chicken with little or no cheese.

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When you eat away from home you are never sure how the food is prepared. But with a little planning and careful attention, you can make good choices.

• Ask how the food is made. Some foods contain added sugar or are cooked with high-fat ingredients. Foods that are served with a red sauce may have added sugar in the sauce to make them taste sweeter. French fries may be soaked in sugar-water to make them crispier.

• Eat only the amount of food you should have.

– Ask for a take home box at the beginning of your meal and put the extra food in the box or share your meal with a friend.

– Order meat that is baked, broiled, grilled or steamed rather than fried. Avoid breaded food.

– Ask for the kid’s meal or the senior meal. It’s usually the same food, but the portions are smaller.

– If you go to a restaurant that puts bread or chips on the table, ask them not to.

• Know how many carbs are in the food you want to order. You can look up almost any restaurant or fast food place on line to see how many calories, carbohydrates and other nutrients (such as fats and sodium) are in the foods they serve. This will help you decide if the food is a good choice.

• Order ala carte. There is no reason that you have to order a big meal. Order what you want and know is right for you.

• If you take insulin before your meal, you may need to bring it with you. Some people take a shot just before they eat; others take it within 15 minutes after a meal. Talk to your healthcare provider about when to take your insulin. Do not take your insulin before your food is served. If there is a delay, you could have low blood sugar levels.

• Do you need dessert? Many restaurants have fruit instead of high-sugar desserts. Instead of going home feeling overly full with a high blood sugar level, plan ahead and take control by choosing wisely.

O R A L D I A B E T E S M E D I C AT I O N S ( P I L L S ) If you have Type 2 diabetes and meal planning, exercise and weight loss do not lower your blood sugar enough, your healthcare provider may want you to take oral diabetes medications (pills). Diabetes pills: • stimulate the pancreas to make more insulin • sensitize the body’s cells to use the insulin more efficiently • increase the glucose excretion from the kidneys If your medication is not listed here, it may be new. Ask your healthcare provider for information.

Type

Brand name

Generic name

How it works

Possible side effects

Sulfonylureas

Glynase® Glucotrol® Glucotrol XL® Amaryl®

Glyburide Glipizide

Stimulates the pancreas to release more insulin

Low blood sugar

Meglitinides

Prandin® Starlix®

Repaglinide Nateglinide

Stimulates the pancreas to release insulin for 2 hours after taken

Low blood sugar

Biguanides

Glucophage® Glucophage XR® Glumetza® Fortamet® Riomet® (liquid)

Metformin Metformin XR

Sensitizes the body to use the insulin it makes effectively. Keeps the liver from releasing excess glucose, especially during times of stress

Abdominal discomfort, nausea, diarrhea for for 10 to 14 days

Carbohydrate Inhibitor

Precose® Glyset®

Acarbose Miglitol

Slows the digestion of carbohydrate foods

Adominal discomfort, nausea

Thiazolidinedione (TZD)

Actos®

Pioglitazone

Sensitizes the body to use the insulin it makes

Fluid retention

Avandia®

Rosiglitazone

effectively

Dipeptidl Peptidase 4 Inhibitor (DPP-4)

Januvia® Onglyzia® Tradjenta® Nesina®

Sitagliptin Saxagliptin Linagliptin Alogliptin

Inhibits the DPP-4 hormone to allow effective use of the GLP-1 hormone

Nausea, joint pain

Sodium Glucose Cotransporter 2 Inhibitor (SGLT-2)

Invokana® Farxiga® Jardiance® Steglatro®

Canagliflozin Dapagliflozin Empagliflozin Ertugliflozin

Causes excretion of glucose in the urine in the urine

Bladder, vaginal or genital infections, dehydration

Glucagon-like Peptide-1 (GLP-1)

Rybelsus®

Semaglutide

Replaces the incretin hormone GLP-1 the body uses

Nausea, loss of appetite

Glimepride

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C O M B I N AT I O N O R A L M E D I C AT I O N S Combination medications are two diabetes medications in one pill. They have the same benefits and side-effects of each one of the pills.

Medication name

Combination of

Type of medication

Actoplus Met®

Actos® & Metformin

TZD & Metformin

Actoplus Met XR®

Actos® & Metformin XR

TZD & Metformin

Avandamet®

Avandia® & Metformin

TZD & Metformin

Avandaryl®

Avandia® & Amaryl

TZD & Sulfonylurea

Duetact®

Actos® & Amaryl

TZD & Sulfonylurea

Glucovance®

Glyburide® & Metformin

Sulfonylurea & Metformin

Glyxambi®

Jardiance® & Tradjenta®

SGLT2 & DPP4

Invokamet®

Invokana® & Metformin

SGLT2 & Metformin

Invokamet XR®

Invokana® & Metformin XR

SGLT2 & Metformin

Janumet XR®

Januvia & Metformin XR

DPP-4 & Metformin XR

Juvisync®

Simvastatin & Januvia

Cholesterol lowering & DPP4

Jentadueto®

Tradjenta® & Metformin

DPP-4 & Metformin

Jentadueto XR®

Tradjenta® & Metformin XR

DPP-4 & Metformin

Kombiglyze XR®

Onglyza & Metformin XR

DPP-4 & Metformin

Metaglip®

Glipizide® & Metformin

Sulfonylurea & Metformin

Oseni®

Nesina® & Actos®

DPP-4 & TZD

Prandimet®

Prandin® & Metformin

Meglitide & Metformin

Qtern®

Farxiga® & Onglyza®

SGLT2 & DPP-4

Steglujan®

Steglatro® & Januvia®

SGLT2 & DPP-4

Segluromet®

Steglatro® & Metformin

SGLT2 & Metformin

Synjardy®

Jardiance® & Metformin

SGLT2 & Metformin

Synjardy XR®

Jardiance® & Metformin XR

SGLT2 & Metformin

Trijardy XR®

Jardiance & Tradjenta &Metformin

SGLT2 & DPP4 & Metformin

Xigduo XR®

Farxiga® & Metformin XR

SGLT2 & Metformin

Kazano®

Nesina® & Metformin

SGLT2 & Metformin

• Keep a list of each medication you take in your wallet or your purse. Include over-the-counter and herbal medications, vitamins and all of your prescriptions. Include medication allergies or reactions you have had and which medications caused problems for you. Also include: –– name of the medication and dose (mgs, units, etc.)

–– how much you take each time you take it and the time of day you take it –– the purpose (what the medication is supposed to do) • Report any side effects you have. If you have side effects, stop taking the medication. Call your healthcare provider right away and find out what you should do.

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I N J E C T A B L E M E D I C AT I O N S ( t h a t a r e n o t i n s u l i n ) Several medications are available in an injectable form. These medications contain ingredients that cannot be put into a pill. The injectable medications listed here are not insulin. Instead, they help replace or enhance a hormone that your body naturally makes.

These medications help the body use insulin.

Type

Brand name

Generic name

How often to take

What it does

Possible side effects

Amylin

Symlin®

Pramlintide

Taken before each meal

Replaces the Nausea hormone amylin the body does not make

Glucagon like Peptide-1 (GLP-1)

Byetta® Victoza® Bydureon® Trulicity® Adlyxin® Ozempic®

Exenatide Liraglutide Exenatide XR Dulaglutide Lixisenatide Semaglutide

2 x a day 1 x a day 1 x a week 1 x a week 1 x a day 1 x a week

Replaces the incretin hormone GLP-1 the body loses

Nausea Diarrhea Headache

Inhaled insulin Inhaled insulin is a type of insulin that is inhaled through your mouth and into your lungs. It is used to control blood sugar. Inhaled insulin is usually used at meal time to replace your meal time injection of rapid-acting insulin. Inhaled insulin comes in an inhaler similar to the inhaler a person with asthma uses. It is a fine powder that you breathe into your lungs. It enters the tiny blood vessels through your lungs.

If you use inhaled insulin, you still have to inject a long-acting insulin. If you smoke or if you have lung disease, you may not be able to use an inhaled insulin. If you are interested in using inhaled insulin, ask your healthcare provider for information.

Insulin and GLP-1 combinations An injectable combination of insulin and a GLP-1 have the same benefits and side effects of each of the medications listed here. They are injected only once a day.

Type

Brand name

Generic name

How often to take it

Insulin & GLP-1

Soliqua®

Insulin Glargine & Lixisenatide

once a day

Insulin & GLP-1

Xultophy®

Insulin Degludec & Liraglutide

once a day

If a new medication of any type has been prescribed, find out if the medication replaces any medication you are currently taking. Ask if there are other medications you should stop taking.

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INSULIN If your body is not making enough insulin or using it efficiently, you may need insulin shots (injections). The purpose of insulin is to lower your blood sugar. There is no one “right” insulin dose. Every person with diabetes is different and has different needs.

How much insulin do you need? You need as much insulin as it takes to control your blood sugar. As you work with your healthcare provider, the amount of insulin you need will be adjusted.

There are many kinds of insulin. They are different in how fast or how slow they work. The challenge is determining which insulin is the best for you.

Normally, your body makes insulin 24 hours a day. This is called your basal or background insulin. When you have diabetes your body may not make enough insulin. Basal insulin is the continuous insulin that works throughout the day and night (that would normally be made and used by your body) that you will need to inject. Medium, long-acting or ultra-long acting insulin is used for basal insulin.

Normally, whenever you eat a meal or your blood sugar goes up, your pancreas releases extra insulin to help bring your blood sugar back down to normal levels. This extra insulin is called the bolus insulin. Bolus insulin is the dose of insulin that you will need to inject that works for a short time such as before a meal or when you have high blood sugar levels. Rapid or fast-acting insulin is used for bolus insulin.

CARE OF INSULIN Insulin is a sensitive medication. If it gets too hot or too cold it can be destroyed. Since it is generally clear, you cannot tell if your insulin has gone bad by looking at it. You can only tell when your blood sugar goes up for no reason.

The insulin vial or pen you are using does not have to be stored in the refrigerator once you have started using it. You should, however, keep your extra unused vials or pens in the door of the refrigerator. Your insulin should be kept at a consistent room temperature between 36 and 86 degrees Fahrenheit. If you are traveling, keep your insulin with you. Do not leave your insulin in a hot or cold car. If you are flying, do not keep it in your luggage.

Carry your insulin with you.

4 2

MORE ABOUT INSULIN Check the expiration date on your insulin before you open it. Throw away any outdated bottles of insulin. Unopened insulin is good until the expiration date on the vial or pen.

Once you start using a vial of insulin or an insulin pen, it is only good for a set number of days.

Type of insulin Pens or cartridges with cloudy insulin

How long to use after opening 10 to 14 days

Vials, pens or cartridges

28 days

Levemir®, Toujeo® U300

42 days

Tresiba®

56 days

U100 insulin All types of insulin have 100 units of insulin in every milliliter or cc.

Some insulin is now made in different concentrations. For example, with Humalog® U200 and Tresbia® U200, the U200 means there is half the volume of fluid. Toujeo® U300 contains one-third less fluid. The dose is the same, but there is less fluid in some types of insulin.

The only exception is Regular U500 insulin. This type of insulin is 5 times stronger than normal insulin. If you take this type of insulin, it’s important to let all of your healthcare providers know that you are taking U500 insulin.

Pre-mixed insulin Pre-mixed insulin or a pre-mixed insulin pen contains two kinds of insulin already mixed together. The mixing of the insulin is already done for you. Many pre-mixed insulins come in insulin pens or cartridges.

Insulin pens and insulin vials If you are using an insulin vial, you will have to insert the needle from the insulin syringe into the vial of insulin –– then draw the insulin from the vial into the syringe. It is important to get rid of air bubbles that may form in the insulin that is now in your syringe. Also, be sure you have the correct dose of insulin. There are 1000 units of insulin in a vial of insulin. If you are using an insulin pen. Be sure to prime your pen. Then simply screw the needle into the end of the pen, dial in the desired insulin dose and push down on a button to deliver the insulin.

4 3

WHERE TO INJECT INSULIN For insulin to be absorbed by your body, it should be injected into the fatty tissue just under your skin. The best places to inject insulin are the abdomen, buttocks, hips, thighs and upper arms.

Different areas absorb insulin faster than other areas. Insulin enters the bloodstream fastest from the abdomen and more slowly from the buttocks. Your doctor or diabetes educator will help you decide which areas should be used for your injections.

CHANGING INJECTION SITES Giving your insulin injection in the same spot can cause sores, lumps, indentations and a thickening of the skin. This makes it harder for insulin to be absorbed. That’s why you will need to change the area (site) you use for your injection. For example, some people will give their long-acting injections in the abdomen. They may then use their arms or legs as an injection site before their meals. That way, each site is used only once a day.

Injection sites should be 1 inch apart. Do not inject too close to moles or scars. Be sure to clean the site thoroughly before you give the injection. If you took a shower right before your injection, your skin is already clean, but if you came in from outdoors or if it has been a while since you had a shower, you will need to wash the area with soap and water or use an alcohol wipe.

When you clean the site, be sure to rub it a few times. The use of friction is actually what helps clean your skin.

What you do after your injection can make a difference in how quickly insulin is absorbed.

Parts of your body that are used during strenuous work or exercise will absorb insulin faster than other areas. For example, if you are going to use your arms and legs for strenuous work or exercise, you may be advised to use another site for your injection.

Keep your injection sites about 1” apart.

4 4

TYPES OF INSULIN All insulin lowers blood sugar. Insulin works in these different ways: • onset - how soon it begins to work

Brand name

Generic name

Rapid-acting insulin (clear) Apidra® Glulisine Humalog® Lispro Novolog® Aspart Humalog®U200 Lispro Fiasp® Aspart & Vitamin B3

• peak - when it works the hardest • duration - how long it keeps working

Onset

Peak

Duration

Vial

5 to 15 min 5 to 15 min 5 to 15 min 5 to 15min 2 1/2 to 4 min

1 to 2 hrs 1 to 2 hrs 1 to 2 hrs 1 to 2 hrs 1 to 2 hrs

3 to 4 hrs 3 to 4 hrs 3 to 4 hrs 2 to 4 hrs 3 to 4 hrs

x x x

Insulin Pen

x

x x x x x

Rapid-acting INHALED insulin (inhaled through the mouth using an inhaler device) Afrezza® 15 min 1 hour 2 to 4 hrs Fast-acting insulin (clear ) Regular Regular U500

30 to 60 min 30 to 60 min

2 to 4 hrs 2 to 4 hrs

5 to 6 hrs 6 to 10 hrs

x x

x x

Intermediate-acting insulin (cloudy) NPH

1 to 1 1/2 hrs

6 to 10 hrs

14 to 16

x

x

Long-acting insulin (clear) Basaglar® Glargine Lantus® Glargine Levemir® Detemir Toujeo® U300 Glargine

1 to 2 hrs 1 to 2 hrs 1 to 2 hrs 1 to 2 hrs

Flat Flat Flat Flat

21 to 24 hrs 21 to 24 hrs 21 to 24 hrs 36 hrs

x x x

x x x x

Ultra long-acting insulin (clear) Tresbia® Degludec Tresbia® U200 Degludec

1 to 2 hrs 1 to 2 hrs

Flat Flat

42 hrs 42 hrs

30 min 30 min

2 to 6 hrs 2 to 6 hrs

10 to 16 hrs 10 to 16 hrs

x x

x x

30 min

1 to 4 hrs

10 to 16 hrs

x

x

30 min

2 to 5 hrs

10 to 16 hrs

x

x

30 min

1 to 4 hrs

10 to 16 hrs

x

x

Premixed insulin (cloudy) Humulin® 70/30 (NPH/Regular) Novolin® 70/30 (NPH/Regular) Humalog® Mix 50/50 NPH Lispro Humalog® Mix 75/25 NPH Lispro Novalog® Mix 70/30 NPH/ Aspart

x x

Long, ultra-long and intermediate-acting insulins work for a long time. It is best if they are given at the same time each day - usually morning or bedtime. Rapid and fast-acting insulins are often given before a meal or when blood sugar is high. They should be taken 15 to 30 minutes before a meal (or as your healthcare provider recommends). The timing of injections may depend on what time of day you eat.

New types of insulin are being developed all the time. If your insulin does not appear on this chart or if you have questions about your insulin, talk to your healthcare provider.

45

H O W T O D R AW U P O N E T Y P E O F I N S U L I N 1. Wash your hands with soap and water.

5. Push the needle into the bottle. Keep the

Check the label on the insulin bottle. Make sure it is the right type. Check the expiration date. Don’t use outdated insulin.

bottle in an upright position. Push the air from the syringe into the bottle. This makes it easier to draw out the insulin.

2. Gently roll the bottle of insulin. Be sure the insulin is completely mixed. If the insulin is cloudy, always roll the bottle at least 20 times to make sure it is mixed well.

3. Wipe the top of the bottle with alcohol.

Remove the needle cap from the syringe.

Do not touch the needle.

6. Keep the needle in the bottle. Turn the bottle upside down. Pull the plunger back. Fill the syringe with the number of units you need.

4. Fill the empty syringe with air equal to the amount of insulin you will take.

7. Look at the insulin in the syringe. If you see air bubbles, push the insulin back into the bottle and slowly draw it up again. Pull the needle out of the bottle. If you need to lay the syringe down before taking your injection, put the needle cap back on.

4 6

HOW TO MIX TWO INSULINS Your doctor may prescribe a mixed dose of two different insulins for better blood sugar control. You will need to combine them in one syringe and take them as one injection.

4. Inject the air from your syringe into the bottle of cloudy insulin.

You can identify the insulin by how it looks: • rapid-acting and fast-acting insulins are clear • intermediate-acting insulins are cloudy • long-acting and ultra-long acting insulins are clear (the long-acting and ultra-long acting insulins cannot be mixed with any other insulin) The only insulins that can be mixed together are the rapid-acting, the fast-acting and the intermediateacting insulins.

5. Do not draw up the cloudy insulin yet. Re1. Gently roll the cloudy bottle of insulin. Be

move the needle from the bottle of cloudy insulin (syringe should be empty).

sure the insulin is completely mixed.

6. Fill your syringe with air equal to the

2. Wipe off the tops of both insulin bottles with

amount of clear insulin you will be taking.

Inject the air from your syringe into the bottle of clear insulin.

the same alcohol swab.

3. Remove the needle cap from the syringe.

Do not touch the needle. Fill the empty syringe with air equal to the amount of cloudy insulin you will be taking.

Draw up the clear insulin first. Then draw up the cloudy insulin.

7. Draw up the amount of clear insulin you will need. Remove air bubbles from the insulin.

Now insert the needle back into the cloudy insulin. Draw up the amount of cloudy insulin you need.

4 7

HOW TO INJECT INSULIN 1. Clean the injection site with soap and

4. Let go of the pinched skin. Push the

water or an alcohol swab. Let the area dry.

plunger all the way down.

2. Remove the needle cover. Hold the syringe like a pencil. Gently pinch up a fold of skin.

5. Once the insulin is injected, slowly count to 5 and pull the needle out. Place an alcohol wipe or cotton ball at the site and apply pressure. Do not massage the area.

3. Position the needle at a 90 degree angle to the injection site (straight up and down).

Insert the entire length of the needle into the fold of skin.

6. Put your equipment in a covered, puncture-proof container. Mark it with “do not recycle” and throw it away.

Some areas of the country require that all syringes, needles, and lancets be destroyed.

Check with your local waste authority if you have questions about equipment disposal.

If you have questions about injecting your insulin or about the type of insulin you are using, talk to your doctor or diabetes educator.

Do not change the amount of insulin you take without your doctor’s approval.

4 8

USING AN INSULIN PEN If you are using medication that is injected with an insulin pen, follow these instructions or ask your healthcare team for information.

1. Wash your hands. Remove the cap from the pen and wipe the rubber stopper with an alcohol swab.

2. If the insulin in the pen is cloudy, mix the insulin by gently shaking the pen back and forth from top to bottom 20 times. Repeat until the insulin appears uniformly white and cloudy.

3. Remove the protective tape from the pen needle and screw it onto the pre-filled pen.

When you are ready to give your injection, remove the needle cap. Every time you use your pen it will need to be primed. Priming your pen means that you are getting your pen ready for use by making sure that it is releasing insulin and there are no air bubbles. Air bubbles do not hurt you, but because they take up space you do not get an accurate dose.

4. To prime your pen, turn the dose dial to 2

5. Priming is complete when a stream of insulin appears from the needle tip. If this does not happen, repeat the procedure until a short stream of insulin appears.

6. Dial the the number of units of insulin you need to inject. If you passed the number of units you need, the dose can be corrected by dialing back and forth.

7. Choose your injection site. Clean the site with soap and water or an alcohol swab. Position the pen at a 90 degree angle to the injection site. Insert the entire length of the needle into the skin. (For a very thin person or a small child, the skin should be gently pinched at the injection site.)

8. Push the button all the way in, keep the needle in the skin for at least the slow count of 5 to ensure that the full dose of insulin has been delivered. You will know that all of the insulin has been delivered when the pen dial is at 0.

units. Hold the pen with the needle pointing up.

Tap the reservoir gently a few times. With the needle pointing up, press the button as far as it will go and see if a short stream of insulin is pushed out of the needle.

9. Keep the button pushed in until the needle is withdrawn from the skin. Carefully recap the needle. Remove the needle from the pen and dispose of the needle after your injection. Store your pen without the needle attached.

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INSULIN PUMP An insulin pump is a device that delivers insulin at a programmed rate 24 hours a day. The insulin pump uses rapid-acting insulin only. If you use an insulin pump, you will not need to take any other injections.

Types of insulin pumps One type of pump contains a cartridge of rapid-acting insulin. A needle is inserted into the abdomen. The needle is attached to a tube and the tube is connected to the pump. The needle and tubing are called an infusion set.

Another type of pump is a tube-free pump or pod. It attaches tightly to the body. A reservoir holds and delivers the insulin. A wireless connection is used to send a blood sugar reading to the pod. The pod is programmed to deliver the exact amount of insulin you need.

Basal and bolus rates The insulin pump releases small amounts of rapid-acting insulin all day to keep blood glucose levels steady between meals and during sleep.

This continuous delivery of insulin is called a basal rate.

Basal insulin takes the place of long-acting insulin.

At meal or snack times, you can program the pump to deliver the amount of extra insulin you need to match the carbohydrates in the food you are eating. You also can tell the pump to deliver extra insulin to correct high blood sugar levels. This extra insulin at specific times is called a bolus rate. Bolus insulin takes the place of the rapid-acting insulin that is taken before meals and at times when blood sugar levels are too high.

The insulin pump cannot control blood sugar by itself. You still have to check your blood sugar and determine how many carbohydrates you are eating at meal time.

Insulin pumps can work along with some continuous glucose monitoring systems (CGMs).

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LOW BLOOD SUGAR (HYPOGLYCEMIA) Low blood sugar is also called hypoglycemia. It is possible to have a low blood sugar reading when you take insulin or other diabetes medications. Normally, blood sugar levels below 70 mg/dL are considered too low for people taking diabetes medication. Most people with diabetes have a low blood sugar reading at one time or another. A low blood sugar reading can occur if you miss or delay a meal or eat less than usual, if you are more physically active than usual or if you take too much insulin or other medication.

Symptoms of low blood sugar (hypoglycemia) Mild symptoms:

Moderate symptoms:

Severe symptoms:

shakiness, weakness sweating, dizziness fast heart rate blurred vision trouble concentrating tingling in fingers or lips anxiety, headache

impaired motor function confusion inappropriate behavior combative behavior

seizures coma

Treatment of low blood sugar (hypoglycemia) Mild symptoms:

Moderate symptoms:

Severe symptoms:

Take 15 grams of carbohydrates, such as: • 3 - 4 glucose tablets • 8 Lifesavers® • 1/2 c. fruit juice • 1/2 c. regular soda pop • 8 oz. of milk

Take 30 grams of carbohydrates, such as: • 1 c. fruit juice • 1 c. regular soda pop • 1 tube of glucose gel

Take Glucagon and call 911.

A family member or friend will need to give you a Glucagon injection.

If you do not feel better in 15 minutes, recheck your This is an emergency. blood sugar. Take another You need to be taken to If you do not feel better in 30 grams of carbohydrates. the hospital right away.

15 minutes, recheck your blood sugar. Take another If you do not improve after 15 grams of carbohydrate. taking your second 30 If you do not improve after grams of carbohydrate, call taking your second 15 grams for medical help. of carbohydrate, call for medical help.

Once your blood sugar is above 80 mg/dL, if your next meal is more than 1 hour away, you should eat a snack which contains at least 15 grams of carbohydrates. Always carry some form of fast-acting sugar with you.

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SEVERE LOW BLOOD SUGAR It is possible for your blood sugar to get so low that you cannot safely swallow anything. You may pass out, be unresponsive or have a seizure. The time to prepare for severe low blood sugar is BEFORE it happens. Talk to your family and others who spend time with you. Tell them you could develop severe low blood sugar and may not be able to take care of yourself. Explain what to do if this happens. Make sure they know this is an emergency. They should call 911 and then give you Glucagon. If they are not comfortable giving you this medication, be sure they know they must call 911 for help.

For your family, friends and others: Glucagon is a hormone made by the pancreas that raises blood sugar. Glucagon works by causing the liver to release stored sugar, which raises the amount of sugar in the blood. This drug works very fast. Glucagon comes in these ways: • Glucagon kit - comes with a syringe with fluid in it and a bottle of powder. The fluid in the syringe must be mixed with the powder and then drawn back into the syringe and injected. It does not matter where on the body you give the injection.

• Gvoke® PFS - comes in a prepared (filled) syringe. You simply remove the syringe from the package and inject the glucagon according to the directions. You do not have to mix the liquid with anything else.

• Baqsimi® - comes as a nasal powder in a device that is used to spray the powder into the nose. It does not need to be inhaled. It is absorbed through the nasal membranes.

What to do after severe low blood sugar: • You may have been unresponsive or very impaired during a severe low blood sugar.

Be sure someone stays with you until you are feeling well and you can eat.

• The risk of having another severe low blood sugar is high. After an episode of severe low blood sugar, be sure to eat a good meal that includes carbohydrates and proteins.

• Check your blood sugar frequently until you know your blood sugar is stable.

How to prevent severe low blood sugar: • Carry a quick source of carbohydrate with you. This source should be at least 15 grams of carbohydrate in a sugar form that will dissolve in your mouth.

• Be consistent with the time of your meals, snacks, exercise and medications. Don’t skip meals. Eat about the same amount of carbohydrates at each meal.

• Take the exact amount of medication you were told to take and take it on a schedule.

• Plan ahead. If you know you are going to be more active, you may not need as much insulin or you may need to plan to eat extra snacks.

• Record severe low blood sugar reactions. Tell your healthcare provider how often you develop severe low blood sugar (such as frequency, time of day and severity).

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HIGH BLOOD SUGAR High blood sugar is also called hyperglycemia. High blood sugar is any number above your target blood sugar range, which for most people is 80 to 130 mg/dL before meals. Generally, blood sugar levels of more than 150 mg/dL are considered high. High blood sugar can occur for many reasons, such as lack of exercise, skipping medication or not taking the right amount, stress, illness, overeating or not following your meal plan.

Everyone has high blood sugar from time to time. When your blood sugar is high and you don’t know why, it can make you feel anxious. Any kind of stress or illness can cause your blood sugar to go up. Your blood sugar levels can even go over 200 mg/dL or 300 mg/dL. Signs of high blood sugar: • going to the bathroom frequently • feeling very thirsty • being very tired • blurred vision

• headache • weakness • trouble concentrating • moodiness, irritability

Treatment for high blood sugar: • Follow your meal plan as closely as you can.

• Keep taking your normal diabetes medications.

• Drink water or any sugar-free fluid –– at least 8 ounces every hour.

• Check your blood sugar every 2 to 4 hours.

If you are taking insulin: • Take extra insulin according to your healthcare provider’s instructions.

• Keep in close contact with your healthcare team. They can help you bring your blood sugar back down to your target range.

• Check your blood sugar 2 hours after giving yourself the extra insulin.

• Check your urine for ketones if your blood sugar is greater than 240 mg/dL or if you are feeling ill.

• Keep drinking water and sugar-free fluids. High blood sugar levels can cause dehydration.

• If your blood sugar does not come down and/or your ketones stay positive, contact your healthcare provider again.

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KETOACIDOSIS If there is not enough insulin in your body to use sugar for energy, your body will break down your own fat and use it for energy. When fat is used for energy, it releases waste products called ketones. Ketones can build up in your blood and spill into your urine. The buildup of ketones in your blood can lead to a very serious condition called diabetic ketoacidosis.

If it is not treated right away, ketoacidosis can lead to a coma or even death. When ketones build up in your blood, they can affect your breathing as well. It may be hard to breathe or you may have very rapid breathing and a fruity odor to your breath. Generally, when you have ketoacidosis, your blood sugar levels are very high, but ketoacidosis can occur even when your blood sugar levels are within your target range.

Signs of ketoacidosis • positive urine ketones • rapid breathing • nausea and/or vomiting • abdominal cramping and pain • shortness of breath • fruity smell to the breath • muscle aches or stiffness • confusion

When you have high blood sugar levels that won’t come down when you take extra insulin AND you have positive urine ketones, call your healthcare provider right away or go to the hospital for treatment.

Treatment • Contact your healthcare provider and let them know that you are not feeling well. When you are sick you may not make the best decisions.

• Let a family member or friend know you are not feeling well. Ask them to check on you at least every 1 to 2 hours.

• Take extra insulin as directed by your healthcare provider.

• Keep drinking water or any sugar-free fluids. You should drink at least 8 ounces of fluid every hour.

• If you are unable to drink or if you are vomiting, call your healthcare provider right away. You may need to go to the hospital for extra fluids and insulin.

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TESTING FOR KETONES Ketones are produced when your body is not using sugar for energy (usually due to a lack of insulin). Ketones in your urine may be a sign that your diabetes is badly out of control. Small amounts of ketones may not be a sign of a serious problem. For example, if you skipped breakfast and have not eaten in several hours, you may spill some ketones into your urine. This does not mean that you are in danger of going into diabetic ketoacidosis. However, moderate or large amounts of ketones in your urine can signal a medical emergency.

To test for ketones, get a sample of your urine in a clean container.

Place a ketone test strip in your urine sample. Wait for the strip to change color. Then compare the strip to the color chart on the bottle or package which comes with your strips. The color chart will give you a range of the amount of ketones in your urine. Write down the results of your test.

There are many products available for ketone testing that can be bought at your local drug store without a prescription.

You should check for ketones, IF YOU: • have Type 1 diabetes and your blood sugar goes above 240 mg/dL • have any type of diabetes and you are sick, stressed, pregnant OR if you have blood sugar levels above 240 mg/dL • you do not feel well, yet your blood sugar is in the normal range or low

What should you do if you have ketones in your urine?

• If your blood sugar is above 240 mg/dL OR if you do not feel well AND the ketones in your urine are positive, call your doctor. You will be told what to do. You also will be told whether or not you need more insulin.

• If your blood sugar is above 240 mg/dL and you feel well, but there are positive ketones in your urine twice in a row, call your doctor. You will be told what to do. You also will be told whether or not you need more insulin.

• Try to drink 8 ounces of sugar-free fluid, especially water, every hour. If you are unable to drink fluids or if you are vomiting, call your doctor. You may need to go to the hospital for treatment.

• Let a friend or family member know you are not feeling well. Ask them to check on you at least every 1 to 2 hours.

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SICK DAY GUIDELINES When you are sick, diabetes is harder to control. Even a cold can cause your blood sugar to be high. If you have Type 1 diabetes and your blood sugar stays too high, ketones can appear in your urine and ketoacidosis can occur. High blood sugar, along with sweating, vomiting or diarrhea can lead to extra fluid loss and dehydration.

Follow these guidelines when you are sick: • Always keep drinking fluids to stay hydrated.

• Take your insulin or diabetes medications even if you don’t feel well. Call your healthcare provider if you are not sure how much to take. An illness is stressful for your body and may cause your blood sugar to go up so you may need extra medication.

• Try to stay on your meal plan. You may need to make some changes in what you eat. Try to eat the same amount of carbohydrates as you normally would to prevent low blood sugar.

• Test your blood sugar often. You may need to test your blood sugar every 2 to 4 hours. Test often until you feel better and your blood sugar levels return to your target range.

Call your healthcare provider if you have: – diarrhea or vomiting that lasts 6 to 12 hours or longer – urine ketones in moderate or high amounts – blood sugar greater than 240 mg/dL twice in a row When you talk to your doctor, report: – your symptoms – your temperature (if elevated) – how long you have been sick – how much you are able to eat or drink – your blood sugar levels – your ketone levels – how much of your diabetes medications you are taking – which over-the-counter medications you are taking 5 6

SICK DAY GUIDELINES When you are sick, you may not be able to eat foods from your normal meal plan. Here are some foods which contain carbohydrates that may be easier to eat. Choose from some of these foods and try to stay at about the same amount of carbohydrates as your normal meal plan.

Every food and drink listed here contains 15 grams of carbohydrates.

Your healthcare provider may suggest a clear liquid diet for a short time. Here are some clear liquid choices.

Clear liquids: • 3/4 c. regular ginger ale • 1/3 c. grape juice • 1/2 c. apple juice • popsicle (1 single bar or 1/2 of twin bar)

• 1 c. Gatorade® • 1/2 c. Kool-aid® • 1/2 c. lemonade • 1/2 c. 7-up®

You also may want to try sugar-free fluids. These foods have few, if any, carbohydrates and also are considered clear liquids: • sugar-free soda pop • tea • coffee • sugar-free popsicle • 1 c. G2 Gatorade®

• sugar-free Kool-aid® • sugar-free lemonade • sugar-free jello • broth

Other foods and drinks that may be suggested: • 1 c. milk • 1/4 c. custard • 1/2 c. pudding • 1/2 c. hot chocolate • 1/2 c. chocolate milk • 1 c. cream soup

• 1/2 c. ice cream • 1/4 c. sherbet • 1/3 c. regular jello • 1/2 c. cooked cereal • 6 saltine crackers

Talk to your healthcare provider or your diabetes educator about which foods and drinks you should have. If your illness lasts more than 24 hours and you cannot eat or drink, call your healthcare provider right away.

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C O M P L I C AT I O N S When blood sugar levels are high for a long time, the blood vessels throughout your body may be damaged. The American Diabetes Association states that A1c levels greater than 7% are the main predictor of developing complications. To prevent the complications of diabetes, work closely with your healthcare team to keep your blood sugar in good control.

Blood vessels carry blood from your heart to the tissues and organs throughout your body. Healthy blood vessels are smooth and elastic, allowing blood to flow easily through them. Damaged blood vessels become hard and rough. Cholesterol and other fats in your bloodstream are likely to stick to the rough, damaged lining inside the blood vessels. The buildup of these materials form fatty deposits that can narrow blood vessels and block blood flow. When your body does not get all the blood it needs, your nerves, feet, kidneys, eyes and heart may be damaged.

To prevent or delay the development of complications: • Keep your blood sugar in good control. Good control means blood sugar levels of less than 150 mg/dL and an A1c level of less than 7%.

• Maintain a healthy weight. If you are overweight, losing 5 to 7% of your current weight can reduce your risk of developing diabetes complications.

• Exercise every day. Your goal is 150 minutes of exercise a week. Exercise helps keep your blood moving through your blood vessels and regular exercise can help you control your blood sugar.

• Do not use tobacco in any form. The nicotine in tobacco can damage the insides of your bloods vessels and cause them to narrow.

• Control your cholesterol and other blood lipids (fats). Keeping your cholesterol and other blood lipids within a healthy range will help prevent the build up of fatty deposits inside your blood vessels.

• Control your blood pressure. High blood pressure damages the lining inside the blood vessels and strains the heart muscle.

The American Diabetes Association recommends that people with diabetes check their blood pressure at home to help identify high blood pressure. Checking blood pressure levels regularly also can help people with diabetes stay on track with taking any prescribed blood pressure medication. Discuss home blood pressure monitoring with your healthcare provider.

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YOUR NERVES People with diabetes can develop nerve damage called neuropathy.

Neuropathy occurs when high blood sugar levels destroy the nerve fibers that tell the body there is pain. For example, when you have neuropathy you may touch a hot pan and not feel the pain of a burn. Symptoms of neuropathy include numbness, tingling, burning and aching.

There are two kinds of neuropathy: peripheral neuropathy and autonomic neuropathy.

Peripheral neuropathy occurs in the parts of the body that are the farthest away from the heart, such as the feet, legs and hands. A person with peripheral neuropathy may not feel the pain of a sore until it is very deep and large. Sores can develop on your legs or feet. (See page 58 for foot care guidelines.)

Autonomic neuropathy affects certain body functions. These are functions you don’t really think about, but that your body automatically does, such as sweating to cool your body when you are hot. Here are some body functions that can be affected by autonomic neuropathy.

• Digestion. Normally, when you eat, your body automatically starts digesting food.

Some people develop a condition called gastroparesis, which can delay or slow the digestion process.

• Bladder function. Some people develop what is called a neurogenic bladder. A person with this disorder may not feel like he/she has to go to the bathroom, or he/she may not be able to empty the bladder completely.

• Bowel function. A person with autonomic neuropathy may have alternating bouts of diarrhea and constipation.

• Blood pressure. Normally, your blood pressure should automatically adjust when you go from a sitting to a standing position. If it does not, you can feel dizzy when you move too quickly. This condition is called orthostatic hypotension.

• Sweating. When you are hot, your body should automatically sweat to cool you down. If you do not sweat, you will get over heated and your skin will get very dry.

• Hypoglycemic unawareness. With this condition, you lose the ability to know or feel that your blood sugar is getting too low. This is dangerous because you can develop severe low blood sugar without being aware of any symptoms.

If you think you have neuropathy, talk to your healthcare provider about your symptoms. Report any changes in body functions right away.

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YOUR FEET Loss of feeling in your feet may be due to damage to the nerves that lead to your legs, feet and toes. This is called peripheral neuropathy.

Neuropathy can cause your feet and legs to hurt and ache much of the time.

Poor blood flow also can lead to nerve damage. In addition, if blood flow is poor, it takes a long time for wounds to heal.

• You MUST check your feet every day. Look for cuts, scratches, blisters, sores or bruises. Call your healthcare provider if you have: • an open sore anywhere that does not heal • any infection in a cut or blister • a red, tender toe –– possibly an ingrown toenail • any change in feeling –– pain, tingling or numbness • any puncture wound or injury made by cutting your nails • any callus that changes color or looks red and/or swollen

If you can’t see your feet, feel them every day. Rub lotion on your feet and legs. Feel for any changes. If you have an injury, you should see signs of healing within 3 days. If it is not getting better within 3 days, see your healthcare provider. Every time you see your healthcare provider ask him/her to check your feet.

• Wash your feet every day. Before you step into the water, test the temperature with your inner arm –– it should be warm not hot. Don’t soak your feet.

After washing, dry your feet thoroughly, especially between the toes. Use a moisturizing cream to soften dry skin.

• Cut your nails straight across to prevent injury or an ingrown toe nail.

Do not trim corns or calluses or use iodine, peroxide or strong antiseptics on your feet. Trim your nails after a bath or shower when your nails are softer. If you need help cutting your nails, talk to your healthcare provider or see a podiatrist (foot specialist).

• Wear shoes that fit well. Shoes that are too tight can cut off blood flow.

Shoes that are loose can rub and cause sores. Before putting on shoes, put your hand in your shoes to check for anything that could injure your feet.

Don’t go barefoot. Wear protective shoes at all times. Wear socks that are not tight around your legs or ankles. If your feet are cold put on socks. Do not use a hot water bottle or heating pad to warm your feet.

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YOUR EYES Diabetes can affect your eyes in many ways. In some cases, changes may be temporary and can be helped by better diabetes control. If diabetes has been present for a long time, it can cause changes in your eyes that threaten your vision.

Retinopathy is the result of changes in the retina, the tissue at the back of the eye, that changes light into visual image. It is a common causes of blindness.

There are treatments for retinopathy that can prevent blindness or minimize vision loss. High blood pressure also may contribute to retinopathy. Controlling your blood pressure and having regular eye exams will safeguard your vision.

Diabetes does not cause cataracts (clouding of the lens of the eye) or glaucoma (the build up of pressure in the eye) but it may contribute to these eye problems. Surgery may be needed to correct cataracts. Glaucoma can be treated with medication or surgery.

See an eye specialist (ophthalmologist or optometrist) once a year for a complete dilated eye exam. Call your eye specialist right away if you have sudden blurred vision, black spots, lines or flashing lights in your field of vision.

YOUR SKIN To keep your skin healthy, bathe or shower daily. Use a lanolin-based lotion to prevent dry skin. Dry your skin thoroughly. Apply talcum powder between skin folds. Wear cotton underwear. Change your underwear and stockings each day. To avoid fungus, wear slippers when using a public locker room or shower.

Treat bacterial infections right away. Bacterial infections can develop quickly from a minor injury. Infections caused by fungus also are a problem. Women may be bothered by vaginal yeast infections; in men, the genitals may become infected.

Infected areas are often red, inflamed and itchy. See your healthcare provider if you have these symptoms. Treat small cuts, broken skin or insect bites right away.

Clean your skin. Cover it with a bandage. If the area has not started to heal within 48 hours or if you notice redness or swelling, see your healthcare provider.

YOUR TEETH AND GUMS Dental problems tend to be more serious when diabetes is present. You can prevent tooth decay and periodontal disease (a disease caused by food collecting around the teeth and gums) by brushing your teeth every day. Floss every day to remove food your toothbrush can’t reach. Have your teeth cleaned every 6 months.

See your dentist if you have unusual pain, swelling or excessive bleeding.

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YOUR HEART AND BLOOD VESSELS Diabetes can damage the blood vessels throughout your body, which increases your risk of cardiovascular disease, heart attack, stroke and loss of circulation in the legs.

People with diabetes are more likely to have high cholesterol, a risk factor for cardiovascular disease. Cholesterol is a fatty substance (lipid) that is produced in your body. It circulates through your body in your blood. You need some cholesterol for normal body function; however, if there is more cholesterol in your blood than your body can use or get rid of, the excess cholesterol builds up inside your blood vessels in the form of fatty deposits.

A blood test called a lipid profile typically measures total cholesterol, LDL (bad) cholesterol, HDL (good) cholesterol and triglyceride levels. Triglycerides are another type of fat found in your blood. High levels of triglycerides do not cause blocked blood vessels, but people who have higher amounts of this type of fat tend to have higher levels of total cholesterol and LDL (bad) cholesterol. A diet rich in alcohol, sugar and fat can increase triglycerides.

Have a lipid profile done at least once a year.

To keep your heart and blood vessels healthy:

• Keep your blood sugar within a healthy range.

• Control your cholesterol. Eating too much saturated fat and trans fat can cause high cholesterol. Trans fats are worse for your heart and blood vessels than any other type of fat. Eat foods that are low in total fat and saturated fat. Avoid foods which contain trans fats.

• Maintain a healthy weight. Being overweight makes your

heart work harder. People who are overweight are also more likely to have high blood pressure and high blood cholesterol.

• Control your blood pressure. High blood pressure damages the blood vessels. People with diabetes are more likely to have high blood pressure than people who do not have diabetes. Have your blood pressure checked regularly. If it’s high, work with your healthcare provider to control it.

• Don’t use tobacco. Tobacco narrows blood vessels and increases your risk of heart disease. If you use tobacco, find a way to quit.

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TOBACCO, SMOKING AND E-CIGARETTES (vaping) When you have diabetes the nicotine in tobacco changes the body’s cells so that they do not respond well to insulin, which leads to high blood sugar. It’s a fact –– using tobacco makes diabetes harder to control. All forms of tobacco (cigarettes, electronic cigarettes (vaping), cigars, pipe tobacco and smokeless tobacco) –– can cause long-term health problems, which can be more severe when you have diabetes.

The nicotine in tobacco products makes your blood vessels harden and narrow, causing blood flow problems. Having diabetes makes you more likely to develop heart disease, so you definitely do not want the extra risk that comes with using any type of tobacco product. If you have diabetes and you use tobacco, you are more likely to have heart and kidney disease, poor blood flow in your legs and feet, retinopathy and peripheral neuropathy.

Electronic nicotine delivery systems Electronic nicotine delivery systems are sometimes called vapes, vape pens, e-cigarettes and e-hookahs. These devices mimic the experience of smoking a cigarette. They contain a combination of nicotine and other chemicals. They work by heating the liquid inside to a high enough temperature to create an aerosol or vapor that is inhaled and exhaled.

You may be tempted to use an electronic nicotine delivery system as a way to transition to not smoking or you may believe these devices are safe when compared to other forms of tobacco. Scientists are studying the effects of electronic nicotine delivery systems, but evidence suggests that people who use these devices increase their odds of suffering a stroke or a heart attack, developing heart disease, lung disease and other health problems. And using these devices definitely make it harder to control your blood sugar.

Electronic nicotine delivery systems are not considered a safe alternative to smoking or a safe and effective way to stop smoking. If you use these products, make a decision to quit.

Quitting Fortunately, you can reduce your health risks by quitting any type of tobacco product. Talk to your healthcare provider about safe and effective ways to quit. Some people taper off by reducing the number of tobacco products they use until they are tobacco free. Other people quit all at once. There are also nicotine replacement products and medications that may help you quit, but you should talk to your healthcare provider before you try them.

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YOUR KIDNEYS People with diabetes are at risk for developing kidney disease. The kidneys help keep the right fluid balance in the body by filtering waste products from the blood. If there is not enough blood flow to your kidneys to filter waste products from your blood, these waste products build up in your blood. See your healthcare provider each year for kidney function tests, such as blood creatinine, a urine microalbumin or a GFR (glomular filtration rate).

People with high blood sugar levels are at a higher risk for developing bladder and urinary tract infections. Signs of an infection include frequent urination, a burning sensation when urinating, cloudy or foul-smelling urine, low back pain and fever or chills. If you have any of these symptoms, contact your healthcare provider.

SLEEP APNEA People with sleep apnea often have high morning blood sugars and a higher Hemoglobin A1c. Sleep apnea is a condition in which a person stops breathing for short periods during the night. Without proper rest, the body is under stress. This leads to high morning blood sugars. A person who has sleep apnea also may suffer from daytime sleepiness, difficulty concentrating and even heart failure. If you can answer yes to any of these questons, talk to your healthcare provider about getting tested for sleep apnea.

• Do you have high blood pressure?

• Do you snore?

• Do you wake up just as tired as when you went to bed?

The risk for sleep apnea is higher for people who are overweight.

Weight loss often improves sleep apnea.

SEXUAL PROBLEMS Usually, people with diabetes are able to perform sexual activities normally, but problems can occur due to nerve damage or poor circulation.

Men may suffer from impotence (inability to have or maintain an erection).

Women may have a decrease in vaginal lubrication or an inability to reach orgasm. Sexual problems are not always permanent. They may be caused by stress, medication or a change in hormone levels. For men, impotence may occur during a period of high blood sugar, then go away once blood sugar levels return to normal. If you are having problems, talk to your healthcare provider so that the cause can be identified and treatment can be discussed.

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M E D I C A L I D E N T I F I C AT I O N It’s a good idea to wear medical identification. Should you be injured, your ID will let people know you have diabetes. One type of identification is called Medic Alert. It is recognized worldwide as identification of a health problem.

A bracelet or necklace can be purchased which lists your medical condition as well as a 24-hour emergency number. Ask your healthcare team where to get medical identification or contact Medic Alert Foundation at 1-(800) 432-5378 or www.medicalert.org

WORK Your diabetes should not prevent you from working. Having diabetes or other health problems may make it unwise to choose certain types of jobs for safety or other reasons.

Type 1 diabetes is protected under a special law called the Americans with Disabilities Act. This law protects all people with disabilities. It ensures that you cannot be discriminated against for most jobs because you have diabetes.

It is a good idea to tell your employer you have diabetes in case you have to adjust your schedule for meals or visits to the doctor. Also, let your co-workers know about your diabetes. Make sure they know what to do in case of an emergency.

Provide emergency contacts including family members and healthcare professionals.

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T R AV E L

•

Check your blood sugar more often so you know how changes in your diet, exercise and sleep affect you. Always carry fast-acting carbohydrates with you in case you have low blood sugar.

• Pack snacks for the ride to account for a delay or sudden change in plans.

• Ask your healthcare provider to write a letter on letterhead stationery

explaining anything that another physician would need to know to care for you. The letter also may come in handy in case you are questioned about medications or equipment you are carrying.

• If you take insulin and plan to cross time zones, ask your healthcare provider, nurse or diabetes educator how to adjust your medication.

• Pack extra supplies. Put them in the bags you keep with you. Whether you travel by car, plane, bus or boat keep your “carry-on” bag with you.

• Stay hydrated. Drink plenty of non-alcoholic, caffeine-free beverages.

• Wear sunscreen with an SPF of 30 or higher. Reapply often.

• Never walk barefoot, even on the beach. Always wear a protective shoe with a closed toe. Check your feet each day for cuts, sores or blisters.

• Wear medical identification, such as a bracelet or necklace, which shows you have diabetes.

If you travel by car, stop every couple of hours. Walk for a few minutes to improve blood flow. If you plan to get more exercise than usual during your trip, adjust your medication and food intake.

If you travel by plane, carry the diabetes supplies you need with you.

Your insulin and blood testing strips should be kept with you and not placed in your general luggage. Bring them in the original box with the pharmacy label attached which tells the name of the medication or supply and your name. All lancets must be capped and enclosed with the glucose monitor.

Check with the airline before you go to be sure of their policy. Make sure you understand how to pack your supplies so that you will not have problems when you prepare to board your flight.

If you are traveling outside the United States, have any immunizations (shots) you need in advance of your travel date.

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STRESS MANAGEMENT Your body reacts to stress by sending out hormones which can cause your blood sugar to increase. Stress also can upset your daily routines, making it harder to care for your diabetes. So many things in life can cause stress. Your stress may be related to: • relationships with your family or friends • job performance or pressure • changes in finances • physical illness or injury • the pressure you put on yourself to do everything for everyone

You can’t eliminate stress entirely, but you can learn to cope with stress more effectively. Learning to cope with stress also will help you manage your diabetes. Start by learning to recognize some of the signs of stress.

Some of the signs of stress are: • elevated blood sugar levels • back pain and/or muscle aches • sleeping all the time or not sleeping • fatigue and/or low energy level • lack of appetite or overeating

• anger, anxiety, nervousness • depression • lack of interest in people or activities • poor concentration, forgetfulness

Guidelines for coping with stress: • Identify the cause of your stress. Once you have pinpointed the cause, ask yourself if there is anything you can do to change the situation. If there is, make a plan and take control. If there is nothing you can do, work toward accepting what you cannot change and learn to let go.

• Eliminate some of your stressors. If you’ve reached the limit of what you can do, say “no” to added responsibilities. If you’ve already got too much to do, take a look at your tasks. Drop the ones that aren’t really necessary to the bottom of your list or eliminate them.

• Exercise regularly. Exercise burns stress hormones, relaxes your body and your mind and helps you control your blood sugar. Some of the best exercises for relieving stress are aerobic exercises, such as walking, biking and swimming. If aerobic exercises are not for you, take a basic yoga, tai chi or pilates class to get your muscles moving while your mind unwinds.

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STRESS MANAGEMENT • Make time for fun. The thought of taking time for fun may seem unrealistic, but if you don’t spend time doing something you enjoy, the demands of life can get you down. Decide what you can do to rearrange your activities so that you can do something you enjoy.

• Get enough sleep. It is common to have trouble falling asleep or awaken during the night when you are feeling stressed. To help you get the rest you need, cut out caffeine. Go to bed at the same time each night. If you can’t sleep, get up and do something until you feel tired. Getting enough sleep will help you cope with stress and manage your diabetes.

Learn how to relax. The art of relaxing is something you have to learn and practice. To relax, find a quiet place where you won’t be bothered.

Here are some relaxation exercises you can learn and practice in your quiet place. Spend 5 minutes or 30 minutes or the amount of time you need in your quiet place.

Progressive muscle relaxation involves tightening and then releasing muscles so that you can learn to relax.

Visualization involves creating positive mental images that help you cope with stressful situations. Repeatedly thinking about positive images can help you change negative thoughts that may be contributing to our stress.

Guided imagery is a form of visualization in which a person listens to a coach or uses an audiotape to go on a mental “journey” to a peaceful place, such as a tropical beach. As you imagine the sights and sounds of a peaceful place, you feel calm and relaxed.

Meditation involves focusing your attention so completely on one thing that you block out everything else around you. This exercise promotes deep relaxation and mental stillness.

Yoga is the practice of uniting mind, body and spirit through meditation and stretching exercises which increase strength and flexibility.

Talk to your diabetes educator about stress management techniques or consider taking a stress management class. People who are able to manage stress experience peace of mind and better blood sugar control.

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PROBLEM SOLVING Controlling your blood sugar is always a challenge. For example, you tried to plan your meals and activities then it rained and your family wanted to go out to eat. Every day we all use problem-solving skills. If something does not work or something unexpected happens, think about what you can change or do in a different way.

Here is an example: You brought your lunch to work — a sandwich, a salad and an apple. The boss decides to treat the office staff to pizza. What can you do? You can eat by yourself and be angry, you can forget about eating healthy and eat all the pizza you want, OR you can try some problem solving skills.

1. The problem: I planned for a healthy lunch. The boss ordered pizza and I want to be part of the group.

2. What can I do: I can look up how many carbs are in a piece of pizza from the restaurant the pizza came from so I know how much I can eat. I can make sure I have a sugar-free drink or water to supplement my meal. I can eat my apple with my meal or I can choose to eat it for my snack.

3. Did the solution work: Check your blood sugar 2 hours after your meal and determine if you counted the carbs correctly or if you ate too much pizza.

Everyone had a great time and I felt as though I fit in with the group without eating more than I should have had (according to my meal plan).

4. What did I learn: By thinking through a situation I can stay on my meal plan and still enjoy social activities. It is not something that happens every day, but it is a part of my life that I want to enjoy.

Whenever there is a challenge to work through, think about these things: 1. What is the problem? Think about the options you have, both good and bad. Think about what it is you really want to be able to do. In the example above, you really wanted to participate.

2. What can I do? How can I stay on my diabetes meal plan and still participate?

3. Did the solution work? In this example it did. But what if your blood sugar had gone very high? What did you learn from this? There is no failure.

There are only learning opportunities. What can you do different next time?

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GET THE SUPPORT YOU NEED Let your friends, family and co-workers know you are trying to eat healthy meals and be more active. If they know it is important to you, they will give you the encouragement you need to keep it up. If your friends or family members are not supporting you, you may need to ask for the type of support you need. Tell them what they can do to be helpful. Help your loved ones learn more about diabetes. When they know more they will be better able to support you in a positive way.

BE PROACTIVE – KNOW YOUR GOALS You may be able to prevent or delay the development of diabetes complications if you take a proactive role in the management of your health care. Here are some goals to keep in mind.

BLOOD SUGAR A1C:

7% or less

Have your A1c checked every 3 months or as often as your healthcare provider recommends. Also, check your blood sugar as often as your healthcare provider recommends.

Blood sugar before a meal:

80 - 130 mg/dL

American Heart Assoc. 2018 Blood Pressure Guidelines:

Blood sugar 1 to 2 hours after the beginning of a meal: Less than 180 mg/dL

Category

Systolic Upper #

Diastolic Lower #

Normal

Less than 120 and

Less than 80

BLOOD PRESSURE (American Diabetes

Elevated

120 - 129

and

Less than 80

High blood pressure (Hypertension) Stage 1

130 - 139

or

80 - 89

Lower goals may be recommended.

Ask your healthcare provider about your goals.

High blood pressure (Hypertension) Stage 2

140 or higher

or

90 or higher

Have your blood pressure checked every time you see your healthcare provider. Check with your healthcare provider regarding his or her recommended blood pressure guidelines.

Hypertensive crisis (contact your doctor immediately)

Higher than 180 and/or

Association Standards of care)

Lower than 140/90 mm Hg*

higher than 120

Since recommendations may vary, ask your healthcare provider for advice regarding blood pressure levels that are right for you.

BLOOD LIPIDS Total Cholesterol:

Less than 200

This number may be lower depending on whether you have heart disease or other health conditions.

LDL (bad) cholesterol:

100 mg/dL or 70 mg/dL or lower if you have heart disease

HDL (good) cholesterol:

Men: more than 40 mg/dL

Triglycerides:

Less than 150 mg/dL

Women: more than 50 mg/dL

Have a lipid profile done at least once a year.

URINE ALBUMIN AND KIDNEY FUNCTION f Normal urine albumin-to-creatinine ratio:

lower than 30mg/g

Normal estimated glomular filtration ratio:

greater than 60 mL

Have a urine albumin test done at least once a year.

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It is possible for these goals to change. Always check with your healthcare providers regarding the most current guidelines and for advice concerning your personal goals.

NOTES OR QUESTIONS:

F O R M O R E I N F O R M AT I O N O N DIABETES: American Association of Diabetes Educators (check this website for the names of diabetes educators in your area) www.diabeteseducator.org American Diabetes Association www.diabetes.org Academy of Nutrition and Dietetics www.eatright.org

Author: Pam Wollenburg, A.P.R.N., C.D.C.E.S. Editorial contributions: Kristi Eden, R.N., C.D.C.E.S. Paul Daugherty, M.S., A.C.S.M., R.C.E.P. Jenna Mayers, R.D., L.M.N.T., C.D.C.E.S.

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