This file is a (revised) compilation of 13 files useful to newly diagnosed or other information-seeking Type II Diabetics. The files included may also be found separately in our Diabetes Forum libraries. The 11 files are: MISCON.TXT, NIDDM.NIH, NIDDM2.NIH, NIDDMC.TXT, LOWFAT.TXT, LRFAT.TXT, OBESE.TXT, FEAR.THD, GRAZE.THD, BLURVISN.THD, METFOD.TXT, FINGRSTK.THD and TESTINFO.TXT Compiled by: Sysop Brooke Disbrow January 1995, revised April 1995 and September 1995 *----------++++++++++----------* MISCON.TXT MISCONCEPTIONS OF THE TYPE II DIABETIC DIET MISCONCEPTIONS There is widespread agreement that diet is the primary treatment of Type II diabetes (maturity-onset diabetes). The is also widespread misconceptions about the best type of diet for diabetes. Most diabetics feel they must "watch their sugar" in their diet. They are unaware of the importance of dietary fat in causing and controlling diabetes. In fact, because much dietary fat is "hidden", most people are under the misconception that their own particular diet consists of very little fat. Many diabetics are in constant fear of a "hypoglycemic" attack. If they feel tired, if they feel weak, they jump to the conclusion that there sugar is too low, and they eat a large quantity of sugar. Studies have shown that the vast majority of these episodes in Type II diabetics are not due to hypoglycemic. The result of this misconception is that many diabetics whose sugar never goes below 180 mg. are frequently increasing their sugar intake because of the fear of hypoglycemia, or even worse, they are frequently increasing the quantity of food they eat, thinking they are not eating enough. The few occurrences of hypoglycemia that occasionally occur in type II diabetics may be due to the patient taking too much medicine; either insulin or oral diabetic medicine. Another important factor involved is the high insulin levels that most type II diabetics have. These high levels, along with the abnormal insulin release of diabetics, can lead to wide variations of blood sugars; and there is evidence that a diabetic can get symptoms of hypoglycemic, in spite of having a normal or high blood sugar. THE FACTS The average American eats 42% of his or her calories from fat. Much of the fat is hidden. There are some people who develop cravings for fats in food, and may eat 50 to 60% of his or her calories from fat. Simple sugars can raise the blood sugar in diabetics. However, fats raise the blood sugar much more in diabetics. FOOD AND THE ETIOLOGY OF TYPE II DIABETES A number of studies have been done that have helped to clarify the relationship between the type of foods one eats, and diabetes. CHEMICAL DIABETES INDUCED BY EXCESS FATS Anderson "creates" diabetics in two weeks Anderson feed 20 year old normal men diets of various concentrations of corn oil (as fat), and sucrose (as simple sugars). After two weeks, the group on the 80% sucrose - 5% fat diet tested normal for diabetes. The other group, on a diet of 20% sucrose- 65% fat, tested diabetic, with a 2-hour glucose tolerance test reading of 184 mg.%. Those on the 5% fat diet stayed on it for 7 more weeks; their GTT's at the end of the test were still normal. Anderson's study showed that, even with a diet high in simple sugars, a low-fat content would seem to be effective in maintaining normal blood sugar responses. Sweeney "creates" diabetics in two days Sweeney tests groups of young medical students on different dietary regimens. One group's diet was high in protein; another's was high in fat; a third group received no food; a fourth group was fed a high-carbohydrate diet. A glucose tolerance test was made after two days. The high-protein group tested borderline diabetic; the high-fat and starvation groups were both quite diabetic (their two-hour postglucose blood values exceeded 170 mg.%). Only the high-carbohydrate group tested normal. Felber "creates" diabetics in two hours Felber gave five normal young men intravenous fats 2 hours before a glucose tolerance test, and continued them throughout the test. The glucose tolerance test was abnormal. (Another words, it tested positive for diabetes). TYPE II DIABETES REVERSED ON LOW-FAT DIETS Singh placed 80 newly diagnosed diabetics on a sugar-free, 12% fat diet. In 6 weeks, 62% no longer required insulin; by 18 weeks, 72% tested normal. The remainder were satisfactorily sustained on minimal insulin doses. Gulati showed similar results on a sugar-free, 15% fat diet. Kiehm placed 13 male diabetics on a 9% fat, 75% carbohydrate (mostly complex) diet. After 2 weeks, 9 no longer required medications and one was on a reduced dose. Barnard, et. al, placed 69 diabetics on a 75% carbohydrate, 10% fat diet for 26 days. Fasting glucose was reduced from an average of 180 mg. to 134 mg. Oral medications were discontinued in 24 of 31 patients, insulin was discontinued in 13 of 18 patients. At 2 to 3 year follow-up, those patients who remained on the diet plan remained off oral agents or insulin, while some of those that increased the fat on the diet were back on medicine. Barnard et. al has had similar results with patients totalling in the thousands. Many studies have been done on the relationship of type II diabetes, and the percentage of fat, and carbohydrates. There are no valid studies that contradict the above studies. THE HISTORY OF "DIABETIC DIET" RECOMMENDATIONS 3,000 years ago, the Egyptians knew the best diabetic diet. They didn't understand how it worked, they just knew that it worked. They noticed that only royalty got diabetes in Egypt, and their cure was to send the diabetic to live with the peasants for a few months. A few hundred years ago the equivalent of the Surgeon General of England noticed that diabetics spilled sugar in their urine. He incorrectly concluded that diabetics could not handle carbohydrates, so he recommended a low carbohydrate diet. This was probably the first high fat, high protein, diet recommendation. This advice influenced treatment of diabetics for hundreds of years; and it's influence remains with us today. A low carbohydrate, high fat diet, remained the recommended diabetic diet to relatively recently. Several decades ago, a 56% fat diabetic diet was recommended. This was reduced to 40% fat in the 1960's. In the 1970's, John Anderson, M.D. (one of the researchers mentioned above) advocated at 20% fat diet for diabetics. The American Diabetic Association would not accept the 20% fat diet; it compromised by recommending a 30% fat diet. This figure remains the current recommendation, although the ADA recommends a 20% fat diet for those diabetics with elevated cholesterol levels that don't go down to normal on the 30% fat diet. Since most foods without added fat have less than 15% fat, a 30% fat diet has many high fat foods included in the overall diet. For instance, margarine is 100% fat, mayonnaise is over 80% fat, peanut butter is over 40% fat, and many fried foods are over 50% fat. Barnard, et. al, has had the most success of any published results by treating diabetics with a maximum 15% fat diet. GENETICS AND DIABETES With all this talk about high fat diets as the cause of diabetics, where do genetics fit in? Most diabetics think they are destined to have diabetes because one of their parents, or their grandparents, had diabetes. There is no question that some people do not get significant diabetes, no matter what they eat, while others gets diabetes in their 40's. Genetics works in combination with the diet. If an individual has a strong family history of type II diabetes, but eats an 15% fat diet, the chance of getting diabetes is almost zero. On the other hand, if an individual with a family history of diabetes eats a 42% fat diet (the average diet for this country), or more, than he or she has an extremely high chance of getting type II diabetes. CONCLUSION The medical literature shows the following: 1, Type II diabetes is largely avoidable. 2. Type II diabetes can be very effectively treated, and often eliminated, by eating less than 15% fat in the diet. 3. Although a large quantity of simple sugar is not good for diabetes, fat in the diet is far worse. Unfortunately, the emphasis has been misplaced in recent times. This is Vol.1, Issue 6, of The Low Fat Lifestyle Newsletter, published monthly by Robert C. Baker, M.D. *----------++++++++++----------* NIDDM.NIH NONINSULIN-DEPENDENT DIABETES U.S. Department of Health and Human Services Public Health Service National Institutes of Health This booklet is about NONINSULIN-DEPENDENT DIABETES. The word "diabetes" in the text of this booklet refers to noninsulin-dependent diabetes unless otherwise specified. INTRODUCTION Ten million Americans -- about 1 in 20 -- have diabetes. Over 90 percent of these people have a form of the disease called NONINSULIN-DEPENDENT DIABETES. This kind of diabetes begins in adulthood. Because the symptoms of this disease can be mild, about half of the people who have noninsulin-dependent diabetes don't know it. Over time, however, diabetes can slowly damage the heart, blood vessels, eyes, kidneys, and nerves. The damage can occur even in someone who is not aware that he or she has the disease. Treatment can control noninsulin-dependent diabetes, and, most experts feel, reduce the chances that these harmful changes or complications will threaten health. In many cases, weight control alone can control diabetes. However, the treatment that exists now is not a cure. Until a cure is found, treatment must continue throughout a person's life. For this reason, day-to-day treatment is largely up to the person with diabetes, working with a doctor's advice. Treatment is most successful when the person with diabetes understands the disease and how to treat it, and why treatment can preserve health. This booklet is about noninsulin-dependent diabetes. It is not a guide to treatment and does not replace the advice of a doctor. Only a doctor who has seen someone in his or her office and has access to medical tests and records can suggest treatment. This booklet is one of many sources of extra information about diabetes. Local diabetes groups and clinics also sponsor meetings and educational programs about diabetes and how it is treated. These programs can be a rich resource through which people with diabetes can learn about the disease from health experts and from other people who have diabetes. A resource list at the back of this booklet has a list of groups that can direct someone with diabetes to such programs. ********* POINTS TO REMEMBER ********* - Noninsulin-dependent diabetes is more common than most people realize. - Treatment can control noninsulin-dependent diabetes, reduce the likelihood of long-term problems from this disease, and increase the chances of a long, healthy life. *************************************** WHAT IS DIABETES? There are two major types of diabetes -- INSULIN-DEPENDENT and NONINSULIN-DEPENDENT. Over 90 percent of people with diabetes have noninsulin-dependent diabetes, the kind this booklet is about. These two types of diabetes are different diseases. This distinction is not always clear in news reports and magazine articles on diabetes. The causes, short-term effects, and treatments for the two diseases differ. At the same time, both diseases can cause the same long-term health problems. Both kinds of diabetes affect the body's ability to use digested food for energy. Diabetes does not interfere with digestion. Instead, it prevents someone's body from using an important product of digestion -- glucose -- for energy. Glucose is a form of sugar. (Table sugar or sucrose is a combination of glucose and another kind of sugar, fructose.) After a meal, the body digests or breaks down some food into glucose. Circulating blood carries the glucose all over the body. When some part of the body needs energy, it metabolizes, or, in a manner of speaking, burns the glucose for fuel. For body tissues to metabolize glucose for energy, a substance called insulin must be present. Insulin is a hormone, one of many the body produces. Some hormones control how quickly children grow in height and when they begin to mature sexually. Other hormones affect how fast a person's heart beats and the level of blood pressure. The hormone insulin makes it possible for the body to use glucose in blood for energy. Insulin is made by a gland called the pancreas located just below the stomach. The pancreas responds to the amount of glucose in blood. After a meal, the amount of glucose present in blood increases. In response to this increase, the pancreas secretes enough insulin to permit body tissues to use the glucose required for energy, and store what is left for future use. Glucose can be stored int he liver or in muscle in the form of glycogen -- a substance made up of chains of sugar molecules -- or in the form of fat. In someone with diabetes, this process does not work properly. The reason depends on whether the diabetes is insulin-dependent or noninsulin-dependent diabetes. In people with insulin-dependent diabetes, the pancreas fails to produce insulin. We don't yet understand how this happens. This condition usually begins in childhood and is sometimes called type I or juvenile-onset diabetes. People with this kind of diabetes must have daily insulin injections in order to survive. In people with noninsulin-dependent diabetes, on the other hand, the pancreas usually continues to produce at least some insulin, but the insulin fails to limit the level of blood glucose. When insulin is present, but does not keep blood glucose normal, the condition is called insulin resistance. Insulin resistance is an important factor in noninsulin-dependent diabetes. Noninsulin-dependent diabetes is also called type II or adult-onset diabetes. The disease most often begins in a person's adult years. It may begin gradually and can escape notice for some time. When noninsulin-dependent diabetes is diagnosed in someone, the disease can very often be treated with diet and exercise. ********* POINTS TO REMEMBER ********* - Diabetes interferes with the body's use of food for energy. - Most people with diabetes have noninsulin-dependent diabetes, which is different in many ways from insulin-dependent diabetes. At the same time, insulin-dependent and noninsulin-dependent diabetes can cause the same long-term health problems. ************************************** SYMPTOMS The symptoms of noninsulin-dependent diabetes can be vague. They may include fatigue or an ill feeling, frequent urination, especially at night, and unusual thirst. Frequent urination is one way the body gets rid of excess glucose. Loss of fluid leads to thirst. Other symptoms that may occur with diabetes are sudden weight loss, blurred vision, and slow healing of infections of the skin, gums, and urinary tract. Women may notice itching in the genital area. It is also possible to have diabetes without any symptoms, or with symptoms that may begin so gradually that they are easy to ignore. In this case, a doctor may first suspect diabetes that are often linked to diabetes. For instance, heart disease, numbness in the feet and legs, or sores in these areas that are slow to heal may prompt a doctor to check for diabetes. Of course, some people who have these symptoms may not have diabetes. If you or someone you know has these complaints, a doctor should be able to determine exactly what is causing the problems. ********* POINTS TO REMEMBER ********* - The symptoms of noninsulin-dependent diabetes can be subtle. - The symptoms of diabetes include fatigue or a feeling of illness, great thirst, frequent urination, sudden weight loss, blurred vision, slow healing of infections, and genital itching. ************************************** WHAT CAUSES NONINSULIN-DEPENDENT DIABETES? There is no simple answer for what causes noninsulin-dependent diabetes. Eating lots of sugar, for example, does not in itself cause diabetes. Eating lost of sugar, like eating other rich, fatty goods, can cause weight gain. Most people who develop diabetes are overweight. Obesity is a major factor in noninsulin-dependent diabetes. At one time, doctors thought that diabetes was always caused by too little insulin. Eventually scientists found that this was true for one kind of diabetes -- insulin-dependent -- but that most people with diabetes could continue to make insulin. This group of people has noninsulin-dependent diabetes. In people with noninsulin-dependent diabetes, the insulin that is present does not lower blood glucose as it should, a condition called insulin resistance. Scientists are still searching for why this happens. There are at least two possibilities. One possible cause of insulin resistance is a problem with insulin receptors on the surfaces of cells. Insulin receptors are locations on cells to which insulin must bind to have any effect. Like an electrical appliance that needs to be plugged into an outlet in order to work, insulin has to bind to a receptor to function. Several things can go wrong with receptors. In some cases, there may not be enough receptors for insulin to bind to. A defect in the receptors may keep insulin from binding. A second possible cause of insulin resistance involves what happens after insulin plugs into the receptor. In some cases, insulin binds to the receptor, but the next steps that should occur inside the cell do not. Even with insulin bound to its receptor, the cells do not carry out the job of using glucose. Scientists are now studying the inner workings of cells to see why this might happen. Being overweight increases a person's chances of having diabetes. Obesity is a very important factor in noninsulin-dependent diabetes. At this time, however, scientists do not yet fully understand why obesity increases someone's chances of developing diabetes. Scientists should have the answers to these questions in the next few years. This research will help answer why diabetes occurs and why obesity is such an important factor in the disease. ********* POINTS TO REMEMBER ********* - No one knows for sure exactly what causes diabetes in every case. ************************************** WHO DEVELOPS NONINSULIN-DEPENDENT DIABETES? Age, sex, weight, physical activity, diet and lifestyle, and family health history all affect someone's chances of developing diabetes. For example, 80 percent of people who find out that they have diabetes are overweight. Someone who is overweight has a greater chance of developing diabetes than someone who is slim. For this reason, excess weight is called a risk factor for diabetes. On the other hand, most overweight people will never develop diabetes and some slim people will. Excess weight, therefore, is not the only risk factor for diabetes. The chances that someone will one day develop diabetes are increased if his or her parents or a brother or sister have the disease. A family history of diabetes is therefore a risk factor for diabetes. Diabetes is more common in blacks and hispanics than whites. It is not clear whether this is the result of heredity, factors in the environment such as diet, or both types of factors. The highest rate of diabetes in the world is found in an Arizona community of American Indians. In this country, women are about as likely as men to develop diabetes. The chances of developing diabetes increase as a person gets older. No one can change his or her family history, age, or race. However, it is possible to control weight and physical fitness. A doctor can assess whether someone is at risk for diabetes and, if so, how to lower the chances of developing the disease. ********* POINTS TO REMEMBER ********* - The following factors increase someone's chances of one day developing diabetes: excess weight, family history of diabetes, advancing age. ************************************** HOW A DOCTOR DIAGNOSES DIABETES A doctor can look for diabetes by noting symptoms such as thirst and frequent urination and by running tests that measure the amount of glucose in urine or blood. A number of different tests can detect glucose. A urine test measures glucose in urine. Glucose in urine can be a sign of diabetes because when blood glucose rises above a certain point, the kidneys eliminate the excess glucose in urine. A blood test measures glucose in blood. A blood test can be done in the morning before breakfast (fasting glucose test) or after a meal (postprandial glucose test). The oral glucose tolerance test is also a blood test for diabetes. In some cases, a glucose tolerance test can detect diabetes even when a simple blood test does not. In this test, blood glucose is measured before and after the person being tested has consumed a liquid that tastes like a very sweet, thick soft drink. The drink has a measured amount of glucose and sometimes other sugars in it. The oral glucose tolerance test measures how the body responds to an increase in blood glucose after eating. Normally the amount of glucose in a person's blood rises quickly in response to a meal and then falls gradually again as insulin goes to work helping the body use the glucose. With diabetes, however, blood glucose may be high all the time. Or, the blood glucose level may be within the normal range much of the time, but after a meal it may rise much higher than normal. A doctor will decide, based on these tests and a physical exam, whether someone has diabetes. Treatment depends on how severe the diabetes is. If a blood test is only slightly abnormal, the doctor may want to monitor blood glucose periodically in the future. If a person is overweight, he or she will probably be advised to lose weight. The doctor may also keep track of the condition of someone's heart, because diabetes increases the risk of heart disease. ********* POINTS TO REMEMBER ********* A doctor will diagnose diabetes by looking for four kinds of evidence: - factors that make diabetes more likely, like excess weight and the presence of diabetes in the family - symptoms of diabetes, like thirst and fatigue - complications of the disease, like heart trouble - signs of glucose or sugar in blood or urine tests ************************************** HOW NONINSULIN-DEPENDENT DIABETES IS TREATED The goals of diabetes treatment are to keep blood glucose within a normal range and to prevent the complications of diabetes. Why control blood glucose? In the first place, diabetes can cause short-term effects that are unpleasant and sometimes dangerous. These include thirst, frequent urination, weakness, lack of ability to concentrate, loss of coordination, and blurred vision. Loss of consciousness is possible with very high or low blood sugar levels but is more of a hazard in insulin-dependent than in noninsulin-dependent diabetes. In the second place, many experts feel that the long-term complications of diabetes result from years of high blood glucose. Research is under way to confirm this in human patients and to find to what extent careful control of diabetes will help prevent complications. In the meantime, most doctors feel that if people with diabetes are careful to try and control blood glucose levels, they will reduce the risk of complications from this disease. A National Institutes of Health expert panel in 1986 recommended that the basis of treatment for noninsulin-dependent diabetes was diet aimed at keeping someone at normal weight. In people who are overweight, losing weight is the one treatment that is clearly effective in keeping diabetes under control. In some people, exercise can help weight and diabetes control. When diet and exercise alone do not control diabetes, two other kinds of treatment are available: oral diabetes drugs or insulin injections. The treatment that a doctor suggests for someone with diabetes depends on the person's age, lifestyle, and how severe the diabetes is. A doctor may suggest more than one approach to treatment to find one that works well. Treatment for diabetes works best when the person with diabetes, working with his or her doctor, achieves a balance between diet and exercise and any necessary medication, such as oral drugs and insulin. By following a doctor's advice, someone with diabetes can control the disease and lower the chances of having related problems like heart disease. Treatments now used for diabetes do not cure the disease but control it. For treatment to be effective, it must continue throughout the life of the person with diabetes. ********* POINTS TO REMEMBER ********* - Diabetes should be treated to avoid unpleasant symptoms, like thirst and weakness, and to reduce the chances of long-term problems, like heart and eye disease. - Diet aimed at weight control is the mainstay of diabetes treatment. Exercise can sometimes help weight and diabetes control. If diet and exercise are not effective alone, oral drugs and insulin may be used. - The best treatment balances any different treatments being used. - There is no known cure for diabetes -- treatment must continue throughout a person's lifetime. ************************************** DIET Diet is a mainstay of diabetes treatment. A diet can help someone with diabetes: - Achieve and maintain desirable weight. Many people with diabetes could control the disease by keeping their weight under control. - Avoid extremes of blood glucose. - Limit foods that may contribute to heart and blood vessel disease. These conditions are more frequent in people with diabetes than in those without. Although doctors prescribe diet as a part of diabetes treatment, they cannot always take the time or have the knowledge of diet planning needed to design a personalized diet for someone. A professional who is knowledgeable about both diabetes and diet can design a diet that is healthy, but at the same time appealing and flexible, with foods that are tasty as well as healthy. No one has to be limited to a pre-printed, standard diet. Someone with diabetes can get assistance in the following ways: - A doctor may be able to recommend a local nutritionist or dietician with knowledge of diabetes. - The local American Diabetes Association, American Heart Association, or American Dietetic Association may be able to offer names of qualified dieticians or nutritionists. - The above organizations can provide or refer someone to printed information on diet that is helpful in understanding the principles behind designing a diet for diabetes. - It may be possible to find a local diabetes center with a staff dietician or nutritionist at a large medical clinic, hospital, or medical university. A regional center, such as at a medical university, may be able to recommend local resources in a community. Among the guidelines used to shape a diet for diabetes are the following: - Many experts, including the American Diabetes Association, recommend that someone consume 50 to 60 percent of their daily calories as carbohydrate, 12 to 20 percent as protein, and no more than 30 percent as fat. - Spacing meals through the day rather than eating heavy meals once or twice a day, can help avoid extremes of blood glucose. - With few exceptions, the best way to lose weight is gradually, for example, one or two pounds a week. Very restrictive diets must never be undertaken without the supervision of a doctor. - People with diabetes have twice the risk of heart disease as those without diabetes. Diabetes raises the risk that someone will develop heart diseases. High blood cholesterol level raises the risk of heart disease. Losing weight can help lower blood cholesterol as will limiting saturated fats and cholesterol in the diet in favor of unsaturated and mono- unsaturated fats. (Meats and dairy products are the major sources of saturated fats; most vegetable oils are high in unsaturated fats, and olive oil is a good source of monounsaturated fat. Organ meats and egg yolks are particularly high in cholesterol.) A doctor or nutritionist can advise someone on this aspect of diet. - Fiber is a form of indigestible food from plants. Fruits and vegetables (especially with their skins), peas and beans, and foods made with whole grains are high in fiber. Studies have shown that fiber may help limit blood glucose. However, it appears that this helpful effect requires that a person each much more fiber than the average American now consumes. A doctor or nutritionist can advise someone on adding fiber to a diet. Exchange lists are a frequently used framework for a diet for diabetes. Exchange lists place foods that offer similar nutrients and calories (energy) into groups. With the help of a nutrition counselor, a person on a diet plans the number of servings or exchanges from each exchange list he or she should have during the day to maintain a certain calorie level. The person can then choose any of the foods within each exchange list to fulfill that day's quota for that list. Diets that use exchange lists offer a person more choices of different foods than do preprinted diets. More information on exchange lists is available from nutritionists and from the American Diabetes Association. Continuing research may lead to new approaches to diets for diabetes. For example, foods that are rich in carbohydrates (starches and sugars) are broken down into glucose during digestion. Breads, cereals, fruits, and vegetables contain carbohydrates. After consumption of these foods, blood glucose rises. Research is showing, however, that it is more difficult than was once thought to predict to what extent different carbohydrates will affect blood glucose level. Because one of the goals of a diet for diabetes is to avoid extremes in blood glucose level, it would be helpful to have reliable information on the effects of foods on blood glucose. For example, research is testing the concept that foods with sugar raise blood glucose more than foods with starch. In order to answer this question, scientists are studying how foods affect blood glucose. The "glycemic index" is a way of describing how much a food affects blood glucose in comparison with the effect of consumed glucose on blood glucose. Much more information on the effects of foods on blood glucose is needed before this information can be used as a basis for diet planning. We know that, in general, raw, unpeeled foods will raise blood glucose less than foods that have been mashed and cooked a long time. Someone with diabetes may want to ask a doctor or nutritionist about the glycemic index of foods and whether this kind of information may be helpful to use in diet planning. ALCOHOL Most people who have diabetes can drink alcohol safely if they are cautious. On the other hand, too much alcohol can cause special problems for someone with diabetes: - One problem is that alcohol has calories without the vitamins, minerals, and other nutrients that are essential for maintaining good health. The calories in alcohol must be taken into account when someone is trying to limit his or her calorie intake. - Alcohol on an empty stomach can lead to low blood glucose or hypoglycemia. Hypoglycemia is a particular risk in people who use oral drugs or insulin for diabetes. Severe hypoglycemia can cause shaking, dizziness, and collapse. People who don't know of someone's diabetes may take these symptoms for drunkenness and neglect to seek medical help. - Two oral diabetes drugs -- tolbutamide and chlorpropamide -- can cause dizziness, flushing, and nausea when they are combined with alcohol. A doctor can advise someone who takes these drugs on the safety of drinking. - One of the most important functions of the liver is its role in storing and releasing energy in the form of glucose. A liver damaged from drinking can add to the problem of blood glucose control that a person with diabetes already has. - Frequent heavy drinking can raise the levels of fats in blood. High blood fat levels increase the risk of heart disease. A doctor can discuss whether it is safe for an individual with diabetes to drink. A dietician can also provide information on the sugar and alcohol content of various alcoholic drinks. ********* POINTS TO REMEMBER ********* - A diabetes diet should do three things: achieve ideal weight; avoid high blood glucose; and limit foods that contribute to heart disease. - A diabetes diet can be planned for a person by a nutritionist or dietician. ************************************** EXERCISE Exercise has many benefits. For someone with diabetes, exercise together with diet can often control diabetes. First, exercise uses calories. Using extra calories helps control weight. Regular exercise can also improve the body's response to the hormone insulin. As a result, exercise can make oral diabetes drugs and insulin more effective and can help keep the level of glucose in blood under control. Third, regular, sustained exercise reduces some risk factors for heart disease. For example, exercise can lower the amount of fats and cholesterol in blood, both of which increase heart attack risk. Exercise increases the amount of one kind of cholesterol, HDL cholesterol, that reduces heart disease risk. Exercise can reduce blood pressure and the amount the heart has to work during exercise and at rest. Abrupt, strenuous exercise can strain muscles and the circulatory system and can increase the risk of a heart attack during exercise. A thorough physical exam by a doctor is the only way to find out whether it is safe to exercise. The doctor can determine how well controlled a person's diabetes is, the condition of the heart and circulatory system, and whether diabetic complications are present that may make certain kinds of exercise unwise. Someone who has not been active can, for example, walk for 15 or 20 minutes, three or four times a week. If desired, the speed or distance of the walks or the frequency of the exercise can be increased over several weeks. The goal in exercise is to have some kind of physical activity that a person will enjoy and do regularly, at least several times a week, for many years. It does no good to do very hard exercise for 6 months and quit. Strenuous exercise can lower blood glucose too much in someone who is taking oral diabetes drugs or insulin. Someone who is exercising can carry a food or drink with sugar in it to take if he or she senses signs of low blood sugar or hypoglycemia. These signs include nervousness, shakiness, weakness, sweating, headache, blurred vision, and hunger. Another precaution is a bracelet that tells that the wearer has diabetes. An identification bracelet will alert a stranger that the wearer has diabetes and may need special medical help when ill or injured. A doctor may advise someone with high blood pressure or complications of diabetes such as problems affecting the blood vessels of the eyes, to avoid exercise that raises blood pressure. Lifting heavy objects, exercises that make someone strain against very heavy or immobile objects, and exercises that strain the upper body raise blood pressure. People who have lost sensitivity in their feet from diabetes can enjoy exercise and also protect their feet by choosing shoes carefully and checking their feet for breaks in the skin. Swimming or bicycling can be easier on the feet than running. A doctor can answer questions about the safety of exercise for someone with diabetes. ********* POINTS TO REMEMBER ********* - Exercise has three major benefits: it uses calories, it improves the body's response to insulin, and it reduces risk factors for heart disease. - Exercise should be started slowly and with the advice of a doctor. ************************************** ORAL DRUGS Oral diabetes drugs, or oral hypoglycemics, can lower blood glucose in people who have diabetes, but who are able to make some insulin. Oral hypoglycemics are an option if diet and exercise fail to control diabetes. Oral diabetes drugs are not oral insulin. Insulin cannot be taken by mouth because it would not survive the digestive tract -- that is why it has to be taken by injection. Oral drugs are not a substitute for diet and exercise. They are effective only in people whose diet and weight are under control. Experts do not understand exactly how each oral drug works. The drugs can increase the amount of insulin produced and they may also affect how insulin acts to lower blood glucose. Oral diabetes drugs are most likely to be useful in people who developed diabetes after the age of 40 and who have had diabetes less than 5 years, who are normal weight or somewhat overweight (not underweight or grossly obese), and who have never received insulin or have not required more than 40 units of insulin a day. Oral drugs are not recommended for a woman who is pregnant or nursing. The effect of these drugs on an infant are unknown. In addition, insulin can provide better control of diabetes during pregnancy. You may have heard that there is some question as to whether oral diabetes drugs increase the risk of a heart attack. However, experts disagree on this point. Oral drugs are still prescribed for many people with noninsulin- dependent diabetes. The Food and Drug Administration (FDA), the agency of the Federal Government that approves drugs for use in this country, requires that oral diabetes drugs carry a warning with regard to the increased risk of heart attack. Whether or not someone uses a drug depends on its benefits and risks, a subject that a doctor can put into perspective. Six FDA-approved oral diabetes drugs are now on the market. Their generic names are tolbutamide, chlorpropamide, tolazamide, acetohexamide, glyburide, and glipizide. The generic name refers to the chemical that gives each drug its particular effect. Some of these drugs are made by more than one drug company and as a result have more than one brand name in addition to the generic name. All six drugs are different types of one class of drug, called sulfonylureas. The drugs differ somewhat in how they affect someone's metabolism. It is best to discuss these specifics with a doctor. Experiences with the newer versions of these drugs -- glyburide and glipizide -- will show how these drugs compare in effectiveness with the older drugs. A doctor will choose a drug for someone with diabetes based on the person's general health, how much his or her blood glucose needs to be lowered, the person's eating habits, and any side-effects the drug has. Side effects of oral drugs are reported to be infrequent. Because the drugs lower blood glucose, someone taking oral drugs needs to be careful about doing other things at the same time that also lower blood sugar, such as skipping meals and exercising long and hard. Some drugs taken for other purposes can also lower blood sugar -- a doctor should be consulted to ensure that drugs will not react with each other in a harmful way. Lowering blood sugar too much -- a condition called hypoglycemia -- will result in symptoms like headache, weakness, shakiness, and if the condition is severe enough, collapse. Oral diabetes drugs can cause symptoms like nausea, skin rashes, headache, either water retention or diuresis (increased urination), and a variety of other side effects. Someone taking the drugs may be more sensitive to direct sunlight. Sometimes the effects with subside with time. A doctor should be consulted for advice if they persist. For reasons that are not always clear, oral diabetes drugs sometimes fail to help some people for whom they are prescribed. In some cases, the drugs fail in people who are helped at first by the drugs. Research is continuing on how these drugs work and why, in some cases, they don't work. ********* POINTS TO REMEMBER ********* - Oral diabetes drugs may be used when diet and exercise alone do not control diabetes. - Oral diabetes drugs are not a substitute for diet and exercise. ************************************** INSULIN Like oral diabetes drugs, insulin is an alternative for some people with noninsulin-dependent diabetes who cannot control their blood glucose level with diet and exercise. In certain special situations, such as surgery and pregnancy, insulin is an important, and usually temporary, means of controlling blood glucose level. When diet and exercise have failed to control diabetes, doctors decide which treatment to try next on a case-by-case basis. Sometimes it is not clear cut whether insulin or oral drugs are best. Someone's weight, age, and the severity of his or her diabetes make a difference in this decision. In addition, the viewpoint of the doctor toward the use of oral drugs versus insulin can affect this decision. Experts disagree in some cases on which treatment, if either, is more effective. A doctor is likely to prescribe insulin if neither diet, exercise, or oral drugs work, or if someone has an adverse reaction to oral drugs. In addition, someone may have to take insulin if his or her blood glucose fluctuates a great deal, in a way that is difficult to control. Weight control is important for insulin to be effective. Insulin does not free someone from the need to follow a diet. A doctor who prescribes insulin will instruct a person with diabetes on how to purchase, mix, and inject insulin. There are a number of different types of insulin available that vary in purity, concentration, and rapidity of action. They also vary as to where they come from. In the past, all commercially available insulin was extracted from the pancreas glands of cows and pigs. Human insulin is now available in two forms, one made using genetic engineering and one that involves chemically changing pork insulin to human insulin. The best source of information on all the many aspects of using insulin is a doctor. The American Diabetes Association has general information on insulin that may also be useful. The association's address is in the resource list at the end of this booklet. Even people who can control their diabetes with other means besides insulin may need insulin at certain times. A section of this booklet called "special situations" describes how insulin is used in a pregnant mother and for surgery. ********* POINTS TO REMEMBER ********* - Insulin may be used when diet, exercise, or oral drugs do not control diabetes. - Weight control is important when insulin is used. - Insulin is used in special situations such as surgery and pregnancy. ************************************** KEEPING TRACK OF GLUCOSE LEVELS When someone's body is operating normally, it automatically monitors the level of glucose in blood. If blood glucose gets too high or too low, the body will adjust how it uses or removes the sugar to bring the level back to normal. This system operates in much the same way that cruise control adjusts the speed of a car. With diabetes, the body does not do the job of controlling blood glucose automatically. To make up for this, someone with diabetes has to keep track of blood glucose and adjust treatment to bring blood glucose back to normal. A doctor can measure blood glucose during an office visit. However, blood glucose level varies day to day and hour to hour. Someone who visits the doctor only every few weeks won't know how his or her blood glucose is day to day. Do-it-yourself tests provide a way to know what blood glucose is each day. The easiest test someone can do at home is a urine test. When the level of glucose in blood reaches a certain point above normal, the kidneys try to get rid of the excess glucose in urine. Glucose in urine, therefore, reflects an excess of glucose in blood. Urine testing is easy. Tablets or paper strips dipped in urine change color. A color chart shows whether or not there is glucose present. However, urine testing is not the best way to monitor diabetes. A measurement of glucose in urine actually reflects a high level of blood glucose a few hours earlier. In addition, not everyone's kidneys work in exactly the same way. Even when the amount of glucose in two people's urine is the same, their blood glucose levels may be different. Finally, certain drugs and vitamin C can affect the accuracy of urine tests. It is more accurate to measure blood glucose directly. There are a number of kits on the market that allow people with diabetes to test their blood glucose at home. The test involves pricking a finger to draw a drop of blood. A spring-loaded "lancet" will do this automatically. A strip of special paper moistened by the blood drop changes color and in this way tells how much glucose the blood contains. The color strips can be read using a chart, or with a small device that will read the strip automatically. A doctor may suggest that someone test his or her blood glucose several times a day. Self blood glucose monitoring can show how the body responds to meals, exercise, stress, and diabetes treatment. A doctor can perform another test that will measure how well treatment has been working for the past few months. This test measures the amount of glucose that has become attached to hemoglobin, the molecule in red blood cells that gives blood its red color. Over time, hemoglobin exposed to glucose in blood will take up some of the glucose. How much glucose becomes attached depends on the concentration of glucose in blood. Once glucose becomes attached to the hemoglobin molecule in blood cells, it remains attached until the blood cells die and are replace with new blood cells. Using a "glycosylated hemoglobin" test, a doctor can tell whether blood glucose has been very high over the last few months. A doctor can best explain what particular results mean for a glycosylated hemoglobin test. ********* POINTS TO REMEMBER ********* - Keeping track of blood glucose level is an important way to know how well diabetes treatment is working. ************************************** COMPLICATIONS A key goal of diabetes treatment is to prevent the complications of this disease. Diabetes can, over time, damage the heart, blood vessels, eyes, kidneys, and nerves. Someone with diabetes may not be aware at first that the damage is taking place. Diabetes is like high blood pressure in this way. It is important to treat diabetes, because like high blood pressure, it can cause damage even before it makes someone feel ill. How diabetes causes long-term problems is not yet clear. However, certain changes in small blood vessels and nerves are very common in people with diabetes. These changes are thought to be the first step in many of the problems that diabetes causes. Scientists are not yet able to predict who, among people with diabetes, will have complications and what the chances are that someone will have such problems. While complications are most likely to appear in someone who has had diabetes for many years, a person can have diabetes without knowing it. A complication may be the first sign. At this time, health care that includes identification and treatment of diabetes is the only means known by which people who have diabetes can reduce the risk of complications. HEART Heart disease is the most common life-threatening disease linked to diabetes. Diabetes doubles someone's risk of heart disease. In coronary heart disease the arteries supplying the muscle of the heart with blood become narrowed by deposits of fat and cholesterol. If the narrowing decreases the blood supply to the heart too much, the heart muscle can be damaged. The damage, in the form of a heart attack, can be fatal. Scientists do not yet understand why diabetes adds to the risk of developing heart disease. Other risk factors for heart disease include hypertension or high blood pressure, obesity, high amounts of fats and cholesterol in blood, and cigarette smoking. Taking action to reduce the impact of these risk factors, along with treating diabetes, can reduce the risk of heart problems. The American Heart Association has publications that explain heart disease and how to prevent it. The association's address is listed in the resources section of this booklet. KIDNEYS Kidney disease is another condition that affects people with diabetes more frequently than others. The kidneys filter waste products from blood and get rid of them in urine. In this way also, the kidneys maintain the proper fluid balance in the body. The kidneys are essential. People can live without one kidney, but those without both must have special treatment, dialysis, to fill in for the function of the kidneys. Most people with diabetes will not be affect by kidney disease. Treatment for diabetes can help reduce further the chances of kidney damage. Someone with diabetes can also watch for other factors that might add to the risk of kidney disease. High blood pressure, for example, can increase the risk of kidney trouble. Regular blood pressure checks and treatment, if high blood pressure is diagnosed, can help prevent kidney disease. Urinary tract infections can also affect the kidneys. Urinary tract infections occur when bacteria grow in the bladder, the tubes leading from the kidney to the bladder, and the tubes from the bladder to the outside of the body. Sometimes diabetes affects the ability of a person to empty his or her bladder completely. This problem occurs because diabetes reduces the effectiveness of nerves that control the bladder. Infections can begin more easily when the bladder cannot be completely emptied. The symptoms of urinary tract infections include frequent, painful urination, blood in the urine, and pain in the lower abdomen and back. Without prompt examination and treatment by a doctor such infections can reach the kidneys, causing pain, fever, and possibly kidney damage. Antibiotics are used to treat urinary tract infections. A doctor may also suggest that someone with a bladder infection drink more water than usual. Water retention is a condition in which fluid collects in someone's body and causes swelling, often in the legs and hands. Kidney problems are among the causes of water retention or edema. A doctor can check to see if swelling or water retention is related to kidney function. A doctor in general practice treating someone with diabetes may suggest a visit to a nephrologist if signs of kidney problems appear. A nephrologist is a doctor who is specially trained to diagnose and treat kidney problems. A nephrologist can identify the cause of any problems and how best to lower the chances of any serious kidney illness. EYES Diabetes can affect the eyes in several different ways. In most cases the effects are temporary or can be helped by better diabetes control. In some cases, however, long-term diabetes can cause changes in the eyes that threaten vision. Good diabetes care and a yearly visit to an ophthalmologist, a medical doctor who is trained to treat eye problems, can help ensure the health of someone's eyes. Blurry vision is one effect diabetes can have on the eyes. The reason may be that changing levels of glucose in the blood can also affect the balance of fluid in the lens of the eye. The lease works like a flexible camera lens to focus images. If the lens absorbs more water than normal and swells, the focusing power of the lens also changes. Diabetes may also affect the function of nerves that control vision, and this may also cause blurry vision. Diabetes treatment can help keep glucose levels stable and help prevent these changes in vision. Cataract and glaucoma are both eye diseases that can occur in people who do not have diabetes. These problems occur more frequently in people with diabetes than in those without the disease. Cataract is a clouding of the normally clear lens of the eye. Glaucoma is a condition in which pressure within the eye can damage the optic nerve that transmits visual images to the brain. Both of these conditions can be treated. Early diagnosis and treatment of cataract and glaucoma makes successful treatment most likely. DIABETIC RETINOPATHY Retinopathy means disease of the retina, the light sensing tissue at the back of the eye. Diabetic retinopathy is a disease of the retina caused by diabetes. Many people who have had diabetes for 25 years or more will have changes in their eyes that can be seen by a doctor. In most people, however, the disease will not seriously affect vision. A yearly eye examination makes it possible for an eye doctor or ophthalmologist to catch changes before vision is affected and the illness becomes harder to treat. Diabetic retinopathy causes changes in the tiny vessels that supply the retina with blood. The blood vessels may swell and leak fluid. When retinopathy is more severe, new blood vessels may grow from the back of the eye and bleed into the clear gel that fills the eye, the vitreous. Treatment for diabetic retinopathy can help prevent loss of vision and can, in some case, restore vision lost as a result of this disease. A yearly eye exam is the best way to make sure that changes that may threaten vision are diagnosed early and that effective treatment is carried out when it can be most helpful. High blood pressure may contribute to diabetic retinopathy. Checking for high blood pressure and treating it if it is present can help safeguard vision. There is also evidence that smoking can cause diabetic retinopathy to worsen. Blurred vision that lasts longer than a day or so, sudden loss of vision in either eye, or black spots, lines, or flashing lights in the field of vision should be brought to the attention of a doctor right away. Scientists are testing new means of treating diabetic retinopathy. For additional information on eye complications of diabetes and the treatment of these conditions, see the resource list at the end of this booklet. LEGS AND FEET Leg and foot problems can arise in people with diabetes from a combination of changes in the blood vessels and nerves in these parts of the body. Peripheral vascular disease is a condition in which blood vessels become narrowed by fatty deposits. Peripheral vascular disease is more frequent and often more severe in people with diabetes than in others. The disorder can reduce the blood supply to the legs and feet. In addition, diabetes can dull the sensitivity of nerves. Someone with this condition, called peripheral neuropathy, might not notice a sore spot caused by tight shoes or by the pressure of walking. If such a spot is ignored, it can enlarge and become infected. Reduced blood supply from peripheral vascular disease makes healing more difficult. Proper foot care and regular visits to a doctor can prevent foot and leg sores and help ensure that any that do appear do not become infected and painful. Helpful measures include inspecting the feet daily for cuts or sore spots. Blisters and sore spots are less likely with shoes that fit well and socks or stockings that do not bind. A doctor may also suggest washing the feet daily, filing thick calluses, and using lotions that keep the feet from getting too dry. Shoe inserts and sometimes special shoes can be used to prevent too much pressure on any one part of the foot. Diabetic neuropathy, or nerve disease, can dull nerves, but it can also be very painful. Someone with painful diabetic neuropathy may feel a burning pain that may be relieved by moving around or that makes it very painful to touch anything. A person with neuropathy may be depressed. Scientists are not sure whether the depression is itself an effect of neuropathy, or if it is simply a response to pain. Treatment for painful diabetic neuropathy is aimed at relieving pain and depression. Aspirin and other pain-killing drugs may be prescribed. A sore on the foot or leg, whether or not it is painful, requires a doctor's immediate attention. Treatment will help heal sores and can help prevent new ones. These problems with the feet and legs are the reason that people with diabetes have amputations -- surgical removal of limbs -- more often than people without diabetes. Proper care of the feet and legs can prevent ulcers and infections and the more serious problems they can lead to. OTHER EFFECTS OF DIABETIC NEUROPATHY Nerves help provide muscle tone and feeling, but they also help control functions like digestion and blood pressure. Diabetes can cause changes in these nerves and the functions they control. These changes and the effects they cause are most frequent in people who have had other complications of diabetes, like problems with their feet. Someone who has had diabetes for some years, for example, and who has other complications, may find that spells of indigestion or diarrhea are connected with the diabetes. A doctor may prescribe drugs to help these symptoms. Antibiotics are sometimes used to treat diarrhea. Diabetes over time can affect the nerves that control erection in men. In some men, this can cause impotence that shows up gradually, without any loss of desire for sex. A doctor can find out whether impotence is the result of physical changes, such as diabetes, or emotional changes. On that basis, the doctor can suggest treatment or counseling. SKIN AND TEETH People with diabetes are more prone to infections that people without diabetes. Someone with diabetes may have infections like boils more often than other people. A woman may have vaginal infections that occur more often than in other women. Infections are less likely to become severe if they are treated early. Watching for infections, treating them early, and following a doctor's advice to prevent infections can help make sure that they are mild and infrequent. Infection can also affect the teeth and gums. Periodontal disease is an inflammation of the tissues that surround and support the teeth. It is a very common problem in people with and without diabetes, and it is a major reason that people lose teeth as they get older. An important cause of periodontal disease is bacterial growth on the teeth and gums. Treating diabetes and following a dentist's advice on dental care can help prevent periodontal disease. EMERGENCIES Very high blood glucose levels cause symptoms that for most people are hard to ignore: frequent urination and great thirst. However, someone who is old or in ill health may not be alert enough to notice trouble signs. Without treatment, a person with high blood glucose or HYPERglycemia can lose more and more fluid. He or she may become weak, confused, or unconscious. Breathing is shallow and pulse is rapid. The person's lips and tongue will be dry, and his or her hands and feet will be cool. A doctor should be called right away if someone has these symptoms. The opposite of high blood glucose -- very low blood glucose or HYPOglycemia -- is also a danger. Hypoglycemia can occur when someone has not eaten enough to balance the effects of insulin or oral drugs. Prolonged, hard exercise in someone taking oral diabetes drugs or insulin can also cause hypoglycemia, as can alcohol. Someone whose blood glucose has become too low for some reason may feel nervous, shaky, and weak. The person may sweat, feel hungry, and have a headache. Severe hypoglycemia can cause loss of consciousness. A person with hypoglycemia who is conscious should eat or drink something with sugar in it such as orange juice or sugar cubes. If the person is unconscious, he or she should be taken to a hospital emergency room right away. Identification such as a bracelet that states that the wearer has diabetes, will let friends know that these symptoms are a warning of illness that requires urgent medical help. ********* POINTS TO REMEMBER ********* - Diabetes can cause long-term complications such as heart, kidney, eye, and nerve disease. - Careful treatment of diabetes, and watching out for signs of complications, can lower the chances that someone will be troubled by these conditions. - An identification bracelet stating that the wearer has diabetes can help ensure that friends or strangers won't ignore symptoms that signal a medical emergency. ************************************** SPECIAL SITUATIONS SURGERY Surgery is stressful, both physically and mentally. Stress can raise blood glucose levels and disturb the balance of blood glucose even in someone who is careful about control. In order to make sure that surgery and recovery are successful for someone with diabetes, a doctor will test blood glucose and keep it under careful control, probably with insulin. Careful control makes it possible for someone with diabetes to have surgery with little or no more risk than someone without diabetes. In order to plan and carry out surgery safely, the surgeon and attending physicians must know that the person they are treating has diabetes. While tests before surgery can spot diabetes, the best way to ensure that the doctors have this essential information is to tell them. A doctor will consider diabetes before prescribing drugs or other treatment, or planning surgery. A surgical team will also need to evaluate the possible effect of any complications of diabetes someone may have, such as heart or kidney problems. PREGNANCY Bearing a child puts extra demands on the body of the mother. Diabetes makes it more difficult for her body to adjust to these demands, and it can cause problems for both mother and baby. Some mothers may develop a form of diabetes during pregnancy, which is called gestational diabetes. Although this kind of diabetes often disappears after the baby's birth, treatment is still needed during pregnancy to make sure that the diabetes does no harm to either the mother or the fetus. The baby of a woman whose diabetes is not well-controlled may be unusually large at birth. The risk of premature birth, and problems in the baby such as breathing difficulties, low blood sugar, and death is increased. Uncontrolled diabetes that is present in a mother before she becomes pregnant increases the risk of congenital or inborn defects in the baby. Blood glucose monitoring and treatment with insulin can make it likely that a baby born to a mother with diabetes will be healthy in every way. Oral diabetes drugs are not used during pregnancy because the effects of these drugs on the unborn baby are not known. By working with a doctor who is trained to treat mothers with diabetes, the mother can make sure her blood glucose is normal and at the same time make sure her baby is well nourished. Birth defects most often occur in the early weeks of pregnancy, when the baby's organs are being formed, and often before the mother has even confirmed that she is pregnant. For this reason, careful diabetes control needs to begin before she becomes pregnant, so that her diabetes will not increase the risk of defects. Gestational diabetes develops most frequently in the middle and later months of pregnancy, after the time of greatest risk for birth defects. However, the other risks mentioned before are still present, and the mother's diabetes must be controlled. About half of women with gestational diabetes will no longer have abnormal blood glucose tests shortly after they give birth. However, many mothers who have gestational diabetes will develop noninsulin-dependent diabetes later in their lives. Regular check-ups can ensure that if a mother does develop diabetes later, it will be caught and treated quickly. WILL THE CHILD OF A PARENT WITH DIABETES ALSO HAVE DIABETES? Scientists estimate that the child of a parent with noninsulin-dependent diabetes has about a 10 to 15 percent chance of developing noninsulin-dependent diabetes. (Diabetes occurs in about 5 percent of the general population.) If both parents have diabetes, the child's risk of having the disease is increased. The health habits of the child through his or her life affect the risk of having diabetes. Obesity, for example, may increase the risk of diabetes or cause it to occur earlier in life. Noninsulin-dependent diabetes in a parent has no effect on the chances that that person's child will have insulin-dependent diabetes, the more severe form of diabetes. STRESS AND ILLNESS One way the body responds to stress is to increase the level of blood glucose. This response is one of the ways the body equips itself to respond to what causes the stress. In someone who is being treated for diabetes, however, stress may increase the need for treatment to lower blood glucose levels. Illness such as a cold or flu is a form of physical stress. A doctor can help someone with diabetes plan what to do for a cold or flu. People with or without diabetes can lose fluids when they are ill, so doctors suggest drinking fluids. For someone with diabetes, drinking fluids is especially important. If blood glucose level is high, the body tries to get rid of glucose through urine and this fluid needs to be replaced. A doctor can help if nausea makes eating or taking oral diabetes drugs a problem. Not eating can increase the risk of low blood glucose, while stopping oral drugs during illness can lead to very high blood glucose. In addition, a doctor may prescribe insulin temporarily for someone with diabetes who cannot take any drugs by mouth. Drugs prescribed for illnesses other than diabetes can affect blood glucose level. A doctor who knows that his or her patient is taking drugs for diabetes can make sure that any additional drugs pose no special hazard. Great thirst, rapid weight loss, high fever, or very high urine or blood glucose are signs that blood glucose level is out of control. If a person has these symptoms, a doctor should be called right away. Like illness, stress that results from losses or conflicts at home or on the job can also affect the control of diabetes. Urine and blood glucose checks can be clues to the effects of stress. If someone finds that stress is making diabetes control difficult, a doctor can help with advice on treatment and may suggest sources of help for coping with stress. ********* POINTS TO REMEMBER ********* - Certain special situations such as pregnancy, surgery, and illness call for extra careful diabetes control. - Special control may require the use of insulin, even in people who don't normally use insulin for control of diabetes. ************************************** COPING WITH DIABETES Good diabetes care means daily effort to follow a diet, keep active, and sometimes to take drugs. People who don't have the disease may not be aware of the day-to-day responsibility diabetes involves. Talking with other people who have diabetes or who treat people with diabetes may help someone who gets tired of daily treatment, or feels alone. The diabetes organizations on the list at the back of this booklet can help locate discussion groups or counselors familiar with diabetes. The general advice for people with diabetes -- to be educated with respect to their health, eat a healthy diet, exercise, and be aware of any changes in health -- is the advice doctors urge for any individual who wants to maintain good health. People with or without diabetes can live to a ripe old age, especially if they take care of their health. ********* POINTS TO REMEMBER ********* - Good diabetes care is a day-to-day responsibility. - Local diabetes organizations may have helpful programs in which people with diabetes can exchange experiences and support. - The good health care urged for people with diabetes would be beneficial to anyone who wishes to maintain good health. ************************************** FINDING HELP Diabetes is a disease in which the person affected must be responsible for daily care. A doctor who has seen someone in his or her office and has results of medical tests to refer to is the best source of advice on how to carry out this care. A doctor in family practice or internal medicine can diagnose and treat diabetes. The local chapters of the American Diabetes Association or the Juvenile Diabetes Foundation may have lists of doctors who specialize in treating people with diabetes. Another alternative is to call a local medical society or hospital or find out where the closest university medical center is -- that is, a university with a medical school affiliated with a teaching hospital. These centers may have special diabetes clinics or may be able to suggest doctors in the community. Doctors are also listed in the yellow pages of the telephone book -- diabetologists specialize in diabetes treatment. ********* POINTS TO REMEMBER ********* - Medical guidance is available from a variety of sources such as diabetes groups, local medical societies and hospitals, and diabetes clinics. ************************************** PRINTED INFORMATION While information in books and magazines cannot replace a doctor's personal advice, they may help someone understand diabetes and learn about current ideas in diabetes treatment. The American Diabetes Association has brochures about diabetes and diabetes treatment. These publications are written for people with no medical background. The address of the American Diabetes Association is in the resources section at the back of this booklet. Brochures from other organizations are sometimes filed in local public libraries. There are also commercially printed books about diabetes available in book stores and libraries. Local chapters of the American Diabetes Association, hospitals, and medical centers sometimes sponsor educational programs on diabetes and diabetes treatment. These programs can be very helpful by giving current information and having people available to answer questions. A doctor or local diabetes groups are good sources of information on such programs. ********* POINTS TO REMEMBER ********* - Additional information is available from the American Diabetes Association, in local bookstores and libraries, and from local diabetes programs and groups. ************************************** RESOURCES ON DIABETES American Diabetes Association National Service Center 1660 Duke Street P. O. Box 25757 Alexandria, VA 22313 (703) 549-1500 A private, voluntary organization that fosters public awareness of diabetes and supports and promotes diabetes research. Has printed information on many aspects of diabetes, and local affiliates sponsor community programs. Local affiliates can be found in the telephone directory or through the national office. American Dietetic Association 430 North Michigan Avenue Chicago, IL 60611 (312) 822-0330 A professional organization that can help someone locate a nutritionist in the community. American Heart Association 7320 Greenville Avenue Dallas, TX 75231 A private, voluntary organization that has literature on heart disease and how to prevent it. Contact the local affiliate of the American Heart Association, listed in telephone directories. Juvenile Diabetes Foundation, International 432 Park Avenue, South New York, NY 10016 (212) 889-7575 A private, voluntary organization with an interest in type I or insulin- dependent diabetes. Local affiliates are located across the country. National Eye Institute Building 31, Room 6A32 National Institutes of Health Bethesda, MD 20892 Copies of a booklet on how diabetes affects the eyes is available from the National Eye Institute, a component of the Federal Government's National Institutes of Health. National Diabetes Information Clearinghouse Box NDIC Bethesda, MD 20892 The National Diabetes Information Clearinghouse has a variety of publications for distribution to the public and to health professionals. The clearinghouse is a program of the National Institute of Diabetes and Digestive and Kidney Diseases, a component of the Federal Government's National Institutes of Health. National Heart, Lung, and Blood Institute Building 31, Room 4A21 National Institutes of Health Bethesda, MD 20892 (301) 496-4236 Information on heart disease is available from this component of the Federal Government's National Institutes of Health. National Institutes of Health Publication No. 87-241 March, 1987 *----------++++++++++----------* NIDDM2.NIH DIET AND EXERCISE IN NONINSULIN-DEPENDENT DIABETES MELLITUS National Institutes of Health Consensus Development Conference Statement Volume 6, Number 8 December 10, 1986 INTRODUCTION Diabetes mellitus is a major health problem. It is a leading cause of death. It is the chief reason for new blindness, kidney failure, and limb amputation. Dialysis for kidney failure from diabetes alone costs over $1 billion annually, and this is expected to double over the next few years. Moreover, diabetes is a major emotional burden for many families. Noninsulin-dependent diabetes, (NIDDM, also called adult-onset or Type II diabetes) affects about 10 million Americans, mid-age or older, or approximately 90 percent of all diabetic people. The cornerstone of therapy is a style of life centered around diet and supplemented, if needed, by insulin or oral agents. With the very high association of NIDDM with overnutrition and overweight (approximately 80 percent of patients), much dietary effort is directed to caloric reduction, with exercise as an auxiliary means to increase caloric loss and to assist in glucose regulation. The therapeutic aim is normalization of blood glucose and lipid levels with the hope of diminishing cardiovascular risk and preventing complications. There has been much interest in recent years in clarifying the underlying relationships between NIDDM and obesity, heredity, nutrition, physical activity, and other factors. Much has been learned from clinical studies in individuals with and without NIDDM and from parallel studies in experimental animals. However, conflicting claims have emerged for the effectiveness of new dietary strategies and exercise programs. Many of these have been publicized in the professional and lay literature, and this has caused some concern and confusion. In an effort to resolve this problem, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and the NIH Office of Medical Applications of Research, in collaboration with Institute National de la Sante' et de la Recherche Medicale (INSERM), France, sponsored a Consensus Development Conference on Diet and Exercise in Noninsulin- Dependent Diabetes Mellitus, December 8-10, 1986. The conference brought together researchers, clinicians, other health professionals, and representatives of the public. Following 2 days of presentations and discussion by invited experts and the audience, a consensus panel, drawn from the health care and diabetes-interested communities, weighed the scientific evidence and formulated a draft statement in response to several questions: * What is the significance of excess body fat in the patient with noninsulin- dependent diabetes mellitus? How can weight reduction be achieved and maintained? * What are the appropriate components of the dietary prescription for patients with noninsulin-dependent diabetes mellitus? * What are the benefits and risks of exercise in patients with noninsulin- dependent diabetes mellitus? How should exercise be prescribed? * What is the evidence that weight control, diet, and/or exercise can prevent noninsulin-dependent diabetes mellitus? * What are the directions for future research? ______________________________________________________________ 1. WHAT IS THE SIGNIFICANCE OF EXCESS BODY FAT IN THE PATIENT WITH NONINSULIN-DEPENDENT DIABETES MELLITUS? HOW CAN WEIGHT REDUCTION BE ACHIEVED AND MAINTAINED? There is strong evidence that NIDDM is genetically determined. Based on considerable epidemiological data, it is apparent that obesity and aging promote the development of the disease in susceptible individuals. The prevalence of the disease increases steadily from the fourth decade. Individuals who are 20 to 30 percent overweight are clearly at an increased risk for NIDDM, and the risk accelerates with increased body weight. Data suggest that in addition to the degree of obesity, an increasing duration of obesity and the specific distribution of excess body fat are associated with the development of NIDDM. With regard to fat distribution, upper body or android obesity appears to be more strongly associated with diabetes than lower body or gynoid obesity. Individuals with a family history of NIDDM may develop the disease when they have only modest excess of body fat. These people should be assessed routinely for the presence of carbohydrate intolerance and encouraged to maintain desirable body weight. Extensive studies demonstrate that obesity is characterized by insulin resistance. In the obese nondiabetic individual, the principal target tissues for insulin (liver, skeletal muscle, and adipose tissue) do not respond appropriately to those levels of the hormone found in nonobese individuals. The obese nondiabetic person can compensate for this impairment of hormone action by secreting increased amounts of insulin. Weight reduction in these nondiabetic individuals leads to reversal of insulin resistance and the return to a normal pattern of insulin secretion. Pancreatic beta-cell dysfunction and insulin resistance are the cardinal pathophysiologic features of NIDDM. Both of these cellular alterations may be genetically determined. Although insulin resistance is present in the nonobese patient with NIDDM, associated obesity further aggravates the severity of impaired hormone action. Weight loss in the obese diabetic, as in the nondiabetic, ameliorates insulin resistance, and usually there is accompanying improvement in carbohydrate tolerance. Frequently, hyperglycemia is reduced when a low calorie diet is employed even before there is much weight loss. Furthermore, some studies have also shown modest improvement in beta-cell function when the blood glucose is lowered by diet or other means. Some investigators are concerned that the hyperinsulinemia in NIDDM may contribute to the increased incidence of macrovascular disease. This possibility arises from the observation that the two most common conditions of hyperinsulinemia (obesity and NIDDM) are independently associated with increased cardiovascular risks. There are also data suggesting that the actions of insulin are not uniformly impaired in hyperinsulinemic states. Thus, it is possible that certain insulin-regulated, atherogenic processes may be accelerated in NIDDM with or without obesity. At present, the relationship between hyperinsulinemia and cardiovascular disease is largely speculative, and more definitive answers await additional investigation. The cellular mechanisms of insulin action have been partially elucidated. There is universal agreement that insulin initiates its actions by interacting with specific receptors located on the surface of the target cell. The possibility that there is a receptor deficiency in human obesity and NIDDM has been extensively investigated. Most studies have examined the receptor status in readily available circulating monocytes or erythrocytes. The number of insulin receptors is often decreased in these cells, but the relevance of these findings to the major target tissues (liver, muscle, fat) for insulin action is not known. In fact, results of studies of insulin receptors in fat cells from individuals with NIDDM are conflicting, and studies are just emerging using human muscle and liver. The majority of investigators agree that cellular alterations, other than decreased receptor number, contribute to the insulin resistance of both obesity and NIDDM. Current areas of investigation include (1) functions of the insulin receptor subsequent to hormone binding, (2) the glucose transporter process in muscle and adipose tissue, and (3) the status of those factors that may be the intracellular mediators of insulin action. Although the cellular alterations responsible for insulin resistance and beta-cell dysfunction in NIDDM are poorly understood, future studies of the beta cell and insulin action should provide new insights into the pathophysiology of this disease. Blood glucose usually returns toward normal as weight loss occurs in the obese diabetic patient. Weight loss also improves hypertension, hypertriglyceridemia, and hypercholesterolemia. Achieving the goal of desirable weight is not easy. Twenty-five years ago, one-quarter of the patients who needed to lose 20 to 40 pounds were successful, and merely 5 percent lost more than 40 pounds. At that time, weight loss programs generally emphasized moderated caloric restriction and dietary counseling. Recently, several more successful strategies for weight loss have been developed. All these approaches continue to rely on reduced calorie ingestion. Although moderate caloric restriction (500 to 1,000 kcal below daily requirements) is preferred, fasts of several days' duration and very low calorie diets (to 400-600 kcal intake per day) for several weeks have been successfully employed with careful medical supervision. Other successful programs have utilized support groups, behavioral therapy, and/or exercise in combination with caloric restriction. In recent years, the public has become aware of the health hazards of obesity. Low calorie foods and beverages are readily available, and health clubs exist in many neighborhoods. While all of these benefit those who need or desire to lose weight, weight reduction continues to be difficult. Furthermore, most individuals who lose weight will regain some or all of the lost weight. A greater understanding and resolution of the pathophysiology and behavioral determinants underlying altered eating behavior are needed. While acknowledging the poor prognosis for weight loss maintenance, the panel recommends that most obese patients with NIDDM be maintained on diets moderately restricted in calories. Ideally, this diet should be associated with behavior therapy, group support, and nutritional counseling. An intensive support program of considerable duration may improve the likelihood of maintaining a desirable weight. Increased physical activity and, if appropriate, structured exercise programs are also considered useful adjunctive therapy. ________________________________________________________________ 2. WHAT ARE THE APPROPRIATE COMPONENTS OF THE DIETARY PRESCRIPTION FOR PATIENTS WITH NONINSULIN-DEPENDENT DIABETES MELLITUS? In individuals with NIDDM, the primary goal for treatment is to reduce blood glucose levels to normal. The diet for all persons with NIDDM should be nutritionally sound, and it should satisfy the recommended dietary allowances (RDA) and follow the "Dietary Guidelines for Americans" (Home and Garden Bulletin #232, 2nd Edition, Washington, D.C.: USDA and HHS, 1985). Since most persons with NIDDM have excess body fat, the primary dietary treatment is reduction of weight through caloric restriction. Some people with NIDDM have additional medical problems (e.g., lipoprotein disorders and hypertension) that require additional dietary recommendations. CALORIES A weight-reducing diet should be nutritionally complete, using a variety of foods. Moderate caloric restriction of 500-1,000 kcal below daily requirements may be optimal in producing a gradual sustained weight loss. After the desired weight has been achieved, maintenance of that reduced weight may be sustained by adjusting the caloric intake. With low caloric intake, nutrient deficiencies should be avoided. For lean persons with NIDDM, caloric intake should be adequate to maintain body weight. FAT AND CARBOHYDRATE A diet reduced in total and saturated fat and cholesterol has been recommended for all Americans to decrease the risk of coronary heart disease (CHD). Patients with NIDDM are at increased risk for CHD by virtue of their diabetes. In addition, they frequently demonstrate blood lipid abnormalities, including reduced high density lipoprotein-cholesterol (HDL-C) and elevated triglyceride concentrations. The initial approach for normalizing serum lipids in the majority of patients with NIDDM is to reduce hyperglycemia. High carbohydrate diets (50-60 percent of total calories) may effect these changes in some patients by enhancing insulin sensitivity. When blood glucose is normalized, the panel recommends that patients with NIDDM should further attempt to reduce their risk of CHD by reducing low density lipoprotein-cholesterol. Present recommendations for the general population include a reduction of total fat intake to less than 30 percent of calories, with saturated fat comprising less than 10 percent of total calories. This may be suitable for some but not all NIDDM patients (as discussed below). A reduction of calories from fat usually requires an increase in calories from carbohydrates. High carbohydrate diets may be harmful in some patients by reducing HDL-C and increasing triglycerides. These diets are less effective than weight loss in normalizing blood glucose and may represent a serious lifestyle alteration for many patients. Consequently, the panel suggests that patients' adherence to a regimen of caloric restriction for weight loss is more important than alterations in the macronutrient composition of the diet. Also, both serum lipid and glucose concentrations should be monitored to determine the effectiveness of any dietary changes. OTHER CARBOHYDRATE ISSUES SUCROSE (Table Sugar) In the past, individuals with NIDDM have been advised to avoid all sucrose. The use of sucrose as a taste additive in mixed meals is acceptable (up to 5 percent of carbohydrate calorie intake) in patients who are lean and do not have carbohydrate-aggravated hyperlipidemia. The advisability of added sucrose intake above 5 percent of carbohydrate calories requires further investigation. FIBER Dietary fiber is plant material that is resistant to enzymes produced by humans. Most Americans consume 13 to 19 grams of dietary fiber per day. Some studies have suggested that dietary fiber is effective in controlling blood glucose and reducing plasma cholesterol, especially when used in very high carbohydrate diets (greater than 50 percent of calories); however, the results of these studies are inconclusive. Furthermore, high fiber diets may be less palatable, may require substantial changes in traditional eating patterns, may have effects on other nutrients, and may be contraindicated in patients with autonomic neuropathy. Therefore, the panel reaffirms that the primary dietary intervention in NIDDM is weight reduction. However, if individuals desire to increase the fiber content of their diet, foods high in soluble fiber could replace some other carbohydrates. The use of purified fiber supplements is not recommended at this time for diabetes therapy. GLYCEMIC INDEX Individual foods containing carbohydrate can have a high, medium, or low impact on postprandial blood glucose. This response can be quantified as "glycemic index." Several problems have been identified with the application of this methodology to the design of general guidelines of a dietary prescription for patients with NIDDM. Many factors contribute to a different glycemic response from the same food. These include processing, cooking, and food storage time. Other considerations include the variable degree of mastication in the elderly with dental problems, the diurnal variation in absorption, and racial and ethnic differences. Some studies have shown diminution of glycemic effects when foods are combined in a mixed meal. For these reasons at this time the panel does not recommend the use of specific glycemic indices in the dietary therapy of patients with NIDDM. PROTEIN There is no need to change the standard 12 to 20 percent protein content of the diet, providing RDA requirements are met, except in those who have specific problems in which protein intake should be reduced (i.e., in people with NIDDM who have renal disease). EDUCATION Different educational methods will be appropriate for individual patients and for varying ethnic diets. Whatever plan is used, intensive and frequent followup and support are needed until fasting euglycemia is achieved and maintained. Behavior modification and exercise may be combined with diet instruction to enhance weight loss efforts. Changes in diet need to be made gradually. No single educational tool can accommodate the needs of all individuals with NIDDM. When diet therapy alone is unsuccessful or unacceptable because of quality of life issues or failure to reduce hyperglycemia, then alternative euglycemic therapy is indicated. _________________________________________________________________ 3. WHAT ARE THE BENEFITS AND RISKS OF EXERCISE IN PATIENTS WITH NONINSULIN-DEPENDENT DIABETES MELLITUS? HOW SHOULD EXERCISE BE PRESCRIBED? The effect of regular physical exercise alone on metabolic control in NIDDM is quite variable and frequently of small magnitude. Greater improvement in glucose homeostasis can usually be obtained by weight loss. Despite the relatively small impact of exercise demonstrated to date, regular physical exercise may be a therapeutic component supplementing diet in selected patients. There is epidemiologic and clinical evidence that physical activity may reduce the incidence of coronary heart disease (CHD) in the general population. The risk-benefit ratio of exercise in NIDDM remains to be defined. Because many of the complications of NIDDM are related to atherosclerotic cardiovascular disease, an increase in physical activity for NIDDM patients appears prudent. This recommendation is made despite the absence of conclusive studies and with recognition that improvements in CHD risk factors may not occur in those with NIDDM. Furthermore, the consensus panel seeks to emphasize that the possible benefits of body fat reduction outweigh putative exercise effects. Vigorous exercise appears to blunt the rise in blood glucose that follows carbohydrate ingestion. In addition, exercise training may increase insulin sensitivity, but this change appears to be an acute effect associated with recent exercise and is reversed within 2 to 3 days by physical inactivity. Physical activity may assist in reducing body fat, but exercise without caloric restriction appears ineffective. Patients who exercise regularly may negate its weight-reducing effects by curtailing their usual activities and by increasing caloric intake. Complications of exercise in NIDDM patients include cardiac events (infarction, arrhythmias, and sudden death), bone and soft tissue injuries, and retinal damage in patients -- particularly with proliferative retinopathy. The incidence of these complications with exercise has not been defined. NIDDM patients should undergo a thorough medical evaluation prior to increasing physical activity. The components of the evaluation will vary depending on the severity and duration of the diabetes, the presence of complications, the likelihood of asymptomatic CHD, and the intensity of the activity. Because of the possible risks of retinal detachment and vitreous hemorrhage during exercise in patients with retinopathy, exercise that requires straining and breath holding (such as weight lifting) should be discouraged. Special attention should also be given to care of the feet during exercise. In planning and recommending an exercise program for NIDDM patients, health professionals should be aware of several factors. The threshold of energy expenditure required to reduce postprandial hyperglycemia and to enhance insulin sensitivity has not been defined. The same holds true for the use of physical activity in lowering the incidence of CHD. The panel believes that NIDDM patients should tailor an increase in their overall physical activity to their physical capacity, preferences, age, and lifestyle. Also, because many of the metabolic effects of exercise are short-lived, it is extremely important that NIDDM patients choose exercises that they are likely to engage in frequently and continue over their lifetimes. _________________________________________________________________ 4. WHAT IS THE EVIDENCE THAT WEIGHT CONTROL, DIET, AND/OR EXERCISE CAN PREVENT NONINSULIN-DEPENDENT DIABETES MELLITUS? Approximately 80 percent of persons with NIDDM have excess body fat. Cross-sectional population-based studies show that the prevalence of NIDDM increases with increasing body weight and that the risk of NIDDM is particularly high among obese persons with a family history of this disorder. These relationships suggest that avoidance or elimination of obesity in people whose relatives have NIDDM may delay or prevent the development of NIDDM. Weight reduction is best achieved through the use of hypocaloric diets. In normal weight people, there is no evidence that manipulation of dietary constituents (e.g., reducing refined carbohydrates or increasing complex carbohydrates or increasing dietary fiber) influences the risk of NIDDM. The possibility that exercise may prevent NIDDM is suggested by the observation that prolonged strenuous exercise in individuals with NIDDM may normalize fasting blood glucose and glucose tolerance. However, there are as yet no irrefutable data to demonstrate that weight control, dietary modification, or exercise are effective in preventing or delaying NIDDM. Nevertheless, in the opinion of the panel, it is prudent to maintain or achieve normal body weight in an attempt to minimize the risk of NIDDM in susceptible persons. ______________________________________________________________ 5. WHAT ARE THE DIRECTIONS FOR FUTURE RESEARCH? Many of the issues discussed in this consensus conference need further research in laboratory, clinic, and community-based settings. The following major topics are suggested: QUESTIONS RELATED TO OBESITY * What is the etiology of the insulin resistance in the obese state? * What is the etiologic basis of the obesity itself, from genetic, environmental, behavioral, and nutritional aspects? * What are effective strategies for therapy of the obese state, particularly as it relates to diabetes? QUESTIONS RELATED TO DIABETES AND ITS PREVENTION * What is the etiology of the beta-cell deficiency in NIDDM? * What is the pathophysiology of the insulin resistance in the diabetic state without obesity? * What is the nature of the inherited component in NIDDM? * What is the relative effectiveness of regular physical activity and/or weight control in the prevention and treatment of NIDDM and its complications? * What are predictors for the eventual development of NIDDM? QUESTIONS RELATED TO NUTRITION * What is the relationship of particular diets such as high carbohydrate diets to glucose and lipid metabolism? * What are the roles of other dietary alterations such as changes in fiber content, various carbohydrates, and other foods on carbohydrate and lipid homeostasis? * What are the optimal strategies to improve acceptance of therapeutic regimens? QUESTIONS RELATED TO EXERCISE * What are the potential mediators of exercise effects? * Under what conditions and in which NIDDM patients is exercise likely to be effective in enhancing glucose homeostasis and reducing coronary heart disease? * Under what conditions is exercise likely to be counterproductive? QUESTIONS RELATED TO COMPLICATIONS * What are the contributions of hyperinsulinemia, obesity, and glucose control to the risk of complications in NIDDM? * What are the relationships of the carbohydrate and lipoprotein abnormalities and their treatments to the risk of macrovascular disease in NIDDM? ____________________________________________________- _____________ CONCLUSION Noninsulin-dependent diabetes mellitus (NIDDM or Type II diabetes) is a major health problem. It is highly correlated with obesity and, thereby, with overeating. Normal weight maintenance continues as the cornerstone of therapy with oral agents or insulin added, if needed, to maintain blood glucose normal or near normal. For overweight individuals, reduced-calorie diets should be prescribed and attempts made to alter lifestyle within an acceptable degree for any given patient to encourage weight reduction. These alterations include increased physical activity, perhaps as prescribed exercise regimens, with the recognition that exercise alone is usually ineffective for weight loss unless accompanied by an appropriate diet. Weight loss diminishes hyperglycemia to or toward normal. Exercise itself may have a small but transient direct effect in lowering blood glucose and insulin resistance. Various food combinations, and even different processing or cooking of the same foods, may produce different glucose responses. Incomplete information on these and other factors that affect this phenomenon in individual subjects minimizes the role of the glycemic index in overall diabetes management. Similarly, foods high in soluble fiber may diminish glucose elevation after meals and may be of use in individual patients, but high-fiber goods appear to be less important than adhering to a calorie- restricted diet and achieving weight loss in the obese diabetic person. Approximately four out of five patients with NIDDM are significantly overweight, and the panel's attention was focused on this group throughout its deliberations. Specific recommendations for diet and activity in the normal-weight NIDDM patient were not addressed except for endorsement of a lifestyle that avoids the development of obesity. Finally, it appears prudent to prevent or reverse obesity, especially in individuals with a family history of diabetes, in the hope that the onset of diabetes may be prevented or postponed. ______________________________________________________________ MEMBERS OF THE CONSENSUS DEVELOPMENT PANEL WERE: George F. Cahill, Jr., M.D. Panel Chairman Vice President Howard Hughes Medical Institute Bethesda, MD Elsworth R. Buskirk, Ph.D. Professor of Applied Physiology Pennsylvania State University University Park, PA Linda M. Delahanty, M.S., R.D. Clinical Nutrition Specialist Massachusetts General Hospital Department of Dietetics Boston, MA Stefan S. Fajans, M.D. Professor of Internal Medicine Chief Division of Endocrinology and Metabolism University of Michigan Medical Center Ann Arbor, MI James B. Field, M.D. Rutherford Professor of Medicine Baylor College of Medicine Houston, TX Harmon E. Holverson, M.D. Diplomate, ABFP Private Practice Emmett, ID Joan Williams Hoover Director Consumer Health Information United Seniors Consumer Cooperative Washington, D.C. Ralph I. Horwitz, M.D. Associate Professor of Medicine and Epidemiology Yale University School of Medicine New Haven, CT Kathryn Iacocca Hentz President Iacocca Foundation New York, NY John M. Lachin, Sc.D. Professor of Statistics Codirector, Biostatistics Center Department of Statistics, Computer and Information Systems George Washington University Rockville, MD Dean H. Lockwood, M.D. Professor of Medicine Head Endocrine Metabolism Unit University of Rochester Medical Center Rochester, NY F. John Service, M.D., Ph.D. Professor of Medicine Mayo Medical School Consultant in Endocrinology and Metabolism Mayo Clinic Rochester, MN Paul D. Thompson, M.D. Associate Professor of Medicine Brown University Program in Medicine Miriam Hospital Providence, RI Madelyn L. Wheeler, M.S., R.D. Cordinator Research Dietetics Diabetes Research and Training Center Indiana University Medical Center Indianapolis, IN MEMBERS OF THE PLANNING COMMITTEE WERE: George F. Cahill, Jr., M.D. Panel Chairman Vice President Howard Hughes Medical Institute Bethesda, MD Eveline Eschwege, M.D., M.P.H. Directeur de l'Unite' de Recherches Statistiques INSERM Villejuif France Phillip Gorden, M.D. Director National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health Bethesda, MD Van S. Hubbard, M.D., Ph.D. Director Nutrient Metabolism Obesity, Eating Disorders, and Energy Regulation Programs National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health Bethesda, MD F. Xavier Pi-Sunyer, M.D. Director Division of Endocrinology and Diabetes St. Luke's-Roosevelt Hospital Center Associate Professor of Medicine Columbia University New York, NY Martin Rose, M.D., J.D. Chief Medical Officer Office of the Director Office of Medical Applications of Research National Institutes of Health Bethesda, MD Robert Sherwin, M.D. Associate Professor of Medicine Yale University School of Medicine New Haven, CT Robert E. Silverman, M.D., Ph.D. Chairperson Chief Diabetes Programs Branch Division of Diabetes, Endocrinology, and Metabolic Diseases National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health Bethesda, MD Simeon I. Taylor, M.D., Ph.D. Senior Investigator Diabetes Branch National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health Bethesda, MD Georges Tschobroutsky, M.D. Professor University Pierre et Marie Curie Head Department of Diabetology Hotel-Dieu Hospital Paris France Judith Wylie-Rosett, Ed.D. Assistant Professor Epidemiology and Social Medicine Albert Einstein College of Medicine Bronx, NY _________________________________________________________________ Michael J. Bernstein Director of Communications Office of Medical Applications of Research National Institutes of Health Bethesda, MD Charlotte Armstrong Public Affairs Specialist National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health Bethesda, MD THE CONFERENCE WAS SPONSORED BY: National Institute of Diabetes and Digestive and Kidney Diseases Phillip Gorden, M.D. Director NIH Office of Medical Applications of Research Itzhak Jacoby, Ph.D. Acting Director *----------++++++++++----------* NIDDMC.TXT Measures of Metabolic Control in NIDDM Patients: Fasting plasma glucose (approx meter readings in parens) good: 80-120 (70-100) acceptable: 120-140 (100-120) fair: 140-180 (120-150) poor: >180 (>150) Plasma glucose two hours after a meal (approx meter readings in parens) good: 80-140 (70-120) acceptable: 140-180 (120-150) fair:180-235 (150-200) poor: >235 (>200) Hemoglobin A1c good: <6.0 acceptable: 6.0-7.5 fair: 7.5-9.0 poor: >9.0 Total cholesterol good: <200 acceptable: 200-220 fair: 220-240 poor: >240 HDL cholesterol good: >40 acceptable: 35-40 fair: 30-35 poor: <30 Trigylcerides good: <150 acceptable: <150-200 fair: <200-240 poor: >240 Adapted from a table derived from recommendations of the American Diabetes Association and the European NIDDM Policy Group. The original is in the Nov 2 1989 issue of the New England Journal of Medicine. *----------++++++++++----------* LOWFAT.TXT WHY GO ON A LOW FAT DIET? According to the American Heart Association, added fat in the diet is a leading cause of heart disease. According to the American Cancer Society, added fat in the diet is a leading cause of many types of cancer. "BUT I DON'T EAT MUCH FAT IN MY DIET!" Because much of the fat in our diet is hidden, most people think that they are already on a low fat diet. Everyone is familiar with the fat that can be cut off meat. Not many people realize that some cuts of meat still can contain up to 60% fat. Some candies and "sweets" contain up to 70% fat. Everyone know that most potato chips are salty; not many know that they contain up to 80% fat. Everyone knows that candy bars contain sugar; not many know that they contain up to 60% fat. Overall, Americans eat 42% of our calories as fat. We owe it all to machinery, because the overall fat content of truly natural foods is less than 10%. For instance, one tablespoonful of corn oil (100% fat), contains the amount of fat in 14 ears of corn. Many people eat a tablespoonful of corn oil daily - very few people have ever eaten 14 ears of corn in one day. The food industry even has us convinced that there are "good fats." After all, polyunsaturated fats lower the cholesterol, they tell us. (They don't mention that polyunsaturated fats impair the immune system, lower the HDL cholesterol (the good cholesterol), and cause cancer the same way saturated fats do. Fish oils, olive oil, cod liver oil, all are supposed to have benefits, according to the food industry. DO WE NEED FAT? The answer is yes. The requirement of fat in the diet is approximately 4% of calories. Since almost all foods have over this amount of fat, it is impossible to develop a fat deficiency unless an individual is eating insufficient calories over a long period of time. (Another words, it is only possible to develop a fat deficiency if a person is starving.) HOW CAN YOU REDUCE THE FAT IN YOUR DIET? You have probably been eating a high fat diet (without knowing it) from the time you were several years old. Many people find it easier to gradually reduce the fat in their diet, rather than make sudden changes. What follows are a number of hints on reducing the fat in your diet. (These recommendations do not apply to children under 2 years of age. Also, remember, growing children should not be calorie restricted. REDUCING FAT 1. Mix regular milk with 2% milk. Use 2% milk. Mix 2% milk with 1% milk. DO EACH STEP Use 1% milk. OVER ONE MONTH Mix 1% milk with skim milk. Use skim milk. Have you ever seen children who will only drink skim milk? Who, when they taste regular milk, they spit it out, and complaint bitterly about the taste? I have seen many children like this. This should tell us something about acquired tastes. 2. Do the same thing for cottage cheese - going from regular cottage cheese, to 2% cottage cheese, to 1% cottage cheese. 3. Use lower fat cuts of meat and poultry only - such as chicken (white meat), turkey (white meat), round beef, flank beef. 4. Most people eat one or two fresh fruits a day. Gradually increase that to 3 fruits a day. Fruit juices don't count - they lack the fiber, and do not satisfy hunger - in fact, they may stimulate the appetite in some people. You will probably find that fruit satisfies the craving for sugar that many people have. 5. Try to eat a salad daily, using a no-fat salad dressing. Over several months, increase the size of the salad; they promote yourself to 2 salads a day. You will notice that you are acquiring a taste for vegetables that you never had before. 6. When an ice cream craving attack occurs, run to the refrigerator and get out a frozen banana, Put it in the blender with vanilla extract, add frozen raspberries if you like, and in minutes you have "ice cream" - the healthy variety. 7. Cut down the margarine or butter you add to bread over 2 months. Use a no-sugar added jelly; apple butter; or even try eating bread dry. 8. Eat less french fries over 2 months - start eating a baked potato at least once a week, then twice a week, then daily. For a topping, use a no-oil salad dressing, instead of butter or margarine. 9. Next time you are at a restaurant, order fish or chicken, baked or broiled in water - not in butter or margarine. Congratulations - you have just cut the calories of the main course in half. 10. Time for dessert? Try a fresh fruit cup. 11. Try whole wheat bread, instead of white bread. (I know what some of you are going to say - if God didn't want us to eat white bread, he wouldn't have invented the milling machine). 12. Remember - you don't have to eat meat everyday. Try spaghetti, preferably whole wheat, with a no-oil spaghetti sauce. 13. Scrambled eggs for breakfast? If you make it using 4 eggs, throw away 2 of the yokes. Experiment making egg white omelettes, with tumeric to give it a yellow color. 14. Don't skip meals. That's the easiest way to get cravings for sugars, or fats. Eat a cereal for breakfast, with a piece of fruit, and bread. Snack between meals if possible on low fat foods. 15. Do you like popcorn? Bring it along to work or in the car with you, for a snack. 16. Are you the cook in your house? Learn to use small amounts of various spices, to replace fats, in cooking. Recipes are available in various low fat cookbooks. "SIDE EFFECTS" TO EXPECT ON THIS TYPE OF LOW FAT EATING: 1. Energy. 2. Lack of constipation. 3. Lower cholesterol and triglycerides. 4. Good health. 5. Relatively easy weight loss (if overweight). 6. Dramatically better diabetes control. IS LOW-FAT EATING SOMETHING NEW? Our ancestors ate low-fat food for 100,000 generations. It has "only" been the last 1000 generations that we have switched to high fat food. IS LOW-FAT EATING "DRASTIC"? Eating a wide variety of natural foods, flavored with spices and herbs shouldn't be looked at as drastic. The definition of drastic is having people suffer from a wide variety of degenerative diseases, including heart disease and cancer, that are largely dietary caused. This is Volume 1, Issue 4, of the Low Fat Lifestyle Healthletter, written by Robert C. Baker, M.D., 819 South Broadway, Pitman, New Jersey, 08071. *----------++++++++++----------* LRFAT.TXT Going On A Low-Fat Diet When there is fat in your bloodstream it blocks the effectiveness of the insulin in your body, whether you are producing it or you are taking it by injection. You'll want to keep testing your blood sugars on a more regular basis once you switch to a low-fat diet because there is a good chance that your insulin requirements will be lower! Your blood glucose readings might not only get better but you'll also find that you'll lose any extra pounds much easier once you get on a low-fat diet. Do you find yourself craving for that chocolate bar or a piece of cake?? Think you have a sweet tooth?? Well, you might be surprised to learn that you might not be craving the sugar content of that food, but the FAT that's in the food. We do need to include some percentage of fat in our diets (30 percent or less), but most of us eat too much fat! Fat is the part of food that makes it rich and creamy, what makes that steak so tender, and fat is what makes the ice cream melt in our mouths. If you want to lose weight and make your blood glucose levels get better try to make some low fat choices! It might help you cut the fat out of your diet more easily if you think in terms of "fat grams" instead of the percentage of fat you eat per day. To figure out your fat gram budget for each day multiply the number of calories you eat per day time the percentage of fat you want your diet to be. For example: 1500 calories X .20 (20 percent fat diet) = 300 fat calories Divide the resulting number by 9 (the number of calories in a gram of fat) to find your daily fat gram allowance. 300 divided by 9 = 33 fat gram calories per day. If you're eating an 1800 calorie diet you can have 40 grams of fat. A 1200 calorie diet give you 27 grams of fat per day. Check the fat gram content of everything you eat and you can stay within your budget. After a little practice counting the fat grams will become second nature! Unlike money a fat budget doesn't have to be cut all the way from day one, especially if you're finding it hard to cope with giving up all the fatty foods you love. You might try having one low-fat meal a day to get accustomed to eating this way. Then work your way up to a full low-fat day per week. Spread a sandwich with half regular mayonnaise and half of the fat free kind. Mix half 2 percent milk and half skim milk on your cereal. Then gradually change the portions until you feel you can make the switch to a fat free way of life! One thing to keep in mind: Eating in a low-fat way is a bonus..You can eat a greater volume of food for fewer overall calories and less fat! When you try to cut back on your fat intake you have to know the right moves to make, otherwise you won't be too successful. Swapping a hamburger for tuna salad on a croissant might SOUND like the right thing to do until you add up the fat content of the croissant and the mayonnaise you mix with the tuna! Some people also might exchange the ice cream they want for muffins, not knowing that some muffins are loaded with fat! Switch to the right foods and know your facts! By trimming down your daily fat intake you'll lose weight naturally. This is because fat calories are more easily stored on your body as fat, than are carbohydrate or protein calories. Some experts think a diet that is 20 to 25 percent fat is high enough to taste good, but low enough to lose weight on, as well as being low enough to lower the risk of coronary disease. Some of the worse fatty-food culprits are fatty dressings and spreaks, sour cream, buter, cream sauce, etc. Don't cut out energy rich carbohydrates such as pasta, bread, rice and potatoes. in your quest to start a low-fat way of life. Carbohydrate is your body's most effective kind of fuel. One thing you can also do is keep a food diary. Record ALL the foods and drinks you consume on three consecutive weekdays and one weekend day. Be sure to include oils used in cooking, cream in your coffee, and dressinggs and sauces added to the meats and vegetables you eat, plus snacks. By doing this you can get a clear picture of your eating habits and have a better grasp of where you need to make changes. *----------++++++++++----------* GRAZE.THD #: 117351 S7/Diet & Exercise 12-Jan-93 18:24:51 Sb: #Meal frequency Fm: Bruce MacDougall 71545,1520 To: All In this forum, we have often discussed the merits of more frequent and smaller meals. Well, the current issue of Diabetes Care (January 1993) has a report on a study of the effects of this kind of diet in a group of 12 diabetic subjects. The results are what you might expect - "In conclusion, consuming frequent meals acutely reduces blood glucose fluctuations, and lowers average insulin and FFA [free fatty acid] levels in NIDDM subjects. Consequently, our results suggest that increased partitioning of caloric intake may be beneficial in older NIDDM subjects, and we call for long-term experiments." BTW, one interesting item mentioned in this study is that the Canadian Diabetes Association recommends fewer and larger meals, and the British Diabetes Association just the opposite. Bruce * Reply: 117399 #: 117399 S7/Diet & Exercise 12-Jan-93 18:55:46 Sb: #117351-#Meal frequency Fm: SYSOP*Dave Groves 76703,4223 To: Bruce MacDougall 71545,1520 (X) Thanks, Bruce. It is always nice to see theories developed here in the forum put to the test and proven scientifically. Moral then is to GRAZE and NOT eat "3 squares a day" eh? Any comment on the weight gain/loss in the group? * Reply: 117631 #: 117631 S7/Diet & Exercise 13-Jan-93 16:12:15 Sb: #117399-#Meal frequency Fm: Bruce MacDougall 71545,1520 To: SYSOP*Dave Groves 76703,4223 (X) Dave, I certainly wouldn't consider this one study as proof. It involved 12 subjects, one day of two meals, and a second day of six meals a week later. Note that the authors use words like "suggest" and call for long-term experiments. * Reply: 117671 #: 117671 S7/Diet & Exercise 13-Jan-93 18:00:02 Sb: #117631-Meal frequency Fm: SYSOP*Dave Groves 76703,4223 To: Bruce MacDougall 71545,1520 (X) Ok, n = too small. It is a helpful indication then. *----------++++++++++----------* OBESE.TXT From the Commentary Column of the July/August 1990 of "Practical Diabetology" (150 West 22nd Street, New York, NY 10011), Joan Williams Hoover writes (and we reprint here with her kind permission): O B E S I T Y A N D T Y P E I I D I A B E T E S ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ It's time we reconsidered those old cliche's that pass for knowledge about Type II diabetes and the role of obesity. We have allowed assumptions about weight to become an unnecessary emotional burden for patients. By perhaps perpetuating the status quo, we have deterred creative thought about the true nature of the disease. Our present system of care isn't working very well. Many people with Type II diabetes continue to feel poorly for years, and most do not succeed in losing weight. The therapy we offer them consists of diets, maintenance plans, and lots of guilt. This treatment continues until, eventually, they develop diabetic complications. It's just not good enough. It is estimated that 80% of those who develop Type II diabetes are obese (20% or more above their ideal weight). Obesity is therefore considered a prime cause of Type II dia- betes. Usually the admonition to lose weight is the therapy prescribed. Clearly, bodies feel better and function better when they are at ideal weight. However, there are many questions that should arise but don't when this oversimplified solution is applied to those with Type II diabetes: 1. Two million Americans who have Type II diabetes are NOT overweight. If they are not fat, what, then, caused their diabetes? What therapy is prescribed for them? If you can have Type II diabetes without obesity, are diabetes and obesity separate problems that should be treated separately? 2. Approximately 34 million Americans can be classified as obese. If obesity is viewed as a prime factor in the development of Type II diabetes, why does only one in every four obese people have this disease? 3. If obesity is a factor in causing diabetes, why does most research focus on why a person has diabetes and so little on why a diabetic person is fat? Perhaps it is the insulin imbalance, not the lack of willpower, that is causing the excessive hunger. Glib prescriptions for weight loss fail because they can't be fulfilled. Fewer than 15% of all people who manage to lose weight are able to sustain the loss. If significant weight loss doesn't occur and blood glucose levels do not improve, physicians often assume that the patient is lying, cheating, or both. More often, the patient is only trying hard and failing at an impossi- ble task. By assuming that it is the patient who has failed through noncompliance, we imply that the ensuing complications must consequently be the patient's own fault. This attitude blames the victim and adds an intolerable emotional burden to what is already a difficult case. For too many years, we have followed a scenario in which we don't know the true cause of Type II diabetes, so we prescribe an ineffective therapy to which many cannot adhere. Then, when faced with failure, we blame the patient. By doing so, the comfort and support that the patient needs are also withdrawn. That's not good medicine. It gives neither honor nor pride to the provider nor benefit to the patient. It is time to abandon the old cliche' that equates obesity with diabetes and blames the patients for their disease and their lack of success with the therapy. It's time to share the dilemma of this disease with frustrated patients. Pounds of ugly guild could be removed once patients learn tht it is often medical knowledge that is imperfect, and not always themselves. Somehow, we must take a fresh look at the cause of Type II diabetes and at its subsequent therapy. The present treatment is difficult, burdensome, and ineffective. It continues to fail the needs of 10 million patients. It's time to find better answers. SIDE BAR: ~~~~~~~~~ WHY OBESITY? Obesity is not a diagnosis. It is a symptom that tells you something is wrong. Almost no one chooses to be obese. Overeating is only one reason for being overweight, and there are a number of different motivations for it: * To be sociable. Imagine a party, or even a business lunch, without food. * To show affluence. This is especially true following a period of financial deprivation. * As a substitute for love or a cure for loneliness. Sometimes comfort can be found in chocolate cake. * Out of habit. Were you raised to clean up your plate? Were your good deeds rewarded with a cookie? * To celebrate. The "fatted calf" concept predates the Old Testament. * Out of boredom. Eating is a proven and pleasant way to pass time. * As a tranquilizer. In times of stress, a carbohydrate load or a full stomach can be very effective therapy. * To show hospitality. Traditionally, the host who gives his guest the gift of food also partakes of the gift. * To survive. If you perceive hard times ahead, you may take on additional calories to endure the famine. The reasons for overeating are as diverse as the population. Obviously, you can't ride into this battle brandishing a 1200-calorie diet and expect to win. However, if you can identify the cause of obesity in your patient and deal effectively with it, you might be amazed to see the problem resolve itself. Nagging, threats, anger, scorn or the imposition of guilt and fear will have little impact on a person struggling with an excess of weight. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Ms. Hoover has written and lectured as an advocate for diabetes patients for over a quarter of a century. She has served prominently with a variety of national and international diabetes organizations and is a member of the editorial board of Practical Diabetology. *----------++++++++++----------* FEAR.THD CompuServe Diabetes Forum fear S 6 / Oral Medications Date Range: 23-Sep-91 to 12-Oct-91 #51612 Fm: Cindy Santomassimo 70632,1410 To: Bobette H Pestana 70511,2060 Dt: 23-Sep-91 I am a new Type II diabetic. I was diagnosed in July. ( Actually a self-diagnosi s. Something told me to buy clinistix.) I immediately saw my GP who took blood tests and put me on 2.5 mg of micronase in the am. That was it. No diet. No dietition. No warning about possible low blood sugars because of the micronaise. I took it upon myself to go to a DTC in Waltham Mass. I saw an associated endocrinologist. She told me to test my blood. ( I bought a One Touch 2) I took the outpatient classes. SInce July I have lost over 30 lbs. I have not had a BG over 164. (my two week average right now is 109) But I can not shake this feeling that the process of dying has begun for me at 36. I keep getting panic attacks. THey hit me especially when I am alone in my car. O get them when I do my walk (WHich I do...2-2.5 miles 3-4 times a week) Man, I am SCARED! Every time I read about diabetic complications, I hear another nail being driven in my coffin. I started reading these conferences to see if I can find some encouragement but, all that seems to jump out at me is the negative stuff of what I will probably die of. I can't get it out of my head... I need some positive role models. SOme sucess stories of longevity and normal lives with diabetes. PLEASE!! #51614 reply to #51612 Fm: SYSOP*Tracey Agnew 76702,1653 To: Cindy Santomassimo 70632,1410 Dt: 23-Sep-91 Cindy, First let me congratulate you on swiftly catching on you had DM and your EXCELLENT glycemic control. You have empowered yourself by learning about your disease, but yes it comes with a price of sometimes knowing too much. I have had Type I IDDM for 15 years and believe me I know the fears you speak of. The point is, YOU, Cindy, are doing everything you can within your power to control the disease. You should be proud of yourself!! With the healthy life you are now living I'd place odds on your outliving your insurance examiner! As to role models, how about Mary Tyler Moore? She has been on insulin most of her life and has managed a brilliant career, first in dance, and then as an actress. Bill Carlson is an IRONMAN TRIATHLETE!!! Having diabetes does not mean an automatic sentence to a dismal life of complications. Sadly, that is sometimes the case. But with the positive steps you have taken and your wonderful control with diet, exercise, and oral meds, you have every reason to not worry! Tracey #51621 reply to #51612 Fm: SYSOP*Dave Groves 76703,4223 To: Cindy Santomassimo 70632,1410 Dt: 23-Sep-91 Cindy, we do exist! (I won't say great role models, but I will say people who are leading fun lives with diabetes and doing well). You don't give your age, but the DTC visit says you will be getting some of the best and most comprehensive care and education available. Associate SYSOP*Tracey Agnew has been diabetic for 15 years and has a 2 year old son. I've been diabetic 37 years this week. And have shown minimal complications, Tom Beatson has been diabetic 48 years and rides in major bicycle rallies. I've been fully around the world, climbed the Great Wall of China, watched the changing of the Guard at midnight at Lennin's tomb in Red Square and eaten a small portion of Baked Alaska in the Eiffel Tower. Getting the diagnosis confirmed as you did suggests that you have avoided one of the major causes of complications! Most diabetics go through a 6-12 month "denial" phase during which the condition deteriorates and during which the high blood sugars, acid blood, and ketones start the insidious complications process with a vengence. Your level headed, intelligent response to the symptoms, your knowledge of the disease and your ability to realistically confront it all, are admirable. That you knew to test and talk to your doctor is almost amazing. Congratulations, and Welcome to the forum! I cannot promise you a complication free course with your diabetes, I can tell you that you are on the right track and that there is every reason to believe that you will have a long and healthy life based on what you have done so far. No BG's higher than 164 and average BG's of 109 are exquisite! That should give you a perfectly "normal" Glycosylated Hemoglobin A1c and that's the only measure that we have been able to associate with complications. Your glucose will not be a problem if you can maintain this level of control. There are two other #51622 reply to #51612 Fm: SYSOP*Dave Groves 76703,4223 To: Cindy Santomassimo 70632,1410 Dt: 23-Sep-91 critical factors in the battle against complications that are as or more important than even glucose control in Type II diabetes. They are blood pressure and Lipids (cholesterol and triglycerides). If these are in normal ranges than you need have almost no fear of complications, provided you are able to keep on the good track you have started. I am concerned, however, about your panic attacks. You are taking an oral hypoglycemic agent and it is quite possible that these are not true panic attacks, but rather symptoms of LOW blood sugar! How many blood sugars have you taken below 70 mg/dl and what has been your lowest since diagnosis? Can you bring yourself together during a panic attack to take a blood sugar while the attack is going on? How long do they usually last? #51639 reply to #51612 Fm: Bobette 70511,2060 To: Cindy Santomassimo 70632,1410 Dt: 23-Sep-91 Cindy, After 10 years with Type II (with a lot of denial), I finally went through the DTC program and it did help a lot. Also, one BIG help I found was the book -Managing Type II Diabetes- published by DCI Publishing P.O. Box 739, Wayzata, Minnesota 55391 (1SBN 0-937721-24-7). I ordered it direct ($9.95), later found the local Diabetes Shop stocked it. Among other concerns, it deals very well with emotions, relating the stages to the stages of grief. I had a real scary reaction to oral medication years ago (no, I wasn't really warned what it would be like), and it remained my biggest fear for a long time. I guess fear of complications was a more productive fear. At least you are not in denial, which is a very UNproductive stage! I think experience helps to deal with fear. You'll get a lot of support here so hang in. Bobette #51641 reply to #51639 Fm: Bobette 70511,2060 To: Bobette 70511,2060 Dt: 23-Sep-91 Another thought - Do you get cable TV? -Living With Diabetes- on LIFETIME is filled with positive role models (along with this forum!). #51642 reply to #51612 Fm: Rilla Moulden 73307,3160 To: Cindy Santomassimo 70632,1410 Dt: 23-Sep-91 Hi Cindy! I am also a newly diagnosed Type II since June 22. I was on Micronase 2.5 mg for a month but then got everything under control with diet and exercise. I can remember exactly how you feel and sometimes still I get depressed about the constant "presence" of this disease. But usually I am so busy and have enough other stressful things in my life I totally (almost) forget to "worry" about the diabetes! (grin) The folks on here have been *extremely* helpful and good friends. I think that you will like it here. Another thing I found helpful was the book DIABETES: A GUIDE TO LIVING WELL, by Lowe and Arsham. Both authors are M.D.'s and both have had DM for a long time. The book not only covers the basics of DM but also gives the person many ways of feeling empowered to deal with the emotional aspects of the disease. I found it very helpful especially at the beginning. Welcome to the Forum! Looking forward to "seeing" you around on the board and maybe even in CO sometime. Rilla #51663 reply to #51612 Fm: Tom Beatson 70324,166 To: Cindy Santomassimo 70632,1410 Dt: 23-Sep-91 Hi Cindy, As Dave Groves mentioned, I've been a diabetic for 48 years, and seem to have pretty much avoided the serious complications. Of course, I'm a Type I, not a Type II. I have found that it's easier to face each problem matter of factly. I just don't become concerned with what may or may not be somewhere down the road. If I encounter another problem later on, I'll face it when I get there. I'm getting ready to ride my bicycle in a 110-mile event in November. How do I know I can do it? Well, this year will be the 7th year I have done this ride, and every time I started it I finished it. So I know I can do it. My fastest time was in 1990, and I have what seem to me to be very reasonable expectations that I can do even better this year. Does that sound like diabetes is getting the better of me? I don't think so! I hope you will make a serious attempt to overcome your fears, because there are so many more important things to look forward to. Tom Beatson #51688 reply to #51612 Fm: Michael S. Warden 70720,3660 To: Cindy Santomassimo 70632,1410 Dt: 23-Sep-91 Cindy: I too am a newly diagnosed Type II Diabetic (August '91). I found out I had the disease when I went to my family physician for a routine checkup and advice about an exercise/weight loss program (which I'm sure was actually subconsciously prompted by a general feeling of unease about several minor symptoms: rapid loss of near vision focus, and persistently itching feet for no apparent reason). I told a friend the day before I saw the doctor that I was pretty sure that I was going to be told I had Diabetes, but I'm not sure I really believed it, even as I said it. I'm 48 years old, and have a 5 year old daughter. My first thought upon hearing the diagnosis was "OK, what do I have to do to keep going, as healthy as possible, for as long as possible"? My second thoughts were "What exactly is Diabetes anyway; what will it do to me; how long have I got; and where can I find out more about it"? I was put on 1.25mg of Micronase; attended a Diabetes/Nutrition class; began a serious diet; bought a One Touch II blood glucose meter and began using it (before my doc had suggested it); and began to read all I could about Diabetes. Like Rella, I found the book "Diabetes - A Guide To Living Well" to be very informative and helpful and would strongly recommend it to you. I'm now off the Micronase (took it for about a month) and am diet/exercise controlled. I've begun exercising, although I hope to improve in this area. I've been on a 1950 calorie diet and losing about 1.5-2.0 pounds a week. The positive comments about my appearance alone from my wife, friends, and acquaintances make the diet worthwhile! #51689 reply to #51612 Fm: Michael S. Warden 70720,3660 To: Cindy Santomassimo 70632,1410 Dt: 23-Sep-91 I'm convinced that the diet/exercise program I've begun as a result of having Diabetes gives me every opportunity to live a longer, healthier life than I would have if I hadn't gotten Diabetes. I'm certain that I would have succumbed to coronary disease long before "my time" because of my unhealthy diet and lifestyle. I know this sounds crazy, but I'm well on the way to being healthier than my so-called 'healthy' friends who do not have Diabetes. The only real problem I've had was a minor one with the Micronase. I had to be very careful to eat each meal and snack that I was supposed to, when I was supposed to. If I didn't, I would get very rapid onset of hypoglycemia symptoms. I was able to measure my BG at these times and confirm the problem. I think this helped me stay on my diet/exercise program to try to get off the medication. My worst day was a business trip I had to take soon after my diagnosis. I got up very early, had a long day, couldn't stick to my diet, became very tired, and ended up the day feeling VERY bad and discouraged. I'm much more careful about my meal schedules now and last week when I went on essentially the same trip, I actually had a good time and felt great when I got home. Diabetes research has a LONG way to go to suit me, but with better Diabetic drugs, better BG meters, better Diabetic treatment regimens, better food labeling, and healthier food available in many stores and restaurants, Diabetes is not too bad a disease for a person with a good attitude and supportive friends to have. In fact, of all the really serious diseases to choose from, Diabetes is undoubtedly the one I'd pick if I had to make a choice! Don't worry about the fear, we've all got a little of it, and I believe it's good for the attitude. There's nothing like a little fear to keep you focused and help you pay attention to what you need to do! Welcome to the club! -mike- #51714 reply to #51612 Fm: Amy Shappell 70007,5116 To: Cindy Santomassimo 70632,1410 Dt: 24-Sep-91 Cindy, Welcome to the forum. I am sure you will hear from lots of other members...I'm not sure I would call myself 'a success story', or a 'positive role model', but I have had type I diabetes for ten years and am living a happy, normal life with no signs of complications, except for a slight neuropathy (nerve damage) in my feet. Am thinking about having a baby soon (in the next year or two.) How's that sound? Amy #52335 reply to #51612 Fm: DART WINSHIP 70712,2161 To: Cindy Santomassimo 70632,1410 Dt: 30-Sep-91 Hi Cindy Just saw ur msg Compuserve is new to me Nancy my wife is an RN and she might be able to help u as she had MS and now immune system probs. Nutrition has been of GREAT help to her When she gets home I'll have her "ring" u up Regards Dart #53327 reply to #52335 Fm: barbara hill-dryden 76347,1473 To: DART WINSHIP 70712,2161 Dt: 12-Oct-91 Dear Cindy: I was diagnosed as Type II five years ago. After some pretty drawstic symptoms - visual difficulties, motor problems, fainting a couple of times, etc., I learned that my blood glucose count was 418. I have been on a diet/exercise/glucotrol regimen ever since. At age 63, I commute to a job 1 1/2 hours away. As a lawyer, I have to be alert, energetic, attentive to details, and productive. Two years ago, I remarried, and can assure you I have a full, rich life. Yes, there is life after diagnosis - iot just requires adopting different habits. Even with my hectic schedule, I eat at the same time each day, eat the prescribed diet, test myself regularly, and I have never returned to such a high glucose level. Diabetes is a patient-driven disease. It is all up to you. You can manage it. As someone else suggested, the "anxiety attacks" could be hypoglycemia. My doctor's suggestion for that condition was twofold. TYest yourself regularly. If your blood glucose rea reading is below 65, eat some fruit - like an orange. Don't eat candy. If I were you, I'd bond with an endocrinologist and follow instructions. Meanwhile, go on with your life. GOOD LUCK!! #51697 Fm: Ed Huntress 76537,513 To: Cindy Santomassimo 70632,1410 Dt: 23-Sep-91 Cindy, I'm another fairly long-timer (20 years, 43 yrs. old, Type I), and I, too, was afraid of the complications when I first learned I was diabetic. Of course, everything I read and heard about diabetes was negative (except for the stuff that obviously was written to "buck up our spirits" -- who needs that when you're fighting fear and depression, right? Yuck!!) But six months later, after I noticed that I was still alive and as strong and healthy as ever, I found that dealing with diabetes had become an automatic part of my life -- one of the PITAs like having to bathe and shave. Although learning about diabetes and dealing with it was basically negative stuff (hey, telling people how wonderful it is wouldn't be very constructive, you know?), it eventually fit in, psychologically, with other negative stuff, like taxes and the fact that I'm short. It never fades into the woodwork, but it stops looking like a tragedy after it sinks in that you're just a stick-shift, manually-cranked machine in a world of automatic cruisers with self-starting engines. After a couple of years go by and the world hasn't caved in, you no longer feel like you're sitting at sea on a cake of ice that's melting out from under you. You get resourceful, in lots of little ways, about keeping diabetes from wrecking your fun. You may also develop an outlook on life that is focused more on enjoying the present and taking things as they come. That part can be pretty darned good. Being able to share your fears and feelings on a forum such as this, with other in similar situations, is something that should help anyone over the rough spots. It's also fun to share stories about little triumphs. For example, I spent three days traipsing through the Arizona desert last spring. Due to a mixup in plans, I was stuck climbing up foothills (some feet they must have in AZ!) for 14 hours without much food or water, and generally off my schedule. I got through it without any real problem. Two other guys, slightly younger and not diabetic, faded. *----------++++++++++----------* BLURVISN.THD From: Edward Harp, 73753,2162 To: ALL Topic: Blurred Vision Msg #441296 Section: Ask the Doc [16] Forum: Diabetes+ Date: Thu, Jul 6, 1995, 3:42:23 AM Yes, another question from me! Sheesh, I cannot get enough information right now! Anyway, the symptom that finaly got me to the doc was waking up with blurred vision. Since getting my BG under control, I have seen some improvement, but my eyes still are changing quite a bit and I am currently somewhat near sighted. Yesterday I was FAR sighted! I write software for a living and I am having a time seeing. What I would like to know is how long might these symptoms continue? I have maintained my BG, even taking the BG monitor to the doc to compare its results with theirs to make sure I am not being fooled. Also, what causes this blurriness in the first place? I would guess I am not suffering from retinal neuropathy at this point. Note I was exposed to those pupil dialation drops last week having gone to an optometrist just before the fateful doc appointment where I was dx'd with DM. Yes, I plan to see an opthalmologist ASAP. Thanks, Edward Harp ------------------------------------------------------------------------------- From: Dr. Dansereau-SYSOP, 71520,3617 To: Edward Harp, 73753,2162 Topic: Blurred Vision Msg #441346, reply to #441296 Section: Ask the Doc [16] Forum: Diabetes+ Date: Thu, Jul 6, 1995, 7:15:20 AM Ed, First, as you are saying, see an ophthalmologist first. Since your blood sugar was high, your cornea was used to high blood sugar. Now that you are controlling better your glycemia, your cornea is trying to adjust to this and this is why you have blurred vision. It will take some time before things get back to normal. Ask your eye doctor what he thinks on this and let us know after you see him-her. -Ron Dansereau ------------------------------------------------------------------------------- From: Kemp Randolph, 72370,3642 To: Dr. Dansereau-SYSOP, 71520,3617 Topic: Blurred Vision Msg #441745, reply to #441346 Section: Ask the Doc [16] Forum: Diabetes+ Date: Fri, Jul 7, 1995, 8:35:03 AM Ron, I've heard of this effect before but have never liked the explanation that it's a change in the geometric optics of the eye (change of index of refraction, lens curvature, or ?)--perhaps due to an osmotic effect. Given the lack of blood througout the eyeball itself, except for the retina, etc. at the back, it seems even harder to understand. I hope this opthalmologist has an explanation. Kemp ------------------------------------------------------------------------------- From: Bruce Beale-SYSOP, 100345,3667 To: Kemp Randolph, 72370,3642 Topic: Blurred Vision Msg #441757, reply to #441745 Section: Ask the Doc [16] Forum: Diabetes+ Date: Fri, Jul 7, 1995, 9:27:24 AM >> never liked the explanation that it's a change in the geometric optics of the eye << Kemp, Neither have I. The effect is so variable. -Bruce Beale ------------------------------------------------------------------------------- From: Dr. Dansereau-SYSOP, 71520,3617 To: Kemp Randolph, 72370,3642 Topic: Blurred Vision Msg #441934, reply to #441745 Section: Ask the Doc [16] Forum: Diabetes+ Date: Fri, Jul 7, 1995, 7:02:03 PM Kemp, Oh well, if you have a better explanation, I would be glad to hear about it. (g) -Ron Dansereau ------------------------------------------------------------------------------- From: Kemp Randolph, 72370,3642 To: Dr. Dansereau-SYSOP, 71520,3617 Topic: Blurred Vision Msg #442115, reply to #441934 Section: Ask the Doc [16] Forum: Diabetes+ Date: Sat, Jul 8, 1995, 8:06:02 AM Ron, No, I don't have a >>better explanation<< yet, but before poking around elsewhere for one and then moving the followup to Section 11 for speculating, what's the direction of the effect? Is a stronger or weaker prescription needed while all this is going on? Perhaps some who've had the experience would like to comment? Kemp ------------------------------------------------------------------------------- From: Shap Wolf, 73300,352 To: Edward Harp, 73753,2162 Topic: Blurred Vision Msg #441662, reply to #441296 Section: Ask the Doc [16] Forum: Diabetes+ Date: Fri, Jul 7, 1995, 1:03:04 AM Edward- I just asked my opthamologist yesterday when my eyes were going to settle down--I had the same symptoms you describe, and was diagnosed Type II May 26th with bg of 600. He said they aren't really sure, but it seems the increased bg causes the cells in the eye's lens to swell. The lens is made up of many, many layers, like an onion, and they think swelling causes separation of the layers. This not only accounts for the blurred vision, but also for the increased sensitivity to bg changes, as they aren't sure if the separated layers ever fully recover--or are always looser and more ready to part in the presence of swollen cells from high bg. My solution was to get refracted every 10-14 days and go to Lenscrafters. They (and probably other sources) will remake your lenses for free if the Dr. changes your prescription w/in 90 days. I've had 3 new sets now, and each one works well for a week or so. The last refraction showed things were settling down a lot, so this might be where I'm stable. The other thing I did was go to a local store specializing in low-vision products, and got some nice clip-on magnifiers (German-made, $57, ouch!). They help when my vison shifts away from being able to do close work. Good luck! At least you and I were luckier than a friend I found out about--she had gone to an optometrist for 2 months and had 4 different prescriptions made before anyone suggested it might be DM! :-( --Shap ------------------------------------------------------------------------------- From: Byard Edwards, 76103,3705 To: Edward Harp, 73753,2162 Topic: Blurred Vision Msg #442027, reply to #441296 Section: Ask the Doc [16] Forum: Diabetes+ Date: Fri, Jul 7, 1995, 11:58:29 PM as you have imagined, the varying levels of glucose have induced glycocylated proteins in your lenses which act as osmotic molecules pulling and holding water in the lenses which in turn changes your lenses refraction. Unfortunately, the reversal of the process is rather slow and may take upto 8 weeks after stabilizing your glucose at a new level. Caveat: no new prescription lenses for 2-3 months after gaining control of your glucose. ------------------------------------------------------------------------------- From: Kemp Randolph, 72370,3642 To: Byard Edwards, 76103,3705 Topic: Blurred Vision Msg #442182, reply to #442027 Section: Ask the Doc [16] Forum: Diabetes+ Date: Sat, Jul 8, 1995, 10:25:19 AM Byard, Yes, osmotic effects may be involved, but glycosation is normally described as irreversible. Perhaps you're right that there is some small rate in the opposite direction for these proteins, but the lens also has very little need for or access to glucose.(Evolution has a way of matching need to access. In fact are there even any cells in the lens to create a need?) In short very slow access/removal as well as slow chemistry. The other problem with any lens explanation is the delicate nature of its optical transparency. The physicist George Benedek at MIT has written extensively on this. The molecular changes in cataract formation are very slight changes in the random pattern of long chain molecules lying in the plane of the lens. It's hard to believe the osmotic changes you describe wouldn't also effect that. People get a temporary pair of glasses that allows them to see clear images during all this, don't they? I prefer to think that the eyeball itself is changed for high BG (also slowly - no blood supply except to the thin retina). Whether osmotic or molecular or cellular, the end effect being a different "index of refraction". That would have just as much effect on the optical power of the eye as a lens change. Kemp ------------------------------------------------------------------------------ From: Byard Edwards, 76103,3705 To: Kemp Randolph, 72370,3642 Topic: Blurred Vision Msg #442568, reply to #442182 Section: Ask the Doc [16] Forum: Diabetes+ Date: Sun, Jul 9, 1995, 12:11:27 AM surely someone has clamped the glucose of experimental mammals to 400-500 mg/% for a few months and observed the alteration in lens,globe,vitreous humor,ect. Do you know of any such publications? ------------------------------------------------------------------------------- From: Kemp Randolph,72370,3642 To: Byard Edwards, 76103,3705 Topic: Blurred Vision Msg #442851, reply to #442568 Section: Ask the Doc [16] Forum: Diabetes+ Date: Sun, Jul 9,1995, 6:43:25 PM Byard, I can find them, but lets get the circumstances and effect straight first. Does the blurring occur when the BG is high and steady or only when it's changing. If the latter, it may be hard to find such animal work with the right measurements in it. Second, what's the direction of the effect, is the optical power of the eye larger or smaller during whichever period. Kemp ------------------------------------------------------------------------------ From: Patience, 75342,3332 To: Kemp Randolph, 72370,3642 Topic: Blurred Vision Msg #442883, reply to #442851 Section: Ask the Doc [16] Forum: Diabetes+ Date: Sun, Jul 9, 1995, 8:41:24 PM PMFJI, but I was just dx'd in January, after denying symptoms for about 6 weeks. My eyes went through changes before and after dx. Thirst started just before Thanksgiving. (I knew all I needed was a humidifier). By mid-December, I was having trouble opening my eyes at night, felt like the fluid was half formed jello. Noticed road signs were getting slightly blurry. In general at that time, something just didn't feel right with my glasses, but I was more concerned about where my next drink was coming from. Didn't bother to come up with a rationalization for the eyes, was on my third thirst rationalization. They estimated at dx that I'ld been at about 500 for a month, but that was a casual, off the cuff statement. Within days of being put on insulin, my normally nearsighted eyes were far-sighted. They stayed far-sighted, with gradual improvement, for about four weeks, then normal, then slightly worse. By six weeks I was back to my normal glasses prescription. Based on the time lag of thirst onset and when I noticed my eyes bothering me, I'ld say high BG's came first, then change. 2 cents. -Patience *----------++++++++++----------* METFOD.TXT ---------------------------------------------------------------------- Reprinted by permission from Diabetes Self-Management magazine, March/April 1995 issue. For subscription information, call (800) 234-0923. ---------------------------------------------------------------------- SPECIAL REPORT METFORMIN - GOOD NEWS FOR TYPE II's by Janet Blodgett, M.D. If you were diagnosed as having Type II diabetes, you have probably been exercising regularly and watching what you eat. To help further control your diabetes, your doctor may have prescribed pills that seem to do the trick, but oral diabetes medicine has some unpleasant side effects and may not work forever. Your only other choice, injecting insulin, is something you would like to avoid for as long as possible. Don't you wish there was another option? Well, now there is. A drug called metformin, which received Food and Drug Administration approval in late December of 1994, is expected to have a major impact on the treatment of Type II (non-insulin-dependent) diabetes. Metformin effectively controls blood glucose levels without the side effects of the diabetric drugs that are available now. So if you are currently treating your diabetes with pills or with diet and exercise alone, this new medication may work well for you. What is metformin? Metformin has actually been around for about 30 years in Europe and 20 years in Canada. It belongs to a class of antidiabetic drugs called biguanides. These agents were developed in the 1920's and were originally available in the United States. However, complications resulting primarily from phenformin, a related, but less effective drug, tarnished the reputation of all the biguanides and the class of drugs was pulled from the market in 1977. Now, after three decades of safe and effective use, the Food and Drug Administration retested metformin and approved it for use alone and in combination with sulfonylureas, the traditional oral diabetes medicine in use long before the approval of metformin. Metformin is manufactured and distributed by Bristol-Myers Squibb under the brand name of Glucophage. Normally, insulin works like a key to unlock a passage into the cells so that glucose can enter and be used for fuel. But with Type II diabetes, your cells are resistant to insulin, so they cannot effectively process your blood glucose. Rather than flooding your bloodstream with extra insulin to overwhelm the less-than-hospitable receptors on your body's cells, metformin works by sensitizing your cells to insulin's effects. Thus, the receptors work more efficiently so you can process glucose using the insulin that your body already makes. As a result, you can lower both your blood glucose levels and circulating insulin levels, which protects the blood vessels throughout your body. In addition, metformin has a number of secondary benefits over currently available pharmacologic treatments. Metformin lowers the levels of triglycerides and other fatty blood components, and, in many people, works as an appetite suppressant. These traits further recduce insulin resistance and improve triglyceride and cholesterol levels, thus keeping blood glucose levels in check while reducing the risk of heart disease and other complications. This aspect of metformin makes it a welcome addition to the repertoire of diabetes treatment. The old order Right now there are several ways to improve your insulin sensitivity. Sometimes, losing weight and changing your diet and exercise habits will help. However, most people with Type II diabetes need to take oral medicine and eventually insulin injections to maintain normal blood glucose levels. Although highly effective in improving blood glucose and triglyceride levels, a regimen of increased exercise, imporoved diet, and weight loss alone is rarely successful in treating diabetes over the long term. Indeed, few people achieve their ideal body weight through diet and exercise and those who do lose weight often gain it right back. So people with Type II diabetes often need to use some sort of pharmacological therapy to manage their diabetes. Currently there are two types of drug therapies available: oral agents called sulfonylureas and insulin injections. Sulfonylureas work primarily by stimulating the pancreas to produce more insulin so that cells will be more likely to process the glucose coursing through the bloodstream. This therapy also increases the number of insulin receptors on the cell surface. Both of these effects result in lower glucose levels. Currently, if you cannot take oral agents, or if they stop working, the next step is to take insulin, either alone or in combination with the oral agents. Unfortunately, both sulfonylureas and injected insulin have several conterproductive side effects. Oral agents generally become less effective over time because the overworked pancreas eventually becomes exhausted and burns out. When this happens, people must begin taking insulin injections. Furthermore, both therapies promote weight gain because they allow you to absorb calories from blood glucose that would otherwise spill out in your urine. This weight gain can worsen insulin resistance and increase the risks of heart disease. In addition, it is not healthy to have too much insulin flowing through your system. High levels of insulin, or hyperinsulinemia, is known to contribute to the development of atherosclerosis, or hardening of the arteries. Severe vascular disease, particularly coronary artery disease, is the most common cause of hospitalization and death for people with Type II diabetes. So it's a good idea to try to avoid any therapies that worsen this condition. Insulin and oral agents can also promote hypoglycemia, so you always have to be on the alert for such reactions. Why use metformin? The introduction of metformin is an exciting prospect since it addresses many of the limitations of the other therapies. Most important, metformin sensitizes the tissue in your body to the effects of the insulin your body makes without stimulating your pancreas to make more insulin. Because metformin does not affect the action of your pancreas, taking the drug does not cause pancreatic exhaustion, which is the reason that sulfonylureas eventually stop working. Furthermore, you won't have super-high levels of insulin in your bloodstream, as people with Type II diabetes tend to have when they use just sulfonylureas or insulin. In addition, metformin can lower levels of triglycerides and other fatty blood components. Since heart disease is a problem for many people who have Type II diabetes, this is a welcome bonus. Metformin can also act as an appetite suppressant, thus promoting weight loss and improving insulin sensitivity and cardiovascular health. Another side effect connected with insulin and sulfonylurea therapies is hypoglycemia. Metformin alone does not cause hypoglycemia because it does not raise your circulating insulin level the way other medications do. Of course, if you take metformin in combination with sulfonylureas, you will still need to watch out for hypoglycemia. Is metformin for you? Metformin is an exciting alternative for many people with Type II diabetes. It may be a good choice for you if you are currently controlling your diabetes with diet and exercise alone or if you are now taking a sulfonylurea. Taken alone, metformin will allow your body to make better use of your own insulin. If you take metformin in combination with a sulfonylurea, you can achieve a collaborative effect. The sulfonylurea makes your pancreas produce more insulin while the metformin makes your tissures use that insulin better. These methods are in many ways superior to existing treatments. If you are already taking insulin, chances are that metformin will not be a good choice for you, since you probably don't produce enough insulin naturally or with the help of sulfonylureas. Metformin has not been approved for use with insulin. It is also important to note that people with kidney disease cannot use metformin since they may experience more serious side affects than other users. Of course, like all drugs, metformin does have some side effects, most notably gastrointestinal discomfort. About 10% to 30% of users experience loss of appetite, nausea, stomach discomfort, and diarrhea. However, these symptoms are temporary and disappear over time. Also, they can be lessened or alleviated by lowering the dose. A rare, but serious, side effect is a toxic condition called lactic acidosis. It occurs when your tissues are not getting enough oxygen to survive. Although the risk of developing lactic acidosis from metformin is much lower than from the other biguanides, people with kidney disease are at the greatest risk of experiencing this side effect. Thus, physicians in the United States will be given specific guidelines for selecting patients who can safely use the drug. The next step Metformin is not just another oral agent. Rather, it is an exciting drug that should have a major impact on the treatment of Type II diabetes. Whether you use it alone or with sulfonylureas, it can keep your blood glucose levels steady while lowering your levels of circulating insulin and triglycerides, thereby reducing your risks of heart disease. And it does all this with fewer side effectrs than other available treatments. So see your doctor to find out if metformin is the right treatment for you. ---------------------------------------------------------------------- Dr. Janet Blodgett is an Assistant Professor of Medicine in the Division of Diabetes at the University of Texas Health Science Center at San Antonio. *----------++++++++++----------* FINGRSTK.THD From: Brooke Disbrow-SYSOP, 74627,3163 To: Dennis Alvernaz, 72760,244 Forum: Diabetes+ Date: Thu, Jul 13, 1995, 10:46:23 PM Dennis, PMFJI. Are you sticking the SIDE of the tip? That's where you should. Also, reuse your lancets. Most of us find that a lancet feels better the more it's used. I use about one a month now. Also, no alcohol on the finger. Just wash it (I don't even wash usually). Alcohol dries it out and hurts a little, too. Finally, I prick only my left hand, and only the two fingers that seem the least sensitive. Brooke [Added later] Other tips: To get that droplet more easily: 1. Shake hands in downward motion below heart for a while. 2. Make sure hands are *warm*. 3. "Milk" after sticking instead of just squeezing near the hole. Never use feet or toes. Earlobe may be used but it may spout a little. ------------------------------------------------------------------------------- From: Ann, 76413,2114 To: Brooke Disbrow-SYSOP, 74627,3163 Forum: Diabetes+ Date: Fri, Jul 14, 1995, 3:02:31 AM Brooke, I really agree about reusing lancets. I'm using one now that I think I've had in there since March, and when I pricked my finger tonight I couldn't believe it bled because I hadn't felt anything! That box of 200 lancets will probably last me the rest of my life! (Or until the cure is found!) -Ann ------------------------------------------------------------------------------- From: Holly Crockett-SYSOP, 72253,502 To: Ann, 76413,2114 Forum: Diabetes+ Date: Fri, Jul 14, 1995, 3:16:28 AM yep I only change the lancets when my daughter has been playing with it. Then they begin to hurt. I found other uses for the extra lancets I have. They are good for map pins and also for lancing boils. Also they dig out splinters and thorns much better that what else I have around the house. -Holly Crockett ------------------------------------------------------------------------------- From: Dennis Alvernaz, 72760,244 To: Brooke Disbrow-SYSOP, 74627,3163 Forum: Diabetes+ Date: Fri, Jul 14, 1995, 10:11:09 AM Brooke, Actually, I have been sticking the pad. Seemed more "meaty" to me, like a little pillow full of blood. I'll try the side. I'm running out of lancets. I left most of them in Fresno. So I guess I'll have to start to reuse too. What do you do with them between tests? Do you use alcohol to clean it after a test? Do you keep in in the lancer? Or what? Dennis ------------------------------------------------------------------------------- From: Brooke Disbrow-SYSOP, 74627,3163 To: Dennis Alvernaz, 72760,244 Forum: Diabetes+ Date: Fri, Jul 14, 1995, 10:32:07 AM Dennis, Keep them in the launcher. I dab mine with the kleenex I use to staunch the blood flow. As a result my bloodstream is now loaded with kleenex lint. I haven't used an alcohol wipe in ten months. Don't say you're running out of lancets. Forum members will send you thousands of their extras they can't get rid of any other way! Brooke ------------------------------------------------------------------------------- From: Dennis Alvernaz, 72760,244 To: Brooke Disbrow-SYSOP, 74627,3163 Forum: Diabetes+ Date: Fri, Jul 14, 1995, 8:52:02 PM Brooke, I guess I just lancet-o-lot. I'm just a Camelot kind of guy! Ok keep them in launcher. I'll have to start using kleenex instead of my undershirt. Dennis ------------------------------------------------------------------------------- From: Brooke Disbrow-SYSOP, 74627,3163 To: Dennis Alvernaz, 72760,244 Forum: Diabetes+ Date: Fri, Jul 14, 1995, 9:18:05 PM Dennis, >>lancet-o-lot...instead of my undershirt<< They actually *let* you minister to people? Brooke ------------------------------------------------------------------------------- From: Dennis Alvernaz, 72760,244 To: Brooke Disbrow-SYSOP, 74627,3163 Forum: Diabetes+ Date: Sat, Jul 15, 1995, 11:44:15 AM Brooke, Yes, they actully let me minister to people! However, mostly only on weekends! And I just found a wonderful red towel to use in the good ole lancing time! This behavior, BTW, is common to us who live alone. Our loveable eccentricity. Hugs, Dennis ------------------------------------------------------------------------------- From: Brooke Disbrow-SYSOP, 74627,3163 To: Dennis Alvernaz, 72760,244 Forum: Diabetes+ Date: Sat, Jul 15, 1995, 12:20:00 PM Dennis, Most "guy" eccentricity is definitely *not* loveable. Do you then drop the towel on the floor? Brooke ------------------------------------------------------------------------------- From: Dennis Alvernaz, 72760,244 To: Brooke Disbrow-SYSOP, 74627,3163 Forum: Diabetes+ Date: Sat, Jul 15, 1995, 1:49:07 PM Brooke, I can see that my lancet hygene is a turnoff! So much for airing my bloody laundry in public! Dennis ------------------------------------------------------------------------------- From: John Davis, 73455,43 To: Dennis Alvernaz, 72760,244 Forum: Diabetes+ Date: Sat, Jul 15, 1995, 11:25:04 AM >>I'll have to start using kleenex instead of my undershirt. Actually there is a best way to staunch the flow of blood after a test. Seems that sliva causes blood to coagulate and stops the flow faster than anything short of stypic pencels (and much more painlessely than thost things) So, as "The Count" would say. Suck on it. (keeps the shirt clean too) ------------------------------------------------------------------------------- From: Dennis Alvernaz, 72760,244 To: John Davis, 73455,43 Forum: Diabetes+ Date: Sat, Jul 15, 1995, 1:32:27 PM John, Saliva works. You know, I kind of automatically lick my finger with blood on it. Must be one of those natural reactions built into the genes or something. I just didn't know it was a coagulant. Actually I usually have to wipe on something when my drop starts to roam over the finger and I have to start over. In that case I felt that my saliva might wreck the next reading. Dennis ------------------------------------------------------------------------------- From: Sande Francis, 70762,2401 To: Dennis Alvernaz, 72760,244 Topic: Reusing Lancets Msg #445302, reply to #445058 Section: News & Newcomers [2] Forum: Diabetes+ Date: Sun, Jul 16, 1995, 3:41:14 AM ick!!! there are germs in your mouth! i would never lick my fingers - there are germs on your fingers, too!! of course, i kiss my dogs all the time. i keep a folder paper towel on the kitchen counter where i test, and i after i wrest that reluctant bit of blood onto my test strip, if there is any left on my fingertip, i just blot it on the paper towel. i have such a hard time getting enuff blood anyway that i dont worry about bleeding all over anything. :) Hugs and Kisses from Sande (Fresno, CA, USA) ------------------------------------------------------------------------------- From: shula,manchester,u.k, 100417,1501 To: Sande Francis, 70762,2401 Forum: Diabetes+ Date: Sun, Jul 16, 1995, 4:22:06 PM >> blot it on the paper towel << sande & dennis something i found by accident was that if i used a softer absorbent paper towel the bleeding took longer to stop than a firm matt napkin or paper tissue - this didnt wick up the blood so much and spread it more. i usually cut up paper towels in small trips to keep in the meter case, these i then put, with the used strips in small poly bags that i buy for small jewellry parts, about 1.5"x2", but money, coin, change bags would do. these then are trashed as they fill up. whne i ran out of my towel pieces, i bought a mini pack of kleenex which are much more fine in texture, i just now cut them up. btw i have just had a tetanus booster after my last one 10 years ago. my doctor agreed this was a very good idea, after someone mentioned it here. i never use alcohol to swab, but i keep a few mediswabs handy in the meter case if i am unable to rinse or wash my hands away from home. and my arm is up in a lump with the tetanus shot :( shusafe -shulabeth,manchester,u.k ------------------------------------------------------------------------------- From: Holly Crockett-SYSOP, 72253,502 To: Dennis Alvernaz, 72760,244 Forum: Diabetes+ Date: Fri, Jul 14, 1995, 3:50:13 PM I just recap the lancet and store it in the meter case. You will have a lot less pain in the long run if you do test from the side of your fingers. You use the pads all the time so they will stay tender, if you test from the sides you will not keep putting pressure on the healing puncture. -Holly Crockett ------------------------------------------------------------------------------- From: Dennis Alvernaz, 72760,244 To: Holly Crockett-SYSOP, 72253,502 Forum: Diabetes+ Date: Sat, Jul 15, 1995, 12:01:08 AM Holly, I'll give the sides a try this evening. Already I have to break a habit! Thanks for the rationale of using the sides. Sure makes sense. Hugs, Dennis ------------------------------------------------------------------------------- From: Joseph E. Brown, 74132,1071 To: Holly Crockett-SYSOP, 72253,502 Forum: Diabetes+ Date: Sat, Jul 15, 1995, 1:05:03 PM >> I just recap the lancet and store it in the meter case. << Please explain. My One Touch Basic glucometer has a pen-sized contrapton called "Penlet II" in it that is spring-loaded and has a trigger button on the underside. The lancets I use are blue and have a twist-off cap that, as far as I can determine, cannot be put back on the lancet. I just leave the lancet "loaded" in the penlet, since it is retracted at all times except when it is viciously jabbing into my finger. Joe ------------------------------------------------------------------------------- From: Holly Crockett-SYSOP, 72253,502 To: Joseph E. Brown, 74132,1071 Forum: Diabetes+ Date: Sat, Jul 15, 1995, 3:09:22 PM I am sorry I wasn't very clear, I usually reset my lancet launcher so the next time I need it I don't have to do it with one hand. I use the one from the Glucometer Elite because it doesn't seem to hurt as much but it is not as easy to set. You have to take the cap off the front and push the front assembly in to lock it. I hope this explains my comment, I am just not withit lately it seems. (sigh) -Holly Crockett ------------------------------------------------------------------------------- From: Joseph E. Brown, 74132,1071 To: Holly Crockett-SYSOP, 72253,502 Forum: Diabetes+ Date: Sat, Jul 15, 1995, 7:42:27 PM I hate having a disease that involves equipment. ------------------------------------------------------------------------------- From: Ann B. in Puyallup WA, 76413,2114 To: Joseph E. Brown, 74132,1071 Forum: Diabetes+ Date: Sun, Jul 16, 1995, 1:38:30 AM Keep it loaded, it will get less vicious. Ann [Puyallup WA] ------------------------------------------------------------------------------- From: Joseph E. Brown, 74132,1071 To: Ann B. in Puyallup WA, 76413,2114 Forum: Diabetes+ Date: Sun, Jul 16, 1995, 12:53:19 PM You promise? ------------------------------------------------------------------------------- From: Patience, 75342,3332 To: Joseph E. Brown, 74132,1071 Forum: Diabetes+ Date: Sun, Jul 16, 1995, 7:19:11 AM Hi again. I have the same testing system. What I do is take the Penlet, remove the cap, wipe around the sharp part with an alcohol wipe, thereby pushing it in to load it, and replace the cap. Then the hard part is pushing the button to "unload" it into the finger. -Patience ------------------------------------------------------------------------------- From: Joseph E. Brown, 74132,1071 To: Patience, 75342,3332 Forum: Diabetes+ Date: Sun, Jul 16, 1995, 1:16:02 PM Hi again. I just HATE sticking my finger. I just HATE HATE HATE HATE it (I hate it all four times a day). I wonder if I can get a spiggot installed somewhere? Joe ------------------------------------------------------------------------------- From: Brooke Disbrow-SYSOP, 74627,3163 To: Joseph E. Brown, 74132,1071 Forum: Diabetes+ Date: Sun, Jul 16, 1995, 1:35:29 PM Joe, PMFJI. If you haven't already, please read message #444387 in this thread. Brooke ------------------------------------------------------------------------------- From: Patience, 75342,3332 To: Joseph E. Brown, 74132,1071 Forum: Diabetes+ Date: Sun, Jul 16, 1995, 7:45:25 PM >> I just HATE sticking my finger. << me too. Back in January, when I first started, it could take up to a half hour for me to: set up strip in meter, get out record book, "lock and load" lancet launcher wash hands double check launcher locked and loaded work up courage to push the button (minutes) remember to turn the meter on work up courage again (minutes) push button get the sample out possibly start over because the poke wasn't deep enough, cold hands under warm water for minutes work up courage again push button, remembering to hold hand steady to get a good poke get sample on strip. The quick part, 45 seconds for One Touch II to do test Read chart for insulin dosage Get correct syringe (use 2, one for R one for Nph) Got through steps of loading syringe Go to bathroom and access injection spot (clothing removal if need be) Work up courage to put syringe into the skin (more minutes) Inject Clean up. One night it took *six* pokes to get a reading. After 6 months (on last Thursday) I now move faster than geologic time. -Patience ------------------------------------------------------------------------------- From: John Davis, 73455,43 To: Joseph E. Brown, 74132,1071 Forum: Diabetes+ Date: Sun, Jul 16, 1995, 9:04:02 PM >> The lancets I use are blue and have a twist-off cap that... Now Joe, Please don't tell me you use MONOLET drill bits? Many of us have switched to B-D ultra fine 29ga lancets They are green and the cap can be replaced. However even though I use them I don't re-cap. I just leave in the lancet (soft touch in my case) ------------------------------------------------------------------------------- From: Brooke Disbrow-SYSOP, 74627,3163 To: John Davis, 73455,43 Forum: Diabetes+ Date: Sun, Jul 16, 1995, 9:07:01 PM John, BD UltraFines are blue/green. Brooke ------------------------------------------------------------------------------- From: Sande Francis, 70762,2401 To: Dennis Alvernaz, 72760,244 Forum: Diabetes+ Date: Sun, Jul 16, 1995, 3:41:12 AM hey, dennis - i have a couple of boxes of brands i dont use any more, if you need some. i've switched to the B-D ultra fine lancets and since i use one until the tip bends over, the box of 200 i bought will last forever... :) Hugs and Kisses from Sande (Fresno, CA, USA) ------------------------------------------------------------------------------- From: shula,manchester,u.k, 100417,1501 To: Sande Francis, 70762,2401 Forum: Diabetes+ Date: Sun, Jul 16, 1995, 4:22:08 PM >> until the tip bends over << i actually found this once or twice, so it pays to look at a lancet closely if its especially painful. heaven knows how they got like that but they were tearing chunks out of me shusore -shulabeth,manchester,u.k ------------------------------------------------------------------------------- From: Dennis Alvernaz, 72760,244 To: Sande Francis, 70762,2401 Forum: Diabetes+ Date: Sun, Jul 16, 1995, 8:44:11 PM Sande, I'll remember that name "B-D" for the lancets. I have started using them more than once too, primarly because I forget the box of 200 I bought in Fresno when I came to Yosemite. I'm slowing mastering the fine art of the lancet. Dennis *----------++++++++++----------* TESTINFO.TXT Diabetic Tests: Dave Groves wrote this in late 1994 in response to a request to explain what the different tests are that diabetics undergo. Glycated Hemoglobin Tests: -A1c (a specific 'fraction' of the hemoglobin) Normal range: 4.5 - 6.5 Intermediate intercept and shallower slope than other tests, the DCCT test devised and used to measure 60 day average blood glucose control. Preferred and more expensive test due to more stable and predictable results. -A1 (a specific 'fraction' of hemoglobin) Normal range: 5 - 7.5 Higher intercept with slop about equal to A1c, slightly higher. -Glycohemoglobin (Total glycated hemoglobin) Normal range: 4 - 9 Low intercept and steep slope. Least accurate, least predictive, cheapest glycated Hgb test. Fructosamine: Another measure of protein glycation believed to cover 30-40 day average glycemia. Cheaper than Hbg tests above, and recently suggested to be overly sensitive to prior three days' glycemia. C-Peptide: Proxy measure of insulin production by measuring C-Peptide chain presence that results from cleaving the C-chain out of proinsulin to form insulin. Basic measure of insulin dependence, often used to distinguish Type I from Type II diabetes. Challenged C-Peptide: C-Peptide measure before and after stimulation of insulin production by injection of glucagon. (Yes, though glucagon is used to cure severe imsulin reaction, it is a STRONG insulin production stimulant and may be counterindicated for treating insulin shock in Type II diabetics for this reason.) Blood Glucose: - Fasting Glucose Test: Any pre-meal glucose reading, generally four hours or more from previous meal, usually the first reading of the day. Tends to be quite low compared to over-all total day's average unless there is substantial dawn phenomenon, rebound or Somogyi effect. - Post Prandial Glucose Test: Any post-meal reading, generally 1.5 - 2 hours after the meal when glucose is normally the highest. - "Midnight" Glucose Test: Generally 2-3 A.M. readings which often show unanticipated highs or lows due to rebound or overmedication. Glucose Blood Sampling Information: 1. Venous (taken from vein through needle) sample generally runs 12% below capillary (finger stick) readings. 2. Whole blood sample usually runs 15% above plasma sample. *----------++++++++++----------*