In Type II diabetes, which used to be called adult-onset or non-insulin-dependent diabetes, the body produces insulin but either does not produce enough to properly convert food into energy or is not able to use the insulin it does make. This form of diabetes usually occurs in people who are over 40, overweight, and have a family history of diabetes. (In Type I diabetes, which used to be called juvenile-onset or insulin-dependent diabetes, the body completely stops producing insulin. People with Type I diabetes must take daily insulin injections to survive. This form of diabetes usually develops in children or young adults but can occur at any age.)

In some people with Type II diabetes, the body fails to produce enough insulin to meet their needs, and glucose that can't get into the cells builds up in the bloodstream. In many others, the pancreas is actually producing more insulin than would normally be needed to convert the food they've eaten into energy; because their cells are resistant to the effects of insulin in the bloodstream, the cells don't become unlocked and allow in enough of the glucose in the blood.

Scientists don't know exactly what causes this insulin resistance, and many expect that there are several different defects in the process of unlocking cells that cause insulin resistance. Medications for Type II diabetes focus on different parts of this insulin-cell interaction to help improve blood glucose control. Some medications stimulate the pancreas to produce more insulin. Others improve how the body uses insulin by working on insulin resistance. Physical activity also seems to lessen insulin resistance.

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Genetics does, however, play an important part in determining who develops Type II diabetes. Studies show that if one parent has the disease, children have a 7 to 14 percent chance of developing it. If both parents have Type II diabetes, this increases to a 45 percent chance. If an identical twin has Type II diabetes, there's a 58 to 75 percent chance that the other twin will develop it, too. By contrast, a person with no diabetes in the family has an 11 percent chance of developing Type II diabetes by age 70.

While Type II diabetes may have a strong genetic basis in some patients, the development of the disease in most people is dependent upon the effects of such environmental and behavioral factors as obesity and a sedentary lifestyle or an underlying susceptibility that is poorly understood.

Susceptibility to certain complications of diabetes also seems to be linked to genetics. However, careful blood glucose control is still an important mitigating factor.

• are age 45 or older
• are overweight
• are physically inactive
• have previously been identified as having impaired fasting glucose (IFG), a higher-than-normal level of blood glucose after fasting
• have previously been identified as having impaired glucose tolerance (IGT), a measure of how the body has processed a glucose solution two hours after drinking it
• have a family history of diabetes
• are members of certain ethnic groups (including Asian-American, African-American, Hispanic American, and American Indian)
• have had gestational diabetes or have given birth to a child weighing more than 9 pounds
• have elevated blood pressure
• have an HDL cholesterol level (the "good" cholesterol) of 35 mg/dl or lower and/or a triglyceride level of 250 mg/dl or higher
• have polycystic ovary syndrome
• have a history of vascular disease

Prevention overview

While Type II diabetes is not completely understood, recent research does suggest that certain lifestyle changes can prevent or delay the onset in adults who are at high risk of getting the disease. Modest weight loss (of 5 to 10 percent of body weight) and modest physical activity (30 minutes a day) are recommended goals.

In people with pre-diabetes, the two-hour blood glucose level is between 140 and 199 mg/dl, and the fasting plasma glucose level is between 100 and 125 mg/dl. Those identified by the oral glucose tolerance test are said to have "impaired glucose tolerance (IGT)," and those identified by the fasting plasma glucose test are said to have "impaired fasting glucose (IFG)."

A reading of normal for the first test is no higher than 140 mg/dl at the two-hour mark. For the fasting plasma glucose test, normal is under 100 mg/dl. Diabetes is defined as a glucose tolerance level of 200 mg/dl or a fasting plasma glucose level of 126 mg/dl or greater on two separate occasions. Or, if diabetes symptoms exist and two blood draws taken at random show levels of 200 mg/dl or higher, diabetes is indicated.

Studies indicate that most people with pre-diabetes develop diabetes within 10 years. This risk rises as people become more overweight and more sedentary, and if they have a family history of diabetes.

A recent study found that people with glucose levels in the upper half of the impaired glucose tolerance range could lower their risk of developing diabetes by 58 percent by following a healthful diet and a moderate exercise program that enabled them to lose about 5 to 7 percent of their body weight. People taking the medication metformin reduced their risk by 31 percent. Though researchers studied the interventions only in people in the upper half of the danger zone, many researchers think it is reasonable to assume that millions more people would also benefit from cutting back on fats and portion sizes; emphasizing fruits, vegetables, and lean cuts of meat; and walking 30 minutes a day.

Symptoms

Sometimes people with Type II diabetes do not have any symptoms. But when they do, the symptoms include:

• Excessive thirst
• Frequent urination
• Weight loss
• Blurred vision
• Increased hunger
• Frequent skin, bladder, or gum infections
• Irritability
• Tingling or numbness in hands or feet
• Wounds that are slow to heal
• Extreme unexplained fatigue

Tests overview

Several tests are used to diagnose diabetes and to monitor it. In this section, you will find information on:

The OGTT requires a fast of eight to 12 hours, after which a person's blood glucose is measured before drinking a glucose-containing solution and then again two hours later. In normal glucose tolerance, blood glucose rises no higher than 140 mg/dl two hours after the drink. In people with pre-diabetes or impaired glucose tolerance (IGT), the two-hour blood glucose is between 140 and 199 mg/dl. If the two-hour blood glucose rises to 200 mg/dl or above, the diagnosis is diabetes.

In the fasting plasma glucose test, a person's blood glucose is measured once after a fast of eight to 12 hours. A person with normal blood glucose has a blood glucose level below 100. A person with impaired fasting glucose has a blood glucose level between 100 and 125 mg/dl. If the fasting blood glucose level rises to 126 mg/dl or above, the person has diabetes.

The OGTT includes measures of blood glucose levels after a fast and after a glucose challenge. In 1997, an American Diabetes Association (ADA) expert panel recommended that doctors use the fasting plasma glucose test to screen their patients for diabetes because the test is easier and less costly than the OGTT. On the other hand, the OGTT is more sensitive in identifying people with problems that may first appear only after high glucose intake.

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Your doctor or diabetes team will help you decide what type of meter to buy. Most new meters today read the glucose level as if the blood sample were plasma rather than whole blood, since that's the way results are reported by your doctor's office or lab. By having the meter record results as "plasma glucose," you and your healthcare team can more easily compare your lab tests with your home tests. Plasma numbers run 10 to 12 percent higher than those for whole blood; if your pre-meal plasma glucose target is 90 to 130 mg/dl, the target would be 80 to 120 mg/dl if your meter reads whole blood.

To understand what the readings mean for you, you will need to know:

• your target blood glucose range. A range of 90 to 130 mg/dl before meals is suggested for most people with diabetes. Ask your doctor what yours should be.
• when to check your blood glucose. Some people check two times a day every day; others check four times a day. Ask your healthcare provider for guidance.
• It's a good idea to write down your blood glucose numbers in a diary or logbook and look for patterns over time. For example, are your blood glucose readings before breakfast higher or lower than your target? Once you see patterns, you can look for causes--and avoid them.

A terrific result does not necessarily mean that your blood glucose has been continuously under control; people with highs and lows that balance each other out could also get a great reading. This is why daily blood glucose readings are so important. A reading that falls between 7 and 8 for more than six months, or a reading over 8, suggests that the treatment plan needs to be changed.

Treatment overview

There is no cure for diabetes. But when a treatment plan results in blood glucose levels that are normal or nearly so, a person's risk of developing complications is much lower.

There are certain things that all people with diabetes need to do to be healthy: have a meal plan and engage in regular physical activity (which can help the body use insulin so it can better convert glucose into energy for cells). Some people also need to take insulin or "oral agents," pills that help the body produce insulin and/or use insulin more effectively.

Many people with Type II diabetes can manage the disease with meal planning and physical activity alone. If Type II diabetes is diagnosed early, when the body is still producing and using insulin fairly effectively, changing eating habits and being more active may be sufficient to control blood glucose. On the other hand, many individuals have high blood glucose levels for years before they are diagnosed, and the disease may have progressed to the point where medication is also necessary. In both cases, the goal is to take whatever actions are needed to keep blood glucose levels as close to normal as possible in order to avoid complications.

When you eat is also important. Your meals and medication work together so that your body can use the sugar from the food for energy or store it for a later time. A dietitian can help you formulate a meal plan.

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The balance between the amount of carbohydrate you eat and the available insulin determines how much your blood glucose level goes up after meals or snacks. To help control your blood glucose, you need to know what foods contain carbohydrate, the size of a "serving" of different foods, and how many carbohydrate servings to eat each day. There's no magic number of daily servings that's right for everyone; instead, it is important to work with a dietitian to determine what will work for you. By checking your blood glucose, you can see whether changes are needed. If your levels are too high, for example, you may need to eat fewer carbohydrate servings, be more physically active, or work with your diabetes team to adjust your medications.

Foods that contain carbohydrate include grains, pasta, and rice; breads, crackers, and cereals; starchy vegetables such as potatoes, corn, peas, and winter squash; legumes such as beans, peas, and lentils; fruits and fruit juices; milk and yogurt; and sweets and desserts. Nonstarchy vegetables such as broccoli, salad greens, and green beans are very low in carbohydrate.

Carbohydrate counting can be used by anyone with diabetes, not just people taking insulin. This method can ensure that the right amount of carbohydrate is eaten at each meal and snack. Likewise, insulin and medications may be adjusted based on what the person wants to eat. For example, if you want to eat a much larger meal, this approach can help you determine how much extra insulin to take.

The only way you can tell if you are eating the right amount is to measure your foods carefully:

• Practice, practice, practice. Don't rely on measuring once and then just "guesstimating." Pull out the scales at least once a week to check yourself.
• Use a glass that you know holds only 4 or 8 ounces. You can also place a piece of tape on the outside of a glass to mark off a serving.
• A bread serving is based on a 1-ounce slice of bread. Many single bread servings may weigh more than 1 ounce and therefore have more impact on blood glucose. Check labels of such items as light breads, bagels, or rolls.
• Know the weight of fruit servings for portion control.
• Check your cereal portion using measuring cups.

Some alcoholic beverages are high in sugar and carbohydrate: sweet wines, sweet vermouth, and wine coolers, for example. Use these sparingly.

When making the decision about whether to use alcohol, you should understand what the potential effects of alcohol are on your health. Although alcohol has little effect on blood glucose control, it may worsen other medical problems. Make sure you discuss the use of alcohol with your doctor. Here are some general guidelines:

• With your doctor's approval, alcohol should be limited to two drinks a day. A "drink" is defined as a 12-ounce beer (preferably light beer); a 4-ounce glass of wine; a 2-ounce glass of dry sherry; or 1.5 ounces of a distilled beverage, such as whisky, rye, vodka, or gin. Even if your doctor approves the use of alcohol, however, you still may want to avoid the extra calories if you are trying to lose weight.
• Alcoholic beverages can make your blood glucose drop. Avoid the risk of low blood glucose by having your drink at mealtime or by having a snack along with the drink.
• Avoid drinks that contain large amounts of sugar.
• Drink with caution, and carry identification that says you have diabetes. Signs of low blood glucose are similar to those of intoxication. Make sure your companions know you have diabetes and know how to treat you if necessary.
• People taking oral hypoglycemic agents may have a reaction to alcohol. Discuss this with your doctor.

In the past five years or so, several other types of diabetes pills have come on the market. They work in a variety of other ways on the multiple factors that are believed to contribute to high blood glucose. These medications include:

• Insulin sensitizers, which help keep blood glucose levels within a target range by making the body more sensitive to insulin's effects. These medications may also help decrease the amount of glucose released by the liver. Examples of insulin sensitizers include Actos (pioglitazone) and Avandia (rosiglitazone).
• Starch blockers. These medications help control blood glucose by slowing the digestion of carbohydrates (sugars and starches) in the small intestine. They decrease peaks in blood glucose levels that occur after eating by delaying absorption of carbohydrates (sugars and starches) into the bloodstream. Examples of these medications are Precose (acarbose) and Glyset (miglitol).
• Prandin (repaglinide) and Starlix (nateglinide), which stimulate the pancreas to produce more insulin right after a meal.
• Medications that reduce the amount of glucose the liver releases between meals. Examples: Glucophage (metformin); Riomet (metformin liquid); and Glucophage XR, Fortamet, and Glumetza (metformin extended release).

Frequently, physicians will prescribe one type of oral medication and discover it isn't helping to control blood glucose effectively. In the past, the patient would most likely have been put on insulin. Now, physicians can try another type of medication--or one of three combination drugs. Glucovance combines glyburide and metformin to both stimulate insulin production and decrease the amount of glucose produced in the liver. Metaglip, a combination of glipizide and metformin, works similarly. Avandamet is a combination of rosiglitazone and metformin. It helps your muscles use insulin more effectively and decreases the amount of glucose released by the liver.

• Rapid-acting insulins include insulin aspart (Novolog) and insulin glulisine (Apidra). They begin to act in 10 to 30 minutes, and reach their peak in 30 minutes to three hours, and their effects last between three and five hours.
• Short-acting insulin is regular insulin. It begins to work in 30 to 60 minutes, peaks in one to five hours, and lasts as long as eight hours.
• Intermediate-acting insulin, NPH, begins working in between one and four hours. It peaks at between four and 12 to 15 hours, and lasts up to 26 hours.
• Long-acting insulin, glargine (Lantus), begins working in between one and two hours, does not peak but has consistent effects, and lasts as long as 24 hours.

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Effective, safe use of the pump requires a commitment to checking blood glucose at least four times a day, counting carbohydrates, and adjusting your insulin doses based on blood glucose levels, carbohydrate intake, and physical activity.

The main advantages of pump therapy are:

• increased flexibility in lifestyle
• predictable and precise insulin delivery
• the ability to accurately deliver one tenth of a unit of insulin
• tighter blood glucose control, while reducing the risk of low blood glucose
• reducing episodes of severe hypoglycemia
• reducing wide fluctuations in blood glucose, and helping manage the "dawn phenomenon" (the early-morning rise in blood glucose).

The main disadvantages of pump therapy are:

• the risk of skin infections at the catheter site
• the cost
• the need to check blood glucose at least four times per day.

• Store unopened bottles in the refrigerator and do not use after the expiration date. Don't freeze insulin.
• Store bottles you are using at room temperature (59 to 86 degrees Fahrenheit) for 28 to 30 days. The strength of the insulin may be altered after that.
• Avoid exposing the bottles to temperature extremes (less than 36 degrees Fahrenheit or more than 86 degrees Fahrenheit).
• Don't use regular insulin if it becomes cloudy in appearance.
• Don't use intermediate-acting insulin if it becomes clumped or crystallized or if the bottle becomes frosted.
• Make sure that you recheck your dosage whenever you change insulin.
• Get guidance from your healthcare team before mixing insulins or prefilling syringes.

• People who have poorly controlled diabetes sometimes experience weight loss because their bodies are unable to properly convert food into energy. Taking insulin helps reverse that process and can result in a weight gain.
• When blood glucose runs high, you can become dehydrated as your body works to clear itself of all that excess glucose. Getting your blood glucose under better control may cause you to retain fluid.
• Once you start taking insulin injections, glucose in your blood can get into the body's cells and be used rather than remaining in your bloodstream and being excreted in your urine.
• High blood glucose may cause people to feel hungry and eat more, because not all the food taken in can be properly processed to nourish the cells. Frequently, eating patterns continue after insulin has been started and allows more-efficient use of nutrients.

Some people cut back on their insulin once they discover they can lose a few pounds quickly by doing so. But when they go back to using the right amount of insulin, they discover that they gain the weight back--and perhaps more--in equally rapid fashion. Manipulating insulin to lose weight is an unhealthy habit to get into. Letting your blood glucose run high can lead to long-term complications. Better to make careful adjustments in how much you eat.

Managing overview

Everyone who has diabetes should be seen at least once every six months by an endocrinologist or a diabetologist and periodically by other members of a treatment team, including a diabetes educator and a dietitian, who will help develop a meal plan. Ideally, you should also consult an exercise physiologist about a physical activity plan and perhaps a social worker, psychologist, or other mental health professional for help with the stresses of living with a chronic disease. It's extremely important to see an ophthalmologist annually, so any eye problems can be treated before they become serious.

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How to get back on track?

• Remember that success depends upon having realistic, practical, and achievable goals. Define one action you could take to start to improve your situation--preferably a fairly easy action that makes success likely.
• If a specific obstacle keeps getting in your way, try to define it concretely. When, where, and why does the problem occur? Consider changing your behavior or your environment, either to make handling the issue easier or to avoid it.
• Consider: Are there other people who could help you? Moral support at home, at work, and in social situations can make a big difference. Decide what kind of support you need, and ask.
• Understand that strong negative feelings about diabetes are normal. Talking with family, friends, health professionals, and other people with diabetes about your feelings can help you to better tolerate them and react in constructive rather than self-destructive ways.
• Keep your eye on the rewards of good care, not the consequences of failure. Fears about complications may motivate you for a short time, but in the long run most people either dismiss their fears or become paralyzed by them. Rather, focus on how great you've felt when you've managed the disease well.

When the damaged nerves influence how well your stomach and intestines clear food through your system, a condition called gastroparesis develops; symptoms can include abdominal discomfort, nausea, vomiting, and bloating. Nerve damage in other areas of the body might mean incomplete emptying of the bladder, incontinence, or sexual dysfunction. Damage to nerves that regulate blood flow and blood pressure can cause significant drops in blood pressure--and lightheadedness or fainting--when you sit or stand.

If you begin to show signs of neuropathy, the most important thing you can do is try and prevent further damage by making sure your blood glucose is under control. Sometimes, improving blood glucose control can lessen symptoms of neuropathy over time, even as it's helping to prevent further damage. Nerves do not grow back, however. Once pain is replaced with numbness--a sign the nerves are dead--the numbness will not go away.

One of the most commonly used and effective medications is gabapentin (Neurontin), which has relatively few side effects. A topical cream (capsaicin) may help relieve the pain of neuropathy by blocking nerve signals. An analgesic ointment such as Ben Gay may also help.

Surprisingly, clinicians have found that certain antidepressants seem to be effective at helping patients tune out their pain. Antidepressants can take several weeks to work, so patients should wait a month before deciding whether a drug is helpful or not.

Some patients have experienced success with other forms of pain management--biofeedback, meditation, hypnosis, and acupuncture, for example.

Other factors can cause or exacerbate sexual dysfunction, including self-consciousness and fear of failure. If you are experiencing impotence or sexual dysfunction, it's important to see your doctor for an accurate diagnosis of your condition. People who experience sexual difficulties can lead more enjoyable, fulfilling sex lives by learning about causes, treatment options, and how to discuss their feelings and needs with a doctor and partner.

There's no certain way to avoid heart disease and circulation problems. But there are things to do to cut your risk:

• If you smoke, stop.
• Lose weight if you are overweight.
• Keep your blood pressure in the proper range.
• Be physically active.
• Keep your blood fats and cholesterol levels in a healthy range.
• Keep your blood glucose under control.

You can lower your chances of developing foot problems by treating your feet gently:

• Wash your feet in warm, soapy water every day. To avoid drying out your skin and getting cracks, don't soak your feet or use hot water, and choose mild soap. Towel off carefully, including between the toes.
• Apply lotion but not between the toes. Put talcum powder on your feet if they sweat.
• Check every day for dry skin, cracks, or cuts, and inform your doctor if you find cuts that are not healing. If you cannot easily inspect your feet, use a mirror or ask for help.
• File your toenails with an emery board, rounding the edges. Do not use scissors. Get assistance if you do not see clearly.
• See a doctor to determine the best treatment for corns and calluses. Never cut them.
• See a foot doctor regularly if you have poor circulation, nerve damage, or thick toenails.

• Physical activity can lower the level of blood glucose and improve the body's ability to use glucose. With regular exercise, the amount of insulin needed decreases.
• Physical activity can also help reverse the resistance to insulin that occurs as a result of being overweight. There is an increase in the number of insulin receptors, improving the body's ability to use insulin.
• Physical activity decreases the risk of heart problems, a major health concern of people with diabetes.
• Exercise can reduce the body's level of low-density lipoprotein (LDL), or bad cholesterol, which forms plaque that obstructs blood vessels. It also raises levels of good cholesterol, high-density lipoprotein (HDL), which is protective against heart disease. Regular physical activity has been shown to improve blood pressure, too.

Someone with Type II diabetes may be able to control his or her blood glucose with regular physical activity combined with a meal plan. This section has information on:

An exercise program should be individually tailored and designed to complement your lifestyle. Many factors--such as the time of day you exercise and the type and duration of your exercise--will determine whether adjustments should be made in your medications or your meal plan. Discuss your exercise program with your exercise physiologist to determine the type of adjustments you need to make. Start your program gradually, and set realistic goals.

Some tips on exercise:

• If you are over 35, you may need a stress test before beginning to exercise regularly.
• Test your blood glucose before and after exercise.
• Do not exercise if your blood glucose is over 250 mg/dl and there are ketones in your urine. If no ketones are present, do not exercise if blood glucose is 400 mg/dl or more.
• Plan exercise to prevent low blood glucose reactions. That means you should exercise 1 to 1½ hours after eating, check blood glucose before and after exercise, always carry a carbohydrate snack with you (glucose tablets, juice, etc.), and drink plenty of fluids.

To avoid problems:

• Check your blood glucose before exercising. Do not exercise if the reading is over 250 mg/dl and you have ketones.
• If the reading is 400 or more and no ketones are present, do not exercise.

When you exercise, the body uses two sources of fuel to generate energy: glucose and free fatty acids--or fat. The glucose, stored in the body in a form called glycogen, comes from the blood, the liver, and the muscles. During the first 15 minutes of exercise, most of the glycogen is drawn from the bloodstream or the muscles. After 15 minutes of exercise, the body is fueled more by glycogen stored in the liver, and, after 30 minutes of exercise, by the free fatty acids.

The body will replace its depleted glycogen stores, but this process may take four to six hours, or even 12 to 24 hours when the physical activity has been intense. During this period, a person with diabetes is at higher risk for hypoglycemia--though there are precautions that can prevent it:

• Check your blood glucose before exercising to make sure your blood glucose is sufficient. If necessary, eat an appropriate snack.
• Avoid exercise at the peak of your insulin action.
• Avoid late-evening exercise. Exercise should be completed two hours before bedtime.
• Avoid alcohol before and immediately after exercise.
• Avoid hot tubs, saunas, and steam rooms directly after exercise. Otherwise, your heart rate will remain elevated longer, and your blood glucose may continue to drop.
• Check with your doctor about the length, intensity, and duration of your planned exercise program.
• Check your blood glucose immediately after exercise to prevent low blood glucose from occurring hours after exercise. It may also be necessary to check your blood glucose more often for two to four hours after exercise. Intense exercise may cause your blood glucose to drop for the next 24 hours.

What should you do if you find your blood glucose is less than 100 mg/dl immediately after exercise?

• Follow post-exercise snack guidelines. If you are not scheduled for a snack or a meal for 30 to 60 minutes after exercise, 15 grams of carbohydrate should be sufficient to prevent low blood glucose. If no meal or snack is scheduled for more than one hour, take 15 grams of carbohydrate and 7 to 8 grams of protein.
• Increase carbohydrate intake before exercise.
• Decrease the dose of active insulin for the next exercise session.
• Consider decreasing the insulin dosage following exercise.
• If your blood glucose at bedtime is still less than 100 mg/dl, double your bedtime snack or, if possible, decrease your bedtime insulin dose.

• Snacks may be necessary for exercise beginning two hours or more after your last meal.
• You may need a snack if you exercise for an hour or more.
• Long-duration or all-day activities may require both a snack adjustment and an insulin or medication adjustment.
• If you are attempting to lose weight, adjust your insulin or medication rather than eating extra food.

• Take your usual diabetes medication even if you can't eat normally, unless your healthcare provider instructs you differently. In some cases, additional medication is required.
• Check your blood glucose every three to four hours, including during the night. Have someone do it for you if you are too sick to do it yourself.
• Check for ketones if your plasma blood glucose is 250 mg/dl or higher, unless otherwise instructed by your healthcare team.
• Write the results of your blood glucose and ketone checks down, and have them ready if you need to call your healthcare provider.
• Drink plenty of fluids--about 6 to 8 ounces every hour you are awake. If you are able to eat your meals, drink fluids that are sugar free and caffeine free. If you are unable to eat, alternate sugar-free fluids one hour with fluids containing sugar the next. Include liquids with salt, too, such as bouillon or clear soup.
• Rest. Stay warm.
• Call your healthcare provider if: you are vomiting or have diarrhea for more than two hours; you have a fever; your blood glucose values remain above 250 mg/dl for at least two checks or do not decrease with extra insulin (whether or not you have ketones); you have stomach pains that won't go away.

You'll want to use birth control to prevent an unplanned pregnancy; your goal is to conceive after your blood glucose levels have been well controlled for several months. During the earliest weeks of fetal growth, the risk of birth defects is heightened if blood glucose levels are not in control.

During pregnancy, your dietary needs and your insulin needs are bound to change as your body does. It'll be even more vital than usual to get good medical care and nutritional guidance.

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In general, high blood glucose, also called hyperglycemia, is reached when the level is 160 mg/dl or when it is above your individual target. If your blood glucose is high for long periods, you run an increased risk of complications over the long term: eye disease, kidney disease, heart attacks, and strokes, to name a few. High blood glucose can pose health problems in the short term as well. Your treatment plan may need adjustment if your blood glucose stays over 180 mg/dl for three days in a row.

Symptoms of high blood glucose include increased thirst, increased urination, dry mouth or skin, tiredness or fatigue, blurred vision, more frequent infections, slow-healing cuts and sores, and unexplained weight loss.

High blood glucose can be caused by too much food; too little physical activity; poorly calibrated treatment; or illness, infection, injury, or surgery.

What should you do if you have hyperglycemia?

• Be sure to drink plenty of water or noncaloric, caffeine-free fluids.
• Follow your diabetes treatment plan.
• If you take diabetes pills, take the prescribed amount at the correct time, and if you take insulin, talk to your healthcare provider about adjusting it.
• If your blood glucose is 250 mg/dl or greater and you are on insulin, check your urine for ketones. If they are present, call your healthcare team.
• Ask yourself what may have caused the high blood glucose, and take action to correct it. Ask your healthcare team if you are not sure what to do.
• Call your healthcare provider if your blood glucose is over 180 mg/dl for three days in a row and you're not sure what to do.

Hypoglycemia is usually unpleasant, with the most common symptoms being shakiness and sweatiness and having one's heart pound. The most common reasons for hypoglycemia are too much insulin, too little food, or too much activity. A less common but occasional cause is drinking alcoholic beverages. Most hypoglycemia, if quickly and appropriately treated, is more of an inconvenience than a cause for alarm.

However, severe hypoglycemia can cause mental confusion, antagonistic behaviors, unconsciousness, and seizures. The biggest danger is not the condition itself but what may happen as a result: a motor vehicle accident caused by passing out at the wheel or swerving into oncoming traffic, or a tumble down stairs, for example. In rare cases, seizures can result in brain damage.

To avoid problems with hypoglycemia:

• Recognize the symptoms, which are specific to each individual and may change over time. If you have symptoms, test immediately if possible to see if your blood glucose is low.
• Understand the interaction between food intake, treatment, and physical activity so you can anticipate when hypoglycemia is a risk.
• Always carry carbohydrate. Don't overdo it: The most common error is to overtreat low blood glucose.
• Check blood glucose levels again in 15 minutes, and repeat treatment if symptoms persist or blood glucose levels have not risen to your target level or above.
• Check blood glucose levels before driving if you think you may be low--and stop the car immediately if you're already underway. Treat immediately with the appropriate amount of fast-acting carbohydrate. Check blood glucose levels again in 15 minutes, and do not start driving again until you're no longer hypoglycemic.

Call the doctor if your blood glucose is 250 mg/dl or higher for more than two readings and you:

• Are urinating more frequently than usual
• Are excessively thirsty
• Feel ill
• Have a fever
• Feel sick to your stomach or are throwing up
• Experience confusion or vision impairment

• Ask your doctor for a green light.
• Get a letter saying you have diabetes from your doctor. You may need it if you are ever challenged for having syringes and medications with you.
• Get prescriptions for syringes and medicines. You will need them if you lose your supply.
• If you will be traveling across time zones, check with your medical team to find out what that will mean to your insulin intake and eating schedules.
• Ask your doctor for names of other physicians along your route.
• Get any necessary shots a month before you travel.
• When you pack, carry medical necessities (plus extras) and snacks in a small travel bag--and then, when you travel, keep it with you at all times.
• Take along all the syringes that will be needed during your trip. Pack alcohol to wipe off the tops of insulin bottles. Take a glucagon kit, and your monitor and strips to check your blood for glucose. Bring foot care supplies.
• Store insulin so that it is neither too cold (below 35 degrees) nor too hot (above 90 degrees).

• Carry a card that says you have diabetes. It should include your name, address, and phone number; your doctor's name and phone number; and the kind and dosages of all medications you take. Wear a bracelet or necklace with the same information on it.
• Do not skip meals or snacks. Keep food with you to treat an insulin reaction. Pull off the road if you have a reaction while driving.
• Check your blood glucose more often. Match the amount of food you eat and your medication dose with your activity. You will need more food for walking, swimming, or skiing than for sitting in movie theaters. Follow your meal plan and exercise program when traveling.