What is it?

Overview

What Is It?
Diabetes is a chronic condition in which the body produces too little insulin or can't use available insulin efficiently.

Diabetes is a chronic condition in which the body produces too little insulin or can't use available insulin efficiently. Insulin is a hormone vital to helping the body use digested food for growth and energy.

An estimated 23.6 million Americans (approximately eight percent of the population) have diabetes, and about 1.6 million more aged 20 or older were diagnosed with the disorder in 2007, according to the American Diabetes Association. Untreated, diabetes can cause long-term complications that affect almost every part of the body, making it the sixth leading cause of death in theUnited States.

You are at higher risk for developing type 2 diabetes if you are overweight, don't exercise and are over 30, or if you have close relatives with diabetes, especially type 2 diabetes. Higher-risk ethnic groups include African American, Latino/Hispanic, Native American, AlaskaNative, Asian or Pacific Islander American heritage. s. Native Americans and Alaska Natives are at more than twice the risk of Caucasians for developing type 2diabetes.

Although diabetes is a potentially life-threatening condition, people with well-managed diabetes can expect to live healthy lives.

How Diabetes Develops

Much of the food we eat is broken down by digestive juices into a simple sugar called glucose, which is the body's main source of energy. Glucose passes into the bloodstream and, from there, into cells, which use it for energy. However, most cells require the hormone insulin to "unlock" them so glucose can enter. Insulin is normally produced by beta cells in the pancreas (a large gland behind the stomach). In healthy people, the process of eating signals the pancreas to produce the right amount of insulin to enable the glucose from the food to get into cells. If this process fails or doesn't work properly, diabetes develops.

In people with diabetes, the pancreas produces little or no insulin, or the body's cells do not respond to the insulin that is produced. As a result, glucose builds up in the blood, overflows into the urine and passes out of the body. Thus, the body loses its main source of fuel even though the blood contains large amounts of glucose.

Types of Diabetes

There are several types of diabetes:

• In type 1 (insulin-dependent) diabetes, the pancreas makes little or no insulin because the insulin-producing beta cells have been destroyed. Type 1 diabetes is less common than type 2 diabetes, accounting for about five to 10 percent of diabetes cases. Formerly known as "juvenile diabetes," type 1 typically develops during childhood or young adulthood but can appear at any age.
  
  Type 1 diabetes is classified as an autoimmune disease—a condition that results when the immune system turns against a specific part or system of the body. In diabetes, the immune system attacks and destroys the insulin-producing beta cells in the pancreas. At present, scientists do not know exactly what causes the body's immune system to attack the beta cells, but they believe that both genetic and environmental factors are involved.
• In type 2 (noninsulin-dependent) diabetes, the pancreas makes insulin but the body does not respond to it properly (insulin resistance). In time, the pancreas can fail to produce enough of its own insulin and requires insulin replacement. Type 2 diabetes most often occurs in overweight or obese adults after the age of 30, but may also develop in children. Factors that contribute to insulin resistance and type 2 diabetes are genetics, obesity, physical inactivity and advancing age.
  
  Type 2 diabetes is on the rise in the United States, and rates are expected to continue increasing for several reasons, according to the CDC. The increasing prevalence of obesity among Americans is a major contributor to the rise in type 2 diabetes. According to the National Health and Nutrition Examination Survey 2001-2004, about two-thirds of Americans are overweight, and almost one-third are obese. And the number of obese children in the United States is growing. Another reason is related to the relatively low levels of physical activity among American adults. (About 50 percent of American adults don't get enough physical activity.) Other factors contributing to the rise of type 2 diabetes include:
  • The increasing age of the population
  • The fast growth rate of certain ethnic populations at high risk for developing the condition, including Latino and Hispanic Americans
• A third type of diabetes, gestational diabetes, is one of the most common problems of pregnancy. Left uncontrolled, it can be dangerous for both baby and mother.
  
  During normal pregnancy, hormones produced by the placenta increase the mothers' resistance to insulin. Gestational diabetes results when the insulin resistance exceeds the body's capacity to make additional insulin to overcome it. This resistance usually disappears when the pregnancy ends, but women who have had gestational diabetes have a greater risk of developing type 2 diabetes later in life. All pregnant women are routinely screened for gestational diabetes between their 24th and 28th weeks.
• A new term, "pre-diabetes," describes an increasingly common condition in which blood glucose levels are higher than normal, but not high enough for a diagnosis of diabetes. About 57 million people in the United States have prediabetes.
  
  Those with prediabetes have impaired fasting glucose (between 100 and 126 mg/dL after an overnight fast), or they have impaired glucose tolerance as indicated by one or more simple tests used to measure glucose levels. The ADA reports that in one study, about 11 percent of people with prediabetes developed type 2 diabetes each year during the average three years of follow-up. Other research shows that most people with this condition go on to develop type 2 diabetes within 10 years unless they make modest changes in their diet and level of physical activity.
  
  Some long-term damaging effects to the body, particularly the heart and circulatory system, may start during the prediabetes phase of the disease.

Women and Diabetes: Special Concerns

In the United States, 11.5 million (10.2 percent) women age 20 and older have diabetes. Women with diabetes develop heart disease more often than other women, and their heart disease is more severe. Women under age 50 with diabetes are more vulnerable to heart attacks and strokes than those without diabetes because the disease seems to cancel the protective effects of estrogen on a woman's heart prior to menopause. Women with diabetes are also at even greater risk for developing heart disease after menopause.

According to the cholesterol management guidelines issued in May 2001 by the National Cholesterol Education Program, National Heart, Lung, and Blood Institute (NHLBI) and updated in 2004, diabetes poses as great a risk for having a heart attack in 10 years as heart disease itself and should be managed as aggressively as heart disease. A survey showed that most people with diabetes don't know that heart disease and stroke are the major causes of death of people with diabetes. In fact, approximately two-thirds of people with diabetes die from cardiovascular disease, and they die younger than women without diabetes.

Women with diabetes have lower levels of high-density lipoproteins (HDL) cholesterol (the good cholesterol) and higher levels of triglycerides, or fats, in the blood. Elevated low-density lipoproteins (LDL) cholesterol is a major cause of coronary heart disease and should be treated aggressively. Although LDL cholesterol (the type of cholesterol that contributes to plaque buildup in your arteries) levels are not higher in women with diabetes, studies find that reducing LDL levels to less than 100 mg/dL can help prevent heart attacks and strokes in women with diabetes.

High cholesterol is typically treated with specially designed diets low in saturated fat, weight loss, exercise and, if necessary, medication.

For more information on the new guidelines, visit www.nhlbi.nih.gov/guidelines/cholesterol/index.htm.

Other health issues of concern to women with diabetes include:

• High blood pressure. The goal for blood pressure among those with diabetes is less than 130/80 mm Hg, according to the American Diabetes Association.
• Urinary tract and vaginal infections. Urinary tract infections and vaginal yeast infections are more common in women with diabetes. The fungi and bacteria that cause these infections thrive in a high-sugar environment, and the body's immune system can't fight them as effectively when blood glucose levels are too high.
• Menstrual problems. Irregular menstrual periods are common in women with diabetes, especially if their blood sugar isn't well controlled. Blood sugar levels may rise, and insulin needs may increase before a woman's period and fall once it begins.
• Adverse reactions to hormonal birth control methods. Contraceptives containing hormones (such as birth control pills), IUDs that contain progesterone, and long-lasting progestin implants and injections may alter blood glucose levels. Birth control pills may increase insulin resistance in some women with diabetes. Women with type 2 diabetes may find it harder to manage their blood glucose while taking birth control pills. Although rare in healthy individuals, the risk of complications from birth control pills, such as high blood pressure and stroke, are greater for women with diabetes. However, the American Diabetes Association says most birth control methods are safe for women with diabetes—talk to your health care professional about any potential risks.

Management is Key to Living Well with Diabetes

Although diabetes is a chronic and potentially life-threatening condition, it can be effectively controlled and managed once it has been accurately diagnosed. The goal of diabetes management, according to the American Association of Clinical Endocrinologists, is to prevent short-term and long-term complications from developing.

Without proper management, individuals with either type 1 or type 2 diabetes can develop serious or deadly complications from high glucose levels including blindness, kidney disease and nerve damage, as well as vascular disease that can lead to amputations, heart disease and strokes. Uncontrolled diabetes can complicate pregnancy; birth defects also are more common in babies born to women with uncontrolled diabetes.

For women with type 1 diabetes, controlling blood sugar levels may mean three to four (and sometimes more) shots of insulin a day, adjusting insulin doses to food and exercise, testing blood glucose up to eight times a day depending on their health care providers' recommendations and adhering to a planned diet.

Type 2 diabetes may be controlled initially by a planned diet, exercise and daily monitoring of glucose levels. Frequently, oral drugs that lower blood glucose levels or insulin injections need to be added to this regimen.

Treating diabetes comprehensively—that is, managing not only blood glucose, but also blood pressure and cholesterol—is crucial to helping prevent heart attacks and stroke. The good news is that women with diabetes who maintain lower blood glucose, blood pressure and cholesterol levels can lower their risk of cardiovascular disease. To reduce your risk, follow the "ABC" approach recommended by the National Diabetes Education Program, National Institute of Health and the American Diabetes Association. The ABCs are easy to remember:

• A stands for the A1C, or hemoglobin A1C test, which measures average blood glucose over the previous two to three months.
• B is for blood pressure.
• C is for cholesterol.

Diabetes treatment guidelines issued by the American College of Physicians (ACP) and published in the April 2003 issue of the Annals of Internal Medicine emphasize the importance of aggressive blood pressure control in lowering the risk for heart disease, stroke and early death in type 2 diabetes patients. Until these guidelines were released, the focus in diabetes care has been on tightly controlling blood sugar, but new evidence suggests that both blood sugar and blood pressure are very important in managing the disease.

The ACP recommends that patients with diabetes and high blood pressure strive for blood pressure levels of less than 130/80 mm Hg, and that thiazide diuretics and angiotensin-converting enzyme (ACE) inhibitors be used as first-line agents to control blood pressure in most patients with diabetes.

Diagnosis

Diagnosis

According to the American Diabetes Association, the incidence of diabetes increased by more than 13.5 percent from 2005 to 2007. The number of Americans with diabetes is growing by an alarming eight percent per year, and the disease is the single most prevalent chronic illness in children.

According to the American Diabetes Association, diabetes is developing at younger ages in high-risk groups.

Symptoms of type 1 diabetes include increased thirst and urination, constant hunger, weight loss, blurred vision and extreme tiredness.

The symptoms of type 2 diabetes appear gradually and are vaguer than those associated with type 1 diabetes. Symptoms include feeling tired or sick, frequent urination (especially at night), unusual thirst, weight loss, blurred vision, frequent infections and slow wound healing.

If you are 45 or older, you should be tested for diabetes. A normal initial test should be followed up with retesting at three-year intervals or at the frequency recommended by your health care professional based on other risk factors.

For individuals at high risk for developing diabetes, the guidelines issued by ACE and AACE recommend that screening begin at age 30. Any one of the following risk factors can increase your chances of developing diabetes:

• being more than 20 percent above your ideal body weight

• having a first-degree relative with diabetes (mother, father, sibling or child)

• being a member of a high-risk ethnic group (African American, Native American, Alaska native, Asian and Pacific Islander American, or Latino/Hispanic American)

• delivering a baby weighing more than nine pounds or having diabetes during a pregnancy

• having blood pressure at or above 140/90 mm/Hg

• having abnormal blood fat levels, such as high-density lipoproteins (HDL) less than or equal to 35 mg/dL or triglycerides greater than or equal to 250 mg/dL

• having polycystic ovary syndrome

• test results showing impaired glucose tolerance or impaired fasting glucose (between 100 and 125 mg/dL after an overnight fast) and a blood glucose level of 140–199 mg/dL two hours after drinking the glucose drink provided in the oral glucose tolerance test (OGTT). This condition, termed "prediabetes," is now recognized as a risk factor for developing diabetes later in life.

If you are pregnant, you should be tested for gestational diabetes during the 24th to 28th weeks of pregnancy if you are over 25, overweight, have a family history of diabetes or are a member of a high-risk ethnic group.

For those at risk, consultation with a health care professional and testing are the next steps. Be sure to tell your health care professional if you are taking any medications. Certain drugs, including glucocorticoids, furosemide, thiazides, estrogen-containing products, beta blockers and nicotinic acid, can result in high blood sugar levels.

For an accurate diagnosis, you should go to a health care professional's office or medical lab to have a fasting blood glucose sample taken. While finger-stick screenings-the kind given at mobile health fairs-are more convenient and cheaper, they are less reliable and precise and must be confirmed by medical lab testing. A fasting finger-stick test result of 110 mg/dL or more should send you to a health care professional for further testing. If you've eaten shortly before the finger-stick test, see a health care professional if your reading is 140 mg/dL or higher.

The easiest, most economical test for diabetes is one that measures fasting plasma glucose. This blood test is usually done in the morning, after an overnight fast, at a health care professional's office or lab. The normal, nondiabetic range for blood glucose is from 70 to 99 mg/dL. A level over 126 mg/dL usually means diabetes (except for newborns and some pregnant women). A fasting blood glucose test of 99 mg/dL or greater, but less than 126 mg/dL, indicates impaired fasting glucose, now recognized as prediabetes.

Another blood test, the so-called "casual" or random plasma glucose test, can be taken any time of day. Diabetes is indicated if your glucose level is greater than or equal to 200 mg/dL and you have symptoms such as increased thirst and urination, constant hunger, weight loss, blurred vision and extreme tiredness in the case of type 1 diabetes, and feeling tired or ill, frequent urination (especially at night), unusual thirst, weight loss, blurred vision, frequent infections and slow wound healing in the case of type 2. An oral glucose tolerance test (OGTT), which takes three hours and involves three to six blood samples, is also available; its value lies in measuring how glucose levels change in response to a high glucose load.

A positive reading on any of these tests should be followed up with a second test on a different day to confirm the diagnosis. A positive finger-stick test should be followed with two of the venous tests to confirm a diagnosis.

Treatment

Treatment

Developing a chronic disease is not your fault, although many women who develop type 2 diabetes may feel this way, especially when obesity is an issue. If you are diagnosed with diabetes, it is essential that you receive comprehensive information-whether from a primary health care professional, certified diabetes educator or endocrinologist-on how to manage your condition and avoid complications.

Many people with diabetes don't have access to the help they need to adequately manage their condition. In addition, learning diabetes management skills takes time. People with diabetes need to regularly review and revise their strategies for managing their disease, under the guidance of their health care professionals.

Women with diabetes should be seen regularly by a health care professional who monitors their diabetes and checks for complications. Healthcare professionals who specialize in diabetes are called endocrinologists or diabetologists. In addition, people with diabetes often see ophthalmologists for eye examinations, podiatrists for routine foot care, registered dietitians for help in planning meals and diabetes educators for instruction in day-to-day care.

The goal of diabetes management is to keep blood glucose levels as close to normal as possible (without causing adverse consequences, such as hypoglycemia) to prevent complications associated with the condition. One government study proved that keeping blood sugar levels close to normal reduces the risk of developing major complications of diabetes. The National Diabetes Education Program urges people with diabetes to control not only their blood glucose, but also their blood pressure and cholesterol. This comprehensive management of diabetes is crucial to helping prevent heart attack and stroke.

Living with diabetes can be overwhelming at times. Like all chronic diseases, it affects every aspect of your daily routine. Diabetes management is not as simple as just taking a pill. It requires timing of meals, checking blood sugar and being vigilant about exercise, all in accordance with a personalized management plan developed in consultation with health care professionals.

Managing What You Eat

Your blood sugar can stabilize or skyrocket, depending on what you eat. Food is a mixture of fats, proteins and carbohydrates. All three are necessary parts of a healthy eating plan, but people with diabetes need to be most concerned about carbohydrates.

Carbohydrates in food end up as sugar (glucose) when they are absorbed into the bloodstream. The more carbohydrates you eat, the higher your blood sugar level. Although all carbohydrates raise blood sugar, different foods have different effects, depending on the type of food, which foods your carbohydrates are eaten with and how the food is prepared.

Raw foods, for example, are digested more slowly than cooked foods. Foods that are broken down more slowly release glucose into the blood more slowly. Foods that contain fat also take longer to digest than foods without fat. That's why an ice cream cone or a chocolate bar may not cause blood sugar levels to rise as quickly as you might expect. Checking your blood sugar two hours after eating carbohydrates is the best way to learn the effects of different foods.

Moderation is key. At one time, people with diabetes were told not to eat sweets at all. Today, sweets and snacks are allowed, but portions need to be small and balanced during the day.

Unlike carbohydrates, fats do not raise blood sugar levels but fatty foods increase insulin resistance and do add pounds. Plus, a high-fat diet increases your risk for heart disease.

Cutting back on dietary fat, which contributes to high cholesterol levels, is important for people with diabetes because they are already at higher risk for heart disease. Women on low-fat diets should be aware that some low-fat and nonfat foods contain considerably more carbohydrates than the full-fat versions.

For women with type 1 diabetes, who must take insulin daily, balancing food intake with insulin and exercise is essential to prevent high blood sugar (called hyperglycemia) or low blood sugar (called hypoglycemia) in which blood sugar levels dip below 70 mg/dl.

Hypoglycemia can occur suddenly. Early indicators of low blood levels include: shakiness and sweating, dizziness, pounding heart, weakness, hunger and confusion. Both hyperglycemia and hypoglycemia can be life threatening.

To determine how much insulin is needed to prevent blood sugar problems, it is important to know how meals and snacks influence blood sugar levels. Generally, the more carbohydrates you eat, the more insulin you need; the fewer carbohydrates you eat, the less insulin you need. Still, only by checking blood sugar two to three hours after eating can you know the effect of different kinds and amounts of food.

The American Diabetes Association recommends limiting saturated fat intake to less than 7 percent of total daily calories and minimizing intake of trans fat. In addition, the ADA recommends monitoring carbohydrates through carbohydrate counting, exchanges or estimation based on experience. It suggests that the glycemic index and glycemic load, which rank foods based on how they affect blood sugar, may also help people with diabetes control blood sugar levels.

The American Diabetes Association provides the Diabetes Food Pyramid, which divides foods into the following six groups:

• Grains and starches: six to 11 servings per day
• Vegetables: three to five servings per day
• Fruit: two to four servings per day
• Milk and dairy: two to three servings per day
• Meat and meat substitutes: four to six servings per day
• Fats, sweets and alcohol: keep servings small and save for a special treat

In addition, the American Diabetes Association offers the following tips:

• Eat lots non-starchy vegetables and pick from a rainbow of colors to maximize variety. Choose vegetables such as spinach, carrots, broccoli or green beans with meals.

• Choose whole, frozen or canned fruit in water or its own juice instead of juices or sweetened canned fruit.

• Choose whole-grain foods, like brown rice or whole-wheat spaghetti, over processed grain products.

• Include dried beans (like kidney or pinto beans) and lentils in your meals.

• Eat fish two to three times per week.

• Choose lean meats like cuts of beef and pork that end in "loin," such as pork loin and sirloin. Remove the skin from chicken and turkey.

• Choose nonfat dairy products, such as skim milk, nonfat yogurt and nonfat cheese.

• Drink water and calorie-free "diet" drinks instead of regular soda, fruit punch, sweet tea and other sugar-sweetened drinks.

• Cook with liquid oils instead of solid fats that can be high in saturated and trans fats. And if you're trying to lose weight, watch your portion sizes of added fats.

• Account for carbohydrate content from all nutritive sweeteners (sucrose, fructose, corn syrup, fruit juice, honey, molasses, dextrose, maltose, sorbitol, mannitol and xylitol). They can affect blood glucose levels.

• Sodium: People differ in their sensitivity to sodium and its effect on blood pressure. Limit your intake to 2,300 mg per day. Because it is impractical to assess how sensitive you are to sodium, sodium recommendations for people with diabetes are the same as those for the general population.

• Vitamins and mineral supplements: Talk to your health care professional about whether you need to take a daily multivitamin. Research indicates that the best approach is to eat a balanced daily diet, with plenty of fruits, vegetables and whole-grain carbohydrates.

For more information on nutrition and diabetes, check out www.diabetes.org/food-nutrition-lifestyle/nutrition.jsp.

Weight Management and Exercise

More than 85 percent of people newly diagnosed with prediabetes or type 2 diabetes are overweight, making weight management very important.

Although we still don't know why, being overweight makes you less responsive to insulin, while losing weight has the opposite effect. You don't have to lose a lot of weight to see an improvement. Even losing 7 percent to 10 percent of your body weight helps. The focus for women with diabetes, however, should be on improving blood glucose levels-not on the scale.

Exercise is another cornerstone of any diabetes treatment plan. Besides burning calories and promoting weight loss, exercise reduces blood sugar levels and makes cells more sensitive to insulin, allowing some people with diabetes to use less medication.

Exercise has psychological benefits too. People who exercise are generally more aware of their bodies and the factors that affect their blood sugar. They often have a more positive outlook and are better able to manage their condition. Improved self-focus, self-esteem and positive outlook may be especially important for women.

Regular exercise is an essential part of managing type 1 diabetes, too, but management of blood sugar during exercise can be complicated. Those with type 1 diabetes have to adjust their food or insulin to keep their blood sugar from getting too high or too low. A vigorous workout, for example, can increase the amount of glucose the liver releases into the bloodstream, causing blood sugar levels to rise, especially right after exercising. Strenuous exercise can push high blood sugar levels even higher if there isn't enough circulating insulin available, leading to a life-threatening condition called diabetic ketoacidosis. Or, if blood sugar levels are low when exercise starts or if exercise is prolonged, low blood sugar or hypoglycemia can result.

Women with type 2 diabetes may also have low blood sugar after exercise, especially those using oral medications or insulin. Low blood sugar can last for hours as the muscles use glucose from the blood to replenish that used during a workout.

Thus, it's important to know and heed the signs of low blood sugar and be prepared to adjust meals or medication to keep sugar levels from plummeting. You need to check blood sugar levels before, during and after exercise to see what affect your workout has. No two people with diabetes will have the same response to exercise.

Before starting an exercise program, check with your health care professional. Exercise is a two-sided coin. It is the most important thing you can do to improve blood sugar and prevent diabetes complications, but the wrong type of exercise can make diabetes-related problems worse. Bouncing can aggravate diabetic eye disease, for example. Exercises that strain the upper body or require heavy lifting can raise blood pressure. Activities such as running and high-impact aerobics may be too hard on the feet and legs if you have any nerve damage.

To avoid injury, start slowly and don't overdo the intensity. Be sure to include a warm-up and cool-down phase. And understand that the effect of exercise on insulin resistance is short-lived. You have to stay with it to see improvement.

Exercise doesn't have to be sports-oriented or vigorous, however. It can be recreational, such as gardening, hiking, swimming or dancing. Brisk walking is one of the best things to do. Aim for at least 30 minutes of exercise a day, at least five days a week. If you're trying to lose weight, you may want to exercise more than 30 minutes a day.

These guidelines can help keep exercise safe and healthy:

• Ask your health care professional what blood sugar and heart rate guidelines to aim for before, during and after exercise.

• Do different activities, such as walking, biking and swimming, to stay motivated and to lessen the chance of injury.

• Carry medical ID and never exercise alone.

• Keep a log to track blood sugar response to different types of exercise.

• Keep a source of concentrated carbohydrate like a sports drink or raisins available in case blood sugar levels drop.

• Check your feet for blisters, bunions and calluses.

• Wear pool shoes in the pool to avoid scraping the soles of your feet.

• Don't exercise in extreme temperatures.

• Don't exercise if you have untreated eye problems such as blurred vision.

• If you have heart disease or high blood pressure, avoid exercises such as pushing against a wall or lifting and holding heavy weights, that involve keeping your muscles contracted.

Medical Treatments

Along with lifestyle modifications, medical treatment is essential to the management of type 1 diabetes. While not a cure, insulin is the most powerful glucose-lowering agent available. Insulin therapies administered two times or more per day through injections or pump therapy can stabilize and manage the disease, helping delay or avoid complications.

Most insulin is still primarily administered as an injection, using a small short needle. At this point, insulin can't be delivered in a pill, because it is a protein; that means your body would break it down and digest it before it could get into your bloodstream. However, investigators are exploring ways of making insulin easier to take, including insulin pills with a special coating or altered structure to get it through the stomach (not much research has been done on insulin pills at this point, though), skin patches, insulin that is delivered as a spray into the back of the mouth and inhaler devices.

Insulin devices have become more convenient in recent years. Insulin pens, for example, can be helpful if you take at least three doses of insulin a day and want to carry insulin with you. An insulin pen looks like a pen with a cartridge that holds 150 or 300 units of insulin. A fine, short needle, similar to the needle on an insulin syringe, is on the tip of the pen. You turn a dial to select the desired dose of insulin and press a plunger on the end to deliver the insulin just under the skin.

The FDA has also approved insulin jet injectors, which look like large pens and send a fine spray of insulin through the skin by a high-pressure air mechanism. Insulin jet injectors are costly and have other downsides so they are not widely used. If you plan to purchase one, try out several models before you buy.

There are several types of insulin with varying speeds of action. They range from rapid-acting, which begins working within 15 minutes after injection, to very long-acting, which works evenly for up to 24 hours. Many people with insulin-dependent diabetes take two types of insulin. How quickly or slowly insulin works in your body depends on your own response, where on your body you inject insulin, the type and amount of exercise you do and the length of time between your shot and exercise.

If you have type 2 diabetes, you may be able to manage your blood sugar with lifestyle or oral medications as long as your pancreas continues to make insulin. . However, because diabetes is a progressive disease, most people eventually need medication to help their body better use insulin, and some eventually require insulin.

Medications used to manage type 2 diabetes can be divided into two groups: those that augment your own supply of insulin and those that make your own insulin more effective.

Insulin-Augmenting Agents

• Sulfonylureas stimulate the beta cells of your pancreas to secrete more insulin. Examples include: glyburide, glimepiride (Amaryl) and extended-release glipizide (Glucotrol XL).

• Meglitinides also stimulate your pancreas to make more insulin, but have a shorter onset of action and shorter half-life than the sulfonylureas. The drug in this class is repaglinide (Prandin).

• D-phenylalanine derivatives help the pancreas produce insulin earlier after a meal and release the insulin for a shorter time compared to sulphonylureas. This helps lower your blood glucose after you eat a meal and is less likely to cause low sugars several hours after the meal. Nateglinide (Starlix), which is also known as a meglitinide, currently is the only medicine in this relatively new group of diabetes pills.

• DPP-4 inhibitors (Dipeptidyl peptidase-4 inhibitors), approved in 2006, help improve A1C without causing low blood sugar. They work by preventing the breakdown of naturally occurring blood sugar-lowering compounds in the body, called GLP-1 and GIP. GLP-1 increases the amount of insulin made in the pancreas and decreases glucose made in the liver. Since GLP-1 works only when glucose levels are elevated, DPP-4 inhibitors lower blood sugar levels only when they are elevated and do not cause hypoglycemia. Sitagliptin (Januvia) is currently the only DPP-4 available.

• Exenatide (Byetta) is an injectable drug approved in 2005 to help the pancreas produce insulin more efficiently. It is in the incretin mimetics class of drugs. These drugs mimic the effects of incretins, hormones produced by the intestine and released into the blood in response to food. Exenatide is used in combination with metformin or a sulfonylurea and has been shown to aid with weight loss and blood sugar regulation in people with type 2 diabetes.

• Pramlintide (Symlin) also is an injectable drug approved in 2005 for treatment of type 1 and type 2 diabetes. It is a synthetic analogue of human amylin, which works with insulin to delay gastric emptying and inhibit the release of glucagon. When used with insulin, metformin or sulfonylurea, it has been shown to help with weight loss and reduction in A1C levels.

Insulin-Assisting Agents

• Alpha-glucosidase inhibitors slow the absorption of carbohydrates you eat, thus preventing blood glucose levels from rising too much. They work by inhibiting a specific enzyme found in the small intestine, which normally breaks down carbohydrates into sugars. Acarbose (Precose) and meglitol (Glyset) are the two insulin-assisting agents currently available in this class.

Insulin Sensitizing Agents

• Biguanides help your liver respond better to insulin, decreasing the amount of sugar it releases. Other beneficial effects include a reduction in plasma triglyceride levels and low-density lipoprotein (LDL) cholesterol levels. Metformin (Glucophage and Glucophage XR [extended-release]) are currently the only agents in this class available in the United States. Both Glucophage and Glucophage XR may cause lactic acidosis, the buildup of lactic acid in the body.

• Thiazolidinediones are insulin sensitizers that work to overcome insulin resistance by making the body's cells more sensitive to insulin. Pioglitazone (ACTOS) and rosiglitazone (Avandia) are examples of drugs in this class.

If one type of medication alone fails to control your blood sugar, your health care professional may prescribe two or three of these medications, or one or more of them with insulin.

Of course, taking certain glucose-lowering medication can push blood sugar too low (which is hypoglycemia), as can skipping a meal or eating too little, exercising more than usual or drinking alcohol. You will know your blood sugar is low (70 mg/dL or less) when you feel one or more of the following: dizzy or light-headedness, hungry, nervous and shaky, sleepy or confused or sweaty. Test your glucose to make sure it's low, and if it is at or below 70 mg/dL, consume 15 grams of carbohydrate-for example, drinking a half cup of juice or three-fourths of a cup of regular (not diet!) soda or taking three to four glucose tabs.

On the other hand, a person can become very ill if blood sugar levels rise too high, a condition known as hyperglycemia. Severe hypoglycemia and hyperglycemia, which can occur in people with type 1 diabetes or type 2 diabetes, are both potentially life-threatening emergencies.

Ask your health care professional or diabetes teacher about the best testing tools for you and how often to test. Many glucose monitors are available, ranging widely in price and features. In addition to meter prices, compare costs of supplies-test strips and lancets-because in the long run, these add up to more than the monitor cost. All monitors require needle sticks, but most meters allow testing on alternate sites such as the palm or forearm.

Verify your monitor's accuracy and your skill at conducting the test by taking it with you to an appointment with a health care professional and running the test at the same time as a venous test. The doctor's test should come within 15 percent of your monitor's number.

You should track your readings with a log or diary (often available from your health care professional). Increasingly, patients and their health care professionals can use computerized systems to upload meter results and automatically generate comprehensive charts. Also, the simple statistics and graphs built into the meter itself can be helpful.

In addition, your doctor should measure your A1C level a minimum of two times a year. (If you change diabetes treatment, or if you are not meeting your blood glucose goals, you and your doctor will want to check your A1C level more often, about every three months). This test measures how much glucose has become attached to a protein called hemoglobin in your red blood cells. Because the glucose sticks to the hemoglobin for several months, it provides a long-term picture of your blood glucose control.

Ideally, your results should be below seven percent.

Other Considerations with Diabetes

• Drugs. If you have diabetes, you should always consult with your health care professional when considering taking any medication, even over-the-counter remedies.

• Menopausal hormone therapy. Menopausal hormone therapy may pose risks for diabetic women in addition to the risks identified in 2002 by the Women's Health Initiative (WHI). Specifically, the hormone therapy used in the study increased levels of triglycerides (a type of fat-like cholesterol found in the bloodstream), a red flag for women with diabetes, who may have higher triglyceride levels to begin with.

  If you are using hormone therapy, talk with your health care professional first before stopping your medication.

Prevention

Prevention

Some risk factors for diabetes can't be changed, such as family history of the disease, advancing age or ethnic heritage. However, evidence suggests that people who are at risk for developing diabetes may reduce their risks by controlling their weight and exercising. (Always consult with your health care professional about diet and exercise programs.)

The Diabetes Prevention Program (DPP), a major clinical trial sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), compared diet and exercise to treatment with the oral anti-diabetic drug metformin(Glucophage) in 3,234 people with impaired glucose tolerance (IGT), a condition that often precedes diabetes.

The study found that diet and exercise could delay diabetes in a diverse American population of overweight people by about 58 percent. This group got at least 150 minutes of physical activity per week, usually with walking or other moderate-intensity exercise, and lost five to seven percent of their body weight. Participants randomized to treatment with metformin reduced their risk of type 2 diabetes by 31 percent.

Screening for Diabetes

If you're overweight and age 45 or older, you should be screened for diabetes via regular office visits with your primary care physician using either the fasting blood glucose test, which identifies impaired fasting glucose, or the oral glucose tolerance test, which identifies impaired glucose tolerance.

You should also be screened if you're younger than 45 and are significantly overweight and have one or more of the following risk factors:

• A family history of diabetes

• A low HDL cholesterol and high triglycerides

• High blood pressure

• A history of gestational diabetes or giving birth to a baby weighing more than nine pounds

• Are a member of a higher-risk minority group (African Americans, American Indians, Alaska Natives, Hispanic Americans/Latinos and Asian American/ Pacific Islanders are at increased risk for type 2 diabetes.)

Treating diabetes comprehensively—that is, managing not only blood glucose, but also blood pressure and cholesterol—is crucial to helping prevent heart attack and stroke. The good news is that women with diabetes who maintain lower blood glucose, blood pressure and cholesterol levels can lower their risk of cardiovascular disease.

If you have type 1 diabetes, comprehensive diabetes treatment usually includes at least the following:

• Testing blood sugar levels at least twice a day, sometimes four or more times daily

• Three or more daily insulin injections or use of an insulin pump

• Adjustment of insulin doses according to food intake and exercise

• A diet and exercise plan

• Scheduled visits to a health care team composed of a health care professional, nurse educator, dietitian and behavioral therapist as needed

For those with type 2 diabetes, good management includes at least the following components:

• A proper diet, exercise and weight loss (if needed)

• Testing blood sugar levels per your health care professional's recommendation

• Scheduled visits to a health care team composed of a health care professional, nurse educator, dietitian and behavioral therapist as needed.

If these measures don't work, you might have to take diabetes medication or insulin shots.

Diabetes-Related Complications

If you have diabetes, you should have your eyes examined for diabetic retinopathy at least once a year by an eye specialist, or ophthalmologist. Progressive damage to the eye's retina caused by long-term uncontrolled diabetes can result in loss of vision. People with both type 1 and type 2 diabetes are at risk for developing diabetic retinopathy.

Diabetic retinopathy is a disease of the small blood vessels of the retina of the eye. When retinopathy starts, the tiny blood vessels in the retina become swollen, leaking fluid into the center of the retina. Your vision may become blurred, a condition called background retinopathy.

About 80 percent of people with nonproliferative (background) retinopathy never have serious vision problems, and the disease never goes beyond this first stage. However, if retinopathy progresses, the damage to your sight can be more serious. Abnormal blood vessels grow over the surface of the retina. These vessels may break and bleed into the clear gel that fills the center of the eye, blocking vision. Scar tissue may form near the retina, pulling it away from the back of the eye.

The incidence and severity of retinopathy increases with the duration of diabetes and appears to be worse if diabetes control is poor in the first years of onset. Typically, the disease can progress silently for many years. Symptoms of advanced disease can include decreased visual acuity and floaters (spots in front of your eyes) and loss of vision. Early detection by a dilated eye exam and treatment can prevent or significantly delay progression. The earlier treatment is begun, the better the chances for recovery.

Almost everyone who has diabetes for more than 30 years shows signs of retinal damage, and African Americans and women with diabetes are at higher risk of developing retinopathy. If you control your diabetes (and high blood pressure, if present) it may slow the progression of this condition.

Diabetic nephropathy, or kidney damage, is a leading cause of kidney failure and dialysis. Patients with diabetes should be screened with blood tests and urine tests for signs of early kidney damage, such as protein spilling into the urine. Certain medications, such as ACE inhibitors and angiotensin receptor blockers, may slow the progression of kidney failure. Aggressive control of high blood pressure, as well as smoking cessation, is also important to protect your kidneys.

Diabetic neuropathy, or nerve damage, is another major complication that can be minimized by intensive glucose management.

• Check your feet and toes daily for any cuts, sores, bruises, bumps or infections, using a mirror if necessary.

• Wash your feet daily, using warm (not hot) water and a mild soap. If you have neuropathy, you should test the water temperature with your wrist before putting your feet in the water. Health care professionals do not advise soaking your feet for long periods because keeping your feet in water for extended periods may erode protective calluses. Dry your feet carefully with a soft towel, especially between the toes.

• Cover your feet (except for the skin between the toes) with petroleum jelly, a lotion containing lanolin, or cold cream before putting on shoes and socks. In people with diabetes, the feet tend to sweat less than normal. Using a moisturizer helps prevent dry, cracked skin.

• Wear thick, soft socks and avoid wearing slippery stockings, mended stockings or stockings with seams.

• Wear shoes that fit your feet well and allow your toes to move.

• Never go barefoot, especially on the beach, hot sand or rocks.

• Cut your toenails straight across, but be careful not to leave any sharp corners that could cut the next toe.

• Use an emery board or pumice stone to file away dead skin, but do not remove calluses, which act as protective padding. Do not try to cut off any growths yourself, and avoid using harsh chemicals, such as wart remover, on your feet.

• If your feet are cold at night, wear socks. (Do not use heating pads or hot-water bottles.)

• Avoid sitting with your legs crossed. Crossing your legs can reduce the flow of blood to the feet.

• Ask your health care professional to check your feet at every visit, and call him or her if you notice that a sore is not healing well.

• If you are not able to take care of your own feet, ask your health care professional to recommend a podiatrist (specialist in the care and treatment of feet) who can help.

Facts to Know

Facts to Know

1. The three major categories of diabetes are type 1, type 2 and gestational diabetes. The latter occurs during pregnancy and is usually temporary (lasting only through pregnancy). Type 1 or type 2 diabetes can lead to serious complications from high glucose levels, including blindness, kidney disease and nerve damage, as well as vascular disease that can lead to amputations, heart disease and stroke. Gestational diabetes places a woman at greater risk of developing type 2 at some later time in her life.

2. The term "prediabetes" describes an increasingly common condition in which blood glucose levels are higher than normal but not yet diabetic. Research supported by the U.S. Department of Health and Human Services has shown that most people with this condition go on to develop type 2 diabetes within 10 years unless they make modest changes in their diet and level of physical activity, which can help them reduce their risks and avoid the debilitating disease.

3. An estimated 23.6 million people in the United States have diabetes, and about 5.7 million of those do not know they have it. Another 57 million people have prediabetes. About 1.6 million people were diagnosed with diabetes in 2007 and more than 200,000 die from the disease each year.

4. Diabetes can strike at any age, but your risk for developing the disease increases as you age. According to the American Diabetes Association, the prevalence of diabetes increased by 13.5 percent between 2005 and 2007. The number of Americans with diabetes is growing by an alarming eight percent per year, and the disease is the single most prevalent chronic illness in children.

5. Key risk factors that you can control are obesity and sedentary lifestyle. If you are more than 20 percent above your ideal weight and rarely exercise, have your glucose tested and discuss a fitness plan with a health care professional. Losing even 7 percent to 10 percent of your body weight and exercising for 30 minutes most days of the week cuts your chances of developing diabetes.

6. Risk factors that you can't control are age, family history of diabetes and ethnic heritage. African Americans, Latino/Hispanics, Native Americans, Pacific Islanders and Asians are all more likely to develop type 2 diabetes (although Northern Europeans are more likely to contract type 1).

7. The preferred test for diabetes, because it is easy and inexpensive, is one that measures fasting plasma glucose. The normal, nondiabetic range for blood glucose is from 70 to 100 mg/dL. A level over 126 mg/dL usually means diabetes. A fasting plasma glucose test of 100 mg/dL or greater, but less than 126 mg/dL, indicates impaired fasting glucose or prediabetes, a frequent precursor to diabetes.

8. If you are diagnosed with diabetes, you can cut by half or more your risk of developing many of the associated complications-such as kidney disease and neuropathy-by following a glucose management regimen, which includes testing blood sugar; possibly taking oral or injectable incretin medications or administering insulin if necessary); following a diet and exercise plan; and frequently consulting a health care team.

9. You should not smoke.

10. There is no cure for diabetes. However, it is almost always manageable, either with diet and exercise alone or with the addition of oral medication, injectable incretin medications or insulin. Diet and exercise also are key to reducing risk.

11. It's important to control the "ABCs" of diabetes: A for the A1C test (hemoglobin A1C); B for blood pressure and C for cholesterol. The National Institutes of Health and the American Diabetes Association recommend the following target numbers: A1C: below 7 (an average blood glucose of 150); blood pressure below 130/80; and LDL cholesterol below 100. Talk to your health care professional about your "ABC" targets and your blood pressure (keeping it at less than 130/80) and cholesterol (LDL less than 100 mg/dL and HDL greater than 40 mg/dL for men and greater than 50mg/dl for women is preferred for individuals with diabetes; LDL less than 70 mg/dL is desirable for those with both diabetes and heart disease).

Questions to Ask

Questions to Ask

Review the following Questions to Ask about diabetes so you're prepared to discuss this important health issue with your health care professional.

1. Am I at risk for diabetes?

2. What signs and symptoms indicate that I may have diabetes?

3. What type of tests should I have to find out if I have diabetes?

4. What can I do to prevent the disease from developing, if other members of my family have it?

If you have already been diagnosed with diabetes, ask these questions:

1. What are my "ABC" numbers? A for A1C (or hemoglobin A1C) test; B is for blood pressure; and C is for cholesterol.

2. What should my "ABC" target numbers be?

3. What actions should I take to reach my "ABC" numbers?

4. When and under what conditions should I test my blood sugar?

5. When should I see a dietitian to review what I eat?

6. What effect has diabetes had on my eyes, kidneys, nerves and heart? What tests do I need to monitor these body functions?

7. Which exercises are best for me?

8. Do you think my daily regimen is helping me control my diabetes, or do I need to change it? What changes do I need to make to the food I eat or the insulin I take? Should I exercise more?

9. How should I take care of my feet? What types of socks and shoes should I wear?

10. Are there any new medications or combinations of medications that could help me manage my type 2 diabetes?

Key Q&A

Key Q&A

1. Could I have diabetes and not know it?

   Yes! According to the American Diabetes Association, 5.7 million of the 23.6 million Americans with diabetes have not been diagnosed. The onset of type 2 diabetic symptoms is usually gradual. Those symptoms include feeling tired or ill, frequent urination (especially at night), unusual thirst, weight loss, blurred vision, frequent infections and slow healing of sores. If you have any of these symptoms, seek testing immediately. Since some people do not have any symptoms initially, you should also be tested if you have any of the major risk factors, which include obesity, lack of exercise, a close relative with diabetes, high blood pressure or cholesterol level and giving birth to a baby that weighs more than nine pounds. You are also at elevated risk if you are over 45 or are of African American, American Indian, Alaska Native, Asian and Pacific Islander American or Latino/Hispanic descent.

2. Can I just take one of those finger-stick tests at the health fair?

   No! These tests measure glucose levels in the capillaries, whereas the more reliable tests for diagnosis tap into your veins to get a truer reading. If you do have the opportunity to have a finger-stick test, be sure to follow up with a glucose test recommended and administered by your health care professional. Finger-stick tests may be used as an initial diabetes screening tool and for glucose monitoring of those with confirmed diabetes.

3. What is the best test for diabetes?

   For most people, a fasting plasma glucose test is optimal. This blood test is usually done at a health care professional's office or in a lab in the morning after an overnight fast and before you've eaten. The normal, non-diabetic range for blood glucose is from 70 to 100 mg/dL. A level over 126 mg/dL usually means diabetes (except for newborns and some pregnant women). A fasting plasma glucose test of 100 mg/dL or greater, but less than 126 mg/dL, indicates impaired fasting glucose or prediabetes, a frequent precursor to diabetes.

4. I've got diabetes. How do I prevent debilitating damage to my eyes, kidneys and feet?

   Keeping your blood glucose and blood pressure in good control are the best means to reduce the risk of complications. Aim for an A1C under 7 percent.

5. How do I reduce my risk for heart disease and stroke, the biggest killers of people with diabetes?

   Women with diabetes who keep their blood glucose, blood pressure and cholesterol levels in the recommended range can lower their risk of cardiovascular disease. Data from the National Health and Nutrition Examination Survey show that women with diabetes are at particular risk for heart disease and stroke. Deaths from heart disease for women with diabetes increased 23 percent in the past 30 years, compared to a 27 percent decrease in women without diabetes.

6. What is intensive glucose management?

   Intensive glucose management may be used for patients who take insulin, particularly those with type 1 diabetes. Plans are individually tailored and involve frequently testing blood sugar, administering insulin on the basis of food intake and exercise, following a diet and exercise plan and frequently consulting a health care team. It all boils down to keeping your glucose level in the normal range as much of the time as possible. Intensive management is not for everyone—risks should be discussed with your health care professional.

7. Is injecting insulin painful?

   No, because the needles are very small. It is virtually painless.

8. What medications are available to treat type 2 diabetes?

   For type 2 diabetes, as long as your body is making enough insulin, you won't need insulin injections. Sometimes lifestyle modifications are sufficient to keep type 2 under control in the early years, but many types of medications can help those with type 2 diabetes lower their blood sugar by such means as stimulating insulin production, decreasing the amount of sugar made by the liver, slowing starch absorption and boosting insulin sensitivity. You and your health care professional can decide what is best for you.

9. What causes hypoglycemia and hyperglycemia?

   Both hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) can occur when patients take oral medications or insulin to treat diabetes. They can occur from taking too much or too little medication or from eating too much or too little food or from excessive exercise. Learning how to manage your diabetes properly is the key to avoiding hypoglycemia and hyperglycemia.

Lifestyle Tips

Lifestyle Tips

1. When traveling by car

   Schedule a pre-travel checkup with your health care professional about four to six weeks before your trip, for any kind of travel. Check your glucose just before leaving, and don't leave before dealing with it and rechecking if it is below normal. Bring snacks and drinks with you, and if you're on a long trip, a meal just in case. Put insulin under the seat in a cooler or thermal bag, but not in the trunk, on the dashboard or on ice. Plan stops for checking glucose and stretching, and pull over at the first signs of hypoglycemia.

2. When traveling by air

   Call your airline to find out how to bring syringes and lancets through security checkpoints. Keep the outside boxes of your insulin and/or glucagon, so the prescription labels can be shown to security, bring a medical letter documenting your diabetes, and speak to the security guard in advance. Carry snacks in case your meal doesn't arrive soon enough. Don't pack insulin in your checked luggage; it will be damaged by extreme temperatures in the cargo hold. Keep your diabetes supplies nearby, not in the overhead compartment, so they're accessible at all times. Drink bottled water to stay hydrated.

3. When dining out

   Dining out can be an enjoyable experience for people with diabetes with a little advance planning. Concentrate on the three Ps: planning, portions and preparation. Many restaurants publish their menus online. Take a look at the menu and decide before you go what you are going to have. This can help avoid overeating and assist you in figuring out the carbohydrate and fat content of the meal in advance if you are dosing insulin to your food intake. As for portions, splitting a meal with a friend or having the server wrap half of the meal before it comes to the table can help you stick to your meal plan while taking care of tomorrow's lunch. Finally, remember that you are in charge. If the menu doesn't explain how a dish is prepared, ask. Most restaurants are happy to substitute something else that is already on the menu, such as another vegetable in place of rice.

4. Cut down the costs of diabetes

   Check your health insurance to know exactly what it covers. Be sure to comparison-shop when buying supplies. Blood glucose meters may be available for free if you buy 100 test strips, but pay attention to quality and meter features. Buy only the amount of test strips you can use before they expire. Don't split your test strips or reuse lancets. You can reuse syringes, although after about five uses the needle begins to get dull. Instead of alcohol wipes, use soap and water to clean your hands or the skin at the injection site.

5. More cost-cutting tips for managing diabetes

   Instead of expensive, packaged "dietetic" foods, shop for healthy basic foods. Begin collecting free make-ahead or no-time healthy recipes from diabetes associations and other sources. Clip coupons and look for weekly specials. If you're given a brand prescription, ask if a generic would work and if free samples are available. Ask your pharmacy about discounts and rebates. Check out free offers from diabetes associations and manufacturers of diabetes drugs or equipment. Know the insurance laws in your state or learn more about Medicare coverage. If necessary, find out if you qualify for state or drug manufacturer patient assistance programs.

6. If you are sick

   Your blood sugar will often be higher than usual when you are sick so continue to take your usual medication, including injections. . The only exception is if your health care professional advises you to change it. Check blood glucose every three to four hours around the clock. Write these results down so you can communicate them over the phone if necessary. It is important to keep hydrated. Drink fluids that are sugar-free, but if you can't eat, alternate them with fluids containing sugar, such as juice or regular soda. Rest and call your health care professional if you are vomiting or have diarrhea, excessively high blood sugars or ketones or if you have any questions or concerns. Putting together a sick day kit ahead of time can help prepare you for emergencies.

7. Organizers you can use

   Diabetes management software allows you to analyze trends in your blood glucose levels, and some programs allow direct downloads from your meter. One such program is Diabetes Pilot, which can be used with desktop computers, Palm handhelds, and pocket PC handhelds. Many meters come with their own software for downloading. You may also try commercial or free programs, but check their compatibility with your meter and (for Web-based software) privacy policies. The MEDport Organizers are zippered soft cases in different sizes that carry your supplies and have a cool side for insulin. The Day-to-Day Diabetes Calendar provides helpful information and inspiring words about diabetes management. A vibrating alarm watch, available from many manufacturers, can serve as a nondisruptive reminder system.

8. Caring for your feet

   Wash your feet with soap and warm water (not hot) every day, and pat dry carefully, including between the toes. Use lotion, especially over your heels. Check your feet daily. Use a mirror if necessary to see the soles of your feet. Ask your health care professional how to treat corns, calluses, bunions or cracks in the skin of your heel. Call your health care professional if you see swelling or redness or feel numbness or tingling in either foot. Don't go barefoot. Wear well-fitting shoes and seamless socks, and don't let your feet get too hot or cold.

Organizations and Support

Organizations and Support

For information and support on coping with Diabetes, please see the recommended organizations, books and Spanish-language resources listed below.

Organizations

American Association of Diabetes Educators (AADE)
Website: http://www.aadenet.org
Address: 200 West Madison Street, Suite 800
Chicago, IL 60606
Hotline: 1-800-338-3633
Email: aade@aadenet.org

American Diabetes Association
Website: http://www.diabetes.org
Address: ATTN: National Call Center
1701 North Beauregard Street
Alexandria, VA 22311
Hotline: 1-800-DIABETES (1-800-342-2383)
Email: askada@diabetes.org

American Occupational Therapy Association
Website: http://www.aota.org
Address: 4720 Montgomery Lane
P.O. Box 31220
Bethesda, MD 20824
Hotline: 1-800-377-8555
Phone: 301-652-2682

CDC Diabetes Public Health Resource
Website: http://www.cdc.gov/diabetes
Address: National Center for Chronic Disease Prevention and Health Promotion
4770 Buford Highway NE, Mailstop K-10
Atlanta, GA 30341
Hotline: 1-800-CDC-INFO (1-800-232-4636)
Phone: 770-488-5000
Email: cdcinfo@cdc.gov

Centers for Disease Control and Prevention (CDC) Division of Diabetes Translation
Website: http://www.cdc.gov/diabetes
Address: 4770 Buford Highway NE, Mailstop K-10
Atlanta, GA 30341
Hotline: 1-800-CDC-INFO (1-800-232-4636)
Phone: 770-488-5000
Email: cdcinfo@cdc.gov

International Diabetes Federation
Website: http://www.idf.org
Address: Avenue Emile de Mot 19, B-1000
Brussels
Belgium, -Intl-
Phone: 32-2-538 55 11
Email: info@idf.org

Joslin Diabetes Center
Website: http://www.joslin.org
Address: One Joslin Place
Boston, MA 02215
Hotline: (800) JOSLIN-1
Phone: 617-732-2400
Email: diabetes@joslin.harvard.edu

Juvenile Diabetes Research Foundation International
Website: http://www.jdrf.org
Address: 120 Wall Street
New York, NY 10005
Hotline: 1-800-533-CURE (1-800-533-2873)
Email: info@jdrf.org

National Diabetes Education Program
Website: http://ndep.nih.gov
Address: 1 Diabetes Way
Bethesda, MD 20814
Hotline: 1-888-693-NDEP (1-888-693-6337)
Phone: 301-496-3583
Email: ndep@mail.nih.gov

National Institute of Diabetes, Digestive and Kidney Diseases (NIDDK)
Website: http://www.niddk.nih.gov
Address: Building 31, Room 9A06
31 Center Drive, MSC 2560
Bethesda, MD 20892
Phone: 301-496-3583

Books

101 Tips on Nutrition for People with Diabetes
by Patricia Bazel Geil, Lea Ann Holzmeister

101 Tips for Staying Healthy with Diabetes (& Avoiding Complications)
by University of New Mexico Diabetes Care Team

All-Natural Diabetes Cookbook
by Jackie Newgent

Complete Idiot's Guide to Type 2 Diabetes
by M.D. Mayer B. Davidson, Debra L. Gordon

Diabetes 911: How to Handle Everday Emergencies
by by Larry Fox, Sandra Weber

Diabetes A to Z: What You Need to Know About Diabetes
by American Diabetes Association

Diabetes Eye Care Sourcebook
by Donald S. Fong, Demi, M.D. Ross

Diabetes Meal Planning Made Easy, 4th Edition
by Hope S. Warshaw

50 Things You Need to Know about Diabetes: Expert Tips for Taking Control
by Kathleen Stanley

Joslin Cooks!
by Joslin Diabetes Center

Joslin Diabetes Quick and Easy Cookbook
by Bonnie Polin Frances Giedt

Joslin's Guide to Managing Childhood Diabetes: A Family Teamwork Approach
by Lori Laffel, M.D.

Mediterranean Diabetes Cookbook
by Amy Riolo

Stress-Free Diabetes: Your Guide to Health and Happiness
by Joseph P. Napora

The Type II Diabetes Sourcebook
by David Drum, Terry Zierenberg

Spanish-language Resources

National Institite of Diabetes and Digestive and Kidney Diseases
Website: http://www.niddk.nih.gov/health/spanish.htm
Address: Office of Communications & Public Liaison NIDDK, NIH
Building 31. Rm 9A06
31 Center Drive, MSC 2560
Bethesda, MD 20892
Phone: 301-496-3583

Medline Plus: Diabetes
Website: http://www.nlm.nih.gov/medlineplus/spanish/ency/article/001214.htm
Address: Customer Service
US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

American Diabetes Association
Website: http://www.diabetes.org/espanol/default.jsp
Address: ADA National Call Center
1701 North Beauregard Street
Alexandria, VA 22311
Hotline: 1-800-342-2383
Email: AskADA@diabetes.org

National Diabetes Information Clearinghouse
Website: http://diabetes.niddk.nih.gov/index_sp.htm
Address: National Diabetes Information Clearinghouse
1 Information Way
Bethesda, MD 20892
Hotline: 1-800-860-8747
Email: ndic@info.niddk.nih.gov

Center for Disease Control
Website: http://www.cdc.gov/SPANISH/enfermedades/diabetes.html
Address: CDC Info
1600 Clifton Rd
Atlanta, GA 30333
Hotline: 1-800-232-4636
Email: cdcinfo@cdc.gov