Diabetes

Overview

What Is It?

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 25.8 million people in the United States, or approximately 8.3% of the population, have diabetes. In 2010, about 1.9 million people age 20 or older were diagnosed, according to the American Diabetes Association (ADA).

You are at higher risk for developing type 2 diabetes if you are overweight, don't exercise, are over 45, or have close relatives with diabetes, especially type 2 diabetes. Higher-risk ethnic groups include African American, Latino/Hispanic, Native American, Alaska Native, Asians and Pacific Islanders. Native Americans and Alaska Natives are at more than twice the risk of Caucasians for developing type 2 diabetes.

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 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 5 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. 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 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. The increasing prevalence of obesity among Americans is a major contributor to the rise in type 2 diabetes. According to the Centers for Disease Control and Prevention (CDC), 34 percent of adults are obese and 34 percent are overweight (and not obese), for a total of 68 percent of adults who are over their ideal weight. And adults aren't the only ones struggling with their weight. The CDC reports that 17 percent of children age 12 to 19, 20 percent of children age 6 to 11 and 10 percent of children age 2 to 5 are obese. Another reason is related to the relatively low levels of physical activity among American adults. (At least 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 mother's 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 35 to 60 percent chance of developing diabetes during the 10 to 20 years after their pregnancy, according to the CDC. 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 women age 20 and older (10.2 percent) have diabetes. Women with diabetes develop heart disease more often than other women, and their heart disease is more severe. In fact, approximately two-thirds of women with diabetes die from cardiovascular disease, and they die younger than women without diabetes. 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 before menopause. Women with diabetes are also at even greater risk for developing heart disease after menopause.

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 link between diabetes and heart disease, check out the National Heart, Lung and Blood Institute's web site at www.nhlbi.nih.gov.

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 glucose isn't well controlled. Blood glucose 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 is to prevent short-term and long-term complications from developing, according to the American Association of Clinical Endocrinologists.

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 glucose (blood sugar) levels may mean three to four (and sometimes more) shots of insulin a day, adjusting insulin doses to food and exercise, checking 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 glucose, but new evidence suggests that both blood glucose 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

According to the CDC, one in three people who were born in the United States in the year 2000 will eventually be diagnosed with diabetes, and the number of people with diabetes will increase by 165 percent by the year 2050.

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 of any age who are overweight or obese, the American Diabetes Association recommends screening for those who have one or more of the following additional risk factors:

• A family history of diabetes (mother, father, sibling or child with 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.)
• Polycystic ovary syndrome
• Test results showing impaired glucose tolerance or impaired fasting glucose

If you are pregnant, you should be tested for gestational diabetes during the 24th to 28th weeks of pregnancy.

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 glucose (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 100 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 two to 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.

The hemoglobin A1C test, which is used primarily to assess blood glucose control in people who have diabetes, may also be used to help determine if you have diabetes. There are currently no screening guidelines for the A1C, but the American Diabetes Association recommends an A1C goal of less than 7 percent and the American Association of Clinical Endocrinologists recommends a goal of less than 6.5 percent.

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 one or two of the venous tests to confirm a diagnosis.

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. Health care 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 glucose 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 glucose 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 glucose 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 glucose (sugar) when they are absorbed into the bloodstream. The more carbohydrates you eat, the higher your blood glucose level. Although all carbohydrates raise blood glucose, 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 glucose levels to rise as quickly as you might expect. Checking your blood glucose 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 glucose levels but fatty foods do add pounds. Plus, a diet high in saturated fats increases insulin resistance and 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 glucose (called hyperglycemia) or low blood glucose (called hypoglycemia) in which blood glucose 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. If you suffer from hypoglycemic unawareness, you should keep with you a supply of glucagon, a medication that replicates the glucagon produced by the pancreas. It is usually injected beneath the skin and quickly raises very low blood glucose levels. Glucagon is sold in powder and liquid form and must be mixed just before it is used.

To determine how much insulin is needed to prevent blood glucose problems, it is important to know how meals and snacks influence blood glucose 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 glucose 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 glucose, may also help people with diabetes control blood glucose levels.

The American Diabetes Association offers the following tips:

• Eat a lot of 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 such as cuts of beef and pork that end in "loin," for example. 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, but research shows that reducing your sodium intake can reduce 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. There is currently no proof that herbs or dietary supplements have a significant impact on blood glucose levels.

For more information on nutrition and diabetes, check out https://www.diabetes.org/food-and-fitness/food.

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 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 glucose 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 glucose. 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 glucose during exercise can be complicated. Those with type 1 diabetes have to adjust their food or insulin to keep their blood glucose 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 glucose levels to rise, especially right after exercising. Strenuous exercise can push high blood glucose levels even higher if there isn't enough circulating insulin available, leading to a life-threatening condition called diabetic ketoacidosis. Or, if blood glucose levels are low when exercise starts or if exercise is prolonged, low blood glucose or hypoglycemia can result.

Women with type 2 diabetes may also have low blood glucose after exercise, especially those using oral medications or insulin. Low blood glucose 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 glucose and be prepared to adjust meals or medication to keep glucose levels from plummeting. You need to check blood glucose 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 glucose 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, most days of the week. If you're trying to lose weight, you may need to exercise 60 to 90 minutes a day.

These guidelines can help keep exercise safe and healthy:

• Ask your health care professional what blood glucose 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 glucose response to different types of exercise.
• Keep a source of concentrated carbohydrate like a sports drink or glucose tabs available in case blood glucose 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 want to carry insulin with you. 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. These are not widely used, partly because of cost. 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 glucose 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. Talk with your health care provider about the advantages and possible side effects of medications; some have potentially serious side effects.

Insulin-Augmenting Agents

• Sulfonylureas stimulate the beta cells of your pancreas to secrete more insulin. Examples include: glyburide (Micronase), glimepiride (Amaryl) and extended-release glipizide (Glucotrol and 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 drugs in this class are repaglinide (Prandin) and nateglinide (Starlix).
• DPP-4 inhibitors (Dipeptidyl peptidase-4 inhibitors) help improve A1C without causing low blood glucose. They work by preventing the breakdown of naturally occurring blood glucose-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 glucose levels only when they are elevated and do not cause hypoglycemia. Sitagliptin (Januvia) and saxagliptin (Onglyza) are currently the only two DPP-4 inhibitors available.
• Exenatide (Byetta) is an injectable drug that helps 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 glucose regulation in people with type 2 diabetes.
• Liraglutide (Victoza) is an injectable drug, similar to exenatide, but with a long-acting formulation. It helps the pancreas produce insulin more efficiently. Like exenatide, it may help with weight loss and blood glucose regulation in people with type 2 diabetes.
• Pramlintide (Symlin) also is an injectable drug 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 glucose 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.
• 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 glucose, 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 glucose 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 glucose 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. Check 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. Recheck your blood glucose in 15 minutes. If it is not above 80mg/dL, repeat the treatment. The lower your blood glucose, the greater the amount of carbohydrate you will need to bring it up and the longer it may take to reach an acceptable level.

On the other hand, a person can become very ill if blood glucose 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 using it 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. Your monitor's number should come within 20 percent of the laboratory test.

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 7 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 women with diabetes 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

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 walking or other moderate-intensity exercise, and lost 5 to 7 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.)
• Polycystic ovary syndrome
• Test results showing impaired glucose tolerance or impaired fasting glucose

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:

• Checking blood glucose levels at least twice a day, usually 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)
• Checking blood glucose 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

While you may not be able to prevent diabetes, there are many steps you can take to delay or lessen the severity of possible 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

1. The three major categories of diabetes are type 1, type 2 and gestational diabetes. 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 occurs during pregnancy and usually lasts only through pregnancy but places a woman at greater risk of developing type 2 later in life.
2. The term "prediabetes" describes an increasingly common condition in which blood glucose levels are higher than normal but not yet diabetes. 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.
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 National Diabetes Information Clearinghouse, 10.7 percent of Americans aged 20 and older have diabetes compared to 23.1 percent of Americans aged 60 and older.
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 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, Alaska Natives, Pacific Islanders and Asians are all more likely to develop type 2 diabetes (although Northern Europeans are more likely to contract type 1).
7. 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 checking blood glucose; possibly taking oral or injectable incretin medications or administering insulin if necessary); following a diet and exercise plan; not smoking; and frequently consulting a health care team.
8. 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.
9. 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 and HDL greater than 60 mg/dL. LDL less than 70 mg/dL is desirable for those with both diabetes and heart disease.

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

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 to see if it is in target range just before leaving. It it is low, treat it with 15 grams of carbohydrate. . 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. If you suffer from hypoglycemic unawareness, always take glucagon with you when you travel. 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 glucose 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 glucose 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.

Organizations and Support

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

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

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

Medivizor
Website: https://medivizor.com

National Diabetes Education Program
Website: https://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: https://www.niddk.nih.gov
Address: Building 31, Room 9A06
31 Center Drive, MSC 2560
Bethesda, MD 20892
Phone: 301-496-3583

The Association of Asian Pacific Community Health Organizations (AAPCHO)
Web Site: https://www.aapcho.org/
Address: 300 Frank H Ogawa Plaza, Suite 620
Oakland, CA 94612
Phone: 510-272-9536
Email: nagrewe@aapcho.og

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: https://www.niddk.nih.gov/health-information/informacion-de-la-salud/diabetes
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: https://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: https://www.diabetes.org/es/
Address: ADA National Call Center
1701 North Beauregard Street
Alexandria, VA 22311
Hotline: 1-800-342-2383
Email: AskADA@diabetes.org

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