http://www.diabetes.org/A.D.A

create a meal plan works with your schedule keeps your weight on track improves your blood glucose, blood pressure, and cholesterol numbers.

Carbohydrate Counting

How Much Carb?A place to start is at about 45-60 grams of carbohydrate at a meal. What Foods Have Carbohydrate?starchy foods like bread, cereal, rice, and crackers fruit and juice milk and yogurt dried beans like pinto beans and soy products like veggie burgers starchy vegetables like potatoes and corn sweets and snack foods like sodas, juice drinks, cake, cookies, candy, and chips Non-starchy vegetables have a little bit of carbohydrate but in general are very low.

How Much Carbohydrate is in These Foods?15 grams of carbohydrate in:1 small piece of fresh fruit (4 oz) 1/2 cup of canned or frozen fruit 1 slice of bread (1 oz) or 1 (6 inch) tortilla 1/2 cup of oatmeal 1/3 cup of pasta or rice 4-6 crackers 1/2 English muffin or hamburger bun 1/2 cup of black beans or starchy vegetable 1/4 of a large baked potato (3 oz) 2/3 cup of plain fat-free yogurt or sweetened with sugar substitutes 2 small cookies 2 inch square brownie or cake without frosting 1/2 cup ice cream or sherbet 1 Tbsp syrup, jam, jelly, sugar or honey 2 Tbsp light syrup 6 chicken nuggets 1/2 cup of casserole 1 cup of soup 1/4 serving of a medium french fry

Protein and FatAlways include a source of protein and fat to balance out your meal.Using Food LabelsLook at the serving size. All the information on the label is about this serving of food. If you will be eating a larger serving, then you will need to double or triple the information on the label. Look at the grams of total carbohydrate. Total carbohydrate on the label includes sugar, starch, and fiber. Know the amount of carb you can eat, figure out the portion size to match. If you are trying to lose weight, look at the calories. Comparing products can be helpful to find those lower in calories per serving. To cut risk of heart disease and stroke, look at saturated and trans fats. Look for products with the lowest amount of saturated and trans fats per serving. For people with high blood pressure, look at the sodium. Look for foods with less sodium.

Glycemic Index and Diabetes

What is the glycemic index?measures how a carbohydrate-containing food raises blood glucose. Foods are ranked based on how they compare to a reference food either glucose or white bread. A food with a high GI raises blood glucose more than a food with a medium or low GI. Examples of carbohydrate-containing foods with a low GI include dried beans and legumes (like kidney beans and lentils), all non-starchy vegetables and some starchy vegetables, most fruit, many whole grain breads and cereals (like barley, whole wheat bread, rye bread, and all-bran cereal). Meats and fats dont have a GI because they do not contain carbohydrate.

What affects the GI of a food?Fat and fiber tend to lower the GI of a food. As a general rule, the more cooked or processed a food, the higher the GI; however, this is not always true. Below are a few specific examples of other factors that can affect the GI of a food:Ripeness and storage time the more ripe a fruit or vegetable is, the higher the GI Processing juice has a higher GI than whole fruit; mashed potato has a higher GI than a whole baked potato, stone ground whole wheat bread has a lower GI than whole wheat bread. Cooking method: how long a food is cooked (al dente pasta has a lower GI than soft-cooked pasta) Variety: converted long-grain white rice has a lower GI than brown rice but short-grain white rice has a higher GI than brown rice.

Other things to consider if using the GI:The GI value represents the type of carbohydrate in a food but says nothing about the amount of carbohydrate typically eaten. Portion sizes are still relevant for managing blood glucose and for losing or maintaining weight. The GI of a food is different when eaten alone than it is when combined with other foods. When eating a high GI food, you can combine it with other low GI foods to balance out the effect on blood glucose levels. Many nutritious foods have a higher GI than foods with little nutritional value. For example, oatmeal has a higher GI than chocolate. Use of the GI needs to be balanced with basic nutrition principles of variety for healthful foods and moderation of foods with few nutrients.

Create Your PlateUsing your dinner plate, put a line down the middle of the plate. Then on one side, cut it again so you will have 3 sections on your plate. Fill the largest section with non-starchy vegetables such as: spinach, carrots, lettuce, greens, cabbage, bok choy green beans, broccoli, cauliflower, tomatoes, vegetable juice, salsa, onion, cucumber, beets, okra, mushrooms, peppers, turnip Now in one of the small sections, put starchy foods such as: whole grain breads, such as whole wheat or rye whole grain, high-fiber cereal cooked cereal such as oatmeal, grits, hominy, or cream of wheat rice, pasta, dal, tortillas cooked beans and peas, such as pinto beans or black-eyed peas potatoes, green peas, corn, lima beans, sweet potatoes, winter squash low-fat crackers and snack chips, pretzels, and fat-free popcorn

And then on the other small section, put your meat or meat substitutes such as: chicken or turkey without the skin fish such as tuna, salmon, cod, or catfish other seafood such as shrimp, clams, oysters, crab, or mussels lean cuts of beef and pork such as sirloin or pork loin tofu, eggs, low-fat cheese Add an 8 oz glass of non-fat or low-fat milk. If you dont drink milk, you can add another small serving of carb such as a 6 oz. container of light yogurt or a small roll. And a piece of fruit or a 1/2 cup fruit salad and you have your meal planned. Examples are fresh, frozen, or canned in juice or frozen in light syrup or fresh fruit.

SnacksSnacks with less than 5 grams of carbohydrate 3 celery sticks + 1 Tablespoon of peanut butter 5 baby carrots 5 cherry tomatoes + 1 Tablespoon ranch 1 hard-boiled egg 1 cup cucumber slices + 1 Tablespoon ranch dressing cup of fresh blueberries 1 cup of salad greens, 1/2 cup of diced cucumber, and with vinegar and oil 1 frozen sugar-free popsicle 1 cup of light popcorn 2 saltine crackers 10 gold-fish crackers 16 green olives cup sugar-free gelatin 1 piece of string cheese stick 2 Tablespoons pumpkin or sesame seeds of a whole avocado (~4 g.)

About 10-20 grams of carbohydrate cup almonds or other nuts cup dried fruit and nut mix 1 cup chicken noodle, tomato (made with water), or vegetable soup 1 small apple or orange 3 cups light popcorn 1/3 cup hummus + 1 cup raw fresh cut veggies (green peppers, carrots, broccoli, cucumber, celery, cauliflower or a combination of these) cup cottage cheese + cup canned or fresh fruit 1 cheese quesadilla (made with one 6-inch corn or whole wheat tortilla + 1 oz shredded cheese) + cup salsa 2 rice cakes (with a 4-inch diameter) + 1 Tablespoon peanut butter 5 whole wheat crackers (or oz) + 1 piece of string cheese turkey sandwich (1 slice whole wheat bread + 2 oz turkey + mustard) cup tuna salad + 4 saltines

About 30 grams of carbohydrate (good to eat before exercise) peanut butter sandwich (1 slice whole wheat bread + 1 Tablespoon peanut butter) + 1 cup milk 6 oz light yogurt + cup berries (blueberries, blackberries, raspberries, or a combination of these) 1 English muffin + 1 teaspoon low-fat tub margarine 3/4 cup whole grain, ready-to-eat cereal + cup fat-free milk 1 medium banana + 1 Tablespoon peanut butter

If you choose to drink alcohol, limit the amount and have it with food. Talk with your health care team about whether alcohol is safe for you. Women should drink 1 or fewer alcoholic beverages a day (1 alcoholic drink equals a 12 oz beer, 5 oz glass of wine, or 1 oz distilled spirits (vodka, whiskey, gin, etc.). Men should drink 2 or fewer alcoholic drinks a day. If you drink alcohol at least several times a week, make sure your doctor knows this before he/she prescribes a diabetes pill.

Alcohol

CarbohydratesStarchStarchy vegetables like peas, corn, lima beans, and potatoes Dried beans, lentils, and peas such as pinto beans, kidney beans, black eyed peas, and split peas Grains like oats, barley, and rice. (The majority of grain products in the US are made from wheat flour. These include pasta, bread, and crackers but the variety is expanding to include other grains as well.) The grain group can be broken down even further into whole grain or refined grain.A grain, let's take wheat for example, contains three parts:bran germ endosperm The bran is the outer hard shell of the grain. It is the part of the grain that provides the most fiber and most of the B vitamins and minerals. The germ is the next layer and is packed with nutrients including essential fatty acids and vitamin E. The endosperm is the soft part in the center of the grain. It contains the starch. Whole grain means that the entire grain kernel is in the food.If you eat a whole grain food, it contains the bran, germ, and endosperm so you get all of the nutrients that whole grains have to offer. If you eat a refined grain food, it contains only the endosperm or the starchy part so you miss out on a lot of vitamins and minerals. Because whole grains contain the entire grain, they are much more nutritious than refined grains.

SugarSugar is another type of carbohydrate. You may also hear sugar referred to as simple or fast-acting carbohydrate. There are two main types of sugar:naturally occurring sugars such as those in milk or fruit added sugars such as those added during processing such as fruit canned in heavy syrup or sugar added to make a cookie On the nutrition facts label, the number of sugar grams includes both added and natural sugars.There are many different names for sugar. Examples of common names are table sugar, brown sugar, molasses, honey, beet sugar, cane sugar, confectioner's sugar, powdered sugar, raw sugar, turbinado, maple syrup, high-fructose corn syrup, agave nectar, and sugar cane syrup.You may also see table sugar listed by its chemical name, sucrose. Fruit sugar is also known as fructose and the sugar in milk is called lactose. You can recognize other sugars on labels because their chemical names also end in "-ose." For example glucose (also called dextrose), fructose (also called levulose), lactose, and maltose.

FiberFiber comes from plant foods so there is no fiber in animal products such as milk, eggs, meat, poultry, and fish. Fiber is the indigestible part of plant foods, including fruits, vegetables, whole grains, nuts, and legumes. When you consume dietary fiber, most of it passes through the intestines and is not digested.For good health, adults need to try to eat 25 to 30 grams of fiber each day. Most Americans do not consume nearly enough fiber in their diet, so while it is wise to aim for this goal, any increase in fiber in your diet can be beneficial. Most of us only get about what is recommended. Fiber contributes to digestive health, helps to keep you regular and helps to make you feel full and satisfied after eating. Additional health benefits, of a diet high in fiber such as a reduction in cholesterol levels have been suggested by some so may be an additional benefit.Good sources of dietary fiber include:Beans and legumes. Think black beans, kidney beans, pintos, chick peas (garbanzos), white beans, and lentils. Fruits and vegetables, especially those with edible skin (for example, apples, corn and beans) and those with edible seeds (for example, berries). Whole grains such as: Whole wheat pasta Whole grain cereals (Look for those with three grams of dietary fiber or more per serving, including those made from whole wheat, wheat bran, and oats.) Whole grain breads (To be a good source of fiber, one slice of bread should have at least three grams of fiber. Another good indication: look for breads where the first ingredient is a whole grain. For example, whole whe+at or oats.) Many grain products now have "double fiber" with extra fiber added. Nuts try different kinds. Peanuts, walnuts and almonds are a good source of fiber and healthy fat, but watch portion sizes, because they also contain a lot of calories in a small amount. In general, an excellent source of fiber contains five grams or more per serving, while a good source of fiber contains 2.5 - 4.9 grams per serving.It is best to get your fiber from food rather than taking a supplement. In addition to the fiber, these foods have a wealth of nutrition, containing many important vitamins and minerals. In fact, they may contain nutrients that haven't even been discovered yet!It is also important that you increase your fiber intake gradually, to prevent stomach irritation, and that you increase your intake of water and other liquids, to prevent constipation.Because fiber is not digested like other carbohydrates, for carbohydrate counting purposes, if a serving of a food contains more than or equal to 5 grams of dietary fiber, you can subtract half the grams of dietary fiber from the total carbohydrate serving of that food.

Diabetes SuperfoodsBeansWhether you prefer kidney, pinto, navy or black beans, you cant find better nutrition than that provided by beans. They are very high in fiber giving you about 1/3 of your daily requirement in just a cup and are also good sources of magnesium, and potassium. They are considered starchy vegetables but a cup provides as much protein as an ounce of meat without the saturated fat. To save time you can use canned beans, but be sure to drain and rinse them to get rid of as much sodium as possible.Dark Green Leafy Vegetables Spinach, collards, kale these powerhouse foods are so low in calories and carbohydrates, you cant eat too much.Citrus FruitGrapefruit, oranges, lemons and limes. Pick your favorites and get part of your daily dose of soluble fiber and vitamin C.Sweet PotatoesAstarchy vegetable packed full of vitamin A and fiber. Try in place of regular potatoes for a lower GI alternative.BerriesWhich are your favorites: blueberries, strawberries or another variety? Regardless, they are all packed with antioxidants, vitamins and fiber. Make a parfait alternating the fruit with light, non-fat yogurt for a new favorite dessert.

Tomatoes An old standby where everyone can find a favorite. The good news is that no matter how you like your tomatoes, pureed, raw, or in a sauce, youre eating vital nutrients like vitamin C, iron, vitamin E.Fish High in Omega-3 Fatty AcidsSalmon is a favorite in this category. Stay away from the breaded and deep fat fried variety... they dont count in your goal of 6-9 ounces of fish per week.Whole Grains Its the germ and bran of the whole grain youre after. It contains all the nutrients a grain product has to offer. When you purchase processed grains like bread made from enriched wheat flour, you dont get these. A few more of the nutrients these foods offer are magnesium, chromium, omega 3 fatty acids and folate.Pearled barley and oatmeal are a source of fiber and potassium. NutsAn ounce of nuts can go a long way in providing key healthy fats along with hunger management. Other benefits are a dose of magnesium and fiber. Some nuts and seeds, such as walnuts and flax seeds, also contain omega-3 fatty acids.Fat-free Milk and YogurtEveryone knows dairy can help build strong bones and teeth. In addition to calcium, many fortified dairy products are a good source of vitamin D. More research is emerging on the connection between vitamin D and good health.Some of the above list can be tough on the budget depending on the season and where you live. Look for lower cost options such as fruit and vegetables in season or frozen or canned fish. Foods that every budget can live with year round are beans and rolled oats or barley that you cook from scratch.

FruitsThe best choices of fruit are any that are fresh, frozen or canned without added sugars. General tipsChoose canned fruits in juice or light syrup Dried fruit and fruit juice are also nutritious choices, but the portion sizes are small so they may not be as filling as other choices. TipsFor Carb counters A small piece of whole fruit or about cup of frozen or canned fruit has about 15 grams of carbohydrate. Servings for most fresh berries and melons are from - 1 cup. Fruit juice can range from 1/3 -1/2 cup for 15 grams of carbohydrate. Only 2 tablespoons of dried fruit like raisins or dried cherries contains 15 grams of carbohydrate so be cautious with your portion sizes! Fruit can be eaten in exchange for other carbohydrates in your meal plan such as starches, grains, or dairy.For Plate Method If using the plate method, having a small piece of whole fruit or a cup of fruit salad for dessert is a great compliment to the non-starchy vegetables, small portion of starch and protein foods that are on your plate. For using the Glycemic Index Most fruits have a low glycemic index because of their fructose and fiber content. Melons and pineapple have medium GI values as do some dried fruits such as dates, raisins, and sweetened cranberries. Overall, fruit is encouraged when using the glycemic index to guide food choicesso enjoy.

Common FruitsThe following is a list of common fruits:Apples Applesauce Apricots Banana Blackberries Blueberries Cantaloupe Cherries Dates Dried fruit Figs Fruit cocktail Grapefruit

Grapes Honeydew melon Kiwi Mango Nectarine Orange Papaya Peaches Pears Pineapple Plums Raspberries Strawberries Tangerines Watermelon

DairyLow-fat Milk and Yogurt Including sources of dairy products in your diet is an easy way to get calcium and high-quality protein. Many dairy products, like no sugar added, fat-free yogurt, can be eaten as a dessert with only about 15 grams of carbohydrate and 100 calories per 6 oz container. What are the best choices?The best choices of dairy products are:Fat-free or low-fat (1% milk) Plain non-fat yogurt non-fat light yogurt without added sugar unflavored soy milk If you are lactose intolerant, you may want to try fortified soy milk as a source of calcium and vitamin D.General tips:Each 1 cup serving of milk or2/3 cup serving of yogurt has about 12 grams of carbohydrate and 8 grams of protein. If you are trying to switch to lower fat dairly products, take the time to get used to the taste and texture difference. For example, first change from whole milk to 2%. Then to 1% or non-fat milk. Switching from whole to 1% milk will save you 70 calories and 4 grams of saturated fat in every serving! Tips for Carb Counters 1 cup of milk or yogurt is equal to 1 small piece of fruit or 1 slice of breadTips for the Plate Method Your meal plan calls for 8 ounces of milk. If you dont drink milk, you can substitute another carbohydrate containing food like a piece of fruit or a small dinner roll.Tips for using the Glycemic Index Milk has a low glycemic index so choose lower-fat dairy products to fit into your meals.

Non-starchy VegetablesWhat are the best choices?The best choices are fresh, frozen and canned vegetables and vegetable juices without added sodium, fat or sugar.General tips:If using canned or frozen vegetables, look for ones that say low sodium or no salt added on the label. As a general rule, frozen or canned vegetables in sauces are higher in both fat and sodium. If using canned vegetables with sodium, drain the vegetables and rinse with water then warm in fresh water. This will cut back on how much sodium is left on the vegetables. For good health, try to eat at least 3-5 servings of vegetables a day. This is a minimum and more is better! A serving of vegetables is: cup of cooked vegetables or vegetable juice 1 cup of raw vegetables

Common Non-starchy VegetablesThe following is a list of common non-starchy vegetables:Amaranth or Chinese spinach Artichoke Artichoke hearts Asparagus Baby corn Bamboo shoots Beans (green, wax, Italian) Bean sprouts Beets Broccoli Brussels sprouts Cabbage (green, bok choy, Chinese) Carrots Cauliflower Celery Chayote Coleslaw (packaged, no dressing) Cucumber Daikon Eggplant Greens (collard, kale, mustard, turnip) Hearts of palm Jicama Kohlrabi Leeks Mushrooms Okra Onions Pea pods Peppers Radishes Rutabaga Salad greens (chicory, endive, escarole, lettuce, romaine, spinach, arugula, radicchio, watercress) Sprouts Squash (cushaw, summer, crookneck, zucchini) Sugar snap peas Swiss chard Tomato Turnips Water chestnuts Yard-long beans

Artificial SweetenersCurb Your CravingsFoods and drinks that use artificial sweeteners are another option that may help curb your cravings for something sweet. Sometimes artificial sweeteners are also called low-calorie sweeteners, sugar substitutes, or non-nutritive sweeteners. They can be used to sweeten food and drinks for less calories and carbohydrate when they replace sugar. However, many foods containing artificial sweeteners still have calories and carbs, so be sure to check the nutrition facts label. Their sweetening power is at least 100 times more intense than regular sugar, so only a small amount is needed when you use these sugar substitutes. Also, with the exception of aspartame, all of the sweeteners listed below cannot be broken down by the body. They pass through our systems without being digested so they provide no extra calories.

FDA ApprovedThere are five artificial sweeteners that have been tested and approved by the U.S. Food and Drug Administration (FDA):acesulfame potassium (also called acesulfame K) aspartame saccharin sucralose neotame These sweeteners are used by food companies to make diet drinks, baked goods, frozen desserts, candy, light yogurt, and chewing gum. You can buy them to use as table top sweeteners. Add them to coffee, tea, or sprinkle them on top of fruit. Some are also available in granular versions which can be used in cooking and baking. Whats The Deal With Stevia?Stevia (sometimes called Rebaudioside A or rebiana) is now generally recognized as safe (GRAS) by the FDA as a food additive and table top sweetener. When something is generally recognized as safe by the FDA, it means that experts have agreed that it is safe for use by the public in appropriate amounts. Stevia is several hundred times sweeter than sugar. It comes from the sweetest part of the stevia plant and is an ingredient in many foods that you can buy at the store.

Cutting Calories and CarbohydrateArtificial sweeteners have no carbohydrates and do not increase blood glucose levels. In the past, there was some concern that low-calorie sweeteners caused cancer and other health conditions. However, numerous studies have shown that they do not andseveral sweeteners have been permitted for use.

Top 10 Benefits of Being ActiveImprove blood glucose management. Activity makes your body more sensitive to the insulin you make. Activity also burns glucose (calories). Both actions lower blood glucose. Lower blood pressure. Activity helps your heart pump stronger and slower. Improve blood fats. Exercise can raise good cholesterol (HDL) and lower bad cholesterol (LDL) and triglycerides. These changes are heart healthy. Take less insulin or diabetes pills. Activity can lower blood glucose and weight. Both of these may lower how much insulin or diabetes pills you need to take. Lose weight and keep it off. Activity burns calories. If you burn enough calories, you'll trim a few pounds. Stay active and you'll keep the weight off. Lower risk for other health problems. Reduce your risk of a heart attack or stroke, some cancers, and bone loss. Gain more energy and sleep better. You'll get better sleep in less time and have more energy, too. Reduce stress, anxiety, and depression.Work out or walk off daily stress. Build stronger bones and muscles. Weight-bearing activities, such as walking, make bones stronger. Strength-training activities, such as lifting light weights (or even cans of beans), make muscles strong. Be more flexible. Move easier when you are active.

Types of ExerciseAerobic ExerciseAerobic exercise increases your heart rate, works your muscles, and raises your breathing rate. For most people, it's best to aim for a total of about 30 minutes a day, at least 5 days a week. If you haven't been very active recently, you can start out with 5 or 10 minutes a day. Increase your activity sessions by a few minutes each week. If your schedule doesn't allow for 30 minutes straight of exercise throughout the day, you can break it up into no less than 10-minute spurts to get the same health benefits. For example, you might takea brisk 10-minute walk after each meal. If you're trying to lose weight, you may want to exercise more than 30 minutes a day. Here are some examples of aerobic exercise:Take a brisk walk (outside or inside on a treadmill) Go dancing Take a low-impact aerobics class Swim or do water aerobic exercises Try ice-skating or roller-skating Play tennis Ride your bicycle outside Stationary bicycle indoors

Strength TrainingStrength training, done2-3 times a week, helps build strong bones and muscles.It makes everyday chores like carrying groceries easier for you. With more muscle, you burn more calories, even at rest. Strength training can also help to prevent weight gain. Here are some ways to do it:Join a class to do strength training with weights, elastic bands, or plastic tubes Lift light weights at home Try calisthenics Flexibility ExercisesFlexibility exercises, also called stretching, help keep your joints flexible and reduce your chance of injury during other activities. Gentle stretching for 5 to 10 minutes helps your body warm up and get ready for aerobic activities such as walking or swimming. Your health care team can provide information on how to stretch. Improve your flexibility by:Taking an aerobics or fitness classes that includes stretching Doing yoga or Pilates Stretching on your own before and after exercising

Light-IntensityOne minute burns 3.5 calories. 30 minutes burns 105 calories.Walking slowly Golf, powered cart Slow treading in the swimming pool Light gardening or pruning Bicycling, very light effort Dusting or vaccuming Gentle stretching

Moderate-IntensityOne minute burns 3.5 to 7 calories. 30 minutes burns 105 to 210 calories.-Walking briskly -Golf, pulling or carrying clubs -Swimming, recreational -Mowing lawn, power motor -Tennis, doubles -Bicycling (or using a stationay bike) 5 to 9 mph, level terrain, or with a few hills -Scrubbing floors or washing windows -Weight lifting, machines or free weights

High-IntensityOne minute burns more than 7 calories. 30 minutes burns more than 210 calories.-Race walking, jogging or running -Swimming laps -Mowing lawn, handmower -Tennis, singles -Bicycling more than 10 mph, or on steep uphill terrain -Moving or pushing furniture -Circuit training

Eye ComplicationsYou may have heard that diabetes causes eye problems and may lead to blindness. People with diabetes do have a higher risk of blindness than people without diabetes. But most people who have diabetes have nothing more than minor eye disorders. With regular checkups, you can keep minor problems minor. And if you do develop a major problem, there are treatments that often work well if you begin them right away. Eye InsightTo understand what happens in eye disorders, it helps to understand how the eye works. The eye is a ball covered with a tough outer membrane. The covering in front is clear and curved. This curved area is the cornea, which focuses light while protecting the eye. After light passes through the cornea, it travels through a space called the anterior chamber (which is filled with a protective fluid called the aqueous humor), through the pupil (which is a hole in the iris, the colored part of the eye), and then through a lens that performs more focusing. Finally, light passes through another fluid-filled chamber in the center of the eye (the vitreous) and strikes the back of the eye, the retina. Like the film in a camera, the retina records the images focused on it. But unlike film, the retina also converts those images into electrical signals, which the brain receives and decodes. One part of the retina is specialized for seeing fine detail. This tiny area of extra-sharp vision is called the macula. Blood vessels in and behind the retina nourish the macula. The smallest of these blood vessels are the capillaries.

GlaucomaPeople with diabetes are 40% more likely to suffer from glaucoma than people without diabetes. The longer someone has had diabetes, the more common glaucoma is. Risk also increases with age. Glaucoma occurs when pressure builds up in the eye. In most cases, the pressure causes drainage of the aqueous humor to slow down so that it builds up in the anterior chamber. The pressure pinches the blood vessels that carry blood to the retina and optic nerve. Vision is gradually lost because the retina and nerve are damaged. There are several treatments for glaucoma. Some use drugs to reduce pressure in the eye, while others involve surgery. CataractsMany people without diabetes get cataracts, but people with diabetes are 60% more likely to develop this eye condition. People with diabetes also tend to get cataracts at a younger age and have them progress faster. With cataracts, the eye's clear lens clouds, blocking light. To help deal with mild cataracts, you may need to wear sunglasses more often and use glare-control lenses in your glasses. For cataracts that interfere greatly with vision, doctors usually remove the lens of the eye. Sometimes the patient gets a new transplanted lens. In people with diabetes, retinopathy can get worse after removal of the lens, and glaucoma may start to develop.

RetinopathyDiabetic retinopathy is a general term for all disorders of the retina caused by diabetes. There are two major types of retinopathy: nonproliferative and proliferative. Nonproliferative retinopathy In nonproliferative retinopathy, the most common form of retinopathy, capillaries in the back of the eye balloon and form pouches. Nonproliferative retinopathy can move through three stages (mild, moderate, and severe), as more and more blood vessels become blocked. Although retinopathy does not usually cause vision loss at this stage, the capillary walls may lose their ability to control the passage of substances between the blood and the retina. Fluid can leak into the part of the eye where focusing occurs, the macula. When the macula swells with fluid, a condition called macula edema, vision blurs and can be lost entirely. Although nonproliferative retinopathy usually does not require treatment, macular edema must be treated, but fortunately treatment is usually effective at stopping and sometimes reversing vision loss. Proliferative retinopathy In some people, retinopathy progresses after several years to a more serious form called proliferative retinopathy. In this form, the blood vessels are so damaged they close off. In response, new blood vessels start growing in the retina. These new vessels are weak and can leak blood, blocking vision, which is a condition called vitreous hemorrhage. The new blood vessels can also cause scar tissue to grow. After the scar tissue shrinks, it can distort the retina or pull it out of place, a condition called retinal detachment. Your retina can be badly damaged before you notice any change in vision. Most people with nonproliferative retinopathy have no symptoms. Even with proliferative retinopathy, the more dangerous form, people sometimes have no symptoms until it is too late to treat them. For this reason, you should have your eyes examined regularly by an eye care professional.

Am I at risk for retinopathy?Several factors influence whether you get retinopathy: blood sugar control blood pressure levels how long you have had diabetes genes The longer you've had diabetes, the more likely you are to have retinopathy. Almost everyone with type 1 diabetes will eventually have nonproliferative retinopathy. And most people with type 2 diabetes will also get it. But the retinopathy that destroys vision, proliferative retinopathy, is far less common. People who keep their blood sugar levels closer to normal are less likely to have retinopathy or to have milder forms. How is it treated?Huge strides have been made in the treatment of diabetic retinopathy. Treatments such as scatter photocoagulation, focal photocoagulation, and vitrectomy prevent blindness in most people. The sooner retinopathy is diagnosed, the more likely these treatments will be successful. The best results occur when sight is still normal. In photocoagulation, the eye care professional makes tiny burns on the retina with a special laser. These burns seal the blood vessels and stop them from growing and leaking. In scatter photocoagulation (also called panretinal photocoagulation), the eye care professional makes hundreds of burns in a polka-dot pattern on two or more occasions. Scatter photocoagulation reduces the risk of blindness from vitreous hemorrhage or detachment of the retina, but it only works before bleeding or detachment has progressed very far. This treatment is also used for some kinds of glaucoma. Side effects of scatter photocoagulation are usually minor. They include several days of blurred vision after each treatment and possible loss of side (peripheral) vision. In focal photocoagulation, the eye care professional aims the laser precisely at leaking blood vessels in the macula. This procedure does not cure blurry vision caused by macular edema. But it does keep it from getting worse. When the retina has already detached or a lot of blood has leaked into the eye, photocoagulation is no longer useful. The next option is vitrectomy, which is surgery to remove scar tissue and cloudy fluid from inside the eye. The earlier the operation occurs, the more likely it is to be successful. When the goal of the operation is to remove blood from the eye, it usually works. Reattaching a retina to the eye is much harder and works in only about half the cases.

Foot ComplicationsPeople with diabetes can develop many different foot problems. Even ordinary problems can get worse and lead to serious complications. Foot problems most often happen when there is nerve damage, also called neuropathy, which results in loss of feeling in your feet. Poor blood flow or changes in the shape of your feet or toes may also cause problems.NeuropathyAlthough it can hurt, diabetic nerve damage can also lessen your ability to feel pain, heat, and cold. Loss of feeling often means you may not feel a foot injury. You could have a tack or stone in your shoe and walk on it all day without knowing. You could get a blister and not feel it. You might not notice a foot injury until the skin breaks down and becomes infected.Nerve damage can also lead to changes in the shape of your feet and toes. Ask your health care provider about special therapeutic shoes, rather than forcing deformed feet and toes into regular shoes.Skin ChangesDiabetes can cause changes in the skin of your foot. At times your foot may become very dry. The skin may peel and crack. The problem is that the nerves that control the oil and moisture in your foot no longer work.After bathing, dry your feet and seal in the remaining moisture with a thin coat of plain petroleum jelly, an unscented hand cream, or other such products. Do not put oils or creams between your toes. The extra moisture can lead to infection. Also, don't soak your feet that can dry your skin.CallusesCalluses occur more often and build up faster on the feet of people with diabetes. This is because there are high-pressure areas under the foot. Too much callus may mean that you will need therapeutic shoes and inserts.Calluses, if not trimmed, get very thick, break down, and turn into ulcers (open sores). Never try to cut calluses or corns yourself - this can lead to ulcers and infection. Let your health care provider cut your calluses. Also, do not try to remove calluses and corns with chemical agents. These products can burn your skin.Using a pumice stone every day will help keep calluses under control. It is best to use the pumice stone on wet skin. Put on lotion right after you use the pumice stone.

Foot UlcersUlcers occur most often on the ball of the foot or on the bottom of the big toe. Ulcers on the sides of the foot are usually due to poorly fitting shoes. Remember, even though some ulcers do not hurt, every ulcer should be seen by your health care provider right away. Neglecting ulcers can result in infections, which in turn can lead to loss of a limb.What your health care provider will do varies with your ulcer. Your health care provider may take x-rays of your foot to make sure the bone is not infected. The health care provider may clean out any dead and infected tissue. You may need to go into the hospital for this. Also, the health care provider may culture the wound to find out what type of infection you have, and which antibiotic will work best. Keeping off your feet is very important. Walking on an ulcer can make it get larger and force the infection deeper into your foot. Your health care provider may put a special shoe, brace, or cast on your foot to protect it.If your ulcer is not healing and your circulation is poor, your health care provider may need to refer you to a vascular surgeon. Good diabetes control is important. High blood glucose levels make it hard to fight infecton.After the foot ulcer heals, treat your foot carefully. Scar tissue under the healed wound will break down easily. You may need to wear special shoes after the ulcer is healed to protect this area and to prevent the ulcer from returning.Poor CirculationPoor circulation (blood flow) can make your foot less able to fight infection and to heal. Diabetes causes blood vessels of the foot and leg to narrow and harden. You can control some of the things that cause poor blood flow. Don't smoke; smoking makes arteries harden faster. Also, follow your health care provider's advice for keeping your blood pressure and cholesterol under control.If your feet are cold, you may be tempted to warm them. Unfortunately, if your feet cannot feel heat, it is easy for you to burn them with hot water, hot water bottles, or heating pads. The best way to help cold feet is to wear warm socks.Some people feel pain in their calves when walking fast, up a hill, or on a hard surface. This condition is called intermittent claudication. Stopping to rest for a few moments should end the pain. If you have these symptoms, you must stop smoking. Work with your health care provider to get started on a walking program. Some people can be helped with medication to improve circulation.Exercise is good for poor circulation. It stimulates blood flow in the legs and feet. Walk in sturdy, good-fitting, comfortable shoes, but don't walk when you have open sores.

AmputationPeople with diabetes are far more likely to have a foot or leg amputated than other people. The problem? Many people with diabetes have artery disease, which reduces blood flow to the feet. Also, many people with diabetes have nerve disease, which reduces sensation. Together, these problems make it easy to get ulcers and infections that may lead to amputation. Most amputations are preventable with regular care and proper footware.For these reasons, take good care of your feet and see your health care provider right away about foot problems. Ask about prescription shoes that are covered by Medicare and other insurance. Always follow your health care provider's advice when caring for ulcers or other foot problems. One of the biggest threats to your feet is smoking. Smoking affects small blood vessels. It can cause decreased blood flow to the feet and make wounds heal slowly. A lot of people with diabetes who need amputations are smokers.

Skin ComplicationsDiabetes can affect every part of the body, including the skin. As many as 33 percent of people with diabetes will have a skin disorder caused or affected by diabetes at some time in their lives. In fact, such problems are sometimes the first sign that a person has diabetes. Luckily, most skin conditions can be prevented or easily treated if caught early. Some of these problems are skin conditions anyone can have, but people with diabetes get more easily. These include bacterial infections, fungal infections, and itching. Other skin problems happen mostly or only to people with diabetes. These include diabetic dermopathy, necrobiosis lipoidica diabeticorum, diabetic blisters, and eruptive xanthomatosis. You may also be interested in our book, Uncomplicated Guide To Diabetes' Complications, 3rd Edition. General Skin ConditionsBacterial InfectionsSeveral kinds of bacterial infections occur in people with diabetes: Styes (infections of the glands of the eyelid) Boils Folliculitis (infections of the hair follicles) Carbuncles (deep infections of the skin and the tissue underneath) Infections around the nails Inflamed tissues are usually hot, swollen, red, and painful. Several different organisms can cause infections, the most commong being Staphylococcus bacteria, also called staph. Once, bacterial infections were life threatening, especially for people with diabetes. Today, death is rare, thanks to antibiotics and better methods of blood sugar control. But even today, people with diabetes have more bacterial infections than other people do. Doctors believe people with diabetes can reduce their chances of these infections by practicing good skin care. If you think you have a bacterial infection, see your doctor.

Fungal InfectionsThe culprit in fungal infections of people with diabetes is often Candida albicans. This yeast-like fungus can create itchy rashes of moist, red areas surrounded by tiny blisters and scales. These infections often occur in warm, moist folds of the skin. Problem areas are under the breasts, around the nails, between fingers and toes, in the corners of the mouth, under the foreskin (in uncircumcised men), and in the armpits and groin. Common fungal infections include jock itch, athlete's foot, ringworm (a ring-shaped itchy patch), and vaginal infection that causes itching. If you think you have a yeast or fungal infection, call your doctor. You will need a prescription medicine to cure it. ItchingLocalized itching is often caused by diabetes. It can be caused by a yeast infection, dry skin, or poor circulation. When poor circulation is the cause of itching, the itchiest areas may be the lower parts of the legs. You may be able to treat itching yourself. Limit how often you bathe, particularly when the humidity is low. Use mild soap with moisturizer and apply skin cream after bathing.

Diabetes-Related Skin ConditionsDiabetic DermopathyDiabetes can cause changes in the small blood vessels. These changes can cause skin problems called diabetic dermopathy. Dermopathy often looks like light brown, scaly patches. These patches may be oval or circular. Some people mistake them for age spots. This disorder most often occurs on the front of both legs. But the legs may not be affected to the same degree. The patches do not hurt, open up, or itch. Dermopathy is harmless and doesn't need to be treated.

Necrobiosis Lipoidica DiabeticorumAnother disease that may be caused by changes in the blood vessels is necrobiosis lipoidica diabeticorum (NLD). NLD causes spots similar to diabetic dermopathy, but they are fewer, larger, and deeper. NLD often starts as a dull, red, raised area. After a while, it looks like a shiny scar with a violet border. The blood vessels under the skin may become easier to see. Sometimes NLD is itchy and painful. Sometimes the spots crack open. NLD is a rare condition. Adult women are the most likely to get it. As long as the sores do not break open, you do not need to have it treated. But if you get open sores, see your doctor for treatment.

AtherosclerosisAtherosclerosis is a thickening of the arteries that can affect the skin on the legs. People with diabetes tend to get atherosclerosis at younger ages than other people do. As atherosclerosis narrows the blood vessels, the skin changes. It becomes hairless, thin, cool, and shiny. The toes become cold. Toenails thicken and discolor. And exercise causes pain in the calf muscles because the muscles are not getting enough oxygen. Because blood carries the infection-fighting white cells, affected legs heal slowly when the skin in injured. Even minor scrapes can result in open sores that heal slowly. People with neuropathy are more likely to suffer foot injuries. These occur because the person does not feel pain, heat, cold, or pressure as well. The person can have an injured foot and not know about it. The wound goes uncared for, and so infections develop easily. Atherosclerosis can make things worse. The reduced blood flow can cause the infection to become severe.Allergic ReactionsAllergic skin reactions can occur in response to medicines, such as insulin or diabetes pills. You should see your doctor if you think you are having a reaction to a medicine. Be on the lookout for rashes, depressions, or bumps at the sites where you inject insulin. Diabetic Blisters (Bullosis Diabeticorum)Rarely, people with diabetes erupt in blisters. Diabetic blisters can occur on the backs of fingers, hands, toes, feet, and sometimes, on legs or forearms. These sores look like burn blisters and often occur in people who have diabetic neuropathy. They are sometimes large, but they are painless and have no redness around them. They heal by themselves, usually without scars, in about three weeks. The only treatment is to bring blood sugar levels under control.

Eruptive XanthomatosisEruptive xanthomatosis is another condition caused by diabetes that's out of control. It consists of firm, yellow, pea-like enlargements in the skin. Each bump has a red halo and may itch. This condition occurs most often on the backs of hands, feet, arms, legs, and buttocks. The disorder usually occurs in young men with type 1 diabetes. The person often has high levels of cholesterol and fat in the blood. Like diabetic blisters, these bumps disappear when diabetes control is restored.

Digital SclerosisSometimes, people with diabetes develop tight, thick, waxy skin on the backs of their hands. Sometimes skin on the toes and forehead also becomes thick. The finger joints become stiff and can no longer move the way they should. Rarely, knees, ankles, or elbows also get stiff. This condition happens to about one third of people who have type 1 diabetes. The only treatment is to bring blood sugar levels under control.

Disseminated Granuloma AnnulareIn disseminated granuloma annulare, the person has sharply defined ring- or arc-shaped raised areas on the skin. These rashes occur most often on parts of the body far from the trunk (for example, the fingers or ears). But sometimes the raised areas occur on the trunk. They can be red, red-brown, or skin-colored. See your doctor if you get rashes like this. There are drugs that can help clear up this condition. Acanthosis NigricansAcanthosis nigricans is a condition in which tan or brown raised areas appear on the sides of the neck, armpits, and groin. Sometimes they also occur on the hands, elbows, and knees. Acanthosis nigricans usually strikes people who are very overweight. The best treatment is to lose weight. Some creams can help the spots look better.

ABCs of Heart DiseaseKeeping your ABCs in check can also help you lower your risk for heart disease and stoke. The ABCs are an easy way to remember some of the most important health issues related to diabetes. As a man with diabetes, it's important to stay informedabout related health complications, take a look at the ABCs, and speak with your healthcare provider to see if these issues are affecting you. A is for A1CYour A1C reflects your average blood glucose level for the two to three month period before the test. Your healthcare provider uses it to determine how well you are managing your blood sugar. A goal of less than 7 percent is desirable, which corresponds to an average blood glucose level of 150 mg/dL.B is blood pressure Men with diabetes should aim for a blood pressure level below 130/80 mm Hg. You should monitor blood pressure at each routine diabetes visit.

C is for cholesterol (lipids) A complete cholesterol test, referred to as a lipid panel or lipid profile, includes the measurement of four types of fats (lipids) in your blood, low-density lipoprotein (LDL), high-density lipoprotein (HDL) cholesterol, total cholesterol and triglycerides. LDL is sometimes called the "bad"cholesterol. Too much of it in your blood causes the accumulation of fatty deposits (plaques) in your arteries (atherosclerosis), which reduces blood flow. HDL is sometimes called the "good"cholesterol because it helps carry away LDL cholesterol, thus keeping arteries open and blood flowing more freely. Total cholesterol is the sum of your blood's cholesterol content. Triglycerides are another type of fat in the blood. When you eat, your body converts any calories it doesn't need to use right away into triglycerides, which are stored in fat cells and released later for energy. Note: Now you know your ABCs. Speak with your healthcare provider about ways to keep your ABCs in control.

High Blood Pressure (Hypertension)As many as 2 out of 3 adults with diabetes have high blood pressure. Because of the risks of high blood pressure to people with diabetes, the American Diabetes Association and the National Institutes of Health recommend a lower blood pressure target than the general public (less than 130/80 mmHg). Blood pressure can be controlled with lifestyle changes, such as diet and exercise, and medication.An important part of taking care of yourself is keeping your blood pressure under control. High blood pressure also called hypertension raises your risk for heart attack, stroke, eye problems, and kidney disease. As many as 2 out of 3 adults with diabetes have high blood pressure. Having your blood pressure checked regularly and taking action to reach your blood pressure target can prevent or delay diabetes problems.What is high blood pressure?Blood pressure is the force of blood flow inside your blood vessels. When your health care team checks your blood pressure, they record two numbers, such as 130/80 mmHg. You'll hear them say this as "one-thirty over eighty." Both numbers are important:The first number is the pressure as your heart beats and pushes blood through the blood vessels. Health care providers call this the "systolic" pressure. The second number is the pressure when the vessels relax between heartbeats. It's called the "diastolic" pressure. When your blood moves through your vessels with too much force, you have high blood pressure. Your heart has to work harder when blood pressure is high, and your risk for diabetes problems goes up. High blood pressure is a problem that won't go away without treatment.

What is the recommended target for blood pressure?Both diabetes and high blood pressure increases your risk of heart attack, stroke, and eye and kidney disease. Because of this, people with diabetes have a lower blood pressure target than the general public. The American Diabetes Association (ADA) and the National Institutes of Health recommend a target blood pressure of less than 130/80 mmHg for people with diabetes. When you keep your blood pressure below 130/80 mmHg, you'll be lowering your risk for diabetes problems.How do I know if I have high blood pressure?High blood pressure is a silent problem you won't know you have it unless your health care provider checks your blood pressure. The ADA recommends that you have your blood pressure checked at every office visit, or at least 2 to 4 times a year.How is it treated?Both lifestyle changes and medication help control blood pressure. Treatment differs from one person to the next. Work with your health care provider to find a treatment that's right for you.

Lifestyle changesLifestyle changes can help control your blood pressure as well as your blood glucose and blood lipids (cholesterol) levels. From the steps below, decide which steps you would be willing to try. If you need more information about how to make these changes, talk with your health care team.

Make Wise Food ChoicesEat a serving of fruit at each meal. Eat one or two servings of vegetables at lunch and at dinner. Switch to low-fat or fat-free dairy products (such as low-fat cheese and skim milk). Eat whole-grain breads (such as whole-wheat bread) and cereals. Eat nuts or peanut butter sometimes. Choose lean meats and meat substitutes (such as chicken without the skin, fish, lean beef, such as flank steak or chuck roast, boiled ham, or pork tenderloin). Cook using low-fat methods such as baking, roasting, broiling, or grilling. Add little or no salt to your food at the table and during cooking. Try herbs and spices instead of salt. Check food labels and choose foods with less than 400 mg of sodium per serving.

Lose Weight or Take Steps to Prevent Weight GainCut down on calories and fat. Try to be more physically active.

Be Physically ActiveCheck with your doctor to find out which activities will be safe for you. Try to do a total of about 30 minutes of aerobic exercise, such as brisk walking, most days of the week. If you're just starting out, start with 5 minutes a day and gradually add more time.Be Careful With AlcoholTalk with your health care team about whether it's wise to drink alcoholic beverages. If and when you drink alcoholic beverages, limit yourself to one serving a day (for women) or two servings a day (for men).Quit SmokingTalk with your health care team about methods that can help.

MedicationSeveral types of medication are available. Not everyone takes the same blood pressure medication, and many people take more than one kind. Which ones you take will depend on your blood pressure readings and other factors, such as cost.ACE inhibitors These medications lower blood pressure by keeping your blood vessels relaxed. ACE inhibitors prevent a hormone called angiotensin from forming in your body and narrowing your blood vessels. These medications also help protect your kidneys and reduce your risk of heart attack and stroke. ARBs These medications keep the blood vessels open and relaxed to help lower blood pressure. Like ACE inhibitors, ARBs protect your kidneys. Beta blockers These medications help lower blood pressure and relax your heart by allowing it to beat slower and less forcefully. Beta blockers help prevent heart attack and stroke. Calcium channel blockers These medications help the blood vessels relax by keeping calcium out of your blood vessels and heart. Diuretics These medications, sometimes called "water pills," help rid your body of extra water and sodium through urine.Are there potential side effects?Some blood pressure medications produce side effects. Always talk to your health care team if you think your medication is causing a problem. Your health care team may be able to substitute another medication.

Mental Health

AngerAnger can start at diagnosis with the question, "Why me?" You may dwell on how unfair diabetes is: "I'm so angry at this disease! I don't want to treat it. I hate it!"DenialDenial is that voice inside repeating: "Not me." Most people go through denial when they are first diagnosed with diabetes. "I don't believe it. There must be some mistake," they say.DepressionFeeling down once in a while is normal. But some people feel a sadness that just won't go away. Life seems hopeless. Feeling this way most of the day for two weeks or more is a sign of serious depression.

Diabetes and Hearing Loss

Diabetes and hearing loss are two of Americas most widespread health concerns. Nearly 26 million people in the U.S. have diabetes, and an estimated 34.5 million have some type of hearing loss.The numbers are similar is there a link?Yes, says the National Institute of Health (NIH). In fact, the NIH has found that hearing loss is twice as common in people with diabetes as it is in those who dont have the disease. Also, of the 79 million adults thought to have pre-diabetes, the rate of hearing loss is 30% higher than in those with normal blood sugar.How does diabetes contribute to hearing loss?Hearing depends on small blood vessels and nerves in the inner ear. Researchers believe that, over time, high blood glucose levels can damage these vessels and nerves, diminishing the ability to hear.I dont think I have any problem with my hearing.Are you sure? For most people, hearing loss happens over time. The symptoms can be hard to notice. Quite often, family members and friends notice hearing loss before the person experiencing it.Your doctor may not always screen for hearing loss during a physical. Even if your doctor does check for hearing loss, you may still pass the screening test in a quiet exam room. Common signs of hearing loss include:Frequently asking others to repeat themselves Trouble following conversations that involve more than two people Thinking that others are mumbling Problems hearing in noisy places such as busy restaurants Trouble hearing the voices of women and small children Turning up the TV or radio volume too loud for others who are nearby

Im not even 65 how could my hearing be bad already?Most people with hearing loss are younger than 65. Hearing problems can even happen in children. What should I do if I suspect a hearing loss?Talk to your primary care doctor. You may then want to seek help from hearing specialist like: an audiologist, a licensed hearing aid dispenser or a doctor who specializes in hearing problems. From a full hearing exam, youll learn more about your hearing loss. You will also be told what can be done to treat it.What can be done to treat a hearing loss?Sometimes the problem is just an earwax build-up and the patient is referred to a doctor to remove the wax. Treatment will depend on the type of hearing loss. The most common type of hearing loss is called sensorineural hearing loss, This is the kind usually found with diabetes. It cannot usually be cured. However, most cases of sensorineural hearing loss can be treated with hearing aids.How can I be sure that hearing aids will help?Hearing aids have changed a lot in the past few years. Instead of making all sounds louder, like the old kind, newer hearing aids are better at making what you want to hear more clear. These hearing aids also have special features. They may have automatic volume control and can reduce background noise.But I dont want to be seen wearing hearing aids.Hearing aids are getting smaller and smaller. It is unlikely anyone will notice when you are wearing them. The truth is, people are more likely to notice your hearing loss. People who dont treat their hearing problems can become depressed and try to avoid their friends. On the other hand, studies show that people who wear hearing aids often have a better quality of life.

Diabetes and Oral Health Problems

The more severe form of gum disease is called periodontitis. When you reach this stage, your gums begin to pull away from your teeth. Pockets form between your teeth and gums. These fill with germs and pus, and deepen. When this happens, you may need gum surgery to save your teeth. If nothing is done, the infection goes on to destroy the bone around your teeth. The teeth may start to move or get loose. Your teeth may fall out or need to be pulled.Is There an Association Between Gum Disease and Diabetes?For the nearly 24 million Americans that have diabetes, many may be surprised to learn about an unexpected complication associated with this condition. Research shows that there is an increased prevalence of gum disease among those with diabetes, adding serious gum disease to the list of other complications associated with diabetes, such as heart disease, stroke and kidney disease.

Is There a Two-Way Street?Emerging research also suggests that the relationship between serious gum disease and diabetes is two-way. Not only are people with diabetes more susceptible to serious gum disease, but serious gum disease may have the potential to affect blood glucose control and contribute to the progression of diabetes. Research suggests that people with diabetes are at higher risk for oral health problems, such as gingivitis (an early stage of gum disease) and periodontitis (serious gum disease). People with diabetes are at an increased risk for serious gum disease because they are generally more susceptible to bacterial infection, and have a decreased ability to fight bacteria that invade the gums.The Surgeon General's Report on Oral Health states that good oral health is integral to general health. So be sure to brush and floss properly and see your dentist for regular checkups.If I Have Diabetes, am I at Risk for Dental Problems?If your blood glucose levels are poorly controlled, you are more likely to develop serious gum disease and lose more teeth than non-diabetics. Like all infections, serious gum disease may be a factor in causing blood sugar to rise and may make diabetes harder to control.Other oral problems associated to diabetes include: thrush, an infection caused by fungus that grows in the mouth, and dry mouth which can cause soreness, ulcers, infections and cavities.

How Can I Help Prevent Dental Problems Associated with Diabetes?First and foremost, control your blood glucose level. Then, take good care of your teeth and gums, along with regular checkups every six months. To control thrush, a fungal infection, maintain good diabetic control, avoid smoking and, if you wear them, remove and clean dentures daily. Good blood glucose control can also help prevent or relieve dry mouth caused by diabetes.What Can I Expect at My Checkup? Should I Tell My Dental Professional About My Diabetes?People with diabetes have special needs and your dentist and hygienist are equipped to meet those needs - with your help. Keep your dentist and hygienist informed of any changes in your condition and any medication you might be taking. Postpone any non-emergency dental procedures if your blood sugar is not in good control.

GastroparesisGastroparesis is a type of neuropathy (nerve damage) in which food is delayed from leaving the stomach. This nerve damage can be caused by long periods of high blood sugar. Delayed digestion makes the management of diabetes more difficult. It can be treated with insulin management, drugs, diet, or in severe cases, a feeding tube. Gastroparesis is a disorder affecting people with both type 1 and type 2 diabetes in which the stomach takes too long to empty its contents (delayed gastric emptying). The vagus nerve controls the movement of food through the digestive tract. If the vagus nerve is damaged or stops working, the muscles of the stomach and intestines do not work normally, and the movement of food is slowed or stopped. Just as with other types of neuropathy, diabetes can damage the vagus nerve if blood glucose levels remain high over a long period of time. High blood glucose causes chemical changes in nerves and damages the blood vessels that carry oxygen and nutrients to the nerves.

What are the symptoms?Signs and symptoms of gastroparesis include the following: Heartburn Nausea Vomiting of undigested food Early feeling of fullness when eating Weight loss Abdominal bloating Erratic blood glucose (sugar) levels Lack of appetite Gastroesophageal reflux Spasms of the stomach wall These symptoms may be mild or severe, depending on the person.What are the complications?Gastroparesis can make diabetes worse by making it more difficult to manage blood glucose. When food that has been delayed in the stomach finally enters the small intestine and is absorbed, blood glucose levels rise. If food stays too long in the stomach, it can cause problems like bacterial overgrowth because the food has fermented. Also, the food can harden into solid masses called bezoars that may cause nausea, vomiting, and obstruction in the stomach. Bezoars can be dangerous if they block the passage of food into the small intestine.

How is it diagnosed?The diagnosis of gastroparesis is confirmed through one or more of the following tests: Barium X-ray After fasting for 12 hours, you will drink a thick liquid containing barium, which covers the inside of the stomach, making it show up on the X-ray. Normally, the stomach will be empty of all food after 12 hours of fasting. If the X-ray shows food in the stomach, gastroparesis is likely. If the X-ray shows an empty stomach, but the doctor still suspects that you have delayed emptying, you may need to repeat the test another day. On any one day, a person with gastroparesis may digest a meal normally, giving a falsely normal test result. If you have diabetes, your doctor may have special instructions about fasting. Barium Beefsteak Meal You will eat a meal that contains barium, which allows the doctor to watch your stomach as it digests the meal. The amount of time it takes for the barium meal to be digested and leave the stomach gives the doctor an idea of how well the stomach is working. This test can help find emptying problems that do not show up on the liquid barium X-ray. In fact, people who have diabetes-related gastroparesis often digest fluid normally, so the barium beefsteak meal can be more useful.

Radioisotope Gastric-Emptying Scan You will eat food that contains a radioisotope, a slightly radioactive substance that will show up on the scan. The dose of radiation from the radioisotope is small and not dangerous. After eating, you will lie under a machine that detects the radioisotope and shows an image of the food in the stomach and how quickly it leaves the stomach. Gastroparesis is diagnosed if more than half of the food remains in the stomach after two hours. Gastric Manometry This test measures electrical and muscular activity in the stomach. The doctor passes a thin tube down the throat into the stomach. The tube contains a wire that takes measurements of the stomach's electrical and muscular activity as it digests liquids and solid food. The measurements show how the stomach is working and whether there is any delay in digestion. Blood tests The doctor may also order laboratory tests to check blood counts and to measure chemical and electrolyte levels.

To rule out causes of gastroparesis other than diabetes, the doctor may do an upper endoscopy or an ultrasound. Upper Endoscopy After giving you a sedative, the doctor passes a long, thin tube called an endoscope through the mouth and gently guides it down the esophagus into the stomach. Through the endoscope, the doctor can look at the lining of the stomach to check for any abnormalities. Ultrasound To rule out gallbladder disease or pancreatitis as a source of the problem, you may have an ultrasound test, which uses harmless sound waves to outline and define the shape of the gallbladder and pancreas.

How is it treated?The most important treatment goal for diabetes-related gastroparesis is to manage your blood glucose levels as well as possible. Treatments include insulin, oral medications, changes in what and when you eat, and, in severe cases, feeding tubes and intravenous feeding. Insulin for blood glucose controlIf you have gastroparesis, your food is being absorbed more slowly and at unpredictable times. To better manage blood glucose, you may need to try the following: Take insulin more often Take your insulin after you eat instead of before Check your blood glucose levels frequently after you eat and administer insulin whenever necessary Your doctor will give you specific instructions based on your particular needs. MedicationSeveral drugs are used to treat gastroparesis. Your doctor may try different drugs or combinations of drugs to find the most effective treatment.

Meal and Food ChangesChanging your eating habits can help control gastroparesis. Your doctor or dietitian will give you specific instructions, but you may be asked to eat six small meals a day instead of three large ones. If less food enters the stomach each time you eat, it may not become overly full. Or the doctor or dietitian may suggest that you try several liquid meals a day until your blood glucose levels are stable and the gastroparesis has improved. Liquid meals provide all the nutrients found in solid foods, but can pass through the stomach more easily and quickly. The doctor may also recommend that you avoid high-fat and high-fiber foods. Fat naturally slows digestion something you don't need if you have gastroparesis and fiber is difficult to digest. Some high-fiber foods like oranges and broccoli contain material that cannot be digested. Avoid these foods because the indigestible part will remain in the stomach too long and possibly form bezoars. Feeding TubeIf other approaches do not work, you may need surgery to insert a feeding tube. The tube, called a jejunostomy tube, is inserted through the skin on your abdomen into the small intestine. The feeding tube allows you to put nutrients directly into the small intestine, bypassing the stomach altogether. You will receive special liquid food to use with the tube. A jejunostomy is particularly useful when gastroparesis prevents the nutrients and medication necessary to regulate blood glucose levels from reaching the bloodstream. By avoiding the source of the problem (the stomach) and putting nutrients and medication directly into the small intestine, you ensure that these products are digested and delivered to your bloodstream quickly. A jejunostomy tube can be temporary and is used only if necessary when gastroparesis is severe. It is important to note that in most cases treatment does not cure gastroparesis it is usually a chronic condition. Treatment helps you manage gastroparesis, so that you can be as healthy and comfortable as possible.

Ketoacidosis (DKA)

Ketones are produced when your body starts burning fat for energy instead of glucose. Dangerously high levels of ketones can lead to diabetic coma or death. Know the warning signs and check urine for ketones, especially when sick. Ketoacidosis (key-toe-ass-i-DOE-sis) is a serious condition that can lead to diabetic coma (passing out for a long time) or even death. When your cells don't get the glucose they need for energy, your body begins to burn fat for energy, which produces ketones. Ketones are acids that build up in the blood and appear in the urine when your body doesn't have enough insulin. They are a warning sign that your diabetes is out of control or that you are getting sick. High levels of ketones can poison the body. When levels get too high, you can develop diabetic ketoacidosis, or DKA.Ketoacidosis may happen to anyone with diabetes, though it is rare in people with type 2. Some older people with type 2 diabetes may experience a different serious condition called hyperosmolar nonketotic coma (hi-per-oz-MOE-lar non- key-TOT-ick KO-ma) in which the body tries to get rid of excess sugar by passing it into the urine.Treatment for ketoacidosis usually takes place in the hospital. But you can help prevent ketoacidosis by learning the warning signs and checking your urine and blood regularly.

What are the warning signs of ketoacidosis?Ketoacidosis usually develops slowly. But when vomiting occurs, this life-threatening condition can develop in a few hours. Early symptoms include the following:Thirst or a very dry mouth Frequent urination High blood glucose (sugar) levels High levels of ketones in the urine Then, other symptoms appear:Constantly feeling tired Dry or flushed skin Nausea, vomiting, or abdominal pain (Vomiting can be caused by many illnesses, not just ketoacidosis. If vomiting continues for more than 2 hours, contact your health care provider.) A hard time breathing (short, deep breaths) Fruity odor on breath A hard time paying attention, or confusion

Ketoacidosis is dangerous and serious. If you have any of the above symptoms, contact your health care provider IMMEDIATELY, or go to the nearest emergency room of your local hospital.How do I check for ketones?You can detect ketones with a simple urine test using a test strip, similar to a blood testing strip. Ask your health care provider when and how you should test for ketones. Many experts advise to check your urine for ketones when your blood glucose is more than 240 mg/dl.When you are ill (when you have a cold or the flu, for example), check for ketones every 4 to 6 hours. And check every 4 to 6 hours when your blood glucose is more than 240 mg/dl.Also, check for ketones when you have any symptoms of ketoacidosis.What if I find higher-than-normal levels of ketones?If your health care provider has not told you what levels of ketones are dangerous, then call when you find moderate amounts after more than one test. Often, your health care provider can tell you what to do over the phone.Call your health care provider at once if you experience the following conditions:Your urine tests show high levels of ketones. Your urine tests show high levels of ketones and your blood glucose level is high. Your urine tests show high levels of ketones and you have vomited more than twice in four hours. Do NOT exercise when your urine tests show ketones and your blood glucose is high. High levels of ketones and high blood glucose levels can mean your diabetes is out of control. Check with your health care provider about how to handle this situation.

What causes ketoacidosis?Here are three basic reasons for moderate or large amounts of ketones:Not enough insulin Maybe you did not inject enough insulin. Or your body could need more insulin than usual because of illness. Not enough food When you're sick, you often don't feel like eating, sometimes resulting in high ketone levels. High levels may also occur when you miss a meal. Insulin reaction (low blood glucose) If testing shows high ketone levels in the morning, you may have had an insulin reaction while asleep.

Neuropathy (Nerve Damage)

Nerve damage from diabetes is called diabetic neuropathy (new-ROP-uh-thee). About half of all people with diabetes have some form of nerve damage. Itis more common in those who have had the disease for a number of years and can lead to many kinds of problems. Over time excessblood glucose can injure the walls of tiny blood vessels that nourish your nerves, especially in the legs.Nerves send messages to and from your brain about pain, temperature and touch. They tell your muscles when and how to move. They also control body systems that digest food and pass urine.If you keep your blood glucose levels on target, you may help prevent or delay nerve damage. If you already have nerve damage, this will help prevent or delay further damage. There are alsoother treatments that can help.

Peripheral NeuropathyTinglingMy feet tingle. I feel "pins and needles" in my feet. Pain or increased sensitivityI have burning, stabbing or shooting pains in my feet. My feet are very sensitive to touch. For example, sometimes it hurts to have the bed covers touch my feet. Sometimes I feel like I have socks or gloves on when I don't. My feet hurt at night. My feet and hands get very cold or very hot. Numbness or weaknessMy feet are numb and feel dead. I don't feel pain in my feet, even when I have blisters or injuries. I can't feel my feet when I'm walking. The muscles in my feet and legs are weak. I'm unsteady when I stand or walk. I have trouble feeling heat or cold in my feet or hands. OtherIt seems like the muscles and bones in my feet have changed shape. I have open sores (also called ulcers) on my feet and legs. These sores heal very slowly.

DiagnosisFoot exams. Your health care provider should look at your feet at each office visit to check for injuries, sores, blisters or other problems. As a reminder, take off your shoes and socks when you're in the exam room.Have a complete foot exam once a year. If you already have foot problems, have your feet checked more often. A complete foot exam includes a check of the skin on your feet, your foot muscles and bones, and your blood flow. Your provider will also check for numbness in your feet by touching your foot with a monofilament. It looks like a stiff piece of nylon fishing line or a bristle in a hairbrush.Other ways to check your nerves include using a tuning fork. It may be touched to your foot to see if you can feel it moving.Nerve conduction studies and electromyography (EMG). If the doctor thinks you might have nerve damage, you may have tests that look at how well the nerves in your arms and legs are working. Nerve conduction studies check the speed with which nerves send messages. An EMG checks how your nerves and muscles work together.

TreatmentTo treat nerve damage, you will need to keep your blood glucose levels in your target range, manage your pain and protect your feet. Many people get depressed when they have nerve damage and may need medication for depression as well as counseling.Medications. Medications to relieve pain and reduce burning, numbness and tingling are available. Some of these are known for their use in other conditions but they still seem to help those with nerve damage. Choices include medications also used for:seizure prevention depression pain Speak with your doctorto find outwhat treatments are best for you.

Autonomic NeuropathyAutonomic neuropathy affects the autonomic nerves, which control the bladder, intestinal tract, and genitals, among other organs.Paralysis of the bladder is a common symptom of this type of neuropathy. When this happens, the nerves of the bladder no longer respond normally to pressure as the bladder fills with urine. As a result, urine stays in the bladder, leading to urinary tract infections.Autonomic neuropathy can also causeerectile dysfunction (ED)when it affects the nerves that control erection with sexual arousal. However, sexual desire does not usually decrease.Diarrhea can occur when the nerves that control the small intestine are damaged. The diarrhea occurs most often at night. Constipation is another common result of damage to nerves in the intestines.Sometimes, the stomach is affected. It loses the ability to move food through the digestive system, causing vomiting and bloating. This condition, called gastroparesis, can change how fast the body absorbs food. It can make it hard to match insulin doses to food portions.Scientists do not know the precise cause of autonomic neuropathy and are looking for better treatments for his type of neuropathy.

SymptomsThis type of nerve damage affects the nerves in your body that control your body systems. It affects your digestive system, urinary tract, sex organs, heart and blood vessels, sweat glands, and eyes. Look at the list below and make a note aboutany symptomsyou have. Bring this list to your next office visit.About my digestive systemI get indigestion or heartburn. I get nauseous and I vomit undigested food. It seems like food sits in my stomach instead of being digested. I feel bloated after I eat. My stomach feels full, even after I eat only a small amount. I have diarrhea. I have lost control of my bowels. I get constipated. My blood glucose levels are hard to predict. I never know if I'll have high or low blood glucose after eating. About my urinary tractI have had bladder control problems, such as urinating very often or not often enough, feeling like I need to urinate when I don't, or leaking urine. I don't feel the need to urinate, even when my bladder is full. I have lost control of my bladder. I have frequent bladder infections.

About my sex organs(For men) When I have sex, I have trouble getting or keeping an erection. (For women) When I have sex, I have problems with orgasms, feeling aroused, or I have vaginal dryness. About my heart and blood vesselsI get dizzy if I stand up too quickly. I have fainted after getting up or changing my position. I have fainted suddenly for no reason. At rest, my heart beats too fast. I had a heart attack but I didn't have the typical warning signs such as chest pain. About my body's warning system for low blood glucose levels (hypoglycemia)I used to get nervous and shaky when my blood glucose was getting too low, but I no longer have those warning signals. About my sweat glandsI sweat a lot, especially at night or while I'm eating. I no longer sweat, even when I'm too hot. The skin on my feet is very dry. About my eyesIt's hard for my eyes to adjust when I go from a dark place into a bright place or when driving at night.

DiagnosisTo diagnose this kind of nerve damage, you will need a physical exam and special tests as well. For example, an ultrasound test uses sound waves to check on your bladder. Stomach problems can be found using x-rays and other tests. Reporting your symptoms plays a big part in making a diagnosis.TreatmentThere are a number of treatments for damage to nerves that control body systems. For example, a dietitian can help you plan meals if you have nausea or feel full after eating a small amount. Some medications can speed digestion and reduce diarrhea. Problems with erections can be treated with medications or devices.

Additional Types of Neuropathy

Charcot's JointCharcot's Joint, also called neuropathic arthropathy, occurs when a joint breaks down because of a problem with the nerves. This type of neuropathy most often occurs in the foot. In a typical case of Charcot's Joint, the foot has lost most sensation. The person no longer can feel pain in the foot and loses the ability to sense the position of the joint. Also, the muscles lose their ability to support the joint properly. The foot then becomes unstable, and walking just makes it worse. An injury, such as a twisted ankle, may make things even worse. Joints grind on bone. The result is inflammation, which leads to further instability and then dislocation. Finally, the bone structure of the foot collapses. Eventually, the foot heals on its own, but because of the breakdown of the bone, it heals into a deformed foot.People at risk for Charcot's Joint are those who already have neuropathy. They should be aware of symptoms such as swelling, redness, heat, strong pulse, and insensitivity of the foot. Early treatment can stop bone destruction and aid healing.

Cranial NeuropathyCranial neuropathy affects the 12 pairs of nerves that are connected with the brain and control sight, eye movement, hearing, and taste.Most often, cranial neuropathy affects the nerves that control the eye muscles. The neuropathy begins with pain on one side of the face near the affected eye. Later, the eye muscle becomes paralyzed. Double vision results. Symptoms of this type of neuropathy usually get better or go away within 2 or 3 months.

Compression MononeuropathyCompression mononeuropathy occurs when a single nerve is damaged. It is a fairly common type of neuropathy. There seem to be two kinds of damage. In the first, nerves are squashed at places where they must pass through a tight tunnel or over a lump of bone. Nerves of people with diabetes are more prone to compression injury. The second kind of damage arises when blood vessel disease caused by diabetes restricts blood flow to a part of the nerve.Carpal tunnel syndrome is probably the most common compression mononeuropathy. It occurs when the median nerve of the forearm is compressed at the wrist. Symptoms of this type of neuropathy include numbness, swelling, or prickling in the fingers with or without pain when driving a car, knitting, or resting at night. Simply hanging your arm by your side usually stops the pain within a few minutes. If the symptoms are severe, an operation can give complete relief from pain.

Femoral NeuropathyFemoral neuropathyoccurs most often in people with type 2 diabetes. A pain may develop in the front of one thigh. Muscle weakness follows, and the affected muscles waste away. A different kind of neuropathy that also affects the legs is called diabetic amyotrophy. In this case, weakness occurs on both sides of the body, but there is no pain. Doctors do not understand why it occurs, but blood vessel disease may be the cause.Focal NeuropathyFocal Neuropathy affects a nerve or group of nerves causing sudden weakness or pain. It can lead to double vision, a paralysis on one side of the face called Bell's palsy, or a pain in the front of the thigh or other parts of the body. Thoracic/Lumbar RadiculopathyThoracic or lumbar radiculopath is another common mononeuropathy. It is like femoral neuropathy, except that it occurs in the torso. It affects a band of the chest or abdominal wall on one or both sides. It seems to occur more often in people with type 2 diabetes. Again, people with this neuropathy get better with time.Unilateral Foot DropUnilateral foot drop is when the foot can't be picked up. It occurs from damage to the peroneal nerve of the leg by compression or vessel disease. Foot drop can improve.

Steps to Prevent or Delay Nerve Damage

There's a lot you can do to prevent or delay nerve damage. And, if you already have diabetic neuropathy (nerve damage), these steps can prevent or delay further damage and may lessen your symptoms.Keep your blood glucose levels in your target range.Meal planning, physical activity and medications, if needed, all can help you reach your target range. There are two ways to keep track of your blood glucose levels:Use a blood glucose meter to help you make decisions about day-to-day care. Get an A1C test (a lab test) at least twice a year to find out your average blood glucose for the past 2 to 3 months. Checking your blood glucose levels will tell you whether your diabetes care plan is working or whether changes are needed.Report symptomsof diabetic neuropathy. If you have problems, get treatment right away. Early treatment can help prevent more problems later on. For example, if you take care of a foot infection early, it can help prevent amputation. Take good care of your feet. Check your feet every day. If you no longer can feel pain in your feet, you might not notice a foot injury. Instead, use your eyes to look for problems. Use a mirror to see the bottoms of your feet. Use your hands to feel for hot or cold spots, bumps or dry skin. Look for sores, cuts or breaks in the skin. Also check for corns, calluses, blisters, red areas, swelling, ingrown toenails and toenail infections. If it's hard for you to see or reach your feet, get help from a family member or foot doctor. Protect your feet. If your feet are dry, use a lotion on your skin but not between your toes. Wear shoes and socks that fit well and wear them all the time. Use warm water to wash your feet, and dry them carefully afterward. Get special shoes if needed. If you have foot problems, Medicare may pay for shoes. Ask your health care team about it. Be careful with exercising. Some physical activities are not safe for people with neuropathy. Talk with a diabetes clinical exercise expert who can guide you.

Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)

Hyperosmolar Hyperglycemic Nonketotic Syndrome, or HHNS, is a serious condition most frequently seen in older persons. HHNS can happen to people with either type 1 or type 2 diabetes, but it occurs more often in people with type 2. HHNS is usually brought on by something else, such as an illness or infection.In HHNS, blood sugar levels rise, and your body tries to get rid of the excess sugar by passing it into your urine. You make lots of urine at first, and you have to go to the bathroom more often. Later you may not have to go to the bathroom as often, and your urine becomes very dark. Also, you may be very thirsty. Even if you are not thirsty, you need to drink liquids. If you don't drink enough liquids at this point, you can get dehydrated.If HHNS continues, the severe dehydration will lead to seizures, coma and eventually death. HHNS may take days or even weeks to develop. Know the warning signs of HHNS.

What are the warning signs?Blood sugar level over 600 mg/dl Dry, parched mouth Extreme thirst (although this may gradually disappear) Warm, dry skin that does not sweat High fever (over 101 degrees Fahrenheit, for example) Sleepiness or confusion Loss of vision Hallucinations (seeing or hearing things that are not there) Weakness on one side of the body If you have any of these symptoms, call someone on your health care team.

How can I avoid it?The best way to avoid HHNS is to check your blood sugar regularly. Many people check their blood sugar several times a day, such as before or after meals. Tal