Diabetes-Cardiovascular Disease ToolkitPreventing weight gain or losing weight may be part of your...

Diabetes-Cardiovascular Disease ToolkitPatient education tools focused on reducing cardiovascular disease in people with diabetes

1. All About Pre-DiabetesDescribes pre-diabetes and suggests waysthat those with pre-diabetes can preventdiabetes.

2. Getting the Very Best Care for YourDiabetesProvides a summary of American DiabetesAssociation Standards of Medical Care.

3. Taking Care of Type 2 DiabetesGives a general introduction to type 2diabetes for the newly diagnosed.

4. All About Blood Glucose for Peoplewith Type 2 DiabetesDescribes what affects blood glucose,reviews blood glucose monitoring, andprovides guidelines for treatinghypoglycemia.

5. All About Insulin ResistanceDiscusses the relationship between insulinresistance and diabetes and includes tips fordecreasing insulin resistance with exerciseand food changes.

6. Protect Your Heart: Make Wise FoodChoicesProvides general nutrition information forsomeone who is newly diagnosed.

7. Protect Your Heart: Choose Fats WiselyProvides additional information on types offat such as saturated, trans, monounsaturated,and polyunsaturated and food sources foreach.

8. Protect Your Heart: Cook with Heart-Healthy Foods Includes information about selectinglean meats and poultry and low-fatdairy products, and using alternativeseasonings and ingredient substitutions.

9. Protect Your Heart: Check Food Labelsto Make Heart-Healthy ChoicesProvides keys to understanding food labels.

10. All About Carbohydrate CountingDescribes how to count carbohydrates byusing standard carbohydrate serving sizesand by reading food labels.

11. Protect Your Heart by Losing Weight Includes strategies for losing weight,including changing habits, cutting back oncalories, and increasing physical activity.

12. All About Physical Activity for Peoplewith DiabetesCovers the benefits and different types ofphysical activity.

13. Getting Started with Physical ActivityDiscusses beginning a new exercise routineincluding which precautions to take andhow activity may affect blood glucose.

14. Learning How to Change HabitsProvides a step-by-step plan for changingbehavior.

15. Recognizing and Handling Depressionfor People with DiabetesDiscusses the link between diabetes anddepression, as well as treatment options.

Table of Contents

16. Treating High Blood Pressure in Peoplewith DiabetesDefines high blood pressure and discusseslifestyle and medication treatments.

17. Treating High Cholesterol in Peoplewith DiabetesDefines cholesterol and discusses lifestyleand medication treatments.

18. Taking Care of Your HeartCovers prevention and treatment of a heartattack.

19. Know the Warning Signs of a HeartAttackFocuses on awareness of the warning signsof a heart attack and the importance ofseeking immediate medical attention.

20. Taking Aspirin to Protect Your HeartDescribes the benefits and importance oftaking aspirin.

21. All About StrokeIncludes information on the relationshipbetween stroke and diabetes and theprevention, diagnosis, and treatmentof stroke.

22. All About Peripheral Arterial DiseaseIncludes information on the relationshipbetween PAD and diabetes and theprevention, diagnosis, and treatment of PAD.

23. Medical Tests and Procedures for Findingand Treating Heart and Blood VesselDiseaseDescribes tests commonly used to diagnoseheart and blood vessel disease.

24. Managing Your MedicinesIncludes tips and a chart for keeping track ofmultiple medications.

25. My Game Plan: Food and ActivityTrackerContains charts to track food and physicalactivity for one week.

26. Blood Glucose LogContains charts to track blood glucose resultsfor one month.

American Diabetes Association1–800–DIABETES (342–2383) www.diabetes.org

©2004 by the American Diabetes Association, Inc. 03/04

What is pre-diabetes?Pre-diabetes is a condition that comes beforetype 2 diabetes. Blood glucose (sugar) levels arehigher than normal but aren’t high enough to becalled diabetes. Pre-diabetes is a silent disease,meaning you can have it but not know it. Thegood news is that cutting back on calories andfat, being physically active, and losing weightcan reverse pre-diabetes and therefore delay orprevent type 2 diabetes. Diabetes doesn’t goaway once you have it, so it’s better toprevent it in the first place.

How can type 2 diabetes bedelayed or prevented?In a recent study, people at high risk for type 2diabetes greatly reduced their risk of getting it byeating less than usual, increasing their physicalactivity, and losing weight. They

• cut down on fat

• cut back on calories

• exercised about 30 minutes a day, 5 days aweek, usually by brisk walking

• lost weight—an average of 15 pounds in thefirst year of the study

These strategies worked equally well for menand women and particularly well for people aged60 and older. Several other studies also haveshown that type 2 diabetes can be delayed orprevented.

Am I likely to have pre-diabetes?As you get older, especially if you’re overweight,your chances of having pre-diabetes increase.Your doctor should check your blood glucoselevel if you are

• 45 or older and overweight

• under age 45 and overweight and haveother risk factors for diabetes

If you are 45 or older and your weight is normal,ask your doctor if you need to be checked forpre-diabetes.

Are you at increased risk for diabetes?You’re at risk for diabetes if you

• are overweight

• are physically inactive

• have a parent, brother, or sister with diabetes

• are African American, Native American,Asian American, Pacific Islander, orHispanic American

• have had a baby weighing more than 9pounds or have had gestational diabetes

• have high blood pressure (over 140/90mmHg)

• have low HDL cholesterol (35 mg/dl or lower)or high triglycerides (250 mg/dl or higher)

Pre-diabetes is a condition that comes before type 2diabetes.

Toolkit No. 1

All About Pre-Diabetes

How can I find out whetherI have pre-diabetes?Pre-diabetes has no symptoms. You’ll need ablood test to check your blood glucose level.Your doctor will use one of these two tests:

The fasting plasma glucose test measures yourblood glucose after you have gone overnightwithout eating. This test is most reliable whendone in the morning. Pre-diabetes is diagnosedwhen fasting glucose levels are between 100and 125 mg/dl. These glucose levels areabove normal but not high enough to becalled diabetes. A fasting plasma glucoseof 126 mg/dl or higher means diabetes.

The oral glucose tolerance test measures yourblood glucose after an overnight fast and 2hours after you drink a sweet liquid providedby the doctor or laboratory. Pre-diabetes isdiagnosed when blood glucose is between140 and 199 mg/dl 2 hours after drinking theliquid. These glucose levels are above normalbut not high enough to be called diabetes. A 2-hour blood glucose of 200 mg/dl or highermeans diabetes.

How can I reverse pre-diabetes? To help bring your blood glucose levels backto normal, you can

• cut back on calories and fat

• increase your physical activity

Doing so will make it more likely that you’lllose weight. If you’re overweight, losing 5 to 7percent of your total weight can help you a lot.For example, if you weigh 200 pounds, yourgoal would be to lose 10 to 15 pounds.

Cutting Back on Calories and FatPlace a check mark next to steps you’d like totry for cutting down on calories and fat.

❒ I’ll cut back on my usual serving sizes.❒ I’ll order the smallest portion size when I’m

eating out. Or I’ll share an entree.❒ I’ll try calorie-free drinks or water instead of

regular soft drinks and juice.❒ I’ll try low-fat versions of the foods I usually

eat. I’ll check the labels to make sure thecalories are reduced too.

❒ When cooking, I’ll bake, broil, or grill anduse nonstick pans and cooking sprays.

❒ I’ll eat more vegetables and whole grainfoods.

❒ Other steps I’ll take to cut down on caloriesand fat are

________________________________________

________________________________________

________________________________________

Increasing Your Physical ActivityPlace a check mark next to the ways you’ll tryto add physical activity to your daily routine.

❒ I’ll take the stairs instead of the elevator.❒ I’ll park at the far end of the parking lot.❒ I’ll find an activity I enjoy, such as working

in the yard or riding a bike.❒ I’ll take a walk every day, working up to

30 minutes of brisk walking, 5 days a week.Or I’ll split the 30 minutes into two or threewalks.

❒ I’ll try strength training by lifting light weightsseveral times a week.

❒ Other ways I’ll try to add physical activity tomy daily routine are

________________________________________

________________________________________

________________________________________

Are there any medicationsto treat pre-diabetes?No drug has been approved by the U.S. Foodand Drug Administration specifically for pre-diabetes. However, several medications availableby prescription for diabetes or weight loss havebeen used in studies. Though certain drugs doseem to delay or prevent diabetes, they don’twork nearly as well as eating less, being active,and losing weight. At this time, expertsrecommend eating less, increasing physicalactivity, and losing weight as the best ways totreat pre-diabetes, instead of taking medications.



Following guidelines from the American DiabetesAssociation (ADA) can help people with diabeteslive longer, healthier lives. Called the Standardsof Care, these guidelines describe basic care forpeople with diabetes. Getting up-to-date carefor diabetes can help you prevent long-termproblems such as heart disease, stroke, and eye,foot, or kidney problems.

Most of the day-to-day care of diabetes is up toyou. You can make choices that will have apositive effect on your diabetes. You choosewhat, when, and how much to eat. You decidewhether to be physically active. You take yourmedications and keep track of your bloodglucose (sugar) levels on your own. Yourhealth care team helps by providing information,teaching you about diabetes care, and checkingon your A-1-C, blood pressure, cholesterol, andother measures.

What should happen during visitsto my health care provider?The Standards of Care describe what shouldhappen at your health care provider visitsthroughout the year. You can use the followingsections to make sure your health care team isup-to-date on what you need for good diabetescare.

Check at Every Office VisitBlood PressureYour blood pressure numbers tell you the forceof blood flow inside your vessels. When yourblood pressure is high, your heart has to workharder. If your blood pressure is not on target,meal planning, physical activity, and medicationscan help. Work with your health care team toplan your strategy.

WeightPreventing weight gain or losing weight may bepart of your diabetes care plan. If you need tolose weight, a 10- to 15-pound loss can help youreach your blood pressure, blood glucose, andcholesterol goals. Work with your health careteam to plan your strategy.

Smoking If you smoke, ask your health care providerabout a plan to help you quit.

Check at Least Every 3–6 MonthsA-1-CThe A-1-C is the blood glucose check “witha memory.” It tells you your average bloodglucose for the past 2 to 3 months. If your A-1-C is not on target, meal planning, physicalactivity, and medications can help. Work withyour health care team to plan your strategy.

Check at Least Once a YearCholesterol Your cholesterol numbers tell you the amountof fat in your blood. Some kinds, like HDLcholesterol, help protect your heart. Others, likeLDL cholesterol, can clog your blood vessels andlead to heart disease. Triglycerides are anotherkind of blood fat that raises your risk for a heartattack or a stroke. If your cholesterol levels arenot on target, meal planning, physical activity,and medications can help. Work with yourhealth care team to plan your strategy.

MicroalbuminThe microalbumin test is a check for smallamounts of protein in the urine. The resultswill tell you how well your kidneys function.

Your health care team can teach you about diabetes care.

Toolkit No. 2

Getting the Very Best Care for Your Diabetes

Foot ExamYour health care provider can check yourfeet for signs of nerve damage or otherproblems. Foot problems can be avoidedif detected and treated early. One of themost important foot tests is to see whetheryou can feel the vibration of a tuning forkor the light touch of a thin wire called amonofilament.

Eye ExamYour health care provider can refer you toan eye doctor to check the blood vesselsin your eyes for early warning signs ofdamage. The eye doctor must put drops inyour eyes that dilate your pupils in order todo a thorough exam. Treatment can helpslow eye disease if it’s found early.

Flu Shot and Pneumonia VaccineEvery year, ask for a flu shot to keepfrom getting sick. You should get thepneumonia vaccine at least once. Whenyou turn 65, you should get anotherpneumonia vaccine, unless you havehad one within the past 5 years.

Diabetes Education and NutritionCounselingIf you need a change in your diabetesmanagement plan, your health careprovider should refer you for diabeteseducation and nutrition counseling.

How can I take charge of mydiabetes care?Review the following list and place a checkmark next to the things you’d like to talkabout with your health care team. Takethis list with you to your next checkup.

❒ What are the best targets for my A-1-C,blood pressure, and cholesterol?

❒ What can help me reach my A-1-Ctarget?

❒ When is my next A-1-C check?

❒ What can help me reach my bloodpressure target?

❒ What can help me reach my cholesteroltargets?

❒ How can I learn more about taking careof my diabetes?

Tracking Your TargetsThe ADA suggests these targets for most people withdiabetes. You may have different targets. You can recordyour targets and your results in the spaces provided here.

What to Do ADATargets

MyTargets

My Results

Date Date

At Every Office Visit

Review bloodglucose numbers

Before meals 90–130 mg/dl

2 hours after thestart of a meal

Below 180 mg/dl

Check bloodpressure

Below 130/80mmHg

Review meal plan

Review activitylevel

Check weight

Discuss questionsor concerns

At Least Every 3–6 Months

A-1-C Below 7%

At Least Once a Year

Physical exam

Cholesterol

LDL cholesterol Below 100 mg/dl

HDL cholesterol

Above 40 mg/dl(for men)

Above 50 mg/dl(for women)

Triglycerides Below 150 mg/dl

Dilated eye exam

MicroalbuminBelow 30 µg/mgcreatinine

Flu shot

Once

Pneumoniavaccine



What is type 2 diabetes?Everyone’s blood has some glucose (sugar) in itbecause your body needs glucose for energy.Normally, your body breaks food down intoglucose and sends it into your bloodstream.Insulin, a hormone made by your pancreas, helpsget the glucose from the blood into the cells tobe used for energy. In people with type 2diabetes, the pancreas doesn’t make enoughinsulin or the insulin doesn’t work very well, orboth. Without insulin, your blood glucose rises.

How can type 2 diabetes affect me?Type 2 diabetes sometimes leads to problemssuch as heart disease, stroke, nerve damage, andkidney or eye problems. But the good news isthat keeping blood glucose, blood pressure, andcholesterol on target can help delay or preventproblems.

How is type 2 diabetes managed?Most of the day-to-day care of diabetes is up toyou. Your plan for taking care of your diabeteswill include

• choosing what, how much, and when to eat

• including physical activity in your daily routine

• taking medications (if needed) to help youreach your blood glucose, blood pressure,and cholesterol targets

What can I do to take care ofmy diabetes?• Choose targets for the ABCs of diabetes care:

➢ A: your A-1-C check for average bloodglucose

➢ B: your blood pressure

➢ C: your cholesterol levels

• Work with your health care team to make aplan that helps you reach your targets.

• Keep track of your numbers.

• If you’re not reaching your targets, changeyour plan as needed to stay on target.

Your Blood Glucose Targets established by the American DiabetesAssociation (ADA) are listed below. Yourpersonal targets may differ. Talk with your healthcare team about the best targets for you.

You’ll check your own blood glucose using ablood glucose meter. The meter tells you whatyour blood glucose is at a particular moment.

At least twice a year, your doctor should order anA-1-C check. The results will give your averageblood glucose for the past 2 to 3 months.

ADA Targets forBlood Glucose

My UsualResults My Targets

Before meals: 90 to 130 mg/dl

2 hours after thestart of a meal: less than 180 mg/dl

______ to ______

less than ______

______ to ______

less than ______

ADA Target forthe A-1-C

My LastResult My Target

Below 7%

Regular physical activity can lower your blood glucose,blood pressure, and cholesterol levels.

Toolkit No. 3

Taking Care of Type 2 Diabetes

Your Blood PressureAt every office visit, your health care team shouldcheck your blood pressure.

Your Cholesterol/TriglyceridesEvery year, your health care team should checkyour cholesterol and triglyceride levels.

What do I need to know aboutmeal planning, physical activity,and medications?

Meal PlanningMany people think that having diabetes meansyou can’t eat your favorite foods. But you canstill eat the foods you like. It’s the amount thatcounts. Ask for a referral to a dietitian whospecializes in diabetes. Together, you’ll design apersonalized meal plan that can help you reachyour goals.

• Count carbohydrates (also called carbs).Carbohydrate foods—bread, tortillas, biscuits,rice, crackers, cereal, fruit, juice, milk, yogurt,potatoes, corn, peas, sweets—raise your bloodglucose levels the most. Keeping the amountof carbohydrate in your meals and snacksconsistent can help you reach your bloodglucose targets.

• Choose foods low in saturated fat. Cuttingdown on foods that have saturated fat canhelp you lower your cholesterol and preventheart disease. Foods high in saturated fatinclude meats, butter, whole milk, cream,cheese, lard, shortening, many baked goods,and tropical oils such as palm and coconut oil.

• Lose weight if needed. Try to lose weight bycutting back on food portions and increasingyour daily activity.

• Increase the fiber in your diet. Includehigh-fiber foods, such as fruits, vegetables,dried beans and peas, oatmeal, and wholegrain breads and cereals, in your diet.

Physical ActivityRegular physical activity helps lower your bloodglucose, blood pressure, and cholesterol levels.It also keeps your joints flexible, strengthens yourheart and bones, tones your muscles, and helpsyou deal with stress. Your health care team maywant to check your heart function before youstart doing new activities. They can help youplan what kinds of physical activities are best foryou. The different kinds of activities include

• Being active throughout the dayExamples: gardening, taking the stairs insteadof the elevator, or walking around while youtalk on the phone—working up to about 30minutes of activity a day

• Aerobic exerciseExamples: walking, dancing, rowing,swimming, or riding a bicycle—working upto about 30 minutes a day, 5 days a week

• Strength trainingExample: lifting light weights several timesa week

• StretchingExample: stretching your whole body,especially your arms and legs

MedicationsMany people need medications along with mealplanning and physical activity to reach theirblood glucose, blood pressure, and cholesteroltargets. If you’ve had type 2 diabetes for a while,you may need a change in your diabetes pills toreach your blood glucose targets. If you needinsulin shots, it doesn’t mean that your diabetesis getting worse. It just means that you need achange in how you reach your target numbers.If it’s difficult for you to reach your targetnumbers, talk with your health care teamabout whether medications can help.



ADA Target My Last Result My Target

Below 130/80 mmHg

TypesADA

TargetsMy LastResult

MyTarget

LDL cholesterol Below 100 mg/dl

HDLcholesterol

Above 40 mg/dl(for men)

Above 50 mg/dl(for women)

Triglycerides Below 150 mg/dl

Keeping your blood glucose (sugar) in therecommended target range can prevent or delaythe long-term health problems caused bydiabetes. Most of the steps needed to takecare of diabetes are things you do yourself:

• using a meal plan

• being physically active

• taking medications

• trying to reach your blood glucose targets mostof the time

• keeping track of your blood glucose numbersusing a blood glucose meter and the results ofyour A-1-C checks

Why should I try to keep myblood glucose on target?The closer your blood glucose stays to yourtarget range, the more you’ll lower your risk ofblindness or diabetic eye disease, kidney disease,foot problems, nerve damage, tooth and gumdisease, and skin problems. You may also loweryour risk for heart attack or stroke.

What makes my blood glucoselevels rise or fall?Blood glucose levels rise and fall throughout theday. One key to taking care of your diabetes isunderstanding why they rise or fall. If you knowthe reasons, you can take steps to help keep yourblood glucose on target.

What can make blood glucose rise?• a meal or snack with more food or more

carbohydrates (carbs) than usual

• inactivity

• not enough diabetes medication

• side effects of other medications

• infection or other illness

• changes in hormone levels, such as duringmenstrual periods

• stress

What can make blood glucose fall?• a meal or snack with less food or fewer

carbs than usual

• drinking alcoholic beverages, especiallyon an empty stomach

• missing a meal or snack

• extra activity

• too much diabetes medication

• side effects of other medications

What are the blood glucosetargets for people with diabetes?The targets recommended by the AmericanDiabetes Association (ADA) are listed below.Talk with your health care team about yourpersonal targets.

Many people use a meter to check their blood glucoseseveral times a day.

Toolkit No. 4

ADA Targets forBlood Glucose

My UsualResults My Targets

Before meals: 90 to 130 mg/dl

2 hours after thestart of a meal: less than 180 mg/dl

______ to ______

less than ______

______ to ______

less than ______

All About Blood Glucosefor People with Type 2 Diabetes

What’s the best way to keep trackof my blood glucose levels?Checking your blood glucose will tell youwhether you’re reaching your blood glucosetargets. There are two ways to do it:

• using a blood glucose meter to learn whatyour blood glucose is at a particular moment

• getting a blood glucose check called an A-1-C at least twice a year

Both ways can be useful to you.

Using a blood glucose meterMany people use their meter to check their bloodglucose several times a day. Talk with yourhealth care team about when and how often tocheck your blood glucose. They can give you arecord book where you can write down yourblood glucose numbers. You can learn how touse this information to make decisions aboutfood, physical activity, and medications.

Your results tell you how well your diabetes careplan is working. You’ll be able to look at yourrecord book and see patterns—similar resultsover and over. Looking at these patterns canhelp you and your health care team fine-tuneyour diabetes care plan in order to reach yourtargets.

Getting an A-1-C blood glucose checkThe A-1-C check is the blood glucose check “witha memory.” It tells you what your average bloodglucose level has been for the past 2 to 3 months.If your number is 7% or higher, you may need achange in your diabetes care plan.

Translate your A-1-CFind your A-1-C number on the left. Then, checkthe chart to learn your average blood glucose forthe past 2 to 3 months.

My A-1-C

My last A-1-C was ____.

My target for myA-1-C is _____.

My next A-1-C checkwill be __________.

(date)

What if my blood glucoseis frequently too high?Call your health care provider for an earlyappointment if your blood glucose numbers areoften higher than your targets. Talk with yourhealth care team about recommended changes inyour meal plan, your physical activity, or yourdiabetes medications when high blood glucoseoccurs.

What if my blood glucose is too low?Low blood glucose, also called hypoglycemia,occurs when your blood glucose level dropsbelow 70 mg/dl. Symptoms include hunger,shakiness and nervousness, sweating, light-headedness, sleepiness, confusion, and anxiety.

If you think your blood glucose is too low, useyour meter to check it. If the result is 70 mg/dlor below, follow these treatment guidelines tobring it back up to a safer range. Have one ofthe items in this list right away to raise yourblood glucose:• 2 to 5 glucose tablets• 1⁄2 cup (4 ounces) of fruit juice• 1⁄2 cup (4 ounces) of a regular (not diet)

soft drink• 8 ounces of milk• 5 to 7 pieces of hard candy• 2 teaspoons of sugar or honey

After 15 minutes, check your blood glucoseagain. If it’s still below 70 mg/dl, have anotherserving. Repeat these steps until your bloodglucose is at least 70 mg/dl.

What should I do about frequentlow blood glucose?If your blood glucose is often low, you may needa change in your meal plan, physical activity, ordiabetes medications. Keep track of low bloodglucose episodes in your record book and notepossible causes, such as unexpected physicalactivity. Then talk it over with your health careteam.



A-1-CAverage

blood glucose

6% 135

7% 170

8% 205

9% 240

10% 275

11% 310

12% 345

Insulin resistance is a condition that increasesyour chances of developing type 2 diabetesand heart disease. When you have insulinresistance, your body has problems respondingto insulin. Eventually, your blood glucose(sugar) levels rise above normal. The goodnews is that cutting calories, adding physicalactivity to your daily routine, and losing weightcan reverse insulin resistance and lessen yourchances of getting type 2 diabetes and heartdisease.

What does insulin do?Insulin’s job is to help the body use glucose forenergy. It’s a hormone, one of the chemicalsyour body makes to help trigger or regulateprocesses in the body. Insulin is made by thepancreas, an organ located behind the lowerpart of the stomach. Your pancreas usuallymakes just the right amount of insulin to matchthe food you eat.

Insulin acts as the doorman at the entrance toyour cell. Food arrives at the door of a cell inthe form of blood glucose. When your insulinis working effectively, it opens the door, just likea doorman. Then blood glucose enters the cellwhere it is used for energy.

When you have insulin resistance, your cellsdon’t respond to insulin—they resist insulin’scommands—and insulin can’t do its job. Bloodglucose still arrives at the cell door, but insulincan’t work effectively and the door to the cellwon’t open. Your pancreas tries to keep bloodglucose levels normal by making extra insulin.At first, the extra insulin helps. But after awhile, even extra insulin can’t open the celldoors and your blood glucose can rise. If yourblood glucose is high, you may have either pre-diabetes or even diabetes.

What are the risk factors forinsulin resistance?You’re more likely to have insulin resistanceif you

• are overweight

• are physically inactive

• are a woman with a waist measurement atyour belly button over 35 inches or a manwith a waist measure over 40 inches

• have a parent, brother, or sister with type 2 diabetes

• have polycystic ovary syndrome

• are over age 45

• have a blood pressure over 140/90 mmHg

• have low HDL (good) cholesterol levels (35 mg/dl or lower)

• have high levels of a fat called triglyceridesin the blood (250 mg/dl or higher)

All of these risk factors put you at risk for heartdisease.

Physical activity, such as walking, can prevent or reverseinsulin resistance.

Toolkit No. 5

All About Insulin Resistance

How is insulin resistancediagnosed?At this time, there is no commonly used test todiagnose insulin resistance. People with insulinresistance usually have no symptoms. Yourdoctor can review your risk factors and thenconsider whether you’re likely to be insulin-resistant. If you have a risk factor for insulinresistance, your doctor should check yourfasting blood glucose levels to see whetheryou have pre-diabetes or even diabetes.

How can I prevent or reverseinsulin resistance? You can cut calories and be physically active. If you do, it’s more likely you’ll lose weight.Remember, you don’t have to lose a lot; evena loss of 10 pounds can help.

Cut caloriesPlace a check mark next to the steps you’d liketo try for cutting down on calories every day. A dietitian can help you find other ways to cutcalories and plan healthy meals.

❒ I’ll cut back on my usual serving sizes.❒ I’ll order the smallest portion size when I’m

eating out. Or I’ll share an entree. ❒ I’ll try calorie-free drinks or water instead of

regular soft drinks and juice.❒ I’ll try low-fat versions of the foods I usually

eat. I’ll check the labels to make sure thecalories are reduced too.

❒ I’ll choose baked, grilled, and steamed foodsinstead of fried.

❒ I’ll eat more vegetables and whole grainfoods.

❒ I’ll ask for salad dressings and sauces “on theside” and then use as little as possible.

❒ I’ll use nonstick pans or cooking sprays.❒ I’ll cut back on high-fat toppings, such as

butter, margarine, sour cream, regular saladdressing, mayonnaise, and gravy. Instead,I’ll season my food with barbecue sauce,salsa, lemon juice, or other low-fat choices.

❒ I’ll stock my kitchen with low-calorie, low-fatsnacks. I’ll keep serving sizes small.

❒ Another way I’ll try to cut calories is

_______________________________________

_______________________________________

Be physically activePlace a check mark next to the ways you’ll tryto add physical activity to your routine.

❒ I’ll take the stairs instead of the elevator.❒ I’ll walk around while I talk on the phone.❒ I’ll find an activity I enjoy, such as dancing,

gardening, or playing with the kids.❒ I’ll be active around the house by working

in the garden and washing the car. ❒ I’ll get up to change the TV channel.❒ I’ll take the dog for a walk.❒ I’ll park at the far end of the shopping center

lot and walk to the store.❒ At the grocery store, I’ll walk down every

aisle.❒ I’ll take a walk every day after lunch,

working up to 30 minutes of brisk walking,5 days a week. Or I’ll split the 30 minutesinto two or three walks.

❒ I’ll try strength training by lifting light weightsseveral times a week.

❒ Another way I’ll try to add physical activity tomy day is ______________________________

_______________________________________

_______________________________________

Does insulin resistance affectpeople who already have type 2diabetes?Yes, insulin resistance usually starts beforetype 2 diabetes is diagnosed and then continues,making it more difficult for you to reach yourblood glucose targets. If you have type 2diabetes, you can fight insulin resistance bycutting calories, being physically active, andlosing weight if you need to. Talk with yourhealth care team about ways to achieve yourgoals using meal planning, physical activity,and medications.



How can food choices help keepmy heart and blood vesselshealthy?Diabetes increases your chances of having a heartattack or a stroke. But you can protect yourheart and blood vessels by

• eating less of the foods that raise your bloodcholesterol and your chances of heart disease

• eating more of the foods that lower yourcholesterol and your chances of heart disease

Choosing foods wisely can also help you loseweight and keep your blood glucose (sugar)levels on target.

How can I make wise foodchoices?Try these steps to help protect your heart andblood vessels:

• Eat less fat, especially saturated fat andtrans fats, and fewer high-cholesterolfoods. Saturated fat is found in meat, poultryskin, butter, 2% or whole milk, ice cream,cheese, lard, and shortening. You’ll also wantto cut back on foods that contain palm oil orcoconut oil.

Trans fats are produced when liquid oils areturned into solids. This process is calledhydrogenation. Cut back on foods that listhydrogenated or partially hydrogenated oils onthe labels. This type of fat is found in crackersand snack foods, baked goods like cookiesand donuts, french fries, and stick margarine.Use a soft margarine in place of butter or stickmargarine. Look for soft margarine in a tubthat lists a liquid oil such as corn, safflower,soybean, or canola oil as the first ingredient.

Egg yolks and organ meats such as liver arehigh in cholesterol. Check the Nutrition Factsand the list of ingredients on food labels.

• Choose the kinds of fat that can helplower your cholesterol. If you use cookingoil, choose olive oil or canola oil. Nuts have a

healthy type of fat as well. Corn oil, sunfloweroil, and safflower oil also protect your heart.However, all oils, nuts, and fats are high incalories. If you’re trying to lose weight, you’llwant to keep servings small.

• Have fish 2 or 3 times a week. Albacoretuna, herring, mackerel, rainbow trout,sardines, and salmon are high in omega-3 fattyacids, a type of fat that may help lower bloodfat levels and prevent clogging of the arteries.

• Use special cholesterol-loweringmargarine. Having 2 to 3 tablespoons of acholesterol-lowering margarine every day canlower your cholesterol. These margarinescontain plant stanols or plant sterols,ingredients that keep cholesterol from beingabsorbed. You’ll find several types at thegrocery store in the margarine section.

Toolkit No. 6

Making wise food choices can protect your heart and blood vessels.

Protect Your Heart:Make Wise Food Choices

• Cook with less fat. You can cut down ontotal fat by broiling, microwaving, baking,roasting, steaming, or grilling foods. Usingnonstick pans and cooking sprays instead ofcooking with fat also helps.

• Eat more foods that are high in fiber.Foods high in fiber may help lower bloodcholesterol. Fiber also can prevent problemswith the digestive system such as constipation.Oatmeal, oat bran, dried beans and peas (suchas kidney beans, pinto beans, and black-eyedpeas), fruits, and vegetables are good sourcesof fiber.

• Include more soy protein in your mealsand snacks. Replacing foods high insaturated fat with soy-containing foods mayhelp lower your cholesterol. Foods with soyprotein include soybeans, tofu, miso, tempeh,soy nuts, soy milk, textured soy protein, soyprotein powder, and items that are made fromsoybeans, such as burgers.

• Limit your alcoholic beverageconsumption. Drinking light to moderateamounts of alcohol is associated with a lowrisk of heart disease, perhaps by raising HDL(good) cholesterol levels. There isn’t enoughinformation to recommend that people whodon’t drink should start drinking alcohol toreduce heart risk. But, for those who do drinkalcohol, 1 serving daily for women and up to 2 servings daily for men have been associatedwith good health. Drinking more than 1 to 2drinks per day isn’t helpful; it contributesunnecessary calories and may actually raiseyour blood pressure and triglycerides. Inaddition, it can cause other health problems.It’s best to discuss drinking alcohol with yourhealth care provider to find out whether itmay be helpful for you.



A day of heart-healthy meals

Breakfast Lunch Dinner Between-meal snacks

• fresh orange sections

• oatmeal with 1% milkand raisins

• toast with cholesterol-lowering margarine

• coffee with 1% milk

• sliced turkey on wholewheat bread with lettuceand mustard

• carrot sticks

• cherry tomatoes

• fresh apple

• baked chicken

• baked potatowith cholesterol-lowering margarine and low-fat sour cream

• steamed green beans

• tossed salad with low-fatsalad dressing

• low-fat frozen yogurt

• dried fruit

• air-popped popcorn

• rice cakes with peanut butter

For more help, ask your health care team for copies of these brochures:

• Toolkit No. 7: Protect Your Heart: Choose Fats Wisely

• Toolkit No. 8: Protect Your Heart: Cook with Heart-Healthy Foods

• Toolkit No. 9: Protect Your Heart: Check Food Labels to Make Heart-Healthy Choices

Why should I choose fats wisely?Diabetes increases your chances of having a heartattack or a stroke. But you can protect yourheart and blood vessels by choosing fats wisely.Some kinds of fat, such as butter and shortening,can increase your cholesterol and your chancesof heart disease. Other kinds, such as olive oiland canola oil, protect your heart by loweringyour cholesterol levels.

All fats are high in calories. If you’re trying tolose weight, you’ll still want to limit the amountof fat you eat. The types and amounts of fatappear in the Nutrition Facts area of food labels.

How can I choose fats wisely?Try these steps to protect your heart and bloodvessels:

• Eat less total fat, especially less saturated fatand trans fat.

• Cut back on foods that are high in cholesterol.

• Choose the kinds of fat that can help loweryour cholesterol levels.

Fats that increase your chances of heart disease and strokeSaturated fat, trans fat, and cholesterol increaseyour blood cholesterol and can cause a buildupof materials that can clog your blood vessels.The blood supply to your heart can be blocked,leading to a heart attack. A blockage in theblood vessels going to your brain can resultin a stroke.

Saturated fatSaturated fat can raise your cholesterol level.

Trans-unsaturated fatty acids (trans fats)Trans fats can also raise your cholesterol level.

Sources of saturated fat

• bacon and bacon grease

• butter

• chocolate

• coconut and coconut oil

• cream sauce

• high-fat dairy products,such as cheese, cream,ice cream, whole milk,2% milk, and sour cream

• fatback and salt pork

• gravy made with meatdrippings

• lard and shortening

• high-fat meats likeregular ground beef,bologna, hot dogs,sausage, and spareribs

• palm oil and palmkernel oil

• poultry skin

Toolkit No. 7

Eating low-saturated-fat, low-cholesterol foods can protectyour heart and blood vessels.

Sources of trans fat

• processed foods like snacks and baked goods withhydrogenated oil or partially hydrogenated oil

• stick margarines

• shortening

• some fast food items such as french fries

Protect Your Heart: Choose Fats Wisely

CholesterolYour body makes some of the cholesterol in yourblood. The rest comes from the foods you eat.Foods from animals are the main sources ofdietary cholesterol.

Omega-3 fatty acids This type of fat helps prevent clogging of thearteries. Some types of fish are high in omega-3fatty acids. Eat fish, prepared a low-fat way, 2or 3 times a week. Choose broiling, baking,grilling, or steaming. You can also buy tunapacked in water and make tuna fish salad withlow-fat or fat-free mayonnaise.



Sources of cholesterol

• high-fat dairy products

• egg yolks

• liver and other organ meats

• high-fat meat and poultry

Sources of monounsaturated fat

• avocado

• canola oil

• nuts like almonds, cashews, pecans, and peanuts

• olive oil and olives

• peanut butter and peanut oil

• sesame seeds

Sources of polyunsaturated fat

• corn oil

• cottonseed oil

• safflower oil

• soybean oil

• sunflower oil

• walnuts

• pumpkin or sunflower seeds

• soft (tub) margarine

• mayonnaise

• salad dressings

Sources of omega-3 fatty acids

• albacore tuna

• herring

• mackerel

• rainbow trout

• sardines

• salmonFats that can protect your heartMonounsaturated fats, polyunsaturated fats, andspecial cholesterol-lowering margarines canactually protect your heart by lowering yourblood cholesterol. That’s why it’s better to usethem instead of saturated fat. Another kind ofprotective fat, called omega-3 fatty acids, is foundin some types of fish.

Monounsaturated fatMonounsaturated fat, one type of unsaturated fat,can lower your blood cholesterol.

Polyunsaturated fatPolyunsaturated fat, another type of unsaturatedfat, protects your heart.

Special cholesterol-loweringmargarineHaving 2 to 3 tablespoons of a cholesterol-lowering margarine every day can lower yourcholesterol. These margarines contain plantstanols or plant sterols, ingredients that keepcholesterol from being absorbed. You’ll findseveral types at the grocery store in themargarine section.

For more help, ask your health care team forcopies of these brochures:

• Toolkit No. 6: Protect Your Heart: Make WiseFood Choices

• Toolkit No. 8: Protect Your Heart: Cook withHeart-Healthy Foods

• Toolkit No. 9: Protect Your Heart: Check FoodLabels to Make Heart-Healthy Choices

You can protect your heart and blood vessels by eating less saturated fat and by choosing thetypes of fats that help your cholesterol levels.The ingredients you use and the way you cookcan make a big difference. Try these tips:

• Cook with less fat.

• Choose lean meats, poultry, and pork.

• Choose low-fat dairy foods.

• Substitute lower-fat ingredients in recipes.

Cook with less fatUse a low-fat or fat-free way to cook. You cancut down on total fat by broiling, microwaving,baking, roasting, steaming, or grilling foods.Nonstick pans and cooking sprays also workwell.

Boost the flavor with seasonings and saucesinstead of fats. Look for recipes that use herbsand spices for flavor instead of fat. Try theseways to season food:

• Squeeze fresh lemon juice on steamedvegetables, broiled fish, rice, or pasta.

• Try lemon pepper or mesquite seasoning onchicken.

• Use onion and garlic to liven up meats andvegetables.

• Try baking chicken or pork with barbecuesauce or low-fat Italian dressing.

Trim the fat when possible. Cut away visiblefat from meat and poultry. Roast food on a rackto let the fat drip off. Make soups a day ahead soyou can chill them and then remove the fat thathas risen to the top.

Choose lean cuts of beef, poultry,and porkTo help keep your cholesterol on target, chooselean cuts of meat and poultry. Try some of yourfavorite recipes with these lean choices:

• When selecting beef, choose lean cuts suchas round, sirloin, and flank steak; tenderloin;rib, chuck, or rump roast; T-bone, porterhouse,or cubed steak.

• Choose poultry such as chicken, turkey, orCornish hen without the skin. The whitebreast meat is lower in fat than the darkermeat in the thigh and leg pieces.

• Lean types of pork include ham, Canadianbacon, pork loin, and center loin chops.

Choose low-fat dairy productsDairy products can be part of your meal plan. To cut back on saturated fat, choose items madewith non-fat or low-fat milk. Some low-fatchoices are listed below.

• Milk: Fat-free (skim), 1/2%, and 1% milk and low-fat buttermilk

• Yogurt: low-fat or fat-free yogurt

• Cheese: cottage cheese, grated Parmesan, and any cheese with 3 grams of fat or less per ounce

• For a frozen treat, try low-fat ice cream orfrozen yogurt instead of ice cream. You canalso freeze regular yogurt for a treat.

Toolkit No. 8

Choosing lean meats with less saturated fat can help lowerblood cholesterol.

Protect Your Heart:Cook with Heart-Healthy Foods

Substitute lower-fat ingredients in your favorite recipes Try extra-lean ground beef or ground turkey instead of ground beef. Use low-fat mayonnaise andsalad dressings instead of the regular types. Try plain yogurt in place of sour cream or mayonnaise.You can substitute up to half the margarine or butter in some recipes with applesauce.

For more help, ask your health care team for copies of these brochures:

• Toolkit No. 6: Protect Your Heart: Make Wise Food Choices

• Toolkit No. 7: Protect Your Heart: Choose Fats Wisely

• Toolkit No. 9: Protect Your Heart: Check Food Labels to Make Heart-Healthy Choices

A day of heart-healthy meals

Breakfast Lunch Dinner Between-meal snacks

• bran cereal with skimmilk and sliced banana

• rye toast withcholesterol-loweringmargarine

• orange juice

• coffee with skim milk

• split pea soup

• tuna salad made withlow-fat mayonnaise

• whole-grain crackers

• celery and carrot sticks

• fresh orange

• grilled chicken breastwithout skin marinated inlow-fat Italian dressing

• rice

• steamed broccoli

• tossed salad with low-fatsalad dressing

• fresh pear

• oatmeal cookie

• raw vegetables with low-fat dip

• fresh fruit

• oat bran muffin

• whole-grain crackers withlow-fat cheese

Wise food choices: What to try and why

Instead of... Try this... Why?

whole milk or 2% milk 1% milk or skim milk less total fat, less saturated fat, and lesscholesterolregular cheese low-fat cheese

snack foods with hydrogenated oil,palm oil, or coconut oil

fat-free or low-fat snack foods less total fat, less saturated fat

regular mayonnaise non-fat plain yogurt or low-fatmayonnaise in dips and recipes or mustard on sandwiches

less total fat

sour cream non-fat sour cream less total fat, less saturated fat

regular stick margarine special cholesterol-lowering margarine or soft tub margarine

lowers cholesterol, fewer trans fats

fried chicken baked chicken less total fat, less saturated fat

bologna, salami, or pastrami sliced turkey, lean ham, or low-fat cold cuts

less total fat, less saturated fat

cookies with hydrogenated oil, palm oil, or coconut oil

an orange, an apple, a pear, or some prunes

more fiber, no fat

pork chop pork loin less total fat, less saturated fat

short ribs grilled or baked salmon or tuna,grilled T-bone steak

less total fat, less saturated fat; fish is asource of omega-3 fatty acids



You can make heart-healthy choices by checkingfood labels.

• The Nutrition Facts tell you the serving sizeand the amount of various nutrients such astotal fat, saturated fat, cholesterol, sodium, andfiber per serving.

• Nutrient content claims such as “low-fat”provide a reliable description of the product.

• The list of ingredients shows the ingredientsin descending order by weight.

The Nutrition FactsHere’s an example of a Nutrition Facts section.At the top, you’ll see the serving size and thenumber of servings per container. How does theserving size compare to your usual serving? Forexample, if you usually eat 2 cups of chili withbeans, you’ll need to double all of the numbersin this Nutrition Facts section.

Total AmountsTo make heart-healthy food choices, check thetotal amounts so you can cut back on

• total fat

• saturated fat

• cholesterol

• sodium

You’ll also see information on fiber. To loweryour risk of heart disease, choose foods withmore fiber.

How to use information on totalamounts Total amounts are shown in grams, abbreviatedas g, or in milligrams, shown as mg. A gram is a very small amount and a milligram is one-thousandth of that. For example, a nickelweighs about 5 grams. So does a teaspoonful ofmargarine. Here are ways to use the informationon total amounts:

• Compare labels of similar foods. Choose theproduct with a smaller amount of saturated fat,cholesterol, and sodium. Try to select foodswith more fiber.

• Keep in mind that a low-fat food has 3 gramsof fat per serving.

• Choose food with the least amount ofsaturated fat. Look for foods with 1⁄3 or lessof the total fat as saturated fat.

• Another practical way of choosing lower-fatfoods is to select foods that have 3 grams offat or less for every 100 calories, every 15grams of carbohydrate, or every 7 to 8 gramsof protein.

How much fat should I eat in a day?A general guideline is 40 to 60 grams of fat perday for many women or for people on lowercalorie diets and 60 to 80 grams of fat per day for most men. Talk with your health care teamabout how many grams of fat would be right foryou. Some people may need more or less fat

Toolkit No. 9

Chili with Beans

Nutrition FactsServing Size: 1 cup (253 g)Servings per container: 2

Amount per Serving:

Calories 260 Calories from Fat 72

% Daily Value

Total Fat 8g 13%

Saturated Fat 3g 17%

Cholesterol 130mg 44%

Sodium 1010mg 42%

Total Carbohydrate 22g 7%

Dietary Fiber 9g 36%

Sugars 4g

Protein 25g

Protect Your Heart: Check Food Labelsto Make Heart-Healthy Choices

depending on their targets for blood glucose(sugar) and cholesterol.

Check food labels to see how much fat you’regetting. You can also ask your health care teamfor saturated fat, cholesterol, sodium, and dietaryfiber targets. Write your daily targets here:

• Total fat (grams): ____________

• Saturated fat (grams): ____________

• Cholesterol (milligrams): ____________

• Sodium (milligrams): ____________

• Dietary fiber (grams): ____________

Nutrient Content ClaimsA quick way to find heart-healthy foods is tocheck the nutrient content claims on the label.For example, you’ll see the claim “less sodium”on some brands of chili with beans. This meansthe product has at least 25% less sodium than theregular version. You can rely on claims such as“low fat” because the government has definedthose terms, as shown here. It’s against the lawfor food manufacturers to make false claims.

List of Ingredients Ingredients are listed in descending order byweight, meaning that the first ingredient makesup the largest proportion of the food. Check theingredient list to spot things you’d like to avoid,such as coconut oil or palm oil, which are high in saturated fat. Also try to avoid hydrogenatedoils. They are not listed by total amount on thelabel, but you can choose foods that don’t listhydrogenated or partially hydrogenated oil in theingredient list. For example, this ingredient listfor chili with beans shows no hydrogenated oil.Or look for heart-healthy ingredients such as soy.



Claims for fat

Fat free: less than 0.5 g of fat or saturated fat per serving

Saturated fat free: less than 0.5 g of saturated fat andless than 0.5 g of trans fatty acids

Low fat: 3 g or less of total fat

Low saturated fat: 1 g or less

Reduced fat or less fat: at least 25% less fat than theregular version

Claims for sodium

Sodium free or salt free: less than 5 mg per serving

Very low sodium: 35 mg or less

Low sodium: 140 mg or less

Reduced sodium or less sodium: at least 25% lesssodium than the regular version

Claims for cholesterol

Cholesterol free: less than 2 mg per serving

Low cholesterol: 20 mg or less

Reduced cholesterol or less cholesterol: at least 25%less cholesterol than the regular version

Claims for fiber

High fiber: 5 g or more per serving

Good source of fiber: 2.5 g to 4.9 g per serving

Chili with BeansIngredients: water, beef, beans, tomatoes, modifiedfood starch, chili powder, salt, sugar, flavoring.

For more help, ask your health care team forcopies of these brochures:

• Toolkit No. 6: Protect Your Heart: Make WiseFood Choices

• Toolkit No. 7: Protect Your Heart: ChooseFats Wisely

• Toolkit No. 8: Protect Your Heart: Cook withHeart-Healthy Foods

What is carbohydrate counting?Counting carbohydrates is one way to plan yourmeals and keep your blood glucose (sugar) ontarget. Carbohydrates are one of the three mainenergy sources in food, along with protein andfat. It’s the balance between the carbohydratesyou eat and insulin that determines how muchyour blood glucose levels rise after you eat. Withthe right balance of carbohydrates and insulin,your blood glucose level will usually stay in yourtarget range. Counting carbohydrate servings canhelp you reach your blood glucose goals andprevent diabetes complications. You can learn touse carbohydrate counting to choose what andhow much to eat. Carbohydrate counting can beeasier to use than other meal planning methods.If you take insulin, you can use carbohydratecounting to decide how much insulin to take.

Which foods have carbohydrate?The foods listed in the chart below are mostlycarbohydrate. These foods affect your bloodglucose much more than other foods such asmeat and meat substitutes, vegetables, or fats.

Large servings of salads or cooked vegetables(such as 11⁄2 cups of cooked carrots) are countedas carbohydrate servings too. Some foods,such as pizza, casseroles, and soups, are acombination of carbohydrate, protein, and fat.

How many servings ofcarbohydrate foods are best forme at each meal and snack?The recommended number of servings isbased on your weight, activity level, diabetesmedications, and goals for your blood glucoselevels. A member of your health care team,such as a dietitian, can work with you to makea personalized plan. For many people, having3 or 4 servings of carbohydrate foods at eachmeal and 1 or 2 servings for snacks works well.

What about other foods such asmeats, vegetables, and fats?To have a balanced meal plan, you’ll want toinclude protein foods, such as beef, chicken,and fish, as well as vegetables and a moderateamount of healthy fats, such as olive oil and nuts.Talk with your health care team about what toeat for your meals and snacks.

Toolkit No. 10

Carbohydrate counting can help you choose what and howmuch to eat.

All About Carbohydrate Counting

Carbohydrate foods

• bagels, biscuits, bread,crackers, taco shells,and tortillas

• dried beans (such askidney or pinto beans) andpeas (such as black-eyedor split peas)

• ready-to-eat or cookedcereal

• fruit (canned, dried, andfresh) and fruit juice

• pasta and rice • milk, soy milk, and yogurt

• starchy vegetables suchas corn, peas, potatoes,and sweet potatoes

• sweets such as cake,cookies, ice cream, jam,jelly, and sugar

• pancakes and waffles • popcorn, potato chips, andpretzels

Why should I pay attention toserving sizes for carbohydratefoods?The amount of carbohydrate you eat can make abig difference in your blood glucose. If you eatmore carbohydrate than usual at a meal, yourblood glucose level is likely to be higher thanusual several hours afterward.

The chart below shows the size of one servingfor each food. One carbohydrate serving equals15 grams of carbohydrate. You can check servingsizes with measuring cups and spoons or a foodscale, or by using the Nutrition Facts section onthe package.

How to use the Nutrition Facts onfood labelsTo determine your serving size, check the labelfor the number of carbohydrate grams (g),remembering that one carbohydrate servingis equal to 15 grams of carbohydrate.

• If the total carbohydrate is 15 grams, thencheck the top of the food label for the servingsize for one serving.

One carbohydrate serving: 6 crackers

• If the total is more than 15, then divide thetotal by 15. For example, a food with 30grams of carbohydrate contains 2 carbohydrateservings, because 30 divided by 15 equals 2.

One carbohydrate serving: 2 cookies

• If the total is less than 15, then multiply theserving size so that your serving will have 15grams of carbohydrate.

One carbohydrate serving: 3 pieces

How do I get started withcarbohydrate counting?Ask your health care provider how you can learnmore about carbohydrate counting. A dietitiancan help you make a plan.



Serving sizes for some carbohydrate foods(approximately 15 grams of carbohydrate)

apple: 1 small (4 ounces) milk: 1 cup

bagel: 1/4 large (1 ounce) orange juice: 1/2 cup

banana: 1 small(4 ounces)

pasta (cooked): 1/3 cup

biscuit: 1 peach: 1 medium(4 ounces)

bread: 1 slice peas: 1/2 cup

cake (unfrosted): 2-inchsquare

pinto beans or kidneybeans: 1/2 cup

cereal (ready-to-eat):3/4 cup

popcorn: 3 cups popped

cereal (cooked): 1/2 cup potato, mashed: 1/2 cup

cookies: 2 small (about2/3 ounce)

potato chips: 3/4 ounce(about 15-20)

corn: 1/2 cup pretzels: 3/4 ounce

crackers (saltines): 6 rice: 1/3 cup

fruit, canned: 1/2 cup sugar: 1 tablespoon

hamburger bun: 1/2 bun sweet potato: 1/2 cup

ice cream (light): 1/2 cup taco shells: 2 (6-inch size)

jam or jelly: 1 tablespoon tortilla: 1 (6-inch size)

Nutrition FactsServing Size: 6 crackers

Total Carbohydrate: 15g

Nutrition FactsServing Size: 4 cookies


Nutrition FactsServing Size: 1 piece


Losing weight lowers your risk of heart diseaseand stroke because it helps you control bloodglucose (sugar), blood pressure, and cholesterollevels. You don’t have to lose a lot of weight tosee the benefits—even a loss of 10 to 15 poundscan help a lot.

Weight loss can be a struggle because it meansmaking changes in the way you eat and in yourlevel of physical activity. The older we get, theharder it is for us to lose weight because we burnfewer calories. We also tend to be less active.Losing weight takes time—and that can befrustrating. The good news is that you canlose weight and keep it off, even if you’venever done it before.

What strategies can help melose weight?Here’s what works for people who have lostweight and kept it off:

• They cut back on calories and fat.

• They’re physically active most days of theweek.

• They eat breakfast every day.

• They keep a record of their weight, what theyeat and drink, and what they do for physicalactivity.

Some people attend weight-loss programs; othersuse these strategies on their own. Think aboutwhich approach will work best for you. Justremember that studies show it’s much easier tolose weight when you use a combination of mealplanning and physical activity.

What’s the secret to changinghabits?Understanding the process for changing habitscan make it easier for you to change the wayyou eat and increase your activity. Everychange involves several stages, and each stageis important. Here’s an example. Sue used tohave ice cream almost every night for her snack.But she wanted to lose weight.

• At first, she wasn’t interested in making achange. She wasn’t ready to give up herice cream. She thought it would be toohard to do.

• Then she thought about ways she could cutcalories to lose weight. She decided that oneway might be to eat something instead of icecream. She wasn’t ready to try it but thoughtshe might be ready in the future.

• After a while, she decided that soon she’d beready to make a change in her snack, evenwithin the month. She made a realistic plan—she’d have fruit instead of ice cream severaltimes a week.

• Then she took action. She bought her favoritefruit and started eating it four times a weekinstead of ice cream.

• Now, after more than 6 months of her newhabit, it’s part of her routine.

Think about what stage you’re in for changesyou’d like to make. Are you in the early stages—not ready for a change yet? Or maybe you’reinterested in losing weight but you haven’t taken

Toolkit No. 11

Regular physical activity, like dancing, can help you lose weight.

Protect Your Heart by Losing Weight

action. The next step is to decide what you’rewilling and able to do. Then plan exactly howand when you’ll do it.

Strategies for Losing WeightChoose things to do that will help you loseweight. Put a check mark next to the thingsyou’re willing and able to do. Or write downyour own ideas. Remember that every step youtake helps move you toward your goal.

How to cut back on calories and fat❒ Eat smaller servings of high-calorie favorites.

❒ When you eat out, split a main dish with afriend or family member. Or take some homefor tomorrow.

❒ Ask for salad dressings and sauces “on theside” and then use as little as possible.

❒ Include a fruit or a vegetable with every mealor snack.

❒ Cook in low-fat ways: roast, broil, grill,microwave, steam, or bake. Use nonstickpans or cooking sprays.

❒ Substitute low-fat ingredients in your favoriterecipes. For example, try low-fat cheeseinstead of the regular kind.

❒ Cut back on high-fat toppings, such as butter,margarine, sour cream, regular salad dressing,mayonnaise, or gravy. Instead, season yourfood with herbs, spices, salsa, lemon juice,or other low-fat choices.

❒ Check food labels. Choose the products withfewer calories and less fat.

❒ Stock your kitchen with low-calorie, low-fatsnacks, such as air-popped popcorn, pretzels,and fruit. Keep serving sizes small.

❒ Other things I can do: _____________________

_________________________________________

How to be more physically active❒ Take a 30-minute walk every day. Or split up

your daily activity—try a 10-minute walk aftereach meal. If you haven’t been very activerecently, check with your health care teamfirst. Start off with a 10- to 15-minute walkevery other day, then little by little walkfarther and walk more often.

❒ Find a physical activity you enjoy, likeswimming, dancing, bicycling, or doingthe exercises on TV programs.

❒ Be active around the house: work in the yard,play with the kids, get up to change the TVchannel, and walk around while you talk onthe phone.

❒ Take the stairs instead of the elevator.

❒ Take the dog for regular walks.

❒ Walk instead of drive whenever you can.

❒ Park at the far end of the shopping center lotand walk to the store.

❒ Other things I can do: _____________________

_________________________________________

How to keep a record of your progressKeep track of your weight loss efforts. Manypeople find that writing everything down helpskeep them on target. Use a small notebook andkeep it with you all day.

• Write down everything you eat and drink.Include the serving size. Some people settarget levels of calories or grams of fat andkeep track of their daily totals.

• Make a note of what kind of physical activityyou’ve done and for how long.

• You may want to check your weight once aweek and write it down or use your clothes asa measure of weight loss. Are your pants a bitloose around the waist? Can you fit into theblouse you haven’t worn for years?

How a support system can helpMany people find it motivating to meet on aregular basis with people who are also trying tolose weight. You may want to consider joining a group for weight loss, exercise, or generalsupport. Or create your own support system by talking with friends and family about yoursuccesses and your struggles. Find a walkingbuddy or friends who also want to improve theirhealth and work together to set goals for success.



Why is physical activityimportant for people withdiabetes?Here’s what physical activity can do for you:

• It lowers your blood glucose (sugar),blood pressure, and cholesterol.

• It lowers your risk for heart disease andstroke.

• It relieves stress.

• It helps insulin work better.

• It strengthens your heart, muscles, andbones.

• It improves your blood circulation andtones your muscles.

• It keeps your body and your joints flexible.

Even if you’ve never exercised before, you can find ways to add physical activity to yourday. You’ll experience benefits even if youractivities aren’t strenuous. Once physicalactivity is a part of your routine, you’llwonder how you did without it.

If I haven’t been very activelately, what should I do first?Start with a checkup—your health careprovider will check your heart, blood vessels,eyes, kidneys, feet, and nervous system. Ifthe tests show signs of disease, your providercan recommend physical activities that willhelp you but won’t make your conditionworse.

For more information about making physicalactivity a part of your routine, ask your healthcare team for a copy of Toolkit No. 14:Learning How to Change Habits.

What kinds of physical activityare best?A comprehensive physical activity routineincludes four kinds of activities:

• being active throughout the day

• aerobic exercise, such as brisk walking,swimming, or dancing

• strength training, such as lifting light weights

• flexibility exercises, such as stretching

Being active throughout the dayBeing active helps burns calories. Place a checkmark next to the things you’d like to try:

❒ Walk instead of drive whenever possible.

❒ Take the stairs instead of the elevator.

❒ Walk around while I talk on the phone.

❒ Work in the garden, rake leaves, or washthe car.

❒ Play with the kids.

❒ Carry things upstairs in two trips insteadof one.

Toolkit No. 12

Find an activity you enjoy, such as a dance aerobics class.

All About Physical Activity for People with Diabetes

❒ Park at the far end of the shopping center lotand walk to the store.

❒ Others things I can do: ____________________

________________________________________

________________________________________

Aerobic exerciseAerobic exercise makes your heart and bonesstrong, relieves stress, helps your insulin workbetter, and improves blood circulation. Inaddition, it cuts your risk for heart disease bylowering your blood glucose, blood pressure, andcholesterol levels. For most people, it’s best toaim for a total of about 30 minutes a day, at least5 days a week. If you haven’t been very activerecently, you can start out with 5 or 10 minutesa day and work up to more time each week.Or split up your activity for the day—try a brisk10-minute walk after each meal. Your health careteam can show you how to warm up and stretchbefore aerobic exercise and how to cool downafterward.

Here are some examples of aerobic exercise:

• Take a brisk walk every day.

• Go dancing or take a dance aerobics class.

• Swim or do water aerobic exercises.

• Take a bicycle ride outdoors or use astationary bicycle indoors.

My plan for aerobic exercise:

What I’ll do: ________________________________

___________________________________________

What I need to get ready: ____________________

___________________________________________

Which days and times: _______________________

How long each session will be: _______________

How I’ll warm up and cool down for eachsession: ____________________________________

___________________________________________

___________________________________________

Strength trainingStrength training helps build strong bones andmuscles and makes everyday chores like carryinggroceries easier for you. With more muscle,you burn more calories, even at rest. Do yourstrengthening routine several times a week.Here are some ways to do strength training:

• Lift light weights at home.

• Join a class to do strength training withweights, elastic bands, or plastic tubes.

My plan for strength training:

What I’ll do: _______________________________

___________________________________________


___________________________________________



Flexibility exercisesFlexibility exercises, also called stretching, helpkeep your joints flexible and reduce your chancesof injury during activities. Gentle stretching for 5to 10 minutes helps your body warm up and getready for aerobic activities and cool down afteryour activity. Your health care team can provideinformation on how to stretch.

My plan for flexibility exercises:

What I’ll do: ________________________________

___________________________________________


___________________________________________



To learn more about how to get started with aphysical activity routine, ask your health careteam for a copy of Toolkit No. 13: GettingStarted with Physical Activity.



No matter how old you are or what kind ofshape you’re in, physical activity can do a lotfor you. If you’re interested in becoming moreactive, these steps will help you get ready for aroutine that’s safe and enjoyable.

• Have a checkup and find out which activitieswill be safe for you.

• Choose what you’ll do for your routine andmake detailed plans.

• Find out how physical activity can affect yourblood glucose (sugar) levels.

• Learn how to avoid low blood glucose andwhat to do if it happens.

• Plan how to have water, snacks, and treatmentfor low blood glucose available.

• Arrange a way to carry medical identification.

Use the checklist on page 2 to check off eachstep after you’ve done it. Then you’ll be readyto start your new, active lifestyle.

Have a checkupStart by seeing your health care provider for acheck of your heart, blood vessels, eyes, kidneys,feet, and nervous system. If the tests showsigns of disease, your health care provider canrecommend physical activities that will help youbut won’t make your conditions worse. Forexample, if your feet are numb, you might notnotice blisters or other injuries. In that case,swimming may be better for you than walkingbecause you’ll be less likely to injure your feet.

Choose what you’ll do andmake plansAfter you talk with your health care team aboutactivities that are best for you, think about whatyou’d like to do. First think of ways to be moreactive throughout the day. For example, youcould take the stairs instead of the elevator.You’ll also benefit by including these kindsof activities:• aerobic exercise, such as brisk walking,

swimming, or dancing

• strength training, such as lifting light weights

• flexibility exercises, such as stretching

Choose things you enjoy, such as walking witha friend or a dance aerobics class. Try to makeyour plans realistic and achievable. For example,if you don’t have time to walk for 30 minutes at atime, plan on walking for 10 minutes after eachmeal. If you haven’t been very active recently,start slowly and add more activity gradually.Your health care team can show you how towarm up before your workout and cool downand stretch afterward.

Write down what you’ll do, where and whenyou’ll do it, how often, and for how long. Thinkabout what you’ll do if you can’t carry out yourusual plan. For more information about eachkind of activity, talk with your health care teamor request a copy of Toolkit No. 12: All AboutPhysical Activity for People with Diabetes.

Toolkit No. 13

Think of ways to be more active throughout the day.

Getting Started with Physical Activity

Find out how activity affectsblood glucose levels Physical activity usually lowers blood glucoselevels. That’s why you’ll want to check yourglucose levels before you exercise. If your bloodglucose is below 100 mg/dl, have a smallcarbohydrate snack such as fruit or crackers.

However, if your blood glucose is high (above300 mg/dl) even before you exercise, physicalactivity can make it go even higher. That’s whenyou’ll want to be cautious about doing somethingactive. For those with type 1 diabetes, if yourfasting glucose level is above 250 mg/dl and youhave ketones in your urine, it’s best to avoidphysical activity. Talk with your health care teamabout whether to exercise when your bloodglucose is high.

You can get to know how various activities affectyour blood glucose by checking your levelsbefore and after exercise and keeping track ofyour results.

Learn all about low blood glucoseLow blood glucose, also called hypoglycemia,can occur during or after physical activity, evenchores like shoveling snow or raking the leaves.If your blood glucose is below 100 mg/dlbefore physical activity, have a snack. Duringactivity, check your blood glucose if you noticesymptoms of low blood glucose such as hunger,nervousness, shakiness, or sweating. If it’s70 mg/dl or below, follow these treatmentguidelines to bring it back up to a safer range:

• Have one of these items right away to raiseyour blood glucose:

– 2 to 5 glucose tablets

– 1⁄2 cup (4 ounces) of fruit juice

– 1⁄2 cup (4 ounces) of a regular (not diet)soft drink

– 8 ounces of milk

– 5 to 7 pieces of hard candy

– 2 teaspoons of sugar or honey

• After 15 minutes, check your blood glucoseagain. If it’s still below 70 mg/dl, haveanother serving.

• Repeat these steps until your blood glucoseis at least 70 mg/dl.

Plan what things to take with youYou’ll be ready for anything by having water andsnacks handy during activity. Make sure youdrink plenty of water before, during, and afterphysical activity to keep hydrated. And alwayscarry a source of carbohydrate, such as glucosetablets, to treat low blood glucose if it happens.

Have a medical ID with youYou’ll want to protect yourself in case ofemergency by wearing a medical identificationbracelet or necklace or attaching a medical ID tagto your shoes or clothes. You also may want tocarry another form of identification duringexercise, such as a wallet card.



What I need to do to get started with physical activityGet started by choosing something to do today.Place a check mark next to each step afteryou’ve done it. If you have a question for yourdoctor about something, place a question marknext to it and take this list to your next officevisit.

❒ I’ve had a checkup with my doctor.

❒ I’ve learned which activities will be safe for me.

❒ I’ve thought of ways to be more activeduring the day.

❒ I’ve chosen ways to do aerobic exercise,strength training, and flexibility exercises.

❒ I’ve made a specific, realistic plan for eachtype of activity.

❒ I know how physical activity can affect myblood glucose levels.

❒ I know how to avoid low blood glucose andwhat to do if it happens.

❒ I know when to avoid exercise.

❒ I’m prepared to carry glucose tablets or othersources of sugar to treat low blood glucose.

❒ I have a form of medical ID to wear or carry.

A lot of your diabetes care is up to you. Youmay have already changed some habits to takebetter care of yourself. Perhaps you exercisemore now than you did before you werediagnosed with diabetes. Maybe you’d like tochange other habits but you’re stuck—you feellike you just can’t get started. Changing habitscan be hard to do. But you can learn a step-by-step approach that will help you reachyour goals.

What happens when you changea habit?Every change involves several stages:

• Precontemplation. Maybe you think that achange would help but you’re not ready orinterested. You feel the change would be toohard to make.

• Contemplation. You’re thinking aboutmaking a change, but not right away. At thisstage, the costs of making the change stilloutweigh the benefits.

• Preparation. You’re ready to make thechange within the month. You’ve made arealistic plan and you’ve gathered what youneed to carry out your plan.

• Action. You’ve taken action and started yournew routine. But sometimes you’re tempted togo back to your previous habits.

• Maintenance. After more than 6 months ofyour new routine, you’re used to doing it. It’snow a habit.

Think about what stage you’re in for changesyou’d like to make. Are you in the early stages—not yet ready for a change? Or maybe you’d liketo make a change but you don’t know how.Knowing what stage you’re in can help youchoose the best approach to changing habitsand attaining your goals.

Changing Habits: Getting StartedThink about your diabetes care. Then fill in youranswers.

What’s my goal?

___________________________________________

___________________________________________

What change would help me reach my goal?

___________________________________________

___________________________________________

What stage am I in for this change?

❒ I’m not ready to change right now.

❒ I’m thinking about doing it sometime.

❒ I might do it in the next month.

❒ I’m doing it now.

❒ I’ve been doing it for more than 6 months.

Toolkit No. 14

You can make it easier to eat low-fat foods by stocking upon fruits and vegetables.

Learning How to Change Habits

Not quite ready to take action? Here’s what to do next.To move from the “not-ready” stage to the actionstage:

• Consider the benefits of the change. Forexample, if you took a half-hour walk everymorning, how would that help your health?What effect would it have on your weight?

• Answer these questions: What part of this change would be hard forme? ____________________________________

Why haven’t I made this change before?________________________________________

How can I work around these problems?________________________________________

Ready to make a change?Here’s what to do next.To change a habit, you’ll need a realistic,achievable plan. Your plan should be as specificas possible. Your health care team can provideinformation to help you. Write your plan here:

• Here’s what I’ll do:

________________________________________Example: I’ll take a brisk walk 5 days a weekfor half an hour.

• Here’s when I’ll do it:

________________________________________Example: I’ll walk after breakfast.

• Here’s what I need to get ready:

________________________________________Example: I’ll need comfortable walking shoes.

• This might get in the way of my plan:

________________________________________Example: If it’s raining, I won’t be able towalk outside.

• If that happens, I’ll do this instead:

________________________________________Example: I’ll go to the recreation center andwalk around inside.

• Here’s when I’ll start:

________________________________________Example: I’ll start my walks on Monday.

Ready to take action or alreadytaking action?Here’s what to do next.Once you’ve started your new habit, you’ll wantto take steps to keep doing what you’re doing.These steps can help:

• Set up things around you so it’ll be easier tostick with your new habit. For example, stockup on vegetables and fruit instead of high-fatsnacks.

• Make it easy to find time for your new habitby changing your schedule or your routine. If you prefer to walk in the morning beforework, get up a little earlier so you’ll have time.

• Think about roadblocks that might come upand plan ways to get around them.

• Ask for support from family, friends, and yourhealth care team. For example, ask a familymember to watch the kids while you go for awalk.

• If you sometimes slip up and go back to yourold habit, don’t despair. You can start freshtomorrow.

• Keep track of your efforts by writing downwhat you’re doing.

• Vary your routine to keep it interesting. Forexample, if you’re tired of walking aroundyour neighborhood, walk inside the shoppingmall instead.

• Reward yourself for sticking with your plan.

Remember: it takes time to make new habits,but your patience and persistence will pay off inthe long run.



What does depression have to do with diabetes?Serious depression is common in people withdiabetes. In fact, diabetes doubles the risk fordepression. As many as one of every threepeople with diabetes experiences symptoms ofdepression. It’s especially common in women.Men experience it too but may be less likelyto seek treatment. The good news is thattreatment can help.

What are the symptoms of depression?Depression is a medical condition that’s morethan just feeling sad, stressed, or irritable once ina while. Most people with depression will haveseveral of the following symptoms for most of theday, almost every day, for at least 2 weeks:

• feeling down and depressed

• losing interest in their usual activities

• feeling that things that used to make themhappy no longer bring pleasure

• experiencing weight loss or gain

• having trouble sleeping (insomnia) or sleeping too much

• feeling agitated and nervous or feelingsluggish, like they’re moving slowly

• having crying spells or being very emotional

• feeling very tired and having no energy

• having trouble focusing or making decisions

• thinking about death or suicide

Symptoms like these are normal after majorlosses, such as the death of a loved one,diagnosis of a new medical problem, or losing ajob, but people should start feeling better after afew weeks. People with depression can’t tracetheir symptoms directly to medications, medicalconditions, or loss of a loved one.

Contrary to what many people used to believe,depression is not a sign of personal weakness orfailure. Telling someone “Pull yourself out of it!”can’t cure depression.

What causes depression?Researchers believe that depression is caused bya combination of physical, psychological, andgenetic factors. Differences in how the brainworks, how a person reacts to stressful eventssuch as chronic illness or divorce, and a historyof depression in the family can all make someonemore likely to get depression.

It isn’t clear whether diabetes causes depressionor exactly how depression is related to diabetes.But we do know that diabetes can cause peopleto feel overwhelmed by the demands of day-to-day care. It’s common for people with diabetesto worry about possible long-term complications,the cost of diabetes care, and the effects ofdiabetes on family and work life. As with anychronic illness, people wonder, “Why did I haveto be the one to get diabetes?”

Toolkit No. 15

When you have depression, talking with a friend or familymember can be a comfort.

Recognizing and Handling Depressionfor People with Diabetes

How does depression affectdiabetes? Depression can make it hard for you to focus ontaking care of yourself. You might feel that it’stoo much trouble to check your blood glucose(sugar) or try to choose healthy foods. Thingscan seem hopeless. When you don’t take care ofyourself, blood glucose levels can rise. Frequenthigh blood glucose levels over time raise yourrisk for diabetes-related complications. Studieshave shown that depression can even makeaches and pains seem worse.

What should I do if I think I have depression?If you have symptoms of depression, it’simportant to get help as soon as you can. The sooner you get treatment, the sooner you’llfeel better. Make an appointment to see yourhealth care provider. Explain how you’ve beenfeeling and ask whether you might have seriousdepression. After asking about your symptomsand doing other checks as needed, your healthcare provider will discuss treatment options withyou, such as starting treatment right away orseeing a specialist.

What is the treatment fordepression? Depression is treated with medication andcounseling (also called psychotherapy). Somepeople use both treatments; others find thateither medication or counseling alone helpsthem. Your health care provider can explainboth kinds of treatments to help you choosewhat to do.

Antidepressant medications help change theway your brain works. There are severaldifferent types of medications. Your healthcare provider can prescribe the best type ofmedication for you. You’ll want to keep in mindthat some antidepressants take several weeks toimprove your mood. But eventually medicationcan help you feel back to normal and can restoreyour sense of well-being.

Counseling can teach you the skills you need tocope with the stresses in your life. Sometimes it helps to talk about problems with someonewho is objective. A counselor can offer a freshperspective on what’s going on in your life.

Other ways to cope withdepressionMany people find that having the support offamily and friends can be a comfort. Findsomeone to talk with about what’s going on.Or if it’s hard for you to talk about your feelings,sometimes just spending time with family andfriends can help you feel better.

Physical activity can also help you feel betterboth when you’re depressed and once you’refeeling better. Take a walk every day, playwith the kids, or find another activity you enjoy,like dancing, walking, or swimming. Activitycan lift your spirits and provide other healthbenefits as well.

Remember your risk fordepressionDepression can come and go throughout life,especially if you have diabetes and are at highrisk for depression. Knowing the symptomsand taking action to get help when depressionoccurs will help you return to “your old self”as soon as possible.



An important part of taking care of yourself iskeeping your blood pressure under control. Highblood pressure—also called hypertension—raisesyour risk for heart attack, stroke, eye problems,and kidney disease. As many as 2 out of 3adults with diabetes have high blood pressure.Having your blood pressure checkedregularly and taking action to reach yourblood pressure target can prevent or delaydiabetes problems.

What is high blood pressure?Blood pressure is the force of blood flow insideyour blood vessels. When your health care teamchecks your blood pressure, they record twonumbers, such as 130/80 mmHg. You’ll hearthem say this as “130 over 80.” Both numbersare important:

• The first number is the pressure as your heartbeats and pushes blood through the bloodvessels. Health care providers call this the“systolic” pressure.

• The second number is the pressure when thevessels relax between heartbeats. It’s calledthe “diastolic” pressure.

When your blood moves through your vesselswith too much force, you have high bloodpressure. Your heart has to work harder whenblood pressure is high, and your risk for diabetesproblems goes up. High blood pressure is aproblem that won’t go away without treatment.

What is the recommended targetfor blood pressure?Both diabetes and high blood pressure increaseyour risk of heart attack, stroke, and eye andkidney disease. Because of this, people withdiabetes have a lower blood pressure target thanthe general public. The American DiabetesAssociation (ADA) and the National Institutesof Health recommend a target blood pressure ofless than 130/80 mmHg for people with diabetes.When you keep your blood pressure below

130/80 mmHg, you’ll be lowering your risk fordiabetes problems.

How will I know if I have highblood pressure?High blood pressure is a silent problem—youwon’t know you have it unless your health careprovider checks your blood pressure. The ADArecommends that you have your blood pressurechecked at every office visit, or at least two tofour times a year. Keep track of your bloodpressure by recording the results of yourcheckups here.

Toolkit No. 16

Choosing foods wisely, being physically active, and takingmedications are all part of treating high blood pressure.

ADA blood pressure target: Below 130/80 mmHg

Office Visit My Results My Target

Date:

Date:

Date:

Date:

Treating High Blood Pressure in People with Diabetes

What treatments arerecommended?Both lifestyle changes and medication helpcontrol blood pressure. Treatment differs fromone person to the next. Work with your healthcare provider to find a treatment that’s right foryou.

Lifestyle changesLifestyle changes can help control your bloodpressure as well as your blood glucose (sugar)and blood lipid (cholesterol and triglyceride)levels. Place a check mark next to steps you’rewilling to try.

Make wise food choices❒ I’ll eat a serving of fruit at each meal.

❒ I’ll eat one or two servings of vegetables atlunch and at dinner.

❒ I’ll switch to low-fat or fat-free dairy products(such as low-fat cheese and skim milk).

❒ I’ll eat whole-grain breads (such as whole-wheat bread) and cereals.

❒ I’ll eat nuts or peanut butter sometimes.

❒ I’ll choose lean meats and meat substitutes(such as chicken without the skin, fish, leanbeef such as flank steak or chuck roast, boiledham, or pork tenderloin).

❒ I’ll cook using low-fat methods such as baking,roasting, broiling, or grilling.

❒ I’ll add little or no salt to my food at the tableand during cooking.

❒ I’ll try herbs and spices instead of salt.

❒ I’ll check food labels and choose foods withless than 400 mg of sodium per serving.

Lose weight or take steps to preventweight gain❒ I’ll cut down on calories and fat.

❒ I’ll try to be more physically active than I amnow.

Be physically active❒ Before I start a new routine, I’ll check with my

doctor to find out which activities will be safefor me.

❒ I’ll try to do a total of about 30 minutes ofaerobic exercise, such as brisk walking, mostdays of the week. If I’m just starting out, I’llbegin with 5 minutes a day and gradually addmore time.

Be careful with alcohol❒ I’ll talk with my health care team about

whether it’s wise for me to have alcoholicbeverages.

❒ If and when I drink alcoholic beverages, I’lllimit myself to 1 serving a day (for women)or 2 servings a day (for men).

Quit smoking❒ I’ll talk with my health care team about

methods that can help.

MedicationsSeveral types of medications are available.Not everyone takes the same blood pressuremedication, and many people take more thanone kind. Which ones you take will depend onyour blood pressure readings and other factorssuch as cost.

• ACE inhibitors—These medications lowerblood pressure by keeping your blood vesselsrelaxed. ACE inhibitors prevent a hormonecalled angiotensin from forming in your bodyand narrowing your blood vessels. Thesemedications also help protect your kidneysand reduce your risk of heart attack andstroke.

• ARBs—These medications keep the bloodvessels open and relaxed to help lower bloodpressure. Like ACE inhibitors, ARBs alsoprotect your kidneys.

• Beta blockers—These medications helplower blood pressure and relax your heart byallowing it to beat slower and less forcefully.Beta blockers help prevent heart attack andstroke.

• Calcium channel blockers—Thesemedications help the blood vessels relax bykeeping calcium out of your blood vesselsand heart.

• Diuretics—These medications, sometimescalled “water pills,” help rid your body ofextra water and sodium through urine.



Keeping your cholesterol and other blood lipids(fats) under control can help you preventdiabetes problems. Diabetic dyslipidemia, acondition in which your blood lipids are offtarget, can lead to heart attack and stroke. Formost people, treatment for off-target blood lipidsincludes both lifestyle changes, such as choosingfoods wisely, and medication. You can takesteps to keep your blood lipids on target.

What are the different kinds ofblood lipids and what do they do?There are several kinds of lipids in your blood,and each type affects your health differently.

• LDL cholesterol is sometimes called badcholesterol. This lipid can narrow or blockyour blood vessels. Blocked vessels can leadto a heart attack or a stroke. Reaching yourLDL target is the most effective way toprotect your heart and blood vessels.

• HDL cholesterol is sometimes called goodcholesterol or “helpful” cholesterol. This lipidhelps remove deposits from the insides of yourblood vessels and keeps them from gettingblocked.

• Triglycerides are another kind of lipid. Hightriglyceride levels increase your risk of a heartattack or stroke.

How does diabetes affect myblood lipids?Many people with diabetes have problems withtheir blood lipid levels—HDL (good cholesterol)levels that are too low and triglyceride levelsthat are too high. Also, in people with diabetes,LDL (bad cholesterol) particles are unusuallysmall and dense, which can be especially harmfulto blood vessels. This combination of factorsmeans an increased risk of heart attack andstroke. But the good news is that taking stepsto keep your lipids within the target range willlower your risk for these problems.

How will I know if my blood lipidlevels are off target?You won’t know that your lipids are at dangerouslevels unless you have a blood test to check yourblood lipid levels. The American DiabetesAssociation (ADA) recommends that you haveyour levels checked at least once a year. Somepeople may need to be checked more often.

What are the recommendedtargets for blood lipids?See the chart below for targets suggested by theADA. You can also record the results of yourlatest blood lipid check here.

Have your blood lipids checked at least once a year to helpprevent or delay a heart attack or a stroke.

Type ofBlood Lipid My Results ADA Targets

LDL cholesterol below 100 mg/dl

HDL cholesterol above 40 mg/dl(for men)

above 50 mg/dl(for women)

Triglycerides below 150 mg/dl

Toolkit No. 17

Treating High Cholesterol in People with Diabetes

What treatments arerecommended?Both lifestyle changes and medication helpcontrol blood lipids. Treatment differs from oneperson to the next. Work with your health careprovider to find a treatment that’s right for you.

Lifestyle changesLifestyle changes can help control your bloodlipids as well as your blood glucose and bloodpressure levels. If your blood lipid levels are offtarget, you’ll want to consider making lifestylechanges right away. Place a check mark nextto steps you’re willing to try.

Make wise food choices❒ I’ll eat less fat, especially saturated fat (found

in fatty meats, poultry skin, butter, 2% orwhole milk, ice cream, cheese, palm oil,coconut oil, trans fats, hydrogenated oils,lard, and shortening).

❒ I’ll choose lean meats and meat substitutes(such as chicken without the skin, lean beefsuch as flank steak or chuck roast, boiled ham,or pork tenderloin).

❒ I’ll switch to low-fat or fat-free dairy products(such as low-fat cheese and skim milk).

❒ I’ll cut back on foods that are high incholesterol (such as egg yolks, high-fat meatand poultry, liver and other organ meats, andhigh-fat dairy products like whole milk).

❒ I’ll choose the kinds of fat that can protect myheart, such as olive oil, canola oil, corn oil,sunflower oil, and safflower oil. Nuts alsohave a healthy type of fat.

❒ I’ll eat fish 2 or 3 times a week, choosingthose high in heart-protective fat (such asalbacore tuna, herring, mackerel, rainbowtrout, sardines, and salmon).

Lose weight or take steps to prevent weight gain❒ I’ll cut down on calories and fat.

❒ I’ll try to be more physically active than I amnow.

Be physically active❒ Before I start a new routine, I’ll talk with my

doctor about safe activities for me.

❒ I’ll try to do a total of about 30 minutes ofaerobic exercise, such as brisk walking, mostdays of the week. If I’m just starting out, I’llbegin with 5 minutes a day and gradually addmore time.

Be careful with alcohol❒ I’ll talk with my health care team about

whether it’s wise for me to drink alcohol.

❒ If and when I drink alcoholic beverages,I’ll limit myself to no more than 1 serving(for women) or 2 servings (for men) daily.

Quit smoking❒ I’ll talk with my health care team about

methods that can help.

Stay on target with your blood glucose (sugar)❒ I’ll help lower my LDL cholesterol and

triglycerides by keeping my blood glucoseunder control with meal planning, physicalactivity, and medication (if needed).

MedicationsSeveral types of medication are available. Noteveryone takes the same blood lipid medication,and many people take more than one kind.The medications you take will depend on yourblood lipid levels and other factors such as cost.Lifestyle changes along with medications canhelp you reach your targets. Some medicationscan help prevent heart attacks and strokes.

• Statins—These medications lower LDLcholesterol, boost HDL levels, and lowertriglyceride levels. Studies have shown thatthey are the most effective medication forlowering LDL cholesterol.

• Fibric acid derivatives, also called fibrates—These medications lower triglycerides andraise HDL levels. They may either lower,raise, or not change LDL cholesterol.

• Nicotinic acid, also called niacin—Thismedication lowers triglycerides, raisesHDL levels, and lowers LDL cholesterol.

• Cholesterol absorption inhibitors—Thistype of medication lowers LDL cholesteroland triglycerides and raises HDL levels.

• Bile acid sequestrants—These medicationslower LDL cholesterol and can raise HDLlevels. They either have no effect ontriglycerides or, in some cases, they canraise triglyceride levels.



Maybe your health care provider has told youthat you are at high risk for heart disease. Or,perhaps you have already had a heart attack.Having diabetes means that you are much morelikely to have coronary artery (heart) disease, aheart attack, or a stroke. The good news is thatyou can take steps to prevent heart disease orreduce your chances of having another heartattack. Lifestyle changes, such as choosing foodswisely and being physically active, as well astaking medication, can help.

What is coronary artery disease?Coronary artery disease is caused by a narrowingor blocking of the blood vessels that go to yourheart. It’s the most common form of heartdisease. Your blood carries oxygen and otherneeded materials to your heart. Blood vessels toyour heart can become partially or totally blockedby fatty deposits. A heart attack occurs when theblood supply to your heart is reduced or cut off.

What steps can I take to preventcoronary artery disease?You can lower your risk by keeping your ABCsof diabetes on target with wise food choices,physical activity, and medication. Losing weightcan also help you manage your ABCs andprevent heart disease. Every step you take willhelp. The closer your numbers are to yourtargets, the better your chances of preventingheart disease or cutting your risk for anotherheart attack. If you smoke, get help to quit.

A is for A-1-CAn A-1-C is the blood glucose (sugar) check“with a memory.” It tells you your averageblood glucose for the past 2 to 3 months.The American Diabetes Association (ADA)recommends that people aim for an A-1-C below7%. Talk with your health care team about thebest target for you and fill in the chart.

B is for blood pressureYour blood pressure numbers tell you the forceof blood inside your blood vessels. When yourblood pressure is high, your heart has to workharder than it should. The ADA recommendsthat you keep your blood pressure below 130/80mmHg (said as “130 over 80”).

C is for cholesterolYour cholesterol numbers tell you the amountof fat in your blood. Some kinds, like HDLcholesterol, help protect your heart. Other kinds, like LDL cholesterol, can clog your bloodvessels and lead to heart disease. Triglyceridesare another kind of blood fat that raises your riskfor heart disease. The following chart gives thetargets suggested by the ADA. You can also

Toolkit No. 18

Medication, along with lifestyle changes, can help youprevent a heart attack.

ADA Target My Results My Target

Below 7%

ADA Target My Results My Target

Below 130/80 mmHg

Taking Care of Your Heart

record the results of your latest blood lipid (fat)check here.

What can I do to reach myABC targets?Making wise food choices, being physicallyactive, and taking medications can help youreach your targets.

Make wise food choices Many people find that changing what they eatcan make a big difference in their blood glucose,blood pressure, and cholesterol levels. Below areseveral strategies for making wise food choices.Place a check mark next to steps you’re willing totry. For more information about how to makethese changes, talk with your health care team.

❒ I’ll eat less fat, especially saturated fat (foundin fatty meats, poultry skin, butter, 2% orwhole milk, ice cream, cheese, palm oil,coconut oil, trans fats, hydrogenated oils,lard, and shortening).

❒ I’ll choose lean meats and meat substitutes.

❒ I’ll switch to low-fat or fat-free dairy products.

❒ I’ll eat at least 5 servings of fruits andvegetables each day.

❒ I’ll cut back on foods that are high incholesterol (such as egg yolks, high-fat meatand poultry, and high-fat dairy products).

❒ I’ll choose the kinds of fat that can help lowermy cholesterol, such as olive oil or canola oil.Nuts also have a healthy type of fat.

❒ I’ll eat fish 2 or 3 times a week, choosing kindsthat are high in heart-protective fat (such asalbacore tuna, herring, mackerel, rainbowtrout, sardines, and salmon).

❒ I’ll cook using low-fat methods (such asbaking, roasting, or grilling foods or by usingnonstick pans and cooking sprays).

❒ I’ll eat less salt and sodium.

Lose weight or take steps to preventweight gain❒ I’ll cut down on calories and fat.

❒ I’ll try to be more physically active than Iam now.

Be physically activeBefore you start a new routine, check with yourhealth care team to find out which activities willbe safe for you. Then think about how you canadd more activity to your routine. If you’re juststarting out, begin with 5 minutes a day andgradually add more time. Then work up to doinga total of about 30 minutes of aerobic exercise,such as brisk walking, most days of the week.

Take medications Medications are available to help you reach yourABC targets and lower your risk of a heart attack.You may need several medications to stay ontrack.

Some types of blood pressure and cholesterol-lowering medications can protect your heart.Your health care provider can provideinformation about which medications are best for you.

Aspirin can also help lower your risk of heartdisease. Ask your provider whether taking a low-dose aspirin every day would be wise.

What can help me quit smoking?If you’re ready to quit, talk with your health careteam. They can help you find ways to quit.Joining a support group or smoking-cessationprogram can also help.



Type ofBlood Lipid My Results ADA Targets

LDL cholesterol below 100 mg/dl

HDL cholesterol• for men• for women

above 40 mg/dl

above 50 mg/dl

Triglycerides below 150 mg/dl

Real-Life Stories from People with DiabetesAfter my heart attack last year, I finally startedtaking my health seriously. Before that, Ihadn’t paid much attention to my diabetes.But now I try to eat right and exercise, and Itake several pills a day to keep my bloodglucose, blood pressure, and cholesterol ontarget. I want to be around for a long time!

Roberto H., age 70 • type 2 diabetes

What is a heart attack?A heart attack occurs when the blood vesselsthat go to your heart become partially or totallyblocked by fatty deposits and the blood supplyis reduced or cut off. Then oxygen and otherneeded materials aren’t carried to the heart andheart muscle dies. Another name for a heartattack is myocardial infarction, or MI. If youhave diabetes, you’re at risk for a heartattack.

What are the warning signsof a heart attack?Become familiar with these signs and call 911right away if they occur:

• chest pain or discomfort

• pain or discomfort in your arms, back, jaw,neck, or stomach

• shortness of breath

• sweating or light-headedness

• indigestion or nausea

• tiredness

You may not experience all of these signs, andthey may come and go. Chest pain that doesn’tgo away after resting a few minutes may signala heart attack.

Why is it important to call 911right away if I’m having warningsigns of a heart attack?After a heart attack, early intervention such asgetting clot-busting drugs is imperative—doingso can save your life. Health care providers canalso use special procedures that open up bloodvessels, preventing further damage to the heart.These steps work best within an hour of the firstsymptoms of a heart attack. It’s wise to reviewthe symptoms of a heart attack with family andfriends and to tell them about the importance ofcalling 911.

Are the signs of a heart attackdifferent for people withdiabetes?Diabetes can affect your nerves and, therefore,make heart attacks painless or “silent.” A silentheart attack means that you may not have anywarning signs, or they may be very mild. Specialtests may be needed to help your doctor make adiagnosis.

Toolkit No. 19

Calling 911 right away if you have warning signs of a heartattack can help save your life.

Real-Life Stories from People with DiabetesWhen I had my heart attack, I felt sick to mystomach and had some pain in my neck andmy arms—those were the only warning signs.I thought it might be a heart attack, so I called911 right away and soon I was at the hospital.They did some tests and gave me medicationthat broke up the blood clot that was blockinga blood vessel to my heart.

Carol Y., age 68 • type 2 diabetes

Know the Warning Signs of a Heart Attack



What are the benefits oftaking aspirin?Studies have shown that taking a low-doseaspirin every day significantly lowers the riskof heart attack and stroke. Aspirin can benefitpeople at high risk of a heart attack, such asthose with diabetes and other risk factors suchas high blood pressure. It can also help peoplewith diabetes who have had a heart attack or astroke, or who have heart disease. However,aspirin’s effects have not been studied in peopleunder age 30.

How does aspirin lower my risk fora heart attack? Exactly why aspirin works is not completelyunderstood, but it may be because it helps keepred blood cells from clumping together. Thesecells seem to clump together more readily inpeople with diabetes. When blood cells clump,a blood clot can form and narrow or block ablood vessel. This can lead to a heart attackor stroke.

Is aspirin safe for everyone?Taking a daily low-dose aspirin isn’t safe foreveryone—it’s best to ask your health careprovider whether you should take aspirin. Insome people, aspirin can irritate the lining ofthe stomach, resulting in pain, nausea, vomiting,or bleeding. You should avoid taking aspirin if • you’re allergic to it• you have a tendency to bleed• you’ve recently had bleeding from your

digestive tract• you have liver disease that’s currently active• you’re under 21 years of ageCheck with your health care provider to seewhether aspirin therapy is right for you.

How much aspirin should I takeevery day?Your health care provider can suggest the lowestpossible dosage for you. Most people take apill containing a dosage between 75 and 162

milligrams every day. The low-dose version maybe labeled “baby aspirin.”

What form of aspirin isrecommended?Some health care providers recommend theenteric-coated form of aspirin. This form ofaspirin is coated with a substance that allows itto pass through the stomach without dissolving.Instead, the aspirin is absorbed in the intestine,decreasing the risk of side effects.

Toolkit No. 20

Taking a low-dose aspirin daily can lower your risk for aheart attack.

Taking Aspirin to Protect Your Heart



Real-Life Stories from People with DiabetesI take an aspirin every day to protect myheart—it’s one of the easiest things I do to stayhealthy. To help me remember to take theaspirin and all my other pills, I use a pillboxthat has a compartment for each day of theweek.

Thomas D., age 80 • type 2 diabetes

What is a stroke?A stroke, sometimes called a “brain attack,”occurs when the blood supply to part of yourbrain is interrupted and brain tissue is damaged.The most common cause is a blocked bloodvessel. Stroke can cause physical problems suchas paralysis, problems with thinking or speaking,and emotional problems.

What does diabetes have to dowith strokes?If you have diabetes, you’re much more likelyto have a stroke, heart disease, or a heart attack.In fact, 2 out of 3 people with diabetes die fromstroke or heart disease. But you can cut yourchances of having these problems by takingspecial care of your heart and blood vessels.

How do I know whether I’m athigh risk for a stroke?Just having diabetes puts you at risk, but yourrisk is even greater if

• you have high blood pressure

• you have abnormal blood cholesterol levels

• you smoke

• you’ve already had a stroke or a transientischemic attack (TIA), also called a mini-stroke

• you have a family history of stroke or TIAs

You can’t change your family history, but takingcare of your diabetes and the conditions thatcome with it can lower your chances of havinga stroke. It’s up to you.

How can I lower my risk ofhaving a stroke?You can lower your risk by keeping your bloodglucose (sugar), blood pressure, and cholesterolon target with meal planning, physical activity,and medication. Quitting smoking is importanttoo. Every step you take will help. The closeryour numbers are to your targets, the better yourchances of preventing a stroke.

What are the warning signsof a stroke?Typical warning signs of a stroke developsuddenly and can include

• weakness or numbness on one side of yourbody

• sudden confusion or trouble understanding

• trouble talking

• dizziness, loss of balance, or trouble walking

• trouble seeing out of one or both eyes

• double vision

• severe headache

Sometimes one or more of these warning signsoccur but then disappear. That condition, calleda TIA, occurs when blood flow is temporarilyblocked. It means you may be at risk for afuture stroke.

If you have warning signs of a stroke, call 911right away. Getting treatment can help preventpermanent damage to your brain. It’s wise toreview the symptoms of a stroke with family andfriends and to tell them about the importance ofcalling 911.

Toolkit No. 21

It’s wise to review the symptoms of a stroke with familyand friends and to tell them about the importance ofcalling 911.

All About Stroke

How is a stroke diagnosed?A number of tests may be done if a stroke issuspected:

• Your doctor will examine you to check forany changes in body function. For example,the doctor can check your ability to moveyour arms and legs. The doctor also willcheck brain functions such as your abilityto read or to describe a picture.

• A CT or MRI (magnetic resonance imaging)uses special scanning techniques to provideimages of the brain.

• An ECG (electrocardiogram) providesinformation on heart rate and rhythm.

• An ultrasound examination can showproblems in the carotid (ca-RAH-tid) arteries,which carry blood from the heart to the brain.

• A cerebral (seh-REEB-rahl) arteriogram isa test in which a catheter is inserted into anartery and positioned in the neck. Dye isinjected and X rays show whether arteriesare narrowed or blocked.

What are the treatmentsfor stroke?Treatment you need right away“Clot-busting” drugs must be given within hoursafter a stroke to minimize damage. That’s whyit’s important to call 911 if you’re havingsymptoms.

Surgical treatments you may needSeveral options for surgical treatment of blockedblood vessels are available. These include

• Carotid artery surgery, also called carotidendarterectomy (en-dar-teh-REK-teh-mee)is used to remove buildups of fat inside theartery and to restore blood flow to the brain.

• Carotid stenting is a procedure used toremove a blockage in a blood vessel to thebrain. A small tube with a balloon attachedis threaded into the narrowed or blockedblood vessel. Then the balloon is inflated,opening the narrowed artery. A wire tube,or stent, may be left in place to help keepthe artery open.

Other treatmentsTreatment following a stroke includesrehabilitation therapies to restore function or helppeople relearn skills. Physical, occupational,and speech therapy may be included, as well aspsychological counseling. Steps to prevent futureproblems should include smoking cessation, mealplanning, physical activity, and medications tomanage blood glucose, blood pressure, andcholesterol levels.



Real-Life Stories from People with DiabetesI never knew I was at risk for a stroke. Butafter I had my stroke, I learned that havingdiabetes puts you at high risk for both a strokeand a heart attack, because diabetes candamage your blood vessels. Now I’m gettingmy blood glucose, blood pressure, andcholesterol under control so I can avoidanother stroke.

Luis Z., age 75 • type 2 diabetes

What is peripheral arterialdisease?Peripheral (puh-RIF-uh-rul) arterial (ar-TEER-ree-ul) disease, also called PAD, occurs whenblood vessels in the legs are narrowed orblocked by fatty deposits. Blood flow to yourfeet and legs decreases. If you have PAD, youhave an increased risk for heart attack andstroke. An estimated 1 out of every 3 peoplewho have diabetes and are over the age of 50has this condition. However, many of thosewith warning signs don’t realize that they havePAD and therefore don’t get treatment.

What does diabetes have todo with PAD?If you have diabetes, you’re much more likelyto have PAD, a heart attack, or a stroke. Butyou can cut your chances of having thoseproblems by taking special care of your bloodvessels.

How do I know whether I’m athigh risk for PAD?Just having diabetes puts you at risk, but yourrisk is even greater if

• you smoke

• you have high blood pressure

• you have abnormal blood cholesterol levels

• you already have heart disease, or have hada heart attack or a stroke

• you’re overweight

• you’re not physically active

• you’re over age 50

• you have a family history of heart disease,heart attacks, or strokes

You can’t change your age or your familyhistory, but taking care of your diabetes andthe conditions that come with it can loweryour chances of having PAD. It’s up to you.

What are the warning signsof PAD?Many people with diabetes and PAD don’t haveany symptoms. Some people may experiencemild leg pain or trouble walking and believethat it’s just a sign of getting older. Others mayhave the following symptoms:

• leg pain, particularly when walking orexercising, which disappears after a fewminutes of rest

• numbness, tingling, or coldness in the lowerlegs or feet

• sores or infections on your feet or legs thatheal slowly

If you have warning signs of PAD, talk with your healthcare provider.

Toolkit No. 22

All About Peripheral Arterial Disease

How is PAD diagnosed?The ankle brachial (BRAY-kee-al) index (ABI)is one test used to diagnose PAD. This testcompares the blood pressure in your ankle tothe blood pressure in your arm. If the bloodpressure in the lower part of your leg is lowerthan the pressure in your arm, you may havePAD. An expert panel brought together by theAmerican Diabetes Association recommendsthat people who have diabetes and are over theage of 50 have an ABI to test for PAD. Peoplewho have diabetes and are younger than 50may benefit from testing if they have other riskfactors for PAD.

These other tests can also be used todiagnosis PAD:

• Angiogram (AN-gee-oh-gram): a test inwhich dye is injected into the blood vesselsusing a catheter and X rays are taken to showwhether arteries are narrowed or blocked

• Ultrasound: a test using sound waves toproduce images of the blood vessels on aviewing screen

• MRI (magnetic resonance imaging): a testusing special scanning techniques to detectblockages within blood vessels

How is PAD treated?People with PAD are at very high risk for heartattacks and stroke; therefore, it is very importantthat cardiovascular risk factors be managed.Follow these steps:

• Get help to quit smoking. Your health careprovider can help you.

• Aim for an A-1-C below 7%. The A-1-C testmeasures your average blood glucose (sugar)over the past 2 to 3 months.

• Lower your blood pressure to less than130/80 mmHg.

• Get your LDL cholesterol below 100 mg/dl.

• Talk to your health care provider abouttaking aspirin or other antiplatelet medicines.These medicines have been shown to reduceheart attacks and stroke in people with PAD.

Studies have found that exercise, such aswalking, can be used both to treat PAD andto prevent it. Medications may help relievesymptoms.

In some cases, surgical procedures are usedto treat PAD:

• Angioplasty, also called balloonangioplasty: a procedure in which a smalltube with a balloon attached is inserted andthreaded into an artery; then the balloon isinflated, opening the narrowed artery. A wiretube, called a stent, may be left in place tohelp keep the artery open.

• Artery bypass graft: a procedure in whicha blood vessel is taken from another part ofthe body and is attached to bypass a blockedartery.



Real-Life Stories from People with DiabetesLast summer my leg muscles had beenhurting, even when I walked a short distance.The pain would stop when I rested, but thenit would come back. At first, I thought it wasjust old age. I told my health care team aboutthe pain and also mentioned that there was asore on my foot that wasn’t healing. They didsome tests and said I had PAD. Now the painis gone—I’m taking pills for the PAD and I gofor a walk almost every day.

Sylvia P., age 60 • type 2 diabetes

What does diabetes have to dowith heart and blood vesseldisease?If you have diabetes, you’re much more likelyto have

• heart disease, also called coronary arterydisease

• blood vessel disease, such as atherosclerosis(hardening of the arteries) or peripheralarterial disease (PAD)

• a heart attack

• a stroke

You can cut your chances of having theseproblems by taking special care of your heart andblood vessels. In addition to regular checkups,your health care team can do special tests tocheck the condition of your heart and bloodvessels. If you already have heart or blood vesselproblems, your health care team can use specialprocedures to open up or bypass narrowed orblocked blood vessels. Choosing foods wisely,being physically active, and taking medicationscan also help you stay healthy.

This toolkit defines some of the medical tests andprocedures used for finding and treating heartand blood vessel disease. Terms are listed inalphabetical order.

Angiogram or arteriogramIn an angiogram (AN-gee-oh-gram) orarteriogram (ar-TEER-ee-oh-gram), dye is injectedinto the blood vessels using a catheter (smalltube) and X rays are taken. This test showswhether arteries are narrowed or blocked. Acoronary angiogram checks for narrowing orblockages in the blood vessels that go to theheart. A cerebral arteriogram checks theblood vessels that go to the brain.

AngioplastyAngioplasty (AN-gee-oh-plas-tee), also calledballoon angioplasty, is a procedure used toremove a blockage in a blood vessel to the heart

(coronary angioplasty) or the brain. A smalltube with a balloon attached is threaded into thenarrowed or blocked blood vessel. Then theballoon is inflated, opening the narrowed artery.A wire tube, called a stent, may be left in placeto help keep the artery open.

Ankle brachial indexA test called an ankle brachial index (BRAY-kee-al) or ABI is used to diagnose PAD. Thehealth care provider compares the blood pressurein the ankle with that in the arm. Lower bloodpressure in the lower part of the leg comparedwith the pressure in the arm may indicate PAD.

CABGSee the definition for coronary artery bypassgraft.

Cardiac catheterizationCardiac catheterization (CATH-ih-ter-ize-A-shun)is used in conjunction with other tests. A smalltube is inserted into an artery and guided intothe blood vessel of the heart.

Carotid artery surgeryCarotid artery surgery, also called carotidendarterectomy (en-dar-teh-REK-teh-mee),is used to remove buildups of fat inside theartery and to restore blood flow to the brain.

Toolkit No. 23

A number of medical tests and procedures are available todiagnose and treat heart and blood vessel disease.

Medical Tests and Procedures for Finding andTreating Heart and Blood Vessel Disease

Chest X rayA chest X ray shows the size and shape of theheart and can also show congestion in the lungs.

Coronary artery bypass graftDuring a coronary artery bypass graft, also calleda bypass or CABG (pronounced “cabbage”), ablood vessel taken from the leg, wrist, or chestis attached to the coronary artery to bypass ablockage and restore blood flow to the heart.A bypass graft can also be used for bloodvessels leading to the brain.

CT scanA CT (computed tomography), also called aCAT scan, uses special scanning techniques toprovide images of organs such as the brain.

ECGSee the definition for electrocardiogram.

EchocardiogramAn echocardiogram (EK-oh-CAR-dee-oh-gram)uses very-high-frequency sound waves(ultrasound) to produce images of the heartand blood vessels on a screen. Results indicatewhether the heart is pumping blood correctly.A stress echocardiogram uses either exerciseor medication and ultrasound to provide imagesof the heart and blood vessels under stress.

EKGSee the definition for electrocardiogram.

ElectrocardiogramAn electrocardiogram (ee-LEC-tro-CAR-dee-oh-gram), also called an ECG or EKG, providesinformation on heart rate and rhythm and showswhether there has been damage or injury to theheart muscle.

Exercise perfusion testAn exercise perfusion (per-FYOO-shun) test,also called a stress nuclear perfusion test,uses small amounts of radioactive material toproduce images of blood flow to the heart asyou exercise.

Exercise stress testExercise stress tests are used to find heart diseasethat is evident only during physical activity.These tests can also be used to help a patientchoose the most appropriate physical activityprogram. Also called a treadmill test, a stresstest uses an ECG to measure how the heartperforms during activity, such as walking on amoving treadmill. A medication stress testuses medication instead of exercise to increasethe heart rate.

Holter monitoringA Holter monitor is a small, portable machinethat records the heart’s electrical activity. Theperson wearing the monitor keeps track ofsymptoms and activities for the evaluation period.Readings on the machine are compared with thesymptoms.

MRIMRI (magnetic resonance imaging) uses specialscanning techniques to provide images of bodytissues. MRA (magnetic resonance angiography)uses MRI to examine blood vessels.

Nuclear ventriculographyNuclear ventriculography (ven-trick-yu-LAH-greh-fee), also called radionuclide (ray-dee-oh-NEW-clyde) ventriculography, uses small amounts ofradioactive material to check heart function eitherwhile the body is at rest or during exercise. Thistest can also be used to check the blood vesselsthat go to the brain.

PET scanA PET (positron emission tomography) scan usesspecial scanning techniques to provide images ofbody tissues.

Stress testSee the definition for exercise stress test.



When you’re taking several medicines, it can behard to keep track of them. But you’ll feel betterif you take steps to manage your medicines.These tips can help you stay healthy:

• Know the basics about your medicines, suchas what they’re for and when to take them.

• Take your medicines as recommended.

• Tell your health care providers which medicines(prescription and nonprescription) and dietarysupplements (such as vitamins) you use.

Knowing the basicsAsk your health care provider or your pharmacistthese questions about your medicines. Write theinformation on the “My Medicines” chart.

❒ What are the names of my medicines (brandand generic names)?

❒ What’s the strength? (for example, the numberof milligrams, abbreviated as mg)

❒ What’s this medicine for?

❒ How long will it take this medicine to work?

❒ How much should I take for one dose?

❒ When should I take it? How many times aday? At what times?

❒ Should I take it on an empty stomach?

❒ Should I avoid any foods or medicines whenI take it?

❒ Should I avoid alcoholic beverages when I’mtaking this medicine?

❒ How does this medicine affect my bloodglucose (sugar) level?

❒ Do I need to avoid driving when I take thismedicine?

❒ What side effects might happen with thismedicine?

❒ What should I do if I experience side effects?

❒ What should I do if I miss a dose?

❒ How should this medicine be stored?

❒ How long will this supply last? What aboutrefills?

Taking your medicines asrecommendedWhen you don’t take a medicine as prescribed,the effect on your health can be unpredictable—or even dangerous. If you’re not taking yourmedicine, think about the reasons. Are thereunpleasant side effects? Is the medicine tooexpensive? Is it hard to remember to take it?Tell your health care providers. They may beable to help.

Tips to help you remember to takeyour medicines• Try using a pill organizer with a compartment

for each day of the week.

• Link your pill-taking to something in yourdaily routine. For example, take your morningmedicine right after you brush your teeth.

• Use a chart to check off when you’ve takenyour medicines.

Telling your health care providersabout your medicinesSome combinations of prescription medicines,nonprescription medicines, and dietarysupplements can be harmful. Each of your healthcare providers should be aware of all of themedicines you take, including nonprescriptionmedicines (such as aspirin and laxatives) anddietary supplements (vitamins, minerals, herbs,and other substances). Use the “My Medicines”chart to list all of your medicines. Take a copywith you when you see each of your health careproviders. You can also give a copy to a friendor a family member.

Toolkit No. 24

Real-Life Stories from People with DiabetesThe herbal supplement from the health foodstore was all natural so I didn’t think it coulddo any harm. I told my doctor about it andthen I learned that it could keep my bloodpressure medicine from working.

Bernice L., age 75 • type 2 diabetes

Managing Your Medicines

Datestarted

Prescription medicines

Nonprescription medicines and dietary supplements (vitamins, minerals, herbs, and other substances)

Notes**When to takeHow muchto takeUsed for

Name and strength* of medicine

My Medicines



*Strength means the number of milligrams (mg) or otherunits. You can find this information on the label.

**Foods or other medicines that should not be taken withthis medicine, side effects, and other notes.

Toolkit No. 25

My Game Plan:Food and Activity Tracker

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MAKE ONE (1) COPY OF THIS PAGE.

Tips for Heart-Healthy Eating• Eat smaller portions.

• Choose non-fat or low-fat dairy products.

• Choose lean meats.

• Remove skin from chicken and other poultry.

• Eat at least 5 servings of vegetables and fruits everyday.

• Split entrees and desserts with a friend when eatingout.

• Ask for dressings, sour cream, and sauces on the side.

Tips to Increase Your Activity• Take the stairs instead of the elevator.

• Park your car at the far end of the parking lot.

• Take a 5- to 10-minute walk after each meal.

• Play with a child.

• Work in the yard or garden.

• Take an exercise class.

• Go dancing with friends.

For more information on diabetes, meal planning, orexercise, contact the American Diabetes Association at1–800–DIABETES (342–2383) or visit diabetes.org.Adapted from “Small Steps. Big Rewards. Prevent Type 2 Diabetes,”a campaign of the National Diabetes Education Program.Visit www.ndep.nih.gov for more information.

Name: __________________________________________

Date: From ________________ to __________________

MY GOALS THIS WEEK

For cutting calories: _______________________________

________________________________________________

For getting more physical activity:___________________

________________________________________________

Sample Entry:

DAY: Monday DAILY FOOD AND DRINK TRACKER

TIME AMOUNT/NAME/DESCRIPTION

8:00 AM 1/2 cup oatmeal

1 cup 2% milk

TO MAKE MORE WEEKLY TRACKERS: Make one (1) copy of this pageand three (3) copies of the next page. Cut the pages in half, placing thispage on top. Staple in the upper left-hand corner and fold to fit in yourpocket or purse.


DAY: DAILY FOOD AND DRINK TRACKER


DAILY FOOD AND DRINK TRACKER (CONTINUED)


DAILY PHYSICAL ACTIVITY

TYPE OF ACTIVITY MINUTES

TOTAL

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TOTAL







TOTAL

Toolkit No. 26

Blood Glucose Log


MAKE ONE (1) COPY OF THIS PAGE.

If you have high blood glucose, make notes in yourlog and talk with your health care team about possiblechanges to your meal plan, physical activity, or diabetesmedications.

Low blood glucose occurs when your blood glucoselevel drops below 70 mg/dl. Symptoms include:

• hunger

• nervousness and shakiness

• sweating

• light-headedness or confusion

• sleepiness

If you think your blood glucose is too low, check it.If it’s 70 mg/dl or less, have one of these items rightaway:

• 2 to 5 glucose tablets

• 1/2 cup (4 ounces) of fruit juice

• 1/2 cup (4 ounces) of a regular (not diet) soft drink

• 8 ounces of milk

• 5 to 7 pieces of hard candy

• 2 teaspoons of sugar or honey

After 15 minutes, check your blood glucose again. Ifit’s still below 70 mg/dl, have another serving. Repeatthese steps until your blood glucose is at least 70 mg/dl.

Name: __________________________________________

Date: From _________________ to _________________

My Doctor

Name: __________________________________________

Phone: _________________________________________

My Diabetes Educator

Name: __________________________________________

Phone: _________________________________________

TO MAKE MORE MONTHLY LOGS: Make one (1) copy of this page andtwo (2) copies of the next page. Cut the pages in half, placing this pageon top. Staple in the upper left-hand corner and fold to fit in your pocketor purse.FOR DIABETES INFORMATION: Contact the American DiabetesAssociation at 1–800–DIABETES (342–2383) or visit diabetes.org.


My blood glucose targets

Before meals: _________________ to ___________________

2 hours after the start of a meal: Less than ______________

Date Time Breakfast Medication/Comment Time Lunch Medication/Comment Time Dinner Medication/Comment Time Snack/Other Medication/Comment

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