Take Charge doc - Hawaii Department of Health

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Take Charge ofYour Diabetes

Hawaii Revised Edition1999

Diabetes Awareness CoalitionState of Hawai‘i, Department of Health, Diabetes Control Program

Papa Ola LökahiU.S. Department of Health and Human Services

Public Health ServiceCenters for Disease Control and Prevention

National Center of Chronic Disease Prevention and Health PromotionFunded by Alpha Gamma Delta Foundation

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Suggested citation:Centers for Disease Control and Prevention. Take Charge of Your Diabetes.Hawai‘i Revised Edition 1999. Department of Health and Human Services.

This publication is in the public domain. Anyone may reproduce any or all ofthe contents.

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In ancient Hawai‘i, runnerswere chosen to deliver messagesfor the ali‘i or chiefs. Those cho-sen for this honor were thefastest and brightest. They hadto be in excellent health—in body,mind, and spirit. It is said thatthe best of these special runnerswas so quick he could deliver alive fish to the other side of anisland; mentally so keen andassured that he could accuratelyrecite long and complex messagesafter running great distances.

He stands for the health each

of us can achieve. He reminds usto look to our rich heritage of val-ues, skills and knowledge of guid-ance for healthy living today.Even in our modern world, wecan eat the right kinds of foods asthe Hawaiians did. We can workhard and play hard. We canmaintain honest relationships.We can live a life of respect forthe ‘äina. Each of us can commitourselves to learn and use thebest from the past and present.We can be as healthy as this run-ner from the past.

OLA

HEALTH LIFE

Table of Contents

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Mahalo Nui Loa! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2 Controlling Your Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

3 Keeping Track of Your Blood Glucose. . . . . . . . . . . . . . . . . . . . . . . . . . 31

4 Feelings about Having Diabetes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

5 Eye Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

6 Kidney Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

7 Heart and Blood Vessel Problems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

8 Nerve Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

9 Foot Problems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

10 Dental Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

11 Vaccinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

12 Pregnancy, Diabetes, and Women’s Health . . . . . . . . . . . . . . . . . . . . 71

RECORDSRecord for Sick Days. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75Tests and Goals for Each Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85Tests and Goals for Each Year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95Glucose Log Sheet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101Your Health Care Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

APPENDIXESGlossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

This guide was written by theCenters for Disease Control andPrevention’s Division of DiabetesTranslation, which is part of theNational Center for ChronicDisease Prevention and HealthPromotion. William H. Herman,M.D., M.P.H., was the generaleditor of the first book, TakeCharge of Your Diabetes: AGuide for Care, printed in1991. People with diabetes whoread the first book were asked tohelp us make this book evenmore helpful.

The American Association forDiabetes Educators did a surveyamong people with diabetes anddiabetes educators to learn whatpeople liked and didn’t like aboutthe first book. Special thanks forhelping conduct this survey go toBetty Brackenridge, Linda Haas,Julie Meye, Jean Betschart, KrisErnst, and Robert Anderson.Focus groups made up of personswith diabetes were held byHealth Promotion Council of SEPennsylvania and Casals andAssociates of Washington, D.C.The groups gave us valuableinput to help make this bookmore useful.

Important support for thisbook’s emphasis on glucose con-trol came from the DiabetesControl and Complications Trial.Conducted by the NationalInstitute of Diabetes andDigestive and Kidney Disease,this important study providedscientific proof that glucose con-trol can help prevent or delaycomplications of diabetes.

The Hawai‘i edition wasadapted for Hawai‘i residents bythe Diabetes AwarenessCoalition, Papa Ola Lökahi andthe Hawai‘i State DiabetesControl Program of the Hawai‘iDepartment of Health.Significant assistance with theinformation on nutrition andexercise came from the Hawai‘iDepartment of Health’s NutritionBranch and the Physical ActivityPromotion Project, and MauliOla, Native HawaiianCommunity Nutrition Initiative.

Special thanks to the peopleliving with diabetes in Hawai‘iwho reviewed the material andcontributed their thoughts andideas to help bring the book clos-er to home. Feedback was given

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Mahalo Nui Loa!

by members of the diabetes sup-port groups at Castle MedicalCenter, Molokai, and PaloloValley Homes. These groups pro-vided us with valuable insights,information and suggestions tomake the book more appropriate

for use in Hawai‘i.

Production and publishingwere sponsored by the AlphaGamma Delta Foundation. Thelayout and graphics were provid-ed by ‘A‘a Hui Designs.

Take Charge of Your Diabetes

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your eyes, your kidneys and yournerves. It can lead to problemswith the blood circulation of yourbody. Even your teeth and gumscan be harmed. And diabetes in

pregnancy can cause specialproblems. Many of theseproblems don’t have to hap-pen. You can do a lot to pre-vent them, and there are peo-ple in your community whocan help. This book can helpyou find how to get the helpyou need to prevent prob-lems.

Today and every day, youneed to balance your food,

physical activity, and medicine.Testing your own blood glucose

(also called blood sugar) helpsyou see how this balance is work-ing out. You can then make choic-es that help you feel well day-to-day and protect your health.

Feeling healthy can allow youto play a big part in the life ofyour family and community. Youmay even want to join a commu-nity group to help others dealwith their diabetes.

Take Charge of Your Diabeteswas written to help you take

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Diabetes touches almost everypart of your life. It’s a serious,lifelong condition, but there’s somuch you can do to protect yourhealth. You can take charge ofyour health—not only for today,but for the coming years.

Diabetes can cause healthproblems over time. It can hurt

1 Introduction

Take charge of your health—for today andfor the coming years

important steps to prevent prob-lems caused by diabetes. You’lllearn many useful things:

• What problems diabetes cancause.

• How to work with a healthcare team to prevent theproblems.

• Why it is important to getyour blood glucose closer tonormal.

• How to find out aboutresources in your communi-

ty to help you prevent prob-lems.

It’s important to work with aprimary care provider, as well asother members of a team thatcare about your health. To findout about resources in your com-munity, telephone one of thegroups listed below:

• Your state medical associa-tion, listed in the businesssection of your phone book.

• Your state Department ofHealth’s Diabetes Control


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A community group can help make lifebetter for people living with diabetes.

Program, listed in yourphone book.

• Local hospitals, listed in theyellow pages.

• Diabetes organizations, list-ed on page 119 of this book.

Ask your health care team tolook over this book with you.

Stay in touch with them so youwill know the latest news aboutdiabetes care.

Balance is the key word in liv-ing well with diabetes. Strive forbalance in all parts of your life.With the support of your familyand friends, your health care

team, and your community, youcan take charge of your diabetes.

What Is Diabetes?

Most of the food we eat isturned into glucose (sugar) forour bodies to use for energy. Thepancreas, an organ near thestomach, makes a hormone calledinsulin to help glucose get intoour body cells. When you havediabetes, your body either doesn’tmake enough insulin or can’t useits own insulin very well. Thisproblem causes glucose to buildup in your blood.

Signs and Symptoms ofDiabetes

You may recall having somesigns before you found out youhad diabetes:

• Being very thirsty.

• Urinating often especially atnight.

• Having blurry vision fromtime to time.

• Feeling very tired much of thetime.

Introduction

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Work with your health care team to takecharge of your diabetes.

• Losing weight without trying.

• Having very dry skin.

• Having sores that are slow toheal.

• Getting more infections thanusual.

• Losing feeling or getting atingling feeling in the feet.

• Vomiting.

Types of Diabetes

There are two main typesof diabetes:

• Type 1.

• Type 2.

Another type of diabetesappears during pregnancy insome women. It’s called gesta-tional diabetes.

One out of ten people withdiabetes has Type 1 diabetes.These people usually find outthey have diabetes when they arechildren or young adults. Peoplewith Type 1 diabetes must injectinsulin every day to live. Thepancreas of a person with Type 1

makes little or no insulin.Scientists are learning moreabout what causes the body toattack its own beta cells or thepancreas (an autoimmuneprocess) to stop making insulin inpeople with certain sets of genes.

Most people with diabetes—nine out of ten— have Type 2diabetes. The pancreas of peoplewith Type 2 diabetes keeps mak-ing insulin for some time, but thebody can’t use it very well. Mostpeople with Type 2 find out abouttheir diabetes after age 30 or 40.


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Whether you have Type 1 or Type 2 diabetes,work closely with your health care provider.

Certain risk factors make peo-ple more likely to get Type 2 dia-betes. Some of these are:

• A family history of diabetes.

• Lack of exercise.

• Weighing too much.

• Being of Asian/PacificIslander, Native Hawaiian,American Indian,Hispanic/Latino or AfricanAmerican heritage.

On the next page is a weightchart. If you weigh more than theweight that matches your heighton the chart, tell your health careprovider. You can help manageyour diabetes by controlling yourweight, making healthy foodchoices, and getting regular phys-ical activity. Some people withType 2 diabetes may also need totake diabetes pills or insulinshots to help control their dia-betes.

Introduction

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Whether you have Type 1 or Type 2 diabetes,learn what your community has to offer you.

Women(shows 20% over ideal weights)

Height Weight (w/out shoes) (w/out clothing)

Feet Inches Pounds

4 9 134

4 10 137

4 11 140

5 0 143

5 1 146

5 2 150

5 3 154

5 4 157

5 5 161

5 6 164

5 7 168

5 8 172

5 9 175

5 10 178

5 11 182

Men(shows 20% over ideal weights)

Height Weight (w/out shoes) (w/out clothing)

Feet Inches Pounds

5 1 157

5 2 160

5 3 162

5 4 165

5 5 168

5 6 172

5 7 175

5 8 179

5 9 182

5 10 186

5 11 190

6 0 194

6 1 199

6 2 203

6 3 203


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At-Risk Weight Chart

There’s good news for peoplewith diabetes. Keeping yourblood glucose (also called bloodsugar) close to normal helps pre-vent or delay some diabetes prob-lems.

New studies have shown thatthrough such control, at least

half of the expected eye disease,kidney disease, and nerve dam-age was prevented or slowed.

You can get more informationon managing your diabetesthrough the National DiabetesInformation Clearinghouse at 1-800-GET-LEVEL (1-800-438-5383).

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2 Controlling Your Diabetes

You may find that your community supports your efforts to control your diabetes.

Diabetes and Your Diet

To keep your blood glucose ata healthy level, you need to keepa balance between these things:

• What you eat and drink

• When you eat and drink

• How much you eat and drink

• How much physical activityyou do

• Your diabetes pills or insulin,if you need it

People living with diabetes donot have to follow strange dietsor eat only certain foods. But it isimportant for people living withdiabetes to make healthy eatingchoices! Healthy eating meanseating a wide variety of foods.People with diabetes will alsoneed to think about how the foodthey eat will affect their bloodglucose.

Your goals of healthy eatingare to:

• maintain healthy blood glu-cose levels

• maintain or achieve healthybody weight

• eat the right amount of nutri-tion for good health

One of the risk factors for dia-betes is weighing too much. Yourbody uses something calledinsulin to change the food you eatinto energy. Having too muchbody fat can make it hard forinsulin to do its job. This is called“insulin resistance.” If you weightoo much, losing weight, even aslittle as 5-10 pounds, can helpyou to control blood glucose bet-ter. Making healthy eating choic-es can be a challenge. Look for aRegistered Dietitian (R.D.) tohelp you with a meal plan. Andkeep in mind, there is a lot tolearn about healthy eating, so donot try to do it all in one session!


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If you weigh too much, losingweight can help you to bettercontrol your blood glucose.

Guidelines for Healthy Eating

Careful meal planning is oneof the most important things youcan do to manage your diabetes.People with diabetes can usemeal planning and exercise tobest manage their diabetes. Thegoals of meal planning are to eatthe right foods in the rightamounts at the right times tokeep blood glucose level normal.See a Registered Dietitian to helpyou with the following guidelines:

1. Eat Three Meals a DaySpread your meals throughoutthe day to keep blood glucoseat healthy levels. This meanseating three meals a day, withno more than five hoursbetween meals. Do not skipmeals! Add snacks if neces-sary.

2. Pay Attention to Portion SizesThis helps to reach or main-tain a reasonable body weight.By controlling portion sizes,you can better control yourblood glucose better.

3. For Meals, Choose FoodsFrom Three or More FoodGroupsBy eating foods from three ormore food groups, you cankeep your blood glucose at

healthy levels. Example:starch, vegetables and protein.

4. Choose Foods Lower in FatSelect foods such as non-orlow-fat dairy products, leanercuts of meat, fish, or poultryand low-fat snack foods. Eatless fried foods and use lowerfat cooking methods. Go easyon the butter or margarineand mayonnaise.

5. Choose Foods High in FiberChoose foods such as wholegrain bread and cereals,beans, and fresh vegetablesand fruits.

6. Limit Sweets and AlcoholThese types of foods upsetyour blood glucose levels andshould be limited.Ask your dietit-ian how tosafelyincludethese inyour mealplan.


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Healthy eating means eating awide variety of foods. The foodguide pyramid shows a healthyand balanced way to eat. Thefoods closer to the base of thisguide are naturally lower in fatand calories. Eat more of theseevery day. The foods closer to thetop of the pyramid are naturallyhigher in fat and calories. Eatless of these every day.

Meal Planning

Keep in mind that a personwith diabetes does not need spe-cial foods. As long as your blood

glucose is under control, you canstill enjoy your favorite foods. Toplan your meals, keep in mindwhen you eat, how much you eat,and what you eat.

• What you eat and drinkThe majority of the glucose inyour blood after a meal comesfrom carbohydrates in yourfood. As carbohydrates are bro-ken down and absorbed, theamount of glucose in yourblood goes up. Your dietitiancan help you learn theamounts of carbohydrates youshould have for meals andsnacks.


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FOOD GUIDE PYRAMID Fats and OilsUSE SPARINGLY

Protein Group (meat, poultry & fish)2-3 SERVINGS

Fruit Group2-4 SERVINGS

Whole Grains andCereal Group6-11 SERVINGS

Milk and Calcium Group2-3 SERVINGS

Vegetable Group3-5 SERVINGS

• When you eat and drinkIf you have diabetes, it is bestto eat at the same times eachday. For people with Type 2diabetes, this might make iteasier for your body to releaseinsulin. If you are taking

insulin shots, eating at thesame time each day will helpthe insulin work better. Somepeople will also need to havesnacks during the day.

• How much you eat and drinkThe amount of food you eat ordrink at one time has a bigeffect on your blood glucose. Ifyou eat too much, your bloodglucose will go too high.Eating too much can alsocause you to gain weight.

Figuring Out Serving Sizes

If you have diabetes, servingsize (how much you eat of a food)can have a big effect on your


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If you are taking insulin shots, eating at thesame time each day will help the insulinwork better.

Ask your market to carry moreheart-healthy foods.

blood glucose. This makes learn-ing to judge serving size veryimportant. Sometimes a portionthat is the right size for you canbe measured using your ownhand. Here is a guide to help youcompare some common amountsof foods. If you have questionsabout how big or how many serv-ings are right for you, ask yourdietitian.

Rice, pasta, breads and cereals

• 1 cup of cooked brown rice orbeans is the size of a fist.

• 1/3 cup of cooked brown rice orbeans is one serving.

• 1/2 cup of cooked taro, pastaor potatoes is the size of 1/2 ofa tennis ball.

• 1 slice of bread, or 1/2 of abun.

Fruit

• 1 medium piece of fruit is thesize of a tennis ball.

• 4 1/2 inch banana or 1/2 of apapaya or grapefruit is oneserving.

Vegetables

• 1/2 cup cooked vegetables, 7-8baby carrots or carrot sticks,or 1 ear of corn.

• 1 serving fresh or raw vegeta-bles is the size of your fist.

• 1 cup of fresh leafy greens isabout 4 lettuce leaves.

• a medium potato


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Sometimes a portion that is the right size foryou can be measured using your own hand.

Talk to a dietitian to help you plan your meals.

Poultry, fish and meat

• 3 ounces of poultry, fish ormeat is the size of a deck ofcards, or the size of a cassettetape.

Dairy

• 1 ounce of cheese is the size ofa tube of lipstick, or a slice ofsingle wrap cheese.

Label Reading

Most foods in the grocery storemust have a nutrition label andan ingredient list. You can usethis label to learn how to fit foodsinto your meal plan. Learning toread food labels can also help youto choose foods that are better foryour health.

1. Serving Size: Is the amountyou eat the same as the serv-ing size on the label? Forexample, the serving size hereis 1/2 cup. So, if you eat 1 cup,remember, that is 2 servings! (1/2 cup serving x 2 =1 cup)

2. Calories and Calories from Fatare shown. The total caloriesinclude carbohydrate, proteinand fat.

3. Total Fat represents the gramsof fat in a single serving. Avoidproducts with high saturatedfat grams.

4. Total Carbohydrate gives theamount of carbohydrates ingrams per serving.

5. % Daily Value shows how foodsfit into a daily diet of 2,000calories. If you need more calo-ries, your own daily value maybe higher than what is listedon the label. If you need less,your own daily value may belower.


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2.

5.

1.

3.

4.

Nutrition FactsServing Size 1/2 cup (114g)Servings Per Container 1

Amount Per Serving

Calories 100 Calories from Fat 0

% Daily Value*

Total Fat 0g 0%

Saturated Fat 0g 0%

Cholesterol <5mg 2%

Sodium 140mg 6%

Total Carbohydrate 17g 6%

Dietary Fiber 0g 0%

Sugars 13g

Protein 9g

Vitamin A 0% • Vitamin C 0%

Calcium 30% • Iron 4%

*Percent Daily Values are based on a 2,000calorie diet. Your daily values may be higheror lower depending on your calorie needs.


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Instead of this... Try this!

Fatty, fried, or processed meat, fish, Lean meats, poultry without skin, tofu, or chicken beans, or fish

Butter, margarine, oil when cooking Nonstick pan, nonfat cooking spray, ora small amount of broth or wine

Cooking meat straight from the package Trimming off fat you can see, then simmer and drain the meat before adding to a recipe

Frying Baking, broiling, grilling, or steaming(easy on the sauce)

High fat cheeses like cheddar, Low-fat cheeses and cheeses made with Swiss, or American skim milk, such as mozzarella and

ricotta. Also, hard cheeses such asParmesan.

Coconut milk Low fat coconut milk

Salad dressing Low fat or fat-free salad dressingor flavored vinegar or lemon

In baking: a whole egg 2 egg whitesOil or fat Applesauce for 1/2 of oil or fatSour cream Plain yogurt or low-fat sour cream

Also control fat intake by limiting very high fat meats like luncheon meat, corned beef,spareribs and turkey tail, and limit portion sizes to 3 ounces.

Your doctor may want you tolimit other things in your diet,like sodium, cholesterol and satu-rated fat. These are also listed onthe food label. A dietitian canteach you more about readingfood labels and choosing appro-priate foods.

How to Cut Down the Fat

High-fat foods can add a lot ofcalories and may cause weightgain or make it hard to loseweight. Weighing too much canmake diabetes more difficult tocontrol. Here are some ways todecrease the fat in your diet:

Dining Out

The fact that you have dia-betes does not mean that youcannot eat out. You can maintainyour life-style and eat withoutproblems simply by learning howto choose foods carefully. Hereare a few guidelines that willhelp when dining out:

Before You Dine Out

• Know your meal plan andcarry it with you.

• Practice weighing and mea-suring foods at home.

• If on insulin, try to eat yourmeal on schedule.

Choosing a Restaurant

• Choose a restaurant thatallows substitutions and pre-pares food to order.

• Do not hesitate to explain tothe waiter or waitress thatyou would like to makechanges or substitutions toyour meal.

• Ethnic restaurants offer low-fat menu selections.

Healthful Food Choices

• Ask questions about how thefood is prepared and what theingredients are.

• Restaurant portions can belarge, so plan to share withsomeone else or request a dog-gie bag.

• Avoid table sugar, sugaredfoods and beverages.

• Drink 8-10 glasses of water aday.

• Plain is best. Creamed foods,foods with sauces or gravies,and battered-fried foods arehigher in fat and calories.


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Do not hesitate to explain that you wouldlike to make changes or substitutions to yourmeal.


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Local Foods

Do you know how healthy your favorite local or ethnic foods are? Arethey high or low in fat and calories? You can choose the better choice for ahealthier diet! Remember to keep in mind portion sizes when makingfood choices.

Better Choice Higher Fat and Calorie Choice

ChineseClear, broth-type soups * Fried noodlesSteamed rice Egg foo youngStir fry chicken, seafood, tofu, lean Peking duck

meat, steamed fish, or vegetables Egg rolls, spareribs

FilipinoAdobo w/lean chicken or pork Adobo, CascaronUtong Guisantes, DinoguanMungo beans LumpiaGelatin Most other dessertsPancitSoups: Kalamungay or okra *

HawaiianLow fat laulau, such as Pork laulau

skinless chicken or fish laulau Kälua pigChicken or squid lü‘au w/low-fat Chicken lü‘au with coconut milk

coconut milkHaupia w/low fat coconut milk HaupiaSweet potato, breadfruit, poi and taroLimu Poke, Lomi salmon

ItalianPasta primavera, red sauces Sausages, meatballsMinestrone soup * Veal or chicken parmigianaMarinara, clam or wine sauces Fettucini Alfredo, white or cream saucesThin crust pizza with vegetable Lasagna, cheese-filled pasta dishes

toppings and low-fat cheese

(* These are foods high in salt.)


JapaneseMiso soup * TempuraTeriyaki, yakitori dishes * Tonkatsu (fried pork)Yakimono (broiled) dishes * Torikatsu (fried chicken)Somen *, soba Butter mochi Sushi *, sashimi, Sukiyaki *Skinless, trimmed meats, poultry & fishKanten, mochi

KoreanSkinless BBQ chicken Meat or Fish JunHot or cold Kook-soo Kalbi *Kim chee *, other vegetables Fried ManduChop chae * Deep fried vegetablesSeaweed or tofu soup *

MexicanCeviche Fried tortilla chips *, Nachos, quesadillasSalsa Refried beans (if cooked with lard)Beans, skinless chicken or seafood Chimichanga, tostadoBurrito or soft shell taco made or taco (fried tortillas)

w/beans or lean meat Sour cream, guacamole, regular cheeseYellow or plain rice

PortugueseCaldo verde Portuguese bean soup *Midnight chicken soup Portuguese sausageSweet bread (in moderation) MalasadasPortuguese pickled vegetables *

SamoanFa‘alifu, Faiai Valuvalu, Fa‘alifu, Faiai Valuvalu,

Kopai, Suaalaisa, Suamasi, Kopai, Suaalaisa, Suamasi,and taro or breadfruit pudding and taro or breadfruit puddingmade with low fat coconut milk made with regular coconut creamor 1% milk or coconut milk

Steamed fish or lean chicken Corned beef *, luncheon meatTuna packed in water Tuna or sardines packed in oil2% milk or low fat coconut milk Miti, or coconut milkSteamed or boiled taro, or yam



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ThaiSummer rolls Spring rollsTom Yom soup * Tom kha soup *Thai chicken (no cashews) CurriesStir fry chicken, seafood, tofu Satays

or lean meat Fried riceVegetables, steamed riceGreen papaya salad

Salad BarSteamed or fresh vegetables Oil and vinegar salads

and fresh fruit like pasta saladBeans, peas, corn Mayonnaise based saladsWater packed tuna like macaroni saladTofu, low or non-fat cottage cheese Cheese, nuts, seeds, olivesReduced fat salad dressing Salad dressing

Bacon bits , croutons

Fast FoodsRegular hamburger (no mayonnaise) Specialty burger /cheeseburgerGrilled chicken or fish Fried or breaded chicken or fishGarden Salad w/low-fat dressing Chef salad, Regular salad dressingDiet drink, orange juice French friesNon-fat or skim milk Milkshakes



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Baked Won Ton

From: Kama‘äina Cookingwith Hawai‘i Association ofDiabetes Educators

1 carrot grated or finely diced1 onion grated or finely diced1/2 pound imitation crab meat,

chopped1/8 teaspoon black pepper1 container (15 oz.), Ricotta

cheese*1/4 teaspoon garlic powder40 won ton wrappers1 tablespoon olive oil

Preheat oven to 350 degrees.Combine vegetables, cheese, crabmeat, garlic powder, and pepper.Place 1 tablespoon cheese mix-ture on center of won ton. Brushedges with water. Fold corners toseal. Arranged on greased bak-ing dish. Lightly brush won tonwith oil. Bake 25 minutes untilcrisp and brown. Makes 20 serv-ings of won tons.

Calories: 114Carbohydrate: 16 gCholesterol: 11 mgDietary fiber: less than 1 gSodium: 266 mgProtein: 2 gFat: 3 g

* To lower the fat use Ricotta cheese madewith skim milk.

Chicken with Snow Peas

From: Kama‘äina Cookingwith Hawai‘i Association ofDiabetes Educators

1 pound boneless, skinlesschicken thighs or breasts

2 tablespoons low-sodium soysauce

3/4 teaspoon dried ginger pow-der

4 teaspoon corn starch2 round onion, chopped3 tablespoons chicken broth**2 tablespoons vegetable oil1/2 pound snow peas4 cloves garlic, chopped1/2 cup water

Cut chicken into cubes. Insmall bowl combine broth, soysauce, cornstarch and set aside.Heat oil in wok, add chicken andstir fry. Remove chicken. Add gar-lic, ginger, snow peas and water.Add in chicken and soy saucemixture. Stir rapidly. Serves 4.

Calories: 376Carbohydrate: 15 gCholesterol: 116 mgSodium: 486 mgDietary fiber: 3 gProtein: 36 gFat: 19 g

** To reduce the sodium use reduced sodi-um chicken broth.


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Crispy Cress Tofu Salad

From: 5 A Day the Hawai‘iWay: Easy island recipes

—Bill Smith

2 cups watercress, chopped16 ounce soft tofu, strained and

cubed2 tablespoons green onions,

chopped1/2 bag bean sprouts1 clove garlic1 teaspoon grated ginger1 tablespoon soy sauce1/2 tablespoon peanut oil

Arrange watercress on a plateor in a bowl. Place remainingingredients over watercress. Heatpeanut oil and pour on top ofsalad. Makes 8 side salads.

Calories: 54Carbohydrate: 3 gCholesterol: 0Sodium: 87 mgDietary Fiber: 0Protein: 5 gFat: 3 g

The 5 A Day Sushi


—Naomi Ichimura

Sour rice:2 cups cooked rice5 tablespoon rice vinegar2 tablespoon sugar1 tablespoon olive oil

In a big bowl, mix all ingredi-ents together. Cool and set aside.

1/2 cup cooked green peas1 Japanese cucumber, cut in 1/2

inch cubes1/2 ripe avocado, peeled and cut

into 1/2 inch cubes1 small can cooked mushrooms,

cut in half10 olives, cut in half 1 medium tomato, cut in 1/2

inch cubes1 orange, peeled and cut into

1/2 inch pieces1 papaya, peeled and cut into

1/2 inch cubesLightly toss all ingredients

with sour rice mixture. Serves 4.

Calories: 329Carbohydrate: 58 gCholesterol: 0Sodium: 226 mgDietary Fiber: 8 gProtein: 6 gFat: 9.5 g


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Popeye’s Favorite Eggplant


—Caryn Stankiewicz

2 long eggplants2 thumb size ginger1 tablespoon soy sauce1 1/2 tablespoon olive oil

Cut the crowns off the egg-plant. Cut the pieces in half(lengthwise), then slice into twoinch pieces. Microwave the egg-plant for four minutes.Meanwhile, peel the outer layerof ginger and grate; mix withshoyu. Fry the eggplant in asmall, non-stick pan with olive oiluntil lightly browned on bothsides. Drain eggplant on a papertowel. Serve with ginger-shoyusauce. Serves 2.

Calories: 173Carbohydrate: 29 gCholesterol: 0Sodium: 269 mgDietary Fiber: 0Protein: 5 gFat: 6 g

Peanut Butter Cups

From: The Diabetic DessertCookbook—Coleen Howard

4 cups carob1/8 teaspoon artificial sweetener

(Equal®)2 cups smooth dietetic peanut

butter

Melt carob and artificialsweetener in double boiler.Remove from heat. Pour meltedcarob into chocolate molds. Fill tohalf full. Then add peanut butter,leaving enough room at the top toadd more carob. Add enoughcarob to completely cover.Refrigerate until set, approxi-mately 20 minutes. Cut into 1”square X 1/2” deep. Makes 80pieces.

Calories: 91.9Carbohydrate: 7.25 gCholesterol: .907 mgSodium: 1.09 mgDietary Fiber: .422 gProtein: 3.42 gFat: 5.85 g


21

Turkey Tofu Loaf


—Bill Smith

1 1/2 pound ground turkey16 ounce soft tofu, drained and

mashed2 tablespoons green onions,

chopped2 tablespoons white onions,

chopped2 tablespoons water chestnuts,

chopped2 tablespoons celery, chopped1 cup grated carrots2 teaspoons soy sauce1 tablespoon oyster sauce

Mix all ingredients except soysauce and oyster sauce, and placein a loaf pan. Bake 45 minutes at350 degrees. Top with soy sauceand oyster sauce. Serves 10.

Calories: 141Carbohydrate: 3 gCholesterol: 54 mgSodium: 174 mgDietary Fiber: 0Protein: 15 gFat: 7 g

White Omelette


—Derek Traya

3 egg whites1 tablespoon fresh basil, minced1/4 cup fresh mushrooms, sliced1 small tomato, diced2 cups fresh spinachsalt and pepper to taste

Beat egg whites until stiffpeaks form. Fry the egg whites asyou would prepare a regularomelette. For the filling, combinethe basil, mushrooms, tomatoand spinach in just a tiny bit ofolive oil. Add salt and pepper totaste or substitute by using Mrs.Dash. Garnish with fresh basil.Serves 2.

Calories: 100Carbohydrate: 12 gCholesterol: 0Dietary fiber: 5 gSodium: 252 mgProtein: 14 gFat: 0.9 g


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Diabetes and Exercise

Exercise is an important toolin managing your diabetes. It canhelp you control your blood sugarand your weight. Exercise canalso help prevent heart problems.Many people say they feel betterwhen they get regular exercise.Here are some other benefits ofexercise:

• Strengthens heart, lungs, andbones

• Increases muscle tone,strength and endurance

• Controls weight and body fat

• Lowers blood pressure

• Improves your body’s ability toprevent a cold


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• Increases energy

• May decrease insulin dosageon exercise days

• Better sex

• Improves sleep

• Relieves stress

• Makes you feel good!

How to Get Started!

Starting an exercise programcan be easier than you maythink. Here are quick and easysteps to start exercising:

1. Talk with your doctor aboutfinding an activity that’s rightfor you.

2. Choose activities that youenjoy.

3. Start slowly, and don’t over doit.

4. Set realistic goals.

5. Make exercise a daily part ofyour life.

Your Exercise Program

You’ve made the importantdecision to exercise and stayhealthy. Before you begin anyexercise program, it is importantto talk to your doctor and healthcare team. They will want tomake sure you don’t have healthproblems that may keep you fromexercising safely. Work togetherto design an exercise plan that isbest for you.

To make sure that you get themost benefit out of your activity,there are a few things you shouldthink about as you plan yourexercise program. These thingsinclude: how often, how hard, andfor how long you should exercise.You should also consider whattype of exercise you would like todo.

How often should you exercise?

You should do some physicalactivity most days of the week.It’s better to walk 10 or 20 min-

utes each day than one hour oncea week. A good goal is to exerciseat least 3 times a week, or everyother day. Also, try to fit exerciseinto your day. Take the stairsinstead of using the elevator ortake a walk during your lunchbreak. For those on insulin, doingphysical activity everyday canhelp reduce the amount of insulinneeded each day.

How hard should you exercise?

You can decide what you canand cannot do, and how hard youcan push yourself. Keep the paceof the exercise comfortable. Tomeasure the intensity of yourworkout, here are two simplemethods:

• Talk Test: This test is simplytesting if you are exercising ata pace that allows you to carryon a conversation while youworkout. If you cannot talkduring exercise, you are exer-cising too hard and you shouldmake changes to your exerciseprogram.

• Rate of Exercise: This methodhelps you rate “How you feel”or your comfort level duringthe work-out. The recommend-ed range is usually between 5(hard) and 7 (very hard). You


24

should never feel like you areexercising at a 10 level.

For how long should you exer-cise?

Start with a 20 minuteworkout, with a warm up and acool down phase. If you cannotdo 20 minutes of exercise, dowhat you can and graduallyincrease the amount of timeyou are active.

Lucky you live in Hawai‘i

Hawai‘i’s sunny blue skies,beautiful beaches, and warmweather makes it easy to findoutdoor activities to do year-round. Here are a few exerciseideas:

beach walking wind-surfingwater aerobics hulahiking yogasurfing canoe paddlingtai chi kayakingswimming walkingdiving huntingmartial arts yard worksnorkeling activities with bicycling your children


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Rate of Exercise Scale

0 Nothing at all - lying down 0.5 very, very easy 1 very easy2 easy3 moderate4 somewhat hard5 hard67 very hard8910 very, very hard

—as hard as you can exercise

What type of exercise should youdo?

Choose an activity you reallylike. The more fun it is, the morelikely you will do it each day. It isalso a good idea to vary the typeof activity you do, so that you donot become bored or tired doingjust one type of activity all thetime. Make exercise a regularpart of your daily life.

Tips to keep motivated:

• Vary your activities

• Go easy at first

• Start with one activity, thengradually add others

• Find a friend to exercise with

• Make exercise a family affair

• Reward yourself as you reachyour exercise goals

The Exercise Activity

Each exercise activity shouldinclude 3 basic parts:

• the warm up phase

• the active phase

• the cool-down phase

1. The Warm Up phase:The warm up phase is impor-tant to get your body ready forexercise. Do 5 - 10 minutes ofslow, easy movements, such aswalking. Stretch out yourmuscles, but avoid bouncing.Talk to your diabetes educatoror physical activity expert tofind out what kind of stretchesyou should do. Continue


26

Exercise with a partner.

Swimming is a good way to getregular exercise.

warming up andgraduallyincrease thepace untilyou reach achallenginglevel.Rememberthat youshould beable to talk.

2. The Active phase:The active phase should

include exercises that uselarge musclegroups contin-uously for aperiod oftime. Thistype of exer-cise gets yourheart to beatfaster. Listento your body,and try not toover exertyourself. Workgradually toreach youroptimal work-out. The goalis to be physi-cally active forat least 20minutes, 3 ormore times aweek.

•Important! If you think youare having a low blood sugarepisode, (if you become dizzy,light-headed, or faint), stopthe exercise and test yourblood. If this is not possible,treat the symptoms and testas soon as you can.

3. The Cool Down phase:Never abruptly stop exercis-ing. Gradually slow down to arelaxed pace.This shouldtake 5 - 10minutes.Stretchout yourmuscles.Continue cooling down untilyour heart and breathing ratehas returned to normal.

Special tips for people withdiabetes to keep in mind:

• Drink plenty of fluids.Drinking 8 large glasses ofwater a day is recommended.

• Wear a necklace, tag, orbracelet that identifies you asa person with diabetes.

• Exercise with a partner.

• Wear socks and properly fittedshoes.


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• Check your feet daily for blis-ters, redness, cuts, or opensores.

There is a risk of having lowblood glucose levels during orafter exercise, especially for peo-ple with Type 1 diabetes and peo-ple with Type 2 diabetes on cer-tain medication. To avoid havinglow blood glucose levels whileexercising:

• Know your blood sugar levelbefore and after you exercise.

• Carry a fast acting sugar, suchas raisins or glucose tablets.

• Eat 1 - 3 hours before youplan on exercising.

• Talk to your health care teamabout changes in medication.

• Try not to exercise wheninsulin is working at it’s peak.

• If you are taking insulin,rotate injection site away fromthe muscle you are going to beusing.

• Find out how your blood glu-cose levels respond to differenttypes of exercise by takingblood glucose readings before,during, and after exercise.

• Try to exercise at the sametime each day.

• Never skip meals or snacksbefore exercising.

• You may need to eat more foodafter exercise, depending onhow long and hard you exer-cise.


28

Walking is a good way to get regular exercise

• Listen to your body. If some-thing doesn’t feel right, stopthe activity and test yourblood glucose level.

• If you don’t feel well, call yourdoctor or health care profes-sional.

A Few Things About DiabetesMedicine

If you take diabetes pills orinsulin injections to control yourdiabetes, ask your health careprovider to explain how thesework. It’s important to know howand when to take diabetes medi-cine. If you take other medicines


29

that are sold with or without aprescriptions, ask your doctorhow these can affect your dia-betes control. When you takeinsulin injections or diabetespills, your blood glucose levelscan get too low.

If you inject insulin, yourhealth care team should be ableto tell you

• How to give yourself injections.

• When you need to change yourinsulin dose.

• How to safely dispose ofneedles.

Be sure you know how and when to takeyour diabetes medicine.

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It’s important to your healthto control your blood glucose (alsocalled blood sugar). Keeping yourglucose close to normal helps pre-vent or delay some diabetes prob-lems, such as eye disease, kidney

disease, and nerve damage. Onething that can help you controlyour glucose level is to keep trackof it. You can do this by:

• Testing your own glucose anumber of times each day(self-monitoring blood glu-cose). Many people with dia-betes test their glucose two tofour times a day.

• Getting a hemoglobin A1c testfrom your health care providerabout every 3 months if youtake insulin and at least every6 months if you don’t takeinsulin.

These testscan help youand the rest ofyour diabeteshealth careteam—doctor,diabeteseducator, andothers—worktogether to

help youcontrol your blood

glucose.

Testing Your Blood GlucoseEach Day

You can do a test to find outwhat your blood glucose is at anymoment. Your health care teamcan show you how to do the testyourself. Using a finger prick,you place a drop of blood on aspecial coated strip, which

3 Keeping Track of Your Blood Glucose

Keep a daily record of your blood glucose levels.

“reads” your blood glucose. Manypeople use an electronic meter toget this reading.

Blood glucose testing can helpyou understand how food, physi-cal activity, and dia-betes medicine affectyour glucose level.Testing can help youmake day-to-day choic-es about how to balancethese things. It can alsotell you when your glu-cose is too low or toohigh so that you cantreat these problems.

Ask your health careteam to help you set agoal for your glucoserange and show youhow to record your glu-

cose readings in a logbook orrecord sheet. If you need a dailylogbook, ask your health careprovider for one. Or you canmake copies of page 104 if you

take insulin or page 102 if youdon’t take insulin. A sample

log sheet is filled out toshow you how to use each.

Be sure to write downeach glucose reading andthe date and time youtook it. When you reviewyour records, you can see apattern of your recent glu-

cose control. Keeping track ofyour glucose on a day-to-day

basis is one of the best ways youcan take charge of your diabetes.


32

Testing your own blood glucose level is a keyto taking charge of your diabetes.

Think of your daily log sheet as a diary for takingcharge of your diabetes.

Getting a Summary Lab Test(Hemoglobin A1c)

A hemoglobin A1c test usesblood drawn from a vein in yourarm to sum up your diabetes con-trol for the past few months.Hemoglobin A1c measures howmuch glucose has been stickingto part of the hemoglobin in yourred blood cells. Since each redblood cell is replaced by a newone every four months, this testsummarizes how high the glucoselevels have been during the life ofthe cells.

If your most recent blood glu-cose readings have been nearnormal (70-140 mg/dL, with thehigher readings occurring aftermeals), the hemoglobin A1c testwill be near normal (usually

about 6%-7%). If you’ve hadmany readings above normal, theextra glucose sticking to your redblood cells will make your hemo-globin A1c test read higher.

You should get a hemoglobinA1c test at least two times ayear. People who take insulinneed to get this test about fourtimes a year. Ask your healthcare provider for the results andrecord them on page 87. This testwill help you and your diabetescare team keep track of youraverage blood glucose control.

Ask your team to tell you thenormal range of values and helpyou set a goal for yourself. Writeyour goals down on page 87 ofthis guide. If your hemoglobinA1c is high, work with your team

to adjust yourbalance of food,physical activi-ty, and dia-betes medicine.When yourhemoglobinA1c test resultis near yourgoal, you’llknow you’vebalancedthings well.

33


Use your hemoglobin A1c test to track your glucose control.


34

Signs of Low Blood Glucose

Some possible signs of lowblood glucose:

• feeling nervous, shaky orsweaty

• feeling tired

• getting confused

• passing out

• having seizures

The signs may be mild at first.But a low glucose level can quick-ly drop much lower if you don’ttreat it. If you have any signsthat your glucose may be low,test it right away. If it’s less than60 to 70 mg/dL, you need to treatit right away.

Treating Low Blood Glucose

If you feel like your blood glu-cose is getting too low but youcan’t test it right then, play itsafe—go ahead and treat it. Eat10 to 15 grams of carbohydrateright away. The following areexamples of foods and liquidswith this amount of carbohy-drate.

If you have signs that your blood glucoseis low but you can’t test it right then....

...go ahead and treat it!

Treat it every 15 minutes, until your glucoselevel is normal.

35

Check your blood glucoseagain in 15 minutes. Eat another10 to 15 grams of carbohydrateevery 15 minutes until your bloodglucose is above 70 mg/dL or yoursigns have gone away.

Eating an item on the list onthis page will keep your glucoseup for only about 30 minutes. Soif your next planned meal orsnack is more than 30 minutesaway, you should go ahead andeat something like crackers and atablespoon of peanut butter or aslice of cheese.

In your glucose logbook orrecord sheet, write down thenumbers and the times when lowlevels happen. Think about what

may be causing them. If youthink you know the reason, writeit beside the numbers you record-ed. You may need to call yourhealth care provider to talk aboutchanging your diet, activity, ordiabetes medicine.


Write in in your logbookwhy you had a lowblood glucose level.

Food and Liquids for Low Blood Glucose(each item equals about 10 to 15 grams of carbohydrate)

Food Item Amount

Sugar Packets 2 to 3

Fruit juice 1/2 cup (4 ounces)

Soda (not diet) 1/2 cup (4 ounces)

Hard candy 3 to 5 pieces

Sugar or honey 3 teaspoons

Glucose tablets 2 to 3


36

Tell family members, closefriends, teachers and people atwork that you have diabetes. Tellthem how to know when yourblood glucose is low. Show themwhat to do if you can’t treat your-self. Someone will need to giveyou fruit juice, soda pop (notdiet), or sugar.

If you can’t swallow, someonewill need to give you a shot ofglucagon and call for help.Glucagon is a prescription medi-cine that raises the blood glucoseand is injected like insulin. If youtake insulin, you should have aglucagon kit handy. Teach familymembers, roommates, andfriends when and how to use it.

Waiting to treat low blood glu-cose is not safe. You may be indanger of passing out. If you getconfused, pass out, or have aseizure, you need emergencyhelp. Don’t try to drive yourselfto get help. Be prepared for anemergency.

Preventing Low Blood Glucose

Keep a balance

Try to stay close to your usualschedule of eating, activity, andmedicine. If you’re late getting ameal or if you’re more active thanusual, you may need an extrasnack.

Test your blood glucose

Keeping track of your bloodglucose is a way to know when ittends to run low. Show your log-book or record sheet to yourhealth care providers. Be sure tolet them know if you’re having anumber of low glucose readings aweek.

To be safe, always check yourglucose before doing any of thesethings:

• Driving a vehicle.• Using heavy equipment.• Being very physically active.• Being active for a long time.

In a low blood glucose emergency,you may need to go to the hospital.

Ask your health care teamwhether you should test your glu-cose before (or during) any otheractivities. Write these in thespace below.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Be prepared

Always carry some type of car-bohydrate with you so you’ll beready at any time to treat a lowglucose level. See the box on page

37

35 for snacks that have 10-15grams of carbohydrate.

Always wear something (likean identification bracelet) thatsays you have diabetes. Carry acard in your wallet that says youhave diabetes and tells if you usemedicine to treat it.

Having Problems With HighBlood Glucose

For most people, blood glucoselevels that stay higher than 140mg/dL (before meals) are toohigh. Talk with your health careteam about the glucose rangethat is best for you.

Eating too much food, beingless active than usual, or takingtoo little diabetes medicine aresome common reasons for high


Always carry along some foodwith carbohydrates in it.

Wear something that lets othersknow you have diabetes, in caseof an emergency.


38

blood glucose (or hyperglycemia).Your blood glucose can also go upwhen you’re sick or under stress.

Over time, high blood glucosecan damage body organs. For thisreason, many people with dia-betes try to keep their blood glu-cose in control as much as theycan.

Some people with diabetes arein danger of diabetic ketoacidosiswhen their glucose level stayshigh. You can tell if you’re in dia-betic ketoacidosis by checkingyour urine for ketones. If youhave ketones in your urine, callyour doctor or go to the hospitalright away. The most commonreason for diabetic ketoacidosis isnot taking your insulin. If youhave Type 1 diabetes, ask yourhealth care team about diabeticketoacidosis.

Your blood glucose is morelikely to go up when you’re sick,for example, when you have theflu or an infection. You’ll need totake special care of yourself dur-ing these times.

Signs of High Blood Glucose

Some common signs of high

blood glucose are:

• dry mouth

• thirst

• urinating often

• feeling tired

• blurred vision

• losing weight without trying

• stomach pain, feeling sick toyour stomach, or even throw-ing up

Frequent urination can be asign of high blood sugar.

39

If you have any signs thatyour glucose is high, test yourblood. In your logbook or on yourrecord sheet, write down yourglucose reading and the time youdid the test. If your glucose ishigh, think about what couldhave caused it to go up. If youthink you know of something,write this down beside your glu-cose reading.

Preventing High BloodGlucose

Keep a balance

Try to stay with your food andactivity plan as much as you can.Take your diabetes medicine

about the sametime each day.

Work withyour health

care teamto setgoals forweight,glucoselevel andactivity.

Test your blood glucose

Keep track of your glucose andgo over your records often. You’lllearn how certain foods or activi-

ties affect your glucose.

Show your records to yourhealth care team. Ask how youcan change your food, activity,and medicine to avoid or treathigh blood glucose. Ask when youshould call for help.

Taking Care of Yourself WhenYou’re Sick

Keep Taking Medicine

Be sure to keep taking yourdiabetes pills or insulin. Don’tstop taking them even if youcan’t eat. Your health careprovider may even advise you totake more insulin during sick-ness.


Balance is the key to takingcharge of your diabetes.

You’ll need to take special care of yourself when you’re sick.


40

What to Eat or Drink When You’re Sick(each item equals one bread or fruit exchange*)

Food Item Amount

Fruit juice 1/3 to 1/2 cup

Fruit-flavored drink 1/2 cup

Soda (regular, not diet) 1/2

*Jell-O™ (regular, not sugar free) 1/2 cup

*Popsicle™ (regular, not sugar free) 1/2 twin

Sherbet 1/4 cup

Saltine crackers 6 squares

Milk 1 cup

Thin soup (ex: vegetable, chicken noodle) 1 cup

Thick soup (ex: cream of mushroom, tomato) 1/2 cup

Ice cream (vanilla) 1/2 cup

Pudding (sugar-free) 1/2 cup

Pudding (regular) 1/4 cup

Macaroni, noodles, rice, mashed potatoes 1/2 cup (cooked)

* Use of trade names is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.

Keep Eating

Try to eat the same amount offruits and breads as usual. If youcan, eat your regular diet. Ifyou’re having trouble doing this,use food exchanges: eat enoughsoft foods or drink enough liquidsto take the place of the fruits andbreads you usually eat. A foodexchange is a measured portionof one type of food that can beeaten instead of another type offood. A food exchange will giveyou similar nutrients. Use thelist on the previous page to makefood exchanges for bread or fruit.

Drink Liquids

Drink extra liquids. Try todrink at least 1/2 cup (4 ounces)to 3/4 cup (6 ounces) every half-hour to hour, even if you have todo this in small sips. These liq-

uids should not have calories.Water, diet soda pop, or tea with-out sugar are good choices.

Check for Changes

• Test your blood glucose atleast every 4 hours. If yourglucose is 240 mg/dL or high-er, test your urine for ketones.Ketones are chemicals theliver makes when there’s notenough insulin in your blood.It’s easy to test for ketones.Buy urine ketone strips at thedrug store. Urinate on the padpart of the strip. Compare thecolor that the strip becomes tothe color example on the pack-age. If the pad turns a purplecolor, call your health careprovider right away.

• Weigh yourself every day.Losing weight without tryingis a sign of high blood glucose.

• Check your temperature everymorning and evening. A fevermay be a sign of infection.

• Every 4 to 6 hours, check howyou’re breathing and decidehow alert you feel. Havingtrouble breathing, feelingmore sleepy than usual, or notthinking clearly can be dangersigns.

41


Be sure to drinkextra fluids whenyou’re sick.


42

Keep Records

Use the “Records for SickDays,” starting on page 75. Ask afamily member or friend to helpif you need it.

Call for Help

Ask your health care providerwhen you should call. Duringyour sick times, you may need tocall every day for advice.

You should call your healthcare provider or go to an emer-gency room if any of the followinghappens:

• You feel too sick to eat normal-ly and for more than 6 hours

can’t keep food or liquidsdown.

• You have severe diarrhea.

• You lose 5 pounds or morewithout trying to.

• Your temperature is over101°F.

• Your blood glucose level islower than 60 mg/dL or staysover 300 mg/dL.

• You have moderate or largeamounts of ketones in yoururine.

• You’re having trouble breath-ing.

• You feel sleepy or can’t thinkclearly.

Managing Your Diabetes atWork, School, and in Travel

Staying in charge of your dia-betes no matter what your dayholds—work, school, travel, orspecial events—takes planningahead. Many days will gosmoothly, but some days will holdsurprises, such as extra activityor delays that throw your sched-ule off. Plan ahead for these

You may need to call your doctor dailywhen you’re sick.

43

times by always keeping a treat-ment for low blood glucose withyou (see page 35 some choices). Ifyou have any signs that your glu-cose may be low (see page 34), goahead and treat it right away.Stay as close to your eating,activity, and medicine scheduleas you can. Keep track of yourglucose so you can pick upchanges early. Always wear iden-tification that says you have dia-betes.

Talk with your health careteam about your planned sched-ule and activities. Ask for help inplanning ahead for work, travel

and special events. When youread the rest of this section, youmay think of more questions toask.

At Work and School

Talk with your health careteam about the type of activityyou do at work or at school. Fromtime to time, you and your healthcare team may need to makechanges in your activity, medi-cine, or eating.

Many people take supplies fortesting their glucose to work andto school so they can test at regu-


Stay in charge of your diabetes no matter what you day holds—by planning ahead.


44

lar break times. Some peoplechoose to show their fellow work-ers, their teacher, or their class-mates how to help if they shouldever have a problem. They teachthem how to tell when their glu-cose is low and how to treat it(see pages 34-36). Some peoplelike to have written steps on fileat their place of work or withtheir teacher.

In Travel

When you plan a trip, thinkabout your day-to-day scheduleand try to stay as close to it asyou can. For example, if you usu-ally test your blood glucose atnoon and then eat lunch, plan todo this on your trip, as well.

Trips can hold surprises—indelays and change. Even thetypes of food and supplies youcan buy on your trip may not bethe same as those you get athome.

Before you travel, work withyour health care provider to planyour timing for medicine, foodand activity. Talk about what todo if you find changes in yourglucose readings.

Plan ahead for trips:

• Keep snacks with you thatcould be used to prevent—ortreat—low blood glucose.

Talk with your health care provider aboutbalancing your daily activities and yourglucose needs.

45

• Carry extra food and drinksupplies with you, such ascracker packs and small cansof juices or bottled water.

• Carry plenty of glucose testingsupplies with you.

• Take along all the diabetesmedicine you’ll need.

When you travel, be sure to:

• Test your glucose often andkeep track of it.

• Wear identification that saysyou have diabetes.

• Let others know how they canhelp you.

If you’re traveling in a differ-ent time zone, you may need tochange your timing of food, medi-

cine, and activity. Ask yourhealth care provider to help

you with this. Talk aboutthe food and drink choic-

es that would behealthy for you. Ifyou’ll be in anothercountry, ask yourdoctor to write aletter explainingthat you havediabetes. It’salso a good ideato get your doc-tor to write aprescription foryou to getinsulin or sup-plies if needed.


No matter where you travel, you can take charge of your diabetes.

47

Living with diabetes isn’t easy.It’s normal to feel troubled withit. Tell your health care team howyou feel. Point out any problemsyou have with your diabetes careplan. Your diabetes educator orother health care provider maybe able to help you think of waysto deal with these problems.

Talk about the stresses youfeel at home, school, and work.How do you cope with these pres-sures? If your feelings are gettingin the way of taking care of your-self, you need to ask for help.

Support Groups

It helps to talk with other peo-ple who have problems like yourown. You may want to thinkabout joining a diabetes supportgroup. In support groups, peoplewho have just found out theyhave diabetes can learn from peo-ple who have lived with it for along time. People can talk aboutand share how they deal withtheir diabetes. They can also talkabout how they take care of theirhealth, how they prepare food,and how they get physical activi-

4 Feelings About HavingDiabetes

Ask your family to help you manage your diabetes.


48

ty. Family members who do nothave diabetes may want to join asupport group, too. Ask yourhealth care team about supportgroups for people with diabetesand their families and friends. Ifthere is not a support group inyour area, you may want to call adiabetes organization (see the liston page 119) about starting agroup.

Counseling

One-on-one and family coun-seling sessions may also help. Besure to see a counselor whoknows about diabetes and itscare. Ask your health careprovider to help you find a coun-selor.

It can help to talk with other people who have problems like your own.

49

Diabetic eye disease (alsocalled diabetic retinopathy) is aserious problem that can lead toloss of sight. There’s a lot you cando to take charge and preventsuch problems. A recent studyshows that keeping your bloodglucose closer to normal can pre-vent or delay the onset of diabeticeye disease. Keeping your bloodpressure under control is alsoimportant. Finding and treatingeye problems early can help savesight.

Signs of Diabetic Eye Disease

Since diabetic eye disease maybe developing even when yoursight is good, regular eye examsare important for finding prob-lems early. Some people maynotice signs of vision changes. Ifyou’re having trouble reading, ifyour vision is blurred, or if you’reseeing rings around lights, darkspots, or flashing lights, you mayhave eye problems. Be sure to tellyour health care team or eye doc-tor about any eye problems youmay have.

Protecting Your Sight

Keep Your Blood GlucoseUnder Control

High Blood Glucose can dam-age your eyes as time goes by.Work with your health care teamto keep your glucose levels asclose to normal as you can.

5 Eye Problems

If you’re having trouble with your vision, talk with your health care team or eye doctor.


50

Keep Your Blood PressureUnder Control

High blood pressure can dam-age your eyes. Have your healthcare provider check your bloodpressure at least four times ayear. If your blood pressure ishigher than 140/90, you maywant to buy a blood pressure cuffand check your blood pressure athome. Ask your health careprovider where you can buy acuff.

Get Regular Eye Exams

Even if you’re seeing fine, youneed regular, complete eye examsto protect your sight. Ask yourhealth care provider to help youfind an eye doctor who cares forpeople. Before the exam, a doctoror nurse will put eye drops inyour eyes to dilate the pupils.

You should have your eyesdilated and examined once ayear. Keep track of these examson page 97. Even if you’ve lostyour sight from diabetic eye dis-ease, you still need to have regu-lar eye care. If you haven’talready had a complete eye exam,you should have one now if any ofthese conditions apply to you:

• You’ve had Type 1 diabetes for5 or more years.

• You have Type 2 dia-betes.

• You’re going throughpuberty and you havediabetes.

• You’re pregnant andyou have diabetes.

• You’re planning tobecome pregnant andyou have diabetes.

You may want to check your blood pressureat home.

51

If you can’t afford an eyeexam, ask about a paymentplan or a free exam. Ifyou’re 65 or older, Medicaremay pay for diabetic eyeexams (but not glasses).Ask your eye doctor toaccept the Medicare fee asfull payment.

Discuss Your PhysicalActivity Plan

If you have diabetic eyedisease, talk with yourhealth care provider aboutthe kind of physical activitythat is best for you.

Treating Diabetic Eye Disease

Treating eye problems earlycan help save sight. Lasersurgery may help people whohave advanced diabetic eye dis-ease. An operation called vitrecto-my may help those who have losttheir sight from bleeding in theback of the eye.

If your sight is poor, an eyedoctor who is an expert in lowvision may be able to give youglasses or other devices that canhelp you use your limited visionmore fully. You may want to askyour health care provider aboutsupport groups and job trainingfor people with low vision.

5 Eye Problems

Think of a way to remind yourself toget an eye exam each year.

Get a complete eye exam each year.

53

Diabetes can cause diabetickidney disease (also called dia-betic nephropathy), which canlead to kidney failure. There’s alot you can do to take charge andprevent kidney problems. Arecent study shows that control-ling your blood glucose can pre-vent or delay the onset of kidneydisease. Keeping your blood pres-sure under control is also impor-tant.

The kidneys keep the rightamount of water in the body andhelp filter out harmful wastes.These wastes then pass from thebody in the urine. Diabetes cancause kidney disease by damag-ing the parts of the kidneys thatfilter out wastes. When the kid-neys fail, a person has to havehis or her blood filtered througha machine (a treatment calleddialysis) several times a week orhas to get a kidney transplant.

Testing Your Kidneys

Your health care provider canlearn how well your kidneys areworking by testing for albumin (aprotein) in the urine. Albumin inthe urine is an early sign of dia-betic kidney disease. You shouldhave your urine checked for albu-min every year.

Your health care provider canalso do a yearly blood test tomeasure your kidney function. Ifthe tests show albumin in theurine or if your kidney functionisn’t normal, you’ll need to bechecked more often.

6 Kidney Problems

Take care of your kidneys by controlling yourblood glucose and blood pressure.


54

On page 97, write down thedates and results of these tests.Ask your health care provider toexplain what the results mean.

Protecting Your Kidneys

Keep Your Blood GlucoseUnder Control

High blood glucose can dam-age your kidneys as time goesby. Work with your health careteam to keep your glucose levelsas close to normal as you can.

Keep Your Blood PressureUnder Control

High blood pressure can dam-age your kidneys. You may wantto check your blood pressure athome to be sure it stays lowerthan 140/90. Have your healthcare provider check your bloodpressure at least four times ayear. Your doctor may have youtake a blood pressure pill, calledan ACE inhibitor, to help protectyour kidneys.

Choose Healthy Foods

You may want to talk to yourhealth care team about cutting

Work with your health care provider to prevent kidney problems.

Controlling your blood glucose levels and yourblood pressure may help to prevent or delay kid-ney failure.

55

back on foods that are high inproteins (such as meat, milk andcheese). A diet high in proteinscan cause more damage to yourkidneys over time. Eating lesssalt is also a good idea.

Preventing and TreatingInfections

Bladder and kidney infectionscan damage your kidneys. Callyour health care provider rightaway if you have any of thesesigns of bladder infection:

• Cloudy or bloody urine.

• Pain or burning when you uri-nate.

• An urgent need to urinateoften.

Call your health care providerright away if you have any ofthese signs of kidney infections:

• Back pain.

• Chills.

• Fever.

• Ketones in the urine.

Your health care provider willtest your urine. If you have abladder or kidney infection, you’llbe given medicine to stop theinfection. After you take all themedicine, have your urinechecked again to be sure theinfection is gone.

Know the Effects of SomeMedicines and X-Ray Dyes

If you have kidney disease,ask your health care providerabout the possible effects thatsome medicines and X-ray dyescan have on your kidneys.

6 Kidney Problems

Tell your health care provider if you haveany signs of kidney or bladder infection.

57

Heart and blood vessel prob-lems are the main causes of sick-ness and death among peoplewith diabetes. These problemscan lead to high blood pressure,heart attacks, and stroke.Heart and blood vesselproblems can alsocause poor blood flow(circulation) in thelegs and feet.

You’re more likelyto have heart andblood vessel prob-lems if you smokecigarettes, havehigh blood pres-sure, or have toomuch cholesterolor other fats inyour blood. Talkwith your healthcare team aboutwhat you can do tolower your risk forheart and bloodvessel problems.

Signs of Heart and BloodVessel Problems

If you feel dizzy, have suddenloss of sight, slur your

speech, or feel numb orweak in one arm or

leg, you may be hav-ing serious heart andblood vessel prob-lems. Your bloodmay not be gettingto your brain aswell as it should.

Danger signs ofcirculation prob-lems to the heartinclude chest painor pressure, short-ness of breath,swollen ankles, orirregular heart-beats. If you haveany of these signs,go to an emergencyroom or call yourhealth careprovider rightaway.

7 Heart and Blood VesselProblems

You can do a lot to keep yourheart and blood vessels healthy.

about how to safely lose weight.Ask about a physical activity orexercise program for you. Seepages 9-28 to read more abouthealthy choices for food and phys-ical activity.

Don’t Use Tobacco

Smoking cigarettes causeshundreds of thousands of deathseach year. When you have dia-betes and also use tobacco, therisk of heart and blood vesselproblems is even greater. One ofthe best choices you can make foryour health is to never startsmoking—or if you smoke, toquit.

At least once a year, yourhealth care provider will ask youabout tobacco use. If you smoke,ask your provider about thingsyou can do to help you stop, suchas joining a stop-smoking pro-gram.


58

Signs of circulation problemsto your legs are pain or crampingin your buttocks, thighs, or calvesduring physical activity. Even ifthis pain goes away with rest,report it to your health careprovider.

Preventing and ControllingHeart and Blood VesselProblems

Eat Right and Get PhysicalActivity

Choose a healthy diet, low insalt, fat and cholesterol. Workwith a dietitian to plan healthymeals. If you're overweight, talk

If you’re overweight, talk with your dietitianabout how to safely lose weight.

Not smoking is the healthiestchoice you’ll make for your heart.

Check Your Blood Pressure

Get your blood pressurechecked at each visit. Recordthese numbers on page 87. Ifyour blood pressure is higherthan 140/90, you may want tobuy a blood pressure cuff andcheck your blood pressure athome. Ask your health careprovider where you can buy acuff.

If your blood pressure is stillhigh after 3 months, you mayneed medicine to help control it.Many medicines are available totreat high blood pressure. If youhave side effects from the medi-cine, ask your health careprovider to change it.

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7 Heart and Blood Vessel Problems

Check Your Cholesterol

Get your cholesterol checkedonce a year. Record the results onpage 97. Your total cholesterolshould be lower than 200 mg/dL.Ask your health care team toexplain what your HDL and LDLlevels are.

If your cholesterol is higherthan 200 mg/dL on two or morechecks, you can do several thingsto lower it. You can work withyour health care team to improveyour blood glucose control, youcan lose weight (if you’reoverweight), and you can cutdown on foods that are high infat and cholesterol. Ask yourhealth care team about foods thatare low in fats. Also ask about aphysical activity program.

Get your blood pressure checked regularly.

Choose heart-healthy foodsfor your meal plan.

If your cholesterol is still highafter 6 months, you may needmedicine to help control it. Yourhealth care provider will adviseyou about what medicine to take.

Ask if You Need anElectrocardiogram (EKG)

If you’re having heart andblood circulation problems, anEKG may help you and yourhealth care provider know if youneed to change your treatment.


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61

Diabetic nerve damage (alsocalled diabetic neuropathy) is aproblem for many people withdiabetes. Over time, high bloodglucose levels damage the deli-cate coatings of nerves. Thisdamage can cause a number ofproblems, such as pain in yourfeet. There’s a lot you can do totake charge and prevent nervedamage. A recent study showsthat controlling your blood glu-cose can help prevent or delaythese problems. Controlling yourblood glucose may also helpreduce the pain from some typesof nerve damage.

Some Signs of Diabetic NerveDamage

Some signs of diabetic nervedamage are pain, burning, tin-gling, or loss of feeling in the feetand hands. It can cause you tosweat abnormally, make it hardfor you to tell when your bloodglucose is low, and make you feellight-headed when you stand up.

Nerve damage can lead toother problems. Some people

develop problems swallowing andkeeping food down. Nerve dam-age can also cause bowel prob-lems, make it hard to urinate,cause dribbling with urination,and lead to bladder and kidneyinfections. Many people withnerve damage have trouble hav-ing sex. For example, men canhave trouble keeping their peniserect, a problem called impo-tence. If you have any of theseproblems, tell your health careprovider. There are ways to helpin many cases.

8 Nerve Damage

Having trouble telling your glucose islow may be signs of nerve damage.

slowly. You may not even beaware you’re losing feeling inyour feet. Ask your health careprovider to check your feet ateach visit. At least once a year,your provider should test howwell you can sense temperature,pinprick, vibration, and positionof your feet.

If you have signs of nervedamage, your provider may wantto do more tests. Testing can helpyour provider know what iswrong and how to treat it. Keeptrack of your foot exams on page97.

Check Your Feet for Changes

If you’ve lost feeling in yourfeet, you’ll need to take specialcare of them. Check your feeteach day. Wear shoes that fitwell. You’ll read more about footcare in the next chapter.


62

Protecting Your Nerves FromDamage

Keep Your Blood Glucose inControl

High blood glucose can dam-age your nerves as time goes by.Work with your health care teamto keep your glucose levels asclose to normal as you can.

Have a Physical Activity Plan

Physical activity or exercisemay help keep some nerveshealthy, such as those in yourfeet. Ask your health care teamabout an activity that is healthyfor you.

Get Tests for Nerve Damage

Nerve damage can happen

Tell your health care provider if youhave trouble with sexual function.

At least once a year, your health careprovider should do a complete checkof your feet and nerves.

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Nerve damage, circulationproblems, and infections cancause serious foot problems forpeople with diabetes. There’s alot you can do to prevent prob-lems with your feet. Controllingyour blood glucose and not smok-ing or using tobacco can help pro-tect your feet. You can also takesome simple safeguards each dayto care for and protect your feet.Measures like these have pre-vented many amputations.

It’s helpful to understand whyfoot problems happen. Nervedamage can cause you to losefeeling in your feet. Sometimesnerve damage can deform or mis-shape your feet, causing pressurepoints that can turn into blisters,sores, or ulcers. Poor circulationcan make these injuries slow toheal.

Signs of Foot Problems

Your feet may tingle, burn, orhurt. You may not be able to feeltouch, heat, or cold very well. Theshape of your feet can changeover time. There may even bechanges in the color and temper-ature of your feet. Some peoplelose hair on their toes, feet, andlower legs. The skin on your feetmay be dry and cracked. Toenailsmay turn thick and yellow.Fungus infections can growbetween your toes. Blisters,sores, ulcers, infected corns, andingrown toenails need to be seenby your health care provider orfoot doctor (podiatrist) rightaway.

Protecting Your Feet

Get Your Health CareProvider to Check Your Feet atLeast Four Times a Year

Ask your health care providerto look at your feet at least fourtimes a year. As a reminder, takeoff your shoes and socks whenyou’re in the exam room. Have

9 Foot Problems

Take extra careof your feet toprevent injuries.


64

your sense of feeling and yourpulses checked at least once ayear. If you have nerve damage,deformed or misshaped feet, or acirculation problem, your feetneed special care. Ask yourhealth care provider to show youhow to care for your feet. Alsoask if special shoes would helpyou.

Check Your Feet Each Day

You may have serious footproblems yet feel no pain. Lookat your feet every day to see ifyou have scratches, cracks, cuts,or blisters. Always check betweenyour toes and on the bottoms ofyour feet. If you can’t bend overto see the bottoms of your feet,use a mirror that won’t break. Ifyou can’t see well, ask a familymember or friend to help you.Call your health care provider at

once if you have a sore on yourfoot. Sores can get worse quickly.

Wash Your Feet Daily

Wash your feet every day. Drythem with care, especiallybetween the toes. Don’t soak yourfeet—it can dry out your skin,and dry skin can lead to infec-tions. If you have dry skin, rub athin coat of oil, lotion, or creamon the tops and bottoms of yourfeet—but not between your toes.Moisture between the toes willlet germs grow that could causean infection. Ask your health careprovider for the name of a goodlotion or cream.

Ask your health care provider to checkyour feet at least four times a year.

Be sure to dry between your toes.

65

Trim Your Toenails Carefully

Trim your toenails after you’vewashed and dried your feet—thenails will be softer and safer tocut. Trim the nails to follow thenatural curve of your toes. Don’tcut into the corners. Use anemery board to smooth off theedges.

If you can’t see well, or if yournails are thick or yellowed, getthem trimmed by a foot doctor oranother health care provider. Ifyou see redness around the nails,see your health care provider atonce.

Treat Corns and CallusesGently

Don’t cut corns and calluses.Ask your health care providerhow to gently use a pumice stoneto rub them. Don’t use razorblades, corn plasters, or liquidcorn or callus removers- they candamage your skin.

Protect Your Feet From Heatand Cold

Hot water or hot surfaces area danger to your feet. Beforebathing, test the water with abath thermometer (90° to 95°F issafe) or with your elbow. Wear

shoes and socks when you walkon hot surfaces, such as beachesor the pavement around swim-ming pools. Be sure to use a sun-screen on the tops of your feet.You also need to protect your feetfrom the cold. If you feet are coldat night, wear socks. Don’t usehot water bottles, heating pads,or electric blankets—they canburn your feet. Don’t use strongantiseptic solutions or adhesivetape on your feet.

Wear Proper Footwear Always

Wear proper footwear at alltimes. When indoors, wear indoorslippers. When at the beach,wear foot gear that will protectyour feet.

9 Foot Problems

Protect your feet from hot surfaces.


66

Wear shoes that fit well andprotect your feet. Don’t wearplastic shoes or sandals withthongs between the toes. Askyour health care provider whattypes of shoes are good choicesfor you.

New shoes should be comfort-able at the time you buy them—don’t expect them to stretch out.Slowly break in new shoes bywearing them only one or twohours a day.

Choose socks made of cottonor wool—they help keep your feetdry.

Before you put on your shoeseach time, look and feel insidethem. Check for any loose objects,nail points, torn linings, andrough areas—these can causeinjuries. If your shoe isn’t smoothinside, wear other shoes.

Be Physically Active

Physical activity can helpincrease circulation in your feet.There are many ways you canexercise your feet, even duringtimes you’re not able to walk. Askyour health care team aboutthings you can do to exerciseyour feet and legs.

Wear shoes that fit well and protectyour feet.

Walking may be a healthy activity for you.

67

Because of high blood glucose,people with diabetes are morelikely to have problems withtheir teeth and gums. There’s alot you can do to take charge andprevent these problems. Caringfor your teeth and gums everyday can help keep them healthy.

Keeping your blood glucose undercontrol is also important.Regular, complete dental carehelps prevent dental disease.

Signs of Dental Disease

Sore, swollen, and red gumsthat bleed when you brush yourteeth are a sign of a dental prob-lem called gingivitis. Another

problem, called periodontitis,happens when your gums shrinkor pull away from your teeth.Like all infections, dental infec-tions can make your blood glu-cose go up.

Preventing Dental Problems

Keep Your Blood Glucose inControl

High blood glucose can causeproblems with your teeth andgums. Work with your healthcare team to keep your glucoselevels as close to normal as youcan.

Brush Your Teeth Often

Brush your teeth at leasttwice a day to prevent gum dis-ease and tooth loss. Be sure tobrush before you go to sleep. Usea soft toothbrush and toothpastewith fluoride. To help keep bacte-ria from growing on your tooth-brush, rinse it after each brush-ing and store it upright with thebristles at the top. Get a newtoothbrush at least every 3 months.

10 Dental Disease

Healthy teeth and gums depend on regularcare and controlling your blood glucose.


68

Floss Your Teeth Daily

Besides brushing, you need tofloss between your teeth each dayto help remove plaque, a filmthat forms on teeth and cancause tooth problems. Flossingalso helps keep your gums

healthy. Your dentist or dentalhygienist will help you choose agood method to remove plaque,such as dental floss, bridge clean-ers, or water spray. If you’re notsure of the right way to brush orfloss, ask your dentist or dentalhygienist for help.

Get Regular Dental Care

Get your teeth cleaned andchecked at your dentist’s office atleast every 6 months. If you don’thave a dentist, find one or askyour health care provider for thename of a dentist in your commu-nity.

See your dentist right away ifyou have any signs of dental dis-ease, including bad breath, a badtaste in your mouth, bleeding orsore gums, red or swollen gums,sore or loose teeth, or troublechewing.

Give your dentist the nameand telephone number of yourdiabetes health care provider.Each time you make a visit,remind your dentist that youhave diabetes.

Plan dental visits so they don’tchange the times you take yourinsulin and meals. Don’t skip ameal or diabetes medicine beforeyou visit. Right after breakfastmay be a good time for your visit.

Protect your teethby brushing twiceor more a day andflossing each day.

See your dentist at least every 6 months.

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If you have diabetes, takeextra care to keep up-to-date onyour vaccinations (also calledimmunizations). Vaccines canprevent illnesses that can be veryserious for people with diabetes.This sections talks about somevaccines you need to know about.

Influenza Vaccine

Influenza (often called the flu)is not just a bad cold. It’s a seri-ous illness that can lead to pneu-monia and even death. The fluspreads when influenza viruses

pass from one person to the noseand throat of others. Signs of theflu may include sudden highfever, chills, body aches, sorethroat, runny nose, dry cough,and headache.

People with diabetes whocome down with the flu maybecome very sick and may evenhave to go to the hospital. If youget the flu, you’ll need to takespecial care of yourself (see pages39-42).

You can help keep yourselffrom getting the flu by getting aflu shot every year. Everyonewith diabetes—even pregnantwomen—should get a yearly flushot. The best time to get one isbetween October and mid-November, before the flu seasonbegins. This vaccine is fully cov-ered under Medicare Part B.

11 Vaccinations

The flu is a serious illness that can putyou in the hospital. A yearly flu shot canhelp prevent this.


70

Tetanus / Diphtheria (Td)Toxoid

Tetanus (or lockjaw) and diph-theria are serious diseases.Tetanus is caused by a germ thatenters the body through a cut orwound. Diphtheria spreads whengerms pass from one person tothe nose or throat of others.

You can help prevent tetanusand diphtheria with a combinedshot called Td toxoid. Most peo-ple get Td toxoid as part of theirroutine childhood vaccinations,but all adults need a Td boostershot every 10 years. Other vac-cines may be give at the sametime as Td toxoid.

Other Vaccines

You may need vaccines to pro-tect you against other illnesses.Ask your health care provider ifyou need any of these:

• Measles/Mumps/Rubella vac-cine

• Hepatitis A and B vaccines

• Varicella (chickenpox) vaccine

• Polio vaccine

• Vaccines for travel to othercountries

How to Get More Information

Call the immunization pro-gram in your state health depart-ment to find out where you canget vaccinations in your area.Keep your vaccination recordsup-to-date so you and your healthcare provider will know what vac-cines you may need. You canrecord this information on page97 of this book.

For more information on vacci-nations, call the NationalImmunization InformationHotline at:

1-800-232-2533 (English) or 1-800-232-0233 (Spanish).

These are toll-free calls.

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Becoming Pregnant When You Have Diabetes

Women with diabetes canhave healthy babies, but ittakes planning ahead andeffort. Pregnancy can makeboth high and low bloodglucose levels happenmore often. It can makediabetic eye disease anddiabetic kidney diseaseworse. High glucose levelsduring pregnancy are danger-ous for the baby, too.

Talk to your health careprovider about birth control if

you would like information aboutfamily planning.

Protecting Your Baby andYourself

Keeping your glucose levelsnear normal before and duringpregnancy can help protect youand your baby. That’s why it’s soimportant to plan your pregnan-cies ahead of time.

If you want to have a baby,discuss it with your health care

12 Pregnancy, Diabetes, and Women’s Health

You can protect you and your baby bycontrolling your blood glucose beforeand during pregnancy.

Your blood glucose and hemoglobin A1crecords will help you and your health careteam know when your glucose range issafe for pregnancy.


72

provider. Work with your dia-betes care team to get and keepyour blood glucose in the normalor near-normal range before youbecome pregnant. Your glucoserecords and your hemoglobin A1ctest results will show when youhave maintained a safe range fora period of time.

You may need to change yourmeal plan and your usual physi-cal activity, and you may need totake more frequent insulin shots.Testing your glucose severaltimes a day will help you see howwell you’re balancing things.Record the test results in yourlogbook or on a log sheet (seesample pages on 101 and 103).

Get a complete check of youreyes and kidneys before you tryto become pregnant. Don’t smoke,drink alcohol, or use drugs—doing these things can harm youand your baby.

Having Diabetes DuringPregnancy

Some women have diabetesonly when they’re pregnant. Thiscondition, which is called gesta-tional diabetes, can be controlledjust like other kinds of diabetes.Glucose control is the key. Yourhealth care team can help youtake charge of gestational dia-betes.

Controlling Diabetes forWomen’s Health

Some women with diabetesmay have special problems,

such as bladder infections.See page 55 to find outabout the signs of bladderand kidney infections. Ifyou have an infection, itneeds to be treated right

away. Call your doctor.

Some women get yeastinfections in their vagina,

If you learn you have diabetes when you’repregnant, work closely with your healthcare team.

73

especially when their blood glu-cose is high. A sign of yeast infec-tion may be itching in the vagina.If you notice vaginal itching, tellyour health care provider. Youmay learn about medicines youcan buy at the drugstore andabout how to prevent yeast infec-tions.

Some women with diabetesmay have trouble with sexualfunction. Discomfort caused byvaginal itching or dryness can betreated.

Ask your doctor how often youshould get a Pap smear and amammogram (breast X-ray).

12 Pregnancy, Diabetes, and Women’s Health

Getting Pap smears and mammogramsis important to every woman’s health.

Regular Pap smears and mam-mograms help detect cervical andbreast cancer early. All women-whether or not they have dia-betes- need to keep up with thesetests.

Records for Sick Days

75

How often Question Answer

Every day How much doyou weigh today? ______pounds

Every evening How much liquiddid you drink today? ______glasses

Every morning What is your _______a.m.and evening temperature? _______p.m.

Every 4 hours How much Time Doseor before diabetes medicine ______ ______every meal did you take? ______ ______

______ ____________ ____________ ____________ ______

Every 4 hours What is your Time Glucoseor each time blood glucose ______ ______you pass urine level? ______ ______

______ ____________ ____________ ____________ ______

Every 4 hours What are your Time Ketonesor each time urine ketones? ______ ______you pass urine ______ ______

______ ____________ ____________ ____________ ______

Every 4 to How are you Time Condition6 hours breathing? ______ __________

______ ________________ ________________ ________________ ________________ __________

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Reminders for Sick Days

Call your health care provider if any of these happen to you:

• You feel too sick to eat normally and are unable to keep down food formore than 6 hours.

• You’re having severe diarrhea.

• You lose 5 pounds or more.

• Your temperature is over 101°F.

• Your blood glucose is lower than 60 mg/dL or remains over 300 mg/dL.

• You have moderate or large ketones in your urine.

• You’re having trouble breathing.

• You feel sleepy or can’t think clearly.

If you feel sleepy or can’t think clearly, have someone call your healthcare provider or take you to an emergency room.

77

Records for Sick DaysHow often Question Answer





______ ____________ ____________ ____________ ______


______ ____________ ____________ ____________ ______


______ ____________ ____________ ____________ ______

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______ ________________ ________________ ________________ ________________ __________












79






______ ____________ ____________ ____________ ______


______ ____________ ____________ ____________ ______


______ ____________ ____________ ____________ ______

80


______ ________________ ________________ ________________ ________________ __________












81






______ ____________ ____________ ____________ ______


______ ____________ ____________ ____________ ______


______ ____________ ____________ ____________ ______

82


______ ________________ ________________ ________________ ________________ __________












83






______ ____________ ____________ ____________ ______


______ ____________ ____________ ____________ ______


______ ____________ ____________ ____________ ______

84


______ ________________ ________________ ________________ ________________ __________












85

• Bring your blood glucose logbook and go over the readings with yourprovider.

• Get a hemoglobin A1c test (about every 6 months if you don’t takeinsulin, about every 3 months if you take insulin). Write down theresult (see page 87) and set a target goal for your next test.

• Get your weight checked and write it down (see page 87). You maywant to set a goal for your next visit.

• Get your blood pressure checked and write it down. You may want toset a goal for your next visit.

• Get your feet checked at least four times a year.

• Bring a list of questions or other things you want to talk about.

• Bring your reminder sheet about “Things to Do at Least Once a Year”(see page 95) to help keep track of these.

Things to Do at Each Visit WithYour Health Care Provider

SAMPLE86

Each VisitHave your health care provider do these tests and set goals with you.

(Record dates and results in the boxes below.)

Tests and Goals Dates and Results

Blood Glucose (mg/dl)

Hemoglobin A1cTest/Goal (%)

Weight/Goal(pounds)

Blood Pressure(goal:_120_/ 80mm Hg)

Foot Check

6/1/98

145

9/11/98

118

1/5/99

180

5/3/99

105

9/7/99

110

9%

8%

8.9%

8%

8.4%

7.5%

not done 8.2%

7.5%

180

170

175

165

172

165

170

165

165

160

140/90 140/86 138/84 136/82 124/80

X X X X X

87






Weight/Goal(pounds)

Blood Pressure(goal:____/____mm Hg)

Foot Check

88






Weight/Goal(pounds)


Foot Check

89






Weight/Goal(pounds)


Foot Check

90






Weight/Goal(pounds)


Foot Check

91






Weight/Goal(pounds)


Foot Check

92






Weight/Goal(pounds)


Foot Check

93






Weight/Goal(pounds)


Foot Check

94






Weight/Goal(pounds)


Foot Check

95

• Get a flu shot (October to mid-November)

• Get a pneumonia shot (if you’ve never had one).

• Get a dilated eye exam.

• Get a foot exam (including check of circulation and nerves).

• Get a kidney test:__ Have your urine tested for albumin.__ Have your blood creatinine measured.__ Get a 24-hour urine test (if your doctor advises).

• Get your blood fats checked for:__ Total cholesterol.__ High-density lipoprotein (HDL).__ Low-density lipoprotein (LDL).__ Triglycerides.

• Get a dental exam (at least twice a year).

• Talk with your health care team about:__ How well you can tell when you have low blood glucose.__ How you are treating high blood glucose.__ Tobacco use (cigarettes, cigars, pipes, smokeless tobacco).__ Your feelings about having diabetes.__ Your plans for pregnancy (if a woman).__ Other _______________________

Things to Do at Least Once a Year

SAMPLE96

At Least Once a YearHave your health care provider do these tests and other services for you.

You may want to set some goals for these.(Record dates and results in the boxes below.)

Tests and Other Services Dates and Results

Flu Shot

Urine Protein orAlbumin (mg)

Blood Creatinine (mg/dl)

Total Cholesterol (mg/dl)

HDL Cholesterol (mg/dl)

LDL Cholesterol (mg/dl)

Triglycerides (mg/dl)

Tobacco Use

Eye Exam (dilated)

Foot Exam

2/9/971

40

2/9/97 2/2/98 1/28/99

2/2/985

50

1/28/99

55

1.0 1.2 1.1

190 180 175

30 35 40

150 140 135

338 300 250

5 cigars/day 2 cigars 0

8/11/97 10/1/98 11/8/99

11/9/97 8/6/98 9/5/99

97




Flu Shot







Tobacco Use

Eye Exam (dilated)

Foot Exam

98




Flu Shot







Tobacco Use

Eye Exam (dilated)

Foot Exam

99




Flu Shot







Tobacco Use

Eye Exam (dilated)

Foot Exam

100




Flu Shot







Tobacco Use

Eye Exam (dilated)

Foot Exam

SAMPLE101

Glucose Log SheetUse this log sheet—or one like it that your health care provider may give you—

to keep a record of your daily blood glucose levels.

Daily Log Week Starting____________________

R=Regular N=NPH L=Lente or Ultralente (UL)

Breakfast

Dose BloodSugar Dose Blood

Sugar Dose BloodSugar Dose Blood

Sugar Dose BloodSugar

Lunch Dinner Bedtime OtherNotes

Mon

Tues

Wed

Th

urs

Fri

Sat

Su

n

*Missed evening walk.

Start back tomorrow!

108

112

125

114

156

128

120

118

109

122

129

148

119

121

130

185

135

125

*168

112

*151

*121

*242

130

*151

133

129

11pm

*Sick with flu?

Drinking diet soda. Ketones negative.

Feeling better today

*Extra juice made sugar go up.

*Lunch at church.

January 18, 1999SAMPLE

102





Breakfast





Mon

Tues

Wed

Th

urs

Fri

Sat

Su

n

SAMPLE103





Breakfast





Mon

Tues

Wed

Th

urs

Fri

Sat

Su

n

Insu

lin

type

R

R

R

R

R

R

R

N

N

N

N

N

N

N

L

L

L

L

L

L

L

*Worked out longer than usual-

Drank orange juice.121

112

109

111

102

124

*175

187

104

158

114

112

99

118

161

110

68

118

110

105

130

*242

113

115

122

109

155

10pm

*Dinner out. Also no a.m.

exercise. Ketones negative.

*Did not eat much lunch-

Busy day!

*Slept late.

January 18, 1999SAMPLE

*6310:00 a.m.

9010:15 p.m.

161

115

4

8

8

8

8

8

8

8

4

4

4

4

3

4

4

3

2

3

2

2

3

2

8

8

8

8

8

8

9

20

20

20

20

20

20

20

104





Breakfast





Mon

Tues

Wed

Th

urs

Fri

Sat

Su

n

Insu

lin

type

R

R

R

R

R

R

R

N

N

N

N

N

N

N

L

L

L

L

L

L

L

105

Primary Doctor

Name: ______________________________________________________________

Telephone number: __________________________________________________

Your Questions:______________________________________________________

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Important points: ____________________________________________________

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Your Health Care Providers

106

Eye Doctor (Ophthalmologist, Optometrist)

Name: ______________________________________________________________


Your Questions:______________________________________________________

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107

Foot Doctor (Podiatrist)

Name: ______________________________________________________________


Your Questions:______________________________________________________

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108

Dentist

Name: ______________________________________________________________


Your Questions:______________________________________________________

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109

Dietitian

Name: ______________________________________________________________


Your Questions:______________________________________________________

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110

Diabetes Educator

Name: ______________________________________________________________


Your Questions:______________________________________________________

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111

Counselor

Name: ______________________________________________________________


Your Questions:______________________________________________________

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112

Other

Name: ______________________________________________________________


Your Questions:______________________________________________________

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Albumin A protein found inblood plasma and urine. Thepresence of albumin in theurine can be a sign of kidneydisease.

Autoimmune process Aprocess where the body’simmune system attacks anddestroys bony tissue that itmistakes for foreign matter.

Beta cells Cells that makeinsulin. Beta cells are found inareas of the pancreas calledthe islets of Langerhans.

Bladder A hollow organ thaturine drains into from the kid-neys. From the bladder, urineleaves the body.

Blood glucose The main sugarthat the body makes from thefood we eat. Glucose is carriedthrough the bloodstream toprovide energy to all of thebody’s living cells. The cellscannot use glucose withoutthe help of insulin.

Blood pressure The force of theblood against the artery walls.

Two levels of blood pressureare measured: the highest, orsystolic, occurs when the heartpumps blood into the bloodvessels, and the lowest ordiastolic occurs when theheart rests.

Blood sugar see Blood glucose.

Calluses Thick, hardened areasof the skin, generally on thefoot, caused by friction orpressure. Calluses can lead toother problems, including seri-ous infection and even gan-grene.

Carbohydrate One of threemain groups of foods in thediet that provide calories andenergy. (Proteins and fats arethe others.; Carbohydrates aremainly sugars (simple carbo-hydrates) and starches (com-plex carbohydrates, found inbread, pasta, beans) that thebody breaks down into glu-cose.

Cholesterol A substance similarto fat that is found in theblood, muscles, liver, brain,

113

Glossary

and other body tissues. Thebody produces and needs somecholesterol. However, toomuch cholesterol can makefats stick to the walls of thearteries and cause a diseasethat decreases or stops circu-lation.

Corns A thickening of the skinof the feet or hands, usuallycaused by pressure againstthe skin.

Diabetes The short name forthe disease called diabetesmellitus. Diabetes resultswhen the body cannot useblood glucose as energybecause of having too littleinsulin or being unable to useinsulin. See also Type 1 dia-betes, Type 2 diabetes, andGestational diabetes.

Diabetes pills Pills or capsulesthat are taken by mouth tohelp lower the blood glucoselevel. These pills may work forpeople who are still makinginsulin.

Diabetic eye disease A diseaseof the small blood vessels ofthe retina of the eye in peoplewith diabetes. In this disease,the vessels swell and leak liq-uid into the retina, blurring

the vision and sometimesleading to blindness.

Diabetic ketoacidosis Highblood glucose with the pres-ence of ketones in the urineand bloodstream, often causedby taking too little insulin orduring illness.

Diabetic kidney diseaseDamage to the cells or bloodvessels of the kidney.

Diabetic nerve damageDamage to the nerves of aperson with diabetes. Nervedamage may affect the feetand hands, as well as majororgans.

EKG exam A test that measuresthe heart’s action. Also calledan electrocardiogram.

Flu An infection caused by the‘flu’ virus. The flu usuallycauses fever, cough,headaches, congestion, andsore throat.

Food exchanges A way to helppeople stay on special foodplans by letting them replaceitems from one food groupwith items from anothergroup.


114

Gestational diabetes A type ofdiabetes that can occur inpregnant women who have notbeen known to have diabetesbefore. Although gestationaldiabetes usually subsides afterpregnancy, many women whohave had gestational diabetesdevelop Type 2 diabetes laterin life.

Gingivitis A swelling and sore-ness of the gums that withouttreatment, can cause seriousgum problems and disease.

Glucagon A hormone that rais-es the blood glucose level.When someone with diabeteshas a very low blood glucoselevel, a glucagon injection canhelp raise the blood glucosequickly.

Glucose A sugar in our bloodand a source of energy for ourbodies.

Heart attack Damage to theheart muscle caused when theblood vessels supplying themuscle are blocked, such aswhen the blood vessels areclogged with fats (a conditionsometimes called hardening ofthe arteries).

HDL (high-density lipoprotein) A

combined protein and fatlikesubstance. Low in cholesterol,it usually passes freelythrough the arteries.Sometimes called “good choles-terol.”

Hemoglobin A1c A test thatsums up how much glucosehas been sticking to part ofthe hemoglobin during thepast 3-4 months. Hemoglobinis a substance in the red bloodcells that supplies oxygen tothe cells of the body.

High blood glucose A conditionthat occurs in people with dia-betes when their blood glucoselevels are too high. Symptomsinclude having to urinateoften, being very thirsty, andlosing weight.

High blood pressure A condi-tion where the blood circulatesthrough the arteries with toomuch force. High blood pres-sure tires the heart, harmsthe arteries, and increases therisk of heart attack, stroke,and kidney problems.

Hormone A chemical that spe-cial cells in the body release tohelp other cells work. Forexample, insulin is a hormonemade in the pancreas to help

Appendixes

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the body use glucose as ener-gy.

Hyperglycemia see High bloodglucose.

Hypertension see High bloodpressure.

Hypoglycemia see Low bloodglucose.

Immunization Sometimescalled vaccination; a shot orinjection that protects a per-son from getting an illness bymaking the person ‘immune’ toit.

Impotence A condition of beingunable to keep an erect penisand ejaculate. Some men whohave had diabetes a long timebecome impotent if theirnerves have become damaged.

Influenza A contagious viral ill-ness that strikes quickly andseverely. Signs include highfever, chills, body aches, runnynose, sore throat, andheadache.

Inject To force a liquid into thebody with a needle andsyringe.

Insulin A hormone that helps

the body use blood glucose forenergy. The beta cells of thepancreas make insulin. Whenpeople with diabetes can’tmake enough insulin, theymay have to inject it fromanother source.

Insulin-dependent diabetessee Type 1 diabetes.

Ketones Chemical substancesthat the body makes when itdoesn’t have enough insulin inthe blood. When ketones buildup in the body for a long time,serious illness or coma canresult.

Kidneys Twin organs found inthe lower part of the back. Thekidneys purify the blood of allwaste and harmful material.They also control the level ofsome helpful chemical sub-stances in the blood.

Laser surgery Surgery thatuses a strong ray of speciallight, called a laser, to treatdamaged parts of the body.Laser surgery can help treatsome diabetic eye diseases.

Low blood glucose A conditionthat occurs in people with dia-betes when their blood glucoselevels are too low. Symptoms


116

include feeling anxious or con-fused, feeling numb in thearms and hands and shakingor feeling dizzy.

LDL (or low-density lipoprotein)A combined protein and fatlikesubstance. Rich in cholesterol,it tends to stick to the walls inthe arteries sometimes called“bad cholesterol.”

Meal plan A guide to help peo-ple get the proper amount ofcalories carbohydrates, pro-teins, and fats in their diet.See also Food exchanges.

Mg/dL Milligrams per deciliter.Term used to describe howmuch glucose (sugar) is in aspecific amount of blood. Inself-monitoring of blood glu-cose, test results are given asthe amount of glucose in mil-ligrams per deciliter of blood.A fasting reading of 70 to 110mg/dL is considered in thenormal (nondiabetic) range.

Nephropathy See Diabetic kid-ney disease.

Neuropathy See Diabetic nervedamage.

Non-insulin-dependent dia-betes See Type 2 diabetes.

Pancreas An organ in the bodythat makes insulin so that thebody can use glucose for ener-gy. The pancreas also makesenzymes that help the bodydigest food.

Periodontitis A gum disease inwhich the gums shrink awayfrom the teeth. Without treat-ment, it can lead to tooth loss.

Plaque A film of mucus thattraps bacteria on the surfaceof the teeth. Plaque can beremoved with daily brushingand flossing of teeth.

Retinopathy See Diabetic eyedisease.

Risk factors Traits that make itmore likely that a person willget an illness. For example, arisk factor for getting Type 2diabetes is having a familyhistory or diabetes.

Self-monitoring blood glucoseA way for people with diabetesto find out how much glucoseis in their blood. A drop ofblood from the fingertip isplaced on a special coatedstrip of paper that “reads”(often through an electronicmeter) the amount of glucosein the blood.

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Stroke Damage to a part of thebrain that happens when theblood vessels supplying thatpart are blocked, such aswhen the blood vessels areclogged with fats (a conditionsometimes called hardening ofthe arteries).

Support group A group of peo-ple who share a similar prob-lem or concern. The people inthe group help one another bysharing experiences, knowl-edge, and information

Type 1 diabetes A condition inwhich the pancreas makes solittle insulin that the bodycan’t use blood glucose asenergy. Type 1 diabetes mostoften occurs in people youngerthan age 30 and must be con-trolled with daily insulininjections.

Type 2 diabetes A condition inwhich the body either makestoo little insulin or can’t usethe insulin it makes to useblood glucose as energy. Type2 diabetes most often occurs inpeople older than age 40 andcan often be controlledthrough meal plans and physi-cal activity plans. Some peoplewith Type 2 diabetes have totake diabetes pills or insulin.

Ulcer A break or deep sore inthe skin. Germs can enter anulcer and may be hard to heal.

Vitrectomy An operation toremove the blood that some-times collects at the back ofthe eyes when a person haseye disease.

Yeast infection A vaginal infec-tion that is usually caused bya fungus. Women who havethis infection may feel itching,burning when urinating, andpain, and some women have avaginal discharge. Yeast infec-tions occur more frequently inwomen with diabetes.


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American Association of Diabetes Educators 444 North Michigan Avenue, Suite 1240 Chicago, Illinois 60611 800-832-6874 800-TEAM-UP4 (for names of diabetes educators)

American Diabetes Association1660 Duke StreetAlexandria, Virginia 22314800-DIABETES (342-2383)800-232-3472703-549-1500

American Dietetic Association216 West Jackson Boulevard, Suite 800Chicago, Illinois 60606-6995800-745-0775800-366-1655 (consumer nutrition hotline, Spanish speaker available)

American Heart Association National Center7272 Greenville AvenueDallas, Texas 75231214-373-6300

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Resources

The following is a list of orga-nizations that can offer informa-tion on diabetes over the phoneor can send written materials.

Ask your health care team to

help you find other resources ofinformation or support.

For a listing of local organiza-tions, refer to the 1999 DiabetesResource Guide.

American Optometric Association 1505 Prince St. Alexandria, Virginia 22314 800-262-3947 703-739-9200

Indian Health Service Diabetes Program 5300 Homestead Road N.E. Albuquerque, New Mexico 87110 505-248-4182

International Diabetic Athletes Association 1647-B West Bethany Home Road Phoenix, Arizona 85015 800-898-IDAA602-433-2113

Juvenile Diabetes Foundation International 432 Park Avenue South New York, New York 10016-8013 800-223-1138

Medical Eye Care for the Nation’s Disadvantaged Senior Citizens The Foundation of the American Academy of Opthalmology P.O. Box 429098 San Francisco, California 94142-9098 800-222-EYES (3937)

National Eye Institute National Eye Health Education Program 2020 Vision Place Bethesda, Maryland 20892-3655 800-869-2020 (to order materials) 301-496-5248


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National Institute of Diabetes and Digestive and Kidney Diseases National Diabetes Information Clearinghouse 1 Information Way Bethesda, Maryland 20892-3560 800-GET LEVEL (800-438-5383) 301-654-3327

U.S. Public Health Service Office of Minority Health Resource Center P.O. Box 37337 Washington, DC 20013-7337 800-444-MHRC (6472)

Others: ____________________________________________________________

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Appendixes

121

Notes


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Take Charge doc - Hawaii Department of Health

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