High Blood Pressure: Controlling your risk
High blood pressure (hypertension) is linked to stroke, contributes to heart disease and circulation disorders (peripheral vascular disease). Two national expert committees (American Diabetes Association and the Joint National Committee on Prevention Detection, Evaluation and Treatment of High Blood Pressure (JNC-VT) recommend a blood pressure goal of < 130/80 mm Hg.
A reasonable goal for blood pressure for patients with diabetes is 120/80. In a recent study (HOT trial), the greatest reduction in heart attacks, strokes, and gangrene (macrovascular events) was found with diastolic blood pressure < 80mmHg.
Blood pressure control is critical and the use of ACE inhibitors and angiotensin receptor blockers (ARBs) to slow the progression of renal disease should drastically reduce the incidence of blindness, dialysis and amputations.
HgbA1c: What is it and why is it important to monitor?
The normal hemoglobin A1c varies depending upon the laboratory used. The goal should be as close to the upper limit of normal as possible. The American College of Endocrinology recommends 6.5. Both the DCCT and the UKPDS have shown relatively tight control of diabetes decreases the incidence of microvascular complications of diabetes. Keeping the A1c closer to 6.5 or 7 also helps keep triglycerides – a type of blood fat closer to target
For every 1-% reduction in glycosylated hemoglobin, it is possible to achieve a 22 to 35% reduction in microvascular complications.
Microalbumin: What is it and why is it important to monitor?
This test should be done yearly looking for protein in the kidney. This predicts the onset of diabetic kidney disease. If found a special clas of medications (ACE inhibitor) is started to protect the kidneys.
Diabetes is the leading cause of kidney failure and transplantation nationwide. 46% of patients with type 1 diabetes and 10 to 30% of patients with type 2 diabetes will develop microalbuminuria, proteinuria, and end stage renal disease (ESRD) secondary to diabetes.
To prevent kidney disease:
Keep blood sugars within normal
Keep Hgb A1c < 6.5
Control blood pressure < 130/80
Treat microalbuminuria type 1 use ACE; type 2 use ARB
Correct dyslipidemia – keep LDL below 100 mg/dl
Dilated eye exam: Regular eye exams can prevent blindness
Because diabetes is the leading cause of blindness, annual dilated eye exams are critical.
In this exam, the doctor looks inside your eye for signs of bleeding.
People with type 1 diabetes should have their first eye exam 3 to 5 years after diagnosis and once patient is 10 years old, annually.
Type 2 patients should have their first eye exam at diagnosis and annually afterwards.
For those women who become pregnant and have preexisting diabetes, eye exams should occur before conception and during the first trimester. Follow up should occur as indicated based on the results of the first trimester exam.
It is very possible that there could be bleeding occurring behind your eye and you do not notice any change in vision. This exam can detect retinopathy which would be treated with laser treatments and stop the bleeding as well as prevent blindness.
Because people with diabetes can get very sick from the flu, it is recommended that all people with diabetes get a flu shot yearly. The recommended age is 6 months or older beginning in September.
Because people with diabetes are susceptible to pneumococcal infections, A pneumonia vaccine is recommended. A one time revaccination is recommended for individuals above 64 years of age previously immunized when they were < 65 years of age if the vaccine was administered more than 5 years ago.
Lipid Goals and Management
A lipid panel should be done annually for people with diabetes.
Type 2 diabetes is associated with a two to four fourfold excess risk of coronary heart disease (CHD).
The goal for total cholesterol is to keep it below 200 mg/dl. If your cholesterol is elevated, think about your diet. A diet that is low in saturated fat can help to lower this value. For example, limited quantities of meat, substitute polyunsaturated margarine or monounsaturated fats for saturated fats such as butter, coconut, cream and
LDL cholesterol (“Bad Cholesterol”)
The LDL goal is < 100 mg/dl. If the LDL is above 130, people may require medication.
HDL cholesterol (“Good Cholesterol”)
The HDL goal is recommended to be above 45 mg/dl for men and above 40mg/dl for women.
Triglycerides should be kept below 150 mg/dl. If this blood fat is high, blood glucose control is the first recommendation to lower this level.
All people with diabetes should receive an annual foot examination to identify high-risk foot conditions. Patients should look at their feet daily. Trim nails straight across. Do not soak feet. Do not perform bathroom surgery. People with Medicare who quality can receive a free pair of shoes annually.
Blood Glucose Monitoring
It is very important that people with diabetes check their blood sugar levels to assess how their diabetes plan is working. For those people who are diet controlled, they may wish to check blood sugar before a meal and 2 hours afterwards to assess how the meal affected the blood sugar. Target blood sugars before meals are 80 to 110 and blood sugars 2 hours after meals should be below 140 mg/dl.
When selecting a meter to use, find out which meter company’s strips are the least expensive. Many insurance companies have preferred meters and therefore the co-payment for the test strips is less.
Many of the meters can be obtained for free because the meter company wants you to continue to purchase their test strips.
Companies who manufacture meters include Roche, Lifescan, Precision, Freestyle, Bayer, etc.
Hypoglycemia: Low Blood Sugar
Hypogycemia can happen when meals are delayed, you exercise more than usual or you take too much medication to manage your diabetes.
If you never experience hypoglycemia and you are on medication, it could mean that your blood sugars are not well controlled.
To treat hypoglycemia, you need to know the rule of 15. You test your blood sugar and you are below 70 and feel shakey. You take glucose tablets equal to 15g of carbohydrate or other quick acting carbohydrate. 4 oz of fruit juice or sweetened soda will work if you are not on a starch blocker medication.
Wait 15 minutes and retest. The new reading should be 15 points higher than the previous. If he symptoms have not gone away and you still feel low, treat again.
Hyperglycemia: High Blood Sugar
Hyperglycemia occurs when blood sugar is above target. High blood sugar is a blood sugar above 140mg/dl 2 hours after a meal.
It is important to know that the high blood sugar symptoms of excessive thirst, urination, and hunger do not generally occur until the blood sugar is about 300 mg/dl.
You need to report blood sugars that are consistently above 140 mg/dl to your diabetes educator and physician. It may mean that you need a change in medication.
If blood sugars are high, it is important to drink a lot of water.
If blood sugars are above 140 mg/dl and you have tried various oral agents (pills) available, it is time to consider insulin. Insulin is not the enemy and you will be very surprised that an injection hurts less than a blood sugar test. Insulin is a protein that helps to unlock the cell wall to allow the sugar to enter and feed the cells.
There are many different types of insulin available. There are very fast acting insulin such as Humalog and Novolog that are taken with meals to cover the carbohydrate you eat as well as to lower an existing high blood sugar. NPH is more intermediate acting insulin and is generally taken at breakfast and again at bedtime to cover your basal insulin needs. Glargine or Lantus is new insulin used to cover basal needs for 24 hours. It is often supplemented with a fast acting insulin.
Your insulin plan should include: when to take your insulin; how much insulin you need to meet bolus insulin needs at meals and how much insulin you need to manage your blood glucose between meals.
Meal Plan for Diabetes
There is no one diet for diabetes management. A healthy meal plan controls carbohydrate and limits fat. Carbohydrate has a direct impact on blood sugar and initially limiting carbohydrate but not eliminating it can control blood sugar for some people. It is important that all Americans receive a minimal of 130 grams of carbohydrate each day. It is critical that you learn how foods affect blood sugar. It is important to learn how to read labels for carbohydrate and fat. Fad diets are not recommended because they re too high in fat and people with diabetes are at higher risk for heart disease.
It is helpful for all people with a diagnosis of diabetes to meet with a registered dietitian to assess your food intake and to obtain suggestions to improve on your food choices and ultimately your health.
Dietitians do understand that it is extremely difficult to change eating habits, but even minor changes that can benefit you tremendously.
The American Diabetes Association recommends the use of an 81 to 325 mg enteric-coated aspirin to prevent heart disease. The Physician’s Health study showed that aspirin reduced the risk of MI by 44% in those over the age of 55 years. Other studies (Antiplatelet Trialists’ Collaboration and the Early treatment Diabetic Retinopathy Study) found that patients with diabetes using aspirin either had a reduction in the incidence of MI or reduced the risk of having a vascular event to levels approaching those of patients without diabetes. Although the benefits of aspirin are almost common knowledge, it is till underutilized. Aspirin decreases mortality by about 25% for MI patients, which is similar to the benefit from thrombolytic agents.
It should be regarded as a serious clinical omission for individuals with chest pain not to have aspirin prescribed. People with aspirin allergy, bleeding tendency, anticoagulant therapy, recent gastrointestinal bleeding and clinically active hepatic disease are not candidates for aspirin therapy. The use of aspirin has not been studied in people under the age of 30 years.