Diabetes Mellitus (DM)

Diet management is very important in people with both types of diabetes mellitus. Doctors recommend a healthy, balanced diet and efforts to maintain a healthy weight. People with diabetes can benefit from meeting with a dietitian or a diabetes educator to develop an optimal eating plan. Such a plan includes avoiding simple sugars and processed foods, increasing dietary fiber, limiting portions of carbohydrate-rich, and fatty foods (especially saturated fats). People who are taking insulin should avoid long periods between meals to prevent hypoglycemia Hypoglycemia Hypoglycemia is abnormally low levels of sugar (glucose) in the blood. Hypoglycemia is most often caused by drugs taken to control diabetes. Much less common causes of hypoglycemia include other... read more . Although protein and fat in the diet contribute to the number of calories a person eats, only the number of carbohydrates has a direct effect on blood glucose levels. The American Diabetes Association has many helpful tips on diet, including recipes. Even when people follow a proper diet, cholesterol-lowering drugs Lipid-lowering drugs Dyslipidemia is a high level of lipids (cholesterol, triglycerides, or both) or a low high-density lipoprotein (HDL) cholesterol level. Lifestyle, genetics, disorders (such as low thyroid hormone... read more are needed to decrease the risk of heart disease.

People with type 1 diabetes and certain people with type 2 diabetes may use carbohydrate counting or the carbohydrate exchange system to match their insulin dose to the carbohydrate content of their meal. "Counting" the amount of carbohydrate in a meal is used to calculate the amount of insulin the person takes before eating. However, the carbohydrate-to-insulin ratio (the amount of insulin taken for each gram of carbohydrate in the meal) varies for each person, and people with diabetes need to work closely with a dietician who has experience in working with people with diabetes to master the technique. Some experts have advised use of the glycemic index (a measure of the impact of an ingested carbohydrate-containing food on the blood glucose level) to delineate between rapid and slowly metabolized carbohydrates, although there is little evidence to support this approach.

Exercise, in appropriate amounts (at least 150 minutes a week spread out over three days), can also help people control their weight and improve blood glucose levels. Because blood glucose levels go down during exercise, people must be alert for symptoms of hypoglycemia. Some people need to eat a small snack during prolonged exercise, decrease their insulin dose, or both.

Many people, especially those with type 2 diabetes, are overweight or obese. Some people with type 2 diabetes may be able to avoid or delay the need to take drugs by achieving and maintaining a healthy weight. Weight loss is also important in these people because excess weight contributes to complications of diabetes. When people with diabetes have trouble losing weight with diet and exercise alone, doctors may give weight-loss drugs or recommend bariatric surgery Bariatric Surgery Bariatric (weight-loss) surgery alters the stomach, intestine, or both to produce weight loss. In the United States, about 160,000 people have bariatric surgery each year. This number accounts... read more (surgery to cause weight loss).

Proper care of feet and regular eye examinations can help prevent or delay the onset of complications of diabetes. People with diabetes are vaccinated against Streptococcus pneumoniae, and doctors usually recommend they receive annual flu vaccination because people with diabetes are at risk of infection.

Blood glucose levels can be measured easily at home or anywhere.

A fingerstick glucose test is most often used to monitor blood glucose. Most blood glucose monitoring devices (glucose meters) use a drop of blood obtained by pricking the tip of the finger with a small lancet. The lancet holds a tiny needle that can be jabbed into the finger or placed in a spring-loaded device that easily and quickly pierces the skin. Most people find that the pricking causes only minimal discomfort. Then, a drop of blood is placed on a reagent strip. The strip contains chemicals that undergo changes depending on the glucose level. The glucose meter reads the changes in the test strip and reports the result on a digital display. Some devices allow the blood sample to be obtained from other sites, such as the palm, forearm, upper arm, thigh, or calf. Home glucose meters are smaller than a deck of cards.

Continuous glucose monitoring (CGM) systems use a small glucose sensor placed under the skin. The sensor measures blood glucose levels every few minutes. There are two types of CGMs, with different purposes:

Professional CGMs collect continuous blood glucose information over a period of time (72 hours to up to 14 days). Health care providers use this information to make treatment recommendations. Professional CGMs do not provide data to the person with diabetes.

Personal CGMs are used by the person and provide real-time blood glucose data on a small portable monitor or on a connected smart phone. Alarms on the CGM system can be set to sound when blood glucose levels drop too low or climb too high, so the device can help people quickly identify worrisome changes in blood glucose.

Previously, CGMs required frequent calibration with fingerstick glucose testing. Also their results were not accurate enough so that people always had to do a fingerstick to verify a reading on their CGM before calculating a dose of insulin (for example, before meals or to correct a high blood sugar). However, recent technological advances have improved CGMs and promise to continue doing so for the foreseeable future. They can now be worn for up to 14 days, often do not require calibration, and can be used for insulin dosing without fingerstick glucose confirmation. Finally, there are now systems in which the CGM device communicates with insulin pumps Insulin Replacement Therapy Many people with diabetes require drugs to lower blood glucose levels, relieve symptoms, and prevent complications of diabetes. There are two types of diabetes mellitus Type 1, in which the... read more to either stop delivery of insulin when blood glucose is dropping (threshold suspend), or to give daily insulin (hybrid closed loop system).

CGM systems are particularly helpful in certain circumstances, such as in people with type 1 diabetes who have frequent, rapid changes in blood glucose (particularly when the glucose levels sometimes go very low), which are difficult to identify with fingerstick testing.

Most people with diabetes should keep a record of their blood glucose levels and report them to their doctor or nurse for advice in adjusting the dose of insulin or the oral antihyperglycemic drug. Many people can learn to adjust the insulin dose on their own as necessary. Some people who have mild or early type 2 diabetes that is well-controlled with one or two drugs may be able to monitor their fingerstick glucose levels relatively infrequently.

Although urine can also be tested for the presence of glucose, checking urine is not a good way to monitor treatment or adjust therapy. Urine testing can be misleading because the amount of glucose in the urine may not reflect the current level of glucose in the blood. Blood glucose levels can get very low or reasonably high without any change in the glucose levels in the urine.

Doctors can monitor treatment using a blood test called hemoglobin A1C. When the blood glucose levels are high, changes occur in hemoglobin, the protein that carries oxygen in the blood. These changes are in direct proportion to the blood glucose levels over an extended period. The higher the hemoglobin A1C level, the higher the person's glucose levels have been. Thus, unlike the blood glucose measurement, which reveals the level at a particular moment, the hemoglobin A1C measurement demonstrates whether the blood glucose levels have been controlled over the previous few months.

People with diabetes aim for a hemoglobin A1C level of less than 7%. Achieving this level is difficult, but the lower the hemoglobin A1C level, the less likely people are to have complications. Doctors may recommend a slightly higher or lower target for certain people depending on their particular health situation. However, levels above 9% show poor control, and levels above 12% show very poor control. Most doctors who specialize in diabetes care recommend that hemoglobin A1C be measured every 3 to 6 months.

Fructosamine, an amino acid that has bonded with glucose, is also useful for measuring blood glucose control over a period of a few weeks and is generally used when hemoglobin A1C results are not reliable, such as in people who have abnormal forms of hemoglobin.

In addition to learning about diabetes itself, older people may have to learn how to fit management of diabetes in with their management of other disorders. Learning about how to avoid complications, such as dehydration, skin breakdown, and circulation problems, and to manage factors that can contribute to complications of diabetes, such as high blood pressure and high cholesterol levels, is especially important. Such problems become more common as people age, whether they have diabetes or not.

Many older people have difficulty following a healthy, balanced diet that can control blood glucose levels and weight. Changing long-held food preferences and dietary habits may be hard. Some older people have other disorders that can be affected by diet and may not understand how to integrate the dietary recommendations for their various disorders.

Some older people cannot control what they eat because someone else is cooking for them—at home or in a nursing home or other institution. When people with diabetes do not do their own cooking, the people who shop and prepare meals for them must also understand the diet that is needed. Older people and their caregivers usually benefit from meeting with a dietitian to develop a healthy, feasible eating plan.

Older people may have a difficult time adding exercise to their daily life, particularly if they have not been active or if they have a disorder that limits their movement, such as arthritis. However, they may be able to add exercise to their usual routine. For example, they can walk instead of drive or climb the stairs instead of take the elevator. Also, many community organizations offer exercise programs designed for older people.

Taking the drugs used to treat diabetes, particularly insulin, may be difficult for some older people. For those with vision problems or other problems that make accurately filling a syringe difficult, a caregiver can prepare the syringes ahead of time and store them in the refrigerator. People whose insulin dose is stable may purchase prefilled syringes. Prefilled insulin pen devices may be easier for people with physical limitations. Some of these devices have large numbers and easy-to-turn dials.

Poor vision, limited manual dexterity due to arthritis, tremor, or stroke, or other physical limitations may make monitoring blood glucose levels more difficult for older people. However, special monitors are available. Some have large numerical displays that are easier to read. Some provide audible instructions and results. Some monitors read blood glucose levels through the skin and do not require a blood sample. People can consult a diabetes educator to determine which meter is most appropriate.

The most common complication of treating high blood glucose levels is low blood glucose levels (hypoglycemia Hypoglycemia Hypoglycemia is abnormally low levels of sugar (glucose) in the blood. Hypoglycemia is most often caused by drugs taken to control diabetes. Much less common causes of hypoglycemia include other... read more ). The risk is greatest for older people who are frail, who are sick enough to require frequent hospital admissions, or who are taking several drugs. Of all available drugs to treat diabetes, long-acting sulfonylurea drugs are most likely to cause low blood glucose levels in older people. When they take these drugs, they are also more likely to have serious symptoms, such as fainting and falling, and to have difficulty thinking or using parts of the body due to low blood glucose levels.

Hypoglycemia in older people may be less obvious than in younger people. Confusion caused by hypoglycemia may be mistaken for dementia Dementia Dementia is a slow, progressive decline in mental function including memory, thinking, judgment, and the ability to learn. Typically, symptoms include memory loss, problems using language and... read more or the sedative effect of drugs. Also, people who have difficulty communicating (as after a stroke Overview of Stroke A stroke occurs when an artery to the brain becomes blocked or ruptures, resulting in death of an area of brain tissue due to loss of its blood supply (cerebral infarction) and symptoms that... read more or as a result of dementia) may not be able to let anyone know they are having symptoms.