DESCRIPTION

Diabetes is a disease in which the body either does not produce or cannot properly use the pancreatic hormone insulin. Insulin controls the amount of glucose (sugar) in the blood and the rate at which glucose is absorbed into the cells. The cells need glucose to produce energy. Furthermore, glucose must be maintained at a certain minimum for the brain to function normally. After eating a meal that contains carbohydrate or protein, the blood sugar normally rises to between 120 and 130 milligrams per decaliter (mg/dL), but generally not above 140 mg/dL. This increase triggers a release of insulin from cells in the pancreas called beta-cells. The insulin "opens the doors" of cells throughout the body, allowing glucose to enter them. As glucose enters the cells, the blood sugar level falls back toward normal and the release of insulin tapers off until the next time protein or carbohydrates are eaten. Every day, every hour, blood sugar levels vary, even in people who do not have diabetes. If blood sugar falls too low hypoglycemia, a person's ability to reason can become impaired. If blood sugar is too high (hyperglycemia) the person has diabetes.

In people with diabetes, glucose builds up in the bloodstream instead of being taken into and used by the cells, leading to hyperglycemia. If it is not properly controlled, diabetes can lead to heart disease, kidney disease, edema, nerve damage, and infections of the mouth, gums, lungs, skin, feet, bladder, and genital areas. Skin sores may develop and fail to heal properly.

According to figures published by the American Diabetes Association (ADA), 18.2 million people in America, or 6.3 percent of the population, have diabetes. This disease is the sixth leading cause of death in the United States and the primary cause of blindness in people between the ages of 20 and 74. The death rate for African-Americans with diabetes is 27 percent higher than the death rate for Caucasians who have the disease. Unfortunately, 2/3 of the people diagnosed with diabetes do not associate the disease with an increased risk of cardiovascular problems, such as heart disease and stroke. To someone with diabetes, controlling the blood sugar must be done in conjunction with controlling cholesterol and blood pressure.

There are two basic types of diabetes: diabetes insipidus and diabetes mellitus.

DIABETES INSIPIDUS

This is a rare metabolic disorder caused either by a deficiency of the pituitary hormone vasopressin or by the inability of the kidneys to respond properly to this hormone. Failure to produce adequate amounts of vasopressin is usually the result of damage to the pituitary gland. Diabetes insipidus is characterized by extreme thirst and by the production of enormous amounts of urine, regardless of how much liquid is consumed.

DIABETES MELLITUS

This results from a defect in the production of insulin by the pancreas. Without insulin, the body cannot utilize glucose (blood sugar), its principal energy source. As a result, the level of glucose circulating in the blood is high and the level of glucose absorbed by the body tissues is low. Perhaps more than most diseases, diabetes mellitus is associated with diet. It is a chronic disorder of carbohydrate metabolism that over time increases the risk of kidney disease, atherosclerosis, blindness, and neuropathy (loss of nerve function). It also creates a predisposition to infections such as candidiasis and can complicate pregnancy. Although genetics may make a person susceptible to diabetes, a diet high in refined, processed foods and low in fiber and complex carbohydrates is believed to be behind most cases of the disease. Those who are overweight face the greatest risk of developing diabetes.

Some individuals have impaired glucose tolerance (IGT),indicating an asymptomatic subclinical, or latent, form of diabetes. IGT describes those whose plasma glucose levels and responses to glucose are intermediate, somewhere between those of a diabetic and a healthy person.

This page will primarily discuss diabetes mellitus.

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CAUSES

Diabetes mellitus is generally divided into two categories: Type I, called insulin-dependent or juvenile diabetes (IDDM) and Type II, or non-insulin-dependent diabetes (NIDDM).

TYPE I (TYPE 1)

Type I diabetes affects 5 to 10 percent of people with diabetes and usually starts at an early age. It is an auto-immune disease in which the body's immune system attacks and is associated with destruction of the beta cells of the pancreas, which manufacture insulin. This type of diabetes occurs mostly in children and young adults. Experts believe this may result from an immune response after a viral infection or something related to nutrition.

TYPE II (TYPE 2)

Type II diabetes mellitus, by far the most common form of diabetes, affects 90 to 95 percent of diabetes sufferers. It is often referred to as maturity-onset diabetes, is most likely to occur in people with a family history of diabetes. In this type of the disorder, the pancreas does not produce enough insulin to fuel the cells. Although the insulin is produced, it may be ineffective. The cells may also become resistant to the effects of what little insulin there is in the bloodstream. Many people have Type 2 diabetes and are completely unaware of it. In fact, as many as 5.2 million Americans may have the disease and not yet be diagnosed. This type of diabetes usually has an onset during later adulthood and is linked to a poor diet. Unfortunately, it is now becoming more common in young people.

The first clinical study sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) has begun in 12 medical centers around the country. The five-year study called Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY), will compare three treatments of type 2 diabetes in children and teens to determine how well and how long each treatment approach controls blood glucose levels. The treatments will involve FDA-approved drugs and life-style changes. TODAY is the first clinical study aimed at showing the effects of lowering weight by cutting calories and increasing physical activity in youths with type 2 diabetes.

RISK FACTORS

It is now recognized that obesity and type 2 diabetes are among the most serious health challenges facing American's youth. During the last 30 years, the number of overweight children in the United States has more than doubled. Known risk factors for type 2 diabetes include:

• Age (risk increases with age).
• Overweight, as measured by a body mass index (BMI), of 25 or higher (23 or higher for Asian-Americans and 26 or higher for Pacific Islanders).
• Blood pressure of 140/90 mm/Hg or higher.
• Abnormal blood fat levels, including levels of HDL (good) cholesterol, less than 40 mg/dL for men and less than 30 mg/dL for women, and triglycerides of 250 mg/dL or higher.
• Having a parent, brother, or sister with diabetes.
• Ethnicity (African-Americans, American Indians, Alaskan natives, Asian-Americans, Pacific Islanders, and Hispanics have a greater risk than do Caucasians).
• Birth weight of less than 5.5 pounds or more than 9 pounds.
• A history of diabetes in pregnancy, or having given birth to a baby weighing more than 9 pounds.
• Inactivity, defined as exercising fewer than 3 times per week.

Epidemiological data from around the world show that the United States is not the only area that has this problem. Within the next 30 years, diabetes is projected to increase by 50 percent in Great Britain, 72 to 78 percent in New Zealand and Australia, and an incredible 184 percent in Mexico.

GESTATIONAL DIABETES

Gestational diabetes is a form of the condition that develops during pregnancy, affecting about 4 percent of pregnant women. Hormonal changes during pregnancy can affect the body's resistance to insulin. Most often, this condition disappears after delivery, but it seems to be a sign that the woman is more likely to develop type 2 diabetes in later life.

MoonDragon's ObGyn Information: Pregnancy & Diabetes

IMPAIRED GLUCOSE TOLERANCE (IGT)

Impaired glucose tolerance is a condition that affects about 11 percent of American adults. In people with IGT, blood glucose levels are above normal, but are not of diabetic levels. However, about 7 percent of people with IGT go on to develop type 2 diabetes.

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FREQUENT SIGNS & SYMPTOMS

People with diabetes are subject to episodes of both high (hyperglycemia) and low blood sugar (hypoglycemia).

TYPE I

COMMON SIGNS & SYMPTOMS OF TYPE 1 DIABETES

• Irritability.
• Frequent urination.
• Abnormal thirst.
• Nausea or vomiting.
• Weakness.
• Fatigue.
• Weight loss despite a normal (or even increased) intake of food.
• Unusual hunger.
• In children, frequent bed wetting. Especially by a child who did not previously wet the bed, is a common sign.

Episodes of very high blood glucose levels (hyperglycemia) and episodes of very low blood glucose levels (hypoglycemia). Either of these conditions can lead to a serious medical emergency.

Episodes of hypoglycemia, which strike suddenly, can be caused by a missed meal, too much exercise, or a reaction to too much insulin.

INITIAL SIGNS OF HYPOGLYCEMIA (LOW BLOOD SUGAR)

• Hunger.
• Sweating.
• Dizziness.
• Confusion.
• Palpitations.
• Numbness or tingling of the lips.

If not treated, the individual may experience:

• Double vision.
• Trembling.
• Disorientation.
• May act strangely.
• May eventually lapse into a coma.

In contrast, a hyperglycemic episode can come on over a period of several hours or even days. The risk for hyperglycemia is greatest during illness, when insulin requirements rise; blood sugar can creep up, ultimately resulting in coma, a reaction also known as diabetic ketoacidosis. One of the warning signs of developing hyperglycemia is the inability to keep down fluids. Possible long-term complications include stroke, blindness, heart disease, kidney failure, gangrene, and nerve damage.

TYPE II

COMMON SIGNS AND SYMPTOMS OF TYPE 2 DIABETES:

• Frequent urination.
• Extreme hunger.
• Unexplained weight loss.
• Extreme fatigue.
• Blurred vision.
• Itching of skin.
• Unusual thirst.
• Irritability.
• Drowsiness.
• Skin infections, infections of gums, vagina or bladder.
• Slow healing of wounds, cuts, and bruises.
• Tingling or numbness in the feet, legs, or hands.

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OTHER SIGNS THAT MAY BE ASSOCIATED WITH DIABETES

• Lingering flu-like symptoms.
• Loss of hair on the legs.
• Increased facial hair.
• Small yellow bumps known as xanthomas anywhere on the body.
• Balanoposthitis (inflammation of the penial glans and foreskin) often is the first sign of diabetes and is usually associated with frequent urination day and night.

An estimated 5.5 million Americans are being treated for diabetes. Studies indicate that there are 5 million adults with undetected type II diabetes, and another 20 million have impaired glucose tolerance that may lead to full-blown diabetes. The National Institute of Health report that undiagnosed diabetes has caused millions of people to lose their vision. In addition, complications of diabetes are the third leading cause of death in the United States. Urinalysis can often detect unsuspected diabetes.

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PREVENTION

Maintain your ideal weight and eat a well-balanced diet consisting of whole foods.

Get moderate exercise regularly.

Research indicates that supplementation with the hormone dehydroepiandrosterone (DHEA) in the form of 7-keto-DHEA may help prevent diabetes.

HerbalRemedies: 7 Keto DHEA, Metabolite of DHEA, NOW Foods, 25 mg, 60 Caps
7 KETO DHEA capsules are a potent, natural metabolite for DHEA. 7 KETO DHEA is a powerful antioxidant that aids fat metabolism and supports the production of lean muscle tissue. DHEA is the most plentiful hormone in the human body, but its production declines with age. As the levels of DHEA decrease, so does this important metabolite.

MoonDragon's Health Therapy: DHEA Therapy

IF YOU ARE AT RISK OR HAVE DIABETES

If diabetes runs in your family or if you have concerns about diabetes, consider joining a self-help group for diabetics. It will provider you with advice and access to courses or seminars. Research the disease and learn as much as you can about it.

If you are an insulin-dependent diabetic, keep carbohydrates with you in case of low blood sugar.

Strenuous activity can cause a serious drop in blood sugar. Test your levels and eat carbohydrates if necessary.

If you are pregnant, your midwife will check your urine at each visit for many things, including ketones (a byproduct of fat metabolism) and glucose in the urine. If you have a repeated positive urine test (more than one test with positive results), you may be questioned about our dietary habits and have your blood tested for glucose levels. You may be instructed about eating a well-controlled diabetic diet to keep your glucose levels within a normal range. Pregnancy can put a burden on may systems in the mother and someone who is borderline or has pre-diabetic tendencies may have abnormal glucose levels showing up during her pregnancy (gestational diabetes). Be sure to follow your midwife's suggestions and recommendations to keep it under control until after you deliver your baby. You should be watched and monitored carefully throughout the remainder of your pregnancy.

DIAGNOSIS & TREATMENT

Chances are pretty good that you or someone you know has diabetes. There are more than 5 million Americans currently being treated for this disease. Diabetes occurs when the body does not produce or use insulin, the hormone that helps move ingested sugars out of the blood and into the cells, as it should. In some types of diabetes, the target tissues just don't respond, but in the most common type of diabetes, diabetes mellitus, the production of insulin is impaired, which can greatly increase blood-sugar levels. Untreated, this rise in sugar can lead to coma or even death. There are two forms of diabetes mellitus: Type 1, or juvenile diabetes that develops during childhood or early adulthood and type 2, or adult-onset diabetes that usually occurs after the age of 40. Treatment for Type I requires a carefully adjusted diet and insulin injections in precise dosages. Exercise, diet and natural remedies, combined with medication, can help control type 2 diabetes.

TEST YOUR URINARY SUGAR LEVEL YOURSELF Even in the early stages of the disease, elevated sugar levels are detectable in the urine. You can purchase test strips in a pharmacy or medical supply store to check your urinary glucose level. Collect midstream morning urine. Dip the test strip in the urine and leave it there for approximately 1 minute (follow direction label on the test strip box or bottle). Wipe off the excess on the side of the container. After 1-2 minutes, a change in color on the strip indicates glucose levels that are elevated. If this occurs, you should consult with your health care provider.

URINE TEST STRIPS

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CONSIDERATIONS



GENERAL TREATMENT OVERVIEW

A Type II diabetic's course of treatment depends on the severity of the disease. Your health care provider (or midwife, if you are pregnant) should determine your insulin needs, if insulin is required, and how eating habits should be adjusted. it is also important to maintain your normal weight and get moderate exercise. Limiting breads, rolls, rice, pastas, chips, potatoes and sweets may be required. Choose instead fresh vegetables and proteins, such as salmon, tuna, beans and nuts.

DRUGS USED IN THE TREATMENT OF DIABETES

To compensate for the lack of insulin production, a person with type 1 diabetes must inject insulin on a daily basis. Injections are necessary because insulin cannot be absorbed from the gastrointestinal tract into the bloodstream if taken orally. Insulin pumps and pens (individual, disposable pre-filled insulin syringes in the form of a pen) are also available for the delivery of insulin. Because the management of type 1 diabetes is such a complex challenge, it is imperative that a person with this condition have a good relationship with the health care provider prescribing the insulin. There are many insulin formulations on the U.S. market. See table below.

Rosiglitazone (Avandia) is a drug sometimes prescribed for type 2 diabetes. This drug controls blood sugar by adjusting the sensitivity of fat and muscle tissue to the insulin of the body.

Trials of a promising new diabetes vaccine, produced by Clinalfa, a subsidiary of Merck, are underway. The vaccine contains a molecule that is similar to a part of the insulin-producing cells in the pancreas. This molecule when added to human blood, forms a protective barrier against the white blood cells that typically destroy the insulin-producing cells. In effect, the vaccine would inoculate someone receiving it against getting diabetes, possibly for life.

People with diabetes who experience the pain associated with nerve damage (diabetic peripheral neuropathy) have a new treatment option - the first FDA-approved drug for managing the burning, tingling, and numbing sensations in the extremities that mark this condition. The drug, duloxetine (Cymbalta), was approved in September 2004 for treating the condition, the most common complication of diabetes. In clinical trials, people treated with Cymbalta reported less pain than those given a placebo. Treated with Cymbalta, 58 percent of the people reported at least a 30 percent sustained reduction in pain. Only 34 percent of the people treated with a placebo reported sustained pain reduction. Most commonly reported side effects included nausea, dry mouth, constipation, and diarrhea. In a few cases, patients experienced dizziness and hot flashes.

ORAL MEDICATIONS FOR TYPE 2 DIABETES Type 2 diabetes may be managed with any number of different drugs. Following is a quick reference guide to the major medications currently used for this purpose, together with how they act in the body, generic and brand names, and general comments. ACTION IN THE BODY GENERIC NAME BRAND NAMES COMMENTS Sulfonylureas Stimulates beta cells to release insulin. Chlorpropamide Diabinese Taken 1 or 2 times daily before meals. First-generation drug.   Glipizide Glucotrol Second-generation drug. Used in smaller doses than first-generation agents.   Glyburide DiaBeta Micronase Glynase Second-generation drug. Smaller doses.   Glimepiride Amaryl Second-generation drug. Smaller doses. Meglitinides Stimulate the pancreas to release more insulin. Repaglinide Prandin Taken before each of three meals. Nateglinides Works similarly to sulfonylureas. Nateglinide Starlix Taken before each of three meals. Biguanides Sensitizes the body to insulin already present. Metformin Metformin Extended Release Metaformin With Glyburide Glucophage Glucophage XR Glucovance Taken two times daily with food for best results. Thiazolidinediones (Glitazones) Helps insulin work better in muscle and fat and lowers insulin resistance. Rosiglitazone Pioglitazone Avandia Actos Taken once or twice daily with food. Very rare but serious side effects on the liver are possible. Alpha-Glucose Inhibitors Slows or blocks breakdown of starches and sugars; action slows rise in blood sugar after eating. Acarbose Miglitol Precose Glyset Should be taken with first bite of meals.

INSULIN PREPARATIONS FOR TYPE 1 DIABETES Type 1 diabetes may be managed with injections of the hormone insulin, as well as with close attention to diet and other lifestyle factors. Not all insulins are the same, however, and it may take some trial and error to find the one or ones that are right for any given individual. The principle differences are related to the speed with which they take effect, and the period of time they remain active in the body. Following is a quick reference guide to the major types of insulin available. EXAMPLES ONSET OF ACTION PEAK OF ACTION DURATION OF ACTIONS Long-Acting Insulin Humalog (Lispro) 15 minutes 30-90 minutes 3-5 hours NovoLog (Aspart) 15 minutes 40-50 minutes 3-5 hours Short-Acting Insulin (Regular) Humulin R 30-60 minutes 50-120 minutes 5-8 hours Novolin R 30-60 minutes 50-120 minutes 5-8 hours Intermediate-Acting Insulin (NPH) Humulin L 1-2.5 hours 7-15 hours 18-24 hours Humulin N 1-3 hours 8 hours 20 hours Novolin N 1-3 hours 8 hours 20 hours Intermediate- & Short-Acting Insulin Mixtures Humulin 50/50 Humulin70/30 Humalog Mix 75/25 Humalog Mix 50/50 Novolin 70/30 Novolog Mix 70/30 The onset, peak and duration of action of these mixtures reflects a composite of the intermediate- and short- or rapid-acting components, with one peak of action. Long-Acting Insulin Ultralente 4-8 hours 8-12 hours 36 hours Lantus (Glargine) 1 hour None 24 hours

Since 1982, most of the newly approved insulin preparations have bee produced by inserting portions of DNA (recombinant DNA) into special lab-cultivated bacteria or yeast. This process allows the bacteria or yeast cells to produce complete human insulin. Recombinant human insulin has all but completely replaced animal-derived insulin, such as pork or beef insulin. Recently, insulin analogs have been produced that have a structure differing slightly from human insulin (usually by one or two amino acids). This changes the onset and peak of action times. See table above.

Strict glucose control in type 1 diabetes also reduces the risk of atherosclerosis, according to a study reported in The New England Journal of Medicine. Intensive glucose control was found to greatly reduce damage to the eyes, nerves and kidneys. Researchers also concluded that the tight control also benefited the heart. Strict glucose control involves at least 3 insulin injections per day, or the use of an insulin pump, plus frequent self-monitoring.

The FDA has approved pramlintide (Symlin), a new drug for people with diabetes who cannot adequately control their blood glucose levels with insulin. It is intended to be used along with insulin to help lower blood glucose during the 3 hours after meals. Pramlintide must be kept separately from insulin and never mixed, nor should the same syringe be used to administer both, to prevent alteration of the activity of the insulin.

NEW INSULIN DELIVERY METHODS

Insulin inhalers are now in development. The dose is inhaled through the mouth into the lungs, and from there, the dry or dissolved insulin can easily be absorbed into the bloodstream. The benefits to this method of ingestion, as compared with injection, are obvious. The drawbacks, however, are in accurately administering the correct dose in the correct form. The inhalers deliver only up to 10 percent of the drug into the lungs, making it more expensive because more insulin is needed. The size of the drug particles is also critical - if they are too small, the drug will bind together, if too large, the insulin will not be able to reach the lungs.

DIABETES & PREGNANCY

A woman with diabetes who wants to become pregnant should watch her blood sugar levels long before she plans to conceive. The fetus has the greatest chance of developing birth defects during the first 5 to 8 weeks of pregnancy, before most women know they are pregnant. It usually takes a few months to get the blood sugar under proper control; if a woman begins to monitor her blood sugar level the day she conceives, damage may already be done by the time it is under control.

Women with diabetes who do become pregnant are considered high risk and will need carefully managed care during her prenatal period and possibly for the postpartum period for her and her newborn. These women are not usually considered for a homebirth option, and may not be considered for a birthing center option as well, depending upon the guidelines set up by these midwives and health care providers. It will be very important to find a pregnancy and birth practitioner that is well informed about diabetic management during pregnancy and one that is willing to work with the woman's birth experience desires.

MoonDragon's ObGyn Information: Pregnancy & Diabetes

MoonDragon's Nutrition Information: Gestational Diabetes Diet

KEEP A JOURNAL

Keep a journal to monitor your progress. Eventually, your journal should answer the following questions:

• What does your blood-sugar/glucose curve look like with an average diet and average insulin administration (if you are required to use insulin)?



• To what extent does physical activity reduce your sugar level, and does your insulin need to be reduced as a result?



• How does the insulin work when you inject it in different sites, such as your abdomen or upper thigh?



• How does your blood-sugar/glucose level change in stressful situations?

GLUCOSE MANAGEMENT

Because the management of type I diabetes is such a complex challenge, it is important that a person with this condition have a good relationship with the health care provider prescribing the insulin. There are more than 30 insulin formulations in the U.S. market, but all are variations of several basic types. The most commonly used are purified porcine (pork), purified bovine (beef), and recombinant DNA-origin (human) insulin. Purified porcine insulin is insulin derived from the pancreases of pigs that has undergone further purification; purified bovine insulin is cattle-pancreas-derived insulin that has undergone further purification. Recombinant DNA-origin insulin production is genetically engineered by inserting the human gene for insulin production into a non-disease-producing laboratory strain of Escherichea coli bacteria or yeast.

Since people with type II diabetes are less able than most people to perceive sweet tastes, and this may make it more difficult for them to lose weight. Because they do not recognize the sweet taste of substances, they often consume sugary products that they do not appreciate as sweet. If a person with type II diabetes attains a better understanding of food, exercises greater care in choosing foods, and reads food product labels carefully, he or she should be able to control the problem and avoid the need for treatment with drugs or insulin.

Type II diabetes can usually be controlled by dietary modification and exercise; insulin treatment is not usually required. Obesity is a major factor in type II diabetes, and a weight reduction program is often all that is required to control it.

Some people with diabetes may be able to abandon insulin injections for an inhaler in a few years or less. Researchers at John Hopkins School of Public Health in Baltimore reported that an experimental aerosol inhaler normalized blood glucose levels in six volunteers with type II diabetes, according to an article by Mike Snider in USA Today.

• CBS News: Insulin Inhaler
• NPR: Insulin Inhaler Cleared for Use by Diabetics
• International Herald Tribune: Pfizer Markets First Insulin Inhaler for Diabetes Sufferers
• NJBiz: Pfizer's Insulin Inhaler May Cause Lung Cancer
• CNN: Insulin Inhaler May Replace Injections
• Bessed: Insulin Inhaler
• Diabetes Monitor: Inhaled Insulin
• Pharmalot: Exhale - Lilly Bails On Alkermes Insulin Inhaler
• Exubra Official Site: Announcement about Exubra Insulin Inhaler being discontinued, October 18th, 2007.

Research indicates that supplementation with the hormone dehydroepiandrosterone (DHEA) may help prevent diabetes. See DHEA Therapy.

DIABETIC COMPLICATIONS

There is no cure for diabetes, but the disease can be managed. The major danger with diabetes is not the disease itself but the complications that can arise if insulin levels are not maintained at a constant level. Consistently high blood sugar levels can, over time, lead to blindness, kidney failure, heart disease, limb amputations, and nerve damage.

EYE DAMAGE & BLINDNESS

Retinopathy (damage to the retina) from diabetes is the leading cause of blindness in the United States in adults between the age of 20 and 74. One in twenty people with type I diabetes and one in fifteen people with type II diabetes develop retinopathy. However, the incidence of blindness from diabetic retinopathy has dropped with the use of laser surgery. If persons in the later stages of retinopathy are left untreated, almost 50 percent lose their sight within 5 years. Of those who receive laser treatment, only 5 percent lose their sight. Persons with diabetes should get annual retinal examinations to check on their condition.

Elevated glucose levels in the lens of the eye can result in the accumulation of substances called polyols, whose presence can ultimately cause damage to the lens. High polyol concentrations resulting from high glucose levels can persist even if glucose levels subsequently return to normal. Flavonoids, such as quercetin, help to inhibit the accumulation of polyols.

Glycosylation - the binding of glucose and other sugars onto proteins in the blood, nerve cells, and lenses of the eyes - may be responsible for many of the long-term effects of diabetes. Research at the University of Surrey's School of Biological Sciences and the Academic Unit of Diabetes and Endocrinology of London's Whittington Hospital have shown that vitamin C may inhibit this destructive process. Researchers state that if glycosylation is part of the normal aging process, taking vitamin C supplements may slow it.

MoonDragon's Health & Wellness: Diabetic Retinopathy

KIDNEY DAMAGE (NEPHROPATHY)

Diabetic nephropathy (damage to the kidneys from diabetes) is quite common and has been a leading cause of death among people with diabetes. Diabetes accounts for 40 percent of the people who have kidney failure. It is important to monitor kidney function periodically. Controlling wide springs in blood sugar levels reduces the risks of these complications. Nephropathy is becoming less common as more people recognize the necessity of maintaining a stable blood sugar level. A low-protein diet containing less than 40 grams of protein each day is recommended for prevention and treatment of diabetic nephropathy.

Diabetes and high blood pressure often go hand in hand, and both can lead to kidney disease. Treating high blood pressure is important. In one recent study, hypertensive diabetics who took drugs called angiotensin converting enzyme (ACE) inhibitors cut their risk of developing serious kidney disease in half.

Researchers at the University of Colorado Health Sciences Center found that diabetics who smoke are two to three times more likely than nonsmoking diabetics to develop kidney damage, often leading to the need for dialysis or a transplant. Smoking constricts blood vessels. In people with diabetes, this helps to push large protein molecules out of the vessels and into the kidneys. That can eventually lead to kidney failure.

NERVE DAMAGE (NEUROPATHY)

Diabetic neuropathy (damage to the nerves caused by diabetes) usually affects the peripheral nerves, such as those in the feet, hands, and legs. Symptoms include numbness, tingling, and pain. Amitriptyline and desipramine, common antidepressant drugs, have proved to be successful in the treatment of this condition. They work by increasing levels of the neurochemical that carries messages between cells, thus increasing sensation.

Autonomic neuropathy may lead, among other complaints, to a buildup of gastric juices in the stomach. Too much stomach acid can cause nausea and diarrhea, but the condition can be relieved by either antibiotic treatment or by eating smaller, low-fat meals.

For men, neuropathy or circulatory problems can lead to erectile dysfunction (ED). Sildenafil (Viagra) may be able to alleviate this problem. Your health care provider will probably want to do a stress test before prescribing this drug.

It is vital for people who have diabetes to take care or their feet. Nerve damage can lead to lack of sensation in the feet, and once the skin is broken, sores there may not heal. Treatment for diabetic foot problems include becaplermin (Regranex), a topical gel that encourages tissue growth in the wound, and Dermagraft. Dermagraft is a skin substitute used to help wound closure associated with diabetic foot ulcers. It helps replace and rebuild damaged tissue.

FOOT ULCERS & ASSOCIATED FOOT PAIN

A wound dressing, called Apligraf, is available that helps heal diabetic food ulcers, open foot sores that can lead to amputation. It is manufactured by Organogenesis. Inc.

Magnet therapy helps some people with diabetes in coping with food pain associated with the disorder.

MoonDragon's Health Therapy: Pain Control

HYPOTHYROIDISM

Hypothyroidism may be a leading cause of diabetes. Well-known researcher and author Stephen Langer, M.D., has noticed that neuropathies, together with other diabetic complications, disappear when thyroid hormone is administered. Many complications of diabetes and hypothyroidism are a result of clogged arteries, which prevent the blood from delivering nutrients and oxygen and carrying off waste products and debris.

MoonDragon's Health & Wellness: Hypothyroid

CARDIOVASCULAR DISEASE

Cardiovascular disease is 2 to 4 times more common among people with diabetes, and is the leading cause of diabetes-related deaths. The risk of stroke is also 2 to 4 times higher in people with diabetes, and 60 to 65 percent have high blood pressure as well.

Coronary artery disease is common in people with diabetes. Women with diabetes are particularly at risk. A 16 year study published in Circulation: Journal of the American Heart Association by Frank B. Hu, M.D., lead author and associate professor of nutrition and epidemiology at Harvard School of Public Health, indicates that women with type 2 diabetes who consumed fish 5 or more times a week had a 64 percent reduction in coronary heart disease and a 52 percent reduction in total mortality compared with women who ate fish less than 5 times per month. This was attributed to the higher consumption of omega-3 fatty acids associated with this diet. Concerns with environmental toxins found in fresh fish point to fish oil supplements as an acceptable substitute for the actual consumption of fish. Dr. Hu did not study supplements specifically, but did not rule out their theoretical use as substitutes. It is probable that the consumption of omega-3 fatty acids would have the same effect on men.

HerbalRemedies: Wild Salmon Oil Capsule, NOW Foods, 120 EPA/80 DHA, 2000 mg, 250 Softgels

HerbalRemedies: Omega 3 Fish Oil, NOW Foods, Lemon Flavored, All Natural, 7 oz.

HerbalRemedies: Barlean's Fish Oil, Omega-3, EPA/DHA, 250 Softgels

On days having high levels of airborne particulates, such as dust and soot, people with diabetes are twice as likely to be hospitalized for cardiovascular problems. Exposure to these particles may affect heart rate and inflammation in the heart. This places diabetics with cardiovascular problems at greater risk. If you have diabetes, check air quality levels and stay indoors during periods of risk.

People with diabetes should be vigilant about blood fat and cholesterol levels. Optimum cholesterol levels are LDL (bad cholesterol), less than 130; HDL (good cholesterol), 60 or above; triglycerides, 150 or under. Your health care provider may set different levels for you if you are diagnosed with diabetes.

DIABETIC KETOACIDOSIS (DKA) & HYPEROSMOLAR SYNDROME

If diabetes is left untreated, it can lead to diabetic ketoacidosis or hyperosmolar syndrome. DKA occurs when the body is so low in insulin that it starts using stored fat as fuel. When this fat breaks down, a substance known as ketones can cause the body to become excessively acidic. Ketoacidosis is most often seen in people with type 1 diabetes. Symptoms include nausea, difficulty breathing , sweet breath, and confusion that can progress to coma. Hyperosmolar syndrome is a result of a combination of very high blood sugar levels (but without the presence of ketones) and dehydration. It is more common in older people with type 2 diabetes who are taking steroid medications. The condition may be prompted by stress from a major illness. With hyperosmolar syndrome, blood sugar levels are so high that the blood thickens. Symptoms include confusion, tiredness, and coma. Hyperosmolar syndrome can sometimes be the first indication of diabetes in older adults. Both of these conditions require the immediate attention of a health care provider. Urinalysis can often detect unsuspected diabetes.

GASTROPARESIS

Gastroparesis, which affects up to 75 percent of people with diabetes, causes bloating, loss of appetite, vomiting, and dehydration. With this condition, the flow of food from the stomach to the intestine is blocked or slowed. Because timing of the digestive process is disrupted, this can complicate efforts to control blood sugar levels with medication. Researchers at John Hopkins University School of Medicine have found that sildenafil (Viagra) could be an effective remedy for the condition. Sildenafil appears to cause muscles in the digestive tract to relax.

OTHER CONSIDERATIONS

Caiapo, an extract of white sweet potatoes that is taken as a supplement in Japan, has recently been studies for its efficacy and tolerability. Dr. Bernard Ludvik of the University of Vienna Medical School found that subjects with type 2 diabetes experienced improvement in both blood sugar and cholesterol levels when taking caiapo. Subjects who took a placebo experienced no significant change.

Cinnamon, a spice third only to pepper and mustard in popularity, may be a possible and pleasant treatment for diabetes. In a small study, taking 1 or 2 teaspoonfuls a day in capsule form was show to lower blood sugar, triglycerides and cholesterol. Mostly associated with pastry products, cinnamon is also an excellent spice for teas, meats, and vegetables, as well as fruits such as apples, bananas, and peaches. the continuous ingestion of table cinnamon is, however, probably not advisable due to the potential toxic buildup of certain cinnamon compounds. It would be safer to use an aqueous extract, such as Cinnulin PF from NutraVitals, that contains the active type-A polymers that appear to be the beneficial compounds found in the spice, but without the toxic agents found in table cinnamon. These type-A polymers act to make insulin receptor sites more sensitive to insulin. Cinnulin PF is taken at a dose of 125 to 250 mg, 2-3 times daily for best results.

Cut back on soft drinks that contain sugar. That is the conclusion drawn by a study that appeared in the Journal of the American Medical Association. Women who drank more than one sugar-sweetened soft drink a day were found to be twice as likely to develop diabetes than those who did not. Even when other factors, such as weight, diet, and life-style differences, were factored in, researchers still found that the soft-drink group was 1.3 times more likely to develop the disease. It was hypothesized that in addition to the extra calories, the increase in risk might be attributable to the high amount of rapidly absorbed sugars that cause a dramatic rise in glucose and insulin. Neither diet soda nor fruit juice indicated a problem in the study, but sugared fruit punch showed higher results similar to sugared soda.

Monitoring blood sugar levels is a key component in treatment and management of the disease. Research has indicated that the people who keep their blood sugar levels within individual target ranges set by their health care providers stand a good chance of reducing the risk of associated complications. In many cases, intensive lifestyle changes in the diet and exercise actually can prevent, reduce, or delay the risk of developing adult-onset diabetes.

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DIABETES SELF-TESTS There are several ways to test yourself for diabetes. The tests used for type 1 diabetes are also for self-monitoring by persons diagnosed with the condition. Home testing tends to be slightly less accurate than tests done in a health care provider's office. GLUCOSE BLOOD TESTING STRIPS & METERS Type I Diabetes (Insulin-Dependent or Juvenile-Onset Diabetes) To test for type I diabetes: 1. Purchase chemically treated plastic strips at drugstore for testing blood. 2. Prick your finger and apply a drop of blood to the tip of the strip. 3. Wait one minute and compare the color on the strip to a color chart, which lists various glucose levels. There are also electronic devices available that can analyze the test strips for you and give you a numerical readout of the glucose level. There are more than 100 different brands and types of glucometers used for home-testing blood glucose levels. Many of these devices are available free or have a large rebate attached if you have a health care provider's prescription. They are easily available through your pharmacy or medical supply stores with various styles to choose from. Each work on the same principles, though their detailed use may vary slightly. Be sure to read any instructions carefully. They are easy to use and give you your blood glucose level results quickly with minimal discomfort. You simply prick your finger with the spring-loaded needle, apply a drop of your blood to the test strip, and place it in the machine for analysis. This test gives you an immediate blood sugar result. It is a device that all people with diabetes should have available, own and use frequently every day as directed by your health care provider. A FEW TYPES OF NEW GLUCOSE MONITORING & NEEDLE MANAGEMENT SYSTEMS A new automated home blood glucose monitor called Sof-Tact, uses a suction (vacuum) to hold the skin in place while an integrated device lances the skin. The device then transfers the blood sample to a biosensor strip to deliver a blood glucose test result within 20 seconds. The device, for use on the forearm or upper arm, is manufactured by Abbot Laboratories. A continuous glucose monitoring system, the CGMs System Gold, is available from MiniMed. It records blood glucose levels at 5-minute intervals for periods up to 3 days. Data can be downloaded into a computer for review by a health care provider. This device should be used along with traditional finger stick tests for calibration purposes. A portable, battery-operated laser, called a Lasette, is available for use in drawing blood without using the traditional lancets. it is manufactured by Cell Robotics International, Inc. The FDA recently approved a wristwatch-like glucose monitoring device for use by children and adolescents. The device, called the GlucoWatch G2 Biographer, manufactured by Cygnus, Inc., was previously approved for use by adults. Fluid is extracted through the skin as the device is worn and the glucose level is measured and displayed. Up to 6 painless measurements per hour for a thirteen hour period are possible. The device must be warmed up and calibrated using a finger stick. A needle management system, called the Q-103 Needle Management System, is available to remove certain hypodermic needles from insulin syringes and to store them safely for later disposal. The device holds as many as 5000 needles, and is produced by QCare International LLC. FASTING BLOOD SUGAR GUIDELINE The following is an approximate guideline for fasting blood sugar levels for people who have not been diagnosed with diabetes. Fasting blood sugar levels should be measured from 6 to 8 hours after eating. The measurement is milligrams of glucose per one-tenth liter (mg/dL) of blood: 70-100 - Normal. 100-125 - Impaired glucose tolerance / borderline. 126 and over for a 2 or 3 day period: Possible diabetes. If you test at random, without fasting, any reading less than 100 mg/dL is considered normal. If you get a number between 100 and 199 mg/dL, it suggests prediabetes. A blood sugar level of 200 mg/dL and above is an indicator of diabetes. Charts are often published containing different figures. Those might be the ones used by diagnosed diabetics and are target goals. As such, they will be somewhat higher. See the Quick Reference Guide - Goals For Blood Glucose Control. HEMOGLOBIN A1c TEST There is another test that is used normally as a diabetes management tool rather than a screening test. This is the hemoglobin A1c lab test. It is based on the notion that sugar is sticky, and the longer it is around the harder it is to get off. The red blood cells in the bloodstream usually live for about 3 months, circulating around the body all that time. As they circulate, blood sugar sticks to them, and if it can be measured, it will tell you how much sugar has been in the blood over the life of those cells, or about 3 months. The normal range for this test is 4 to 5.9 percent, but people can have 8 percent or above if they have poorly controlled diabetes. Those whose diabetes is under control usually have about a 7 percent or lower reading. There is a correlation between average blood sugar levels in mg/dL and A1c as follows: A1c of 6: 135 mg/dL. A1c of 7: 170 mg/dL. A1c of 8: 205 mg/dL. A1c of 9: 240 mg/dL. A1c of 10: 275 mg/dL. A1c of 11: 310 mg/dL. A1c of 12: 345 mg/dL. THE SUGAR-TASTE TEST Type 2 Diabetes (Maturity-Onset Diabetes) People with type 2 diabetes mellitus are less able and often cannot perceive sweet tastes than most people. This may make it more difficult for them to lose weight. Because they do not recognize the sweet taste of substances, they often consume sugary products that they do to appreciate as sweet. This abnormality may play an important role in how individuals with diabetes perceive the taste of their food, and also in how well they comply with the dietary aspects of treatment. Because our society as a whole is addicted to sugar, this distorted taste perception is very common among the population in general. If a person with type 2 diabetes attains a better understanding of food, exercises greater care in choosing foods, and reads food products carefully, he or she should be able to control the problem and avoid the need for treatment with drugs or insulin. The following test can detect an impaired ability to taste sweets: 1. Do not consume stimulants (coffee, tea, soda) or sweets for one hour before the test. 2. Fill seven identical glasses with 8 ounces of water each and label the glasses as having no sugar, 1/4 teaspoon sugar, 1/2 teaspoon sugar, 1 teaspoon sugar, 1-1/2 teaspoons sugar, 2 teaspoons sugar, and 3 teaspoons sugar. Add the appropriate amount of sugar to each glass, then ask someone else to arrange the order of the glasses and hide the labels. 3. Take a straw and sip from each glass, then write down the amount of sugar you think it contains. Between sips, rinse your mouth with pure water. Healthy people generally notice a sweet taste when a teaspoon or less of sugar is added to 8 ounces of water. By contrast, people with adult-onset diabetes usually do not notice sweetness until 1-1/2 to 2 teaspoons of sugar have been added to the water.

GLUCOSE TESTING METERS



QUICK REFERENCE GUIDE - GOALS FOR BLOOD GLUCOSE CONTROL

WHEN CHECKED	GOAL FOR PEOPLE WITH NO DIABETES DIAGNOSIS	GOAL FOR PEOPLE WITH DIABETES
Before Breakfast (fasting)	Less than 110 mg/dL	90 - 130 mg/dL
Before Lunch, dinner, and snack	Less than 110 mg/dL	90 - 130 mg/dL
Two hours after meals	Less than 140 mg/dL	Less than 160 mg/dL
At bedtime	Less than 120 mg/dL	110 - 150 mg/dL
Anytime (A1c hemoglobin)	Less than 6 percent	7 percent

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TRAVELING WITH TYPE 1 DIABETES

When you have Type 1 diabetes you can usually do everything you want to do when you travel. But it does take planning ahead to handle your diabetes.

How you prepare depends on where you are going and for how long. Two weeks backpacking through Europe takes different planning than a week at the beach. Will you be crossing time zones? What kind of food will you eat and when? Will you be more active or less active than usual?

TRAVEL TIPS

Carry essential supplies and insulin on you at all times.

Have several copies of a medical letter stating you have diabetes and are carrying syringes or pen needles on you to give to customs agents. Do not give away the original of this letter.

Do not store insulin in the baggage compartment of planes because it will freeze.

Get a specialist's help before you leave on adjusting insulin doses and food through time zones.

If you use an insulin pump, follow the manufacturer's guidelines for flying.

Don't expose your insulin to extremes of temperature. If necessary carry it in an insulated bag or small wide mouthed thermos flask.

Always obtain medical insurance when traveling.

Check the strength of any insulin you get overseas (some countries market different strength insulin).

Check your blood glucose frequently while traveling.

GETTING READY

Consider telling your travel agent that you have diabetes and explain some of the particular needs that traveling with diabetes entails. That way together, you can plan a suitable itinerary that will be more likely to meet your needs.

IMMUNIZATIONS

Get immunization shots (if you need them) at least one month before you leave. Find out what is required for where you are going and make sure you get the right shots, on time. If the shots make you unwell, you will have time to recover before your trip. You should have a medical check-up 4 to 6 weeks before your trip to make sure all bases are covered and you are in a healthy range before you leave.

HEALTH INSURANCE

Health insurance for your trip is an absolute must. Handling your diabetes while traveling is a challenge and you are more likely to have problems with unexpected low or high blood glucose levels. All travelers are prone to infectious illnesses as they travel through new countries. If you develop an infection it can result in serious problems such as ketoacidosis. It is very important you can access good quality healthcare if you need it.

DIABETES RELATED DOCUMENTS

Before any trip, get two papers from your health care provider:

• A letter for customs.
• A letter for a health care provider (should you need to see one when you are away) with your prescription.

THE LETTER FOR CUSTOMS:

Should state that you have diabetes and are carrying syringes or insulin pens and needles for your diabetes.

Store the original of this letter safely with your travel documents. Have enough photocopies of the letter to give to the customs agents at each border you are crossing. Do NOT give away your original!

THE LETTER & PRESCRIPTION FOR A HEALTH CARE PROVIDER:

Explain you have Type 1 diabetes and what insulin type and doses you are on. Also the times you usually take your insulin. The prescription should be for insulin or diabetes pills. You should have more than enough insulin and syringes or pills to last through the trip. But the prescription may help in case of emergency. In the United States, prescription rules may vary from state to state.

The prescription laws may be very different in other countries. If you are going out of the country, write for a list of International Diabetes Federation groups. Write to: IDF, 1 rue Defaeqz, B-1000, Belgium (www.idf.org).

You may want to get a list of English-speaking foreign health care providers from the International Association for Medical Assistance to Travelers (IAMAT), 1623 Military Road, #279, Niagara Falls, NY 14304 (www.iamat.org). IAMAT can be reached at 716-754-4883. If an emergency occurs while you are traveling and you do not have such a list, contact the American Consulate, American Express, or local medical schools for a list of health care providers.

List the pen device or syringes you use plus the blood glucose meter you use and the testing strips.

Note any other medical conditions you have.

List any allergies you have or any foods or medications to which you are sensitive.

Supplies of diabetes medications.

Make sure you have a full supply of all your diabetes medications before you leave.

TRAVELING DIABETIC SUPPLIES

The prescription to get filled before you leave should give you:

• Ample supplies of insulin and test strips. Enough to get you through to the next time that you will be settled in a country where you are certain you can get supplies (never run low on insulin or test strips while you are traveling).



• A supply of individually foil-wrapped urine ketone testing strips.



• Two glucagon hypokits if you are traveling with a companion.

OTHER MEDICAL SUPPLIES

It is often sensible to get a prescription from your health care provider for anti-nausea and vomiting medication, anti diarrhoea medication, and some basic antifungal and antibiotic medication. Doing this means you will have the medications you need should you become sick overseas and are unable to get medical help quickly. Discuss your needs with your health care provider and remember to get he/she to give you instructions on when and how to use the medication. Get the prescription filled before you leave and carry these medications on you.

DIABETES IDENTIFICATION

No matter where you go, wear a medical ID bracelet or necklace that states you have diabetes and take insulin. It is also wise to carry a card in your wallet or amongst your traveling papers that states you have Type 1 diabetes and are on insulin. If you are leaving the country learn how to say, "I have diabetes" and "sugar or orange juice, please" in the language or languages of the countries you will be visiting. The identification should be written in the language of the places you are visiting.

Visit the Medic Alert Website for more information about obtaining a medical ID bracelet.

MANAGING LOW BLOOD GLUCOSE LEVELS

Always carry a source of simple carbohydrate on you e.g., orange juice, glucose tablets, jelly beans. It also pays to carry a small complex carbohydrate snack on you (e.g., muesli bar). People on holiday often drink more alcohol than usual. Try to drink only moderately, and be aware of the safety guidelines for drinking alcohol when on insulin.

MANAGING SICKNESS & HIGH BLOOD GLUCOSE LEVELS

If you get sick overseas you may not have access to the same level of health care that you have in most parts of the United States. You may get sick in some very inconvenient places overseas where quality medical services may be lacking or non-existent.

It is important for you to be really clear about how you go about managing sickness and high blood glucose levels. You also need to have the tools for avoiding ketoacidosis on you at all times. These tools are:

• In-date, individual foil-wrapped urine ketone testing strips (with the color matching guide chart that comes with them).
• A good supply of unsweetened fluids. The best is a supply of bottled water.
• A good supply of short-acting insulin that has been stored properly.
• Anti-nausea and vomiting medicine.
• Anti-diarrhea medicine.
• A supply of a basic broad-spectrum antibiotic tablets.
• Anti-fungal cream.
• Your own knowledge about managing your diabetes during illness.
• Basic guidelines written down (for yourself and others) on managing Type 1 diabetes in illness.

PACKING YOUR SUPPLIES

Pack more medication and blood-testing supplies than you think you will need. Pack all of these in your personal carry bag so that your medication and testing supplies are always with you. This way you are less likely to get separated from your essential supplies if your luggage goes astray. Also the temperature in the baggage compartments of some planes can be very low. This can damage your insulin, testing strips or meter. If you have questions about what you can bring with you in a carry-on bag (new Homeland Security Regulations since 9-11), contact your airline or airport security. Traveling guidelines can be found at www.diabetes.org.

Whether you travel by car, plane, boat, bike, or foot, you will want to keep this "carry-on" bag with you at all times. Your carry bag should contain:

• All the insulin and delivery devices (syringes or pen) you will need for the trip.
• Blood testing supplies (include extra batteries for your glucose meter).
• Ketone (urine) testing sticks.
• All oral medications you take (an extra supply is a good idea).
• Your other medications such as glucagon, anti-diarrhea medication, antibiotics, and anti-nausea drugs.
• Your ID and diabetes identity card stating your name and the fact you are on insulin.
• A well-wrapped, air-tight snack pack supply of simple carbohydrate e.g., glucose tablets, small juice pack, jelly beans.
• A well-wrapped snack pack of something containing complex carbohydrate e.g., muesli bar, crackers, cheese, peanut butter, fruit, juice box, and some form of sugar (hard candy or glucose tablets) to treat low blood glucose.
• A clear, written guide sheet for managing Type 1 diabetes through illness.

TIPS FOR TRAVELING BY AIR

Under normal conditions, insulin can safely pass through X-ray machines at airport terminals. If the insulin remains in the path of the X-ray longer than normal, or if it is repeatedly exposed to X-rays, be careful. This can affect the stability of your insulin. If you have concerns about X-rays, you can request hand-inspection. Also, insulin never should be placed in checked baggage. Passenger baggage stored in cargo holds is subject to powerful X-rays. It also could be affected by severe changes in pressure and temperature. Inspect your insulin before injecting each dose. If you notice anything unusual about the appearance of your insulin or you notice that your insulin needs are changing, call your health care provider.

Transportation Security Administration (TSA) recommends that passengers traveling with prescription liquid medications such as insulin, Symlin, Byetta, or a Glucagon Emergency Kit should make sure their medications are clearly identified with a prescription label matching the name of the passenger. Although having a prescription label is not required by TSA, making it available with the medication will expedite the security check-in process.

Please Note: There has been no change in protocol for airline passengers with diabetes who are traveling with insulin pumps or continuous glucose monitoring devices. Pump and CGMS wearers may request a visual inspection rather than walking through the metal detector or being hand-wanded.

Please Note: For passengers with diabetes, TSA does allow multiple containers of glucose gel, cakemate or liquid of 5 oz. to treat low blood sugar. Passengers should consider alternative forms of carbohydrates to treat hypoglycemia such as glucose tablets, Life Savers, gumdrops, or raisins.

TSA recommends that travelers with disabilities and medical conditions may want to consider the following.

• Arrive at the airport 2-3 hours prior to flight.
• Review TSA's Web site for travel updates.
• Bring required prescription labels for medication.
• Bring prescriptions for medical devices when possible.
• Pack medications in a separate clear bag and place in your carry-on luggage.
• Be patient with lines, delays, and new screening procedures.

American Diabetic Association: Traveling With Diabetic Supplies

Food: Some people have found that if they request special diabetes meals on airlines, they get served meals that are very low in carbohydrates. Discuss the meals with your flight attendant. It is often best to order standard meals and to make healthy choices within that. Always have some appropriate snacks with you also in case your flight or in-flight meal is delayed or the meal does not have enough carbohydrates. If no food is offered on your flight, bring a meal on board for yourself. Keep your diabetic medications and emergency snacks with you at your seat. Do not store them in an overhead bin.

Hypoglycemia Control: Make sure you carry a supply of simple carbohydrates on you, e.g., glucose tablets, raisins, fruit juice or jelly beans. Also carry urine ketone testing strips.

Safety: The cabin staff need to know that you have diabetes (especially if you are traveling alone) and are on insulin (in case you get unwell during the trip). If you plan on using the restroom for insulin injections, ask for an aisle seat for easier access.

On-Board Insulin Injection: When drawing up your dose of insulin, do not inject air into the bottle (the air on your plane will probably be pressurized).

Insulin Pump: If you are on an insulin pump make doubly sure that the safety plug (for waterproofing the pump when swimming) is NOT in your pump. If you leave this plug in your pump when flying your pump can deliver wrong doses due to pressure changes in the atmosphere. Otherwise, a pump is an ideal way to deliver your insulin across time zones as you can pump and dose for meals in the normal way with no real change to your dosages.

Avoid Risks of Blood Clots In Your Legs: Keep up a good level of activity during your journey. Walk around in the terminal before boarding. When you are booking your seat try to get an aisle seat. Because you have diabetes you are more likely to develop blood clots in your legs. To prevent this happening it is essential that you get up and walk around in flight for a few minutes every hour while you are awake. Doing simple stretching exercises when seated also helps. Move your ankles in circles and point and release your toes often. This encourages good blood flow in your legs.

Blood Glucose Testing: Test your blood glucose levels frequently when traveling through time zones. The timing of your eating and insulin administration will be changed. It is also easy to mix up the effects of jet lag with either high or low blood glucose levels, so it pays to know what your glucose levels are doing. Remember when you are tired it is easy to neglect your diabetes. But it is at these times that you need to know more about what is happening.

Once You Have Arrived At Your Destination: After a long flight, take it easy for a few days. Test your blood glucose often. If you take insulin, plan your activities so you can work in your insulin and meals. If you are more active than usual, your blood glucose could go too low. Take along snacks when hiking or sightseeing. Don't assume you will be able to find food wherever you are.

TRAVELING WITH INSULIN

Keep these things in mind when you travel with insulin:

• Insulin does not need to be refrigerated, but if insulin is stored in very hot or very cold temperatures it may lose its strength.



• The glove compartment or trunk of your car are not good places to store your insulin as they can get very hot. Nor are backpacks or cycle bags exposed to direct sunlight.



• If you plan to travel by car or bike or be out in the elements, take steps to protect your insulin.



• At room temperature the insulin you have opened (and are using) retains its potency for 30 days.



• There are travel packs available to keep your insulin cool. They are insulated bags. Diabetes Supplies Ltd can supply these bags. Another option some people use to keep their insulin cool is a small wide-mouthed thermos. This can be bulky however and if you are hiking or traveling light you may prefer an insulated bag.

INSULIN DOSES WHEN TRAVELING

Managing your insulin doses while traveling is complex, especially if you are crossing time zones rapidly (by air). Crossing time zones, effectively, makes your day either longer or shorter, so you will need to adjust your insulin doses (and food) to compensate for this. Traveling westward means a longer day, so more insulin may be needed. Traveling eastward means a shorter day and if you inject insulin, less may be needed.

The safest way to plan your insulin management when traveling is to work it through with your specialist diabetes team before you leave. Give yourself plenty of time to plan by making this appointment well in advance of your departure date.

Take your full travel itinerary when you see the team. Make sure you come away with a plan you are happy with and that you understand. This plan should be written down. See more on managing your insulin across time zones in the Tips for Travel by Air section.

INSULIN MANAGEMENT & TIME ZONES

Making dose changes to your insulin as you cross time zones is complex. Work out a plan in conjunction with your specialist diabetes team, in advance, as to how you will manage your insulin doses. In general, you should stick with the exact brand and formulation of insulin that you have been prescribed by your health care provider. However, if you run out while you are on the road, and your regular brand is unavailable, you may substitute another brand's equivalent formulation (for example, NovoLog for Humalog, Humulin R for Novolin R). Changes in formulation (for example, from rapid-acting Humalog to short-acting Humulin R) require medical supervision.

Insulins used in the United States are all of the strength U-100. In foreign countries, insulins may come as U-40 or U-80. If you need to use these insulins, you must buy new syringes to match the new insulin to avoid a mistake in your insulin dose. If you use U-100 syringes for U-40 or U-80 insulin, you will take much less insulin than your correct dose. If you use U-100 insulin in a U-40 or U-80 syringe, you will take too much insulin.

A simple way that some people choose to manage their insulin crossing time zones is to use short acting insulin only for the flight. Once they get into the time zone of the country they are traveling to they reintroduce the intermediate-acting insulin. In this system you dose with short acting insulin every 4-6 hours (before snacks or meals which are taken at these times also) until you are established back onto your usual insulins in the new time zone. BUT get advice, before you leave, on the dosages you need if you are using this system. Other people adjust the dose of their intermediate insulin up or down according to whether the time zone change means that their day will be getting longer or shorter by more than 2 hours. Get advice before you travel on a plan that will suit you.

TIPS FOR TRAVELING BY SEA

With the wide array of mouth-watering foods available on cruise holidays, it is easy for your diabetes management to get out of kilter. Talk to your diabetes educator or dietitian before you leave about how you plan to deal with the food aspect of the trip. It is often helpful to get a sample menu from the cruise line so you can get an idea of the types of foods that will be served.

Cruise ships offer some great activities to help you stay active. These range from aerobics classes, swimming, gym workouts, dancing, or strolling the deck at sunset.

It is a good idea to make the cruise staff aware of your diabetes in case any problems arise. Keep a card or ID on you that states you have diabetes and that you are on insulin.

Because you are crossing time zones slowly the changes in your insulin dosing times will happen gradually and usually without the need for planned changes.

TIPS FOR TRAVELING BY CAR

Do not leave your medications in the trunk, glove compartment, or near a window. They might overheat. If possible, carry a cooler in the car to keep medications cool.

Bring extra food with you in the car in case you cannot find a restaurant. Test your glucose before and during driving and treat any low blood glucose levels promptly. Check your glucose often. Changes in diet, activity, and time zones can affect your blood glucose in unexpected ways.

Stay comfortable and reduce your risk for blood clots by moving around every hour or two. Stop and stretch your legs. Wear comfortable clothes and shoes.

Protect your feet. Never go barefoot, even in the shower or pool.

Always tell at least one person traveling with you about your diabetes.

TIPS FOR TRAVELING BY FOOT
(Or other physically active means e.g. cycling or kayaking.)

A holiday in the great outdoors can be a wonderful retreat from the pressures of everyday life. But there are a few things to consider before you go. Here are some tips:

Avoid going camping or hiking alone.

Tell someone where you will be and when you expect to return, so you can be found if there is an emergency.

Carry all your insulin supplies (as outlined above). Make sure you carry an in-date glucagon kit and teach your travel companion when and how to use glucagon.

The key to enjoying a trip of this kind is to try to avoid things that may severely alter your blood glucose levels. Be aware of safety and try to avoid sunburn, injuries, blisters, insect bites and contaminated food or water. Make sure your footwear is sturdy and fits you well. Do not use brand new shoes to hike in, try them out before the trip.

Eat and drink enough to meet your needs. Take extra food, water, medication and supplies of simple carbohydrate (e.g., glucose, sugar).

Hiking, cycling or kayaking nearly always means you are a lot more physically active than usual, so you may need to significantly reduce all your insulin doses. You will also need to increase your carbohydrate food intake. Have a good understanding of how to reduce your insulin to compensate for increased activity. Your specialist diabetes team can help you with this before you go.

GENERAL TRAVEL TIPS

Test your blood glucose frequently. Your whole routine of activity and food is likely to be very different. The type of food you eat may also change your insulin requirements.

Keep a daily record of insulin doses and test results (to help you identify any trends, and to help any medical advisors that you may need to see).

If you are having problems with your blood glucose levels, follow the guidelines you worked out with your team before you went away and/or contact a hospital or diabetes health care provider in the area for advice.

If you do visit a hospital take along as much supporting documentation as you can (your medications, test results, travel/medical insurance forms etc.).

Some insulins have different names and are supplied in different strengths in other countries. If you have to use insulin from another country make sure it is either the same strength as you are used to or a diabetes specialist has helped you make the necessary dose adjustments to take a different strength insulin.

Avoid using local needles if not sterile.

It is smart to watch what you eat and drink when traveling. Avoid tap water overseas (including ice cubes made from tap water). Ask for a list of ingredients for unfamiliar foods. Some foods may upset your stomach and this may make your blood glucose management more difficult.

Wear comfortable shoes and never go barefoot. Check your feet every day. Look for blisters, cuts, redness, swelling, and scratches. Get medical care at the first sign of infection or inflammation on your feet.

Go wherever your heart leads you. But remember that you take your diabetes with you. Your self care is your traveling friend.

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HERBAL & HOLISTIC RECOMMENDATIONS

HERBS

Beanpod tea, made up of kidney, white, navy, lima, and northern beans, detoxifies the pancreas.

Most legumes are a good meal choice for diabetics. even though beans contain starch, they are also rich in protein, fiber and saponins, all of which can help to balance blood sugar. Eat bean burritos, make chili with beans, put kidney beans in salads and prepare bean dips. Homemade bean soup is always nice, especially during the winter months when it is cold and miserable outdoors.

Bitter Melon (Momordica Charantia), Gudmar (Gymnema sylvestre), and Gulvel/Guduchi (Tinospora Cordifo) are herbal remedies used in Ayurvedic medicine to regulate blood sugar levels.

HerbalRemedies: GlyMordica Bitter Melon, 100% Natural, 450 mg, 60 Caps
Bitter melon is one of the few agents which has the potential to bolster a flagging pancreas. Known for it's ability to help with liver problems, Diabetes and HIV also an excellent natural common cold remedy.

HerbalRemedies: Momordica Charantia Powder, Alternative Health & Herbs, 4 oz.
Momordica Charantia is an antibiotic, antiviral, immunosuppressive, insulinomimetic, and hypotensive. Also known as Bitter Melon, Momordica is used for diabetes, rheumatoid arthritis, systemic lupus erythematosus. Lowers blood sugar. Momordica is an antibiotic, antiviral, immunosuppressive, insulinomimetic, and hypotensive.

HerbalRemedies: Momordica Tincture, 100% Organic, 2 fl. oz.
It has been suggested that Bitter Melon, Momordica, has anti-tumor and antiviral actions. MAP 30 is a protein found in Bitter Melon that is believed to have multiple functions that could be beneficial in treating HIV infection.

HerbalRemedies: Gymnema Extract, Standardized, Nature's Way, 260 mg, 60 Caps
Gymnema Extract is standardized to 75% gymnemic acids and Gymnema is a traditional Ayurvedic medicine and is referred to as destroyer of sugar because chewing the leaves blocks the taste of sweetness.

HerbalRemedies: Gymnema Sylvestre Tincture, 100% Organic, 2 fl. oz.
For diabetes, hypoglycemia, and as a digestive tonic. Used for weight reduction, to help prevent tooth decay, and restore pancreatic function. Helps to block the absorption of sugar in the digestive tract.

HerbalRemedies: Blood Sugar Formula With Gymnema Extract, Nature's Way, 90 Caps
Blood Sugar Formula with Gymnema Extract represents the powerful synergy of current scientific research and traditional herbal medicine.

HerbalRemedies: Glucose Metabolic Support, NOW Foods, 90 Caps
Glucose Metabolic Support contains GlucoTrim, a new dietary ingredient, and extracts of Gymnema, which has been used for centuries by Ayurvedic medical practitioners for glucose metabolism.

HerbalRemedies: Guduchi Stem Powder, Certified Organic, Banyan Botanicals, 1/2 lb.
Certified Organic Guduchi Stem Powder (Tinospora Cordifolia) is a slightly bitter herb that balances all doshas, and is especially useful for a variety of pitta-related conditions.

Cedar berries are excellent nourishment for the pancreas.

HerbalRemedies: Diabetic Insulin Support, Natural Insulin Tincture, 100% Organic, 2 fl. oz.
The Diabetic Insulin Support, natural insulin, provides synergistic support for the adrenals, kidneys and pancreas and may help those with insulin dependent diabetes. May help those with insulin dependent diabetes decrease dependence on insulin. Cleansing & detoxification formula. Suggested Dosage or Use: 6-12 drops or more, 3 times per day as needed. Ingredients: Cedar Berries; Uva Ursi; Licorice; Mullein; Cayenne Pepper (Capsicum Annum).

Dandelion root protects the liver, which converts nutrients into glucose. Note: If you suffer from gallbladder problems, avoid large quantities of dandelion.

Fenugreek seeds have been shown to reduce cholesterol and blood sugar levels. This can be purchased under the brand name Sugar-Down (unable to find this product under this brand name online).

Fenugreek seeds and blackberry and blueberry leaves have a beneficial effect on pancreatic function. Mix in equal parts to make a tea blend. Use 1 teaspoon of the mixture for each cup of water. Steep for 30 minutes and then strain. Drink as much as 2 quarts daily.

Take Garlic capsules and/or eat fresh Garlic in salad dressings or prepare a Garlic tincture. For the tincture, peel 8-10 whole bulbs of garlic and place in a blender with enough vodka or brandy to cover. Purée and transfer to a glass jar. Ensure that the garlic is fully covered by adding additional vodka, as needed. Let stand in a dark, warm place for about 2 weeks, shaking it daily. Filter out the garlic pieces and take 1 teaspoon of the tincture 3-4 times daily.

Ginseng tea is believed to lower the blood sugar level. Caution: Do not use this herb if you have high blood pressure.

HerbalRemedies: Panax Ginseng (Korean Ginseng) Herbal Tea, 20 Tea Bags

HerbalRemedies: American Ginseng, Whole Root, 4 oz. bulk

Huckleberry helps to promote insulin production.

HerbalRemedies: Huckleberry (Vaccinium Myrtillus) Tincture, 100% Organic, 2 fl. oz.
Huckleberry leaf is used by naturopathic physicians to treat sugar diabetes and ailments of the kidneys and gallbladder.

Stimulate the metabolism. Because the excessive sugars and fats in the blood stream can cause damage to the blood vessels, it is especially important for diabetics to maintain healthy circulation. Ensuring that all organs get enough oxygen is the only way to prevent complications, such as blindness, loss of kidney function and circulatory disease in the extremities. Blueberries and Hawthorn berries can help protect blood vessels from damage, too, just as keeping blood-sugar and cholesterol levels in check and stave off many complications. Regular use of saunas and hot baths can help stimulate the elimination of toxins from the body.

Blueberries for health. Blue and purple pigments, or anthocyanosides, are found in blueberries, bilberries and other fruits. Anthocyanosides improve circulation and help protect blood-vessel walls from damage. Use commercial capsules, drink unsweetened blueberry juice and eat fresh blueberries. You can freeze some for use during the winter months.

Juniper berries have been found to lower blood glucose levels.

Other herbs that may be beneficial for diabetes include Bilberry, Buchu, Dandelion root, Goldenseal, and Uva Ursi. CAUTION! Do not take goldenseal on a daily basis for more than one week at a time, and DO NOT USE IT DURING PREGNANCY. If you have a history of cardiovascular disease, diabetes, or glaucoma, use it only under a health care provider's supervision.

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RECOMMENDATIONS

Opinions may differ as to the optimal ratio of dietary carbohydrates, proteins and fats for prevention and treatment of diabetes. However, it is safe to say that carbohydrates trigger the release of insulin. As more carbohydrates are consumed, more insulin is produced. The current epidemic of obesity and diabetes in the United States indicates that we are asking our bodies to burn the wrong fuel - refined carbohydrates in this case. It has been suggested by Dr. Gerald Reaven of Stanford University that a diet consisting of 45 percent complex carbohydrates, 40 percent "good" (polyunsaturated) fats, and 15 percent protein will benefit individuals with insulin resistance, the precursor to diabetes. It is estimated that as many as 70 to 80 million Americans may be affected by insulin resistance syndrome. Medications such as metformin (Glucophage) and rosiglitazone (Avandia) are prescribed to combat insulin resistance.

Eat a low-fat, high-fiber diet including plenty of raw fruits and vegetables as well as fresh vegetable juices. This reduces the need for insulin and also lowers the level of fats in the blood. Fiber helps to reduce blood sugar surges. For snacks, eat oat or rice bran crackers with nut butter or cheese. Legumes, root vegetables, and whole grains are also good. Remember to regulate your carbohydrate intake. See Hypoglycemic Diet for helpful dietary suggestions to prevent hypoglycemic episodes.

The types of carbohydrates consumed are at least as important as the total carbohydrate loading. High-glycemic foods such as white rice, white flour products, pasta, starchy vegetables, and many processed foods are quickly converted into blood sugar during digestion, causing insulin to go up. Carbohydrates found in lower glycemic foods such as asparagus, broccoli, cabbage, green beans, and low-starch vegetables and fruits are converted into blood sugar more slowly, which only gradually raises insulin levels. Avoiding "white foods" might be best.

Supplement your diet with spirulina. Spirulina helps stabilize blood sugar levels. Other foods that help normalize blood sugar include berries, brewer's yeast, dairy products (especially cheese), egg yolks, fish, garlic, kelp, sauerkraut, soybeans, and vegetables.

HerbalRemedies: Spirulina, 100% Organic, NOW Foods, 500 mg, 120 VCaps

HerbalRemedies: Spirulina Powder, 100% Natural, NOW Foods, 1 lb.

HerbalRemedies: Spirulina Natural, Earth Rise, 500 mg, 180 Tabs

HerbalRemedies: Spirulina Natural Green Super Food For Longevity, Earth Rise, 500 mg, 360 Tabs

Get your protein from vegetable sources, such as grains and legumes. Fish and low-fat dairy products are also acceptable sources of protein. Kidney function in people with type 2 diabetes seems to benefit from dietary soy protein. This protein also raises the level of "good" cholesterol.

HerbalRemedies: Soy Protein, Unflavored, NOW Foods, 1 lb.

HerbalRemedies: Soy Protein Isolate Powder, 1 lb.

Avoid saturated fats, trans-fats, hydrogenated or partially hydrogenated oils, and simple sugars (except when necessary to balance an insulin reaction). While total fat intake does not seem to change the risk of getting diabetes, the trans-saturated fats and hydrogenated oils found in most fast foods can greatly increase the risk. Beneficial fats and oils include extra virgin olive oil, fish oil, almond oil and butter, avocados, nuts and seed oils such as sesame, flax sunflower, and pumpkin.

Eat more complex carbohydrates or reduce your insulin dosage before exercise. Exercise produces as an insulin-like effect in the body. Talk to your health care provider about the right approach for you.

Type 2 diabetes can be controlled by diet and exercise alone, but oral medications or injections of insulin can be added if regulating the diet does not work. Obesity is a major factor in type 2 diabetes, and a weight reduction program is often all that is required to control it.

It was once thought that people with diabetes should avoid sweetened foods. For weight control, this is still the case. However, research has shown that sugar - a simple carbohydrate - does not cause the greatest increase in blood glucose. Eating baked potatoes or some breakfast cereals causes a greater rise in blood sugar. Indeed carrots raise blood sugar more than ice cream does. It is on this principle that many high-protein, low-carbohydrate diets are based. It is essential, therefore, that people with diabetes measure their intake of both simple and complex carbohydrates - not simply those coming from sugar.

MoonDragon's ObGyn Information: Obesity - Description Overview

MoonDragon's ObGyn Information: Obesity - Herbal Suggestions For Weight Loss

MoonDragon's ObGyn Information: Obesity - Holistic & Dietary Information

MoonDragon's Nutrition Information: Diets - Weight Control Diet

MoonDragon's Nutrition Information: Diets - Weight Loss Diet

Do not take fish oil capsules or supplements containing large amounts of para-aminobenzoic acid (PABA), and avoid salt and white flour products. Consumption of these products results in an elevation of blood sugar.

Eat more carbohydrates or reduce your insulin dosage before exercise. Exercise produces an insulin-like effect in the body. Discuss with your health care provider about the right approach for you.

A higher magnesium intake lowers the risk of getting type 2 diabetes. The journal Diabetes Care published a study in which overweight women who consumed large amount of magnesium were 22 percent less likely to develop type 2 diabetes than women who consumed lower amounts. A diet rich in nuts, whole grains, and vegetables that are high in magnesium may be beneficial.

Do not take supplements containing amino acid cysteine. It has the ability to break down the bonds of the hormone insulin and interferes with absorption of insulin by the cells.

Do not take extremely large doses of vitamins B-1 (thiamine) and C. Excessive amounts may inactivate insulin. These vitamins may, however, be taken in normal amounts. See Nutrient Table for recommendations.

If symptoms of hyperglycemia develop, go to the emergency room of the nearest hospital or medical center. This is a potentially dangerous situation. Intravenous administration of proper fluids, electrolytes, and insulin may be required.

Avoid taking large amounts of vitamin B-3 (Niacin). However, small amounts (50 to 100 milligrams daily), taken by mouth, may be beneficial. In one study, large amounts of niacin raised blood sugar levels in people with non-insulin-dependent diabetes by as much as 16 percent. Over time, this could cause dependence on insulin or medication. Niacin can also cause the level of uric acid in the blood to rise, indicating probable kidney dysfunction and an increased risk of gout. However, niacinamide, a form of niacin, shows down the destruction and enhances the regeneration of the insulin-producing beta cells in the pancreas, and therefore may be helpful for those with type I diabetes.

Chromium deficiency may be a key player in the type 2 diabetes problem. In addition, chromium may help improve body composition - that is, the ratio of fat to muscle. Chromium is not generally available in plant foods as plants have no requirement for it and thus do not concentrate it. Brewer's yeast, beer, whole grains, cheese, broccoli, and meat are good dietary sources, but not all are good choices for people with diabetes. Inorganic forms of chromium are poorly absorbed. Chromium picolinate is an effective organic form that is readily available as a supplement. See Nutrient Table for dosage and details.

Many nutrients recommended for people with diabetes are available in combination supplements. One company that produces a line of specialty supplements for people with diabetes is Progressive Research Labs of Houston.

If you have a child with diabetes, be sure his or her teacher knows how to respond to the warning signs of hypoglycemia and hyperglycemia.

If symptoms of hypoglycemia develop, immediately consume fruit juice, soda pop, or anything else that contains sugar. If that fails to help within 20 minutes, repeat this regimen. If the second treatment fails, or if you cannot ingest food, seek immediate medical attention and/or administer a glucagon injection. Anyone who has insulin-dependent diabetes should always carry a glucagon kit and know how to use it.

MoonDragon's Nutrition Information: Diets - Hypoglycemic Diet

Avoid tobacco in any form. It constricts the blood vessels and inhibits circulation. Keep your feet clean, dry, and warm, and wear only white cotton socks and well-fitting shoes. Lack of oxygen (because of poor circulation) and peripheral nerve damage (with loss of pain sensation) are major factors in the development of diabetic foot ulcers. Try to avoid injury, and take measures to improve the circulation in the feet and legs. See Circulatory Problems.

Alcohol now and then may help. A growing body of evidence links moderate alcohol consumption with reduced risks of heart disease. The same may be true for type 2 diabetes. Moderate amounts of alcohol-a drink a day for men, a drink every other day for women-increases the efficiency of insulin at getting glucose inside cells. And some studies indicate that moderate alcohol consumption decreases the risk of type 2 diabetes. (4, 14) If you already drink alcohol, the key is to keep your consumption in the moderate range. If you don't drink alcohol, there's no need to start-you can get the same benefits by losing weight, exercising more, and changing your eating patterns.

Chromium Picolinate: A Complementary Nutritional