Diabetes QuickRefGide

Michigan Diabetes Outreach Network
QUICK REFERENCE GUIDE TO DIABETES

FOR HEALTH CARE PROVIDERS
Table of Contents
Chapter 1: Screening and Diagnosis of Diabetes

Chapter 2: Diabetes Standards of Care: Prevention of Complications
Chapter 3: Nutrition and Diabetes
Chapter 4: Physical Activity and Diabetes
Chapter 5: Oral Pharmacological Treatment of Type 2 Diabetes
Chapter 6: Insulin and Other Drugs Used in the Treatment of Type 2 Diabetes
Chapter 7: Insulin and Type 1 Diabetes
Chapter 8: Insulin Regimens and Other Drugs Used in the Treatment of
Type 1 Diabetes
Chapter 9: Education Concerns of Insulin
Chapter 10: Insulin Pumps: What, When, Who and How
Chapter 11: Self-Monitoring of Blood Glucose (SMBG)
Chapter 12: Gestational Diabetes Mellitus (GDM)
Chapter 13: Diabetes and Hypertension
Chapter 14: Lipid Management in Diabetes
Chapter 15: Sick Day Management
Chapter 16: Special Issues: Behavior Change
Chapter 17: Special Issues: Concerns of Children
Chapter 18: Acute Complications of Diabetes
Chapter 19: Chronic Complications of Diabetes
This resource may be printed and copies may be made as needed.
Revised June 2006

Paula Ackerman, MS, RD, CDE; Robin Williams, MA, RD, CDE; Julie Walters, RD,
CDE; Carolyn Jennings, RD, CDE; Cathy Francke, RD, CDE; Veronica Evans, RN;
Kathy Knapp, RN, CDE; Emily Lambright, RN
A special project of the Michigan Diabetes Outreach Network
Chapter 1
Screening and Diagnosis of Diabetes
Criteria for screening adults for type 2 diabetes or pre-diabetes:
• All adults over 45 years of age, especially those with a BMI > 25
o If blood glucose normal and no risk factors present, retest in 3 years
• Testing should be considered in younger adults or be carried out more

frequently in individuals who are overweight (BMI > 25) and who have
additional risk factors such as:
o Physically inactive most of the time
o Parent or sibling with diabetes
o Member of a high risk ethnic group (African American, Latino, Asian
American, Native American, or Pacific Islanders)
o Hypertensive (> 140/90 mmHg)
o HDL-cholesterol < 35 mg/dl
o Fasting triglycerides > 250 mg/dl
o History of vascular disease
o Woman with history of gestational diabetes or delivery of baby weighing
more than 9 lbs.
o Diagnosis of polycystic ovary syndrome
o Previously diagnosed with impaired glucose tolerance (IGT) or impaired
fasting glucose (IFG)
o Presence of other clinical conditions associated with insulin resistance
(i.e. acanthosis nigricans).
Screening should be carried out within a health care setting versus a

community setting where there is absence of follow-up care.
Criteria for screening type 2 diabetes in children:
• Overweight (classified by any of the following)

o BMI >85th percentile for age and sex
o Weight for height > 85th percentile
o Weight > 120% ideal for height
• Plus any two of the following risk factors:

o Parent or sibling with type 2 diabetes
o Member of a high risk ethnic group (African American, Latino, Asian
American, Native American, or Pacific Islander)
o Signs of insulin resistance or conditions associated with insulin
resistance (acanthosis nigricans, hypertension, dyslipidemia, or
polycystic ovary syndrome)
Screening (fasting plasma glucose preferred) should be done at age 10 or at the

onset of puberty and repeated every 2 years.
Diabetes and Pre-diabetes Diagnosis:

There are three methods of diagnosing diabetes and each must be confirmed on a
subsequent day by any of the following methods:
1. Symptoms of diabetes (polyuria, polydipsia and unexplained weight loss)

plus a casual plasma glucose > 200 mg/dl.
(Casual: any time of the day without regard to time of last meal).
This is the most common method for diagnosing type 1 diabetes
2. Fasting plasma glucose (Fasting: no caloric intake for at least 8 hours).

Preferred method for type 2 diabetes and pre-diabetes
3. 2 hour postprandial plasma glucose during an oral glucose tolerance test

using 75 gram glucose load.
Diagnostic Criteria
Fasting Plasma Glucose 2 hours post prandial
Normal < 100 mg/dl < 140 mg/dl
Pre-diabetes 100-125 mg/dl 140 – 199 mg/dl
Diabetes > 126 mg/dl > 200 mg/dl
Gestational Diabetes Mellitus (GDM) Screening and Diagnosis:
• At first prenatal visit, assess risk. If woman is at high risk for GDM (i.e. marked
obesity, a personal history of GDM, glucosuria or a strong family history of
diabetes), she should be tested as soon as possible.
• High-risk women found not to have GDM on initial screen and average risk
women should be tested between 24 and 28 weeks of gestation.
• Either of the following approaches should be used:
o One-step approach: A 100 gm oral glucose tolerance test (OGTT). Two
or more abnormal plasma glucose values during this test is diagnostic of
GDM (see below)
Diagnostic Criteria for the 100 g OGTT

Time Venous plasma glucose
(hours) value (mg/di)
0 > 95
1 > 180
2 > 155
3 > 140
o Two-step approach: Measure plasma or serum glucose concentration 1

hour after a 50-gram oral glucose challenge test (GCT). If the glucose
threshold value is > 140 mg/dl, perform a 100 OGTT (see diagnostic
criteria above). When the two-step approach is used, a glucose
threshold value greater than 140 identifies approximately 80 % of
women with GDM, and the result is further increased to 90% by using a
threshold of 130 mg/dl.
References:
American Diabetes Association (2006). Clinical Practice Recommendations. Diabetes

Care, Vol 29 (1).
Chapter 2
Diabetes Standards of Care: Prevention of Complications
To Do At Every Visit:
• Check blood pressure (adult target <130/80).
• Measure weight.
• Review self-monitored blood glucose (SMBG) values, and assess client’s
ability to use data for pattern management.
• Review/adjust medications.
• Look for symptoms associated with diabetes-related complications.
• Assess physical activity, lifestyle changes, and self-management skills.
• Consider referral for medical nutrition therapy, diabetes self-management
education, and/or psychosocial assessment if needed.
• Counsel on smoking cessation, if indicated.
• Recommend regular use of low dose aspirin therapy for the prevention of
CVD, unless contraindicated.
• Visually inspect feet. (The practice of foot exams at every office visit has
been shown to reduce the rate of amputations by 50%).
Twice a year:
• A1C (quarterly if client is not meeting goals).
• Refer for dental exam.
Annually:
• Lipid profile (every 2 years if normal).1
• Serum creatinine and calculated GFR in adults2; urinalysis for protein,
ketones, sediment, and if negative for protein microalbumin.3
• Refer for dilated eye exam by ophthalmologist or specially trained
optometrist4 (if normal, an eye exam may be advised every 2-3 years).
• Comprehensive foot exam, including monofilament testing
• Influenza vaccination.
1
1 For children with type 1 who are over age 12: at diagnosis, once blood glucose is under control.
If normal, then every 5 years until age 18 (then annually). Children with type 2: at diagnosis
when blood glucose is under control. If normal, repeat every 2 years.
2
Check creatinine in children if proteinuria is present
3
For type1: only after they have had diabetes for at least 5 years.
4
For type 1: within 3-5 years of onset of diabetes, then annually
2
3
4
Lifetime:
• Pneumococcal vaccination (usually only once, repeat if over 65 or

immunocompromised and last vaccination was more than 5 years ago).
Diabetes Self-Management Education for Persons with Diabetes
• Client and family education, following the National Standards for Diabetes
Self-Management Education.
• Individualized nutrition plan and instructions, ideally with a registered
dietitian.
• Self-monitoring instructions and guidelines.
• Medication review (including prescription, non-prescription and herbal).
• Recommendations for lifestyle changes (meal planning, physical activity,
smoking cessation).
• Establishment of short and long term goals.
• Podiatry consultation, or specialized services, if needed.
• Dental hygiene.
• Referral for dilated eye exam.
• Women of childbearing age-discussion of need for optimal blood glucose
control prior to conception and family planning.
• Agreement on continuing support, follow-up, and return appointments.
• Instructions on when to contact the health care team.
References:
American Diabetes Association (2006). Clinical Practice Recommendations.
Diabetes Care, Vol 29 (1).
The National Diabetes Education Program Publication No. NDEP-12.

Chapter 3
Nutrition and Diabetes
Meal plans for persons with diabetes can vary dramatically based on lipid levels,
glucose control, weight loss goals, insulin use, activity habits and other health
concerns. The majority of persons with diabetes are overweight, and it has been
discovered that even a small amount of weight loss (10-20 pounds or 5-9 kg) can
greatly assist with glycemic control, even if the person does not attain a desirable
body weight. For most individuals, therapeutic lifestyle change (TLC) is the best
strategy for weight loss. TLC involves a reduction in calorie intake combined with
an increase in physical activity.
In General, Persons with Diabetes...
• Do not need any special diet foods (Some of the reduced calorie items
can be useful).
• Benefit from eating on a regular basis (every 4-5 hours).
• Benefit from eating consistent amounts of carbohydrates (from fruit,
milk, bread/starch, and sweets) at meals.
• Benefit from eating high fiber foods (dried beans, fruits, vegetables and
whole grains) everyday.
• Can eat foods that are good for the whole family.
• Benefit from decreasing portion sizes, if weight is a concern.
• Benefit from limiting alcohol and if drinking, only drinking with meals.
• Benefit from eating a wide variety of foods.
• Need to limit the amount of saturated fat and hydrogenated or trans fat
consumed - found in animal products such as cheese, hamburger,
bacon, butter, as well as processed snack foods, shortening and other
fats which are solid at room temperature.
Regular meetings with a registered dietitian are recommended to help

persons with diabetes develop a meal plan that works for them.
Sugar and Diabetes
Most persons with diabetes can also include some sugar in their meal plan.
Sugar containing foods must be substituted for some of the other carbohydrate
(bread and starches, fruits, vegetables or milk) at a meal. Also, if the product is
high in fat, less fat should be added to the rest of the meal.
Fat Intake and Diabetes

Because individuals with diabetes have an increased risk of heart disease, it is
recommended they follow the guidelines from the National Cholesterol Education
Program for fat intake. These guidelines recommend a total fat intake of 25-35%
of calories, with < 7% from saturated fat. Fat intake from trans fat should be
minimal. When substituted for saturated fats, monounsaturated fats can
decrease LDL cholesterol and triglyceride levels without decreasing HDL levels.
Monounsaturated fats are found in most nuts, olive oil, canola oil, peanut butter
and avocados.
Sugar-free Products
Not all sugar-free products are reduced calorie items. If it contains aspartame,
saccharin, acesulfame K, or sucralose, the calorie and carbohydrate content may
be lower than the regular product, and it may be useful for the person with
diabetes. If the item is sweetened with fruit juice, honey, fructose, sugar alcohol
(e.g. sorbitol), molasses or any other sugar replacement product, it may not be a
calorie or carbohydrate-reduced product! There is no real benefit to using these
products in place of sugar-sweetened products.
Additional Help for the Overweight Client

• Determine if your client is truly ready to lose weight. Are they intending to
make changes within the next six months to lose weight? If no, client may
need to explore in more detail the benefits of weight loss.
• Set reasonable goals. A 10-15% weight loss is generally achievable.
• Do they have a problem with binge eating or bulimia? An eating disorder
clinic or specially trained counselor may be needed.
• A good understanding of nutrition is necessary--a registered dietitian can
help.
• Mild caloric restrictions are easier to adapt to (250-500 calorie deficit.)
• Surgical intervention or medication may be options for some obese
persons.
• Regular physical activity is key in helping maintain weight loss.
Many nutrition handouts are available through the Diabetes Outreach

Networks (go to www.diabetesinmichigan.org).
References:
Chapter 4
Physical Activity and Diabetes
Benefits of Regular Physical Activity for Persons with Diabetes
• Reduces the risk of Coronary Artery Disease

o Decreases plasma cholesterol, triglycerides and LDL-cholesterol
o Increases HDL-cholesterol, especially when coupled with weight loss
• Assists with blood pressure control
• Improves insulin sensitivity
• Reduces hyperinsulinemia
• Reduces body fat and may assist with weight loss
• Increases muscle mass
• Improves quality of life/self-esteem
• Can reduce stress
For those with type 2 diabetes, regular activity may also:

• Reduce A1C levels
• Decrease or eliminate the need for insulin or oral agents
• Improve insulin sensitivity
• Help achieve and maintain desirable body weight
For those with type 1 diabetes:

• Regular physical activity has not been shown to consistently improve blood
glucose control (unless coupled with food and insulin adjustments).
• Exercise-induced hypoglycemia is common due to accelerated absorption
of insulin and increased insulin sensitivity. One of the most common times
for hypoglycemia is 6-12 hours after the activity.
Risks of Physical Activity in Persons with Diabetes
1. Hypoglycemia (for those treated with insulin and insulin secretagogues, such
as sulfonylureas, meglitinide or nateglinide or combination drugs containing
these)
 Exercise induced hypoglycemia

• Monitor blood glucose levels before and after activity.
• If on insulin:
 Assure insulin is injected into subcutaneous fat layer
 Be aware that the risk of hypoglycemia is greatest when insulin
is peaking. Try to avoid activity when insulin is peaking, if
practical.
 Lower insulin dose that is peaking during the activity. May start
with a 30-50% reduction.
 Carbohydrate replacement may be needed if activity is
unplanned or during activities of long duration.
 Post-exercise, late-onset hypoglycemia (occurs 4 or more hours after

activity and is more common in those with type 1 diabetes)
• Monitor blood glucose levels frequently during the post-activity period
• Pre-activity snacks (15-30 minutes prior to the activity) can reduce
hypoglycemia when activity is less than 45 minutes in duration.
• May need carbohydrate replacement during the post-activity period.
• Activity prior to bedtime may cause nocturnal hypoglycemia.
• If on insulin, decrease insulin that is peaking during the post-activity
period.
Carbohydrate Replacement for Physical Activity

Intensity Duration Carbohydrate Needed Frequency
Mild-moderate < 30 minutes None
Moderate 30 – 60 minutes 15 grams Each hour
High > 1 hour 30 – 50 grams Each hour
2. Hyperglycemia (after very strenuous, high-intensity activities)

• Check ketones when blood glucose is greater than 300 mg/dl (type 1) or
400 mg/dl (type 2) (Joslin).
o If moderate to large ketones are present, activity may worsen blood
glucose levels. Delay activity until ketones are absent.
o If no ketones are present, activity may help lower blood glucose.
Begin activity and check glucose after 15 minutes. If blood glucose is
higher, stop the activity.
• For those with type 1 diabetes, diabetic ketoacidosis (DKA) may result if
activity begins when blood glucose is elevated and/or ketones are present.
Medical treatment is necessary.
3. Dehydration
• Adequate fluid is needed before, during and after being active. (Fluid
should be calorie free and caffeine-free, water is ideal.)
4. Exacerbation of cardiovascular disease, such as:

 Presence of silent heart disease (arrhythmia, cardiac dysfunction)
 Excessive increases in blood pressure with activity
 Angina
 Myocardial infarction
 Sudden death
5. Worsening of chronic complications with inappropriate activities.

• Retinopathy: Avoid strenuous, high intensity activities, heavy weight
lifting, scuba diving, activities that require the head to be lower than the
waist, jarring activities (jogging or racquetball) and competitive sports.
Walking, swimming, stationary cycling and best.
• Peripheral Vascular Disease (PVD): Non-weight bearing activities are

best. Walking is helpful for those with intermittent claudication. Severe
PVD is an absolute contraindication for a walking program.
• Peripheral Neuropathy: Avoid weight-bearing activities and jogging. Be

cautious of over stretching. Well fitting shoes are crucial. Daily range-of-
motion activities, cycling and swimming are best.
• Autonomic Neuropathy: Avoid strenuous, high intensity activities and

being active in temperature extremes. Recumbent cycling and water
aerobics are best.
• Nephropathy: Low-intensity aerobic activities are best (walking,

swimming, cycling). Exercise tolerance is generally diminished.
• Hypertension: Avoid heavy lifting, straining and excessive arm

movements (especially over the head, which can cause dramatic
elevations in blood pressure for some).
Physical Activity Recommendations

Type 2 diabetes: 30 – 60 minutes daily up to 5 times a week.
Type 1 diabetes: all levels of activity can be performed by those without

complications and are in good glycemic control.
For the older adult: 30-40 minutes 5-6 times a week.
For weight loss: at least 60 minutes most days of the week.

Activity Sessions
Warm-up: Each activity session should begin with a couple of minutes of light
activity, followed by stretching.
Activity: Aerobic activity (e.g. walking, swimming or biking). Depending on fitness

level, the activity session can last from 5-60 minutes. Most need to start out with a
short activity period and add 1-2 minutes every 1-2 weeks. The person should be
able to talk during the activity and feel that they are working 'somewhat hard'.
Activity sessions may be split into 2 or more sessions per day. For example, a 30
minute daily activity could be broken down into three 10 minute sessions.
Cool-down: Slow down the pace for a couple of minutes. End with more
stretching.
Safety Tips
1. To prevent hypoglycemia:
o Carry a rapidly absorbed carbohydrate source
o Monitor blood glucose regularly
2. Wear or carry diabetes identification
3. To prevent injury:
o Use proper equipment and shoes
o Include a warm-up and cool-down period
o Avoid activity in extreme temperatures (hot, humid or freezing)
o Stop activity if pain, light-headedness or shortness of breath occurs.
4. To avoid dehydration:
o Drink plenty of fluids
A graded stress test may be necessary to evaluate the safety of some activities for
people with diabetes. A graded activity test is recommended if one or more of the
following are true:
• Older than 35
• Older than 25 years and
o has had type 2 diabetes for more than 10 years
o has had type 1 diabetes for more than 15 years
• Other heart disease risk factors present (smoking, high cholesterol, high
blood pressure, etc)
• Presence of microvascular disease (proliferative retinopathy or
nephropathy, including microalbuminuria)
• Peripheral vascular disease
• Autonomic neuropathy
References: American Diabetes Association (2006). Clinical Practice

Recommendations. Diabetes Care, Vol 29 (1).
QUICK REFERENCE GUIDE TO DIABETES FOR HEALTH
CARE PROVIDERS
Chapter 5
Oral Pharmacological Treatment of
Type 2 Diabetes
Pharmacological therapy is recommended after 4-12 weeks if an individualized meal

plan, activity, and weight loss trial (if needed) have failed to control blood glucose
(BG). If the BG remains above 126 mg/dl fasting and over 200 mg/dl 1-2 hours
postprandial, pharmacological treatment should be initiated.
Those with extremely high blood glucose and symptoms such as polyuria, and
polydipsia, may need insulin to be started immediately. Insulin may be needed for a
short period of time or indefinitely. A review and alteration of the other medications
one is taking may help to control blood glucose; hyperglycemia may result from
nicotinic acid, thiazide diuretics (large doses), beta blockers, Indocin, Dilantin,
corticosteroids and fertility agents.
There are currently 6 classifications of oral therapy for type 2 diabetes

• Sulfonylureas
• Benzoic Acid Derivatives
• D-Phenylalanine Derivatives
• Biguanides
• Thiazolidinediones
• Alpha Glucosidase Inhibitors
Medication Failures
• After 5 years, approximately 50% of patients will require medication

adjustments.
• Combination therapies can be tried before discontinuing the failed drug
(i.e. add metformin if person has failed with sulfonylurea to control BG).
• If combination therapy fails to control BG, insulin or other injectible
medication is the next line of treatment - see Chapter 6 Insulin and Other
Drugs in the Treatment of Type 2 Diabetes.
Sulfonylureas
Primary Function: Stimulate the pancreas to make more insulin. Over time, the
body’s ability to make insulin may lessen. If this happens, these drugs lose their
ability to control blood glucose.
Agent Typical Dosage Max dosage

1st Generation
Tolbutamide (Orinase) 0.25-2.0 g/day (divided) 3 g/day
Tolazamide (Tolinase) 100-1000 mg/day (divided) 1000 mg/day
Chlorpropamide (Diabenese) 100-500 mg bid 750 mg/day
2nd Generation
Glyburide (DiaBeta, Micronase) 1.25 – 2.5 mg bid 29 mg/day
Glyburide (Glynase) 0.75 – 12.0 mg/day 20 mg/day
Glipizide (Glucotrol) 2.5 – 20.0 mg bid 40 mg/day
Glipizide (Glucotrol XL) 2.5 – 10 mg bid 20 mg/day
Glimepiride (Amaryl) 1-8 mg/day 8 mg/day
Dosing
• Start at lowest possible dose and increase every 1-2 weeks until glucose
control or maximum dose Is reached.
• Renal insufficiency may require dose reduction.
• There is no benefit to using two sulfonylureas (i.e. Diabeta and Glucotrol)
together.
• Fasting plasma glucose (FPG) 126-200 mg/dl may respond to monotherapy
along with dietary management.
• FPG greater than 200 mg/dl may need 2 agents or insulin.
• If sulfonylurea alone fails to control blood glucose, combination therapy or
insulin may be used to achieve blood glucose control.
Side Effects
• Skin rashes
• Hypoglycemia
• GI (5%)
• Weight gain
• Hepatic changes (rare)
• Hyperinsulinemia
• Disulfiram like reaction with alcohol (1st generation only)
Contraindications
• Allergy to sulfa drugs
• Type 1 diabetes
• Serious illness/severe infection
• Pregnancy and lactation
• Surgery or trauma
• Diabetic Ketoacidosis (DKA)
• Severe renal or hepatic disease
• Elderly, debilitated or malnourished persons
Candidates for Initial Use: Type 2 diabetes, no dyslipidemia, not overweight,

and FPG > 20 mg/dl above target
Benzoic Acid Derivative
Repaglinide (Prandin)
Primary Function: Enhances insulin secretion. Is a short-acting agent. The amount

of repaglinide-induced insulin release depends on the blood glucose level. Insulin
release diminishes as the glucose level declines.
Precautions
• Has the potential to cause hypoglycemia, but to a lesser extent than
sulfonylureas.
• May be taken with decreased kidney function.
• Longer half-life may be found with antifungals, erythromycin and
clarithormycin.
• Accelerated repaglinide metabolism and shortened drug effect may be
found with use of rifampin, phenobarbital, carbamazepine, and
troglitazone.
Dosing
• Is available in 0.5 mg, 1 mg and 2 mg dosage units. Maximum dose is 16
mg per day.
• Initial dose for clients not previously treated with BG lowering agents: 0.5
mg/meal
• Initial dose for clients previously treated with BG lowering agents or A1C >
8%: 1-2mg/meal.
• Take with meals. Number of daily doses is determined by the number of
meals eaten.
• If a meal is skipped, the dose is skipped; if a meal is added, a dose is
added for that meal.
Side Effects • Back pain

• Hypoglycemia (16-31%) • Headache
• GI (4%)
• Upper respiratory infections
Contraindications
• Impaired hepatic function
• Type 1 diabetes
• Back pain
• Headache
• Diabetic Ketoacidosis
Candidates for Initial Use: Type 2 diabetes, no dyslipidemia, with or without

renal failure, not overweight, and FPG > 20 mg/dl above target
D-Phenylalanine Derivative
Nateglinide (Starlix)
Primary Function: Stimulates insulin secretion when needed (postprandial), then

allows insulin concentrations to return to baseline.
Precautions
• Is very rapid-acting.
• Not recommended for combination with a sulfonylurea or Prandin.
Dosing
• Is available in 60 mg and 120 mg tablets.
• Typical dose: 120 mg taken just before meals. (60 mg tid can be used for
those near their A1C goal)
• Take with meals. Number of daily doses is determined by the number of
meals eaten.
• If a meal is skipped, the dose is skipped; if a meal is added, a dose is
added for that meal.
Side Effects
• Hypoglycemia (2.4%)
• Dizziness (3.6%)
• Weight gain of < 1 kg
Contraindications
• Type 1 diabetes
• Diabetic Ketoacidosis
Candidates for Initial Use: Type 2 diabetes with the ability to produce insulin,
significant postprandial hyperglycemia not
controlled by nutrition therapy and exercise.
_________________________________________________________
Alpha Glucosidase Inhibitors
Acarbose (Precose) and Miglitol (Glyset)
Primary Function: Lowers postprandial BG by delaying carbohydrate digestion and

slows absorption.
Benefits
• Does not cause hypoglycemia.
• Can decrease postprandial blood glucose by about 50 mg/dl and A1c by
approximately 0.5-1%.
Precautions
• Generally will not be effective in the treatment of significant fasting
hyperglycemia.
• If hypoglycemic reactions occur, oral glucose (not sucrose) must be used
for treatment.
• Should not be used if the client is using any rapid-acting insulin {lispro
(Humalog), aspart (Novolog) or glulisine (Apidra)}. Their mechanisms of
action are similar.
• Should not be used with metformin--severe GI side effects may occur.
• Check serum transaminase level every 3 months during the first year and
then periodically. If elevated, discontinue acarbose. (Liver abnormalities do
not seem to be a concern with miglitol.)
Dosing and Administration

• Both are available in 25 mg, 50 mg and 100 mg tablets.
• Given with the first few bites of major meals.
• Precose: starting dose 25 mg qd (to decrease side effects), add second
dose after 2 weeks and third dose after an additional 2 weeks. Increase to
50 mg tid for 4-8 weeks .
 Maximum dose for those under 60 kg : 50 mg tid
 Maximum dose for those 60 kg and over: 100 mg tid
• Glyset: starting dose of 25 mg tid for 4-8 weeks, then 50 mg tid for 3
months. Increase to 100 mg tid if tolerated and needed.
 Maximum dose: 100 mg tid
• May be used alone or in combination therapy
Side Effects
• Most common: GI (abdominal pain, diarrhea, flatulence)
• Increased serum AST or ALT (Acarbose doses > 200 mg tid)
Contraindications
• Safety not tested for pregnancy or lactation
• Chronic intestinal problems or diseases present (inflammatory bowel
disease, colonic ulceration, obstructive bowel disease and gastroparesis).
• severe liver and renal disease (creatinine > 2.0).
Candidates for Initial Use: Type 2 diabetes, dyslipidemia, obesity, and significant
postprandial hyperglycemia
Biguanides
Metformin (Glucophage, Glucophage XR)
Primary Function: Decreases glucose output from the liver. Does not stimulate
insulin release.
Benefits
• Controls BG without causing hypoglycemia or weight gain in most people.
A 2-5 kg weight loss is typical.
• Studies show a decrease in triglycerides (16%), LDL-cholesterol (8%) and
total cholesterol (5%); along with an increase in HDL-cholesterol (2%).
Precautions
• Educate client to immediately report symptoms associated with lactic
acidosis (severe weakness, cold, labored breathing, stomach pain, light
headed or irregular heart rate).
• Evaluate kidney and liver (LFT) before initiating metformin. Test creatinine
and LFTs every 6-12 months while on metformin therapy.
Dosing
• Metformin (Glucophage) is available in 500 mg and 850 mg dosage units.
Glucophage XR is available in a 500 mg dosage unit.
• Start at 500 mg per day or 500 mg bid (XR: 500 mg with evening meal)
• Increase by 500 mg per day every 2 weeks (1 week for XR) up to a
maximum effective dose of 2000 mg. (Usual dose 1500-2000 mg per day
split into two or three doses - 850 mg tablet in the AM and another in the
PM.)
• Fasting plasma glucose 126-200 mg/dl may respond to monotherapy along
with dietary management.
• Fasting plasma glucose 200-275 mg/dl may respond to a combination
therapy or insulin.
Side Effects
• Common: GI (abdominal bloating, nausea, cramping, diarrhea, feeling of
fullness)
• Minor effects: agitation, headache, metallic taste
• Rare: lactic acidosis, reduction of B12 levels
Contraindications
• Type 1 diabetes.
• Pregnancy and lactation.
• Acute or chronic of lactic acidosis.
• Hepatic dysfunction
• Renal dysfunction with serum creatinine >1.5 mg/dl for men and >1.4 mg/dl
for women.
• Over age 80
• History of alcoholism or binge drinking
• Metformin should be temporarily discontinued in any situation that
predisposes the individual to acute renal dysfunction including:
o Cardiac collapse
o Acute myocardial infarctions
o Acute exacerbated congestive heart disease.
o Use of iodinated contrast media (withhold 48 hours before and after
test)
Candidates for Initial Use: Type 2 diabetes, dyslipidemia, obesity or genetic

factors favoring insulin resistance and FPG > 20 mg/dl
above target
_________________________________________________________
Thiazolidinediones
Pioglitizone (Actos) and Roisglitizone (Avandia)
Primary Function: Decreases insulin resistance and increases glucose uptake in

muscle and adipose tissue.
Benefits
• Useful in those with renal dysfunction or other conditions in which
metformin is contraindicated.
• Generally well tolerated.
Precautions
• Liver toxicity was been reported with the use of Rezulin. It was withdrawn
from the U.S. market on 3/21/00.
• Liver function tests should occur with Actos and Avandia. Check serum
transaminase levels (ALT) prior to starting therapy, every 2 months during
the first year, and then periodically.
• Do not use if ALT exceeds 2.5 X upper limit of normal or if active liver
disease is present.
• If ALT exceeds 3 X upper limit of normal during treatment, recheck as soon
as possible. Discontinue drug if ALT remains > 3 X upper limit of normal.
• Check liver function immediately if signs of hepatic dysfunction occur
(nausea, vomiting, abdominal pain, fatigue, anorexia)
Dosing – Actos
• Approved for monotherapy or in combination with sulfonylurea, metformin
or insulin
• Available in 15 mg, 30 mg and 45 mg tablets.
• Initial starting dose in monotherapy or combination therapy is 15 mg or 30
mg once daily, taken without regard to meal.
• Maximum dose is 45 mg once per day
• If used with insulin, insulin may need to be decreased by 10-25% if patient
reports hypoglycemia.
• Sulfonylurea dose may need to be lowered if hypoglycemia occurs.
• Some studies showed a 5-26% decrease in triglycerides and a 6-13%
increase in HDL-cholesterol.
Dosing - Avandia
• Approved for monotherapy or for use with sulfonylurea, metformin or
insulin
• Avandia is available in 2 mg, 4 mg and 8 mg tablets.
• Usual starting dose is 2 mg/day - single dose or divided into 2 doses/day.
• Max dose 8 mg/day. 4 mg bid is more effective than 8 mg once a day.
• Studies show small increases in HDL-cholesterol and LDL-cholesterol.
Side Effects
• Increased hepatic enzymes
• Weight gain
• Plasma volume expansion
• Edema
• May make oral contraceptive less effective
Contraindications
• Pregnancy or lactation
• Children
• Hepatic dysfunction
• NYHA Class III or IV Heart Failure
• Pre menopausal anovulatory women with insulin resistance.
Candidates for Initial Use: Type 2 diabetes, obesity or genetic factors favoring
insulin resistance and FPG > 20 mg/dl above target
Combination Therapy
Candidates for Combination Therapy: When other therapies reach maximum

doses and target BG levels not met (FPG > 140 mg/dl, postprandial BG > 180 mg/dl,
A1C > 7-8%).
Glucovance (glyburide/metformin)
• Available in 1.25/250 mg, 2.5/500 mg and 5/500 mg dosage units
• Side effects similar to those noted for glyburide and metformin.
• Contraindicated in those populations not indicated for use of gyburide and
metformin.
Metaglip (glipizide/metformin)
• Available in 2.5/250 mg and 2.5/500 mg dosage units
• Side effects similar to those noted for glipizide and metformin.
• Contraindicated in those populations not indicated for use of glipizide and
metformin.
AvandaMet (Avandia/metformin)
• Available in 1/500 mg, 2/500 mg and 4/500 mg dosage units
• Side effects similar to those noted for rosiglitazone (Avandia) and
metformin.
• Contraindicated in those populations not indicated by use of rosiglitazone
(Avandia) and metformin.
ACTOplus Met (Actos/metformin)

• Available in 15/500 mg or 15/850 mg dosage units.
• Side effects similar to those noted for pioglitazone (Actos) and metformin.
• Contraindicated in those populations not indicated by use of pioglitazone
(Actos) and metformin.
Avandaryl (Avandia/Amaryl)
• Available in 4/1 mg, 4/2 mg and 4/4 mg dosage units.
• Side effects similar to those noted for rosiglitazone (Avandia) and
glimepiride (Amaryl).
• Contraindicated in those populations not indicated by use of rosiglitazone
(Avandia) and glimepiride (Amaryl).
Chapter 6
Insulin and Other Drugs Used in the
Treatment of Type 2 Diabetes
Insulin
Insulin is used in type 2 diabetes when blood glucose (BG) levels exceed 126
mg/dl fasting or exceed 200 mg/dl postprandial after trying meal planning,
activity, and weight loss.
Some may need to be started on insulin immediately, especially if they have

unexplained weight loss and severe hyperglycemia.
Hyperinsulinemia
The theoretical disadvantage of hyperinsulinemia from using insulin injections does not
outweigh the proven benefits of glycemic control.
Starting insulin
• Lean patients: 15 units NPH or Lente per day

• Obese patients: 20-30 units of NPH or Lente per day
Doses can be increased 2-5 units every 3-4 days, depending on blood glucose levels.
Some may need over 100 units of insulin per day to control blood glucose.
Adjunct Therapies for Type 2 Diabetes
Exanatide (Byetta)
was released for use in 2005 and is used in addition to insulin and/or analogs to
assist in gaining better control of blood glucose levels. Pramlintide acetate
(Symlin®) is a synthetic analog of human amylin. Amylin is a hormone also
made and secreted by the beta cells, and therefore lacking in persons with type 1
diabetes. In those without diabetes, it is secreted along with insulin to control
post-prandial blood glucose levels. Its anti-hyperglycemic effects include:
• Slowing gastric emptying
• Suppressing glucagon release, resulting in less glucose release from the
liver.
• Regulation of food intake due to modulation of appetite.
Pramlintide acetate is administered by subcutaneous injection prior to meals to

mimic normal levels. Injection technique is the same as that for insulin. It cannot
be mixed with insulin and may require pre-meal insulin be reduced to prevent
hypoglycemia. Side effects may include nausea, vomiting, dizziness, indigestion,
stomach pain, decreased appetite and fatigue. Its use is contraindicated in those
with gastroparesis, hypoglycemia unawareness, women who are pregnant or
breastfeeding and children.
Vials in use can be stored at room temperature (less than 77°F) for 28 days and
then discarded. Vials not in use should be stored in the refrigerator and
discarded after the expiration date.
Chapter 7
Insulin and Type 1 Diabetes
Some insulin must be available at all times for persons with type 1 diabetes. Insulin
doses may be reduced but usually should never be completely eliminated; to do so
can be life threatening.
Starting Insulin Doses
Start Dosage Eventual Dosage

(u/kg/day) (u/kg/day)
Prior to puberty 0.2 - 1.0 0.5 - 1.0
Pubertal 0.3 - 1.5 0.8 - 1.5
Post pubertal 0.3 - 1.2 0.8 - 1.2
Initial dose is higher if: Insulin dose is lower if:

• Obese • Thin
• Long duration of symptoms • No co-morbid illnesses
• Extreme hyperglycemia • Minimal hyperglycemia
• Recent illness • No DKA, minimal ketones
• Just post-DKA episode • Early pubertal
• Mid-late pubertal • Minimal symptoms of diabetes
(wt. loss, polydipsia, polyphagia)
Additional Information:
• Generally 0.5-1 unit per kg body wt. (adolescents often need closer to 1
unit per kg)
• Insulin dose should mimic the normal physiologic insulin secretion and take
into account the persons lifestyle.
• Long-acting insulin and insulin analogs can be used to provide basal
insulin needs, coupled with rapid or short-acting insulin to cover food intake
and for correction of hyperglycemia.
• Total Daily Dose:
~50-65% is basal
~35-50% is bolus (meal coverage)
• Infants and small children may only need NPH in the AM and evening or
may need insulin diluted.
Pre-dinner NPH can be delayed until bedtime to prevent nocturnal hypoglycemia or

counteract the "Dawn Phenomenon". A "honeymoon phase" may occur within a few
weeks after diagnosis and last for several months to 2 years. During this time,
insulin needs are reduced to about 0.1-0.3 units per kg and only one injection per
day may be required. Insulin should be reduced when child leaves the pubertal
phase, otherwise obesity and unexplained hypoglycemia can result.
Activity
Adjustments in food intake or insulin dose are often needed for activity (see Chapter
4 Physical Activity and Diabetes)
Adjustment of Insulin (Twice - Daily Insulin Regimens)

Problems should occur 3 days in a row before changes are initiated.
• Fasting hyperglycemia: Check 3 AM blood glucose. If it is >70 mg/dl,
o Increase evening NPH by 10% or
o Changing NPH dose from pre-supper to pre-bed (may lower risk of
nocturnal hypoglycemia and eliminate the need for a bedtime snack)
• Fasting hypoglycemia (and low 3 AM blood glucose): Reduce evening
NPH by 15%, and possibly move NPH to bedtime if 3 AM is still low.
• Elevated midmorning or pre-lunch blood glucose: Increase AM rapid-
acting insulin by 10%.
• Pre-lunch blood glucose <70 mg/dl: If using short-acting insulin, change
to rapid-acting. If still low, reduce AM rapid-acting insulin by 15%.
• Pre-supper blood glucose higher than desired: Increase AM NPH by
10%.
• Elevated evening blood glucose (>180 mg/dl after supper and pre-bed
over 120 mg/dl after bedtime snack for 3 days): Increase pre-supper Rapid
insulin by 10%.
Also, make certain that the insulin injection is given 30 minutes before meal if using
short-acting insulin. Rapid-acting insulin can be given at the time of eating typically
15 minutes before eating. Rapid-acting insulin can also be given after the meal if the
amount of consumption cannot be predicted (e.g. picky eaters). It may also be
useful to check technique and injection sites used. The exact amount of change
needed will vary from person to person.
Intensive Therapy
Research shows that keeping blood glucose levels as close to normal as possible
resulted in the development of significantly fewer complications. Intensive therapy
generally involves making adjustments in insulin doses (via multiple insulin
injections or use of an insulin pump) to accommodate activity, food intake and pre
and post-meal blood glucose levels. However, it can be risky for extremely young
children and infants because of the risk of permanent damage from hypoglycemic
events. See Chapter 8 for sample insulin regimens.

Chapter 8
Insulin Regimens and Other Drugs Used in
the Treatment of Type 1 Diabetes
Standard Insulin Regimens
There are many different insulin protocols in use. These are just six commonly
used methods of delivering insulin.
One injection of long-acting insulin used in conjunction with oral meds or alone in
type 2 diabetes. This helps reduce the liver’s release of glucose overnight.
Conventional Therapy
Can be premixed, but doing so will reduce flexibility of doses.
Can be premixed, but doing so will reduce flexibility of doses.

Intensive Therapy
Intermediate-acting insulin moved to bedtime (HS) to reduce nocturnal

hypoglycemia and/or reduce fasting hyperglycemia.
Comparison of Rapid Acting Insulin Analogs and Short Acting
Insulin
• Can generally make a 1:1 substitution (rapid for short)

• Rapid associated with lower postprandial blood glucose, and quicker
correction of hyperglycemia
• Fewer hypoglycemic episodes with rapid;
• Faster recovery from hypoglycemia with rapid
• High fat meals or gastroparesis – short may be best choice
• High carbohydrate meals – rapid more effective to lower postprandial
blood glucose (BG) excursions
• Decreased need for between meal snacks when using rapid
• Rapid can be given immediately after the meal when food intake is not
predictable.
• May need more basal insulin when using rapid versus short
• Rapid may be superior for:
o insulin pump use
o those using long-acting for basal and rapid before meals and
snacks
Adjunct Therapies for Type 1 Diabetes
Pramlintide acetate was released for use in 2005 and is used in addition to
insulin and/or analogs to assist in gaining better control of blood glucose levels.
Pramlintide acetate (Symlin®) is a synthetic analog of human amylin. Amylin is a
hormone also made and secreted by the beta cells, and therefore lacking in
persons with type 1 diabetes. In those without diabetes, it is secreted along with
insulin to control post-prandial blood glucose levels. Its anti-hyperglycemic
effects include:
• Slowing gastric emptying
• Suppressing glucagon release, resulting in less glucose release from the
liver.
• Regulation of food intake due to modulation of appetite.
Pramlintide acetate is administered by subcutaneous injection prior to meals to

mimic normal levels. Injection technique is the same as that for insulin. It cannot
be mixed with insulin and may require pre-meal insulin be reduced to prevent
hypoglycemia. Side effects may include nausea, vomiting, dizziness, indigestion,
stomach pain, decreased appetite and fatigue. Its use is contraindicated in those
with gastroparesis, hypoglycemia unawareness, women who are pregnant or
breastfeeding and children.
Vials in use can be stored at room temperature (less than 77°F) for 28 days and
then discarded. Vials not in use should be stored in the refrigerator and
discarded after the expiration date.
References:
Chapter 9
Education Concerns of Insulin
Mixing Insulin
• Glargine and detemir should not be mixed with other insulins
• Regular, Lispro, Aspart, Glulisine and NPH can be mixed - some premixed
insulins are available for those unable to mix insulin for themselves.
• Glulisine mixed with NPH must be injected immediately after mixing
• Always draw up Regular or rapid-acting insulin first when mixing insulins.
Insulin mixed at home should generally be administered immediately after mixing.
Storage of Insulin
• In general, insulin vials in use can be stored at room temperature (59°-86°F)
for 1 month. Back stock should be kept refrigerated but never frozen.
- Some analogs recommend <77°F, check package insert
• See manufacturer guidelines for cartridges, pre-filled pens.
• Avoid freezing temperatures and temperatures above 86 degrees.
• Insulin should not be left in cars or checked in airline baggage.
Do not use Insulin if:

• Sediment is present.
• Clumping or frosting is apparent.
• Clear insulin is cloudy or discolored.
• It is beyond the expiration date.
• Stored improperly.
Injecting Insulin
• Sites to use in descending order of absorption: abdomen, upper arm,
anteriolateral thigh, and buttocks.
• Give injections in different areas, abdomen may be used for most injections,
but rotations around abdominal area must occur. Do not inject within a 2"
radius of umbilicus.
• Inject into subcutaneous tissue.
• 90 degree injection angle works for most. Children and very thing adults may
need to use a shorter syringe length or 45 degree angle.
• Massaging injection site is usually not recommended.
• Avoid injecting into an area that will soon be used in an activity or one that has
just been used as absorption is increased.
• Avoid injecting immediately before using sauna, hot tub, or hot shower as
temperature may increase absorption speed of insulin.
• Insulin and Insulin Analogs
Type of Insulin Onset Peak Duration When to
(Trade Name) Appearance (hours) (hours) (hours) administer
Rapid Acting
Lispro (Humalog®) Clear 0.25 - 0.5 0.5 - 4 4–6 0 -15 min before
meals*
Aspart (Novolog®) Clear < 0.5 1 -3 3–5 0 -15 min before
meals*
Glulisine (Apidra™) Clear 0.25 0.5 – 1.5 3-5 0 -15 min before
meals*
Short Acting
(Regular)
Humulin® R, Clear ½-1 2-3 6-8 30-45 minutes
Novolin® R before meals
Intermediate Acting
NPH, Humulin® N, Cloudy 2-4 6 – 10 14 – 18 Before am & pm
Novolin® N meals or before
am meal & at HS
Long Acting
Glargine (Lantus®) Clear 1 No peak Up to 24 am or HS
Do NOT mix
Detemir (Levemir®) Clear ~1 No peak Up to 24 Once or twice
daily
Combinations
Humulin® 50/50 Cloudy ½-1 2½ - 5 14 – 18 Before breakfast &
dinner
Humulin® 70/30 Cloudy ½-1 1½ - 16 14 – 18 Before breakfast &
dinner
Novolin® 70/30 Cloudy ½ 2 – 12 Up to 24 Before breakfast &
dinner
Humalog® Mix 75/25 Cloudy <½ 1 – 6½ ~ 22 Before breakfast &
dinner
Novolog® Mix 70/30 Cloudy <½ 1–4 Up to 24 Before breakfast &
dinner
The action time of any insulin may vary in different individuals or at different times in the same individual.
Variables include size of dose, injection site, physical activity and body temperature.
References:
Care, Vol 29 (1).
Core Curriculum for Diabetes Educators, Diabetes Management Therapies 5th Edition.
AADE. 2003.
Product labeling information
QUICK REFERENCE GUIDE TO DIABETES FOR HEALTH
CARE PROVIDERS
Chapter 10
Insulin Pumps: What, When, Who, and How
Continuous subcutaneous insulin infusion (CSII) therapy, also known as insulin pump
therapy, has been commercially available for more than 20 years. Recently, insulin
pump use has greatly increased. The pumps now available have many important safety,
memory, and calculation features that make using a pump much easier than in the past.
Indications for Use

• Inability to normalize blood glucose on current insulin regimen. (Elevated A1C)
• Severe hypoglycemia
• Hypoglycemia unawareness
• Client preference/need for normalizing lifestyle
• Recurrent hospitalizations
• Preconception and pregnancy
• Gastroparesis
• Dawn Phenomenon
• Symogi effect.
How it works:
The pump is approximately the size of a pager and must be worn 24 hours a day. A
syringe, holding up to 300 units of insulin, is connected to tubing which is connected to
an infusion site where the insulin is deposited subcutaneously. There are two basic
delivery rates.
Basal rate: Delivers insulin continuously (every few minutes) in tiny amounts at
various rates individual to each patient. Basal rates are determined first and
usually require more frequent monitoring when pump therapy is first initiated.
Once established basal rates seldom change except in children as they grow and
develop, illness, exercise, etc…
Bolus rate: Boluses are delivered by the pump user to correct elevated blood
glucose levels or to cover food intake. This is a larger amount of insulin and can
be given all at once or over a period of time.
Infusion sets come in many types with different cannula lengths and must be changed
by the person with diabetes every 48-72 hours.
Criteria for screening adults and children with diabetes for possible
pump use:
• Willing to monitor and record blood glucose a minimum of 4 times per day
• Responsible
• Willing and able to learn how to count carbohydrates. (Some math skills
needed for person with diabetes or their caregiver)
• Willing to commit to medical follow-up.
• Able to or can learn to problem solve.
• Preferably currently using MDI and able to adjust insulin to meet changes in
lifestyle.
Benefits
• Improved glucose control (Lower A1C).
• Delivers insulin in a more physiological manner.
o Both the basal and bolus doses can be adjusted in > 0.05 increments
depending on the brand of pump.
• Normalization of lifestyle.
o Pump users have more flexibility in eating, sleeping, exercising, etc.
• Less frequent and less severe hypoglycemia.
• Predictable absorption
• Programmable delivery
• Uses only rapid or short acting insulin.
o Aspart and Glulisine are both approved by the FDA for use in pumps.
o Lispro, although not FDA approved for use in pumps, has been deemed
appropriate for use by the American Diabetes Association (ADA).
• Pump companies have 24/7 customer support lines.
Risks
• The greatest risk associated with pump therapy is ketoacidosis. Because the
pumps use only rapid or short acting insulin, delivery must be constant. If the
infusion line becomes occluded or the pump runs out of insulin, blood glucose
and ketones can quickly rise. Testing blood glucose levels 4 times per day
enables the person to detect possible problems early enough to intervene and
prevent severe DKA.
o Person should always have syringes and vials of insulin available in case
of pump malfunction.
• Skin infections and reactions to the tape may occur at the insertion site.
Changing the site every 2-3 days, and using proper insertion technique
diminishes the occurrence of infection.
• Hypoglycemia is always a risk for anyone who takes insulin. Those on pump
therapy have been shown to have a decrease in hypoglycemic events.
Chapter 11
Self Monitoring of Blood Glucose (SMBG)
Self-monitoring of blood glucose (SMBG) allows persons with diabetes to evaluate

their individual response to therapy and assess whether glycemic targets are being
met. Results of SMBG can be useful in preventing hypoglycemia and adjusting
medications, medical nutrition therapy (MNT) and physical activity. The frequency
and timing of SMBG should be determined by individual needs and goals of each
person with diabetes.
• SMBG should be carried out three or more times daily in those with type 1
diabetes, pregnant women using insulin and those on multiple insulin
injections.
• For those using less frequent insulin injections or oral agents or MNT alone,
SMBG is useful in achieving glycemic goals.
• Postprandial glucose may be targeted if A1C goals are not met despite
reaching preprandial glucose goals.
• Persons with diabetes should be routinely evaluated to assess their technique
and ability to use data to adjust therapy.
Another test of glycemic control is the A1C test, which measures the average blood
glucose control over the past 2-3 months. See table below for the correlation
between A1C level and mean plasma glucose.
A1C Mean Plasma Glucose

6% 135 mg/dl
7% 170 mg/dl
8% 205 mg/dl
9% 240 mg/dl
10% 275 mg/dl
11% 310 mg/dl
12% 345 mg/dl
A1C is the primary target for glycemic control and should be checked routinely in all
persons with diabetes:
• at least two times a year in those with stable glycemic control.

• quarterly in those whose therapy has changed or who are not meeting
glycemic goals.
Blood glucose and A1C goals must be individualized based on age, ability to
recognize hypoglycemia, history of hypoglycemia and self-management capabilities.
This is especially important for children, adolescents, pregnant women and older
adults. More stringent goals (A1C <6%) may further reduce complications at the cost
of increased risk of hypoglycemia, especially in those with type 1 diabetes. Less
stringent goals are be indicated in those with severe or frequent hypoglycemia. See
table below for target blood glucose and A1C goals for persons with diabetes.
Target Glycemic Goals for Persons with Diabetes

Under age 6* Age 6-12* Age 13-19* Adults * Adults**
Before 100 – 180 < 180 90 – 130 90 – 130 < 110 mg/dl
meals mg/dl mg/dl mg/dl mg/dl
Peak post < 180 mg/dl ---
meal --- --- ---
--- < 140 mg/dl
2 hours
post meal
Bedtime 110 – 200 100 – 180 90 – 150 --- ---
mg/dl mg/dl mg/dl
A1C 7.5 – 8.5% < 8% < 7.5 % < 7.0 % < 6.5 %
* American Diabetes Association
** American Association of Clinical Endocrinologists
References:
American Association of Clinical Endocrinologist (AACE). Medical Guidelines for

the Management of Diabetes Mellitus, Endocr Pract. 2002;8 (Suppl 1).
Chapter 12
Gestational Diabetes Mellitus (GDM)
Risk assessment should be identified at the first prenatal visit. Women who meet
all of the following criteria are considered low risk: under the age of 25, are of
normal weight, have no family history of diabetes, have no history of abnormal
glucose tolerance, have no history of poor obstetric outcome, and not members
of a high risk ethnic group. No screening is required for those at low risk of
developing GDM.
Women who are at high risk of developing diabetes (marked obesity, prenatal
history of GDM, glycosuria, strong family history of diabetes) should be tested
immediately, and retested at 24-28 weeks, if necessary. All others should be
screened at 24-28 weeks of pregnancy.
Diagnostic Tests
Random 50 gram, 1 hour glucose challenge
• Glucose >200 mg/dl, diagnosis of gestational diabetes is made.

• If >140 mg/dl: administer 100 gram glucose, 3 hour oral glucose
tolerance test (3 days unrestricted carbohydrate diet of at least 150
grams per day, followed by 8-14 hour overnight fast).
Three hour, 100 gram glucose oral glucose tolerance test (after an 8-14
hour fast)
• Diagnosis of gestational diabetes is made when 2 or more values from
this test are:
o > 95 mg/dl at fasting
o > 180 mg/dl at 1 hour
o > 155 mg/dl at 2 hours
o > 140 mg/dl at 3 hours
• If only 1 out of 3 values is abnormal, retest at 32 weeks.
Nutritional Intervention
All women should meet with a registered dietitian for assistance with meal
planning, with calories sufficient for adequate weight gain. Carbohydrates should
be based on the effect on the blood glucose and spaced throughout the day into
3 meals and 2-4 snacks. Carbohydrates can be limited to 35-40% of total
calories, and are generally less well tolerated in the morning. A moderate
restriction of no more than 30-45 grams at breakfast is usually recommended,
with monitoring of blood glucose response. Non-nutritive sweeteners are
generally safe in pregnancy. Supplementation with folic acid (400 ug per day) is
recommended for all women before and during pregnancy.
Monitoring
• Weight gain (usually about 1-2 pounds per week for the second and
third trimesters). Recommend at least 15 pounds for the obese, and up
to 40 pounds for the underweight.
• AM urine ketones - if present, may need additional carbohydrate
calories before bed or may need shorter period to time between
evening snack and breakfast.
• Food intake and blood glucose levels - fasting, before meals, and 1-2
hours after meals.
Meal plan is adjusted based on weight gain, AM ketones, and blood glucose
levels.
Blood Glucose Goals (plasma values)
ADA* ACOG**
Fasting <105 mg/dl < 95 mg/dl
Pre-meal --- 60-105 mg/dl
1 hour postprandial <155 mg/dl 130-140 mg/dl
2 hour postprandial <130 mg/dl < 120 mg/dl
* American Diabetes Association
** American College of Obstetricians and Gynecologists
Insulin Administration
Generally started if nutritional therapy fails to keep blood glucose <105 mg/dl
fasting or <130 mg/dl 2-hour postprandial.
Starting doses for gestational diabetes, in third trimester:
• 0.7 units/kg/day, give 2/3 in the morning as 2/3 NPH, 1/3 R (some use
70/30). Give the other 1/3 in the evening as 2/3 NPH and 1/3 R.
• Obese: 0.8-1 unit per kg per day in at least 2 doses per day
• Fasting hyperglycemia: may treat with HS dose of 10 units NPH
Oral hypoglycemic agents and insulin analogs are not approved for use in
gestational diabetes at this time.
Activity and Pregnancy

• Activity may help with glycemic control.
• If active prior to pregnancy, a woman with gestational diabetes can
usually continue being active.
• Heart rate should not exceed 140 beats per minute.
• Activities of less than 15-20 minutes may be indicated.
• Moderate, regular activity, especially after meals may have a positive
impact on blood glucose levels.
Breast Feeding
• Should be strongly encouraged for as long as possible.
• May help with weight loss postpartum and reduce the risk of future
diabetes.
Diabetes after Delivery

• Most women return to normal blood glucose following delivery.
• An estimated 40-60% of women with gestational diabetes eventually
develop diabetes as they age
o risk of developing diabetes can be minimized if women engage in
regular physical activities and maintain desirable body weight.
• A 2 hour oral glucose tolerance test with 75 grams of glucose is
recommended at the first 6-8 week postpartum visit.
References:
Jovanovic, L (Ed) (2000). Medical Management of Pregnancy Complication

Diabetes, 3rd Ed. Alexandria, VA: American Diabetes Association.
Chapter 13
Diabetes and Hypertension
Hypertension (HTN) is twice as common in persons with diabetes compared to the
general population. For persons with diabetes, HTN contributes to the development and
progression of chronic complications, such as retinopathy, chronic kidney disease and
peripheral vascular disease. Achieving and maintaining normal blood pressure levels can
also minimize the risk of developing these complications. Controlling HTN begins with
detection and diagnosis. Health care professionals are strongly encouraged to check
blood pressure at each visit. Following proper blood pressure monitoring technique is
essential to obtain accurate blood pressure readings.
Diagnosis, Classification and Treatment of Blood Pressure

Blood Systolic Diastoic No Risk At least one risk TOD/CCD** and/or
Pressure BP BP Factors*, No factor (not DM) diabetes (with or
Classification mmHg mmHg TCD/CCD** No TOD/CCD** without risk factors)
Normal < 120 and < 80 Lifestyle Lifestyle Changes Lifestyle Changes
Changes
Prehypertension 120–139 or 80–89 Lifestyle Lifestyle Changes Lifestyle Changes +
Changes (up (up to 6 months) Drug Therapy (if SBP
to 12 months) > 130 and DBP > 80)
Stage 1 140–159 or 90–99 Lifestyle Lifestyle Changes Lifestyle Changes +
Hypertension Changes + + Drug Therapy Drug Therapy
Drug Therapy
Stage 2 & 3 > 160 or > 100 Lifestyle Lifestyle Changes Lifestyle Changes +
Hypertension Changes + + Drug Therapy Drug Therapy
Drug Therapy
If systolic and diastolic BP fall into two separate categories, use the higher category status.
*Cardiovascular Risk Factors = hypertension, cigarette smoking, obesity (BMI > 30), physical inactivity,
dyslipidemia, diabetes, microalbuminuria, age (over 55 for men; over 65 for women), family history of
premature cardiovascular disease (men under age 55 or women under age 65).
**TOD/CCD = Target Organ Damage and Clinical Cardiovascular Disease. TOD includes left ventricular
hypertrophy, angina, prior myocardial infarction, prior coronary revascularization, heart failure, stroke or
transient ischemic attack, chronic kidney disease, peripheral arterial disease or retinopathy.
According to the Joint National Committee on Prevention, Detection, Evaluation and
Treatment of High Blood Pressure (JNC 7) and the American Diabetes Association, the
goal of treating hypertension is to achieve and maintain blood pressure less than 130/80
mmHg for persons with diabetes or chronic kidney disease.
Most persons with high blood pressure, especially those over age 50, will reach their
diastolic BP goal when the systolic BP is at goal. Therefore, the primary focus of therapy
should be to achieve the systolic BP goal.
Nonpharmacological Treatment
Modification Recommendation Average SBP
Reduction
Weight Maintain normal body weight: 5-20 mmHg per
Reduction Body Mass Index (BMI) of 18.5-24.9 10 kg weight loss
DASH Eating Adopt a diet rich in fruits, vegetables and low-fat
Plan dairy products with reduced total & saturated fat. 8-14 mmHg
See DASH handout at end of guideline.
Dietary Reduce daily sodium to less than 2400 mg. 2-8 mmHg
Sodium Eat more fresh, unsalted foods
Restriction Use herbs and spices to season foods
Choose foods with <5% Daily Value for sodium
Physical Regular aerobic physical activity (brisk walking) at
Activity least 30 minutes per day most days of the week. 4-9 mmHg
Moderation Limit alcohol intake to 2 drinks per day (men) or
of Alcohol 1 drink per day (women) 2-4 mmHg
Consumption 1 drink = 12 oz beer, 5 oz wine and 1½ oz liquor
Pharmacological Treatment
More than 2/3 of those with diabetes and HTN will require two or more different
medications to achieve the goal BP of less than 130/80 mmHg. See below for evidence-
based recommendations for the pharmacological treatment of diabetes and HTN.
Condition Recommended drug therapy
Type 1 or 2 diabetes with NO cardiovascular ACE inhibitor or ARB
risk factors or proteinuria Thiazide Diuretic (shown to reduce risk
of stroke and cardiovascular events)
Type 1 diabetes with any degree of ACE inhibitor (shown to delay the
albuminuria progression of nephroathy)
Type 2 diabetes and microalbuminuria ACE inhibitor or ARB (shown to delay
the progression to macroalbuminuria)
Type 2 diabetes and macroalbuminuria, ARB should be strongly considered
nephropathy or renal insufficiency
Those over age 55 with cardiovascular risk ACE Inhibitor should be considered
factors (history of cardiovascular disease, (to reduce the risk of cardiovascular
smoking, dyslipidemia, overweight) events)
Those with recent myocardial infarction (MI) Beta blocker should be added to
current treatment (to reduce mortality)
Those with microalbuminuria or overt Non-Dihydropyridine Calcium-
nephropathy in which ACE Inhibitors or Channel Blocker should be
ARBs are not tolerated considered.
Commonly Used Oral Antihypertensive Medications

Class Drug (Trade Name)
Thiazide hydrochlorothiazide (Microzide, HydroDIURIL)
Diuretics indapamide (Lozol)
ACE Inhibitors benazepril (Lotensin) lisinopril (Prinivil, Zestril)
enalapril (Vasotec) quinapril (Accupril)
fosinopril (Monopril) ramipril (Altace)
ARBs candesartan (Atacand) losartan (Cozaar)
irbesartan (Avapro) valsartan (Diovan)
Beta Blockers atenolol (Tenormin) metoprolol (Lopressor)
nadolol (Corgard) metoprolol extended release (Toprol XL)
Dihydropyridine amlodipine (Norvasc) nifedipine long-acting
Calcium-Channel felodipine (Plendil) (Adalat CC, Procardia XL)
Blockers
Non- Diltiazem extended release (Cardizem CD, Dilacor XR, Tiazac)
dihydropyridine diltiazem extended release (Cardizem LA)
Calcium-Channel verapamil immediate release (Calan, Isoptin)
Blockers verapamil long acting (Calan SR, Isoptin SR)
verapamil (Coer, Covera HS, Verelan PM)
Alpha 1 Blockers doxazosin (Cardura) terazosin (Hytrin)
prazosin (Minipress)
Summary
The treatment of HTN involves considerable knowledge of the recommended lifestyle
changes and medications. Because high blood pressure is often asymptomatic, lifestyle
changes can be difficult to maintain. Since medications may be expensive and may have
unpleasant side effects, some stop treating their high blood pressure with unfortunate
results. Health care providers should explore these issues and involve the physician, as
needed, to help persons with diabetes achieve their blood pressure goal. The keys are to
treat hypertension aggressively and to keep blood glucose under good control to
minimize the possibility of developing or exacerbating complications.
For more information on Diabetes and Hypertension, check out the Diabetes and
Hypertension independent study module at www.diabetesinmichigan.org. Click on
independent study modules.
References:
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation
and Treatment of High Blood Pressure, NIH Publication No. 03-5231, National High Blood
Pressure Education Program, May 2003.
American Diabetes Association. Position Statement: Treatment of Hypertension in

Adults with Diabetes. Practical Diabetology, March 2003.
Wylie-Rosett J. Hypertension and Diabetes: Clinical Synergy and Challenges. On the

Cutting Edge, 2004: Vol 25 (4): 4-8.
DASH Eating Plan
Food Group Servings based on: Examples Comments
1600 2000 3100 Serving Sizes
Calories Calories Calories
Grains/Grain 6 per day 7-8 per day 12-13 per day 1 slice bread Choose whole grains. On the food label, look
products ½ - 1 cup ready-to-eat cereal for whole wheat flour as first ingredient and at
½ cup cooked rice, pasta, cereal least 2 grams fiber per serving.
Vegetables 3–4 per day 4–5 per day 6 per day 1 cup raw leafy vegetables Choose variety of vegetables.
½ cup cooked vegetable Rich sources of potassium, magnesium and
6 oz vegetable juice fiber.
Fruits 4 per day 4 – 5 per day 6 per day 1 medium fruit Choose variety of fruits.
¼ cup dried fruit Good source of potassium, magnesium and
½ cup fresh, frozen or canned fruit fiber.
4 oz fruit juice
Low-fat or fat-free 2–3 per day 2 – 3 per day 3–4 per day 8 oz 1%, ½ % or skim milk Major source of calcium and protein.
dairy products 6-8 oz yogurt Choose low-fat and fat-free dairy products.
1 ½ oz cheese
Lean meats, 1-2 per day 2 per day 2-3 per day 3 oz cooked lean meat, skinless Choose lean and trim away visible fats. Bake,
poultry and fish poultry or fish boil, roast, broil versus frying
Nuts, seeds and 3 per week 4–5 per week 1 per day 1/3 cup or 1½ oz nuts Rich source of energy, magnesium, potassium,
dried beans 1 Tbsp or ½ oz seeds protein and fiber.
½ cup cooked dried beans
Fats and oils 2 per day 2 – 3 per day 4 per day 1 tsp soft tub margarine High in calories. Limit portions.
1 Tbsp low-fat mayonnaise Limit saturated fats (solid at room
2 Tbsp light salad dressing temperature).
1 tsp vegetable oil Best oils: canola, olive
Sweets 0 5 per week 2 per day 1 Tbsp sugar, jam or jelly Sweets should be low in fat
½ oz jelly beans
8 oz lemonade
Source: http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/index.htm
How to Lower Calories on the Dash Eating Plan
To increase fruits
• Eat a medium apple instead of 4 shortbread cookies (save 80 calories).
• Eat ¼ cup dried fruit instead of a 2 oz bag of pork rinds (save 230 calories).
To increase vegetables:
• Have a hamburger that’s 3 oz meat instead of 6 oz. Add ½ cup of carrots and ½ cup spinach. (save 200 calories)
• Instead of 5 oz chicken, have a stir-fry with 2 oz chicken and 1½ cup raw vegetables. Use a small amount of vegetable
oil. (save 50 calories).
• Add fresh or frozen vegetables to soups, pastas or rice.
To increase low-fat or fat-free dairy products:

• Drink skim milk instead of 2% milk (save 30 calories per cup) or whole milk (save 60 calories per cup).
• Have ½ cup low-fat frozen yogurt instead of 1½ oz chocolate bar (save 110 calories).
Other calorie saving tips: Tips for reducing salt

• Use low-fat or fat-free condiments. • Eat more fresh, unsalted foods.
• Use half the amount of regular vegetable oil, soft or liquid • Avoid adding salt to homemade foods. Use
margarine or salad dressing. spices for flavoring.
• Eat smaller portions, cutting back gradually. • Read food labels and look for:
• Check the food labels to compare fat content in packaged foods • foods with < 5% of Daily Value for sodium
(low-fat and fat-free does not always mean lower in calories). • snack foods or salad dressings with < 200
• Limit foods with lots of added sugar (pies, sweetened yogurts, mg of sodium per serving
candy bars, ice cream, sherbet, regular soft drinks and fruit drinks) • sides (soups, rice, pasta, potatoes) with <
• Eat fruits canned in their own juice. 350 mg of sodium per serving
• Snack on fruit, vegetable sticks or unbuttered, unsalted popcorn. • frozen meals or fast foods with < 800 mg of
• Drink water or club soda. sodium.
The DASH (Dietary Approaches to Stop Hypertension) Study was a National Institutes of Health research project.
Following the DASH Eating Plan lowered blood pressure levels in those with normal and elevated blood pressure 6
levels without reducing sodium or using drugs.
Chapter 14
Lipid Management in Diabetes
Lipid abnormalities are common in persons with diabetes (up to 70% of type 2
have lipid disorders). Some problems can be resolved through blood glucose
control. Others will require dietary or pharmacological intervention.
Desirable Lipid Levels (fasting)
Cholesterol LDL-cholesterol HDL-cholesterol Triglycerides

(mg/dl) (mg/dl) (mg/dl) (mg/dl)
Adults <200 <100 >40 (men) <150
> 50 (women)
Children <200 <100 >35 <150
Testing (Fasting Lipid Profile)

• Adults: At diagnosis and every year
• Children with type 1 diabetes (over age 12): Screen at diagnosis, but
after glycemic control is achieved. If initial screening is normal, repeat
screening every 5 years. If levels are abnormal, follow-up in 3 months
and again at 6 months to assess effectiveness of treatment.
• Children with type 1 diabetes (under age 12): There is no need to

screen in absence of parental history of dyslipidemia or early coronary
disease. If levels are abnormal, follow-up in 3 months and again at 6
months to assess effectiveness of treatment.
• Children with type 2 diabetes: Screen at diagnosis, regardless of

age, but after glycemic control is achieved. If levels are normal, repeat
screening every 2 years.
Type 1
• Blood glucose control will often help correct dyslipidemia.
• Check thyroid function.
Type 2
• Most common type of dyslipidemia: high triglycerides with low HDL.
• Usually have smaller, denser, more atherogenic LDL-particles
• Obesity exacerbates dyslipidemia.
• If no evidence of macrovascular disease; weight loss, increased
activity, limiting alcohol, and controlling glucose can help.
Lifestyle Therapies for Dyslipidemia

1. Improved BG control
• Most beneficial for those with type 1 diabetes
• Will help with hypertriglyceridemia
• May decrease LDL-cholesterol up to 15%
2. Fat restriction
• Saturated fat : < 10% of total calories (may need < 7% or total calories)
• Trans fats : minimal intake
• Dietary cholesterol: < 200 mg/day
3. Increase fiber
• Soluble fiber: 10-25 grams/day
• Plant stanols/sterols: 2 grams/day
4. Modest weight loss

• Will lead to decrease in triglyceride levels, increased HDL-cholesterol
levels, and a modest lowering of LDL-cholesterol.
5. Increased physical activity

• Will lead to decrease in triglyceride levels, increased HDL-cholesterol
levels, and a modest lowering of LDL-cholesterol.
6. Smoking cessation
• Will lead to improvements in lipid profile.
Treatment of Diabetic Dyslipidemia in Adults (order of priorities)

1. LDL-cholesterol lowering
• 1st Choice: HMG CoA Reductase Inhibitors (statins)
• 2nd Choice: Bile Acid Binding Resins (resins) or Fibric Acid Derivatives
(fibrates)
2. HDL-cholesterol raising
• 1st Choice: behavioral interventions (see above)
• 2nd Choice: Nicotinic acid (with caution due to BG raising) or fibrates
3. Triglyceride lowering
• 1st priority: BG control
• 1st Choice: fibrates
• Statins are moderately effective in those with elevated LDL also.
4. Combined hyperlipidemia
• 1st Choice: Lifestyle intervention plus a statin

• 2nd Choice:Lifestyle intervention plus a fibrate
• 3rd Choice: Lifestyle intervention plus a resin and a fibrate OR lifestyle
intervention plus a statin and nicotinic acid (must monitor BG carefully)
Treatment of Diabetic Dyslipidemia in Children

1. Lifestyle intervention (see above) for LDL-cholesterol of 100-129 mg/dl
2. Consider pharmacological intervention for LDL cholesterol 130-159 mg/dl

• Maximize lifestyle intervention
• Base decision on complete CVD risk profile, including assessment of
blood pressure, family history and smoking status.
3. Pharmacological intervention for LDL cholesterol 160 mg/dl

• Bile acid sequestrants (resins) are often recommended as first choice in
this age group.
• Statins can be used with caution. Initiate at lowest available dose and
increase based on LDL levels and side effects, and monitor LFTs.
• Statins should be discontinued if there is complaint of significant muscle
pain or soreness.
4. Elevated triglycerides
• Maximize lifestyle intervention
• If levels > 1000 mg/dl, treatment is necessary. Consider fibrate.
• Fish oil supplementation with omega-3 fatty acids may help lower
triglycerides that are not responding to medication.
Resources:
Diabetes Care. Vol 29 (1).
American Diabetes Association (2003). Management of Dyslipidemia in Children

and Adolescents with Diabetes. Diabetes Care 26:2194-2197.
Chapter 15
Sick Day Management
Knowing how to manage illness is important for persons with diabetes in order to
avoid hospitalization.
Sick Day Guidelines

• Always take insulin or diabetes medication (often extra insulin is required).
o Less insulin may be needed if person is vomiting or has diarrhea.
o Omission of insulin is a common cause of ketosis.
• Test blood glucose frequently. All persons with diabetes should test their
blood glucose at home when ill, even if they do not monitor regularly.
o For those with type 1, check every 4 hours
o For those with type 2, check 2-4 times a day.
• Record blood glucose (BG) and response to treatment. Share with the
healthcare provider.
• Test for urine ketones every 4 hours (type 1 diabetes).
• Hypoglycemia is rare, yet may occur with nausea and vomiting of short
duration without fever.
• Over the counter (OTC) and prescription medicines, along with herbal
therapies, can contribute to hyperglycemia and hypoglycemia.
• Record weight changes (loss may signal dehydration) and breathing
difficulties.
• Try to eat usual amount of carbohydrate.
o If having difficulty eating, eat or drink 15 grams of carbohydrate every
hour or 45-50 grams of carbohydrate every 3-4 hours.
o Soft food or liquids may be easier to consume (see below).
• Drink extra water or sugar-free, caffeine-free fluids (8 oz every hour when
awake).
Foods for Sick Day Management (~15 grams carbohydrate each)

½ (4 oz) cup juice 1 cup (8 oz) milk 1 slice toast
1cup (8 oz) sports drink ½ cup unsweetened 3 squares graham
(Gatorade, Powerade) applesauce crackers
½ cup (4 oz) regular pop 1 cup soup ½ - 1 cup cold cereal
½ cup regular gelatin 6 saltine crackers ½ cup hot cereal
½ cup sugar-free pudding ½ twin popsicle 1/3 cup rice
½ cup ice cream 6 oz light yogurt 1/3 cup pasta
½ cup frozen yogurt ¼ cup sherbet ½ cup mashed potatoes
Nausea/Vomiting
Blood glucose: Action
over 250 mg/dl Drink calorie-free, caffeine-free liquids in place of meal.
180-250 mg/dl Drink/eat 15 grams of carbohydrate in place of meal.
Also, probably need additional liquid from water or
calorie-free caffeine source.
under 180 mg/dl Try to drink or eat usual mealtime carbohydrate amount.
If vomiting occurs after insulin administration, may need
to sip sugar water every 20-30 minutes to maintain BG
levels between 100-180 mg/dl.
under 100 mg/dl and May require hospitalization.
vomiting persists
Adjusting Insulin for Illness (no nausea/vomiting)

• Continue usual dose of intermediate-acting (NPH) or long-acting insulin
(Lantus)
• Supplemental doses of rapid-acting (Humalog, Novolog) or short-acting
(Regular) insulin may be needed due to elevated BG levels or the presence
of large or persistent ketones.
o Rapid-acting or short-acting insulin may be given every 1-4 hours.
o Dose is dependent on severity of illness.
o During most illnesses, 10% of total daily insulin dose can be safely given
as a supplemental dose.
o If BG is greater than 300 mg/dl with large ketones, 20% of total daily
dose can be given as a supplemental dose.
• Adjustments need to be individualized for each person.
• If hyperglycemia persists, additional doses of rapid or short-acting insulin
may be needed throughout the day.
When to Call Physician

• Fever greater than 100 degrees for 24 hours
• Persistent hyperglycemia (BG over 300 mg/dl)
• Persistent diarrhea (more than 8 hours)
• Vomiting and unable to take fluids for over 4 hours
• Sick longer then 24 hours
• Severe abdominal pain (more common in type 1)
• Difficulty breathing (more common in type 1)
• Moderate to large ketones (more common in type 1)
• Other unexplained symptoms (if in doubt, contact your health care provider)
Preventing Illness
• Get influenza vaccination yearly.
• Get pneumococcal vaccination. If receive first dose prior to age 65, give
another single re-vaccination after age 65 (if 5 or more years have lapsed
since the previous dose).
• Practice good hygiene and hand washing.
• Eat a healthful diet.
• Get plenty of rest.
• Stay hydrated.
• Don't smoke.
References:
Care, Vol 29 (1).
Chapter 16
Special Issues: Behavior Change
How to Help Your Clients Change Their Behavior
Determine what your client wants to change:
• If client does not want to alter health threatening behavior, assist them
with determining personal benefits of changing.
• Those who desire change may need help with:
o Setting goals (i.e. maintain fasting blood glucose between 80 and
120 mg/dl)
o Breaking goal into easy to follow steps. For example to achieve
blood glucose goals they could:
 Meet with a dietitian for assistance with meal planning.
 Start walking 10 minutes, 3x per week.
 Join a diabetes support group
 Continue learning about diabetes
o Knowing how to problem solve (How will you maintain healthy
habits when you go on vacation?)
o Developing a support system (and dealing with people who may
undermine success)
o Managing stress (Uncontrolled stress often causes a person to
return to unhealthy behavior)
o Developing behavioral change strategies (such as eating only in the
kitchen)
References:
Diabetes Care. Supplement. Vol 29.
Chapter 17
Special Issues: Concerns of Children
Parents and children need to accomplish ordinary tasks in each development

stage of childhood. The main job of a child is to grow.
Parent Roles
• Forcing a child to eat and withholding food does not work.

• Set regular meal and snack times for your child.
• You are responsible for selecting the foods offered and determining
snack and meal times.
• Everyone in the family can and should eat the same foods. Children
with diabetes do not need special foods.
• Some of the sugar-free items (sugar-free soda, gelatin or pudding) may
be helpful if your child needs less carbohydrate at a snack or meal.
• Set a good example. Eat what you want your children to eat.
• Provide your child with support and show interest in your child's
diabetes care.
• Provide your child with more snacks (or less insulin) if activity level
goes up.
• If a child won't eat and extra carbohydrate is needed, have some
options available (examples: juice, regular soda, crackers).
• Be aware of behavior changes (crying, irritability) that may signal a low
blood glucose level.
• Always be prepared (glucagon kit, extra carbohydrate sources, insulin,
testing supplies, etc).
Children with diabetes...
• Need to eat when hungry.

• Need to grow and develop.
• Need to have insulin and diet therapy adjusted to fit their lifestyles.
• Need to take gradual charge of their diabetes with parental support.
• Need to be able to do the things other children do.
• May benefit from attending summer camp for children with diabetes.
Type 2 Diabetes in Youth…
• While children with or at risk for type 2 diabetes may be overweight,

most of the above guidelines are still applicable.
• Type 2 diabetes in youth can be greatly modified by lifestyle changes.
• It is important for the whole family to be supportive, focusing on eating
well and increasing physical activity. This way everyone can be
healthier.
• Teach children to tune in to their body signals, so they can learn to eat
when physically hungry and stop before they are too full.
• Avoid using food as a reward
• Eat regular meals and snacks. Don’t forget to eat breakfast!
• Aim for 5 a day (fruit and vegetable servings).
• Reduce or eliminate sweetened drinks. Have water instead.
• Move more. Sit less. Limit screen time to a maximum of 2 hours a day.
• Realize some overweight children may do well to just maintain their
weight until they can grow into it.
• Let your child know he or she is accepted unconditionally, whatever his
or her weight.
References:
Healthy Kids Healthy Weight: Tips for Families with Kids of all Shapes and Sizes;
Michigan Department of Community Health, Michigan Department of Education:
www.mihealthtools.org/schools
The Surgeon General’s Call to Action to Prevent and Decrease Overweight and
Obesity: Overweight in Children and Adolescents:
http://www.surgeongeneral.gov/topics/obesity/
Chapter 18
Acute Complications of Diabetes:
Hypoglycemia and Hyperglycemia
Hypoglycemia is often defined as plasma blood glucose levels lower than

approximately 72 mg/dl. Hypoglycemic episodes can vary greatly in severity of
symptoms.
Signs/ Mild: sweating, trembling, difficulty concentrating,

Symptoms lightheadedness, lack of coordination
Severe: inability to self-treat due to mental confusion,
lethargy or unconsciousness.
Causes Too much diabetes meds/insulin
Too much activity
Not eating enough carbohydrate
Drinking too much alcohol
Advancing age and poor nutrition
Treatment Mild hypoglycemia: 15/15 rule
1. Check blood glucose (BG)
If BG is 50-69: give 15 grams carbohydrate
If BG is <50: give 30 grams carbohydrate
2. Wait 15 minutes and recheck BG
If BG < 70, repeat step 1
If BG > 70, monitor for signs/symptoms of low BG.
(May need to eat an additional snack if next meal
is more than 1 hour away).
Severe hypoglycemia:
1. If able to swallow without risk of aspiration, offer juice or
non-diet soft drink or place glucose gel, honey, syrup or
jelly inside the person’s cheek.
2. If unable to swallow without risk of aspiration: give
glucagon injection. Recommended doses are:
older children and adults: 1 mg
children under age 5: 0.5 mg
infants: 0.25 mg
Examples of 15 grams of carbohydrate include 3 glucose tablets, 8 Lifesavers®, 2

Tbsp raisins, 4 oz non-diet soft drinks, 4 oz fruit juice or 8 oz nonfat milk. It is best to
avoid food high in fat content as they may slow gastric emptying and absorption of
carbohydrate, taking longer to raise blood glucose levels.
Hyperglycemia
Signs/ Increased thirst, increased urination, excessive hunger,

Symptoms blurred vision, weight loss (related to lack of insulin).
Weakness, lethargy, malaise and headache.
Nausea, vomiting, fruity breath, and abdominal pain (related
to ketosis).
Difficulty breathing (related to the metabolic acidosis).
Causes Not enough diabetes meds/insulin or physical activity
Eating too much carbohydrate
Stress
Treatment Fluids (caffeine free and carbohydrate/calorie free)
Check ketones
Insulin to correct hyperglycemia for some
Prolonged hyperglycemia can lead to diabetic ketoacidosis (DKA) or hyperosmolar

hyperglycemic state (HHS), both of which are life threatening. DKA is a complication
that results from the lack of insulin and is most frequently seen in those with type 1
diabetes. It is characterized by hyperglycemia, ketosis, acidosis, dehydration and
electrolyte imbalance.
HHS is most frequently seen in older adults with type 2 diabetes. It is similar to DKA
except that insulin deficiency is not as prevalent. It is characterized by severe
hyperglycemia, absence of significant ketones, profound dehydration and mental
status changes.
Comparison of DKA and HHS Features

Feature DKA HHS
Age Under 40 years of age Over 60 years of age
Duration of symptoms Less than 2 days More than 5 days
Plasma BG level < 600 mg/dl > 600 mg/dl
Sodium concentration Normal or low Normal or high
Bicarbonate Low Normal
concentration
Ketone bodies 4+ Less than 2+
Arterial pH Low Normal
Serum osmolality < 320 mOsm/kg >320 mOsm/kg
Prognosis 3-10% mortality 10-20% mortality
Priorities of Treatment 1. Provide insulin 1. Fluid/electrolyte
2. Correct fluid/electrolyte replacement
imbalances 2. Adequate insulin
References:
Franz MJ et al. (2003). A Core Curriculum for Diabetes Educators, 5th Ed., Diabetes
Complications. American Association of Diabetes Educators, Chicago.
Chapter 19
Chronic Complications of Diabetes
Chronic complications of diabetes include cardiovascular disease, neuropathy,

nephropathy, retinopathy, periodontal disease, as well as complications from flu and
pneumonia.
Research Studies
Striving for optimal glycemic control is the cornerstone in the prevention of diabetes
complications. The Diabetes Control and Complications Trial (DCCT) compared
intensive vs. conventional control in persons with type 1 diabetes. Intensive diabetes
care reduced the risk of:
• Retinopathy 76%
• Neuropathy 60%
• Nephropathy 50% and
• Cardiovascular disease 35%.
Most participants were then enrolled in the Epidemiology of Diabetes Interventions

and Complications (EDIC), an 8 year observation study. It showed further risk
reduction in:
• Heart and blood vessel disease by 42%
• Heart attack, stroke, or heart and blood vessel disease-related death by 57%.
Similarly, the United Kingdom Prospective Diabetes Study (UKPDS) showed that
improved blood glucose control in those with type 2 diabetes reduced risk of:
• Retinopathy by 21%
• Nephropathy by 33%.
The UKPDS also showed that improved blood pressure control reduced incidence of
stroke and microvascular complications.
However, in light of recommended treatment goals, only:

• 37% of adults with diagnosed diabetes achieved an A1C of <7%
• 36% had a blood pressure <130/80 mmHg
• 48% had a cholesterol <200 mg/dl
• 7.3% met all three above goals.
Cardiovascular Disease (CVD), the number one killer in those with diabetes,
includes coronary artery disease, myocardial infarction, peripheral vascular disease
and cerebral vascular disease. Risk factors for CVD include duration of diabetes, age,
genetics, race and gender, along with modifiable risk factors listed in the table below.
Guidelines for Reducing Risk of CVD

Goal
Blood Pressure Check at every medical visit
Optimal: < 120/80 mmHg
Minimal goal: < 130/80 mmHg
Take medications as prescribed
Cigarette Smoking Advise not to smoke
Smoking cessation counseling for those who smoke
Diabetes Strive for near normal blood glucose levels
Monitor blood glucose levels regularly
Diet Limit saturated fats to <7% of total calories
Limit dietary cholesterol to < 200 mg
Limit intake of trans fatty acids
DASH Diet (See chapter 13 Hypertension and Diabetes)
Lipids Check lipid profile at least once a year
LDL cholesterol < 100 mg/dl
HDL cholesterol > 40 mg/dl (men); > 50 mg/dl (women)
Triglycerides < 150 mg/dl
Non-HDL cholesterol* < 130 mg/dl
Physical Activity 30 minutes of moderate-intensity activity on most
(preferably all) days of the week
Weight BMI of 18.5-24.9
management Waist circumference: < 35“ (women); < 40“ (men)
Antiplatlet agents Consider low dose aspirin in those over age 40
Consider other antiplatlet agent if contraindication to aspirin
* Current NCEP/ATP III guidelines suggest that "non-HDL cholesterol" (total

cholesterol minus HDL) be utilized in those with triglycerides 200 mg/dl.
Lower Extremity Complications and Neuropathies
Diabetic neuropathy involves acute nerve abnormalities, followed by more chronic
nerve damage, atrophy and loss. Up to 70% of persons with diabetes have nerve
damage, which can lead to lower limb amputation. Common foot problems associated
with diabetes include circulation, structural and neuropathic issues.
An annual comprehensive foot exam including a 5.07 monofilament test is

recommended to screen for neuropathy. Suggested sites for monofilament testing
are shown below.
Persons with diabetes should be taught to examine their feet daily and report changes
to their health care provider, including redness, swelling, ulcers, temperature change
or structural changes. Reducing risk for lower extremity complications includes
smoking cessation, controlling blood lipids, blood pressure and blood glucose, weight
management and being physically active.
Autonomic neuropathy affects blood flow, perspiration and skin hydration. This can
lead to dry, cracking skin and calluses. It may also impair one’s ability to fight
infection. Autonomic neuropathy can also affect other body systems:
• Genitourinary: problems with bladder, erectile dysfunction.
• Gastrointestinal: gastroparesis, diarrhea, constipation
• Cardiovascular: orthostatic hypotension, silent heart attack
• Impaired insulin counter-regulation: hypoglycemia unawareness
• Sudomotor: abnormal sweating
• Pupillary: difficulty seeing in the dark.
Nephropathy
Diabetic nephropathy occurs in 20-40% of those with diabetes. Risk factors are listed
below.
Non-modifiable risk factors Modifiable risk factors

Duration of diabetes Hypertension
Family history of hypertension or Hyperglycemia
diabetic nephropathy Dyslipidemia
Race (higher in African American, Smoking
Hispanic and Native Americans)
Gender (men higher than women)
A family history of high blood pressure and/or the presence of hypertension increase
the risk to develop kidney disease and hypertension speeds the progress of kidney
disease when it already exists.
Guidelines for reducing one’s risk of Kidney Disease

Goal
Blood Pressure Check at every medical visit
Optimal: < 120/80 mmHg
Minimal goal: < 130/80 mmHg
Cigarette Smoking Advise not to smoke
Smoking cessation counseling for those who smoke
Diabetes Strive for near normal blood glucose levels
Monitor blood glucose levels regularly
Diet Avoid a high protein diet. Limiting protein to 0.8 g/kg if
any evidence of chronic kidney disease.
DASH Diet (See chapter 13 Hypertension and Diabetes)
Lipids Check lipid profile at least once a year
LDL cholesterol < 100 mg/dl
HDL cholesterol > 40 mg/dl (men); > 50 mg/dl (women)
Triglycerides < 150 mg/dl
Non-HDL cholesterol* < 130
Lab Testing Microalbumin: < 30 ug/mg
Type 1: within 5 years of diagnosis, then annually
Type 2: at diagnosis, then annually
Serum Creatinine and Calculated GFR*: annually
Weight BMI of 18.5-24.9
management Waist circumference: < 35“ (women); < 40“ (men)
* For GFR calculator: go to www.nkdep.nih.gov/professionals/gfr_calculators/

Retinopathy
Diabetes is the leading cause of blindness in the US among those aged 20-74. Eye
disease is 25 times more common among persons with diabetes than the general
population. Listed below are common eye problems in persons with diabetes.
Functional losses Treatment Prevention

Cataracts Blurry vision Surgery to BG control
(clouding of Reduced night vision replace the Annual eye exam
the lens of the Problems with glare lens
eye) Fading of colors
Glaucoma None in early stages Lower eye Annual eyeball pressure
(group of eye Loss of peripheral vision pressure check
diseases that Difficulty with night or (eye drops
damage the low vision or surgery)
optic nerve)
Retinopathy None in early stages Dependent Annual dilated eye exam
(microvascular Later: blurry vision, on severity Strive for optimal blood
disease of the floaters, flashing lights, pressure, lipid and
retina) sudden vision loss glycemic control
Smoking cessation
Periodontal Disease
Periodontal disease is the most common oral complication of diabetes. It is more
prevalent in those with poorly controlled diabetes. Prevention of periodontal disease
involves striving for optimal glycemic control, good oral hygiene (regular brushing and
flossing of teeth) and follow-up every 6 months with a dental professional.
Flu and Pneumonia

Influenza and pneumonia are common, preventable infectious diseases associated
with high mortality and morbidity in those with chronic diseases. Vaccination
guidelines are listed below.
• Influenza: annual to all with diabetes 6 months of age.
• Pneumonia: one lifetime vaccine for adults with diabetes. A one-time
revaccination is recommended for those >65 years of age previously immunized
when they were <65 years of age if the vaccine was administered >5 years ago.
References:
Franz MJ et al. (2003). A Core Curriculum for Diabetes Educators, 5th Ed., Diabetes
Complications. American Association of Diabetes Educators, Chicago.
Saydah SH, Fradkin J, Cowie CC: Poor control of risk factors for vascular disease
among adults with previously diagnosed diabetes. JAMA 291:335–342, 2004.

Diabetes Care. Supplement. Vol 29.

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Michigan Diabetes Outreach Network

QUICK REFERENCE GUIDE TO DIABETES

Chapter 1: Screening and Diagnosis of Diabetes

This resource may be printed and copies may be made as needed.

Revised June 2006

Criteria for screening adults for type 2 diabetes or pre-diabetes:

• Testing should be considered in younger adults or be carried out more

Screening should be carried out within a health care setting versus a

• Overweight (classified by any of the following)

• Plus any two of the following risk factors:

Screening (fasting plasma glucose preferred) should be done at age 10 or at the

Diabetes and Pre-diabetes Diagnosis:

1. Symptoms of diabetes (polyuria, polydipsia and unexplained weight loss)

2. Fasting plasma glucose (Fasting: no caloric intake for at least 8 hours).

3. 2 hour postprandial plasma glucose during an oral glucose tolerance test

Diagnostic Criteria for the 100 g OGTT

o Two-step approach: Measure plasma or serum glucose concentration 1

American Diabetes Association (2006). Clinical Practice Recommendations. Diabetes

• Pneumococcal vaccination (usually only once, repeat if over 65 or

Diabetes Self-Management Education for Persons with Diabetes

The National Diabetes Education Program Publication No. NDEP-12.

In General, Persons with Diabetes...

Regular meetings with a registered dietitian are recommended to help

Fat Intake and Diabetes

Additional Help for the Overweight Client

Many nutrition handouts are available through the Diabetes Outreach

Benefits of Regular Physical Activity for Persons with Diabetes

• Reduces the risk of Coronary Artery Disease

For those with type 2 diabetes, regular activity may also:

For those with type 1 diabetes:

 Exercise induced hypoglycemia

 Post-exercise, late-onset hypoglycemia (occurs 4 or more hours after

Carbohydrate Replacement for Physical Activity

2. Hyperglycemia (after very strenuous, high-intensity activities)

4. Exacerbation of cardiovascular disease, such as:

5. Worsening of chronic complications with inappropriate activities.

• Peripheral Vascular Disease (PVD): Non-weight bearing activities are

• Peripheral Neuropathy: Avoid weight-bearing activities and jogging. Be

• Autonomic Neuropathy: Avoid strenuous, high intensity activities and

• Nephropathy: Low-intensity aerobic activities are best (walking,

• Hypertension: Avoid heavy lifting, straining and excessive arm

Physical Activity Recommendations

Type 1 diabetes: all levels of activity can be performed by those without

For the older adult: 30-40 minutes 5-6 times a week.

For weight loss: at least 60 minutes most days of the week.

Activity: Aerobic activity (e.g. walking, swimming or biking). Depending on fitness

References: American Diabetes Association (2006). Clinical Practice

Pharmacological therapy is recommended after 4-12 weeks if an individualized meal

There are currently 6 classifications of oral therapy for type 2 diabetes

• After 5 years, approximately 50% of patients will require medication

Agent Typical Dosage Max dosage

Candidates for Initial Use: Type 2 diabetes, no dyslipidemia, not overweight,

Primary Function: Enhances insulin secretion. Is a short-acting agent. The amount

Side Effects • Back pain

Candidates for Initial Use: Type 2 diabetes, no dyslipidemia, with or without

Primary Function: Stimulates insulin secretion when needed (postprandial), then

Alpha Glucosidase Inhibitors

Acarbose (Precose) and Miglitol (Glyset)

Primary Function: Lowers postprandial BG by delaying carbohydrate digestion and

Dosing and Administration

Metformin (Glucophage, Glucophage XR)

Candidates for Initial Use: Type 2 diabetes, dyslipidemia, obesity or genetic

Pioglitizone (Actos) and Roisglitizone (Avandia)

Primary Function: Decreases insulin resistance and increases glucose uptake in