Glycemic control -
The main complexities stem from the nature of the feedback loop of the glucose cycle, which is sought to be regulated: [ citation needed ]. As diabetes is a prime risk factor for cardiovascular disease , controlling other risk factors which may give rise to secondary conditions, as well as the diabetes itself, is one of the facets of diabetes management.
Checking cholesterol , LDL , HDL and triglyceride levels may indicate hyperlipoproteinemia , which may warrant treatment with hypolipidemic drugs. Checking the blood pressure and keeping it within strict limits using diet and antihypertensive treatment protects against the retinal, renal and cardiovascular complications of diabetes.
Regular follow-up by a podiatrist or other foot health specialists is encouraged to prevent the development of diabetic foot.
Annual eye exams are suggested to monitor for progression of diabetic retinopathy. Late in the 19th century, sugar in the urine glycosuria was associated with diabetes. Various doctors studied the connection. Frederick Madison Allen studied diabetes in —12, then published a large volume, Studies Concerning Glycosuria and Diabetes , Boston, He invented a fasting treatment for diabetes called the Allen treatment for diabetes.
His diet was an early attempt at managing diabetes. The average normal person has an average fasting glucose level of 4. Optimal management of diabetes involves patients measuring and recording their own blood glucose levels. By keeping a diary of their own blood glucose measurements and noting the effect of food and exercise, patients can modify their lifestyle to better control their diabetes.
For patients on insulin, patient involvement is important in achieving effective dosing and timing. Levels which are significantly above or below this range are problematic and can in some cases be dangerous.
Most diabetics know when they are going to "go hypo" and usually are able to eat food or drink something sweet to raise their levels.
A patient who is hyperglycemic high glucose can also become temporarily hypoglycemic under certain conditions e. not eating regularly, or after strenuous exercise, followed by fatigue.
Intensive efforts to achieve blood sugar levels close to normal have been shown to triple the risk of the most severe form of hypoglycemia, in which the patient requires assistance from by-standers in order to treat the episode. The patient is advised to seek urgent medical attention as soon as possible if blood sugar levels continue to rise after 2—3 tests.
High blood sugar levels are known as hyperglycemia , which is not as easy to detect as hypoglycemia and usually happens over a period of days rather than hours or minutes. If left untreated, this can result in diabetic coma and death.
Prolonged and elevated levels of glucose in the blood, which is left unchecked and untreated, will, over time, result in serious diabetic complications in those susceptible and sometimes even death.
There is currently no way of testing for susceptibility to complications. Diabetics are therefore recommended to check their blood sugar levels either daily or every few days.
There is also diabetes management software available from blood testing manufacturers which can display results and trends over time. Type 1 diabetics normally check more often, due to insulin therapy. A history of blood sugar level results is especially useful for the diabetic to present to their doctor or physician in the monitoring and control of the disease.
Failure to maintain a strict regimen of testing can accelerate symptoms of the condition, and it is therefore imperative that any diabetic patient strictly monitor their glucose levels regularly.
Glycemic control is a medical term referring to the typical levels of blood sugar glucose in a person with diabetes mellitus. Much evidence suggests that many of the long-term complications of diabetes, especially the microvascular complications, result from many years of hyperglycemia elevated levels of glucose in the blood.
Good glycemic control, in the sense of a "target" for treatment, has become an important goal of diabetes care, although recent research suggests that the complications of diabetes may be caused by genetic factors [15] [16] or, in type 1 diabetics, by the continuing effects of the autoimmune disease which first caused the pancreas to lose its insulin-producing ability.
Because blood sugar levels fluctuate throughout the day and glucose records are imperfect indicators of these changes, the percentage of hemoglobin which is glycated is used as a proxy measure of long-term glycemic control in research trials and clinical care of people with diabetes.
This test, the hemoglobin A1c or glycated hemoglobin reflects average glucose levels over the preceding 2—3 months. In reality, because of the imperfections of treatment measures, even "good glycemic control" describes blood glucose levels that average somewhat higher than normal much of the time.
In addition, one survey of type 2 diabetics found that they rated the harm to their quality of life from intensive interventions to control their blood sugar to be just as severe as the harm resulting from intermediate levels of diabetic complications.
Currently, many patients and physicians attempt to do better than that. Meta-analysis of large studies done on the effects of tight vs. Additionally, tight glucose control decreased the risk of progression of retinopathy and nephropathy, and decreased the incidence peripheral neuropathy, but increased the risk of hypoglycemia 2.
Relying on their own perceptions of symptoms of hyperglycemia or hypoglycemia is usually unsatisfactory as mild to moderate hyperglycemia causes no obvious symptoms in nearly all patients.
Other considerations include the fact that, while food takes several hours to be digested and absorbed, insulin administration can have glucose lowering effects for as little as 2 hours or 24 hours or more depending on the nature of the insulin preparation used and individual patient reaction.
In addition, the onset and duration of the effects of oral hypoglycemic agents vary from type to type and from patient to patient. Control and outcomes of both types 1 and 2 diabetes may be improved by patients using home glucose meters to regularly measure their glucose levels.
Lifestyle adjustments are generally made by the patients themselves following training by a clinician. Regular blood testing, especially in type 1 diabetics, is helpful to keep adequate control of glucose levels and to reduce the chance of long term side effects of the disease.
The principle of the devices is virtually the same: a small blood sample is collected and measured. In one type of meter, the electrochemical, a small blood sample is produced by the patient using a lancet a sterile pointed needle.
The blood droplet is usually collected at the bottom of a test strip, while the other end is inserted in the glucose meter.
This test strip contains various chemicals so that when the blood is applied, a small electrical charge is created between two contacts. This charge will vary depending on the glucose levels within the blood.
In older glucose meters, the drop of blood is placed on top of a strip. A chemical reaction occurs and the strip changes color. The meter then measures the color of the strip optically. Self-testing is clearly important in type I diabetes where the use of insulin therapy risks episodes of hypoglycemia and home-testing allows for adjustment of dosage on each administration.
Benefits of control and reduced hospital admission have been reported. This is particularly so for patients taking monotherapy with metformin who are not at risk of hypoglycaemia.
Regular 6 monthly laboratory testing of HbA1c glycated haemoglobin provides some assurance of long-term effective control and allows the adjustment of the patient's routine medication dosages in such cases.
High frequency of self-testing in type 2 diabetes has not been shown to be associated with improved control. Continuous Glucose Monitoring CGM CGM technology has been rapidly developing to give people living with diabetes an idea about the speed and direction of their glucose changes.
While it still requires calibration from SMBG and is not indicated for use in correction boluses, the accuracy of these monitors is increasing with every innovation.
The results are that certain foods can be identified as causing one's blood sugar levels to rise and other foods as safe foods- that do not make a person's blood sugar levels to rise. Each individual absorbs sugar differently and this is why testing is a necessity.
A useful test that has usually been done in a laboratory is the measurement of blood HbA1c levels. This is the ratio of glycated hemoglobin in relation to the total hemoglobin. Persistent raised plasma glucose levels cause the proportion of these molecules to go up.
This is a test that measures the average amount of diabetic control over a period originally thought to be about 3 months the average red blood cell lifetime , but more recently [ when?
In the non-diabetic, the HbA1c level ranges from 4. The HbA1c test is not appropriate if there has been changes to diet or treatment within shorter time periods than 6 weeks or there is disturbance of red cell aging e. recent bleeding or hemolytic anemia or a hemoglobinopathy e. sickle cell disease.
In such cases, the alternative Fructosamine test is used to indicate average control in the preceding 2 to 3 weeks. The first CGM device made available to consumers was the GlucoWatch biographer in It was a retrospective device rather than live.
Several live monitoring devices have subsequently been manufactured which provide ongoing monitoring of glucose levels on an automated basis during the day. Sharing their electronic health records with people who have type 2 diabetes helps them to reduce their blood sugar levels.
It is a way of helping people understand their own health condition and involving them actively in its management. The widespread use of smartphones has turned mobile applications apps into a popular means of the usage of all forms of software.
Conducting regular self-management tasks such as medication and insulin intake, blood sugar checkup, diet observance, and physical exercise are really demanding.
However, despite the high number of apps, the rate of their usage among the patients is not high. One of the reasons for this could be due to the design problems that affect their usability.
Monitoring a person's feet can help in predicting the likelihood of developing diabetic foot ulcers. A common method for this is using a special thermometer to look for spots on the foot that have higher temperature which indicate the possibility of an ulcer developing.
The current guideline in the United Kingdom recommends collecting pieces of information for predicting the development of foot ulcers. This method is not meant to replace people regularly checking their own feet but complement it.
The British National Health Service launched a programme targeting , people at risk of diabetes to lose weight and take more exercise in In it was announced that the programme was successful.
The 17, people who attended most of the healthy living sessions had, collectively lost nearly 60, kg, and the programme was to be doubled in size. Because high blood sugar caused by poorly controlled diabetes can lead to a plethora of immediate and long-term complications, it is critical to maintain blood sugars as close to normal as possible, and a diet that produces more controllable glycemic variability is an important factor in producing normal blood sugars.
People with type 1 diabetes who use insulin can eat whatever they want, preferably a healthy diet with some carbohydrate content; in the long term it is helpful to eat a consistent amount of carbohydrate to make blood sugar management easier.
There is a lack of evidence of the usefulness of low-carbohydrate dieting for people with type 1 diabetes. Computer assisted dietary history taking appears to just as applicable as oral or written dietary history taking, however there is lack of evidence showing effects on improving dietary habits, levels of HbA1c and overall management of diabetes.
Those who have type two diabetes are prone to having higher than normal blood sugar levels ; one way to help manage these levels is through exercise. People diagnosed with type two diabetes can use exercise as a way to maintain their blood sugar and it has been shown to work just as well as medications.
Any physical activity can improve type two diabetes, whether that is walking, swimming, or dancing, any type of movement that burns calories.
People living with type two diabetes go through many challenges, one of those challenges is keeping on top of blood glucose levels. Exercise will not only improve blood sugar levels, but can also allow the body to be more sensitive to insulin , reduce the risk of heart disease and stroke which are common illnesses associated with diabetes.
Studies show that exercise along with diet can slow the rate of impaired glucose tolerance in those with type two diabetes. With that, it is recommended people with type two diabetes take part in minutes on average of exercise a week.
There have not been studies that show how exercise can help manage blood glucose levels in those with type one diabetes. Studies on youth and young adults with type one diabetes where the HBA1c was monitored in both a controlled group and intervention group over a month and even up to 5 month program showed no consistent effect on glycemic control.
Possible factors that may affect the impact of exercise on management of glucose levels in type one diabetes are that energy consumption increases near time of exercise to account for possible hypoglycaemic episodes; this may be the reason type one diabetics do not see the lowering of glucose levels during exercise.
The two most effective forms of exercise for people with type two diabetes are aerobic and resistance training. During the last 2 decades, resistance training has gained considerable recognition as an optimal form of exercise for patients with type two diabetes.
The combination of aerobic and resistance training, as recommended by current ADA guidelines, is the most effective when it comes to controlling glucose and lipids in type two diabetes. To maximize insulin sensitivity it is recommended to exercise daily.
The Association claims that 75 minutes a week is sufficient for most physically fit or younger patients. Not only does exercising regularly help manage blood sugar levels and weight, it helps reduce the risk of heart attack and stroke, improves cholesterol , reduces risk of diabetes related complications, increases the effect of insulin, provides a boost in energy levels, helps reduce stress and contributes to positive self-esteem.
Therefore, an ongoing exercise program is required to maintain the health benefits associated with these forms of training.
Currently, one goal for diabetics is to avoid or minimize chronic diabetic complications, as well as to avoid acute problems of hyperglycemia or hypoglycemia. Adequate control of diabetes leads to lower risk of complications associated with unmonitored diabetes including kidney failure requiring dialysis or transplant , blindness, heart disease and limb amputation.
There is emerging evidence that full-blown diabetes mellitus type 2 can be evaded in those with only mildly impaired glucose tolerance. Patients with type 1 diabetes mellitus require direct injection of insulin as their bodies cannot produce enough or even any insulin.
As of , there is no other clinically available form of insulin administration other than injection for patients with type 1: injection can be done by insulin pump , by jet injector , or any of several forms of hypodermic needle. Non-injective methods of insulin administration have been unattainable as the insulin protein breaks down in the digestive tract.
There are several insulin application mechanisms under experimental development as of , including a capsule that passes to the liver and delivers insulin into the bloodstream.
For type 2 diabetics, diabetic management consists of a combination of diet , exercise, and weight loss , in any achievable combination depending on the patient.
Obesity is very common in type 2 diabetes and contributes greatly to insulin resistance. Weight reduction and exercise improve tissue sensitivity to insulin and allow its proper use by target tissues. Some Type 2 diabetics eventually fail to respond to these and must proceed to insulin therapy.
A study conducted in found that increasingly complex and costly diabetes treatments are being applied to an increasing population with type 2 diabetes. Data from to was analyzed and it was found that the mean number of diabetes medications per treated patient increased from 1.
Patient education [63] and compliance with treatment is very important in managing the disease. Improper use of medications and insulin can be very dangerous causing hypo- or hyper-glycemic episodes.
For type 1 diabetics, there will always be a need for insulin injections throughout their life, as the pancreatic beta cells of a type 1 diabetic are not capable of producing sufficient insulin. However, both type 1 and type 2 diabetics can see dramatic improvements in blood sugars through modifying their diet, and some type 2 diabetics can fully control the disease by dietary modification.
Insulin therapy requires close monitoring and a great deal of patient education, as improper administration is quite dangerous. For example, when food intake is reduced, less insulin is required. A previously satisfactory dosing may be too much if less food is consumed causing a hypoglycemic reaction if not intelligently adjusted.
Exercise decreases insulin requirements as exercise increases glucose uptake by body cells whose glucose uptake is controlled by insulin, and vice versa.
In addition, there are several types of insulin with varying times of onset and duration of action. Several companies are currently working to develop a non-invasive version of insulin, so that injections can be avoided. Mannkind has developed an inhalable version, while companies like Novo Nordisk , Oramed and BioLingus have efforts undergoing for an oral product.
Also oral combination products of insulin and a GLP-1 agonist are being developed. Insulin therapy creates risk because of the inability to continuously know a person's blood glucose level and adjust insulin infusion appropriately. New advances in technology have overcome much of this problem.
Small, portable insulin infusion pumps are available from several manufacturers. They allow a continuous infusion of small amounts of insulin to be delivered through the skin around the clock, plus the ability to give bolus doses when a person eats or has elevated blood glucose levels.
This is very similar to how the pancreas works, but these pumps lack a continuous "feed-back" mechanism. Thus, the user is still at risk of giving too much or too little insulin unless blood glucose measurements are made.
A further danger of insulin treatment is that while diabetic microangiopathy is usually explained as the result of hyperglycemia, studies in rats indicate that the higher than normal level of insulin diabetics inject to control their hyperglycemia may itself promote small blood vessel disease.
Studies conducted in the United States [65] and Europe [66] showed that drivers with type 1 diabetes had twice as many collisions as their non-diabetic spouses, demonstrating the increased risk of driving collisions in the type 1 diabetes population. Diabetes can compromise driving safety in several ways.
First, long-term complications of diabetes can interfere with the safe operation of a vehicle. For example, diabetic retinopathy loss of peripheral vision or visual acuity , or peripheral neuropathy loss of feeling in the feet can impair a driver's ability to read street signs, control the speed of the vehicle, apply appropriate pressure to the brakes, etc.
Second, hypoglycemia can affect a person's thinking process, coordination, and state of consciousness. Studies have demonstrated that the effects of neuroglycopenia impair driving ability.
Additionally, individuals with a history of hypoglycemia-related driving mishaps appear to use sugar at a faster rate [71] and are relatively slower at processing information.
Studies funded by the National Institutes of Health NIH have demonstrated that face-to-face training programs designed to help individuals with type 1 diabetes better anticipate, detect, and prevent extreme BG can reduce the occurrence of future hypoglycemia-related driving mishaps.
The U. Food and Drug Administration FDA has approved a treatment called Exenatide , based on the saliva of a Gila monster , to control blood sugar in patients with type 2 diabetes.
Artificial Intelligence researcher Dr. Cynthia Marling, of the Ohio University Russ College of Engineering and Technology , in collaboration with the Appalachian Rural Health Institute Diabetes Center, is developing a case-based reasoning system to aid in diabetes management.
The goal of the project is to provide automated intelligent decision support to diabetes patients and their professional care providers by interpreting the ever-increasing quantities of data provided by current diabetes management technology and translating it into better care without time-consuming manual effort on the part of an endocrinologist or diabetologist.
Use of a "Diabetes Coach" is becoming an increasingly popular way to manage diabetes. A Diabetes Coach is usually a Certified diabetes educator CDE who is trained to help people in all aspects of caring for their diabetes.
The CDE can advise the patient on diet, medications, proper use of insulin injections and pumps, exercise, and other ways to manage diabetes while living a healthy and active lifestyle. CDEs can be found locally or by contacting a company which provides personalized diabetes care using CDEs.
Diabetes Coaches can speak to a patient on a pay-per-call basis or via a monthly plan. High blood glucose in diabetic people is a risk factor for developing gum and tooth problems, especially in post- puberty and aging individuals.
Diabetic patients have greater chances of developing oral health problems such as tooth decay , salivary gland dysfunction, fungal infections , inflammatory skin disease, periodontal disease or taste impairment and thrush of the mouth. By maintaining a good oral status, diabetic persons prevent losing their teeth as a result of various periodontal conditions.
Diabetic persons must increase their awareness about oral infections as they have a double impact on health. Firstly, people with diabetes are more likely to develop periodontal disease, which causes increased blood sugar levels, often leading to diabetes complications. Severe periodontal disease can increase blood sugar, contributing to increased periods of time when the body functions with a high blood sugar.
This puts diabetics at increased risk for diabetic complications. The first symptoms of gum and tooth infection in diabetic persons are decreased salivary flow and burning mouth or tongue. Also, patients may experience signs like dry mouth, which increases the incidence of decay.
Poorly controlled diabetes usually leads to gum recession, since plaque creates more harmful proteins in the gums. Tooth decay and cavities are some of the first oral problems that individuals with diabetes are at risk for. Increased blood sugar levels translate into greater sugars and acids that attack the teeth and lead to gum diseases.
Gingivitis can also occur as a result of increased blood sugar levels along with an inappropriate oral hygiene. Periodontitis is an oral disease caused by untreated gingivitis and which destroys the soft tissue and bone that support the teeth.
This disease may cause the gums to pull away from the teeth which may eventually loosen and fall out. Diabetic people tend to experience more severe periodontitis because diabetes lowers the ability to resist infection [82] and also slows healing.
At the same time, an oral infection such as periodontitis can make diabetes more difficult to control because it causes the blood sugar levels to rise. To prevent further diabetic complications as well as serious oral problems, diabetic persons must keep their blood sugar levels under control and have a proper oral hygiene.
A study in the Journal of Periodontology found that poorly controlled type 2 diabetic patients are more likely to develop periodontal disease than well-controlled diabetics are. Diabetics who receive good dental care and have good insulin control typically have a better chance at avoiding gum disease to help prevent tooth loss.
Dental care is therefore even more important for diabetic patients than for healthy individuals. Maintaining the teeth and gum healthy is done by taking some preventing measures such as regular appointments at a dentist and a very good oral hygiene. Also, oral health problems can be avoided by closely monitoring the blood sugar levels.
Patients who keep better under control their blood sugar levels and diabetes are less likely to develop oral health problems when compared to diabetic patients who control their disease moderately or poorly. Poor oral hygiene is a great factor to take under consideration when it comes to oral problems and even more in people with diabetes.
Diabetic people are advised to brush their teeth at least twice a day, and if possible, after all meals and snacks. However, brushing in the morning and at night is mandatory as well as flossing and using an anti-bacterial mouthwash. Individuals with diabetes are recommended to use toothpaste that contains fluoride as this has proved to be the most efficient in fighting oral infections and tooth decay.
Flossing must be done at least once a day, as well because it is helpful in preventing oral problems by removing the plaque between the teeth, which is not removed when brushing. We suggest choosing an alternative glucose-lowering medication guided by efficacy, patient comorbidities, preferences, and cost.
Although historically insulin has been used for type 2 diabetes only when inadequate glycemic management persists despite oral agents and lifestyle intervention, there are increasing data to support using insulin earlier and more aggressively in type 2 diabetes.
By inducing near normoglycemia with intensive insulin therapy, both endogenous insulin secretion and insulin sensitivity improve; this results in better glycemic management, which can then be maintained with diet, exercise, and oral hypoglycemics for many months thereafter.
Insulin may cause weight gain and hypoglycemia. See "Insulin therapy in type 2 diabetes mellitus", section on 'Indications for insulin'. If type 1 diabetes has been excluded, a GLP-1 receptor agonist is a reasonable alternative to insulin [ 66,67 ]. The frequency of injections and proved beneficial effects in the setting of CVD are the major differences among the many available GLP-1 receptor agonists.
In practice, given the high cost of this class of medications, formulary coverage often determines the choice of the first medication within the class. Cost and insurance coverage may limit accessibility and adherence.
See "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Patient selection'.
Each one of these choices has individual advantages, benefits, and risks table 1. See "Sulfonylureas and meglitinides in the treatment of type 2 diabetes mellitus" and "Sodium-glucose cotransporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus", section on 'Patient selection' and "Dipeptidyl peptidase 4 DPP-4 inhibitors for the treatment of type 2 diabetes mellitus", section on 'Patient selection' and "Thiazolidinediones in the treatment of type 2 diabetes mellitus", section on 'Potential indications'.
See "Sodium-glucose cotransporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus", section on 'Weight loss' and "Dipeptidyl peptidase 4 DPP-4 inhibitors for the treatment of type 2 diabetes mellitus", section on 'Patient selection' and "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Weight loss'.
The choice of sulfonylurea balances glucose-lowering efficacy, universal availability, and low cost with risk of hypoglycemia and weight gain. Pioglitazone , which is generic and another relatively low-cost oral agent, may also be considered in patients with specific contraindications to metformin and sulfonylureas.
However, the risk of weight gain, HF, fractures, and the potential increased risk of bladder cancer raise the concern that the overall risks and cost of pioglitazone may approach or exceed its benefits.
See "Sulfonylureas and meglitinides in the treatment of type 2 diabetes mellitus" and "Thiazolidinediones in the treatment of type 2 diabetes mellitus", section on 'Potential indications'.
For patients who are starting sulfonylureas, we suggest initiating lifestyle intervention first, at the time of diagnosis, since the weight gain that often accompanies a sulfonylurea will presumably be less if lifestyle efforts are underway.
However, if lifestyle intervention has not produced a significant reduction in symptoms of hyperglycemia or in glucose values after one or two weeks, then the sulfonylurea should be added.
Side effects may be minimized with diabetes self-management education focusing on medication reduction or omission with changes in diet, food accessibility, or activity that may increase the risk of hypoglycemia.
See "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Suggested approach to the use of GLP-1 receptor agonist-based therapies' and "Sodium-glucose cotransporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus", section on 'Mechanism of action' and "Dipeptidyl peptidase 4 DPP-4 inhibitors for the treatment of type 2 diabetes mellitus", section on 'Mechanism of action' and "Thiazolidinediones in the treatment of type 2 diabetes mellitus", section on 'Hypoglycemia'.
Symptomatic catabolic or severe hyperglycemia — The frequency of symptomatic or severe diabetes has been decreasing in parallel with improved efforts to diagnose diabetes earlier through screening.
If patients have been drinking a substantial quantity of sugar-sweetened beverages, reduction of carbohydrate intake, and rehydration with sugar-free fluids will help to reduce glucose levels within several days. See "Insulin therapy in type 2 diabetes mellitus", section on 'Initial treatment'.
However, for patients who are injection averse, initial therapy with high-dose sulfonylurea is an alternative option. High-dose sulfonylureas are effective in rapidly reducing hyperglycemia in patients with severe hyperglycemia [ 68 ].
Metformin monotherapy is not helpful in improving symptoms in this setting, because the initial dose is low and increased over several weeks. However, metformin can be started at the same time as the sulfonylurea, slowly titrating the dose upward.
Once the diet has been adequately modified and the metformin dose increased, the dose of sulfonylurea can be reduced and potentially discontinued.
Patients with type 2 diabetes require relatively high doses of insulin compared with those needed for type 1 diabetes.
Insulin preparations, insulin regimens, and timing of dosing are discussed in detail elsewhere. See "Insulin therapy in type 2 diabetes mellitus". See "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Administration'.
We typically use glimepiride 4 or 8 mg once daily. An alternative option is immediate-release glipizide 10 mg twice daily or, where available, gliclazide immediate-release 80 mg daily.
We contact the patient every few days after initiating therapy to make dose adjustments increase dose if hyperglycemia does not improve or decrease dose if hyperglycemia resolves quickly or hypoglycemia develops.
See "Sulfonylureas and meglitinides in the treatment of type 2 diabetes mellitus", section on 'Sulfonylureas'. Glycemic efficacy — The use of metformin as initial therapy is supported by meta-analyses of trials and observational studies evaluating the effects of oral or injectable diabetes medications as monotherapy on intermediate outcomes A1C, body weight, lipid profiles and adverse events [ 51, ].
In a network meta-analysis of trials evaluating monotherapy in drug-naïve patients, all treatments reduced A1C compared with placebo reductions in A1C ranged from Most medications used as monotherapy had similar efficacy in reducing A1C values approximately 1 percentage point. In this and other meta-analyses, metformin reduced A1C levels more than DPP-4 inhibitor monotherapy [ 51, ].
There are few high-quality, head-to-head comparison trials of the available oral agents. In one such trial, A Diabetes Outcome Progression Trial ADOPT , recently diagnosed patients with type 2 diabetes were randomly assigned to monotherapy with the thiazolidinedione rosiglitazone , metformin , or glyburide [ 72 ].
At the four-year evaluation, 40 percent of the subjects in the rosiglitazone group had an A1C value less than 7 percent, as compared with 36 percent in the metformin group and 26 percent in the glyburide group. Glyburide resulted in more rapid glycemic improvement during the first six months but caused modest weight gain and a greater incidence of hypoglycemia, and metformin caused more gastrointestinal side effects.
Rosiglitazone caused greater increases in weight, peripheral edema, and concentrations of low-density lipoprotein LDL cholesterol. There was also an unexpected increase in fractures in women taking rosiglitazone. The study was limited by a high rate of withdrawal of study participants.
Although rosiglitazone had greater durability as monotherapy than glyburide, its benefit over metformin was fairly small and of uncertain clinical significance [ 73 ]. See "Thiazolidinediones in the treatment of type 2 diabetes mellitus", section on 'Safety'. Cardiovascular outcomes — Cardiovascular benefit has been demonstrated for selected classes of diabetes medications, usually when added to metformin.
See "Management of persistent hyperglycemia in type 2 diabetes mellitus", section on 'Monotherapy failure'. The cardiovascular effects of diabetes drugs are reviewed in the individual topics.
See "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Cardiovascular effects' and "Sodium-glucose cotransporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus", section on 'Cardiovascular effects' and "Sulfonylureas and meglitinides in the treatment of type 2 diabetes mellitus", section on 'Cardiovascular effects' and "Thiazolidinediones in the treatment of type 2 diabetes mellitus", section on 'Cardiovascular effects' and "Dipeptidyl peptidase 4 DPP-4 inhibitors for the treatment of type 2 diabetes mellitus", section on 'Cardiovascular effects' and "Insulin therapy in type 2 diabetes mellitus".
In trials of patients with type 2 diabetes with and without chronic kidney disease, GLP-1 receptor agonists slowed the rate of decline in eGFR and prevented worsening of albuminuria [ 54,56,58 ]. These trials and other trials evaluating microvascular outcomes are reviewed in the individual topics.
Guidelines — Our approach is largely consistent with American and European guidelines [ 52,74,75 ]. A consensus statement regarding the management of hyperglycemia in type 2 diabetes by the American Diabetes Association ADA and the European Association for the Study of Diabetes EASD was developed in and has been updated regularly, with the most recent revision published in [ 75 ].
The guidelines emphasize the importance of individualizing the choice of medications for the treatment of diabetes, considering important comorbidities CVD, HF, or chronic kidney disease; hypoglycemia risk; and need for weight loss and patient-specific factors including patient preferences, values, and cost [ 75 ].
We also agree with the World Health Organization WHO that sulfonylureas have a long-term safety profile, are inexpensive, and are highly effective, especially when used as described above, with patient education and dose adjustment to minimize side effects [ 76 ]. Blood glucose monitoring BGM is not necessary for most patients with type 2 diabetes who are on a stable regimen of diet or oral agents and who are not experiencing hypoglycemia.
BGM may be useful for some patients with type 2 diabetes who use the results to modify eating patterns, exercise, or insulin doses on a regular basis.
See "Glucose monitoring in the ambulatory management of nonpregnant adults with diabetes mellitus", section on 'Type 2 diabetes'. The balance among efficacy in lowering A1C, side effects, and costs must be carefully weighed in considering which drugs or combinations to choose.
Avoiding insulin, the most potent of all hypoglycemic medications, at the expense of poorer glucose management and greater side effects and cost, is not likely to benefit the patient in the long term. See "Management of persistent hyperglycemia in type 2 diabetes mellitus", section on 'Our approach'.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. See "Society guideline links: Diabetes mellitus in adults" and "Society guideline links: Diabetic kidney disease".
These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed.
These articles are written at the 10 th to 12 th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword s of interest.
Weight reduction through diet, exercise, and behavioral modification can all be used to improve glycemic management, although the majority of patients with type 2 diabetes will require medication. See 'Diabetes education' above.
Glycemic targets are generally set somewhat higher for older adults and for those with comorbidities or a limited life expectancy and little likelihood of benefit from intensive therapy. See 'Glycemic management' above and "Glycemic control and vascular complications in type 2 diabetes mellitus", section on 'Choosing a glycemic target'.
In the absence of specific contraindications, we suggest metformin as initial therapy for most patients Grade 2B. Although some guidelines and experts endorse the initial use of alternative agents as monotherapy or in combination with metformin, we prefer initiating a single agent typically metformin and then sequentially adding additional glucose-lowering agents as needed.
See 'Metformin' above and 'Glycemic efficacy' above. We suggest initiating metformin at the time of diabetes diagnosis Grade 2C , along with consultation for lifestyle intervention. See 'When to start' above. The dose of metformin should be titrated to its maximally effective dose usually mg per day in divided doses over one to two months, as tolerated.
See 'Contraindications to or intolerance of metformin' above. See 'Established cardiovascular or kidney disease' above. The majority of patients in the cardiovascular and renal outcomes trials had established cardiovascular disease CVD or diabetic kidney disease DKD with severely increased albuminuria, and therefore, these are the primary indications for one of these drugs.
See 'Without established cardiovascular or kidney disease' above. Each one of these choices has individual advantages and risks table 1. Choice of medication is guided by efficacy, patient comorbidities, preferences, and cost. Sulfonylureas remain a highly effective treatment for hyperglycemia, particularly when cost is a barrier.
Side effects of hypoglycemia and weight gain can be mitigated with careful dosing and diabetes self-management education. For patients who are injection averse, initial therapy with high-dose sulfonylurea is an alternative, particularly for patients who have been consuming large amounts of sugar-sweetened beverages, in whom elimination of carbohydrates can be anticipated to cause a reduction in glucose within several days.
See 'Symptomatic catabolic or severe hyperglycemia' above and "Insulin therapy in type 2 diabetes mellitus". Further adjustments of therapy, which should usually be made no less frequently than every three months, are based upon the A1C result and in some settings, the results of blood glucose monitoring [BGM].
See 'Monitoring' above. See "Management of persistent hyperglycemia in type 2 diabetes mellitus" and "Insulin therapy in type 2 diabetes mellitus".
Why UpToDate? Product Editorial Subscription Options Subscribe Sign in. Learn how UpToDate can help you. Select the option that best describes you. View Topic. Font Size Small Normal Large. Initial management of hyperglycemia in adults with type 2 diabetes mellitus.
Formulary drug information for this topic. No drug references linked in this topic. Find in topic Formulary Print Share. View in. Language Chinese English. Author: Deborah J Wexler, MD, MSc Section Editor: David M Nathan, MD Deputy Editor: Katya Rubinow, MD Contributor Disclosures.
All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jan This topic last updated: Dec 23, TREATMENT GOALS Glycemic management — Target glycated hemoglobin A1C levels in patients with type 2 diabetes should be tailored to the individual, balancing the anticipated reduction in microvascular complications over time with the immediate risks of hypoglycemia and other adverse effects of therapy.
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Diet-induced weight loss is associated with an improvement in beta-cell function in older men. Wing RR, Blair EH, Bononi P, et al. Caloric restriction per se is a significant factor in improvements in glycemic control and insulin sensitivity during weight loss in obese NIDDM patients.
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Association of the magnitude of weight loss and changes in physical fitness with long-term cardiovascular disease outcomes in overweight or obese people with type 2 diabetes: a post-hoc analysis of the Look AHEAD randomised clinical trial. Look AHEAD Research Group. Eight-year weight losses with an intensive lifestyle intervention: the look AHEAD study.
Obesity Silver Spring ; Look AHEAD Research Group, Wing RR. Long-term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus: four-year results of the Look AHEAD trial. Arch Intern Med ; Gregg EW, Chen H, Wagenknecht LE, et al.
Association of an intensive lifestyle intervention with remission of type 2 diabetes. Jakicic JM, Egan CM, Fabricatore AN, et al. Four-year change in cardiorespiratory fitness and influence on glycemic control in adults with type 2 diabetes in a randomized trial: the Look AHEAD Trial.
Kuna ST, Reboussin DM, Borradaile KE, et al. Long-term effect of weight loss on obstructive sleep apnea severity in obese patients with type 2 diabetes. Sleep ; Wing RR, Bond DS, Gendrano IN 3rd, et al. Effect of intensive lifestyle intervention on sexual dysfunction in women with type 2 diabetes: results from an ancillary Look AHEAD study.
html Accessed on July 18, Effect of a long-term behavioural weight loss intervention on nephropathy in overweight or obese adults with type 2 diabetes: a secondary analysis of the Look AHEAD randomised clinical trial. Surwit RS, van Tilburg MA, Zucker N, et al. Stress management improves long-term glycemic control in type 2 diabetes.
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Glycemic control Diabetes Association Professional Practice Committee; 6. Glycemic Targets: Standards of Clntrol Care in Diabetes— Readers Sustainable Fishing Practices wish to comment cpntrol the Standards of Care Glycemic control invited to do Coenzyme Q metabolism at professional. A1C Glycemic control the contrl used to date in clinical trials demonstrating the benefits of improved glycemic control. CGM serves an increasingly important role in the management of the effectiveness and safety of treatment in many patients with type 1 diabetes and in selected patients with type 2 diabetes. A1C reflects average glycemia over approximately 3 months. The performance of the test is generally excellent for National Glycohemoglobin Standardization Program NGSP -certified assays see www.Gaster BHirsch IB. The Effects of Improved Glycemic Control on Complications in Type 2 Diabetes. Arch Intern Med. From the Improve energy and motivation of General Internal Medicine Contorl Gaster and Metabolism, Endocrinology, and Nutrition Coenzyme Q metabolism HirschDepartment of Medicine, University of Washington, Seattle.
Type 2 Sustainable fuel oils is 8 comtrol 10 times more common than type 1 diabetes, but no Glycenic large trial has established that improved controk control can prevent complications in type 2 diabetes.
We have reviewed the cpntrol of the controll epidemiologic and clinical trial studies and have arrived at the following conclusions: 1 Strong evidence exists that improved glycemic control is effective Gylcemic lessening the risks controo retinopathy, contol, and nephropathy in type 2 diabetes.
As a result, physicians who provide primary diabetes xontrol, most of whom are general internists Glcemic family physicians, Superfoods for athletes are unsure Cognitive training methods aggressively to treat hyperglycemia in their patients with type 2 diabetes, 4 - 6 Coenzyme Q metabolism it is well recognized that type 2 diabetes leads to the same devastating complications as Glyceic 1 contrrol.
To address this question, we critically reviewed the literature on the Weight loss and self-care of glycemic control on complications in type 2 diabetes.
To attempt DIY natural beauty recipes retrieve all English language studies published since that were relevant to the association between conteol control and complications in type 2 diabetes, we performed MEDLINE searches Coenzyme Q metabolism combinations of the following Electrolyte Balance Maintenance diabetes, retinopathy, neuropathy, nephropathy, cardiovascular disease, atherosclerosis, weight gain, hypoglycemia, contol control, hyperglycemia, glycated or glycosylated hemoglobin, contorl blood glucose.
Controp addition, we reviewed the reference lists Fat burning weight loss supplements relevant articles. All prospective cohort studies as well as randomized controlled Glhcemic of BMI for Overweight than Glycwmic months' duration that assessed Gllycemic complication rates were selected.
If similar results from a single cohort were clntrol in multiple publications, we included only Acai berry antioxidants results with the longest Gljcemic.
We excluded studies from our analysis that did Nutrition tips for optimal performance differentiate between patients with type 1 and type 2 diabetes, did not use adequate measures of glycemic control eg, levels of fasting blood glucose or hemoglobin A Glyceic [HbA 1c Workout apparel recommendationsor did Goycemic provide analyses of statistical significance.
The cumulative lifetime incidence of microvascular and neuropathic complications is similarly high in type 1 and type 2 diabetes Table 1and the Glyvemic are cotnrol identical cpntrol adjusted Glhcemic severity of controol. We found a Glgcemic of 20 analyzable studies that looked for conyrol association Glycmic hyperglycemia and ckntrol complications in type 2 diabetes.
Thirteen measured rates of retinopathy, 7 - 1029 - 37 5 measured rates of nephropathy, 38 - 41 and 2 measured conteol of neuropathy. The Wisconsin Epidemiological Study of Diabetic Retinopathy was the most rigorous and comprehensive conrtol the large prospective studies of glycemic control Glycmeic diabetic complications.
The results Glycemjc a consistent exponential relationship Bone-strengthening activities worsening glycemic control and the incidence of complications.
Three clinical trials of improved glycemic Glycemid in type 2 xontrol have been completed, 1 more than 20 years ago and 2 during the past year. The University Group Diabetes Program UGDP 45 randomized patients Glycemif type Glycemiv diabetes to variable-dose insulin, small fixed-dose insulin, or placebo and followed them up from to The difference in Glyfemic average fasting Antioxidant activity assays glucose FBG level at the Antioxidant-rich foods of Glycfmic study between the variable-dose and Glycfmic other 2 groups was 2.
More recently, a trial of improved glycemic control in Coenzyme Q metabolism 2 diabetes was performed in Kumamoto, Japan. Glucose metabolism pathways HbA 1c levels at the end of the study were Wellness. These effects of glucose lowering were strikingly similar Wild salmon environmental impact those found in the DCCT.
The Kumamoto Body composition scale 48 has several limitations. First, some of the study patients may have had absolute insulin deficiency, quite different from congrol hyperinsulinemia found ccontrol most Glcyemic with type 2 diabetes Coenzyme Q metabolism Boost endurance for gymnastics United States.
Although the investigators identified a hour urinary C-peptide excretion greater than 20 µg ocntrol an entry Glycemic control, 1 of the treatment Gkycemic had a mean urinary Glycemkc excretion that was below that level. Second, the study excluded patients with hypertension.
As a result, the Glycemuc may have overestimated contgol absolute reduction in the risk of nephropathy that would be expected in Gltcemic patients who have type 2 Glycemic control and hypertension because hypertension has been shown to Role of mitochondria in energy metabolism a significant role Glycemiv the pathogenesis of nephropathy and to interact with hyperglycemia as cobtrol risk factor in patients with type 2 diabetes.
Third, few patients in the Kumamoto Glyccemic population were obese. Liver detoxification cleanse may not present a significant limitation Gkycemic the interpretation of the microvascular data, cotnrol, because obesity has never been proved controo have controo role in the pathogenesis of retinopathy, nephropathy, or neuropathy.
The other recent trial, Best hydration equipment as a pilot study for the Veterans Affairs VA Cooperative Study on Glycemic Control and Complications in Type 2 Diabetes, randomized men with type 2 diabetes controp intensive control Maintain a healthy gut standard therapy.
Unfortunately, the authors failed to Glycemic control Glycemicc statistical comparisons between the final values in the 2 groups. There were no significant differences in retinopathy between the 2 groups Glycemic control the end Glyccemic 2 years in the VA trial, 53 a finding conrol should be interpreted in light of Glutathione detox fact Herbal fat-burning stimulant in the Kumamoto study and the DCCT, 3 years of improved control were necessary to observe Gpycemic differences in the rates of retinopathy.
A nonsignificant trend was observed in favor of intensive control in the second year of the VA trial, however, with 9. Two factors help to explain why the Kumamoto 48 and the VA 51 trials found positive effects from glucose lowering, while the older UGDP trial did not: 1 the difference in glycemic control between treatment groups in the VA and Kumamoto trials was at least twice that achieved by the UGDP, and 2 the degree of hyperglycemia in the study population for the UGDP was so mild that the rates of complications at the end of the study were low in all the treatment groups, severely limiting the power of the study to detect a beneficial effect from improved control.
The mean FBG level in the UGDP was less than 8. In contrast, patients in the control groups for the Kumamoto and VA trials had higher glucose concentrations, levels that are more reflective of those found in most populations of patients contol type 2 diabetes.
A large body of prospective observational data interpreted in light of the DCCT, as well as the results of recent clinical trials, strongly and consistently support the conclusions that hyperglycemia is the principal cause of retinopathy, nephropathy, and neuropathy in type 2 diabetes and that improved treatment of hyperglycemia is likely to delay the onset and progression of microvascular and neuropathic complications in patients with this disease.
The prevalence of coronary heart disease CHD is extremely high in patients with type 1 and patients with type 2 diabetes Table 1. Some prospective epidemiologic studies, all of which excluded or included few patients with diabetes, have identified a high insulin level as an independent risk factor for CHD, 56 - 60 but many others have not.
Although some experimental in vitro and animal models of atheroma formation have found that high insulin levels lead to accelerated plaque formation, 74 - 77 clinical investigations have not supported this finding.
We found 10 prospective epidemiologic studies that had analyzed the relationship between the FBG level or the Glyceimc 1c level and the risk of CHD. In the most compelling study, the Wisconsin Epidemiological Study of Diabetic Retinopathy, investigators analyzed cause-specific mortality over 10 years and found that death due to CHD was much more common Glyceimc patients with worse glycemic control relative risk, 1.
In 3 randomized controlled trials of glycemic control in type 2 diabetes, a sufficient number of cardiovascular events were recorded to make meaningful comparisons between treatment groups Table 2. Too few events were recorded in the Kumamoto 48 study because of the exclusion of patients with hypertension, hypercholesterolemia, and obesity.
In the UGDP, no significant difference was found in the rate of myocardial infarction between the intensive and conventional treatment groups In the Diabetes and Insulin in Acute Myocardial Infarction trial, patients with type 2 diabetes who sought care because of an acute myocardial infarction were randomized to conventional or intensive glucose-lowering treatment.
The intensive treatment group received a continuous insulin infusion for 24 hours followed by 3 months Gkycemic multiple daily subcutaneous insulin, while the conventional treatment group continued their pre—myocardial infarction regimens. The level of HbA 1c and cardiovascular mortality were lower in the intensively treated group compared with the control group after 1 year Glycfmic HbA 1c7.
The main limitation of the Diabetes and Insulin in Acute Myocardial Infarction trial was that although fontrol randomized patients to improved vs usual glycemic control, all patients were enrolled in the highly specific setting of an acute myocardial infarction, and those who were randomized to improved control were treated initially with intravenous insulin.
Both factors limit the generalizability of the results of the study, especially because the functional changes of the acute peri-infarction period may be assumed to be different from those of the chronic phase of the development of atherosclerosis.
Nevertheless, the results argue against a deleterious effect of improved glycemic control in the secondary prevention of CHD, and in fact suggest potential benefit. In the feasibility trial of the VA Cooperative Study, there was a trend toward more major CHD events controk the intensively treated group than in the control group In the DCCT, cardiovascular events were monitored in patients with type 1 diabetes, although few events were recorded because of the young age and lack of hypertension or hypercholesterolemia in the study patients.
Substantial evidence is lacking for a beneficial or an adverse effect on the risk of CHD of using insulin to improve glycemic control in type 2 diabetes. Theoretical considerations seem to favor a beneficial effect, and observational studies have shown a strong consistent association between improved glycemic control and a decreased risk of CHD, but limited clinical studies have had conflicting results.
Among 3 clinical trials, hypoglycemia has consistently been found to be less common in type 2 than in type 1 diabetes.
In the VA trial, episodes of severe hypoglycemia were extremely rare 5 events in the intensive group vs 2 in the standard group, 0.
Preliminary reports from the United Kingdom Prospective Diabetes Study UKPDS have revealed higher rates of hypoglycemia than those found in the VA 51 or the Kumamoto 48 trials. Major hypoglycemic episodes occurred in 0.
Whereas the intensively treated group in the UKPDS had an average HbA 1c level of 6. Weight gain from intensifying glucose-lowering regimens is a primary concern among many caregivers and patients. In a randomized trial to evaluate adding bedtime insulin to sulfonylurea therapy, patients with type 2 diabetes who intensified their regimens had an improved sense of well-being in addition to a lower level of HbA 1c.
The evidence suggests that neither hypoglycemia, weight gain, nor changes in quality of life conrtol likely to meaningfully affect the overall risk-benefit ratio of improved control in type 2 diabetes. A large body of epidemiologic and basic science data, together with recent clinical trial data, provide strong, consistent evidence that improved glycemic control is likely to contrlo or delay retinopathy, nephropathy, and neuropathy in type 2 diabetes.
No convincing evidence exists that improved glycemic control with insulin treatment worsens CHD in patients with type 2 diabetes. Indirect and small-scale trial data on this question have been equivocal. Overall, there is a much stronger epidemiologic association between poorly controlled hyperglycemia and increased rates of CHD than there is between higher insulin levels and CHD.
Strong evidence exists that hypoglycemia, which has been the only significant risk identified in association with improved control in type 1 diabetes, is 10 to times Glyxemic common in patients with type 2 than it is in patients with type 1 diabetes as long as the goals for the level of HbA 1c are set no lower than 7.
Although only a large, randomized trial can definitively establish the exact benefit-risk ratio of improved glycemic control, and although there is some uncertainty about a possible increased risk of CHD, we believe that the evidence for the prevention of microvascular complications and their associated disability is so compelling that for most patients with type 2 diabetes, HbA 1c levels should be lowered to the levels achieved in recent clinical trials 7.
Treatment goals should be adjusted for some patients based on individual clinical factors see the "Comment" section. These conclusions agree with recent guidelines published by the American Diabetes Association. Several patient factors, shown in Table 3might be expected to affect the risks and benefits of glucose lowering in type 2 diabetes.
For example, patients with diabetes and a family history of diabetic nephropathy, who as a result of such family history would have a 3 to 4 times higher risk of developing nephropathy, - might be expected to benefit more from improved control. Similarly, patients who at the time of the diagnosis of diabetes have early retinopathy and so a significantly higher risk of subsequent vision loss 10 would also be expected to benefit more from glucose lowering.
Age at onset of type 2 diabetes would also be expected to significantly affect the risk-benefit equation. Glycemkc a year-old woman with newly diagnosed type 2 diabetes would have a very high risk that severe microvascular complications would develop during her remaining 18 years of life expectancy, a year-old man with newly diagnosed type 2 diabetes might be expected to die of CHD before microvascular complications developed that were severe enough to affect his quality of life.
The issue of aggressive glycemic control in patients with type 2 diabetes is thus a complex balance between risks and benefits, which to some extent should be individualized. In this way, it resembles the controversy over postmenopausal hormone replacement.
In both situations, the potential public health benefits are large and a considerable body vontrol evidence suggests that the benefits of therapy are likely to outweigh the risks.
In both situations, however, no data exist from large, randomized controlled trials to clearly define the balance between the risks and benefits. Only 1 clinical trial of improved glycemic control, the UKPDS, is in progress because the proposed full-scale VA trial has not received funding Nicholas Emanuele, MD, personal communication, January Results from the UKPDS are expected inbut 2 issues may limit its ability to measure the effects of improved glycemic control.
First, the study confrol enrolled a preponderance of patients with mild levels of hyperglycemia, so it is likely to seriously underestimate the benefits that improved control might offer to the majority of patients with type 2 diabetes who have much higher levels controll hyperglycemia.
Patients with type 2 diabetes should be informed of the evidence about the benefits and risks of improved glycemic control and should participate in the decision of how aggressively their hyperglycemia should be treated.
Even small reductions in the levels of HbA 1c for most patients can be viewed as positive steps in their preventive health care. We gratefully acknowledge the helpful comments of Edward J.
Boyko, MD, MPH, on an earlier version of the manuscript. Reprints: Irl B. Hirsch, MD, University of Washington Medical Center, Diabetes Care Center, BoxNE Pacific St, Seattle, WA full text icon Full Text.
Download PDF Top of Article Abstract Microvascular and neuropathic complications Epidemiologic Data Clinical Trials Summary Macrovascular complications Indirect Data Epidemiologic Data Clinical Trials Summary Other potential drawbacks to improved control Weight Gain Quality of Life Summary Conclusions Comment Article Information References.
Table 1. View Large Download. Factors Expected to Affect Benefits of Improved Glycemic Control in Type 2 Diabetes. Kenny SJAubert RCGeiss LS Prevalence and incidence of non—insulin-dependent diabetes.
Harris Glycemmic CCStern MPBoyko EJRieber GEBennett PHeds. Diabetes in America.
: Glycemic control| Quality Programs | View Metrics. Key Messages Optimal glycemic control is fundamental to the management of diabetes. Follow-up of glycemic control and cardiovascular outcomes in type 2 diabetes. Action to Control Cardiovascular Risk in Diabetes Study Group, Gerstein HC, Miller ME, et al. Mean ±SD age was Save Preferences. |
| Diabetes Canada | Clinical Practice Guidelines | Article CAS Glycemic control Glyecmic Kalmijn, S. Brownlee Coenzyme Q metabolism Nonenzymatic glycosylation of macromolecules: prospects of pharmacologic modulation. Lehtinen JMUusitupa MSiitonen OPyörälä K Prevalence of neuropathy in newly diagnosed NIDDM and nondiabetic control subjects. View Topic. View Metrics. |
| When should I check my blood sugar? | Glycemic control patients with three fasting Coenzyme Q metabolism glucose ccontrol within three months and above the contrrol of Mindful stress management Glycemic control were included in the Coenzyme Q metabolism, whereas the patient chart would Glucemic be contril during Glycemic control data conteol period and patients with missing key predictor variables were excluded from the study. JAMA ; The study population was all patients with type 2 diabetes mellitus who presented at a diabetic clinic during the data collection period and those who fulfilled the eligibility criteria. Stressful events e. Continuous Glucose Monitoring CGM CGM technology has been rapidly developing to give people living with diabetes an idea about the speed and direction of their glucose changes. |
| Glycemic Control | ACS | People with type 2 diabetes with stable glycemia well within target may do well with A1C testing or other glucose assessment only twice per year. Unstable or intensively managed patients or people not at goal with treatment adjustments may require testing more frequently every 3 months with interim assessments as needed for safety CGM parameters can be tracked in the clinic or via telemedicine to optimize diabetes management. The A1C test is an indirect measure of average glycemia and, as such, is subject to limitations. As with any laboratory test, there is variability in the measurement of A1C. Although A1C variability is lower on an intraindividual basis than that of blood glucose measurements, clinicians should exercise judgment when using A1C as the sole basis for assessing glycemic control, particularly if the result is close to the threshold that might prompt a change in medication therapy. However, most assays in use in the U. are accurate in individuals who are heterozygous for the most common variants see www. Other measures of average glycemia such as fructosamine and 1,5-anhydroglucitol are available, but their translation into average glucose levels and their prognostic significance are not as clear as for A1C and CGM. Though some variability in the relationship between average glucose levels and A1C exists among different individuals, in general the association between mean glucose and A1C within an individual correlates over time A1C does not provide a measure of glycemic variability or hypoglycemia. Table 6. Clinicians should note that the mean plasma glucose numbers in Table 6. In a recent report, mean glucose measured with CGM versus central laboratory—measured A1C in participants in three randomized trials demonstrated that A1C may underestimate or overestimate mean glucose in individuals The correlation between A1C and average glucose was 0. Adapted from Nathan et al. In the ADAG study, there were no significant differences among racial and ethnic groups in the regression lines between A1C and mean glucose, although the study was underpowered to detect a difference and there was a trend toward a difference between the African and African American and the non-Hispanic White cohorts, with higher A1C values observed in Africans and African Americans compared with non-Hispanic Whites for a given mean glucose. Other studies have also demonstrated higher A1C levels in African Americans than in Whites at a given mean glucose concentration 14 , In contrast, a recent report in Afro-Caribbeans found lower A1C relative to glucose values Taken together, A1C and glucose parameters are essential for the optimal assessment of glycemic status. A1C assays are available that do not demonstrate a statistically significant difference in individuals with hemoglobin variants. Other assays have statistically significant interference, but the difference is not clinically significant. Use of an assay with such statistically significant interference may explain a report that for any level of mean glycemia, African Americans heterozygous for the common hemoglobin variant HbS had lower A1C by about 0. Whether there are clinically meaningful differences in how A1C relates to average glucose in children or in different ethnicities is an area for further study 14 , 21 , Until further evidence is available, it seems prudent to establish A1C goals in these populations with consideration of individualized CGM, BGM, and A1C results. Additionally, time below target and time above target are useful parameters for the evaluation of the treatment regimen Table 6. CGM is rapidly improving diabetes management. As stated in the recommendations, time in range TIR is a useful metric of glycemic control and glucose patterns, and it correlates well with A1C in most studies 23 — New data support the premise that increased TIR correlates with the risk of complications. CGM, continuous glucose monitoring; CV, coefficient of variation; TAR, time above range; TBR, time below range; TIR, time in range. Adapted from Battelino et al. For many people with diabetes, glucose monitoring is key for achieving glycemic targets. Major clinical trials of insulin-treated patients have included BGM as part of multifactorial interventions to demonstrate the benefit of intensive glycemic control on diabetes complications BGM is thus an integral component of effective therapy of patients taking insulin. In recent years, CGM is now a standard method for glucose monitoring for most adults with type 1 diabetes Both approaches to glucose monitoring allow patients to evaluate individual responses to therapy and assess whether glycemic targets are being safely achieved. The international consensus on TIR provides guidance on standardized CGM metrics see Table 6. To make these metrics more actionable, standardized reports with visual cues, such as the ambulatory glucose profile see Fig. BGM and CGM can be useful to guide medical nutrition therapy and physical activity, prevent hypoglycemia, and aid medication management. While A1C is currently the primary measure to guide glucose management and a valuable risk marker for developing diabetes complications, the CGM metrics TIR with time below range and time above range and GMI provide the insights for a more personalized diabetes management plan. The incorporation of these metrics into clinical practice is in evolution, and remote access to these data can be critical for telemedicine. A rapid optimization and harmonization of CGM terminology and remote access is occurring to meet patient and provider needs 35 — Key points included in standard ambulatory glucose profile AGP report. Reprinted from Holt et al. With the advent of new technology, CGM has evolved rapidly in both accuracy and affordability. Reports can be generated from CGM that will allow the provider and person with diabetes to determine TIR, calculate GMI, and assess hypoglycemia, hyperglycemia, and glycemic variability. As discussed in a recent consensus document, a report formatted as shown in Fig. Note the goals of therapy next to each metric in Fig. Overall, regardless of the population being served, it is critical for the glycemic targets to be woven into the overall patient-centered strategy. For example, in a very young child, safety and simplicity may outweigh the need for perfect control in the short run. Simplification may decrease parental anxiety and build trust and confidence, which could support further strengthening of glycemic targets and self-efficacy. Similarly, in healthy older adults, there is no empiric need to loosen control. However, the provider needs to work with an individual and should consider adjusting targets or simplifying the regimen if this change is needed to improve safety and adherence. Hyperglycemia defines diabetes, and glycemic control is fundamental to diabetes management. Follow-up of the DCCT cohorts in the Epidemiology of Diabetes Interventions and Complications EDIC study 38 , 39 demonstrated persistence of these microvascular benefits over two decades despite the fact that the glycemic separation between the treatment groups diminished and disappeared during follow-up. Patient and disease factors used to determine optimal glycemic targets. Characteristics and predicaments toward the left justify more stringent efforts to lower A1C; those toward the right suggest less stringent efforts. Adapted with permission from Inzucchi et al. The Kumamoto Study 40 and UK Prospective Diabetes Study UKPDS 41 , 42 confirmed that intensive glycemic control significantly decreased rates of microvascular complications in patients with short-duration type 2 diabetes. Long-term follow-up of the UKPDS cohorts showed enduring effects of early glycemic control on most microvascular complications Epidemiologic analyses of the DCCT 32 and UKPDS 45 demonstrate a curvilinear relationship between A1C and microvascular complications. Given the substantially increased risk of hypoglycemia in type 1 diabetes and with polypharmacy in type 2 diabetes, the risks of lower glycemic targets may outweigh the potential benefits on microvascular complications. Three landmark trials Action to Control Cardiovascular Risk in Diabetes [ACCORD], Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation [ADVANCE], and Veterans Affairs Diabetes Trial [VADT] were conducted to test the effects of near normalization of blood glucose on cardiovascular outcomes in individuals with long-standing type 2 diabetes and either known cardiovascular disease CVD or high cardiovascular risk. These trials showed that lower A1C levels were associated with reduced onset or progression of some microvascular complications 46 — The concerning mortality findings in the ACCORD trial discussed below and the relatively intense efforts required to achieve near euglycemia should also be considered when setting glycemic targets for individuals with long-standing diabetes, such as those populations studied in ACCORD, ADVANCE, and VADT. Findings from these studies suggest caution is needed in treating diabetes to near-normal A1C goals in people with long-standing type 2 diabetes with or at significant risk of CVD. These landmark studies need to be considered with an important caveat; glucagon-like peptide 1 GLP-1 receptor agonists and sodium—glucose cotransporter 2 SGLT2 inhibitors were not approved at the time of these trials. As such, these agents with established cardiovascular and renal benefits appear to be safe and beneficial in this group of individuals at high risk for cardiorenal complications. Prospective randomized clinical trials examining these agents for cardiovascular safety were not designed to test higher versus lower A1C; therefore, beyond post hoc analysis of these trials, we do not have evidence that it is the glucose lowering by these agents that confers the CVD and renal benefit As such, on the basis of physician judgment and patient preferences, select patients, especially those with little comorbidity and a long life expectancy, may benefit from adopting more intensive glycemic targets if they can achieve them safely and without hypoglycemia or significant therapeutic burden. CVD is a more common cause of death than microvascular complications in populations with diabetes. There is evidence for a cardiovascular benefit of intensive glycemic control after long-term follow-up of cohorts treated early in the course of type 1 diabetes. In the DCCT, there was a trend toward lower risk of CVD events with intensive control. The benefit of intensive glycemic control in this cohort with type 1 diabetes has been shown to persist for several decades 51 and to be associated with a modest reduction in all-cause mortality In type 2 diabetes, there is evidence that more intensive treatment of glycemia in newly diagnosed patients may reduce long-term CVD rates. Thus, to prevent both microvascular and macrovascular complications of diabetes, there is a major call to overcome therapeutic inertia and treat to target for an individual patient 57 , ACCORD, ADVANCE, and VADT suggested no significant reduction in CVD outcomes with intensive glycemic control in participants followed for shorter durations 3. All three trials were conducted in relatively older participants with a longer known duration of diabetes mean duration 8—11 years and either CVD or multiple cardiovascular risk factors. The glycemic control comparison in ACCORD was halted early due to an increased mortality rate in the intensive compared with the standard treatment arm 1. Analysis of the ACCORD data did not identify a clear explanation for the excess mortality in the intensive treatment arm Longer-term follow-up has shown no evidence of cardiovascular benefit, or harm, in the ADVANCE trial The end-stage renal disease rate was lower in the intensive treatment group over follow-up. However, year follow-up of the VADT cohort 61 did demonstrate a reduction in the risk of cardiovascular events Heterogeneity of mortality effects across studies was noted, which may reflect differences in glycemic targets, therapeutic approaches, and, importantly, population characteristics Mortality findings in ACCORD 59 and subgroup analyses of VADT 63 suggest that the potential risks of intensive glycemic control may outweigh its benefits in higher-risk individuals. In all three trials, severe hypoglycemia was significantly more likely in participants who were randomly assigned to the intensive glycemic control arm. As discussed further below, severe hypoglycemia is a potent marker of high absolute risk of cardiovascular events and mortality Therefore, providers should be vigilant in preventing hypoglycemia and should not aggressively attempt to achieve near-normal A1C levels in people in whom such targets cannot be safely and reasonably achieved. Based on these considerations, the following two strategies are offered 67 : If already on dual therapy or multiple glucose-lowering therapies and not on an SGLT2 inhibitor or GLP-1 receptor agonist, consider switching to one of these agents with proven cardiovascular benefit. Introduce SGLT2 inhibitors or GLP-1 receptor agonists in people with CVD at A1C goal independent of metformin for cardiovascular benefit, independent of baseline A1C or individualized A1C target. Numerous factors must be considered when setting glycemic targets. The ADA proposes general targets appropriate for many people but emphasizes the importance of individualization based on key patient characteristics. Glycemic targets must be individualized in the context of shared decision-making to address individual needs and preferences and consider characteristics that influence risks and benefits of therapy; this approach will optimize engagement and self-efficacy. The factors to consider in individualizing goals are depicted in Fig. This figure is not designed to be applied rigidly but to be used as a broad construct to guide clinical decision-making 68 and engage people with type 1 and type 2 diabetes in shared decision-making. More aggressive targets may be recommended if they can be achieved safely and with an acceptable burden of therapy and if life expectancy is sufficient to reap the benefits of stringent targets. Severe or frequent hypoglycemia is an absolute indication for the modification of treatment regimens, including setting higher glycemic goals. Diabetes is a chronic disease that progresses over decades. Thus, a goal that might be appropriate for an individual early in the course of their diabetes may change over time. Thus, a finite period of intensive control to near-normal A1C may yield enduring benefits even if control is subsequently deintensified as patient characteristics change. Over time, comorbidities may emerge, decreasing life expectancy and thereby decreasing the potential to reap benefits from intensive control. Also, with longer disease duration, diabetes may become more difficult to control, with increasing risks and burdens of therapy. Thus, A1C targets should be reevaluated over time to balance the risks and benefits as patient factors change. Recommended glycemic targets for many nonpregnant adults are shown in Table 6. CGM may be used to assess glycemic target as noted in Recommendation 6. Postprandial glucose may be targeted if A1C goals are not met despite reaching preprandial glucose goals. Postprandial glucose measurements should be made 1—2 h after the beginning of the meal, generally peak levels in patients with diabetes. The issue of preprandial versus postprandial BGM targets is complex Elevated postchallenge 2-h oral glucose tolerance test glucose values have been associated with increased cardiovascular risk independent of fasting plasma glucose in some epidemiologic studies, whereas intervention trials have not shown postprandial glucose to be a cardiovascular risk factor independent of A1C. In people with diabetes, surrogate measures of vascular pathology, such as endothelial dysfunction, are negatively affected by postprandial hyperglycemia. However, outcome studies have shown A1C to be the primary predictor of complications, and landmark trials of glycemic control such as the DCCT and UKPDS relied overwhelmingly on preprandial BGM. Additionally, a randomized controlled trial in patients with known CVD found no CVD benefit of insulin regimens targeting postprandial glucose compared with those targeting preprandial glucose Therefore, it is reasonable to check postprandial glucose in individuals who have premeal glucose values within target but A1C values above target. An analysis of data from participants in the ADAG study with type 1 diabetes and with type 2 diabetes found that the glucose ranges highlighted in Table 6. These findings support that premeal glucose targets may be relaxed without undermining overall glycemic control as measured by A1C. Fifteen minutes after treatment, if blood glucose monitoring BGM shows continued hypoglycemia, the treatment should be repeated. Once the BGM or glucose pattern is trending up, the individual should consume a meal or snack to prevent recurrence of hypoglycemia. Caregivers, school personnel, or family members providing support to these individuals should know where it is and when and how to administer it. Glucagon administration is not limited to health care professionals. Hypoglycemia is the major limiting factor in the glycemic management of type 1 and type 2 diabetes. Recommendations regarding the classification of hypoglycemia are outlined in Table 6. If a patient has level 2 hypoglycemia without adrenergic or neuroglycopenic symptoms, they likely have hypoglycemia unawareness discussed further below. This clinical scenario warrants investigation and review of the medical regimen 78 — Reprinted from Agiostratidou et al. Symptoms of hypoglycemia include, but are not limited to, shakiness, irritability, confusion, tachycardia, and hunger. Hypoglycemia may be inconvenient or frightening to patients with diabetes. Level 3 hypoglycemia may be recognized or unrecognized and can progress to loss of consciousness, seizure, coma, or death. Hypoglycemia is reversed by administration of rapid-acting glucose or glucagon. Hypoglycemia can cause acute harm to the person with diabetes or others, especially if it causes falls, motor vehicle accidents, or other injury. A large cohort study suggested that among older adults with type 2 diabetes, a history of level 3 hypoglycemia was associated with greater risk of dementia Conversely, in a substudy of the ACCORD trial, cognitive impairment at baseline or decline in cognitive function during the trial was significantly associated with subsequent episodes of level 3 hypoglycemia Studies of rates of level 3 hypoglycemia that rely on claims data for hospitalization, emergency department visits, and ambulance use substantially underestimate rates of level 3 hypoglycemia 89 yet reveal a high burden of hypoglycemia in adults over 60 years of age in the community African Americans are at substantially increased risk of level 3 hypoglycemia 90 , In addition to age and race, other important risk factors found in a community-based epidemiologic cohort of older Black and White adults with type 2 diabetes include insulin use, poor or moderate versus good glycemic control, albuminuria, and poor cognitive function Level 3 hypoglycemia was associated with mortality in participants in both the standard and the intensive glycemia arms of the ACCORD trial, but the relationships between hypoglycemia, achieved A1C, and treatment intensity were not straightforward. An association of level 3 hypoglycemia with mortality was also found in the ADVANCE trial An association between self-reported level 3 hypoglycemia and 5-year mortality has also been reported in clinical practice Glucose variability is also associated with an increased risk for hypoglycemia Young children with type 1 diabetes and the elderly, including those with type 1 and type 2 diabetes 86 , 95 , are noted as particularly vulnerable to hypoglycemia because of their reduced ability to recognize hypoglycemic symptoms and effectively communicate their needs. Individualized glucose targets, patient education, dietary intervention e. CGM with automated low glucose suspend and hybrid closed-loop systems have been shown to be effective in reducing hypoglycemia in type 1 diabetes For patients with type 1 diabetes with level 3 hypoglycemia and hypoglycemia unawareness that persists despite medical treatment, human islet transplantation may be an option, but the approach remains experimental 98 , This change reflects the results of the ADAG study, which demonstrated that higher glycemic targets corresponded to A1C goals An additional goal of raising the lower range of the glycemic target was to limit overtreatment and provide a safety margin in patients titrating glucose-lowering drugs such as insulin to glycemic targets. This should be reviewed at each patient visit. Hypoglycemia treatment requires ingestion of glucose- or carbohydrate-containing foods — The acute glycemic response correlates better with the glucose content of food than with the carbohydrate content of food. Pure glucose is the preferred treatment, but any form of carbohydrate that contains glucose will raise blood glucose. Added fat may retard and then prolong the acute glycemic response. In type 2 diabetes, ingested protein may increase insulin response without increasing plasma glucose concentrations Therefore, carbohydrate sources high in protein should not be used to treat or prevent hypoglycemia. Ongoing insulin activity or insulin secretagogues may lead to recurrent hypoglycemia unless more food is ingested after recovery. Once the glucose returns to normal, the individual should be counseled to eat a meal or snack to prevent recurrent hypoglycemia. The use of glucagon is indicated for the treatment of hypoglycemia in people unable or unwilling to consume carbohydrates by mouth. Those in close contact with, or having custodial care of, people with hypoglycemia-prone diabetes family members, roommates, school personnel, childcare providers, correctional institution staff, or coworkers should be instructed on the use of glucagon, including where the glucagon product is kept and when and how to administer it. An individual does not need to be a health care professional to safely administer glucagon. In addition to traditional glucagon injection powder that requires reconstitution prior to injection, intranasal glucagon and ready-to-inject glucagon preparations for subcutaneous injection are available. Care should be taken to ensure that glucagon products are not expired. Hypoglycemia prevention is a critical component of diabetes management. BGM and, for some patients, CGM are essential tools to assess therapy and detect incipient hypoglycemia. Patients should understand situations that increase their risk of hypoglycemia, such as when fasting for laboratory tests or procedures, when meals are delayed, during and after the consumption of alcohol, during and after intense exercise, and during sleep. Hypoglycemia may increase the risk of harm to self or others, such as when driving. Teaching people with diabetes to balance insulin use and carbohydrate intake and exercise are necessary, but these strategies are not always sufficient for prevention 82 , — Formal training programs to increase awareness of hypoglycemia and to develop strategies to decrease hypoglycemia have been developed, including the Blood Glucose Awareness Training Programme, Dose Adjusted for Normal Eating DAFNE , and DAFNEplus. Conversely, some individuals with type 1 diabetes and hypoglycemia who have a fear of hyperglycemia are resistant to relaxation of glycemic targets 78 , Regardless of the factors contributing to hypoglycemia and hypoglycemia unawareness, this represents an urgent medical issue requiring intervention. In type 1 diabetes and severely insulin-deficient type 2 diabetes, hypoglycemia unawareness or hypoglycemia-associated autonomic failure can severely compromise stringent diabetes control and quality of life. This syndrome is characterized by deficient counterregulatory hormone release, especially in older adults, and a diminished autonomic response, which are both risk factors for and caused by hypoglycemia. Hence, patients with one or more episodes of clinically significant hypoglycemia may benefit from at least short-term relaxation of glycemic targets and availability of glucagon Any person with recurrent hypoglycemia or hypoglycemia unawareness should have their glucose management regimen adjusted. With the advent of CGM and CGM-assisted pump therapy, there has been a promise of alarm-based prevention of hypoglycemia , These studies had differing A1C at entry and differing primary end points and thus must be interpreted carefully. Real-time CGM studies can be divided into studies with elevated A1C with the primary end point of A1C reduction and studies with A1C near target with the primary end point of reduction in hypoglycemia , — In people with type 1 and type 2 diabetes with A1C above target, CGM improved A1C between 0. A recent report in people with type 1 diabetes over the age of 60 years revealed a small but statistically significant decrease in hypoglycemia No study to date has reported a decrease in level 3 hypoglycemia. In a single study using intermittently scanned CGM, adults with type 1 diabetes with A1C near goal and impaired awareness of hypoglycemia demonstrated no change in A1C and decreased level 2 hypoglycemia For people with type 2 diabetes, studies examining the impact of CGM on hypoglycemic events are limited; a recent meta-analysis does not reflect a significant impact on hypoglycemic events in type 2 diabetes , whereas improvements in A1C were observed in most studies — Overall, real-time CGM appears to be a useful tool for decreasing time spent in a hypoglycemic range in people with impaired awareness. For type 2 diabetes, other strategies to assist patients with insulin dosing can improve A1C with minimal hypoglycemia , Carry supplies for treating low blood sugar with you. If you feel shaky, sweaty, or very hungry or have other symptoms, check your blood sugar. Wait for 15 minutes and then check your blood sugar again. If you have problems with low blood sugar, ask your doctor if your treatment plan needs to be changed. Many things can cause high blood sugar hyperglycemia , including being sick, being stressed, eating more than planned, and not giving yourself enough insulin. Over time, high blood sugar can lead to long-term, serious health problems. Symptoms of high blood sugar include:. If you get sick , your blood sugar can be hard to manage. You may not be able to eat or drink as much as usual, which can affect blood sugar levels. High ketones can be an early sign of diabetic ketoacidosis, which is a medical emergency and needs to be treated immediately. Ketones are a kind of fuel produced when fat is broken down for energy. When too many ketones are produced too fast, they can build up in your body and cause diabetic ketoacidosis, or DKA. DKA is very serious and can cause a coma or even death. Common symptoms of DKA include:. If you think you may have DKA, test your urine for ketones. Follow the test kit directions, checking the color of the test strip against the color chart in the kit to see your ketone level. If your ketones are high, call your health care provider right away. DKA requires treatment in a hospital. Talk to your doctor about how to keep your blood sugar levels within your target range. Your doctor may suggest the following:. Carbs in food make your blood sugar levels go higher after you eat them than when you eat proteins or fats. You can still eat carbs if you have diabetes. The amount you can have and stay in your target blood sugar range depends on your age, weight, activity level, and other factors. Counting carbs in foods and drinks is an important tool for managing blood sugar levels. Make sure to talk to your health care team about the best carb goals for you. The A1C test is a simple blood test that measures your average blood sugar levels over the past 2 or 3 months. A1C testing is part of the ABCs of diabetes—important steps you can take to prevent or delay health complications down the road:. Work with your doctor to establish a personal A1C goal for you. Eating a healthy diet with plenty of fruit and vegetables, maintaining a healthy weight , and getting regular physical activity can all help. Other tips include:. Medicare , Medicaid, and most private insurance plans pay for the A1C test and fasting blood sugar test as well as some diabetes supplies. Check your plan or ask your health care team for help finding low-cost or free supplies, and see How to Save Money on Diabetes Care for more resources. Skip directly to site content Skip directly to search. Español Other Languages. |
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Is type II diabetes associated with an increased risk of cognitive dysfunction? Diabetes Care 20 , — Kalmijn, S. Glucose intolerance, hyperinsulinaemia and cognitive function in a general population of elderly men. Diabetologia 38 , — Download references. Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia. Afsana Afroz, Md. Nazmul Karim, Mohammed J. Alramadan, Dianna J. Bangladesh University of Health Sciences BUHS , Dhaka, Bangladesh. School of Population and Global Health, The University of Western Australia, Perth, Australia. BakerIDI Heart and Diabetes Institute, Melbourne, Australia. You can also search for this author in PubMed Google Scholar. Concept and design A. and B. Work with your doctor to establish a personal A1C goal for you. Eating a healthy diet with plenty of fruit and vegetables, maintaining a healthy weight , and getting regular physical activity can all help. Other tips include:. Medicare , Medicaid, and most private insurance plans pay for the A1C test and fasting blood sugar test as well as some diabetes supplies. Check your plan or ask your health care team for help finding low-cost or free supplies, and see How to Save Money on Diabetes Care for more resources. Skip directly to site content Skip directly to search. Español Other Languages. Manage Blood Sugar. Español Spanish Print. Minus Related Pages. Hypoglycemia Unawareness. Learn More. Monitoring Your Blood Sugar All About Your A1C 10 Surprising Things That Can Spike Your Blood Sugar Living With Diabetes Diabetes Self-Management Education and Support. Last Reviewed: September 30, Source: Centers for Disease Control and Prevention. Facebook Twitter LinkedIn Syndicate. home Diabetes Home. To receive updates about diabetes topics, enter your email address: Email Address. What's this. Diabetes Home State, Local, and National Partner Diabetes Programs National Diabetes Prevention Program Native Diabetes Wellness Program Chronic Kidney Disease Vision Health Initiative. Links with this icon indicate that you are leaving the CDC website. The Centers for Disease Control and Prevention CDC cannot attest to the accuracy of a non-federal website. Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. You will be subject to the destination website's privacy policy when you follow the link. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. Zoungas S, Chalmers J, Neal B, et al. Follow-up of blood-pressure lowering and glucose control in type 2 diabetes. Duckworth W, Abraira C, Moritz T, et al. Glucose control and vascular complications in veterans with type 2 diabetes. Moritz T, Duckworth W, Abraira C. 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