Diabetic Ketoacidosis – Part 1

Diabetic ketoacidosis (DKA) is generally a complication for people with type 1 diabetes, but some people with type 2 diabetes do develop DKA. If you have type 2, especially when you are older, you are more likely to have a condition with some similar symptoms called HHNS (hyperosmolar hyperglycemic nonketotic syndrome). I will cover this in some future blogs.

DKA starts with high ketone levels when you body doesn't have enough insulin. This means your cells can't use the glucose in your blood for energy, and your body starts using fat for fuel instead. The ketones start building in your blood and if not corrected soon, the excess can change the chemical balance of your blood and change how your body works.

People with type 1 diabetes are at risk for ketoacidosis, since their bodies don't make any insulin. Your ketones can also go up when -

1. You miss a meal,
2. You're sick or stressed,
3. You have an insulin reaction.

When your blood glucose level is over 240 mg/dl (13.3 mmol/L) or you have symptoms of high blood glucose, such as:

• Dry mouth
• Feeling really thirsty
• Peeing a lot

When you have the above symptoms, it is important to test your ketones. For this you can use your blood glucose meter that measure ketones or use a urine test strip. Try to bring your blood glucose level down and check you ketones again in 30 minutes. Call your doctor or go to the emergency room right away if that doesn't work. This is more important if your ketones aren't normal and if you have one or more of the following symptoms:

• You have been vomiting for more than 2 hours
• You feel queasy or your belly hurts
• Your breath smells fruity
• You are tired, confused, or woozy headed
• You are having a difficult time breathing

You may have to go to the hospital. You'll probably need insulin through an IV to bring your ketones down and fluids to get you hydrated and balance your blood chemistry again. If you don't treat ketoacidosis, you could pass out, go into a coma, and possibly die. Your doctor may change your insulin dose or the kind you use to prevent it from happening again.

Good glucose management should help you avoid ketoacidosis. Take your medicines as directed, follow your meal plan closely, maintain your exercise regimen, and test your blood glucose regularly. When you have an episode of ketoacidosis, always run down a checklist:

1. Make sure your insulin has not expired.
2. Do not use it if it has clumps (insulin should be either clear or evenly cloudy with small flecks.
3. If you are using an insulin pump, look closely for insulin leaks, and check your tube connections for air bubbles.
4. Lastly, talk to your doctor if your blood sugar levels are often out of your target range
   
   
   
   
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Hyperglycemia – Part 3

Yes, emergency complications of hyperglycemia happen all too frequently, especially among the elderly and occasionally the not so elderly that are in severe depression.  If blood sugar rises high enough for a prolonged period, it can lead to two serious conditions.

• Diabetic ketoacidosis. Diabetic ketoacidosis develops when you have too little insulin in your body. Without enough insulin, glucose can't enter your cells for energy. Your blood sugar level rises and your body begins to break down fat for energy. This process produces toxic acids known as ketones. Excess ketones accumulate in the blood and eventually "spill over" into the urine. Left untreated, diabetic ketoacidosis can lead to diabetic coma and be life threatening.

• Hyperglycemic Hyperosmolar Nonketotic Syndrome. This condition occurs when people produce insulin, but it doesn't work properly. Blood glucose levels may become very high, greater than 600 mg/dl (33.3 mmol/L). Because insulin is present but not working properly, the body can't use either glucose or fat for energy. Glucose is then dumped in the urine, causing increased urination. Left untreated, diabetic hyperosmolar syndrome can lead to coma and life-threatening dehydration. Prompt medical care is essential.

Illness or infections can cause your blood sugar to rise, so it's important to plan for these situations. Talk to your doctor about creating a sick-day plan. Questions to ask include:

• How often should I monitor my blood sugar during an illness?
• Does my insulin injection or oral diabetes pill dose change when I'm sick?
• When do I test for ketones?
• What if I'm unable to eat or drink?
• When do I seek medical help?

Some people will tell you to let your doctor set your blood glucose target, but I say that they should not. They can make suggestions and help guide you, but they should never set your goals. Too often, doctors only use the ADA target blood glucose levels. For many people who have diabetes, target levels set by the American Diabetes Association (ADA) are:

• Fasting at least eight hours (fasting blood sugar level) — between 90 and 130 mg/dl (5 and 7 mmol/L)
• Before meals — between 70 and 130 mg/dl (4 and 7 mmol/L)
• One to two hours after meals — lower than 180 mg/dl (10 mmol/L)

Your target blood glucose range should differ, especially if you're pregnant or you develop diabetes complications. Your target blood glucose range may change as you get older, too. Sometimes reaching your target blood glucose range is a challenge. But the closer you get, the better you'll feel.

If you have any signs or symptoms of severe hyperglycemia, even if they're subtle, check your blood sugar level. If your blood sugar level is 240 mg/dl (13.1 mmol/L) or above, use an over-the-counter urine ketones test kit. If the urine test is positive, your body may have started making the changes that can lead to diabetic ketoacidosis. You'll need your doctor's help to lower your blood sugar level safely.  During an appointment, your doctor should conduct an A1c test. This blood test indicates your average blood sugar level for the past two to three months. It works by measuring the percentage of blood glucose attached to hemoglobin, the oxygen-carrying protein in red blood cells.

An A1c level of 7 percent or less means that your treatment plan is working and that your blood sugar was consistently within the normal range. If your A1c level is higher than 7 percent, your blood glucose, on average, was above the normal range. In this case, your doctor may recommend a change in your diabetes treatment plan.

Keep in mind that the normal range for A1c results may vary somewhat among labs. If you consult a new doctor or use a different lab, it's important to consider this possible variation when interpreting your A1c test results.

How often you need the A1c test depends on the type of diabetes you have, The medications you are taking, and how well you're managing your blood sugar. Most people with type 2 diabetes, on no or oral medications are mostly tested twice per year. If you are type 1 or type 2 on insulin, you should be tested at least four times per year.

Hyperglycemia – Part 2

I know some stubborn people with diabetes that will not contact their doctor and then often forget about what has happened for the period between appointments. You should make an appointment with your doctor if:

1. You experience ongoing diarrhea or vomiting, but you're able to take some foods or drinks
2. You have a fever that lasts more than 24 hours
3. Your blood glucose is more than 240 mg/dl (13.3 mmol/L) even though you've taken your diabetes medication
4. You have trouble keeping your blood glucose within the desired range

During digestion, your body breaks down carbohydrates from foods, such as bread, rice, and pasta, into various sugar molecules. One of these sugar molecules is glucose, which is the main energy source for your body. Glucose is absorbed directly into your bloodstream after you eat, but it can't enter the cells of most of your tissues without the help of insulin, a hormone secreted by your pancreas.

When the level of glucose in your blood rises, it signals your pancreas to release insulin. The insulin, in turn, unlocks your cells so that glucose can enter and provide the fuel your cells need to function properly. Any extra glucose is stored in your liver and muscles in the form of glycogen.

This process lowers the amount of glucose in your bloodstream and prevents it from reaching dangerously high levels. As your blood sugar level returns to normal, so does the secretion of insulin from your pancreas. Diabetes drastically diminishes the effects of insulin on your body, either because your pancreas doesn't produce enough insulin (type 1 diabetes) or because your body is resistant to the effects of insulin or doesn't produce enough insulin to maintain a normal glucose level (type 2 diabetes). As a result, glucose tends to build up in your bloodstream and may reach dangerously high levels (hyperglycemia) if not treated properly. Insulin or other drugs are used to lower blood sugar levels.

Many factors can contribute to hyperglycemia, including:

1. Not using enough insulin or oral diabetes medication
2. Not injecting insulin properly or using expired insulin
3. Not following your diabetes eating plan
4. Being inactive
5. Having an illness or infection
6. Using certain medications, such as steroids
7. Being injured or having surgery
8. Experiencing emotional stress, such as family conflict or workplace challenges

Illness or stress can trigger hyperglycemia because hormones produced to combat illness or stress can also cause your blood sugar to rise. Even people who don't have diabetes may develop hyperglycemia during severe illness. But people with diabetes may need to take extra diabetes medication to keep blood glucose near normal during illness or stress. Always make sure that you contact your doctor when blood glucose levels are above 200 mg/dl.

Untreated hyperglycemia can cause long-term complications. These include:

• Cardiovascular disease
• Nerve damage (neuropathy)
• Kidney damage (nephropathy) or kidney failure
• Damage to the blood vessels of the retina (diabetic retinopathy), potentially leading to blindness
• Clouding of the normally clear lens of your eye (cataract)
• Feet problems caused by damaged nerves or poor blood flow that can lead to serious infections
• Bone and joint problems, such as osteoporosis
• Skin problems, including bacterial infections, fungal infections and nonhealing wounds
• Teeth and gum infections

Concluded in next blog.

Hyperglycemia – Part 1

Hyperglycemia or high blood glucose levels are more common than even I realized. In talking with a doctor recently, he made mention of the number of patients he serves who don't worry about blood glucose readings consistently over 200 mg/dl (11.1 mmol/L). I asked why they are not concerned. He admitted he does not understand why as he has told them about the complications that can develop and losing their eyesight, kidney failure, heart problems, and that readings consistently over 150 mg/dl (8.3 mmol/L) would cause the complications. He said that they even see readings near 300 mg/dl (16.7 mmol/L). HbA1c readings were mostly between 8.0 and 11.9% on a regular basis.

He has tried to educate them, and teach them what testing can tell them, but nothing changes. Other patients are doing excellent and he had no concerns about their developing complications. He is not concerned about patients that have excursions into blood glucose levels above 150 mg/dl. Yes, he is concerned about hyperglycemia and how it affects people with diabetes.

Several factors can contribute to hyperglycemia,

1. Food
2. Physical activity choices
3. Illness
4. Nondiabetes medications
5. Too low a dose of glucose-lowering medication

It's important to treat hyperglycemia, because if left untreated, hyperglycemia can become severe and lead to serious complications requiring emergency care, such as diabetic coma. In the long term, persistent hyperglycemia, even if not severe can lead to complications affecting your eyes, kidneys, nerves, and heart. This is why you should be instructed about testing and why you need to contact your doctor if you have consistent elevated blood glucose readings.

Symptoms of hyperglycemia generally don't happen until blood glucose is elevated above 200 mg/dl (11.1 mmol/L). Then the symptoms can develop slowly over several days or weeks. The longer blood glucose levels remain elevated, the more serious the symptoms become.

Recognizing the early symptoms of hyperglycemia can help you treat the condition promptly. Watch for:

• Frequent urination
• Increased thirst
• Blurred vision
• Fatigue
• Headache

If hyperglycemia goes untreated, it can cause toxic acids (ketones) to build up in your blood and urine (ketoacidosis). Signs and symptoms include:

• Fruity-smelling breath
• Nausea and vomiting
• Shortness of breath
• Dry mouth
• Weakness
• Confusion
• Abdominal pain
• Coma

If you let hypoglycemia get to the level above, call 911 or emergency medical assistance if:

1. You're sick and can't keep any food or fluids down, and
2. Your blood glucose levels are persistently above 240 mg/dl (13.3 mmol/L) with ketones in your urine

Continued in the next blog.

Our Support Group's March Meeting

We had planned for a meeting on March 7, but had some conflicts and Tim postponed it to March 14. The main problem was that on Friday, March 6, Brenda was rushed to the Hospital and then transferred to another hospital. With that information, we didn't need to wonder as this meant it had to be a heart problem.

It has been more than a week now and she is still not home. Tim said that she had requested that we go ahead with the meeting and had passed this request through her daughter. Tim and her daughter have been in almost daily contact and Tim passes information to the rest of us in emails. Because of the distance and the fact that in the beginning, Brenda was in isolation, people were asked not to make the trip. Max and Allen did make the trip on Wednesday, but they could not visit her. Brenda was able to acknowledge them from her bed, but that was it.

We had a full explanation when we started the meeting and everyone understood that it was serious as she had a heart attack and was lucky to be alive. It was one of the grandchildren that had called 911, and then called her mother. Brenda's daughter arrived, as she was loaded into the ambulance and picked up the children and went to the hospital. The decision was made to transfer her mother to another hospital and she selected the one about two and a half hours away. Not that by helicopter, but it is still some distance by auto.

Tim stated that there was really no program now as Brenda and Jason were working on one and Jason said that all the work was at Brenda's house as she was putting a few things on slides. At that point, Rose asked if Tim could bring up a few of my blogs that I was posting on diabetes complications. Earl seconded this and said he was learning a lot and some things he didn't want to learn, but should.

Tim asked if that was okay and no one opposed this. Tim asked which to start with and I suggested with the eye disease I suggested that he pull up the January 21, 2014 blog or near that date. Tom raised his hand and said he had a question he wanted to ask. Tim told him to ask. Tom asked which complications I was going to cover. I said I have covered eye diseases which Tim will display shortly, I have covered depression, neuropathy which is nerve damage, hypoglycemia which is low blood glucose, nephropathy which is kidney disease, and I have atherosclerosis which is heart disease being posted. Next, I will have hyperglycemia, followed by diabetic ketoacidosis and then hyperglycemic hyperosmolar nonketotic syndrome.

Tom asked what was next. I said gastroparesis, foot care, and preventing amputations, infections, periodontal disease, fatty liver disease, diabetic skin problems, Alzheimer's disease, deafness, and gestational diabetes. Then I am planning on doing some blogs on related problems. This will include polypharmacy, sleep apnea, statins, and sleep. There may be a topic or two more, but this is my goal.

At that point, Tim had my first blog on eye disease on the screen and said he was ready to begin. He started with this:

Risk factors for cataracts include:

• Most cataracts are due to aging
• Diseases, like diabetes
• Eye injury or trauma
• Eye surgery for another problem
• Inheritance or pregnancy-related causes
• Overexposure of the eyes to the sun's damaging ultraviolet rays
• Smoking
• Certain medications

This generated some discussion and Tim asked me what stage my cataracts were considered. I said at the early stage and I was being checked every six months. My next appointment was in April.

Then we moved on to this:

The most common cataract symptoms include:

• Blurred or cloudy vision
• Faded colors
• Increased glare from headlights, lamps, or sunlight
• Poor night vision
• Multiple images in a single eye, or double vision
• Frequent prescription changes for your eyeglasses or contact lenses

For early cataracts, these steps may help:

• Obtaining a new prescription for eyeglasses or contact lenses
• Using brighter lighting
• Using magnifying lenses
• Wearing sunglasses

I said that as of yet I have not noticed any of symptoms except the glare of certain headlights, and my wife even has problems with them. I said this is one reason when you have diabetes to have a dilated eye exam once a year and have a good eye exam as you become older. I said they also check my vision and record the proposed prescription every year so that when I need surgery, they will have all the information needed.

More discussion followed with some on glaucoma. Tim said we can cover more of Bob's blogs in the future as it looks like there will be plenty to get our attention. Tim said the meeting is over and some started to leave. Tom stopped me and asked to follow me home. We left then.

Atherosclerosis – Part 5

Lifestyle changes can help you prevent or slow the progression of atherosclerosis.

• Stop smoking. Smoking damages your arteries. If you smoke or use tobacco in any form, quitting is the best way to halt the progression of atherosclerosis and reduce your risk of complications.
• Exercise most days of the week. Regular exercise can condition your muscles to use oxygen more efficiently. Physical activity can also improve circulation and promote development of new blood vessels that form a natural bypass around obstructions (collateral vessels). Exercise helps lower blood pressure and reduces your risk of diabetes. It is always suggested that your doctor approve any exercise regimen if you have not been a participant in regular exercise.

Ideally, you should exercise 30 to 60 minutes most days of the week. If you can't fit it all into one session, try breaking it up into 10-minute intervals. You can take the stairs instead of the elevator, walk around the block during your lunch hour, or do some situps or pushups while watching television.

• Eat healthy foods. A heart-healthy diet based on fruits, vegetables, and low in saturated fat, cholesterol and sodium, can help you control your weight, blood pressure, cholesterol and blood sugar. Try substituting whole-grain bread in place of white bread; grabbing an apple, a banana, or carrot sticks as a snack; and reading nutrition labels as a guide to controlling the amount of salt and fat you eat. I am not promoting whole grains like the source does and I do not believe cholesterol reduction improves atherosclerosis. Those of us with diabetes will need to limit or eliminate whole grains. We also need to be careful of carbohydrate-laden fruits, like bananas, and certain vegetables, as carrots are sources of carbohydrates.
• Lose extra pounds and maintain a healthy weight. If you're overweight, losing as few as 5 to 10 pounds (about 2.3 to 4.5 kilograms) can help reduce your risk of high blood pressure and high cholesterol, two of the major risk factors for developing atherosclerosis. Losing weight helps reduce your risk of diabetes or control your condition if you already have diabetes.
• Manage stress. Reduce stress as much as possible. Practice healthy techniques for managing stress, such as muscle relaxation and deep breathing.
• Tightly manage your diabetes. While this may not be a lifestyle change, it is necessary to prevent more damage to your arteries and minimize atherosclerosis.
  

If you have high cholesterol, high blood pressure, diabetes or another chronic disease, work with your heart doctor to manage the condition and promote overall health.

It's thought that some foods and herbal supplements can help reduce your high cholesterol level and high blood pressure, two major risk factors for developing atherosclerosis. With your doctor's OK, consider these supplements and products:

• Alpha-linolenic acid (ALA)
• Artichoke
• Barley
• Blond psyllium (found in seed husk and products such as Metamucil)
• Calcium
• Cocoa
• Cod liver oil
• Coenzyme Q10
• Garlic
• Oat bran (found in oatmeal and whole oats)
• Omega-3 fatty acids
• Sitostanol (found in oral supplements and some margarines, such as Benecol) and be sure that the margarines have no transfats.

Warning – Talk to your heart doctor before adding any of these supplements to your atherosclerosis treatment. Some supplements can interact with medications, causing harmful side effects.

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You can also practice relaxation techniques, such as yoga or deep breathing, to help you relax and reduce your stress level. These practices can temporarily reduce your blood pressure, reducing your risk of developing atherosclerosis.

The same healthy lifestyle changes recommended to treat atherosclerosis also help prevent it. These include:

• Quitting smoking
• Eating healthy foods
• Exercising regularly
• Maintaining a healthy weight
• Tightly managing diabetes

Just remember to make changes one step at a time, and keep in mind what lifestyle changes are manageable for you in the long run. While lifestyle changes does not include tightly managing diabetes, this is necessary to prevent atherosclerosis.

Atherosclerosis – Part 4

Lifestyle changes, such as eating a healthy diet and exercising, are often the best treatment for atherosclerosis. Properly managing diabetes is a must to assist in keeping atherosclerosis from happening or getting worse. Sometimes, medication or surgical procedures may be recommended.

Various drugs can slow, or even reverse, the effects of atherosclerosis. Here are some common choices:

• Cholesterol medications. Aggressively lowering your low-density lipoprotein (LDL) cholesterol, the "bad" cholesterol, can slow, stop, or even reverse the buildup of fatty deposits in your arteries. Boosting your high-density lipoprotein (HDL) cholesterol, the "good" cholesterol, may help, too. Your doctor can choose from a range of cholesterol medications, including drugs known as statins and fibrates. In addition to lowering cholesterol, statins have additional effects that help stabilize the lining of your heart arteries and prevent atherosclerosis.
• Anti-platelet medications. Your doctor may prescribe anti-platelet medications, such as aspirin, to reduce the likelihood that platelets will clump in narrowed arteries, form a blood clot, and cause further blockage.
• Beta-blocker medications. These medications are commonly used for coronary artery disease. They lower your heart rate and blood pressure, reducing the demand on your heart and often relieve symptoms of chest pain. Beta-blockers reduce the risk of heart attacks and some heart rhythm problems.
• Angiotensin-converting enzyme (ACE) inhibitors. These medications may help slow the progression of atherosclerosis by lowering blood pressure and producing other beneficial effects on the heart arteries. ACE inhibitors can also reduce the risk of recurrent heart attacks.
• Calcium channel blockers. These medications lower blood pressure and are sometimes used to treat angina.
• Water pills (diuretics). High blood pressure is a major risk factor for atherosclerosis. Diuretics lower blood pressure.
• Other medications. Your doctor may suggest certain medications to control specific risk factors for atherosclerosis, such as diabetes. Sometimes specific medications to treat symptoms of atherosclerosis, such as leg pain during exercise, are prescribed.

Sometimes more aggressive treatment is needed. If you have severe symptoms or a blockage that threatens muscle or skin tissue survival, you may be a candidate for one of the following surgical procedures:

• Angioplasty and stent placement. In this procedure, your heart surgeon inserts a long, thin tube (catheter) into the blocked or narrowed part of your artery. A second catheter with a deflated balloon on its tip is then passed through the catheter to the narrowed area. The balloon is then inflated, compressing the deposits against your artery walls. A mesh tube (stent) is usually left in the artery to help keep the artery open. Been there, had this done.
• Endarterectomy. In some cases, fatty deposits must be surgically removed from the walls of a narrowed artery. When the procedure is done on arteries in the neck (the carotid arteries), it's called a carotid endarterectomy.
• Thrombolytic therapy. If you have an artery that's blocked by a blood clot, your heart surgeon may use a clot-dissolving drug to break it apart.
• Bypass surgery. Your heart surgeon may create a graft bypass using a vessel from another part of your body or a tube made of synthetic fabric. This allows blood to flow around the blocked or narrowed artery.