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30 Things You Should Know About Managing Diabetes. Diabetes Forecast. 61(4): 54-56. April 2008.

This article presents some common issues that are important for managing diabetes by grouping them into brief suggestions or reminders in six sections: insulin; blood glucose monitoring; hypoglycemia and hyperglycemia; medications; kidney complications, or diabetic nephropathy; and eye complications, or diabetic retinopathy. The author presents this information in a brief, easy-to-read format, to bring readers up to date and to prevent being overwhelmed with the mass of information that is available on diabetes. Specific topics covered include the use of insulin in type 2 diabetes, insulin storage, blood glucose meter accuracy, health insurance coverage for test strips, the importance of written records, how to treat hyperglycemia, how to treat hypoglycemia, symptoms, different types of medications available for type 2 diabetes, individual responses to medication, the role of a pharmacist, why kidneys get damaged by diabetes, recommended screening tests for kidney function, blood pressure control, annual screening for eye problems, and the role of cholesterol.

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American Diabetes Association: Clinical Practice Recommendations 2008. Diabetes Care. 31(Suppl 1): S1-S110. January 2008.

This special supplement issue of Diabetes Care journal contains the latest update of the American Diabetes Association’s (ADA) major position statement, “Standards of Medical Care in Diabetes.” The position statement contains all of the ADA’s key recommendations, including national standards for diabetes self-management education (DSME). This special issue presents selected position statements about certain topics not adequately covered in the standards. These topics are the diagnosis and classification of diabetes mellitus, nutrition recommendations and interventions for diabetes, diabetes care in schools and daycare settings, diabetes management in correctional institutions, hypoglycemia and employment or licensure, third-party reimbursement for diabetes care, self-management education, and supplies. A brief summary of the revisions made for the 2008 clinical practice recommendations begins the special supplement, followed by a more detailed executive summary of the changes. The publication includes a list of technical reviews, a list of committee reports and consensus statements, and a list of position statements.

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Beating the Lows: What You Need to Know About Hypoglycemia. Diabetes Forecast. 61(2): 29-30. February 2008.

This article helps readers newly diagnosed with diabetes to understand hypoglycemia, the condition of low blood glucose levels. The author reviews the causes, symptoms, treatment, and prevention of hypoglycemia, focusing on practical approaches to everyday activities and diabetes care. Blood glucose levels can drop too low when a person with diabetes exercises longer or harder than usual, eats too little, delays a meal, eats too few carbohydrates, mistakenly takes too much insulin, or drinks alcohol on an empty stomach. Combinations of insulin, sulfonylureas, or meglitinides with other diabetes pills and injectable drugs carry a risk of hypoglycemia. Symptoms of hypoglycemia can include nervousness, shakiness, hunger, lightheadedness, sweating, irritability, impatience, chills, sleepiness, nausea, and confusion or other unusual behavior. The author briefly describes hypoglycemia unawareness, which can happen in a person who experiences repeated episodes of hypoglycemia. This occurs more often in people who practice tight diabetes control. Readers are encouraged to test their blood glucose levels as soon as they feel the symptoms of a potential episode of hypoglycemia. To counter mild-to-moderate hypoglycemia, patients should eat or drink something containing 15 grams of carbohydrate, wait 15 minutes, and test their blood glucose again. This pattern can be repeated if needed. The article concludes with a list of suggestions that can help prevent hypoglycemia. 1 figure.

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Blood Glucose Monitoring: A Practical Guide for Use in the Office and Clinic Setting. Diabetes Spectrum. 21(2):100-111. Spring 2008.

This article describes a method for evaluating and interpreting self-monitoring of blood glucose (SMBG) results in the office and clinic setting. The authors contend that such interpretation in the presence of patients may facilitate improved patient-provider discussion, clinical decisions, and the ability to manage glycemic patterns. They outline key steps that should be included in a systematic review of SMBG data: identifying the degree of blood glucose control using mean and standard deviation or variance, identifying patient safety concerns with regard to hypoglycemia, understanding the factors influencing blood glucose control by noting trends and patterns, suggesting strategies for achieving improved blood glucose control, and providing reinforcement to patients with diabetes that this information is valuable and useful in their care. Specific topics include patient records and logbook reviews, meter memories and computation, meter downloads and analysis, problems with basal glucose control, problems with prandial glucose control, frequency of testing, and continuous glucose monitoring (CGM). The article includes case studies that illustrate the process for using and interpreting electronic SMBG downloads. One chart summarizes selected diabetes management software programs. 5 figures. 4 tables. 17 references.

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Case Study: Conception as a Potential Consequence of Diabetes Treatment. Clinical Diabetes. 26(2): 83-84. Spring 2008.

This article presents a case report of a 45-year-old caucasian woman with a medical history of type 2 diabetes, polycystic ovarian syndrome (PCOS), hypertension, and gastroesophageal reflux disease. She had a history of one normal, healthy pregnancy and delivery without complication. The authors describe her clinical care, notably the antihyperglycemic medications, including pioglitazone, which has a potential effect of increasing fertility in women with PCOS. The authors review the patient’s nonadherence to some of the antihyperglycemic agents, her concerns about hypoglycemia, patient education needs, her unexpected pregnancy, and the changes in medications that were required as a result of the pregnancy, notably, weaning off the analgesics that were prescribed for her neuropathic pain. The patient experienced a miscarriage at approximately 8 weeks’ gestation, after which she expressed interest in attempting another pregnancy. She was encouraged to improve her glycemic control and blood pressure before attempting another pregnancy. The authors describe the relationship between PCOS and insulin resistance, the mechanisms by which metformin and thiazolidinediones increase fertility in women with PCOS, and the importance of preconception care in all women with diabetes. Tight glycemic goals should be met before conception to reduce the risks of spontaneous abortions and fetal malformations. Medication alterations to improve safety during pregnancy should include discontinuation of oral hypoglycemic agents, statins, and angiotensin-converting enzyme (ACE) inhibitors. 9 references.

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Choosing an Insulin Regimen for Patients With Type 2 Diabetes. Clinical Diabetes. 26(2): 63-64. Winter 2008.

This article reports on a randomized, controlled study undertaken to compare three insulin regimens used for patients with type 2 diabetes: biphasic insulin aspart twice daily, prandial insulin aspart three times daily, or basal insulin detemir once daily—with the option of using twice daily if needed. Participants were 708 adult patients (64 percent male), with a mean age of 61.7 years, with type 2 diabetes, glycosylated hemoglobin (A1C) levels between 7 and 10 percent on oral hypoglycemic drugs, and a willingness and ability to inject insulin and perform self-monitoring of blood glucose (SMBG). Patients were recruited from 58 clinical centers in the United Kingdom and Ireland. After 52 weeks, the mean A1C was 7.3 percent for the biphasic insulin group; 7.2 percent for the group on prandial insulin; and 7.6 percent for basal insulin. Few patients achieved an A1C of less than 6.5 percent. Hypoglycemia was experienced more in the biphasic and prandial groups than in the basal insulin group; no severe hypoglycemia occurred. This article summarizes these research results, referring readers to the original publication of the study (Holman et al., New England Journal of Medicine, volume 357, 2007). The author provides a commentary about this study, supporting the work that helps clinicians determine appropriate insulin regimens for their patients with type 2 diabetes. The author cautions that the outcomes obtained in clinical care may differ from those achieved in the research setting, which included more structured patient assessment and follow-up. 2 references.

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Combined Therapy with Insulin Plus Oral Agents: Is There Any Advantage? An Argument in Favor. Diabetes Care. 31(Suppl 2): S125-S130. February 2008.

This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers the use of combined therapy with insulin plus oral agents for patients with type 2 diabetes. The authors describe an argument in favor of combined therapy in a recent debate examining the advantages and limitations of this approach. They describe the pharmacologic rationale for combining agents, present some new physiologic evidence for combining an oral agent with insulin, and offer a few examples of clinical studies showing advantages of combined therapy over insulin used alone. The authors conclude that, when oral therapy is continued during insulin therapy, enhancing either the availability or effectiveness of endogenous insulin, glycemic stability may improve and may lead to better overall glycemic control with similar hypoglycemic risk, or equal glycemic control with less hypoglycemia. In the case of metformin, combination with insulin limits the risk of weight gain. The authors call for additional, longer term medical outcome studies that compare insulin alone with insulin plus oral therapy. 5 figures. 28 references.

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Continuous Glucose Monitoring: The Future of Diabetes Management. Diabetes Spectrum. 21(2):112-119. Spring 2008.

This article brings readers up to date on continuous glucose monitoring (CGM), technology used to provide real-time information about interstitial fluid glucose levels as part of a diabetes management plan. CGM provides short-term feedback about the effectiveness of diabetes interventions such as insulin administration, and it provides warnings when glucose concentrations become dangerously high or low. The authors stress that CGM has made the attainment of near-normal blood glucose concentrations an achievable goal for most patients with diabetes. However, they note that several challenges remain to be addressed, including the high cost of the devices, limitations in approved clinical uses, and insurance coverage for the technology. The article reviews the strengths and weaknesses of current CGM technology and provides information about how these devices can best be used in clinical practice for the care of people with diabetes. The authors conclude that CGM can offer diabetes patients a major advance in improving glycosylated hemoglobin (A1C) values and reducing the occurrence of disruptive hypoglycemia. 3 figures. 2 tables. 20 references.

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Diabetes Technology During the Past 30 Years: A Lot of Changes and Mostly for the Better. Diabetes Spectrum. 21(2): 78-83. Spring 2008.

This article offers a critical review of the changes in technology in the field of diabetes care and management, including those in glucose measurement, insulin administration, and types of insulin. The author describes the technology and equipment but focuses more on issues of patient compliance and quality of life. The author stresses that diabetes is still all-encompassing, needing attention multiple times a day, whether it’s checking blood glucose levels, calculating each meal and snack, or remaining vigilant to symptoms of hypoglycemia. Technological advances have not eased this burden of managing diabetes. Other topics addressed include parent-child relations, the members of the patient care team, attempts to match insulin dosage to food intake, the need for mathematical skills on the part of patients or parents, self-monitoring of blood glucose (SMBG), point-of-care glycosylated hemoglobin (A1C) tests, analog insulins, insulin pumps, patient selection for new technologies, and the use of continuous glucose monitoring (CGM). 5 figures. 35 references.

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Dipeptidyl Peptidase-IV Inhibitors: Pharmacological Profile And Clinical Use. Clinical Diabetes. 26(2): 53-57. Spring 2008.

This article reviews a new category of medications, the dipeptidyl peptidase-IV (DPP-IV) inhibitors, notably sitagliptin, the first DPP-IV to be approved. Sitagliptin is approved for the management of hyperglycemia in patients with type 2 diabetes; a second agent, vildagliptin, is in the approval process. The DPP-IV agents accentuate the activity of endogenously produced antihyperglycemic incretin hormones, such as GLP-1, and are generally well tolerated. The author reviews the pharmacology and clinical use of these agents. Topics include clinical trials of these drugs; side effects, contraindications, and precautions; pharmacokinetics and drug interactions; and dosage and indications. The author concludes that DPP-IV inhibitors are a safe and effective method for modestly reducing hyperglycemia in patients with type 2 diabetes, without causing weight gain, significant hypoglycemia, or other major side effects. They are given orally and can be taken in a single daily dose. 1 table. 35 references.

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Early Patient and Clinician Experiences with Continuous Glucose Monitoring. Diabetes Spectrum. 21(2):128-133. Spring 2008.

This article reports on a study that evaluated data from a 12-week study of patients using the FreeStyle Navigator continuous glucose monitoring (CGM) system. The authors note that CGM can assist in overcoming some of the limitations of self-monitoring of blood glucose (SMBG) by providing the ability to track glucose levels 24 hours a day, observe glucose trends and patterns, and receive alarms or alerts for actual and impending hypoglycemia and hyperglycemia. In the study, the authors evaluated responses to questionnaires from both clinicians and patients. Topics include initial impression and ease of use, important features and benefits, data management software, patient compliance, overall experience, future purchase and usage of CGM devices, training materials and content, and individual versus group training. Clinicians noted the ability to train easily on the CGM system, and both patients and clinicians felt they were able to make more informed decisions on therapy adjustments based on information from the receiver and the data management reports. Patients liked the ability to make day-to-day decisions based on the 1-minute glucose readings, threshold and projected glucose alarms, and the glucose trend arrows that allowed them to observe the rate and direction of glucose change. The authors conclude that CGM can be a valuable adjunct to diabetes care but improvement in control depends on the willingness and ability of patients to use CGM information to modify their diabetes management. 3 figures. 1 table. 6 references.

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Executive Summary: Standards of Medical Care in Diabetes: 2008. Diabetes Care. 31(Suppl 1): S5-S11. January 2008.

This executive summary is from the special supplement issue of Diabetes Care journal that contains the latest update of the American Diabetes Association’s (ADA) major position statement, “Standards of Medical Care in Diabetes.” The position statement contains all of the ADA’s key recommendations, including national standards for diabetes self-management education (DSME). The executive summary outlines the revisions to the clinical practice recommendations made for 2008, covering the diagnosis of diabetes, testing for pre-diabetes and diabetes, testing for type 2 diabetes in children, the detection and diagnosis of gestational diabetes mellitus, the prevention or delay of type 2 diabetes, self-monitoring of blood glucose (SMBG), glycemic goals, medical nutrition therapy, DSME, physical activity, psychosocial assessment and care, hypoglycemia, immunization, hypertension control, dyslipidemia management, antiplatelet agents, smoking cessation, coronary heart disease (CHD), nephropathy, retinopathy, neuropathy, foot care, children and adolescents, preconception care, older adults, diabetes care in the hospital, diabetes care in schools and daycare settings, diabetes care at diabetes camp, diabetes management in correctional institutions, emergency and disaster preparedness, and third-party reimbursement. The standards are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. Targets that are desirable for most patients with diabetes are provided. The recommendations included are screening, diagnostic, and therapeutic actions known or believed to favorably affect health outcomes of patients with diabetes. For each recommendation, the ADA has assigned a letter grade that represents the level of supporting evidence.

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Glycemic Control and Hemoglobinopathy: When A1C May Not Be Reliable. Diabetes Spectrum. 21(1):46-49. Winter 2008.

This article, from a series that presents patient cases using an evidence-based practice framework, describes a situation in which glycosylated hemoglobin (A1C) measures may not be a reliable marker for glycemic control and hemoglobinopathy. The case patient was an 11-year-old African-American girl newly diagnosed with type 1 diabetes and Hashimoto’s thyroiditis, who was being followed up after her initial hospitalization for diabetic ketoacidosis 2 weeks previously. The author describes her medication compliance, symptoms, concerns about preprandial hypoglycemia, and vital signs. The review of the patient’s laboratory records show that A1C was not measured by the laboratory because of an abnormal hemoglobin peak. The author considers whether hemoglobinopathies affect the clinical reliability of A1C measurement and, if so, what alternate method of assessment should be used for monitoring these patients. The author reports the results of a literature review, discussing hemoglobinopathy in patients with diabetes, variation by laboratory method, assessment of glycemic control using fructosamine, and an evidence grading system for clinical practice recommendations. The author concludes with an overview of the case patient’s present situation and recommendations for improvement of care and ongoing measurement of the child’s blood glucose levels. 33 references.

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Glycemic Variability: Should We and Can We Prevent it?. Diabetes Care. 31(Suppl 2): S150-S154. February 2008.

This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, reviews the issue of blood glucose variability in patients with diabetes. The authors note that diabetes is characterized by glycemic disorders that include both sustained chronic hyperglycemia and acute glucose fluctuations. Ample evidence exists regarding the complications associated with chronic hyperglycemia, but there is less documentation about the role of glucose variability. The authors hypothesize that both upward, or postprandial, and downward, or interprandial, acute fluctuations of glucose around a mean value will activate the oxidative stress. They suggest that a comprehensive antidiabetes strategy should be aimed at reducing to a minimum the different components of dysglycemia, which can include A1C , fasting and postprandial glucose, as well as glucose variability. They conclude with a brief discussion of the newer treatment options including the glucagon-like peptide (GLP-1) agonists and the DPP-IV inhibitors that act through the incretin pathway. 2 figures. 36 references.

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Hyperinsulinemic Hypoglycemia Following Roux-en-Y Gastric Bypass Surgery. Practical Diabetology. 27(11): 10-18. March 2008.

This article describes the problem of hyperinsulinemic hypoglycemia following Roux-en-Y gastric bypass (RYGB) surgery for obesity. The RYGB procedure combines a restrictive and malabsorptive approach to reduce caloric intake. The authors briefly review issues of patient selection, the surgery itself, and peri- and postoperative complications. They present two case series of patients who developed hyperinsulinemic hypoglycemia 1 to 2 years after their RYGB procedure. They describe nesidioblastosis, defined as excessive function of pancreatic beta cells, and hypoglycemia, including the pathophysiology of these conditions, their interplay, presentation and differential diagnosis, diagnostic tests, and treatment approaches. The authors caution that symptoms resemble dumping syndrome, so clinicians must remain cognizant of the possibility of hyperinsulinemia in this patient population. Treatment consists of dietary and pharmacologic therapies that aim to blunt the insulin response to meals or inhibit insulin secretion altogether. After dietary strategies, drug therapies are used, notably alpha-glucosidase inhibitors such as acarbose or miglitol. If a patient cannot tolerate or is refractory to medical therapy, surgical intervention in the form of a partial pancreatectomy is the next step. 8 figures. 4 references.

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Hypoglycemia And Employment/Licensure. Diabetes Care. 31(Suppl 1): S94. January 2008.

This brief position statement on hypoglycemia and employment or licensure is from the special supplement issue of Diabetes Care journal that contains the latest update of the American Diabetes Association’s (ADA) major position statement, “Standards of Medical Care in Diabetes.” Selected position statements are provided about certain topics not adequately covered in the standards. This position statement reprints the 1984 ADA policy on employment, which states that “any person with diabetes, whether insulin dependent or non-insulin dependent, should be eligible for any employment for which he/she is otherwise qualified.” The position statement notes that discrimination in employment and licensure against people with diabetes still occurs. The effects of diabetes, notably hypoglycemia, are unique to each individual. The position statement considers the incidence and impact of hypoglycemia on daily activities, concluding that people with diabetes should be individually considered for employment based on the requirements of the specific job. Factors to be considered in this decision should include the individual’s medical condition, treatment regimen, and medical history. 1 reference.

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Hypoglycemia in Type 1 Diabetes: A Still Unresolved Problem in the Era of Insulin Analogs And Pump Therapy. Diabetes Care. 31(Suppl 2): S121-S124. February 2008.

This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers the problem of hypoglycemia in patients with type 1 diabetes. The authors remind readers of the benefits of tight blood glucose control, in terms of reducing long-term complications of diabetes, but note that strict control carries an increased risk of severe hypoglycemia. Recurrent episodes of hypoglycemia, especially at young ages, can lead to hypoglycemia unawareness, can exert adverse effects on neurocognitive function, and can cause significant emotional morbidity in the child and parents. The authors discuss hypoglycemia and insulin analog therapy, as well as hypoglycemia in patients using continuous subcutaneous insulin infusion—CSII or insulin pumps—therapy. They note that, unfortunately, the newer modalities have not resulted in the expected drop in rates of hypoglycemic episodes. The authors conclude with a brief discussion of the ideal solution, an “artificial pancreas,” noting that the technology required for such a device is still under development. 42 references.

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Insulin And Incretins. Clinical Diabetes. 26(1): 35-39. Winter 2008.

This article is part of a 12-part series for physicians in training that reviews the fundamentals of diabetes care; this article summarizes the use of insulin and Incretins. The author notes that insulin has been combined with additives and modified at the molecular level to changes its pharmacokinetic properties. Some insulin preparations accelerate insulin’s effects in the bloodstream, and others prolong the pharmacokinetic profile. The author describes specific drugs, including regular insulin, insulin analogs, inhaled insulin, protamine solutions, zinc solutions, and long-acting insulin analogs, including glargine and detemir. The article outlines standard insulin regimens, newer insulin regimens, the approach to initiating insulin therapy, and the use of incretins, such as exenatide, and the amylin analog, pramlintide. The author emphasizes that good understanding of the pharmacokinetics of insulin action and proper management on insulin regimens allow health care providers and patients to control blood glucose levels and safely avoid hypoglycemia and hyperglycemia. 32 references.

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Insulin as a First-Line Therapy in Type 2 Diabetes: Should the Use of Sulfonylureas be Halted?. Diabetes Care. 31(Suppl 2): S136-S139. February 2008.

This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers the use of insulin as a first-line therapy in patients with type 2 diabetes, supplanting the use of sulfonylurea compounds. The authors explore the advantages and drawbacks to each therapy, focusing on the evidence base, the limitations of present information, other treatment options, pathogenesis, and the impact of specific drug regimens on cardiovascular disease (CVD). The authors conclude that it is not easy to recommend a simple treatment regimen for patients with type 2 diabetes, and the complexities are not only based on whether or not insulin should be a first-line therapy. They stress that appropriate therapy of type 2 diabetes needs to be highly individualized, taking contraindications and potential downsides of treatment options into account and trying to define and target the leading pathogenetic defects behind the prevailing metabolic phenotype. Cost considerations must be figured into the decision. A patient care algorithm for the management of hyperglycemia in type 2 diabetes is presented. 1 figure. 23 references.

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Intensive Insulin Therapy for the Critically Ill Patient. IN: Vanhorebeek, I.; Van den Berghe, G. Controversies in Treating Diabetes: Clinical and Research Aspects. Totowa, NJ: Humana Press. 2008. pp 157-178.

This chapter about intensive insulin therapy for the critically ill patient is from a book that addresses diabetes controversies, specifically in the etiology and management of the disease. The authors of this chapter consider the clinical complications associated with critical illness (CI), hyperglycemia in CI, blood glucose control with intensive insulin therapy in CI, the risk of hypoglycemia, the mechanism by which intensive insulin therapy achieves blood glucose control, and mechanisms explaining the improved outcome with intensive insulin therapy in these CI patients. The authors conclude that the simple metabolic intervention of maintaining normal blood glucose levels with intensive insulin therapy improves the survival of critically ill patients and reduces morbidity. Both strict glycemic control itself and other metabolic and nonmetabolic effects of the insulin administered contribute to these benefits. 3 figures. 101 references.

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Joslin's Insulin Deskbook: Designing And Initiating Insulin Treatment Programs. Boston, MA: Joslin Diabetes Center. 138 p.

This handbook helps health care providers understand the complexities of insulin therapy for their patients with diabetes. The book contains three key chapters from the larger Joslin's Diabetes Deskbook, which discuss insulin and its use in the clinical arena. The first chapter reviews the general principles of insulin therapy, covering endogenous insulin; insulin for exogenous therapy; insulin purity; insulin types, brands, and modes of delivery; insulin antibodies; insulin allergy; storage considerations; syringes and other injection devices; syringe preparation techniques; injection techniques; common mixtures; insulin pens; automatic injection aids and jet injectors; injection aids for people with low vision; injection sites; syringe reuse; and disposal of syringes. Chapter 2 walks readers through the design of a conventional insulin treatment program. Topics include the indications for insulin therapy in type 1 diabetes and in type 2 diabetes; the goals of insulin treatment; glucose monitoring programs for patients using insulin; the initiation of insulin therapy for type 1 diabetes, including choosing and designing an appropriate program; the initiation of insulin therapy for type 2 diabetes; the implications of insulin quality; specific insulin regimens; intensified conventional therapy; modifying the insulin treatment program; rebound hyperglycemia; and adjustment guidelines. The final chapter addresses physiologic insulin treatment programs, including patient selection, replacement therapy, estimating starting doses, descriptions of basal insulin patterns, preparing patients to start physiologic insulin, the health care providers most appropriate for managing replacement therapy, treatment adjustments, coping with hyperglycemia and hypoglycemia, weight gain and loss on physiologic insulin, insulin pump therapy, complications of insulin therapy, exercise and sick day adjustments, going off the insulin pump, and the role of pramlintide. Each chapter is illustrated with line drawings and tables.

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Long-Acting Insulin Analogs Versus Insulin Pump Therapy for the Treatment of Type 1 And Type 2 Diabetes. Diabetes Care. 31(Suppl 2): S140-S145. February 2008.

This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, reports on the use of long-acting insulin analogs versus insulin pump therapy for the treatment of patients with either type 1 or type 2 diabetes. The authors consider whether multiple daily injection (MDI) regimens based on new long-acting insulin analogs such as glargine and detemir have now replaced the need for continuous subcutaneous insulin infusion (CSII). They discuss hypoglycemia, elevated glycosylated hemoglobin (A1C ) levels and glycemic variability, the dawn phenomenon, the problems of poor control in type 2 diabetes, and CSII as a management strategy in type 2 diabetes. They conclude that long-acting insulin analogs have not yet replaced the need for insulin pump therapy in type 1 diabetes, and CSII is the best current treatment option for some people with type 1 diabetes. In type 2 diabetes, CSII and MDI produce similar glycemic control, although there is little research on the use of MDI based on long-acting analogs compared with insulin pumps. 4 figures. 2 tables. 47 references.

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Managing Preexisting Diabetes for Pregnancy: Summary of Evidence And Consensus Recommendations for Care. Diabetes Care. 31(5): 1060-1079. May 2008.

This article presents consensus panel recommendations for the medical care of pregnant women with preexisting diabetes, including type 1 and type 2 diabetes. The document is designed to help clinicians deal with the broad spectrum of problems that arise in the management of diabetes before and during pregnancy, and to prepare women with diabetes for treatment that may reduce complications in the years after pregnancy. Guidelines are presented in two sections. The first section addresses managing preexisting diabetes for pregnancy, including the organization of preconception and pregnancy care, initial evaluation, glycemic control, perinatal outcome and glycemic goals, assessment of metabolic control, medical nutrition therapy, insulin therapy, oral antihyperglycemic agents for type 2 diabetes, physical activity and exercise, and behavioral therapy. The second section covers the management of diabetes complications, including diabetic ketoacidosis (DKA), maternal hypoglycemia, thyroid disorders, management of cardiovascular risk factors, screening for cardiovascular disease (CVD), hypertension, diabetic nephropathy, diabetic retinopathy, and diabetic neuropathies. Practical suggestions, including recommended laboratory values and goals, are highlighted. The recommendations for diagnostic and therapeutic actions are based on a grading system adapted by the American Diabetes Association that was used to clarify and codify the research evidence available.

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Nuts And Bolts of Achieving End Points with Real-Time Continuous Glucose Monitoring. Diabetes Care. 31(Suppl 2): S146-S149. February 2008.

This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, reviews the basics of using real-time continuous glucose monitoring (RT-CGM) as a component of comprehensive diabetes management. The author cautions that RT-CGM is most appropriate in patients who are skilled in diabetes self-management. Training issues include the implications of the physiologic lag between interstitial and capillary blood glucose levels, as well as the increased risk among RT-CGM users for hypoglycemia related to blind postprandial bolusing. Patients must understand the importance of calibrating their equipment during steady-state conditions to improve sensor accuracy. In addition, they need to use fingerstick measurements for treatment decision making when the glucose level is changed rapidly. The author notes that consideration of “insulin on board” and the impact of the glycemic index of different foodstuffs on postprandial glucose patterns can help minimize the risk for hypoglycemia from supplemental boluses taken to correct postprandial hyperglycemia. The article includes colorful figures that help readers learn to translate the data received from RT-CGM. 4 figures. 9 references.

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Physiologic Insulin Treatment Programs. IN: Beaser, R.S. Joslin's Insulin Deskbook: Designing And Initiating Insulin Treatment Programs. Boston, MA: Joslin Diabetes Center. pp 77-134.

This chapter is from a handbook that helps health care providers understand the complexities of insulin therapy for their patients with diabetes. The author addresses physiologic insulin treatment programs, including patient selection, replacement therapy, estimating starting doses, descriptions of basal insulin patterns, preparing patients to start physiologic insulin, the health care providers most appropriate for managing replacement therapy, treatment adjustments, coping with hyperglycemia and hypoglycemia, weight gain and loss on physiologic insulin, insulin pump therapy, complications of insulin therapy, exercise and sick day adjustments, going off the insulin pump, and the role of pramlintide. The author concludes by cautioning that developing a proper routine for, and method of, physiologic insulin replacement therapy takes time and effort. Developing a routine requires a major, long-term commitment on the part of the patient and medical and educational support from a skilled health care team. The chapter is illustrated with line drawings and tables. Readers are referred to the more comprehensive Joslin's Diabetes Deskbook: A Guide for Primary Care Providers for more information. 8 figures. 1 table.

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Prevention of Hypoglycemia While Achieving Good Glycemic Control in Type 1 Diabetes: The Role of Insulin Analogs. Diabetes Care. 31(Suppl 2): S113-S120. February 2008.

This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers the prevention of hypoglycemia while achieving good glycemic control in patients with type 1 diabetes. The authors focus on the role of insulin analogs as a tool to achieve good glycemic control and prevent hypoglycemia. Topics include the physiology of plasma glucose homeostasis, a definition of hypoglycemia, the frequency of hypoglycemia, normal responses to hypoglycemia and their pathophysiology in diabetes, antecedent hypoglycemia as a primary cause of hypoglycemia unawareness, the mechanisms of hypoglycemia unawareness, the benefits of insulin analogs versus human nonmodified insulin, and regimens of multiple daily injections and continuous subcutaneous insulin infusion (CSII). Now that soluble long-acting insulin analogs are available, multiple daily injections are no longer considered inferior to CSII in terms of A1C and frequency of hypoglycemia. The authors conclude that, when combined with appropriate patient education and motivation of the subjects with type 1 diabetes, insulin regimens based on insulin analogs—either multiple daily injections or CSII—can successfully achieve appropriate glycemic targets, thus protecting against the risk of long-term complications; prevent hypoglycemia unawareness; and improve quality of life. 3 figures. 76 references.

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Standards of Medical Care in Diabetes: 2008. Diabetes Care. 31(Suppl 1): S12-S54. January 2008.

This section is from the special supplement issue of Diabetes Care journal that contains the latest update of the American Diabetes Association’s (ADA) major position statement, “Standards of Medical Care in Diabetes.” These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. Targets that are desirable for most patients with diabetes are provided. The recommendations included are screening, diagnostic, and therapeutic actions known or believed to favorably affect health outcomes of patients with diabetes. For each recommendation, the ADA has assigned a letter grade that represents the level of supporting evidence. Standards of care are categorized into 11 sections: classification and diagnosis; testing for pre-diabetes and diabetes in asymptomatic patients; detection and diagnosis of gestational diabetes mellitus (GDM); the prevention or delay of type 2 diabetes; diabetes care, including medical nutrition therapy (MNT) and diabetes self-management education (DSME); the prevention and management of diabetes complications, including hypertension, cardiovascular disease, dyslipidemia, nephropathy, retinopathy, neuropathy, and foot care; diabetes care in specific populations, including children, adolescents, and older adults; diabetes care in specific settings, such as hospitals, schools, daycare settings, diabetes camps, and correctional institutions; hypoglycemia and employment/licensure; third-party reimbursement for diabetes care, self-management education, and supplies; and strategies for improving diabetes care. 15 tables. 332 references.

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Treatment of Type 2 Diabetes with Combined Therapy: What Are the Pros and Cons?. Diabetes Care. 31(Suppl 2): S131-S135. February 2008.

This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers the advantages and limitations of the treatment of type 2 diabetes with combination therapy. The authors recommend a stepwise approach for the treatment of type 2 diabetes, tailored according to the natural course of the disease, including adding insulin when hypoglycemic oral agents fail. They stress that treatment with insulin alone should eventually be considered in a relevant number of cases. Insulin can result in protective effects on beta-cell survival and function, resulting in more stable metabolic control. In comparison, treatment with most insulin secretagogues has been associated with increased beta-cell apoptosis, reduced responsiveness to high glucose, and impairment of myocardial function during ischemic conditions. Insulin treatment, particularly with rapid-acting analogs, has been demonstrated to successfully control postprandial hyperglycemia. The authors voice a final concern about combination regimens in the evidence that polypharmacy can reduce patient compliance to the treatment regimen. 56 references.

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Understanding Insulin And Amylin. 3rd ed. Timonium, MD: Milner-Fenwick. 2008. (DVD).

This DVD program reviews how insulin works in the body and how it can be used to help people with diabetes keep their blood glucose levels in a healthy range. The program introduces amylin, another pancreatic hormone, and explains how taking the drug pramlintide (Symlin) can help people who use insulin maintain greater control of their blood glucose levels. Other topics include insulin and amylin safety, storage, recordkeeping, hypoglycemia, and how to handle sick days. Viewers are reminded of the importance of a comprehensive self-management plan for keeping diabetes under control. The video depicts a variety of people who share their experiences with diabetes management, insulin use, and pramlintide use. Simple graphics are used to explain most of the topics covered. Viewers are referred to the American Association of Diabetes Educators website for more information and to find a local diabetes educator.

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Understanding Insulin. 3rd ed. Timonium, MD: Milner-Fenwick. 2008. (DVD).

This DVD program describes insulin and how it is used by people with diabetes to help keep their blood glucose levels in a healthy range. The program discusses insulin’s mechanism of action and the onset, peak, and duration of different types of insulin. Other topics include insulin safety, storage recommendations, hypoglycemia, and coping with sick days. Viewers are reminded of the importance of a comprehensive self-management plan for keeping diabetes under control. The video depicts a variety of people who share their experiences with diabetes management and insulin use. Simple graphics are used to explain most of the topics covered. Viewers are referred to the American Association of Diabetes Educators website for more information and to find a local diabetes educator.

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Use of Continuous Glucose Monitoring to Evaluate the Glycemic Response to Food. Diabetes Spectrum. 21(2): 134-137. Spring 2008.

This article considers the use of continuoug glucose monitoring (CGM) to evaluate the glycemic response to food in patients with diabetes. CGM can be used to track glucose levels 24 hours a day, observe glucose trends and patterns, and send alarms or alerts for actual and impending hypoglycemia and hyperglycemia. Glucose values, trend arrows, line graphs, and alarms viewed on the device screen provide real-time perspective. The authors discuss factors affecting postprandial glycemia (PPG), how to evaluate personal glycemic responses to food, PPG response to mixed meals, prandial insulin dosing, timing of the meal bolus, different types of boluses, and insulin sensitivity determined with CGM. The authors conclude by supporting the use of CGM for clinicians and patients to more effectively and easily evaluate the patient’s glycemic response to various types of foods and meals. This information gives patients the ability to more effectively adjust prandial insulin and lifestyle therapy based on their food choices. However, clinicians must take the responsibility for training patients in how to interpret the data and make appropriate decisions. 3 figures. 11 references.

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Acute Complications of Diabetes. IN: Scobie, I.N. Atlas of Diabetes Mellitus. 3rd ed. New York, NY: Informa Healthcare USA. 2007. pp 63-68.

This chapter about the acute complications of diabetes is from an atlas of diabetes mellitus that offers text and pictures to familiarize clinicians with the most current information about diabetes and its diagnosis and treatment. The volume portrays the wide and varied expressions of diabetes and its complications as an aid to their more ready recognition in clinical practice. This chapter discusses hypoglycemia, diabetic ketoacidosis, and hyperosmolar nonketoacidotic coma. The chapter offers full-color photographs and figures representing these same topics, including the symptoms of hypoglycemia in diabetes, brain activation in patients with hypoglycemia, the biochemical features of diabetic ketoacidosis, the causes of death in diabetic ketoacidosis, and the biochemical features of diabetic hyperosmolar nonketotic coma. 5 figures. 5 references.

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Advances and Emerging Opportunities in Type 1 Diabetes: A Strategic Plan. Nephrology News & Issues. 21(3): 28-31. February 2007.

Type 1 diabetes develops as a consequent of the body’s failure to produce insulin and is associated with an array of microvascular complications such as kidney and eye disease, macrovascular complications such as cardiovascular and peripheral vascular disease, and neuropathy. The National Institutes of Health (NIH) recently announced the Type 1 Diabetes Research Strategic Plan (www.T1Diabetes.nih.gov/plan), designed to guide research in type 1 diabetes for the next decade. This article reviews this plan, describing the key objectives that will guide NIH efforts to achieve six goals: identify the genetic and environmental causes of type 1 diabetes, prevent or reverse type 1 diabetes, develop cell replacement therapy, prevent or reduce hypoglycemia in type 1 diabetes, prevent or reduce the complications of type 1 diabetes, and attract new talent and apply new technologies to research on type 1 diabetes. The author notes that, as the leading cause of kidney failure and blindness in the United States and a major contributor to cardiovascular disease and early death, diabetes is a disease deserving of further intensive research to identify its causes, prevention, management, and, ultimately, its cure. 2 references.

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American Diabetes Clinical Practice Recommendations 2007. Diabetes Care. 30 (Suppl 1): S1-S103. January 2007.

This supplement to the Diabetes Care journal contains the American Diabetes Association’s (ADA) Standards of Medical Care in Diabetes, the major position statement of the organization. In addition, this issue includes selected position statements on certain topics not adequately covered in the Standards of Medical Care in Diabetes. The introductory materials explain the differences between a position statement, an ADA statement, a technical review, and a consensus statement. The position statements included are: Standards of Medical Care in Diabetes, 2007; the Diagnosis and Classification of Diabetes Mellitus; Nutrition Recommendations and Interventions for Diabetes; Diabetes Care in the School and Day Care Setting; Diabetes Care at Diabetes Camps; Diabetes Management in Correctional Institutions; Hypoglycemia and Employment or Licensure; and Third-Party Reimbursement for Diabetes Care, Self-Management Education, and Supplies. The supplement also includes a list of technical reviews, committee reports and consensus statements, a list of position statements and ADA statements, and the National Standards for Diabetes Self-Management Education. Each standard includes a statement of the problem, and then lists recommendations; relevant references are also included.

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Are You Low? Hypoglycemia Unawareness. Diabetes Forecast. 60(2): 25-27. February 2007.

This patient education article helps readers understand hypoglycemia unawareness, a condition that can develop over time in patients with diabetes. In hypoglycemia unawareness, the patient stops having symptoms of low blood glucose and thus cannot know when they need to treat their hypoglycemia. Typical symptoms of hypoglycemia include shakiness, nervousness, dizziness, hunger, lightheadedness, increased heartbeat, sweating, headache, problems with concentration, confusion, clumsiness, heightened emotions, and nausea. The article reminds readers of how to treat hypoglycemia and of the importance of treating the condition right away to prevent going into a coma. People who develop hypoglycemia unawareness tend to be people who have had diabetes for several years. Readers are encouraged to consult with their health care providers if they experience hypoglycemia episodes without any warning or symptoms ahead of time. A final section presents suggestions for people who have hypoglycemia unawareness to help them avoid episodes of hypoglycemia. 1 figure.

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Assessing Glycemic Control Using Home Blood Glucose Monitoring, Continuous Glucose Sensing, and Glycated Hemoglobin (A1C) Testing. IN: Unger, J. Diabetes Management in Primary Care. Philadelphia, PA: Lippincott Williams and Wilkins. 2007. p. 321-362.

Self blood glucose monitoring (SMBG) allows patients to take charge of their own diabetes management. This chapter about SMBG, continuous glucose sensing, and glycated hemoglobin (A1C) testing is from a textbook that offers primary care physicians evidence-based guidelines for evaluating and treating all patients with diabetes. In this chapter, the author discusses blood glucose meters and computer-based data management systems, the link between glycemic variability and long-term diabetes-related complications, glycated hemoglobin testing, improving the utility of SMBG, and the role of continuous glucose monitoring. The author emphasizes that both the chronic and sustained levels of hyperglycemia, as well as the acute daily fluctuations of glucose levels, are important factors in managing diabetes. The degree of chronic hyperglycemia is determined by A1C testing. The chapter includes a list of “take-home points” that summarize the concepts discussed, as well as case reports that illustrate the topics covered. 17 figures. 4 tables. 38 references.

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Bronx Bilingual Diabetes Education Address Diversity: Spanish-English Diabetes Education Program Reflects Community Needs. Diabetes Educators Handbook. p. 18. July 2007.

This brief article describes a bilingual, Spanish-English diabetes education program in the Bronx, New York, which addresses diversity and reflects community needs. The author notes that knowledge of nutrition and diabetes self-management can be particularly problematic in communities where many of the people do not speak English as their native language. This program supports the needs of the bilingual community by providing classes in two languages and concentrating on hands-on activities to enhance learning. Program goals include assisting the patient in moving from information to action, tackling nutrition labels, identifying signs and symptoms of hypoglycemia and hyperglycemia, managing multiple medications, and preparing for doctor visits. The program uses the down time while patients are waiting to see the physician, as well as 2-hour diabetes education classes, as the basic opportunities for education. One sidebar lists a few possible teaching approaches to enhance learning.

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Case Study: Diagnostic Dilemma in a Patient With Insulinoma. Clinical Diabetes. 25(4): 152-154. Fall 2007.

This article presents a case study of a diagnostic problem in a person with insulinoma. The patient was a 70-year-old woman who was referred to the diabetes clinic for work-up for hypoglycemia. She had known coronary artery disease (CAD) and had had a coronary artery bypass graft. Her symptoms included fatigue and some depression. Despite very low blood glucose levels, the woman had hypoglycemia unawareness. The authors describe the various diagnostic tests used to evaluate this woman, including the need for three fasting studies and repeated drug screens. A magnetic resonance imaging (MRI) and angiogram of the abdomen finally showed a 1.6 centimeter enhancing mass at the head of the pancreas. Surgical excision was recommended for curative treatment, and the surgical pathology was consistent with insulinoma. In follow-up, the woman had mild hyperglycemia, suggesting that the insulinoma may have been masking mild type 2 diabetes. The authors review the symptoms of hypoglycemia, offer suggestions for the work up of hypoglycemia, consider why one of the sulfonylurea drug screen came back positive in this woman, and discuss the best imaging modalities for the diagnosis of insulinoma. 2 tables. 8 references.

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Case Study: Exercise-Related Hypoglycemia in Type 2 Diabetes Treated With Oral Glucose-Lowering Medications. Clinical Diabetes. 25(4): 150-151. Fall 2007.

This article presents a case of exercise-related hypoglycemia in a person with type 2 diabetes who was being treated with oral glucose-lowering medications. The case is a 58-year-old African-American man who was diagnosed with type 2 diabetes at the age of 52 years. In addition to diabetes, he had a history of hypertension and coronary artery disease (CAD). The man had completed 2 months of supervised exercise when he returned to his primary care physician after experiencing hypoglycemia both during and after exercise. He was exercising three mornings per week from 7:30 a.m. to 8:30 a.m. in the rehabilitation program and was walking 30 to 45 minutes on weekend days. The author describes the changes in medication that the man followed, notably discontinuing glyburide and initiating glimepiride; his metformin dosage did not change. Follow up demonstrated that his blood glucose values during and after exercise were subsequently within his target range. The author discusses how metabolic adaptations to exercise contribute to improved glycemic control and reduced cardiovascular risk factors in type 2 diabetes, how these adaptations contribute to the development of hypoglycemia in individuals treated with sulfonylureas, and why medication adjustments are the first option to consider when a pattern of exercise-related hypoglycemia occurs. 6 references.

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Comparing Oral Medications for Adults With Type 2 Diabetes: Clinician’s Guide. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ). 2007. 4 p.

This guide helps clinicians understand the current thinking on oral hypoglycemia agents used for adult patients with type 2 diabetes. The guide summarizes evidence from both observational studies and controlled trials that compare the effectiveness and safety of oral hypoglycemia agents. Standard oral hypoglycemic regimens include single drugs and combinations of two or three drugs from different classes, such as metformin and a sulfonylurea. Choosing among available oral hypoglycemia agents requires consideration of their benefits as well as their adverse effects and cost. The dose and prices of the drugs reviewed in the comparative studies are listed on the back page. As single agents, all second-generation sulfonylureas, thiazolidinediones, metformin, and repaglinide work well to reduce hemoglobin A1C levels by about 1 percentage point on average. Combination therapies reduce HbA1c levels about 1 percentage point more than single drug therapies. People taking sulfonylureas, thiazolidinediones, and repaglinide gain about 2 to 10 pounds. Metformin does not cause weight gain. This guide does not address insulin, combining oral medications with insulin, older first-generation sulfonylureas, or the new class of DPP-4 inhibitors. Readers are encouraged to consult the Agency for Healthcare Research and Quality’s website at www.effectivehealthcare.ahrq.gov for more information.

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Considerations for the Pharmacological Treatment of Diabetes in Older Adults. Diabetes Spectrum. 20(4): 329-247. Fall 2007.

This article reviews the normal physiological and pharmacodynamic changes of aging and relates this information to the process of making good therapeutic decisions for the pharmacological treatment of diabetes in older adults. The authors discuss the evidence basis for treatment of older adults, or the lack of said evidence, and suggest a general approach to therapy. They note that aging is associated with defects in glucose metabolism and utilization. The primary risk of aggressive diabetes treatment in older adults is hypoglycemia. However, this can often be successfully managed with careful monitoring and effective communication between health care providers and patients. One detailed chart lists specific drugs commonly used by people with type 2 diabetes, along with hepatic, renal, and geriatric considerations for the use of these drugs. Drugs included are metformin, glimeperide, glipizide, glyburide, repaglinide, nateglinide, acarbose, miglitol, pioglitazone, rosiglitazone, sitagliptin, exenatide, and pramlintide. The authors recommend the use of a four-step approach to older adults with type 2 diabetes: achievement of glycemic goals; initial therapy with lifestyle and metformin; rapid addition of medications when goals are not met; and early addition of insulin therapy when glycemic goals are not met. 1 figure. 2 tables. 42 references.

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Contribution of Medications to Hypoglycemia Unawareness. Diabetes Spectrum. 20 (2): 77-80. Spring 2007.

This article reviews hypoglycemia unawareness and summarizes the effects of medications that may influence a patient’s perception of their own hypoglycemia. The author notes that much is known regarding risk factors, biochemical causes, and populations at greatest risk for the development of hypoglycemia unawareness. The article begins by discussing hypoglycemia counterregulation, the role of insulin, and the symptoms of hypoglycemia. The author then considers the effects of specific medication groups on hypoglycemia unawareness, including beta-adrenergic antagonists, beta-adrenergic agonists, methylxanthines, and selective serotonin reuptake inhibitors (SSRIs). Beta blockers may have a slight moderating effect on the adrenergic symptoms of hypoglycemia; as they are also reasonable choices for the management of hypertension and for their cardioprotective effects in patients with diabetes, they should not be discouraged. Beta-adrenergic agonists, methylxanthines, and the amino acid alanine may cause an upregulation of hypoglycemia awareness and should be studied further. SSRIs should be used in patients with diabetes when the risk-benefit considerations include the possibility of reduction in hypoglycemia awareness. 1 figure. 1 table. 21 references.

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Counterregulatory Deficiencies in Diabetes. IN: Frier, B. and Fisher, M., eds. Hypoglycaemia in Clinical Diabetes. 2nd ed. Somerset, NJ: John Wiley & Sons. 2007. pp 121-140.

This chapter on counterregulatory deficiencies in diabetes is from a textbook that provides in-depth information for the understanding and management of hypoglycemia in clinical diabetes care. The authors discuss normal glucose counterregulation; defective hormonal glucose counterregulation; the role of glucagon, catecholamines, cortisol, and growth hormone; mechanisms of counterregulatory failure; the systemic mediator theory; brain fuel transport; brain metabolism; the impact of age and obesity on glucose counterregulation; human insulin and counterregulation; and treatment of counterregulatory failure. They conclude that people with diabetes almost inevitably lose their ability to release glucagon in response to a fall in blood glucose within 5 years of diagnosis. After 10 years, a significant proportion of patients has deficient epinephrine responses and is at increased risk of more protracted hypoglycemia and neuroglycopenia. 12 figures. 67 references.

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Current and Future Perspectives on the Role of Hormonal Interplay in Glucose Homeostasis. Diabetes Educator. 33 (Suppl 2): S32-S46. February 2007.

This special supplement to the Diabetes Educator journal provides a continuing education program on the role of hormonal interplay in glucose homeostasis. This program was first presented at the American Association of Diabetes Educators' (AADE) 2006 Annual Meeting in Los Angeles, CA. The program covers the physiology of glucose regulation and describes various barriers to achieving glycemic control, including patients' fear of insulin-induced hypoglycemia, inadequate postprandial glucose control, excessive glucose fluctuations, and unwanted weight gain. The authors then provide clinical trial data that demonstrate the effectiveness and safety of pramlintide, a synthetic analog of human amylin, that is used in conjunction with insulin to help overcome these obstacles to normalizing glucose levels in patients with type 1 or type 2 diabetes. Pramlintide has been administered to more than 5,300 individuals in clinical studies, leading to its approval by the Food and Drug Administration (FDA). The authors conclude that appropriate patient selection, careful patient instruction, and insulin dose adjustments help reduce the increased risk of insulin-induced severe hypoglycemia that has been associated with pramlintide use. The document includes a posttest with which readers can qualify for continuing education credits for nurses, dietitians, or pharmacists. 14 figures. 4 tables. 28 references.

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Diabetes Care at Diabetes Camps. Diabetes Care. 30 (Suppl 1): S74-S76. January 2007.

The mission of camps specialized for children and youth with diabetes is to facilitate a traditional camping experience in a medically safe environment. This supplement to the Diabetes Care journal contains the American Diabetes Association’s (ADA) Standards of Medical Care in Diabetes, the major position statement of the organization. This section of the supplement presents a position statement on Diabetes Care at Diabetes Camps. Readers are reminded that camps are also designed to enable children with diabetes to meet and share their experiences with one another while they learn to be more responsible for their condition. Topics covered include daily diabetes management at camp, medical staff composition and staff training, the treatment of diabetes-related emergencies such as hypoglycemia and ketosis, the use of a written camp management plan, diabetes education and psychological issues at camp, and clinical research projects conducted at diabetes camps. 10 references.

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Diabetes Management in Correctional Institutions. Diabetes Care. 30 (Suppl 1): S77-S84. January 2007.

There are approximately 80,000 inmates incarcerated in prisons and jails in the United States who have diabetes—prevalence of 4.8 percent of the total incarcerated population. This supplement to the Diabetes Care journal contains the American Diabetes Association’s (ADA) Standards of Medical Care in Diabetes, the major position statement of the organization. This section of the supplement presents a Position Statement on Diabetes Management in Correctional Institutions. The Statement emphasizes that people with diabetes in correctional facilities should receive care that meets national standards. Diabetes management is based on having access to needed medical personnel and equipment, particularly for self-management of diabetes. This Statement provides a general set of guidelines for diabetes care in correctional institutions, not an overall diabetes management manual. Topics include the intake medical assessment, including the components of reception screening, intake screening, intake physical examination, and laboratory tests; screening for diabetes; a management plan; nutrition and food services; urgent and emergency issues, including hyperglycemia and hypoglycemia; medication; the routine screening for and management of diabetes complications; blood glucose monitoring and other tests of glycemia; self-management education; staff education; alcohol and drugs; transfer and discharge; sharing of medical information and records; children and adolescents with diabetes; and pregnancy. 1 figure. 2 tables. 15 references.

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Diabetes Medications Supplement: Working Together to Manage Diabetes. Rev. ed. Bethesda, MD: National Diabetes Education Program. 2007. 8 p.

This medication supplement guide is to help health care professionals understand the medications commonly used for people with diabetes. The guide consists of nine detailed charts: oral agents used to treat type 2 diabetes; oral agents with glucose-lowering activity; insulins; recommended storage for different types of insulin; incretins and amylins; hypoglycemia treatment, notably glucagon; recommended control measures; medications to lower high blood pressure; and medications for the treatment of dyslipidemia. Most of the charts include the drug category, generic name and brand name of the drug, recommended dosage limits, side effects, and special considerations. The insulin chart notes type of insulin, onset of action, peak of action, effective duration, maximal duration, and comments for each type. Readers are referred to the National Diabetes Education Program (NDEP) contact sites at 1–800-438-5383 or www.ndep.nih.gov for more information.

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Diabetic Encephalopathy. IN: Veves, A.; Malik, R.A., eds. Diabetic Neuropathy: Clinical Management. 2nd ed. Totowa, NJ: Humana Press. 2007. pp 187-205.

This chapter on diabetic encephalopathy is from a comprehensive textbook that provides general practitioners details on the latest techniques for the clinical management of diabetic neuropathy. The author notes that diabetes and its treatments are associated with both functional and structural disturbances in the brain. Acute disturbances, related to acute hypoglycemia or hyperglycemia and stroke, are not covered in this chapter. The author focuses on changes in cerebral function and structure that develop more insidiously. The term diabetic encephalopathy is used to encompass functional impairment of cognition, cerebral signal conduction, neurotransmission and synaptic plasticity, and underlying structural pathology associated with diabetes. The author reviews relevant animal studies, focusing on the cellular and molecular events that underlie changes in cognition. The author also reviews human studies, providing an overview of the nature and severity of the changes in cognition that occur in diabetes; neurophysiological and neuroimaging studies of patients with diabetes are covered. The chapter concludes with a practical guide for the clinical care of a person with diabetes who has complaints of cognitive dysfunction. As with other diabetes complications, the maintenance of adequate glycemic control while avoiding hypoglycemia, and the treatment of vascular risk factors, appear to be the most practical means of preventing end-organ damage to the brain. 3 figures. 2 tables. 116 references.

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Diabetic Neuropathy: Clinical Management. 2nd ed. Totowa, NJ: Humana Press. 2007. 516 p.

This comprehensive textbook provides general practitioners details about the latest techniques for the clinical management of diabetic neuropathy. The text offers 28 chapters, covering the historical aspects of diabetic neuropathies, epidemiology, genomics, hyperglycemia-initiated mechanisms, neuronal and Schwann cell death, animal studies, the structure and function of the spinal cord in diabetes mellitus, diabetic encephalopathy, microangiopathy, the peripheral nervous system, the pathogenesis of human diabetic neuropathy, clinical features of diabetic polyneuropathy, microvascular disease, macrovascular disease, clinical diagnosis of diabetic neuropathy, punch skin biopsy, the use of aldose reductase inhibitors, other therapeutic agents, the pathophysiology of neuropathic pain, treatment of painful diabetic neuropathy, focal and multifocal diabetic neuropathy, hypoglycemia and the autonomic nervous system, cardiovascular autonomic neuropathy, postural hypotension and anhidrosis, gastrointestinal syndromes due to diabetes mellitus, genitourinary complications, and the management of diabetes-related foot complications. Each chapter includes a summary, a list of key words, and an extensive list of references. A subject index concludes the volume.

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DPP-4 Inhibitors: Review of Vildagliptin Phase 3 Data. Review of Endocrinology. 1(2): 47-51. June 2007.

This article reports on the Phase 3 research data on the DPP-4 inhibitor called vildagliptin. The authors note that the extensive clinical trial program has provided evidence of the consistent glucose-lowering efficacy of vildagliptin across a wide range of clinical uses. They describe monotherapy trials of vildagliptin in drug naïve patients, as well as combination therapy trials in which vildagliptin was added to existing oral antidiabetes therapy. Vildagliptin has also been added to existing insulin therapy with good results in patients with long-standing disease. Vildagliptin therapy was weight-neutral and well tolerated, with a low incidence of hypoglycemia. The authors conclude that vildagliptin has the potential to be a useful addition to the treatment options for people with type 2 diabetes. 2 figures. 1 table. 17 references.

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Educating Patients With Type 2 Diabetes on a New Class of Drug, Dipeptidyl Peptidase 4 Inhibitors. Diabetes Educator. 33(Suppl 5):111S-113S. May - June 2007.

New and innovative antihyperglycemic therapies for people with type 2 diabetes have recently become available. This article is from a special supplement about an American Association of Diabetes Educators’ continuing education program called a Multidisciplinary Approach in Addressing Novel Mechanisms in the Management of Type 2 Diabetes, held in Los Angeles in August 2006. In this article, the author considers patient education approaches for people with type 2 diabetes who are being treated with dipeptidyl peptidase 4 (DPP-4) inhibitors. DPP-4 inhibitors, including sitagliptin and vildagliptin, can be given orally once a day and are not associated with an increased risk for hypoglycemia or weight gain. Patient adherence to any drug regimen remains a problem; reports show that adherence to oral medications ranges from 65 to 85 percent. The author briefly reviews some of the reasons for patient nonadherence and offers suggestions about how diabetes educators can be an active part of the diabetes patient care team. The patient with a good health care team, appropriate support, and adequate diabetes self-management education (DSME) is more likely to comply with drug regimens and prevent complications. 1 figure. 1 table. 8 references.

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Frequency, Causes and Risk Factors for Hypoglycaemia in Type 1 Diabetes. IN: Frier, B. and Fisher, M., eds. Hypoglycaemia in Clinical Diabetes. 2nd ed. Somerset, NJ: John Wiley & Sons. 2007. pp 48-82.

This chapter on the frequency, causes, and risk factors for hypoglycemia in type 1 diabetes is from a textbook that provides in-depth information for the understanding and management of hypoglycemia in clinical diabetes care. The author provides various definitions of hypoglycemia, including biochemical definitions as well as clinical definitions. The author discusses the frequency of hypoglycemia, the severity of hypoglycemia, the occurrence of asymptomatic, biochemical hypoglycemia, the causes of hypoglycemia, the role of patient error, the impact of alcohol and exercise on hypoglycemia, intensive insulin therapy as a risk factor for hypoglycemia, acquired hypoglycemia syndromes, the genetic predisposition to hypoglycemia, patients with absent endogenous insulin secretion, nocturnal hypoglycemia, microvascular complications, and social and psychological factors associated with hypoglycemia. The author notes that episodes of hypoglycemia can be classified as mild or severe depending on whether the individual is able to self-treat. Although hypoglycemia is common, most episodes can be handled by the patient or family and only rarely require emergency services intervention. 7 figures. 5 tables. 94 references.

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Getting a Grip on Diabetes: Quick Tips and Techniques for Kids And Teens. 2nd ed. Alexandria, VA: American Diabetes Association. 2007. 191 p.

Authors and brothers Spike and Bo Loy know what it is like to grow up with diabetes because both have lived with it for more than 10 years. This book explains how to control blood sugar levels in a way teenagers can identify with and understand. The book includes 23 chapters that discuss blood glucose, hyperglycemia, hypoglycemia, managing growth spurts, getting organized for diabetes care, elementary school issues, outdoor school and camp, sports, pursuing academics, eating out at restaurants, traveling with one’s family, driving, partying, starting college, traveling alone, insulin, insulin pumps, dealing with doctors, coping with sick days, accidents, surgery, meals and snacks, nutrition, schedules, siblings, practical tips for everyday diabetes management, and diabetes research. The book includes special “What the Doc Says” comments in each section from Marc Weigensberg, MD. The book concludes with a list of the authors’ favorite products and supplies, and a list of recommended books. A subject index is provided. The book is illustrated with black-and-white photographs of the boys and their activities growing up.

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Goals of Metabolic Management of Gestational Diabetes: Is At All About the Sugar?. Diabetes Care. 30(Suppl 2): S180-S187. July 2007.

Gestational diabetes mellitus (GDM), defined as glucose intolerance first recognized in pregnancy, has been traditionally considered a disorder primarily of carbohydrate metabolism. Thus, blood glucose levels have become the main focus of monitoring and directing treatment during pregnancy for these women. This article reviews the goals of metabolic management of GDM. The authors note that the traditional focus on glycemic metabolism ignores the role of other potential fetal fuels such as proteins and lipids in the pathophysiology of GDM. Topics discussed include the glycemic profile in normal and diabetic pregnancy, the diurnal glycemic profile in nondiabetic pregnancies, postprandial glycemic profile and its use in management approaches, glycemic profile in relation to maternal weight, the problem of undiagnosed hyperglycemia and hypoglycemia, the role of the HbA1c test in the management of GDM, the use of anthropometric measurements and ultrasound for assessment of fetal growth in GDM, the interrelationship between level of glycemia and perinatal fetal mortality, the impact of obesity not complicated by GDM, amino acids and protein metabolism in GDM, and lipid metabolism and GDM. The authors conclude that GDM is characterized by many metabolic changes diverting physiology to pathophysiology in pregnancy. 3 tables. 79 references.

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Guide to Insulin And Type 2 Diabetes. Alexandria, VA: American Diabetes Association. 2007. 234 p.

This handbook helps people with type 2 diabetes understand the role of insulin in a comprehensive program of care to manage their disease. The author first reminds readers that type 2 diabetes is a progressive disease, so even patients who are doing all the recommended strategies of diet, exercise, and medications may still find the need to incorporate insulin to maintain appropriate blood glucose levels. The book includes chapters that cover the basics of blood glucose physiology and the normal progression of type 2 diabetes, the psychological aspects of adding insulin into a care regimen, the myths surrounding insulin, the different types of insulin, the usual insulin regimen, using insulin to cover meals, carbohydrate counting, sliding scales and pattern management, preventing and treating hypoglycemia, sick-day guidelines, and special circumstances such as traveling, pregnancy, and religious fasting. A final section walks readers through the practical aspects of buying, storing, and injecting insulin. Throughout the book are lengthy quotes from people who have experienced the shift to insulin therapy and who share their thoughts and perspectives about the topics under consideration. The book concludes with a subject index, a description of some of the other titles available from the American Diabetes Association (ADA), and a summary of the activities and contact information for various components of the ADA.

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Handling Diabetes Emergencies: Your Guide to Recognizing And Treating Problems Fast. South Deerfield, MA: Channing Bete Company. 2007. 4 p.

This pocket-sized guide to diabetes emergencies helps patients recognize and treat problems quickly. The guide focuses on problems with blood glucose levels, offering a chart of the common warning signs and recommended treatments for hypoglycemia, hyperglycemia, and ketoacidosis. Basic information about each condition is provided, and readers are encouraged to follow a healthy routine to help avoid problems with blood glucose levels. The guide provides space for patients to record the contact information for their health care providers. The guide is illustrated with full-color photographs and graphics.

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High Expectations for Sitagliptin. Today's Dietitian. 9(2): 22-24. February 2007.

This article reviews the use of sitagliptin, a dipeptidyl peptidase IV (DPP–IV) inhibitor that prolongs the physiologic action of the incretin hormones, which are involved in blood glucose regulation. Incretin hormones are produced in cells lining the gut; concentrations of these hormones rise rapidly after food is ingested. GLP-1 stimulates first-phase, glucose-dependent (meal-induced) insulin secretion from the pancreas. GLP–1 inhibits gastric emptying and inhibits glucagon secretion from the alpha cells of the pancreas. GIP, in contrast, stimulates insulin secretion from the pancreas and regulates the proliferation and survival of beta cells. DPP-IV is a membrane-associated enzyme found in cells throughout the body; it neutralizes the incretin hormones and plays a role in immune function by stimulating T-cell activation and proliferation. Sitagliptin blocks the production of DPP–IV temporarily, so impaired incretin hormones have a longer life span and thus have more time to lower blood glucose levels. It is glucose-dependent, so it works only when food is ingested; thus, hypoglycemia associated with this drug is rare. Sitagliptin has been approved for use as a monotherapy, or in combination with metformin or pioglitazone. The article concludes with a summary of the dosing recommendations for sitagliptin. 6 references.

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Hypoglycaemia in Children With Diabetes. IN: Frier, B. and Fisher, M., eds. Hypoglycaemia in Clinical Diabetes. 2nd ed. Somerset, NJ: John Wiley & Sons. 2007. pp 190-216.

This chapter on hypoglycemia in children with diabetes is from a textbook that provides in-depth information for the understanding and management of hypoglycemia in clinical diabetes care. The author stresses that children are very susceptible to repeated and severe episodes of hypoglycemia, with long-term consequences. This chapter examines the etiology, physiology, consequences, and management of episodes of hypoglycemia during childhood. Specific topics include a definition of hypoglycemia in childhood diabetes; nocturnal hypoglycemia; risk factors for hypoglycemia; glycemic control; the varying insulin requirements at different ages; intensive insulin regimens; diet and nutrition; physical activity and exercise; genetics; counterregulation in childhood, glucagon; epinephrine response; the effect of sleep stage on counterregulation; and the consequences of hypoglycemia, including cognitive impairment, hypoglycemic hemiplegia, and fear of hypoglycemia. A final section of the chapter focuses on the management of hypoglycemia, including prevention, patient education, insulin use, diet therapy, and exercise. 3 figures. 3 tables. 109 references.

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Hypoglycaemia in Clinical Diabetes. 2nd ed. Somerset, NJ: John Wiley & Sons. 2007. 346 p.

This textbook provides in-depth information for the understanding and management of hypoglycemia in clinical diabetes care. The editors note that hypoglycemia may be becoming even more prevalent as patients with diabetes are trying to achieve stricter metabolic targets to control their blood glucose levels. The book includes 14 chapters: normal glucose metabolism and responses to hypoglycemia; the symptoms of hypoglycemia and its effects on mental performance and emotions; the frequency, causes, and risk factors for hypoglycemia in type 1 diabetes; nocturnal hypoglycemia; moderators, monitoring, and management of hypoglycemia; counterregulatory deficiencies in diabetes; impaired awareness of hypoglycemia; risks of strict glycemic control; hypoglycemia in children with diabetes; hypoglycemia in pregnancy; hypoglycemia in type 2 diabetes and in elderly people; mortality, cardiovascular morbidity, and the possible effects of hypoglycemia on diabetes complications; the long-term effects of hypoglycemia on cognitive function and the brain in people with diabetes; and living with hypoglycemia. Each chapter includes figures and tables, and concludes with a list of references. A subject index concludes the text.

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Hypoglycaemia in Pregnancy. IN: Frier, B. and Fisher, M., eds. Hypoglycaemia in Clinical Diabetes. 2nd ed. Somerset, NJ: John Wiley & Sons. 2007. pp 216-238.

This chapter on hypoglycemia in pregnancy is from a textbook that provides in-depth information for the understanding and management of hypoglycemia in clinical diabetes care. The authors describe why hypoglycemia is a recognized problem during pregnancy and how this influences the management of diabetic pregnancies. They stress that meticulous control of blood glucose before conception and throughout the pregnancy is the cornerstone of management to reduce congenital anomalies, neonatal morbidity, and mortality. However, this tight control may lead the woman to experience more frequent episodes of hypoglycemia. Topics covered include metabolic changes during pregnancy, the frequency of hypoglycemia in diabetic pregnancy, preconception care, organization of clinical care, optimizing insulin regimens, dietary and lifestyle management, management and timing of delivery, management of diabetes during labor, the risks of maternal hypoglycemia to the mother, microvascular complications of pregnancy, and complications in the infant of the diabetic mother. The authors conclude there is no evidence to suggest that hypoglycemia has an adverse effect on the human fetus or the infant of a diabetic mother, although significant maternal morbidity may occur. 3 figures. 6 tables. 56 references.

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Hypoglycaemia in Type 2 Diabetes and in Elderly People. IN: Frier, B. and Fisher, M., eds. Hypoglycaemia in Clinical Diabetes. 2nd ed. Somerset, NJ: John Wiley & Sons. 2007. pp 238-264.

This chapter on hypoglycemia in type 2 diabetes and in elderly people is from a textbook that provides in-depth information for the understanding and management of hypoglycemia in clinical diabetes care. The authors note that as both the prevalence of type 2 diabetes and life expectancy increases, it is inevitable that the number of older people with insulin-treated diabetes will increase. Topics include the pathophysiology of hypoglycemia, the effects of aging on the body’s responses to hypoglycemia, counterregulation, moderators of hypoglycemia in type 2 diabetes, hypoglycemia and oral diabetes agents, insulin secretagogues, studies comparing hypoglycemia secondary to insulin or oral antidiabetes agents, inhaled insulin and hypoglycemia, incretin mimetics and hypoglycemia, and the morbidity of hypoglycemia and indications for emergency treatment. 4 figures. 5 tables. 138 references.

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Hypoglycemia and Employment/Licensure. Diabetes Care. 30 (Suppl 1): S85. January 2007.

Despite the significant medical and technological advances made in managing diabetes, discrimination in employment and licensure against people with diabetes still occurs. Much of this discrimination may be founded on concerns that hypoglycemia will cause sudden unexpected incapacitation. This article is from a supplement to the Diabetes Care journal that contains the American Diabetes Association’s (ADA) Standards of Medical Care in Diabetes, the major position statement of the organization. This section of the supplement presents a position statement on hypoglycemia and employment and licensure. The section first reviews the problem of hypoglycemia and then explains how and when hypoglycemia can become a concern. The authors stress that most people with diabetes can manage their disease in such a way that there is only minimal risk of incapacitation from hypoglycemia. In addition, people with diabetes vary widely in their responses to the disease. Thus, people with diabetes should be individually considered for employment based on the requirements of the specific job. It is inappropriate to consider all people with diabetes the same.

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Hypoglycemia and the Autonomic Nervous System. IN: Veves, A.; Malik, R.A., eds. Diabetic Neuropathy: Clinical Management. 2nd ed. Totowa, NJ: Humana Press. 2007. pp 379-388.

This chapter on hypoglycemia and the autonomic nervous system is from a comprehensive textbook that provides general practitioners details on the latest techniques for the clinical management of diabetic neuropathy. The author notes that intensive diabetes management regimens have increased the incidence of severe hypoglycemic events, with resulting morbidity and even mortality. Hypoglycemia provokes a sequence of counterregulatory metabolic, neural, and clinical responses. For example, insulin secretion decreases whereas glucagon, epinephrine, norepinephrine, pancreatic polypeptide, cortisol, and growth hormone increase. Decreased symptom perception can be due to decreased autonomic nervous system activation, resulting in a cycle of hypoglycemic unawareness and decreased counterregulatory hormone responses to the hypoglycemia. The author concludes that the mechanisms of hypoglycemia-induced autonomic failure are not fully understood. 2 figures. 69 references.

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Hypoglycemic Disorders. IN: Gardner, D.; Shoback, D., eds. Greenspan's Basic and Clinical Endocrinology. 8th ed. Columbus, OH: McGraw Hill. 2007 . pp 748-769.

This chapter on hypoglycemic disorders is from a textbook on endocrinology that describes the scientific principles and clinical management of patients with endocrine-related diseases and disorders. The authors note that, under the usual metabolic conditions, the central nervous system is completely dependent on plasma glucose and counteracts declining blood glucose concentrations with a carefully programmed response. Topics discussed include the pathophysiology of the counterregulatory response to neuroglycopenia; the maintenance of euglycemia in the postabsorptive state, that is, longer than 4 to 6 hours after a meal; the role of the kidney; the classification of hypoglycemic disorders into symptomatic and asymptomatic hypoglycemia; the clinical presentation of hypoglycemia; the documentation of low plasma glucose values; the reversibility of symptoms with treatment; specific hypoglycemia conditions, including insulin reaction, sulfonylurea overdose, surreptitious insulin or sulfonylurea administration, autoimmune hypoglycemia, pentamidine-induced hypoglycemia, and pancreatic beta cell tumors; symptomatic fasting hypoglycemia that presents without hyperinsulinism, including that due to ethanol and to nonpancreatic tumors; nonfasting hypoglycemia, also called reactive hypoglycemia, including postgastrectomy alimentary hypoglycemia, postgastric bypass hypoglycemia, functional alimentary hypoglycemia, pancreatic islet hyperplasia in adults, and late hypoglycemia, also called occult diabetes; and congenital hyperinsulinism. 3 figures. 5 tables. 43 references.

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Impaired Awareness of Hypoglycaemia. IN: Frier, B. and Fisher, M., eds. Hypoglycaemia in Clinical Diabetes. 2nd ed. Somerset, NJ: John Wiley & Sons. 2007. pp 141-170.

This chapter on impaired awareness of hypoglycemia is from a textbook that provides in-depth information for the understanding and management of hypoglycemia in clinical diabetes care. The author defines hypoglycemia unawareness as an acquired abnormality that is effectively a complication of insulin therapy and one that should be considered along with the other complications of diabetes in terms of morbidity. Topics covered in the chapter include normal physiological responses to hypoglycemia, perceiving hypoglycemia, the prevalence of hypoglycemia unawareness, the pathogenesis of hypoglycemia unawareness, the role of peripheral autonomic neuropathy, hypoglycemia-associated autonomic failure, central nervous system adaptation to hypoglycemia, episodic hypoglycemia, the long-term effect of hypoglycemia on cognitive function, and treatment strategies. The author concludes that when hypoglycemia unawareness results from strict glycemic control, the total insulin dose should be reduced, the insulin regimen should be reviewed for suitability, and overall glycemic control should be relaxed. 9 figures. 7 tables. 86 references.

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Insulin Analogs and Pregnancy. Diabetes Spectrum. 20(2): 94-101. Spring 2007.

Diabetes during pregnancy is a major risk factor for poor fetal, neonatal, and maternal outcomes; however, this risk can be greatly reduced by the early use of medical nutrition therapy (MNT) and insulin treatment. This article explores the use of insulin analogs and pregnancy, focusing on the newer, rapid-acting insulin analogs lispro and aspart. The author stresses that maintaining maternal glycemic as near to normal as possible reduces the risk of congenital anomalies, macrosomia, neonatal hypoglycemia, and large-for-gestational-age infants. Topics include pregestational diabetes; gestational diabetes mellitus (GDM); the use of NPH insulin during pregnancy; current categories for drug use in pregnancy; long-acting insulin analogs, such as glargine and detemir, problems with retinopathy and insulin analogs; concerns about congenital anomalies and insulin analogs; and macrosomia and insulin analogs. The author concludes that, when compared with human regular insulin, the rapid-acting insulin analogs are effective at reducing hyperglycemia during pregnancy, with a safety profile that resulted in a lower incidence of neonatal complications. The long-acting insulin analogs do not yet have sufficient safety evaluation in clinical studies to warrant their use during pregnancy. The article includes a patient treatment algorithm as a guideline for all insulin-requiring pregnant women with type 2 diabetes, GDM, or type 1 diabetes. 1 figure. 7 tables. 67 references.

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Insulin Pump Therapy. IN: Unger, J. Diabetes Management in Primary Care. Philadelphia, PA: Lippincott Williams and Wilkins. 2007. p. 265-320.

Insulin pump therapy allows patients to manage their diabetes intensively by using a method that is pharmacologically superior to multiple daily injections (MDI). This chapter about insulin pump therapy is from a textbook that offers primary care physicians evidence-based guidelines for evaluating and treating all patients with diabetes. In this chapter, the author discusses the evolution of modern insulin pump technology, patient selection for pump therapy, improved overall glycemic control and reduced glycemic variability in patients using insulin pumps, talking about pump therapy with prospective patients, initiating pump therapy in the primary care setting, fine-tuning pump therapy, long-term follow-up of insulin pump patients, exercising with an insulin pump, and the use of insulin pump therapy in patients with type 2 diabetes. The author concludes that, compared with MDIs, insulin pump therapy has better insulin pharmacokinetics, less variability in insulin absorption, and decreased risk of hypoglycemia. Patients using insulin pumps enjoy greater lifestyle flexibility and often become more proactive in their approach to diabetes self-management. Although more expensive than MDIs, pump therapy offers patients a much more physiologic approach to controlling their diabetes. Careful evaluation of pump candidates, ongoing patient education, and timely follow-up visits are vital to the success of pump therapy. The chapter includes a list of “take-home points” that summarize the concepts discussed, as well as case reports that illustrate the topics covered. 3 appendices. 9 figures. 9 tables. 32 references.

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Living With Hypoglycaemia. IN: Frier, B. and Fisher, M.; Frier, B., eds. Hypoglycaemia in Clinical Diabetes. 2nd ed. Somerset, NJ: John Wiley & Sons. 2007. pp 309-332.

This chapter on living with hypoglycemia is from a textbook that provides in-depth information for the understanding and management of hypoglycemia in clinical diabetes care. The author notes that because hypoglycemia can occur at any time of the day or night, is often unpredictable, affects intellectual and physical performance, and disrupts the life of the affected individual and others, its effects have an impact on every aspect of everyday living. Adverse experiences of severe hypoglycemia can influence the subsequent behavior of an individual as he or she attempts to avoid further events, and the effect on a patient’s self-care of diabetes may result in poor glycemic control. Topics include psychosocial effects, including fear of hypoglycemia; exercise; the prevention of hypoglycemia following exercise, sports, and recreational activities; the effect of hypoglycemia on automobile driving; the risk of accidents and restriction of driving licenses and vocational driving licenses; advice for drivers who have diabetes; medico-legal aspects; travel; employment; specialist medical reports for employment; school and academic examinations; police custody and hypoglycemia; and the management of diabetes in prison. 2 figures. 10 tables. 63 references.

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Long-Term Effects of Hypoglycaemia on Cognitive Function And the Brain in Diabetes. IN: Frier, B. and Fisher, M., eds. Hypoglycaemia in Clinical Diabetes. 2nd ed. Somerset, NJ: John Wiley & Sons. 2007. pp 284-308.

This chapter on the long-term effects of hypoglycemia on cognitive function and the brain in diabetes is from a textbook that provides in-depth information for the understanding and management of hypoglycemia in clinical diabetes care. The authors review the effects of diabetes on the brain, with an emphasis on the chronic complications of hypoglycemia. Topics include hypoglycemia and mental functions in children and adolescents, evidence for the neuropsychological deterioration following repeated hypoglycemia in adults, hypoglycemia-induced neurological syndromes, reversible effects of hypoglycemia on the brain, convulsions and associated morbidity, permanent neurological effects of hypoglycemia on the brain, structural changes of the brain in diabetes, the effect of hypoglycemia on cerebral blood flow and structure, structural changes associated with hypoglycemia, the mechanisms of hypoglycemia-induced brain injury, and evidence for diabetic encephalopathy. The authors conclude that hypoglycemia should be considered as a possible diagnosis in all patients with diabetes presenting with any neurological syndrome. The pathogenesis of diabetic encephalopathy is not known, but hypoglycemia probably plays a significant contributory role. 10 figures. 4 tables. 88 references.

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Moderators, Monitoring And Management of Hypoglycaemia. IN: Frier, B. and Fisher, M., eds. Hypoglycaemia in Clinical Diabetes. 2nd ed. Somerset, NJ: John Wiley & Sons. 2007. pp 100-120.

This chapter on moderators, monitoring, and management of hypoglycemia is from a textbook that provides in-depth information for the understanding and management of hypoglycemia in clinical diabetes care. The authors note that despite advances in insulin pharmacology and delivery and in patient education, the lifetime frequency of symptomatic hypoglycemia remains substantial, with the average patient likely to experience thousands of episodes over the course of his or her life with insulin-treated diabetes. They review risk factors for the development of hypoglycemia and address lifestyle moderators, including alcohol and hypoglycemia, and caffeine. The authors also address monitoring, including self-awareness self-monitoring of blood glucose (SMBG), and continuous glucose monitoring systems (CGMS). Treatment of hypoglycemia can be thought of as a spectrum of increasing therapeutic complexity, depending on the severity of the hypoglycemia and the clinical status of the patient. 11 figures. 3 tables. 65 references.

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Mortality, Cardiovascular Morbidity and Possible Effects of Hypoglycaemia on Diabetic Complications. IN: Frier, B. and Fisher, M., eds. Hypoglycaemia in Clinical Diabetes. 2nd ed. Somerset, NJ: John Wiley & Sons. 2007. pp 265-284.

This chapter on mortality, cardiovascular morbidity, and possible effects of hypoglycemia on diabetes complications is from a textbook that provides in-depth information for the understanding and management of hypoglycemia in clinical diabetes care. The authors examine the epidemiology and causes of death from hypoglycemia in patients with diabetes, including those risk factors that appear to be associated with sudden death. They explore the “dead in bed” syndrome in detail, drawing comparisons with other syndromes of sudden death in people who do not have diabetes. Putative mechanisms and risk factors for sudden death are described. Hypoglycemia may cause significant cardiovascular morbidity in people with diabetes, and the effects on heart disease and cardiovascular disease are examined. The authors conclude with a discussion of the hypothesis that hypoglycemia may worsen the chronic microvascular complications of diabetes. Although hypoglycemia occurs commonly in people with type 1 diabetes, and even severe episodes are not infrequent, sudden and unexpected deaths from hypoglycemia are rare. 5 figures. 6 tables. 60 references.

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Nocturnal Hypoglycaemia. IN: Frier, B. and Fisher, M., eds. Hypoglycaemia in Clinical Diabetes. 2nd ed. Somerset, NJ: John Wiley & Sons. 2007. pp 82-100.

This chapter on nocturnal hypoglycemia is from a textbook that provides in-depth information for the understanding and management of hypoglycemia in clinical diabetes care. The author notes that people with type 1 diabetes are often as concerned about episodes of hypoglycemia as they are worried about the prospect of developing complications of their disease. The author considers nocturnal hypoglycemia, noting that even asymptomatic episodes may have consequences beyond the immediate situation. Asymptomatic episodes may contribute to hypoglycemia unawareness and deficient counterregulation and may be associated with cognitive impairment and the increased risk of sudden death during sleep in young people with type 1 diabetes. Topics include the epidemiology of nocturnal hypoglycemia; the causes of nocturnal hypoglycemia, which can include impaired counterregulatory responses, supine posture, and sleep itself; the consequences of nocturnal hypoglycemia, including impaired awareness of hypoglycemia, sudden death, and neurological consequences; the prediction of nocturnal hypoglycemia; the Somogyi phenomenon of rebound hyperglycemia; and clinical solutions, including dietary measures, pharmaceutical interventions, the timing and type of insulin, and the use of continuous subcutaneous insulin infusion (CSII). 4 figures. 5 tables. 64 references.

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Normal Glucose Metabolism And Responses to Hypoglycaemia. IN: Frier, B. and Fisher, M., eds. Hypoglycaemia in Clinical Diabetes. 2nd ed. Somerset, NJ: John Wiley & Sons. 2007. pp 1-24.

This chapter on normal glucose metabolism and responses to hypoglycemia is from a textbook that provides in-depth information for the understanding and management of hypoglycemia in clinical diabetes care. The authors note that blood glucose concentrations are normally regulated within a narrow range, despite wide variability in carbohydrate intake and physical activity. They focus on the mechanisms that protect against hypoglycemia in healthy individuals and the physiological consequences of low glucose concentrations. Topics include normal glucose homeostasis, fasting and fed states, the effects of glucose deprivation on central nervous system metabolism, counterregulation during hypoglycemia, hormonal changes during hypoglycemia, activation of the autonomic nervous system, neuroendocrine activation, hemodynamic changes during hypoglycemia, changes in regional blood flow, and functional changes in hypoglycemia. The authors conclude that many symptoms of hypoglycemia result from the activation of the autonomic nervous system and help to warn the individual that blood glucose is low. This encourages the ingestion of carbohydrates, thus helping to restore glucose concentrations. Activation of the autonomic nervous system increases sweating, and together with the inhibition of sweating, this predisposes to hypothermia, which may be neuroprotective. 10 figures. 6 tables. 48 references.

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Oral Antidiabetic Drugs in Pregnancy: The Other Alternative. Diabetes Spectrum. 20(2): 101-105. Spring 2007.

This article reviews the use of oral antidiabetic drugs in pregnancy, an accepted treatment option for women with gestational diabetes mellitus (GDM). The author outlines the intensified management approach and describes the use of oral antidiabetic agents, primarily glyburide, to prevent glycemic extremes of hypoglycemia and hyperglycemia in pregnant women with GDM and type 2 diabetes. The author stresses that, regardless of the mode of therapy, whole patient care consisting of glucose monitoring, patient education, diet adherence and exercise, will determine overall success in managing this disease and maximizing perinatal outcome. A patient care algorithm is also included. 36 references.

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Overcoming Barriers to the Initiation of Insulin Therapy. Clinical Diabetes. 25(1): 36-38. Winter 2007.

This article explores some of the barriers to the initiation of insulin therapy in patients with type 2 diabetes, noting that new recommendations for these patients call for more rapid use of both oral medications and insulin therapy. Although most health care providers agree that insulin is an effective therapy for the management of type 2 diabetes, many still consider insulin therapy as the last resort and indicate that their patients are hesitant to take insulin. The author of this article recommends physicians first assess the patient‘s perspective regarding insulin therapy; many barriers can be identified from this discussion. The author briefly discusses some of these barriers, which include beliefs that the insulin use demonstrates personal failure, insulin is not effective, insulin injections are painful, insulin causes complications or death, fear of hypoglycemia, insulin causes weight gain, and insulin use will have a negative impact on lifestyle. The next section considers provider-identified barriers to insulin therapy and how to address each of them. These suggestions include referring patients for diabetes self-management education and medical nutrition therapy (MNT), providing ongoing self-management support, using strategies already proven successful, and addressing emotional issues. 4 references.

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Owning Up: Chris Matthews. Diabetes Forecast. 60(13): 40-44. November 2007.

This article shares the story of Chris Matthews, the MSNBC host and commentator, who recently experienced a serious health episode that included being diagnosed with diabetes. The author interviews Mr. Matthews about his years of ignoring diabetes, even though he was prescribed metformin, and how a high blood glucose scare in Thanksgiving of 2007 sent him to the hospital. The interview covers topics including the symptoms of his high blood glucose; small changes in dietary behaviors that have resulted in better care of his diabetes; the use of other medications including insulin; the difference between changing dietary habits and giving up alcohol, which he did 14 years ago; the role of denial even in patients who have been diagnosed with diabetes; coping with hypoglycemia; the importance of stress awareness and stress reduction; and ways to share his knowledge with others. A sidebar lists Mr. Matthew’s current shows and new book, Life’s A Campaign: What Politics Has Taught Me About Friendship, Rivalry, Reputation, and Success. 2 figures.

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Perspectives in Gestational Diabetes Mellitus: A Review of Screening, Diagnosis, and Treatment. Clinical Diabetes. 25(2): 57-62. Spring 2007.

Gestational diabetes mellitus (GDM) affects approximately 7 percent of all pregnancies and is defined as carbohydrate intolerance during gestation. This review article addresses screening recommendations, diagnosis, and treatment of GDM. The authors stress that it is important to detect women with GDM because the condition can be associated with several maternal and fetal complications, including macrosomia, birth trauma, cesarean section, and problems in the newborn, such as hypocalcemia, hypoglycemia, and hyperbilirubinemia. The authors discuss several treatment options as well as the need for long-term risk modification and postpartum follow-up care. Several agents that are both effective and safe can be used to treat women with GDM if diet and exercise alone are not enough; these include human insulin, insulin analogs, and glyburide. Patients who have experienced GDM during their pregnancy have a higher risk of developing type 2 diabetes in the future, so it is important to continue screening these patients and to educate them about their risk factors. 3 tables. 58 references.

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Physiologic Insulin Replacement Therapy. IN: Unger, J. Diabetes Management in Primary Care. Philadelphia, PA: Lippincott Williams and Wilkins. 2007. p. 192-264.

This lengthy chapter about physiologic insulin replacement therapy is from a textbook that offers primary care physicians evidence-based guidelines for evaluating and treating all patients with diabetes. In this chapter, the author stresses that understanding the pharmacokinetics and glucodynamic profiles of different insulin preparations is necessary to direct patients toward the treatment protocols that will allow them to maintain a safe and practical level of hemoglobin A1C. Patients with type 2 diabetes may be able to attain their target goal of A1C using “treat-to-target” protocols that use either basal insulin or mixed insulin analog in addition to oral agents. Most patients with type 1 diabetes should optimize their management using basal-bolus insulin. The author covers the history of insulin, the pathogenesis of type 1 diabetes, determining appropriate glycemic targets, strategies to reduce the costs of managing diabetes, the psychological impact of introducing insulin therapy, hypoglycemia, reducing hyperglycemia, ways to optimize patient adherence and remove barriers to insulin therapy, and insulin analogue formulations. The chapter includes a list of “take-home points” that summarize the concepts discussed, as well as case reports that illustrate the topics covered. 13 figures. 18 tables. 101 references.

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Picture This: Looking at the Diabetic Brain. Diabetes Forecast. 60(11): 23. October 2007.

This article summarizes a recent study that focused on how blood glucose levels, particularly in people with diabetes, affect the brain. In this study, brain images using magnetic resonance imaging (MRI) were taken of people with and without diabetes to see whether and how their brains differ. The images were then subjected to a computerized imaging technology called voxel-based morphometry, which measures subtle changes in brain density. The results showed that people with diabetes had lower brain density in certain regions compared with those without diabetes. Those with worse blood glucose control had lower brain density in some regions than those with better control. The author discusses these results and some follow-up research that investigates how the brain responds to changes in blood glucose levels in real time. Another issue under study is the presence of hypoglycemia unawareness.

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Pills for Type 2 Diabetes: A Guide for Adults. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ). 2007. 14 p.

This patient education guide provides information about the various drugs that may be used to treat type 2 diabetes. In type 2 diabetes, the body either does not make enough insulin or it does not use insulin as effectively as it should. The guide reviews the common kinds of diabetes medications, how they work in type 2 diabetes, their side effects, and costs. The authors remind readers that different kinds of diabetes pills work in different ways to control blood glucose levels, and sometimes combining two different kinds of diabetes pills can work better to lower blood glucose than a single medication can. Specific medications covered include biguanides, sulfonylureas, meglitinides, thiazolidinediones, and alpha-glucosidase inhibitors. The guide also describes self-monitoring of blood glucose (SMBG) tests, and readers are encouraged to perform an SMBG test and to have their glycosylated hemoglobin levels checked a few times a year. Some common side effects of diabetes medications include weight gain, stomach problems, swelling, effects on cholesterol levels, hypoglycemia, lactic acidosis, and congestive heart failure. The guide does not cover the other components of treating type 2 diabetes, including diet and exercise. Readers are encouraged to consult the Agency for Healthcare Research and Quality’s website at www.effectivehealthcare.ahrq.gov or the Medline Plus website at www.nlm.nih.gov/medlineplus/diabetes.html for more information.

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Preconception Counseling and Type 2 Diabetes. Diabetes Spectrum. 20(2): 117-123. Spring 2007.

This article reviews the idea of preconception counseling for women who have type 2 diabetes. The author first reviews the recommendations of professional groups, including the American Diabetes Association and the American College of Obstetricians and Gynecologists, both of which recommend preconception counseling (PC) for all women with diabetes who have child-bearing potential. The author then reviews characteristics of women seeking PC and presents a case study of a 33-year-old African American woman, diagnosed with type 2 diabetes after the birth of her second child, who wants to know about additional pregnancies. The author conducted a literature study that would address some of the questions raised by this patient’s concerns. The author discusses the information found in 15 relevant studies, including metabolic control, rates of spontaneous abortion, perinatal mortality, congenital anomalies, pregnancy and delivery complications, macrosomia, and neonatal hypoglycemia. A final section considers the implications of these findings for clinical practice care of women with diabetes who are seeking preconception counseling. 3 tables. 34 references.

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Products for Treating Low Blood Glucose. Diabetes Forecast. 60(1): RG52-RG54. January 2007.

This article, from the annual resource guide that is published as a supplement to Diabetes Forecast, brings readers up-to-date on products for treating low blood glucose levels. The author first reviews the causes of hypoglycemia—low blood glucose—and its symptoms, and then considers approaches to treating the condition. The author reviews three things to remember when considering purchasing a commercial product to treat hypoglycemia: how fast it works, the form it comes in, and cost. One section briefly considers products that contain ingredients that are designed to either aid in the prevention of hypoglycemia or lessen the rise in blood glucose after meals or snacks. One chart summarizes the features of the products discussed. 1 table.

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Psychological Insulin Resistance: The Patient Perspective. Diabetes Educator. 33(Suppl 7): 241S-244S. July - August 2007.

This article is from a special supplement about an American Association of Diabetes Educators’ continuing education program called The Tipping Point: Overcoming Psychological Insulin Resistance, held in Los Angeles, in August 2006. In this article, the author offers the type 2 diabetes patient’s perspectives on psychological insulin resistance (PIR). The author reminds readers that because type 2 diabetes is a progressive disease, most patients will likely require insulin therapy at some point. However, studies of compliance rates with oral antidiabetes drugs and insulin show that compliance rates range from 36 to 93 percent, with the average compliance rate for insulin being about 63 percent. Thus, PIR poses a significant barrier to what is already a difficult situation. The author reviews the attitudes toward insulin therapy, beliefs underlying PIR, the belief on most patients’ part that insulin is ineffective, strategies for overcoming PIR, the problem of clinicians who harbor negative beliefs about insulin therapy, and anxiety about insulin therapy and potential episodes of hypoglycemia. The author concludes by encouraging diabetes educators to play an important role in educating physicians, patients, and the community about the role of insulin in type 2 diabetes and to share the good news about the safety and effectiveness of contemporary insulin preparations. Insulin therapy can be an appropriate, effective, and flexible treatment option during all stages of type 2 diabetes. 2 figures. 1 table. 19 references.

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Removing Barriers to Insulin Therapy. Diabetes Educator. 33(Supl 3): S60-S65. March-April 2007.

This section on removing barriers to insulin therapy is from a special supplement of the Diabetes Educator that presents a continuing education program on early intervention with insulin analogs, from the American Association of Diabetes Educators (AADE) 2006 Annual Meeting in Los Angeles. The author stresses that understanding patient-oriented concerns is critical to helping patients overcome the psychological resistance to initiating insulin therapy. The article identifies 10 reasons that patients resist starting insulin and presents strategies for supporting patients through the decision-making process. The ten reasons are: lack of knowledge, cultural taboos and family beliefs, fear of needles or injection pain, fear of hypoglycemia, fear of weight gain, inconvenience associated with insulin therapy, viewing insulin as a sign that one's diabetes is worse or more serious, personal failure, insulin causes complications, and fear that insulin therapy will require constant demands and decision making. The author concludes by describing strategies that diabetes educators can employ to help create a culture that is more receptive to insulin. By inviting patients to voice their concerns, engaging in active listening, and providing both accurate information and emotional support, educators facilitate the transition to insulin and also contribute to a culture that encourages and supports the most effective diabetes management. 2 tables. 14 references.

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Risks of Strict Glycaemic Control. IN: Frier, B. and Fisher, M., eds. Hypoglycaemia in Clinical Diabetes. 2nd ed. Somerset, NJ: John Wiley & Sons. 2007. pp 171-190.

This chapter on the risks of strict glycemic control is from a textbook that provides in-depth information for the understanding and management of hypoglycemia in clinical diabetes care. The author notes that, in general, the main risk of intensified diabetes therapy remains hypoglycemia. Topics include a definition of hypoglycemia; factors predisposing patients to severe hypoglycemia in intensified insulin therapy regimens; the link between intensified insulin therapy and risk of severe hypoglycemia; cerebral adaptation and cognitive function; other risks of intensified insulin therapy, notably diabetic ketoacidosis and hyperinsulinemia; strategies to avoid hypoglycemia; and patients who are unsuitable for intensive diabetes management and tight control of blood glucose. 4 figures. 2 tables. 77 references.

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Self-Monitoring of Blood Glucose. Chevy Chase, MD: Hormone Foundation. 2007. 1 p.

This brief fact sheet reviews the use of self-monitoring of blood glucose (SMBG) as part of a comprehensive program of treating diabetes, a disease characterized by blood glucose levels that are higher than normal. The fact sheet first outlines the three main types of diabetes: type 1, type 2, and gestational diabetes. The fact sheet then answers common questions about the importance of controlling blood glucose levels, complications associated with hyperglycemia and hypoglycemia, how blood glucose levels can be checked with a small battery-operated meter, and how often blood glucose levels should be checked. The fact sheet concludes with a section of practical strategies for incorporating this information into one’s daily diabetes care. Readers are referred to the Hormone Foundation’s website at www.hormone.org and other resources for more information. One figure lists recommended target blood glucose values and how to know when to call a health care provider for a value that is out of the range noted. The fact sheet is also available in Spanish. 4 references.

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Standards of Medical Care in Diabetes-2007. Diabetes Care. 30 (Suppl 1): S4-S41. January 2007.

This supplement to the Diabetes Care journal contains the American Diabetes Association’s (ADA) Standards of Medical Care in Diabetes, the major position statement of the organization. This section of the supplement presents the Standards of Medical Care in Diabetes (2007) in the areas of Classification and Diagnosis; Screening for Diabetes; Detection and Diagnosis of Gestational Diabetes Mellitus; the Prevention or Delay of Type 2 Diabetes; Diabetes Care; the Prevention and Management of Diabetes Complications; Diabetes Care in Specific Populations, including children and adolescents, preconception care, and older individuals; Diabetes Care in Specific Settings, including the hospital, school and day care settings, diabetes camps, correctional institutions, and emergency and disaster preparedness; Hypoglycemia and Employment or Licensure; Third-Party Reimbursement for Diabetes Care; and Strategies for Improving Diabetes Care. Each standard includes a statement of the problem, and then lists recommendations; relevant references are also included. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided with the standards. The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. 1 figure. 11 tables. 234 references.

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Symptoms of Hypoglycaemia and Effects on Mental Performance and Emotions. IN: Frier, B. and Fisher, M., eds. Hypoglycaemia in Clinical Diabetes. 2nd ed. Somerset, NJ: John Wiley & Sons. 2007. pp 25-48.

This chapter on the symptoms of hypoglycemia and its effects on mental performance and emotions is from a textbook that provides in-depth information for the understanding and management of hypoglycemia in clinical diabetes care. The author stresses that the most obvious benefit of knowing about the symptoms of hypoglycemia is the ability to recognize the onset of a hypoglycemic episode as early as possible. Topics include identifying the symptoms of hypoglycemia, which commonly include sweating, trembling, difficulty concentrating, dizziness, and hunger; the individuality of hypoglycemic symptom clusters; classifying the symptoms as autonomic, neuroglycopenic, or general malaise; typical symptoms in children and in older people; symptom interpretation and intervention strategies; acute hypoglycemia and cognitive functioning; and acute hypoglycemia and emotions. The author concludes by reiterating the importance of accurate patient knowledge about the symptoms of hypoglycemia in order to avoid the dangers of hypoglycemia. 3 figures. 2 tables. 72 references.

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Treatment With Insulin and Its Analogs in Pregnancies Complicated by Diabetes. Diabetes Care. 30(Suppl 2): S220-S224. July 2007.

This article presents a literature review about the safety and effectiveness of insulin analogs in pregnancy, with the goal of enabling clinicians to choose the optimal insulin treatment protocol to achieve and maintain normoglycemia throughout pregnancies complicated by diabetes. Topics include the rationale for the use of nonimmunogenic insulins during pregnancy, long-acting insulin analogs such as insulin glargine and insulin detemir, and the potential risks associated with insulin analogs. The authors note that, if postprandial glucose is the target of treatment, the rapid-acting insulin lispro and insulin aspart appear to be as safe and effective as regular human insulin in women with GDM and they achieve better postprandial glucose concentrations with less late prandial hypoglycemia. If the patient has elevated fasting and postprandial blood glucose levels and requires multiple daily injections to achieve good glycemic control, a basal-bolus regimen should be considered. 1 table. 44 references.

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Use of Insulin Pump Therapy in the Pediatric Age-Group: Consensus Statement from the European Society for Pediatric Endocrinology, the Lawson Wilkins Pediatric Endocrine Society and the International Society for Pediatric and Adolescent Diabetes, Endorsed by the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 30(6): 1653-1662. June 2007.

This article presents a consensus statement on the use of insulin pump therapy in the pediatric age group, implemented primarily to avoid recurrent episodes of hypoglycemia in patients seeking to achieve near-normal blood glucose ranges. Continuous subcutaneous insulin infusion (CSII) is used to closely simulate the normal pattern of insulin secretion and offers more flexibility and more precise insulin delivery than multiple daily injections (MDI). The consensus panel was convened to clear up controversy as to whether CSII has advantages over MDI in terms of reduction in blood glucose levels, occurrence of severe hypoglycemic events, episodes of diabetic ketoacidosis (DKA), and frequency of hospitalizations in young patients. In addition, physicians need guidelines for choosing patients for whom CSII therapy might be appropriate. Recommendations are provided in the areas of glycosylated hemoglobin (A1C) levels, severe hypoglycemia, blood glucose variability, physical activity and exercise, weight gain, metabolic deterioration, infusion site reactions, psychosocial issues, pump features, selecting an insulin pump, catheter features, calculating and timing the prandial (bolus) insulin requirement, monitoring patients on CSII, cost-effectiveness, and terminating CSII. The authors conclude that CSII use in children and adolescents may be associated with improved glycemic control and improved quality of life and poses no greater, and possibly less, risk than MDI. Minimizing the risks of CSII entails the same interventions that promote safety in all patients with type 1 diabetes, including proper education, frequent blood glucose monitoring, attention to diet and exercise, and the ongoing of communication with a diabetes team. 1 table. 95 references.

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What I Need to Know About Eating and Diabetes. Bethesda, MD: National Diabetes Information Clearinghouse. 2007. 45 p.

This booklet helps people with type 1 or type 2 diabetes understand their disease and learn how to take care of themselves and their diabetes with healthy eating. Written in nontechnical language, the booklet covers blood glucose levels; diabetes medications, including insulin, and the recommended timing for medications and meals; the role of physical activity; the diabetes food pyramid; coping with low blood glucose, also known as hypoglycemia; determining a good level of caloric intake; starches; vegetables; fruits; milk; meat, meat substitutes; fats and sweets; alcoholic drinks; meal planning; measuring food portions; and coping with sick days. The sections on specific food types include suggestions for portion control, food preparation techniques, and shopping. The booklet includes spaces for readers to individualize information for their own situation and goals. The booklet offers ideas on where to find additional information about diabetes and self-care. A final section briefly summarizes the activities of the National Diabetes Information Clearinghouse. The booklet is illustrated with black-and-white line drawings and simple graphics of food items. 30 figures. 7 tables.

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Consensus Development Conference on Pramlintide in the Management of Type 1 and Type 2 Diabetes. Lakeville, CT: The Diabetes Education Group. 2006. 13 p.

This review article reflects consensus opinion on the best practices for using pramlintide in the management of patients with type 1 or type 2 diabetes who also use insulin. In patients with diabetes, the dual defects of insulin and amylin secretion in response to food intake contribute to postprandial hyperglycemia and wide fluctuations of blood glucose, which increase the risk for long-term complications of the disease. Pramlintide, a synthetic analog of amylin, was recently approved as an adjunct treatment for diabetes patients who use mealtime insulin. Clinical trials have shown that pramlintide suppresses postprandial glucagon secretion, slows gastric emptying, reduces postprandial glucose levels, and improves glycemic control while facilitating weight loss. Anecdotal accounts indicate that optimized pramlintide therapy may confer a greater sense of well-being or vigor. The primary safety concerns associated with this drug are insulin-induced hypoglycemia and nausea during the start of therapy. The authors note that individualized insulin dosing and timing regimens, frequent blood glucose monitoring, and gradual titration can prevent or reduce these side effects. 7 figures. 5 tables. 61 references.

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Diabetes And Driving. IN: Katsilambros, N., et al. Diabetes in Clinical Practice: Questions and Answers From Case Studies. Somerset, NJ: John Wiley & Sons. 2006. pp 311-318.

This chapter on diabetes and driving is from a book that deals with various aspects of diabetes in clinical practice, presented in the form of questions concerning diabetes diagnosis, management, and therapy, all based on real-life case studies. Topics covered include assessing driving risks in patients with diabetes, who should advise patients about driving, pregnancy and an increased risk of hypoglycemia, hypoglycemia unawareness and its impact on driving safety, and European and British guidelines for commercial drivers with diabetes. The chapter presents four detailed case studies, with relevant questions posed and answered. Readers are walked through the diagnostic and patient care management process for the case studies presented. One table summarizes the British regulations on the driving licenses of individuals with diabetes mellitus. 1 table. 8 references.

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Diabetes And Pregnancy. IN: Katsilambros, N., et al. Diabetes in Clinical Practice: Questions and Answers From Case Studies. . Somerset, NJ: John Wiley & Sons. 2006. pp 121-140.

This chapter on gestational diabetes is from a book that deals with various aspects of diabetes in clinical practice, presented in the form of questions concerning diabetes diagnosis, management, and therapy, all based on real-life case studies. The author notes that every degree of glucose impairment that occurs or is detected for the first time during pregnancy is called gestational diabetes. Topics covered include the classification of gestational diabetes, how gestational diabetes is diagnosed, the hypothesis that development of gestational diabetes represents the first manifestation of type 2 diabetes, how metabolic disturbances of the mother with diabetes affect the fetus, macrosomia and its causes, congenital malformations in diabetes pregnancies, hypoglycemia in neonates, the management of pregnancy in women with type 1 diabetes, diabetic complications that are contraindications for pregnancy in women with diabetes, the role of a proper diet in pregnancy, insulin therapy in women with gestational diabetes, childbirth considerations in this population, contraception, and the risks of passing diabetes to one’s child. The chapter presents three case studies, which are individually discussed, and relevant questions are posed and answered. Readers are walked through the diagnostic and patient care management processes for the case studies presented. 4 tables. 11 references.

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Diabetes And the Young. IN: Katsilambros, N., et al. Diabetes in Clinical Practice: Questions and Answers From Case Studies. Somerset, NJ: John Wiley & Sons. 2006. pp 141-146.

This chapter on diabetes and the young is from a book that deals with various aspects of diabetes in clinical practice, presented in the form of questions concerning diabetes diagnosis, management, and therapy, all based on real-life case studies. Topics covered include the psychosocial consequences of receiving a diagnosis of a chronic disease, the process of adjusting to a diagnosis of diabetes in a child or adolescent, parent-child interactions and sharing of self-care, and coping with changes of adolescence. Parent and patient education strategies should cover insulin injections, hypoglycemia, hyperglycemia, self-monitoring of blood glucose (SMBG), nutrition, exercise, and rules for days of acute illness. The chapter presents five case studies, which are individually discussed, and relevant questions are posed and answered. Readers are walked through the diagnostic and patient care management processes for the case studies presented. 2 references.

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Diabetic Ketoacidosis and Hypersmolar Hyperglycemic State. IN: Nilsson, K.R.; Piccini, J.P., eds. Osler Medical Handbook. Philadelphia, PA: Saunders. 2006. pp. 312-320.

This chapter on diabetic ketoacidosis and the hyperosmolar hyperglycemic state (HHS) is from a handbook that provides the essentials of diagnosis and treatment, as well as the latest in evidence-based medicine, for residents working bedside, in-patient care. The chapter begins with a presentation of essential Fast Facts and concludes with Pearls and Pitfalls useful to the practicing internist. The body of the chapter is divided into sections: Epidemiology, Clinical Presentation, Diagnosis, and Management. Specific topics covered in this chapter include the triad of hyperglycemia, acidemia, and ketonemia that define diabetic ketoacidosis (DKA); the symptoms of HHS, including hyperglycemia, hyperosmolarity, and altered mental status; mortality rates for DKA and HHS; the role of infection in triggering DKA and HHS; the role of nonadherence to insulin therapy as a cause of DKA and HHS, a problem that is the most common precipitant of DKA and HHS in urban African-Americans; the role of volume depletion in the development of HHS, as severe hyperglycemia develops when fluid intake fails to compensate for fluids lost through osmotic diuresis; treatment strategies, including administration of intravenous fluid to correct dehydration and hyperosmolarity, administration of insulin to reverse hyperglycemia and ketoacidosis (in DKA), correction of electrolyte abnormalities, identification of precipitants, and frequent patient monitoring; the complications of treatment, including hypoglycemia, hypokalemia, and cerebral edema (rare); and the American Diabetes Association recommendations for the diagnosis and treatment of DKA and HHS. The chapter concludes with a lengthy list of references, each labeled with a 'strength of evidence' grade to help readers determine the type of research available in that reference source. 1 figure. 1 table. 5 references.

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Exanatide: A Novel Treatment Approach for Patients with Type 2 Diabetes. Practical Diabetology. 25(01): 6-18. March 2006.

Incretins are gastrointestinal hormones that enhance glucose-dependent insulin secretion in response to food. Exenatide (Byetta) injection is the first medication in a new class of drugs, called incretin mimetics, approved by the Food and Drug Administration (FDA). Exenatide improves glycemic control and offers the advantages of a unique mechanism of action, effects on multiple glucoregulatory systems in a glucose-dependent manner, restoration of first- and second-phase insulin secretion, and the ability to cause sustained weight loss. This article reviews the mechanism of action, efficacy in clinical studies, safety, and dosing of exenatide for patients with type 2 diabetes. The authors report in detail on the research studies that led to FDA approval of exenatide, then offer practical suggestions for using exenatide in a program of diabetes management for patients with type 2 diabetes who have not achieved adequate glycemic control with metformin (a sulfonylurea compound). Some disadvantages of exenatide therapy can include mild to moderate nausea and moderate sulfonylurea-induced hypoglycemia, when given in combination. The authors conclude that exenatide offers people with type 2 diabetes another opportunity to improve their glycemic control and provides additional glucose-dependent glucoregulatory effects. 9 figures. 14 references.

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First Inhaled Insulin Product Approved. FDA Consumer. 40(2): 28-29. March- April 2006.

This article reports on the recent approval (January 2006) of Exubera, a powdered form of human insulin that is inhaled into the lungs through the patient’s mouth using a specially designed inhaler. The author briefly reviews the different major types of diabetes, then outlines the research studies that resulted in the approval of Exubera. Peak insulin levels were achieved in about 50 minutes, range 30 minutes to 90 minutes, with Exubera inhaled insulin compared with 105 minutes, range 60 to 240 minutes, with regular insulin. In type 1 diabetes, inhaled insulin may be added to longer-acting insulins as a replacement for short-acting insulin taken with meals. In type 2 diabetes, inhaled insulin may be used alone, along with oral medications that control blood sugar, or with longer-acting insulins. As with other insulin products, hypoglycemia is a side effect of Exubera, and patients need to monitor their blood glucose levels regularly. Exubera is not for patients who smoke or those who have quit smoking within the previous six months; baseline tests for lung function are recommended before beginning treatment. 1 figure.

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Following the Path to Better Diabetes Control: A Guide to Educating Patients on Basal Insulin Therapy. Bridgewater, NJ: Sanofi Aventis Group. 2006. (flipchart).

This laminated flipchart is designed to help diabetes educators bring their patients up to date on the use of basal insulin as part of their program of diabetes management. The introductory section reviews the different types of diabetes, the problem of hyperglycemia, the complications caused by hyperglycemia, the use of different types of insulin to manage blood glucose levels, and how to deal with hypoglycemic reactions. Other topics include the influence of meals and meal planning, self-monitoring of blood glucose (SMBG), the importance of recordkeeping, how to measure and inject insulin, the causes and symptoms of low blood glucose levels, and nocturnal hypoglycemia. The chart concludes with a glossary of relevant terms and a list of diabetes websites through which patients can obtain additional information. The flipchart is heavy duty, laminated cardboard, with the teaching points on one side of each sheet and a more colorful, graphically-pleasing presentation of the information on the patient side of the chart.

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Glycemic Index: Measuring the Impact of Carbohydrate on Postprandial Blood Glucose. IN: Pediatric Diabetes: Health Care Reference and Client Education Handouts. Chicago, IL: American Dietetic Association. 2006. pp. 12-14.

The glycemic index is a method of measuring the acute postprandial glycemic impact of a carbohydrate-containing food. This chapter on the use of the glycemic index (GI) is from a resource book that provides health-care professionals with practical, age-appropriate diabetes self-management and nutrition education materials for children and adolescents with type 1 and 2 diabetes. In this chapter, the author discusses which patients may be good candidates for using the glycemic index, the effectiveness of the GI in diabetes meal planning, how glycemic load is determined, appropriate use of the GI, and counseling selections. The author cautions that there are very few studies on the use of low-GI diets in children, yet flexible dietary instruction based on the Food Guide Pyramid with an emphasis on low-GI foods can improve glycosylated hemoglobin levels (a measure of blood glucose over time) without additional risk of hypoglycemia. 7 references.

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Healthy Aging with Diabetes. Diabetes Self-Management. 23(1): 20-22. January February 2006.

This article explores issues that older people with diabetes may face as they age. The author discusses the effects of diabetes on aging and vice versa, offering recommendations for readers who want to stay healthy and full of vitality well into old age. Topics include the basal metabolic rate, aerobic capacity, glucose intolerance, changes in bone metabolism and strength, problems with joints (including arthritis), blood pressure, visual and hearing acuity, cognitive changes associated with aging, nonenzymatic glycation, advanced glycosylation endproducts (AGEs), the interplay of diabetes complications and aging, the impact of aging on blood glucose control strategies, coping with multiple medications (for comorbid conditions as well as for diabetes), and hypoglycemia. The article concludes with a list of suggestions to help counteract the effects of diabetes and aging, including pay attention to monitoring numbers (blood glucose, blood pressure, blood lipid), stay physically active, eat healthy foods, get adequate sleep, take medications carefully, get regular checkups, stay mentally active, and give up vices, especially smoking.

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Hypoglycaemia. IN: Katsilambros, N., et al. Diabetes in Clinical Practice: Questions and Answers From Case Studies. Somerset, NJ: John Wiley & Sons. 2006. pp 71-80.

This chapter on hypoglycemia is from a book that deals with various aspects of diabetes in clinical practice, presented in the form of questions concerning diabetes diagnosis, management, and therapy, all based on real-life case studies. The author notes that episodes of hypoglycemia are usually perceived and treated by the patients themselves. However, if not detected early enough, hypoglycemia can lead to serious problems, including coma. Topics covered include the effects of hypoglycemia in type 1 and type 2 diabetes, the causes of hypoglycemia in a person with diabetes, the symptoms of hypoglycemia, the indications for hospitalization for episodes of hypoglycemia, and posthospitalization patient care and follow-up. The chapter presents five case studies, which are individually discussed, and relevant questions are posed and answered. Readers are walked through the diagnostic and patient care management processes for the case studies presented. 3 references.

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Hypoglycemia in Newborns and Infants. Advances in Pediatrics. 53: 5-22. August 2006.

This article reviews the problem of hypoglycemia in newborns and infants. The authors first describe the changes that must occur at birth when the umbilical cord is cut and the infant goes from total dependence on maternal nutrient supply to independence from the mother and dependence on endogenous fuels. This change requires an immediate, coordinated, and integrated series of hormonal and enzymatic changes, including surges in glucagon and catecholamines, with decreases in insulin concentrations. The authors focus on the application of newer biochemical and molecular techniques that have been used to define hypoglycemic syndromes, particularly those that are due to hyperinsulinemia. Topics include the sensing of hypoglycemia by ATP-regulated potassium channels and the ventromedial hypothalamic nucleus for counter regulation, mechanisms of hypoglycemic central nervous system damage, the signs and symptoms of hypoglycemia, classification, and the management of hyperinsulinemic hypoglycemic of infancy. 2 figures. 3 tables. 66 references.

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Hypoglycemia in Type 1 and Type 2 Diabetes: Physiology, Pathophysiology and Management. Clinical Diabetes. 24(3): 115-121. Summer 2006.

This article reviews the physiology, pathophysiology and management of hypoglycemia in type 1 and type 2 diabetes. The authors note that the threat of hypoglycemia is the major limiting factor in intensive glycemic control for both types of diabetes. The authors focus on the physiology of the normal counter-regulatory responses to hypoglycemia and the deficient counter-regulatory defenses that occur in patients with diabetes. They contend that the combination of understanding the physiological reaction and monitoring glycemic therapy can help reduce the prevalence of iatrogenic hypoglycemia. Topics include the symptoms of hypoglycemia, hypoglycemia and glycemic thresholds, counter-regulatory hormone responses to hypoglycemia in older adults, and exercise-related hypoglycemia. The article concludes with a section of strategies to reduce the risk of iatrogenic hypoglycemia. 3 tables. 48 references.

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Inhalable Insulin is On the Way. Diabetes Forecast. 59(4): 15. April 2006.

This brief article alerts readers to the new, inhalable insulin called Exubera (Pfizer, Inc., and Nektar Therapeutics). Exubera is a mealtime insulin in powdered form that patients use not more than 10 minutes before eating. The insulin is delivered in a special inhaler that is used by drawing a regular breath. The inhaler does not require batteries or electricity, and weighs about 4 ounces. For patients with type 1 diabetes, Exubera may be used in place of mealtime injections of rapid-acting insulin, but patients would still need to take their regular injections of longer-acting insulin. For patients with type 2 diabetes, Exubera may be used as an alternative to diabetes pills or mealtime insulin injections, or in combination with pills or longer-acting injectable insulin. Side effects can include low blood glucose (hypoglycemia), dry mouth, chest discomfort, and decreased lung capacity. Readers are referred to the Pfizer education number for more information (800-398-2372 or www.exubera.com).

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Learning to Use Pramlintide. Practical Diabetology. 25(1): 42-46. March 2006.

Pramlintide (Symlin) was approved in 2005 for use together with insulin in patients with type 1 and type 2 diabetes. Pramlintide is a synthetically produced analog of the hormone amylin and reduces postprandial hyperglycemia, or high blood glucose levels after a meal, and glycosylated hemoglobin—HbA1c, a measure of blood glucose over time—while reducing body weight. This article reviews current knowledge about pramlintide, in terms of mechanism of action, effectiveness, and clinical use. Pramlintide is approved only for use by patients already taking both basal and mealtime insulin. It is administrated subcutaneously in the same manner as insulin and is given immediately before major meals. Clinical observations suggest that many patients feel better when taking pramlintide, even more so than would be expected by improvements in HbA1c or weight. Dosing strategies can be used to avoid the main adverse effect of pramlintide, which is insulin-induced hypoglycemia that can accompany the initiation of pramlintide. 3 tables. 5 references.

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Managing the Diabetic Patient in a Weight-Loss Program. Diabetes Spectrum. 25(4): 30-36. December 2006.

This review provides the strategies and guidelines necessary to manage overweight and obese individuals with diabetes in a weight-loss program. The author stresses that to safely improve blood glucose levels, blood pressure, and lipids, the optimal approach to weight management is close medical monitoring by an experienced health care professional in a structured program. The author describes the initial patient evaluation, establishing goals, medical monitoring, lifestyle change strategies, and medication management. Successful management of obesity can be particularly rewarding for the patient with diabetes, resulting in improved glycemic control and reduced medication needs. However, the interplay of reduced caloric intake and oral hypoglycemic agents is complex and must be closely monitored to avoid complications such as hypoglycemia. 1 figure. 3 tables. 19 references.

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Medical Treatment of the Obese Patient with Type 2 Diabetes. IN: Obesity and Diabetes. Totowa, NJ: Humana Press. 2006. pp. 471-486.

This chapter, from a comprehensive textbook on diabetes and obesity, focuses on the medical treatment of type 2 diabetes, with a special emphasis on the approach to the obese patient with this disease. Topics include the pathophysiology and natural history of type 2 diabetes, the goals of therapy and monitoring in type 2 diabetes, medical nutrition therapy (MNT) and exercise, oral antihyperglycemic agents, available insulin formulations, the approach to insulin use in obese patients with type 2 diabetes, and future therapies. The authors conclude that the goal of treatment is to achieve and maintain near-normal glycemic control without increasing the risk of hypoglycemia. MNT and exercise form the cornerstone of a comprehensive management program, but the vast majority of patients require drug therapy to achieve and maintain optimal blood glucose levels. For the obese patient with diabetes, insulin sensitizers are effective medications, and combination therapy with insulin secretagogues and sensitizers should be considered in patients with suboptimal control. Insulin remains an important component of the treatment regimens for patients not achieving target blood glucose goals with oral agents. 1 figure. 4 tables. 110 references.

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New Therapies in Diabetes. IN: Katsilambros, N., et al. Diabetes in Clinical Practice: Questions and Answers From Case Studies. . Somerset, NJ: John Wiley & Sons. 2006. pp 409-436.

This chapter on new therapies in diabetes is from a book that deals with various aspects of diabetes in clinical practice, presented in the form of questions concerning diabetes diagnosis, management, and therapy, all based on real-life case studies. Topics covered include the use of continuous subcutaneous insulin infusion pumps, the different types of insulin pumps available, the components of an insulin pump, how the basal rate is determined, how the boluses are determined, patient indications for the use of an insulin pump, the use of an insulin pump to help prevent hypoglycemia unawareness, complications associated with an insulin pump, patient care management and follow up for a patient using an insulin pump, the use of inhaled insulin, the metabolism of inhaled insulin, complications regarding the use of inhaled insulin, the use of inhaled insulin in patients who smoke, kidney and pancreas transplantation, transplantation of pancreatic islets, glucagon-like peptide (GLP-1) in patients with type 2 diabetes, amylin, pramlintide, and the artificial pancreas. The chapter presents one detailed case study, with relevant questions posed and answered. Readers are walked through the diagnostic and patient care management process for the case study presented. 1 figure. 28 references.

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Nutrition Support and Hyperglycemia. IN: Mechanick, J.; Brett, E., eds. Nutritional Strategies for the Diabetic and Prediabetic Patient. Boca Raton, FL: CRC Press. 2006. pp. 171-192.

This chapter on nutrition support and hyperglycemia is from a book written to advance physicians’ knowledge in nutrition as it relates to diabetes and to help them provide evidence-based recommendations to their patients with diabetes. Hyperglycemia in patients receiving nutrition support may be due to type 1 diabetes, type 2 diabetes, or stress hyperglycemia. Stress hyperglycemia is the presence of elevated glucose during an acute illness, in a patient without a prior diagnosis of diabetes, which normalizes after the illness. The author covers the causes of hyperglycemia, the rationale for glycemic control in hospitalized patients, clinical practice guidelines for glycemic control among hospitalized patients, nutrition support, parenteral nutrition, enteral nutrition, and hypoglycemia. The sections on parenteral and enteral nutrition discuss macronutrient requirements, insulinization, and micronutrient supplements. The author notes that the majority of patients who receive nutrition support are hospitalized patients with acute illnesses that require temporary nutrition support. 1 figure. 4 tables. 169 references.

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Pancreas and Islet Transplantation in Type 1 Diabetes. Diabetes Care. 29(4): 935. April 2006.

Successful pancreas transplantation has been demonstrated to be effective in significantly improving the quality of life of people with diabetes, primarily by eliminating the acute complications commonly experienced by patients with type 1 diabetes (hypoglycemia, marked hyperglycemia, and ketoacidosis). This brief article presents the position statement of the American Diabetes Association (ADA) on pancreas and islet transplantation in patients with type 1 diabetes. The recommendations are based on an ADA technical review and recent extensive review on the subject (both of which are available from the ADA for readers seeking additional information). Pancreas transplantation eliminates the need for exogenous insulin, frequent daily blood glucose measurements, and many of the dietary restrictions imposed by diabetes. Pancreas-only and islet transplants require lifelong immunosuppression to prevent rejection of the graft and potential recurrence of the autoimmune process that might again destroy pancreatic islet beta cells. The recommendations state that pancreas transplantation should be considered an acceptable therapeutic alternative to continued insulin therapy in diabetic patients with imminent or established end-stage renal disease who have had or plan to have a kidney transplant because the successful addition of a pancreas does not jeopardize patient survival, may improve kidney survival, and will restore normal glycemia. The recommendations outline patient-selection considerations and the recent work on pancreatic islet transplants. 2 references.

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Physical Activity, Exercise and Type 2 Diabetes: A Consensus Statement from the American Diabetes Association. Diabetes Care. 29(6): 1433-1438. June 2006.

This consensus statement from the American Diabetes Association summarizes the most clinically relevant recent advances related to people with type 2 diabetes and the recommendations that follow from these advances. Topics include physical activity and the prevention of type 2 diabetes; the effects of structured exercise interventions on glycemic control and body weight in type 2 diabetes; physical activity, aerobic fitness, and risk of cardiovascular and overall mortality; recommended frequency of exercise; exercise for weight loss and weight maintenance; the role of resistance training; flexibility exercises (stretching); evaluation of the diabetic patient before recommending an exercise program; exercise in the presence of nonoptimal glycemic control, including managing hyperglycemia and hypoglycemia; and exercise in the presence of specific long-term complications of diabetes, notably retinopathy, peripheral neuropathy, autonomic neuropathy, and microalbuminuria and nephropathy. A final section offers specific recommendations in the areas of lifestyle measures for the prevention of type 2 diabetes, aerobic exercise, resistance exercise, and prevention of hypoglycemia. 70 references.

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Physical Activity. IN: Mensing, C., ed. Art and Science of Diabetes Self-Management Education. Chicago, IL: American Association of Diabetes Educators. pp. 298-319.

A lifestyle the incorporates sufficient physical activity aids in diabetes prevention and is extremely beneficial to general health. This chapter on physical activity is from a comprehensive text that serves as a resource for all health professionals, community professionals, and individuals who provide education to individuals with diabetes. The author reviews current physical fitness terminology, including health-related physical fitness; the role of physical activity in diabetes prevention and treatment; the effect of physical activity on diabetes management, including cardiovascular exercise, resistance exercises, and flexibility exercises; the physiological responses to physical activity, notably changes associated with blood glucose levels; hypoglycemia and physical activity; self-management strategies for safe physical activity, including adding carbohydrates, medication adjustments, and problem-solving; the four components of the exercise prescription, including intensity, mode, frequency, and duration; physical activity in special populations, including children and teens, and elderly adults; and medical considerations, including the need for preactivity medical exam and assessment, cardiovascular disease, neuropathy, nephropathy, and retinopathy. The author stresses that learning to overcome barriers that interfere with a more physically active lifestyle is a large part of diabetes self-management education. The chapter includes a list of key points, a summary of teaching strategies, case studies, suggested Internet resources, a glossary of key terms, and a list of references. 13 tables. 45 references.

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Products for Treating Low Blood Glucose. Diabetes Forecast. 59(1): RG60-RG62. January 2006.

For people with diabetes, a drop in blood glucose can occur when they take too much insulin or oral medications; eat too little food or inadequate nutrients to cover their insulin or oral medication; do not eat at the appropriate time; or get more physical activity than they prepared for. This section on products for treating low blood glucose is from a special issue of Diabetes Forecast that offers the annual guide to diabetes products and services. The author first reviews the physiology of hypoglycemia (low blood glucose), including the symptoms, the causes, and suggestions for how to prevent and treat low blood glucose reactions. In addition to juice and other carbohydrates, there are commercially-manufactured products that are available to treat low blood glucose. The author reviews three points to consider when purchasing these products: how quickly it works, the form it comes in, and costs. Specific products described include ExtendBar that provides a continuous glucose supply for up to 9 hours; Glucerna Shakes, weight-loss shakes, meal, and snack bars, that contains carbohydrates that are digested slowly to help minimize peaks in blood glucose; and Enterex Diabetic Drink, which offers complete and balanced nutrition with no sugar added for meal replacement. One chart briefly summarizes the products described. 1 table.

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Pumping Insulin. 4th ed. San Diego, CA: Torrey Pines Press/ Diabetes Mall. 2006. 332 p.

This book is a guide for using a smart insulin pump for diabetes control. The book consists primarily of figures, charts, examples, tables, and sidebars of tips that provide basic and advanced information about the use of an insulin pump. The authors caution that specific treatment plans, insulin dosages, and other aspects of health care for a person with diabetes must be based on individualized treatment protocols under the guidance of their own health care team. The book offers 27 chapters in six sections: getting ready; the essentials of pump training; how to set and adjust doses; troubleshooting; special considerations; and resource materials, including carbohydrate counting, references, a glossary, and a subject index. Specific topics covered include the benefits of pumping, high blood glucose complications also known as hyperglycemia, modeling the pancreas, patient selection issues, how to select an insulin pump, the features of different insulin pumps, carbohydrate counting, the glycemic index, recordkeeping, basal dosing, bolus dosing, lifestyle issues, control tools and tips, hypoglycemia and hypoglycemia unawareness, ketoacidosis, managing site and skin problems, exercise, children and teens using insulin pumps, pumps and type 2 diabetes, and using insulin pumps during pregnancy. 29 figures. 89 tables. 132 references.

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Smart Snacking. IN: Pediatric Diabetes: Health Care Reference and Client Education Handouts. Chicago, IL: American Dietetic Association. 2006. pp. 20-21.

This chapter on smart snacking is from a resource book that provides health-care professionals with practical, age-appropriate diabetes self-management and nutrition education materials for children and adolescents with type 1 and 2 diabetes. In this chapter, the author discusses the role of snacking in a diabetes meal plan for children, indications for addition of snacks or change in snacking patterns, special snacking considerations (school, weekends, camp, social events), and counseling suggestions. The author stresses that snacks play a key role in fulfilling the goals of medical nutrition therapy in children and adolescents with diabetes: to prevent hunger between meals, to assist in providing adequate energy for growth and development, and to help prevent hypoglycemia. The author recommends that the child be given some control over eating by starting with snacks, an approach that can be particularly useful if the caregiver providers reasonable limited choices. Snacks are also an easy way to incorporate fruits, vegetables, and calcium-rich foods into the diet. 4 references.

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Special Considerations in Older Adults with Diabetes: Meeting the Challenge. Diabetes Spectrum. 19(4): 229-233. Fall 2006.

This article addresses the special considerations in managing older adults with diabetes. The author stresses that thoroughness and vigilance are prime qualities that are needed in managing older adults with diabetes, especially in the areas of assessment and treatment. The author reviews the principles of diabetes care, functional impairment in diabetes and the role of comprehensive geriatric assessment, diabetes and cognitive performance, depression and diabetes, hypoglycemia in older patients, and the importance of goal-setting in this patient population. The major medical goals in managing older patients with diabetes are to achieve freedom from hyperglycemic symptoms, prevention of undesirable weight loss, avoidance of hypoglycemia and other adverse drug reactions, estimation of cardiovascular risk, screening for and preventing vascular complications, detection of cognitive impairment and depression, detection of functional disabilities, and achievement of a normal life expectancy for patients where possible. Patient-oriented goals include the maintenance of general well-being and good quality of life, the acquisition of skills and knowledge to adapt to lifestyle changes, and the encouragement of diabetes self care. 5 tables. 29 references.

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Standards of Medical Care in Diabetes 2006, Part 2: Diabetes Care. Practical Diabetology. 25(2): 8-34. 2006.

This second installment of the Standards of Medical Care in Diabetes (American Diabetes Association, 2006) covers diabetes care, including initial evaluation, management, glycemic control, self-monitoring of blood glucose (SMBG), glycosylated hemoglobin testing (HbA1c), medical nutrition therapy, weight management, diabetes self-management education (DSME), physical activity, psychosocial assessment and care, referral for diabetes management, intercurrent illness, hypoglycemia recommendations, and immunization recommendations. MNT issues covered include dietary carbohydrate, dietary protein, dietary fats, optimal macronutrient mix, fiber, reduced-calorie sweeteners, antioxidants, chromium, and alcohol. In each section, the guidelines review the recommended health care and focus on the role of the members of the health care team, including the patient. 81 references.

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Treating Low Blood Glucose. IN: Pediatric Diabetes: Health Care Reference and Client Education Handouts. Chicago, IL: American Dietetic Association. 2006. pp. 28-30.

Children can experience symptoms of hypoglycemia or low blood glucose levels as a result of delayed meals or snacks, increased levels of physical activity, many types of diabetes medications, or illness. This chapter on treating low blood glucose (hypoglycemia) is from a resource book that provides health-care professionals with practical, age-appropriate diabetes self-management and nutrition education materials for children and adolescents with type 1 and 2 diabetes. In this chapter, the author discusses low blood glucose in children, the interplay of physical activity and low blood glucose, rebounding (reactive hypoglycemia or Somogyi reaction), treating severely low blood glucose levels, and counseling suggestions. The author also reviews the use of glucagon kits to treat hypoglycemia in children. 9 references.

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Treatment of Diabetes With Pills. IN: Katsilambros, N., et al. Diabetes in Clinical Practice: Questions and Answers From Case Studies. Somerset, NJ: John Wiley & Sons. 2006. pp 341-370.

This chapter on treating diabetes with oral medication is from a book that deals with various aspects of diabetes in clinical practice, presented in the form of questions concerning diabetes diagnosis, management, and therapy, all based on real-life case studies. Topics covered include the five categories of antidiabetes pills, notably sulfonylureas, meglitinides, biguanides, thiazolidinediones, and alpha-glucosidase inhibitors; the use of medications to help prevent complications in patients with type 2 diabetes; how each type of oral medication should be used and their mechanism of action; medications that may interfere with diabetes medications; undesirable side effects of each type of antidiabetes medication; and recommendations for combining antidiabetes medications. Specific drugs discussed include repaglinide, nateglinide, metformin, and acarbose. The chapter presents three detailed case studies, with relevant questions posed and answered. Readers are walked through the diagnostic and patient care management process for the case studies presented. 2 figures. 1 table. 21 references.

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Your Guide to Diabetes: Type 1 and Type 2. Bethesda, MD: National Diabetes Information Clearinghouse. 2006. 62 p.

This booklet helps people with type 1 or type 2 diabetes understand their disease and learn how to take care of themselves and how to prevent some of the serious problems diabetes can cause. Diabetes is a disease in which blood glucose levels are above normal. People who have diabetes often experience complications due to these high blood glucose levels, including in the heart, blood vessels, eyes, and kidneys. This booklet, written in nontechnical language, offers six sections covering the different types of diabetes, their causes, the signs and symptoms, and recommended blood glucose levels; everyday diabetes care, including meal planning, physical activities, diabetes medications, self-monitoring of blood glucose (SMBG), and recordkeeping; hyperglycemia and hypoglycemia; the complications associated with diabetes, including those affecting the heart and blood vessels, eyes, kidneys, nerves, and gums and teeth; diabetes care in special circumstances, such as illness, at school or work, away from home, and during pregnancy; and where to find additional information about diabetes and self-care. A final section briefly summarizes the activities of the National Diabetes Information Clearinghouse. The booklet is illustrated with black-and-white line drawings. 18 figures. 3 tables.

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Adjusting Insulin Doses: From Knowledge to Decision. Patient Education and Counseling. 56(1): 98-103. January 2005.

This article reports on a study that investigated the reasons for the absence of adjustment of insulin doses in patients with poorly-controlled Type 1 diabetes. The study included 28 patients whose HbA1c (glycosylated hemoglobin, a measure of blood glucose over time) was higher than 8.5 percent during the last 6 months. The patients performed at least three capillary blood glucose determinations per day, and completed a questionnaire on the degree of confidence in their own knowledge, the nature of their health beliefs, their fear of hypoglycemia, and their own appreciation on how they adjust their insulin doses (subjective score). An analysis of the patients' diabetes logbooks provided an objective score of the adjustment of doses actually performed. There was not a significant correlation between the subjective and objective scores of adjustment. There was a significant negative correlation between the score of uncertainty on knowledge and the subjective score of adjustment of the insulin doses, but not with the objective score. There was a significant correlation between the score of positive health beliefs and the subjective score of adjustment of the insulin doses, but not with the objective score. The fear of hypoglycemia was the most frequently given reason for not adjusting the insulin doses, when the question was asked to the patients with an open answer. The authors conclude that their study illustrates the difference between thinking and doing. The degree of confidence in one's own knowledge, the health beliefs, and the fear of hypoglycemia differently influence the perception that the patients have of their behavior, and what they really do. 1 figure. 2 tables. 18 references.

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Adventure Travel and Type 1 Diabetes: The Complicating Effects of High Altitude. Diabetes Care. 28(10): 2563-2572. October 2005.

In keeping with recommendations to stay physically fit, increasing numbers of people with type 1 diabetes now participate in extreme forms of physical activity, including high-altitude trekking and mountain climbing. However, exercise at altitude imposes a number of unique challenges for people with type 1 diabetes, including impairment in glycemic control and additional problems for patients with complications. This article reviews what is known about the impact of altitude on individuals with type 1 diabetes, then offers strategies for dealing with these challenges. High altitude is defined as 3,000 to 5,000 meters (10,000 to 16,000 feet) and extreme altitude as that greater than 5,000 meters. The author reviews three studies in this area, then discusses acute altitude sickness (also called acute mountain sickness or AMS), the effects of altitude on glycemic control and on glucose meter performance, altitude-induced anorexia, altitude and temperature, and other concerns including the impact of long-distance travel, poor hygiene, gastrointestinal disturbances, food supplies, and isolation. The author concludes that there are no absolute contraindications to travel at high or extreme altitudes for the knowledgeable individual with type 1 diabetes who is free of complications. However, there is some risk, including the possible consequences of hypoglycemia, illness, or injury. Specific recommendations for individuals with type 1 diabetes traveling at altitude are summarized in a table. 1 figure. 3 tables. 78 references.

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Amylin: Insulin's Partner. Diabetes Self-Management. 22(4): 40-43. July-August 2005.

This article describes pramlintide (brand name Symlin), a synthetic analog of amylin, a neuroendocrine hormone that can be used in conjunction with insulin. Amylin is currently approved for people with type 1 diabetes and people with type 2 diabetes who use insulin. The author describes how the medication works in tandem with insulin, how amylin can ease problems with high postprandial (after a meal) blood glucose levels, oxidative stress, and the history of pramlintide's journey from research laboratory to FDA approval. The author notes that side effects associated with pramlintide, including nausea and hypoglycemia, occur early in the course of treatment and tend to ease over time.

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Back to School: Getting Your Child, And the School, Ready. Diabetes Vital. 1(3): 8-9. Fall 2005.

This article helps parents review the steps they can take to help their child with diabetes adjust to a new school year. Parents are encouraged to involve all the adults who will be interacting with the child, including the principal, teachers, nurse, bus drivers, coaches, and other school staff members. The author provides specific suggestions for providing information to the school, including recordkeeping, educating the staff about the disease of diabetes, establishing any special permission for snacks or breaks, and providing contact information for parents and other emergency helpers (such as health care providers). The article concludes by reminding parents of the importance of including the child in these plans and discussions. A diabetes education website address is also provided, for readers looking for additional information (www.ndep.nih.gov/diabetes/youth/youth.htm). One sidebar lists the symptoms of, causes of, and treatment for hypoglycemia (low blood glucose) and hyperglycemia (high blood glucose).

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Blood Glucose Awareness Training: What is It, Where is It, and Where is It Going?. Diabetes Spectrum. 19(1): 43-49. Winter 2005.

Management of type 1 diabetes requires a balance of insulin, caloric intake, and metabolic demand (such as exercise). This can best be accomplished with awareness of the blood glucose levels as well as where those levels are going and knowledge of how to manipulate insulin, calories, and exercise to manage blood glucose. This article describes Blood Glucose Awareness Training (BGAT), a psychoeducational intervention that can be used to address the need for better understanding of blood glucose. The authors review 15 research studies from the United States and Europe that focus on BGAT. These studies have validated the benefits of BGAT which include: improved accuracy of blood glucose estimations, improved detection of hypoglycemia and hyperglycemia, improved judgments related to decisions to self-treat when blood glucose is low, reduction in motor vehicle mishaps across time, reduction in episodes of severe hypoglycemia, and reduction in fear associated with hypoglycemia, while improving diabetes knowledge and quality of life. The authors describe how BGAT has recently been reconfigured for internet delivery, making it available both for clinicians to use with their patients and for individuals with type 1 diabetes to pursue as a self-directed tutorial. 2 tables. 32 references.

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Blood Glucose Monitoring: What Do the Numbers Tell You?. Diabetes Self-Management. 22(5): 65-68. September- October 2005.

This article helps readers understand the results that they get from checking their blood glucose levels. The author notes that many people dutifully check their blood glucose levels but have no idea what the numbers mean. The situation is complicated by the fact that blood glucose levels constantly fluctuate and are influenced by many factors. The author first reviews the physiology of insulin and how insulin production and metabolism differ in type 1 and type 2 diabetes. The next section discusses target goals for blood glucose and suggestions for self monitoring of blood glucose (SMBG), including how often to check, when to check, and record-keeping. The final section of the article offers suggestions for addressing common problems, including higher blood glucose levels in the morning, high blood glucose levels all day, blood glucose levels within range, except for two hours after eating, and a sudden change in blood glucose patterns. One sidebar considers the use of blood glucose meter averages; most blood glucose meters store a certain number of readings in their memory and also report either a 14-day or 30-day average of readings. Readers are encouraged to work closely with their health care providers to understand their blood glucose readings and implement that understanding into their regular program of diabetes care.

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Burden of Mortality Attributable to Diabetes: Realistic Estimates for the Year 2000. Diabetes Care. 28(9): 2130-2135. September 2005.

Routinely reported statistics based on death certificates seriously underestimate mortality from diabetes, primarily because individuals with diabetes most often die of cardiovascular and renal disease and not from a cause uniquely related to diabetes, such as ketoacidosis or hypoglycemia. This article reports on a study undertaken to estimate the global number of excess deaths due to diabetes in the year 2000. The authors used a computerized generic formal disease model (DisMod II), used by the World Health Organization to assess disease burden through modeling the relationships between incidence, prevalence, and disease-specific mortality. Baseline input data included population structure, age-specific and sex-specific estimates of diabetes prevalence, and available published estimates of relative risk of death for people with diabetes compared to people without diabetes. The results showed that the excess global mortality attributable to diabetes in the year 2000 was estimated to be 2.9 million deaths, equivalent to 5.2 percent of all deaths. Excess mortality attributable to diabetes accounted for 2 to 3 percent of deaths in the poorest countries and over 8 percent in the United States, Canada, and the Middle East. In people aged 35 to 64 years, 6 to 27 percent of deaths were attributable to diabetes. The authors conclude that globally, diabetes is likely to be the fifth leading cause of death. 1 figure. 3 tables. 28 references.

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Can't Feel Your Lows?: Understanding Hypoglycemia Unawareness. Diabetes Forecast. 58(12): 55-56. December 2005.

This article reviews the problem of hypoglycemia unawareness, the inability of a person to feel the symptoms of low blood glucose levels. Normal signs of hypoglycemia include sweating, shakiness, and dizziness. The author notes the fact that the more often a person experiences hypoglycemia, the higher the likelihood that hypoglycemia unawareness may occur. People who at one time were able to feel symptoms of low blood glucose at 70 milligrams per deciliter may get to where they do not feel the symptoms of hypoglycemia until their blood glucose levels drop to 60, 50, or even lower. The author also discusses intensive diabetes management and how striving for tight blood glucose control may result in more frequent episodes of hypoglycemia unawareness. The author concludes with a brief section on the role of ongoing patient education to better combat the problem of hypoglycemia unawareness.

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Collaborative Islet Transplant Registry Annual Report. Bethesda, MD: National Diabetes Information Clearinghouse. 2005. 214 p.

The number of transplant centers performing clinical islet cell transplantation continues to increase, as does the number of centers participating in and reporting to the Collaborative Islet Transplant Registry (CITR). The CITR was founded in September 2001 to provide support for logistics, data capture, quality control monitoring, statistical design and analysis, and other Registry activities. This second Annual Report of the CITR describes the progress in islet or beta cell transplantation. The information is drawn from 19 North American islet transplant programs, representing 138 transplant recipients. The information is presented in four sections: a summary of Registry data; islet-transplant-alone recipient, donor, and outcome information; islet-after-kidney recipient, donor, and outcome information; and Registry data quality. The Report describes patient care, surgical experiences, follow-up care, complications, hypoglycemia, insulin independence, and immunosuppression in these patients. The Report provides data on the recipients, pancreas donors, pancreas preservation, islet processing, islet infusions, recipient treatment, post-transplant islet function, and adverse events. The Report is designed to provide information that can form the basis necessary for the development of islet transplantation as a curative therapy for type 1 diabetes. Readers are referred to the Registry’s website, www.citregistry.org, for more information. 210 figures.

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Collaborative Islet Transplant Registry Annual Report. Bethesda, MD: National Diabetes Information Clearinghouse. 2005. (CD-ROM)

The number of transplant centers performing clinical islet cell transplantation continues to increase, as does the number of centers participating in and reporting to the Collaborative Islet Transplant Registry (CITR). The CITR was founded in September 2001 to provide support for logistics, data capture, quality control monitoring, statistical design and analysis, and other Registry activities. This CD-ROM provides the second Annual Report of the CITR, supporting the mission of supporting progress and promoting safety in islet or beta cell transplantation. The disk contains the Annual Report in PDF format, March 2005 Case Report Forms in PDF format, and the figures and tables from the Annual Report in 210 PowerPoint slides. The information is drawn from 19 North American islet transplant programs, representing 138 transplant recipients. The Report describes patient care, surgical experiences, follow-up care, complications, hypoglycemia, insulin independence, and immunosuppression in these patients. The Report provides data on the recipients, pancreas donors, pancreas preservation, islet processing, islet infusions, recipient treatment, post-transplant islet function, and adverse events. The Report is designed to provide information that can form the basis necessary for the development of islet transplantation as a curative therapy for type 1 diabetes. Readers are referred to the Registry’s website, www.citregistry.org, for more information. 210 figures.

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Current and Future Approaches to Monitoring Glycemia. Advanced Studies in Medicine. 5(10): S1117-S1128 p. December 2005.

The goal of blood glucose monitoring in diabetes is to obtain useful information about the patient’s overall glucose status in order to normalize glucose, prevent hypoglycemia, and minimize hyperglycemia through meaningful and timely interventions. This review article outlines current and future approaches to monitoring glycemia. The author stresses that self-monitoring of blood glucose (SMBG) is the foundation of diabetes care. Studies have shown a direct correlation between the use of SMBG and improved glycosylated hemoglobin (HbA1c) levels, a measure of blood glucose levels over time. Recommendations for patients with type 1 diabetes are to use SMBG at least 3 times daily; the optimal frequency for patients with type 2 diabetes is unknown, but the frequency should be sufficient to reach glucose goals. The accuracy of the results is instrument- and user-dependent, thus the clinician should evaluate each patient’s technique frequently, including use of alternate-site testing. The author considers several obstacles to optimal SMBG, including denial, ignored results, clinician passivity, pain, expense, and inconvenience, any of which can severely compromise a treatment plan. The article concludes with a section on the emerging technology of continuous glucose monitoring (CGM), including a review of the currently available CGM meters, in addition to those meters under development and review by the US Food and Drug Administration. The author focuses on the strengths and limitations of HbA1c measurement and the physiology behind its use as a diabetes marker. Four sidebars cover diabetic ketoacidosis; the electrochemistry of second-generation blood glucose meters; the role of the diabetes educator in implementing continuous glucose monitoring; and the history of the use of HbA1c in diabetes management. 7 figures. 4 tables. 25 references.

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Detection, Prevention, and Treatment of Hypoglycemia in the Hospital. Diabetes Spectrum. 18(1): 39-44. Winter 2005.

The threat of hypoglycemia is one barrier to providing optimal glycemic control in the inpatient setting. Nurses, physicians, and other health care workers must be vigilant in detecting, treating, and most of all preventing hypoglycemia (low blood glucose levels) in patients with diabetes who are hospitalized. This article discusses the hospital care of this patient population. The author covers detection of hypoglycemia, including signs and symptoms and risk factors; prevention, including recognition of precipitating factors, scheduled insulin therapy, inpatient use of oral agents, bedside glucose monitoring, the role of medical nutrition therapy (MNT), and applying systems; and treatment strategies. The author concludes that identifying risk factors, implementing protocols, avoiding traditional sliding scale insulin regimens, and changing unsafe prescribing behaviors, are ways to avoid severe hypoglycemic events. Reviewing hypoglycemia signs and symptoms with the entire inpatient team, including patients and their significant others, allows for early detection and treatment. The article includes a patient care algorithm.

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Diabetes Care in an Urban Specialty Clinic. Diabetes Spectrum. 18(3): 174-176. Summer 2005.

Interpersonal health communication can affect individuals? awareness, knowledge, attitudes, self-efficacy, skills, and commitment to behavior change. This article reviews the impact of cultural issues, location of the health care setting, and resources on the provision of diabetes care. The author focuses on diabetes care in an urban specialty clinic and uses case studies to illustrate the concepts being discussed. The first case study features an empowered middle-aged woman with longstanding type 2 diabetes; the second case study reports on recurrent hypoglycemia in an individual with type 1 diabetes and a history of alcohol abuse. The author emphasizes that personalizing and involving people in their own care facilitates sustained behavior change. Health communication cannot compensate for inadequate health care or inadequate access to health care services, nor produce sustained change in complex health behaviors without some type of support network. The author cautions that health care providers working with people who have limited resources and education sometimes make the inaccurate assumption that these individuals cannot adequately understand self-care practice recommendations. 5 references.

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Executive Summary. IN: Collaborative Islet Transplant Registry Annual Report. Bethesda, MD: National Diabetes Information Clearinghouse. pp. 1-3.

The number of transplant centers performing clinical islet cell transplantation continues to increase, as does the number of centers participating in and reporting to the Collaborative Islet Transplant Registry (CITR). The CITR was founded in September 2001 to provide support for logistics, data capture, quality control monitoring, statistical design and analysis, and other Registry activities. This introductory chapter from the second Annual Report of the CITR describes the progress in islet or beta cell transplantation. This chapter briefly summarizes the annual information that was drawn from 19 North American islet transplant programs, representing 138 transplant recipients. The information focuses on islet-transplant-alone recipients (n = 118), donor, and outcome information. The summary briefly describes patient care, surgical experiences, follow-up care, complications, hypoglycemia, insulin independence, and immunosuppression in these patients. The median age of islet-transplant-alone recipients was 41.6 years and duration of diabetes was 29 years. More than 66 percent of the recipients were female, and all had type 1 diabetes. The median age of the deceased donor for these recipients was 44 years (range 8 to 65 years); 53 percent of the donors were male, and approximately 66 percent were white. At the time of this report, follow-up evaluations had been completed for 112 out of 118 patients. Of these 112 patients, 55 (49.1 percent) are insulin independent, while 39 (34.8 percent) are insulin dependent. Fifteen patients (13.4 percent) have experienced graft failure, while three participants have an unknown insulin status. There is a striking decrease in the occurrence of severe hypoglycemic events subsequent to the first infusion. The majority of the recipients received daclizumab for induction and sirolimus combined with tacrolimus for maintenance immunosuppression. Information about adverse events, received from 18 of the 19 transplant centers, show that almost 74 percent of the recipients experienced at least one adverse event in year 1, while 36 percent experienced one or more serious adverse events in the first year post-transplant. Overall, 77 serious adverse events were reported to the Registry, with 22 percent (n = 17) of them classified as life-threatening and 58 percent (n = 45) requiring an inpatient hospitalization. Ninety-five percent of these adverse events were resolved without residual effects. Readers are referred to the Registry’s website, www.citregistry.org, for more information.

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Exenatide Versus Insulin Glargine in Patients with Suboptimally Controlled Type 2 Diabetes. A Randomized Trial. Annals of Internal Medicine. 143(8): 559-569. October 2005.

This article reports on a study that compared the effects of exenatide and insulin glargine (both injectable drugs) on blood glucose control in patients with type 2 diabetes mellitus that is suboptimally controlled with metformin and a sulfonylurea (oral hypoglycemic agents). The 26-week multicenter, open-label, randomized, controlled trial utilized 82 outpatient study centers in 13 countries and included 551 patients with type 2 diabetes and inadequate glycemic control. Inadequate glycemic control is defined as hemoglobin A1c (HbA1c, a measure of blood glucose over time) level ranging from 7.0 percent to 10.0 percent, despite combination metformin and sulfonylurea therapy. Baseline mean HbA1c level was 8.2 percent for patients receiving exenatide and 8.3 percent for those receiving insulin glargine. At week 26, both exenatide and insulin glargine reduced hemoglobin A1c levels by 1.11 percent. Exenatide reduced postprandial glucose excursions (changes in blood glucose levels after a meal) more than insulin glargine, while insulin glargine reduced fasting glucose concentrations more than exenatide. Body weight decreased 2.3 kilograms with exenatide and increased 1.8 kilograms with insulin glargine. Rates of symptomatic hypoglycemia were similar, but nocturnal hypoglycemia occurred less frequently with exenatide. Gastrointestinal symptoms were more common in the exenatide group than in the insulin glargine group, including nausea (57.1 percent versus 8.6 percent), vomiting (17.4 percent versus 3.7 percent) and diarrhea (8.5 percent versus 3.0 percent). The authors conclude that exenatide and insulin glargine achieved similar improvements in overall glycemic control in this patient population. Exenatide was associated with weight reduction and had a higher incidence of gastrointestinal adverse effects than insulin glargine. 3 figures. 3 tables. 34 references.

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Getting Down to Basals. Diabetes Self-Management. 22(4): 60-68. July-August 2005.

Basal insulin is a steady dose of insulin used to match the liver's secretion of glucose into the bloodstream (and to prevent the liver from oversecreting glucose). Basal insulin is necessary for maintaining blood glucose control. This article considers basal insulin requirements, starting doses, fine-tuning basal insulin and pump basal rates and the Somogyi phenomenon. Taking too much basal insulin, or taking it at the wrong times, can result in frequent (and perhaps severe) hypoglycemia, as well as weight gain. Taking too little basal insulin will produce high blood glucose and make it very difficult to set appropriate mealtime bolus doses. The author concludes by encouraging readers to work closely with their endocrinologists or other health care providers to determine their best basal insulin regimen. 2 figures. 2 tables.

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Glucagon-Like Peptide-1 as a Treatment Option for Type 2 Diabetes and Its Role in Restoring Beta-Cell Mass. Diabetes Technology & Therapeutics. 7(4): 651-657. August 2005.

The "incretin effect" describes the enhanced insulin response from orally ingested glucose compared with intravenous glucose leading to identical postprandial plasma glucose excursions. It makes up to 60 percent of the postprandial insulin secretion but is diminished in people with type 2 diabetes. Gastrointestinal hormones promoting the incretin effect are called incretins. This article reviews the use of the incretin called glucagon-like peptide-1 (GLP-1) as a treatment option for type 2 diabetes. The author focuses on the role of GLP-1 in restoring beta-cell mass. The author hypothesizes the GLP-1 may represent an attractive therapeutic method for type 2 diabetes because of its multiple effects, including a slowing of gastric emptying and the simulation of satiety by acting as a transmitter in the central nervous system. GLP-1 also inhibits glucagon secretion and rarely causes hypoglycemia. The author briefly reports on long-acting GLP-1 analogs (Liraglutide and exanadin-4) that are resistant to degradation and a dipeptidyl peptidase IV inhibitor (Vildagliptin), all of which are currently under study. 3 figures. 3 tables. 38 references.

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Glucose Monitoring in Diabetes Care: Evidence, Challenges, and Opportunities. Advanced Studies in Medicine. 5(10): S1100-S1116. December 2005.

Glycemic control, or lack thereof, affects both health care costs and risk of complications from diabetes. This review article outlines the evidence, challenges, and opportunities related to blood glucose monitoring in diabetes care. The authors note that the rate of increase in risk of microvascular complications over the range of blood glucose values (measured by HbA1c, glycosylated hemoglobin) appears to be greater than the rate of risk increase for macrovascular complications. HbA1c is the general primary target for glycemic control, however the authors encourage the individualization of treatment goals in clinical practice. Certain groups, including children, the elderly, and pregnant women, require special consideration. Most patients do not achieve their treatment goals, partly due to a lack of awareness of their glycemic levels and fear of hypoglycemia (low blood glucose levels). The authors stress that patient empowerment involves more than providing the patient with information about diabetes mellitus; it requires practical interventions that facilitate collaborative relationships between health care providers and patients and that enable patients to become responsible for managing their own diabetes. Any member of the diabetes healthcare team can motivate patients by increasing the patient’s knowledge of the disease, and each practitioner should take advantage of opportunities to educate patients and ensure adequate patient contact. The article includes three sidebars that summarize the findings of relevant research studies. 8 figures. 8 tables. 39 references.

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Help Your Child Manage Diabetes: A Parent's Handbook. South Deerfield, MA: Channing Bete Company. 2005. 31 p.

This booklet is designed to help parents of a child newly diagnosed with diabetes understand the basics of caring for a child with diabetes. The booklet covers a description of diabetes, its causes and symptoms; the role of support and emotional health; a plan for diabetes management; blood glucose monitoring; general health approaches, including nutrition and physical activity; diabetes medications, including insulin and its administration and the role of diabetes pills; hypoglycemia and hyperglycemia; diabetes care in the school setting; foot care; and other safety tips. A summary page reminds parents to test the child?s blood glucose, follow a healthy meal plan, encourage the child to be physically active, make sure the child takes all medications, keep good records, and involve the whole family in eating better and staying healthy. The booklet includes a food and medications care chart, a list of resources, a wallet card for the child to carry, and plenty of blank space for individualizing recommendations and management strategies for the child and his or her family. The brochure is illustrated with black-and-white photographs of children and their families, as well as figures and charts designed to increase understanding of the material presented. 5 figures. 2 tables.

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Home Blood Glucose Prediction: Validation, Safety, and Efficacy Testing in Clinical Diabetes. Diabetes Technology & Therapeutics. 7(3): 487-496. June 2005.

Patients with diabetes do daily self-monitoring of blood glucose (SMBG). For such patients, the authors devised a model that predicts not only the expected blood glucose level at the next meal but also the pending risks of hypoglycemia. This article reports on a study undertaken to validate the predictions based on this model and to provide evidence of the safety and effectiveness of using predicted data in dosing decision support for routine patient care. The prediction model is a computer program that access a central database into which daily records of SMBG are entered. Over the 6-month study period a total of 30,129 blood glucose levels were reported by the 54 study patients, and some 24,953 blood glucose predictions were made. Of these, 83 percent were in the clinically acceptable zones of the Clarke Error Grid. When these data were used for dosing decision support in the poor control group, glycated hemoglobin levels fell significantly from 9.7 percent (plus or minus 1.7 percent) to 7.9 percent (plus or minus 1.2 percent), and hypoglycemia dropped fourfold. Total daily insulin doses declined 22 percent, while body weight remained constant. In the parallel tight control group (n = 24), glycated hemoglobin also fell, but only slightly, while daily insulin doses, rates of hypoglycemia, and body weight remained constant. The authors conclude that the use of this computer model generated meaningful predictions of blood glucose levels and was helpful in decision support for managing medication doses safely and effectively. 1 figure. 3 tables. 30 references.

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Hospital Food Tips: Practical Advice for Eating Healthy When Hospitalized. Diabetes Forecast. 58(9): 59-60. September 2005.

This article provides nutrition tips for readers with diabetes who need to have hospital care. Readers are encouraged to take an active role in managing most or all aspects of their own diabetes care. Topics include the different meal plans that may be used in the hospital, the need to maintain caloric intake, how to avoid low blood glucose (hypoglycemia) in the hospital, working with the hospital dietitian, liquid diets (usually used just after surgery), adjusting insulin or other medications to manage times during the hospital stay when fasting is required, and how to manage a missed meal while hospitalized. The author tries to explain the various situations that patients may encounter regarding medications and food.

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How Good is Your Glucose Control?. Diabetes Technology & Therapeutics. 7(6): 863-875. December 2005.

Blood glucose control is the basis of the management of diabetes and maintenance of health. Blood glucose control is usually measured by self monitoring of blood glucose (SMBG), used to evaluate present glycemic status and response to therapy, and HbA1c (glycosylated hemoglobin), a measurement of blood glucose levels over time that is not sensitive to low blood glucose dips (hypoglycemia). This article reports on the use of an additional measure of performance in diabetes management in general and of glycemic control in particular. The authors adapted a graphical method of analysis from the statistician's toolbox (known as the lag plot) to form a visual measure of performance. The lag plot can use SMBG data sets from any source, including memory meters and registry databases in call centers. Data are retrieved, processed, formatted, and then plotted on a PC screen or printer. The resulting lag plots visually characterize the performance of glucose control achieved over periods ranging from days to months. The authors describe the clinical use of the lag plot in seven case studies ranging from a person without diabetes, through glucose intolerance, early onset type 2 diabetes, type 1 diabetes, intensified therapy, pump therapy, and finally islet call transplantation. The visual comparisons before and after action or referral show the impact of interventions, incidences of hypoglycemia, and changes in the polyglycemia of unstable diabetes. The authors conclude that the simple lag plot can empower patients and their providers to identify problems in glycemic control, seek proactive action, adopt beneficial strategies, evaluate outcomes, and, most importantly, rule out interventions with no benefit. 5 figures. 2 tables. 34 references.

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Hyperglycemia in the Hospital. Diabetes Spectrum. 18(1): 20-27. Winter 2005.

This article reviews the use of subcutaneous insulin for hospitalized patients with diabetes mellitus. The authors discuss the rationale for using insulin; scheduled insulin therapy to cover basal and nutritional needs; correction therapy; dose determination; establishment of timing of insulin action appropriate to the pattern of carbohydrate exposure; education of caregivers; and the design of hospital systems that will promote quality and help staff to manage complexity. The authors conclude with a brief discussion of how hospitals can move in the direction of intensifying treatment of hospital hyperglycemia, which will result in improved patient outcomes and cost reductions.. They focus on the importance of a multidisciplinary team of health caregivers and hospital administrators, working together to design and implement these initiatives. Recommended strategies include screening for hyperglycemia; knowledge of appropriate glycemic targets; spread of the use of intravenous insulin infusion; recognition of unsafe situations leading to hypoglycemia or ketosis; preservation of basal insulin regimens for type 1 diabetes; facilitation of inpatient diabetes self-management for experienced and competent patients; elimination of sliding scale monotherapy; creation of order sets and computerized clinical systems that facilitate regimen selection, intensification, and daily revision of insulin therapy; and appropriate patient education and discharge planning. 6 figures. 2 tables. 74 references.

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Hypoglycemia in Type 2 Diabetes: Pathophysiology, Frequency, and Effects of Different Treatment Modalities. Diabetes Care. 38(12): 2948-2961. December 2005.

This article reports on a literature review of hypoglycemia (low blood glucose levels) in type 2 diabetes, focusing on pathophysiology, frequency, and the effects of different treatment modalities. The authors used the bibliographic database PubMed to identify publications in English from 1984 until 2005 related to hypoglycemia associated with treatment of type 2 diabetes, and the bibliographies were searched for additional citations. Specific topics include normal physiological responses to hypoglycemia, the effects of aging on the responses to hypoglycemia, the effects of type 2 diabetes on the responses to hypoglycemia, morbidity of hypoglycemia in type 2 diabetes and in the elderly, epidemiological data from interventional trials and from observational studies, moderators of hypoglycemia in type 2 diabetes, oral antidiabetes agents, alternative insulin regimens, and new agents for the treatment of type 2 diabetes. The author concludes that in older people, effective self-treatment of hypoglycemia may be compromised by the juxtaposition of the glycemic thresholds for onset of symptoms and cognitive dysfunction, which occur almost simultaneously, and these age-related changes will be relevant to many people with type 2 diabetes. The author cautions that the lack of data from elderly people is of concern, as this age-group is at greatest risk from the morbidity of hypoglycemia. 5 figures. 2 tables. 151 references.

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Inhaled Insulin Improves Glycemic Control When Substituted for or Added to Oral Combination Therapy in Type 2 Diabetes: A Randomized, Controlled Trial. Annals of Internal Medicine. 143(8): 549-558. October 2005.

Patients with type 2 diabetes who do not achieve glycemic control with oral drug therapy eventually require insulin. This article reports on a study undertaken to determine the effect on glycemic control of inhaled insulin alone or added to dual oral therapy (insulin secretagogue and sensitizer) after failure of dual oral therapy. The open-label, randomized, controlled trial set in 48 outpatient centers in the United States and Canada included 309 patients with type 2 diabetes, no clinically significant respiratory disease, and HbA1c (glycosylated hemoglobin, a measure of blood glucose over time) level of 8 percent to 11 percent who were receiving dual oral therapy. The patients were given inhaled insulin (Exubera), titrated to blood glucose, administered alone (n = 104) or added to dual oral agents (n = 103) versus oral therapy alone (n = 99). Results showed that reductions in HbA1c level were greater with inhaled insulin. HbA1c level less than 7 percent was achieved by 32 percent of the patients using inhaled insulin plus oral agents and by 1 percent of patients on oral agent therapy. Hypoglycemia, mild weight gain, mild cough, and insulin antibodies were more frequent with inhaled insulin than with oral agent therapy alone. Pulmonary function was similar in all groups. The authors conclude that inhaled insulin improved overall glycemic control and HbA1c level when added to or substituted for dual oral agent therapy with an insulin secretagogue and sensitizer. Similar to other insulin therapies, hypoglycemia and mild weight gain occurred. 4 figures. 3 tables. 42 references.

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Insulin Pump Therapy in Preschool Children with Type 1 Diabetes Mellitus Improves Glycemic Control and Decreases Glucose Excursions and Risk of Hypoglycemia. Diabetes Technology & Therapeutics. 7(6): 876-884. December 2005.

Hypoglycemia (low blood glucose levels) in preschool children limits the effectiveness of insulin therapy. This article reports on a study of insulin pump therapy (continuous subcutaneous insulin infusion or CSII) in preschool children with type 1 diabetes. The authors test the hypothesis that, compared with twice-daily insulin injection, CSII decreases the standard deviation (SD) of the mean daily blood glucose (BG) and improves glycemic control. The study was also designed to evaluate the effect of CSII on parental anxiety using the Parental Stress Index (PSI) scale. The study included 10 subjects younger than 6 years of age and currently receiving insulin injections. Each underwent two 72-hour monitoring periods on an insulin pump and then was started on CSII and remonitored 3 and 6 months later. There was a 22 percent decrease in the BG variability and a 13 percent decreased in HbA1c (glycosylated hemoglobin, a measure of blood glucose over time) in children on CSII. There was a decrease in the 24-hour median number and duration of hypoglycemic episodes, as well as the median number and duration of nighttime episodes. There was no statistically significant change found in the PSI score. The authors conclude that CSII in preschool children is feasible and safe. 3 figures. 1 table. 20 references.

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Joslin's Diabetes Mellitus. 14th ed. Philadelphia, PA: Lippincott Williams and Wilkins. 2005. 1209 p.

The comprehensive diabetes textbook reflects the practice and experiences of the physicians of the Joslin Diabetes Center and updates the information presented in the last version of the text published 10 years ago. The text offers 70 chapters in eight sections: basic mechanisms of islet development and function; hormone action and the regulation of metabolism; the definition, genetics, and pathogenesis of diabetes; obesity and lipoprotein disorders; treatment of diabetes mellitus; biology of the complications of diabetes; clinical aspects of managing diabetic complications; and hypoglycemia and islet cell tumors. Specific topics include genetic regulation of islet function, insulin biosynthesis, insulinlike growth factors, glucagon and glucagonlike peptides, fat and protein metabolism in diabetes, maturity-onset diabetes of the young (MODY), syndromes of extreme insulin resistance, diabetes in minorities in the United States, lipid disorders in diabetes, medical nutrition therapy (MNT), psychological issues in diabetes, iatrogenic hypoglycemia, the economic and social costs of diabetes, diabetic neuropathy, diabetic nephropathy, diabetic retinopathy, cardiovascular disease in diabetes, erectile dysfunction, diabetes and wound healing, and endocrine tumors of the pancreas. Each chapter is illustrated with tables and figures and includes a list of references; a subject index concludes the volume.

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Living Your Life With Diabetes: A Self-Care Handbook. South Deerfield, MA: Channing Bete Company. 2005. 30 p.

This booklet helps readers recently diagnosed with diabetes understand the complexities of a basic diabetes care program. The booklet begins with a description of both type 1 and type 2 diabetes, as well as an overview of the three components of care: medications, including insulin; exercise; and meal planning. The booklet then covers each of these components in detail, including blood sugar monitoring (SMBG), using a food pyramid, carbohydrate counting, exchange lists, food labels, meal planning, exercise, insulin and diabetes pills, preparing and giving an insulin shot, coping with sick days, hypoglycemia, hyperglycemia, ketone testing, long term complications and how to prevent them, foot care, travel tips, and emotional health. The booklet focuses on practical tips and guidelines to help readers quickly learn about and undertake the care required for diabetes management. A tear-out card is provided, on which readers can record their medication schedule. The inside front cover also provides space to record health care providers' names and telephone numbers. 18 figures. 3 tables.

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Lows and Your Pregnancy. Diabetes Forecast. 58(4): 61-64. April 2005.

For women with gestational diabetes, tight control of blood glucose during pregnancy is good for both mother and child, but it may put the mother at risk for low blood glucose (hypoglycemia). This article reviews how to prevent hypoglycemia and how to handle episodes of low blood glucose. The author notes that the hormones produced in the placenta during pregnancy may boost the mother's blood glucose so much that the body needs three times the amount of insulin used before the pregnancy. The author briefly reviews the complications associated with hyperglycemia during pregnancy, target blood glucose levels, and the symptoms and treatment of hypoglycemia. One sidebar outlines a recommended plan for coping with a measured low blood glucose level. The author concludes that keeping tabs on blood glucose levels, maintaining tight control on diabetes, and knowing how and when to treat a low blood glucose level can help ensure that the pregnancy goes smoothly. 3 figures.

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Management of Competitive Athletes with Diabetes. Diabetes Spectrum. 18(2): 102-107. Spring 2005.

This article describes an effective management plan for an athlete with type 1 diabetes. Such a plan must consider the energy demands of intense competition and training, the athlete's goals, factors related to competitive sports that may affect glucose homeostasis, and strategies that may be employed to allow safe, effective sports participation. One section addresses how to minimize risky behaviors, including omission of insulin for weight loss. The authors focus on nutrition, diet therapy and energy needs. They caution that the most common acute risks for competitive athletes with diabetes are exercise-induced hypoglycemia and deterioration of hyperglycemia and ketosis brought on by physical activity during periods of hypoinsulinemia. The authors conclude that athletes should be appropriately screened, counseled to avoid risky behaviors, and provided with specific recommendations for glucose monitoring and insulin and diet adjustments so that they may anticipate and compensate for glucose responses during sports competition. 1 figure. 38 references.

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Managing Prediabetes: Self-Care Handbook. South Deerfield, MA: Channing Bete Company. 2005. 31 p.

This booklet is designed to educate people who have been diagnosed with pre-diabetes, a condition in which the blood glucose levels are elevated, but not to such an extent that a diagnosis of diabetes is warranted. The booklet covers the dangers of prediabetes, the risk factors for diabetes, diagnostic tests and monitoring strategies that may be used, lifestyle changes, setting goals, determining a healthy weight, weight loss tips, nutrition basics, meal planning, the role of exercise, keeping records of food and activities, dealing with stress, and family considerations. The booklet is filled with charts and illustrations, places to record individualized information, and black-and-white photographs of a variety of people undertaking a variety of activities. A tear-out card is included that readers can bring with them to their health care appointments; the card includes room to record blood glucose test results and special instructions. The booklet concludes with a list of the answers to common questions about prediabetes, as well as a list of resource organizations through which readers can get more information. 5 figures. 5 tables.

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Maternal and Fetal Complications Associated with Gestational Diabetes Mellitus. IN: Thomas, A.M.; Gutierrez, Y.M., eds. American Dietetic Association Guide to Gestational Diabetes Mellitus. Chicago, IL: American Dietetic Association. 2005. pp. 27-34.

This chapter on the maternal and fetal complications associated with gestational diabetes mellitus (GDM) is from a Guide that serves as a resource for health professionals involved in the care of women who develop diabetes during their pregnancy. The Guide helps readers to promote sound nutrition principles in GDM, to achieve optimal outcomes for the woman and her infant. The authors of this chapter begins by describing the maternal complications of GDM: hypertension, polyhydramnios, difficult birth, preterm delivery, and Cesarean section. The chapter then goes on to address the fetal complications, including macrosomia, neonatal hypoglycemia, respiratory distress syndrome, neonatal hypocalcemia, neonatal hyperbilirubinemia, polycythemia, and congenital anomalies. The authors conclude that if maternal euglycemia is obtained and maintained at optimal levels during pregnancy through medical nutrition therapy (MNT) and other necessary interventions, the risk of complications will be minimized and the maternal and fetal outcomes are improved. 54 references.

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Medical Identification. Diabetes Self-Management. 22(2): 55-57. March-April 2005.

This article provides information about the use of medical identification tags for people who have diabetes. Identification tags can provide awareness of the existence of diabetes; this can assist in diagnosis, medication choice and possibly prevent hypoglycemia from becoming severe. The author describes the different levels of hypoglycemia and their symptoms, and the different types of identification jewelry available. The article concludes with a list of manufacturers with their contact information and a brief description of their products.

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Medications and Supplements. IN: Thomas, A.M.; Gutierrez, Y.M., eds. American Dietetic Association Guide to Gestational Diabetes Mellitus. Chicago, IL: American Dietetic Association. 2005. pp. 65-80.

This chapter on medications and supplements in gestational diabetes mellitus (GDM) is from a Guide that serves as a resource for health professionals involved in the care of women who develop diabetes during their pregnancy. The Guide helps readers to promote sound nutrition principles in GDM, to achieve optimal outcomes for the woman and her infant. The author of this chapter begins by summarizing the types, action, peak times, and duration of insulin used in pregnancy. Other topics covered include the treatment modalities used for hypoglycemia, the use of oral agents used to treat diabetes in pregnancy, the use of multivitamin-mineral supplements in pregnancy, and the benefits and adverse effects of herbal and botanical supplements on pregnancy outcome. The author concludes that the goal in the management of GDM is normoglycemia. The first course of treatment is medical nutrition therapy (MNT); if blood glucose levels cannot be maintained by MNT, insulin must be initiated. The author emphasizes that nutrition assessment and counseling are recommended for all pregnant women. 6 figures. 4 tables. 64 references.

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New Medications for Diabetes Management. Today's Dietitian. 7(7): 20-22. July 2005.

This article describes some of the new medications used for diabetes management. As the understanding of diabetes increases, it becomes apparent that there is more to diabetes management than a simple balance of blood glucose and insulin. The broadened scope views diabetes as a disease that involves the whole gastrointestinal tract and other hormones in addition to insulin. This view may help to explain those patients who, despite their best efforts and the efforts of their medical team, cannot achieve their glycemic goals. The author describes two new medications, both of which are injectable: exenatide (an incretin mimetic) and pramlintide (an amylinomimetic). Both medications slow gastric emptying time, so certain other medications may also be affected by this reaction. Adequate adjustments to medications and insulin are needed to prevent hypoglycemia, especially with pramlintide. Exenatide is approved for use in people with type 2 diabetes who are currently using oral hypoglycemic agents (namely sulfonylureas and metformin) and who are poorly managed on their present protocol. Pramlintide is designed for use in patients with type 1 diabetes or type 2 diabetes who use insulin and who have not reached optimal results from insulin therapy. Pramlintide cannot be mixed with insulin, however, and must be injected separately, prior to meals. References for this article are available online (email to TDeditor@gvpub.com).

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Overcoming Barriers to Intensive Insulin Administration. Reducing Cardiovascular Risk in the Patient with Type 2 Diabetes (AADE Proceedings). p. 7-8. 2005.

This article, from the proceedings of a symposium on reducing cardiovascular risk in people with type 2 diabetes, considers strategies to overcome barriers to intensive insulin administration. The author argues that in order to reach and maintain blood glucose target levels, clinicians must implement more intensive treatment regimens than the traditional stepwise approach that begins with lifestyle modifications, then hypoglycemia agents, then adds insulin. However, the earlier use of exogenous insulin preserves and improves beta cell function, helps to restore normal insulin sensitivity, and improves the effectiveness of oral medications. Some of the barriers to insulin therapy include patient reluctance, concerns about lifestyle changes and restrictions, social embarrassment, painful injections, and the association of insulin with worsening health. Physicians and patients both worry about weight gain and hypoglycemia associated with insulin use. Many primary care providers lack the experience and support they need (access to other diabetes health care providers, for example) to successfully manage insulin regimens. The author focuses on the implementation of simple insulin regimens as a vital part of the care of patients with type 2 diabetes. 7 references.

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Physical Activity: The Magic of Movement. Diabetes Self-Management. 22(1): 7-12. January-February 2005.

This article explores the benefits of physical activity for people with diabetes. These benefits can include lower blood glucose readings, reduced stress, and decreased body fat. The authors explain how exercise can lower blood glucose by both burning glucose and by improving the body's ability to use insulin. This improvement in insulin sensitivity may even allow some people with Type 2 diabetes to reduce or discontinue blood-glucose-lowering medications. The cardiovascular benefits are also particularly important in a patient population at high risk for cardiovascular complications. Other topics covered include steps to take before undergoing an exercise program, how diabetes complications can affect one's choice of physical activities, the significant health benefits that can be obtained by a moderate amount of physical activity, the importance of warm-up and cool-down periods, foot care, use of medical identification tags, the need to have a carbohydrate source available during and after exercise, and hypoglycemia concerns. The authors conclude by recommending that patients make a commitment to physical activity and work with their doctor to plan a individualized exercise prescription.

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Pramlintide Use in Type 1 Diabetes Resulting in Less Hypoglycemia. Diabetes Spectrum. 19(1): 50-52. Winter 2005.

This article presents a case report of a 49 year old white male who has had type 1 diabetes for 43 years, and been on an intensive insulin regimen since 1982. The author describes the inclusion of pramlintide to help this patient reduce his incidence of hypoglycemia, which had intensified over the years and even resulted in an automobile accident in 2003. The author presents the case report and then lists the questions that the health care provider must consider. The discussion section offers strategies to improve this patient's care and diabetes control. Pramlintide is an analog of the naturally occurring pancreatic hormone amylin, which works with insulin to suppress glucagon secretion and to regulate gastric emptying. The case report patient had widely fluctuating blood glucose levels, frequent hypoglycemia, persistent postprandial hyperglycemia, and weight gain, despite intensive insulin regimens and skillful diabetes self-management. The author reports on the case patient's management during 18 months on pramlintide (in addition to his regular insulin regimen); since starting pramlintide, the patient's HbA1c has improved, his weight is stable, and he has had less hypoglycemia and less fluctuation in his blood glucose levels. Patient care strategies, including administration and dosing suggestions, are provided. 3 tables. 5 references.

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Problem-Solving School Issues. Diabetes Self-Management. 22(6): 26-31. November-December 2005.

When planning for academic success and physical health in school, the parents of children with diabetes must address both practical and psychological considerations. This article offers advice to parents for problem-solving school issues. Topics include the importance of having a plan in place before school starts, meeting with school personnel, recordkeeping, understanding the child's rights as protected by legislation, and handling emotional issues. A final section answers frequently asked questions, including the topics of snack foods at school, insulin administration and dosage, overtreatment of hypoglycemia, and helping a child evolve to self-care over time. The author emphasizes the importance of good communication between parent and child as well as between the family and school personnel. One sidebar lists the signs of depression in children and adolescents; another provides a list of recommended resources on dealing with school issues. 7 references.

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Recommendations for Management of Diabetes During Ramadan. Diabetes Care. 28(9): 2305-2311. September 2005.

Muslims who fast during Ramadan must abstain from eating, drinking, use of oral medications, and smoking from predawn to after sunset; however, there are no restrictions on food or fluid intake between sunset and dawn. This article outlines recommendations for patients with diabetes who follow the fasting requirements of the Muslim season of Ramadan. The Koran specifically exempts the sick from the duty of fasting, especially if fasting might lead to harmful consequences for the individual. Patients with diabetes fall under this category because their chronic metabolic disorder may place them at high risk for various complications if the pattern and amount of their meal and fluid intake is markedly altered. However, many patients with diabetes insist on fasting during Ramadan. The authors note their goals as threefold: to invite an open dialogue on this important topic; to offer a set of medical opinions and suggestions; and to identify topics of research needed to answer important medical questions regarding fasting during Ramadan. The authors emphasize that fasting, especially for patients with type 1 diabetes with poor glycemic (blood glucose) control, is associated with multiple risks. These risks include hypoglycemia (low blood glucose levels), hyperglycemia (high blood glucose levels), diabetic ketoacidosis (a metabolic complication that can result in coma), and dehydration and thrombosis (the development of clots). The authors conclude by stressing that a patient's decision to fast should be made after ample discussion with his or her physician concerning the risks involved. Patients who insist on fasting should undergo pre-Ramadan assessment and receive appropriate education and instructions related to physical activity, meal planning, glucose monitoring, and dosage and timing of medications. Close follow-up is essential to reduce the risk for complications. 3 tables. 30 references.

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Seven Tips for Commuting with Diabetes. Diabetes Self-Management. 22(5): 88-91. September-October 2005.

In this article, the author shares his experiences and knowledge gained from trying to manage his type 2 diabetes while balancing a lifestyle that included a large chunk of time spent commuting to work. The author focuses on strategies to fit diabetes care around work and family obligations. Seven tips are outlined: read your insurance plan, carry enough supplies and medicines, exercise during the lunch hour, get organized about meal planning, seek out coworkers with diabetes, keep on top of hypoglycemia (low blood glucose levels), and use a calendar. In each category, the author provides practical suggestions for establishing and maintaining healthy diabetes care habits.

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Spoken Knowledge in Low Literacy in Diabetes Scale: A Diabetes Knowledge Scale for Vulnerable Patients. Diabetes Educator. 31(2): 215-214. March-April 2005.

This article reports on a study that developed and validated a new knowledge scale for patients with type 2 diabetes and poor literacy: the Spoken Knowledge in Low Literacy patients with Diabetes (SKILLD). The authors evaluated the 10-item SKILLD among 217 patients with type 2 diabetes and poor glycemic control at an academic general medicine clinic. Performance on the SKILLD was compared to patient socioeconomic status, literacy level, duration of diabetes, and glycated hemoglobin (HbA1c, a measure of blood glucose levels over time). Respondents' mean age was 55 years and they had diabetes for an average of 8.4 years; 38 percent had less than a sixth-grade literacy level. Less than one third of patients knew the signs of hypoglycemia or the normal fasting blood glucose range. The reliability and validity of the SKILLD was good. Higher performance on the SKILLD was significantly correlated with higher income, education level, literacy status, duration of diabetes, and lower HbA1c. The author concludes that the SKILLD is a practical scale for patients with diabetes and low literacy. 5 tables. 29 references.

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Take a Bite Out of Hypoglycemia: 10 Proven Strategies for Cutting Down on Low Blood Glucose. Diabetes Self-Management. 22(2): 47-54. November-December 2005.

Hypoglycemia presents a serious threat to a person's physical, intellectual, and emotional well-being. This article offers 10 strategies for reducing the occurrence of low blood glucose (hypoglycemia) in people with diabetes. The author first describes the complications associated with hypoglycemia, why it occurs, current guidelines for using anti-diabetes medications safely, and suggestions for adjusting medications and mealtimes. The author then lists 10 hypoglycemia prevention strategies: (1)match insulin or other medications to individual needs; (2)set an appropriate target goal; (3)take a look at scheduling; (4)use caution when adjusting medications; (5)adjust doses based on carbohydrate intake; (6)extend or delay mealtime insulin when necessary; (7)adjust for physical activity; (8)be aware of alcohol's effects; (9)check blood glucose levels often; and (10)perform recordkeeping to support accurate monitoring of the patient's care. These strategies are designed not to eliminate hypoglycemia, but to reduce its frequency and severity. One sidebar offers tables to help insulin users account for unused insulin (when adding rapid-acting insulin into the equation). 10 figures. 1 table.

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Taking Control of Your Diabetes. Clearwater, FL: CCS Medical. 2005. 52 p.

This booklet is designed to help readers who are newly diagnosed with type 2 diabetes understand and manage their disease. The booklet is also helpful for readers who havehad diabetes for a while and who may have experienced a change in health that requires a new treatment strategy. The booklet first reviews the types of diabetes and general signs and symptoms of the disease. Then it discusses diabetes care management in detail, covering meal planning, counting carbohydrates, the use of exchange lists, food labels, snack ideas, the importance of portion control, the use of sweeteners, dietetic foods, cholesterol, sodium, alcohol, dietary fiber, eating out at restaurants, weight control, exercise, insulin, oral medications, other medications, testing for control (including self-monitoring of blood glucose, or SMBG), low blood glucose (hypoglycemia), high blood glucose (hyperglycemia), testing for ketones, care during illness (sick-day management), complications, and the psychosocial impact of living with diabetes. Readers are encouraged to share the booklet with friends and family so they, too, can understand diabetes and how it can be managed. The booklet is illustrated with line drawings and tables that clarify the material presented. 14 figures. 7 tables.

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Understanding Your Blood Glucose: A New Internet-Based Program. Diabetes Forecast. 58(5): 66. May 2005.

This article describes a new Internet-based program that can help people with diabetes anticipate and treat serious blood glucose-related problems. The Blood Glucose Awareness Training (BGAT) is an intensive 8-week training program designed to help adults with Type 1 diabetes to anticipate, identify, prevent, and treat hypoglycemia (low blood glucose) and hyperglycemia (high blood glucose). The BGATHome can be completed from one's home computer. Participants read a chapter a week online and then apply the information in that chapter to their daily routines. For example, one chapter teaches users how to plot insulin curves so that one can anticipate when the combined insulins will be most and least active; another chapter teaches how high and low blood glucose levels can affect moods and relationships, and how users can use mood changes to better detect changes in blood glucose levels. The article concludes with information for readers who would like to test the online version of BGAT (www.study.bgathome.com).

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Use of Inhaled Insulin in a Basal-Bolus Insulin Regimen in Type 1 Diabetic Subjects: A 6-month, Randomized, Comparative Trial. Diabetes Care. 28(7): 1630-1635. July 2005.

Patient acceptance of an insulin regimen that features the use of a basal-bolus strategy for type 1 diabetes has been slow, despite the demonstrated benefits for glycemic control. This article reports on a study that investigated whether a basal-bolus insulin regimen involving rapid-acting, dry powder, inhaled insulin could provide glycemic control comparable with a basal-bolus subcutaneous regimen. The study included patients aged 12 to 65 years with type 1 diabetes who received twice-daily subcutaneous NPH insulin and who were randomized to premeal inhaled insulin (n = 163) or subcutaneous regular insulin (n = 165) for 6 months. Results showed that mean glycosylated hemoglobin (HbA1c, a measure of blood glucose over time) decreased comparably from baseline in both the inhaled and subcutaneous insulin groups, with a similar percentage of subjects achieving HbA1c results less than 7 percent. Although 2-hour postprandial (after a meal) glucose reductions were comparable between the groups, fasting plasma glucose levels declined more in the inhaled than in the subcutaneous insulin group. Inhaled insulin was associated with a lower overall hypoglycemia rate but higher severe hypoglycemia rate. However, four subjects accounted for nearly half of the severe events in the inhaled group. Most of these occurred early in the study and the subjects completed the study without continued severe hypoglycemia. Increased insulin antibody serum binding without associated clinical manifestations occurred in the inhaled insulin group. Pulmonary function between the groups was comparable, except for a decline in carbon monoxide-diffusing capacity in the inhaled insulin group without any clinical correlates. The authors conclude that inhaled insulin may provide an alternative for the management of type 1 diabetes, as part of a basal-bolus strategy in patients who are unwilling or unable to use pre-prandial insulin injections. 2 figures. 4 tables. 26 references.

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What to Do in the ICU: Tight Blood Glucose Control Matters Here, Too. Diabetes Forecast. 58(9): 53-54. September 2005.

Tight control of blood glucose greatly benefits critically ill patients, especially those with cardiac problems or infections. This article discusses patient care management for people with diabetes who are receiving care in the intensive care unit (ICU) at a hospital. The author reports on a study published in the New England Journal of Medicine (2001) in which the researchers published striking results involving mortality rates of patients in the ICU. In this study, 1,548 patients admitted to the ICU on mechanical ventilators after complicated surgeries or trauma were divided into intensive therapy or conventionally treated groups. The death rate for the intensively treated patients who stayed in the ICU for prolonged periods was 50 percent lower than for those in the conventional treatment group. In addition, those patients whose levels were kept in the 80 to 110 milligrams per deciliter range were taken off ventilators sooner, remained in the ICU for less time, needed fewer blood transfusions, and were less likely to develop kidney failure than those in the conventionally treated group. The author also briefly discusses concerns about hypoglycemia (low blood glucose) associated with tight blood glucose control. The article concludes with a section discussing the guidelines for all patients with diabetes who may be undergoing care in the hospital.

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Wizdom: A Kit of Wit and Wisdom for Kids with Diabetes (and Their Parents) Alexandria, VA: American Diabetes Association. 2005.

This kit contains two books, juggling balls, and a pen. The book, Wizdom: For Kids Only, is introduced by two teenagers with diabetes, helps kids newly diagnosed with type 1 diabetes understand some of the basics of diabetes management. The first chapter introduces the characters of Amazing Audrey and AJ; Audrey is a diabetes wizard and AJ is newly diagnosed with diabetes and given the task of being a wizard apprentice. The remaining 14 chapters follow these two characters as they cover a definition of diabetes, the juggling act of diabetes care, insulin and how to administer it, food habits and nutrition, carbohydrate counting, food labeling, exercise, blood glucose self-monitoring (SMBG), hypoglycemia (low blood glucose levels), hyperglycemia (high blood glucose levels), the emotional impact of diabetes, coping with depression, talking about diabetes, school and diabetes care, discrimination and patient rights, coping with sick days, the members of the diabetes care team, and resources where readers can find additional information. Throughout the book are definitions of medical terms, colorful illustrations, lift-the-flap diagrams, and quick quizzes on the material covered. The book also includes a spinner that helps readers understand the meaning of different blood glucose levels, a set of four laminated recipe cards, and a page of colorful stickers depicting Audrey and AJ in their magician's clothes. The book is spiral-bound. 10 references. The second book, Wizdom: For Parents Only is introduced by the parent of a child with diabetes and a physician who works with children with diabetes and helps the parents of kids newly diagnosed with type 1 diabetes understand some of the basics of diabetes management. After an introductory chapter that defines diabetes and its symptoms, the book includes 14 chapters that cover the juggling act of diabetes care, insulin and how to administer it, food habits and nutrition, carbohydrate counting, food labeling, exercise, blood glucose self-monitoring (SMBG), hypoglycemia (low blood glucose levels), hyperglycemia (high blood glucose levels), the emotional impact of diabetes, coping with depression, talking about diabetes, parenting and family life, school and diabetes care, discrimination and patient rights, coping with sick days, the members of the diabetes care team, handling special occasions, specific concerns about teens and diabetes, and resources where readers can find additional information. Throughout the spiral bound book are definitions of medical terms and colorful illustrations. 43 references.

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12-Month Efficacy and Safety of Insulin Detemir and NPH Insulin in Basal-Bolus Therapy for the Treatment of Type 1 Diabetes. Diabetes Technology & Therapeutics. 6(5): 579-588. October 2004.

This article reports on a study that compared the long-term safety and efficacy of the basal insulin preparations, insulin detemir and NPH insulin, basal-bolus therapy for patients with type 1 diabetes. The patients received insulin detemir or NPH insulin twice daily in addition to mealtime human soluble insulin. After an initial 6-month treatment period, patients were invited to participate in a 6-month extension period. A total of 289 patients from the group of 421 elected to continue in the trial, of which 252 completed. Glycemic control and fasting plasma glucose were similar in both treatment groups at end point, with hemoglobin A1c (a measure of blood glucose levels over time) little changed from baseline and fasting plasma glucose slightly decreased. There was some evidence for a risk reduction for hypoglycemia in association with insulin detemir, although this was not statistically significant, and hypoglycemic (low blood glucose) events were fewer in each of the 12 months. There was a significant treatment difference with regard to weight outcome; NPH insulin was associated with weight gain (1.4 kg), but there was no mean weight gain (-0.3 kg) in the insulin detemir cohort. The authors conclude that glycemic control is maintained with insulin detemir during long-term treatment. At equivalent glycemic control to NPH insulin, insulin detemir is associated with a lack of weight gain and a trend towards a reduced risk of nocturnal hypoglycemia when used in basal-bolus therapy with mealtime soluble human insulin. 3 figures. 2 tables. 37 references.

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Acute Hyperglycemia Alters Mood State and Impairs Cognitive Performance in People with Type 2 Diabetes. Diabetes Care. 27(10): 2335-2340. October 2004.

This article reports on a study of the effects of acute hyperglycemia on a range of important cognitive function and key mood states in a group of people with type 2 diabetes. The study included 20 subjects with type 2 diabetes, median age of 61.5 years, known duration of diabetes 5.9 years, body mass index (BMI) 29.8, and HbA1c (glycosylated hemoglobin, a measure of blood glucose over time) of 7.5 percent. Treatment modalities ranged from antidiabetes medications to insulin. Tests of information processing, immediate and delayed memory, working memory, and attention were administered, along with a mood questionnaire, during each experimental condition. The results showed that speed of information processing, working memory, and some aspects of attention were impaired during acute hyperglycemia. Subjects were significantly more dysphoric during hyperglycemia, with reduced energetic arousal and increased sadness and anxiety. The authors conclude that these findings are of practical importance because intermittent or chronic hyperglycemia is common in people with type 2 diabetes and may interfere with many daily activities through adverse effects on cognitive function and mood. 1 figure. 3 tables. 31 references.

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All About Blood Glucose for People with Type 2 Diabetes. Alexandria, VA: American Diabetes Association. 2004. 2 p.

Cardiovascular disease (CVD) is the leading cause of death among people with diabetes, accounting for at least two out of three diabetes-related deaths. This fact sheet on blood glucose in type 2 diabetes is from a set of 26 reproducible patient education handouts on topics related to diabetes CVD. In people with type 2 diabetes, the pancreas does not make enough insulin or the insulin does not work properly, or both. However, keeping blood glucose, blood pressure, and cholesterol on target can help prevent or delay problems. The fact sheet emphasizes that the closer the blood glucose stays to the targets, the more patients can lower their risk of blindness or diabetic retinopathy (eye disease), diabetic nephropathy (kidney disease), foot problems, nerve damage (diabetic neuropathy), tooth and gum disease (periodontal disease), and skin problems; patients may also lower their risks for heart attack and stroke. Topics include the causes of blood glucose levels rising and falling, blood glucose level targets for people with diabetes, how to keep track of blood glucose levels, the use of a blood glucose meter, problems with hyperglycemia (high levels of blood glucose), and problems with hypoglycemia (low levels of blood glucose). The fact sheet includes blank space for readers to record their goals and test results for blood glucose. 1 figure. 2 tables.

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Blood Glucose Log. Alexandria, VA: American Diabetes Association. 2004. 2 p.

Cardiovascular disease (CVD) is the leading cause of death among people with diabetes, accounting for at least two out of three diabetes-related deaths. This fact sheet is from a set of 26 reproducible patient education handouts on topics related to diabetes CVD. The fact sheet offers a brief summary of strategies for coping with low blood glucose levels (hypoglycemia); the bulk of the fact sheet then reproduces blank forms for readers to keep track of their medications and blood glucose levels. Each form includes space to record the date, the time, blood glucose level, and comments for breakfast, lunch, dinner, and snack times. There is also space to record the contact information for one's health care providers, as well as blood glucose targets. The fact sheet offers enough forms to track three weeks (readers are encouraged to photocopy enough forms for each month). Readers are also encouraged to contact the American Diabetes Association (800-342-2383 or www.diabetes.org) for more information.

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Diabetes Management in Correctional Institutions. Diabetes Care. 27(Supplement 1): S114-S120. January 2004.

This article provides a general set of guidelines for diabetes care in correctional institutions (a position statement of the American Diabetes Association). It is not designed to be a diabetes management manual. Rather, the discussion focuses on those areas where the care of people with diabetes in correctional facilities may differ from care of people with diabetes who are not in correctional facilities. Topics covered include intake medical assessment, including reception screening, intake screening, and intake physical examination and laboratory; screening for diabetes; patient care management plans; nutrition and food services; urgent and emergency issues, including hyperglycemia and hypoglycemia; medications; routine screening for and management of diabetes complications; monitoring glycemia; self-management education; staff education; alcohol and drugs; transfer and discharge considerations; sharing of medical information and records; children and adolescents with diabetes; and pregnancy. Recommendations for care are provided in each category. The authors conclude that patients must have access to medication and nutrition needed to manage their disease. In patients who do not meet treatment targets, medical and behavioral plans should be adjusted by health care professionals in collaboration with the prison staff. 1 figure. 2 tables. 15 references.

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Diabetes Self-Management Education. In: Hormel, A.P. and Mother, R. Davidson's Diabetes Mellitus: Diagnosis and Treatment. 5th ed. Orlando, FL: W.B. Saunders Company. 2004. p. 365-460.

Diabetes care is a complex balancing act in which individuals with the disease must assume much of their care; thus, they must be provided the opportunity to have the tools necessary to successfully manage their condition. Diabetes self-management education (DSME) must be an integral component of care for all patients to achieve successful diabetes and health-related outcomes. This chapter on DSME is from a textbook that provides readers with current information on the diagnosis and treatment of patients with diabetes, including the latest advances, medications, and research studies. In this chapter, the author reviews the goals of DSME; the possible impact of the educator's philosophy on self-management education; six components of the teaching and learning process; and ten key content areas for DSME. Topics include personal lifestyle, national standards for DSME, preteaching assessment, learning styles, behavior change strategies, curriculum development, nutrition management, exercise, monitoring blood glucose and ketone levels, medications (including insulin) for diabetes treatment, drug interactions, preventing and treating acute complications (hypoglycemia, hyperglycemia), sick day guidelines, foot care, autonomic neuropathy, peripheral neuropathy, hypoglycemia unawareness, oral health, and special populations. 19 figures. 11 tables. 4 references.

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Efficacy and Safety of Inhaled Insulin (Exubera) Compared With Subcutaneous Insulin Therapy in Patients With Type 2 Diabetes: Results of a 6-month, Randomized, Comparative Trial. Diabetes Care. 27(10): 2356-2362. October 2004.

This article reports on a study of the effectiveness and safety of inhaled insulin (Exhubera), compared with subcutaneous insulin therapy in patients with type 2 diabetes. The authors studied glycemic control in patients using inhaled, dry-powder insulin plus a single injection of long-acting insulin (n = 149), compared to that in patients (n = 150) using a conventional regimen (at least two daily insulin injections). The efficacy end point was the change in HbA1c (glycosylated hemoglobin, a measure of blood glucose levels over time) between baseline and 6 months later. The results showed that blood glucose levels decreased similarly in the inhaled and subcutaneous insulin groups. HbA1c levels less than 7 percent was achieved in more patients receiving inhaled (46.9 percent) than subcutaneous (31.7 percent) insulin. Overall hypoglycemia (events per subject-month) was slightly lower in the inhaled group, with no difference in severe events. Other adverse events, with the exception of increased cough in the inhaled insulin group, were similar. Treatment satisfaction was greater in the inhaled insulin group. The authors conclude that inhaled insulin appears to be effective, well-tolerated, and well accepted in patients with type 2 diabetes; inhaled insulin also provides glycemic control comparable to the conventional subcutaneous regimen. 1 figure. 2 tables. 28 references.

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Getting Started with Physical Activity. Alexandria, VA: American Diabetes Association. 2004. 2 p.

Cardiovascular disease (CVD) is the leading cause of death among people with diabetes, accounting for at least two out of three diabetes-related deaths. This fact sheet on getting started with physical activity for people with diabetes is from a set of 26 reproducible patient education handouts on topics related to diabetes CVD. The fact sheet first reviews the importance of physical activity for people with diabetes, then suggests ways to begin incorporating physical activity into one's regular habits. The fact sheet recommends a visit to the health care provider before starting a program of physical activity. The fact sheet defines a comprehensive physical activity routine as including four kinds of activities: being active throughout the day, aerobic exercise, strength training, and flexibility exercises (such as stretching). Additional sections discuss how activity affects blood glucose levels, the symptoms of low blood glucose (hypoglycemia), planning for exercise, and the importance of medical identification tags. A checklist of suggestions for getting started with physical activity is also provided. 2 figures.

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GlucoWatch G2TM Biographer Alarm Reliability During Hypoglycemia in Children. Diabetes Technology & Therapeutics. 6(5): 559-566. October 2004.

The GlucoWatch G2 Biographer (GW2B) (Cygnus, Inc., Redwood City, CA) is a new device that provides near-continuous monitoring of glucose values in near real time. This device is equipped with two types of alarms to detect hypoglycemia. The hypoglycemia alarm is triggered when the current glucose measurement falls below the level set by the user. The "down alert" alarm is triggered when extrapolation of the current glucose trend anticipates hypoglycemia to occur within the next 20 min. This article reports on a study undertaken to assess the performance of these alarms. During a 24-hour clinical research center stay, 89 children and adolescents with Type 1 diabetes mellitus (3.5 years to 17.7 years old) wore 174 GW2B devices and had frequent serum glucose determinations during the day and night. Results showed that sensitivity to detect hypoglycemia (reference glucose 60 mg per dL) during an insulin-induced hypoglycemia test was 24 percent with the hypoglycemia alarm alone and 88 percent when combined with the down alert alarm. Overnight sensitivity from 11 p.m. to 6 a.m. was 23 percent with the hypoglycemia alarm alone and 77 percent when combined with the down alert alarm. The authors conclude that the down alert alarm substantially improves the sensitivity of the GW2B to detect hypoglycemia at the price of a large increase in the false alarm rate (up to 62 percent). The utility of these alarms in the day-to-day management of children with diabetes remains to be determined. 2 figures. 3 tables. 16 references.

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Holiday Travel Tips. Diabetes Forecast. 57(12): 71-72. December 2004.

This article offers holiday travel tips for people with diabetes. The suggestions were developed by the Transportation Security Administration (TSA) with the assistance of the American Diabetes Association (ADA). The author provides suggestions for getting through the airline security gate (with medications, syringes, etc.), potential problems with an insulin pump (which will trip the metal detector), and handling a low blood glucose reaction (hypoglycemia) during the security procedure. The ideas provided are designed to encourage the safety and convenience of travelers with diabetes. Readers are referred to the TSA toll-free telephone number to report any experiences with unfair treatment (866-289-9673).

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Hyperglycemic and Hypoglycemic Emergencies. In: Hormel, A.P. and Mother, R. Davidson's Diabetes Mellitus: Diagnosis and Treatment. 5th ed. Orlando, FL: W.B. Saunders Company. 2004. p. 147-187.

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are profound metabolic complications of diabetes and are among the most serious acute complications, along with severe hypoglycemia (low blood glucose levels). Both of the hyperglycemic (high blood glucose conditions) can occur in type 1 or type 2 diabetes, as can hypoglycemia. This chapter on hyperglycemic and hypoglycemic emergencies is from a textbook that provides readers with current information on the diagnosis and treatment of patients with diabetes, including the latest advances, medications, and research studies. This chapter addresses the pathophysiology, causes, signs, symptoms, and treatment of hyperglycemic emergencies, and outlines specific differences between DKA and HHS in these regards. The final section of this chapter focuses on hypoglycemia, its causes, manifestations, and management. 10 figures. 13 tables. 103 references.

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Impact of a Decade of Changing Treatment on Rates of Severe Hypoglycemia in a Population-Based Cohort of Children with Type 1 Diabetes. Diabetes Care. 27(10): 2293-2298. October 2004.

This article reports on a study undertaken to determine the impact of changes to treatment on the incidence of severe hypoglycemia (low blood glucose) and its risk factors in a large population-based cohort of children with Type 1 diabetes (n = 1,335, mean age at entry was 9.5 years). The mean follow-up period was 4.7 years (plus or minus 3.1 years), yielding 6,928 patient-years of data. Patients were reviewed every 3 months for a period between 1992 and 2002; prospected assessment of severe hypoglycemia (an event leading to loss of consciousness or seizure) and associated clinical factors and outcomes was made. A total of 944 severe events were recorded. The incidence of severe hypoglycemia increased significantly by 29 percent per year for the first 5 years but appeared to plateau over the last 5 years. The overall average HbA1c (glycosylated hemoglobin, a measure of blood glucose over time) significantly decreased (by 0.2 percent per year) over the entire follow-up period. An increased risk of severe hypoglycemia was associated with lower HbA1c, younger age, higher insulin dose, male sex, and lower parental socioeconomic status. Of insulin therapies, only pump treatment was associated with reduced rates of severe hypoglycemia. The authors conclude that severe hypoglycemia remains a major problem for children and adolescents with Type 1 diabetes. 2 figures. 3 tables. 25 references.

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Insulin Glulisine Provides Improved Glycemic Control in Patients With Type 2 Diabetes. Diabetes Care. 27(10): 2363-2368. October 2004.

Insulin glulisine is a new analog of human insulin designed for use as a rapid-acting insulin. This article reports on a study that compared the safety and effectiveness of glulisine with regular human insulin (RHI) in combination with NPH insulin. The authors studied 876 relatively well-controlled patients with type 2 diabetes (mean HbA1c levels 7.55 percent). Patients were treated with glulisine and NPH (n = 435) or RHI and NPH (n = 441) for up to 26 weeks in this randomized, multicenter, open label, parallel group study. Subjects continued to use the same dose of prestudy regimens of oral antidiabetes agents, unless hypoglycemia necessitated a dose change. Results showed a slightly greater reduction from baseline to end point HbA1c in the glulisine group versus RHI. Also at end point, lower postbreakfast and postdinner blood glucose levels were noted. Symptomatic hypoglycemia and weight gain were comparable between the two treatment groups. The authors conclude that twice-daily glulisine associated with NPH can provide small improvements in glycemic control compared with RHI in patients with type 2 diabetes who are already relatively well controlled on insulin alone or insulin plus oral antidiabetes drugs. 2 figures. 1 table. 14 references.

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Insulin Therapy. In: Harmel, A.P. and Mathur, R. Davidson's Diabetes Mellitus: Diagnosis and Treatment. 5th ed. Orlando, FL: W.B. Saunders Company. 2004. p. 109-145.

More types of insulin are becoming available, ranging from the traditional insulins to insulin analogues. This diversity of choice, in terms of onset and duration of action, allows use of exogenous insulin to mimic normal physiology more closely, thereby allowing for improvements in glycemic control with less hypoglycemia. This chapter on insulin therapy is from a textbook that provides readers with current information on the diagnosis and treatment of patients with diabetes, including the latest advances, medications, and research studies. The beginning of the chapter focuses on choosing the concentrations and types of insulin to use. Other characteristics of insulin preparations, such as species source and purity, are discussed later in conjunction with a description of the immunologic responses to insulin therapy. Other topics covered include insulin allergy, insulin resistance, and insulin-induced lipoatrophy. One section also considers initiation of insulin therapy in hospitalized patients. The chapter includes illustrative case reports. 10 figures. 11 tables. 109 references.

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Management of Diabetes and Hyperglycemia in Hospitals. Diabetes Care: 27(2): 553-591. February 2004.

Diabetes increases the risk for disorders that predispose individuals to hospitalization, including coronary artery, cerebrovascular and peripheral vascular disease, nephropathy (kidney disease), infection, and lower-extremity amputations. The management of diabetes in the hospital is generally considered secondary in importance compared with the condition that prompted admission. Recent studies have focused attention to the possibility that hyperglycemia (high blood glucose levels) in the hospital is not necessarily a benign condition and that aggressive treatment of diabetes and hyperglycemia results in reduced mortality and morbidity. This article presents a technical review that evaluates the evidence relating to the management of hyperglycemia in hospitals, with particular focus on the issue of glycemic control and its possible impact on hospital outcomes. The review encompasses adult nonpregnant patients who do not have diabetic ketoacidosis or hyperglycemic crises. 2 figures. 11 tables. 449 references.

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Management of Diabetes and Hyperglycemia in Hospitals. Appendix 1: Example of Standardized Subcutaneous Insulin Orders. Diabetes Care: 27(2): 553 Data Supplement. February 2004.

This fact sheet reprints an example of standardized subcutaneous insulin orders used for patients with diabetes who are in the hospital. The orders include space to individualize the blood glucose monitoring tests (when they should take place), prandial (meal time) insulin orders, and basal insulin orders. The treatment for low blood glucose levels (hypoglycemia) are also noted. The second page of the fact sheet lists suggested low dose, medium dose, and high dose approaches to patient care management. A final section offers general insulin dosing recommendations. The author stresses that individual insulin doses vary widely and adjustments should be based on the bedside and laboratory glucose levels. This information serves as an appendix to a related article (Diabetes Care, 27:2, February 2004). 5 tables.

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Management of Diabetes and Hyperglycemia in Hospitals. Appendix 2: Example of a Standardized Intravenous Insulin Infusion. Diabetes Care: 27(2): 553 Data Supplement. February 2004.

This fact sheet reprints an example of standardized intravenous insulin infusion orders used for patients with diabetes who are in the hospital. The fact sheet offers general guidelines, then considers intravenous fluids, initiating the infusion, moving from lower to higher algorithms, patient monitoring, treatment of hypoglycemia (low blood glucose levels), and when to notify the physician. These orders are designed for nursing care. One chart summarizes the different levels of patient care. This information serves as an appendix to a related article (Diabetes Care, 27:2, February 2004). 1 table.

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Medical Approaches to Treatment of the Obese Patient. IN: Obesity and Diabetes. Totowa, NJ: Humana Press. 2006. pp. 457-470.

This chapter on medical approaches to the treatment of obesity is from a comprehensive textbook on diabetes and obesity. The authors note that because even modest weight reduction can produce substantial health benefits, physicians must develop effective office-based approaches to the management of obesity. The authors discuss the realities of treatment, classification and risk assessment of obesity, evaluation of the obese patient, the metabolic syndrome, initiation of pharmacological therapy, medication as adjunctive treatment, strategies for the prevention of relapse following weight loss, drugs approved for clinical use in the treatment of obesity, other drugs still in clinical trials, and special issues in patients with diabetes. The approved drugs are sibutramine and orlistat; drugs still in clinical trials are buproprion, topiramate, zonisamide, rimonabant, leptin, and axokine. Regarding patients with diabetes, management of the disease improves with weight reduction, but hypoglycemia becomes a possibility for those patients taking insulin or oral hypoglycemic medications. Physicians must remember to monitor blood glucose carefully and to reduce or stop diabetes medications as weight loss occurs. The authors stress that medications for the treatment of obesity are considered adjuncts to the overall management plan which should include the use of meal replacements (i.e., shakes, bars, frozen entrees) as means of portion and calorie control, counseling on how to reduce fat and calorie intake, an exercise program that increases activities such as walking, and the use of techniques for positive behavior modification. 8 tables. 28 references.

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Office Management of the Diabetic Patient. In: Hormel, A.P. and Mother, R. Davidson's Diabetes Mellitus: Diagnosis and Treatment. 5th ed. Orlando, FL: W.B. Saunders Company. 2004. p. 259-297.

The mainstay of the treatment of patients with diabetes occurs in an office setting. More than with most diseases, diabetes care requires an ongoing dialogue between patient and physician, and, unlike individuals with other diseases, patients with diabetes themselves make many important decisions about their care. No matter how experienced and dedicated a physician is, both patients' knowledge of diabetes and their appropriate judgments in soliciting help from a physician are usually the critical factors that prevent minor problems from becoming major. This chapter on the office management of the patient with diabetes is from a textbook that provides readers with current information on the diagnosis and treatment of patients with diabetes, including the latest advances, medications, and research studies. In this chapter, the author stresses that a team approach to the management of patients with a chronic disease such as diabetes is crucial. Topics covered in this chapter include the initial patient evaluation and general follow-up, monitoring diabetic control, self-monitoring of blood glucose (SMBG), glycosylated hemoglobin (a measure of blood glucose levels over time), monitoring patients who take insulin, fasting hyperglycemia, monitoring patients who do not take insulin, the 'honeymoon phase' of type 1 diabetes, weight reduction in obese patients with diabetes, hypoglycemia (low blood glucose levels), starvation ketosis, sick day rules, exercise, foot care, travel, dental procedures, surgical and postoperative management, infections in patients with diabetes, and guidelines for influenza and pneumococcal vaccines. 3 figures. 8 tables. 118 references.

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Population-Based Study of Diabetes and Its Characteristics During the Fasting Month of Ramadan in 13 Countries. Diabetes Care. 27(10): 2306-2311. October 2004.

The prevalence of diabetes in several countries with large Muslim populations appears to be similar to the rates observed in western countries and is increasing by 10 percent per year as a result of urbanization and socioeconomic development. There are more than 1 billion Muslims in the world, and the majority of them observe an absolute fast (no food or water) between dawn and sunset 1 lunar month a year (the Holy Month of Ramadan). This article reports on a study that assessed the characteristics and care of patients with diabetes in countries with a sizable Muslim population. The authors studied diabetes features during Ramadan and the effect of fasting on diabetes care. The population-based, retrospective, transversal survey study was conducted in 13 countries. A total of 12,243 patients with diabetes were included in the analysis: 1,070 patients with Type 1 diabetes and 11,173 patients with Type 2 patients. During Ramadan, 42.8 percent of patients with Type 1 diabetes and 78.7 percent with Type 2 diabetes fasted for at least 15 days. Less than 50 percent of the whole population changed their treatment dose. Severe hypoglycemic (low blood glucose) episodes were significantly more frequent during Ramadan compared with other months. Severe hypoglycemia was also more frequent in patients who changed their dose of oral antidiabetic drugs or insulin or who modified their level of physical activity. The authors conclude that the large proportion of both Type 1 and Type 2 diabetes patients who fast during Ramadan represent a significant challenge to their physicians. There is a need to provide more intensive patient education before fasting and a need for more studies assessing the impact of fasting on morbidity and mortality. 3 tables. 34 references.

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Quick Guide to Medications. Chicago, IL: American Association of Diabetes Educators. 2004. 19 p.

Approximately 90 percent of people with diabetes require oral glucose-lowering medications, insulin injections, or both, to reach blood glucose goals. This lengthy brochure is designed to provide in quick reference format an overview of the oral medications used to manage diabetes mellitus. In addition to oral medications and insulin, the drug therapies for a person with diabetes often include other medications to treat the associated conditions or complications of diabetes. The drugs are considered in separate categories: oral glucose-lowering agents, insulins available in the United States, major classes of agents used to treat high blood pressure, and lipid-lowering therapies. Other charts cover a comparison of human insulins and analogs, guidelines for mixing insulin or prefilling syringes, the use of glucagons injection for severe hypoglycemia, drug-food interactions of diabetes medications, adverse effects of drugs on body systems, drug-disease and drug-drug interactions, and drug therapies for the treatment of dyslipidemia in people with diabetes. The brochure emphasizes that health care professionals must be knowledgeable of the total range of therapies that are available for comprehensive diabetes care, not just the therapies that are used for glycemic control. 2 figures. 6 tables. 1 reference.

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Reactive and Fasting Hypoglycemia. 3rd ed. Minneapolis, MN: International Diabetes Center. 2004. [8 p.].

Fasting hypoglycemia (low blood glucose in people who have not eaten for at least eight hours) can be caused by certain conditions that upset the body's ability to balance blood glucose. These conditions include eating disorders, as well as conditions involving the pancreas, pituitary, or adrenal glands, liver, or kidneys. Reactive hypoglycemia occurs after eating meals or snacks that contain mainly carbohydrate foods. Normally, the body would immediately release enough insulin to balance the carbohydrate. With reactive hypoglycemia, insulin is released later and exceeds the amount needed to cover the carbohydrate. This brochure introduces fasting and reactive hypoglycemia and helps readers with diabetes learn how to recognize and avoid these complications. Topics include the causes of hypoglycemia, symptoms, carbohydrate counting, the treatment of hypoglycemia, and practical suggestions for preventing hypoglycemia. Food charts, listing carbohydrate values of common foods, are provided. 1 table.

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Reduced Severe Hypoglycemia with Insulin Glargine in Intensively Treated Adults with Type 1 Diabetes. Diabetes Technology & Therapeutics. 6(5): 589-595. October 2004.

The goal of new therapies introduced for type 1 diabetes should be to decrease hypoglycemic episodes while improving glycemic control. This article reports on a study in which a database was used to computer match the baseline A1C (glycosylated hemoglobin, a measure of blood glucose over time) values in 196 subjects with type 1 diabetes receiving multiple daily injections (MDI) consisting of four or more injections per day. There were 98 patients transferred from NPH to insulin glargine, and 98 patients who remained on NPH throughout the study. The gender distribution and mean age (32 years), duration of diabetes (16 years), and duration of treatment (13 months) were not significantly different between the groups. The majority of patients were well controlled (more 50 percent in both groups had an A1c less than 7 percent). The mean A1C values were not significantly different in the groups at baseline or at follow-up. Severe hypoglycemic episodes per patient per year were significantly lower in the glargine group compared with the NPH group (0.5 vs. 1.2 respectively). The mean end-of-study total and long-acting doses were significantly reduced from baseline in the group that switched to glargine, but not in the group that remained on NPH, with no change in the short-acting dose in either group. The weight gain was significantly higher in the NPH group at the end of the study with no significant change in the glargine group. The authors conclude that transfer to glargine treatment from NPH in MDI regimens significantly reduces severe hypoglycemic episodes despite a decline in long-acting basal insulin without significant weight gain. 2 figures. 1 table. 21 references.

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Taking Charge of Diabetes: A Diary.

This booklet helps people newly diagnosed with diabetes to record and understand their food intake. Understanding food intake and blood glucose levels is the first step to controlling diabetes. The booklet begins with a discussion of some basics of diabetes management, including the importance of frequent blood glucose testing, high blood glucose (hyperglycemia) levels and their symptoms, how to know when symptoms consist an emergency that needs treatment, low blood glucose (hypoglycemia) symptoms and emergency care, the importance of exercise, stress reduction, the different types of meal planning (exchange lists, carbohydrate counting) that may be utilized, food labels, weight loss, and complications and how to prevent them. Most of the brochure consists of a blank food diary that covers three meals plus snacks every day for 11 weeks. Simple exchange lists are provided. The back cover of the brochure provides space for a dietitian or other health care provider to note the recommended personal meal plan. Throughout the brochure facts and practical tips are noted. The brochure is illustrated with cartoon line drawings.

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Type 2 Diabetes BASICS Curriculum Guide. 2nd ed. Minneapolis, MN: International Diabetes Center. 2004. 146 p.

This book is an education program for people with type 2 diabetes who are not treated with insulin. The book is designed to be used as part of a program which is usually taught by certified diabetes educators (CDEs). The book is divided into four sections to coincide with the four sessions of the program. The first section introduces the disease and what causes it, how diabetes is treated, the goals of treatment, blood glucose testing, carbohydrate foods, counting carbohydrates, the role of physical activity, and self-care. The second section covers SMBG (self monitoring of blood glucose), hypoglycemia (low blood glucose) and hyperglycemia (high blood glucose) and how to treat them, the impact of stress and illness on blood glucose, additional carbohydrate counting strategies, following a food plan even at restaurants or while traveling, the impact of alcohol, and how to feel more confident about dealing with diabetes. The third section focuses on the glycosylated hemoglobin (HbA1c) test and why blood glucose levels may be out of target, how diabetes and treatment change over time, the patient health care team, complications and how they can be prevented, the role of dietary fats and how to reduce them, and self care. The final section emphasizes the importance of problem solving skills and strategies for creating life balance, including in the areas of food and nutrition, psychological aspects, and health weight loss. The book is filled with illustrations and charts to help make the information more accessible. Appendices and a glossary of terms complete the volume.

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Absence of Adverse Effects of Severe Hypoglycemia on Cognitive Function in School-Aged Children With Diabetes Over 18 Months. Diabetes Care. 26(4): 1100-1105. April 2003.

Some children with type 1 diabetes may be at risk of cognitive impairments, but mechanisms of this effect have not been confirmed. This article reports on a study undertaken to determine whether severe hypoglycemia (SH) in children with type 1 diabetes is associated with cognitive decline over 18 months. A sample of 142 children (age 6 to 15 years) with type 1 diabetes enrolled in a trial of intensive therapy (IT) or usual care (UC) were tested with a cognitive assessment tool at baseline and at 9 and 18 months. HbA1c (glycosylated hemoglobin, a measure of blood glucose levels over time) was tested quarterly. Over 18 months, 58 of 142 patients (41 percent) experienced 111 SH episodes. Neither occurrence nor frequency of SH was associated with decline in full-scale intelligence quotient (IQ), standard scores for planning, attention, simultaneous processing, or successive processing, or scaled scores on any of eight subtests. The same findings emerged when only patients who had experienced hypoglycemic seizures or coma were included in the SH group for analyses. HbA1c during the trial was not associated with cognitive changes. SH did not induce adverse changes in the measures of cognitive function in this study. 1 figure. 3 tables. 27 references.

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Acarbose. In: Patel, A. Diabetes in Focus. 2nd ed. Lewisville, TX: Pharmaceutical Press. 2003. p. 119-122.

Diabetes mellitus is a common chronic disorder and represents a serious health care challenge. The prevalence of diabetes is increasing worldwide and considerable progress has been made in the understanding of diabetes management. This chapter on drug therapy with acarbose is from a textbook that details the practical pharmaceutical care that pharmacists can provide for people with diabetes. In this chapter, the author reviews the use of acarbose in combination with other antidiabetes drugs for reducing post-prandial hyperglycemia (high blood glucose levels occurring after a meal). Topics include mechanism of action, pharmacokinetics, contraindications, dosage, adverse effects (notably hypoglycemia), drug interactions, and preparations. 1 figure. 5 references.

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B-cell Function and the Development of Diabetes-Related Complications in the Diabetes Control and Complications Trial. Diabetes Care. 26(3): 832-836. March 2003.

In patients with type 1 diabetes, measurement of connecting peptide (C-peptide), co-secreted with insulin from the islets of Langerhans, permits estimation of remaining beta cell secretion of insulin. This article reports on a retrospective analysis undertaken to distinguish the incremental benefits of residual beta cell activity in type 1 diabetes. In the study, stimulated (90 minutes following ingestion of a mixed meal) C-peptide levels were related to measures of diabetic retinopathy (eye disease) and nephropathy (kidney disease) and to incidents of severe hypoglycemia (low blood glucose levels). Results showed that uniformly in the intensive group and partially in the conventional treatment group, any C-peptide secretion, but especially at higher and sustained levels of stimulated C-peptide, was associated with reduced incidences of both retinopathy and nephropathy. Also, continuing C-peptide (insulin) secretion is important in avoiding hypoglycemia (the major complication of intensive diabetes therapy). 1 figure. 4 tables. 22 references.

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Core Curriculum for Diabetes Education. 5th ed.: (Volume 2) Diabetes Management Therapies. Chicago, IL: American Association of Diabetes Educators (AADE). 2003. 341 p.

This guidebook is the second in a series of four handbooks in the CORE Curriculum, a project originally planned to help educators prepare for the Certified Diabetes Educators (CDE) exam. However, the use and scope of the CORE Curriculum has expanded; it is both a key reference for the Advanced Diabetes Management credential exam and an authoritative source of information for diabetes education, training, and management. This first volume covers diabetes management therapies. Topics include medical nutrition therapy for diabetes; physical activity and exercise; pharmacologic (drug) therapies for glucose management; pharmacologic therapies for hypertension (high blood pressure) and dyslipidemia (altered levels of blood fats, including cholesterol); monitoring; pattern management of blood glucose; insulin pump therapy and carbohydrate counting for pump therapy, including the use of insulin-to-carbohydrate ratios; hypoglycemia (low blood glucose levels); and coping with illness and surgery. Each chapter includes an introduction, a list of learning objectives, key definitions (glossary), key educational considerations, self review questions, references, and a post-test (including an answer key). The handbook concludes with a subject index.

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Diabetes and Driving Mishaps: Frequency and Correlations from a Multinational Survey. Diabetes Care. 26(8): 2329-2334. August 2003.

The intensive treatment of diabetes to achieve strict glycemic control is a common clinical goal, but it is associated with an increased incidence of hypoglycemia. Becoming hypoglycemic while driving is a hazardous condition and may lead to a greater incidence of driving mishaps. This article reports on a study that investigated whether diabetes is associated with increased risk of driving mishaps and the correlates of such a relationship. During routine visits to diabetes specialty clinics in seven United States and European cities, consecutive adults with type 1 diabetes, type 2 diabetes, and nondiabetic spouse control subjects (n = 341, 332, and 363, respectively) completed an anonymous questionnaire concerning diabetes and driving. Results showed that drivers with type 1 diabetes reported significantly more crashes, moving violations, episodes of hypoglycemic stupor, required assistance, and mild hypoglycemia while driving as compared with drivers with type 2 diabetes or spouse control subjects. Drivers with type 2 diabetes had driving mishap rates similar to nondiabetic spouses, and the use of insulin or oral agents for treatment had no effect on the occurrence of driving mishaps. Crashes among type 1 diabetes drivers were associated with more frequent episodes of hypoglycemic stupor while driving, less frequent blood glucose monitoring before driving, and the use of insulin injection therapy as compared with pump therapy. One-half of the drivers with type 1 diabetes and three-quarters of the drivers with type 2 diabetes had never discussed hypoglycemia and driving with their physicians. 2 tables. 21 references.

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Diabetes in Infants and Toddlers. Alexandria, VA: American Diabetes Association. 2003. 5 p.

This document is a type of fact sheet that is available online, called PODs (print-on-demand). The fact sheets accompany the Wizdom patient education book series from the American Diabetes Association (ADA); the series is designed for children and adolescents and their families. This fact sheet discusses diabetes in infants and toddlers. Topics include coping with a diagnosis in a very young child, the importance of getting support, emotional considerations, monitoring blood glucose levels, managing a baby's diabetes, working with the patient care team, insulin management, symptoms of hypoglycemia (low blood glucose) and hyperglycemia (high blood glucose) in babies, and using non-food items for rewards. The fact sheet concludes with suggestions for additional information (web sites and other publications). The fact sheets are also available in print format from the ADA (800-342-2383).

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Diabetes Sourcebook. 3rd ed. Detroit, MI: Omnigraphics. 2003. 621 p.

This book provides information for people seeking to understand the risk factors, complications, and management of type 1 diabetes, type 2 diabetes, and gestational diabetes. The book offers 67 chapters in seven sections: diabetes types and diagnosis; lifestyle and related diabetes management concerns; exercise and nutrition for diabetes management; medication management of diabetes; complications of diabetes; treatment of end stage renal disease (ESRD); and diabetes-related research and statistics. Specific topics include risk factors, impaired glucose tolerance (IGT), insulin resistance, HbA1c (glycosylated hemoglobin) testing, blood glucose testing, urine testing, SMBG (self monitoring of blood glucose), non-invasive blood glucose monitors, preventing complications, how stress affect diabetes, alternative therapies for diabetes, exercise, exchange lists, carbohydrate counting, eating at restaurants, insulin administration and dosage, oral medications, amputation, kidney disease (diabetic nephropathy), diabetic retinopathy (eye disease), diabetic neuropathy (nerve disease), gastroparesis (reduced motility of stomach contents), hypoglycemia (low blood glucose levels), hyperglycemia (high blood glucose levels), erectile dysfunction (ED formerly called impotence), research advances in diabetes, and diabetes in ethnic and racial groups. The book includes a glossary of related terms, information about locating financial help for diabetes care, and a list of resources, including organizations, recipes and cookbooks.

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Do All Prepubertal Years of Diabetes Duration Contribute Equally to Diabetes Complications?. Diabetes Care. 26(4): 1224-1229. April 2003.

This article reports on a study that explored the timeline of protection against complications in prepubertal children with diabetes, in particular the effects of diabetes duration before age 5 years. In the study, 193 adolescents with prepubertal diabetes onset were followed longitudinally for retinopathy (eye disease) and microalbuminuria (protein in the urine). Results showed that prepubertal duration improved the prediction for retinopathy over postpubertal duration alone in the young adults. The survival-free period of retinopathy and microalbuminuria was significantly longer (2 to 4 years) for those diagnosed before age 5 years compared with those diagnosed after 5 years. Time to onset of all complications increased progressively with longer diabetes duration before puberty. Higher HbA1c (glycosylated hemoglobin, a measure of blood glucose over time) during adolescence had an independent effect on the risk of retinopathy and microalbuminuria. The authors conclude that the effect of time on the risk of retinopathy and microalbuminuria is nonuniform, with an increasing delay in the onset of complications in those with longer prepubertal duration. These findings are of major clinical importance when setting targets of glycemic control in young children who are at greatest risk of hypoglycemia (low blood glucose levels). 2 figures. 1 table. 28 references.

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Factors Associated with Academic Achievement in Children with Type 1 Diabetes. Diabetes Care. 26(1): 112-117. January 2003.

This article reports on a study that examined academic achievement in children with diabetes and that identified predictors of academic achievement. Participants were 244 children, ages 8 to 18 years, with type 1 diabetes. Results showed that reading scores and grade point averages (GPA) were lower for children with poor metabolic control than for children with average control. Children with hospitalizations for hyperglycemia (high blood glucose levels) had lower overall achievement scores than children with better metabolic control and fewer hospitalizations for hyperglycemia. The authors conclude that, for most children with diabetes, medical variables are not as strongly associated with academic achievement as are factors such as socioeconomic status and behavioral factors. Poor metabolic control and serious hypoglycemia, however, are a potential concern for a subset of these children. 3 tables. 31 references.

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Gastroparesis: A Case of Unexplained Lows. Diabetes Forecast. 56(9): 69-72. September 2003.

Gastroparesis is a form of nerve damage that affects the stomach, resulting in a slowed motility (movement) of gastric contents. Gastroparesis develops in 40 to 50 percent of people who have had type 1 diabetes for more than 20 years and in 30 to 40 percent of those with long-standing type 2 diabetes. This article shares the experience of one person with diabetes who developed gastroparesis. Topics include how gastroparesis is diagnosed, a typical symptom questionnaire, blood glucose (sugar) target ranges, adjusting insulin dosage to carbohydrate intake, diet suggestions for people with gastroparesis, suggested insulin regimens, and strategies for patients using insulin pumps. 3 figures.

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Handbook of Diagnostic Endocrinology. Totowa, NJ: The Humana Press, Inc. 2003. 360 p.

With the rapid development of new and more reliable diagnostic tests, and aided by the molecular and genetic approaches that continue to deepen the understanding of these diseases, the ability to diagnose patients with endocrine disease has dramatically increased. In this book, physicians concisely explain the pathophysiology and clinical manifestations of these disorders and survey all the latest laboratory tests used in their diagnosis. Topics range widely from an overview of the diagnosis of diabetes and the long-term monitoring of its complications to the evaluation of menstrual dysfunction. Other topics include the diagnosis of pituitary tumors, Cushing's syndrome, thyroid disease, and hypoglycemia; the evaluation of endocrine-induced hypertension; the assessment of dyslipidemia and obesity; new approaches to diagnosing hypercalcemia and hypocalcemia, osteoporosis, hypogonadism and erectile dysfunction, and hyperandrogenism in women. The authors review the complex physiological basis of the relevant endocrine processes and provide recommendations for the follow up and long term management of patients. Each chapter concludes with references and the text concludes with a subject index.

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Hypoglycemia in Diabetes. Diabetes Care. 26(6): 1902-1912. June 2003.

Iatrogenic (treatment induced) hypoglycemia (low blood glucose levels) causes recurrent morbidity in most people with type 1 diabetes and in many with type 2 diabetes, and it is sometimes fatal. The barrier of hypoglycemic generally precludes maintenance of euglycemia (best levels of blood glucose) over a lifetime of diabetes and thus precludes full realization of euglycemia's long-term benefits. This article reviews hypoglycemia, notably iatrogenic hypoglycemia. The authors note that iatrogenic hypoglycemia is typically the result of the interplay of absolute or relative insulin excess and compromised glucose counterregulation in type 1 and advanced type 2 diabetes. Reduced sympathoadrenal responses cause hypoglycemia unawareness. Short-term avoidance of hypoglycemia reverses hypoglycemia unawareness in most affected patients. The clinical approach to minimizing hypoglycemia while improving glycemic control includes addressing the issue; applying the principles of aggressive glycemic therapy, including flexible and individualized drug regimens; and considering the risk factors for iatrogenic hypoglycemia. The authors conclude that, pending the prevention and cure of diabetes or the development of methods that provide glucose-regulated insulin replacement or secretion, physicians and patients must learn to replace insulin in a much more physiological fashion to prevent, correct, or compensate for compromised glucose counterregulation. 1 figure. 85 references.

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Hypoglycemia in Type I Diabetes. In: Sperling, M.A. Type 1 Diabetes: Etiology and Treatment. Totowa, NJ: Humana Press Inc. 2003. p. 321-343.

Although the introduction of insulin therapy was life-saving for patients with type 1 diabetes, problems of iatrogenic (caused by the medical therapy) hypoglycemia (low blood glucose levels) were noticeable from the outset. Episodes of hypoglycemia continue to be a daily threat to all patients with type 1 diabetes and can lead to a significant reduction in quality of life. This chapter on hypoglycemia in type 1 diabetes is from a book in which well-recognized physicians and researchers review the latest thinking about the causes of type 1 diabetes and the best approaches to treating both its acute and chronic complications. Topics include the prevalence of hypoglycemia, glucose homeostasis, clinical features, risk factors, nocturnal hypoglycemia, and prevention strategies. The authors conclude that there are many unresolved questions regarding the etiology, sequelae, and prevention of this common acute complication of the treatment of type 1 diabetes. The benefits of long-term good glycemic control cannot be denied, but further progress in the application of intensified diabetes therapy needs to be made before it can be safely applied to all patients with type 1 diabetes. 3 figures. 1 table. 161 references.

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Hypoglycemia. In: Franz, M.J., et al., eds. Core Curriculum for Diabetes Education. 5th ed. (Volume 2) Diabetes Management Therapies. Chicago, IL: American Association of Diabetes Educators (AADE). 2003. p. 277-310.

It is extremely difficult to duplicate normal blood glucose metabolism with insulin therapies. Therefore, blood glucose levels in patients taking insulin tend to fluctuate between abnormally high (hyperglycemia) and abnormally low (hypoglycemia) levels due to under-and over-insulinization relative to food intake, physical activity, and metabolic needs. This chapter on hypoglycemia is from a handbook of the CORE Curriculum, a publication that helps educators prepare for the Certified Diabetes Educators (CDE) exam, serves as a key reference for the Advanced Diabetes Management credential exam, and provides an authoritative source of information for diabetes education, training, and management. This chapter covers mild and severe hypoglycemic episodes, including the symptoms associated with varying levels of severity; the physiological changes that occur with hypoglycemia; the symptoms of hypoglycemia, the effects of hypoglycemia on emotions and behavior, and factors underlying symptoms idiosyncrasy; the causes of hypoglycemia and possible risk factors for individual patients; the treatment for different levels of hypoglycemia, including guidelines for when the person with diabetes is unable to self-treat due to a severe hypoglycemic episode; psychosocial sequelae of hypoglycemia; and general education plans for teaching patients about hypoglycemia as well as more specific assessment and intervention plans for patients experiencing frequent or severe hypoglycemia episodes. The chapter includes an introduction, a list of learning objectives, key definitions (glossary), key educational considerations, self review questions, references, and a post-test (including an answer key). 2 figures. 7 tables. 47 references.

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Hypoglycemic Disorders. In: Hall, J.E.; Nieman, L.K., eds. Handbook of Diagnostic Endocrinology. Totowa, NJ: The Humana Press, Inc. 2003. p. 193-211.

With the rapid development of new and more reliable diagnostic tests, and aided by the molecular and genetic approaches that continue to deepen the understanding of these diseases, the ability to diagnose patients with endocrine disease has dramatically increased. This chapter on hypoglycemic (low blood glucose) disorders is from a book that explains the pathophysiology and clinical manifestations of endocrine disorders and surveys all the latest laboratory tests used in their diagnosis. The author discusses classification of hypoglycemic disorders, and then considers the tests available for their diagnostic evaluation. The author notes that a healthy-appearing patient with no coexisting disease who has a history of neuroglycopenic spells requires an approach quite different from that taken for a patient with concurrent illness or a hospitalized patient with acute hypoglycemia (low levels of blood glucose). Tests discussed include serum glucose levels, the prolonged (72 hour) fast, the mixed meal test, the C-peptide suppression test, insulin antibodies, glycated hemoglobin, and imaging studies. 6 figures. 4 tables. 84 references.

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Impact of Bedtime Snack Composition on Prevention of Nocturnal Hypoglycemia in Adults with Type 1 Diabetes Undergoing Intensive Insulin Management Using Lispro Insulin Before Meals. Diabetes Care. 26(1): 9-15. January 2003.

This article reports on a study undertaken to determine the impact of four bedtime (HS) snack compositions on nocturnal glycemic control, including frequency of hypoglycemia and morning hyperglycemia, in adults with type 1 diabetes using lispro insulin before meals and NPH insulin at bedtime. Substitutions of 15 grams carbohydrate (one starch exchange) for an equivalent amount of uncooked cornstarch or pure protein were compared to a standard snack (control: two starch and one protein exchange) and to no snack (placebo) in 15 adults using a randomized, crossover design. The glycemic level at bedtime mediated the effects observed. A total of 14 hypoglycemic episodes, in 60 percent of patients, and 23 morning hyperglycemic episodes occurred over 50 nights. Most hypoglycemic episodes (10 of 14, 71 percent) occurred with no snack compared to any snack. The standard and protein snacks resulted in no nocturnal hypoglycemia at all HS glucose levels. The authors conclude that the need for and composition of an HS snack depends on the HS glucose such that no snack is necessary at greater than 10 mmol per liter. At levels between 7 and 10 mmol per liter, any snack is advised, and at less than 7 mmol per liter, a standard or protein snack is recommended. 1 figure. 3 tables. 38 references.

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In Sickness and in Health: What's My Role in My Spouse's Diabetes Care?. Diabetes Forecast. 56(1): 30-32. January 2003.

This article helps readers who are the spouse of someone with diabetes understand their own role in coping with this disease. The author notes that there are many different approaches that can be useful, and shares some of the ideas that patients have tried. The author stresses the importance of learning about the disease and remembering that although diabetes cannot be cured, it is controllable. Spouses can be vital members of the patient's health care team. The article offers practical tips in the areas of weight loss, meal planning, lifestyle changes, and food habits. Other topics include sexuality, coping with low blood glucose levels (hypoglycemia), the role of counseling and support groups, and where to get additional information.

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Insulins. In: Patel, A. Diabetes in Focus. 2nd ed. Lewisville, TX: Pharmaceutical Press. 2003. p. 79-102.

Diabetes mellitus is a common chronic disorder and represents a serious health care challenge. The prevalence of diabetes is increasing worldwide and considerable progress has been made in the understanding of diabetes management. This chapter on insulins is from a textbook that details the practical pharmaceutical care that pharmacists can provide for people with diabetes. In this chapter, the author describes how exogenous insulin is given as replacement therapy to compensate for the lack of endogenous insulin in type 1 diabetes and the relative lack of endogenous insulin (due to insulin resistance or a defect in the insulin release mechanism) in type 2 diabetes. Topics include the mechanism of action, the insulin molecule, insulin secretion, insulin receptors, glucose uptake, pharmacokinetics, administration and dosage, adverse effects (hypoglycemia, lipodystrophy, cardiovascular effects, weight gain), and drug interactions. A final section discusses the different types of insulin preparations, insulin formulations, and insulin analogues. 4 figures. 1 table. 21 references.

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Lifestyle Management. In: Patel, A. Diabetes in Focus. 2nd ed. Lewisville, TX: Pharmaceutical Press. 2003. p. 33-44.

Diabetes mellitus is a common chronic disorder and represents a serious health care challenge. The prevalence of diabetes is increasing worldwide and considerable progress has been made in the understanding of diabetes management. This chapter on lifestyle management is from a textbook that details the practical pharmaceutical care that pharmacists can provide for people with diabetes. In this chapter, the author stresses that the maintenance of near-normal blood glucose levels is the key to avoiding both metabolic (diabetic) emergencies and long-term complications in patients with diabetes. The motivation of patients to take responsibility for the day-to-day management of their condition is essential. In order to achieve independence, patients require information and education from health professionals on how to detect, manage, and avoid common problems (particularly hypoglycemia and ketoacidosis) associated with diabetes mellitus. The author reviews each of these conditions, covering definition, signs and symptoms, management, and causes. Additional sections discuss exercise, alcohol consumption, smoking, driving, travel, and vaccination. 5 figures. 13 references.

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Managing School. Alexandria, VA: American Diabetes Association. 2003. 6 p.

This document is a type of fact sheet that is available online, called a POD (print-on-demand). The fact sheets accompany the Wizdom patient education book series from the American Diabetes Association (ADA); the series is designed for children and adolescents and their families. This fact sheet discusses strategies for managing school and diabetes. Topics include the psychosocial impact of diabetes on young people, the diabetes care team and how they can help, the need to educate teachers, coaches and other school personnel about diabetes, diabetes self-care activities at school (insulin shots, SMBG), coping with hypoglycemia (low blood glucose levels) at school, the symptoms of hypoglycemia, the problem of hyperglycemia (high blood glucose levels) and strategies to avoid it, eating in the classroom, and exercise and sports. The fact sheet concludes with suggestions for additional information (web sites and other publications). The fact sheets are also available in print format from the ADA (800-342-2383).

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Mastering Your Diabetes (Before Diabetes Masters You). Alexandria, VA: American Diabetes Association. 2003. 123 p.

This book is written for patients newly diagnosed with diabetes mellitus. Written by a diabetes health care professional who has also lived with diabetes for more than 25 years, the book covers the emotional, physical, and practical aspects of living with diabetes. Fifteen chapters cover adjusting to a diagnosis of diabetes, definition of diabetes (including the different types), the physiology of diabetes, short-term complications of high glucose levels (hyperglycemia), monitoring blood glucose levels (SMBG), medications that are used to treat diabetes, diet therapy to help manage diabetes, hypoglycemia (low blood glucose), the role of exercise, general health care recommendations, sick days, the emotional side of diabetes, long-term complications of diabetes, and how to stay motivated to maintain healthy self-care strategies. A subject index concludes the book.

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Meglitinides. In: Patel, A. Diabetes in Focus. 2nd ed. Lewisville, TX: Pharmaceutical Press. 2003. p. 127-131.

Diabetes mellitus is a common chronic disorder and represents a serious health care challenge. The prevalence of diabetes is increasing worldwide and considerable progress has been made in the understanding of diabetes management. This chapter on drug therapy with meglitinides (a new chemical class of insulin secretagogue drugs) is from a textbook that details the practical pharmaceutical care that pharmacists can provide for people with diabetes. In this chapter, the author reviews the use of two meglitinide analogues, nateglinide and repaglinide, currently licensed in the United Kingdom for use in the management of type 2 diabetes. Nateglinide is licensed for use only in combination with metformin, whereas repaglinide may be used either as monotherapy or in combination with metformin. Topics include mechanism of action, pharmacokinetics, dosage, adverse effects (hypoglycemia, weight gain), drug interactions, and preparations. 1 figure. 4 references.

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Parents' Guide to Getting Out. Alexandria, VA: American Diabetes Association. 2003. 5 p.

This document is a type of fact sheet that is available online, called a POD (print-on-demand). The fact sheets accompany the Wizdom patient education book series from the American Diabetes Association (ADA); the series is designed for children and adolescents and their families. This fact sheet offers information for parents of children with diabetes; in it, parents are encouraged to make time for themselves and their relationship. The author focuses on strategies for parents to use to take care of themselves, in order for them to have enough physical and emotional resources to care for their child with diabetes. Topics include finding child care, support groups (for parents and for teens with diabetes), choosing a child care provider, educating the child care provider, meals and snacks, blood checks, insulin, and coping with hypoglycemia (low blood glucose) and hyperglycemia (high blood glucose). The fact sheet concludes with suggestions for additional information (web sites and other publications). The fact sheets are also available in print format from the ADA (800-342-2383).

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Preadolescent Child with Type I Diabetes. In: Sperling, M.A. Type 1 Diabetes: Etiology and Treatment. Totowa, NJ: Humana Press Inc. 2003. p. 293-305.

Results of the Diabetes Control and Complications Trial (DCCT) indicate that most patients with type 1 diabetes should receive intensive treatments aimed at lowering glucose and glycosylated hemoglobin (HbA1c, a measure of blood glucose over time) levels as close to normal as possible and as soon as possible in order to prevent and delay the development of microvascular complications of the disease. Among the pediatric age groups, the preadolescent child with type 1 diabetes is an ideal candidate for such therapy. This chapter on the management of the preadolescent child with type 1 diabetes is from a book in which well-recognized physicians and researchers review the latest thinking about the causes of type 1 diabetes and the best approaches to treating both its acute and chronic complications. Topics include the goals of treatment, insulin replacement, monitoring glucose control, glycosylated hemoglobin, diet, exercise, outpatient care, hypoglycemia (low blood glucose levels), sick-day rules, and the behavioral and psychosocial aspects of treatment. 3 figures. 1 table. 35 references.

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Prevention and Correction of Hypoglycemia. In: Sperling, M.A. Type I Diabetes: Etiology and Treatment. Totowa, NJ: Humana Press Inc. 2003. p. 145-161.

The increasing incidence of diabetes worldwide has prompted a rapid growth in the pace of scientific discovery and clinical understanding of this disease. This chapter on the prevention and correction of hypoglycemia is from a book in which well-recognized physicians and researchers review the latest thinking about the causes of type 1 diabetes and the best approaches to treating both its acute and chronic complications. The author discusses the clinical context of hypoglycemia (low blood glucose) in diabetes, the physiological prevention or correction of hypoglycemia, clinical risk factors for hypoglycemia, the pathophysiology of glucose counterregulation in diabetes, and hypoglycemia risk reduction in diabetes. The author notes that improving glycemic control while minimizing hypoglycemia in diabetes requires both application of the principles of aggressive therapy (patient education and empowerment, frequent self-monitoring of blood glucose, flexible insulin regimens, individualized glycemic goals, ongoing professional guidance and support) and implementation of hypoglycemia risk reduction. 3 figures. 1 table. 75 references.

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Self-Care for Diabetes. [Autocuidado para la Diabetes.]. Yardley, PA: The StayWell Company: KRAMES Health and Safety Education. 2003. [4 p.].

This brochure, available in English or Spanish, reviews the basic components of diabetes self-management: understanding the disease, monitoring blood glucose, taking medication, and making healthy food choices. Specific topics include the complications that can arise from high blood glucose levels (hyperglycemia), the goals of self-care, monitoring strategies (including SMBG), glycosylated hemoglobin (HbA1c, a measure of blood glucose levels over time), how to treat high blood glucose levels, how to manage episodes of low blood glucose (hypoglycemia), oral medications, insulin, healthy eating, shopping hints, meal planning, foot care, footwear, and the role of exercise. The brochure is printed on heavy cardstock and is illustrated with brightly colored graphics. 7 figures. 1 table.

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Serum ACE Predicts Severe Hypoglycemia in Children and Adolescents With Type 1 Diabetes. Diabetes Care. 26(2): 274-78. February 2003.

This study investigated whether risk of severe hypoglycemia is related to serum (S) ACE (a genotype) level during intensive treatment in children with type 1 diabetes. The study included a cohort of 86 patients with intensively treated type 1 diabetes. Severe hypoglycemia (low blood glucose) was correlated to S-ACE. Patients with S-ACE at the median level of above reported a mean of 3.0 yearly events of severe hypoglycemia compared with 0.5 events in patients with S-ACE lower than the median. Of the patients with an S-ACE at the median level or above, 27 (61 percent) reported severe hypoglycemia, compared with 17 (40 percent) patients with an S-ACE lower than the median. Insulin dose, HbA1c (glycosylated hemoglobin, a measure of blood glucose over time), age, onset age, duration, C-peptide, and sex did not differ between these two groups. The authors conclude that the elevated rate of severe hypoglycemia among patients with higher A-ACE suggests, among other factors, that a genetic determinant for severe hypoglycemia exists. Further evaluation is needed before the clinical usefulness of this test can be elucidated. 1 figure. 2 tables. 34 references.

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Short-Term, Delayed, and Working Memory Are Impaired During Hypoglycemia in Individuals with Type 1 Diabetes. Diabetes Care. 26(2): 390-396. February 2003.

This article reports on a study undertaken to examine the effects of acute insulin-induced hypoglycemia (low blood glucose) on short-term, delayed, and working memory in individuals with type 1 diabetes. Performance in tests of immediate verbal and immediate visual memory was significantly impaired during hypoglycemia. The effect of hypoglycemia on working memory and delayed memory was more profound. Performance in the nonmemory tests, the Trail Making B Test, and the Digit Symbol Test also deteriorated during hypoglycemia. The authors conclude that all of the memory systems examined in the present study were affected significantly by acute hypoglycemia, particularly working memory and delayed memory. Mild (self-treated) hypoglycemia is common in individuals with insulin-treated diabetes; therefore, these observed effects of hypoglycemia on memory are of potential clinical importance because they could interfere with many everyday activities. 1 table. 46 references.

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Sleep-Related Hypoglycemia-Associated Autonomic Failure in Type 1 Diabetes. Diabetes. 52(5): 1195-1203. May 2003.

This article reports on a study of sleep-related hypoglycemia, focusing on the defenses against developing hypoglycemia and how sleep affects them. The authors studied eight adult patients with uncomplicated type 1 diabetes and eight matched nondiabetic control subjects with hyperinsulinemic stepped hypoglycemic clamps. Subjects were tested in the morning, while awake and at night, while awake throughout, and while asleep. Plasma epinephrine, plasma norepinephrine, and pancreatic polypeptide responses to hypoglycemia were reduced during sleep in subjects with diabetes, but not in the control subjects. The diabetes subjects exhibited markedly reduced awakening from sleep during hypoglycemia. Sleep efficiency (percent time asleep) was 77 percent (plus or minus 18 percent) in the subjects with diabetes, but only 26 percent (plus or minus 8 percent) in the control subjects late in the 45 milligram per deciliter hypoglycemic steps. The authors conclude that autonomic responses to hypoglycemia are reduced during sleep in type 1 diabetes. Also, probably because of their reduced sympathoadrenal responses, patients with type 1 diabetes are substantially less likely to be awakened by hypoglycemia. Thus, both physiological and behavioral defenses are further compromised during sleep. This sleep-related hypoglycemia-associated autonomic failure, in the context of imperfect insulin replacement, likely explains the high frequency of nocturnal hypoglycemia in type 1 diabetes. 10 figures. 6 tables. 27 references.

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Special Problems and Management of the Child Less Than 5 Years of Age. In: Sperling, M.A. Type 1 Diabetes: Etiology and Treatment. Totowa, NJ: Humana Press Inc. 2003. p. 279-292.

Diabetes in a child less than 5 years old is characterized by unstable glycemic (blood glucose) control, frequent and asymptomatic hypoglycemia (low blood glucose), and greater risk of severe hypoglycemia. Management of diabetes in young children is complicated by special age-related problems, including difficulties in administering and adjusting small doses of insulin and unpredictable behavior pattern or day-to-day variations in diet and physical activities. This chapter on the special problems and management of the child less than 5 years of age with type 1 diabetes is from a book in which well-recognized physicians and researchers review the latest thinking about the causes of type 1 diabetes and the best approaches to treating both its acute and chronic complications. Topics include the characteristics of type 1 diabetes in young children, treatment objects, and treatment means and strategy. The authors stress that a multidisciplinary approach by a specialized team available for frequent contacts and that gives children and parents an adapted continuing education and support is necessary. In case of severe hypoglycemia despite a well-conducted conventional therapy, a more physiological way of insulin treatment, such as continuous subcutaneous insulin infusion (CSII) has been shown to be well-tolerated by young children and allows achievement of good metabolic control without severe hypoglycemia under the supervision of a specialized team. 3 figures. 3 tables. 54 references.

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Sports, Exercise, and Diabetes. Alexandria, VA: American Diabetes Association. 2003. 5 p.

This document is a type of fact sheet that is available online, called a POD (print-on-demand). The fact sheets accompany the Wizdom patient education book series from the American Diabetes Association (ADA); the series is designed for children and adolescents and their families. This fact sheet offers information on sports, exercise and diabetes, stressing that it really does not matter what activity is chosen, just that kids with diabetes stay active. The fact sheet discusses the emotional benefits of exercise, the wide variety of sports and activities available, the social benefits of exercise, coping with hypoglycemia (low blood glucose) during and after exercise, recordkeeping, how to avoid hyperglycemia, foot care and prevention of foot injuries, regular diabetes care management, how to balance food and insulin with the amount of activity undertaken, equipment and supplies to have available during sports and other activities, and the importance of telling a coach, friend, or other support person about one's diabetes. The fact sheet concludes with suggestions for additional information (web sites and other publications). The fact sheets are also available in print format from the ADA (800-342-2383).

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Staying Healthy with Type 2 Diabetes. [Como Mantenerse Saludable Aunque Tenga Diabetes Tip 2]. Minneapolis, MN: International Diabetes Center. 2003(EN). 2004(SP). 16 p.

This book provides information for people with type 2 diabetes who are not treated with insulin. Written in non-technical language, the book helps readers understand the basics of taking care of themselves. Topics include the emotional reaction to getting a diagnosis of diabetes, the symptoms of diabetes, the importance of staying healthy, foods that make blood glucose (sugar) go up (resulting in hyperglycemia), foods that do not make blood glucose levels go up, the importance of staying active, medicines that may be prescribed, the use of blood glucose testing (SMBG), hyperglycemia, and hypoglycemia (low levels of blood glucose). An illustrated chart is provided for readers to individualize and record a recommended daily schedule. The book is filled with illustrations and charts to help make the information more accessible. Space to record the doctor, nurse, and dietitian telephone numbers is provided on the back cover. The brochure is available in English or Spanish.

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Sulfhonylureas. In: Patel, A. Diabetes in Focus. 2nd ed. Lewisville, TX: Pharmaceutical Press. 2003. p. 103-112.

Diabetes mellitus is a common chronic disorder and represents a serious health care challenge. The prevalence of diabetes is increasing worldwide and considerable progress has been made in the understanding of diabetes management. This chapter on drug therapy with sulfonylureas is from a textbook that details the practical pharmaceutical care that pharmacists can provide for people with diabetes. In this chapter, the author reviews the use of sulfonylureas for the management of type 2 diabetes when dietary management alone has failed. Sulfonylureas may be used as monotherapy or in combination with metformin or insulin. Topics include mechanism of action, pharmacokinetics, dosage, adverse effects (hypoglycemia, cardiovascular effects, weight gain), drug interactions, and preparations. 1 figure. 1 table. 12 references.

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Surgery for the Patient with Type I Diabetes. In: Sperling, M.A. Type 1 Diabetes: Etiology and Treatment. Totowa, NJ: Humana Press Inc. 2003. p. 361-371.

Advances in the treatment of type 1 diabetes have allowed people with this disease to live longer. Consequently, the number of people with type 1 diabetes who require elective and emergency surgery has increased. This chapter on surgery for the patient with type 1 diabetes is from a book in which well-recognized physicians and researchers review the latest thinking about the causes of type 1 diabetes and the best approaches to treating both its acute and chronic complications. Topics include the metabolic consequences of surgery in type 1 diabetes, the preoperative evaluation of patients, the management of patients during surgery, and the management of patients during emergency surgery. The authors stress that the management of patients with type 1 diabetes during surgery requires careful attention to detail and continuous monitoring by a multidisciplinary team experienced in the care of these patients. With appropriate insulin replacement as well as careful monitoring to avoid hyperglycemia or hypoglycemia, there is no reason why outcomes in patients with type 1 diabetes undergoing surgery should be any different from unselected patients undergoing identical surgical procedures. 4 tables. 75 references.

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Surviving Sick Days. Alexandria, VA: American Diabetes Association. 2003. 5 p.

This document is a type of fact sheet that is available online, called a POD (print-on-demand). The fact sheets accompany the Wizdom patient education book series from the American Diabetes Association (ADA); the series is designed for children and adolescents and their families. This fact sheet offers information for coping with sick days. The fact sheet notes that when one of many common illnesses (like a cold or the flu) invades the body, not only do patients have to deal with sniffling and sneezing, headaches and body aches, but they have to cope with their diabetes being out of whack. A cold or the flu creates stress in the body which in turn has an impact on diabetes. Topics covered include the importance of checking blood glucose levels during sick days, changes in symptoms of hypoglycemia and hyperglycemia, insulin use during sick days, the need to check for ketones during sick days, food and nutrition, preventing dehydration, the impact of over-the-counter medications on diabetes, when to contact the health care provider, and how to prepare a sick day kit. The fact sheet concludes with suggestions for additional information (web sites and other publications). The fact sheets are also available in print format from the ADA (800-342-2383).

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Treatment of Hypoglycemia: Is There a Fast-Acting Carbohydrate?. Practical Diabetology. 22(3): 40-41. September 2003.

This article reviews the available research on the treatment of hypoglycemia (low blood glucose levels). Topics include traditional treatment recommendations for hypoglycemia, use of a fast-acting carbohydrate, role of the gastric emptying rate, the role of protein intake, and the role of blood glucose testing and hypoglycemia unawareness. The authors conclude that although glucose is recommended for the treatment of hypoglycemia, patients can use any form of carbohydrate that contains glucose. Initial responses to treatment with 15 to 20 grams of carbohydrate should be seen in approximately 10 to 20 minutes. However, the glucose response to carbohydrate foods is temporary, and individuals must remember to test again approximately one hour after blood glucose levels reach an acceptable range to see whether they need additional carbohydrate. All carbohydrate foods containing glucose will eventually raise glucose levels, so the message to people with diabetes is to test and treat and then test again.

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Type 1 Diabetes: A Healthier Life for Adults With Diabetes. San Bruno, CA: The StayWell Company. 2003. 16 p.

This booklet offers a friendly, graphics-intensive approach to learning about type 1 diabetes and its care. The booklet is designed to educate young adults who have just been diagnosed with type 1 diabetes. Topics include the causes of diabetes, the impact of diabetes on one's daily activities, emotions that can be expected with the diagnosis, the members of the patient care team, how insulin works in the body, how to monitor one's blood glucose (SMBG, self-monitoring of blood glucose), the equipment and supplies used (blood glucose meters, needles, insulin pen, insulin pump), hypoglycemia (low blood glucose) and its symptoms, hyperglycemia (high blood glucose) and its complications, the role of healthy eating, the importance of exercise, getting good medical care, handling sick days, and how to learn more about diabetes. The booklet offers the contact information for four resource organizations through which readers can get more information. The booklet is illustrated with cartoon figures, full-color photographs, and brightly colored graphics.

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Type 2 Diabetes. Yardley, PA: The StayWell Company: KRAMES Health and Safety Education. 2003. 13 p.

This booklet helps readers recently diagnosed with type 2 diabetes understand and manage the disease. Type 2 diabetes is a chronic and progressive condition that makes it hard for the body to break food down into energy. The booklet first describes the professionals who may be a part of the patient care team, including an endocrinologist, a registered dietitian, a diabetes educator, and a psychologist or social worker. The booklet then discusses the pathology of type 2 diabetes, the importance of managing the disease, how to check one's blood glucose (sugar), healthy eating, the role of physical activity and exercise, medications and drug therapy, treating high blood glucose (hyperglycemia) and low blood glucose (hypoglycemia) levels, the need for regular doctor's visits, self care, preventive strategies (i.e., preventing hypoglycemia while driving, preparing for emergencies), preparing for special situations (sick days, travel), and where to find emotional support. The brochure is illustrated with full-color drawings of patients and health care providers. The brochure concludes with the contact information for four resource organizations that can provide assistance. The brochure is also available in Spanish. 39 figures.

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Type I Diabetes: Etiology and Treatment. Totowa, NJ: Humana Press. 2003. 608 p.

The increasing incidence of diabetes worldwide has prompted a rapid growth in the pace of scientific discovery and clinical understanding of this disease. In this book, well-recognized physicians and researchers review the latest thinking about the causes of type 1 diabetes and the best approaches to treating both its acute and chronic complications. The book includes 32 chapters in four sections: etiology (cause), treatment, special management issues, and long-term complications. Specific topics include epidemiology, genetics, prediction and prevention of type 1 diabetes, beta-cell destruction by autoimmune processes, the metabolic basis of insulin secretion, prevention and correction of hypoglycemia, nonautoimmune forms of diabetes, diabetic ketoacidosis, insulin regimens, relationship between metabolic control and complications, insulin delivery systems and glucose sensors, patient and family education, nutritional management, management of diabetes in very young children, children, adolescents, hypoglycemia, pregnancy, surgery for the patient with type 1 diabetes, diabetic retinopathy (eye disease), diabetic nephropathy (kidney disease), diabetic peripheral and autonomic neuropathy (nerve disease), the diabetic foot, atherosclerosis in type 1 diabetes, cutaneous (skin) complications, infection and diabetes, pancreas transplantation, islet transplantation, beta cell replacement therapy, and islet growth factors. Each chapter concludes with a list of references and a subject index concludes the textbook.

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Williams Textbook of Endocrinology. 10th ed. St. Louis, MO: Elsevier, Health Sciences Division. 2003. (CD-ROM)

This textbook of endocrinology serves as a bridge between basic science and clinical endocrinology. Forty-one chapters are provided in ten sections: hormones and hormone action, hypothalamus and pituitary, thyroid, adrenal, reproduction, endocrinology and the life span, mineral metabolism, disorders of carbohydrate and lipid metabolism, polyendocrine disorders, and paraendocrine and neoplastic syndromes. Specific topics include: principles of endocrinology; the endocrine patient; genetic control of peptide hormone formation; mechanism of action of hormones that act as nuclear hormone receptors; mechanism of action of hormones that act at the cell surface; laboratory techniques for recognition of endocrine disorders; neuroendocrinology; the anterior pituitary; the posterior pituitary; thyroid physiology and diagnostic evaluation of patients with thyroid disorders; thyrotoxicosis; hypothyroidism and thyroiditis; nontoxic goiter and thyroid neoplasia; the adrenal cortex; endocrine hypertension; the physiology and pathology of the female reproductive axis; fertility control: current approaches and global aspects; disorders of the testes and the male reproductive tract; sexual dysfunction in men and women; endocrine changes of pregnancy; endocrinology of fetal development; disorders of sex differentiation; normal and aberrant growth; puberty: ontogeny, neuroendocrinology, physiology, and disorders; endocrinology and aging; hormones and disorders of mineral metabolism; metabolic bone disease; kidney stones; type 2 diabetes mellitus; type 1 diabetes mellitus; complications of diabetes mellitus; glucose homeostasis and hypoglycemia; obesity; disorders of lipid metabolism; pathogenesis of endocrine tumors; multiple endocrine neoplasias; the immunoendocrinopathy syndromes; gastrointestinal hormones and gut endocrine tumors; endocrine-responsive cancer; humoral manifestations of malignancy; carcinoid tumors, carcinoid syndrome, and related disorders. Each chapter is written by experts in the field and concludes with extensive references; a subject index concludes the textbook. The CD-ROM format enables powerful search capabilities, as well as links to MEDLINE abstracts for many of the references.

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