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LIVING WELL WITH DIABETES - Washington Association of

1. _ a Tl a oa m SUGAR What did you eat a a Total Number of Carbs for the day Total number of calories for the Day 46 Graph your results Write in blood sugar result Mark x in appropriate box and connect the Xs Breakfast Breakfast Lunch Lunch Dinner Dinner BLOOD SUGAR z ooo T 451 P a a S a a 401 C a a a a 351 a a a a a 301 a T a a a 251 P T a a 201 E T a a a 151 E A T a a a 101 E a a S a a 11 50 My most recent Aic was have been told that my target A1c should be check lt 7 1 lt 6 5 don t check my blood sugar For now I rather not check my blood sugar don t have a blood sugar meter and would like one or upgrade to a newer meter have a blood sugar monitor name My most recent blood sugar results are My blood sugar target is leave blank if you don t know Before Meals 70 to 110 or 70 to 130 After Meals 70 to 140 or 70 to 180 If pregnant Fasting less than 105 one hour after a meal less than 130 two hours after a meal less than 120 MY GOALS FOR MONITORING Use results to improve control this may mean checking blood sugar before and 1 to 2 hours after a meal keeping a glucose and food diary checking blood sugar before and after exercise to see what exercises works best to control blood sugar checking blood sugar before meals to adjust insulin dose check fasting and 1 to 2 hours after a meal Suggest
2. Condiments and Seasonings Condiments and seasonings can make bland food more flavorful You have a number of different choices you can use to enhance the flavor of your food without adding calories or carbohydrates Condiments on the free food list include horseradish lemon juice lime juice low sodium soy sauce mustard and vinegars Seasonings on the diabetic free food list include cooking spray cooking wine flavored extracts garlic herbs hot pepper sauce pimento spices and Worcestershire sauce Other Foods Sugar free foods are not diabetic free foods Many sugar free foods contain carbohydrates Carbohydrates in foods raise blood sugar If a food item is labeled as sugar free read the nutrition facts label for the carbohydrate content A food item with more than 5g of carbohydrate per serving is not a diabetic free food Other diabetic free foods include sugar free gelatin sugar free gum sugar substitute salsa and tossed greens Portion Controlled Diabetic Free Foods Portion sizes count for some diabetic free foods You can have up to three servings a day of a portion controlled diabetic free food Examples of portion controlled diabetic free foods include 1 tos fat free cream cheese 1 tbs fat free mayonnaise 4 tbs fat free margarine 1 tbsp of fat free salad dressing 1 tbs of fat free sour cream 2 tos whipped topping 1 tos unsweetened cocoa 1 tos ketchup 1 1 2 large unsweetened pickles 1 tbs taco sauce one
3. amp Johnson Health Care Systems Patient Assistance Program Phone 1 800 652 6227 Merck Patient Assistance Program Phone 1 800 994 2111 Merck Scherling Plough Pharmaceuticals Merck Sherling Plough Patient Assistance Program Phone 1 800 347 7503 Novartis Pharmaceuticals Corporation Novartis Pharmaceuticals Corporation Patient Assistance Program Phone 1 800 277 2254 Novo Nordisk Inc Novo Nordisk Diabetes Patient Assistance Program Phone 1 866 310 7549 Pfizer Inc Pfizer Helpful Answers Phone 1 800 706 2400 Pfizer Bridge Program Endocrine Care Phone 1 800 645 1280 Pfizer Pfriends Savings Program Phone 1 800 706 2400 Roche Laboratories Inc Roche Laboratories Patient Assistance Program Phone 1 877 757 6243 Sanofi Aventis Sanofi Aventis Patient Assistance Program Phone 1 800 221 4025 scherling Plough CorporationSP Cares Patient Assistance ProgramPhone 1 800 656 9485 Takeda Pharmaceuticals North America Inc Takeda Patient Assistance Program Phone 1 800 830 9159 or 1 877 582 5332 Together Rx Access A free savings program sponsored by Abbott AstraZeneca Bristol Myers Squibb GlaxoSmithKline members of Johnson amp Johnson Family of Companies Novartis Pfizer Sanofi Aventis Group Takeda and TAP Pharmaceutical Products Inc Phone 1 800 444 4106 31 Problem Sick Days You can prepare ahead for an illness by having a sick day meal plan e f your blood glucose is more
4. and activity level in the MyPyramid Plan box www ndep nih gov This government site is completely free of advertisement The site has information on preventing and controlling diabetes www cdc gov diabetes Center for Disease Control and Prevention 1 877 232 3422 www eatright org American Dietetic Association excellent site information on healthy eating although munch of the site is for health care professionals Phone number 1 800 366 1655 in English and Spanish www medicare gov health diabetes asp Centers for Medicare amp Medicaid Services 1 800 MEDICARE or 800 633 4227 www healthypeople gov Healthy People 2010 provides a framework for prevention for the Nation It is a statement of national health objectives designed to identify the most significant preventable threats to health and to establish national goals to reduce these threats www mayoclinic com This is an excellent site for information on chronic diseases including diabetes www webMD com Another excellent site that covers many medical problems as well as diabetes www ready gov Emergency reference material such as a first aid book 63
5. blood sugar control blood pressure levels how long you have had diabetes and genes The longer you ve had diabetes the more likely you are to have retinopathy Almost everyone with type 1 diabetes will eventually have nonproliferative retinopathy And most people with type 2 diabetes will also get it But the retinopathy that destroys vision proliferative retinopathy is far less common People who keep their blood sugar levels closer to normal are less likely to have retinopathy or to have milder forms HEALTHY EYE UNHEALTHY EYE 60 Health services that have been done please leave blank any that are due Dilated eye exam yearly Comprehensive foot exam by doctor or nurse yearly Urine protein test yearly Cholesterol levels yearly Flu vaccine yearly Pneumonia vaccine usually once or twice in your lifetime Teeth cleaned and examined every 6 months Primary Care Provider PCP visit every 3 to 6 months get a good night s sleep and or have sleep apnea that is treated successfully do not smoke or am smoker who is in tobacco cessation program Daily self foot exam Blood pressure other than doctor visits Optional to be done by diabetes educator if time permits comprehensive foot Exam Abnormal findings None infection redness or swelling open sore callus dryness Blood Pressure check Goals for Reducing Risks Reduce risk of complications by obtai
6. air popped popcorn or fresh fruit between meals MEALS Enjoy your food by sitting down and eating slowly Mealtime should be relaxing and enjoyable Do not skip meals Missing a regular meal can make you even hungrier at the next one You may then overeat without meaning to Many people do not like breakfast Even so try to eat something light in the morning It will give you energy for the busy time of day and may prevent a binge later 26 Free Foods The diabetes diet is not a restrictive diet according to MayoClinic com but is a healthy eating plan designed to promote a healthy weight and normal blood sugars The diet consists of a variety of nutritious foods eaten in moderate amounts at consistent mealtimes Some foods on the diabetic meal plan are considered free foods and can be eaten at anytime A diabetic free food has less than 20 calories and 5g of carbohydrate Beverages Diabetic free foods can be enjoyed in moderate amounts as often as you like according to MayoClinic com Drinking fluids regularly helps you stay hydrated Adequate hydration is necessary for everyday bodily functions and helps you maintain your energy levels There are a number of beverage choices you can drink without guilt on the diabetic diet Beverages on the diabetic free food list include broth diet soda club soda plain coffee and tea sugar free drink mixes carbohydrate free flavored waters tonic water sparkling water mineral water and plain water
7. any given day a high or low blood glucose episode or a sick day will require them to make rapid informed decisions about food activity and medications Page 29 and find out more www DiabetesAnswers org node 603 Monitoring Daily self monitoring of blood glucose provides people with diabetes the information they need to assess how food physical activity and medications affect their blood glucose levels Page 40 and find out more Ohttp wadepage org node 600 Healthy Coping An important part of the diabetes educator s work is identifying the individual s motivation to change behavior then helping set achievable behavioral goals and guiding the patient through multiple obstacles They can provide support by encouraging you to talk about your concerns and fears and can help you learn what you can control and offer ways for you to cope with what you cannot Page 48 and find out more http Wwadepage org node 604 Being Active Being active is not just about losing weight It has many health benefits like lowering cholesterol improving blood pressure lowering stress levels and improving your mood If you have diabetes physical activity can also help keep your blood sugar levels closer to normal which helps you successfully manage your diabetes Page 54 and find out more _http www diabetesanswers org node 599 Reducing Risks Diabetes educators assist patients in gaining knowledge about standards of care therapeutic goals and
8. been missing Vegetables also help to fill you up without filing you out It s best not to fill the 1 2 plate with only 1 veggie You get tired of even your favorite foods that way Try a small salad and 1 2 a cooked vegetable so you have more variety Some vegetables are higher in starch carbohydrate These vegetables belong in the Bread and Starch FOUNDATION FOR MEDICAL EDUCATIC N AND RESEARCH section of the plate Corn Peas Yams Potatoes amp ALL RIGHTS RESERVED Winter Squash fit in this section not on the Vegetable Section Winter Squash is squash that has a hard shell So just to review Corn and Peas are not on the vegetable section of the Plate Starch This 1 4 of the plate is where your Breads Starches and Grains stay You can eat a variety of foods in this group Examples are noodles rice bread cereal crackers small tortillas potatoes and dried beans chili For cereal and soup use the small bowl it fits right on this 1 4 of the plate Some vegetables are higher in starch carbohydrate These also belong in this group and include corn peas yams and winter squash OUNDATION FOR MEDIC AL EDUCATION AND RESEARCH mai Wea HTS RESERVED Protein This 1 4 of the plate is where you put your meats You can use any type of meat fish poultry tofu eggs and nuts These are high in protein but are sometimes high in fat Remove visible fat before cooking amp eating Remember low fat foods are b
9. e To keep your skin healthy change the point at which you inject the insulin see figure 2 e Move the place of injection a fingers width from last injection point Special Warning about Exercise Insulin works faster if you inject it before exercising Injecting insulin into a part of the body you are going to exercise causes insulin to work faster and in return your blood sugar level will be low For example if you inject your insulin in your thigh before going running your insulin will work faster and your blood sugars will be low 10 How To Prepare And Inject A Single Dose Of Insulin Injecting Insulin With A Needle And Syringe Supples 1 First wash and dry your hands e Asyringe e Alcohol wipes N e Your bottle of insulin A sharps container a hard metal or plastic container for needle disposal such as a coffee can or laundry soap container _ 2 Look at 3 If you are using a cloudy insulin your insulin make sure the insulin is mixed by make sure your rolling the bottle slowly between clear insulin is your hands or tip it upside down clear and your back and forth about 20 times cloudy insulin is Do NOT shake free of clumps EE Make sure you have the right Insulin check the label 11 4 Know the number of units you are taking My Insulin Worksheet how insulin works helps you plan when you need to inject your insulin The goal of insulin is to keep your body s blood
10. legs toward your shins Stop when you feel a stretch or slight discomfort Hold for 10 30 seconds Straighten up slowly all the way to the Starting position Repeat at least 3 5 times 56 REDUCING RISKS FON FOOT CARE Do Do wash feet daily Do inspect feet and toes daily Do wear thick soft socks Do cut toenails Straight across Do exercise Do see your podiatric physician Do get properly measured and fitted every time you buy new shoes Do wear proper shoes Don t Don t go barefoot Not even in your own home Don t wear high heels sandals and shoes with pointed toes Don t drink in excess Alcohol can contribute to neuropathy nerve damage which is one of the consequences of diabetes Don t wear anything that is too tight around the legs Don t try to remove calluses Know Your ABCs A is for A1C Your A1C check which also may be reported as estimated average glucose eAG tells you your average blood glucose for the past 2 to 3 months B is for blood pressure High blood pressure makes your heart work harder than it should C is for cholesterol Your cholesterol numbers tell j you about the amount of fat in your blood Some kinds like HDL cholesterol help protect your heart Others like LDL cholesterol can clog your arteries High triglycerides raise your risk for a heart attack or a stroke 57 Oral Care There are more bacteria in your mouth right now than there are people on Ear
11. newly diagnosed diabetic or those who need a review of diabetes self management Diabetes Prevention Program Held at the Walla Walla YMCA For Pre daibetes or those who are at risk for diabetes Support Group Meetings discussions on a variety of topics related to diabetes prevention and control 62 Informational Links http mydiabetespartner org index php The American Association of Diabetes Educators has created Side by Side A Partner Approach to Diabetes Self Management Many people with diabetes feel overwhelmed as they work to eat healthy foods exercise monitor their blood glucose take medications and schedule regular check ups This website will help you be in control www diabetes org This is the American diabetes association web site You can t go wrong with the information provided here All kinds of information on all types of diabetes are provided The information on diet is especially useful Phone number 1 800 DIABETES 800 342 2383 www dlife com This is the web site for the TV show dLife Diabetes for Life that currently shows on Sundays on CNBC at 4PM PST This web site has some advertisement but the information provided is very informative It includes recipes videos pod casts and much information on all types of diabetes www mypyramid gov on this government site you get to customize a meal Plan can help specifically for you You get to choose the foods and amounts that are right for you Just enter your age sex
12. piece sugar free candy 2 tsp sugar free jelly and 2 tos sugar free SITAR 0 p _ pancake syrup SEAR ar gee Fiber O as a te Dietary fiber is found in whole grains legumes i a Re y fruits and vegetables Despite fiber being found f nN f in various foods fiber intake among Americans A Aa N 3 is falling far short of the recommendation The National Health and Nutrition Examination Survey found that nine out of 10 Americans are not meeting daily recommendations for dietary fiber Fiber has various health benefits such as maintaining bowel health decreasing cholesterol and providing satiety The addition of fiber rich foods may also be beneficial for diabetics as fiber helps to regulate blood sugar levels after meals Provides Satiety e a 21 Dietary fiber is a non digestible carbohydrate meaning the body does not digest or absorb fiber Rather fiber provides bulk to stool promotes bowel movements binds to toxins in the gut and helps to slow down the digestion process This slowing of digestion allows you to feel fuller faster leading to less food consumed For a diabetic this can help to decrease the overall glycemic load of a meal by decreasing the amount of carbohydrates consumed at one time This also allows for better weight management which is another factor in glycemic control Regulates Blood Glucose Since fiber helps to slow down digestion it slows down the am
13. sugar levels in your target range Write down the insulin you are taking along with the onset peak and duration of insulin Bim COMES 6 Twist the cap from the needle off Pull air into the syringe by pulling the plunger back to the number of units of insulin you need 8 With the needle still in the bottle turn them upside down covering the needle tip with insulin Pull the plunger back slowly to the number of units you need Check for air bubbles inside the syringe If you see a bubble push the insulin back into the bottle and repeat 12 5 Wipe the top of the insulin bottle with alcohol 7 Stick the needle into the center of the top of the bottle and inject air into it 9 Remove the syringe from the bottle Make sure the needle does not touch anything 11 Hold the syringe like a pencil If your needle is 5 mm or 10 Clean your longer pinch your skin up If your needs is 4 mm or shorter inject straight into your skin skin with alcohol and let air dry 12 Push the needle into your skin at a 90 degree angle Thin people may inject at a 45 degree angle Push the plunger in gently and smoothly Count to 5 and pull the needle straight out 13 Dispose of the needle in a sharps container such as a coffee container or laundry soap container In Walla Walla you can bring your sharps container to the local landfill 13 How to Use an I
14. that produce insulin Normally the immune system only attacks and destroys invaders like infection Scientists don t know exactly why the immune system attacks the pancreas but it s believed that it may be triggered by a virus Genetic tendencies and the environment may also play a role in the why a person gets type 1 diabetes Only about 10 percent of all people with diabetes have type 1 A person with type 1 diabetes must take insulin every day to stay alive It is more likely to begin in childhood or the early adult years but it can happen at any age Pye 2 a BURGERS Sun eyes Type 1 diabetes usually develops quickly Symptoms may include extreme thirst excessive urination tiredness constant hunger weight loss blurred vision Type 2 Diabetes The most common form of diabetes is type 2 accounting for about 90 percent of all diabetes cases It tends to occur later in life but can occur earlier if certain risk factors are present A person is more likely to develop type 2 diabetes if they have the following risk factors Family history of diabetes Overweight or obese History of gestational diabetes Inactive lifestyle or having had a baby weighing more than 9 lbs Race ethnicity background African American Asian American Hispanic Latino American Indian Native Hawaiian or other Pacific Islander As type 2 diabetes develops the As type 2 diabetes develops the pancreas Is still prod
15. these problems interfere with you diabetes management sick days low blood sugar high blood sugars emergencies such as power outage Other MY GOALS FOR PROBLEM SOLVING make a sick day kit make a disaster kit be prepared to treats hypoglycemia Wear a medical alert tag identify you as having diabetes important for those prone to hypoglycemia Other 39 MONITORING E WHY Dol O7 ii Need to Check My Blood Glucose Managing your diabetes by setting blood glucose goals Your doctor will help you set goals sometimes called targets for your blood glucose levels These are the ranges of numbers that your blood glucose should fall within most of the time Research has shown that keeping your blood glucose as close to your targets as possible can prevent or slow the complications of diabetes Although diabetes is a condition that does not go away it can be managed by healthy eating being active and if needed taking medication How self monitoring helps you Checking your own blood glucose gives you the information you need to answer these important questions e Is your blood glucose in its target ranges most of the time What is your blood glucose t X level too high too low or ig Forgot a orn ce Walk to right on target Pill TEN Ke Party Post Office e How can correct an out of 5 5 target blood glucose level ay e Do you need to take action to corre
16. which type of combination you use Your healthcare provider can tell you more Check the pills or injectable Check any insulin you are taking medication you are taking Glucophage Metformin Glimepiride Amaryl Glipizide Glucotrol Glipizide ER Glucotrol XL Glyset or Precose Actos or Avandia Prandin or Starlix Januvia Byetta injectable Other RAPID ACTING Apidra Insulin Glulisine Humalog Insulin Lispro Novolog Insulin Aspart SHORT ACTING Humulin or Novolin R Regular INTERMEDIATE ACTING Humulin or Novolin N NPH LONG ACTING Lantus Insulin Glargine Levemir Insulin Detemir Other don t take any medication for diabetes don t know what medications take for diabetes take a medication to lower blood pressure take aspirin ever day take multivitamins take Herbal or alternative medications take a medication to lower cholesterol ee consistently remember to take my medications as directed GOALS Miss fewer medications Carry a wallet ID with list of medications Take medications on time other Managing Your Blood Sugar Levels with Insulin By Jaci Hodnefield OHSU Nursing Student Insulin is a hormone made by your pancreas an organ that sits behind your stomach a e Insulin is needed to move glucose the sugar in your blood fro
17. 00 calories consumed However research conducted specifically on diabetics from the VA Medical Center in Kentucky found that a diet including 55 percent to 60 percent from carbohydrates and 15 g to 25 g of fiber per 1 000 calories provided the best glycemic control and reduction in cholesterol levels Diabetics are at higher risk for heart disease related to high levels of cholesterol triglycerides and blood pressure Increasing fiber intake may not only improve blood sugar levels but also help prevent heart disease EXERCISE Check with your caregivers before starting to exercise if you have not been exercising Work with your caregiver to plan an exercise program special for you Find several types of exercise that you really like and work them into your schedule Meet with an exercise buddy who will help you stay active Many health clubs have evening and morning hours which are helpful Even 20 to 30 minutes a day of activity will help you lower your weight It will lower the fat percent of your body weight and raise the amount of muscle you have This increases the number of calories you burn each day HEALTHY EATING Do you feel you are eating healthy YES NO MY GOALS FOR HEALTHY EATING 1500 calories and135 to 150 grams of Carbohydrate per day 1800 to 2000 calories with 150 to 170 grams of Carbohydrate per day Follow eating schedule better Eat better food Overeat less often Lose pounds in next 9 months
18. Current weight is pounds 28 Problem Solving A person with diabetes must keep their problem solving skills sharp because on any given day a high or low blood glucose episode or a sick day will require them to make rapid informed decisions about food activity and medications This skill is continuously put to use because even after decades of living with the disease stability is never fully attained the disease is progressive chronic complications emerge life situations change and the patient is aging This self care behavior focuses on the what ifs that is what to do if your glucose is too low or too high or what if you become sick what would you do Unfortunately if your glucose is too high or too low it may influence your problem solving skills Have a plan ahead of time so that you will know what to do Problem How to Cut Health Care Cost Related To Diabetes Many people who have diabetes who have estimated healthcare costs totaling about three times that of the Average American without renin cate diagnosed diabetes need help paying some of do you have a Pate the bills It s a good idea to start by looking for an cheaper one 3 insurance plan that covers as many diabetes f related expenses as possible A variety of governmental and nongovernmental programs exist to help depending on whether you qualify Medicare Medicare is a government program providing health care services for people who are 65
19. Diabetes Self Management Education PROVIDENCE St Mary Medical Center LIVING WELL WITH DIABETES Whether you have recently been diagnosed with diabetes or have been living with your condition for some time the information in this book can help you better manage your condition and live a healthier life This book is best used with the individual teaching and diabetes workshops offered at Providence St Mary Medical Center Content Understanding Diabetes Defining Diabetes in Basic Terms Self Care Behaviors Necessary for Diabetes Self Management Page 3 and find out more www DiabetesAnswers org node 6 Taking Medications Diabetes is a progressive condition Depending on what type a person has their healthcare team will be able to determine which medications they should be taking and help them understand how your medications work They can demonstrate how to inject insulin or explain how diabetes pills work and when to take them Page 6 and find out more www DiabetesAnswers org node 601 All about insulin page 9 Healthy Eating Being able to make healthy food choices every day is very important If you understand how the foods you eat affect your blood sugar also known as blood glucose you can make smart food choices that helo contro your diabetes better Page 19 and find out more www DiabetesAnswers org node 598 Problem Solving A person with diabetes must keep their problem solving skills sharp because on
20. SISTENCY Eat about the same amount of food on each section of the plate at each meal If you have your favorite mashed potatoes one day you should not have more on that section of your plate than the day when you had plain noodles This will help you even out your blood sugars For very small eaters and kids try eating 1 4 plate of vegetables Kids may need an extra snack of fruit or bread or milk between meals Question My husband needs more food than me For men we usually add an extra Bread Starch Grain serving at each meal Just use a 2nd small dish like you use for fruits for the extra Bread Starch Grain serving You can add the extra serving between meals as a snack Your Registered Dietitian Educator can help you tailor the diet to your exact needs Question We eat more meat than that e Yes most people eat more protein and fat than we need e By using only a 1 4 a plate of meat you may lower your weight amp cholesterol It s the healthy thing to do Question My husband drinks large glasses of Milk with meals Often we get too many calories from our beverages If he needs to lose weight try cutting down to the smaller size of milk or 2 small cups of milk 22 Remember to drink more water Try at least 3 glasses a day Many people recommend 8 glasses of water a day Question What about eating out e When eating out simply order smaller servings and follow the Plate Method set up e Fill
21. a to go box with the extra food items before you begin your meal It makes it easier to avoid over eating e Salad bars are a great way to get your vegetables but make sure to limit those with lots of mayonnaise Remember potato salad and macaroni salad go on the Bread Starch Grain section of your plate Not the Vegetable portion Question What about FATS Margarine Salad dressings Whip cream Sour cream and Spray Pam e Try to use less Be skimpy e Mayonnaise Try Lite or Fat Free Try Lite Salad Dressings or Fat Free always add on the side even at home Sour Cream Try Lite or Fat Free Spray Pam count 1 2 3 amp stop Spraying Gravy use Fat Free or use fat free broth amp always be skimpy and serve in a small side dish When making homemade skim the fat off the meat broth Remember people with Diabetes are at a higher risk for heart attacks and strokes so try to limit fat intake especially hard saturated fats Your MD should check your cholesterol at least once a year If you can not lower your cholesterol with your diet it is recommended you take medication Question What are the best ways to cook meats grilled broiled baked boiled steamed limit these methods fried breaded with sauce sauteed Question I m following the Plate Method what else can I do to lose weight Make sure the food stacked the highest on the plate is the vegetables Do not let the foods touch each other Exampl
22. affect your blood glucose When you look at the record of your blood glucose results over a period of days you and your doctor may be able to identify what may have caused the readings you see You should not be worried about one blood glucose that is out of range but if there are a number of them that do not fall into range then you need to look for a pattern You want to see if the blood glucoses seem to be high or low at the same time of day for a number of days If you detect such a pattern you need to think about the activities that may have affected that blood glucose result You will then be able to make an informed decision about what you can do to improve your blood glucose There are computer products available to help maintain records and analyze trends related to blood sugar Some diabetes management software is free to download or can be used on line Your meter manufacture probably has free software that you can download to your computer but you may need to purchase a special cable to make the connection to your computer Call the toll free number on the back of your meter for more information 45 Try using a food dairy to check before and after meals also called Testing in Pairs Before After Before After Before After e p e BLOOD SUGAR What did you eat a ee Total Number of Carbs for the day Total number of calories for the Day Now make changes in meals and repeat
23. and vitamin Ce Altitude temperature and humidity Source DIABE Tease Perform quality control checks Use control solutions to ensure that the test strips and meter are working together properly Some meters 43 may also provide electronic test strips that induce a signal to indicate if the meter and only the meter is working correctly Perform a quality control test each time you begin a new bottle of test strips or when you question the accuracy of the results Ask your health care provider to watch you test yourself He or she can tell you if you are using the meter correctly Know when and how to clean your meter Some meters need regular cleaning Others don t need regular cleaning but contain electronic alerts indicating when you should clean them You should follow the directions given in the manual on how to clean the meter Understand what the meter display means The range of glucose values can be different among meters Be sure you know how high and low glucose values are displayed on your meter Sometimes they are displayed as LO or HI when the glucose level is beyond the range that the meter can measure Alternative site testing Some blood glucose meters allow you to use blood from alternative sites to check your blood glucose These sites are the upper arm forearm base of thumb and thigh You should be aware that blood glucose values from these sites may be different than the results you will receive f
24. anies you can call regarding your particular medications as well as a state by state list of local assistance that is available Pharmaceutical Companies Abbott Diabetes Care Patient Assistance Program The Abbott Diabetes Care Patient Assistance Program offers assistance on blood glucose meters and strips to low income patients in the United States In 2006 more than 5 200 patients were approved for assistance at a retail value of approximately 425 000 We donated nearly 3 500 blood glucose meters and more than 35 000 boxes of blood glucose strips For more information about this program visit www abbottdiabetescare com Abbott Laboratories Abbott Patient Assistance Program Phone 1 800 222 6885 Ross Medical Nutritionals Patient Assistance Program Phone 1 800 222 6885 Amylin Pharmaceuticals Inc Amylin Patient Assistance Program Phone 1 800 330 7647 AztraZeneca Pharmaceuticals LP AstraZeneca Foundation Patient Assistance Program Phone 1 800 292 6363 Aventis Pharmaceuticals Inc Sanofi Aventis Patient Assistance Program Phone 1 800 221 4025 Bayer Pharmaceuticals Corporation Bayer Patient Assistance Program Phone 1 800 998 9180 Bristol Myers Squibb Company Bristol Myers Squibb Patient Assistance Foundation Inc Phone 1 800 736 0003 Eli Lilly and CompanyLilly Cares Phone 1 800 545 6962 GlaxoSmithKlineBridges to Access Phone 1 866 728 4368 Commitment to Access Phone 1 866 265 6491 Johnson
25. ant me to try it You are most helpful when you are not being a source of unnecessary temptation Diabetes can be a lot of work and it demands your attention every day It is worth the effort but it is a tough job All that effort can wear you down especially if you never get a break And you can never take a break from diabetes or can you Meditation Source www metta org uk meditate sitting asp When first sitting it is advisable to be in a quiet place which is free from overt disturbance such as people coming and going phones ringing etc Background noise such as traffic or machinery may have to be accepted and indeed can form part of meditation but when first practicing it is advisable to be in a quiet and undisturbed place This is by no means a rule as sitting in the garden or park can be a wonderful environment in which to meditate once meditation has become part of everyday life Many people create a small special space in their home perhaps with an image of Buddha one of the deities or an image of someone special in their life Burning incense nearby can also help to create a relaxing and consistent atmosphere in which to meditate Equally essential oils can be beneficial but as with incense maintain a consistency of smell Or no smell at all If possible one can sit with the knees below the hips i e cross legged on a cushion or special meditation stool This said one can sit on a chair or stool if sitting cross le
26. ant to start of on the right footing There is nothing ridged about most forms of meditation but the points above tend to be universal The basics of sitting are to be sitting upright with the knees below the hips so if you find one cushion still leaves your knees above the line of your hips find an extra cushion to raise you up a little Get as comfortable as you can meditation is not about suffering can recall my first start as being very uncomfortable and my dogged determination to sit rigidly almost forcing myself in to a near lotus position with my back rigidly straight and my eyes clamped tightly shut Good practice for getting the body attuned to sitting but of little use in meditation So be kind to yourself build some comfort into your practice and the actual process might provide early benefits People often say that they have trouble staying awake conversely others talk of going to wonderful places and seeing wonderful insights meeting people etc etc Whilst we need sleep dreams and visions and even euphoric states which are very powerful they are not really meditation So what is meditation hear some of you ask Well it is an opportunity to be as you are for half and hour or more once or twice a day it is an opportunity to let go of the pressure of daily life let go of thoughts all together not to switch off the mind but equally not to get caught up in thoughts Nor is meditation an opportunity to rest in the sense
27. ar balance However the loss of insulin effectiveness can cause the blood sugar levels to rise instead of lower 25 when alcohol is consumed This can have severe long term effects such as liver damage and diabetes Both conditions require medical treatment and can be life threatening if left untreated WEIGHT LOSS TIPS Read more http Awww livestrong com article 293225 diabetic diet free foods ixzz24 yfuk000 INSTRUCTIONS Following are tips that may help you lose weight and keep it off Ask your caregiver for the best diet plan for you DIET PLANS Do not try a crash or fad diet that suggests you eat less than 1000 to 1200 calories each day Keep your kitchen full of healthy foods on your diet plan Eat healthy foods from all 5 food groups each day breads dairy fruits vegetables meat and fish Eat only small amount of fats like 1 to 3 teaspoons each day of oils nuts dressings and margarine Bake roast or broil your food instead of frying FIBER High fiber foods help with weight loss because they help fill you up You may feel full longer because some kinds of fiber help food stay in your stomach longer They also help prevent certain kinds of cancer if eaten over long periods of time Eat high fiber and starchy foods such as whole grain breads pasta and potatoes Other high fiber foods are cooked dried beans raw or steamed vegetables and fruit You should eat 5 or more fruits and vegetables each day The vege
28. at are P N a ye personally rewarding and meaningful like taking an re interesting class or volunteering Push through what you can as you can All of these can be powerful antidepressants a Tr A Te PA m a Jg gt A te Ai 8 Have hope and take action Depression is treatable There are good antidepressant medications and different forms of counseling that have been proven to help people recover from depression Don t suffer needlessly speak with your doctor about getting the help you need Giving up Denial Denial can sometimes be a valuable tool It can be a good way to cope with negative feelings about diabetes especially when you are first diagnosed or when the disease Is feeling out of control But denial becomes a problem when it is your only way of coping Instead of a temporary tool it becomes a permanent way of life The response to all diabetes aggravations becomes I will not think about diabetes anymore This means trouble Many people believe that if they ignore diabetes then it can t hurt them If only this were true When you turn your back on diabetes your long term health will be endangered 49 Diabetes Etiquette For People Who Don t Have Diabetes Your loved ones are probably acting out of concern and worry but it can leave you feeling angry hurt frustrated and alone When loved ones are bugging you about what to eat or what to do you may tend to do the opposite of w
29. autions with dental surgery If you re having dental surgery make sure that your dentist consults with your doctor ahead of time You may need to adjust your diabetes medications or take an antibiotic to prevent infection Look for early signs of gum disease Report any signs of gum disease including redness swelling and bleeding gums to your dentist Also mention any other signs and symptoms such as dry mouth loose teeth or mouth pain Don t smoke Smoking increases the risk of serious diabetes complications including gum disease If you smoke ask your doctor about options to help you quit 58 Kidneys Care Kidneys are remarkable organs Inside them are millions of tiny blood vessels that act as filters Their job is to remove waste products from the blood Sometimes this filtering system breaks down Diabetes can damage the kidneys and cause them to fail Failing kidneys lose their ability to filter out waste products resulting in kidney disease What Can You Do to Lower Your Risk Being involved in your treatment plan is essential Checking your blood glucose levels at home and making sure that your hemoglobin A1C a blood test that tells how well your blood glucose has been controlled over the last few months Is less than seven percent is first and foremost Keeping in good glucose control is the best way to lower your risk of both kidney and heart disease Follow up with your primary care doctor or endocrinologist a
30. ct blood glucose that is 8 am 6 pm too high or low e What changes can you make in the way you eat take your medication or increase your activity that may improve your blood glucose readings Note If your blood glucose was within target range before your favorite snack and out of range a few hours later you may decide to eat less exercise more or give more insulin next time What is causing out of target blood glucose Did you eat too much or skip exercise Are you sick Is your medication working properly Has anything changed in your routine 40 ADA Recommended Targets When to take Action Before eating Less than 100 70 to 130 If less than 70 or greater than 130 2 Hours after eating Less than 130 Less than 180 If less than 70 or greater than 200 Less than 6 Less than 7 If greater than 7 Your tool for better management Have you seen my collection of blood glucose monitors When you self monitor your blood glucose you are checking to see if you are staying within your targets or blood glucose goals If you are outside your targets you may need to take action Think of your results as within your target range high or low rather than good or bad Blood Glucose Monitoring BGM is a useful tool that lets you know if you need to take action or not It puts you in charge of the things that affect blood glucose control Your doctor or diabetes educator will work with you to decide the blood glucose goals that are
31. doctor specializing in diabetes to make sure that you have your urine tested at least once a year to find any early changes in kidney function You should also have your blood checked regularly for calcium phosphorus and parathyroid hormone bone hormone to be sure that your bones are healthy Other tests should include your total blood count so that anemia can be treated early as well as blood cholesterol type and level Make sure you have your blood pressure checked often and remember to take blood pressure medication if prescribed Follow your diet for weight and blood glucose control and get plenty of regular exercise Avoid alcohol and cigarettes If you have any of the symptoms identified above you should see your doctor immediately Read More htto DiabetesAnswers org node 602 Sexual Dysfunction Source H A Feldman Goldstein D G Hatzichristou R J Krane J B McKinley Impotence and its medical and psychological correlates Results of the Massachusetts Male Aging Study J Urol 151 54 61 199 Sexual problems sexual dysfunction are common among people with diabetes particularly in older men who have had diabetes for years In addition many medical experts believe that women with diabetes experience sexual difficulties as a result of complications from the disease People who experience sexual difficulties can lead more enjoyable fulfilling sexual lives by learning about common causes and symptoms of sexual difficu
32. e my meat cannot touch my mashed potatoes By doing this you make the serving size of foods slightly smaller Question How can I learn more To learn more about your meal plan and ways to tailor it to your needs Talk with a Registered Dietitian Carbohydrate Counting Sometimes milk fruits and bread starch grain food groups are called carbohydrate foods Some people with diabetes count carbohydrates at each meal That means that they get a certain number of carbohydrate foods at each meal Using the basic Plate you have 3 servings of carbohydrate foods at each meal which is 45 grams of carbohydrates at each meal All that means is that you have 1 serving of Milk and 1 serving of fruit and 1 serving of Bread Starch Grain at each meal Easy huh 1 Fruit 1 Milk 1 Bread Starch Grain and they all equal about 15 grams of carbohydrates or 1 carbohydrate serving More on htto wadepage org node 598 23 Reading Food Labels Serving Size Serving size is based on the a fm amount of food people Nutrition Facts srcsiycastzoves meal This may or may not be the serving amount you normally eat It is important that you pay Serving Size 3 oz 85g Amount Per Serving As Served 5 the en E a eee size including the number Calories 38 Calories from Fat 0 of servings in the package Daily Value and compare it to how ere much you actually eat Total Fat Og 0 The size of the serving on Saturated Fat 0g 0 MEDo pac
33. e while standing or sitting in a sturdy armless chair Keep your feet flat on the floor shoulder width apart Hold weights at your sides at shoulder height with palms facing forward Breathe in slowly Slowly breathe out as you raise both arms up over your head keeping your elbows slightly bent Hold the position for 1 second Breathe in as you slowly lower your arms Repeat 10 15 times Rest then repeat 10 15 more times Stand on One Foot Exercise Instructions You can do this exercise while waiting for the bus or standing in line at the grocery For an added challenge you can modify the exercise to improve your balance Stand on one foot behind a sturdy chair holding on for balance Hold position for up to 10 seconds Repeat 10 15 times Repeat 10 15 times with other leg Repeat 10 15 more times with each leg Caution more physical active than planned may cause low blood sugar The good news is that low blood sugar is easy to treat see page 38 for the rule of 15 for mild low blood sugar and page 39 for sever low blood sugar If you are having low blood sugar frequently more than once a month please contact your primary care provider 55 Shoulder and Upper Arm Exercise Instructions This exercise to increase flexibility in your shoulders and upper arms will help make it easier to reach for your seatbelt If you have shoulder problems talk with your doctor before t
34. ed for Gestational Diabetes 47 Healthy Coping Source behavioraldiabetesinstitute org Diabetes can affect you physically and emotionally Living with it every day can make you feel discouraged stressed or even depressed It is natural to have mixed feelings about your diabetes management and experience highs and lows The important thing is to recognize these emotions as normal Take steps to reduce the negative impact they could have on your self care The way you deal with your emotional lows is called coping There are lots of ways to cope with the upsets in your life and not all of them are good for your health smoking overeating not finding time for activity or avoiding people and social situations However there are healthy coping methods that you can use to get you through tough times faith based activities exercise meditation enjoyable hobbies joining a support group Having a support network is key to healthy coping Be sure to develop and nurture partnerships in your personal life with your spouse loved ones and friends Go to group educational sessions where you can meet and relate to other people going through the same experiences Build healthy relationships and remember that you re not alone With good care and attention to your diabetes odds are good you can live a long healthy life Many people think they are doomed to suffer terrible complications but this is not true Yes diabetes is a serious di
35. edle cap back on the needle Unscrew the needle from the pen and drop it into your sharps container Store your insulin with the cap on 15 Sample Insulin Worksheet Knowing how your insulin works helps you plan when you need to inject your insulin The goal of insulin is to keep your body s blood sugar levels in your target range Look at the examples and then make your own plan on the next page e Onset is when your insulin starts to work e Peak is when the insulin is working the best e Duration is how long the insulin works insulin Onst Peak Duration lt is important to know your insulin Keep track of the dose in number of units what times to inject the insulin times to eat and times to check your blood sugar level Inject B Sugar Level Lanus 20units units Bedtime Bedtime Bed time Bed time Fasting Niauale Correction Before Te Before 2 hour after g Scale meal away meal meal Novolo Titration Before Right Before 2 hour after g Scale meal away meal meal For the Correction and Titration Scales see page 1 PAT fel LN ol Nav sah PPP EE PPP i e PPP Time B Breakfast L Lunch D Dinner S Snack Caution those taking Insulin are at risk for low blood sugar The good news is that low blood sugar is easy to treat see page 38 for the rule of 15 for mild low blood sugar and page 39 for sever low blood sugar If you are having low blood sugar frequent
36. en sick m Your blood glucose m Your ketone results a What you have been eating and drinking m Your temperature m The name and dosage of all medications you have taken 33 Problem Emergencies Recommended Items to Include in a Basic Emergency Supply Kit e Water one gallon of water per person per day for at least three days for drinking and sanitation e Food atleast a three day supply of non perishable food e Battery powered or hand crank radio anda NOAA Weather Radio with tone alert and extra batteries for both Flashlight and extra batteries First aid kit Whistle to signal for help Dust mask to help filter contaminated air and plastic sheeting and duct tape to shelter in place Moist towelettes garbage bags and plastic ties for personal sanitation Wrench or pliers to turn off utilities Can opener for food if kit contains canned food Local maps Additional Items to Consider Adding to an Emergency Supply Kit Prescription medications and glasses Infant formula and diapers Pet food and extra water for your pet Important family documents such as copies of insurance policies identification and bank account records in a waterproof portable container Cash or traveler s checks and change Emergency reference material such as a first aid book or information from www ready gov Sleeping bag or warm blanket for each person Consider additional bedding if you live in a cold weather climate Complete chan
37. etter for your heart and your waistline Healthier cooking choices include baked broiled and boiled items with little fat added Healthier fats can be found in fish such as salmon and mackerel and nuts except coconut MAY ODUNDA A a h MEDICAL EDUCATION AND RESEARCH ALL Ri SHTS RES 20 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH ALL RIGHTS RESERVED gt J 4 _ pr 4 CUP ao 4s n a eS 1s Now you can set up Lunch amp Dinner meals Fruit A serving of fruit is 1 small piece like a small apple small orange or small orange Use your small dish to hold fruits like applesauce and fruit cocktail It holds a Ye cup When using canned fruit lite packed and juice packed are the best choices Juice servings are about 1 2 of a small coffee cup Remember juice does not fill you up You will feel fuller if you eat a small orange instead of drinking juice Some fruits have less starch carbohydrate so you can eat a little more of them These bonus foods are melons and berries use your small bowl for the right serving size Dairy Find a small coffee cup or glass that holds about 1 cup for foods in this section Fat Free milk Skim milk 1 milk and Lite yogurt are your best choices Use a small dish for servings of Lite ice cream and sugar free pudding to add variety You will need 3 servings per day from this group to get enough calcium Teens and ad
38. f a preexisting condition To find out more about these laws contact your state insurance regulatory office This office can also help you find an insurance company that offers individual coverage Managed Care Most HMOs keep costs down by limiting the choice of doctors to those who belong to the network restricting access to specialists reducing hospital stays and emphasizing preventive care In most managed care plans especially Medicare HMOs you select a primary care physician who will be responsible for directing your care and referring you to specialists when he or she feels it s necessary some plans also cover extra benefits like prescription drugs For more information on managed care organizations particularly the quality of care offered to patients you may want to contact the National Committee for Quality Assurance NCQA at 888 275 7585 or see www ncqa org Medicare also has many publications to help you learn more about managed care Go to www medicare gov on the Internet or call 800 MEDICARE 633 4227 for more information Health Insurance After Leaving a Job If you lose your health coverage when you leave your job you may be able to buy group coverage for up to 18 months under a Federal law called the Consolidated Omnibus Budget Reconciliation Act or COBRA Buying group coverage is cheaper than going out alone to buy individual coverage If you have a disability you can extend COBRA coverage for up to 29 months COBRA may al
39. f your fasting blood sugar is above 250 and or you have urine ketones do not exercise 4 Wear identification That indicates you have diabetes such as an identification bracelet or shoe tag 5 Drink plenty of fluids When you exercise your body uses more fluid to keep you cool Drink fluid before during and after exercise 6 Avoid exercise at the time of the peak of your insulin s action Exercise at that time could cause an unplanned dip in your blood sugar levels 7 Pay attention to your feet Wear comfortable and well fitting shoes and socks Check your feet before and after activities involving feet such as walking for any potential damage such as cuts or blisters Hand Grip Exercise Instructions This simple exercise should help if you have trouble picking things up or holding on to them It also will help you open things like that pickle jar more easily You can even do this exercise while reading or watching TV Hold a tennis ball or other small rubber or foam ball in one hand Slowly squeeze the ball as hard as you can and hold it for 3 5 seconds Relax the squeeze slowly Repeat 10 15 times Repeat 10 15 times with other hand Repeat 10 15 times more with each hand 54 Overhead Arm Raise Exercise Instructions This exercise will strengthen your shoulders and arms It should make swimming and other activities such as lifting and carrying grandchildren easier You can do this exercis
40. feeling well Caution some medication for diabetes missing meals or more physical active than planned may cause low blood sugar The good news is that low blood sugar is easy to treat see page 38 for the rule of 15 for mild low blood sugar and page 39 for sever low blood sugar If you are having low blood sugar frequently more than once a month please contact your primary care provider 42 General instructions for using a blood glucose meter 1 Wash your hands or clean your finger or other site with alcohol If you are using alcohol let it dry before you prick your finger 2 Prick the site with a lancing device 3 Put a little drop of blood on a test strip 4 Follow the instructions that come with your meter for inserting the test strip and using the blood glucose meter 5 In seconds the blood glucose meter reads your blood glucose level Supplies you will use 1 Blood glucose meter reads blood glucose 2 Test strip collects blood sample 3 Lancet or small needle fits into lancing device pricks finger and provides small drop of blood for glucose strip 4 Lancing device pricks finger when button is pressed Most devices have dials to select how deep the needle goes into the skin Start with middle depth If you get more blood than needed dial the number down so the lancet does not go as deep If you get less blood dial the number up so lancet goes deeper 5 Alcohol wipes or soap and wate
41. fully m Check all warnings and cautions m Avoid products containing sugar Select sugar free products and watch for sorbitol mannitol honey and any word that ends in ose dextrose fructose lactose These are all types of Sugar and contain calories m Select products with little or no alcohol m Oral decongestants raise blood glucose and should be taken only with your doctor s consent m Ask your pharmacist for help choosing medications Choosing Over the Counter Medications See the chart below for examples of over the counter medications that have minimal to no effect on blood glucose level Before using any over the counter medications discuss them with your doctor to determine if they are the best choice for you 32 Cough Medications Cepacol tablets sugar free Cerose DM expectorant Colrex expectorant Hytuss tablets Robitussin sugar free Sorbutuss syrup Supercitin Toclonol expectorant Tolu Sed Tolu Sed DM Tussar SF Fever Reducers Pain Relievers Children s Panadol St Joseph aspirin free infant drops Tylenol or Tylenol drops Datril Acetaminophen Antidiarrheals Kaopectate Lomotil liquid Parepectolin Pepto Bismol Tuss Ornade Be a Wise Health Care User Taking good care of yourself using the diabetes self care skills you learn and seeking preventive health care should help you avoid getting sick When you need to see the doctor or any other member of your health care team it is important to be
42. ge of clothing including a long sleeved shirt long pants and sturdy shoes Consider additional clothing if you live in a cold weather climate Household chlorine bleach and medicine dropper When diluted nine parts water to one part bleach bleach can be used as a disinfectant Or in an emergency you can use it to treat water by using 16 drops of regular household liquid bleach per gallon of water Do not use scented color safe or bleaches with added cleaners Fire Extinguisher Matches in a waterproof container Feminine supplies and personal hygiene items Mess kits paper cups plates and plastic utensils paper towels Paper and pencil Books games puzzles or other activities for children 34 Problem Traveling with Diabetes Traveling takes a little bit more planning when you have diabetes So here are some things to consider before you pack your bags and go Food When you travel your eating times may change Bring portable snacks to prevent low blood sugar levels such as nuts cheese sticks nutrition bars and small pieces of fruit Always carry glucose tablets or hard chewable candies to treat low blood sugar If you take insulin ask your doctor to prescribe a glucagon emergency kit Be sure you keep it handy Make sure the person you are traveling with knows how to use it Medicines and Supplies Whether you take oral or injectable medicines it s a good idea to bring twice as much medicine and supplies than y
43. gged is too uncomfortable As with the special meditation stools special round cushions have been created to make sitting more comfortable and are known as Zafu s Whichever method is adopted it can be changed so if you are new to meditation try sitting cross legged on a cushion first and then if after some perseverance this is not possible try a stool or chair 5I lt is important to keep your back straight not ridged but upright and defiantly not slouching this may Cause serious physical problems and make you fall asleep If you suffer more than a little initial discomfort consult your medical practitioner or seek other professional advice about posture The head is tilted forward very slightly and resting comfortably on the spine no chins resting on chests Some people meditate with the eyes open and others with eyes closed If you choose to keep your eyes open then your gaze should not shift around or be focused on any particular object In effect if the eyes are open they should be almost out of focus a soft gaze at a point around 5 feet away can be helpful Some people light a candle and have this as a point of focus even if this is not really focused on Equally if the eyes are closed they are softly closed rather than clamped shut the eyes behind the lids can remain relaxed and looking slightly downwards Even though the lids are closed As above so below whilst starting out on the path of meditation it is perhaps import
44. hat has been suggested Don t think should eat that piece of cake OK then I ll have two pieces Though they mean well they have become the Diabetes Police and you ve become a Diabetes Criminal Your loved ones are probably acting out of concern and worry but it can leave you feeling angry hurt frustrated and alone When loved ones are bugging you about what to eat or what to do you may tend to do the opposite of what has been suggested Don t think should eat that piece of cake OK then I ll have two pieces Though they mean well they have become the Diabetes Police and you ve become a Diabetes Criminal 1 DON T offer unsolicited advice about my eating or other aspects of diabetes You may mean well but giving advice about Someone s personal habits especially when it is not requested isn t very nice Besides many of the popularly held beliefs about diabetes you should just stop eating sugar are out of date or just plain wrong 2 Realize and appreciate that diabetes is hard work Diabetes management is a full time job that didn t apply for didn t want and can t quit It involves thinking about what when and how much eat while also factoring in exercise medication stress blood sugar monitoring and so much more each and every day 3 DON T tell me horror stories about your grandmother or other people with diabetes you have heard about Diabetes is scary enough and stories like the
45. hese pills help control the amount of glucose in your blood They do this by decreasing the amount of p glucose made by your liver and helping your muscles RA Metformin Use insulin more effectively These medications are usually taken with each meal Possible side effects include diarrhea nausea vomiting abdominal bloating excess gas flatulence and Metallic taste in mouth e Sulfonylureas Chlorpropamide Diabinese glipizide Glucotrol and Glucotrol XL glyburide Micronase Glynase and Glimepirde may Diabeta and glimepiride Amaryl Glyburide Diabeta Micronase Sion These pills help the body make more insulin They Micronized glyburide Glynase are usually taken 30 minutes before a meal Possible side effects include hypoglycemia Alpha glucosidase Inhibitors Acarbose and Miglitol These pills slow the digestion of sugars and starches They can help keep your blood sugar from going too high after a meal Take them Miglitol with the first bite of each main meal Possible Glyset side effects include abdominal pain diarrhe and excess gas flatulence Acarbose Precose a7 Thiazolidinediones Pioglitazone Actos and Rosiglitazone Avandia These pills help your muscle cells use insulin better Your doctor may order lab tests to check the Increases the amount l o of glucose taken up by function of your liver before prescribing these pill
46. ht a 3 00 AM blood glucose check may also be needed If you are taking insulin Self monitoring your blood glucose will let you Know if e Your food activity and insulin are matched e An extra dose of insulin is needed to bring your blood glucose to your goal e It is safe for you to drive a car or go to sleep because your blood glucose is too low Change of routine alert No matter what BGM plan you have developed with your health care team it is recommended that you check your blood glucose WHENEVER you have a change in your daily routine Examples 1 A change in your usual meal plan if you eat too much eat out at a restaurant attend a special occasion or are sick and not eating as usual 2 Possible low blood glucose reaction you are shaky tired sweaty hungry confused or have a headache 3 You are sick It is especially important to check your blood glucose when you do not feel well Blood glucose usually increases when you are sick Itis a good idea to check your blood glucose at least every 4 to 6 hours when you are sick Calling your doctor or health care provider with your symptoms and blood glucose results can help the doctor decide on the proper treatment for your illness and prevent problems with your diabetes 4 Possible high blood glucose reaction you are thirsty hungry urinating more often have blurred vision headache or feel tired 5 Before during and or after exercise 6 You are not
47. lancing device Use sides of fingertips instead of fingertip pad 44 Try alternative test sites such as arm or thigh Ask diabetes educator for suggestions 3 Error message Review user manual error codes and problems are identified in manual Make sure right amount of blood is on strip Make sure blood is on correct part of strip Call manufacturer s phone number listed on back of meter or in user manual Ask diabetes educator for suggestions WHAT Should Do With My Results Write your blood glucose results in a logbook and review with your health care team or download or print your Blood Glucose Weekly Log results from your my target range 20 145 me DL_ week starting 3 13 ei eee ae INSULIN _NPH N amp REGULAR R ie matty i breakfast bed comments Also record al og l y OE peo one proef ae feo ate and o a a U time of test bood sucose PSL A NOZA NISO 45 MINUTE BRERWAI insulin dose or medication N10 R3 NIO R3 R5 N STRESSFUL DAY diabetes carbohydrate 64g 679 71g fg AT work medicine e Whether you ate more or less than usual e If you did any exercise e Add comments such as had a headache didn t feel well or felt great etc Keeping these records and going over them with your doctor or diabetes educator will help you notice pattern that may occur and will lead to a better understanding of how food exercise stress medications and other events in your life may
48. le formula describe below under Titrating Carbohydrates add more insulin depending on the amount of carbohydrates you plan to eat Blood Sugar msln waww S o o 301 350 351 400 gt 400 call physician Titrating Carbohydrates Titrating carbohydrates means being able to count the carbohydrates you are going to eat and take insulin according to the amount of carbs The formula is 1 unit of insulin per the number of carbs suggested by your primary care provider For example if you eat 40 carbs during your meal and your primary care provider suggested 1 unit of insulin per 10 carbs you would give yourself 4 units of insulin 40 carbs Fill in this diagram with the suggested amount of carbs from your primary care provider carbs carbs total per 1 unit of insulin 18 Healthy Eating Plate Method for Diabetes Meal Planning What is the Plate Method The Plate Method is an easy way to set up healthy meals for yourself and your family No weighing no carrying around measuring cups and no expensive Special Foods lt can be used to help you eat healthy lose weight lower cholesterol and manage your diabetes Planning your food intake is the 1 step in controlling your blood sugars and diabetes When you eat healthy you feel better and your family eats better also It helps them learn good eating habits for life To begin with you need a basic plate Guess what Plates have gotten bigger so the amou
49. level even higher Gestational Diabetes is another common diabetes diagnosis it occurs in pregnant women who have never had diabetes before but who have high blood sugar levels during pregnancy Usually goes away after pregnancy but indicates a high risk of type 2 diabetes If you have gestational diabetes ask your doctor or diabetes educator for more information GOOD NEWS You can controlled your diabetes with healthy eating being active and if needed taking medications Avoid these complications by controlling your diabetes e Eye disease Amputations Heart attack or stroke Kidney disease sexual dysfunction understand that have Type 2 diabetes Type 1 diabetes Pre diabetes Gestational diabetes don t know Other conditions High Blood Pressure High Cholesterol Drug Allergies Problems with Kidneys Problems with Eyes Numbness Tingling or Pain In Feet Arthritis Asthma Short Of Breath Sleep Apnea or Trouble Sleeping Depression Currently Pregnant Sexual Dysfunction Anxiety or Stress Taking Medications If you need to have diabetes medications it is easier for your doctor to adjust your medications when you re eating habits are not changing You need to contact your MD if your BS levels are elevated Often people will just let their Blood Sugars run high until the next visit DON T DO THIS Types of Diabetes Pills Biguanides Metformin T
50. lties treatment options and how to talk it over with a doctor or mate If you wonder if some of the problems you are experiencing may be symptoms of sexual dysfunction At any given time an estimated 30 million American men experience impotence erectile dysfunction defined as the inability to achieve or maintain an erection sufficient for intercourse more frequent than 59 one out of four times Sexual difficulties in people with diabetes are not always related to their disease Impotence can occur in men of any age but it most often affects older men A recent study of 1 300 males found some degree of erection difficulty in 52 percent of participants ages 40 to 70 Over 50 percent of the estimated 10 million men with diagnosed type 2 diabetes experience impotence In men whose diabetes is well controlled the rate of impotence is about 30 percent Approximately 35 percent of women with diabetes may experience some form of sexual dysfunction related to their disease Of people with complications from diabetes 50 to 70 percent of men and 40 to 50 percent of women may have sexual difficulties because of nerve damage Eye Care High blood sugar can damage the small vessels of the eye This puts people at risk for eye disease Reduce risk by Scheduling an eye exam at least yearly Keep your blood sugar before meals 70 to 130 and two hours after meals less than 180 several factors influence whether you get retinopathy
51. lue as to what has caused the problem or how to correct it At moments like these what may be needed is a hug a sympathetic word or a dozen roses Family and friends need to understand that this kind of support can be very helpful during frustrating times Problem Will diabetes prevent me from working Your diabetes should not prevent you from working Having diabetes or other health problems may make it unwise to choose certain jobs Employers are required to make reasonable accommodation if requested by an employee with a disability unless the accommodation would cause an undue hardship on the employer because of significant difficulty or expense The accommodations that people with diabetes need are usually easy and inexpensive For example a person with diabetes might require accommodations such as e Breaks to check blood glucose levels eat a snack or go to the bathroom e Special permission to eat on the job e The ability to keep diabetes supplies and food nearby e The opportunity to work a modified schedule or to work a standard shift as opposed to a swing shift If you take Precose acarbose or GlysetTM miglitol treatment of low blood glucose should be with glucose tablets not candy or juice 37 Problem Low blood sugar Low Blood Sugars Hypoglycemia is the term meaning low blood sugars When your blood sugar falls too low below 70 mg dL you may feel uncomfortable symptoms that come on fast Symptoms of Low Bl
52. ly more than once a month please contact your primary care provider My Insulin Worksheet Knowing how your insulin works helps you plan when you need to inject your insulin The goal of insulin is to keep your body s blood glucose levels in your target range Write down the insulin you are taking along with the onset peak and duration of the insulin e Onset is when your insulin starts to work e Peak is when the insulin is working the best e Duration is how long the insulin works It is important to know your insulin Keep track of the dose in number of units what times to inject the insulin what times to eat and times to monitor your blood sugar Times to Check Your Sugar Level UAT a PEEB ESTP To G e CERERILE Al o i 2 Time B Breakfast L Lunch D Dinner S Snack 17 Corrective Scale Titrating Carbohydrates This is a pre meal option that is commonly recommended for type 1 diabetics and some Type 2 diabetics who are dependent on insulin for good control It is assumed that that those using this option are also taking long acting insulin such as Lantus or Levemir Your physician nurse or diabetes educator should help you fill out this worksheet Corrective Scale Check your blood sugar before the meal Find the range that your blood sugar falls in see the first column Check the amount of insulin to be drawn up if any see column 2 Then count the carbs you are planning to eat Use the simp
53. m your bloodstream into your body s cells A e Your body s cells use the sugar in your blood as fuel to do their work or 4 they store the sugar in your cells to use later e If you are taking insulin you should how it works such as its onset peak and duration Study the table and chart below find your insulin Insulin Duration of Preparation Action Humalog Apidra minutes 60 minutes Regular U 500 30 to 2to4hours Up to 24 hours 60 minutes Lantus Glargine 1 2 Usually no Up to 24 hours Levemir Detemir hours peak Levemir may have a slight peak after 12 hours and possibly last 18 hours Insulin action Novolin or Humulin 70 30 30 60 2 10 hours 10 18 hours 70 NPH and 30 minutes Regular Humalog 75 25 10 30 1 6 hours 10 24 hours Novolog 70 30 minutes Humalog 50 50 Aspart lispro glulisine Regular NPH Detemir Glargine gt k Plasma Insulin Levels T TO T T Li Li T 7 T T T ToT a 6 E 10 12 14 16 418 Ps a2 24 Injection Areas The areas that you can inject insulin are e Abdomen e Upper arms e Thighs e Buttocks Same time same place a Figure 1 e Insulin works at different rates when given into different parts of the body e Use the same area at the same time each day for steady blood sugar levels Insulin begins to work e The fastest in the abdomen e Slower in the arms and thighs e Slowest site is the buttocks Healthy skin Figure 2
54. ning health services that are due 6l Diabetes Aiswers mao asso ssa ors UBL PROFESSIONA ABETES inks amp CGuceion Hesources amp Sepport What is A E HEALTHY EATING What can eat BEING ACTIVE Why and how should be active MONITORING Why do I need a monitor and how do I use the results TARING MEDICATIONS PROBLEM SOLVING How Go deal wth problems that may occur such as iness travel of hypoglycemia REDUCING RISKS Whal should do to prirent oop alione How do cope wath diabetes Providence St Mary Medical Center Diabetes Education Program Diabetes Education Providence St Mary Medical Center 401 West Poplar Walla Walla WA 99362 Recognition credited by American e Diabetes Association 8 2013 Workshop amp Support Group Meeting Schedule Clases para aprender todo acerca de la diabetes 2013 Referral Form _ Your Goals and Action Plan for Managing Diabetes EDUCATORS Ron Kammer RN CDE phone 509 529 8922 ron kammer providence org Margaret Caicedo ARNP CDE phone 509 522 5118 margaret caicedo providence org Michele Lucas RD CDE phone 509 525 3320 X 2804 michele lucas providence org Christy House RD phone 509 525 3320 x 2805 christy house providence org Services One On One Counseling Individual diabetes counseling is very helpful for specific areas in your diabetes routine that you may find challenging Diabetes Workshops Our Diabetes Education Workshops are for
55. nment pages of your phone book State Children s Health Insurance Program The U S Department of Health and Human Services has established the State Children s Health Insurance Program SCHIP to help children without health insurance SCHIP provides health coverage for children whose families earn too much to qualify for Medicaid but too little to afford private health insurance Consumers can obtain information about the program by calling toll free 877 KIDS NOW 543 7669 or by checking www insurekidsnow gov 29 Providence St Mary Medical Center If you need help paying for you hospital bill including the cost of diabetes education Our financial councilors can explain your options You can meet in person or call 509 522 5804 or 1 800 452 3320 ext 2237 Health Insurance Because health insurance is meant to cover unexpected future illnesses diabetes that has already been diagnosed presents a problem It is considered a preexisting condition so finding coverage may be difficult Many insurance companies have a specific waiting period during which they do not cover diabetes related expenses for new enrollees although they will cover other medical expenses that arise during this time Recent state and Federal laws however may help Many states now require insurance companies to cover diabetes supplies and education The Health Insurance Portability Act passed by Congress in 1996 limits insurance companies from denying coverage because o
56. nsulin Pen Gather your supplies 1 Wash and dry your hands e Your insulin pen e A needle e Alcohol wipes or cotton balls and alcohol e A sharps container 2 Make sure your clear insulin is 3 Pull the outer cap of the pen clear or your off cloudy insulin is free of clumps Check to make sure your insulin pen has the correct insulin Know how many units of insulin you are taking 4 Wipe the rubber seal at the top with alcohol Take the protective paper tab off of your needle Screw the needle onto the pen tightly Remove the outer needle cap Keep it handy for when you are ready to throw it away 14 5 Take off the inner needle cap Prime your pen Dial your pen to 2 Point the pen strain up and push the injection button You should see insulin come out of the needle tip Set your dose Dial your pen to the correct number of units in your prescribed dose 6 If you are taking a cloudy insulin roll it between your hands least 15 20 times 7 Clean your skin with alcohol and let air dry 8 Hold the pen as in the picture with your thumb on the plunger If your needle is 5 mm or longer pinch your skin up If your needs is 4 mm or shorter inject straight into your skin Push the needle into your skin at a 90 degree angle Thin people may inject at a 45 degree angle Push the injection button Pull the pen straight out 9 Put the outer ne
57. nt of food we eat has increased and waist lines have followed A basic sized plate is 9 inches Take a ruler and measure across your plate if the part where you put your food is 9 inches across you have the right sized plate if not measure your salad plate It may be just what you are looking for DO not use an oversized plate and plan on only filling it part way you will be more tempted to overeat Now let s look at your bowl for cereal amp soup A good sized bowl is the one you get a cup of soup in at a restaurant You need a small bowl that holds about 1 cup Next you need a small dish the type you get desserts in at buffet restaurants It holds about 1 2 cup If you are not sure what size bowl and dish to use use measuring cups to find out exactly how much the bowl will hold Measure out 1 cup of dry rice or cereal into a bowl If the bowl looks fairly full it is the perfect size bowl Now measure out 1 2 c of dry rice or cereal into a small dish If the dish looks fairly full it is the right size dish to use Now that you are using the right dishes you are ready Make sure and put the oversized dishes amp bowls out of sight so you do not use them again 19 Vegetables take up 1 2 of the plate This may be more vegetables than you are used o That s O K By increasing your vegetables you are bringing your meals back into balance and adding fiber vitamins and minerals you might have
58. o remember spot each day When you take back control of your environment it no longer controls you Diabetes becomes easier to handle e Keep it ready If you have home exercise equipment make sure it is always set up and ready to go The more effort required to set it up when you need it the less likely you will use it e Put it away Make sure that tempting unhealthy snacks are out of the house or put away in cabinets out of sight 48 Depression Depression is a serious problem and it can be even more serious when you have diabetes People with diabetes are more likely to develop depression than many other people With depression diabetes can become harder to handle and blood sugars are likely to rise When diabetes is out of control this can make it even harder to escape depression It becomes a vicious cycle The good news is that there are effective treatments to help you to break free from depression In turn this can free up the energy to become more active in your diabetes care Watch for the warning signs If you are feeling down or hopeless about life have lost your get up and go or have less interest or pleasure from the things you used to enjoy then talk to your doctor as soon as possible n en 7 Fi Sal l Take action to avoid depression Exercise regularly 4 1 l schedule a fun activity every week and spend time with x people you like Include activities in your daily life th
59. oblem Hyperosmolar Hyperglycemic Nonketotic Syndrome HHNS High blood glucose often more than 600 mg dl can lead to a life threatening problem known as hyperosmolar hyperglycemic nonketotic syndrome HHNS It occurs more often in people with type 2 diabetes HHNS can be caused by an illness infection dehydration or missed diabetes medication and often develops slowly Symptoms of HHNS include m Dehydration m Feeling sluggish m Mental confusion WHEN TO CALL YOUR HEALTH CARE TEAM Call your health care team any time you have symptoms of HHNS How to prevent HHNS when your blood glucose is high m Continue to take your diabetes medication m Test your blood glucose more frequently m Drink more fluids such as water broth and sugar free caffeine free soda and tea m Call your doctor if your blood glucose is more than 240 mg dl for 24 hours Assess your treatment plan or events that may have caused severe hyperglycemia HHNS requires treatment in a hospital with intravenous fluids and insulin until your blood glucose levels are under control Your health care provider will also identify and treat the cause 36 Problem How do I get support from family and friends How do you get the kind of support you need First you have to decide what when and how you want support Then you need to tell the people who are involved with your care what you need Usually family members and friends are willing to help If they have embarrassed
60. oblem Your liver holds an extra store of lf you eat a big meal the pancreas releases a big burst of glucose just in case you ever insulin if you eat a smaller amount the pancreas releases a need it For example if you go smaller burst of insulin Insulin allows the glucose to move from too long without eating your your bloodstream into your body cells liver will release some of this stored glucose back into the bloodstream This glucose is the fuel that gives you energy until you can eat a meal So to summarize the normal process The right amount of insulin from the pancreas keeps your blood glucose level from going too high Glucose stored in the liver Keeps your blood glucose level from dropping too low The blood glucose level normally stays between 70 to 99 mg dl before eating and less than 140 mg dl within the two hours after a meal When diabetes occurs your pancreas makes little or no insulin or your body cells don t respond to the insulin that is produced In either case glucose cannot properly move into the body cells Glucose builds to high levels up in the bloodstream Even though glucose is available in your blood your body cells can t use it Your cells now lack the energy they need to keep your body working properly Type 1 Diabetes In type 1 diabetes little or no oan insulin is released by the ry ay ancreas The body s immune x q Pe ha i x system turns against itself destroying the pancreas cells
61. of sleeping or sitting on the sofa gazing into Space although this is probably closer to the meditation process that we generally realise in the west Most of us struggle to let go of thoughts what will do about Oh know could or maybe someone else can Then could life would be great if they could understand Perhaps I ll try This is how the mind works it has the unceasing capacity to think good thing too otherwise there would not be any works here to read So while first sitting it is sometimes useful to find something to occupy the mind repetitively many people focus on the breath noticing inhale exhale Some also try counting breaths form 0 10 and then start again otherwise we get caught up in was that 27 or 28 etc personally prefer simply noticing the breath It s amazing how the mind will try and stop you doing this if this happens to you don t worry don t even think about what you were thinking or for how long you were thinking just return to noticing inhale exhale In doing this the mind will not switch off but will have the chance to rest with the thoughts troubles and whatever else it has in mind without taking over every part of you 52 The other major distraction to meditation is the process of sitting am doing it right the itch on the end of my nose etc Dealing with this is a balance between real discomfort and distracting yourself If you are really uncomfortable then consider what is requi
62. olescents need 4 servings If you do not drink milk talk to your Registered Dietitian Educator about ways to add calcium to your diet Calcium from milk products can help control blood pressure and help you lose weight easier Calcium is also important for strong bones e You can put any meat you want on the 1 4 plate for meat e Place any Bread Starch food you want on the 1 4 Plate for Breads e Any vegetable can go on the 1 2 for Veggies except vegetables which are a starch and go on the 1 4 plate for Breads Starches Grains Any Fruit can go in the small dish for fruits Any Milk product goes in the Milk section Now let s look at the Breakfast You have a 1 4 of the plate for meat a 1 4 of plate for Breads Starch Grain a dish of fruit any kind you want and a milk serving To set up a Breakfast meal e You can choose to put any meat you want on the 1 4 plate for meat Any Bread Starch Grain food you want on the 1 4 plate for Breads o e Any Fruit which goes in the small dish for fruits e Any Milk serving which goes in the Milk section 1 Fruit 1 Milk 1 Bread Starch Milk Fruits and Breads Starches Grains all affect your blood sugar levels about the same amount That is why these foods can be traded for one another So if you do not want fruit for lunch you could have another serving of milk These foods each break down into sugar a natural fuel in the body Maybe you are thinking you should avoid
63. ood Sugar WEAKNESS FATIGUE HEADACHE ANXIOUS DIZZINESS The Rule of 15 1 Blood sugar is less than When you start to feel symptoms of low blood sugar check your blood sugar 70 mg dL don levels BUT if you don t have your meter go ahead and treat If your blood sugar level is too low it 2 Have 15 grams of fast acting needs to be treated right away with 15 carbs grams of carbs 15 gram carbs o 3 glucose tabs 3 Recheck blood sugar in 15 o Y2 cup of fruit juice soda minutes o 6 7 hard candies not sugar free o 1 tbs of honey or sugar 4 Repeat 15 grams of fast If your blood sugar levels are still low acting carbs until blood sugars after 15 minutes take 15 more grams of are above 70 mg dl carbs If your sugar levels are still low after another 15 minutes call your doctor 38 severe low blood sugar occurs when your blood glucose is so low that you are not alert and need someone to help treat your low blood glucose If you have severe low blood glucose m You may pass out or not be able to swallow m You may need to receive glucagon which is an injectable medicine used to treat low blood glucose when you cannot or will not swallow How to Give Glucagon Glucagon is a hormone made by your body It is not glucose Glucagon causes glucose stored in the liver to be released which raises blood glucose Glucagon is administered by an injection when you cannot or will not swallow during a severe low bl
64. ood glucose episode It is available only by prescription and is sold as a single dose kit Check your glucagon kit regularly to make sure it has not passed its expiration date Someone close to you needs to know when and how to use glucagon Here are instructions for giving glucagon 1 If you find someone who is unresponsive or unconscious call 911 immediately 2 Prepare the kit as directed Glucagon must be mixed with the special solution provided in the kit 3 Glucagon should be given immediately after mixing 4 Position the person on his or her side Vomiting may occur as the person is waking up and this position will help keep fluid from going into the lungs 5 Glucagon is given by injection like insulin It can be injected at a 90 degree angle Straight into the upper arm the outer part of the thigh or buttocks or anywhere insulin is given 6 The full dose is given to adults A smaller amount 20 micrograms is given to infants or children under 44 pounds 20 kg What to Do After Giving Glucagon After receiving glucagon the person should have a snack for example juice with crackers and cheese when he or she wakes up and can swallow The person will usually wake up within 15 minutes Call the doctor to report what happened Be sure to replace the glucagon kit If the person does not wake up within 15 minutes give another dose of glucagon and call 911 or get the person to the nearest emergency room immediately Do any of
65. or irritated you in the past it might be that they don t understand diabetes or they are not sure how to help They simply did what they thought was helpful Therefore you need to e Educate your family and friends about your diabetes e Define how you want family and friends to help e Ask them directly for help and teach them how to give it second family members and friends need to understand diabetes listen to what you think and feel and support or join you in making some healthy changes For example if you are trying to lose weight it simply will be easier if your family also eats the same lower fat foods Your family and friends will also have concerns and worries for example guilt fear anger etc about your diabetes that need to be talked about so that realistic expectations can be set misconceptions corrected and feelings understood Perhaps the two most important guidelines for family members are to have realistic expectations about blood glucose levels and to avoid blame Family members need your help and the help of your healthcare team in order to understand that you cannot always control blood sugar levels even if you follow your diabetes care plan Blaming the person with diabetes for high or low blood sugar levels never helps and frequently causes hurt feelings arguments or serious conflict The key to genuine support is to avoid blame and focus on problem solving With that said there are times when there may be no c
66. ou think you will need When flying always carry diabetes medicines and testing supplies with you Never leave insulin where it may get too hot or too cold Always keep insulin in a cool dry place Let airport security people know that you have diabetes and are carrying supplies with you Make sure your supplies are in the original packaging with original prescription labels Managing Blood Sugar Check your blood sugar often when traveling Doing this will help you to better manage your diabetes while away from home and help to prevent low or high blood sugar Physical Activity You may be more active or less active than usual Remember that your activity level does affect your blood glucose If you are sitting longer than usual move your feet by drawing circles in the air while sitting If you can stretch your legs by taking a short walk every hour when you can One last thing Enjoy your trip This is the payoff for all that planning The more you are ready the better you can manage your diabetes This will make you feel your best so you can have a good time Problem Diabetic Ketoacidosis DKA If you have type 1 diabetes high blood glucose can cause a dangerous condition known as diabetic ketoacidosis DKA This occurs in people with type 1 diabetes because of a lack of insulin an injection was skipped or not enough insulin due to illness or stress When there is too little insulin the body breaks down fat for energy causing ke
67. ount of carbohydrates absorbed into the blood Instead of sharp fast spikes in blood sugar after a meal fiber slows down that process providing a more steady and attenuated increase in blood sugar Overall this helps to prevent wide swings in blood sugar Improves Blood Pressure While not completely understood fiber intake has been associated with improved values of blood pressure Fiber rich foods are high in the minerals potassium and magnesium which may be involved in the reduction of hypertension or high blood pressure Decreases Triglycerides and Cholesterol Triglycerides are fats that originate in some foods naturally and are synthesized from excess carbohydrates or protein Studies indicate that increases in fiber intake leads to decreases in triglycerides Fiber also helps to decrease cholesterol in two ways First fiber acts as a sponge in the gut trapping bile and excreting it from the body Bile is needed to digest fat and is typically recycled and used continuously Cholesterol is needed to make bile so when a decrease of bile occurs cholesterol is used to synthesize more Secondly fiber contains a compound that acts in the liver to prevent the synthesis of new cholesterol Dietary Recommendation The International Life Sciences Institute reviewed past research on fiber and its health benefits and concluded that fiber helps to prevent and manage chronic diseases Its expert panel recommends fiber intake of 14 grams for every 1 0
68. prepared You can prepare by m Having a written list of questions you want to ask m Sharing concerns and symptoms m Reviewing all medications you use including over the counter drugs When you don t feel well the stress of being ill causes your blood glucose to rise often even if you are eating and exercising as usual The goal of sick day management is to prevent a minor illness from developing into a major illness What to Do When You Are Sick m Continue to take your usual daily dose of diabetes medication An exception to this rule is Glucophage metformin If you are unable to eat and drink you may become dehydrated Do not take Glucophage if you are dehydrated m Monitor your blood glucose levels every two to four hours m Monitor your urine or blood for ketones if you have type 1 diabetes m Drink extra fluids m Rest m Involve a family member or friend in your sick day plan Be sure there is someone available to check on you and to help you if necessary m Check with your health care team before you take any nonprescription medications WHEN TO CALL YOUR HEALTH CARE TEAM Call right away if m You vomit more than once every four to six hours m You are unable to eat or drink m You have positive ketones m You have a fever lasting more than 24 hours m You have diarrhea that does not go away for more than six hours When you call be prepared to tell your doctor m How you feel symptoms m How long you have be
69. preventive care services to decrease risks Skills taught include smoking cessation foot inspections blood pressure monitoring self monitoring of blood glucose aspirin use and maintenance of personal care records Page 57 Find out more www DiabetesAnswers org node 602 What is Diabetes Normally most of the food you eat breaks down into glucose which is the same thing as sugar As you digest the food glucose passes from your intestines into your bloodstream You need glucose It is your body s main source of energy But to use glucose for energy it must first get into your body cells Glucose can t move into the cells by itself It needs insulin to help Insulin is a hormone made by the pancreas which is the organ behind your stomach Most of the time the pancreas releases just a small steady stream of insulin But after a meal your pancreas releases a burst of insulin When you are fasting meaning aa 7 you have not eaten in the past Our liver a _ our eight hours the normal blood also pancreas glucose range is below 100 k releases mg dl After eating a meal food i A insulin causes the blood glucose to rise but it will stay under 140 mg dl within the two hours after a meal As insulin moves the glucose into the cells your blood glucose level begins to go down again If your blood glucose level ever drops too low lt 70 mg dl your body automatically takes steps sugar A body cells to correct the pr
70. r to clean fingers or other testing site 6 Control solution checks test strip for accuracy The amount of glucose in the control solution is already known When placed on a test strip value should match control solution value on bottle package of strips or package insert that came with your strips If the result does not fall into the printed range this may mean the strip or control solution is expired damaged has not been properly stored or has not been correctly calibrated measured You should call the company who makes the meter for instructions if this happens 7 User manual provides information about your meter After reading place in safe place so that you can find it when you have a question about your meter 8 Warranty card or papers complete make file copy and send in immediately Tips for Proper Use Read instructions carefully Glucose meters and test strips come with instructions for use Your user manual should also include a phone number that you can use to contact Ti manufacturer Use the test strips that are recommended for your glucose meter It is important to use only the test strips that are specified for your glucose meter Otherwise the device may fail to give results or may give inaccurate results Know the factors that affect meter accuracy These may include e The amount of red blood cells hematocrit in the blood e Other substances present in the blood such as uric acid glutathione
71. r area Try contacting one of the many retreat centres listed here at Metta to attend a meditation evening or retreat many have contact details for local open groups that meet once or twice a week which newcomers are welcome try lf all this seems to much you might like to try pausing a few times a day the benefits of pausing can be substantial and often help to get people started in meditation Read more www DiabetesAnswers orge node 604 MY GOALS FOR HEALTHY COPING Identify healthy ways you can reduce stress or anxiety by getting support from medical team and family friends other 53 BEING ACTIVE WHAT YOU NEED TO KNOW BEFORE STARTING AN EXERCSIE ROUTINE Source www dlife com diabetes food and fitness diabetes and exercise 1 Start with your doctor s recommendation Get a physical exam and guidance on the kind of exercise that may be safest for you 2 Be prepared for the impact of exercise on your blood glucose sugar Exercise uses the sugar from your blood stream so it can lower your blood sugar level especially in people using insulin or certain diabetes pills Carry some form of carbohydrate with you in case you swing too low 3 Check your blood sugar before you exercise In general if your blood sugar is less than 100 take a small snack that includes carbohydrate before you start to exercise If your blood sugar is 300 before exercise wait to exercise until your blood sugar is close to the normal range I
72. rage m influences all the nutrient Cholesterol Og 0 amounts listed on the top waaa aa O O O NO part of the label For Sodium 0g 0H example if a package has Total Carbohydrate 0g 3 4 servings and you eat he Dietary Fiber Oa 8 entire package you ry g 0 quadruple the calories fat etc that are listed on e Og the label Protein Og Se Se Do not confuse portion 0 e 0 size with serving size A Vitamin A 270 Vitamin 10 _ portion size is what you Calcium 2 Iron 0 chose to eat there are N no standard measures for Percent Daily Values are based on a 2 000 calorie this A serving size is a diet Your daily values may be higher or lower standard amount used to help give advice about depending on your calorie needs n A EN ieheles Calories 2 000 2 500 you identify how many calories are in the foods Total Fat Less than 65g 80g you eat and what the Sat Fat Less than 20g 80g nutritional content would Cholesterol Less than 300mg 300mg be in a serving size For Sodium Less than 2 400mg 2 400mg example a slice of bread Total Carbohydrate 300g 375g eee a oneng Dietary Fiber 259 30g pyramid Yet if you eat a sandwich with 2 slices of bread you would have had 2 servings of bread in your portion Calories and Calories from Fat The number of calories and grams of nutrients are provided for the stated serving size This is the part of the food label where you will find the amount of fat per serving Nut
73. red to rectify it before moving move with the purpose of dealing with the discomfort and return to sitting return to the breath If the mind wonders return to sitting return to the present moment DO NOT judge the quality of your sitting leave this for another time When first trying meditation try sitting without even attempting to meditate create your space find a cushion or pillow that meets your needs get to Know how it feels to sit still get a sense of your backside resting get a feel for your back being straight not ridged your head tilted forward and your eyes resting mouth either slightly open or closed Remember you are not meditating yet just getting to know how it is to sit quietly with meditation in mind rest in your body get a sense of the support beneath you If you are new to meditation try starting of with 5 10 minutes every day or less if you can try to extend this to 15 20 or even 30 45 minutes over time If you slip up or do not feel any benefit persevere meditation does work and it is one of the most wonderful ways of finding inner quiet and a sense of peace within mind and body and it s free If you simply cannot get to grips with meditation it can be really helpful to attend a retreat centre for an evening a weekend or a longer period with others in shared meditation Sitting with others is a real help and support for all sorts or reasons There is probably a group who meditate regularly in you
74. rients This section lists the daily amount of each nutrient in the food package These daily values are the reference numbers that are set by the government and are based on current nutrition recommendations Some labels list daily values for both 2 000 and 2 500 calorie diets 24 Daily Value shows how a food fits into a 2 000 calorie day diet For diets other than 2 000 calories divide by 2 000 to determine the Daily Value for nutrients For example if you are following a 1 500 calorie diet your Daily Value goal will be based on 75 for each nutrient not 100 When it comes to fat saturated fat and cholesterol choose foods with a low Daily Value For total carbohydrates dietary fiber vitamins and minerals try to reach your goal for each nutrient Ingredients Each product should list the ingredients on the label They are listed from largest to smallest amount by weight This means a food contains the largest amount of the first ingredient and the smallest amount of the last ingredient Artificial dasha Artificial sweeteners may assist in weight management prevention of dental caries and control of blood glucose for diabetics It has also been suggested that low calorie sweeteners may stimulate the appetite but the bulk of evidence does not support this hypothesis Conclusive research demonstrates that artificial sweeteners have no effect on carbohydrate metabolism short or long term blood glucose control or in
75. right for you The following table provides recommended target blood glucose ranges and shows when you should take action to get your blood glucose back on track Source DIABE Tease WHEN Should I Check My Blood Glucose Deciding on your treatment plan You and your doctor or diabetes educator will decide when you need to check your blood glucose and how often it should be done This will depend on your treatment plan and how often you are willing to check your blood glucose People who manage their diabetes with healthy eating and exercise have a regular daily routine and meet their blood glucose goals may only need to test once a day or a few times a week People who take insulin may need to check four times a day or more You may need to check more often as your treatment plan changes or you are sick or feel stressed When you begin to monitor your blood glucose or if your blood glucose is not well managed you may be asked to check your blood glucose more often than usual This will give you and your doctor the information necessary to make changes to your treatment plan Once you have reached your blood glucose goals you may be able to reduce the number of blood glucose checks you do each day 41 A commonly recommended BGM plan Check blood glucose e Before meals and before taking insulin or medication e Two hours after meals e Before bedtime Note For people who may have low blood glucose reactions during the nig
76. rom a finger The body uses the glucose in your blood at different rates so you can test your fingertip and your arm at the same time and get different results This usually happens when blood glucose is changing quickly after a meal after a dose of insulin or during or after exercise You should check the blood from your fingers in the following situations 3 1 If it has been less than 2 hours after a meal insulin dose or exercise 2 If you think your blood glucose is low or you have a condition called Hypoglycemia Unawareness This happens because you do not have signs of low blood glucose until your blood glucose is very low 3 If the results you receive from the alternative site do not agree with the way you feel Use blood samples from sites other than your fingers only for testing before a meal or more than two hours after a meal Troubleshooting tips 1 Can t get blood out of your finger Place hands under warm water and rub together Hang hand down below waist Grasp finger near area to be pricked and squeeze genily for three seconds Place finger on table or firm surface to avoid moving while pricking If lancing device has dial a depth increase setting by 1 level Use a new lancet every time you check blood glucose 2 Hurts too much If lancing device has dial a depth decrease setting by 1 level Use a new lancet every time you check blood glucose Try a thinner lancet or a different
77. rying this stretch Stand with feet shoulder width apart Hold one end of a towel in your right hand Raise and bend your right arm to drape the towel down your back Keep your right arm in this position and continue holding on to the towel Reach behind your lower back and grasp the towel with your left hand To stretch your right shoulder pull the towel down with your left hand Stop when you feel a stretch or slight discomfort in your right shoulder Repeat at least 3 5 times Reverse positions and repeat at least 3 5 times Ankle Exercise Instructions This exercise stretches your ankle muscles You can stretch both ankles at once or one ata time Sit securely toward the edge of a sturdy armless chair Stretch your legs out in front of you With your heels on the floor bend your ankles to point toes toward you Hold the position for 10 30 seconds Bend ankles to point toes away from you and hold for 10 30 seconds Repeat at least 3 5 times Back Exercise Instructions This exercise is for your back muscles If you ve had hip or back surgery talk with your doctor before trying this stretch Sit securely toward the front of a sturdy armless chair with your feet flat on the floor shoulder width apart Slowly bend forward from your hips Keep your back and neck straight Slightly relax your neck and lower your chin Slowly bend farther forward and slide your hands down your
78. s muscle cells and and regularly while you are taking them possible keeps the liver from side effects include upper respiratory tract overproducing glucose infections headaches weight gain swelling o 80 ee DPP 4 Inhibitors Sitagliptin Januvia Saxagliptin Onglyza Linagliptin Tradjenta These pills help lower blood sugar levels in people with type 2 diabetes They are less likely to cause hypoglycemia They are taken once a day Possible side effects include upper respiratory tract infection stuffy or runny nose sore throat headache Incretins Byetta Bydureon Victoza These are a group of hormones that cause an increase in the amount of insulin after eating even before blood glucose levels become elevated They also slow the rate of absorption of nutrients into the blood stream by reducing gastric emptying and may directly reduce food Bydureon intake Those with pancreatitis should not take DPP 4 or Incretins Call your healthcare provider right away if you have pain in your stomach area abdomen that is severe and will not go away The pain may happen with or without vomiting and may be felt going from your abdomen through to your back Combination Medications for Type 2 Diabetes These medications may help keep your blood glucose within your target range They also help your pancreas make more insulin and may help your muscles use insulin more effectively Side effects depend on
79. se are not reassuring Besides we now know that with good management odds are good you can live a long healthy and happy life with diabetes 4 DO offer to join me in making healthy lifestyle changes Not having to be alone with efforts to change like starting an exercise program is one of the most powerful ways that you can be helpful After all healthy lifestyle changes can benefit everyone 5 DON T look so horrified when I check my blood sugars or give myself an injection It is not a lot of fun for me either Checking blood sugars and taking medications are things must do to manage diabetes well If have to hide while do so it makes it much harder for me 50 6 DO ask how you might be helpful If you want to be supportive there may be lots of little things would probably appreciate your help with However what really need may be very different than what you think need so please ask first 7 DON T offer thoughtless reassurances When you first learn about my diabetes you may want to reassure me by saying things like Hey it could be worse you could have cancer This won t make me feel better And the implicit message seems to be that diabetes is no big deal However diabetes like cancer IS a big deal 8 DO be supportive of my efforts for self care Help me set up an environment for success by supporting healthy food choices Please honor my decision to decline a particular food even when you really w
80. sease and many people do develop severe long term complications but most of these problems are preventable if you have good medical care and take good care of yourself Feeling a little frightened by diabetes is not necessarily a bad thing BUT when your fears get so big that you feel helpless and hopeless it s time to take action You need to harness fear to help you Remember manage diabetes that you ad Spar ih emember that you didn t give yourself didn t give diabetes As people around the world grow heavier and heavier it almost seems like everyone is trying yourself diabetes hard to develop type 2 diabetes Yet most fail to do so Obesity and a sedentary lifestyle are contributors to type 2 diabetes but if you don t have the genes for it you can t develop it For type 1 diabetes your own actions played no role at all It wasnt all those sweets you ate as a child or anything else you did Take Control of your Environment Your environment whether you notice it or not influences your ability to manage diabetes Having willpower isn t enough You need to harness the power of your environment to support rather than hinder your diabetes care Think about it how well you eat is affected by the number of tempting foods in your house and the size of the portions on your plate How faithfully you take your medications is influenced by how many you have and whether you keep them in a convenient easy t
81. so cover young people who were insured under a parent s policy but have reached the age limit and are trying to obtain their own insurance For more information call the Department of Labor at 866 487 2365 or see www dol gov dol topic health plans cobra htm If you don t qualify for coverage or if your COBRA coverage has expired you can still seek other options e Some states require employers to offer conversion policies in which you stay with your insurance company but buy individual coverage Some professional or alumni organizations offer group coverage for members e Your state may be one of 29 with a high risk pool for people unable to get coverage some insurance companies also offer stopgap policies designed for people who are between Jobs Contact your state insurance regulatory office for more information on these and other options Information on consumer health plans is also available at the U S Department of Labor s website at www dol gov dol topic health plans consumerinfhealth htm 30 Prescription Assistance The Partnership for Prescription Assistance https www pparx org Intro php works with pharmaceutical companies doctors other health care providers patient advocacy organizations and community groups to help qualifying patients who lack prescription coverage get the medicines they need through the public and private programs Many patients receive free or nearly free assistance Following is a list of pharmaceutical comp
82. sulin secretion and they are thus an excellent sugar alternative for diabetics There have been a number of health concerns related with these products though the Food and Drug Administration FDA approval gt process for artificial sweeteners involves a comprehensive analysis of scientific data to satisfy safety requirements All generally recognized as safe GRAS sweeteners have undergone extensive safety testing and have been carefully reviewed by the FDA Effects of Alcohol on Diabetes Read more http www livestrong com article 28394 alcohol affect blood sugar levels ixzz1vcrluLJJ Not only does drinking alcohol cause blood sugar to drop it also results in increased difficulty for the body to regulate blood sugar levels Because the liver prioritizes metabolizing alcohol over regulating other blood sugar levels blood sugar does not receive the typical secretions of glucagon to then increase blood sugar levels For this reason it is important for people especially those who have a condition such as diabetes to consume carbohydrates or take a carbohydrate type tablet such as an oral glucose tablet or gel Long Term Blood Sugar Control While the immediate reaction to alcohol consumption may be low blood sugar over time chronic drinking can lead to high blood sugar Frequent heavy drinkers insulin slowly loses effectiveness in regulating blood sugar levels This is the body s way of attempting to maintain blood sug
83. tables may be eaten raw or steamed Eat cooked vegetables without sauces and with little margarine FLUIDS Drink 6 to 8 Soda pop can size glasses of liquid each day Or follow your caregiver s advice if you must limit the amount of liquid you drink Some times when you feel a food craving you are really more thirsty than hungry So make sure that you have water and other low calorie liquids available all the time Limit fruit juices to 1 to 2 small glasses per day because they are high in calories Limit how much alcohol you drink Alcoholic drinks have many calories and can weaken your will power with food Alcohol can also make you hungrier than usual PROTEIN FOODS Make sure your diet plan allows plenty of protein while you are losing weight This will help you feel stronger while you are eating a lot fewer calories Choose meat fish and poultry that is very lean before cooking Remove all fat from meats and skin from poultry before cooking Nuts and seeds are high in fat so limit the amount you eat Do not eat more than 3 to 4 eggs a week Use low fat and fat free dairy products salad dressings and cheeses SNACKS Fresh vegetables with fat free dip are a healthy snack food Fat free rice cakes and rye crackers contain fiber and starch which helps you feel full Avoid foods high in sugar such as candy cookies and pastries Also avoid high fat snacks such as nuts regular chips and chocolate foods Instead try baked or fat free chips
84. th If those germs settle into your gums you ve got gum disease Unfortunately if you have diabetes you are at higher risk for gum problems Poor blood glucose control makes gum problems more likely To help prevent damage to your teeth and gums take diabetes and dental care seriously Make a commitment to managing your diabetes Monitor your blood sugar level and follow your doctor s instructions for keeping your blood sugar level within your target range The better you control your blood sugar level the less likely you are to develop gingivitis and other dental problems Brush your teeth at least twice a day Brush in the morning at night and ideally after meals and snacks Use a soft bristled toothbrush and toothpaste that contains fluoride Avoid vigorous or harsh scrubbing which can irritate your gums Consider using an electric toothbrush especially if you have arthritis or other problems that make it difficult to brush well Floss your teeth at least once a day Flossing helps remove plaque between your teeth and under your gumline If you have trouble getting floss through your teeth use the waxed variety If it s hard to manipulate the floss use a floss holder Schedule regular dental cleanings Visit your dentist at least twice a year for professional cleanings Remind your dentist that you have diabetes To prevent low blood sugar during dental work you might want to eat before your dental visits Take special prec
85. than 240 mg dl drink one cup 8 02 of fluids like water broth or sugar free caffeine free tea or diet soda every one to two hours e f your blood glucose is less than 240 mg dl drink fluids with 10 to 15 grams of carbohydrate every one to two hours e Replace missed meals or snacks with 50 grams of carbohydrate or follow a sick day meal plan designed for you e Some liquids and semi liquids to try Build a Sick Day Kit Along with your sick day meal plan you need a sick day kit The kit might include the following items m Extra blood glucose strips Do not use strips if past the expiration date m Urine ketone strips or blood ketone strips if you have type 1 diabetes m Thermometer m Doctor s phone number m Instructions from the doctor about extra insulin coverage DON T FORGET WHEN YOU ARE SICK m Always take your medications insulin or diabetes pill m Your blood glucose levels will increase m Test your blood glucose and ketones if you have type 1diabetes more often m Keep in touch with your health care team m Be alert to the effects of over the counter drugs on your blood glucose Medications That Can Affect Diabetes Some medications can have an effect on diabetes control For this reason always tell your diabetes health care team about any new medications you are using This includes prescription and nonprescription drugs Follow these guidelines when choosing nonprescription drugs Read all labels care
86. these food groups No You need a variety of foods from all the food groups to be healthy With the Plate Method you can start to control your blood sugar levels When you eat about the same amount of food on your plate at each meal you can help avoid blood sugar swings It is best not to skip a food group You need the nutrients from each food group to stay healthy A diet low in fruits and whole grains is also low in fiber and many vitamins and minerals You cannot trade meat and vegetable servings What are Basic Portion Sizes for 1 4th a plate or small dish or small coffee cup e One deck of cards 1 2 chicken breast small pork chop steak hamburger patty fish filet e One piece one slice toast or one small apple or small banana e One half hamburger bun English muffin large banana or grapefruit e 1 2 cup mashed potatoes cut up fruit or juice e One cup milk yogurt melon berries or soup Question What about snacks Plan on saving the fruit serving at meals and have it later between meals as a snack Question What about desserts Your fruit can be traded for a small dessert use the small dish to help watch the serving size If you trade too often your weight may suffer Also make sure the serving size of desserts is small so it does not raise your blood sugar Question I m not a big eater I can t eat that much food You do not need to fill the parts of the plate top full Remember the key is CON
87. tones to build up in the blood Ketones can cause the blood to be acidic and this can make you very sick diabetic ketoacidosis If ketones are present it is important to act quickly How to prevent DKA when blood glucose levels are high m Follow guidelines for sick days 35 m Don t stop taking your insulin m Test your blood glucose every two to four hours m f your blood glucose is more than 240 mg dl check for ketones in your blood or urine m Drink more fluids such as water sugar free catfeine free soda broth or tea m Once your blood glucose is in control examine your daily activities to help you understand why you became ill If you changed your diet medications or activity level it may have contributed to severe hyperglycemia Early Symptoms of DKA Late Symptoms of DKA Thirst A fruity odor to breath Need to urinate more often Nausea and vomiting Dry mouth Confusion High blood glucose levels Fatigue Ketones in urine or blood Abdominal pain WHEN TO CALL YOUR HEALTH CARE TEAM m If you do not have a plan to adjust insulin during hyperglycemic events m If your blood glucose remains more than 240 mg dl for two tests in a row m f urine or blood ketones are present m f you have vomiting or diarrhea lasting for more than four hours or are unable to eat or drink Unless treated early DKA will require treatment in a hospital with insulin and fluids Your health care provider will also identify and treat the cause of DKA Pr
88. ucing pancreas is still producing some some insulin But the body cells don t respond as they should insulin But the body cells don t This is called insulin resistance When the body cells are respond as they should This is resistant it takes more and more insulin to move glucose into called insulin resistance When the cells the body cells are resistant it takes more and more insulin to move glucose into the cells So the pancreas begins to release a higher than normal amount of insulin This extra insulin production may keep the blood glucose normal or close to normal for many years Type 2 is a progressive condition Eventually the pancreas cannot keep up with the demand 4 Insulin production starts to decline When there is no longer enough insulin released from the pancreas the blood glucose level rises too high Over the years the pancreas may eventually stop making insulin altogether Also in type 2 diabetes the liver releases extra glucose into the bloodstream raising the glucose level even higher Uncontrolled Type 2 diabetes is a progressive condition Eventually the pancreas cannot keep up with the demand Insulin production starts to decline When there is no longer enough insulin released from the pancreas the blood glucose level rises too high Over the years the pancreas may eventually stop making insulin altogether Also in type 2 diabetes the liver releases extra glucose into the bloodstream raising the glucose
89. years and older People who are disabled or have become disabled also can apply for Medicare and limited coverage is available for people of all ages with kidney failure To learn if you re eligible check with your local Social Security office or call the Medicare Hotline listed below Medicare now includes coverage for glucose monitors test strips and lancets as well as medical nutrition therapy services for people with diabetes or kidney disease when referred by a doctor Diabetes self management training therapeutic shoes glaucoma screening and flu and pneumonia shots are also covered For more information about Medicare benefits call the National Diabetes Education Program at 800 438 5383 and request copies of The Power to Control Diabetes Is in Your Hands and Expanded Medicare Coverage of Diabetes Services or read them online at www ndep nih gov click on Control under About Diabetes and Pre Diabetes You can also read the booklet Medicare Coverage of Diabetes Supplies amp Services PDF online or request a copy from Centers for Medicare amp Medicaid Services 7500 Security Boulevard Baltimore MD 21244 1850 Phone 800 MEDICARE 633 4227 Internet www medicare gov Medicaid Medicaid is a state health assistance program for people based on financial need Your income must be below a certain level to qualify for Medicaid funds To apply talk with a social worker or contact your local department of human services Check the gover

LIVING WELL WITH DIABETES - Washington Association of

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