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{{short description|Management of diabetes}} {{short description|Management of diabetes}}
The main goal of '''diabetes management''' is to keep blood glucose levels as normal as possible.<ref name=":3">{{Cite web |title=TDS Health |url=https://online.statref.com/login?path=document%2FGs81yTNniijHr7YSuIlBPj |access-date=2024-10-30 |website=online.statref.com}}</ref> If diabetes is not well controlled, further challenges to health may occur.<ref name=":3" /> People with diabetes can measure blood sugar by various methods, such as with a blood glucose meter or a continuous glucose monitor, which monitors over several days.<ref name=":5">{{Cite web |title=Diabetes - NIDDK |url=https://www.niddk.nih.gov/health-information/diabetes#:~:text=Diabetes%20is%20a%20disease%20that,eye%20problems,%20and%20kidney%20disease. |access-date=2024-10-30 |website=National Institute of Diabetes and Digestive and Kidney Diseases |language=en-US}}</ref> Glucose can also be measured by analysis of a routine blood sample.<ref name=":5" /> Usually, people are recommended to control diet, exercise, and maintain a healthy weight, although some people may need medications to control their blood sugar levels. Other goals of diabetes management are to prevent or treat complications that can result from the disease itself and from its treatment.<ref>{{cite journal | vauthors = Simó R, Hernández C | title = | journal = Revista Espanola de Cardiologia | volume = 55 | issue = 8 | pages = 845–860 | date = August 2002 | pmid = 12199981 | doi = 10.1016/s0300-8932(02)76714-6 }}</ref> The main goal of '''diabetes management''' is to keep blood glucose (BG) levels as normal as possible.<ref name=":3">{{Cite web |title=TDS Health |url=https://online.statref.com/login?path=document%2FGs81yTNniijHr7YSuIlBPj |access-date=2024-10-30 |website=online.statref.com}}</ref> If diabetes is not well controlled, further challenges to health may occur.<ref name=":3" /> People with diabetes can measure blood sugar by various methods, such as with a BG meter or a continuous glucose monitor, which monitors over several days.<ref name=":5">{{Cite web |title=Diabetes - NIDDK |url=https://www.niddk.nih.gov/health-information/diabetes#:~:text=Diabetes%20is%20a%20disease%20that,eye%20problems,%20and%20kidney%20disease. |access-date=2024-10-30 |website=National Institute of Diabetes and Digestive and Kidney Diseases |language=en-US}}</ref> Glucose can also be measured by analysis of a routine blood sample.<ref name=":5" /> Usually, people are recommended to control diet, exercise, and maintain a healthy weight, although some people may need medications to control their blood sugar levels. Other goals of diabetes management are to prevent or treat complications that can result from the disease itself and from its treatment.<ref>{{cite journal | vauthors = Simó R, Hernández C | title = | journal = Revista Espanola de Cardiologia | volume = 55 | issue = 8 | pages = 845–860 | date = August 2002 | pmid = 12199981 | doi = 10.1016/s0300-8932(02)76714-6 }}</ref>


== Description == == Description ==
Diabetes is a chronic disease and it is important to have control of the diabetes as it can cause many complications. Diabetes can cause acute problems such as too low (]) or high blood sugar (]). Diabetes affects the blood vessels in the body, such as capillaries and arteries, which are the routes blood take to deliver nutrients and oxygen to the organs in the body.<ref name=":4">{{Cite journal |last=Kushner |first=Pamela R. |last2=Cavender |first2=Matthew A. |last3=Mende |first3=Christian W. |date=2022-10-14 |title=Role of Primary Care Clinicians in the Management of Patients With Type 2 Diabetes and Cardiorenal Diseases |url=https://diabetesjournals.org/clinical/article/40/4/401/144956/Role-of-Primary-Care-Clinicians-in-the-Management |journal=Clinical Diabetes |language=en |volume=40 |issue=4 |pages=401–412 |doi=10.2337/cd21-0119 |issn=0891-8929 |pmc=9606551 |pmid=36381309}}</ref> By affecting the blood flow, diabetes increases the risk of other conditions such as strokes and heart disease (heart attacks).<ref name=":5" /> Diabetes also affects small blood vessels, such as capillaries, in organs such as the eyes and the kidneys to cause diabetic retinopathy and diabetic nephropathy, respectively.<ref name=":4" /> Diabetes is a chronic disease and it is important to have control of the diabetes as it can cause many complications. Diabetes can cause acute problems such as too low (]) or high blood sugar (]). Diabetes affects the blood vessels in the body, such as capillaries and arteries, which are the routes blood take to deliver nutrients and oxygen to the organs in the body.<ref name=":4">{{Cite journal |last1=Kushner |first1=Pamela R. |last2=Cavender |first2=Matthew A. |last3=Mende |first3=Christian W. |date=2022-10-14 |title=Role of Primary Care Clinicians in the Management of Patients With Type 2 Diabetes and Cardiorenal Diseases |url=https://diabetesjournals.org/clinical/article/40/4/401/144956/Role-of-Primary-Care-Clinicians-in-the-Management |journal=Clinical Diabetes |language=en |volume=40 |issue=4 |pages=401–412 |doi=10.2337/cd21-0119 |issn=0891-8929 |pmc=9606551 |pmid=36381309}}</ref> By affecting the blood flow, diabetes increases the risk of other conditions such as strokes and heart disease (heart attacks).<ref name=":5" /> Diabetes also affects small blood vessels, such as capillaries, in organs such as the eyes and the kidneys to cause diabetic retinopathy and diabetic nephropathy, respectively.<ref name=":4" />


Therefore, it becomes important to lower the sugar levels in the body in addition to control other risk factors that also contribute to the major complications such as smoking, alcohol use, excessive weight, ], and ].<ref name=":3" /> Often, the recommended treatment is a combination of lifestyle changes such as increasing exercise and healthy eating, along with medications to help control the blood glucose levels in the long term.<ref name=":5" /> In addition to management of the diabetes, patients are recommended to have routine follow up with specialist to manage possible common complications due to the diabetes such as foot ulcers, vision changes, and hearing loss.<ref>{{Cite web |last=CDC |date=2024-07-26 |title=Your Diabetes Care Schedule |url=https://www.cdc.gov/diabetes/treatment/your-diabetes-care-schedule.html#:~:text=If%20you're%20meeting%20your%20treatment%20goals,%20visit%20your%20doctor,had%20diabetes-related%20foot%20problems. |access-date=2024-11-06 |website=Diabetes |language=en-us}}</ref> Therefore, it becomes important to lower the sugar levels in the body in addition to control other risk factors that also contribute to the major complications such as smoking, alcohol use, excessive weight, ], and ].<ref name=":3" /> Often, the recommended treatment is a combination of lifestyle changes such as increasing exercise and healthy eating, along with medications to help control the BG levels in the long term.<ref name=":5" /> In addition to management of the diabetes, patients are recommended to have routine follow up with specialist to manage possible common complications due to the diabetes such as foot ulcers, vision changes, and hearing loss.<ref>{{Cite web |last=CDC |date=2024-07-26 |title=Your Diabetes Care Schedule |url=https://www.cdc.gov/diabetes/treatment/your-diabetes-care-schedule.html#:~:text=If%20you're%20meeting%20your%20treatment%20goals,%20visit%20your%20doctor,had%20diabetes-related%20foot%20problems. |access-date=2024-11-06 |website=Diabetes |language=en-us}}</ref>


===Measurement=== ===Measurement===
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] ]
The glucose meter (as seen in image 2) is a common a simple method in which glucose levels can be measured at home or in a clinical setting and is usually done several times per day. The test works by taking a small blood sample of blood using a lancet (a sterile pointed needle) to prick a finger (Image 1). The blood droplet is usually collected at the bottom of a test strip, while the other end is inserted in the glucose meter.<ref>{{Cite web |title=Monitoring blood glucose - Series&mdash;Record your reading: MedlinePlus Medical Encyclopedia |url=https://medlineplus.gov/ency/presentations/100220_5.htm |access-date=2024-10-31 |website=medlineplus.gov |language=en}}</ref> The drop of blood is drawn into the meter and can directly measure the glucose in the sample. The units of blood sugar level from a ], with the result either in mg/dL (milligrams per deciliter in the US) or mmol/L (millimoles per liter in Canada and Eastern The glucose meter (as seen in image 2) is a common a simple method in which glucose levels can be measured at home or in a clinical setting and is usually done several times per day. The test works by taking a small blood sample of blood using a lancet (a sterile pointed needle) to prick a finger (Image 1). The blood droplet is usually collected at the bottom of a test strip, while the other end is inserted in the glucose meter.<ref>{{Cite web |title=Monitoring blood glucose - Series&mdash;Record your reading: MedlinePlus Medical Encyclopedia |url=https://medlineplus.gov/ency/presentations/100220_5.htm |access-date=2024-10-31 |website=medlineplus.gov |language=en}}</ref> The drop of blood is drawn into the meter and can directly measure the glucose in the sample. The units of blood sugar level from a ], with the result either in mg/dL (milligrams per deciliter in the US) or mmol/L (millimoles per liter in Canada and Eastern
]), displaying a reading of 5.4&nbsp;mmol/L (98&nbsp;mg/dL).]] ]), displaying a reading of 5.4&nbsp;mmol/L (98&nbsp;mg/dL).]]
Europe) of blood.<ref name=":7">{{Cite web |title=Monitoring Your Blood |url=https://dtc.ucsf.edu/types-of-diabetes/type1/treatment-of-type-1-diabetes/monitoring-diabetes/monitoring-your-blood/ |access-date=2024-10-31 |website=Diabetes Education Online |language=en-US}}</ref> Control of diabetes may be improved by patients using home ]s to regularly measure their ] levels.<ref>{{Cite web |date=2019-01-15 |title=Blood glucose and blood sugar are interchangeable terms, and both are crucial to the health of the body; especially for people with diabetes. |url=https://www.diabetes.co.uk/diabetes_care/diabetes_and_blood_glucose.html |access-date=2021-09-12 |website=Diabetes |language=en-GB}}</ref> Europe) of blood.<ref name=":7">{{Cite web |title=Monitoring Your Blood |url=https://dtc.ucsf.edu/types-of-diabetes/type1/treatment-of-type-1-diabetes/monitoring-diabetes/monitoring-your-blood/ |access-date=2024-10-31 |website=Diabetes Education Online |language=en-US}}</ref> Control of diabetes may be improved by patients using home ]s to regularly measure their ] levels.<ref>{{Cite web |date=2019-01-15 |title=Blood glucose and blood sugar are interchangeable terms, and both are crucial to the health of the body; especially for people with diabetes. |url=https://www.diabetes.co.uk/diabetes_care/diabetes_and_blood_glucose.html |access-date=2021-09-12 |website=Diabetes |language=en-GB}}</ref>
] ]
]s are another method to measure blood glucose levels. A CGM is a device that sits on the surface of the skin and measures the amount of glucose between the cells with a probe. The device does not directly measure the blood sugar but calculates it based on the sample of the measurements it takes from the probe.<ref name=":7" /> The device will report the glucose level continuously and usually it has an alarm that will alert patients if the glucose level is too high or low.<ref name=":7" /> The device also is able to graph the glucose readings over the time the sensor was in use and is very useful for adjusting treatment.<ref name=":7" /> ]s are another method to measure BG levels. A CGM is a device that sits on the surface of the skin and measures the amount of glucose between the cells with a probe. The device does not directly measure the blood sugar but calculates it based on the sample of the measurements it takes from the probe.<ref name=":7" /> The device will report the glucose level continuously and usually it has an alarm that will alert patients if the glucose level is too high or low.<ref name=":7" /> The device also is able to graph the glucose readings over the time the sensor was in use and is very useful for adjusting treatment.<ref name=":7" />


In addition to the above tests, glucose can be measured on routine labs. One common test ordered by healthcare providers is a Basic Metabolic Panel (BMP) which is a blood test that looks at several different substances in the body, including blood glucose.<ref>{{Cite web |title=Basic Metabolic Panel (BMP): MedlinePlus Medical Test |url=https://medlineplus.gov/lab-tests/basic-metabolic-panel-bmp/ |access-date=2024-10-31 |website=medlineplus.gov |language=en}}</ref> People are told to fast for 8 hours before drawing the labs so that the provider can see the fasting glucose level.<ref name=":5" /> The normal level for fasting blood sugar in non-diabetic patients is 70 to 99 mg/dL (3.9 and 5.5 mmol/L). In addition to the above tests, glucose can be measured on routine labs. One common test ordered by healthcare providers is a Basic Metabolic Panel (BMP) which is a blood test that looks at several different substances in the body, including BG.<ref>{{Cite web |title=Basic Metabolic Panel (BMP): MedlinePlus Medical Test |url=https://medlineplus.gov/lab-tests/basic-metabolic-panel-bmp/ |access-date=2024-10-31 |website=medlineplus.gov |language=en}}</ref> People are told to fast for 8 hours before drawing the labs so that the provider can see the fasting glucose level.<ref name=":5" /> The normal level for fasting blood sugar in non-diabetic patients is 70 to 99&nbsp;mg/dL (3.9 and 5.5&nbsp;mmol/L).


Another useful test that has usually done in a laboratory is the measurement of blood ] levels. In the blood, there is a molecule called ] which carries oxygen to the cells. Glucose can attach itself to this molecule and if the blood glucose is consistently high, the value of the A1c will go up. This test, unlike the other tests, is measured as a percentage because the test measure the proportion of all the hemoglobin that has glucose attached.<ref name=":5" /><ref name=":8">{{Cite web |title=A1C |url=https://medlineplus.gov/a1c.html |access-date=2024-10-31 |website=medlineplus.gov}}</ref> This test measures the average amount of diabetic control over a period of about 3 months.<ref name=":8" /> In non-diabetic people, the HbA1c level ranges from 4.0 to 5.7%.<ref name=":8" /> Regular 6 monthly laboratory testing of ] (glycated hemoglobin) provides some assurance of long-term control and allows the adjustment of the patient's routine medication dosages in such cases. Another useful test that has usually done in a laboratory is the measurement of blood ] levels. In the blood, there is a molecule called ] which carries oxygen to the cells. Glucose can attach itself to this molecule and if the BG is consistently high, the value of the A1c will go up. This test, unlike the other tests, is measured as a percentage because the test measure the proportion of all the hemoglobin that has glucose attached.<ref name=":5" /><ref name=":8">{{Cite web |title=A1C |url=https://medlineplus.gov/a1c.html |access-date=2024-10-31 |website=medlineplus.gov}}</ref> This test measures the average amount of diabetic control over a period of about 3 months.<ref name=":8" /> In non-diabetic people, the HbA1c level ranges from 4.0 to 5.7%.<ref name=":8" /> Regular 6 monthly laboratory testing of ] (glycated hemoglobin) provides some assurance of long-term control and allows the adjustment of the patient's routine medication dosages in such cases.


Optimal management of diabetes involves people measuring and recording their own ] levels. By keeping a diary of their own blood glucose measurements and noting the effect of food and exercise, patients can modify their lifestyle to better control their diabetes. For people on insulin, involvement is important in achieving effective dosing and timing. Optimal management of diabetes involves people measuring and recording their own ] levels. By keeping a diary of their own BG measurements and noting the effect of food and exercise, patients can modify their lifestyle to better control their diabetes. For people on insulin, involvement is important in achieving effective dosing and timing.

===Glycemic control===
''Glycemic control'' is a medical term referring to the typical levels of BG in a person with ]. Much evidence suggests that many of the long-term complications of diabetes, result from many years of ] (elevated levels of glucose in the blood).<ref>{{Cite journal |last1=Nanayakkara |first1=Natalie |last2=Curtis |first2=Andrea J. |last3=Heritier |first3=Stephane |last4=Gadowski |first4=Adelle M. |last5=Pavkov |first5=Meda E. |last6=Kenealy |first6=Timothy |last7=Owens |first7=David R. |last8=Thomas |first8=Rebecca L. |last9=Song |first9=Soon |last10=Wong |first10=Jencia |last11=Chan |first11=Juliana C.-N. |last12=Luk |first12=Andrea O.-Y. |last13=Penno |first13=Giuseppe |last14=Ji |first14=Linong |last15=Mohan |first15=Viswanathan |date=February 2021 |title=Impact of age at type 2 diabetes mellitus diagnosis on mortality and vascular complications: systematic review and meta-analyses |journal=Diabetologia |language=en |volume=64 |issue=2 |pages=275–287 |doi=10.1007/s00125-020-05319-w |issn=0012-186X |pmc=7801294 |pmid=33313987}}</ref>

"Perfect glycemic control" would mean that glucose levels were always normal (70–130&nbsp;mg/dL or 3.9–7.2&nbsp;mmol/L) and indistinguishable from a person without diabetes. Good glycemic control, in the sense of a "target" for treatment, has become an important goal of diabetes care. Poor glycemic control refers to persistently (over several months) elevated BG in the 200 to 500&nbsp;mg/dL (11–28&nbsp;mmol/L). This is also measured by Hb A1c levels, which may range from greater than 9%.


===Goals=== ===Goals===
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The targets are: The targets are:
* Hb<sub>A1c</sub> of less than 6% or 7.0% if they are achievable without significant hypoglycemia<ref name=ADA2019>{{cite journal | author = American Diabetes Association | title = 6. Glycemic Targets: ''Standards of Medical Care in Diabetes-2019'' | journal = Diabetes Care | volume = 42 | issue = Suppl 1 | pages = S61–S70 | date = January 2019 | pmid = 30559232 | doi = 10.2337/dc19-S006 | doi-access = free }}</ref><ref name=pmidpending>{{cite journal | vauthors = Qaseem A, Vijan S, Snow V, Cross JT, Weiss KB, Owens DK | title = Glycemic control and type 2 diabetes mellitus: the optimal hemoglobin A1c targets. A guidance statement from the American College of Physicians | journal = Annals of Internal Medicine | volume = 147 | issue = 6 | pages = 417–422 | date = September 2007 | pmid = 17876024 | doi = 10.7326/0003-4819-147-6-200709180-00012 | doi-access = free }}</ref> * Hb<sub>A1c</sub> of less than 6% or 7.0% if they are achievable without significant hypoglycemia<ref name=ADA2019>{{cite journal | author = American Diabetes Association | title = 6. Glycemic Targets: ''Standards of Medical Care in Diabetes-2019'' | journal = Diabetes Care | volume = 42 | issue = Suppl 1 | pages = S61–S70 | date = January 2019 | pmid = 30559232 | doi = 10.2337/dc19-S006 | doi-access = free }}</ref><ref name=pmidpending>{{cite journal | vauthors = Qaseem A, Vijan S, Snow V, Cross JT, Weiss KB, Owens DK | title = Glycemic control and type 2 diabetes mellitus: the optimal hemoglobin A1c targets. A guidance statement from the American College of Physicians | journal = Annals of Internal Medicine | volume = 147 | issue = 6 | pages = 417–422 | date = September 2007 | pmid = 17876024 | doi = 10.7326/0003-4819-147-6-200709180-00012 | doi-access = free }}</ref>
* ] (before eating) blood glucose: 3.9 to 7.2&nbsp;mmol/L (70 to 130&nbsp;mg/dL)<ref name=ADA2019/> * ] (before eating) BG: 3.9 to 7.2&nbsp;mmol/L (70 to 130&nbsp;mg/dL)<ref name=ADA2019/>
* 2-hour ] (after eating) blood glucose: <10&nbsp;mmol/L (<180&nbsp;mg/dL)<ref name=ADA2019/> * 2-hour ] (after eating) BG: <10&nbsp;mmol/L (<180&nbsp;mg/dL)<ref name=ADA2019/>


Goals should be individualized based on:<ref name=ADA2019/> Goals should be individualized based on:<ref name=ADA2019/>
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In older patients, ]s by the ] recommend, in frail patients who have a life expectancy of less than 5 years, a target a Hb A1c of 8% is appropriate as the risk of very low blood sugar outweighs the long term benefits of a lower A1c.<ref name=pmid12694461>{{cite journal | vauthors = Brown AF, Mangione CM, Saliba D, Sarkisian CA | title = Guidelines for improving the care of the older person with diabetes mellitus | journal = Journal of the American Geriatrics Society | volume = 51 | issue = 5 Suppl Guidelines | pages = S265–S280 | date = May 2003 | pmid = 12694461 | doi = 10.1046/j.1532-5415.51.5s.1.x | s2cid = 9149226 }}</ref> In older patients, ]s by the ] recommend, in frail patients who have a life expectancy of less than 5 years, a target a Hb A1c of 8% is appropriate as the risk of very low blood sugar outweighs the long term benefits of a lower A1c.<ref name=pmid12694461>{{cite journal | vauthors = Brown AF, Mangione CM, Saliba D, Sarkisian CA | title = Guidelines for improving the care of the older person with diabetes mellitus | journal = Journal of the American Geriatrics Society | volume = 51 | issue = 5 Suppl Guidelines | pages = S265–S280 | date = May 2003 | pmid = 12694461 | doi = 10.1046/j.1532-5415.51.5s.1.x | s2cid = 9149226 }}</ref>

Studies have been done to compare the effects of ] vs. conventional, or more relaxed, glycemic control in type 2 diabetics. It shows than to demonstrate a difference in all-cause cardiovascular death, non-fatal stroke, or limb amputation, but decreased the risk of nonfatal heart attack by 15%.<ref name=":16">{{cite journal |display-authors=6 |vauthors=Buehler AM, Cavalcanti AB, Berwanger O, Figueiro M, Laranjeira LN, Zazula AD, Kioshi B, Bugano DG, Santucci E, Sbruzzi G, Guimaraes HP, Carvalho VO, Bordin SA |date=June 2013 |title=Effect of tight blood glucose control versus conventional control in patients with type 2 diabetes mellitus: a systematic review with meta-analysis of randomized controlled trials |journal=Cardiovascular Therapeutics |volume=31 |issue=3 |pages=147–160 |doi=10.1111/j.1755-5922.2011.00308.x |pmid=22212499 |doi-access=free}}</ref> Additionally, tight glucose control decreased the risk of progression of kidney, nerve and eye complications, but increased the risk of hypoglycemia.<ref name=":16" />


==Lifestyle modification== ==Lifestyle modification==
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{{Main|Diet in diabetes}} {{Main|Diet in diabetes}}


There are many diets that are effective at managing diabetes and it is important that patients understand that there is no one diet that all patients should use.<ref name=":6">{{Cite book |last=McDermott |first=Michael |title=Diabetes Secrets |date= |publisher=Elsevier |year=2022 |isbn=978-0-323-79262-2 |pages=52-54}}</ref> Some diets that have commonly been used successfully in diabetes management and help with weight loss include Mediterranean, vegetarian, low carb or carb-controlled.<ref name=":6" /> It is recommended that patients choose a diet that the patient can adhere to in the long run as a diet that is very ideal is impractical if the patient has trouble following it.<ref name=":6" /> There are many diets that are effective at managing diabetes and it is important that patients understand that there is no one diet that all patients should use.<ref name=":6">{{Cite book |last=McDermott |first=Michael |title=Diabetes Secrets |publisher=Elsevier |year=2022 |isbn=978-0-323-79262-2 |pages=52–54}}</ref> Some diets that have commonly been used successfully in diabetes management and help with weight loss include Mediterranean, vegetarian, low carb or carb-controlled.<ref name=":6" /> It is recommended that patients choose a diet that the patient can adhere to in the long run as a diet that is very ideal is impractical if the patient has trouble following it.<ref name=":6" />


A regular diet that has reduced variability in carbohydrates is an important factor in producing normal blood sugars. Patients with diabetes should eat preferably a balanced and ]. Meals should consist of half a plate of non-starchy vegetables, 1/4 plate of lean protein, and 1/4 plate of starch/grain.<ref name=":6" /> Patients should avoid excess simple carbs or added fat (such as butter, salad dressing) and instead eat complex carbohydrates such as whole grains.<ref name=":3" /> In the long term, it is helpful to eat a consistent diet and amount of carbohydrate to make blood sugar management easier.<ref name="t1diet">{{cite web |title=I have Type 1 diabetes – what can I eat? |url=https://www.diabetes.org.uk/diabetes-the-basics/food-and-diabetes/i-have-type-1-diabetes |access-date=14 June 2019 |publisher=]}}</ref> It is important for patients to eat 3 meals a day as well in order to reduce the chances of hypoglycemia, especially with patients that take insulin.<ref name=":3" /> A regular diet that has reduced variability in carbohydrates is an important factor in producing normal blood sugars. Patients with diabetes should eat preferably a balanced and ]. Meals should consist of half a plate of non-starchy vegetables, 1/4 plate of lean protein, and 1/4 plate of starch/grain.<ref name=":6" /> Patients should avoid excess simple carbs or added fat (such as butter, salad dressing) and instead eat complex carbohydrates such as whole grains.<ref name=":3" /> In the long term, it is helpful to eat a consistent diet and amount of carbohydrate to make blood sugar management easier.<ref name="t1diet">{{cite web |title=I have Type 1 diabetes – what can I eat? |url=https://www.diabetes.org.uk/diabetes-the-basics/food-and-diabetes/i-have-type-1-diabetes |access-date=14 June 2019 |publisher=]}}</ref> It is important for patients to eat 3 meals a day as well in order to reduce the chances of hypoglycemia, especially with patients that take insulin.<ref name=":3" />


There is a lack of evidence of the usefulness of low-carbohydrate dieting for people with ].<ref name="ups">{{cite journal |vauthors=Seckold R, Fisher E, de Bock M, King BR, Smart CE |date=March 2019 |title=The ups and downs of low-carbohydrate diets in the management of Type 1 diabetes: a review of clinical outcomes |journal=Diabetic Medicine |type=Review |volume=36 |issue=3 |pages=326–334 |doi=10.1111/dme.13845 |pmid=30362180 |s2cid=53102654 |quote=Low‐carbohydrate diets are of interest for improving glycaemic outcomes in the management of Type 1 diabetes. There is limited evidence to support their routine use in the management of Type 1 diabetes.}}</ref> Although for certain individuals it may be feasible to follow a low-carbohydrate regime combined with carefully managed ] dosing, this is hard to maintain and there are concerns about potential adverse health effects caused by the diet.<ref name="ups" /> In general people with type 1 diabetes are advised to follow an individualized eating plan rather than a pre-decided one.<ref name="ups" /> There is a lack of evidence of the usefulness of low-carbohydrate dieting for people with ] (T1D).<ref name="ups">{{cite journal |vauthors=Seckold R, Fisher E, de Bock M, King BR, Smart CE |date=March 2019 |title=The ups and downs of low-carbohydrate diets in the management of Type 1 diabetes: a review of clinical outcomes |journal=Diabetic Medicine |type=Review |volume=36 |issue=3 |pages=326–334 |doi=10.1111/dme.13845 |pmid=30362180 |s2cid=53102654 |quote=Low‐carbohydrate diets are of interest for improving glycaemic outcomes in the management of Type 1 diabetes. There is limited evidence to support their routine use in the management of Type 1 diabetes.}}</ref> Although for certain individuals it may be feasible to follow a low-carbohydrate regime combined with carefully managed ] dosing, this is hard to maintain and there are concerns about potential adverse health effects caused by the diet.<ref name="ups" /> In general people with T1D are advised to follow an individualized eating plan rather than a pre-decided one.<ref name="ups" />


=== Exercise === === Exercise ===
Along with diet, exercise is also important for the management of diabetes.<ref>{{Cite web |title=TDS Health |url=https://online.statref.com/login?path=document%2Fcz8S6DOdCulIInZg_2AR8D |access-date=2024-10-31 |website=online.statref.com}}</ref> Not only does exercising regularly help manage blood sugar levels and weight, it helps reduce the risk of heart attack and stroke, reduces ] levels, reduces risk of diabetes related complications, increases the effect of insulin, provides a boost in energy levels, helps reduce stress, and contributes to positive self-esteem.<ref>{{Cite web |title=Managing Diabetes |url=https://diabetesresearch.org/managing-diabetes/ |access-date=2022-12-01 |website=DRIF |language=en-US}}</ref> By exercising, the body becomes more sensitive to insulin, allowing for better absorption of glucose by the muscle cells, for up to 24 hours after exercise.<ref>{{Cite web |title=Blood Sugar and Exercise {{!}} ADA |url=https://diabetes.org/healthy-living/fitness/getting-started-safely/blood-glucose-and-exercise |access-date=2022-11-20 |website=diabetes.org}}</ref> Therefore, an ongoing exercise program is required to maintain the health benefits associated with exercising.<ref name=":13">{{Cite journal |last1=KIRWAN |first1=JOHN P. |last2=SACKS |first2=JESSICA |last3=NIEUWOUDT |first3=STEPHAN |date=July 2017 |title=The essential role of exercise in the management of type 2 diabetes |journal=Cleveland Clinic Journal of Medicine |volume=84 |issue=7 Suppl 1 |pages=S15–S21 |doi=10.3949/ccjm.84.s1.03 |issn=0891-1150 |pmc=5846677 |pmid=28708479}}</ref> Along with diet, exercise is also important for the management of diabetes.<ref name="TDS Health">{{Cite web |title=TDS Health |url=https://online.statref.com/login?path=document%2Fcz8S6DOdCulIInZg_2AR8D |access-date=2024-10-31 |website=online.statref.com}}</ref> Not only does exercising regularly help manage blood sugar levels and weight, it helps reduce the risk of heart attack and stroke, reduces ] levels, reduces risk of diabetes related complications, increases the effect of insulin, provides a boost in energy levels, helps reduce stress, and contributes to positive self-esteem.<ref>{{Cite web |title=Managing Diabetes |url=https://diabetesresearch.org/managing-diabetes/ |access-date=2022-12-01 |website=DRIF |language=en-US}}</ref> By exercising, the body becomes more sensitive to insulin, allowing for better absorption of glucose by the muscle cells, for up to 24 hours after exercise.<ref>{{Cite web |title=Blood Sugar and Exercise {{!}} ADA |url=https://diabetes.org/healthy-living/fitness/getting-started-safely/blood-glucose-and-exercise |access-date=2022-11-20 |website=diabetes.org}}</ref> Therefore, an ongoing exercise program is required to maintain the health benefits associated with exercising.<ref name=":13">{{Cite journal |last1=KIRWAN |first1=JOHN P. |last2=SACKS |first2=JESSICA |last3=NIEUWOUDT |first3=STEPHAN |date=July 2017 |title=The essential role of exercise in the management of type 2 diabetes |journal=Cleveland Clinic Journal of Medicine |volume=84 |issue=7 Suppl 1 |pages=S15–S21 |doi=10.3949/ccjm.84.s1.03 |issn=0891-1150 |pmc=5846677 |pmid=28708479}}</ref>


In patients with type 2 diabetes, the combination of ] exercise and ], as recommended by the ] (ADA) guidelines, is the most effective when it comes to controlling glucose and cholesterol.<ref name=":22">{{Cite web |title=My Site – Chapter 10: Physical Activity and Diabetes |url=https://guidelines.diabetes.ca/cpg/chapter10 |access-date=2022-12-01 |website=guidelines.diabetes.ca}}</ref> Aerobic exercise has been shown to largely improve HbA1c, and contributes to weight loss and the enhanced regulation of cholesterol and ]s.<ref name=":13" /> This may be any form of continuous exercise that elevates breathing and heart rate such as walking, swimming, or dancing.<ref>{{Cite web |title=Physical activity |url=https://www.diabetes.ca/managing-my-diabetes/tools---resources/physical-activity |access-date=2022-11-20 |website=DiabetesCanadaWebsite |language=en}}</ref> During the last 20 years, resistance training has gained considerable recognition as an optimal form of exercise for patients with type two diabetes.<ref name=":13" /> By building muscle strength, strength training was linked to a 10% to 15% increase in strength, ], insulin sensitivity, muscle mass and decrease in blood pressure.<ref name=":13" /> In patients with type 2 diabetes (T2D), the combination of ] exercise and ], as recommended by the ] (ADA) guidelines, is the most effective when it comes to controlling glucose and cholesterol.<ref name=":22">{{Cite web |title=My Site – Chapter 10: Physical Activity and Diabetes |url=https://guidelines.diabetes.ca/cpg/chapter10 |access-date=2022-12-01 |website=guidelines.diabetes.ca}}</ref> Aerobic exercise has been shown to largely improve HbA1c, and contributes to weight loss and the enhanced regulation of cholesterol and ]s.<ref name=":13" /> This may be any form of continuous exercise that elevates breathing and heart rate such as walking, swimming, or dancing.<ref>{{Cite web |title=Physical activity |url=https://www.diabetes.ca/managing-my-diabetes/tools---resources/physical-activity |access-date=2022-11-20 |website=DiabetesCanadaWebsite |language=en}}</ref> During the last 20 years, resistance training has gained considerable recognition as an optimal form of exercise for patients with type two diabetes.<ref name=":13" /> By building muscle strength, strength training was linked to a 10% to 15% increase in strength, ], insulin sensitivity, muscle mass and decrease in blood pressure.<ref name=":13" />


Several studies have made it clear that exercise helps with blood sugar control and has shown to lower ] by approximately 0.6% in patients with type 2 diabetes. The ADA recommends 150 minutes of moderate to vigorous aerobic exercise a week spread over 3 to 7 days with no more than 2 day break between days. Moreover, patients should also pair the aerobic exercise with 2 to 3 nonconsecutive sessions of strength training. Several studies have made it clear that exercise helps with blood sugar control and has shown to lower ] by approximately 0.6% in patients with T2D. The ADA recommends 150 minutes of moderate to vigorous aerobic exercise a week spread over 3 to 7 days with no more than 2 day break between days. Moreover, patients should also pair the aerobic exercise with 2 to 3 nonconsecutive sessions of strength training.


In type 1 diabetes, there also have been studies that show that, in children and adolescent, there is an association between exercise and lower HB A1c.<ref name=":9">{{Cite journal |last=García‐Hermoso |first=Antonio |last2=Ezzatvar |first2=Yasmin |last3=Huerta‐Uribe |first3=Nidia |last4=Alonso‐Martínez |first4=Alicia M. |last5=Chueca‐Guindulain |first5=Maria J. |last6=Berrade‐Zubiri |first6=Sara |last7=Izquierdo |first7=Mikel |last8=Ramírez‐Vélez |first8=Robinson |date=June 2023 |title=Effects of exercise training on glycaemic control in youths with type 1 diabetes: A systematic review and meta‐analysis of randomised controlled trials |url=https://onlinelibrary.wiley.com/doi/10.1080/17461391.2022.2086489 |journal=European Journal of Sport Science |language=en |volume=23 |issue=6 |pages=1056–1067 |doi=10.1080/17461391.2022.2086489 |issn=1746-1391}}</ref> Furthermore, studies have shown that the longer the length of the exercise program, there is a further reduction in the HB A1c and patients have less insulin requirements.<ref name=":9" /> Although the population of these studies are limited to patients under the age of 18, exercise is beneficial in managing diabetes, whether its type 1 or 2.<ref name=":5" /> There are many benefits of exercise such as a decreased risk of cardiovascular diseases, including ], ]s, body composition and ].<ref name=":12">{{Cite journal |last=Lumb |first=Alistair |date=2014-12-01 |title=Diabetes and exercise |url=https://www.rcpjournals.org/content/clinmedicine/14/6/673 |journal=Clinical Medicine |language=en |volume=14 |issue=6 |pages=673–676 |doi=10.7861/clinmedicine.14-6-673 |issn=1470-2118 |pmc=4954144 |pmid=25468857}}</ref> In T1D, there also have been studies that show that, in children and adolescent, there is an association between exercise and lower HB A1c.<ref name=":9">{{Cite journal |last1=García-Hermoso |first1=Antonio |last2=Ezzatvar |first2=Yasmin |last3=Huerta-Uribe |first3=Nidia |last4=Alonso-Martínez |first4=Alicia M. |last5=Chueca-Guindulain |first5=Maria J. |last6=Berrade-Zubiri |first6=Sara |last7=Izquierdo |first7=Mikel |last8=Ramírez-Vélez |first8=Robinson |date=June 2023 |title=Effects of exercise training on glycaemic control in youths with type 1 diabetes: A systematic review and meta-analysis of randomised controlled trials |url=https://onlinelibrary.wiley.com/doi/10.1080/17461391.2022.2086489 |journal=European Journal of Sport Science |language=en |volume=23 |issue=6 |pages=1056–1067 |doi=10.1080/17461391.2022.2086489 |pmid=35659492 |issn=1746-1391|hdl=2454/43706 |hdl-access=free }}</ref> Furthermore, studies have shown that the longer the length of the exercise program, there is a further reduction in the HB A1c and patients have less insulin requirements.<ref name=":9" /> Although the population of these studies are limited to patients under the age of 18, exercise is beneficial in managing diabetes, whether its type 1 or 2.<ref name=":5" /> There are many benefits of exercise such as a decreased risk of cardiovascular diseases, including ], ]s, body composition and ].<ref name=":12">{{Cite journal |last=Lumb |first=Alistair |date=2014-12-01 |title=Diabetes and exercise |url=https://www.rcpjournals.org/content/clinmedicine/14/6/673 |journal=Clinical Medicine |language=en |volume=14 |issue=6 |pages=673–676 |doi=10.7861/clinmedicine.14-6-673 |issn=1470-2118 |pmc=4954144 |pmid=25468857}}</ref>


=== Weight Loss === === Weight Loss ===
] ]
In addition to diet and exercise, weight loss is an important tool to help with diabetes management. Type 2 diabetes is often associated with ] and increased abdominal circumference.<ref name=":15">{{Cite book |last=McDermott |first=Michael T. |url=https://en.wikipedia.org/Special:BookSources/978-0-323-79262-2 |title=Diabetes secrets |last2=Trujillo |first2=Jennifer M. |date=2022 |publisher=Elsevier |isbn=978-0-323-79262-2 |location=Philadelphia, PA}}</ref> Often patients who are at risk of diabetes may be able to reverse their progression to type 2 diabetes with weight loss as well.<ref name=":15" /> Weight loss can help reduce the risk of further complications, other health related problems, and helps improve the effects of insulin on the body.<ref name=":15" /><ref>{{Cite web |title=Losing Weight & Diabetes {{!}} ADA |url=https://diabetes.org/health-wellness/weight-management |access-date=2024-11-06 |website=diabetes.org}}</ref> Weight loss helps reduce the destruction of the beta cells, which produce insulin in the body, as well.<ref name=":15" /> In addition to diet and exercise, weight loss is an important tool to help with diabetes management. T2D is often associated with ] and increased abdominal circumference.<ref name=":15">{{Cite book |last1=McDermott |first1=Michael T. |url=https://en.wikipedia.org/Special:BookSources/978-0-323-79262-2 |title=Diabetes secrets |last2=Trujillo |first2=Jennifer M. |date=2022 |publisher=Elsevier |isbn=978-0-323-79262-2 |location=Philadelphia, PA}}</ref> Often patients who are at risk of diabetes may be able to reverse their progression to T2D with weight loss as well.<ref name=":15" /> Weight loss can help reduce the risk of further complications, other health related problems, and helps improve the effects of insulin on the body.<ref name=":15" /><ref>{{Cite web |title=Losing Weight & Diabetes {{!}} ADA |url=https://diabetes.org/health-wellness/weight-management |access-date=2024-11-06 |website=diabetes.org}}</ref> Weight loss helps reduce the destruction of the beta cells, which produce insulin in the body, as well.<ref name=":15" />


It is recommended for patients who have been diagnosed with type 2 diabetes who are ] or obese to lose at least 5% of their weight and maintain the weight loss. There have been studies that have demonstrated that by losing about 5 to 10% of their weight at diagnosis, there is a reduction in heart disease risk factors, lowered Hb A1c, less diabetes medications, lower cholesterol and improved fitness.<ref name=":15" /> Additionally, patients who lose more weight are better off in the long run.<ref name=":15" /> It is recommended for patients who have been diagnosed with T2D who are ] or obese to lose at least 5% of their weight and maintain the weight loss. There have been studies that have demonstrated that by losing about 5 to 10% of their weight at diagnosis, there is a reduction in heart disease risk factors, lowered Hb A1c, less diabetes medications, lower cholesterol and improved fitness.<ref name=":15" /> Additionally, patients who lose more weight are better off in the long run.<ref name=":15" />


Common strategies to help reduce weight many include lifestyle measures such as diet and exercise, behavioral therapy, pharmacologic interventions, and surgery. The goal of weight loss and method for achievement should be individualized based on the patient's desires and motivation.<ref name=":15" /> It is important for providers to help maintain patient motivation to lose weight. Additionally, some medications that reduce blood sugars such as ] may initially cause weight gain due to the increased conversion of blood sugar to stored forms such as fat.<ref name=":15" /> Therefore, in patients with diabetes, providers may try other medications that lower blood sugar but not cause as much weight gain.<ref name=":15" /> Common strategies to help reduce weight many include lifestyle measures such as diet and exercise, behavioral therapy, pharmacologic interventions, and surgery. The goal of weight loss and method for achievement should be individualized based on the patient's desires and motivation.<ref name=":15" /> It is important for providers to help maintain patient motivation to lose weight. Additionally, some medications that reduce blood sugars such as ] may initially cause weight gain due to the increased conversion of blood sugar to stored forms such as fat.<ref name=":15" /> Therefore, in patients with diabetes, providers may try other medications that lower blood sugar but not cause as much weight gain.<ref name=":15" />
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{{Main|Anti-diabetic drug}} {{Main|Anti-diabetic drug}}


There are several medications classes that are commonly used to control blood sugar levels in patients with diabetes. Most of the medications used are either oral or injected.<ref name=":3" /> In patients with type 1 diabetes, insulin is require because the body no longer produces insulin.<ref name=":5" /> In patients with type 2 diabetes, management is largely more variable as lifestyle changes can have a significant impact. However, medications may be added to further help control blood glucose levels if the lifestyle changes are not effectively controlling the condition. Unlike type 1 diabetic patients, patients with type 2 diabetes can still produce insulin, so usually these patients take oral medications first before requiring insulin for diabetic control.<ref name=":5" /> There are several medications classes that are commonly used to control blood sugar levels in patients with diabetes. Most of the medications used are either oral or injected.<ref name=":3" /> In patients with T1D, insulin is require because the body no longer produces insulin.<ref name=":5" /> In patients with T2D, management is largely more variable as lifestyle changes can have a significant impact. However, medications may be added to further help control BG levels if the lifestyle changes are not effectively controlling the condition. Unlike type 1 diabetic patients, patients with T2D can still produce insulin, so usually these patients take oral medications first before requiring insulin for diabetic control.<ref name=":5" />


Patient education<ref>{{cite journal |display-authors=6 |vauthors=Mannucci E, Giaccari A, Gallo M, Bonifazi A, Belén ÁD, Masini ML, Trento M, Monami M |date=February 2022 |title=Self-management in patients with type 2 diabetes: Group-based versus individual education. A systematic review with meta-analysis of randomized trails |journal=Nutrition, Metabolism, and Cardiovascular Diseases |volume=32 |issue=2 |pages=330–336 |doi=10.1016/j.numecd.2021.10.005 |pmid=34893413 |s2cid=244580173}}</ref> and compliance with treatment is very important in managing the disease. Improper use of medications and insulin can be very dangerous causing hypo- or hyper-glycemic episodes. Patient education<ref>{{cite journal |display-authors=6 |vauthors=Mannucci E, Giaccari A, Gallo M, Bonifazi A, Belén ÁD, Masini ML, Trento M, Monami M |date=February 2022 |title=Self-management in patients with type 2 diabetes: Group-based versus individual education. A systematic review with meta-analysis of randomized trails |journal=Nutrition, Metabolism, and Cardiovascular Diseases |volume=32 |issue=2 |pages=330–336 |doi=10.1016/j.numecd.2021.10.005 |pmid=34893413 |s2cid=244580173}}</ref> and compliance with treatment is very important in managing the disease. Improper use of medications and insulin can be very dangerous causing hypo- or hyper-glycemic episodes.
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{{main|Insulin therapy}} {{main|Insulin therapy}}
] ]
] is the hormone that is made by the body that controls the cell intake of glucose. Normally, the ] produces insulin in response to high glucose levels in the body to bring the blood glucose levels down. For type 1 diabetics, there will always be a need for insulin injections throughout their life, as the pancreatic ] of a type 1 diabetic are not capable of producing sufficient insulin.<ref name=":10">{{Cite web |title=TDS Health |url=https://online.statref.com/login?path=document%2FZV_WMCsRcvzxx0h_6lvGwj |access-date=2024-10-31 |website=online.statref.com}}</ref> Insulin can not be taken orally because insulin is a hormone and is destroyed by the digestive track. Insulin can be injected by several methods, including a ], ], or ]. There is also inhaled insulin that can be used in adults with diabetes.<ref>{{Cite web |title=Insulin, Medicines, & Other Diabetes Treatments - NIDDK |url=https://www.niddk.nih.gov/health-information/diabetes/overview/insulin-medicines-treatments |access-date=2024-10-31 |website=National Institute of Diabetes and Digestive and Kidney Diseases |language=en-US}}</ref> ] is the hormone that is made by the body that controls the cell intake of glucose. Normally, the ] produces insulin in response to high glucose levels in the body to bring the BG levels down. For type 1 diabetics, there will always be a need for insulin injections throughout their life, as the pancreatic ]s of a type 1 diabetic are not capable of producing sufficient insulin.<ref name=":10">{{Cite web |title=TDS Health |url=https://online.statref.com/login?path=document%2FZV_WMCsRcvzxx0h_6lvGwj |access-date=2024-10-31 |website=online.statref.com}}</ref> Insulin can not be taken orally because insulin is a hormone and is destroyed by the digestive track. Insulin can be injected by several methods, including a ], ], or ]. There is also inhaled insulin that can be used in adults with diabetes.<ref>{{Cite web |title=Insulin, Medicines, & Other Diabetes Treatments - NIDDK |url=https://www.niddk.nih.gov/health-information/diabetes/overview/insulin-medicines-treatments |access-date=2024-10-31 |website=National Institute of Diabetes and Digestive and Kidney Diseases |language=en-US}}</ref>


There are several types of insulin that are commonly used in medical practice, with varying times of onset and duration of action.<ref name=":10" /> There are several types of insulin that are commonly used in medical practice, with varying times of onset and duration of action.<ref name=":10" />
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- Short acting (i.e. regular insulin) with onset in 30 minutes and duration of about 6 hrs. - Short acting (i.e. regular insulin) with onset in 30 minutes and duration of about 6 hrs.


- Intermediate acting (i.e ] insulin) with onset in 2 hours and duration of about 14 hrs. - Intermediate acting (i.e ] insulin) with onset in 2 hours and duration of about 14 hrs.


- Long acting (i.e. detemir) with onset in 1 hr. and duration of about 24 hrs. - Long acting (i.e. detemir) with onset in 1 hr. and duration of about 24 hrs.


- Premixed which are usually combinations of short and long acting insulin. - Premixed which are usually combinations of short and long acting insulin.


Insulin is usually taken several times per day in patients who require it to control their diabetes.<ref name=":10" /> Often patients usually take long acting insulin once a day and then take insulin before meals. The time of onset of the insulin determines how far in advance patients should take the insulin before they eat.<ref name=":10" /> Insulin is usually taken several times per day in patients who require it to control their diabetes.<ref name=":10" /> Often patients usually take long acting insulin once a day and then take insulin before meals. The time of onset of the insulin determines how far in advance patients should take the insulin before they eat.<ref name=":10" />


] requires close monitoring and a great deal of patient education, as improper administration is quite dangerous. Insulin can easily cause hypoglycemia if the patient does not eat after administering insulin or accidently had too much insulin.<ref name=":10" /> A previously satisfactory dosing may be too much if less food is consumed causing ].<ref name=":10" /> Exercise decreases insulin requirements as exercise increases glucose uptake by body cells whose glucose is controlled by the insulin.<ref>{{Cite web |title=TDS Health |url=https://online.statref.com/login?path=document%2Fcz8S6DOdCulIInZg_2AR8D |access-date=2024-10-31 |website=online.statref.com}}</ref> ] requires close monitoring and a great deal of patient education, as improper administration is quite dangerous. Insulin can easily cause hypoglycemia if the patient does not eat after administering insulin or accidentally had too much insulin.<ref name=":10" /> A previously satisfactory dosing may be too much if less food is consumed causing ].<ref name=":10" /> Exercise decreases insulin requirements as exercise increases glucose uptake by body cells whose glucose is controlled by the insulin.<ref name="TDS Health"/>


Insulin therapy creates risk because of the inability to continuously know a person's blood glucose level and adjust insulin infusion appropriately. New advances in technology have overcome much of this problem. Small, portable insulin infusion pumps are available from several manufacturers. They allow a continuous infusion of small amounts of insulin to be delivered through the skin around the clock, plus the ability to give bolus doses when a person eats or has elevated blood glucose levels. This is very similar to how the pancreas works, but these pumps lack a continuous "feed-back" mechanism. Thus, the user is still at risk of giving too much or too little insulin unless blood glucose measurements are made. Insulin therapy creates risk because of the inability to continuously know a person's BG level and adjust insulin infusion appropriately. New advances in technology have overcome much of this problem. Small, portable insulin infusion pumps are available from several manufacturers. They allow a continuous infusion of small amounts of insulin to be delivered through the skin around the clock, plus the ability to give bolus doses when a person eats or has elevated BG levels. This is very similar to how the pancreas works, but these pumps lack a continuous "feed-back" mechanism. Thus, the user is still at risk of giving too much or too little insulin unless BG measurements are made.


=== Oral Medications === === Oral Medications ===


==== Metformin ==== ==== Metformin ====
One of the most common drugs used in type 2 diabetes, ] is the drug of choice to help patients lower their blood sugar levels. Metformin is an example of a class of medicine called biguanides.<ref name=":11">{{Cite web |title=Metformin: MedlinePlus Drug Information |url=https://medlineplus.gov/druginfo/meds/a696005.html |access-date=2024-11-05 |website=medlineplus.gov |language=en}}</ref> The medication works by reducing the new creation of glucose from the liver and by reducing absorption of sugar from food.<ref name=":11" /> In addition, the medication also works to help increase the effects of insulin on muscle cells, which take in glucose.<ref name=":14">{{Citation |last=Ganesan |first=Kavitha |title=Oral Hypoglycemic Medications |date=2024 |work=StatPearls |url=https://www.ncbi.nlm.nih.gov/books/NBK482386/#:~:text=Oral%20Hypoglycemic%20Medications%20*%20Sulfonylureas%20(glipizide,%20glyburide,,inhibitors%20(dapagliflozin%20and%20canagliflozin)%20*%20Cycloset%20(bromocriptine) |access-date=2024-11-05 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=29494008 |last2=Rana |first2=Muhammad Burhan Majeed |last3=Sultan |first3=Senan}}</ref> The medicine is not used for type 1 diabetes as these patients do not produce any insulin and metformin relies on some insulin production in order to be effective.<ref name=":11" /> There are several preparations of the medication such as tablets, extend release tablets, and liquid suspensions. Metformin is usually started as 500 to 1000 mg tablets twice a day by mouth (PO), usually with meals.<ref name=":11" /> If taking the extended release tablets, they should be always swallowed whole as cutting the tablet will cause faster release of the medication.<ref name=":11" /> The medication most commonly may cause stomach upset and symptoms such as diarrhea but in general is well tolerated and has a relatively low chance of causing ].<ref name=":14" /> One rare (about 1% chance) but serious side affect of metformin is that it can cause lactic acidosis, usually in patients with poor ].<ref name=":14" /> Sometimes, practitioners will slowly increase the dose of the medication to help with tolerance to the medication. One of the most common drugs used in T2D, ] is the drug of choice to help patients lower their blood sugar levels. Metformin is an example of a class of medicine called biguanides.<ref name=":11">{{Cite web |title=Metformin: MedlinePlus Drug Information |url=https://medlineplus.gov/druginfo/meds/a696005.html |access-date=2024-11-05 |website=medlineplus.gov |language=en}}</ref> The medication works by reducing the new creation of glucose from the liver and by reducing absorption of sugar from food.<ref name=":11" /> In addition, the medication also works to help increase the effects of insulin on muscle cells, which take in glucose.<ref name=":14">{{Citation |last1=Ganesan |first1=Kavitha |title=Oral Hypoglycemic Medications |date=2024 |work=StatPearls |url=https://www.ncbi.nlm.nih.gov/books/NBK482386/#:~:text=Oral%20Hypoglycemic%20Medications%20*%20Sulfonylureas%20(glipizide,%20glyburide,,inhibitors%20(dapagliflozin%20and%20canagliflozin)%20*%20Cycloset%20(bromocriptine) |access-date=2024-11-05 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=29494008 |last2=Rana |first2=Muhammad Burhan Majeed |last3=Sultan |first3=Senan}}</ref> The medicine is not used for T1D as these patients do not produce any insulin and metformin relies on some insulin production in order to be effective.<ref name=":11" /> There are several preparations of the medication such as tablets, extend release tablets, and liquid suspensions. Metformin is usually started as 500 to 1000&nbsp;mg tablets twice a day by mouth (PO), usually with meals.<ref name=":11" /> If taking the extended release tablets, they should be always swallowed whole as cutting the tablet will cause faster release of the medication.<ref name=":11" /> The medication most commonly may cause stomach upset and symptoms such as diarrhea but in general is well tolerated and has a relatively low chance of causing ].<ref name=":14" /> One rare (about 1% chance) but serious side affect of metformin is that it can cause lactic acidosis, usually in patients with poor ].<ref name=":14" /> Sometimes, practitioners will slowly increase the dose of the medication to help with tolerance to the medication.


=== Sulfonylureas === === Sulfonylureas ===
Another commonly used class of medications with type 2 diabetes are sulfonylureas. This class of medicine increases the release of insulin from the beta cells in the pancreas. The medication can not be used in patients with type 1 diabetes, as they do not have functioning beta cells and can not produce insulin.<ref name=":14" /> Some common example of a sulfonylurea is glipizide, glyburide, glimepiride and gliclazide. Depending on the medication, there are different size tablets but in general, the sizes range from about 1 mg to 10 mg. Usually the tablet is taken about 30 minutes before a meal and can be either once or twice a day. The most common adverse effects of the medication are lightheadedness and stomach irritation.<ref name=":14" /> Sulfonylureas have a greater risk of hypoglycemia but the risk is still only around 3% of patients who use them.<ref name=":14" /> In patients who have a greater risk of low sugar, such as in the elderly and patients with kidney disease, the starting dose can be as low as 0.5 mg. Another commonly used class of medications with T2D are sulfonylureas. This class of medicine increases the release of insulin from the beta cells in the pancreas. The medication can not be used in patients with T1D, as they do not have functioning beta cells and can not produce insulin.<ref name=":14" /> Some common example of a sulfonylurea is glipizide, glyburide, glimepiride and gliclazide. Depending on the medication, there are different size tablets but in general, the sizes range from about 1&nbsp;mg to 10&nbsp;mg. Usually the tablet is taken about 30 minutes before a meal and can be either once or twice a day. The most common adverse effects of the medication are lightheadedness and stomach irritation.<ref name=":14" /> Sulfonylureas have a greater risk of hypoglycemia but the risk is still only around 3% of patients who use them.<ref name=":14" /> In patients who have a greater risk of low sugar, such as in the elderly and patients with kidney disease, the starting dose can be as low as 0.5&nbsp;mg.

=== GLP-1 agonists ===
Another popular medication that is used in T2D management are ]. This class of medication works by mimicking a hormone called glucagon-like peptide which has many effects in the body.<ref name=":17">{{Cite web |title=GLP-1 agonists: Diabetes drugs and weight loss - Mayo Clinic |url=https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/expert-answers/byetta/FAQ-20057955?p=1 |access-date=2024-11-07 |website=www.mayoclinic.org |language=en}}</ref> One effect of the hormone is that it helps time the release of insulin when patients eat and the BG rises.<ref name=":18">{{Cite web |title=Semaglutide Injection: MedlinePlus Drug Information |url=https://medlineplus.gov/druginfo/meds/a618008.html |access-date=2024-11-07 |website=medlineplus.gov |language=en}}</ref> In addition, it can significantly increase the amount of insulin release as well.<ref>{{Cite journal |last1=Nauck |first1=Michael A. |last2=Meier |first2=Juris J. |date=February 2018 |title=Incretin hormones: Their role in health and disease |url=https://dom-pubs.pericles-prod.literatumonline.com/doi/10.1111/dom.13129 |journal=Diabetes, Obesity and Metabolism |language=en |volume=20 |issue=S1 |pages=5–21 |doi=10.1111/dom.13129 |issn=1462-8902}}</ref> Lastly, the medication also slows down the movement of food through the digestive tract and can increase feeling of fullness while eating, decreasing appetite and weight.<ref name=":18" /> These drugs are very effective at controlling T2D and reducing risk of heart attacks, strokes, and other complications due to diabetes. In addition, patients usually lose weight and have improved blood pressure and cholesterol.<ref name=":17" /> Common names of these medications include ] (Ozempic and Wegovy), ] (Victoza, Saxenda), and ] (Trulicity).<ref name=":17" /> These medications must be injected and are usually injected in the upper arm, thighs or stomach areas.<ref name=":18" /> They are usually given once a week but some of the medication can be as frequent as twice daily.<ref name=":17" /> The dose is usually started low and tapered gradually. Some of the common side effects of the medication is nausea, vomiting and diarrhea. Patients with a family history of ] or ] should not be prescribed the drug may increase the risk of developing ].<ref name=":18" />


== Surgery == == Surgery ==
While weight loss is clearly beneficial in improving glycemic control in patients with diabetes type 2,<ref>{{Cite journal |last1=McCombie |first1=Louise |last2=Leslie |first2=Wilma |last3=Taylor |first3=Roy |last4=Kennon |first4=Brian |last5=Sattar |first5=Naveed |last6=Lean |first6=Mike E. J. |date=2017-09-13 |title=Beating type 2 diabetes into remission |url=https://www.bmj.com/content/358/bmj.j4030 |journal=BMJ |language=en |volume=358 |pages=j4030 |doi=10.1136/bmj.j4030 |issn=0959-8138 |pmid=28903916 |s2cid=28182743}}</ref> maintaining significant weight loss can be a very difficult thing to do. In diabetic people who have a ] of 35 or higher, and who have been unable to lose weight otherwise, ] offers a viable option to help achieve that goal. In 2018 a ] funded study was published which analyzed the effects of three common types of bariatric surgery on sustained weight loss and long-lasting glycemic control in patients with diabetes type 2.<ref>{{Cite journal |last1=Arterburn |first1=David |last2=Wellman |first2=Robert |last3=Emiliano |first3=Ana |last4=Smith |first4=Steven R. |last5=Odegaard |first5=Andrew O. |last6=Murali |first6=Sameer |last7=Williams |first7=Neely |last8=Coleman |first8=Karen J. |last9=Courcoulas |first9=Anita |last10=Coley |first10=R. Yates |last11=Anau |first11=Jane |last12=Pardee |first12=Roy |last13=Toh |first13=Sengwee |last14=Janning |first14=Cheri |last15=Cook |first15=Andrea |date=2018-12-04 |title=Comparative Effectiveness and Safety of Bariatric Procedures for Weight Loss: A PCORnet Cohort Study |journal=Annals of Internal Medicine |language=en |volume=169 |issue=11 |pages=741–750 |doi=10.7326/M17-2786 |issn=0003-4819 |pmc=6652193 |pmid=30383139}}</ref> The results of this study demonstrated that, five years after bariatric surgery, there was meaningfully significant weight loss in a large majority of patients. In addition, and more importantly, this study showed that, in type 2 diabetic patients with a body mass index of 35 or higher, bariatric surgery has the potential to lead to complete remission of diabetes in as many as 40% of those people who have the procedure.<ref>{{Cite journal |last1=Anau |first1=Jane |last2=Arterburn |first2=David |last3=Coleman |first3=Karen J. |last4=Coley |first4=R. Yates |last5=Cook |first5=Andrea J. |last6=Courcoulas |first6=Anita |last7=Janning |first7=Cheri |last8=McTigue |first8=Kathleen |last9=Pardee |first9=Roy |last10=Toh |first10=Sengwee |last11=Wellman |first11=Robert |last12=Williams |first12=Neely |date=2020-11-02 |title=Comparing Three Types of Weight Loss Surgery—The PCORnet Bariatric Study |url=https://www.pcori.org/research-results/2015/comparing-three-types-weight-loss-surgery-pcornet-bariatric-study |doi=10.25302/11.2020.obs.150530683 |s2cid=228814682 |doi-access=free}}</ref> Like any operation, bariatric surgery is not without risks and complications, and those risks need to weighed against the potential benefits in anyone considering going through with such a procedure. While weight loss is clearly beneficial in improving glycemic control in patients with diabetes type 2,<ref>{{Cite journal |last1=McCombie |first1=Louise |last2=Leslie |first2=Wilma |last3=Taylor |first3=Roy |last4=Kennon |first4=Brian |last5=Sattar |first5=Naveed |last6=Lean |first6=Mike E. J. |date=2017-09-13 |title=Beating type 2 diabetes into remission |url=https://www.bmj.com/content/358/bmj.j4030 |journal=BMJ |language=en |volume=358 |pages=j4030 |doi=10.1136/bmj.j4030 |issn=0959-8138 |pmid=28903916 |s2cid=28182743}}</ref> maintaining significant weight loss can be a very difficult thing to do. In diabetic people who have a ] of 35 or higher, and who have been unable to lose weight otherwise, ] offers a viable option to help achieve that goal. In 2018 a ] funded study was published which analyzed the effects of three common types of bariatric surgery on sustained weight loss and long-lasting glycemic control in patients with diabetes type 2.<ref>{{Cite journal |last1=Arterburn |first1=David |last2=Wellman |first2=Robert |last3=Emiliano |first3=Ana |last4=Smith |first4=Steven R. |last5=Odegaard |first5=Andrew O. |last6=Murali |first6=Sameer |last7=Williams |first7=Neely |last8=Coleman |first8=Karen J. |last9=Courcoulas |first9=Anita |last10=Coley |first10=R. Yates |last11=Anau |first11=Jane |last12=Pardee |first12=Roy |last13=Toh |first13=Sengwee |last14=Janning |first14=Cheri |last15=Cook |first15=Andrea |date=2018-12-04 |title=Comparative Effectiveness and Safety of Bariatric Procedures for Weight Loss: A PCORnet Cohort Study |journal=Annals of Internal Medicine |language=en |volume=169 |issue=11 |pages=741–750 |doi=10.7326/M17-2786 |issn=0003-4819 |pmc=6652193 |pmid=30383139}}</ref> The results of this study demonstrated that, five years after bariatric surgery, there was meaningfully significant weight loss in a large majority of patients. In addition, and more importantly, this study showed that, in type 2 diabetic patients with a body mass index of 35 or higher, bariatric surgery has the potential to lead to complete remission of diabetes in as many as 40% of those people who have the procedure.<ref>{{Cite journal |last1=Anau |first1=Jane |last2=Arterburn |first2=David |last3=Coleman |first3=Karen J. |last4=Coley |first4=R. Yates |last5=Cook |first5=Andrea J. |last6=Courcoulas |first6=Anita |last7=Janning |first7=Cheri |last8=McTigue |first8=Kathleen |last9=Pardee |first9=Roy |last10=Toh |first10=Sengwee |last11=Wellman |first11=Robert |last12=Williams |first12=Neely |date=2020-11-02 |title=Comparing Three Types of Weight Loss Surgery—The PCORnet Bariatric Study |url=https://www.pcori.org/research-results/2015/comparing-three-types-weight-loss-surgery-pcornet-bariatric-study |doi=10.25302/11.2020.obs.150530683 |s2cid=228814682 |doi-access=free}}</ref> Like any operation, bariatric surgery is not without risks and complications, and those risks need to weighed against the potential benefits in anyone considering going through with such a procedure.

==Additional Monitoring==
=== Foot checking ===
Monitoring a person's feet can help in predicting the likelihood of developing ]s. A common method for this is using a special ] to look for spots on the foot that have higher temperature which indicate the possibility of an ulcer developing.<ref name=":2">{{Cite journal |date=2022-06-21 |title=Simple tool identifies the people with diabetes most likely to develop foot ulcers |url=https://evidence.nihr.ac.uk/alert/simple-tool-predicts-foot-ulcers-in-diabetes/ |journal=NIHR Evidence |language=en |publisher=National Institute for Health and Care Research |doi=10.3310/nihrevidence_51316 |s2cid=251787297}}</ref> At the same time there is no strong ] supporting the effectiveness of at-home foot temperature monitoring.<ref>{{Cite journal |last1=Golledge |first1=Jonathan |last2=Fernando |first2=Malindu E |last3=Alahakoon |first3=Chanika |last4=Lazzarini |first4=Peter A. |last5=aan de Stegge |first5=Wouter B. |last6=van Netten |first6=Jaap J. |last7=Bus |first7=Sicco A. |date=23 May 2022 |title=Efficacy of at home monitoring of foot temperature for risk reduction of diabetes-related foot ulcer: A meta-analysis |journal=Diabetes/Metabolism Research and Reviews |language=en |volume=38 |issue=6 |pages=e3549 |doi=10.1002/dmrr.3549 |issn=1520-7552 |pmc=9541448 |pmid=35605998 |s2cid=251981184}}</ref>

The current guideline in the United Kingdom recommends collecting 8-10 pieces of information for predicting the development of foot ulcers.<ref>{{Cite web |date=26 August 2015 |title=Diabetic foot problems: prevention and management |url=https://www.nice.org.uk/guidance/ng19/chapter/Recommendations#assessing-the-risk-of-developing-a-diabetic-foot-problem |access-date=2022-09-06 |website=National Institute for Health and Care Excellence (NICE)}}</ref> A simpler method proposed by researchers provides a more detailed risk score based on three pieces of information (insensitivity, foot pulse, previous history of ulcers or amputation). This method is not meant to replace people regularly checking their own feet but complement it.<ref name=":2" /><ref>{{Cite journal |last1=Chappell |first1=Francesca M |last2=Crawford |first2=Fay |last3=Horne |first3=Margaret |last4=Leese |first4=Graham P |last5=Martin |first5=Angela |last6=Weller |first6=David |last7=Boulton |first7=Andrew J M |last8=Abbott |first8=Caroline |last9=Monteiro-Soares |first9=Matilde |last10=Veves |first10=Aristidis |last11=Riley |first11=Richard D |date=25 May 2021 |title=Development and validation of a clinical prediction rule for development of diabetic foot ulceration: an analysis of data from five cohort studies |journal=BMJ Open Diabetes Research & Care |language=en |volume=9 |issue=1 |pages=e002150 |doi=10.1136/bmjdrc-2021-002150 |issn=2052-4897 |pmc=8154962 |pmid=34035053}}</ref>

=== Dental care ===
High BG in diabetic people is a risk factor for developing ] and ] problems. Diabetic patients have greater chances of developing oral health problems such as ], ] dysfunction, ], and ]<ref>{{cite web |title=Oral diabetes care |url=http://www.dentalcarediabetes.com |access-date=2010-05-05}}</ref> Diabetic people tend to experience more severe periodontitis because diabetes lowers the ability to resist infection and also slows healing.<ref>{{cite journal |vauthors=Koh GC, Peacock SJ, van der Poll T, Wiersinga WJ |date=April 2012 |title=The impact of diabetes on the pathogenesis of sepsis |journal=European Journal of Clinical Microbiology & Infectious Diseases |volume=31 |issue=4 |pages=379–388 |doi=10.1007/s10096-011-1337-4 |pmc=3303037 |pmid=21805196}}</ref> In turn, the chronic infection from periodontal disease can make it worse to control the diabetes, leading to worsening of diabetic complications.<ref name="Gum Disease and Diabetes">{{cite web |title=Gum Disease and Diabetes |url=http://www.perio.org/consumer/mbc.diabetes.htm |url-status=dead |archive-url=https://web.archive.org/web/20100612195938/http://perio.org/consumer/mbc.diabetes.htm |archive-date=2010-06-12 |access-date=2010-05-05}}</ref> The oral problems in persons with diabetes can be prevented with a good control of the blood sugar levels, regular check-ups with their dental provider, and good ]. Looking for early signs of gum disease (redness, swelling, ]) and informing the dentist about them is also helpful in preventing further complications. ] is recommended to avoid serious diabetes complications and oral diseases. By maintaining a good oral status, diabetic persons prevent losing their teeth as a result of various periodontal conditions.

=== Digital tools ===
==== Electronic health records ====
Sharing their ]s with people who have T2D helps them to reduce their blood sugar levels. It is a way of helping people understand their own health condition and involving them actively in its management.<ref>{{cite journal |vauthors=Neves AL, Freise L, Laranjo L, Carter AW, Darzi A, Mayer E |date=December 2020 |title=Impact of providing patients access to electronic health records on quality and safety of care: a systematic review and meta-analysis |journal=BMJ Quality & Safety |volume=29 |issue=12 |pages=1019–1032 |doi=10.1136/bmjqs-2019-010581 |pmc=7785164 |pmid=32532814}}</ref><ref>{{Cite journal |date=2020-10-21 |title=Sharing electronic records with patients led to improved control of type two diabetes |url=https://evidence.nihr.ac.uk/alert/sharing-electronic-records-with-patients-led-to-improved-control-of-type-two-diabetes/ |journal=NIHR Evidence |type=Plain English summary |language=en |doi=10.3310/alert_42103 |s2cid=242149388}}</ref>

==== m-health monitoring applications ====
The widespread use of smartphones has turned mobile applications (apps) into a popular means of the usage of all forms of software.<ref>{{Cite journal |vauthors=Jeong JW, Kim NH, In HP |date=July 2020 |title=Detecting usability problems in mobile applications on the basis of dissimilarity in user behavior |journal=International Journal of Human-Computer Studies |language=en |volume=139 |pages=102364 |doi=10.1016/j.ijhcs.2019.10.001 |s2cid=208105117}}</ref> The number of ] accessible in the App Store and Google Play is approximately 100,000, and among these apps, the ones related to diabetes are the highest in number. Conducting regular self-management tasks such as medication and insulin intake, blood sugar checkup, diet observance, and physical exercise are really demanding.<ref>{{cite journal |vauthors=Hood M, Wilson R, Corsica J, Bradley L, Chirinos D, Vivo A |date=December 2016 |title=What do we know about mobile applications for diabetes self-management? A review of reviews |journal=Journal of Behavioral Medicine |volume=39 |issue=6 |pages=981–994 |doi=10.1007/s10865-016-9765-3 |pmid=27412774 |s2cid=29465893}}</ref> This is why the use of diabetes-related apps for the purposes of recording diet and medication intake or BG level is promising to improve the health condition for the patients.


== Complexities == == Complexities ==
Line 115: Line 141:
* As a system, it is sensitive to diet and exercise * As a system, it is sensitive to diet and exercise
* It is affected by the need for patient anticipation due to the complicating effects of time delays between any activity and the respective impact on the glucose * It is affected by the need for patient anticipation due to the complicating effects of time delays between any activity and the respective impact on the glucose
* Management is highly intrusive, and compliance is an issue, since it relies upon user lifestyle change and often upon regular sampling and measuring of blood glucose levels, multiple times a day in many cases * Management is highly intrusive, and compliance is an issue, since it relies upon user lifestyle change and often upon regular sampling and measuring of BG levels, multiple times a day in many cases
* It changes as people grow and develop * It changes as people grow and develop
* It is highly individual * It is highly individual
Line 122: Line 148:


=== Hypoglycemia === === Hypoglycemia ===
Levels which are significantly above or below this range are problematic and can in some cases be dangerous. A level of <70 mg/dL (<3.8&nbsp;mmol/L) is usually described as a ''hypoglycemic attack'' (low blood sugar). Most diabetics know when their hypoglycemic and usually are able to eat food or drink something sweet to raise their levels. Intensive efforts to achieve blood sugar levels close to normal have been shown to triple the risk of the most severe form of hypoglycemia, in which the patient requires assistance from by-standers in order to treat the episode.<ref>{{cite journal |vauthors=Briscoe VJ, Davis SN |year=2006 |title=Hypoglycemia in Type 1 and Type 2 Diabetes: Physiology, Pathophysiology, and Management |journal=Clinical Diabetes |volume=24 |issue=3 |pages=115–21 |doi=10.2337/diaclin.24.3.115 |doi-access=free}}</ref> Among intensively controlled type 1 diabetics, 55% of episodes of severe hypoglycemia occur during sleep, and 6% of all deaths in diabetics under the age of 40 are from nocturnal hypoglycemia in the so-called 'dead-in-bed syndrome,' while National Institute of Health statistics show that 2% to 4% of all deaths in diabetics are from hypoglycemia.<ref>{{cite journal |vauthors=Perlmuter LC, Flanagan BP, Shah PH, Singh SP |date=October 2008 |title=Glycemic control and hypoglycemia: is the loser the winner? |journal=Diabetes Care |volume=31 |issue=10 |pages=2072–2076 |doi=10.2337/dc08-1441 |pmc=2551657 |pmid=18820231}}</ref> Levels which are significantly above or below this range are problematic and can in some cases be dangerous. A level of <70&nbsp;mg/dL (<3.8&nbsp;mmol/L) is usually described as a ''hypoglycemic attack'' (low blood sugar). Most diabetics know when their hypoglycemic and usually are able to eat food or drink something sweet to raise their levels. Intensive efforts to achieve blood sugar levels close to normal have been shown to triple the risk of the most severe form of hypoglycemia, in which the patient requires assistance from by-standers in order to treat the episode.<ref>{{cite journal |vauthors=Briscoe VJ, Davis SN |year=2006 |title=Hypoglycemia in Type 1 and Type 2 Diabetes: Physiology, Pathophysiology, and Management |journal=Clinical Diabetes |volume=24 |issue=3 |pages=115–21 |doi=10.2337/diaclin.24.3.115 |doi-access=free}}</ref> Among intensively controlled type 1 diabetics, 55% of episodes of severe hypoglycemia occur during sleep, and 6% of all deaths in diabetics under the age of 40 are from hypoglycemia at night.<ref>{{cite journal |vauthors=Perlmuter LC, Flanagan BP, Shah PH, Singh SP |date=October 2008 |title=Glycemic control and hypoglycemia: is the loser the winner? |journal=Diabetes Care |volume=31 |issue=10 |pages=2072–2076 |doi=10.2337/dc08-1441 |pmc=2551657 |pmid=18820231}}</ref> ]Hypoglycemia can be problematic if it occurs while driving as it can affect a person's thinking process, coordination, and state of consciousness.<ref name="Cox">{{cite journal |vauthors=Cox DJ, Gonder-Frederick L, Clarke W |date=February 1993 |title=Driving decrements in type I diabetes during moderate hypoglycemia |journal=Diabetes |volume=42 |issue=2 |pages=239–243 |doi=10.2337/diabetes.42.2.239 |pmid=8425660}}</ref><ref>{{cite journal |vauthors=Clarke WL, Cox DJ, Gonder-Frederick LA, Kovatchev B |date=August 1999 |title=Hypoglycemia and the decision to drive a motor vehicle by persons with diabetes |journal=JAMA |volume=282 |issue=8 |pages=750–754 |doi=10.1001/jama.282.8.750 |pmid=10463710 |doi-access=free}}</ref> Some patients are more prone to hypoglycemia as they have reported fewer warning symptoms, and their body released less epinephrine (a hormone that helps raise BG).<ref name="Cox_a">{{cite journal |vauthors=Cox DJ, Kovatchev BP, Anderson SM, Clarke WL, Gonder-Frederick LA |date=November 2010 |title=Type 1 diabetic drivers with and without a history of recurrent hypoglycemia-related driving mishaps: physiological and performance differences during euglycemia and the induction of hypoglycemia |journal=Diabetes Care |volume=33 |issue=11 |pages=2430–2435 |doi=10.2337/dc09-2130 |pmc=2963507 |pmid=20699432}}</ref> Additionally, individuals with a history of hypoglycemia-related driving mishaps appear to use sugar at a faster rate.<ref>{{cite journal |vauthors=Cox DJ, Gonder-Frederick LA, Kovatchev BP, Clarke WL |year=2002 |title=The metabolic demands of driving for drivers with type 1 diabetes mellitus |journal=Diabetes/Metabolism Research and Reviews |volume=18 |issue=5 |pages=381–385 |doi=10.1002/dmrr.306 |pmid=12397580 |s2cid=25094659}}</ref> These findings indicate that although anyone with T1D may be at some risk of experiencing hypoglycemia while driving, there is a subgroup of T1D drivers who are more vulnerable to such events.

It is recommended that drivers with T1D with a history of driving mishaps should never drive when their blood sugar is less than 70&nbsp;mg/dL (3.9&nbsp;mmol/L). Instead, these drivers are advised to treat hypoglycemia and delay driving until their BG is above 90&nbsp;mg/dL (5&nbsp;mmol/L).<ref name="Cox_a" /> Such drivers should also learn as much as possible about what causes their hypoglycemia, and use this information to avoid future hypoglycemia while driving.


=== Hyperglycemia === === Hyperglycemia ===
A patient is considered to have hyperglycemia (high glucose) if the patient has a sugar level of greater than 230–270&nbsp;mg/dL (13–15&nbsp;mmol/L). Sometimes patient may be temporarily hypoglycemic under certain conditions (e.g. not eating regularly, or after strenuous exercise). Patients should closely monitor their sugar levels to ensure that they reduce rather than continue to remain high. High blood sugar levels are not as easy to detect as hypoglycemia and usually happens over a period of days rather than hours or minutes. If left untreated, this can result in ] and death. A patient is considered to have hyperglycemia (high glucose) if the patient has a sugar level of greater than 230–270&nbsp;mg/dL (13–15&nbsp;mmol/L). Sometimes patient may be temporarily hypoglycemic under certain conditions (e.g. not eating regularly, or after strenuous exercise). Patients should closely monitor their sugar levels to ensure that they reduce rather than continue to remain high. High blood sugar levels are not as easy to detect as hypoglycemia and usually happens over a period of days rather than hours or minutes. If left untreated, this can result in ] and death.


Prolonged and elevated levels of glucose in the blood, which is left unchecked and untreated, will, over time, result in serious diabetic complications in those susceptible and sometimes even death. There is currently no way of testing for susceptibility to complications. Diabetics are therefore recommended to check their blood sugar levels either daily or every few days. There is also ] available from blood testing manufacturers which can display results and trends over time. Type 1 diabetics normally check more often, due to insulin therapy. Prolonged and elevated levels of glucose in the blood, which is left unchecked and untreated, will, over time, result in serious diabetic complications in those susceptible and sometimes even death. There is currently no way of testing for susceptibility to complications. Diabetics are therefore recommended to check their blood sugar levels either daily or every few days. There is also ] available from blood testing manufacturers which can display results and trends over time.

===Glycemic control===
''Glycemic control'' is a medical term referring to the typical levels of blood sugar (]) in a person with ]. Much evidence suggests that many of the long-term complications of diabetes, especially the microvascular complications, result from many years of ] (elevated levels of glucose in the blood). Good glycemic control, in the sense of a "target" for treatment, has become an important goal of diabetes care, although recent research suggests that the complications of diabetes may be caused by genetic factors<ref>{{cite journal | vauthors = Tarnow L, Groop PH, Hadjadj S, Kazeem G, Cambien F, Marre M, Forsblom C, Parving HH, Trégouët D, Thévard A, Farrall M, Gut I, Gauguier D, Cox R, Matsuda F, Lathrop M, Vionnet N | display-authors = 6 | title = European rational approach for the genetics of diabetic complications—EURAGEDIC: patient populations and strategy | journal = Nephrology, Dialysis, Transplantation | volume = 23 | issue = 1 | pages = 161–168 | date = January 2008 | pmid = 17704113 | doi = 10.1093/ndt/gfm501 | doi-access = free }}</ref><ref>{{Cite journal |last1=Murdolo |first1=G. |last2=Kempf |first2=K. |last3=Hammarstedt |first3=A. |last4=Herder |first4=C. |last5=Smith |first5=U. |last6=Jansson |first6=P. A. |date=2007-09-01 |title=Insulin differentially modulates the peripheral endocannabinoid system in human subcutaneous abdominal adipose tissue from lean and obese individuals |url=https://doi.org/10.1007/BF03347440 |journal=Journal of Endocrinological Investigation |language=en |volume=30 |issue=8 |pages=RC17–RC21 |doi=10.1007/BF03347440 |pmid=17923791 |s2cid=39337082 |issn=1720-8386}}</ref> or, in type 1 diabetics, by the continuing effects of the ] disease which first caused the pancreas to lose its insulin-producing ability.<ref>{{cite journal | vauthors = Adams DD | title = Autoimmune destruction of pericytes as the cause of diabetic retinopathy | journal = Clinical Ophthalmology | volume = 2 | issue = 2 | pages = 295–298 | date = June 2008 | pmid = 19668719 | pmc = 2693966 | doi = 10.2147/OPTH.S2629 | doi-access = free }}</ref>

"Perfect glycemic control" would mean that glucose levels were always normal (70–130&nbsp;mg/dL, or 3.9–7.2&nbsp;mmol/L) and indistinguishable from a person without diabetes. In reality, because of the imperfections of treatment measures, even "good glycemic control" describes blood glucose levels that average somewhat higher than normal much of the time. In addition, one survey of type 2 diabetics found that they rated the harm to their quality of life from intensive interventions to control their blood sugar to be just as severe as the harm resulting from intermediate levels of diabetic complications.<ref>{{cite journal | vauthors = Huang ES, Brown SE, Ewigman BG, Foley EC, Meltzer DO | title = Patient perceptions of quality of life with diabetes-related complications and treatments | journal = Diabetes Care | volume = 30 | issue = 10 | pages = 2478–2483 | date = October 2007 | pmid = 17623824 | pmc = 2288662 | doi = 10.2337/dc07-0499 }}</ref>

In the 1990s the ] conducted a publicity campaign to persuade patients and physicians to strive for average glucose and hemoglobin A1c values below 200&nbsp;mg/dL (11&nbsp;mmol/L) and 8%. Currently, many patients and physicians attempt to do better than that.

As of 2015 the guidelines called for an HbA<sub>1c</sub> of around 7% or a fasting glucose of less than 7.2&nbsp;mmol/L (130&nbsp;mg/dL); however these goals may be changed after professional clinical consultation, taking into account particular risks of ] and life expectancy.<ref name=ADA2015>{{cite journal | vauthors = Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M, Peters AL, Tsapas A, Wender R, Matthews DR | display-authors = 6 | title = Management of hyperglycaemia in type 2 diabetes, 2015: a patient-centred approach. Update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes | journal = Diabetologia | volume = 58 | issue = 3 | pages = 429–442 | date = March 2015 | pmid = 25583541 | doi = 10.1007/s00125-014-3460-0 | doi-access = free }}</ref><ref name=ADA21015>{{cite journal | vauthors = | title = Standards of medical care in diabetes--2015: summary of revisions | journal = Diabetes Care | volume = 38 | issue = 38 | pages = S4 | date = January 2015 | pmid = 25537706 | doi = 10.2337/dc15-S003 | doi-access = free }}</ref> Despite guidelines recommending that intensive blood sugar control be based on balancing immediate harms and long-term benefits, many people – for example people with a life expectancy of less than nine years – who will not benefit are ] and do not experience clinically meaningful benefits.<ref>{{cite journal | vauthors = Makam AN, Nguyen OK | title = An Evidence-Based Medicine Approach to Antihyperglycemic Therapy in Diabetes Mellitus to Overcome Overtreatment | journal = Circulation | volume = 135 | issue = 2 | pages = 180–195 | date = January 2017 | pmid = 28069712 | pmc = 5502688 | doi = 10.1161/CIRCULATIONAHA.116.022622 }}</ref>

Poor glycemic control refers to persistently elevated blood glucose and glycated hemoglobin levels, which may range from 200 to 500&nbsp;mg/dL (11–28&nbsp;mmol/L) and 9–15% or higher over months and years before severe complications occur. Meta-analysis of large studies done on the effects of ] vs. conventional, or more relaxed, glycemic control in type 2 diabetics have failed to demonstrate a difference in all-cause cardiovascular death, non-fatal stroke, or limb amputation, but decreased the risk of nonfatal heart attack by 15%. Additionally, tight glucose control decreased the risk of progression of retinopathy and nephropathy, and decreased the incidence peripheral neuropathy, but increased the risk of hypoglycemia 2.4 times.<ref>{{cite journal | vauthors = Buehler AM, Cavalcanti AB, Berwanger O, Figueiro M, Laranjeira LN, Zazula AD, Kioshi B, Bugano DG, Santucci E, Sbruzzi G, Guimaraes HP, Carvalho VO, Bordin SA | display-authors = 6 | title = Effect of tight blood glucose control versus conventional control in patients with type 2 diabetes mellitus: a systematic review with meta-analysis of randomized controlled trials | journal = Cardiovascular Therapeutics | volume = 31 | issue = 3 | pages = 147–160 | date = June 2013 | pmid = 22212499 | doi = 10.1111/j.1755-5922.2011.00308.x | doi-access = free }}</ref>

==Additional Monitoring==<!--Linked from 'Blood glucose monitoring'-->
=== Digital tools ===
==== Electronic health records ====
Sharing their ]s with people who have type 2 diabetes helps them to reduce their blood sugar levels. It is a way of helping people understand their own health condition and involving them actively in its management.<ref>{{cite journal | vauthors = Neves AL, Freise L, Laranjo L, Carter AW, Darzi A, Mayer E | title = Impact of providing patients access to electronic health records on quality and safety of care: a systematic review and meta-analysis | journal = BMJ Quality & Safety | volume = 29 | issue = 12 | pages = 1019–1032 | date = December 2020 | pmid = 32532814 | pmc = 7785164 | doi = 10.1136/bmjqs-2019-010581 }}</ref><ref>{{Cite journal |date=2020-10-21 |title=Sharing electronic records with patients led to improved control of type two diabetes |url=https://evidence.nihr.ac.uk/alert/sharing-electronic-records-with-patients-led-to-improved-control-of-type-two-diabetes/ |journal=NIHR Evidence |type=Plain English summary |language=en |doi=10.3310/alert_42103|s2cid=242149388 }}</ref>

==== m-health monitoring applications ====
The widespread use of smartphones has turned mobile applications (apps) into a popular means of the usage of all forms of software.<ref>{{Cite journal| vauthors = Jeong JW, Kim NH, In HP |date=July 2020|title=Detecting usability problems in mobile applications on the basis of dissimilarity in user behavior|journal=International Journal of Human-Computer Studies|language=en|volume=139|pages=102364|doi=10.1016/j.ijhcs.2019.10.001|s2cid=208105117}}</ref> The number of ] accessible in the App Store and Google Play is approximately 100,000, and among these apps, the ones related to diabetes are the highest in number. Conducting regular self-management tasks such as medication and insulin intake, blood sugar checkup, diet observance, and physical exercise are really demanding.<ref>{{cite journal | vauthors = Hood M, Wilson R, Corsica J, Bradley L, Chirinos D, Vivo A | title = What do we know about mobile applications for diabetes self-management? A review of reviews | journal = Journal of Behavioral Medicine | volume = 39 | issue = 6 | pages = 981–994 | date = December 2016 | pmid = 27412774 | doi = 10.1007/s10865-016-9765-3 | s2cid = 29465893 }}</ref> This is why the use of diabetes-related apps for the purposes of recording diet and medication intake or blood glucose level is promising to improve the health condition for the patients.

=== Foot checking ===
Monitoring a person's feet can help in predicting the likelihood of developing ]s. A common method for this is using a special ] to look for spots on the foot that have higher temperature which indicate the possibility of an ulcer developing.<ref name=":2">{{Cite journal |date=2022-06-21 |title=Simple tool identifies the people with diabetes most likely to develop foot ulcers |url=https://evidence.nihr.ac.uk/alert/simple-tool-predicts-foot-ulcers-in-diabetes/ |journal=NIHR Evidence |language=en |publisher=National Institute for Health and Care Research |doi=10.3310/nihrevidence_51316|s2cid=251787297 }}</ref> At the same time there is no strong ] supporting the effectiveness of at-home foot temperature monitoring.<ref>{{Cite journal |last1=Golledge |first1=Jonathan |last2=Fernando |first2=Malindu E |last3=Alahakoon |first3=Chanika |last4=Lazzarini |first4=Peter A. |last5=aan de Stegge |first5=Wouter B. |last6=van Netten |first6=Jaap J. |last7=Bus |first7=Sicco A. |date=23 May 2022 |title=Efficacy of at home monitoring of foot temperature for risk reduction of diabetes‐related foot ulcer: A meta‐analysis |journal=Diabetes/Metabolism Research and Reviews |language=en |volume=38 |issue=6 |pages=e3549 |doi=10.1002/dmrr.3549 |pmid=35605998 |pmc=9541448 |s2cid=251981184 |issn=1520-7552}}</ref>

The current guideline in the United Kingdom recommends collecting 8-10 pieces of information for predicting the development of foot ulcers.<ref>{{Cite web |title=Diabetic foot problems: prevention and management |url=https://www.nice.org.uk/guidance/ng19/chapter/Recommendations#assessing-the-risk-of-developing-a-diabetic-foot-problem |access-date=2022-09-06 |website=National Institute for Health and Care Excellence (NICE)|date=26 August 2015 }}</ref> A simpler method proposed by researchers provides a more detailed risk score based on three pieces of information (insensitivity, foot pulse, previous history of ulcers or amputation). This method is not meant to replace people regularly checking their own feet but complement it.<ref name=":2" /><ref>{{Cite journal |last1=Chappell |first1=Francesca M |last2=Crawford |first2=Fay |last3=Horne |first3=Margaret |last4=Leese |first4=Graham P |last5=Martin |first5=Angela |last6=Weller |first6=David |last7=Boulton |first7=Andrew J M |last8=Abbott |first8=Caroline |last9=Monteiro-Soares |first9=Matilde |last10=Veves |first10=Aristidis |last11=Riley |first11=Richard D |date=25 May 2021 |title=Development and validation of a clinical prediction rule for development of diabetic foot ulceration: an analysis of data from five cohort studies |journal=BMJ Open Diabetes Research & Care |language=en |volume=9 |issue=1 |pages=e002150 |doi=10.1136/bmjdrc-2021-002150 |pmid=34035053 |pmc=8154962 |issn=2052-4897}}</ref>

===Driving===
]
Diabetes can compromise driving safety in several ways. First, long-term complications of diabetes can interfere with the safe operation of a vehicle. For example, ] (loss of peripheral vision or visual acuity), or ] (loss of feeling in the feet) can impair a driver's ability to read street signs, control the speed of the vehicle, apply appropriate pressure to the brakes, etc.

Second, hypoglycemia can affect a person's thinking process, coordination, and state of consciousness.<ref name="Cox">{{cite journal | vauthors = Cox DJ, Gonder-Frederick L, Clarke W | title = Driving decrements in type I diabetes during moderate hypoglycemia | journal = Diabetes | volume = 42 | issue = 2 | pages = 239–243 | date = February 1993 | pmid = 8425660 | doi = 10.2337/diabetes.42.2.239 }}</ref><ref>{{cite journal | vauthors = Clarke WL, Cox DJ, Gonder-Frederick LA, Kovatchev B | title = Hypoglycemia and the decision to drive a motor vehicle by persons with diabetes | journal = JAMA | volume = 282 | issue = 8 | pages = 750–754 | date = August 1999 | pmid = 10463710 | doi = 10.1001/jama.282.8.750 | doi-access = free }}</ref> This disruption in brain functioning is called neuroglycopenia. Studies have demonstrated that the effects of ] impair driving ability.<ref name="Cox" /><ref>{{cite journal | vauthors = Cox DJ, Gonder-Frederick LA, Kovatchev BP, Julian DM, Clarke WL | title = Progressive hypoglycemia's impact on driving simulation performance. Occurrence, awareness and correction | journal = Diabetes Care | volume = 23 | issue = 2 | pages = 163–170 | date = February 2000 | pmid = 10868825 | doi = 10.2337/diacare.23.2.163 | doi-access = free }}</ref> A study involving people with type 1 diabetes found that individuals reporting two or more hypoglycemia-related driving mishaps differ physiologically and behaviorally from their counterparts who report no such mishaps.<ref name="Cox_a">{{cite journal | vauthors = Cox DJ, Kovatchev BP, Anderson SM, Clarke WL, Gonder-Frederick LA | title = Type 1 diabetic drivers with and without a history of recurrent hypoglycemia-related driving mishaps: physiological and performance differences during euglycemia and the induction of hypoglycemia | journal = Diabetes Care | volume = 33 | issue = 11 | pages = 2430–2435 | date = November 2010 | pmid = 20699432 | pmc = 2963507 | doi = 10.2337/dc09-2130 }}</ref> For example, during hypoglycemia, drivers who had two or more mishaps reported fewer warning symptoms, their driving was more impaired, and their body released less epinephrine (a hormone that helps raise BG). Additionally, individuals with a history of hypoglycemia-related driving mishaps appear to use sugar at a faster rate<ref>{{cite journal | vauthors = Cox DJ, Gonder-Frederick LA, Kovatchev BP, Clarke WL | title = The metabolic demands of driving for drivers with type 1 diabetes mellitus | journal = Diabetes/Metabolism Research and Reviews | volume = 18 | issue = 5 | pages = 381–385 | year = 2002 | pmid = 12397580 | doi = 10.1002/dmrr.306 | s2cid = 25094659 }}</ref> and are relatively slower at processing information.<ref>{{cite journal | vauthors = Campbell LK, Gonder-Frederick LA, Broshek DK, Kovatchev BP, Anderson S, Clarke WL, Cox DJ | title = Neurocognitive Differences Between Drivers with Type 1 Diabetes with and without a Recent History of Recurrent Driving Mishaps | journal = International Journal of Diabetes Mellitus | volume = 2 | issue = 2 | pages = 73–77 | date = August 2010 | pmid = 21127720 | pmc = 2993428 | doi = 10.1016/j.ijdm.2010.05.014 }}</ref> These findings indicate that although anyone with type 1 diabetes may be at some risk of experiencing disruptive hypoglycemia while driving, there is a subgroup of type 1 drivers who are more vulnerable to such events.

Given the above research findings, it is recommended that drivers with type 1 diabetes with a history of driving mishaps should never drive when their BG is less than 70&nbsp;mg/dL (3.9&nbsp;mmol/L). Instead, these drivers are advised to treat hypoglycemia and delay driving until their BG is above 90&nbsp;mg/dL (5&nbsp;mmol/L).<ref name="Cox_a" /> Such drivers should also learn as much as possible about what causes their hypoglycemia, and use this information to avoid future hypoglycemia while driving.

===Other regimens===
] can be used in a ] system to aid in diabetes management providing automated support to diabetes patients and their professional care providers.<ref>{{cite journal | vauthors = Schwartz FL, Shubrook JH, Marling CR | title = Use of case-based reasoning to enhance intensive management of patients on insulin pump therapy | journal = Journal of Diabetes Science and Technology | volume = 2 | issue = 4 | pages = 603–611 | date = July 2008 | pmid = 19885236 | pmc = 2769779 | doi = 10.1177/193229680800200411 }}</ref><ref name="walker">{{cite web |vauthors=Walker D |title=Similarity Determination and Case Retrieval in an Intelligent Decision Support System for Diabetes Management |date=November 2007 |url=http://etd.ohiolink.edu/send-pdf.cgi/Walker%20Donald.pdf?acc_num=ohiou1194562654 |access-date=2 October 2009 |archive-date=16 July 2011 |archive-url=https://web.archive.org/web/20110716152505/http://etd.ohiolink.edu/send-pdf.cgi/Walker%20Donald.pdf?acc_num=ohiou1194562654 |url-status=dead }}</ref>

=== Dental care ===
High blood glucose in diabetic people is a risk factor for developing ] and ] problems, especially in post-] and aging individuals. Diabetic patients have greater chances of developing oral health problems such as ], ] dysfunction, ], inflammatory ] disease, ] or taste impairment and thrush of the mouth.<ref>{{cite web|url=http://www.dentalcarediabetes.com| title=Oral diabetes care|access-date=2010-05-05}}</ref> The oral problems in persons with diabetes can be prevented with a good control of the blood sugar levels, regular check-ups and a very good ]. By maintaining a good oral status, diabetic persons prevent losing their teeth as a result of various periodontal conditions.

Diabetic persons must increase their awareness about oral infections as they have a double impact on health. Firstly, people with diabetes are more likely to develop periodontal disease, which causes increased blood sugar levels, often leading to diabetes complications. Severe periodontal disease can increase blood sugar, contributing to increased periods of time when the body functions with a high blood sugar. This puts diabetics at increased risk for diabetic complications.<ref name="Gum Disease and Diabetes">{{cite web|url=http://www.perio.org/consumer/mbc.diabetes.htm|title=Gum Disease and Diabetes|access-date=2010-05-05|archive-url=https://web.archive.org/web/20100612195938/http://perio.org/consumer/mbc.diabetes.htm|archive-date=2010-06-12|url-status=dead}}</ref>

The first symptoms of gum and tooth ] in diabetic persons are decreased salivary flow and burning mouth or ]. Also, patients may experience signs like dry mouth, which increases the incidence of decay. Poorly controlled diabetes usually leads to gum recession, since ] creates more harmful ] in the gums.

Tooth decay and cavities are some of the first oral problems that individuals with diabetes are at risk for. Increased blood sugar levels translate into greater sugars and acids that attack the teeth and lead to gum diseases. ] can also occur as a result of increased blood sugar levels along with an inappropriate oral hygiene. ] is an oral disease caused by untreated gingivitis and which destroys the soft tissue and bone that support the teeth. This disease may cause the gums to pull away from the teeth which may eventually loosen and fall out. Diabetic people tend to experience more severe periodontitis because diabetes lowers the ability to resist infection<ref>{{cite journal | vauthors = Koh GC, Peacock SJ, van der Poll T, Wiersinga WJ | title = The impact of diabetes on the pathogenesis of sepsis | journal = European Journal of Clinical Microbiology & Infectious Diseases | volume = 31 | issue = 4 | pages = 379–388 | date = April 2012 | pmid = 21805196 | pmc = 3303037 | doi = 10.1007/s10096-011-1337-4 }}</ref> and also slows healing. At the same time, an oral infection such as periodontitis can make diabetes more difficult to control because it causes the blood sugar levels to rise.<ref>{{cite web|url=http://www.mayoclinic.com/health/diabetes/DA00013/NSECTIONGROUP=2|title=Diabetes and Dental Care: Guide to a Healthy Mouth|access-date=2010-05-05}}</ref>

To prevent further diabetic complications as well as serious oral problems, diabetic persons must keep their blood sugar levels under control and have a proper oral hygiene. A study in the Journal of Periodontology found that poorly controlled type 2 diabetic patients are more likely to develop periodontal disease than well-controlled diabetics are.<ref name="Gum Disease and Diabetes"/> At the same time, diabetic patients are recommended to have regular checkups with a dental care provider at least once in three to four months. Diabetics who receive good dental care and have good insulin control typically have a better chance at avoiding gum disease to help prevent ].<ref>{{cite web|url=http://www.dentalgentlecare.com/diabetes.htm|title=Diabetes and Oral Health|access-date=2010-05-05|archive-url=https://web.archive.org/web/20100424115557/http://www.dentalgentlecare.com/diabetes.htm|archive-date=2010-04-24|url-status=dead}}</ref>

Dental care is therefore even more important for diabetic patients than for healthy individuals. Maintaining the teeth and gum healthy is done by taking some preventing measures such as regular appointments at a dentist and a very good oral hygiene. Also, oral health problems can be avoided by closely monitoring the blood sugar levels. Patients who keep better under control their blood sugar levels and diabetes are less likely to develop oral health problems when compared to diabetic patients who control their disease moderately or poorly.

Poor oral hygiene is a great factor to take under consideration when it comes to oral problems and even more in people with diabetes. Diabetic people are advised to brush their teeth at least twice a day, and if possible, after all ] and ]. However, brushing in the morning and at night is mandatory as well as ] and using an anti-bacterial ]. Individuals with diabetes are recommended to use ] that contains ] as this has proved to be the most efficient in fighting oral infections and tooth decay. Flossing must be done at least once a day, as well because it is helpful in preventing oral problems by removing the plaque between the teeth, which is not removed when brushing.

Diabetic patients must get professional ]s every six months. In cases when ] is needed, it is necessary to take some special precautions such as adjusting diabetes medication or taking ] to prevent infection. Looking for early signs of gum disease (redness, swelling, ]) and informing the dentist about them is also helpful in preventing further complications. ] is recommended to avoid serious diabetes complications and oral diseases.

Diabetic persons are advised to make morning appointments to the dental care provider as during this time of the day the blood sugar levels tend to be better kept under control. Not least, individuals with diabetes must make sure both their physician and dental care provider are informed and aware of their condition, medical history and periodontal status.


===Medication nonadherence=== ===Medication nonadherence===
Because many patients with diabetes have two or more comorbidities, they often require multiple medications. The prevalence of medication nonadherence is high among patients with chronic conditions, such as diabetes, and nonadherence is associated with public health issues and higher health care costs. One reason for nonadherence is the cost of medications. Being able to detect cost-related nonadherence is important for health care professionals, because this can lead to strategies to assist patients with problems paying for their medications. Some of these strategies are use of generic drugs or therapeutic alternatives, substituting a prescription drug with an over-the-counter medication, and pill-splitting. Interventions to improve adherence can achieve reductions in diabetes morbidity and mortality, as well as significant cost savings to the health care system.<ref>{{cite journal | vauthors = Chan M | year = 2010 | title = Reducing cost-related medication nonadherence in patients with diabetes | url = http://dbt.consultantlive.com/diabetes-management/content/article/1145628/1554670 | journal = Drug Benefit Trends | volume = 22 | pages = 67–71 | access-date = 2010-05-05 | archive-date = 2012-03-04 | archive-url = https://web.archive.org/web/20120304154531/http://dbt.consultantlive.com/diabetes-management/content/article/1145628/1554670 | url-status = dead }}</ref> Smartphone apps have been found to improve self-management and health outcomes in people with diabetes through functions such as specific reminder alarms,<ref>{{cite journal | vauthors = Cui M, Wu X, Mao J, Wang X, Nie M | title = T2DM Self-Management via Smartphone Applications: A Systematic Review and Meta-Analysis | journal = PLOS ONE | volume = 11 | issue = 11 | pages = e0166718 | year = 2016 | pmid = 27861583 | pmc = 5115794 | doi = 10.1371/journal.pone.0166718 | doi-access = free | bibcode = 2016PLoSO..1166718C }}</ref> while working with mental health professionals has also been found to help people with diabetes develop the skills to manage their medications and challenges of self-management effectively.<ref name=":0">{{cite journal | vauthors = Safren SA, Gonzalez JS, Wexler DJ, Psaros C, Delahanty LM, Blashill AJ, Margolina AI, Cagliero E | display-authors = 6 | title = A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in patients with uncontrolled type 2 diabetes | journal = Diabetes Care | volume = 37 | issue = 3 | pages = 625–633 | year = 2013 | pmid = 24170758 | pmc = 3931377 | doi = 10.2337/dc13-0816 }}</ref> Because many patients with diabetes have two or more comorbidities, they often require multiple medications. The prevalence of medication nonadherence is high among patients with chronic conditions, such as diabetes, and nonadherence is associated with public health issues and higher health care costs. One reason for nonadherence is the cost of medications. Being able to detect cost-related nonadherence is important for health care professionals, because this can lead to strategies to assist patients with problems paying for their medications. Some of these strategies are use of generic drugs or therapeutic alternatives, substituting a prescription drug with an over-the-counter medication, and pill-splitting. Interventions to improve adherence can achieve reductions in diabetes morbidity and mortality, as well as significant cost savings to the health care system.<ref>{{cite journal |vauthors=Chan M |year=2010 |title=Reducing cost-related medication nonadherence in patients with diabetes |url=http://dbt.consultantlive.com/diabetes-management/content/article/1145628/1554670 |url-status=dead |journal=Drug Benefit Trends |volume=22 |pages=67–71 |archive-url=https://web.archive.org/web/20120304154531/http://dbt.consultantlive.com/diabetes-management/content/article/1145628/1554670 |archive-date=2012-03-04 |access-date=2010-05-05}}</ref> Smartphone apps have been found to improve self-management and health outcomes in people with diabetes through functions such as specific reminder alarms,<ref>{{cite journal |vauthors=Cui M, Wu X, Mao J, Wang X, Nie M |year=2016 |title=T2DM Self-Management via Smartphone Applications: A Systematic Review and Meta-Analysis |journal=PLOS ONE |volume=11 |issue=11 |pages=e0166718 |bibcode=2016PLoSO..1166718C |doi=10.1371/journal.pone.0166718 |pmc=5115794 |pmid=27861583 |doi-access=free}}</ref> while working with mental health professionals has also been found to help people with diabetes develop the skills to manage their medications and challenges of self-management effectively.<ref name=":0">{{cite journal |display-authors=6 |vauthors=Safren SA, Gonzalez JS, Wexler DJ, Psaros C, Delahanty LM, Blashill AJ, Margolina AI, Cagliero E |year=2013 |title=A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in patients with uncontrolled type 2 diabetes |journal=Diabetes Care |volume=37 |issue=3 |pages=625–633 |doi=10.2337/dc13-0816 |pmc=3931377 |pmid=24170758}}</ref>


===Psychological mechanisms and adherence=== ===Psychological mechanisms and adherence===
As self-management of diabetes typically involves lifestyle modifications, adherence may pose a significant self-management burden on many individuals.<ref name=":1">{{cite journal | vauthors = Gonzalez JS, Tanenbaum ML, Commissariat PV | title = Psychosocial factors in medication adherence and diabetes self-management: Implications for research and practice | journal = The American Psychologist | volume = 71 | issue = 7 | pages = 539–551 | date = October 2016 | pmid = 27690483 | pmc = 5792162 | doi = 10.1037/a0040388 }}</ref> For example, individuals with diabetes may find themselves faced with the need to self-monitor their blood glucose levels, adhere to healthier diets and maintain exercise regimens regularly in order to maintain metabolic control and reduce the risk of developing cardiovascular problems. Barriers to adherence have been associated with key psychological mechanisms: knowledge of self-management, beliefs about the efficacy of treatment and self-efficacy/perceived control.<ref name=":1" /> Such mechanisms are inter-related, as one's thoughts (e.g. one's perception of diabetes, or one's appraisal of how helpful self-management is) is likely to relate to one's emotions (e.g. motivation to change), which in turn, affects one's self-efficacy (one's confidence in their ability to engage in a behaviour to achieve a desired outcome).<ref>{{cite journal | vauthors = Chew BH, Vos RC, Metzendorf MI, Scholten RJ, Rutten GE | title = Psychological interventions for diabetes-related distress in adults with type 2 diabetes mellitus | journal = The Cochrane Database of Systematic Reviews | volume = 9 | pages = CD011469 | date = September 2017 | issue = 9 | pmid = 28954185 | doi = 10.1002/14651858.CD011469 | pmc = 6483710 | veditors = Chew BH }}</ref> As self-management of diabetes typically involves lifestyle modifications, adherence may pose a significant self-management burden on many individuals.<ref name=":1">{{cite journal |vauthors=Gonzalez JS, Tanenbaum ML, Commissariat PV |date=October 2016 |title=Psychosocial factors in medication adherence and diabetes self-management: Implications for research and practice |journal=The American Psychologist |volume=71 |issue=7 |pages=539–551 |doi=10.1037/a0040388 |pmc=5792162 |pmid=27690483}}</ref> For example, individuals with diabetes may find themselves faced with the need to self-monitor their BG levels, adhere to healthier diets and maintain exercise regimens regularly in order to maintain metabolic control and reduce the risk of developing cardiovascular problems. Barriers to adherence have been associated with key psychological mechanisms: knowledge of self-management, beliefs about the efficacy of treatment and self-efficacy/perceived control.<ref name=":1" /> Such mechanisms are inter-related, as one's thoughts (e.g. one's perception of diabetes, or one's appraisal of how helpful self-management is) is likely to relate to one's emotions (e.g. motivation to change), which in turn, affects one's self-efficacy (one's confidence in their ability to engage in a behaviour to achieve a desired outcome).<ref>{{cite journal |vauthors=Chew BH, Vos RC, Metzendorf MI, Scholten RJ, Rutten GE |date=September 2017 |title=Psychological interventions for diabetes-related distress in adults with type 2 diabetes mellitus |journal=The Cochrane Database of Systematic Reviews |volume=9 |issue=9 |pages=CD011469 |doi=10.1002/14651858.CD011469 |pmc=6483710 |pmid=28954185 |veditors=Chew BH}}</ref>

As diabetes management is affected by an individual's emotional and cognitive state, there has been evidence suggesting the self-management of diabetes is negatively affected by diabetes-related distress and depression.<ref>{{cite journal | vauthors = Lustman PJ, Anderson RJ, Freedland KE, de Groot M, Carney RM, Clouse RE | title = Depression and poor glycemic control: a meta-analytic review of the literature | journal = Diabetes Care | volume = 23 | issue = 7 | pages = 934–942 | date = July 2000 | pmid = 10895843 | doi = 10.2337/diacare.23.7.934 | doi-access = free }}</ref> There is growing evidence that there is higher levels of clinical depression in patients with diabetes compared to the non-diabetic population.<ref name="pmid30273857">{{cite journal | vauthors = Hussain S, Habib A, Singh A, Akhtar M, Najmi AK | title = Prevalence of depression among type 2 diabetes mellitus patients in India: A meta-analysis | journal = Psychiatry Research | volume = 270 | issue = | pages = 264–273 | date = December 2018 | pmid = 30273857 | doi = 10.1016/j.psychres.2018.09.037 | s2cid = 52919905 }}</ref><ref>{{cite journal | vauthors = Ali S, Stone MA, Peters JL, Davies MJ, Khunti K | title = The prevalence of co-morbid depression in adults with Type 2 diabetes: a systematic review and meta-analysis | journal = Diabetic Medicine | volume = 23 | issue = 11 | pages = 1165–1173 | date = November 2006 | pmid = 17054590 | doi = 10.1111/j.1464-5491.2006.01943.x | s2cid = 25685073 }}</ref> Depression in individuals with diabetes has been found to be associated with poorer self-management of symptoms.<ref>{{cite journal | vauthors = Gonzalez JS, Peyrot M, McCarl LA, Collins EM, Serpa L, Mimiaga MJ, Safren SA | title = Depression and diabetes treatment nonadherence: a meta-analysis | journal = Diabetes Care | volume = 31 | issue = 12 | pages = 2398–2403 | date = December 2008 | pmid = 19033420 | pmc = 2584202 | doi = 10.2337/dc08-1341 }}</ref> This suggests that it may be important to target mood in treatment. In the case of children and young people, especially if they are socially disadvantaged, research suggests that it is important that healthcare providers listen to and discuss their feelings and life situation to help them engage with diabetes services and self-management.<ref>{{Cite journal |date=2022-03-15 |title=Why don't children and young people engage with diabetes services? |url=https://evidence.nihr.ac.uk/alert/why-dont-young-people-engage-with-diabetes-services/ |journal=NIHR Evidence |type=Plain English summary |language=en |publisher=National Institute for Health and Care Research |doi=10.3310/alert_49448|s2cid=247483863 }}</ref><ref>{{cite journal | vauthors = Sharpe D, Rajabi M, Harden A, Moodambail AR, Hakeem V | title = Supporting disengaged children and young people living with diabetes to self-care: a qualitative study in a socially disadvantaged and ethnically diverse urban area | journal = BMJ Open | volume = 11 | issue = 10 | pages = e046989 | date = October 2021 | pmid = 34645656 | pmc = 8515452 | doi = 10.1136/bmjopen-2020-046989 }}</ref>

To this end, treatment programs such as the Cognitive Behavioural Therapy - Adherence and Depression program (CBT-AD)<ref name=":0" /> have been developed to target the psychological mechanisms underpinning adherence. By working on increasing motivation and challenging maladaptive illness perceptions, programs such as CBT-AD aim to enhance self-efficacy and improve diabetes-related distress and one's overall quality of life.<ref name="Safren, S. 2014">{{cite journal | vauthors = Safren SA, Gonzalez JS, Wexler DJ, Psaros C, Delahanty LM, Blashill AJ, Margolina AI, Cagliero E | display-authors = 6 | title = A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in patients with uncontrolled type 2 diabetes | journal = Diabetes Care | volume = 37 | issue = 3 | pages = 625–633 | year = 2014 | pmid = 24170758 | pmc = 3931377 | doi = 10.2337/dc13-0816 }}</ref>

==Research==
{{see also|Fluorescent glucose biosensors}}

===Type 1 diabetes===
Diabetes type&nbsp;1 is caused by the destruction of enough ]s to produce symptoms; these cells, which are found in the ] in the ], produce and secrete ], the single hormone responsible for allowing ] to enter from the ] into ]s (in addition to the hormone ], another hormone required for glucose ]). Hence, the phrase "curing diabetes type&nbsp;1" means "causing a maintenance or restoration of the ] ability of the body to produce insulin in response to the level of blood glucose" and cooperative operation with counterregulatory hormones.

This section deals only with approaches for curing the underlying condition of diabetes type&nbsp;1, by enabling the body to endogenously, ''in vivo'', produce insulin in response to the level of blood glucose. It does not cover other approaches, such as, for instance, closed-loop integrated glucometer/insulin pump products, which could potentially increase the quality-of-life for some who have diabetes type&nbsp;1, and may by some be termed "artificial pancreas".

==== Encapsulation approach ====
] with encapsulated ] delivering ] ] in response to ]]]

A biological approach to the artificial pancreas is to implant ] containing ], which would secrete the amounts of insulin, ] and glucagon needed in response to sensed glucose.

When islet cells have been transplanted via the ], insulin production (and glycemic control) was restored, but at the expense of continued ] drugs. ] of the islet cells in a protective coating has been developed to block the immune response to transplanted cells, which relieves the burden of immunosuppression and benefits the longevity of the transplant.<ref> {{webarchive|url=https://web.archive.org/web/20090115041618/http://www.isletmedical.com/pages/define_methods.htm |date=2009-01-15 }}</ref>

==== Stem cells ====
{{See also|Type 1 diabetes#Stem cells|Type 2 diabetes#Stem cells}}
Research is being done at several locations in which islet cells are developed from ]s.

Stem cell research has also been suggested as a potential avenue for a cure since it may permit regrowth of Islet cells which are genetically part of the treated individual, thus perhaps eliminating the need for immuno-suppressants. This new method autologous nonmyeloablative hematopoietic stem cell transplantation was developed by a research team composed by Brazilian and American scientists (Dr. Julio Voltarelli, Dr. Carlos Eduardo Couri, Dr Richard Burt, and colleagues) and it was the first study to use stem cell therapy in human diabetes mellitus This was initially tested in mice and in 2007 there was the first publication of stem cell therapy to treat this form of diabetes.<ref name="pmid17426276">{{cite journal | vauthors = Voltarelli JC, Couri CE, Stracieri AB, Oliveira MC, Moraes DA, Pieroni F, Coutinho M, Malmegrim KC, Foss-Freitas MC, Simões BP, Foss MC, Squiers E, Burt RK | display-authors = 6 | title = Autologous nonmyeloablative hematopoietic stem cell transplantation in newly diagnosed type 1 diabetes mellitus | journal = JAMA | volume = 297 | issue = 14 | pages = 1568–1576 | date = April 2007 | pmid = 17426276 | doi = 10.1001/jama.297.14.1568 | doi-access = free }}</ref> Until 2009, there was 23 patients included and followed for a mean period of 29.8 months (ranging from 7 to 58 months). In the trial, severe immunosuppression with high doses of cyclophosphamide and anti-thymocyte globulin is used with the aim of "turning off" the immunologic system", and then autologous hematopoietic stem cells are reinfused to regenerate a new one. In summary it is a kind of "immunologic reset" that blocks the autoimmune attack against residual pancreatic insulin-producing cells. Until December 2009, 12 patients remained continuously insulin-free for periods ranging from 14 to 52 months and 8 patients became transiently insulin-free for periods ranging from 6 to 47 months. Of these last 8 patients, 2 became insulin-free again after the use of sitagliptin, a DPP-4 inhibitor approved only to treat type 2 diabetic patients and this is also the first study to document the use and complete insulin-independendce in humans with type 1 diabetes with this medication. In parallel with insulin suspension, indirect measures of endogenous insulin secretion revealed that it significantly increased in the whole group of patients, regardless the need of daily exogenous insulin use.<ref>{{cite journal | vauthors = Couri CE, Oliveira MC, Stracieri AB, Moraes DA, Pieroni F, Barros GM, Madeira MI, Malmegrim KC, Foss-Freitas MC, Simões BP, Martinez EZ, Foss MC, Burt RK, Voltarelli JC | display-authors = 6 | title = C-peptide levels and insulin independence following autologous nonmyeloablative hematopoietic stem cell transplantation in newly diagnosed type 1 diabetes mellitus | journal = JAMA | volume = 301 | issue = 15 | pages = 1573–1579 | date = April 2009 | pmid = 19366777 | doi = 10.1001/jama.2009.470 | doi-access = free }}</ref>

==== Gene therapy ====
]: Designing a ] to deliberately infect cells with ] to carry on the viral production of ] in response to the blood sugar level.]]

Technology for ] is advancing rapidly such that there are multiple pathways possible to support endocrine function, with potential to practically cure diabetes.<ref> {{webarchive|url=https://web.archive.org/web/20091029114009/http://www.niddk.nih.gov/fund/reports/gene_therapy_summ.htm |date=2009-10-29 }}</ref>
* Gene therapy can be used to '''manufacture insulin directly''': an oral medication, consisting of viral vectors containing the insulin sequence, is digested and delivers its genes to the upper intestines. Those intestinal cells will then behave like any viral infected cell, and will reproduce the insulin protein. The virus can be controlled to infect only the cells which respond to the presence of glucose, such that insulin is produced only in the presence of high glucose levels. Due to the limited numbers of vectors delivered, very few intestinal cells would actually be impacted and would die off naturally in a few days. Therefore, by varying the amount of oral medication used, the amount of insulin created by gene therapy can be increased or decreased as needed. As the insulin-producing intestinal cells die off, they are boosted by additional oral medications.<ref></ref>
* Gene therapy might eventually be used to '''cure the cause of beta cell destruction''', thereby curing the new diabetes patient before the beta cell destruction is complete and irreversible.<ref></ref>
* Gene therapy can be used to '''turn duodenum cells and duodenum adult stem cells into beta cells''' which produce insulin and amylin naturally. By delivering beta cell DNA to the intestine cells in the duodenum, a few intestine cells will turn into beta cells, and subsequently adult stem cells will develop into beta cells. This makes the supply of beta cells in the duodenum self-replenishing, and the beta cells will produce insulin in proportional response to carbohydrates consumed.<ref></ref>

==== Monoclonal antibodies ====
In November 2022 the FDA approved ] a ] drug which aims to delay type 1 diabetes by reprogramming the immune system to stop mistakenly attacking pancreatic cells.<ref name="Stages of Type 1 Diabetes">{{cite journal |last1=American Diabetes Association Professional Practice Committee |date=1 January 2022 |title=2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes—2022 |url=https://diabetesjournals.org/care/article/45/Supplement_1/S17/138925/2-Classification-and-Diagnosis-of-Diabetes |journal=Diabetes Care |volume=45 |issue=45 |pages=S17–S38 |doi=10.2337/dc22-S002 |pmid=34964875 |s2cid=245451959 |access-date=17 November 2022|doi-access=free }}</ref><ref>{{Cite news |date=2022-11-18 |title=Game-changing type 1 diabetes drug approved in US |language=en-GB |work=BBC News |url=https://www.bbc.com/news/health-63663338 |access-date=2022-11-20}}</ref>

===Type 2 diabetes===
Type&nbsp;2 diabetes is usually first treated by increasing physical activity, and eliminating ] and reducing ] and ] intake with a goal of ]. These can restore insulin sensitivity even when the weight loss is modest, for example around 5&nbsp;kg (10 to 15&nbsp;lb), most especially when it is in abdominal fat deposits. Diets that are very low in saturated fats have been claimed to reverse insulin resistance.<ref name="Barnard 2007">{{cite book | vauthors = Barnard N |year=2007 |chapter=13 |title=Dr. Neal Barnard's Program for Reversing Diabetes: The Scientifically Proven System for Reversing Diabetes Without Drugs |publisher=Rodale/Holtzbrinck Publishers |location=New York, NY |isbn=978-1-59486-528-2 |chapter-url-access=registration |chapter-url=https://archive.org/details/drnealbarnardspr00barn |url-access=registration |url=https://archive.org/details/drnealbarnardspr00barn }}</ref><ref name=pmid19386029>{{cite journal | vauthors = Barnard ND, Katcher HI, Jenkins DJ, Cohen J, Turner-McGrievy G | title = Vegetarian and vegan diets in type 2 diabetes management | journal = Nutrition Reviews | volume = 67 | issue = 5 | pages = 255–263 | date = May 2009 | pmid = 19386029 | doi = 10.1111/j.1753-4887.2009.00198.x | s2cid = 1662675 }}</ref>

Cognitive Behavioural Therapy is an effective intervention for improving adherence to medication, depression and glycaemic control, with enduring and clinically meaningful benefits for diabetes self-management and glycaemic control in adults with type 2 diabetes and comorbid depression.<ref name="Safren, S. 2014"/>

] may improve glucose tolerance and insulin sensitivity in diabetic hypogonadal men. The mechanisms by which ] decreases ] is under study.<ref name=pmid18772488>{{cite journal | vauthors = Traish AM, Saad F, Guay A | title = The dark side of testosterone deficiency: II. Type 2 diabetes and insulin resistance | journal = Journal of Andrology | volume = 30 | issue = 1 | pages = 23–32 | year = 2009 | pmid = 18772488 | doi = 10.2164/jandrol.108.005751 | s2cid = 29463129 }}</ref> Moreover, testosterone may have a protective effect on pancreatic beta cells, which is possibly exerted by androgen-receptor-mediated mechanisms and influence of inflammatory cytokines.<ref>{{cite journal | vauthors = Zitzmann M | title = Testosterone deficiency, insulin resistance and the metabolic syndrome | journal = Nature Reviews. Endocrinology | volume = 5 | issue = 12 | pages = 673–681 | date = December 2009 | pmid = 19859074 | doi = 10.1038/nrendo.2009.212 | s2cid = 22307175 }}</ref>

According to a 2002 paper, it has been suggested that a type of ] may normalize blood glucose levels in 80–100% of severely obese patients with diabetes. The precise causal mechanisms are being intensively researched; its results may not simply be attributable to weight loss, as the improvement in blood sugars seems to precede any change in body mass. This approach may become a treatment for some people with type&nbsp;2 diabetes, but has not yet been studied in prospective clinical trials.<ref name=pmid12409659>{{cite journal | vauthors = Rubino F, Gagner M | title = Potential of surgery for curing type 2 diabetes mellitus | journal = Annals of Surgery | volume = 236 | issue = 5 | pages = 554–559 | date = November 2002 | pmid = 12409659 | pmc = 1422611 | doi = 10.1097/00000658-200211000-00003 }}</ref> This surgery may have the additional benefit of reducing the death rate from all causes by up to 40% in severely obese people.<ref name=pmid17715409>{{cite journal | vauthors = Adams TD, Gress RE, Smith SC, Halverson RC, Simper SC, Rosamond WD, Lamonte MJ, Stroup AM, Hunt SC | display-authors = 6 | title = Long-term mortality after gastric bypass surgery | journal = The New England Journal of Medicine | volume = 357 | issue = 8 | pages = 753–761 | date = August 2007 | pmid = 17715409 | doi = 10.1056/NEJMoa066603 | s2cid = 8710295 | doi-access = free }}</ref> A small number of normal to moderately obese patients with type&nbsp;2 diabetes have successfully undergone similar operations.<ref name=pmid17386401>{{cite journal | vauthors = Cohen RV, Schiavon CA, Pinheiro JS, Correa JL, Rubino F | title = Duodenal-jejunal bypass for the treatment of type 2 diabetes in patients with body mass index of 22–34 kg/m2: a report of 2 cases | journal = Surgery for Obesity and Related Diseases | volume = 3 | issue = 2 | pages = 195–197 | year = 2007 | pmid = 17386401 | doi = 10.1016/j.soard.2007.01.009 }}</ref><ref name="NS">{{cite journal | vauthors = Vasonconcelos A |date = September 2007 |title=Could type&nbsp;2 diabetes be reversed using surgery? |journal=] |issue=2619 |pages=11–13 |url=https://www.newscientist.com/channel/health/mg19526193.100-could-type-2-diabetes-be-reversed-using-surgery.html |access-date=26 September 2007}}</ref>


As diabetes management is affected by an individual's emotional and cognitive state, there has been evidence suggesting the self-management of diabetes is negatively affected by diabetes-related distress and depression.<ref>{{cite journal |vauthors=Lustman PJ, Anderson RJ, Freedland KE, de Groot M, Carney RM, Clouse RE |date=July 2000 |title=Depression and poor glycemic control: a meta-analytic review of the literature |journal=Diabetes Care |volume=23 |issue=7 |pages=934–942 |doi=10.2337/diacare.23.7.934 |pmid=10895843 |doi-access=free}}</ref> There is growing evidence that there is higher levels of clinical depression in patients with diabetes compared to the non-diabetic population.<ref name="pmid30273857">{{cite journal |vauthors=Hussain S, Habib A, Singh A, Akhtar M, Najmi AK |date=December 2018 |title=Prevalence of depression among type 2 diabetes mellitus patients in India: A meta-analysis |journal=Psychiatry Research |volume=270 |issue= |pages=264–273 |doi=10.1016/j.psychres.2018.09.037 |pmid=30273857 |s2cid=52919905}}</ref><ref>{{cite journal |vauthors=Ali S, Stone MA, Peters JL, Davies MJ, Khunti K |date=November 2006 |title=The prevalence of co-morbid depression in adults with Type 2 diabetes: a systematic review and meta-analysis |journal=Diabetic Medicine |volume=23 |issue=11 |pages=1165–1173 |doi=10.1111/j.1464-5491.2006.01943.x |pmid=17054590 |s2cid=25685073}}</ref> Depression in individuals with diabetes has been found to be associated with poorer self-management of symptoms.<ref>{{cite journal |vauthors=Gonzalez JS, Peyrot M, McCarl LA, Collins EM, Serpa L, Mimiaga MJ, Safren SA |date=December 2008 |title=Depression and diabetes treatment nonadherence: a meta-analysis |journal=Diabetes Care |volume=31 |issue=12 |pages=2398–2403 |doi=10.2337/dc08-1341 |pmc=2584202 |pmid=19033420}}</ref> This suggests that it may be important to target mood in treatment. In the case of children and young people, especially if they are socially disadvantaged, research suggests that it is important that healthcare providers listen to and discuss their feelings and life situation to help them engage with diabetes services and self-management.<ref>{{Cite journal |date=2022-03-15 |title=Why don't children and young people engage with diabetes services? |url=https://evidence.nihr.ac.uk/alert/why-dont-young-people-engage-with-diabetes-services/ |journal=NIHR Evidence |type=Plain English summary |language=en |publisher=National Institute for Health and Care Research |doi=10.3310/alert_49448 |s2cid=247483863}}</ref><ref>{{cite journal |vauthors=Sharpe D, Rajabi M, Harden A, Moodambail AR, Hakeem V |date=October 2021 |title=Supporting disengaged children and young people living with diabetes to self-care: a qualitative study in a socially disadvantaged and ethnically diverse urban area |journal=BMJ Open |volume=11 |issue=10 |pages=e046989 |doi=10.1136/bmjopen-2020-046989 |pmc=8515452 |pmid=34645656}}</ref>
] is a rare genetic form of diabetes, often mistaken for Type 1 or Type 2. The medical management is variable and depends on each individual case.<ref>{{Cite journal| vauthors = Elkholy S, Lardhi AA |date=2015-05-01|title=Do we need to test for maturity onset diabetes of the young among newly diagnosed diabetics in Saudi Arabia?|journal=International Journal of Diabetes Mellitus|volume=3|issue=1|pages=51–56|doi=10.1016/j.ijdm.2011.01.006|doi-access=free}}</ref>


To this end, treatment programs such as the Cognitive Behavioural Therapy - Adherence and Depression program (CBT-AD)<ref name=":0" /> have been developed to target the psychological mechanisms underpinning adherence. By working on increasing motivation and challenging maladaptive illness perceptions, programs such as CBT-AD aim to enhance self-efficacy and improve diabetes-related distress and one's overall quality of life.<ref name="Safren, S. 2014">{{cite journal |display-authors=6 |vauthors=Safren SA, Gonzalez JS, Wexler DJ, Psaros C, Delahanty LM, Blashill AJ, Margolina AI, Cagliero E |year=2014 |title=A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in patients with uncontrolled type 2 diabetes |journal=Diabetes Care |volume=37 |issue=3 |pages=625–633 |doi=10.2337/dc13-0816 |pmc=3931377 |pmid=24170758}}</ref>
Several immunosuppressive drugs targeting the chronic inflammation in type 2 diabetes have been tested.<ref name="pmid35533739">{{cite journal | vauthors = Mikkelsen RR, Hundahl MP, Torp CK, Rodríguez-Carrio J, Kjolby M, Bruun JM, Kragstrup TW | title = Immunomodulatory and immunosuppressive therapies in cardiovascular disease and type 2 diabetes mellitus: A bedside-to-bench approach | journal = Eur J Pharmacol | year = 2022 | volume = 925 | page = 174998 | pmid = 35533739 | doi = 10.1016/j.ejphar.2022.174998 | s2cid = 248589827 | doi-access = free }}</ref>


== See also == == See also ==

Latest revision as of 19:15, 15 December 2024

Management of diabetes

The main goal of diabetes management is to keep blood glucose (BG) levels as normal as possible. If diabetes is not well controlled, further challenges to health may occur. People with diabetes can measure blood sugar by various methods, such as with a BG meter or a continuous glucose monitor, which monitors over several days. Glucose can also be measured by analysis of a routine blood sample. Usually, people are recommended to control diet, exercise, and maintain a healthy weight, although some people may need medications to control their blood sugar levels. Other goals of diabetes management are to prevent or treat complications that can result from the disease itself and from its treatment.

Description

Diabetes is a chronic disease and it is important to have control of the diabetes as it can cause many complications. Diabetes can cause acute problems such as too low (hypoglycemia) or high blood sugar (hyperglycemia). Diabetes affects the blood vessels in the body, such as capillaries and arteries, which are the routes blood take to deliver nutrients and oxygen to the organs in the body. By affecting the blood flow, diabetes increases the risk of other conditions such as strokes and heart disease (heart attacks). Diabetes also affects small blood vessels, such as capillaries, in organs such as the eyes and the kidneys to cause diabetic retinopathy and diabetic nephropathy, respectively.

Therefore, it becomes important to lower the sugar levels in the body in addition to control other risk factors that also contribute to the major complications such as smoking, alcohol use, excessive weight, high blood pressure, and high cholesterol. Often, the recommended treatment is a combination of lifestyle changes such as increasing exercise and healthy eating, along with medications to help control the BG levels in the long term. In addition to management of the diabetes, patients are recommended to have routine follow up with specialist to manage possible common complications due to the diabetes such as foot ulcers, vision changes, and hearing loss.

Measurement

There are several methods in which blood sugar is measured including with a glucose meter, continuous glucose monitor and routine bloodwork.

Image 1: Picture of healthcare worker using lancet to get blood sample from patient.

The glucose meter (as seen in image 2) is a common a simple method in which glucose levels can be measured at home or in a clinical setting and is usually done several times per day. The test works by taking a small blood sample of blood using a lancet (a sterile pointed needle) to prick a finger (Image 1). The blood droplet is usually collected at the bottom of a test strip, while the other end is inserted in the glucose meter. The drop of blood is drawn into the meter and can directly measure the glucose in the sample. The units of blood sugar level from a glucose meter, with the result either in mg/dL (milligrams per deciliter in the US) or mmol/L (millimoles per liter in Canada and Eastern

Image 2: A modern portable BG meter (OneTouch Ultra), displaying a reading of 5.4 mmol/L (98 mg/dL).

Europe) of blood. Control of diabetes may be improved by patients using home glucose meters to regularly measure their glucose levels.

An image of a continuous glucose monitor attached on the skin

Continuous glucose monitors are another method to measure BG levels. A CGM is a device that sits on the surface of the skin and measures the amount of glucose between the cells with a probe. The device does not directly measure the blood sugar but calculates it based on the sample of the measurements it takes from the probe. The device will report the glucose level continuously and usually it has an alarm that will alert patients if the glucose level is too high or low. The device also is able to graph the glucose readings over the time the sensor was in use and is very useful for adjusting treatment.

In addition to the above tests, glucose can be measured on routine labs. One common test ordered by healthcare providers is a Basic Metabolic Panel (BMP) which is a blood test that looks at several different substances in the body, including BG. People are told to fast for 8 hours before drawing the labs so that the provider can see the fasting glucose level. The normal level for fasting blood sugar in non-diabetic patients is 70 to 99 mg/dL (3.9 and 5.5 mmol/L).

Another useful test that has usually done in a laboratory is the measurement of blood HbA1c (hemoglobin A1c) levels. In the blood, there is a molecule called hemoglobin which carries oxygen to the cells. Glucose can attach itself to this molecule and if the BG is consistently high, the value of the A1c will go up. This test, unlike the other tests, is measured as a percentage because the test measure the proportion of all the hemoglobin that has glucose attached. This test measures the average amount of diabetic control over a period of about 3 months. In non-diabetic people, the HbA1c level ranges from 4.0 to 5.7%. Regular 6 monthly laboratory testing of HbA1c (glycated hemoglobin) provides some assurance of long-term control and allows the adjustment of the patient's routine medication dosages in such cases.

Optimal management of diabetes involves people measuring and recording their own BG levels. By keeping a diary of their own BG measurements and noting the effect of food and exercise, patients can modify their lifestyle to better control their diabetes. For people on insulin, involvement is important in achieving effective dosing and timing.

Glycemic control

Glycemic control is a medical term referring to the typical levels of BG in a person with diabetes mellitus. Much evidence suggests that many of the long-term complications of diabetes, result from many years of hyperglycemia (elevated levels of glucose in the blood).

"Perfect glycemic control" would mean that glucose levels were always normal (70–130 mg/dL or 3.9–7.2 mmol/L) and indistinguishable from a person without diabetes. Good glycemic control, in the sense of a "target" for treatment, has become an important goal of diabetes care. Poor glycemic control refers to persistently (over several months) elevated BG in the 200 to 500 mg/dL (11–28 mmol/L). This is also measured by Hb A1c levels, which may range from greater than 9%.

Goals

They are suggested in clinical practice guidelines released by various national and international diabetes organizations.

The targets are:

  • HbA1c of less than 6% or 7.0% if they are achievable without significant hypoglycemia
  • Preprandial (before eating) BG: 3.9 to 7.2 mmol/L (70 to 130 mg/dL)
  • 2-hour postprandial (after eating) BG: <10 mmol/L (<180 mg/dL)

Goals should be individualized based on:

In older patients, clinical practice guidelines by the American Geriatrics Society recommend, in frail patients who have a life expectancy of less than 5 years, a target a Hb A1c of 8% is appropriate as the risk of very low blood sugar outweighs the long term benefits of a lower A1c.

Studies have been done to compare the effects of tight vs. conventional, or more relaxed, glycemic control in type 2 diabetics. It shows than to demonstrate a difference in all-cause cardiovascular death, non-fatal stroke, or limb amputation, but decreased the risk of nonfatal heart attack by 15%. Additionally, tight glucose control decreased the risk of progression of kidney, nerve and eye complications, but increased the risk of hypoglycemia.

Lifestyle modification

Diet

Main article: Diet in diabetes

There are many diets that are effective at managing diabetes and it is important that patients understand that there is no one diet that all patients should use. Some diets that have commonly been used successfully in diabetes management and help with weight loss include Mediterranean, vegetarian, low carb or carb-controlled. It is recommended that patients choose a diet that the patient can adhere to in the long run as a diet that is very ideal is impractical if the patient has trouble following it.

A regular diet that has reduced variability in carbohydrates is an important factor in producing normal blood sugars. Patients with diabetes should eat preferably a balanced and healthy diet. Meals should consist of half a plate of non-starchy vegetables, 1/4 plate of lean protein, and 1/4 plate of starch/grain. Patients should avoid excess simple carbs or added fat (such as butter, salad dressing) and instead eat complex carbohydrates such as whole grains. In the long term, it is helpful to eat a consistent diet and amount of carbohydrate to make blood sugar management easier. It is important for patients to eat 3 meals a day as well in order to reduce the chances of hypoglycemia, especially with patients that take insulin.

There is a lack of evidence of the usefulness of low-carbohydrate dieting for people with type 1 diabetes (T1D). Although for certain individuals it may be feasible to follow a low-carbohydrate regime combined with carefully managed insulin dosing, this is hard to maintain and there are concerns about potential adverse health effects caused by the diet. In general people with T1D are advised to follow an individualized eating plan rather than a pre-decided one.

Exercise

Along with diet, exercise is also important for the management of diabetes. Not only does exercising regularly help manage blood sugar levels and weight, it helps reduce the risk of heart attack and stroke, reduces cholesterol levels, reduces risk of diabetes related complications, increases the effect of insulin, provides a boost in energy levels, helps reduce stress, and contributes to positive self-esteem. By exercising, the body becomes more sensitive to insulin, allowing for better absorption of glucose by the muscle cells, for up to 24 hours after exercise. Therefore, an ongoing exercise program is required to maintain the health benefits associated with exercising.

In patients with type 2 diabetes (T2D), the combination of aerobic (cardio) exercise and strength training, as recommended by the American Diabetes Association (ADA) guidelines, is the most effective when it comes to controlling glucose and cholesterol. Aerobic exercise has been shown to largely improve HbA1c, and contributes to weight loss and the enhanced regulation of cholesterol and lipoproteins. This may be any form of continuous exercise that elevates breathing and heart rate such as walking, swimming, or dancing. During the last 20 years, resistance training has gained considerable recognition as an optimal form of exercise for patients with type two diabetes. By building muscle strength, strength training was linked to a 10% to 15% increase in strength, Bone Mineral Density, insulin sensitivity, muscle mass and decrease in blood pressure.

Several studies have made it clear that exercise helps with blood sugar control and has shown to lower HbA1c levels by approximately 0.6% in patients with T2D. The ADA recommends 150 minutes of moderate to vigorous aerobic exercise a week spread over 3 to 7 days with no more than 2 day break between days. Moreover, patients should also pair the aerobic exercise with 2 to 3 nonconsecutive sessions of strength training.

In T1D, there also have been studies that show that, in children and adolescent, there is an association between exercise and lower HB A1c. Furthermore, studies have shown that the longer the length of the exercise program, there is a further reduction in the HB A1c and patients have less insulin requirements. Although the population of these studies are limited to patients under the age of 18, exercise is beneficial in managing diabetes, whether its type 1 or 2. There are many benefits of exercise such as a decreased risk of cardiovascular diseases, including blood pressure, lipid profiles, body composition and insulin sensitivity.

Weight Loss

Image of waist circumference, comparing a normal weight to an overweight and obese individual.

In addition to diet and exercise, weight loss is an important tool to help with diabetes management. T2D is often associated with obesity and increased abdominal circumference. Often patients who are at risk of diabetes may be able to reverse their progression to T2D with weight loss as well. Weight loss can help reduce the risk of further complications, other health related problems, and helps improve the effects of insulin on the body. Weight loss helps reduce the destruction of the beta cells, which produce insulin in the body, as well.

It is recommended for patients who have been diagnosed with T2D who are overweight or obese to lose at least 5% of their weight and maintain the weight loss. There have been studies that have demonstrated that by losing about 5 to 10% of their weight at diagnosis, there is a reduction in heart disease risk factors, lowered Hb A1c, less diabetes medications, lower cholesterol and improved fitness. Additionally, patients who lose more weight are better off in the long run.

Common strategies to help reduce weight many include lifestyle measures such as diet and exercise, behavioral therapy, pharmacologic interventions, and surgery. The goal of weight loss and method for achievement should be individualized based on the patient's desires and motivation. It is important for providers to help maintain patient motivation to lose weight. Additionally, some medications that reduce blood sugars such as insulin may initially cause weight gain due to the increased conversion of blood sugar to stored forms such as fat. Therefore, in patients with diabetes, providers may try other medications that lower blood sugar but not cause as much weight gain.

Medications

Main article: Anti-diabetic drug

There are several medications classes that are commonly used to control blood sugar levels in patients with diabetes. Most of the medications used are either oral or injected. In patients with T1D, insulin is require because the body no longer produces insulin. In patients with T2D, management is largely more variable as lifestyle changes can have a significant impact. However, medications may be added to further help control BG levels if the lifestyle changes are not effectively controlling the condition. Unlike type 1 diabetic patients, patients with T2D can still produce insulin, so usually these patients take oral medications first before requiring insulin for diabetic control.

Patient education and compliance with treatment is very important in managing the disease. Improper use of medications and insulin can be very dangerous causing hypo- or hyper-glycemic episodes.

Insulin

Main article: Insulin therapy
Insulin pen used to administer insulin

Insulin is the hormone that is made by the body that controls the cell intake of glucose. Normally, the pancreas produces insulin in response to high glucose levels in the body to bring the BG levels down. For type 1 diabetics, there will always be a need for insulin injections throughout their life, as the pancreatic beta cells of a type 1 diabetic are not capable of producing sufficient insulin. Insulin can not be taken orally because insulin is a hormone and is destroyed by the digestive track. Insulin can be injected by several methods, including a hypodermic needle, jet injector, or insulin pump. There is also inhaled insulin that can be used in adults with diabetes.

There are several types of insulin that are commonly used in medical practice, with varying times of onset and duration of action.

- Rapid acting (i.e. insulin lispro) with onset in 15 minutes and duration of about 4 hrs.

- Short acting (i.e. regular insulin) with onset in 30 minutes and duration of about 6 hrs.

- Intermediate acting (i.e NPH insulin) with onset in 2 hours and duration of about 14 hrs.

- Long acting (i.e. detemir) with onset in 1 hr. and duration of about 24 hrs.

- Premixed which are usually combinations of short and long acting insulin.

Insulin is usually taken several times per day in patients who require it to control their diabetes. Often patients usually take long acting insulin once a day and then take insulin before meals. The time of onset of the insulin determines how far in advance patients should take the insulin before they eat.

Insulin therapy requires close monitoring and a great deal of patient education, as improper administration is quite dangerous. Insulin can easily cause hypoglycemia if the patient does not eat after administering insulin or accidentally had too much insulin. A previously satisfactory dosing may be too much if less food is consumed causing hypoglycemia. Exercise decreases insulin requirements as exercise increases glucose uptake by body cells whose glucose is controlled by the insulin.

Insulin therapy creates risk because of the inability to continuously know a person's BG level and adjust insulin infusion appropriately. New advances in technology have overcome much of this problem. Small, portable insulin infusion pumps are available from several manufacturers. They allow a continuous infusion of small amounts of insulin to be delivered through the skin around the clock, plus the ability to give bolus doses when a person eats or has elevated BG levels. This is very similar to how the pancreas works, but these pumps lack a continuous "feed-back" mechanism. Thus, the user is still at risk of giving too much or too little insulin unless BG measurements are made.

Oral Medications

Metformin

One of the most common drugs used in T2D, metformin is the drug of choice to help patients lower their blood sugar levels. Metformin is an example of a class of medicine called biguanides. The medication works by reducing the new creation of glucose from the liver and by reducing absorption of sugar from food. In addition, the medication also works to help increase the effects of insulin on muscle cells, which take in glucose. The medicine is not used for T1D as these patients do not produce any insulin and metformin relies on some insulin production in order to be effective. There are several preparations of the medication such as tablets, extend release tablets, and liquid suspensions. Metformin is usually started as 500 to 1000 mg tablets twice a day by mouth (PO), usually with meals. If taking the extended release tablets, they should be always swallowed whole as cutting the tablet will cause faster release of the medication. The medication most commonly may cause stomach upset and symptoms such as diarrhea but in general is well tolerated and has a relatively low chance of causing hypoglycemia. One rare (about 1% chance) but serious side affect of metformin is that it can cause lactic acidosis, usually in patients with poor kidney function. Sometimes, practitioners will slowly increase the dose of the medication to help with tolerance to the medication.

Sulfonylureas

Another commonly used class of medications with T2D are sulfonylureas. This class of medicine increases the release of insulin from the beta cells in the pancreas. The medication can not be used in patients with T1D, as they do not have functioning beta cells and can not produce insulin. Some common example of a sulfonylurea is glipizide, glyburide, glimepiride and gliclazide. Depending on the medication, there are different size tablets but in general, the sizes range from about 1 mg to 10 mg. Usually the tablet is taken about 30 minutes before a meal and can be either once or twice a day. The most common adverse effects of the medication are lightheadedness and stomach irritation. Sulfonylureas have a greater risk of hypoglycemia but the risk is still only around 3% of patients who use them. In patients who have a greater risk of low sugar, such as in the elderly and patients with kidney disease, the starting dose can be as low as 0.5 mg.

GLP-1 agonists

Another popular medication that is used in T2D management are glucagon like peptide 1 (GLP-1) agonists. This class of medication works by mimicking a hormone called glucagon-like peptide which has many effects in the body. One effect of the hormone is that it helps time the release of insulin when patients eat and the BG rises. In addition, it can significantly increase the amount of insulin release as well. Lastly, the medication also slows down the movement of food through the digestive tract and can increase feeling of fullness while eating, decreasing appetite and weight. These drugs are very effective at controlling T2D and reducing risk of heart attacks, strokes, and other complications due to diabetes. In addition, patients usually lose weight and have improved blood pressure and cholesterol. Common names of these medications include semaglutide (Ozempic and Wegovy), liraglutide (Victoza, Saxenda), and dulaglutide (Trulicity). These medications must be injected and are usually injected in the upper arm, thighs or stomach areas. They are usually given once a week but some of the medication can be as frequent as twice daily. The dose is usually started low and tapered gradually. Some of the common side effects of the medication is nausea, vomiting and diarrhea. Patients with a family history of medullary thyroid cancer or Multiple Endocrine Neoplasia type 2 should not be prescribed the drug may increase the risk of developing cancer.

Surgery

While weight loss is clearly beneficial in improving glycemic control in patients with diabetes type 2, maintaining significant weight loss can be a very difficult thing to do. In diabetic people who have a body mass index of 35 or higher, and who have been unable to lose weight otherwise, bariatric surgery offers a viable option to help achieve that goal. In 2018 a Patient-Centered Outcomes Research Institute funded study was published which analyzed the effects of three common types of bariatric surgery on sustained weight loss and long-lasting glycemic control in patients with diabetes type 2. The results of this study demonstrated that, five years after bariatric surgery, there was meaningfully significant weight loss in a large majority of patients. In addition, and more importantly, this study showed that, in type 2 diabetic patients with a body mass index of 35 or higher, bariatric surgery has the potential to lead to complete remission of diabetes in as many as 40% of those people who have the procedure. Like any operation, bariatric surgery is not without risks and complications, and those risks need to weighed against the potential benefits in anyone considering going through with such a procedure.

Additional Monitoring

Foot checking

Monitoring a person's feet can help in predicting the likelihood of developing diabetic foot ulcers. A common method for this is using a special thermometer to look for spots on the foot that have higher temperature which indicate the possibility of an ulcer developing. At the same time there is no strong scientific evidence supporting the effectiveness of at-home foot temperature monitoring.

The current guideline in the United Kingdom recommends collecting 8-10 pieces of information for predicting the development of foot ulcers. A simpler method proposed by researchers provides a more detailed risk score based on three pieces of information (insensitivity, foot pulse, previous history of ulcers or amputation). This method is not meant to replace people regularly checking their own feet but complement it.

Dental care

High BG in diabetic people is a risk factor for developing gum and tooth problems. Diabetic patients have greater chances of developing oral health problems such as tooth decay, saliva production dysfunction, fungal infections, and periodontal disease Diabetic people tend to experience more severe periodontitis because diabetes lowers the ability to resist infection and also slows healing. In turn, the chronic infection from periodontal disease can make it worse to control the diabetes, leading to worsening of diabetic complications. The oral problems in persons with diabetes can be prevented with a good control of the blood sugar levels, regular check-ups with their dental provider, and good oral hygiene. Looking for early signs of gum disease (redness, swelling, bleeding gums) and informing the dentist about them is also helpful in preventing further complications. Quitting smoking is recommended to avoid serious diabetes complications and oral diseases. By maintaining a good oral status, diabetic persons prevent losing their teeth as a result of various periodontal conditions.

Digital tools

Electronic health records

Sharing their electronic health records with people who have T2D helps them to reduce their blood sugar levels. It is a way of helping people understand their own health condition and involving them actively in its management.

m-health monitoring applications

The widespread use of smartphones has turned mobile applications (apps) into a popular means of the usage of all forms of software. The number of health-related apps accessible in the App Store and Google Play is approximately 100,000, and among these apps, the ones related to diabetes are the highest in number. Conducting regular self-management tasks such as medication and insulin intake, blood sugar checkup, diet observance, and physical exercise are really demanding. This is why the use of diabetes-related apps for the purposes of recording diet and medication intake or BG level is promising to improve the health condition for the patients.

Complexities

Daily glucose and insulin cycle

The main complexities stem from the nature of the feedback loop of glucose in the blood stream.

  • The glucose cycle is a system which is affected by two factors: entry of glucose into the bloodstream and also blood levels of insulin to control its transport out of the bloodstream
  • As a system, it is sensitive to diet and exercise
  • It is affected by the need for patient anticipation due to the complicating effects of time delays between any activity and the respective impact on the glucose
  • Management is highly intrusive, and compliance is an issue, since it relies upon user lifestyle change and often upon regular sampling and measuring of BG levels, multiple times a day in many cases
  • It changes as people grow and develop
  • It is highly individual

As diabetes is a prime risk factor for cardiovascular disease, controlling other risk factors which may give rise to secondary conditions, as well as the diabetes itself, is one of the facets of diabetes management. Checking cholesterol, LDL, HDL and triglyceride levels may indicate hyperlipoproteinemia, which may warrant treatment with hypolipidemic drugs. Checking the blood pressure and keeping it within strict limits (using diet and antihypertensive treatment) protects against the retinal, renal and cardiovascular complications of diabetes. Regular follow-up by a podiatrist or other foot health specialists is encouraged to prevent the development of diabetic foot. Annual eye exams are suggested to monitor for progression of diabetic retinopathy.

Hypoglycemia

Levels which are significantly above or below this range are problematic and can in some cases be dangerous. A level of <70 mg/dL (<3.8 mmol/L) is usually described as a hypoglycemic attack (low blood sugar). Most diabetics know when their hypoglycemic and usually are able to eat food or drink something sweet to raise their levels. Intensive efforts to achieve blood sugar levels close to normal have been shown to triple the risk of the most severe form of hypoglycemia, in which the patient requires assistance from by-standers in order to treat the episode. Among intensively controlled type 1 diabetics, 55% of episodes of severe hypoglycemia occur during sleep, and 6% of all deaths in diabetics under the age of 40 are from hypoglycemia at night.

Paramedics in Southern California attend a diabetic man who lost effective control of his vehicle due to low blood sugar (hypoglycemia) and drove it over the curb and into the water main and backflow valve in front of this industrial building. He was not injured, but required emergency intravenous glucose.

Hypoglycemia can be problematic if it occurs while driving as it can affect a person's thinking process, coordination, and state of consciousness. Some patients are more prone to hypoglycemia as they have reported fewer warning symptoms, and their body released less epinephrine (a hormone that helps raise BG). Additionally, individuals with a history of hypoglycemia-related driving mishaps appear to use sugar at a faster rate. These findings indicate that although anyone with T1D may be at some risk of experiencing hypoglycemia while driving, there is a subgroup of T1D drivers who are more vulnerable to such events.

It is recommended that drivers with T1D with a history of driving mishaps should never drive when their blood sugar is less than 70 mg/dL (3.9 mmol/L). Instead, these drivers are advised to treat hypoglycemia and delay driving until their BG is above 90 mg/dL (5 mmol/L). Such drivers should also learn as much as possible about what causes their hypoglycemia, and use this information to avoid future hypoglycemia while driving.

Hyperglycemia

A patient is considered to have hyperglycemia (high glucose) if the patient has a sugar level of greater than 230–270 mg/dL (13–15 mmol/L). Sometimes patient may be temporarily hypoglycemic under certain conditions (e.g. not eating regularly, or after strenuous exercise). Patients should closely monitor their sugar levels to ensure that they reduce rather than continue to remain high. High blood sugar levels are not as easy to detect as hypoglycemia and usually happens over a period of days rather than hours or minutes. If left untreated, this can result in diabetic coma and death.

Prolonged and elevated levels of glucose in the blood, which is left unchecked and untreated, will, over time, result in serious diabetic complications in those susceptible and sometimes even death. There is currently no way of testing for susceptibility to complications. Diabetics are therefore recommended to check their blood sugar levels either daily or every few days. There is also diabetes management software available from blood testing manufacturers which can display results and trends over time.

Medication nonadherence

Because many patients with diabetes have two or more comorbidities, they often require multiple medications. The prevalence of medication nonadherence is high among patients with chronic conditions, such as diabetes, and nonadherence is associated with public health issues and higher health care costs. One reason for nonadherence is the cost of medications. Being able to detect cost-related nonadherence is important for health care professionals, because this can lead to strategies to assist patients with problems paying for their medications. Some of these strategies are use of generic drugs or therapeutic alternatives, substituting a prescription drug with an over-the-counter medication, and pill-splitting. Interventions to improve adherence can achieve reductions in diabetes morbidity and mortality, as well as significant cost savings to the health care system. Smartphone apps have been found to improve self-management and health outcomes in people with diabetes through functions such as specific reminder alarms, while working with mental health professionals has also been found to help people with diabetes develop the skills to manage their medications and challenges of self-management effectively.

Psychological mechanisms and adherence

As self-management of diabetes typically involves lifestyle modifications, adherence may pose a significant self-management burden on many individuals. For example, individuals with diabetes may find themselves faced with the need to self-monitor their BG levels, adhere to healthier diets and maintain exercise regimens regularly in order to maintain metabolic control and reduce the risk of developing cardiovascular problems. Barriers to adherence have been associated with key psychological mechanisms: knowledge of self-management, beliefs about the efficacy of treatment and self-efficacy/perceived control. Such mechanisms are inter-related, as one's thoughts (e.g. one's perception of diabetes, or one's appraisal of how helpful self-management is) is likely to relate to one's emotions (e.g. motivation to change), which in turn, affects one's self-efficacy (one's confidence in their ability to engage in a behaviour to achieve a desired outcome).

As diabetes management is affected by an individual's emotional and cognitive state, there has been evidence suggesting the self-management of diabetes is negatively affected by diabetes-related distress and depression. There is growing evidence that there is higher levels of clinical depression in patients with diabetes compared to the non-diabetic population. Depression in individuals with diabetes has been found to be associated with poorer self-management of symptoms. This suggests that it may be important to target mood in treatment. In the case of children and young people, especially if they are socially disadvantaged, research suggests that it is important that healthcare providers listen to and discuss their feelings and life situation to help them engage with diabetes services and self-management.

To this end, treatment programs such as the Cognitive Behavioural Therapy - Adherence and Depression program (CBT-AD) have been developed to target the psychological mechanisms underpinning adherence. By working on increasing motivation and challenging maladaptive illness perceptions, programs such as CBT-AD aim to enhance self-efficacy and improve diabetes-related distress and one's overall quality of life.

See also

* Ambulatory care sensitive conditions

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