Ask the Nurse

Our Clinical Nurse Specialist is in to answer your health-related questions regarding diabetes self-care management.

Unfortunately, due to the large number of questions we receive, we may not be able to respond to all questions. We will, however, try to answer those questions that we feel offer the broadest interest. Please check back periodically to see if your question - or a related question - has been answered. And remember, these responses are for educational purposes only - they should not be substituted for advice by your doctor. If you have an immediate medical concern, you should consult your doctor. If you have a diabetes-related home health care need, please e-mail or call us at 1-888-VNS-1-CALL (1-888-867-1225).

Disclaimer: All information is for educational purposes only and should not be substitued for advice by your doctor.

Question:
I am a RN working with the elderly population in Chicago. We have members in need of diabetic teaching. As a clinical specialist, do you go into the home to teach what is the criteria? Do they have to be home bound?

Answer:
Here at VNSNY, my role is to provide support services to the field staff. In that capacity, I endeavor to keep them up-to-date with the new medications and devices available for the care of patients with diabetes. We write our own teaching materials (translated into several foreign languages) which the nurse takes into the home to assist in teaching the patient and family about diabetes. Many, but not all, of our patients are elderly and homebound as well. Our census is so large that it’s very rare for me to visit patients in their homes since I can have much more impact by helping large groups of nurses improve their skills in this important area of self-management education.

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Question:
I have high blood sugar caused by my liver secreting too much triglycerides. Shouldn't my doctor be treating my liver problem? He now has me on an anti-cholesterol pill and Glucotrol.

Answer:
In Type 2 diabetes, one reason why the blood sugar is high is that the liver secretes too much glucose. Glucose is stored in the liver as glycogen and without enough insulin to "turn off" the glucose, the liver releases glucose and the blood sugar becomes elevated. Another problem in Type 2 diabetes is insulin resistance. Normally insulin can move glucose into the cells of the body so that it can be stored or used for energy. In diabetes insulin and glucose can not easily move into the cells or once the insulin and glucose are in the cell, the glucose cannot be metabolized properly. This is called insulin resistance. Over a period of many years even before a person is diagnosed with diabetes, the body produces large amounts of insulin to overcome this insulin resistance. This causes changes in the body's metabolism of lipids (fats) which are mainly produced in the liver. Often there is an increase in cholesterol, triglycerides, LDLs, and a decrease in HDL's. HDL is a type of lipid that is beneficial to the body.

The best way to treat elevated lipids is through diet, exercise, and medication. A low fat diet in conjunction with weight loss can help to reduce lipid levels. If a person is overweight, even a small weight loss (5 to 10 lbs.) can help to reduce insulin resistance and decrease lipid levels. Exercise can also reduce insulin resistance, assist in weight loss, and help to reduce lipid levels. In some people, lipid-lowering medication is needed. It is important to continue to take this medication as prescribed by your doctor, to keep your lipid levels down and prevent heart disease. It is also important to continue to take your diabetes medication.

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Question:
How much should your blood sugar be reduced for each unit of insulin taken? Is there a formula to utilize?

Answer:
There are formulas to use to estimate the projected reduction in blood glucose per one added unit of Regular Insulin. These formulas are based on the amount of insulin that you currently take and your target blood glucose levels. There are, however, other factors to take into consideration in calculating the amount of insulin you need:

• Activity/exercise level



• Food intake



• Stress



• Presence of illness or infection



• Insulin resistance may increase need for insulin



• Kidney function and other metabolic processes

The best way to calculate your need for insulin or other medication is to keep records of your diet, activity, and daily medication over time. These factors should be reviewed in combination, and shared with your diabetes health team. Your doctor and other health professionals can help you to work out a flexible, individual plan to control your blood glucose and suit your lifestyle. This is called pattern management.

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Question:
I saw the promotion of an instrument attached to my body which dispenses insulin. Is such equipment based on actually monitoring the body' s insulin needs or is it just a fancy timer?

Answer:
What you probably saw advertised was an insulin pump. The insulin pump is a device that automatically dispenses insulin through a needle that you insert under your skin and is attached via a thin tube to the pump. The amount of insulin you receive through the pump is pre-determined by your doctor based on your individual needs. During the day, when you change your activity level or food intake and your blood sugar changes, you can learn to give yourself an extra amount of insulin called a bolus through the pump. At this point in time, the pump is not able to automatically check your blood sugar and provide the amount of insulin you need. Insulin pump users need to check their blood glucose frequently throughout the day. There are some new devices on the market that can automatically check your blood sugar on a very frequent basis. The next step in technology would be the ability of a device to automatically check blood sugar levels and deliver insulin based on those readings.

Many individuals who have switched to insulin pump therapy to manage their diabetes have found they are better able to control blood sugars. People who want to use the pump need to complete an educational process that is usually provided at a diabetes center by an endocrinologist, certified diabetes nurse educator, and dietician.

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Question:
I have late onset Type 2 diabetes. I have it under control with diet and exercise. I took off 60 pounds. I do not take any meds except zocher for cholesterol. If I continue like this will I always have it under control? Will I always avoid other complications?

Answer:
Congratulations, losing weight and starting an exercise program are two of the best things that you can do to control Type 2 diabetes! By losing weight and exercising on a regular basis, you were able to increase your body's ability to use insulin and therefore lower your blood sugar. In order to ensure that your diabetes continues to stay well controlled, you need to maintain your weight and continue a regular exercise program. Two studies, the Diabetes Control and Complications Study and the United Kingdom Diabetes Prospective Study have shown that if the blood sugar is kept as close to normal as possible, the risk for complications related to the eyes, the kidneys, and the feet can be greatly lowered. It is important to have certain screening tests done by your doctor on a regular basis to detect the earliest signs of complications of diabetes. The American Diabetes Association recommends the following tests:

Glycosylated hemogoblin or Hemoglobin Alc every three months: This is a blood test that provides a view of your average blood sugar for a three-month period.

Microalbumin once a year: This is a urine test that can measure a small amount of protein in your urine, which can indicate kidney disease.

Dilated eye exam once a year.

Foot exam by a doctor or a podiatrist once a year. Feet should be inspected daily by the person with diabetes and any unusual findings should be reported to the doctor.

Screening for lipids such as cholesterol, trigycerides, HDL's, and LDL's at least yearly and more often if lipid levels are not within normal range.

Blood pressure screening at each visit to the doctor.

Your doctor may require that some tests be done more frequently depending on individual needs.

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Question:
What does it mean when you get insulin block? My levels are in the 300's and can't get them down with insulin.

Answer:
One of the causes of Type 2 Diabetes (formerly known as adult onset diabetes) is insulin resistance syndrome. Some people with Type 2 Diabetes are actually producing insulin but cannot use it efficiently. Therefore, they need large amounts of insulin to bring the blood sugar to normal levels. There are three ways to reduce insulin resistance and bring your blood sugar down:

1. Weight Loss: If you are overweight, even a small weight loss (5 to 10 pounds) can help to bring down blood sugar levels.

2. Exercise: Walking is the best exercise, even ten minutes a day can make a difference. Always check with your doctor before starting an exercise program.

3. Medication: Some diabetes medication can reduce insulin resistance. Check with your doctor about which medicine is best for you.

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Question:
My husband was recently diagnosed with Type 2 Diabetes. He is checking his blood through daily monitoring. His highest is just after waking up (167). Is this a high level?

Answer:
According to the American Diabetes Association, the normal fasting blood sugar (after 8 hours without eating) is 70-100mg/dL. Some people with Type 2 Diabetes tend to have higher fasting blood sugars due to the fact that the liver releases sugar during the night. There are four issues for you and your husband to consider:

1. Medication: Adjusting the type of medication you are taking for diabetes or the time it is taken may reduce the fasting blood sugar. Check with your doctor.

2. Weight Loss and Exercise: Losing weight and starting a regular exercise program can help to bring down all blood sugars throughout the day.

3. Comparing Blood Sugars: It is important to check blood sugars at other times during the day, such as before dinner. Share this information with your doctor so that he/she can compare them.

4. Hemoglobin A1c Test: A good long-term test of your diabetes control is the hemoglobin A1c. This reflects how your blood sugar control has been over three months. The normal level is 4 to 6%. This normal level can vary depending on the laboratory where the blood is tested.

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Question:
Do you think it would be to my best interest to test myself, even if I am border line diabetic?

Answer:
The American Diabetes Association defines the normal fasting blood sugar (after 8 hours without eating) as 70-110mg/dL. There is no classification called borderline diabetes, but impaired glucose tolerance is defined as fasting blood sugar between 110-126mg/dL. Diabetes in an adult is diagnosed as having two fasting blood sugars above 126mg/dL. The American Diabetes Association recommends that those people with impaired glucose tolerance start a diet and exercise program. Your doctor should periodically check your fasting blood sugar. If you have actual diabetes, it should be treated with diet, exercise, and medication. You may wish to occasionally check your blood sugar at home but diabetes can only be diagnosed through a lab blood sugar.

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Question:
How is proteinuria treated? What kind of diet changes are best?

Answer:
Proteinuria means that there is protein found in a person's urine. This is an abnormal finding which is indicative of nephropathy (kidney disease). Today most clinicians can test for early signs of nephropathy, which is the appearance of low level of albumin (protein) in the urine. This is called microalbuminuria. Urine can be tested for microalbuminuria in the doctor's office and should be performed annually.

How is proteinuria treated? There are several parts to this answer!

1. Controlling your blood glucose -- Based on the findings of the Diabetes Control and Complications Trial (landmark 10 year diabetes study) improving blood glucose control to near normal range has been found to reduce the development and/or progression of nephropathy (kidney disease).

2. Controlling your blood pressure -- According to the American Diabetes Association standards, your blood pressure should be less than or equal to 130 mmHg systolic (which is the top number or the first number) and less than or equal to 85 mmHg diastolic (which is the bottom number or the second number). Controlling your blood pressure can be done through several modes: weight loss, reduction of salt intake, reduction in alcohol consumption, increase in exercise and activity, and medication. The medications that are preferred for treatment are called ACE (Angiotension-converting enzyme) Inhibitors. Speak to your doctor about your specific needs.

3. Dietary Changes -- Studies have shown that restricting protein intake reduces the progression of kidney disease. The general recommendation for people with kidney disease is reducing protein intake to about 10% of their daily calories. It is imperative to consult with a registered dietician who can create a meal plan which would meet ALL of your needs, including cholesterol and triglyceride levels, blood glucose levels and any other medical/social conditions which impace your dietary needs.

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Question:
What is the value of chromium pecolinate in diabetes treatment?

Answer:
According to the latest position statement from the American Diabetes Association, it is felt that if you follow a well-balanced meal plan that there is no need for additional vitamin and mineral supplementation.

Specifically to chromium pecolinate -- the only circumstance that supplementation with this vitamin has been found to be beneficial in blood glucose control has been in people who have chromium deficiency. Most people are not chromium deficient.

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Question:
Any advice to lessen the pain of neuropathy and stop its progression?

Answer:
The best way to stop the progression of painful neuropathy is to keep your blood sugar under control. In some people, controlling blood sugar can help to reduce the pain of neuropathy. Remember that the normal fasting blood sugar is 70 to 110mg/dL and your blood sugar non-fasting should be below 140mg/dL. You and your doctor need to work together to set blood sugar levels that are reasonable for you.

Methods to control the pain of neuropathy that work for some people include: walking to ease leg pain, gentle message, stretching exercises, relaxation exercises, biofeedback, hypnosis, and acupuncture. It is best to avoid alcohol, which can increase pain in some people. Stockings that keep clothing away from sensitive skin may be helpful. If the pain is severe, it may be useful to have your doctor refer you to a pain control clinic.

Medications that may help to relieve the pain of neuropathy include the following:

• Analgesics like ibuprofen (Advil, Motrin).
• Anticonvulsant medications like Dilantin, Tegretol, or Neurontin.
• Antidepressants like Elavil or Tofranil.
• Capsaicin cream (Zostrix) applied to the painful area may provide relief.

ALWAYS CHECK WITH YOUR DOCTOR BEFORE TRYING A NEW THERAPY OR TAKING AN OVER THE COUNTER MEDICATION.

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Question:
Is it necessary to monitor my glucose at the same time every day?

Answer:
Most people are on a regular schedule of checking their blood glucose and tend to check it at the same time(s) every day. If you check your blood glucose every morning, it might be useful to check it before dinner occasionally to make sure that the medicine you are taking is working to control your blood glucose throughout the day. If you take insulin, it is necessary to check your blood glucose at specific times that coincide with the peak times of action of the insulin and/or meals. Almost all health insurance plans now pay for blood glucose meters and strips.

Another test that can give you a good indication of your glucose control is the HbA1c (hemoglobin A1C). This is a blood test that is done every 3 to 6 months, which your doctor will order. The HbA1c gives a summary of what your glucose control has been for a 3-month period. It is measured in a percent (normal is 4-6%). The American Diabetes Association recommends that a person with diabetes have a HbA1c level below 7%.

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Question:
My husband just recently was changed to Lantus injections for his diabetes, he was also placed on Synthroid. Could the Synthroid interfere with the effectiveness of the Lantus?

Answer:
Lantus insulin is a new formulation of insulin that usually only needs to be taken once a day. It lasts for twenty-four hours, providing a steady rate of insulin. It's action is very similar to the normal way the pancreas provides insulin. Some people need to take a short acting insulin in addition to the Lantus to cover the sugar produced after eating meals. Some people who take Lantus also take diabetes pills. Synthroid is a medication that is given for low thyroid function. Thyroid disease seems to occur more often in people with diabetes. It is safe to take both Lantus insulin and Synthroid. Synthroid does not interfere with the effectiveness of Lantus.

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Question:
Any advice to lessen the pain of neuropathy and stop its progression?

Answer:
The best way to stop the progression of painful neuropathy is to keep your blood sugar under control. In some people, controlling blood sugar can help to reduce the pain of neuropathy. Remember that the normal fasting blood sugar is 70 to 110mg/dL and your blood sugar non-fasting should be below 140mg/dL. You and your doctor need to work together to set blood sugar levels that are reasonable for you.

Methods to control the pain of neuropathy that work for some people include: walking to ease leg pain, gentle message, stretching exercises, relaxation exercises, biofeedback, hypnosis, and acupuncture. It is best to avoid alcohol, which can increase pain in some people. Stockings that keep clothing away from sensitive skin may be helpful. If the pain is severe, it may be useful to have your doctor refer you to a pain control clinic.

Medications that may help to relieve the pain of neuropathy include the following:

• Analgesics like ibuprofen (Advil, Motrin).
• Anticonvulsant medications like Dilantin, Tegretol, or Neurontin.
• Antidepressants like Elavil or Tofranil.
• Capsaicin cream (Zostrix) applied to the painful area may provide relief.

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Question:
Is it necessary to monitor my glucose at the same time every day?

Answer:
Most people are on a regular schedule of checking their blood glucose and tend to check it at the same time(s) every day. If you check your blood glucose every morning, it might be useful to check it before dinner occasionally to make sure that the medicine you are taking is working to control your blood glucose throughout the day. If you take insulin, it is necessary to check your blood glucose at specific times that coincide with the peak times of action of the insulin and/or meals. Almost all health insurance plans now pay for blood glucose meters and strips.

Another test that can give you a good indication of your glucose control is the HbA1c (hemoglobin A1C). This is a blood test that is done every 3 to 6 months, which your doctor will order. The HbA1c gives a summary of what your glucose control has been for a 3-month period. It is measured in a percent (normal is 4-6%). The American Diabetes Association recommends that a person with diabetes have a HbA1c level below 7%.

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Question:
How much sugar is there in an average size banana?

Here is how our Diabetes Clinical Nurse Specialist responded: An average banana is 2 diabetic "exchanges" which equals 30 mg of total carbohydrate or "sugar". It's has about 105 calories, depending on size. A medium banana has about 4 gms of fiber which help reduce the carbohydrate load. It also has a good amount of potassium and is basically a "healthy food" which can be incorporated into most meal plans.

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Question:
I recently have had an elevated blood sugar level which was 152. The blood was taken after a 12 hour fast. I never had a blood sugar level at the diabetic level. Can diabetes be controlled simply by diet or is medication needed?

Here is how our Diabetes Clinical Nurse Specialist responded: It was fortunate that you had the fasting blood sugar test done since the results indicated that you did have a reading in the diabetic level. This requires some action on your part and diet is a good place to start. Some people are able to control their diabetes with diet and exercise alone; however, most people will eventually require some medication. Dietary guidelines that would help you begin to control your blood sugar are to limit portions of concentrated sweets such as sodas, cookies, cakes, candies, ice cream as well as other carbohydrates such as bread, potatoes, pasta and rice. Fruits, fruit juices and some starchy vegetables can increase blood sugar as well and should be portion controlled. You can get some benefit from increasing your exercise since the body uses blood sugar (glucose) for energy to perform the exercise you choose. If you are not exercising now, be sure to check with your doctor before beginning any new exercise program. Walking is a safe way for most people to start. It has a low risk of injury and doesn't require any special equipment. Good luck as you move forward on the important road to controlling your blood sugar level.

Please remember this response is for educational purposes only - it should not be substituted for advice from you doctor. If you have an immediate medical concern, please contact your doctor.

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Question:

What are the correct sites for administering insulin for a school aged child?

The injection areas must be examined by the child/parent and health professional at regular intervals to detect bruising, redness, infection, lipoatrophy (pitting of the fatty tissue), or lipohypertrophy (thickening of the fatty tissue). Teach child/parent to rotate injection site to prevent local irritation. Rotating within one area is recommended (eg, rotating injections systematically within the abdomen) rather than rotating to a different area with each injection. This practice may decrease variability in absorption from day to day.

Insulin absorption may vary depending upon several parameters. Abdominal injection provides the most rapid absorption followed by the arms, thighs, and buttocks. Exercise and massage of the injection site may induce more rapid absorption and action from a dose of insulin probably by increasing the rate of blood flow through the tissue around the site.

Please remember, this information is for educational purposes only. It should not be substituted for advice from your doctor. If you have an urgent medical concern, please contact your doctor.

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Question:
Can you offer input on healthy food plan guidelines for my mother with diabetes? For example, should she stay away from spicy or salty?

Because she has diabetes she also needs to limit the amount of foods with added table sugar. This does not mean she can't eat any foods with sugar - it means she must control her portion sizes!

Carbohydrates (called carbs) are the main sources of "sugar" or glucose in your diet. Carbs are found in starchy foods such as bread, rice, potato, cereals, and also in milk, fruits and vegetables. Some foods have a lot of carbs (bread, cereal and fruit) while some have small amounts (green and yellow vegetables). But it all depends on how much you eat! Carbs raise your blood sugar more than protein (meat, fish) and fat (oil, margarine, butter).

Good luck to you and your mother with this complex issue.

Please remember, this response is for educational purposes only. It should not be substituted for advice from your doctor. If you have an urgent medical concern, please contact your doctor.

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