EDITOR’S NOTE:  In the eighth in our year-long series on diabetes, the focus is on the specifics of effectively managing this chronic disease.

It is possible to live a long and healthy life, even with diabetes.

The key to living well with diabetes is learning how to manage the disease. Good management helps prevent or slow the progress of the many complications of diabetes: heart disease, stroke, kidney disease, blindness and nerve damage that causes painful hands and feet.

Other articles in this diabetes series have explained the importance of eating healthy and getting regular exercise. Doing both will help keep blood sugar (glucose) at a safe level, and blood pressure and cholesterol under control.

If you’ve lived with diabetes for a while, you may know how to keep your blood sugar under control most of the time. However, occasionally things get out of whack, for any number of reasons, and adjustments have to be made.

Only about a third of people with type 2 diabetes say they are “very successful” at managing their diabetes, according to a survey by the Consumer Reports National Research Center. This article will explain what to do when your diabetes-care routine gets off the rails.

Blood sugar control

Monitoring and controlling your blood sugar is the most important way to successfully manage diabetes. An A1C test measures your average glucose level over the past three months. Your A1C should be under 7 and your blood sugar should be under 154. If your doctor also does a fasting blood sugar test, it should be between 80 and 130. Your doctor will probably do these tests at least twice a year. These are the same tests your doctor will use to determine if you’re prediabetic.

If these numbers increase to an A1C of 8, blood sugar over 180 and fasting blood sugar sometimes over 130, contact your doctor right away. Your doctor may:

  • Adjust your medications
  • Ask you to check your blood sugar more frequently
  • Advise you to eat healthier
  • Urge you to be more active

Insulin and oral medications

The medicines your doctor prescribes depend on the type of diabetes you have and how well the medicine works to control your blood sugar level.

If you have type 1 diabetes, you must take insulin because your body no longer makes insulin. You will take it several times a day, including with meals, by using a needle, syringe, insulin pen or insulin pump. If you have type 2 diabetes, you may also take insulin or you may just take oral medications.

An insulin pump gives you small regular doses of insulin throughout the day. It is a small machine that you wear outside your body on a belt or in a pocket. It is connected to a small tube and very small needle. The needle is inserted under your skin and stays there for several days. You can also get an additional dose of insulin through the pump at mealtimes. Another type of pump has no tubes but attaches directly to your skin.

Other ways to deliver insulin include inhaling powdered insulin; an injection port to avoid puncturing your skin for each insulin shot; or a jet injector that sends a fine spray of insulin into the skin at high pressure.

Your doctor may prescribe oral medications to help your body better use insulin. Metformin, the most commonly prescribed drug for people with newly diagnosed type 2 diabetes, lowers the amount of glucose made in your liver. Other meds work in different ways to lower blood sugar levels. You may be prescribed a combination of two or more oral meds.

Like many medications, insulin can have unwanted side effects. If you don’t balance your medicines with food and activity, you could have hypoglycemia or hyperglycemia.

Avoiding hypoglycemia

Hypoglycemia is potentially dangerous condition that happens when your blood sugar falls too low (generally below 70 mg/dL). It can be caused by too little food or skipping a meal, too much exercise or a combination of these two factors. If symptoms aren’t recognized and treated quickly, blood sugar levels will continue to fall.

The initial symptoms can vary but often include shakiness or twitching, lightheadedness, feeling tired, paleness, hunger, irritability, rapid heartbeat, sweating, and feeling cold and clammy. If you don’t treat it, hypoglycemia progresses to confusion, feeling like you’re in a fog, clumsiness, drowsiness, weakness, blurred vision or slurred speech, or even unusual behavior (silliness or violence). At its worst, hypoglycemia can cause seizures or coma.

Here’s how to avoid hypoglycemia:

  • Learn how your body reacts when blood sugar drops. Never ignore these symptoms.
  • Keep 15 grams of a fast-acting carbohydrate with you at all times to relieve hypoglycemic symptoms (half-cup of soft drink, 1 cup milk, 2 tablespoons raisins, 3 glucose tablets).
  • Test your blood-sugar with a finger-stick text. Eat or drink something that will quickly boost your blood sugar.
  • Be sure to contact your doctor before changing your eating habits or starting a new diet or exercise program.

Too much glucose = hyperglycemia

Not eating properly, not taking your meds, eating too much food at a meal, illness or even stress can cause your blood sugar to be too high – called hyperglycemia. It can cause these symptoms:

  • Frequently thirsty
  • Feel tired or weak
  • Headaches
  • Peeing frequently
  • Blurred vision

You may need an extra dose of rapid- or short-acting insulin to get back to a normal blood sugar range. If hyperglycemia happens frequently, talk with your care team. They may change your meal plan, the amount of exercise you get or your medicines.

Continuous glucose monitoring

Another way to manage your blood sugar level is through a sensor under your skin that continuously monitors glucose. Continuous glucose monitoring (CGM) is especially helpful for people who have problems with low blood sugar and also use insulin. If the CGM shows that blood sugar is too high or too low, always use a blood glucose meter to check blood sugar before making any changes in your medicines, activity level or what you eat.

Check for ketones

Especially if you have type 1 diabetes, your doctor may want you to check your urine for ketones. When ketone levels get too high, you can develop diabetic ketoacidosis (DKA). DKA is a life-threatening problem that occurs when the body cannot use sugar as a fuel source because there is not enough or no insulin. The body must use fat for fuel. DKA symptoms include:

  • Trouble breathing
  • Nausea or vomiting
  • Stomach pain
  • Confusion
  • Feeling very tired or sleepy

Testing for ketones is simple. It requires that you dip a paper dipstick (available over the counter) in your urine. A color change indicates the presence of ketones. Ask your care team if and when you need to check for ketones.

Other treatment options

Other diabetes treatments include weight-loss surgery that may help improve blood sugar control in obese people who have type 2 diabetes. Losing weight without surgery also improves blood sugar control.

An exciting new type of diabetes management is expected to be available this year. Called an artificial pancreas, it replaces both manual blood sugar testing and insulin shots. It monitors blood sugar levels 24/7 and provides insulin, or a combination of insulin and glucagon, automatically. Patient will still need to manually adjust the amount of insulin the pump delivers at mealtimes.

An experimental treatment for poorly controlled type 1 diabetes is called pancreatic islet transplantation. Pancreatic islets are clusters of cells in the pancreas that make insulin. In type 1 diabetes, the body’s immune system attacks these cells. The destroyed cells are replaced with new cells that make and release insulin. Cells from the pancreas of an organ donor are transplanted to the person with type 1 diabetes. Currently, this procedure is only available to people enrolled in research studies.

Establish a care team

The Consumer Reports survey found that those who are very successful at managing their diabetes used a team of health care providers for their care. A diabetes care team may include:

  • Primary care provider – this can be your family practice provider or an endocrinologist specialist who can provide more specialized diabetes care
  • Dietitian, nurse or certified diabetes educator so you can learn about this disease – “knowledge is power.”
  • Pharmacist
  • Dentist
  • Ophthalmologist for eye care
  • Podiatrist for foot care if your PCP recommends it
  • Counselor or mental health professional, if needed (depression is more common in diabetics)

However, the most important person on your care team is you. While your health care team can help you create a diabetes self-care plan, only you can carry out the plan.

According to the National Institutes of Health, a self-care plan should include:

  • Managing your glucose with a blood glucose meter. You’ll also need regular A1C tests. The A1C goal for most diabetics is 7 or below. Generally, the blood sugar goal is 80 to 130 mg/dL before a meal. About two hours after a meal starts the goal is less than 180 mg/dL. Talk with your health care team about the best target ranges for you. Be sure to tell them if your blood sugar levels frequently go above or below your target range.
  • At least twice a year visits with your care team. If you are having problems reaching your blood sugar, blood pressure or cholesterol goals, you may want to visit with the team more often. Be sure you are checked for A1C, blood pressure, foot injuries/sores, and weight at every visit. Have your care plan and self-care plan updated. At least once a year you should have a cholesterol/triglyceride test, dental and eye exams, and urine and blood test to check for kidney problems. These tests can tell your care team if your medications need to be changed.
  • A plan to make lifestyle changes such as losing weight and keeping it off or a plan to quit smoking. Both smoking and diabetes narrow blood vessels, making your heart work harder.
  • Manage your blood pressure and cholesterol. Your blood pressure goals should be below 140/90 mm Hg. Your team may have a lower target in mind for you and prescribe blood pressure medications. Ask the care team what your cholesterol numbers should be. Cholesterol can often be managed through a healthy diet and exercise. But if that’s not working, you may be prescribed a statin drug to help manage cholesterol. Generally, cholesterol should be below 200 mg.
  • Preventive care will keep you from getting other diseases. An important part of preventive care is keeping your vaccinations current. Ask the care team aboutgetting an annual flu shot, pneumonia vaccines and a tetanus booster every 10 years. Tell the care team if you are not getting enough sleep (7-8 hours). Sleep apnea is common in people with diabetes. Preventing illness is important because your blood glucose is more likely to go up when you’re sick or have an infection.