TAKING CHARGE OF DIABETES | Added: 12, August 2017



WHO HELPS A PERSON WITH DIABETES?

Who are “trained diabetes personnel”?

Trained diabetes personnel are nonmedical people who have received in-depth training about diabetes and diabetes management. They are often hired by school systems to help students with diabetes take care of certain tasks, such as blood glucose monitoring, administering insulin, and helping to recognize possible emergencies, such as hypoglycemia and hyperglycemia. They can also help the school nurse or diabetes-trained health care professional test urine or blood for ketones, if necessary. They are also often referred to as unlicensed assistive personnel, assistive personnel, paraprofessionals, or trained nonmedical personnel.

What is the Diabetes Complications Severity Index?

The Diabetes Complications Severity Index is a tool used to predict deaths and hospitalizations among people with diabetes. It was developed to model the severity of diabetes complications at any one point in time and is used by researchers (used to predict mortality, hospitalizations, and severity of these complications), by hospitals, and even to understand health care costs. The severity index includes seven categories of complications: cardiovascular disease, nephropathy, retinopathy, peripheral vascular disease, stroke, neuropathy, and metabolic problems.

HEALTH-CARE TESTS AND DIABETES

What is the fasting plasma glucose (or fasting blood glucose) test?

The fasting plasma glucose test is a test that measures blood glucose levels after a person has not eaten for at least eight hours (some suggest 12 to 14, depending on the testing lab). Thus, no foods interfere with the results. According to the American Diabetes Association and Harvard Medical School, for the majority of people, a fasting plasma glucose level of less than 100 mg/dL (milligrams per deciliter) is considered normal.

If the blood glucose level is at or above 126 mg/dL, it is an indication of diabetes. If a person’s reading suggests diabetes, most health care professionals suggest a second test to confirm the results, as various conditions (such as excessive stress) can cause blood glucose levels to fluctuate. A person with a blood glucose level between 100 and 126 mg/dL is thought to be prediabetic (for more about prediabetes, see the chapter “Prediabetes and Type 1 Diabetes”).

What is a random plasma glucose (or random blood glucose) test?

A random plasma glucose (also called random blood glucose) test measures the glucose in a person’s blood. For this test, the person does not have to fast. But overall, the amount of carbohydrates, and the amount of time since the person had a snack or meal, can affect the outcome of the test. Although it is usually not as reliable as other tests (see below), it is most often used for emergencies (for example, in a hospital emergency room) or if a doctor needs a faster result of a person’s glucose level. In this case, if the glucose reading is over 200 mg/dl, the person probably has diabetes, although there may be other circumstances that result in a high measurement. If the number is high, then a fasting glucose test (see above) is usually ordered by the person’s health care professional.

How is an oral glucose-tolerance test used to determine blood glucose levels?

An oral glucose-tolerance test is used to determine blood glucose levels after a person has fasted overnight (the usual length of the fast is around 12 hours). The person then drinks a sugar solution, and another reading is taken two hours later. If the levels rise and fall quickly, then the person usually does not have indications of diabetes; if the levels rise above normal and decrease slowly, then it may indicate that the person has diabetes.

While this test is thought to be accurate, it is mostly used for determining gestational diabetes in pregnant women. This is because the fasting plasma glucose test is less time consuming than the oral glucose-tolerance test (the fasting test is done after fasting for around 12 hours only). If an oral glucose-tolerance test is taken, a blood glucose measurement less than 140 mg/dL when the two-hour blood sample is taken is normal; if the reading is 200 mg/dL or higher, then the person is thought to have diabetes. If the number is between 140 and 200 mg/dL, then the person is thought to have prediabetes.

What is a glycated hemoglobin (HbA1c, or more often seen as A1c) test?

A glycated hemoglobin (also called glycosylated hemoglobin or glycohemoglobin) test, or HbA1c, often abbreviated as A1c, measures a person’s blood glucose levels over the preceding two to three months. Glucose in the blood attaches itself to hemoglobin (an oxygen-carrying protein in red blood cells). Thus, the higher a person’s blood glucose level, the more hemoglobin is bound to glucose. Because red blood cells have a lifespan of about three months, the HbA1c measurement-as a percentage-reflects the blood glucose control over that period.

The A1c percentages are often used by health care professionals to diagnose diabetes, and no fasting is required. The percentages are as follows: Normal (no diabetes), when the reading is less than 5.7 percent; prediabetes, when the reading is 5.7 to 6.4 percent; and diabetes, when the reading is 6.5 percent or higher. (The test result may be in error if a person has anemia, kidney disease, or certain blood disorders.) If the level is 7 percent and the person has diabetes, then it often indicates that his or her blood glucose levels are not well controlled.

How can a person with diabetes convert HbA1c (A1c) data into average blood glucose level?

There is a general way for a person with diabetes to convert HbA1c data into average blood glucose level. The following lists this conversion:

HbA1c to Blood Glucose Level Conversion

HbA1c

Blood Glucose Level

6.0 %

135 mg/dl

6.5 %

153 mg/dl

7.0 %

170 mg/dl

7.5 %

188 mg/dl

8.0 %

205 mg/dl

8.5 %

223 mg/dl

9.0 %

240 mg/dl

9.5 %

258 mg/dl

10.0 %

275 mg/dl

10.5 %

293 mg/dl

11.0 %

310 mg/dl

11.5 %

328 mg/dl

12.0 %

345 mg/dl

SELF-MONITORING DIABETES WITH METERS

How does a person with either type 1 or 2 diabetes monitor blood sugar levels?

Most people with diabetes-types 1 and 2 and even some with prediabetes-monitor their blood glucose levels using a blood glucose meter. In general, the glucose meter measures a person’s blood glucose in milligrams per deciliter (seen as mg/dl or mg/dL).

What are test strips?

Most glucometers require what are called test strips in order to obtain a reading of a person’s blood glucose level. The strip contains special enzymes designed to react with the person’s blood.

What is a glucometer?

A glucometer is a meter that measures blood glucose levels. Today’s meters come in all kinds of forms, from talking and large-display meters to those that light up (for testing in the middle of the night, if necessary). Some also have built-in food databases and record-keeping systems. Almost all glucometers measure plasma glucose results by taking the value derived from a drop of whole blood and adding 12 percent to the measured value. For most meters, this is equivalent to a reading that a laboratory obtains.

A glucometer (right) and syringe.

Where does one purchase glucometers?

Most glucometers are found at pharmacies and clinics, and many of them are free through special offers from the manufacturer. (It is the test strips used in the glucometers that often are the more costly items, since many people with diabetes have to test their blood glucose levels several times a day.) Some meters also have mail-in rebates after the meter is purchased, and some even offer trade-in rebates if a person has an older machine. For the coverage of diabetes supplies, such as test strips, patients should contact their insurance company to see what is covered (if anything). At this writing, for people on Medicare, the program will cover the costs of blood testing supplies for people with diabetes.

What is a continuous glucose monitor (CGM)?

A continuous glucose monitor tracks a person’s glucose levels every few minutes. It is also often used in conjunction with a regular blood glucose meter (that does not continuously monitor glucose levels). Once used mainly for young children (especially for nighttime monitoring) and less mobile people, the technology has improved enough for many others to use the device, such as diabetics who travel extensively, who have an active lifestyle, or who can’t stop and monitor their blood glucose levels as much. The monitors have a small filament with a sensor that is inserted just below the skin, usually in an unobtrusive spot, such as just above or below the waist. Using a small radio transmitter, the sensor sends information to a handheld receiver; an iPhone, tablet, or computer can receive the data. The receiver displays the person’s glucose level every few minutes. Depending on the model, special alarms can alert the person to fluctuations in blood glucose levels, especially drops in levels that can lead to hypoglycemia.

What should a person look for when choosing a glucometer?

Choosing a glucose meter is mostly a personal choice (but not always, especially when certain health insurance companies cover only specific types of glucometers). There are some features to think about before picking a meter, including the speed (meters can take anywhere from five to 20 seconds to show results); a beeping or silent monitor for prompts; type of test strips (wrapped or not); or a meter with a memory. Other things to consider include how much the meter has to be cleaned; how portable it is (especially for travel); whether the meter checks for glucose and ketones; the size of blood sample the meter needs; and the types of (and ease of finding) batteries the meter uses. There are more considerations, but these are the most common.

In general, how much fluctuation is there in glucometer readings?

No machine is perfect, and glucometers are no exception. Even if a glucometer is cleaned and calibrated regularly, it may vary in accuracy from other meters, perhaps by as much as 20 percent. If a person with diabetes has any question about the accuracy of a glucometer, it is best to have the device checked out by a health care professional, pharmacy, or diabetes educator.

Can test strips give erroneous readings?

Yes, test strips can give a person with diabetes erroneous readings for a number of reasons. For example, the test strips may be too old. The enzymes that are embedded in the test strip can lose their activity and cause bare spots on the strips, giving an erroneous reading. A person may use the wrong test strips for the glucometer, giving a false or inaccurate reading, or no result. (This is usually because every machine has its own special test strips.) Abnormal readings may also occur if the temperature is too low. Low temperatures often affect the ability to draw blood for testing (blood does not circulate as close to the skin’s surface in lower temperatures as it does in higher temperatures).

Lancets allow you to make a clean, safe prick on the finger to draw a blood sample for testing.

What is a lancet?

In order for patients to get a clean prick of the finger to obtain a blood sample for a glucometer, many companies provide a lancing device, commonly called a lancet. This tool for pricking a finger is usually ad-justable to varying depths into the skin, depending on the individual’s need. The lancet needle has a release button, pricking the finger quickly. For most people, this way of obtaining a drop of blood is easy, fast, and clean.

What are some general steps when a person with diabetes takes his or her blood glucose level?

There are some very general steps a person with diabetes can take when using a blood glucose meter. Some people may have to take other steps, so it is best to check the procedure with a health care professional).

The first step is having everything out that the person will need to take his or her levels, such as the meter, unused test strips, unused lancets, and alcohol swabs. (Make sure the meter’s batteries are charged.)

Next, the person should make sure his or her hands are clean and free of anything that could influence the meter’s reading. (It is best to wash the hands in warm water.)

After drying the hands, the person may shake the hands below the waist, then squeeze (some people refer to it as “milking”) the fingers a few times before using the lancet. This helps to bring the blood flow to the fingertip. (Blood samples are most often taken at the fingertips, where there are fewer nerve endings.)

The lancet device is then put on the side of the fingertip, and the release button on the lancet is pushed. As a small drop of blood appears, it can be helped along if the person gently squeezes from the base of the finger toward the tip until a good drop of blood appears.

From there, the test strip essentially sucks up the drop of blood, and the meter is set to read the blood glucose level.

At this point, some meters will digitally record the person’s blood glucose data for each day. Other meters just give the blood glucose number, meaning it is up to the person to record and keep track of the blood glucose numbers each day (many glucometers come with a free log book).

What events and actions can often throw off blood glucose levels?

Several events and actions can throw off a person’s blood glucose levels, no matter how well the person monitors his or her blood glucose. Ordinary or non-ordinary events such as stress, certain illnesses, unanticipated activity, menstruation, eating, alcohol, or medications can throw the blood glucose levels off balance and cause (sometimes dangerous) fluctuations.

What medical conditions can lead to erroneous readings on a glucometer?

Several medical conditions a person with diabetes can have affect the readings on a glucometer. For example, blood disorders can cause inaccurate readings, such as in people who are anemic whose readings are often falsely high. A person with high levels of hemoglobin in the blood (polycythemia) can experience false low readings. If a person is dehydrated or in shock, he or she may also have false or abnormal glucometer readings.

Do blood glucose meters measure ketones?

Yes, some blood glucose meters measure ketones. This is important to people with diabetes, especially for people with type 1 diabetes. The meters use special blood ketone strips, with the level of ketones shown as a number on the meter display. In most cases, if the ketone reading is moderate or high, and a person’s blood sugar is also high, the person should receive medical attention immediately as high ketones indicate possible diabetic ketoacidosis (for more about diabetic ketoacidosis, see the chapter “Type 1 Diabetes”).

What other things can interfere with blood glucose readings on a glucometer?

Many things can interfere with blood glucose readings on a glucometer. For example, acetaminophen (commonly referred to as Tylenol) and acetaminophen-containing drugs (some over-the-counter cough and cold medications contain the drug, as do some prescription pain medications such as Zutripro) can interact with certain chemicals used in various medical devices. This interaction can cause the person’s blood glucose levels to rise, interfering with the correct readings. In addition, if a person does not clean his or her hands before collecting a blood sample, incorrect readings can result (the more recent meters only need a small sample, and if it is contaminated with other chemicals or dirt, it can throw off the reading). Other more technical conditions may lead to false blood-sugar readings. For example, glucose meters vary in the way they work and are calibrated. Failure to calibrate the meter regularly can lead to false blood glucose readings.

Why do many doctors suggest that blood samples for a glucometer be taken from a person’s fingertips?

For some blood glucose meters, there is a reason for taking most of the blood samples from the person’s fingertips-obtaining it in almost any other part of the body (unless it is necessary) can result in a false reading. That being said, many of the more modern glucose monitors require a tiny blood sample, some as small as a third of a microliter. For many of these machines, the small sample can be taken from other sites on the body, such as the forearm or thigh.

How many times a day should a person with diabetes test his or her blood glucose levels?

There is no set number of times a day that blood glucose levels should be tested. This is because everyone’s needs and blood glucose levels are different. Some health care professionals suggest monitoring after a meal; others advocate testing as many times as possible throughout the day. Most believe it is a good idea to check glucose levels before a person drives, exercises, uses heavy equipment, or performs any high-risk task. But overall, the number of times a person monitors glucose levels depends on the individual, the extent of the diabetes, and the recommendations of health care professionals and diabetes-care team.

Taking blood from the tip of one’s finger provides the most accurate readings of glucose levels.

Who should test their blood glucose levels on a regular basis?

Although not all people with diabetes need to diligently self-monitor their blood sugar levels, whether they should or not seems to depend on what type of diabetes a person develops. Most health care professionals suggest that people who take insulin should test their blood sugar regularly. Those who take oral diabetes medication for type 2 diabetes should test their levels frequently, especially if they are taking sulfonylureas or glinides, both of which can occasionally cause low blood sugar.

In addition, Harvard Medical School suggests that certain situations warrant more frequent testing of blood sugar levels, including very high levels at the time diabetes is diagnosed, recent weight gain or loss (not explained by dieting or stress), exercising more than usual (or even less than usual), a change in a person’s diabetic medications (especially sulfonylureas and glinides), and during an illness, such as a gastrointestinal virus (because even a flu or cold can cause blood sugar levels to fluctuate).

Are there any Internet tools a person can use to manage diabetes?

Yes, thanks to current technology and the Internet, there are many tools that a person with diabetes can use to manage diabetes. For example, there are websites that help keep track of blood glucose readings, which is important for the patient and the health care professionals who are helping their patient to stay healthy. There are also websites that offer diabetes-management assistance, and some clinics and health care providers can send your lab results directly to a patient’s account. The Internet also offers many personal health-management or electronic health record websites, some for free (but such sites may have online advertising) and some for a price. It is up to the individual to decide how much information he or she is willing to provide when signing up for an account. For security purposes, a person with diabetes interested in such a service should do some research on the company before choosing. (For more about the websites, see the “Resources, Websites, and Apps” section of this book.)

DIABETES AND MEDICATION

What types of medicines are used to treat diabetes?

Two main types of medications are used. The first are oral medications, or those that are taken by mouth; these are most often associated with type 2 diabetes. The second type is insulin that is injected or administered using an insulin pump or pen and is most associated with type 1 diabetes. (Insulin cannot be taken as a pill because the acid and digestive enzymes in a person’s stomach destroy the hormone.) According to the Centers for Disease Control and Prevention, the medicines used by adults with diabetes (both type 1 and 2) can be broken down by how they are taken. Among adults, 57 percent take oral medications only, 14 percent take only insulin, 14 percent take a combination of insulin and oral medication, and 15 percent take no medication (mostly people with prediabetes).

How long will it take before someone with diabetes can see an improvement in blood glucose levels-after taking medications and/or making lifestyle changes?

Everyone differs when it comes to how long it takes to see an improvement (or a worsening) in blood glucose levels. And, of course, everyone is different when it comes to taking medications and making lifestyle changes after being diagnosed with diabetes. But, on the average, most people with diabetes will see an improvement in three to four months. Therefore, a follow-up blood glucose test is usually administered three to four months after a diagnosis. There is one caveat: according to the American Diabetes Association, if a person has had uncontrolled diabetes for a long time and has just been diagnosed, most doctors will test the person’s blood glucose levels after two to three weeks to make sure there is an improvement.

Does a person with diabetes always have to take some type of medication?

Unfortunately, if a person has type 1 or type 2 diabetes, then he or she will probably have to take some medication for the rest of his or her life. Diabetes is a progressive disease, and the longer a person has it, the more likely the person will need pharmaceutical help to manage it. Most people with prediabetes-people who have blood glucose levels above the normal range but not high enough to be called diabetes-will not need to take diabetes medication or will take medication only for a short time (until their blood glucose levels are lower and/or stable). And if a person who has prediabetes can maintain normal blood glucose levels and not develop diabetes, then he or she will never need any diabetic medication.

Insulin is only one medication diabetics can take to control blood sugar. For example, metformin works for those with less pronounced cases.

What diabetes medications have recently been approved by the U.S. Food and Drug Administration?

For the past few decades, the U.S. Food and Drug Administration (FDA) has approved many different types of diabetes medications. These include medicines that are taken orally, injected, or inhaled. The following chart lists the diabetes medications that were approved between 2013 and 2016:

Recently Approved Diabetes Medications

Brand Name

Generic Name

Approval Date

Basaglar

insulin glargine injection

December 16, 2015

Tresiba

insulin degludec injection

September 25, 2015

Ryzodeg

insulin aspart: insulin degludec

September 25, 2015

Toujeo

insulin glargine injection

February 25, 2015

Lucentis

ranibizumab

February 6, 2015

Glyxambi

empagliflozin and linagliptin

January 2015

Trulicity

duglaglutide

September 18, 2014

Invokamet

canagliflozin and metformin hydrochloride

August 8, 2014

Jardiance

empagliflozin

August 1, 2014

Afrezza Inhalation Powder

insulin human

June 27, 2014

Tanzeum

abliglutide

May 2014

Farxiga

dapaglifozin

January 2014

Invokana

canagliflozin

March 29, 2016

Nesina

alogliptin benzoate

January 25, 2016

Duetact

pioglitazone hydrochloride and glimepiride

January 2013

Source: FDA website. All FDA-approved medicines used in the treatment of diabetes are either taken orally, injected, or inhaled and can be found listed at what is called Drugs@FDA (http://www.accessdata.fda.gov/cder/drug-satfda/). For drug-labeling information, go to the National Library of Medicine database of current drug information called DailyMed (http://dailymed.nim.nih.gov/dailymed/about.cfm).

What is the common procedure if a person is diagnosed with type 2 diabetes?

According to Harvard Medical School, people who have been newly diagnosed with type 2 diabetes should start by concentrating on lowering their blood glucose levels. The two most frequent steps are making lifestyle choices-mainly eating better and exercising more-and to start taking a medication called metformin. Initially, traditional treatment started with lifestyle changes, and if that did not work, then the person was treated with medications. In the meantime, the disease would progress. Now, most doctors recommend that both lifestyle changes and medication be started when a person is first diagnosed. This is because research has shown that many times, in the early stages of the disease, the insulin-secreting cells in the pancreas that are “wearing out” may be saved. This results in either slowing down the disease’s progression or even, for some people, mitigating the disease before it can take over.

Metformin lowers your HbA1c without causing weight gain or hypoglycemia.

What is metformin?

The type of drug most often used to treat a person who has just been diagnosed with diabetes is called by the generic name metformin (one brand name is Glucophage). It is known to lower a person’s HbA1c by about 1.5 percent and, in most cases, does not cause weight gain or hypoglycemia. It acts by reducing glucose secretion by the liver, lowering the organ’s resistance to insulin, and it decreases blood glucose levels without stimulating the secretion of insulin. It is considered a biguanide (see above for other types of medications), a type of oral diabetes medication, and is most often taken twice a day (usually with breakfast and dinner) or one to two times a day if an extended-release formula is taken. There are some side effects, such as nausea and diarrhea, and in rare cases, it may cause lactic acidosis. In addition, there are often some restrictions to metformin that a person should discuss with his or her health care provider, especially if the person has kidney, heart, or liver disease.

Does metformin have a peculiar smell?

Yes, there is one aspect of the diabetes drug metformin that no one expected. According to most people who take metformin, it has a distinctive smell that some describe as a “fishy” odor. Some doctors are concerned that this characteristic may cause a person to stop taking the drug. And since the drug works so well for most people with type 2 diabetes, stopping metformin would be detrimental to the person’s health! There are potential solutions. One study indicated that switching to certain extended-release versions of the drug may help (these drugs are said to have less smell, if any at all). But the best solution if the smell is a concern-without holding one’s nose as they take the drug-is to contact a health care professional about possible alternative formulations.

Do any non-diabetic medicines affect a person with diabetes?

According to the Centers for Disease Control and Prevention, some non-diabetic medications can affect a person’s blood glucose level. This is a concern if a person already has type 1 or type 2 diabetes. This is also why health care professionals must know the various medications a person with diabetes is taking, including those taken without a prescription (for example, vitamins and herbal supplements). The following are only some types of medications that can cause a problem with blood glucose levels:

barbiturates

thiazide diuretics (given mainly for high blood pressure)

corticosteroids

birth control pills and progesterone

decongestants containing beta-adrenergic agents, such as pseudoephedrin

vitamin B3, also called niacin (but the risk of high blood sugar from niacin decreases after it has been taken for a few months)

Is type 2 diabetes always treated with oral medications?

Most people with type 2 diabetes are commonly treated with oral medications. But if the drugs no longer work, then the person may have to turn to insulin injections. This means either insulin only or oral medications augmented with insulin injections.

What are some possible ways to get off or lower diabetic medication if a person has type 2 diabetes?

Some health care professionals suggest that there are certain specific conditions in which a person with type 2 diabetes may be able to take less diabetes medication or even stop taking medication. One of the major problems in coping with diabetes is that the person usually has to make conscious lifestyle changes. In fact, certain lifestyle changes may help immensely. These include more healthful eating habits, starting or maintaining better exercise routines, and keeping excellent track of blood glucose levels. The following lists some target glucose levels to reach in order to reduce, possibly, or even stop a person’s type 2 diabetes medication (of course, getting off medication also depends on other health conditions and what the health care provider says):

What combination drug was recently approved by the U.S. Food and Drug Administration for type 2 diabetes?

In 2016, the U.S. Food and Drug Administration approved a combination drug that includes metformin (a common treatment for type 2 diabetes) and empagliflozin (an SGLT2 inhibitor). The medicine, called Synjardy, is a joint effort by Boehringer Ingelheim Pharmaceuticals and Eli Lilly and Company. When the kidneys filter blood, they usually reabsorb all the filtered glucose and return it to the bloodstream. One of the primary proteins responsible for reabsorption is called SGLT2. What empagliflozin does is block this reabsorption, causing glucose to be lost in the urine and lowering a person’s blood glucose levels. At the same time, with this combination pill, the metformin decreases the amount of glucose made by the liver. It also improves insulin sensitivity in the liver and in muscle and fat cells. Through trials, researchers found that this combination significantly lowered the HbA1c levels compared with the same dose of either medicine alone. But there are some restrictions. It cannot be used by people with type 1 diabetes or who have diabetic ketoacidosis or severe kidney disease.

126 to 140 or 150 mg/dl-This is still above the normal level, but if these readings are consistently low enough, the person may be able to eventually stop taking medication.

150 to 200 mg/dl-This is above the normal level, but with lifestyle changes, eventually the medication dosage may be lowered. But most people who have levels between these numbers will still need medication, and some may eventually need occasional doses of insulin.

Above 200 mg/dl-At and above this level means that the person with diabetes may need medication or full-time insulin coverage-and maybe even both. If the person with diabetes makes some or all of the above lifestyle changes, it may mean a reduction in medication dose or other adjustments. But it is likely that he or she will need medication for the rest of his or her life.

What are some popular oral medications for people with type 2 diabetes?

A huge range of oral medications has been developed for people with type 2 diabetes-too many to mention in this text. There is a good reason for so many choices as every person who has diabetes has a different body composition and diabetic condition. (For more about listings of the most current medications from government sites, see the chapter “Resources, Websites, and Apps.”) In general, there are several general types of medications. They include the following:

Biguanides-The most commonly prescribed biguanide medication for type 2 diabetes, especially for a person who has just been diagnosed with the disease, is metformin. (For more about metformin, see above.)

Sulfonylurea-The sulfonylureas are the oldest class of oral diabetes medications (often seen as antidiabetic) and often a second choice after metformin. They work by stimulating the pancreas to make more insulin. There are some side effects that must be considered. For example, there is the risk of hypoglycemia, especially for the elderly or those who take a long-acting sulfonylurea (such as glyburide), and even if a person drinks a certain amount of alcohol or skips a meal. It also should not be taken by a person who is allergic to sulfa drugs.

Alpha-glucosidase inhibitors-These diabetic medications slow down the digestive enzyme that breaks down carbohydrates into smaller sugars, so they are more easily absorbed by the intestines. This action causes sugar levels to rise more slowly, and the insulin the body produces has more time to work efficiently, which helps slow down the surge in blood glucose after a meal. Side effects include flatulence and diarrhea, but if the dosage can be built up slowly, then such effects often slowly diminish over time.

Thiazolidinediones-These diabetes medications, also called glitazones, reduce a person’s insulin resistance and are frequently used in conjunction with other diabetes medicines. They help a person with diabetes by making the body’s muscles, fat, and liver more sensitive to insulin and thus more able to absorb nutrients from the blood. There are several side effects, such as weight gain and fluid retention, meaning this drug is not for everyone. Because of these side effects, thiazolidinediones (especially rosiglitazone and pioglitazone) have been linked to increased risk of heart failure and possible increase in bone fractures and loss. Thus, it is best to discuss this type of drug with the health care provider to understand these side effects.

Meglitinides-These drugs work by increasing the amount of insulin produced by the pancreas, thereby lowering blood sugar. They act quickly and do not stay in the body long. Therefore, they are usually ingested at or just before each meal. They are often used for people with type 2 diabetes who eat healthfully and exercise but still cannot sufficiently lower their blood glucose levels. There are several side effects in some people, including weight gain and low blood sugar.

What is lactic acidosis and its connection to some diabetes medications?

Lactic acidosis occurs when the body cannot get rid of lactic acid from the blood. During strenuous exercise, lactic acid (lactate) is created in the muscles and blood as a natural byproduct of the body’s metabolism, primarily because the cells are not getting enough oxygen. Normally, this acid is cleared from the blood by the liver, kidneys, and muscles. Although it rarely happens, if lactic acid builds up to very high levels in the body, then it can cause a life-threatening condition called lactic acidosis.

In some people, lactic acidosis can occur-again, rarely-if they take metformin (Glucophage) to control diabetes, especially if they are experiencing heart or kidney failure and if there is a severe infection present. (Because of this, the FDA states that the drug must carry a warning about its possible lactic acidosis side effect.) It is thought that since the liver filters acid from the body when it produces sugar, and metformin decreases the organ’s ability to produce sugar, lactic acid buildup results. Metformin is not the only drug to have this effect. Two other diabetes medications, phenformin and buformin, also have lactate side effects and have been banned from use in the United States.

What are some of the more recent oral medications for people with type 2 diabetes?

There are several more recent oral medications prescribed for people with type 2 diabetes. The following lists some of them:

DPP-4 inhibitors-These drugs work by blocking an enzyme called DPP-4. DPP-4 normally deactivates a protein (GLP-1, or glucagon-like peptide) that keeps insulin circulating in the blood, and by blocking the enzyme, it helps reduce sugar production, lowering blood glucose levels. The first DPP-4 that was approved by the Food and Drug Administration was Januvia (sitagliptin phosphate), an oral medication taken once a day, either alone or with diet and exercise or in combination with other oral diabetes medications.

Incretin mimetics-These drugs work by mimicking the action of incretin hormones (which help the body make more insulin). They also slow the rate of digestion so that glucose enters a person’s bloodstream more slowly. This medicine makes the person feel full longer, thus reducing food intake, which can help people lose weight while on the medication.

Byetta (exenatide)-This drug is an injectable medication used in combination with other oral diabetes medications. It is not an insulin, and it does not take the place of insulin. It is used for type 2 diabetes only and cannot be given with insulin. It comes in a pre-filled injector pen, with dosages taken twice a day within an hour before morning and evening meals.

Antihyperglycemic synthetic analogs-These drugs are synthetic versions of human substances. For example, there is a human hormone drug called amylin, which is used by the pancreas to lower blood glucose levels.

Symlin (pramlintide acetate)-Symlin is an injectable medication used with insulin for tighter blood glucose control. It can also increase the risk of severe hypoglycemia; therefore, patients who are put on Symlin are selected carefully and monitored closely by their health care providers.

INSULIN

What are the main types of insulin?

There are several types of insulin you can take. Each type serves a different purpose, and you might need to take a combination of the following (note: some references show different times to take effect; thus, the following is only a general guide):

What two ingredients in some type 2 diabetes medication now have FDA warnings?

Not all diabetic medications can be used by people with type 2 diabetes, and some even carry warnings on their labels. For instance, diabetic medications containing saxagliptin (for example, Onglyza) and alogliptin (for example, Nesina) are known to increase the incretin hormones, which increase insulin production after a person eats. But as with any medication, nothing is perfect. In 2014, the Food and Drug Administration added warnings and precautions to diabetes medications containing saxagliptin and alogliptin, as clinical trials linked the substances to an increased risk of heart failure, especially in patients who already had heart or kidney disease.

People who are not diabetic may not realize that there are actually several types of insulin. Some take effect more quickly than others.

Rapid-acting insulin-This type of insulin takes effect in 15 minutes or less and is taken before a meal. In someone without diabetes, the body releases the right amount of insulin when the person eats. This insulin helps someone with diabetes process and use the carbohydrates in the food. (The release of insulin at mealtime is called the bolus secretion; thus, rapid-acting insulin imitates the bolus secretion; see below.)

Regular or short-acting insulin-Regular insulin takes effect within 30 minutes of injection. It is also taken before a meal, but its effect lasts longer than rapid-acting insulin. (Regular or short-acting insulin imitates the bolus secretion; see below.)

Intermediate-acting insulin-This type of insulin lasts for 10 to 16 hours, and is generally taken twice a day. (It imitates basal secretion; see below.)

Long-acting insulin-Long-acting insulin is similar to intermediate-acting insulin, as it imitates the basal secretion. Long-acting insulin lasts for 20 to 24 hours, so the person with diabetes needs to take it only once a day (whereas intermediate-acting insulin is injected twice a day).

Pre-mixed insulin-A pre-mixed insulin combines two other types of insulin. For example, it may include rapid-acting and intermediate-acting insulin. This combination ensures that the person with diabetes has enough insulin to cover bolus and basal secretions.

What is basal insulin?

Another name for slow-acting insulin is basal insulin. It is also called background or long-acting insulin and is used to keep blood glucose levels stable during times when the person with diabetes is not eating, meaning during “fasting” times (the basal secretion is the small amount of insulin that should always be in your blood). Between meals in someone without diabetes, the body steadily releases glucose into the bloodstream, where it provides the body’s cells with energy. In a person with diabetes, the injected basal insulin keeps blood glucose levels under control, as long as it is injected once or twice a day (depending on the insulin).

What is the timing of insulin’s action in the body?

In general, the various types of insulin react in different ways in the body. The following chart shows the type of insulin, how long it takes to begin working, how long it takes to peak, and the estimated duration of the medication. These various medications can be used alone or in combination (see below). In addition, there is no guarantee that each insulin type will work the same for everyone and under every condition. (Note: Some medications, such as the long-acting insulins Lantus and Levemir, differ as to when they start working and their peak and duration. Thus, there are two listings in the chart below):

Types of Insulin

Type

Starts Working

Peaks

Estimated Duration

Very rapid-acting

15 minutes

1–2 hours

3–5 hours

Rapid-acting

30–60 minutes

1–2 hours

5–6 hours

Intermediate-acting

1–2 hours

4–8 hours

8–12 hours

Long-acting

1 hour

none

24 hours

(brand dependent)

3–4 hours

6–8 hours

6–23 hours

What is bolus insulin?

A bolus insulin dose is one that is taken specifically at mealtimes (either before, during, or just after meals) in order to keep a person’s blood glucose level under control following a meal. This type of insulin needs to act quickly to prevent hypoglycemia, and thus, short-acting or rapid-acting insulin is used.

What is a basal-bolus injection regimen?

People with type 1 diabetes and some with type 2 diabetes will often maintain a basal-bolus injection regimen. This schedule combines both the basal insulin and bolus insulin methods. In particular, a basal-bolus injection regime includes an injection at each meal (bolus) and a longer-acting form of insulin (basal) once or twice a day. In this way, the regimen emulates somewhat how a person who does not have diabetes naturally delivers insulin throughout the day. For many people with type 1 diabetes, taking rapid-acting insulin at mealtime and a long-acting insulin once or twice a day is a good way to control their blood glucose levels.

What is the difference between long-acting peaking and long-acting peakless?

Although these terms seem similar, long-acting peaking is a form of insulin that does not begin to lower blood glucose levels until four to six hours after it is injected. It works mostly from eight to 30 hours after injection and continues to work for up to 24 to 36 hours. One example is ultralente insulin. The long-acting peakless is a basal type of insulin. It lowers blood glucose within one to two hours after injection and continues for 24 hours. One example is glargine insulin.

There are several advantages to this regimen, including that it simulates the natural release of insulin in the body. It can often give a person flexibility as to when he or she can eat a meal-and even, if the insulin is adjusted correctly, how many carbohydrates a person with diabetes can consume. (Depending on the person’s condition, he or she may be able to eat more carbohydrates.) There are also some disadvantages to the regimen. For example, it involves taking several daily insulin injections. Hypoglycemia is often a common occurrence on a basal-bolus regimen (which is why it is recommended to keep a blood glucose testing kit and a fast-acting carbohydrate available in case of a low blood glucose level). And depending on a person’s diabetic condition, not everyone will be able to use this regimen. In addition, children who are on this regimen would have to be comfortable getting injections at mealtimes, either at school or other functions-and would have to understand that they need several injections each day.

What is inhalable insulin?

Inhalable insulin is a powdered form of insulin (or dry insulin) that is delivered via inhalation, sending small particles of insulin into the lungs. From there, it is absorbed by the cells in the lungs and then into the bloodstream. It can be used by people with type 1 or type 2 diabetes. The delivery system may be a nebulizer, meaning a device using compressed air that allows the particles to be inhaled (a process called aerosolization), or inhalers that can be activated with the breath (the insulin is inhaled directly through the mouth and into the lungs). The suggested advantage of inhaled insulin is that, because it enters the lungs, the dose can enter the bloodstream more quickly than injected insulin. One form of inhaled insulin called Afrezza has been said to have “peak activity” 12 to 15 minutes after taking the dose, while insulin injections average between 30 and 90 minutes after injecting.

Insulin inhalers are not to be used all the time. They are meant to be used mainly at the start of a meal to help with blood-sugar control. Most research shows inhalers to be safe to use with basal insulin (for more about basal insulin, see above). Of course, there are some warnings. In particular, inhalers are not recommended if the person with diabetes has chronic lung problems or if the person smokes. In addition, the most common adverse reaction with inhalable insulin (or any insulin) is hypoglycemia.

What new manmade version of insulin has recently been approved in the United States?

Research has developed a long-acting, manmade version of natural human insulin, referred to as insulin glargine. Insulin glargine not only replaces the body’s natural insulin but also moves glucose into the tissues and prevents the liver from making extra sugar. This type of insulin was developed by the pharmaceutical company Sanofi US (also known as Sanofi-aventis) and called by the brand name Lantus®. It was already on the market in 2000, but the patent expired in 2015. This meant that other drug companies could start making their own types of insulin glargine, also referred to as “biosimilar insulin.”

Which inhalable insulin was eventually taken off the market?

In January 2006, an inhalable insulin called Exubera, developed by Inhale Therapeutics (later Nektar Therapeutics), was commercially introduced to the public by the pharmaceutical company Pfizer. But because of poor sales, by October 2007, it had been taken off the market.

Thus, in 2016 the U.S. Food and Drug Administration (FDA) approved the first “copycat” version of insulin glargine called Basaglar from Eli Lilly. (It was also the first company to come out with commercially available insulin in the 1920s; for more about the company and the first commercial insulin, see the chapter “Introduction to Diabetes.”) Similar to Lantus®, the newest biosimilar insulin is administered by daily injection. It is used mainly for children and adults with type 1 diabetes and under certain conditions in adults with type 2 diabetes. Other biosimilar insulins will no doubt follow, as long as the pharmaceutical companies who want to develop the insulin go through a rigorous FDA approval process. It is too early to tell whether more insulin glargines on the market will mean lower prices for many of the 10 million Americans with diabetes who use insulin.

Do people with type 2 diabetes need injectable medication that is NOT insulin?

Although some people with type 2 diabetes take oral medication and insulin, there are some who need injectable medications (along with or other than insulin) to help control their blood glucose level. They would take this medication either in conjunction with other diabetes medicines or singularly. (These injectable medications are not for people with type 1 diabetes.) For example, a class of injectable drugs called glucagonlike peptide-1 (GLP-1) agonists are often prescribed, along with a healthful diet and exercise. (These drugs are also associated with a low rate of developing hypoglycemia in people with diabetes.) They include such drugs as Victoza (generic name liraglutide; it is similar to the body’s naturally occurring hormone to help control blood glucose, insulin levels, and digestion), Byetta (exenatide; it helps control blood glucose levels by helping the pancreas produce insulin more efficiently), and Tanzeum (albiglutide; it improves blood glucose levels when used in conjunction with a good diet and exercise). In general, it is thought that the GLP-1 agonists work by stimulating the pancreas’s insulin-producing beta cells in order to release insulin in response to a person’s high blood glucose levels.

Are there any experimental drugs that treat or may eventually treat diabetes?

Yes, there are many experimental drugs and medications that are-and may eventually be-used to treat diabetes or complications from the disease. For example, a drug called Herberprot-B, developed in Cuba, has been used around the world to treat diabetic foot ulcers. (This medicine was not available in the United States because of an embargo on trade with Cuba. In late 2016, it was reported that clinical trials on Herberprot-B were being conducted in the United States, but it is not known when the drug will become available.)

There are also experimental drugs that may or may not help people with diabetes and its complications, with one of the more controversial-and research-contrary-ones being medical marijuana. The reason for the controversy is the profusion of opposing studies about medical marijuana and diabetes. For example, several studies indicated that marijuana users had lower fasting insulin levels and less insulin resistance than non-users. In a different study, it appeared that there was a 30 percent lower risk of developing diabetes for those who used marijuana. But other studies disagreed, including one from the National Institutes of Health that warned that marijuana users had more abdominal fat, along with more insulin-resistant fat cells. Still other studies indicated that former marijuana users had higher glucose and insulin levels in their blood than those who had never used the drug. No one to date can actually say that marijuana can help or hinder a person with diabetes.

MONITORING FOR HYPOGLYCEMIA, HYPERGLYCEMIA, AND DIABETIC KETOACIDOSIS

Why is hypoglycemia a concern for a person with diabetes?

Hypoglycemia-or low blood sugar-is one of the most common, and often dangerous, side effects of any medication for lowering blood glucose. The goal of a person with diabetes should be to keep blood glucose levels as close to normal as possible. If a person with diabetes has a blood glucose level below 70 mg/dl (milligrams per deciliter), he or she can begin to experience a hypoglycemic low. Some causes may be missing or postponing a meal or even eating less than the right amount of carbohydrates; exercising more than usual; emotional upset or stress; injecting the wrong dose of insulin; or consuming too much alcohol for that person. Often, these lows occur for no apparent reason. That is why many health care professionals-and sometimes people with diabetes who have had hypoglycemic episodes-recommend that a person with diabetes always carry some form of quickly absorbed glucose.

What are some symptoms of hypoglycemia?

When people with diabetes become hypoglycemic, they are often extremely confused. At first, the brain sends out signals to raise the glucose level, and the alpha cells in the pancreas release glucagon. This tells the liver and muscles to release the stored glycogen and then change it back to glucose to raise the blood sugar back to normal. In the meantime, the body releases epinephrine, a hormone that increases hunger, causes a resistance to the insulin’s action, and further stimulates the breakdown of the liver’s glycogen into glucose. Other hormones are released, including cortisol, to counteract the insulin and raise the blood glucose levels. The result is that a person can experience dizziness, a pale or flushed face, often dilated pupils, irritability, hunger, sweating, a rapid heartbeat, weakness, nervousness or anxiousness, and shakiness.

Why is it important not to become hypoglycemic?

It is important for a person with diabetes not to become hypoglycemic. Not only does it cause the body to lose control-and, if a person is in the later stages of hypoglycemia, to hurt him- or herself-but it also can take a toll on the body as a whole (especially if it happens many times in a short period). The best way to treat hypoglycemia is to recognize the first symptoms and take action right away. For many people with diabetes, it usually means ingesting something that will get into their system quickly, such as glucose tablets, fruit juice (around 4 to 6 ounces), 2 tablespoons of raisins, or sugary candies. (Do not reach for foods containing chocolate, peanut butter, nuts, or fats unless it is the only sugary food available. The fat can actually delay the rise in blood glucose levels.) Most of these foods will be absorbed into the system quickly and begin to raise blood glucose within five to ten minutes.

The symptoms do not stop there. Later symptoms are caused by the decreasing availability of glucose to help the brain and nervous system. These symptoms include headache, blurred vision, slurred speech, confusion, euphoria, hostility, lack of coordination, drowsiness, possible convulsions and seizures, and loss of consciousness. At this point, emergency help should be called and the person should be taken to the hospital.

What is a glucagon kit?

Although it may never have to be used, a glucagon kit is for a diabetes emergency-in particular for severe hypoglycemia, especially for people with type 1 diabetes. The glucagon (to be injected into the person having a hypoglycemic episode) in the kit will raise the blood glucose levels when a person with diabetes is unconscious or uncooperative while having a severe hypoglycemic attack caused by low blood glucose. The kit contains a liquid and a powder to produce glucagon; the powder must be mixed with the liquid in the kit right before it is injected. The dosing is different for children and adults. In general, if a child weighs less than 50 pounds (22.7 kilograms), half of the dose should be given; if more than 50 pounds, a full dose should be given. But overall, the amount of the dose should be understood by the person administering it, whether family, a friend, or emergency medical technicians.

It is important that people with diabetes help their family and/or friends understand not only where the glucagon kit is located in the person’s home but also how to administer the glucagon. In most cases, if emergency personnel are called when a person with diabetes has severe hypoglycemia, the emergency medical technicians will have such a kit. (Note: Also be aware that glucagon can induce vomiting. If the person having a hypoglycemic episode has eaten recently, then it is best to keep his or her head turned, especially if the person is unconscious.)

Hypoglycemic patients might experience low blood glucose levels without warning-and sometimes without apparent reason. Having a glucagon kit can bring levels back to a normal range quickly.

Is the glucagon in a kit the same as glucagon naturally produced by the body?

Yes, the glucagon (also known as glucagen) in a kit is similar to the glucagon naturally produced by the body. Like the natural hormone, it raises the blood glucose level by releasing glucose stored in the liver. The glucagon in the kit is injected intramuscularly or subcutaneously and takes about ten to 15 minutes to work. But there is one caveat: If the stores in the person’s liver are low, then the injected glucagon may not be effective. In addition, if the person has been drinking alcohol to excess, has a very poor appetite (or has eaten a small amount of food recently), or had a hypoglycemic episode the day before, the glucagon may not work.

Is it possible to overdose injected insulin?

Yes, it is possible to get an overdose of insulin, although it is very rare if a person keeps careful tabs on his or her insulin injections. In this case, an overdose of insulin causes hypoglycemia, or a very low blood glucose level, or glucose levels lower than 4 mmol/l (micromoles per liter). In general, the symptoms of hypoglycemia include anxiety, confusion, sweating or clammy skin, trembling hands, extreme hunger, fatigue, or extreme irritability. If levels continue to fall after an overdose, other more serious conditions can occur, such as seizures or unconsciousness. Not everyone with diabetes experiences these symptoms with low blood sugar. (Although no one knows why at this writing, some people-most often with type 1 diabetes-have few symptoms as their blood sugar drops. This is also why most health care professionals advocate that people with type 1 and 2 diabetes keep tabs on their blood glucose levels periodically throughout the day.)

Overdoses of insulin can occur in people with type 1 diabetes, as they have to inject the hormone into their system. It can also happen to the people with type 2 diabetes who inject insulin (usually because the blood glucose levels cannot be controlled by oral medication or there are changes in lifestyle, diet, or exercise). The following lists several ways in which a person with diabetes can get too much injected insulin:

A person with diabetes injects the insulin but does not eat afterward. Blood glucose rises after a meal, and the injected insulin helps to lower it to a healthy level. If the person does not eat, the insulin can lower the blood glucose to a potentially dangerous level. This is why it is important to time insulin injections with meals.

The person injects too much insulin. This may be because the person is not paying attention, is having difficulty reading the syringe or vials, or is not familiar with a new product for insulin injections. Once again, the extra insulin in the system will lower the blood glucose levels.

The person injects the right amount of insulin but the wrong type. For example, short-acting insulin differs from long-acting insulin. If the person mixing the dosage usually takes ten units of short-acting insulin and 20 units of long-acting insulin but switches the amounts, the incorrect dosage can put too much insulin into the system. (For more about short- and long-acting insulin, see this chapter.)

What is GlucoGel™ (or Gluco Gel or glucogel)?

GlucoGel™ is the brand-name gel used by many people-including emergency medical technicians-to raise blood glucose levels quickly. It also provides a fast-acting energy boost to a person with diabetes. One of the reasons it was developed is that many diabetics having a hypoglycemic episode are irritable, hostile, and unreasonable. Many refuse to eat anything. The gel is easier to administer than food.

Formerly known as Hypostop, GlucoGel™ is a “sugar” gel (around 40 percent dextrose) that is mostly used for hypoglycemia and can be prescribed by a general practitioner or purchased over the counter. It should be used only if the person who is having a hypoglycemic attack can swallow (there is the risk that an unconscious person will choke). The gel must be squeezed from the tube into the mouth and between the teeth and cheek. This is because the gel is absorbed by the lining of the mouth. The person’s blood glucose levels should rise within 15 minutes. After this treatment, it is advised that the person eat a starchy carbohydrate snack such as toast or a sandwich-then check blood glucose levels to see whether they have normalized. If not, the above steps can be repeated as necessary.

How should a person treat an overdose of injected insulin?

There are several ways to handle a minor insulin overdose. If the person has injected a great amount of insulin, seek medical help immediately by calling emergency (911 in the United States). But in most cases, if a person is at home (and conscious), the following are some suggestions from several diabetes organizations in case of a minor overdose:

Don’t panic.

Check blood glucose level. (If it is very low, call emergency.)

Drink a half cup of sweetened fruit juice and/or eat a sweet or glucose tablet. If a meal has been skipped, eat something now. For most people, eating 15 to 20 grams of carbohydrates should raise their blood glucose level.

Rest-don’t walk or exercise. It will affect glucose levels.

Recheck blood glucose level after 15 (some say ten) to 20 minutes after taking in the sugar or carbohydrates. Seek medical help if the level is unaffected by what was eaten.

Pay attention to how the body feels for the next few hours. If the symptoms don’t improve or if other symptoms begin to occur, then seek medical help.

ANIMAL HELP AND DIABETES

What is the role of animals in the lives of humans, including some people with diabetes?

The role of animals is obvious to most people. In particular, domesticated animals-from cats and dogs to hamsters, horses, and goldfish-give emotional support, help to lower blood pressure, and offer companionship. Some special animals even help people with diabetes. For example, there are specially trained dogs that help detect when people are experiencing high and low blood glucose levels. Dogs can also be good for a person with diabetes to help promote exercise and provide social contact. And because most dogs are “creatures of habit,” they can help a person with diabetes maintain a routine to monitor blood glucose and take medications.

What are Diabetic Alert Dogs?

A Diabetic Alert Dog (DAD) is trained to detect a hypoglycemic or hyperglycemic attack in a person with diabetes. During either episode-low or high levels of glucose in the blood-the body releases certain chemicals. The chemical scents are not detectable by humans but can be noticed by specially trained DADs.

How do specially trained Diabetic Alert Dogs help some people with diabetes?

Although not all people with diabetes can benefit from Diabetic Alert Dogs (and not all dogs can be alert-trained), the people who do benefit do so greatly. Because one-eighth of a dog’s brain is composed of the olfactory bulb (tissue located at the front of the dog’s brain that processes scents detected by cells in their nose), dogs can be trained to recognize a single, distinct scent (this is why dogs are also used in such activities as police or forensic work). These dogs do not take the place of monitoring blood glucose levels. But they can detect and alert a person to changes in blood glucose levels or even alert others if the person with diabetes becomes incapacitated. (For resources on these dogs, including organizations such as the Diabetic Alert Dogs of America and Dogs 4 Diabetes, see the resources section at the end of this book.)

A trained Diabetic Alert Dog can detect, through its acute sense of smell, whether a person’s blood glucose is getting too high or low, often even before the patient can tell.

Who may need a specially trained dog to alert him or her to a high or low blood glucose level?

Not everyone with diabetes is a candidate for a dog trained to detect high and low glucose levels in the blood. Therefore, people working with these dogs usually suggest that certain conditions be met to determine whether a person with diabetes is a good fit for such an animal. For example, for people with diabetes using insulin or sulfonylureas (a group of medications used to treat diabetes), very low blood glucose levels can often be a major problem. They need to be paired with dogs that can prevent such events as high and low blood sugar, warning the person if an episode is imminent. This is done by exposing the dog to the smell of sweat or saliva from the person when his or her blood glucose levels are either high or low. The dog is trained to alert a person to high or low blood glucose levels by a recognizable method, such as by nudging or touching the person with its paw.

Are all alert dogs specially trained?

Although most dogs are specifically trained to alert people with diabetes to high and low blood glucose levels, some other dogs seem to do the task naturally. Stories about dogs adopted from a shelter that have helped their owners detect hypoglycemia or hyperglycemic episodes have been reported, but it often takes a special type of dog to take on such a task. This is why, if a person with diabetes wants a diabetes alert dog and already owns a dog, he or she may want to enroll in a workshop in which the person can learn whether the dog is suitable. Most diabetes alert dog trainers also note that although a puppy can be trained as an alert dog, it probably will not be a reliable one until it is at least a year old.

Why do dogs have such a keen sense of smell, especially in comparison with humans?

They have much better scent receptors. It is estimated that a dog’s sense of smell is about a thousand times more sensitive than a human’s. The reason is the receptors-a dog has more than 220 million scent receptors (44 times the number humans have) in its nose, covering an area about the size of a normal handkerchief. Most humans have just over 5 million scent receptors in their nose, which is about the size of a postage stamp. Another way of looking at it is that the dog’s olfactory bulb is 40 times larger than a human’s relative to brain size. And for people who have had certain problems with their sense of smell, such as chronic sinus infections, damaging chemicals, or even medicines that lessen the sense of smell, there are even fewer scent receptors available to smell. (For more about the senses and diabetes, see the chapter “Diabetes and Inside the Human Body.”)