Prevent Diabetes Problems

Prevent diabetes problems: Keep your diabetes under control U.S. Department of Health and Human Services NATIONAL...

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Prevent diabetes problems:

Keep your diabetes under control

U.S. Department

of Health and

Human Services

NATIONAL INSTITUTES OF HEALTH

National Diabetes Information Clearinghouse


Keep your diabetes under control

U.S. Department of Health and Human Services NATIONAL INSTITUTES OF HEALTH


Contents What are diabetes problems? .............................................. 1

Will I have diabetes problems? ............................................ 1

What should my blood glucose numbers be? ...................... 2

How can I find out what my average blood

glucose is? ........................................................................... 3

What should my blood pressure be?.................................... 5

What should my cholesterol be? .......................................... 6

What does smoking have to do with

diabetes problems? .............................................................. 7

What else can I do to prevent diabetes problems? .............. 8

Things to Check for Good Diabetes Care ............................ 9

How to Use the Daily Diabetes Record Page .................... 14

Pronunciation Guide........................................................... 19

For More Information.......................................................... 20

More in the Series .............................................................. 22

Acknowledgments .............................................................. 23

What are diabetes problems? Too much glucose* in the blood for a long time can cause diabetes problems. This high blood glucose, also called blood sugar, can damage many parts of the body, such as the heart, blood vessels, eyes, and kidneys. Heart and blood vessel disease can lead to heart attacks and strokes. You can do a lot to prevent or slow down diabetes problems.

Will I have diabetes problems? Maybe. You may have one or more diabetes problems or none at all. If you get diabetes when you are young, you may not have diabetes problems for many years. If you find out you have diabetes as an adult, you may already have diabetes problems. Either way, keeping your blood glucose, blood pressure, and cholesterol under control can prevent diabetes problems.

*See page 19 for tips on how to say the words in bold type.

Be active to prevent

diabetes problems.

1

What should my blood glucose numbers be? Keeping your blood glucose on target can prevent or delay diabetes problems. The chart below shows target blood glucose levels for most people with diabetes. Target Blood Glucose Levels

for People with Diabetes

Before meals

70 to 130

1 to 2 hours after the start of a meal

less than 180

Talk with your health care provider about what your blood glucose numbers should be and write them here: My Target Blood Glucose Levels

Before meals

______ to ______


less than _______

Talk with your health care provider about when you need to check your blood glucose using a blood glucose meter. You will do the checks yourself. Your health care provider can teach you how to use your meter. 2

Keep track of your blood glucose checks using the record page in this booklet on pages 16 and 17. Make copies yourself or ask your health care provider for a blood glucose record book. Your blood glucose check results will help you and your health care provider make a plan for keeping your blood glucose under control. Always bring your record book to your doctor visits so you can talk about reaching your glucose goals.

How can I find out what my average blood glucose is? Ask your health care provider for the A1C test. This blood test shows the average amount of glucose in your blood during the past 2 to 3 months. Have this test done at least twice a year. If your A1C result is not on target, your health care provider may do this test more often to see if your result is improving as your treatment changes. Your A1C result plus your blood glucose meter results can show whether your blood glucose is under control.

3

The A1C target for most people with diabetes is below 7 percent. Ask your health care provider if this target is right for you. Then write your A1C target here: My A1C target is ____________ percent.

If your A1C test result is on target, then your blood glucose is in a desirable range and your diabetes treatment plan is working. The lower your A1C is, the lower your chance of having health problems. If your result is too high, you may need a change in your diabetes plan. Your health care team can help you decide what part of your plan to change. You may need to change your meal plan, your diabetes medicines, or your physical activity plan. What Your A1C Result Means My A1C Result 6% 7% 8% 9% 10% 11% 12% 4

My Average Blood Glucose

................... ................... ................... ................... ................... ................... ...................

135

170

205

240

275

310

345

What should my blood pressure be? Normal blood pressure will help prevent damage to your eyes, kidneys, heart, and blood vessels. Blood pressure is written with two numbers separated by a slash. For example, 120/70 is said as “120 over 70.” The first number should be below 130 and the second number should be below 80. Keep your blood pressure as close to these numbers as you can. If you already have kidney disease, ask your doctor what numbers are best for you. Meal planning, medicines, and physical activity can help you reach your blood pressure target.

Have your blood pressure checked at every visit.

5

What should my cholesterol be? Normal cholesterol and blood fat levels will help prevent heart disease and stroke, the biggest health problems for people with diabetes. Keeping cholesterol levels under control can also help with blood flow. Have your blood fat levels checked at least once a year. Meal planning, physical activity, and medicines can help you reach your blood fat targets: Target Blood Fat Levels for People with Diabetes Total cholesterol below 200

6

LDL cholesterol

below 100

HDL cholesterol

above 40 (men) above 50 (women)

Triglycerides

below 150

What does smoking have to do with diabetes problems? Smoking and diabetes are a dangerous combination. Smoking raises your risk for diabetes problems. If you quit smoking, you’ll lower your risk for heart attack, stroke, nerve disease, and kidney disease. Your cholesterol and your blood pressure levels may improve. Your blood circulation will also improve. If you smoke, ask your health care provider for help in quitting.

7

What else can I do to prevent diabetes problems? You can do many things to prevent diabetes problems. For example, to keep your feet healthy, check them each day. Ask your health care team whether you should take a low-dose aspirin every day to lower your risk for heart disease. To keep your eyes healthy, visit an eye care professional once a year for a complete eye examination that includes using drops in your eyes to dilate the pupils. Make sure your doctor checks your urine for protein every year. At least once a year, your blood creatinine level should be checked. Also once a year, your health care provider should do a complete foot exam. See page 10 for what you can do each day to stay healthy with diabetes. See pages 11 to 13 for other things for your health care provider to check for good diabetes care.

Check your feet each day to keep them healthy.

8

Things to Check for Good Diabetes Care Taking care of diabetes is a team effort between you and your health care team—doctor, diabetes nurse educator, diabetes dietitian educator, pharmacist, and others. You are the most important member of the team. Take charge of your diabetes by learning what to do for good diabetes care: ●

things to do every day for good diabetes care

(see page 10)

●

things for your health care provider to look at every time you have a checkup (see pages 11 and 12)

●

things for you or your health care provider to do at least once or twice a year (see pages 12 and 13)

Keep a daily record of blood glucose check results. Make copies of the Daily Diabetes Record on pages 16 and 17 in this booklet. This information will help you see whether you are reaching your blood glucose goals. You can prevent or slow down diabetes problems by reaching your blood glucose, blood pressure, and cholesterol goals most of the time.

9

Things to Do Every Day for Good Diabetes Care

Follow the healthy eating plan that you and your

doctor or dietitian have worked out.

Be active a total of 30 minutes most days. Ask

your doctor what activities are best for you.

Take your medicines as directed.

Check your blood glucose every day. Each time

you check your blood glucose, write the number

in your record book.

Check your feet every day for cuts, blisters,

sores, swelling, redness, or sore toenails. Brush and floss your teeth every day. Control your blood pressure and cholesterol. Don’t smoke.

10

Things for Your Health Care Provider to Look at Every Time You Have a Checkup Your blood glucose records

Show your records to your health care provider. Tell your health care provider if you often have low blood glucose or high blood glucose.

Your weight

Talk with your health care provider about how much you should weigh. Talk about ways to reach your goal that will work for you.

Your blood pressure

The goal for most people with diabetes is less than 130/80. Ask your health care provider about ways to reach your goal.

Your medicines

Talk with your health care provider about any problems you have had with your medicines.

Your feet

Ask your health care provider to check your feet for problems.

Your physical activity plan

Talk with your health care provider about what you do to stay active. 11

Your meal plan

Talk about what you eat, how much you eat, and when you eat.

Your feelings

Ask your health care provider about ways to handle stress. If you are feeling sad or unable to cope with problems, ask about how to get help.

Your smoking

If you smoke, talk with your health care provider about how you can quit.

Things for You or Your Health Care Provider to Do at Least Once or Twice a Year A1C test

12

Have this blood test at least twice a year (see pages 3 and 4). Your result will tell you what your average blood glucose level was for the past 2 to 3 months.

Blood lipid (fats) lab tests

Get a blood test to check your • total cholesterol—aim for below 200 • LDL—aim for below 100 • HDL—men: aim for above 40; women: aim for above 50 • triglycerides—aim for below 150

These test results will help you plan how to prevent heart attack and stroke. Kidney function tests

Once a year, get a urine test to check for protein. At least once a year, get a blood test to check for creatinine. The results will tell you how well your kidneys are working.

Dilated eye exam

See an eye care professional once a year for a complete eye exam.

Dental exam

See your dentist twice a year for a cleaning and checkup.

Foot exam

Ask your health care provider to check your feet to make sure your foot nerves and your blood circulation are OK.

Flu shot

Get a flu shot each year.

Pneumonia vaccine

Get one; if you’re over 64 and your shot was more than 5 years ago, get one more.

13

How to Use the Daily Diabetes Record Page Use copies of the record page on pages 16 and 17 to keep track of blood glucose checks, medicines, and notes about things that affect your blood glucose. Make one copy of the record page for each week. This record will help you see whether your diabetes plan is working. Review your record with your health care provider.

Blood Glucose Checks Talk with your health care provider and decide on the best times to check blood glucose. You may be checking blood glucose before meals, after meals, or at bedtime. Write when to check here: ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________

14

If needed, draw a line in the boxes under “Breakfast,” “Lunch,” and “Dinner” to make room for blood glucose check results before and after a meal, like this example:

See page 2 for information about target blood glucose levels.

Medicines Under the heading marked “Medicine,” write the names of your diabetes medicines and the amounts taken.

Notes Write down things that affect your blood glucose level. Some examples are ●

eating more or less than usual

●

forgetting to take your diabetes medicine

●

exercising—write down what kind and for how long

●

being sick or upset about something—being under

stress

●

going to a social event or other special event, or being on vacation 15

Week Starting __________________

Daily Diabetes Record*

Other blood glucose

Breakfast Medicine blood glucose

Lunch Medicine blood glucose

Dinner Medicine blood glucose

Bedtime Medicine blood glucose

Notes: (Special events, sick days, exercise)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

*Keep this copy clean. Make photocopies and write on the copies.

16

17

My Health Care Team Members

Name and Address Doctor

Diabetes dietitian educator Diabetes nurse educator Eye care professional

Dentist

Foot doctor

Pharmacist

Counselor

18

Phone Number

Pronunciation Guide

A1C (AY-WUHN-SEE) cholesterol (koh-LESS-tur-ol) circulation (SUR-kyoo-LAY-shuhn) creatinine (kree-AT-ih-neen) glucose (GLOO-kohss) triglycerides (try-GLISS-ur-eyedz)

19

Prevent diabetes problems �

Keep your kidneys healthy

U.S. Department of Health and Human Services



Contents � What are diabetes problems?.................................. 1 � What should I do each day to stay healthy

with diabetes? ........................................................... 2 � What do my kidneys do?.......................................... 3 � How can I prevent diabetes

kidney problems? ..................................................... 4 � How can my doctor protect my kidneys

during special x-ray tests?........................................ 6 � How can diabetes hurt my kidneys? ....................... 7 � What can I do if I have kidney problems

caused by diabetes?.................................................. 9 � How will I know if my kidneys fail? ...................... 10 � What happens if my kidneys fail? ......................... 11 � Will I know if I start to have kidney problems? ...... 13 � How can I find out if I have

kidney problems? ................................................... 13 � Pronunciation Guide...............................................14 � For More Information ........................................... 15 � More in the Series .................................................. 18 � Acknowledgments .................................................. 19 �

What are diabetes problems? Too much glucose in the blood for a long time can cause diabetes problems. This high blood glucose, also called blood sugar, can damage many parts of the body, such as the heart, blood vessels, eyes, and kidneys. Heart and blood vessel disease can lead to heart attacks and strokes. You can do a lot to prevent or slow down diabetes problems.

Kidneys

Ureters

Bladder

Your kidneys are two bean-shaped organs about the size of your fist. They are located just below the rib cage, near your back.

1

What should I do each day to stay healthy with diabetes? Follow the healthy eating plan that you and your doctor or dietitian have worked out. Be active a total of 30 minutes most days. Ask your doctor what activities are best for you. Take your medicines as directed. Check your blood glucose every day. Each time you check your blood glucose, write the number in your record book. Check your feet every day for cuts, blisters, sores, swelling, redness, or sore toenails. Brush and floss your teeth every day. Control your blood pressure and cholesterol. Don’t smoke.

2

What do my kidneys do? The kidneys act as filters to clean the blood. They get rid of wastes and send along filtered fluid. The tiny filters in the kidneys are called glomeruli.* When kidneys are healthy, the artery brings blood and wastes from the bloodstream into the kidneys. The glomeruli clean the blood. Then wastes and extra fluid go out into the urine through the ureter. Clean blood leaves the kidneys and goes back into the bloodstream through the vein.

Glomeruli (tiny filters in the kidney)

➔

Vein (clean blood leaves the kidney)

➔

➔

Artery (blood and wastes enter the kidney)

Ureter (wastes and fluid go out in urine)

You have two kidneys. Your kidneys clean your blood and make urine. This drawing shows a cross section of a kidney. *See page 14 for tips on how to say the words in bold type.

3

How can I prevent diabetes

kidney problems? � ●

●

Keep your blood glucose as close to your goal as you can. For many people, this level is as close to normal as possible. For others, a higher blood glucose goal may be better. Ask your doctor what blood glucose numbers are healthy for you. Keep your blood pressure below 130/80 to help prevent kidney damage. Blood pressure is written with two numbers separated by a slash. For example, 120/70 is said as “120 over 70.” For some people, a higher blood pressure goal may be better. Ask your doctor what numbers are best for you. If you take blood pressure pills every day, take them as your doctor tells you. Keeping your blood pressure under control will also slow down or prevent damage to your eyes, heart, and blood vessels.

Keep your blood pressure under good control.

4

●

Ask your doctor if you should take pills to slow down kidney damage. Two kinds are available: • ACE (angiotensin-converting enzyme)

inhibitor � • ARB (angiotensin receptor blocker)

●

●

●

Follow the healthy eating plan you work out with your doctor or dietitian. If you already have kidney problems, your dietitian may suggest you cut back on protein, especially animal products such as meat, milk, cheese, and eggs. Have your kidneys checked at least once a year by having your urine tested for protein. This test is called the urinary albumin test. Have your blood tested at least once a year for creatinine. The result of this test should be used to find your glomerular filtration rate (GFR), a measure of kidney function.

Pills can help you control your blood pressure and slow down kidney damage.

5

●

●

●

Have any other kidney tests your doctor thinks you need. Avoid taking painkillers regularly. Daily use of pills like aspirin or acetaminophen can damage the kidneys. Taking a single dose of aspirin every day to protect the heart, however, should be safe. Taking acetaminophen for occasional pain should also be safe. But if you are dealing with chronic pain, such as arthritis, work with your doctor to find a way to control your pain without putting your kidneys at risk. See a doctor right away for bladder or kidney infections. You may have an infection if you have these symptoms: • �pain or burning when you urinate • a frequent urge to go to the bathroom • urine that looks cloudy or reddish • fever or a shaky feeling • pain in your back or on your side below the ribs

How can my doctor protect my

kidneys during special x-ray tests? � X-ray tests using a contrast agent pose a risk to your kidneys. If you need x rays, your doctor can give you extra fluid and medicine before and after the x rays to protect your kidneys. Or your doctor may decide to order a test that does not use a contrast agent.

6

How can diabetes hurt my kidneys? When the kidneys are working well, the tiny filters in your kidneys, the glomeruli, keep blood proteins inside your body. You need these proteins to stay healthy. High blood glucose and high blood pressure damage the kidneys’ filters. When the kidneys are damaged, proteins leak out of the kidneys into the urine. The urinary albumin test detects this loss of protein in the urine. Damaged kidneys do not do a good job of filtering out wastes and extra fluid. Wastes and fluid build up in your blood instead of leaving the body in urine. Kidney damage begins long before you notice any symptoms. An early sign of kidney damage is when your kidneys leak small amounts of a protein called albumin into the urine. But the only way to know about this leakage is to have your urine tested. With more damage, the kidneys leak more and more protein. More and more wastes build up in the blood. This damage gets worse until the kidneys fail. Diabetic kidney disease (DKD) is the medical term for kidney problems caused by diabetes. DKD affects both kidneys at the same time.

7

Healthy kidney

➔

Vein (clean blood)

➔

➔

Artery (blood and wastes)

No albumin, a protein, is leaking from the healthy kidney.

Ureter (wastes and fluid)

Unhealthy kidney

➔

Vein (blood with waste products)

➔ Albumin Ureter (wastes, fluid, and protein)

8

➔

Artery (blood and wastes)

Albumin, a protein, is leaking from the healthy kidney.

What can I do if I have kidney

problems caused by diabetes? � Once you have kidney damage, you can slow it down or stop it from getting worse by controlling your blood glucose and blood pressure. Taking an ACE inhibitor or an ARB is important for both controlling your blood pressure and reducing kidney damage. However, if you are pregnant, you should not take an ACE inhibitor or ARB. If you have diabetes, you should have your urine and blood tested regularly to see how well your kidneys are working. The test results should be given to you as your urine albumin and GFR results.

Keeping blood pressure under control helps to keep your kidneys healthy.

9

How will I know if my kidneys fail? At first, you cannot tell. Kidney damage from diabetes happens so slowly that you may not feel sick at all for many years. You will not feel sick even when your kidneys do only half the job of normal kidneys. You may not feel any signs of kidney failure until your kidneys have almost stopped working. However, getting your urine and blood checked every year can tell you how well your kidneys are working. Once your kidneys fail, you may feel sick to your stomach and tired all the time. Your hands and feet may swell from extra fluid in your body.

You may feel sick to your stomach when your kidneys stop working.

10 �

What happens if my kidneys fail? One way to treat kidney failure is with dialysis. Dialysis is a treatment that does some of the work your kidneys used to do. Two types of dialysis are available (see page 12). You and your doctor will decide what type will work best for you.

Dialysis is a treatment that takes waste products and extra fluid out of your body.

11

1. �Hemodialysis. In hemodialysis, your blood flows through a tube from your arm to a machine that filters out the waste products and extra fluid. The clean blood flows back to your arm. 2. �Peritoneal dialysis. In peritoneal dialysis, your belly is filled with a special fluid. The fluid collects waste products and extra water from your blood. Then the fluid is drained from your belly and thrown away. Another way to treat kidney failure is to have a kidney transplant. This operation gives you a new kidney. The kidney can be from a close family member, friend, or someone you do not know. A new kidney must be a good match for your body. You may be on dialysis for a long time because many people are on a waiting list for a new kidney from donors they do not know. You are more likely to have a kidney transplant if you know someone who is able to donate a kidney to you.

12

Will I know if I start to have kidney problems? Not likely. You will know you have kidney problems if your doctor checks your blood for creatinine to measure your GFR and your urine

for albumin. Do not wait until you feel ill to have

your blood and urine checked for signs of DKD. �

How can I find out if I have kidney problems? Two lab tests can tell you and your doctor how well your kidneys are working. ●

●

Each year, make sure your doctor checks a sample of your urine to see if your kidneys are leaking small amounts of albumin. At least once each year, your doctor should check your blood to measure the amount of creatinine. Creatinine is a waste product your body makes. If your kidneys are not cleaning waste products from your blood, they can build up and make you sick. Your doctor can use your creatinine level to check your GFR. Results of this test tell you how well your kidneys are removing wastes from the blood.

13

Pronunciation Guide albumin (al-BYOO-min) angiotensin (AN-jee-oh-TEN-sin) artery (AR-tur-ee) creatinine (kree-AT-ih-neen) dialysis (dy-AL-ih-siss) glomerular (gloh-MAIR-yoo-lur) glomeruli (gloh-MAIR-yoo-ly) hemodialysis (HEE-moh-dy-AL-ih-siss) inhibitor (in-HIB-ih-tur) peritoneal (PAIR-ih-toh-NEE-uhl)

14 �


Keep your heart and

blood vessels healthy

U.S. Department

of Health and

Human Services




What should I do each day to stay healthy

with diabetes? ...................................................................... 2

What do my heart and blood vessels do? ............................ 3

What can I do to prevent heart disease

and stroke?........................................................................... 4

How do my blood vessels get clogged? ............................... 7

What can happen when blood vessels

are clogged?......................................................................... 8

What are the warning signs of a heart attack?..................... 9

How do narrowed blood vessels cause

high blood pressure?.......................................................... 10

What are the warning signs of a stroke?............................ 12

How can clogged blood vessels hurt my

legs and feet?..................................................................... 13

What can I do to prevent or control PAD? .......................... 14





What are diabetes problems? Too much glucose in the blood for a long time can cause diabetes problems. This high blood glucose, also called blood sugar, can damage many parts of the body, such as the heart, blood vessels, eyes, and kidneys. Heart and blood vessel disease can lead to heart attacks and strokes, the leading causes of death for people with diabetes. You can do a lot to prevent or slow down diabetes problems. This booklet is about heart and blood vessel problems caused by diabetes. You will learn the things you can do each day and during each year to stay healthy and prevent diabetes problems.

Blood vessels

Heart

High blood glucose can cause heart and blood vessel problems.

1

What should I do each day to stay healthy with diabetes? Follow the healthy eating plan that you and your doctor or dietitian have worked out. Be active a total of 30 minutes most days. Ask your doctor what activities are best for you. Take your medicines as directed.

Check your blood glucose every day. Each time you check your blood glucose, write the number in your record book. Check your feet every day for cuts, blisters, sores, swelling, redness, or sore toenails. Brush and floss your teeth every day.

Control your blood pressure and cholesterol.

Don’t smoke.

2

What do my heart and blood vessels do? Your heart and blood vessels make up your circulatory* system. Your heart is a muscle that pumps blood through your body. Your heart pumps blood carrying oxygen to large blood vessels, called arteries, and small blood vessels, called capillaries. Other blood vessels, called veins, carry blood back to the heart.

Heart

Artery

Vein

Capillary

*See page 14 for tips on how to say the words in bold type. 3

What can I do to prevent heart disease and stroke? You can do a lot to prevent heart disease and stroke. l

Keep your blood glucose under control. You can see if your blood glucose is under control by having an A1C test at least twice a year. The A1C test tells you your average blood glucose for the past 2 to 3 months. The target for most people with diabetes is below 7. In some people with heart disease or other special circumstances, their doctor may recommend slightly higher levels of A1C.

l

Keep your blood pressure under control. Have it

checked at every doctor visit. The target for most

people with diabetes is below 130/80.

l

Keep your cholesterol under control. Have it checked at least once a year. The targets for most people with diabetes are • LDL—bad—cholesterol: below 100 • HDL—good—cholesterol: above 40 in men and

above 50 in women • triglycerides—another type of fat in the blood: below 150

4

l

Make physical activity a part of your daily routine. Aim for at least 30 minutes of exercise most days of the week. Check with your doctor to learn what activities are best for you. Take a half-hour walk every day. Or walk for 10 minutes after each meal. Use the stairs instead of the elevator. Park at the far end of the lot.

Choose an activity you like and stay active.

5

l

Make sure the foods you eat are “heart-healthy.” Include foods high in fiber, such as oat bran, oatmeal, wholegrain breads and cereals, fruits, and vegetables. Cut back on foods high in saturated fat or cholesterol, such as meats, butter, dairy products with fat, eggs, shortening, lard, and foods with palm oil or coconut oil. Limit foods with trans fat, such as snack foods and commercial baked goods.

l

Lose weight if you need to. If you are overweight, try to exercise most days of the week. See a registered dietitian for help in planning meals and lowering the fat and calorie content of your diet to reach and maintain a healthy weight.

l

If you smoke, quit. Your doctor can tell you about ways to help you quit smoking.

l

Ask your doctor whether you should take an aspirin every day. Studies have shown that taking a low dose of aspirin every day can help reduce your risk of heart disease and stroke.

l Take

6

your medicines as directed.

How do my blood vessels get clogged? Several things, including having diabetes, can make your blood cholesterol level too high. Cholesterol is a substance that is made by the body and used for many important functions. Cholesterol is also found in some food derived from animals. When cholesterol is too high, the insides of large blood vessels become narrowed or clogged. This problem is called atherosclerosis. Narrowed and clogged blood vessels make it harder for enough blood to get to all parts of your body. This condition can cause problems. Cross section of a healthy blood vessel

Cross section of a narrowed blood vessel

7

What can happen when blood vessels are clogged? When blood vessels become narrowed and clogged, you can have serious health problems:

8

l

Chest pain, also called angina. When you have angina, you feel pain in your chest, arms, shoulders, or back. You may feel the pain more when your heart beats faster, such as when you exercise. The pain may go away when you rest. You also may sweat a lot and feel very weak. If you do not get treatment, chest pain may happen more often. If diabetes has damaged your heart nerves, you may not feel the chest pain. If you have chest pain with activity, contact your doctor.

l

Heart attack. A heart attack happens when a blood vessel in or near your heart becomes blocked. Then your heart muscle can’t get enough blood. When an area of your heart muscle stops working, your heart becomes weaker. During a heart attack, you may have chest pain along with nausea, indigestion, extreme weakness, and sweating. Or you may have no symptoms at all. If you have chest pain that persists, call 911. Delay in getting treatment may make a heart attack worse.

l

Stroke. A stroke can happen when the blood supply to your brain is blocked. Then your brain can be damaged. See page 12 for more information about strokes.

What are the warning signs of a heart attack? You may have one or more of the following warning signs: l

chest pain or discomfort

l

pain or discomfort in your arms, back, jaw, or neck

l

indigestion or stomach pain

l

shortness of breath

l

sweating

l

nausea

l

light-headedness

Or, you may have no warning signs at all. Warning signs may come and go. If you have any of these warning signs, call 911 right away. Getting prompt treatment can reduce damage to the heart.

9

How do narrowed blood vessels cause high blood pressure? Narrowed blood vessels leave a smaller opening for blood to flow through. Having narrowed blood vessels is like turning on a garden hose and holding your thumb over the opening. The smaller opening makes the water shoot out with more pressure. In the same way, narrowed blood vessels lead to high blood pressure. Other factors, such as kidney problems and being overweight, also can lead to high blood pressure. Many people with diabetes also have high blood pressure. If you have heart, eye, or kidney problems from diabetes, high blood pressure can make them worse.

High pressure

Low pressure

A smaller opening in a garden hose makes the water pressure higher.

In the same way, clogged blood vessels lead to high blood pressure.

10

You will see your blood pressure written with two numbers separated by a slash. For example, your reading might be 120/70, said as “120 over 70.” For people with diabetes, the target is to keep the first number below 130 and the second number below 80. If you have high blood pressure, ask your doctor how to lower it. Your doctor may ask you to take blood pressure medicine every day. Some types of blood pressure medicine can also help keep your kidneys healthy. You may also be able to control your blood pressure by l

eating more fruits and vegetables

l

eating less salt and high-sodium foods

l

losing weight if you need to

l

being physically active

l

not smoking

l

limiting alcoholic drinks

To lower blood pressure, get to a healthy weight.

11

What are the warning signs of a stroke? A stroke happens when part of your brain is not getting enough blood and stops working. Depending on the part of the brain that is damaged, a stroke can cause l

sudden weakness or numbness of your face, arm, or leg on one side of your body

l

sudden confusion, trouble talking, or trouble

understanding

l

sudden dizziness, loss of balance, or trouble walking

l

sudden trouble seeing in one or both eyes or sudden double vision

l

sudden severe headache

Sometimes, one or more of these warning signs may happen and then disappear. You might be having a “ministroke,” also called a TIA or a transient ischemic attack. If you have any of these warning signs, call 911 right away. Getting care for a TIA may reduce or prevent a stroke. Getting prompt treatment for a stroke can reduce the damage to the brain and improve chances for recovery.

12

How can clogged blood vessels hurt my legs and feet? Peripheral arterial disease, also called PAD, can happen when the openings in your blood vessels become narrow and your legs and feet don’t get enough blood. You may feel pain in your legs when you walk or exercise. Some people also have numbness or tingling in their feet or legs or have sores that heal slowly.

13

What can I do to prevent or control PAD? l

Don’t smoke.

l

Keep your blood glucose and blood pressure under

control.

l

Keep your blood fat levels close to normal.

l

Be physically active.

l

Ask your doctor if you should take aspirin every day.

You also may need surgery to treat PAD.

Pronunciation Guide

angina (an-JY-nuh)

arteries (AR-tur-eez)

atherosclerosis (ATH-ur-oh-sklur-OH-siss)

capillaries (KAP-ih-lair-eez)

circulatory (SUR-kyoo-luh-TOR-ee)

peripheral arterial disease (puh-RIF-ur-uhl)

(ar-TEE-ree-uhl) (dih-ZEEZ)

transient ischemic attack (TRANZ-see-uhnt)

(iss-KEE-mik) (uh-TAK)

14


Keep your eyes healthy

U.S. Department

of Health and

Human Services





with diabetes? ...................................................................... 2

What can I do to prevent diabetes

eye problems? ...................................................................... 3

How can diabetes hurt my eyes? ......................................... 5

How can diabetes hurt the retinas

of my eyes? .......................................................................... 6

What happens as diabetes retina problems

get worse?............................................................................ 7

What can I do about diabetes

retina problems?................................................................... 9

How do I know if I have retina damage

from diabetes?.................................................................... 10

What other eye problems can happen

to people with diabetes? .................................................... 11





What are diabetes problems? Too much glucose in the blood for a long time can cause diabetes problems. This high blood glucose, also called blood sugar, can damage many parts of the body, such as the heart, blood vessels, eyes, and kidneys. Heart and blood vessel disease can lead to heart attacks and strokes. You can do a lot to prevent or slow down diabetes problems. This booklet is about eye problems caused by diabetes. You will learn the things you can do each day and during each year to stay healthy and prevent diabetes problems.

Retina

Blood vessels on retina

Optic nerve Lens

Vitreous

High blood glucose can cause eye problems.

1


Check your blood glucose every day. Each time you check your blood glucose, write the number in your record book. Check your feet every day for cuts, blisters, sores, swelling, redness, or sore toenails. Brush and floss your teeth every day.

Control your blood pressure and cholesterol.

Don’t smoke.

2

What can I do to prevent diabetes eye problems? You can do a lot to prevent diabetes eye problems. ●

Keep your blood glucose and blood pressure as close to normal as you can.

●

Have an eye care professional examine your eyes once a year. Have this exam even if your vision is OK. The eye care professional will use drops to make the black part of your eyes—pupils—bigger. This process is called dilating* your pupil, which allows the eye care professional to see the back of your eye. Finding eye problems early and getting treatment right away will help prevent more serious problems later on.

Dilated eye.

Undilated eye.


3

4

●

Ask your eye care professional to check for signs of cataracts and glaucoma. See page 11 to learn more about cataracts and glaucoma.

●

If you are planning to get pregnant soon, ask your doctor if you should have an eye exam.

●

If you are pregnant and have diabetes, see an eye care professional during your first 3 months of pregnancy.

●

Don’t smoke.

How can diabetes hurt my eyes? High blood glucose and high blood pressure from diabetes can hurt four parts of your eye: ●

Retina. The retina is the lining at the back of the eye. The retina’s job is to sense light coming into the eye.

●

Vitreous. The vitreous is a jelly-like fluid that fills the back of the eye.

●

Lens. The lens is at the front of the eye. The lens focuses light on the retina.

●

Optic nerve. The optic nerve is the eye’s main nerve to the brain. Retina

Blood vessels on retina

Optic nerve Lens

Vitreous

A side view of the eye.

5

How can diabetes hurt the retinas of my eyes? Retina damage happens slowly. Your retinas have tiny blood vessels that are easy to damage. Having high blood glucose and high blood pressure for a long time can damage these tiny blood vessels. First, these tiny blood vessels swell and weaken. Some blood vessels then become clogged and do not let enough blood through. At first, you might not have any loss of sight from these changes. Have a dilated eye exam once a year even if your sight seems fine. One of your eyes may be damaged more than the other. Or both eyes may have the same amount of damage. Diabetic retinopathy is the medical term for the most common diabetes eye problem.

6

What happens as diabetes retina problems get worse? As diabetes retina problems get worse, new blood vessels grow. These new blood vessels are weak. They break easily and leak blood into the vitreous of your eye. The leaking blood keeps light from reaching the retina. You may see floating spots or almost total darkness. Sometimes the blood will clear out by itself. But you might need surgery to remove it. Over the years, the swollen and weak blood vessels can form scar tissue and pull the retina away from the back of the eye. If the retina becomes detached, you may see floating spots or flashing lights. You may feel as if a curtain has been pulled over part of what you are looking at. A detached retina can cause loss of sight or blindness if you don’t take care of it right away. Call your eye care professional right away if you are having any vision problems or if you have had a sudden change in your vision.

7

Blood vessels on retina Retina

Optic nerve

Lens Vitreous

A retina without any damage. Blood vessels on retina Retina

Optic nerve

Lens Vitreous

A retina with some diabetes damage. Blood vessels on retina Retina

Optic nerve New blood vessels

Lens Vitreous

A retina with a lot of diabetes damage.

8

What can I do about diabetes retina problems? Keep your blood glucose and blood pressure as close to normal as you can. Your eye care professional may suggest laser treatment, which is when a light beam is aimed into the retina of the damaged eye. The beam closes off leaking blood vessels. It may stop blood and fluid from leaking into the vitreous. Laser treatment may slow the loss of sight. If a lot of blood has leaked into your vitreous and your sight is poor, your eye care professional might suggest you have surgery called a vitrectomy. A vitrectomy removes blood and fluid from the vitreous of your eye. Then clean fluid is put back into the eye. The surgery can make your eyesight better.

9

How do I know if I have retina damage from diabetes? You may not have any signs of diabetes retina damage, or you may have one or more signs: ●

blurry or double vision

●

rings, flashing lights, or blank spots

●

dark or floating spots

●

pain or pressure in one or both of your eyes

●

trouble seeing things out of the corners of your eyes

Normal vision

Blurry vision

If you have retina damage from diabetes, you may have blurry or double vision.

10

What other eye problems can happen to people with diabetes? You can get two other eye problems—cataracts and glaucoma. People without diabetes can get these eye problems, too. But people with diabetes get these problems more often and at a younger age. ●

A cataract is a cloud over the lens of your eye, which is usually clear. The lens focuses light onto the retina. A cataract makes everything you look at seem cloudy. You need surgery to remove the cataract. During surgery your lens is taken out and a plastic lens, like a contact lens, is put in. The plastic lens stays in your eye all the time. Cataract surgery helps you see clearly again.

●

Glaucoma starts from pressure building up in the eye. Over time, this pressure damages your eye’s main nerve—the optic nerve. The damage first causes you to lose sight from the sides of your eyes. Treating glaucoma is usually simple. Your eye care professional will give you special drops to use every day to lower the pressure in your eyes. Or your eye care professional may want you to have laser surgery.

11

Pronunciation Guide

cataracts (KAT-uh-rakts) dilating (DY-layt-eeng) glaucoma (glaw-KOH-muh) lens (lenz) optic nerve (AHP-tik) (nerv) retina (RET-ih-nuh) retinopathy (RET-ih-NOP-uh-thee) vitrectomy (vih-TREK-tuh-mee) vitreous (VIT-ree-uhss)

12


Keep your nervous system healthy

U.S. Department

of Health and

Human Services





with diabetes? ...................................................................... 2

What can I do to prevent diabetes from

damaging my nervous system? ........................................... 3

What can I do to take care of my feet?................................. 4

What does my nervous system do? ..................................... 6

How can diabetes hurt my nervous system? ....................... 6

How can diabetes damage to the peripheral

nerves affect me?................................................................. 8

How can diabetes damage to the autonomic

nerves affect me?............................................................... 10

How can diabetes damage to the cranial

nerves affect me?............................................................... 16

How do I know if I have nerve damage? ............................ 17





What are diabetes problems? Too much glucose in the blood for a long time can cause diabetes problems. This high blood glucose, also called blood sugar, can damage many parts of the body, such as the heart, blood vessels, eyes, and kidneys. Heart and blood vessel disease can lead to heart attacks and strokes. You can do a lot to prevent or slow down diabetes problems. This booklet is about nerve problems that can be caused by diabetes. You will learn the things you can do each day and during each year to stay healthy and prevent diabetes problems.

High blood glucose can cause nerve problems.

1


Check your blood glucose every day. Each time you check your blood glucose, write the number in your record book. Check your feet every day for cuts, blisters, sores, swelling, redness, or sore toenails. Brush and floss your teeth every day. Control your blood pressure and cholesterol. Don’t smoke.

2

What can I do to prevent diabetes from damaging my nervous system? Research has shown that people who kept their blood glucose close to normal were able to lower their risk of nerve damage. Here is what you can do to prevent nerve damage: ●

Keep your blood glucose as close to normal as you can.

●

Limit the amount of alcohol you drink.

●

Don’t smoke.

●

Take care of your feet (see pages 4 and 5).

●

Tell your doctor about any problems you have with • your hands, arms, feet, or legs • your stomach, bowels, or bladder

●

Also tell your doctor if you • have problems when you have sex • cannot always tell when your blood glucose is too low • feel dizzy when you go from lying down to sitting or

standing

3

What can I do to take care of my feet? ●

Wash your feet in warm water every day. Make sure the water is not too hot by testing the temperature with your elbow. Do not soak your feet. Dry your feet well, especially between your toes.

●

Look at your feet every day to check for cuts, sores, blisters, redness, calluses, or other problems. Checking every day is even more important if you have nerve damage or poor blood flow. If you cannot bend over or pull your feet up to check them, use a mirror. If you cannot see well, ask someone else to check your feet.

●

If your skin is dry, rub lotion on your feet after you wash and dry them. Do not put lotion between your toes.

Look at your feet every day to check for problems.

4

●

File corns and calluses gently with an emery board or pumice stone. Do this after your bath or shower.

●

Cut your toenails once a week or when needed. Cut toenails when they are soft from washing. Cut them to the shape of the toe and not too short. File the edges with an emery board. If you cannot cut your own toenails, ask someone who can or go to a foot doctor.

●

Always wear shoes or slippers to protect your feet from injuries.

●

Always wear socks or stockings to avoid blisters. Do not wear socks or knee-high stockings that are too tight below your knee.

●

Wear shoes that fit well. Shop for shoes at the end of the day when your feet are bigger. Break in shoes slowly. Wear them 1 to 2 hours each day for the first 1 to 2 weeks.

●

Make sure your doctor checks your feet at each checkup.

Always wear slippers or shoes to protect your feet.

5

What does my nervous system do? Nerves carry messages back and forth between the brain and other parts of the body. All of your nerves together make up the nervous system. Some nerves tell the brain what is happening in the body. For example, when you step on a tack, the nerve in your foot tells the brain about the pain. Other nerves tell the body what to do. For example, nerves from the brain tell your stomach when it is time to move food into your intestines.

How can diabetes hurt my nervous system? Having high blood glucose for many years can damage the blood vessels that bring oxygen to some nerves. High blood

glucose can also hurt the covering on the nerves. Damaged nerves may stop sending messages. Or they may send messages too slowly or at the wrong times. Diabetic neuropathy* is the medical term for damage to the nervous system from diabetes.


6

Cranial nerves go from your brain to your eyes, mouth, ears, and other parts of your head.

Peripheral nerves go from your spinal cord to your arms, hands, legs, and feet.

Central nerves are in your brain and spinal cord.

Autonomic nerves go from your spinal cord to your lungs, heart, stomach, intestines, bladder, and sex organs.

The nervous system has four main parts—cranial, central, peripheral, and autonomic. Diabetes can damage the peripheral, autonomic, and cranial nerves.

7

How can diabetes damage to the peripheral nerves affect me? ●

Peripheral nerves go to the arms, hands, legs, and feet. Damage to these nerves can make your arms, hands, legs, or feet feel numb. Also, you might not be able to feel pain, heat, or cold when you should. You may feel shooting pains or burning or tingling, like “pins and needles.” These feelings are often worse at night. They can make it hard to sleep. Most of the time these feelings are on both sides of your body, such as in both of your feet. But they can be on just one side. Peripheral nerve damage can change the shape of your feet. Foot muscles get weak and the tendons in the foot get shorter. You can get special shoes that are made to fit softly around your sore feet or feet that have changed shape. These special shoes help protect your feet. Medicare and other health insurance programs may pay for special shoes. Talk with your doctor about how and where to get these shoes. Nerve damage from diabetes can increase your risk for carpal tunnel syndrome, which occurs when a nerve from your forearm to your hand is compressed. Carpal tunnel syndrome can cause numbness, tingling, pain, and weakness in your hand and arm.

8

Peripheral Nerves

Peripheral nerves go from your spinal cord to your arms, hands, legs, and feet.

9

How can diabetes damage to the autonomic nerves affect me? ●

Autonomic nerves help you know your blood glucose is low. Some people take diabetes medicines that can accidentally make their blood glucose too low. Damage to the autonomic nerves can make it hard for them to feel the symptoms of hypoglycemia, also called low blood glucose. This kind of damage is more likely to happen if you have had diabetes for a long time. It can also happen if your blood glucose has been too low very often.

10

Autonomic Nerves

Autonomic nerves go from your spinal cord to your lungs, heart, stomach, intestines, bladder, and sex organs.

11

●

Autonomic nerves go to the stomach, intestines, and other parts of the digestive system. Damage to these nerves can make food pass through the digestive system too slowly or too quickly. Nerve problems can cause nausea—feeling sick to your stomach—vomiting, constipation, or diarrhea. Nerve damage to your stomach is called gastroparesis. When nerves to the stomach are damaged, the muscles of the stomach do not work well and food may stay in the stomach too long. Gastroparesis makes it hard to keep blood glucose under control.

12

●

Autonomic nerves go to the penis. Damage to these nerves can prevent a man’s penis from getting firm when he wants to have sex. This condition is called

erectile dysfunction or impotence. Many men who have had diabetes for several years experience it.

●

Autonomic nerves go to the vagina. Damage to these nerves can prevent a woman’s vagina from getting wet when she wants to have sex. A woman might also have

less feeling around her vagina.

Damage to autonomic nerves from diabetes may cause problems with having sex.

13

●

Autonomic nerves go to the heart. Damage to these nerves might make your heart beat faster or at different speeds.

●

Autonomic nerves go to the bladder. Damage to these nerves can make it hard to know when you should go to the bathroom. The damage can also make it hard to feel when your bladder is empty. Both problems can cause you to hold urine for too long, which can lead to bladder infections. Another problem can be leaking drops of urine accidentally.

Damage to autonomic nerves from diabetes

can cause bladder and stomach problems.

14

●

Autonomic nerves go to the blood vessels that keep your blood pressure steady. Damage to these nerves can make your blood move too slowly to keep your blood pressure steady when you change position. When you go from lying down to standing up or when you exercise a lot, the sudden changes in blood pressure can make you dizzy.

Diabetes can damage autonomic nerves that help keep your blood pressure steady.

15

How can diabetes damage to the cranial nerves affect me? ●

Cranial nerves go to the eye muscles. Damage to these nerves usually occurs in one eye, causing double vision. This problem happens all of a sudden and most often lasts for a short time.

●

Cranial nerves go to the sides of the face. Damage to these nerves usually happens on only one side of the face. This nerve damage causes that side of the face to hang lower or sag. Usually the lips and lower eyelid sag. This problem is called Bell’s palsy. It happens all of a sudden.

Cranial Nerves

Cranial nerves go from your brain to your eyes, mouth, ears, and other parts of your head.

16

How do I know if I have nerve damage? If you have one or more of the problems mentioned in this booklet, you may have some nerve damage from diabetes. Tell your doctor about the problem. Ask your doctor what you can do to make the problem better and to stop it from getting worse.

Ask your doctor what you can do about the problems from diabetes nerve damage.

17

Pronunciation Guide

autonomic (AW-toh-NOM-ik)

central (SEN-truhl)

cranial (KRAY-nee-uhl)

erectile dysfunction (ee-REK-tyl) (diss-FUHNK-shuhn)

gastroparesis (GASS-troh-puh-REE-siss)

hypoglycemia (HY-poh-gly-SEE-mee-uh)

impotence (IM-puh-tenss)

neuropathy (noo-ROP-uh-thee)

peripheral (puh-RIF-ur-uhl)

18


Keep your teeth and gums healthy

U.S. Department

of Health and

Human Services





with diabetes? ...................................................................... 2

How can diabetes hurt my teeth and gums?........................ 3

How do I know if I have damage to my teeth

and gums?............................................................................ 5

How can I keep my teeth and gums healthy? ...................... 6

How can my dentist take care of my teeth and gums? ........ 8





What are diabetes problems? Too much glucose in the blood for a long time can cause diabetes problems. This high blood glucose, also called blood sugar, can damage many parts of the body, such as the heart, blood vessels, eyes, and kidneys. Heart and blood vessel disease can lead to heart attacks and strokes. You can do a lot to prevent or slow down diabetes problems. This booklet is about the tooth and gum problems caused by diabetes. You will learn what you can do each day and during each year to stay healthy and prevent diabetes problems.

Teeth

Gums

Tooth

High blood glucose can cause tooth and gum problems.

Gum

1



2

How can diabetes hurt my teeth and gums? Tooth and gum problems can happen to anyone. A sticky film full of germs, called plaque,* builds up on your teeth. High blood glucose helps germs, also called bacteria, grow. Then you can get red, sore, and swollen gums that bleed when you brush your teeth. People with diabetes can have tooth and gum problems more often if their blood glucose stays high. High blood glucose can make tooth and gum problems worse. You can even lose your teeth. Smoking makes it more likely for you to get a bad case of gum disease, especially if you have diabetes and are age 45 or older.


3

Red, sore, and bleeding gums are the first sign of gum disease. These problems can lead to periodontitis. Periodontitis is an infection in the gums and the bone that holds the teeth in place. If the infection gets worse, your gums may pull away from your teeth, making your teeth look long. Call your dentist if you think you have problems with your teeth or gums.

Check your teeth and gums for signs of problems from diabetes.

4

How do I know if I have damage to my teeth and gums? If you have one or more of these problems, you may have tooth and gum damage from diabetes: ●

red, sore, swollen gums

●

bleeding gums

●

gums pulling away from your teeth so your teeth look long

●

loose or sensitive teeth

●

bad breath

●

a bite that feels different

●

dentures—false teeth—that do not fit well

Gums

Teeth

5

How can I keep my teeth and gums healthy? ●

Keep your blood glucose as close to normal as possible.

●

Use dental floss at least once a day. Flossing helps prevent the buildup of plaque on your teeth. Plaque can harden and grow under your gums and cause problems. Using a sawing motion, gently bring the floss between the teeth, scraping from bottom to top several times.

●

Brush your teeth after each meal and snack. Use a soft toothbrush. Turn the bristles against the gum line and brush gently. Use small, circular motions. Brush the front, back, and top of each tooth.

Brush and floss your teeth every day.

6

●

If you wear false teeth, keep them clean.

●

Call your dentist right away if you have problems with your teeth and gums.

●

Call your dentist if you have red, sore, or bleeding gums; gums that are pulling away from your teeth; a sore tooth that could be infected; or soreness from your dentures.

●

Get your teeth cleaned and your gums checked by your dentist twice a year.

●

If your dentist tells you about a problem, take care of it right away.

●

Be sure your dentist knows that you have diabetes.

●

If you smoke, talk with your doctor about ways to quit smoking.

7

How can my dentist take care of my teeth and gums? Your dentist can help you take care of your teeth and gums by ●

cleaning and checking your teeth twice a year

●

helping you learn the best way to brush and floss your teeth

●

telling you if you have problems with your teeth or gums and what to do about them

●

making sure your false teeth fit well

Get your teeth cleaned and checked twice a year.

8

Plan ahead. You may be taking a diabetes medicine that can cause low blood glucose, also called hypoglycemia. Talk with your doctor and dentist before the visit about the best way to take care of your blood glucose during the dental work. You may need to bring some diabetes medicine and food with you to the dentist’s office. If your mouth is sore after the dental work, you might not be able to eat or chew for several hours or days. For guidance on how to adjust your normal routine while your mouth is healing, ask your doctor ●

what foods and drinks you should have

●

how you should change your diabetes medicines

●

how often you should check your blood glucose

Pronunciation Guide

hypoglycemia (HY-poh-gly-SEE-mee-uh) periodontitis (PAIR-ee-oh-don-TY-tiss) plaque (plak)

9


Keep your feet and skin healthy

U.S. Department

of Health and

Human Services



Contents What are diabetes problems? ............................................. 1


with diabetes? ..................................................................... 2

How can diabetes hurt my feet?.......................................... 3

What can I do to take care of my feet?................................ 5

How can my doctor help me take care of my feet? ............. 7

What are common diabetes foot problems?........................ 8

How can special shoes help my feet? ............................... 11

How can diabetes hurt my skin? ....................................... 12

What can I do to take care of my skin? ............................. 13

Pronunciation Guide.......................................................... 14

For More Information ......................................................... 15

More in the Series ............................................................. 17

Acknowledgments ............................................................. 18

What are diabetes problems? Too much glucose in the blood for a long time can cause diabetes problems. This high blood glucose, also called blood sugar, can damage many parts of the body, such as the heart, blood vessels, eyes, and kidneys. Heart and blood vessel disease can lead to heart attacks and strokes. You can do a lot to prevent or slow down diabetes problems. This booklet is about feet and skin problems caused by diabetes. You will learn the things you can do each day and during each year to stay healthy and prevent diabetes problems.

Bone

Blood vessel

Nerve

Skin

High blood glucose can cause feet and skin problems.

1



2

How can diabetes hurt my feet? High blood glucose from diabetes causes two problems that can hurt your feet: ●

Nerve damage. One problem is damage to nerves in your legs and feet. With damaged nerves, you might not feel pain, heat, or cold in your legs and feet. A sore or cut on your foot may get worse because you do not know it is there. This lack of feeling is caused by nerve damage, also called diabetic neuropathy.* Nerve damage can lead to a sore or an infection.

●

Poor blood flow. The second problem happens when not enough blood flows to your legs and feet. Poor blood flow makes it hard for a sore or infection to heal. This problem is called peripheral vascular disease, also called PVD. Smoking when you have diabetes makes blood flow problems much worse.

These two problems can work together to cause a foot problem.


3

For example, you get a blister from shoes that do not fit. You do not feel the pain from the blister because you have nerve damage in your foot. Next, the blister gets infected. If blood glucose is high, the extra glucose feeds the germs. Germs grow and the infection gets worse. Poor blood flow to your legs and feet can slow down healing. Once in a while a bad infection never heals. The infection might cause gangrene. If a person has gangrene, the skin and tissue around the sore die. The area becomes black and smelly. To keep gangrene from spreading, a doctor may have to do surgery to cut off a toe, foot, or part of a leg. Cutting off a body part is called an amputation.

Make sure you wear shoes that fit well.

4

What can I do to take care of my feet? ●

Wash your feet in warm water every day. Make sure the water is not too hot by testing the temperature with your elbow. Do not soak your feet. Dry your feet well, especially between your toes.

●

Look at your feet every day to check for cuts, sores, blisters, redness, calluses, or other problems. Checking every day is even more important if you have nerve damage or poor blood flow. If you cannot bend over or pull your feet up to check them, use a mirror. If you cannot see well, ask someone else to check your feet.

●

If your skin is dry, rub lotion on your feet after you wash and dry them. Do not put lotion between your toes.

Look at your feet every day to check for problems.

5

●

File corns and calluses gently with an emery board or pumice stone. Do this after your bath or shower.

●

Cut your toenails once a week or when needed. Cut toenails when they are soft from washing. Cut them to the shape of the toe and not too short. File the edges with an emery board.

●

Always wear slippers or shoes to protect your feet from injuries.

●

Always wear socks or stockings to avoid blisters. Do not wear socks or knee-high stockings that are too tight below your knee.

●

Wear shoes that fit well. Shop for shoes at the end of the day when your feet are bigger. Break in shoes slowly. Wear them 1 to 2 hours each day for the first few weeks.

●

Before putting your shoes on, feel the insides to make sure they have no sharp edges or objects that might injure your feet.

Always wear slippers or shoes to protect your feet.

6

How can my doctor help me take care of my feet? ●

Tell your doctor right away about any foot problems.

●

Your doctor should do a complete foot exam every year.

●

Ask your doctor to look at your feet at each diabetes checkup. To make sure your doctor checks your feet, take off your shoes and socks before your doctor comes into the room.

●

Ask your doctor to check how well the nerves in your feet sense feeling.

●

Ask your doctor to check how well blood is flowing to your legs and feet.

●

Ask your doctor to show you the best way to trim your toenails. Ask what lotion or cream to use on your legs and feet.

●

If you cannot cut your toenails or you have a foot problem, ask your doctor to send you to a foot doctor. A doctor who cares for feet is called a podiatrist.

7

What are common diabetes foot problems? Anyone can have corns, blisters, and other foot problems. If you have diabetes and your blood glucose stays high, these foot problems can lead to infections. Corns and calluses are thick layers of skin caused by too much rubbing or pressure on the same spot. Corns and calluses can become infected.

Corn and callus.

Blisters can form if shoes always rub the same spot. Wearing shoes that do not fit or wearing shoes without socks can cause blisters. Blisters can become infected.

Blister.

Ingrown toenails happen when an edge of the nail grows into the skin. The skin can get red and infected. Ingrown toenails can happen if you cut into the corners of your toenails when you trim them. You can also get an ingrown 8

toenail if your shoes are too tight. If toenail edges are sharp, smooth them with an emery board.

Ingrown toenail.

A bunion forms when your big toe slants toward the small toes and the place between the bones near the base of your big toe grows big. This spot can get red, sore, and infected. Bunions can form on one or both feet. Pointed shoes may cause bunions. Bunions often run in the family. Surgery can remove bunions.

Bunion.

Plantar warts are caused by a virus. The warts usually form on the bottoms of the feet.

Plantar warts.

9

Hammertoes form when a foot muscle gets weak. Diabetic nerve damage may cause the weakness. The weakened muscle makes the tendons in the foot shorter and makes the toes curl under the feet. You may get sores on the bottoms of your feet and on the tops of your toes. The feet can change their shape. Hammertoes can cause problems with walking and finding shoes that fit well. Hammertoes can run in the family. Wearing shoes that are too short can also cause hammertoes.

Hammertoe.

Dry and cracked skin can happen because the nerves in your legs and feet do not get the message to keep your skin soft and moist. Dry skin can become cracked. Cracks allow germs to enter and cause infection. If your blood glucose is high, it feeds the germs and makes the infection worse.

Dry and cracked skin.

10

Athlete’s foot is a fungus that causes itchiness, redness, and cracking of the skin. The cracks between the toes allow germs to get under the skin and cause infection. If your blood glucose is high, it feeds the germs and makes the infection worse. The infection can spread to the toenails and make them thick, yellow, and hard to cut.

Athlete’s foot.

Tell your doctor about any foot problem as soon as you see it.

How can special shoes help my feet? Special shoes can be made to fit softly around your sore feet or feet that have changed shape. These special shoes help protect your feet. Medicare and other health insurance programs may pay for special shoes. Talk with your doctor about how and where to get them.

11

How can diabetes hurt my skin? Diabetes can hurt your skin in two ways: ●

If your blood glucose is high, your body loses fluid. With less fluid in your body, your skin can get dry. Dry skin can be itchy, causing you to scratch and make it sore. Also, dry skin can crack. Cracks allow germs to enter and cause infection. If your blood glucose is high, it feeds germs and makes infections worse. You may get dry skin on your legs, feet, elbows, and other places on your body.

●

Nerve damage can decrease the amount you sweat. Sweating helps keep your skin soft and moist. Decreased sweating in your feet and legs can cause dry skin.

Drinking fluids helps keep your skin moist and healthy.

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What can I do to take care of my skin? ●

After you wash with a mild soap, make sure you rinse and dry yourself well. Check places where water can hide, such as under the arms, under the breasts, between the legs, and between the toes.

●

Keep your skin moist by using a lotion or cream after you wash. Ask your doctor to suggest one.

●

Drink lots of fluids, such as water, to keep your skin moist and healthy.

●

Wear all-cotton underwear. Cotton allows air to move around your body better.

●

Check your skin after you wash. Make sure you have no dry, red, or sore spots that might lead to an infection.

●

Tell your doctor about any skin problems.

Keep your skin moist by washing with a mild soap and using lotion or cream after you wash.

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Pronunciation Guide

amputation (AM-pyoo-TAY-shuhn) gangrene (GANG-green) neuropathy (noo-ROP-uh-thee) peripheral (puh-RIF-ur-uhl) podiatrist (poh-DY-uh-trist) vascular (VASS-kyoo-lur)

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F e e t Ca n La s t a Li fet i m e A Health Care Provider’s Guide to Preventing Diabetes Foot Problems


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F

“

eet Can Last A Lifetime” was produced by the National Diabetes Education Program (NDEP). The NDEP is a partnership among the National Institutes of Health, the Centers for Disease Control and Prevention, and over 200 organizations. Partners who contributed to the development of this national effort include: American Association of Diabetes Educators

American Diabetes Association

American Orthopaedic Foot & Ankle Society

American Podiatric Medical Association

Centers for Disease Control and Prevention

Health Care Financing Administration

Health Resources and Services Administration

Indian Health Service

Juvenile Diabetes Foundation International

New Mexico Medical Review Association

National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health

Pedorthic Footwear Association

Veterans Health Administration

A joint program of the National Institutes of Health and the Centers for Disease Control and Prevention


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F e e t Ca n La s t a Li fet i m e A Health Care Provider’s Guide to Preventing Diabetes Foot Problems


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Acknowledgments

M

any people have contributed to the development of this kit. Almost 20,000 copies of the kit have been ordered since its first printing in 1998. Before reprinting this second edition, the original materials were reviewed, revised and updated. Representatives from the “Feet Can Last a Lifetime” partner organizations offered substantive comments on the content and presentation of the material for this second edition. They are listed below.

Christine Tobin, R.N., M.B.A., C.D.E.

American Association of Diabetes Educators

David Armstrong, D.P.M.

Council on Foot Care, American Diabetes Association

Robert Frykberg, D.P.M.

Council on Foot Care, American Diabetes Association

Carol Kennedy, R.N., M.A. Marian Parrott, M.D., M.P.H. Robert Anderson, M.D. Pam Colman, D.P.M. Sharley Chen, Director

American Diabetes Association Clinical Affairs, American Diabetes Association American Orthopaedic Foot & Ankle Society American Podiatric Medical Association Lower Extremity Amputation Prevention Program, Bureau of Primary Health Care, HRSA

Melinda Salmon, Public Health Advisor

Centers for Disease Control and Prevention, Division of Diabetes Translation

Dawn Satterfield, C.D.E.

Centers for Disease Control and Prevention, Division of Diabetes Translation

Ann Corken, R.Ph, M.P.H.

Food and Drug Administration

Connie Forster


Sharon Hippler


Fred Pintz, M.D.


Leslie Shainline, R.N.C., M.S.


Stephen Rith-Najarian, M.D.

Bemidji Area Indian Health Service, PHS Indian Hospital, Cass Lake, Minnesota

Lorraine Valdez, R.N., M.P.A., C.D.E. Shira Kandel

Indian Health Service Diabetes Program Juvenile Diabetes Foundation International

Joanne Gallivan, M.S., R.D.

National Diabetes Education Program, NIDDK, National Institutes of Health

Mimi Lising, M.P.H.

National Diabetes Education Program, NIDDK, National Institutes of Health

Nancy Hultquist Jeffrey Robbins, D.P.M.

Pedorthic Footwear Association Veterans Health Administration, Louis Stokes Cleveland DVAMC

Elizabeth Warren-Boulton, R.N., M.S.N., C.D.E.

National Diabetes Education Program, Contract Staff

Rachel Greenberg, M.A.

National Diabetes Education Program, Contract Staff


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Contents of the Kit Introduction.......................................................................................................................... 2 T OOLS FOR D IA BETES FOOT E XAMS Tools for Diabetes Foot Exams............................................................................... 4 Flow Chart for Diabetes Foot Exams..................................................................... 5 Diabetes Foot Exam Procedures............................................................................. 6 Quality of Care Measures........................................................................................7 Foot Exam Instructions............................................................................................ 8 Visual Foot Inspection................................................................................. 8 Annual Comprehensive Diabetes Foot Exam............................................ 9 Annual Comprehensive Diabetes Foot Exam Form.............................................15 M E D I C A R E I N F O R M AT I O N Medicare Coverage of Therapeutic Footwear for People with Diabetes..........18 Statement of Certifying Physician for Therapeutic Footwear............................19 Prescription Form for Therapeutic Footwear........................................................19 R E F E R E N C E A N D R E S O U R C E M AT E R I A L S Prevention and Early Intervention for Diabetes Foot Problems: A Research Review................................................................................................. 22 Resource List...........................................................................................................35 PAT I E N T E D U C AT I O N M AT E R I A L S "Take Care of Your Feet For A Lifetime"—Foot Care Tips for People with Diabetes...................................................................................... 43 "To Do" List—for People with Diabetes.............................................................. 45 ADDI T IO NA L T OOLS High Risk Feet Stickers for Medical Record Flyers for Exam Room—in English and Spanish Quick Reference Pocket Card with Disposable 5.07 (10gram) Monofilament Attached (See insert at page 15)


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Introduction

N

ational Hospital Discharge Survey Data indicate that 86,000 people with diabetes in the United States underwent one or more lower-extremity amputations in 1996. Diabetes is the leading cause of amputation of the lower limbs. Yet it is clear that as many as half of these amputations might be prevented through simple but effective foot care practices. The 1993 landmark study, the Diabetes Control and Complications Trial funded by the National Institute of Diabetes and Digestive and Kidney Diseases, conclusively showed that keeping blood glucose, as measured by hemoglobin A1c, as close to normal as possible significantly slows the onset and progression of diabetic ner ve and vascular complications, which can lead to lower extremity amputations. People who have diabetes are vulnerable to nerve and vascular damage that can result in loss of protective sensation in the feet, poor circulation, and poor healing of foot ulcers. All of these conditions contribute to the high amputation rate in people with diabetes. The absence of nerve and vascular symptoms, however, does not mean that a patient’s feet are not at risk. Risk of ulceration cannot be assessed without careful examination of the patient’s bare feet. Early identification of foot problems and early intervention to prevent problems from worsening can avert many amputations. Good foot care, therefore, is an essential part of diabetes management – for patients as well as for health care providers. This kit is designed for primary care and other health care providers who counsel people with diabetes about preventive health care practices, particularly foot care. “Feet Can Last a Lifetime” is designed to help you implement four basic steps for preventive foot care in your practice: Early identification of the high risk diabetic foot.

The kit includes all of the tools you need to identify and diagnose foot problems and to educate your patients: • A quick-reference pocket card on preventing diabetes foot problems. • A disposable monofilament for sensory testing (attached to pocket card). • Instructions for a visual foot inspection. • Instructions and a reproducible form for an annual comprehensive foot exam. • Prescription forms to facilitate Medicare coverage of therapeutic footwear. • Additional tools to facilitate visual and comprehensive foot exams. • A review of current research. • A list of additional resources. • Patient education materials.

Early diagnosis of foot problems.

All of the materials in the kit may be

Early intervention to prevent further

reproduced without permission and shared

deterioration that may lead to amputation.

with colleagues and patients. Feel free to duplicate the copier-ready masters for

Patient education for proper care of the

your practice. To obtain additional copies of

feet and footwear.

this kit, “Take Care of Your Feet for a Lifetime” companion booklets, and other diabetes information for your patients, call 1-800-438-5383 or visit the NDEP website at

http://ndep.nih.gov on the Internet.

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To o l s f o r Diabetes Foot Exams


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To o l s f o r D i a b e t e s F o o t E x a m s

T

he following section provides tools to help you and your staff incorporate diabetes foot exams into clinical practice and improve patient outcomes. Research indicates that when tools like these are used by providers, more examinations of lower extremities are performed, patients at risk for amputation are identified, and more patients are referred for podiatric care.1 Using these tools also will help providers meet the Healthy People 2010 Diabetes Objectives that include increasing the proportion of persons with diabetes who have at least an annual foot examination and reducing the frequency of foot ulcers and lower extremity amputations in persons with diabetes.

Current clinical recommendations call for a comprehensive foot examination at least once a year for all people with diabetes to identify high risk foot conditions. People with one or more high risk foot conditions should be evaluated more frequently for the development of additional risk factors. People with neuropathy should have a visual inspection of their feet at every contact with a health care provider.2 In communities where the prevalence and incidence of diabetes foot problems are high, providers may determine that inspecting feet at every visit – for both low and high risk patients – is warranted. The following tools will help you incorporate diabetes foot exams into your practice.

instructions for completing a visual inspection of the feet and an annual comprehensive foot exam.

Flow Chart for Diabetes Foot Exams – depicts the

See “Additional Tools” for these items:

desired sequence of exams for patients with low-risk or high-risk feet.

High Risk Feet Stickers – designed for creating

Diabetes Foot Exam Procedures – explains

the recommended procedures for conducting comprehensive foot examinations and visual inspections.

Quality of Care Measures – specifies ways in which

documented foot care practices can be audited to indicate short, intermediate, and long-term outcomes. These outcomes can be used by providers to improve diabetes foot care performance. Foot Exam Instructions – provides step-by-step

Annual Comprehensive Diabetes Foot Exam Form – documents inspection of skin, hair, and nails,

examination of musculoskeletal structures, pedal pulses, and protective sensation, assessment of risk for foot problems, assessment of footwear, and completing a management plan.

brightly colored “high risk” feet stickers on Avery labels to place on the medical record. ExaminationRoomFlyers (English and Spanish) –

encourage patients to remove shoes and socks in preparation for a foot exam.

Litzelman DK, Slemenda CW, Langefeld, CD, et al. Reduction of lower extremity clinical abnormalities in patients with noninsulin-dependent diabetes mellitus. Annals of Internal Medicine 119(1):36-41, 1993. 1

2

4

American Diabetes Association: Clinical Practice Recommendations 2000. Diabetes Care 2000:23(Suppl.1);S55-56.


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Flow Chart for Diabetes Foot Exams*

Start Type 1 and Type 2: when diagnosed

Annual Comprehensive Foot Exam and Risk Categorization Include education for self-care of feet and reassess metabolic control.

Visually inspect feet as warranted

Low Risk Feet

Management plan to support self-care of the feet and identification of foot problems

High Risk Feet

Visually inspect feet at every visit

Management plan to restore and/or maintain integrity of the feet

*Adapted from Population-Based Guidelines for Diabetes Mellitus. Health Promotion and Chronic Disease Prevention Program, Oregon Health Division and Oregon Department of Human Resources, 1997.

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Diabetes Foot Exam Procedures

C a t e g o ry of Patient

Recommended Pro c e d u re

F re q u e n c y

Persons with:

Comprehensive foot exam to identify high

Annually or when a new abnormality is noted

• Type 1 diabetes

risk foot conditions. A physician or other

• Type 2 diabetes

trained health care provider should: • Assess skin, hair and nails, musculoskeletal structure, vascular status, and protective sensation. • Inspect footwear for blood or other discharge, abnormal wear patterns, foreign objects, proper fit, appropriate material, and foot protection. • Educate about self-care of the feet. • Educate about the importance of blood glucose monitoring including the use of the Hemoglobin A1c test. • Reassess metabolic control. Management plan. • The subsequent foot care management plan depends on risk category, foot status, and metabolic control. • High risk patients should be referred to a health care provider with training in foot care.

Persons at: • High risk

Visual foot inspection to identify foot

At every visit

problems. A physician or other trained staff should perform the foot inspection. • Low risk (Refer to chart on page 13 for definitions of risk)

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As warranted


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Quality of Care Measures

Clinical Documentation

M e a s u re s

The following should be document-

Short-term Impact: A successful program will show an

ed in the medical record:

increase in the percentage of the population with diabetes

• Results of the annual comprehensive foot examination including risk assessment. • Results of the visual foot inspection. • Occurrence of patient education.

for whom the following is documented: • A comprehensive foot exam and risk assessment in the past year.* • A visual foot inspection at each routine visit in the past year. • Foot care education in the past year. A survey could be conducted to ask patients to report when they last had a sensory test, foot inspection, and self-care education in the past year. Intermediate-term Impact: A successful program will show a decrease in the incidence of hospital admissions or emergency room visits for lower extremity infections, osteomyelitis, and ulcerations. Long-term Outcomes: A successful program will show a decrease in the incidence of distal and proximal lower extremity amputations.

* This is the only action needed for providers to be in accord with the foot care component of a current set of national quality improvement measures. The Diabetes Quality Improvement Project (DQIP) is a collaborative effort to improve diabetes care and the quality of life for people with diabetes. DQIP uses a set of eight performance measures for diabetes, one of which specifies that “an annual foot exam for adults with diabetes” be documented. Numerous public agencies (the Department of Defense, the Health Care Financing Administration, the Indian Health Service, and the Veterans Health Administration) and private groups (the American Diabetes Association Provider Recognition Program and the National Committee for Quality Assurance) are using some or all of the DQIP measures.

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Foot Exam Instructions Visual Foot Inspection Objectives • Quickly identify an obvious foot problem. • Document foot inspection findings. • Determine the need for a comprehensive foot exam. • Schedule follow-up care and referrals.

Instructions A physician, nurse, or other trained staff may complete this inspection. 1. Inspect the foot between the toes and from toe to heel. Examine the skin for injury, calluses, blisters, fissure, ulcers, or any unusual condition. 2. Look for thin, fragile, shiny, and hairless skin—all signs of decreased vascular supply. 3. Feel the feet for excessive warmth and dryness. 4. Remove any nail polish. Inspect nails for thickening, ingrown corners, length, and fungal infection. 5. Inspect socks or hose for blood or other discharge. 6. Examine footwear for torn linings, foreign objects, breathable materials, abnormal wear patterns, and proper fit. 7. If any new foot abnormality is found, the patient should be scheduled immediately for a comprehensive foot examination. 8. Document findings in the medical record.

Frequency of Inspection Current clinical recommendations 1 call for visual inspection of the feet: • At every visit for people who have neuropathy. • At least twice a year for people with one or more high risk* foot conditions to screen for the development of additional risk factors. • At least annually, or more often if warranted, for low risk feet.* In populations where the prevalence and incidence of diabetes foot problems are high, providers may determine that inspection of the feet at every visit — for both low and high risk patients — is warranted. To facilitate foot inspection and examination, consider adopting a policy such as “For all patients with diabetes, remove shoes and socks in preparation for examination.” *Refer to chart on page 13 for definitions of risk.

1

8

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Annual Comprehensive Diabetes Foot Exam Objectives Completing the comprehensive annual foot exam will enable you to: • Collect the necessary data to assess feet for risk of complications.

• Determine the need for referral to foot care specialists.

• Determine the patient’s risk status.

• Schedule self-management education.

• Document foot exam findings.

• Develop an appropriate management plan.

• Determine the need for therapeutic foot wear.

• Schedule follow-up care and referrals.

Instructions Use copies of the annual comprehensive foot exam form to document findings, or incorporate the assessment questions and foot exam into an already existing overall diabetes care plan. A physician or other trained health care provider should conduct the foot exam. Prepare the patient for examination by removing shoes and socks/hose.

I. Presence of Diabetes Complications Complete the questions as directed. Question 1: Does the patient have any history of the macro- and micro-vascular complications of diabetes or a previous amputation? Patients who have been diagnosed with peripheral neuropathy, nephropathy, retinopathy, peripheral vascular disease or cardiovascular disease are likely to have had diabetes for several years and to be at risk for diabetes foot problems. A positive history of a previous amputation places the patient permanently in the high risk category. Specify the type and date of amputation(s). Question 2: Does the patient have a foot ulcer now or a history of foot ulcer? A positive history of a foot ulcer places the patient permanently in the high risk category. This person always has an increased risk for developing another foot ulcer, progressive deformity of the foot, and ultimately, lower limb amputation.

II. Current History Complete the questions as directed. Question 1: Is there pain in the calf muscles when walking—i.e., pain occurring in the calf or thigh when walking less than one block that is relieved by rest? This question is to determine whether the patient experiences intermittent claudication when walking. This pain is an indication of peripheral vascular disease or impaired circulation. Question 2: Has the patient noticed any changes in the feet since the last foot exam? Patients may notice changes in skin and nail condition or sensory perception if they are performing self-tests with a monofilament.

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Questions 3 and 4: Has the patient experienced any shoe problems? Has the patient noticed any blood or other discharge in socks or hose? New shoes can cause unexpected pressure and irritate underlying skin. Blood or other discharge from a foot wound can be the first indication of a severe foot problem. Question 5: What is the patient's smoking history? Cigarette smoking is a major risk factor for microvascular and macrovascular disease and is likely to contribute to diabetes foot disease. Question 6: What is the patient’s most recent hemoglobin A1c test result? Elevated hemoglobin A1c values are independently associated with a twofold risk of amputation.

III. Foot Exam Complete the questions or fill in the items as directed. Item 1. Condition of the skin, hair and toenails. Questions: Is the skin thin, fragile, shiny and hairless? Are the nails thick, too long, ingrown, or infected with fungal disease? • Examine each foot between the toes and from toe to heel. Record any problems by drawing or labeling the condition on the foot diagram. Skin that is thin, fragile, shiny, and hairless is an indication of decreased vascular supply. Loss of sweating function may cause cracking of the skin and fissures that can become infected. • Remove any nail polish. Check toenails to see if they are ingrown, deformed, or fungal. Thick nails may indicate vascular or fungal disease. If severe nail or dry skin problems are present, refer the patient to a podiatrist or a nurse foot care specialist. Measure, draw in, and label the patient’s skin condition. • Measure and draw on the form any corns, calluses, pre-ulcerative lesions (a closed lesion, such as a blister or hematoma), or open ulcers. • Use the appropriate symbol to indicate what type of lesion is present—i.e., callus, ulcer, redness, warmth, maceration, pre-ulcerative lesion, fissure, swelling or dryness. Maceration is present if the tissue is friable, moist, and soft. • Label areas that are significantly dry, red, or warm (warmer than other parts of the foot or the opposite foot).

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Item 2: Musculoskeletal Deformities • Foot deformities may be the result of diabetic motor neuropathy. The function of intrinsic muscles is lost, causing the toe digits to buckle as other muscles become imbalanced. Muscle wasting occurs. The plantar fat pad becomes displaced and the metatarsal heads become more prominent. Limited joint mobility occurs and contributes to the potential for toe and foot injury. If Charcot foot is present, there are severe bone and joint changes and the foot is swollen and warm to the touch.

Hammer Toes

Claw Toes

Bunions (Hallux Valgus)

Plantar View of Charcot Joint

• Indicate any of the foot deformities listed—i.e., toe deformities, bunions, foot drop, prominent metatarsal heads, or Charcot foot. The more serious deformities are illustrated above. Prominent metatarsal heads are evidence of major deformity such as midfoot collapse. Item 3: Pedal Pulses Check the pedal pulses (posterior tibial and dorsalis pedis) in both feet and note whether pulses are present or absent.

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Item 4: Sensory Exam The sensory testing device supplied in this kit is a 5.07 (10-gram) Semmes-Weinstein nylon monofilament mounted on a holder that has been standardized to deliver a 10-gram force when properly applied. Research has shown that a person who can feel the 10-gram filament in the selected sites is at reduced risk for developing ulcers. Because sensory deficits appear first in the most distal portions of the foot and progress proximally in a “stocking” distribution, the toes are the first areas to lose protective sensation. • The sensory exam should be done in a quiet and relaxed setting. The patient must not watch while the examiner applies the filament. • Test the monofilament on the patient’s hand so he/she knows what to anticipate. • The five sites to be tested are indicated on the examination form. • Apply the monofilament perpendicular to the skin’s surface (see diagram A below). • Apply sufficient force to cause the filament to bend or buckle, using a smooth, not a jabbing motion (see diagram B below). • The total duration of the approach, skin contact, and departure of the filament at each site should be approximately 1 to 2 seconds. • Apply the filament along the perimeter and NOT ON an ulcer site, callus, scar or necrotic tissue. Do not allow the filament to slide across the skin or make repetitive contact at the test site. • Press the filament to the skin such that it buckles at one of two times as you say “time one” or “time two.” Have patients identify at which time they were touched. Randomize the sequence of applying the filament throughout the examination. • To order additional disposable or reusable monofilaments, see the Resource List on page 35. A

Apply the monofilament perpendicular to the skin’s surface.

B

Apply sufficient force to cause the filament to bend or buckle .

IV. Risk Categorization Based on the foot exam, determine the patient’s risk category. A definition of “low risk” or “high risk” for recurrent ulceration and ultimately, amputation, is provided in the following chart, along with minimum suggested management guidelines. Individuals who are identified as high risk may require a more comprehensive evaluation. See the Resource List for obtaining information about other foot exam forms and risk categorization schemes developed by the Bureau of Primary Health Care’s Lower Extremity Amputation Prevention (LEAP) Program, Health Care Financing Administration, and the Veterans Administration.

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Once feet are categorized as high risk, it is unlikely that risk status will change unless vascular surgery is performed. At subsequent visits the provider should assess for the development of additional risk factors and focus on maintaining the integrity of the feet and on metabolic control. Patients should be educated about avoidance of injury, use of therapeutic footwear, and preventive self-care.

Risk Category Defined

Management Guidelines

Low Risk Patients

• Perform an annual comprehensive foot exam.

None of the five high risk

• Assess/recommend appropriate footwear.

characteristics below.

• Provide patient education for preventive self-care. • Perform visual foot inspection at provider’s discretion.

High Risk Patients

• Perform an annual comprehensive foot exam.

One or more of the following:

• Perform visual foot inspection at every visit.

Loss of protective sensation Absent pedal pulses Foot deformity History of foot ulcer Prior amputation

• Demonstrate preventive self-care of the feet. • Refer to specialists and an educator as indicated. (Always refer to a specialist if Charcot foot is suspected.) • Assess/prescribe appropriate footwear. • Certify Medicare patients for therapeutic shoe benefits. • Place a “High Risk Feet” sticker on the medical record.

Management Guidelines for Active Ulcer or Foot Infection • Never let patients with an open plantar ulcer walk out in their own shoes. Weight relief must be provided. • Assess/prescribe therapeutic footwear to help modify weight bearing and protect the feet. • Conduct frequent wound assessment and provide care as indicated. • Demonstrate preventive self-care of the feet. • Provide patient education on wound care. • Refer to specialists and a diabetes educator as indicated. • Certify Medicare patients for therapeutic footwear benefits. • Place a “High Risk Feet” sticker on the medical record.

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V. Footwear Assessment Question 1. Does the patient wear appropriate shoes? Question 2. Does the patient need inserts? Question 3. Should corrective footwear be prescribed? Check inside shoes for foreign objects, torn lining, and proper cushioning. Improper or poorly fitting shoes are major contributors to diabetes foot ulcerations. Counsel patients about appropriate footwear. All patients with diabetes need to pay special attention to the fit and style of their shoes and should avoid pointed-toe and open-toe shoes, high heels, thongs and sandals. Assess the material and construction of footwear. Unbreathable and inelastic materials such as plastic should be avoided. Recommend use of materials such as canvas, leather, suede, and other materials that are breathable and/or elastic. Footwear should be adjustable with laces, Velcro, or buckles. Record the results of your footwear assessment. Properly fitted athletic or walking shoes are recommended for daily wear. If off-the-shelf shoes are used, make sure that there is room to accommodate any deformities. High risk patients may require depth-inlay shoes or custom-molded inserts (orthoses), depending on the degree of foot deformity and history of ulceration. (See Medicare Coverage of Therapeutic Footwear on page 18.)

Shoes must protect and support the feet.

Shoes must accommodate foot deformities.

Shoe shape must match foot shape.

VI. Education Question 1: Has the patient had prior foot care and other relevant diabetes education? Question 2: Can the patient demonstrate appropriate foot care? Indicate whether the patient has received prior education by checking yes or no in the blank. Patient education about foot care and other aspects of self-care is an essential component of preventive diabetes care. Observe whether the patient can demonstrate appropriate self-care of the feet. Refer for smoking cessation counseling if necessary. Determine whether the patient understands the need for, and results of, hemoglobin A1c tests.

VII. Management Plan Complete the management plan, indicating actions for patient education, any diagnostic tests including hemoglobin A 1c, footwear recommendations, referrals, and follow-up care. Note: The management of foot problems may be the responsibility of different health care providers. For example, in some communities, certified nurses provide home health services or practice in primary care or foot care clinics to provide specialized diabetes foot care.

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Annual Comprehensive Diabetes Foot Exam Form Name: _______________________________________________________________ Date: ___________________ ID#: __________________

I. Presence of Diabetes Complications 1. Check all that apply. ❏ Peripheral Neuropathy ❏ Nephropathy ❏ Retinopathy ❏ Peripheral Vascular Disease ❏ Cardiovascular Disease ❏ Amputation (Specify date, side, and level) ______________________________________

2. Any change in the foot since the last evaluation? Y ____ N____ 3. Any shoe problems? Y___ N____ 4. Any blood or discharge on socks or hose? Y____ N____ 5. Smoking history? Y___N___ 6. Most recent hemoglobin A1c result ______% ________ date

Current ulcer or history of a foot ulcer? Y____ N____

III. Foot Exam 1. Skin, Hair, and Nail Condition Is the skin thin, fragile, shiny and hairless? Y ___ N___

For Sections II & III, fill in the blanks with “Y ” or “N” or with an “R,” “L,” or “B” for positive findings on the right, left, or both feet. II. Current History 1. Is there pain in the calf muscles when walking that is relieved by rest? Y____ N____

Are the nails thick, too long, ingrown, or infected with fungal disease? Y ___ N___

Measure, draw in, and label the patient’s skin condition, using the key and the foot diagram below. C=Callus U=Ulcer PU=Pre-Ulcer F=Fissure M=Maceration R=Redness S=Swelling W=Warmth D=Dryness 2. Note Musculoskeletal Deformities ❏ Toe deformities ❏ Bunions (Hallus Valgus) ❏ Charcot foot ❏ Foot drop ❏ Prominent Metatarsal Heads 3. Pedal Pulses Fill in the blanks with a “P” or an “A” to indicate present or absent. Posterior tibial Left_____ Right_____ Dorsalis pedis Left_____ Right_____

4. Sensory Foot Exam Label sensory level with a “+” in the five circled areas of the foot if the patient can feel the 5.07 (10-gram) Semmes-Weinstein nylon monofilament and “-” if the patient cannot feel the filament. Notes

Notes

Right Foot IV. Risk Categorization Check appropriate box. ❏ Low Risk Patient All of the following: ❏ Intact protective sensation ❏ Pedal pulses present ❏ No deformity ❏ No prior foot ulcer ❏ No amputation

❏ High Risk Patient One or more of the following: ❏ Loss of protective sensation ❏ Absent pedal pulses ❏ Foot deformity ❏ History of foot ulcer ❏ Prior amputation

V. Footwear Assessment Indicate yes or no. 1. Does the patient wear appropriate shoes? Y___ N ___ 2. Does the patient need inserts? Y ___ N ___ 3. Should corrective footwear be prescribed? Y ___ N ___ VI. Education Indicate yes or no. 1. Has the patient had prior foot care education? Y __N__ 2. Can the patient demonstrate appropriate foot care? Y__N__ 3. Does the patient need smoking cessation counseling? Y__N__ 4. Does the patient need education about HbA1c or other diabetes self-care? Y__N

Left Foot VII. Management Plan Check all that apply. 1. Self-management education: Provide patient education for preventive foot care. Date: Provide or refer for smoking cessation counseling. Date: Provide patient education about HbA1c or other aspect of self-care. Date: ________ 2. Diagnostic studies: ❏ Vascular Laboratory ❏ Hemoglobin A1c (at least twice per year) ❏ Other: _________ 3. Footwear recommendations: ❏ None ❏ Athletic shoes ❏ Accommodative inserts

❏ Custom shoes ❏ Depth shoes

4. Refer to: ❏ Primary Care Provider ❏ Diabetes Educator ❏ Podiatrist ❏ RN Foot Specialist ❏ Pedorthist ❏ Orthotist

❏ Endocrinologist ❏ Vascular Surgeon ❏ Foot Surgeon ❏ Rehab. Specialist ❏ Other: _________________

5. Follow-up Care: Schedule follow-up visit. Date: _________________

Provider Signature 15


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Medicare Information


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Medicare Coverage of Therapeutic Footwear for People With Diabetes

M

edicare provides coverage for depth-inlay shoes, custom-molded shoes, and shoe inserts for people with diabetes who qualify under Medicare Part B. Designed to prevent lower-limb ulcers and amputations in people who have diabetes, this Medicare benefit can prevent suffering and save money.

How Individuals Qualify

The M.D. or D.O. treating the patient for diabetes must certify that the individual: 1. Has diabetes. 2. Has one or more of the following conditions in one or both feet: • history of partial or complete foot amputation • history of previous foot ulceration • history of pre-ulcerative callus • peripheral neuropathy with evidence of callus formation • poor circulation • foot deformity 3. Is being treated under a comprehensive diabetes care plan and needs therapeutic shoes and/or inserts because of diabetes. Type of Footwear Covered

If an individual qualifies, he/she is limited to one of the following footwear categories within each calendar year: 1. One pair of depth shoes and three pairs of inserts 2. One pair of custom-molded shoes (including inserts) and two additional pairs of inserts. Separate inserts may be covered under certain criteria. Shoe modification is covered as a substitute for an insert, and a custom-molded shoe is covered when the individual has a foot deformity that cannot be accommodated by a depth shoe. What the Physician Needs to Do

1. The certifying physician (the M.D. or D.O.) overseeing the diabetes treatment must review and sign a “Statement of Certifying Physician for Therapeutic Shoes” (see form on page 19).

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2. The prescribing physician (the D.P.M., D.O., or M.D.) must complete a footwear prescription (see form on page 19). Once the patient has the signed statement and the prescription, he/she can see a podiatrist, orthotist, prosthetist or pedorthist to have the prescription filled. The supplier will then submit the Medicare claim form (Form HCFA 1500) to the appropriate Durable Medical Equipment Regional Carrier (DMERC), keeping copies of the claim form and the original statement and prescription. Note that in most cases, the certifying physician and the prescribing physician will be two different individuals. Patient Responsibility for Payment

Medicare will pay for 80% of the payment amount allowed. The patient is responsible for a minimum of 20% of the total payment amount and possibly more if the dispenser does not accept Medicare assignment and the dispenser’s usual fee is higher than the payment amount. The maximum payment amounts per pair as of 2000 are:

Total Amount Allowed

Amount Covered by Medicare

Depth shoes

$126.00

$100.80

Custom-molded shoes

$378.00

$302.40

64.00

$51.20

Inserts or modifications

ICD-9 codes

Because this benefit is available only to people with diabetes, an appropriate ICD- 9 code (250.00-250.93) is required when completing the Statement of Certifying Physician.


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Statement of Certifying Physician for Therapeutic Footwear Patient Name:

HIC #:

Address: I certify that all of the following statements are true: 1. This patient has diabetes mellitus. —ICD-9 Code: (ICD-9 diagnosis codes 250.00-250.93) 2. This patient has one or more of the following conditions (check all that apply): ❏ History of partial or complete amputation of ❏ History of previous foot ulceration the foot ❏ Foot deformity ❏

Peripheral neuropathy with evidence of callus formation

❏

History of pre-ulcerative callus

❏

Poor circulation

3. I am treating this patient under a comprehensive plan of care for his/her diabetes. 4. This patient needs special shoes (depth or custom-molded shoes) and/or inserts because of his/her diabetes. Certifying Physician Information Signature:

Date:

Name:

DEA #

Medicare UPIN #

Medicaid Provider #

P re s c r i p t i o n F o r m f o r T h e r a p e u t i c F o o t w e a r (Prescribing physician may be different from certifying physician.) Patient Name:

HIC# :

Address: Diagnosis: Change to be effected: Additional relevant information, such as systemic conditions or allergies to specific materials:

Prescribing Physician Information Signature:

Date:

Name:

DEA #

Medicare UPIN #

Medicaid Provider # 19


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Reference and Resource Materials


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Prev entio n and Ear ly In terve ntio n for Diabetes Foot Problems: A Research Review

R

esearch articles, most published since 1990, were identified and retrieved through computerized searches of the National Library of Medicine database (MEDLINE). This review is not meant to summarize the entire literature on the subject, but rather to present a condensation and consolidation of the major findings concerned with prevention of and early intervention for diabetes foot disease.

The Scope of the Problem National Goals for Diabetes Foot Care

During their lifetime, 15 percent of people with diabetes will experience a foot ulcer and between 14 and 24 percent of those with a foot ulcer will require amputation (1). National Hospital Discharge Survey data for 1996 indicate that 86,000 people with diabetes underwent one or more lower-extremity amputations (2). Diabetes is the leading cause of amputation of the lower limbs. Yet it is clear that at least half of these amputations might be prevented through simple but effective foot care practices. Healthy People 2010, the U.S. Department of Health and Human Services’ report ( 3) that specifies health objectives for the nation, calls for: a) An increase in the proportion of people with diabetes aged 18 years and older who have at least an annual foot examination (baseline 55 percent, target 75 percent). b) A decrease in foot ulcers due to diabetes (baseline and target figures are “developmental”). c) A decrease in lower extremity amputations due to diabetes (baseline 11 per 1,000, target 5 per 1,000 per year). This objective is based on the estimate that at least 50 percent of the amputations that occur each year in people with diabetes can be prevented through screening for high risk patients and the provision of proper foot care.

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Ethnic Groups At Higher Risk for Amputation

Analysis of a statewide California hospital discharge database indicated that in 1991, the ageadjusted incidence of diabetes-related lower extremity amputations per 10,000 people with diabetes was 95.3 in African Americans, 56.0 in non-Hispanic whites, and 44.4 in Hispanics. Amputations were 1.72 and 2.17 times more likely in African Americans compared with non-Hispanic whites and Hispanics, respectively. Hispanics had a higher proportion of amputations (82.7 percent) associated with diabetes as opposed to other causes of amputation, than did African Americans (61.6 percent) or non-Hispanic whites ( 56.8 percent) (4). Age-adjusted amputation rates in south Texas in 1993 were 60.68 per 10,000 for non-Hispanic whites, 94.08 for Mexican Americans, and 146.59 for African Americans (5). The incidence of amputations for Pima Indians in Arizona was 24.1 per 1,000 person-years compared to 6.5 per 1,000 person-years for the overall U.S. population with diabetes (6). Increased awareness and identification of diabetes-related foot disease is especially important in these high-risk ethnic groups. The President’s Initiative to Eliminate Racial and Ethnic Disparities in Health is focused on eliminating serious disparities in health access and outcomes experienced by racial and ethnic minority populations in six areas of health. Diabetes is one of the targeted areas. A near term goal for this initiative is to reduce lower extremity amputation rates among African Americans with diabetes by 40 percent (7).


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Frequency of Foot Examinations

Foot examinations, both by people with diabetes and their health care providers, are critical preventive actions. In the 1989 National Health Interview Survey (NHIS), 52 percent of all people with diabetes stated that they checked their feet at least daily, but 22 percent stated that they never checked their feet. More self-exams were reported by insulin-treated individuals than those who did not use insulin (8). Estimates of the frequency of provider-performed annual foot examinations vary. Data from the Centers for Disease Control’s Behavioral Risk Factor Surveillance System (BRFSS) indicate that 55 percent of adults with diabetes ages 18 years and older reported having at least an annual foot examination by a health care provider in 1998 (mean value from 39 states) (9). BRFSS data from 1995 to 1998 indicate that 86.3 percent of people with diabetes had seen a physician or other health care provider for diabetes care in the previous 12 months; 67.7 percent of adults with diabetes reported having had their feet examined in the previous 12 months (10). In an earlier nationwide survey, primary care physicians reported performing semi-annual foot examinations for 66 percent of patients with type 1 diabetes and for 52 percent of patients with type 2 diabetes (11). Personal and Financial Costs

Diabetes foot disease is a major burden for both the individual and the health care system and may increase as the population ages. The total annual cost for the more than 86,000 amputations is over $1.1 billion dollars. This cost does not include surgeons’ fees, rehabilitation costs, prostheses, time lost from work, and disability payments (12). Regarding quality of life, a study

of patients with diabetes showed that those with foot ulcers scored significantly lower than those without foot ulcers in all eight areas of a measure of physical and social function (13). Foot disease is the most common complication of diabetes leading to hospitalization. In 1995, foot disease accounted for 6 percent of hospital discharges listing diabetes and lower extremity ulcers, and in 1995 the average hospital stay was 13.7 days. The average hospital reimbursement from Medicare for a lower-extremity amputation in 1992 was $10,969, and from private insurers it was $26,940. At the same time, rehabilitation was reimbursed at a rate of $7,000 to $21,000 (14). Prevalence estimates for ulcers in diabetes patient populations vary. Fifteen percent of all patients with diabetes in a population-based study in southern Wisconsin experienced ulcers or sores on the foot or ankle. The prevalence increased with age, especially in patients who were aged 30 or under at diagnosis of diabetes ( 15). In a large staff-model health maintenance organization, the incidence, outcomes and costs of treatment for foot ulcers were studied over two years in a group of patients with diabetes. In this population, the incidence was nearly 2 percent per year and the direct medical care cost for a 40- to 65-year-old male with a new foot ulcer was $27,987 over the two years after diagnosis ( 16). After an amputation, the chance of another amputation of the same extremity or of the opposite extremity within 5 years is as high as 50 percent. The 5-year mortality rate after lower extremity amputation ranges from 39 to 68 percent (8).

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Causative Factors Risk Factors for Lower Extremity Amputation (LEA)

Peripheral neuropathy, peripheral vascular disease, and prior foot ulcer are independently associated with risk of LEA (17,18). A 1996 study of Pima Indians with diabetes confirmed this finding and included the presence of foot deformity as another independent risk factor (19). The presence of plantar callus also is highly predictive of subsequent ulceration in patients with diabetic neuropathy and is more predictive of ulceration than increased plantar foot pressures (20). Hyperglycemia is an additional risk factor. In a 1996 study, Finnish researchers determined risk factors for amputation in 1,044 middle-aged patients with type 2 diabetes who were followed for up to 7 years. Because the incidence of amputation was similar in both sexes (5.6 percent men and 5.3 percent women), all statistical analyses were carried out combining men and women. This study found that high fasting plasma glucose levels at baseline, high HbA1c, and the duration of diabetes were independently associated with a two-fold risk of amputation. Signs of peripheral neuropathy, bilateral absence of vibration sense, and bilateral absence of Achilles tendon reflexes were two times more frequent in patients with amputation than in patients without amputation (21). The Diabetes Control and Complications Trial (DCCT), a ten-year clinical study that concluded in 1993, demonstrated that keeping blood glucose levels as close to normal as possible slows significantly the onset and progression of eye, kidney, and nerve diseases caused by diabetes. The study showed that any sustained lowering of the blood glucose helps, even if the person has a history of poor control (22). A follow-up study indicated that the reduction in risk for microvascular changes persisted for at least four years after the

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DCCT ended, despite increasing blood glucose levels (23). The United Kingdom Prospective Diabetes Study reported that type 2 patients randomized to intensive blood glucose control with sulfonylureas or insulin had a significantly lower prevalence of neuropathy at 9 and 15 years than patients randomized to conventional therapy (24). Evidence for a relationship between use of tobacco and/or alcohol and ulcers or amputation is variable (14). Cigarette smoking, however, is a major risk factor for microvascular and macrovascular disease and is likely to contribute to diabetes foot disease (25). People with foot and ankle neuropathy are more likely to have gait abnormalities, postural instability, and sway, and are 15 times more likely to suffer some type of injury during ambulation than those without neuropathy (26,27,28,29,30). The most important risk factors for diabetes foot problems, however, are peripheral neuropathy and peripheral vascular disease, as noted by Shaw and Boulton. There also is a complex interplay between these abnormalities and a considerable number of other contributory factors such as limited mobility, altered foot pressures, glycemic control, ethnic background, and more. The authors stress, however, that identification of patients at high risk for ulceration is simple and preventive care should focus on patient education (31). Causal Pathways for Lower Extremity Amputations (LEA)

A study of the causal pathways for LEA in patients with diabetes identified the most common sequences of events. Seventy-three percent of the amputations in study subjects were a result of the causal sequence


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of minor trauma, cutaneous ulceration, and woundhealing failure. Estimates of the cumulative proportions of various causes indicated that 86 percent of amputations were attributed to initial minor trauma causing tissue injury (32). Precipitating or Pivotal Events

In the causal pathway study noted above, foot trauma was caused by shoe-related repetitive pressure leading to cutaneous ulceration in 36 percent of all cases, accidental cuts or wounds in 8 percent, thermal trauma (frostbite or burns) in 8 percent, and decubitus ulceration in 8 percent (32). Similarly, another study found that in one-third of diabetic amputees with peripheral arterial disease, the initial lesion was self-induced. The most common cause of self-injury was ill-fitting new shoes; the second most common cause was cutting toenails improperly (33). Other investigators identified external precipitating factors in 84 percent of study patients with foot ulcers. The most common factors were ill fitting shoes/socks, acute mechanical trauma, stress ulcer, and paronychia (34).

Identifying Patients at Risk Tools to Identify High Risk Feet

The importance of identifying individuals at risk for foot ulceration and LEA and the need for preventive foot care practices for both the provider and the patient are significant ( 35). Identifying patients’ risk category for foot ulceration helps to determine the frequency needed for provider foot examinations, the level of emphasis on self-care of the feet, and patient responsibilities (36). Several simple tools have been developed to identify people at high risk for ulceration. These tools include a patient report and a clinical examination to quantify

loss of peripheral sensation (using a monofilament or vibration perception threshold testing), and to detect the presence of foot deformities, peripheral vascular disease, and prior foot ulcers (37,38). The largest study to use the Semmes-Weinstein 5.07 (10-gram) monofilament is the Strong Heart Study of 3,638 American Indians living in Arizona, North and South Dakota, and Oklahoma ( 39). Use of these measures has been shown to predict subsequent ulceration and amputation (37). In one study, during annual patient examinations, researchers recorded the presence of a foot deformity, history of lower extremity ulceration or amputation, and the ability to perceive the Semmes-Weinstein 5.07 (10-gram) monofilament at eight sites on the plantar surface of each foot. Based on the findings, subjects were classified as sensate or insensate and placed in one of four risk categories. Insensitivity to the monofilament occurred in 68 (19 percent) of the patients screened. Over a 32-month follow-up period, 41 of these patients developed ulcerations and 14 amputations occurred (37). The recommended number of monofilament applications needed to assess the risk for ulceration varies. One study shows that an 8-site 5.07 (10-gram) monofilament examination ( 4 sites per foot) can be completed in 40 seconds and has 90 to 95 percent of the sensitivity of a 16-point examination. The foursite-per-foot examination specifies two of the touch sites – the first and third metatarsal heads. For the other two sites, the authors suggest any toes or other metatarsal heads. All sites should be free of calluses (40). Another study suggests that reasonable sensitivity and specificity ( 80 and 86 percent, respectively) to detect patients with an insensate foot can be

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achieved when the plantar aspect of either the first or fifth metatarsal head cannot feel a 5.07 (10-gram) monofilament (41). A self-administered sensory test with a 5.07 (10gram) monofilament may be useful to identify high risk feet. In a study that compared patient and provider sensory test findings for 145 subjects, 68 percent of patients self-tested without the assistance of another person, and patient/provider disagreement with findings occurred in 12 percent (18) of cases. Sensory loss, previously undetected by providers, was found in 16 percent (23) of patients. Self-administered tests provided patients an opportunity to become more active team members and resulted in early detection of insensate feet. The authors caution that self-testing should not replace regular foot evaluation by a health care provider (42).

Provider and Patient Education Education Reduces Lower Extremity Abnormalities

In a randomized, controlled study, researchers provided intervention patients with foot care education, behavioral contracts, and telephone and postcard prompts. The researchers placed foot care prompts on the medical record, and provided practice guidelines and flow sheets to clinicians assigned to those patients. Results showed that primary care physicians in the intervention group conducted more examinations of lower extremities, identified those at risk for amputation, and referred more patients for specialized foot care. Patients in the intervention group received more patient education, made more changes in appropriate self-care behaviors, and had fewer short-term foot problems than patients in the control group (43). Ollendorf et al. developed a model to estimate the economic benefits of amputation prevention strategies targeted at individuals with a history of foot ulcer over a period of three years. Estimates were based on an

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average lifetime cost of $48,152 for lower extremity amputation. For an estimated 679 individuals during the first year, the total potential economic benefits of strategies to reduce amputation risk ranged from 2–3 million dollars over three years ($ 2,900 to $4,442 per person with a history of foot ulcer). Benefits were highest for patient/provider educational interventions, followed by therapeutic shoe coverage, and multidisciplinary care ( 44). Multidisciplinary team care can be a cost-effective method for foot screening, preventive care, and treatment of active ulcers (43,45,46). One study of team care for high risk patients with a history of foot ulcers found a 2-year foot ulcer incidence rate of 30 percent in the intervention group compared with 58 percent in the standard treatment group. The team involved physicians, nurses, podiatrists and shoe specialists (47). A study of 639 patients in a rural primary care clinic showed significant reductions in lower extremity amputations. This prospective study of American Indians with diabetes, compared three consecutive 2- to 3-year time periods: • a “standard care” period during which patients received foot care at the discretion of the primary care provider; •

a “public health” period during which patients were screened for foot problems and high risk individuals received foot care education and protective footwear;

•

and a “stepped care” period during which comprehensive guidelines for foot management were adapted to their practice and implemented by a 6-person primary care team.

The average annual amputation incidence per 1,000 diabetic person-years was 29 in the first period, 21 in the second, and 15 in the third, an overall 48 percent reduction (48).


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A study was conducted at six Veterans Affairs Medical Centers to determine how accurately and reproducibly primary care providers could carry out a screening examination (including use of a monofilament) for foot ulcer risk among patients with diabetes. Forty primary care providers (including non-physicians) examined 147 patients; 2 primary care providers examined each patient; and a foot care specialist also examined 88 patients. The results showed that the foot examination was reproducible among primary care providers and accurate when compared with a foot care specialist, except in the assessment of foot deformity and pedal pulses (49). When training providers to conduct foot exams, particular attention to these skills may be important. Components of Effective Self-Management

Findings from several studies indicate effective components of patient education that contribute to successful patient outcomes. These include giving detailed foot care recommendations, requesting patient commitment to self-care, demonstrating and practicing foot care procedures, and communicating a persistent message that foot complications can be avoided by self-care. In comparing the effectiveness of intensive versus conventional education, researchers found that patients in the intensive group showed greater improvement in foot care knowledge, better compliance with the recommended foot care routine, improved satisfaction with foot care, and greater reduction in the number of foot problems requiring treatment (50,51). Foot care recommendations and demonstrations should include: washing, drying, and inspecting the feet; applying an emollient; cutting toenails; treating minor foot problems; selecting suitable footwear;

dealing with temperature extremes; and contacting the physician if problems do not resolve quickly. Lubricating the feet may be a simple yet very important way to help prevent foot ulcers. Over a oneyear period, study patients who infrequently lubricated their feet were 3.1 times more likely to have a foot lesion than those who frequently lubricated their feet (52). Patients with high risk feet should inspect them twice a day. Those with peripheral neuropathy, vascular disease, or eye disease should not attempt to cut their own toenails as this can lead to serious selfinflicted injury. It is important for a health care provider or diabetes educator to review with the patient all written takehome instructions for self-care of the feet (36). In a program for African Americans, patients reported that the most useful parts of a take-home packet were the patient instruction booklet, the large hand mirror, and the foot care knowledge self-test with explanations of the answers ( 53). Researchers found that the frequency of desired selfcare behaviors improved when patients were given specific instructions stated as precisely as possible such as “dry between toes,” “file calluses,” and “never go barefoot” rather than more general instructions such as “avoid injury to your feet” (43). Patients should never be allowed to walk on open plantar ulcers since continuous application of mechanical load will prevent healing. Walking aids, footwear modifications, or other interventions must be used to relieve weight (54). Step-by-step guidelines have been published to assist providers to conduct patient education workshops on foot care including how to attract participants, promote the workshop, develop the agenda, identify appropriate speakers, and conduct a post-workshop evaluation ( 55).

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Clinical Issues Provider Foot Care Practices

A documented annual comprehensive foot examination is included in a set of national quality improvement measures for diabetes care as part of the Diabetes Quality Improvement Project (DQIP) (56). Numerous public agencies (the Department of Defense, the Health Care Financing Administration (HCFA), the Indian Health Service, and the Veterans Health Administration) and private groups (the American Diabetes Association Provider Recognition Program and the National Committee for Quality Assurance) are using some or all of this set of eight DQIP performance measures. HCFA is responsible for Medicare and managed care plans that serve Medicare beneficiaries, as well as Medicaid programs. DQIP measures are likely to increase the frequency of documented annual foot exams by health care providers. A study of provider practices found that clinicians were likely to prescribe preventive foot care behaviors when they were aware of a patient’s high risk for LEA as evidenced by prior history of foot ulcer. Clinician awareness of two other major risk factors (peripheral neuropathy or peripheral vascular disease), however, did not increase preventive care practices. The study’s authors concluded that physicians and patients need periodic reminders to identify patients in all high risk categories for ulcer or amputation and to schedule visits for foot care and education in self-care (17). To prevent unnecessary progression of foot problems, proactive communication is recommended between foot care specialists and providers less familiar with diabetes foot care management, as well as timely referral from primary care providers to specialists as necessary (1). Self-care Limitations in the Elderly

Barriers to carrying out daily foot care noted by elderly study subjects included lack of motivation,

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forgetfulness, vision problems, joint and knee problems, and family responsibilities ( 53). The ability of elderly people to identify foot lesions was investigated further in a matched comparison, controlled study. Findings showed that 43 percent of patients with a history of foot ulcers could not reach and remove simulated lesions on their toes; over 50 percent of the older subjects reported difficulty trimming their toe nails; and only 14 percent had sufficient joint flexibility to allow inspection of the plantar aspect of the foot. It can be concluded that elderly people who are unable to perform daily self-care of the feet would benefit more from regular foot care given by others than from intensive education (57). Exercise

In people with diabetes, regular exercise can lower blood glucose, improve insulin sensitivity, raise HDL cholesterol, improve blood flow and heart muscle strength, enhance fibrinolysis, control weight, increase muscle mass, and provide an overall sense of wellbeing. Because of these effects, regular exercise may also delay the onset of neuropathy and atherosclerosis. People who have had type 1 diabetes for more than 10 years, or type 2 diabetes for more than 5 years, should be screened for medical risk prior to beginning an exercise program. While the presence of neuropathy does not rule out exercise, care should be taken not to worsen soft tissue and joint injury or cause foot ulcers or bone injury. Stretching muscles before exercise is important to prevent ligament strain. Swimming or bicycling are recommended forms of exercise because they avoid abrasion to the feet (58). Attention to the construction and fit of footwear is essential.


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Special Footwear for the Insensate Foot Repetitive Stress and Special Footwear

Footwear and the Medicare Shoe Benefit

People with intact sensation respond to repetitive stress that occurs during walking either by shifting the pressure to another part of the foot, by modifying the way the foot meets the ground, by resting, or by checking their shoes for problems. With the loss of peripheral sensation, however, many people with diabetes have no indication of lower extremity pain, pressure, or trauma and do not take measures to modify repetitive pressures. Lack of feeling makes shoe-fitting assistance essential. Properly-constructed and well-fitting shoes and shoe inserts can minimize localized stresses by redistributing forces during walking. Besides helping patients keep feet healthy, shoes and orthoses also can help prevent diabetes complications. Investigators in a recent study found that after healing of the initial ulcer, re-ulceration occurred after one year in 58 percent of patients who resumed wearing their own footwear, compared to 28 percent of those who wore therapeutic footwear (59). Shoe color can contribute to thermal injury of the insensate foot when shoes are worn in the sun for a prolonged period ( 2 to 3 hours). One study showed that after 30 minutes of exposure to radiant heat, the mean increase in temperature was between 7.8 and 13.6 degrees Farenheit greater in a black leather walking shoe than in a similar white shoe (60). Another study compared the prevalence and severity of foot deformities and the development of ulceration in people with diabetes after a great toe amputation. Due to altered pressure distribution, the foot with great toe amputation developed more frequent and more severe deformities of the lesser toes and metatarsophalangeal joints compared to the other intact foot. Because these patients were at high risk for subsequent ulceration, the use of special inserts and footwear to protect the feet was highly recommended (61).

Professionally fitted shoes and prescription footwear are an important part of the overall treatment of the insensate foot because they aid in preventing limb loss. Footwear should relieve areas of excessive pressure, reduce shock and shear, and accommodate, stabilize, and support deformities. The type of footwear provided will depend on the patient’s foot structure, activity level, gait, and footwear preference ( 1). Shoes should be long enough, and have room in the toe area and over the instep. Shoes with laces or Velcro allow adjustment for edema and deformities. Most people with early neuropathic changes can wear cushioned commercial footwear such as walking or athletic shoes. When used in conjunction with an off-the-shelf soft accommodative insole (plastazote/urethane viscoelastic), comfort shoes and athletic footwear were as effective as prescribed depth shoes in reducing certain metatarsal and great toe pressures (62). Some people, however, may need the pressure areas redistributed with custom orthotics that often require prescribed depth footwear. Custom-molded shoes, depth shoes, inserts, and shoe modifications can be fitted and furnished by a podiatrist, orthopedic foot surgeon, orthotist, or pedorthist. Depth-inlay shoes provide more room for toe deformities and for the insertion of customized insoles. Extra-wide shoes provide more room for bunions and other abnormalities. Rocker sole shoes reduce pressure under metatarsal heads and toes. They are particularly useful for reducing the risk of ulceration in patients with a stiff and rigid first metatarsal joint ( 63). Since 1993, the Medicare footwear benefit has made special footwear available to more patients than ever before. To obtain coverage, patients must have physician certification that they are at high risk for ulceration or amputation, receive a written footwear prescription from a podiatrist or other qualified physician,

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and obtain the footwear from a qualified provider or supplier who will then file the appropriate claim forms (64). Utilization of the Medicare benefit was low in 1995 for three states studied – Washington, Alaska, and Idaho. Altogether, less than one percent of beneficiaries with diabetes meeting the appropriate criteria for the footwear benefit had a therapeutic footwear claim (65). Clearly, there is an opportunity to increase awareness of the availability of this benefit and how to obtain reimbursement.

Conclusion The staggering human and economic costs of diabetes foot disease may be reduced significantly with increased practice of several simple preventive care measures designed to prevent foot ulcers and lower extremity amputations. Routine annual foot

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exams to identify high risk feet facilitate early interventions to help reduce the incidence of the most common precipitating events including injury and footwear-related trauma to the insensitive foot. The key elements of preventive care include: annual examination of the feet by health care providers to determine risk factors for ulceration; subsequent examination of high risk feet at each patient visit; patient education about daily self-care of the feet; use of proper footwear; and careful glucose management. National recommendations and objectives support the application of these practices based on the strong and timetested evidence for the prevention of lower extremity ulcers and amputations. These national objectives can serve as a galvanizing call to action for policy makers, health care providers, and people with diabetes to make diabetes foot care and prevention a high priority.


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2. National Hospital Discharge Survey, 1996. Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Care Statistics. Data computed by the Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion. 3. U.S. Department of Health and Human Services: Healthy People 2010. In National Health Promotion and Disease Prevention Objectives. Washington, D.C., U.S. Govt. Printing Office, January 2000. 4. Lavery LA, Ashry HR, van Houtum W, et al. Variation in the incidence and proportion of diabetes-related amputations in minorities. Diabetes Care 19(1):48-52, 1996. 5. Lavery LA, van Houtum WH, Ashry HR, et al. Diabetes-related lower extremity amputations disproportionately affect Blacks and Mexican Americans. Southern Medical Journal 92(6):593-9,1999. 6. Nelson RG, Ghodes DM, Everhart JE, et al. Lowerextremity amputations in NIDDM: 12-year follow-up study in Pima Indians. Diabetes Care 11:8-16, 1988. 7. The President's Initiative to Eliminate Racial and Ethnic Disparities in Health. (http://www.raceandhealth.hhs.gov/). 8. Reiber GE, Boyko EJ, Smith DG. Lower extremity foot ulcers and amputations in diabetes. In Diabetes in America. 2nd ed., National Institutes of Health, NIDDK, NIH Pub. No. 95-1468, 1995. 9. Behavioral Risk Factor Surveillance System, 1996. Centers for Disease Control and Prevention, Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion. 10. Tomar, SL, Lester, A. Dental and other health care visits among US adults with diabetes. Diabetes Care,

16(11):1507-10, 1993. 12. Levin ME. Preventing amputation in the patient with diabetes. Diabetes Care 18:1383-94, 1995. 13. Reiber G, the Diabetes Ulcer Outcome Study Group: Treatment and outcomes of diabetic foot ulcers. (Abstr.) Diabetes S146(Suppl):45, 1997. 14. Mayfield JA, Reiber GE, Sanders LJ, et al. Preventive foot care in people with diabetes (Technical Review). Diabetes Care 21(12):2161-77, 1998. 15. Palumbo PJ, Melton LJ. Peripheral vascular disease in diabetes. In Diabetes in America. Harris MI, Hamman RF, Eds. Bethesda, Md., National Diabetes Data Group, NIH Pub. No. 85-1468, 1985, p.1-21. 16. Ramsey SD, Newton K, Blough D, et al. Incidence, outcomes, and cost of foot ulcers in patients with diabetes. Diabetes Care 22(3):382-8, 1999. 17. del Aguila MA, Reiber GE, Koepsell TD. How does provider and patient awareness of high-risk status for lower extremity amputation influence foot-care practice? Diabetes Care 17(9):1050-54, 1994. 18. Adler AI, Boyko EJ, Ahroni JH, et al. Lower-extremity amputation in diabetes. The independent effects of peripheral vascular disease, sensory neuropathy, and foot ulcers. Diabetes Care 22(7):1029-35, 1999. 19. Mayfield JA, Reiber GE, Nelson RG, et al. A foot risk classification system to predict diabetic amputation in Pima Indians. Diabetes Care 19(7):704-9, 1996. 20. Murray HJ, Young MJ, Hollis S, et al. The association between callus formation, high pressures and neuropathy in diabetic foot ulceration. Diabetic Medicine 13(11):979-82, 1996. 21. Lehto S, Pyorala K, Ronnemaa T, et al. Risk factors predicting lower extremity amputations in patients with NIDDM. Diabetes Care 19(6):607-12, 1996.

under review, 2000.

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22. DCCT Research Group. The effect of intensive treat-

31. Shaw JE, Boulton AJ. The pathogenesis of diabetic

ment of diabetes on the development and progres-

foot problems: An overview. Diabetes 46(Suppl. 2):

sion of long-term complications in insulin-depend-

S58-S61, 1997.

ent diabetes mellitus. New England Journal of Medicine 329 (14):977-86, 1993. 23. The Diabetes Control and Complications Trial/ Epidemiology of Diabetes Interventions and Complications Research Group: Retinopathy and nephropathy in patients with type 1 diabetes four years after a trial of intensive therapy. New England Journal of Medicine 342(6):381-9, 2000. 24. United Kingdom Prospective Diabetes Study Group: Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 352:837-53, 1998. 25. Reducing the Health Consequences of Smoking: 25 Years of Progress: A report of the Surgeon

General 1989. US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion. Office on Smoking and Health, Rockville, MD 20857. 1989, pp. 63-65. 26. Shaw JE, van Schie CH, Carrington AL, et al. An

betic limb amputation. Basis for prevention. Diabetes Care 13(5): 513-21, 1990. 33. Isakov E, Susak Z, Budoragin N, et al. Self injury resulting in amputation among vascular patients: A retrospective epidemiological study. Disability and Rehabilitation 14:78-80, 1992. 34. Apelqvist J, Larsson J, Agardh CD. The influence of external precipitating factors and peripheral neuropathy on the development and outcome of diabetic foot ulcers. Journal of Diabetes Complications 4(1):21-5, 1990.

35. Sanders L J: Diabetes mellitus- prevention of amputation. Journal of the American Podiatric Medical Association 84(7): 322-28, 1994. 36. Ahroni JH: Teaching foot care creatively and successfully. The Diabetes Educator 19(4):3 20-5, 1993. 37. Rith-Najarian SJ, Stolusky T, Gohdes DM. Identifying diabetic patients at high risk for lower extremity amputation in a primary health care setting. A

analysis of dynamic forces transmitted though the

prospective evaluation of simple screening criteria.

foot in diabetic neuropathy. Diabetes Care

Diabetes Care 15(10): 1386-9, 1992.

21(11):1955-9, 1998.

27. Katoulis EC, Ebdon-Parry M, Lanshammar H, et al.

38. Armstrong DG, Lavery LA, Vela SA, et al. Choosing a practical screening instrument to identify patients at

Gait abnormalities in diabetic neuropathy. Diabetes

risk for diabetic foot ulceration. Archives of Internal

Care 20(12): 1904-7, 1997 .

Medicine 158(3): 289-92, 1998.

28. Van Deursen RW, Simoneau GG. Foot and ankle sen-

39. Sosenko JM, Sparling YH, Hu D, et al. Use of the

sory neuropathy, proprioception, and postural stabili-

Semmes-Weinstein monofilament in the strong heart

ty. Journal of Orthopedic Sports Physical Therapy

study. Diabetes Care 22(10): 1715-21,1999.

29(12): 718-26, 1999.

29. Katoulis EC, Ebdon-Parry M, Hollis, S. Postural insta-

40. Smieja M, Hunt DL, Edelman D, et al. Clinical examination for the detection of protective sensation in

bility in diabetic neuropathic patients at risk for foot

the feet of diabetic patients. International

ulceration. Diabetic Medicine 14(4): 296-300, 1997.

Cooperative Group for Clinical Examination Research.

30. Cavanagh PR, Derr JA, Ulbrecht JS, et al. Problems with gait and posture in neuropathic patients with insulin-dependent diabetes mellitus. Diabetic Medicine 9:469-74, 1992.

32

32. Pecoraro RE, Reiber GE, Burgess EM. Pathways to dia-

Journal of General Internal Medicine 14(7): 418-24, 1999.


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41. McGill M, Molyneaux L, Spenser R, et al. Possible sources of discrepancies in the use of

50. Barth R, Campbell LV, Allen S, et al. Intensive education improves knowledge, compliance, and foot

the Semmes-Weinstein monofilament. Diabetes

problems in type 2 diabetes. Diabetic Medicine

Care 22(4): 598-602, 1999.

8:111-17, 1991.

42. Birke JA, Rolfsen RJ. Evaluation of a self-administered sensory testing tool to identify patients at risk of diabetes-related foot problems. Diabetes Care 21(1): 23-5, 1998.

43. Litzelman DK, Slemenda CW, Langefeld, CD, et al. Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes melli-

51. Ward A, Metz L, Oddone EZ, et al. Foot education improves knowledge and satisfaction among patients at high risk for diabetic foot ulcer. The Diabetes Educator 25(4): 560-7, 1999 . 52. Suico JG, Marriott DJ, Vinicor F, et al. Behaviors predicting foot lesions in patients with non-insulin dependent diabetes mellitus. Journal of General Internal Medicine 13(7): 482-4, 1998 .

tus. Annals of Internal Medicine 119(1): 36-41, 1993. 53. Ledda MA, Walker EA. Development and formative 44. Ollendorf DA, Kotsanos JG, Wishner WJ, et al.

evaluation of a foot self-care program for African

Potential economic benefits of lower-extremity

Americans with diabetes. The Diabetes Educator

amputation prevention strategies in diabetes.

23(1): 48-51, 1997 .

Diabetes Care 21(8): 1240-5, 1998 . 45. Boulton AJ: Lowering the risk of neuropathy, foot

54. Caputo GM, Cavanagh PR, Ulbrecht JS, et al. Assessment and management of foot disease in

ulcers and amputations. Diabetic Medicine

patients with diabetes. New England Journal of

15(Suppl.4): S 57-9, 1998 .

Medicine 331(13): 854-60, 1994.

46. Larsson J, Apelqvist J, Agardh CD, et al. Decreasing

55. Marchand LH, Campbell W, Rolfsen RJ. Lessons from

incidence of major amputation in diabetic patients:

“Feet Can Last a Lifetime”: A public health cam-

A consequence of a multidisciplinary foot care team

paign. Diabetes Spectrum 9(4): 214-18, 1996 .

approach? Diabetic Medicine 12(9): 770-6, 1995 . 47. Dargis V, Pantelejeva O, Jonushaite A, et al. Benefits of a multidisciplinary approach in the management of recurrent diabetic foot ulceration in Lithuania: a prospective study. Diabetes Care 22(9): 1428-31, 1999. 48. Rith-Najarian S, Branchaud C, Beaulieu O, et al. Reducing lower-extremity amputations due to diabetes. Application of the staged diabetes management approach in a primary care setting. Journal of Family Practice 47(2): 127-32, 1998 . (See resource list for practice guidelines) 49. Edelman D, Sanders LJ, Pogach L. Reproducibility and accuracy among primary care providers of a screening examination for foot ulcer risk among diabetic patients. Preventive Medicine 27:274-8, 1998.

56. Diabetes Quality Improvement Project. (http://www.diabetes.org/dqip.asp) 57. Thompson FJ, Masson EA. Can elderly diabetic patients co-operate with routine foot care? Age and Aging 21:333-7,1992. 58. Ruderman N, Devlin JT, Eds. Health Professional’s Guide to Diabetes and Exercise. American Diabetes Association, Alexandria, VA 1996. 59. Uccioli L, Faglia E, Monticone G, et al. Manufactured shoes in the prevention of diabetic foot ulcers. Diabetes Care 18(10): 1376-8, 1995 . 60. DeLuca PA, Goforth WP. Effect of shoe color on shoe temperature and potential solar injury to the insensate foot. Journal of the American Podiatric Medical Association 88(7): 344-8, 1998.

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61. Quebedeaux TL, Lavery DC, Lavery LA. The

Therapeutic shoes for individuals with diabetes. In

great toe amputation in diabetes. Diabetes Care

Medicare Carriers Manual, Section 2134.

19(2): 165-7, 1996.

Washington, D C., U.S. Govt. Printing Office, July

62. Lavery LA, Vela SA, Fleischli JG, et al. Reducing

1994, p.2-85.1-2-86.

plantar pressure in the neuropathic foot. A compar-

65. Sugarman JR, Reiber GE, Baumgardner G, et al. Use

ison of footwear. Diabetes Care 20(11): 1706-10, 1997.

of the therapeutic footwear benefit among diabetic

63. Mueller MJ. Therapeutic footwear helps protect the diabetic foot. Journal of the American Podiatric Medical Association 87(8): 360-4, 1997.

34

64. Department of Health and Human Services:

development of foot deformities and ulcers after

Medicare beneficiaries in three states, 1995. Diabetes Care 21(5): 777-81, 1998.


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Resource List 1. Monofilaments for Sensory Testing

Smith & Nephew Inc.

To order monofilaments, call or write to any of the following organizations:

P.O. Box 1005 Germantown, WI 53022-8205 Phone: (800) 558-8633

Center for Specialized Diabetes Foot Care PO Box 373-405 Hayden St.

Set of five assort. size: $99.99 Single 5.07 (10gm): $19.99

Belzoni, MS 39038 Phone: (800) 543-9055 Single 5.07 (10gm): $10.00

2. National Diabetes Education Program (NDEP) – a partnership among the National Institutes of Health, the Centers for Disease Control and

Connecticut Bioinstruments Inc. P.O. Box 2567 Danbury, CT 06813

Prevention, and over 200 organizations Internet: http://ndep.nih.gov To order materials, call: (800) 438-5383

Phone: (800) 336-1935 Single 5.07 (10 gm): $15

Feet Can Last a Lifetime – A Health Care Provider’s Guide to Preventing Diabetes Foot Problems

Lower Extremity Amputation Prevention (LEAP) Program

Copies of this kit are available through the National

HRSA/BPHC/DPSP 4350 East-West Highway, 9th Floor Bethesda, MD 20814

Diabetes Information Clearinghouse by calling (800) 438-5383. In addition, the entire text of the kit may be downloaded from the NDEP website at http://ndep.nih.gov on the Internet.

Phone: (888) 275-4772 Internet: http://www.bphc.hrsa.gov/leap

Take Care of Your Feet for A Lifetime

Disposable 5.07 (10gm): Free (maximum 50)

This 12-page, easy-to read, illustrated patient booklet

(A sample is attached to the pocket card inside this kit)

provides step-by-step instructions for proper foot care. It includes a tear-off reminder sheet of foot care tips

Medical Monofilament Manufacturing, LLC 116 Long Pond Road Plymouth, MA 02360

and a patient “To Do” list. Available in English and Spanish on the NDEP website at http://ndep.nih.gov on the Internet.

Phone: (508) 746-7877 Internet: http://www.medicalmonofilament.com Disposable 5.07 (10gm): Prices available upon request

3. National Diabetes Information Clearinghouse (NDIC) of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

North Coast Medical, Inc. 18305 Sutter Blvd. Morgan Hill, CA 95037-2845 Phone: (800) 821-9319

1 Information Way Bethesda, MD 20892-3560 Internet: http://www.niddk.nih.gov/health/diabetes/ndic (301) 654-3327

Set of six assort. size: $124.95 Single 5.07 (10gm): $24.95

Foot Care and Diabetes 1993 - Present. The database from the diabetes subfile of the

Sensory Testing Systems 1815 Dallas Drive, Suite 11A Baton Rouge, LA 70806 Phone: (225) 923-1297 Single 5.07 (10gm): $10.00

Combined Health Information Database (CHID) can be searched for foot care and diabetes information. Each citation includes the author, title, source, a summary, where to obtain the item, and its price. Formats of audiovisuals are provided. CHID is available at http://chid.nih.gov on the Internet.

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Diabetic Neuropathy: The Nerve Damage of Diabetes

Diabetes, What to Know Head to Toe

This 12-page fact sheet for patients describes the

This patient brochure briefly covers self-care of the

causes, symptoms, and major types of neuropathy, pro-

heart, eyes and feet and is available in English and

vides information about diagnosis and treatment, as

Spanish.

well as the findings of the Diabetes Control and Complications Trial as they relate to neuropathy.

4. American Association of Diabetes Educators 100 West Monroe St., Suite 400 Chicago, IL 60603 Internet: http://www.aadenet.org Phone: (800) TEAM-UP4

First Thing First Series: Foot Care (5093-10) This patient brochure briefly describes the importance of and methods for proper foot care. 101 Foot Care Tips for People with Diabetes (4834-01) This book for people with diabetes provides information about keeping the feet healthy and preventing foot complications.

Use the toll-free number to receive the names and

6. American Orthopaedic Foot & Ankle Society

phone numbers of three certified diabetes educators in

1216 Pine Street, Suite 201

the location you specify.

Seattle, WA 98101

(312) 424-2426 for main location

Diabetes Foot and Skin Care This is one of a series of informative videotapes for patient education. To order or for a free preview, call (800) 432-8433.

Phone: (206) 223-1120 Fax: (206) 223-1178 E-mail: [email protected] Internet: http://www.aofas.org You may order a copy of any brochure by sending a

5. American Diabetes Association

self-addressed, stamped envelope to the address above

1701 N. Beauregard St.

or download a copy from the internet.

Alexandria, VA 22311 Internet: http://www.diabetes.org Phone: (800) 232-6733 for publications (800) 342-2383 for general diabetes information (703) 549-1500 – National Office

Guidelines for Referral This journal reprint outlines five criteria for patient referral to an orthopedist to prevent deterioration or complications of a diabetic ulcer.

Information about local activities including materials

The Diabetic Foot

also is available by calling your local American Diabetes

This patient brochure answers basic questions about

Association at 1-888-DIABETES. Clinical Practice Recommendations • The American Diabetes Association: Standards of

diabetic foot problems and offers information on dayto-day-care to help prevent them. Patient Brochures

Medical Care for Patients With Diabetes Mellitus.

These are short brochures to help patients prevent

Diabetes Care 23 (suppl.1):S32-S42, 2000.

injury and care for their feet:

• The American Diabetes Association: Preventive Foot Care in Patients With Diabetes Mellitus. Diabetes Care 23 (suppl.1):S55-S56, 2000.

• How to Care for Your Diabetic Feet • The Diabetic Foot and Risk: How to Prevent Losing Your Leg • Shoes and Orthotics for Diabetics • Charcot Joints, or Neuropathic Arthropathy • Foot Ulcers and the Total Contact Cast

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Newsletter “FootCare” is a quarterly newsletter offering advice on

The Prevention and Treatment of Complications of Diabetes: A Guide for Primary Care Practitioners

foot care topics for people with diabetes.

This 93-page book describes ways to help the primary

7. American Podiatric Medical Association 9312 Old Georgetown Road Bethesda, MD 20814-1698 Internet: http://www.apma.org To order materials, call (301) 581-9200 Your Podiatric Physician Talks about Diabetes

care provider prevent, detect, and treat major diabetes complications. An office guide in the appendix offers a brief synopsis of the recommendations contained in the body of the text. The guide may be photocopied and placed in the medical record. This book is available only on the Internet.

This patient brochure covers preventive foot care,

The Economics of Diabetes Mellitus: An Annotated Bibliography

warning signs, and the role of the podiatric physician

This bibliography contains most of the important eco-

in foot care.

nomic studies currently available regarding the direct health care costs related to diabetes and interventions

Don’t Let Diabetes Get a Foothold on Your Life

to reduce the burden of diabetes.

This patient brochure presents an overview of potential foot problems affecting people with diabetes. It dis-

Diabetes Surveillance, 1997

cusses diabetes warning signs, preventive foot care,

This report documents the number of diabetes-related

and the role of the podiatric physician in the manage-

hospital discharges with lower extremity amputations

ment of diabetes foot problems.

as a reported procedure between 1990 and 1994.

8. Centers For Disease Control and Prevention– Division of Diabetes Translation Clearinghouse

To order materials, call the Texas Medical Foundation

P.O. Box 8728

Foot Exam Materials for Academic Detailing

9. Health Care Financing Administration at (888) 691-9167.

Silver Spring, MD 20910

A tool kit for implementing an academic detailing

Internet: http://www.cdc.gov/diabetes

intervention for increasing foot exams. The kit

To order, call toll free (877) CDC-DIAB (232-3422)

includes: an implementation plan for the Peer Review Organization, guidelines for the detailer,

Take Charge of Your Diabetes This 76-page spiral-bound book for adults with diabetes focuses on the value of glucose control, team work, community and family support, and simple pre-

principles of academic detailing, podiatry consult request and report forms, exam documentation sheet, chart stickers, references and resources, and a 10-minute video of a foot exam.

ventive steps for helping to promote health and prevent complications (Chapter 9 covers foot care). Yellow record sheets are provided for recording tests that should be done once a year and at every visit.

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MedQuest Data Abstraction and Analysis System, User’s Guide for DQIP

This 41-page booklet for community health representa-

This toolkit includes an introductory video, detailed

tives covers foot problems, foot examinations, and

DQIP specifications and appendix, instructions for

how to care for the diabetic foot and patients with a

installing and using the MedQuest software, instruc-

foot ulcer.

tions for medical record abstraction and running a pre-

The Basic Approach to the Diabetic Foot

programmed analysis report, and ten medical records

A Basic Approach to Caring for the Feet of People with Diabetes

for practice abstraction.

This three-part, 75-slide set teaches providers about foot

Compendium of Diabetes Best Practices

care. Part 1: Injury can lead to amputation; Part 2:

This compendium includes peer reviewed studies and

Examining the feet of a person with diabetes; Part 3:

quality improvement projects that document successful

Foot care for all people with diabetes. (Slides are a

interventions in screening, monitoring and treatment

companion piece to “The Basic Approach to the Diabetic

of diabetic patients for improved outcomes. Tables

Foot” listed above.)

address barriers to high quality diabetes care and effec-

Booklets

tive interventions. Many of the studies and quality

These illustrated patient booklets, each 10-13 pages, are

improvement projects relate specifically to foot care

written at or below 6th grade level.

improvements. Also available at

• Taking Care of Your Feet

www.hcfa.gov/quality/3r.htm on the Internet.

• Footwear for People with Diabetes

Diabetes Interventions Toolkit

Brochures

This kit provides examples of resources and tools that

These are short patient information brochures.

have been used successfully by clinicians, diabetes educa-

• Take Care of Your Feet

tors, peer review organizations, managed care organiza-

• Numbness to Legs, Hands, and Foot/Pain

tions and others to improve care. It includes flowsheets,

• Pain Related to Nerve Damage

algorithms, patient education materials, practitioner toolkits and abstraction tools. Many of the tools specifically address foot care. Also available at http://www.takingondiabetes.org/bestpractices/index on the Internet.

Practice Guidelines Practice guidelines in the form of a decision tree that addresses criteria for diagnosis, risk-factor assessment, treatment options, therapeutic targets, monitoring, and follow-up. To request a copy contact:

10. Indian Health Service

Stephen J. Rith-Najarian M.D.

5300 Homestead Road, NE

Bemidji Area Indian Health Service

Albuquerque, NM 87110

Diabetes Program

Internet: http://www.ihs.gov/medical programs/ diabetes

522 Minnesota Avenue

To order, call (505) 248-4182.

111 Federal Building, Bemidji, MN 56601

Standards of Diabetic Foot Care

E-mail: [email protected].

This 43-page manual for providers includes minimum standards for diabetes foot care within the scope of each IHS facility.

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11. Juvenile Diabetes Foundation International 120 Wall Street New York, NY 10005 Internet: http://www.jdf.org To order call: (800) JDF-CURE

Video on Foot Assessment of the Adult Patient with Diabetes This 5-minute video, produced in collaboration with Kaiser Permanente of the Mid-Atlantic States, shows a clinician discussing the importance of foot screening for patients with diabetes, explains the components of the LEAP Program, and demonstrates how to perform a sim-

Diabetes and Foot Care

ple foot screen using the LEAP monofilament.

This brochure provides general information about the

This video can be viewed directly on the website. Call

effects of diabetes on feet, special self-care, the preven-

(888) 275-4772 to order a free VHS copy.

tion, detection, and proper treatment of foot care problems, and the physician’s role in foot examination and treatment.

Patient Education Booklet Designed to go with the patient video, this simple, easy-to-read booklet reinforces the importance of

12. Lower Extremity Amputation Prevention (LEAP) Program

proper foot care for a patient with diabetes who has lost

HRSA/BPHC/DPSP

and can be adapted to include the clinician’s telephone

4350 East-West Highway, 9th Floor

number. Several translations of this booklet are available

Bethesda, MD 20814

on the website.

Internet: http://www.bphc.hrsa.gov/leap To order the LEAP materials listed below, call the BPHC Information Clearinghouse at (888)275-4772 or preview and download them from the LEAP website.

protective sensation. It is illustrated with simple pictures

Video for Clinicians This 10-minute video, produced by the Texas peer review organization, is a tool for clinicians and demonstrates how to perform a comprehensive foot examination for

Free Brochure and Monofilament

patients with diabetes. This video can be viewed directly

Each LEAP monofilament comes with a brochure on how

on the website. Free single VHS copies are available.

to perform a sensory foot exam. Single copies are avail-

13. Pedorthic Footwear Association

able free to individuals. Clinicians and other health care

7150 Columbia Gateway Dr., Suite G

organizations may obtain up to 50 monofilaments free

Columbia, MD 21046-1151

of charge. Multiple requests from the same organization

Internet: http://www.pedorthics.org

will not be honored.

Phone: (800) 673-8447

Several versions of the LEAP brochure are available on

Diabetes and Pedorthics: Conservative Foot Care

the website—in normal and large print and in English

This patient brochure provides information on pedor-

and in Spanish. Other languages will be added. These

thics and footwear, including the role that a certified

brochures have no copyright restrictions and may be

pedorthist plays in preventing and alleviating diabetes

downloaded and reproduced.

foot complications.

Diabetes Foot Screen Forms

Pedorthics: Foot Care Through Proper Footwear

Both an abbreviated and a comprehensive foot screen

This brochure briefly explains the field of pedorthics

form have no copyright and may be downloaded from

and its practice of designing footwear to accommodate

the website and reproduced.

serious foot problems.

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The Pedorthic Dispenser

14. Veterans Health Administration

Properly fitting therapeutic footwear requires special

Jeffrey M. Robbins, DPM

skills and care. The pedorthic profession focuses on the

Director, VHA Headquarters, Podiatry Service

design, fit, and modification of shoes and related foot

Louis Stokes Cleveland DVAMC

appliances. In addition to pedorthists, other dispensers

10701 East Boulevard

include podiatrists, orthotists, and prosthetists.

Cleveland, Ohio 44106

For a listing of pedorthists, send a self-addressed

To order, call (216) 231-3286 or

stamped envelope to the Board for Certification in

fax (216) 231-3446

Pedorthics, 7150 Columbia Gateway Drive, Suite G,

E-mail: [email protected]

Columbia, MD 21046, or contact the website www.cpeds.org on the Internet.

Free Filaments Monofilaments are available free of charge to the entire Veterans Health Administration. Foot Screening Tool This one-page screening tool documents a foot examination and risk status using monofilament sensory testing.

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Patient Education Materials


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Foot Care Tips Ta k e C a r e o f Yo u r F e e t f o r a L i f e t i m e . 1. Take care of your diabetes.

8. Protect you feet from hot and cold.

• Work with your health care team to keep your blood sugar within a good range.

• Wear shoes at the beach or on hot pavement. • Wear socks at night if your feet get cold.

2. Check your feet every day.

• Don’t test bath water with your feet.

• Look at your bare feet every day for cuts, blisters, red spots, and swelling.

• Don’t use hot water bottles or heating pads.

• Use a mirror to check the bottoms of your feet or ask a family member for help if you have trouble seeing.

9. Keep the blood flowing to your feet.

3. Wash your feet every day.

• Wash your feet in warm, not hot, water every day. • Dry your feet well. Be sure to dry between the toes. 4. Keep the skin soft and smooth.

• Rub a thin coat of skin lotion over the tops and bottoms of your feet, but not between your toes. 5. Smooth corns and calluses gently.

• If your feet are at low risk for problems, use a pumice stone to smooth corns and calluses. Don’t use over-the-counter products or sharp objects on corns or calluses. 6. If you can see and reach your toenails, trim them each week or when needed.

• Trim your toenails straight across and file

the edges with an emery board or nail file. 7. Wear shoes and socks at all times.

• Never walk barefoot. • Wear comfortable shoes that fit well and protect your feet. • Feel inside your shoes before putting them on each time to make sure the lining is smooth and there are no objects inside.

• Put your feet up when sitting. • Wiggle your toes and move your ankles up and down for 5 minutes, 2 or 3 times a day. • Don’t cross your legs for long periods of time. • Don’t smoke. 10. Be more active.

• Plan your physical activity program with your doctor. 11. Check with your doctor.

• Have your doctor check your bare feet and find out whether you are likely to have serious foot problems. Remember that you may not feel the pain of an injury. • Call your doctor right away if you find a cut, sore, blister, or bruise on your foot that does not begin to heal after one day. • Follow your doctor’s advice about foot care. 12. Get started now.

• Begin taking good care of your feet today. • Set a time every day to check your feet. • Complete the “To Do” list on the back of this page and…

take care of your feet for a lifetime.

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To D o L i s t Make plans now to take care of your feet for a lifetime.

Check each item when completed. ❐ Use the list of foot care tips on the reverse side and put it where I will see it every day. ❐ Get a pair of nail clippers if my doctor recommends it. ❐ Get an emery board and a pumice stone if my doctor recommends them. ❐ Buy soft, cotton or wool socks. ❐ Buy a pair of shoes that fit well and cover my feet. ❐ Give away shoes that don’t fit. ❐ Place slippers beside my bed to wear when I get out of bed. ❐ Get a mirror to help me see the bottoms of my feet. ❐ Ask for help from a family member or caregiver if I can’t see my feet. ❐ Keep my next doctor’s appointment. ❐ Ask my doctor if I qualify for special shoes covered by Medicare or other insurance plans. ❐ Ask my doctor or nurse to inspect my feet at every visit. ❐ Plan my physical activity program with my doctor. ❐ Stop smoking.

By when:


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Additional To o l s


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Page 53

Use this copier-ready master to create your own stickers to place on the medical record. This master is designed to be reproduced on brightly colored 1” x 2-5/8” labels from Avery.

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

HIGH RISK FEET

SHOES and SOCKS take ‘em off!

I F YO U H AV E D I A B E T E S Have your doctor check your feet.


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A joint program of the National Institutes of Health and the Centers for Disease Control and Prevention

National Institute of Diabetes and Digestive and Kidney Diseases

NOVEMBER 2000, NDEP-2

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service National Institutes of Health

What I need to know about Diabetes Medicines

U.S. Department of Health and Human Services NATIONAL INSTITUTES OF HEALTH


Contents What do diabetes medicines do? ..................................... 1 What targets are recommended for blood glucose levels? ....................................................... 2 What happens to blood glucose levels in people with diabetes?................................................................... 4 Medicines for My Diabetes ............................................... 6 Types of Diabetes Medicines ............................................ 8 What do I need to know about side effects of medicines? ................................................................. 13 For More Information ...................................................... 14 Acknowledgments .......................................................... 15

*Inserts are in back pocket

What do diabetes medicines do? Over time, high levels of blood glucose, also called blood sugar, can cause health problems. These problems include heart disease, heart attacks, strokes, kidney disease, nerve damage, digestive problems, eye disease, and tooth and gum problems. You can help prevent health problems by keeping your blood glucose levels on target. Everyone with diabetes needs to choose foods wisely and be physically active. If you can’t reach your target blood glucose levels with wise food choices and physical activity, you may need diabetes medicines. The kind of medicine you take depends on your type of diabetes, your schedule, and your other health conditions. Diabetes medicines help keep your blood glucose in your target range. The target range is suggested by diabetes experts and your doctor or diabetes educator. See page 2 for more information about target levels for good health.

You may need diabetes medicines to reach your blood glucose targets.

1

What targets are recommended for blood glucose levels? The National Diabetes Education Program uses blood glucose targets set by the American Diabetes Association (ADA) for most people with diabetes. To learn your daily blood glucose numbers, you’ll check your blood glucose levels on your own using a blood glucose meter. Target blood glucose levels for most people with diabetes Before meals

70 to 130 mg/dL*


Less than 180 mg/dL

My targets

* Milligrams per deciliter.

Also, you should ask your doctor for a blood test called the A1C at least twice a year. The A1C will give you your average blood glucose for the past 3 months. Target A1C result for people with diabetes

My target

Less than 7 percent

Your personal A1C goal might be higher or lower than 7 percent. Keeping your A1C as close to normal as possible—below 6 percent without having frequent low blood glucose—can help prevent long-term diabetes problems. 2

Doctors might recommend other goals for very young children, older people, people with other health problems, or those who often have low blood glucose. Talk with your doctor or diabetes educator about whether the target blood glucose levels and A1C result listed in the charts on page 2 are best for you. Write your own target levels in the charts. Both ways of checking your blood glucose levels are important. If your blood glucose levels are not on target, you might need a change in how you take care of your diabetes. The results of your A1C test and your daily blood glucose checks can help you and your doctor make decisions about l

what you eat

l

when you eat

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how much you eat

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what kind of exercise you do

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how much exercise you do

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the type of diabetes medicines you take

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the amount of diabetes medicines you take

3

What happens to blood glucose levels in people with diabetes? Blood glucose levels go up and down throughout the day and night in people with diabetes. High blood glucose levels over time can result in heart disease and other health problems. Low blood glucose levels can make you feel shaky or pass out. But you can learn how to make sure your blood glucose levels stay on target—not too high and not too low.

What makes blood glucose levels go too high? Your blood glucose levels can go too high if

4

l

you eat more than usual

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you’re not physically active

l

you’re not taking enough diabetes medicine

l

you’re sick or under stress

l

you exercise when your blood glucose level is

already high

What makes blood glucose levels go too low? Your blood glucose levels can go too low if l

you eat less than usual

l

you miss a meal or snack or eat later than usual

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you’re more active than usual

l

you drink alcoholic beverages on an empty stomach

Some diabetes medicines can also lower your blood glucose too much. Ask your doctor whether your diabetes medicines can cause low blood glucose. See Insert N for information about low blood glucose.

The results of your blood glucose checks can help you make decisions about your diabetes medicines, food choices, and physical activity.

5

Medicines for My Diabetes Ask your doctor what type of diabetes you have and check off the answer. I have q type 1 diabetes q type 2 diabetes q gestational diabetes q another type of diabetes: ____________________

Medicines for Type 1 Diabetes Type 1 diabetes, once called juvenile diabetes or insulin-dependent diabetes, is usually first found in children, teenagers, or young adults. If you have type 1 diabetes, you must take insulin because your body no longer makes it. You also might need to take other types of diabetes medicines that work with insulin.

6

Medicines for Type 2 Diabetes Type 2 diabetes, once called adult-onset diabetes or noninsulin-dependent diabetes, is the most common form of diabetes. It can start when the body doesn’t use insulin as it should, a condition called insulin resistance. If the body can’t keep up with the need for insulin, you may need diabetes medicines. Many choices are available. Your doctor might prescribe two or more medicines. The ADA recommends that most people start with metformin, a kind of diabetes pill.

Medicines for Gestational Diabetes Gestational diabetes is diabetes that occurs for the first time during pregnancy. The hormones of pregnancy or a shortage of insulin can cause gestational diabetes. Most women with gestational diabetes control it with meal planning and physical activity. But some women need insulin to reach their target blood glucose levels.

Medicines for Other Types of Diabetes If you have one of the rare forms of diabetes, such as diabetes caused by other medicines or monogenic diabetes, talk with your doctor about what kind of diabetes medicine would be best for you.

7

Types of Diabetes Medicines Diabetes medicines come in several forms.

Insulin If your body no longer makes enough insulin, you’ll need to take it. Insulin is used for all types of diabetes. Your doctor can help you decide which way of taking insulin is best for you.

8

l

Taking injections. You’ll give yourself shots using a needle and syringe. The syringe is a hollow tube with a plunger. You will put your dose of insulin into the tube. Some people use an insulin pen, which looks like a pen but has a needle for its point.

l

Using an insulin pump. An insulin pump is a small machine about the size of a cell phone, worn outside of your body on a belt or in a pocket or pouch. The pump connects to a small plastic tube and a very small needle. The needle is inserted under the skin and stays in for several days. Insulin is pumped from the machine through the tube into your body.

l

Using an insulin jet injector. The jet injector, which looks like a large pen, sends a fine spray of insulin through the skin with high-pressure air instead of a needle.

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Using an insulin infuser. A small tube is inserted just beneath the skin and remains in place for several days. Insulin is injected into the end of the tube instead of through the skin.

If your body no longer makes enough insulin, you’ll need to take it.

9

What does insulin do? Insulin helps keep blood glucose levels on target by moving glucose from the blood into your body’s cells. Your cells then use glucose for energy. In people who don’t have diabetes, the body makes the right amount of insulin on its own. But when you have diabetes, you and your doctor must decide how much insulin you need throughout the day and night. What are the possible side effects of insulin? Possible side effects include l

low blood glucose (for more information, see Insert N)

l

weight gain

How and when should I take my insulin? Your plan for taking insulin will depend on your daily routine and your type of insulin. Some people with diabetes who use insulin need to take it two, three, or four times a day to reach their blood glucose targets. Others can take a single shot. Your doctor or diabetes educator will help you learn how and when to give yourself insulin.

10

Types of Insulin Each type of insulin works at a different speed. For example, rapid-acting insulin starts to work right after you take it. Long-acting insulin works for many hours. Most people need two or more types of insulin to reach their blood glucose targets. Look at the list of types of insulin on Insert C in the pocket of this booklet. Check off the names of the kinds of insulin you take. Then write the names of your insulins under My Insulins in the chart on Insert A.

Diabetes Pills Along with meal planning and physical activity, diabetes pills help people with type 2 diabetes or gestational diabetes keep their blood glucose levels on target. Several kinds of pills are available. Each works in a different way. Many people take two or three kinds of pills. Some people take combination pills. Combination pills contain two kinds of diabetes medicine in one tablet. Some people take pills and insulin.

Diabetes pills help people with type 2 diabetes or gestational diabetes keep their blood glucose levels on target.

11

Your doctor may ask you to try one kind of pill. If it doesn’t help you reach your blood glucose targets, your doctor may ask you to l

take more of the same pill

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add another kind of pill

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change to another type of pill

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start taking insulin

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start taking another injected medicine

If your doctor suggests that you take insulin or another injected medicine, it doesn’t mean your diabetes is getting worse. Instead, it means you need insulin or another type of medicine to reach your blood glucose targets. Everyone is different. What works best for you depends on your usual daily routine, eating habits, and activities, and your other health conditions. For information about the different kinds of pills and what they do, see the cards in the pocket of this booklet. You’ll see the brand name and the generic name—the scientific name—for each medicine. Find your diabetes pills and check off the names. Then write the names of your diabetes pills under My Pills and Injected Medicines in the chart on Insert A.

12

Injections Other Than Insulin In addition to insulin, two other types of injected medicines are now available. Both work with insulin—either the body’s own or injected—to help keep your blood glucose from going too high after you eat. Neither is a substitute for insulin. See the cards in the pocket of this booklet for more information about these injected medicines. Check off the kinds you take. Then write the names of your injected medicines under My Pills and Injected Medicines in the chart on Insert A. Talk with your doctor if you have questions about your diabetes medicines. Do not stop taking your diabetes medicines without checking with your doctor first. See Insert B for a list of questions to ask your doctor about your medicines.

What do I need to know about side effects of medicines? A side effect is an unwanted problem caused by a medicine. For example, some diabetes medicines can cause nausea or an upset stomach when you first start taking them. Before you start a new medicine, ask your doctor about possible side effects and how you can avoid them. If the side effects of your medicine bother you, tell your doctor. 13


Inserts My Diabetes Medicines.............................................. Insert A Questions to Ask about Your Diabetes Medicines .... Insert B Types of Insulin .......................................................... Insert C Glyset and Precose (Alpha-Glucosidase Inhibitors)................................................................... Insert D

Glucophage, Glucophage XR, and Riomet (Biguanides) ............................................................... Insert E Starlix (D-Phenylalanine Derivative) .......................... Insert F Januvia (DPP-4 Inhibitor)........................................... Insert G Prandin (Meglitinide) .................................................. Insert H Amaryl, DiaBeta, Diabinese, Glucotrol, Glucotrol XL, Glynase PresTab, Micronase, tolazamide, and tolbutamide (Sulfonylureas) ....................................... Insert I Actos and Avandia (Thiazolidinediones).................... Insert J Actoplus Met, Avandamet, Avandaryl, Duetact, Glucovance, Janumet, and Metaglip (Combination Diabetes Pills) ............................................................ Insert K Symlin (Amylin Mimetic)............................................. Insert L

Byetta (Incretin Mimetic) ............................................ Insert M

About Low Blood Glucose ......................................... Insert N

National Diabetes Information Clearinghouse • 1–800–860–8747 www.diabetes.niddk.nih.gov/dm/pubs/medicines_ez/index.htm

Insert A


My Diabetes Medicines Write the names of your diabetes medicines here.

My Insulins Brand Name

Generic Name

Type of Insulin

My Pills and Injected Medicines

Brand Name

Generic Name



Insert B

Questions to Ask about Your Diabetes Medicines Ask your doctor these questions when you get a prescription for a medicine. Make copies of this card and use one card for each of your medicines. What are the names of my medicine? Brand name: Generic name: What does my medicine do? When should I start this medicine? This medicine is prescribed by: How long will it take this medicine to work? What is the strength (for example, how many milligrams, written as mg)? How much should I take for each dose? How many times a day should I take my medicine? At what times should I take my medicine? National Diabetes Information Clearinghouse • 1–800–860–8747 www.diabetes.niddk.nih.gov/dm/pubs/medicines_ez/index.htm


Insert B

Should I take it before, with, or after a meal? Should I avoid any foods or medicines when I take it? Should I avoid alcoholic beverages when I take it? Are there any times when I should change the amount of medicine I take? What should I do if I forget to take it? If I’m sick and can’t keep food down, should I still take my medicine? Can my diabetes medicine cause low blood glucose? What should I do if my blood glucose is too low? What side effects can this medicine cause? What should I do if I have side effects? How should I store this medicine?


Insert C

Types of Insulin Each type of insulin has an onset, a peak, and a duration time. The onset is how soon the insulin starts to lower your blood glucose after you take it. The peak is the time the insulin is working the hardest to lower your blood glucose. The duration is how long the insulin lasts—the length of time it keeps lowering your blood glucose. The times shown in the chart are estimates. Your onset, peak, and duration times may be different. You’ll work with your health care team to come up with an insulin plan that works best for you.



Type of Insulin Rapid-acting

Brand Name

Insert C

Insert C


Generic Name

Onset

Peak

Duration

q NovoLog

q Insulin aspart

15 minutes

30 to 90 minutes

3 to 5 hours

q Apidra

q Insulin glulisine

15 minutes

30 to 90 minutes

3 to 5 hours

q Humalog

q Insulin lispro

15 minutes

30 to 90 minutes

3 to 5 hours

q Humulin R

q Regular (R)

30 to 60 minutes

2 to 4 hours

5 to 8 hours

q NPH (N)

1 to 3 hours

8 hours

12 to 16 hours

q Levemir

q Insulin detemir

1 hour

Peakless

20 to 26 hours

q Lantus

q Insulin glargine

Pre-mixed NPH (intermediate-acting) and regular (short-acting)

q Humulin 70/30

q 70% NPH and 30% regular

30 to 60 minutes

Varies

10 to 16 hours

q Humulin 50/50

q 50% NPH and 50% regular

30 to 60 minutes

Varies

10 to 16 hours

Pre-mixed insulin lispro protamine suspension (intermediate-acting) and insulin lispro (rapid-acting)

q Humalog Mix 75/25

q 75% insulin lispro protamine and 25% insulin lispro

10 to 15 minutes

Varies

10 to 16 hours

q Humalog Mix 50/50

q 50% insulin lispro protamine and 50% insulin lispro

10 to 15 minutes

Varies

10 to 16 hours

Pre-mixed insulin aspart protamine suspension (intermediate-acting) and insulin aspart (rapid-acting)

q NovoLog Mix 70/30

q 70% insulin aspart protamine and 30% insulin aspart

5 to 15 minutes

Varies

10 to 16 hours

Short-acting

q Novolin R Intermediate-acting

q Humulin N q Novolin N

Long-acting

q Novolin 70/30

Insert D


Alpha-Glucosidase (AL-fuh-gloo-KOH-sih-dayss) Inhibitor (in-HIB-ih-tur) Brand Name

Generic Name

q Glyset (GLY-set)

q miglitol (MIG-lih-tol)

q Precose (PREE-kohss)

q acarbose (A-kahr-bohss)

What does this type of pill do? This type of pill helps keep your blood glucose from going too high after you eat, a common problem in people with diabetes. It works by slowing down the digestion of foods high in carbohydrate, such as rice, potatoes, bread, milk, and fruit.

Who should not take Glyset or Precose? Talk with your doctor about whether to take this type of pill if l

you have bowel disease or other intestinal conditions

l

you have advanced kidney or liver disease

l

you are pregnant, planning to get pregnant, or

breastfeeding



Insert D

What are the possible side effects? This type of pill doesn’t cause low blood glucose by itself. But your risk of having low blood glucose goes up if you also take l

diabetes pills that cause low blood glucose

l

insulin

Your doctor may ask you to take a lower dose of your other diabetes medicines while you take this type of pill. Taking Glyset or Precose may cause stomach pain, gas, bloating, or diarrhea. These symptoms usually go away after you have taken these pills for a while. If you take Glyset or Precose: What you need to know about low blood glucose If you take Glyset or Precose, only glucose tablets or glucose gel will bring your blood glucose level back to normal quickly. Other quick-fix foods and drinks won’t raise your blood glucose as quickly because Glyset and Precose slow the digestion of other quick-fix foods and drinks.

Insert E


Biguanide (by-GWAH-nyd)

Brand Name

Generic Name

q Glucophage (GLOO-coh-fahj)

q metformin (met-FOR-min)

q Glucophage XR

q metformin—long-acting

q Riomet (RY-oh-met)

q metformin—liquid

What does this type of medicine do? This type of medicine, which comes in pill or liquid form, lowers the amount of glucose made by your liver. Then your blood glucose levels don’t go too high. This type of medicine also helps treat insulin resistance. With insulin resistance, your body doesn’t use insulin the way it should. When your insulin works properly, your blood glucose levels stay on target and your cells get the energy they need. This type of medicine improves your cholesterol levels. It also may help you lose weight.



Insert E

Who should not take Glucophage, Glucophage XR, or Riomet? Talk with your doctor about whether to take this type of medicine if l

you have advanced kidney or liver disease

l

you drink excessive amounts of alcoholic beverages

l

you are pregnant, planning to get pregnant, or breastfeeding



l

insulin

Your doctor may ask you to take a lower dose of your other diabetes medicines while you take this type of pill. You may have nausea, diarrhea, or an upset stomach when you first start taking this type of medicine. These side effects are likely to go away after a while.


Insert E

Rarely, a serious condition called lactic acidosis occurs as a side effect of taking this medicine. Call your doctor right away if you l

become weak and tired

l

become dizzy

l

feel very cold

l

have trouble breathing

l

have unusual muscle pain and stomach problems

l

have a sudden change in the speed or steadiness of your heartbeat

Sometimes you’ll need to stop taking this type of medicine for a short time so you can avoid developing lactic acidosis. If you have severe vomiting, diarrhea, or a fever, or if you can’t keep fluids down, call your doctor right away. You should also talk with your doctor well ahead of time about stopping this type of medicine if l

you’ll be having special x rays that require an injection of dye

l

you’ll be having surgery

Your doctor will tell you when it’s safe to start taking your medicine again.

Insert F


D-Phenylalanine (dee-FEN-il-AL-uh-neen) Derivative (duh-RIV-uh-tiv) Brand Name q Starlix (STAR-liks)

Generic Name q nateglinide (nuh-TEG-lih-nyd)

What does this type of pill do? This type of pill helps your body make more insulin for a short period of time right after meals. The insulin helps keep your blood glucose from going too high after you eat, a common problem in people with diabetes.

Who should not take Starlix? Talk with your doctor about whether to take this type of pill if l


breastfeeding

l

you have liver disease



Insert F

What are the possible side effects? Possible side effects are l

low blood glucose, also called hypoglycemia (HY-poh-gly-SEE-mee-uh)—for more information, see Insert N

l

weight gain

l

dizziness

Insert G


DPP-4 Inhibitor Dipeptidyl (dy-PEP-tih-dil) Peptidase-4 (PEP-tih-dayss-FOR) Inhibitor (in-HIB-ih-tur) Brand Name o Januvia (juh-NOO-vee-uh)

Generic Name o sitagliptin (sih-tuh-GLIP-tin) phosphate (FOSS-fayt)

What does this type of pill do? This type of pill lowers your blood glucose by helping your body make more insulin when it’s needed, especially right after meals. It also helps keep your liver from putting stored glucose into your blood.

Who should not take Januvia? Talk with your doctor about whether to take this type of pill if l


breastfeeding

l

you have kidney disease

l

you have type 1 diabetes and if you have a condition called diabetic ketoacidosis



Insert G



l

insulin

Your doctor may ask you to take a lower dose of your other diabetes medicines while you take this type of pill. Possible side effects are l

a cold

l

runny nose

l

sore throat

l

headache

If you take Januvia and have kidney problems, your health care provider might order blood tests to see how well your kidneys are working.

Insert H


Meglitinide (meh-GLIH-tih-nyde)

Brand Name q Prandin (PRAN-din)

Generic Name q repaglinide (ruh-PAG-luh-nyd)

What does this type of pill do? This type of pill helps your body make more insulin for a short period of time right after meals. The insulin helps keep your blood glucose from going too high after you eat, a common problem in people with diabetes.

Who should not take Prandin? Talk with your doctor about whether to take this type of pill if l


breastfeeding

l




Insert H

What are the possible side effects? Prandin can cause l


l

weight gain

l

upset stomach

l

back pain or a headache

Insert I


Sulfonylurea (SUHL-foh-nil-yoo-REE-uh)

Brand Name

Generic Name

q Amaryl (AM-uh-ril)

q glimepiride (gly-MEP-ih-ryd)

q DiaBeta (dy-uh-BAY-tuh)

q glyburide (GLY-buh-ryd)

q Diabinese (dy-AB-ih-neez)

q chlorpropamide (klor-PROH-puh-myd)

q Glucotrol (GLOO-kuh-trohl)

q glipizide (GLIP-ih-zyd)

q Glucotrol XL (GLOO-kuh-trohl)(EKS-EL)

q glipizide (GLIP-ih-zyd) (long-acting)

q Glynase (GLY-nayz) PresTab

q glyburide (GLY-buh-ryd)

q Micronase (MY-kroh-nayz)

q glyburide (GLY-buh-ryd) Available only in generic form: q tolazamide (tahl-AZ-uh-myd) q tolbutamide (tahl-BYOO-tuh-myd)



Insert I

What does this type of pill do? This type of pill helps your body make more insulin. The insulin helps lower your blood glucose.

Who should not take sulfonylureas? Talk with your doctor about whether to take this type of pill if l

you are allergic to sulfa drugs

l


What are the possible side effects? Possible side effects include l


l

upset stomach

l

skin rash

l

weight gain


Insert J

Thiazolidinedione (THY-uh-ZOHL-ih-deen-DY-ohn) Brand Name ❑ Actos (AK-tohss)

Generic Name ❑ pioglitazone (py-oh-GLIH-tuh-zohn)

❑ Avandia (uh-VAN-dee-uh)

❑ rosiglitazone (rohss-ih-GLIH-tuh-zohn)

In September 2010, the U.S. Food and Drug Administration (FDA) restricted access to Avandia. The FDA based this decision on studies linking Avandia to an increased risk of cardiovascular events, such as heart attacks and strokes. If you are currently taking Avandia: Discuss treatment options with your doctor before stopping your diabetes medicines. Stopping your diabetes medicines without talking with your doctor can cause serious short-term health problems and could increase the risk of long-term diabetesrelated complications. Visit www.fda.gov/Drugs/DrugSafety/ PostmarketDrugSafetyInformationforPatientsandProviders/ ucm226976.htm or call the FDA at 1–888–INFO–FDA (1–888–463–6332) for more information about the FDA’s restrictions on the use of Avandia.



Insert J

What does this type of pill do? This type of pill helps treat insulin resistance. With insulin resistance, your body doesn’t use insulin the way it should. Thiazolidinediones help your insulin work properly. Then your blood glucose levels stay on target and your cells get the energy they need.

Who should not take this type of pill? People with heart failure, also called congestive heart failure, should not take this type of pill. This type of pill can cause heart failure or make it worse.

Heart failure is a condition in which your heart no longer pumps properly. Then your body keeps too much fluid in your legs, ankles, and lungs. Call your doctor right away if you have signs of heart failure. Warning signs include ●

having swelling in your legs or ankles

●

gaining a lot of weight in a short time

●

having trouble breathing

●

having a cough

●

being very tired


Insert J

You should also talk with your doctor about whether to take this type of pill if ●


●


What are the possible side effects? Heart failure is a serious side effect. Avandia is also linked to an increased risk of cardiovascular events, such as heart attacks and strokes. This type of pill doesn’t cause low blood glucose by itself. But your risk of having low blood glucose goes up if you also take ●


●

insulin

Your doctor may ask you to take a lower dose of your other diabetes medicines while you take this type of pill.


Insert J

Possible side effects, in addition to the side effects related to heart failure, are ●

anemia (uh-NEE-mee-uh), a condition that can make you feel very tired

●

an increased risk of getting pregnant even if you’re taking birth control pills

Women who take Actos, Avandia, or combination diabetes pills containing pioglitazone or rosiglitazone may have an increased risk of bone fractures. If you take Actos or Avandia, your health care provider should make sure your liver is working properly. Call your doctor right away if you have any signs of liver disease: nausea, vomiting, stomach pain, tiredness, dark-colored urine, or loss of appetite.


Insert K

Combination Diabetes Pills Combination pills contain two different types of diabetes pills. Several combination pills are available. Brand Name q Actoplus Met (AK-toh-pluhss)(met)

Generic Name q pioglitazone (py-oh-GLIH-tuh-zohn) + metformin (met-FOR-min)

What does this type of pill do? Actoplus Met is a combination of two types of pills. One pill lowers the amount of glucose made by your liver. Both types help your insulin work the way it should. To learn more about the types of pills in Actoplus Met, see l

Insert J for information about pioglitazone

(a thiazolidinedione)

l

Insert E for information about metformin (a biguanide)


Insert K


Brand Name q Avandamet (uh-VAN-duh-met)

Generic Name q rosiglitazone (rohss-ih-GLIH-tuh-zohn) + metformin (met-FOR-min)

What does this type of pill do? Avandamet is a combination of two types of pills. One pill lowers the amount of glucose made by your liver. Both types help your insulin work the way it should. To learn more about the types of pills in Avandamet, see l

Insert J for information about rosiglitazone


l

Insert E for information about metformin (a biguanide) Brand Name

q Avandaryl (uh-VAN-duh-ril)

Generic Name q rosiglitazone (rohss-ih-GLIH-tuh-zohn) + glimepiride (gly-MEP-ih-ryd)

What does this type of pill do? Avandaryl is a combination of two types of pills. One pill helps your insulin work the way it should. The other pill helps your body make more insulin. To learn more about the types of pills in Avandaryl, see l

Insert J for information about rosiglitazone


l

Insert I for information about glimepiride (a sulfonylurea)

Insert K


Brand Name q Duetact (DOO-uh-tak)

Generic Name q pioglitazone (py-oh-GLIH-tuh-zohn) + glimepiride (gly-MEP-ih-ryd)

What does this type of pill do? Duetact is a combination of two types of pills. One pill helps your insulin work the way it should. The other pill helps your body make more insulin. To learn more about the types of pills in Duetact, see l

Insert J for information about pioglitazone


l

Insert I for information about glimepiride (a sulfonylurea) Brand Name

q Glucovance (GLOO-koh-vanss)

Generic Name q glyburide (GLY-buh-ryd) + metformin (met-FOR-min)

What does this type of pill do? Glucovance is a combination of two types of pills. One pill helps your body make more insulin. The other pill lowers the amount of glucose made by your liver and helps your insulin work the way it should. To learn more about the types of pills in Glucovance, see l

Insert I for information about glyburide (a sulfonylurea)

l


Insert K


Brand Name q Janumet (JAN-yoo-met)

Generic Name q sitagliptin (sih-tuh-GLIP-tin) + metformin (met-FOR-min)

What does this type of pill do? Janumet is a combination of two types of pills. One pill helps your body make more insulin when it’s needed, especially right after meals. It also helps keep your liver from putting stored glucose into your blood. The other pill lowers the amount of glucose made by your liver and helps your insulin work the way it should. To learn more about the types of pills in Janumet, see l

Insert G for information about sitagliptin (a DPP-4 inhibitor)

l

Insert E for information about metformin (a biguanide) Brand Name

q Metaglip (MET-uh-glip)

Generic Name q glipizide (GLIP-ih-zyd) + metformin (met-FOR-min)

What does this type of pill do? Metaglip is a combination of two types of pills. One pill helps your body make more insulin. The other pill lowers the amount of glucose made by your liver and helps your insulin work the way it should. To learn more about the types of pills in Metaglip, see l

Insert I for information about glipizide (a sulfonylurea)

l


Insert L


Amylin (AM-ih-lin) Mimetic (mih-MET-ik)

Brand Name o Symlin (SIM-lin)

Generic Name o pramlintide (PRAM-lin-tyd) acetate (ASS-ih-tayt)

What does this medicine do? Symlin helps keep your blood glucose from going too high after you eat, a common problem in people with diabetes. It works by helping food move more slowly through your stomach. Symlin helps keep your liver from putting stored glucose into your blood. It also may prevent hunger, helping you eat less and maybe lose weight. Symlin is for people who already take insulin. However, you should always use a separate syringe to inject Symlin. Symlin is not used in place of insulin. But taking Symlin may change the amount of insulin you take.

Who should not take Symlin? Talk with your doctor about whether you should take this type of medicine if l

you can’t tell when you are having low blood glucose, a condition called hypoglycemia unawareness



Insert L

l

you have recently had severe low blood glucose

l

you have stomach problems caused by diabetes-related nerve damage

l


breastfeeding

Symlin has not been studied for use in children. There may be times when you should not take your usual dose of Symlin. If you’re having surgery or you’re sick and can’t eat, you should not take your Symlin. Ask your doctor about other times to not take it.

What are the possible side effects? Symlin can cause l

nausea and vomiting—most often when you first start taking Symlin

l

swelling, redness, or itching of the skin where Symlin is injected

l

headache

l

decreased appetite

What I need to know about Diabetes Medicines l

stomach pain and indigestion

l

tiredness

l

dizziness

Insert L

This type of medicine doesn’t cause low blood glucose by itself. But your risk of having low blood glucose is higher because Symlin is always taken along with insulin.

Insert M


Incretin (in-KREE-tin) Mimetic (mih-MET-ik) Brand Name ❏ Byetta (by-YAY-tuh)

Generic Name ❏ exenatide (eks-EN-uh-tyd)

What does this medicine do? Byetta helps your body make more insulin when it’s needed. It helps keep your blood glucose from going too high after you eat, a common problem in people with diabetes. It works by helping food move more slowly through your stomach. Byetta helps keep your liver from putting stored glucose into your blood. It also may prevent hunger, helping you eat less and maybe lose weight. Byetta is not used in place of insulin.

Who should not take Byetta? Talk with your doctor about whether you should take this type of medicine if ●

you have severe stomach or digestive problems

●

you have any symptoms of kidney disease or are on dialysis


What I need to know about Diabetes Medicines ●


●

you have type 1 diabetes

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Byetta has not been studied for use in children.

What are the possible side effects? Byetta can cause ●

nausea and vomiting—most often when you first start taking Byetta

●

headache

●

diarrhea

●

dizziness

Byetta also can cause an acid stomach or make you feel nervous.


Insert M

If you take Byetta: What you need to know about problems with your kidneys Talk with your doctor right away if you notice any of the following: ●

changes in the color of your urine, how often you urinate, or the amount you urinate

●

swelling of your hands or feet

●

tiredness

●

changes in your appetite or digestion

●

a dull ache in your mid to lower back

This type of medicine doesn’t cause low blood glucose by itself. But your risk of having low blood glucose goes up if you also take ●


●

insulin

Your doctor may ask you to take a lower dose of your other diabetes medicines while you take this type of medicine.


Insert N

About Low Blood Glucose What is low blood glucose? Low blood glucose, also called hypoglycemia (HY-poh-gly-SEE mee-uh), is when your blood glucose is lower than normal. Blood glucose is too low when it’s below 70 mg/dL. If you don’t eat or drink something to bring your blood glucose level back to normal, you could pass out. Then you might need emergency treatment at a hospital. If you have low blood glucose several times a week, tell your doctor or diabetes educator. You might need a change in your diabetes medicines, meal plan, or activity routine.

What can cause low blood glucose? Diabetes Medicines Some diabetes medicines can cause low blood glucose if there isn’t a balance between your medicines, food, and activity. Ask your doctor whether your diabetes medicines can cause low blood glucose. Other diabetes medicines do not cause low blood glucose on their own. But when they are taken with certain other diabetes medicines, they can increase the risk of low blood glucose.


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Other Causes of Low Blood Glucose Low blood glucose can happen if you skip or delay a meal, eat too little at a meal, get more exercise than usual, or drink alcoholic beverages on an empty stomach.

How will I feel if I have low blood glucose? Low blood glucose can make you feel l

hungry

l

shaky

l

confused

l

dizzy

l

sweaty

l

anxious

l

nervous

l

sleepy

l

weak

Low blood glucose can also happen while you sleep. You might cry out or have nightmares, sweat a lot, feel tired or confused when you wake up, or have a headache when you wake up.


Insert N

What should I do if I have low blood glucose? Follow these steps: 1. If you feel like your blood glucose is low, check your

blood glucose level with your blood glucose meter. 2. If your blood glucose is below 70 mg/dL, have a serving

of a “quick fix” food or drink right away. See the list of Quick-fix Foods and Drinks for Low Blood Glucose on the next page. If you can’t check your blood glucose but you feel like your blood glucose level is low, have something from the quick-fix list. 3. After 15 minutes, check your blood glucose again. If it’s still below 70 mg/dL, have another serving of a quick-fix food or drink. 4. Check your blood glucose again 15 minutes later. If it’s 70 mg/dL or above, you’ll feel better soon. If your blood glucose is still low, have another serving of a quick-fix food or drink. Keep doing so until your blood glucose is 70 mg/dL or above. 5. When your blood glucose has reached 70 mg/dL or

above, think about when your next meal will be. If it will be more than an hour before your next meal, have a snack.


Insert N

Quick-fix Foods and Drinks for Low Blood Glucose l

3 or 4 glucose tablets

l

1 serving of glucose gel—the amount equal to

15 grams of carbohydrate

l

1/2 cup (4 ounces) of any fruit juice

l

1/2 cup (4 ounces) of a regular—not diet—soft drink

l

1 cup (8 ounces) of milk

l

5 or 6 pieces of hard candy

l

1 tablespoon of sugar or honey

Always carry a quick-fix food or drink. You also can keep quick-fix foods in your car, at work, or wherever you go. Then you’ll be ready to take care of yourself if your blood glucose dips too low.

For More Information

Diabetes Teachers (nurses, dietitians, pharmacists, and other health professionals) To find a diabetes teacher near you, call the American Association of Diabetes Educators toll-free at 1–800–TEAMUP4 (832–6874), or look on the Internet at www.diabeteseducator.org and click on “Find a Diabetes Educator.” Dietitians To find a dietitian near you, contact the American Dietetic Association at www.eatright.org and click on “Find a Nutrition Professional.”

To get more information about taking care of diabetes, contact National Diabetes Information Clearinghouse 1 Information Way

Bethesda, MD 20892–3560

Phone: 1–800–860–8747

TTY: 1–866–569–1162

Fax: 703–738–4929

Email: [email protected]

Internet: www.diabetes.niddk.nih.gov

National Diabetes Education Program 1 Diabetes Way

Bethesda, MD 20814–9692

Phone: 1–888–693–NDEP (6337)

TTY: 1–866–569–1162

Fax: 703–738–4929

Email: [email protected]

Internet: www.ndep.nih.gov

American Diabetes Association 1701 North Beauregard Street

Alexandria, VA 22311

Phone: 1–800–DIABETES (342–2383)

Internet: www.diabetes.org

Juvenile Diabetes Research Foundation International 120 Wall Street

New York, NY 10005–4001

Phone: 1–800–533–CURE (2873)

Internet: www.jdrf.org

The National Heart, Lung, and Blood Institute (NHLBI) is part of the National Institutes of Health. To learn more about heart and blood vessel problems, write or call the NHLBI Health Information Center, P.O. Box 30105, Bethesda, MD 20824–0105, 301–592–8573; or see www.nhlbi.nih.gov on the Internet. The National Eye Institute (NEI) is part of the National Institutes of Health. To learn more about eye problems, write or call the NEI, 2020 Vision Place, Bethesda, MD 20892–3655, 301–496–5248; or see www.nei.nih.gov on the Internet. The National Institute of Dental and Craniofacial Research (NIDCR) is part of the National Institutes of Health. To learn more about tooth and gum problems, write or call the NIDCR’s information clearinghouse, the National Oral Health Information Clearinghouse (NOHIC), at 1 NOHIC Way, Bethesda, MD 20892–3500, 1– 866–232–4528; or see www.nidcr.nih.gov/OralHealth on the Internet. The National Institute of Neurological Disorders and Stroke is part of the National Institutes of Health (NIH). To learn more about nervous system problems, write or call the NIH Neurological Institute at P.O. Box 5801, Bethesda, MD

20824, 1–800–352–9424; or see www.ninds.nih.gov on the Internet.

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) is part of the National Institutes of Health. To learn more about feet and skin problems, write or call the National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse, 1 AMS Circle, Bethesda, MD 20892–3675, 1–877–226–4267 (toll-free); or see www.niams.nih.gov on the Internet.

The National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) is part of the National Institutes of Health (NIH). To learn more about kidney problems, write or call NKUDIC, 3 Information Way, Bethesda, MD 20892–3580, 1–800–891–5390; or see www.kidney.niddk.nih.gov on the Internet.

The National Kidney Disease Education Program (NKDEP) is part of the NIH. To learn more about kidney problems, write or call NKDEP, 3 Kidney Information Way, Bethesda, MD 20892, 1–866–454–3639; or see www.nkdep.nih.gov on the Internet.

National Kidney Foundation 30 East 33rd Street New York, NY 10016 Phone: 1–800–622–9010 Internet: www.kidney.org

More in the Series The Prevent Diabetes Problems Series has seven

booklets that can help you learn more about how

to prevent diabetes problems.

For free single copies of these booklets, write, call, fax, or email the National Diabetes Information Clearinghouse 1 Information Way Bethesda, MD 20892–3560 Phone: 1–800–860–8747 TTY: 1–866–569–1162 Fax: 703–738–4929 Email: [email protected] These booklets are also available at www.diabetes.niddk.nih.gov on the Internet.

Acknowledgments Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scientists and outside experts. The National Diabetes Information Clearinghouse (NDIC) thanks the people who helped review or field-test the original version of this publication: � For the American Association of Diabetes Educators Lynn Grieger, R.D., C.D.E. � Arlington, VT � Celia Levesque, R.N.,

C.D.E. Montgomery, AL Teresa McMahon, Pharm.D., C.D.E. Seattle, WA Barbara Schreiner, R.N., M.N., C.D.E. Galveston, TX For the American Diabetes Association Phyllis Barrier, M.S., R.D., C.D.E. Alexandria, VA Linda Haas, Ph.C., R.N., C.D.E. Seattle, WA Kathleen Mahoney, M.S.N., R.N., C.D.E. Drexel Hill, PA Randi Kington, M.S., R.N., C.S., C.D.E. Hartford, CT For the Centers for Medicare & Medicaid Services Baltimore, MD � Jan Drass, R.N., C.D.E. �

For the Diabetes Research and Training Centers Albert Einstein School of Medicine Norwalk Hospital Norwalk, CT Jill Ely, R.N., C.D.E. Sam Engel, M.D. Pam Howard, A.P.R.N., C.D.E. Indiana University School of Medicine Indianapolis, IN Madelyn Wheeler, M.S., R.D., F.A.D.A., C.D.E. VA/JDF Diabetes Research Center Vanderbilt School of Medicine Nashville, TN Ok Chon Allison, M.S.N., R.N.C.S., A.N.P., C.D.E. Barbara Backer, B.S. James W. Pichert, Ph.D. Alvin Powers, M.D. Melissa E. Schweikhart Michael B. Smith Kathleen Wolffe, R.N.

For the Grady Health System Diabetes Clinic Atlanta, GA � Ernestine Baker, R.N., � F.N.P., C.D.E. Kris Ernst, R.N., C.D.E. Margaret Fowke, R.D., L.D. Kay Mann, R.N., C.D.E. For the Indian Health Service Albuquerque, NM � Ruth Bear, R.D., C.D.E. � Dorinda Bradley, R.N., � C.D.E. Terry Fisher, R.N. Lorraine Valdez, R.N., C.D.E. Red Lake, MN Charmaine Branchaud, B.S.N., R.N., C.D.E. For the Medlantic Research Center Washington, DC Resa Levetan, M.D. For the Texas Diabetes Council Texas Department of Health Austin, TX Luby Garza-Abijaoude, M.S., R.D., L.D.

The NDIC also thanks Katherine R. Tuttle, M.D., F.A.S.N., F.A.C.P., of the Providence Medical Research Center, Sacred Heart Medical Center in Spokane, WA, and the University of Washington School of Medicine in Spokane and Seattle for reviewing the updated version of this publication.

National Diabetes Information Clearinghouse 1 Information Way Bethesda, MD 20892–3560 Phone: 1–800–860–8747 TTY: 1–866–569–1162 Fax: 703–738–4929 Email: [email protected] Internet: www.diabetes.niddk.nih.gov The National Diabetes Information Clearinghouse (NDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health of the U.S. Department of Health and Human Services. Established in 1978, the Clearinghouse provides information about diabetes to people with diabetes and to their families, health care professionals, and the public. The NDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about diabetes.

This publication is not copyrighted. The Clearinghouse encourages users of this publication to duplicate and distribute as many copies as desired. This publication is available at www.diabetes.niddk.nih.gov.

This publication may contain information about medications. When prepared, this publication included the most current information available. For updates or for questions about any medications, contact the U.S. Food and Drug Administration toll-free at 1–888–INFO–FDA (1–888–463–6332) or visit www.fda.gov. Consult your doctor for more information.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health

October 2010 The NIDDK prints on recycled paper with bio-based ink.

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Eat & Beat Diabetes with Picture Perfect Weight Loss The Visual Program to Prevent and Control Diabetes

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Gastrointestinal Function in Diabetes Mellitus (Practical Diabetes)

Psychology in Diabetes Care (Practical Diabetes)

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Diabetes: Gut leben mit Typ-2-Diabetes

Psychology in Diabetes Care (Practical Diabetes)

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Power to Prevent: A Family Lifestyle Approach to Diabetes Prevention

The End of Diabetes: The Eat to Live Plan to Prevent and Reverse Diabetes

Obesity and Diabetes (Practical Diabetes)

Obesity and Diabetes (Contemporary Diabetes)

Diabetes and Exercise (Contemporary Diabetes)

Unstable and Brittle Diabetes (Advances in Diabetes)

Nutritional Management of Diabetes Mellitus (Practical Diabetes)

Eat & Beat Diabetes with Picture Perfect Weight Loss The Visual Program to Prevent and Control Diabetes

Geriatric Diabetes

Gastrointestinal Function in Diabetes Mellitus (Practical Diabetes)

Psychology in Diabetes Care (Practical Diabetes)

Diabetes and the Brain (Contemporary Diabetes)

Nutritional Management of Diabetes Mellitus (Practical Diabetes)

Diabetes: Gut leben mit Typ-2-Diabetes

Psychology in Diabetes Care (Practical Diabetes)

Obesity and Diabetes, 2nd edition (Practical Diabetes)

Psychology in Diabetes Care (Practical Diabetes)

American Diabetes Association Complete Guide to Diabetes

Prevent And Reverse Heart Disease

What Nurses Know ... Diabetes

Handbook of Diabetes Management

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