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Dear Patient,

The following is most of what I want you to know about diabetes:

First of all to define diabetes:

There are several types of diabetes. Impaired glucose tolerance is not true diabetes, but a condition which may occur several years before diabetes starts or may be a result of obesity and/or inactivity. We define this condition with a two hour post glucola blood sugar of between 140 to 200. This condition may be reversed with marked weight loss and exercise. The condition is also suspect if the fasting blood sugar is over 110 but under 126.

True diabetes is defined by a blood sugar greater than 126 or a two hour post glucola blood sugar greater than 200. There are several types of true diabetes. Gestational diabetes is diabetes which occurs during pregnancy. Non-insulin dependent diabetes is diabetes that does not require insulin. Insulin dependent diabetes is diabetes which does require insulin.

Diabetic Complications: If diabetes is not well controlled after a number of years, usually we expect diabetic retinopathy which is actually small vessel disease of the retina. This disease causes tiny hemorrhages in the back of the eye which can lead to gradual or sudden blindness. Eye doctors do laser surgery to burn the tiny dot hemorrhages we see in the back of the eye before they bleed. An uncontrolled diabetic can also go on to chronic renal failure and dialysis and can develop diabetic neuropathy with inability to feel their feet. Uncontrolled diabetics may get vascular disease which comes from often a lot of “small dense” LDL. LDL is the low density lipoprotein part of the cholesterol and small dense LDL is the worst type of LDL. Also, high triglycerides and low HDL (the good cholesterol) is very common in diabetics, especially if they are overweight. Vascular disease can produce strokes, heart attacks, peripheral vascular disease of the legs, and impotence. The kidney failure that diabetics get is really a vascular disease of the kidney and can present with protein in the urine. Patient’s who are truly diabetic should get a urine test for protein yearly. None of these complications will occur if a diabetic keeps in good control. We can determine if there is good control by the blood test called hemoglobin A1C. This blood test gives us an average blood sugar reading over a three month period but especially over the past one month. If the diabetic keeps his hemoglobin A1C less than 7 but ideally less than 6.5, no complications of diabetes will develop. Hemoglobin A1C should be checked every three months in diabetic patients. The vascular complications can be prevented by keeping the LDL “bad cholesterol” less than 100. The new NCEP guidelines suggest that the LDL should be less than 100 for diabetic patients. If we know that a diabetic patient has small dense LDL we must get the LDL value less than 70 to prevent heart attacks or strokes and multi-infarct dementia or senility as the patient gets older.

Diabetic Diet:

Diabetic patients should read labels. It is also important to count your carbohydrates and distribute them throughout the day. We really believe that it is possible to keep your carbohydrates less than 30 grams a day.  It is also important that diabetics are aware that sugar- alcohol also called, sorbitol, mannitol, and xylitol can cause bloating, cramps, and diarrhea. Diabetics should avoid these sugar alcohols if that happens but taking probiotics can help prevent this. it is important to understand that if you eat over 100 g of protein a day the amino acids in the protein can increase the glycogen stores in the liver and thereby increase blood sugar. The way to avoid carbohydrates is really not to increase your protein but to increase your olive oil. The Mediterranean diet which includes a lot of olive oil is the most cardioprotective diet. Eat at least 3 tablespoons of olive oil a day on your salads broccoli cauliflower green beans or asparagus or add the olive oil to your protein drinks. The olive oil is one of the best ways to control your hunger and carbohydrate craving. Again carbs are addicting and the more you get the more you want..  
 
Diabetic Treatment:

We have many different types of pills to help control diabetes. Onglyza, Farxiga, Glyburide, Glucophage and Actos do a wonderful job in controlling diabetes and insulin is often not necessary. There are many types of insulin, short-acting insulin is called Regular insulin or Humulin R. Also Humalog and Novolog are our latest Regular short-acting insulins. It is very quick acting and preferred. The intermediate acting insulin is called Lente or NPH insulin or Novolin N or Humulin N. These peak about eight hours later and affect the sugar eight hours after they are taken maximally but help the sugar all along those eight hours as well. Some people peak late, however, and may get a low sugar 12 hours after taking the intermediate acting insulin. Lantus and Levimir are insulins that gives a constant blood level of insulin over a 24 hour period and is almost like having an insulin pump. Many of our patients have insulin pumps which attach to a needle constantly in the abdominal wall skin. These patients give themselves insulin with every meal. Often the most effective way of controlling diabetes is to give a short-acting boost of insulin with every meal in combinations of Lantus and Humalog which are very effective. We suggest that patients who take insulin only give insulin in the lateral abdomen or the outside part of the abdomen, moving up and down the sides of the abdomen, never using the same spot if they can help it. If insulin is given in different parts of the body, different absorption occurs, so in order to get consistent control we suggest that only the abdomen be used. Also, to help know if the patient is in good control, a glucose meter should be purchased by the patient and sugars be checked at least initially four times a day, before each meal and at bedtime. Please only stick the very sides of the ends of your finger when you check your blood sugar. It is quite painless and easy. When the fasting sugars are controlled I may then ask you to do two hours after meal blood sugars to see if these are controlled. Also, a blood sugar at 3 a.m. in the morning can be helpful to determine if there is any low blood sugar during the night. Insulin can be stored anywhere as long as it is not exposed to heat. A good idea is to keep your insulin in a thermos if you are going on a car trip but you do not need to keep insulin in the refrigerator. We do ask our patients on insulin pump though to change their insulin every two days instead of every three days. However, if you wish to, keep you insulin in the refrigerator as long as it is allowed on the insulin bottle for that particular type of insulin.

I know how difficult it is to stick to a diabetic diet, I do so myself because of a triglyceride problem. Occasionally, we can’t help but cheat a little, but I know that the less sugar I have the less I want so staying away from sugar completely is the answer. Also, I believe that diet drinks and sugar substitutes such as Equal which is NutraSweet and saccharin also called Sweet’N Low and other things may add to the brains craving for sugar and remind the brain about sugar so using these sparingly also may be helpful to keep away from real sugar. These sugar substitutes, however, are allowed if you prefer. Also, there are some sugar substitutes that you can cook with.  Splenda in the yellow box has a preparation you can cook with. Also consider all-natural Stevia. It has been shown recently that the artificial sugar substitutes especially Sweet 'N Low can change the G.I. Flora and cause impaired glucose tolerance. Therefore if you use the sugar substitutes always take probiotics. 
 
 
When someone gets the diagnosis of diabetes it is very frightening and threatening but it is comforting to know that with good strict control a diabetic patient can avoid diabetic complications completely and can lead a long and healthy life. 

I hope this letter has been helpful. Do not hesitate to call me with any questions you have about diabetes. Also we have many brochures on diabetes that can be helpful.

Go to www.diabetes.org or www.DiabetesWATCH.com or http://www.joslin.org/LearnAboutDiabetes_Index_home.asp for excellent diabetes info and help but try the very restrictive less than 30 grams of carbohydrate diet first. Many of our patients have gotten off insulin and other diabetic medications this way 

Sincerely,



Edward M. Gaber, MD