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Prescription for Health: Medicines to Control Blood Sugar
Sugar, Is It My Enemy as a Diabetic?
The Results are In!
From the Director's Chair: Diabetes and Vascular Health on Dialysis
Hey, what's the news at WDI? To find out …read on…
Looking for the sweetness in life…
Prescription for Health: Medicines to Control Blood Sugar
Curtis A Johnson, Pharm.D.
WDI Pharmacist
Some of you may remember the 1964 movie "Mary Poppins" in which Julie Andrews sang that "a spoonful of sugar helps the medicine go down." In this issue of our newsletter, perhaps we should change the song's words to "a spoonful of medicine helps the sugar go down." Of course, we don't recommend that you take medicine by the spoonful, but it is important to take your prescribed medicines to keep your blood sugar under control if you have diabetes.
Perhaps you have heard that diabetes has become a major public health concern in Wisconsin and in the United States. Diabetes is now the single most important cause of kidney disease in dialysis patients. We have known for over 10 years that "tight" control of blood sugar (sometimes called blood glucose) in diabetic patients can prevent kidney damage in people who are not on dialysis. We also know that tight blood sugar control is one way of reducing the risks of some other problems that diabetes can cause such as diminished vision and damage to nerves. What do we mean by "tight" blood sugar control? Dr. Kellerman addresses this topic in his article.
The goal of treatment in the diabetic patient is to keep the blood sugar as close to normal as possible. To achieve that goal requires daily use of a small machine (glucometer) that measures the amount of sugar in the blood. Your doctor, dialysis nurse, or dietitian can give you more information about this. As Dr. Kellerman explains, we also check a laboratory test that tells you and WDI staff members how well you blood sugar has been treated. This test is called the Hemoglobin A1C test. You might ask "Is it important for dialysis patients to keep their blood sugar under control?" The answer is "YES, absolutely!" Even though dialysis patients have lost nearly all of their kidney function, controlling blood glucose is very important for preventing other complications of diabetes. How can we work together to achieve this goal?
Medications used to control blood glucose are selected for various reasons. People who have type 1 diabetes will need to use insulin. People with type 2 diabetes may be treated with diet, medicines to be taken by mouth, insulin, or a com-bination of these things. Because type 2 diabetes is often associated with being overweight, losing weight becomes an important part of treatment. Your dietitian can answer questions about how weight loss can help with blood sugar control.
There are many insulin products now being used. Some are designed to lower blood sugar for many hours, and therefore may be given only once or twice a day. Other insulin products lower blood sugar quickly but for shorter periods of time, and therefore may be given several times a day such as before each meal. Most diabetic patients using insulin will be determined by checking the amount of sugar in the blood with glucometer.
There is good news and bad news about insulin. The good news is that the insulin you may be taking is nearly identical to the insulin that normally would be produced in your pancreas. Therefore, treatment with insulin is similar in many respects to nature's way of controlling the amount of sugar in the blood. The bad news is that insulin needs to be given by an injection and that insulin injections do not give the same minute by minute blood sugar control that normally would happen if the pancreas was working properly. Sometimes blood sugar can get too low, a problem that needs to be corrected quickly.
What about taking pills for diabetes? Many dialysis patients with type 2 diabetes have prescriptions for one or more pills that will help lower blood sugar. Unfortunately, people with type 1 diabetes will not get any benefit from oral diabetes medicines. While blood sugar pills have been around for a long time, many new products have been developed in recent years. These products are designed to help the pancreas produce more insulin and to help the body use more efficiently the insulin that is produced in the pancreas. There is also good news and bad news about diabetes pills. The good news is that they can be taken by mouth. The bad news is that they also can cause the blood sugar to go too low. Sometimes, it may be necessary to take diabetes pills in combination with insulin in order to achieve the desired blood sugar goal that your doctor sets for you.
Sugar, Is It My Enemy as a Diabetic?
Carly Truwe, Dietetic Intern
Fran Kittell, RD
Whether it is in the news, in a magazine, or a new celebrity is promoting their latest book, the topic of nutrition seems to be everywhere. In this carbohydrate conscious society it is hard to sort the facts from the fads, and if you are a person with diabetes, you may begin to think that there is not much out there to eat. Are carbohydrates okay? Can I eat fat if I am supposed to be losing weight? Will these high in protein, 'eat all the bacon you want' diets work for me? Let's start at the beginning…we are not going to discuss a specific diet, just a general way of healthy eating.
Whether you are diabetic or not, the key to healthy eating is moderation and variety. Sugar is not your enemy. The new nutrition guidelines discuss how moderate amounts of sugar can be eaten safely. Sugar and starch are carbohydrates that raise your blood glucose level when you eat them. Sugar found in candy and baked goods are called simple sugar. This kind of sugar is digested and absorbed quickly. Vegetables and grains contain starches called complex carbohydrates. Starches have fiber mixed with them that slows down the speed at which your body uses this carbohydrate. For many years nutritionists and diabetes specialists have believed that because sugar is digested and absorbed more quickly than starch, it raises the level of blood glucose faster. Researchers have now found that the total amount of carbohydrates that you eat, not the source, affects blood glucose levels.
This does not mean that you can eat all the cakes and cookies you want. Remember, foods high in sugar are often high in fat and calories and do not satisfy your appetite. Complex carbohydrates are nutrient-dense foods that will satisfy your hunger for a longer period of time compared to simple sugars. By eating enough sugary foods to satisfy your appetite, you might eat too much carbohydrate, raising your blood glucose level too high. For this reason, eating sugary foods in moderation is a key component to a healthy diet. The majority of carbohydrates in your diet should come from complex carbohydrates; but a small amount of sugar can be part of a balanced diet. Remember, moderation and variety. Eat your way to a healthier you!
For additional information and recipe suggestions, please visit the following websites:
- USDA's My Pyramid: http://www.MyPyramid.gov/
- Culinary Kidney Cooks: http://www.culinarykidneycooks.com//
- American Diabetes Association: http://www.diabetes.org/
The Results are In!
Jan Schuh, RN BSN CNS
Several months ago you completed the second annual patient education survey. Thank you to the 81 of you who participated. The top ten topics you wanted to learn more about are listed below.
The survey is a helpful way for WDI to gauge the interest and education needs of patients and families. For example in the 2004 survey many patients were interested in having a support group. As a result, the EASIER program was developed. EASIER is the support and education group that I, along with Chaplain Penny Andrews conduct every month. Penny and I have used the results of the 2004 and 2005 survey to help guide topic selection.
Over the last few months the EASIER program has covered topics on transplantation, exercise, and living longer. Our August meeting will focus on protecting your heart from heart disease. EASIER meets the second Wednesday of every month at 4:30pm in the WDI conference room. Some meetings are taped. For those of you who have not been able to attend, ask to view the videotaped version.
Ann and Fran, the WDI dietitians have responded to your interest in learning more about exercise. This is the second year the exercise program has been offered. Exercise will go a long way in helping you maintain a healthy heart and manage your blood pressure. Sign up now by talking with the dietitians Ann and Fran! There will be an awards banquet, along with prizes at the end of the program.
You also indicated an interest in managing fluids. The social workers offered a class on fluid restrictions and controlling thirst. If there is enough interest they would be willing to present this again. Traveling to other units to dialyze was addressed in the last newsletter. If you missed this issue see Anastasia to get a copy. The dietitians and Lesli, RN both work with calcium and phosphorous balance and have many handouts, videos etc. on this topic
Finally, you can speak with members of the dialysis staff for more information regarding topics of interest. I am happy to speak with you on an individual basis on any of the survey topics. Your primary nurse or Doctor can provide further information. They can review your medications, discuss your lab results, to include your URR, why you have kidney disease, and problems with sleep. There are also handouts and pamphlets on display in the corridor for you to take. If there is anything we do not have and you would like to read or learn more about please let me know.
| Survey Topic |
Responses |
| 1. Preventing heart disease, controlling potassiu |
44 |
| 2. Keeping bones strong- calcium, phosphorus balance |
41 |
| 3. Fluid restriction, controlling thirst |
37 |
| 4. Why I have kidney disease, what kind do I have |
33 |
| 5. How well am I dialyzed- what is URR, kt/V |
30 |
| 6. Exercise, what kind, best time to do |
28 |
| 7. Traveling, making arrangements to go to other units |
27 |
| 8. Problems with sleep |
27 |
| 9. Medication review |
25 |
| 10. Blood pressure, high and low, how to treat it |
24 |
From the Director's Chair:
Diabetes and Vascular Health on Dialysis
Paul Kellerman, Medical Director
There are close to 400,000 U.S. patients on dialysis, and this number unfortunately is growing fast. Approximately half of dialysis patient have diabetes as the cause of their kidney failure. The two major causes of kidney failure are diabetes and hypertension, accounting for about three quarters of dialysis patients. We know that both diabetes and hypertension is increasing in this country, primarily due to the epidemic of obesity over the last 20 years.
Approximately 40% of patients with diabetes develop kidney disease, known as diabetic nephropathy. We also know that we can slow the progression of the kidney disease in patients not yet on dialysis with blood pressure control, sugar control, dietary protein restriction, and certain medications. Hopefully, this will keep some people with diabetic kidney disease off of dialysis.
If you are one of our diabetic patients reading this, you are likely one of the 40% of diabetics who had kidney disease. As a diabetic on dialysis, you may wonder why diabetes control matters once your kidneys no longer function. Diabetes is a disease of small blood vessels that supply blood to all the tissues and organs. High blood sugar results in exposure of your body tissues to sugar by-products that are toxic to blood vessels, particularly very small blood vessels. Thus, aside from the kidneys, the heart, the brain, the nerves, and the eyes are targets for damage from diabetes. Also, because this is a disease of blood vessels, there is early hardening of the arteries, causing early heart attacks, strokes, and poor circulation to the feet. When there is numbness in the feet due to the nerve damage, along with poor circulation, a minor bump that you may not even notice can turn into a foot ulcer. Foot ulcers often don't heal well due to the poor circulation, and can become infected deeply into the bone underneath.
So our concern is most for your "vascular health", to prevent heart attacks, strokes, and circulation, eye and nerve problems. Control of blood sugars is critical to lowering your risk for these serious complications of diabetes, along with control of other risk factors for vascular disease, such as high blood pressure, high blood fats, and smoking.
Every three months, we routinely check a test called a Hemoglobin A1C (HgA1C). This test measures the sugar coating the red blood cells in your blood, and gives you and your caregivers an idea of what your average blood sugars have been running over the last few months. Our goal is to have the HgA1C less than 7% each time we measure it. But this is only a "report card" every three months. The idea is to keep your blood sugars between 100 and 150 mg/dL all of the time, mimicking what it would be like if you did not have diabetes. In some people, this can be done by dietary restriction of sugar alone. Other people may need pills, and some people need insulin injections. It is fairly common for people to need less insulin when they come to dialysis. Our pharmacist, Curt Johnson, has reviewed these medications in his article. But the ONLY way for you to control your blood sugars is to measure the values with a glucometer every day. Particularly with people on medications, we advise measuring sugars 4 times per day - before meals and at bedtime. If this is done, you and your caregivers can help fine-tune the sugars to keep them in a healthy range all day long.
So what can you do if you are a diabetic on dialysis to improve your vascular health? First, test your sugars, record them, and bring them to your doctor (either your primary physician or your nephrologist) so that your diet and medications can be adjusted appropriately. Second, if you smoke, STOP! Your doctors can help you stop smoking with certain medications. Third, work with your kidney doctor to control your blood pressure. Fourth, work with your doctor to control your blood fats (cholesterol and triglycerides). Fifth, monitor your feet daily, looking for any bruising, sores or calluses, and notify your doctor immediately if a lesion appears. Sixth, you should have an eye examination by an ophthalmologist (an M.D. eye specialist) yearly.
Diabetes is a disease where the patient often knows as much or more about their disease than their doctor, because there is so much self-care involved in testing blood sugars and administering insulin. Become an active partner in your diabetes care, and work closely with your doctor to keep your blood vessels, your heart, your brain, your eyes and your nerves in the best shape possible!
Hey, what's the news at WDI? To find out …read on…
- EASIER continues to be a popular support and education program for many of our patients. The last presentation on "Living Well" was so "well" received that the July 13th meeting at 4:30 will be on "Living Well Part II". Hope to see you there!
- WDI's own Dr. A. Vishnu Moorthy is on the Web! Dr Moorthy presented a lecture "Kidney Disease in People with Diabetes: Diagnosis and Management". This is an informative lecture for anyone with diabetes. To hear his webcast log on to http://dhfs.wi.gov/webcast/. Once at the location scroll down until you see the title of the program which was delivered on 5/26/05. Remember, you must have audio on your computer.
- Speaking of the Web, check out the Pathways newsletter on the WDI website at www.wisconsindialysis.org.
- If you are a member of the Wisconsin Chronic Renal Disease (WCRD) program, you should have already received an application to reapply. Remember, the WCRD program must be applied for every year in order for it to continue. If you have questions about the WCRD program ask to speak with your social worker
- The exercise program is going strong. There are nearly 50 patient participants. If you wish to be involved in a program that will help you get that body moving, attend a party and receive a prize, talk with Ann or Fran about signing up!
Looking for the sweetness in life…
Penny Andrews, Chaplain
A couple of phrases came to mind when asked to write something for this issue on diabetes. When life hands you lemons… You know how it goes, 'make lemonade'. Another one is 'look for the silver lining'.
Diabetes challenges one to 'choose life' with every food taken in, and to look for the sweetness in many parts of life not just at the dinner table.
Take stock of your life for a moment, what sweetens your life? Can you list at least three aspects of your life right now that does just that? Some people can be challenged by that question.
I propose the following exercise:
For the next couple of days, pay close attention for an encounter, a moment, an unexpected experience that does indeed sweeten your day. Make note of it, and then say to yourself, 'Thanks'. Some-how, this mental action seems to increase the objective that you are taking note and acknowledging.
In fact a daily affirmation you might want to try just before drifting off to sleep is saying to yourself, 'tomorrow, I will notice three things that sweeten my life.' When you wake in the morning first thing you say to yourself is, 'Today, I will notice three things that sweeten my life'. If you really give this a chance to work, my hunch is that you will find at least three and many more 'sweets'. Try to make this a daily bedtime and morning affirmation.
May sweet things come your way in many different packages----
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