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Developing a chronic disease is not your fault, although many women who develop type 2 diabetes may feel this way, especially when obesity is an issue. If you are diagnosed with diabetes, it is essential that you receive comprehensive information—whether from a primary health care professional, certified diabetes educator or endocrinologist—on how to manage your condition and avoid complications.

Guidelines released in August 2001 by the American College of Endocrinology (ACE) and the American Association of Clinical Endocrinologists (AACE) recommend more stringent treatment standards and lower screening age for people at high risk for diabetes, especially among individuals of ethnic backgrounds. According to the American Diabetes Association, diabetes is developing at younger ages in high-risk groups.

As many as 70 percent of people with diabetes don't have access to the help they need to adequately manage their condition. In addition, learning diabetes management skills takes time. People with diabetes need to regularly review and revise their strategies for managing their disease, under the guidance of their health care professionals.

Women with diabetes should be seen regularly by a health care professional who monitors their diabetes and checks for complications. Health care professionals who specialize in diabetes are called endocrinologists or diabetologists. In addition, people with diabetes often see ophthalmologists for eye examinations, podiatrists for routine foot care, and dietitians for help in planning meals and diabetes educators for instruction in day-to-day care.

The goal of diabetes management is to keep blood glucose levels as close to normal as possible to prevent complications associated with the condition. One government study proved that keeping blood sugar levels as close to normal reduces the risk of developing major complications of diabetes. The National Diabetes Education Program urges people with diabetes to control not only their blood glucose, but also their blood pressure and cholesterol. This comprehensive management of diabetes is crucial to helping prevent heart attack and stroke.

Living with diabetes can be overwhelming at times. Like all chronic diseases, it affects every aspect of your daily routine. Diabetes management is not as simple as just taking a pill. It requires timing of meals, checking blood sugar and being vigilant about exercise, all in accordance with a personalized management plan developed in consultation with health care professionals.

Managing What You Eat

Your blood sugar can plunge or skyrocket, depending on what you eat. Food is a mixture of fats, proteins and carbohydrates. All three are necessary parts of a healthy eating plan, but people with diabetes need to be most concerned about carbohydrates.

Carbohydrates in food end up as sugar when they are absorbed into the bloodstream. The more carbohydrates you eat, the higher your blood sugar level. Although all carbohydrates raise blood sugar, different foods have different effects, depending on the type of food, which foods your carbohydrates are eaten with, and how the food is prepared.

Raw foods for example, are digested more slowly than cooked foods. Foods that are broken down more slowly release glucose into the blood more slowly. Foods that contain fat also take longer to digest than foods without fat. That's why an ice cream cone or a chocolate bar may not cause blood sugar levels to rise as quickly as you might expect. Checking your blood sugar two hours after eating carbohydrates is the best way to learn the effects of different foods.

Moderation is key. At one time, people with diabetes were told not to eat sweets at all. Today, sweets and snacks are allowed, but portions need to be small and balanced during the day.

Unlike carbohydrates, fats do not raise blood sugar levels but fatty foods do add pounds. Plus, a high-fat diet increases your risk for heart disease.

For women with type 1 diabetes, who must take insulin daily, balancing food intake with insulin and exercise is essential to prevent high blood sugar (called hyperglycemia) or low blood sugar (called hypoglycemia) in which blood sugar levels dip below 70 mg/dl.

Hypoglycemia can occur suddenly. Early indicators of low blood levels include: shakiness and sweating, dizziness, pounding heart, weakness and hunger. Both hyperglycemia and hypoglycemia can be life threatening

To determine how much insulin is needed to prevent hypoglycemia, it is important to know how meals and snacks influence blood sugar levels. Generally, the more carbohydrates you eat, the more insulin you need; while the fewer carbohydrates you eat, the less insulin you need. Still, only by checking blood sugar after eating can you know the effect of different kinds and amounts of food.

The American Association of Clinical Endocrinologists (AACE) nutritional guidelines for people with diabetes emphasize that no clear-cut formula exists for carbohydrate, fat or protein intake, but that the key is the amount of calories you take in compared to the amount you expend via physical activity. Specifically:

• Protein should be 10 to 20 percent of your total calories.

• Fat Intake: Normal intake of fat should be limited to a maximum of 30 percent of the total caloric intake. Each gram of fat contains nine calories compared to four calories for each gram of carbohydrate or protein. In overweight persons or those with high cholesterol levels, fat intake should be as low as 15 percent of the caloric intake.

• Carbohydrate: The average amount of carbohydrate recommended for patients with diabetes is 55 to 60 percent of total calories.

• Cholesterol: Limit dietary cholesterol to less than 300 mg daily.

• Alcohol: The effect of alcohol on blood glucose in diabetes has always been confusing. If possible, patients with diabetes should avoid or limit the use of alcohol because it's difficult to predict its effects on blood glucose. The effect depends not only on the amount of alcohol ingested but also on the amount of alcohol ingested in relationship to food consumed. If you drink alcohol without food and you're using insulin or other glucose-lowering agents, you can develop hypoglycemia.

  When calories from alcohol need to be calculated as part of your total calories, substitute it for a fat exchange (one alcoholic beverage = two fat exchanges) or fat calories.

  Ideally, however, you should avoid alcohol if you have a history of alcohol abuse, pancreatitis, high cholesterol, neuropathy or are pregnant.

In addition to AACE recommendations, the American Diabetes Association also provides nutritional guidelines for people with diabetes. These include:

• Account for calories and carbohydrate content from all nutritive sweeteners (sucrose, fructose, corn syrup, fruit juice, honey, molasses, dextrose, maltose, sorbitol, mannitol and xylitol). They can affect blood glucose levels.

• People with diabetes can use the sweeteners saccharin, aspartame, acesulfame K and sucralose as an addition to their meal plans because these sweeteners do not count as a carbohydrate, fat or other exchange.

• Fiber: Try to get 20 to 35 grams dietary soluble and insoluble fiber.

• Sodium: People differ in their sensitivity to sodium and its effect on blood pressure. Limit your intake to 2300 mg per day. Because it is impractical to assess how sensitive you are to sodium, sodium recommendations for people with diabetes are the same as those for the general population.

• Vitamins and minerals: For added nutritional benefits, talk to your health care professional about taking a daily multivitamin.

Weight Management and Exercise

Almost 90 percent of people newly diagnosed with pre-diabetes or type 2 diabetes are overweight, making weight management very important.

Although we still don't know why, being overweight makes you less responsive to insulin, while losing weight has the opposite effect. You don't have to lose 40 pounds to see an improvement. Even losing 10 pounds helps. The focus for women with diabetes should be on improving blood glucose levels, however, not on the scale.

Exercise is another cornerstone of any diabetes treatment plan. Besides burning calories and promoting weight loss, exercise reduces blood sugar levels and makes cells more sensitive to insulin, allowing some people with diabetes to use less medication.

Exercise has psychological benefits too. People who exercise are generally more aware of their bodies and the factors that affect their blood sugar. They often have a more positive outlook and are better able to manage their condition. Improved self-focus, self-esteem and positive outlook may be especially important for women.

Regular exercise is an essential part of managing type 1 diabetes, too, but management of blood sugar during exercise can be complicated. Those with type 1 diabetes have to adjust their food or insulin to keep their blood sugar from getting too high or too low. A vigorous workout, for example, can increase the amount of glucose the liver releases into the bloodstream, causing blood sugar levels to rise, especially right after exercising. Strenuous exercise can push high blood sugar levels even higher if there isn't enough circulating insulin available, leading to a life-threatening condition called diabetic ketoacidosis.

Women with type 2 diabetes may also have low blood sugar after exercise, especially those using oral medications or insulin. Low blood sugar can last for hours as the muscles use glucose from the blood to replenish that used during a workout.

Thus, it's important to know and heed the signs of low blood sugar and be prepared to adjust meals or medication to keep sugar levels from plummeting. You need to check blood sugar levels before, during and after exercise to see what affect your workout has. No two people with diabetes will have the same response to exercise.

Before starting an exercise program, check with your health care professional. Exercise is a two-sided coin. It is the most important thing you can do to improve blood sugar and prevent diabetes complications, but the wrong type of exercise can make diabetes-related problems worse. Bouncing can aggravate diabetic eye disease, for example. Exercises that strain the upper body or require heavy lifting can raise blood pressure. Activities such as running and high-impact aerobics may be too hard on the feet and legs if you have any nerve damage.

To avoid injury, start slowly and don't overdo the intensity. Be sure to include a warm-up and cool-down phase. And understand that the effect of exercise on insulin resistance is short-lived. You have to stay with it to see improvement.

Exercise doesn't have to be sports-oriented or vigorous, however. It can be recreational, such as gardening, hiking, swimming or dancing. Brisk walking is one of the best things to do. Exercising for at least 20 minutes every day is essential; if you're trying to lose weight, aim for at least 30 minutes a day.

These guidelines can help keep exercise safe and healthy:

• Ask your health care professional what blood sugar and heart rate guidelines to aim for before, during, and after exercise.

• Do not exercise until one to three hours after a meal or snack.

• Do different activities, such as walking, biking and swimming, to stay motivated and to lessen the chance of injury.

• Carry medical ID and never exercise alone.

• Keep a log to track blood sugar response to different types of exercise.

• Keep a source of concentrated carbohydrate like a soft drink or raisins available in case blood sugar levels drop.

• Check your feet for blisters, bunions and calluses.

• Wear pool shoes in the pool to avoid scraping the soles of your feet.

• Don't exercise in extreme temperatures.

• Don't exercise if you have untreated eye problems such as blurred vision.

• If you have heart disease or high blood pressure, avoid exercises such as pushing against a wall or lifting and holding heavy weights, that involve keeping your muscles contracted.

Medical Treatments

Along with lifestyle modifications, medical treatment is also essential to the management of type 1 diabetes. While not a cure, insulin is the most powerful glucose-lowering agent available. Insulin therapies administered two times or more per day through injections or other methods can stabilize and manage the disease, helping delay or avoid complications.

Unfortunately, most insulin is still primarily administered as an injection, using a small short needle. However, investigators are exploring ways of making it easier to take, including patches, surgically implanted capsules and inhaler devices. In fact, the FDA approved the first inhaled powder form of insulin—Exubera—in early 2006 for treating adult patients with type 1 and type 2 diabetes.

It's doubtful that insulin will ever be developed as a pill, because it is a protein; that means your body would break it down and digest it before it could get into your bloodstream.

Insulin devices have become more convenient in recent years. Insulin pens, for example, can be helpful if you take at least three doses of insulin a day and want to carry insulin with you. An insulin pen looks like a pen with a cartridge that holds 150 or 300 units of insulin. A fine, short needle, similar to the needle on an insulin syringe, is on the tip of the pen. You turn a dial to select the desired dose of insulin and press a plunger on the end to deliver the insulin just under the skin.

The FDA has also approved insulin jet injectors, which look like large pens and send a fine spray of insulin through the skin by a high-pressure air mechanism. Insulin jet injectors are costly, so try out several models before you purchase one.

There are six types of insulin with varying speeds of action. They range from rapid- acting, which reduces blood sugar levels within five minutes after injection, to very long-acting, which works evenly for 24 hours. Many people with insulin-dependent diabetes take two different types of insulin. How quickly or slowly insulin works in your body depends on your own response, where on your body you inject insulin, the type and amount of exercise you do and the length of time between your shot and exercise.

If you have type 2 diabetes, you can avoid insulin as long as your body makes enough insulin. However, because diabetes is a progressive disease, most people eventually need medication to help their body better use insulin, and some eventually require insulin.

Medications used to manage type 2 diabetes can be divided into two groups: Those that augment your own supply of insulin and those that make your own insulin more effective.

Insulin-Augmenting Agents

• Sulfonylureas stimulate the beta cells of your pancreas to secrete more insulin. Examples include: glyburide, glimepiride (Amaryl) and extended-release glipizide (Glucotrol XL).

• Meglitinides also stimulate your pancreas to make more insulin, but have a shorter onset of action and shorter half-life than the sulfonylureas. The drug in this class is repaglinide (Prandin).

• D-phenylalanine derivatives help the pancreas produce insulin earlier after a meal and release the insulin for a shorter time compared to sulphonylureas. This helps lower your blood glucose after you eat a meal and is less likely to cause low sugars several hours after the meal. Nateglinide (Starlix) currently is the only medicine in this relatively new group of diabetes pills.

Insulin-Assisting Agents

• Alpha-glucosidase inhibitors slow the absorption of carbohydrates you eat, thus preventing blood glucose levels from rising too much. They work by inhibiting a specific enzyme found in the small intestine, which normally breaks down carbohydrates into sugars. Acarbose (Precose) and miglitol (Glyset) are the two insulin-assisting agents currently available in this class.

Insulin Sensitizing Agents

• Biguanides help your liver respond better to insulin, decreasing the amount of sugar it releases. Other beneficial effects include a reduction in plasma triglyceride levels and low-density lipoprotein (LDL) cholesterol levels. Metformin (Glucophage and Glucophage XR [extended-release]) are currently the only agents in this class available in the US. Both Glucophage and Glucophage XR contain a "black box warning" stating that they may cause lactic acidosis, the buildup of lactic acid in the body.

• Thiazolidinediones are insulin sensitizers that work to overcome insulin resistance by making the body's cells more sensitive to insulin. Pioglitazone (Actos) and rosiglitazone (Avandia) are examples of drugs in this class.

If one type of medication alone fails to control your blood sugar, your health care professional may prescribe two or three of these medications, or one or more of them with insulin.

Of course, taking certain glucose-lowering medication can push blood sugar too low (which is hypoglycemia), as can skipping a meal or eating too little, exercising more than usual or drinking alcohol. You will know your blood sugar is low (70 mg/dL or less) when you feel one or more of the following: dizzy or light-headedness, hungry, nervous and shaky, sleepy or confused or sweaty. Test your glucose to make sure it's low, and if it is at or below 70 mg/dL, consume 15 grams of carbohydrate—for example, drinking a half cup of juice or one-third of a cup of regular (not diet!) soda.

On the other hand, a person can become very ill if blood sugar levels rise too high, a condition known as hyperglycemia. Hypoglycemia and hyperglycemia, which can occur in people with type 1 diabetes or type 2 diabetes, are both potentially life-threatening emergencies.

Ask your health care professional or diabetes teacher about the best testing tools for you and how often to test. Many glucose monitors are available, ranging widely in price and features. In addition to monitor prices, compare costs of supplies—sensors, test strips and solutions—because in the long run, these add up to more than the monitor cost. Most monitors require needle sticks, but less invasive products are available.

Verify your monitor's accuracy and your skill at conducting the test by taking it with you to an appointment with a health care professional and running the test at the same time as a venous test. The doctor's test should come within 15 percent of your monitor's number.

You should track your readings with a log or diary (often available from your health care professional). Increasingly, patients and their health care professionals can use computerized systems to upload meter results and automatically generate comprehensive charts. Also, the simple statistics and graphs built into the monitor itself can be helpful.

The American Diabetes Association (ADA) recommends that those with type 1 diabetes have their A1C levels tested every three months and those with type 2 diabetes have them tested at least every six months. This test measures how much glucose has become attached to a protein called hemoglobin in your red blood cells. Because the glucose sticks to the hemoglobin for several months, it provides a long-term picture of your blood glucose control.

While home A1C tests are available, the ADA recommends your first one should be conducted under the guidance of a health care professional.

Ideally, your results should be below seven percent.

Other Considerations with Diabetes

• Drugs. If you have diabetes, you should always consult with your health care professional when considering taking any medication, even over-the-counter remedies.
• Menopausal hormone therapy. Menopausal hormone therapy may pose risks for diabetic women in addition to the risks identified in 2002 by the Women's Health Initiative (WHI). Specifically, the hormone therapy used in the study increased levels of triglycerides (a type of fat-like cholesterol found in the bloodstream), a red flag for women with diabetes, who may have higher triglyceride levels to begin with.

  If you are currently using hormone therapy, talk with your health care professional first before stopping your medication.