Iam a Diabetic.How low should be my Cholesterol

People with diabetes are at high risk for heart disease.Unfortunately, many people are unaware of their risk. Heart disease is one of the most serious diabetes complications, accounting for the majority of diabetes-related deaths.In fact, heart attacks occur at an earlier age in people with diabetes and often result in premature death.Keeping your Cholesterol level with in the specified target is the best way to prevent Heart attack.

A diabetic patient should measure total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides at least once a year.If the levels are high more frequent testing may be needed to see the effect of treatment. LDL cholesterol is more important than total cholesterol for telling whether someone has unhealthy fat levels.
Targets for Lipids are:-

LDL cholesterol should be below 100 mg/dL.

HDL cholesterol should be greater than 50 mg/dL in women and 40 mg/dL in men.

Triglyceride levels should be less than 150 mg/dL.

Action should be taken when LDL cholesterol levels are 100 mg/dL or higher. Generally, lifestyle changes such as losing weight, becoming more active and improving diet will help. If LDL cholesterol is still too high, the person should continue with these steps and start taking a cholesterol-lowering drug.

However, people who already have heart disease or who have high LDL cholesterol levels (200 mg/dL or higher) may have to be started on drugs along with lifestyle changes.

Apolipoproteins

Lipoproteins are complexes of fat and protein, whose main function is to transport lipids. . There are many different apolipoproteins, including:

Apo A1: the major apoprotein of HDL and is a relatively abundant plasma protein

Apo B: the main apolipoprotein of chylomicrons and low density lipoproteins

Apolipoprotein B is a measurement of the total number of atherogenic particles and is therefore thought to be a better marker of risk of Heart Attack and Stroke and a better guide to the adequacy of Cholesterol lowering treatment than any cholesterol index
Apo B should be less than 80mg/dl

The ratio of apolipoprotein B/apolipoprotein A-1 seems superior to the ratio of total cholesterol/HDL cholesterol as an overall index of the risk of heart attack and stroke
The ratio should be less than 0.5

I am a Diabetic.How low should be my blood pressure?

An important part of taking care of yourself is keeping your blood pressure under control. High blood pressure -- also called hypertension -- raises your risk for heart attack, stroke, eye problems, and kidney disease. As many as two out of three adults with diabetes have high blood pressure. Having your blood pressure checked regularly and taking action to reach your blood pressure target can prevent or delay diabetes problems.

What is blood pressure?


Everybody has — and needs — blood pressure. Without it, blood can't circulate through the body. And without circulating blood, vital organs can't get the oxygen and food that they need to work. So it's important to know about blood pressure and how to keep it within a healthy level. Normal blood pressure falls within a range; it's not one set of numbers.

When the heart beats, it contracts and pumps blood to the arteries and creates pressure in them. This pressure (blood pressure) results from two forces. The first force is created as blood pumps into the arteries and through the circulatory system. The second is created as the arteries resist the blood flow.

If you're healthy, your arteries are muscular and elastic. They stretch when your heart pumps blood through them. How much they stretch depends on how much force the blood exerts.

What do blood pressure numbers indicate?

The higher (systolic) number represents the pressure when the heart is contracting and pumping blood.
The lower (diastolic) number represents the pressure when the heart is resting between contractions.
The systolic pressure is always stated first and the diastolic pressure second. For example: 138/86 (138 over 86); systolic = 138, diastolic = 86.


Your heart beats about 60 to 80 times a minute under normal conditions. Your blood pressure rises with each heartbeat and falls when your heart relaxes between beats.
Your blood pressure can change from minute to minute, with changes in posture, exercise or sleeping,
Your blood pressure should normally be less than 120/80 mm Hg (millimeters of mercury) for an adult.
Blood pressure that stays between 120–139/80–89 is called prehypertension
Blood pressure that stays between 140/90 mm Hg or higher is considered high (hypertension).
Your doctor may take several readings over time before deciding whether your blood pressure is high.


What is the recommended target for blood pressure in Diabetes?


Both diabetes and high blood pressure increases your risk of heart attack, stroke, and eye and kidney disease. Because of this, people with diabetes have a lower blood pressure target than the general public. Lower the blood pressure lesser the chance of complication.
The current recommended target for blood pressure in Diabetes is less than 130/80 mmHg. When you keep your blood pressure below 130/80 mmHg, you'll be lowering your risk for diabetes problems.

How will I know if I have high blood pressure?


High blood pressure is a silent killer.It will not produce headache,giddiness or anger.
Only you will know when you measure it.

Most probably you won't know you have it unless your doctor/nurse checks your blood pressure and finds out. It is recommended that you have your blood pressure checked at every visit to your Clinic, or at least two to four times a year.

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WISH EACH ONE OF YOU A VERY HAPPY ONAM

HbA1c and estimated average Glucose

What is HbA1c?

Hemoglobin is the oxygen-carrying pigment that gives blood its red color and also the predominant protein in red blood cells. About 90% of hemoglobin is hemoglobin A. (The "A" stands for adult type) Hemoglobin A1c (HbA1c) is a minor component of hemoglobin A to which glucose is bound. HbA1c also is referred to as glycosylated or glucosylated hemoglobin.

In the normal 120-day life span of the red blood cell, glucose molecules join hemoglobin, forming glycated hemoglobin. Higher the amount of glucose in blood, more glucose gets attached to Hemoglobin there by increasing the percent of HbA1c.

Once a hemoglobin molecule is glycated, it remains that way. A buildup of glycated hemoglobin within the red cell reflects the average level of glucose to which the cell has been exposed during its life cycle. Measuring glycated hemoglobin assesses the effectiveness of therapy by monitoring long-term serum glucose regulation. The HbA1c level is proportional to average blood glucose concentration over the previous four weeks to three months.[ HbA1c is most dependent on the blood glucose values of last 4 weeks.So it is not a very true average of 3 months]





How is HbA1c measured?

A chemical (electrical) charge is present on the molecule of HbA1c, and the amount of the charge differs from the charges on the other components of hemoglobin. The molecule of HbA1c also differs in size from the other components. HbA1c may be separated by charge and size from the other hemoglobin A components in blood by a procedure called high pressure (or performance) liquid chromatography (HPLC). HPLC separates mixtures (e.g., blood) into its various components by adding the mixtures to special liquids and passing them under pressure through columns filled with a material that separates the mixture into its different component molecules. Because HbA1c is not affected by short-term fluctuations in blood glucose concentrations, for example, due to meals, blood can be drawn for HbA1c testing without regard to when food was eaten.

Why measure HbA1c?

HbA1c levels depend on the blood glucose concentration. That is, the higher the glucose concentration in blood, the higher the level of HbA1c. Levels of HbA1c are not influenced by daily fluctuations in the blood glucose concentration but reflect the average glucose levels over the prior six to twelve weeks. Therefore, HbA1c is a useful indicator of how well the blood glucose level has been controlled in the recent past and may be used to monitor the effects of diet, exercise, and drug therapy on blood glucose in diabetic patients.

In healthy, non-diabetic patients the HbA1c level is less than 6% of total hemoglobin. It has been demonstrated that the complications of diabetes can be delayed or prevented if the HbA1c level can be kept close to 7%.

What are the limitations to measuring HbA1c?

Since HbA1c is not influenced by daily fluctuations in blood glucose concentration, it cannot be used to monitor day-to-day blood glucose concentrations and to adjust insulin doses nor can it detect the day-to-day presence or absence of hyperglycemia or hypoglycemia.

HbA1c may be increased falsely in certain medical conditions. These conditions include uremia (kidney failure), chronic excessive alcohol intake, and hypertriglyceridemia. Medical conditions that may falsely decrease HbA1c include acute or chronic blood loss, sickle cell disease or thalassemia. Diabetes during pregnancy, commonly referred to as gestational diabetes, may falsely increase or decrease HbA1c.


HbA1c is a difficult test to perform and lab errors are common especially if done after transportation of the sample in an improper way or if done at a less experienced centre.

What is eAG [estimated average glucose]

It is the HbA1C derived estimate of average glucose using a special formula.Now eAG is considerd more patient friendly than HbA1C though it is derived from measurement of A1C itself
The relationship between A1C and eAG is described by the formula 28.7 X A1C – 46.7 = eAG

Insulins and other Injections to control blood sugar

What is Insulin and how it works?

Inside the pancreas, beta cells make the hormone insulin. With each meal, beta cells release insulin to help the body use or store the blood glucose it gets from food. In people with type 1 diabetes, the pancreas no longer makes insulin. The beta cells have been destroyed and they need insulin shots/injections to use glucose from meals.
People with type 2 diabetes make insulin, but their bodies don't respond well to it. Some people with type 2 diabetes need diabetes pills or insulin injections to help their bodies use glucose for energy.

Insulin cannot be taken as a pill. The insulin would be broken down during digestion just like the protein in food. Insulin must be injected into the fat under your skin for it to get into your blood.

There are many different insulins for many different situations and lifestyles and there are more than 10 types of Insulin in the market. These insulins differ in how they are made, how they work in the body, and price. Insulin is made in labs to be identical to human insulin or it comes from animals (pigs/Cows].

Types of Insulin
Different types of insulin preparations are distinguished by the speed at which the injected insulin is absorbed from the layer under the skin into the blood (onset of action) and by the time it takes for all the injected insulin to be absorbed (duration of action).
It is important to note that the duration and absorption times described below are only approximate. Absorption of insulin always depends on individual factors.

Insulin analogues

Rapid-acting insulin analogue

Onset: 10-20 minutesMaximum effect: 1-3 hours Duration: 3-5 hours
Eg;insulin lispro (Eli Lilly), insulin aspart (Novo Nordisk), or insulin glulisine (sanofi-aventis),

Long-acting insulin analogue



Onset: 1 hour Duration: 24 hours
Eg;glargine[Lantus] and detemir[Levemir]

Biphasic insulin analogue



Onset: 10-20 minutesMaximum effect: 1-4 hours Duration: up to 24 hours
Eg; Novomix,Humalog

Human insulins

Short-acting insulin(soluble human insulin)

This insulin comes in a clear solution, and is intended to be given at meals. An injection should be followed by a meal or snack containing carbohydrates within 30 minutes.



Onset: within 30 minutesMaximum effect: 1-3 hours Duration: 8 hours
Eg;Actrapid,Humisulin R

Intermediate-acting insulin(isophane human insulin, NPH)

An insulin formulation that contains a substance, which delays the absorption of insulin. The combination of insulin and a delaying substance usually results in the formation of crystals that give the liquid a cloudy look. The insulin crystals must be homogenised (mixed) evenly before each injection. Intermediate-acting insulin takes approximately 1 1/2 hours before it begins to have an effect. The largest effect occurs between 4 and 12 hours after the injection, and after approximately 24 hours, the whole dose has been absorbed.



Onset: within 1.5 hours Maximum effect: 4-12 hours Duration: 24 hours
eg;Human Insulin N,Insulatard
Premixed insulin(biphasic human insulin consisting of e.g. 30% soluble and 70% isophane insulin)
Insulin containing a combination of a short-acting and an intermediate-acting insulin in standard proportions. These products eliminate the difficulty some individuals have while mixing insulin. The products come in several different premixed combinations containing 10-50% short-acting insulin and 90-50% intermediate-acting insulin, with the ratio of 30% short acting and 70% intermediate acting being the most used.



Onset: within 30 minutes Maximum effect: 2-8 hours Duration:24 hours
eg; Human Mixtard,Huminsulin 30/70

Two new injectable drugs that are not Insulins recently been approved for use in Diabetes
Pramlintide (brand name Symlin) is a synthetic form of the hormone amylin, which is produced along with insulin by the beta cells in the pancreas. Amylin, insulin, and another hormone, glucagon, work in an interrelated fashion to maintain normal blood glucose levels.
Pramlintide injections taken with meals have been shown to modestly improve A1C levels without causing increased hypoglycemia or weight gain and even promoting modest weight loss. The primary side effect is nausea, which tends to improve over time and as an individual patient determines his or her optimal dose.
Because of differences in chemistry, pramlintide cannot be combined in the same vial or syringe with insulin and must be injected separately. Pramlintide has been approved for people with type 1 diabetes who are not achieving their goal A1C levels and for people with type 2 diabetes who are using insulin and are not achieving their A1C goals.
Exenatide (brand name Byetta) is the first in a new class of drugs for the treatment of type 2 diabetes called incretin mimetics. Exenatide is a synthetic version of exendin-4, a naturally-occurring hormone that was first isolated from the saliva of the lizard known as a Gila monster. Exenatide works to lower blood glucose levels primarily by increasing insulin secretion. Because it only has this effect in the presence of elevated blood glucose levels, it does not tend to increase the risk of hypoglycemia on its own, although hypoglycemia can occur if taken in conjunction with a sulfonylurea. The primary side effect is nausea, which tends to improve over time.
Like pramlintide, exenatide is injected with meals and, as with pramlintide, patients using exenatide have generally experienced modest weight loss as well as improved glycemic control. Exenatide has been approved for use by people with type 2 diabetes who have not achieved their target A1C levels using metformin, a sulfonylurea, or a combination of metformin and a sulfonylurea.

Modified and adapted from ADA and Novo Nordisk websites

Medicines to Control your Blood Sugar

There are six main groups of tablets you may be prescribed to control your diabetes. The way in which they work to help control your diabetes is described below.
1. METFORMIN
This belongs to a group known as Biguanides
Taken 2- 3 times a day with or after food.
How It Works: Metformin improves your body’s responses to insulin and also stops it making too much sugar. Metformin may be used alone or in combination with other treatments e.g Gliclazide or any of those listed below.

2. GLIBENCLAMIDE, GLICLAZIDE, GLIPIZIDE,GLIMEPIRIDE
These belong to the group known as Sulphonylureas
Taken 1-3 times daily, shortly before food.

How It Works: These stimulate the body to make more insulin because it may not be making enough for your needs. This should then lower your blood sugar levels. These may be used alone or in combination with other treatments such as those below.

3. ACARBOSE, Miglitol,Voglibose;
Belongs to a group known as Alpha-Glucosidase Inhibitors
Taken 1-3 times day
How It Works: by delaying the rate at which you digest sugar, which in turns slows down the rate at which your blood sugar rises after you have eaten. It slows down the uptake of starchy and sugary foods from the intestines.It may be used alone or in combination with other medications. It should be chewed with first mouthful of food or swallowed whole with a little liquid immediately before food.
4. ROSIGLITAZONE and PIOGLITAZONE
These belong to a group called Thiazolidinediones
Taken 1-2 times a day with or without food.
How It Works: Glitazone tablets increase the action of your body’s insulin by helping it work more effectively. It may be used alone or in combination with other medication.
5. REPAGLINIDE and NATEGLINIDE
These belong to a group called Prandial Glucose Regulators
Taken up to 3 times a day before food.
How It Works: These help your body produce the right amount of insulin after meals to cope with the increase in sugar in your blood stream.They work very quickly and should be taken shortly before each main meal.
6. Sitagliptin,Vildagliptin
These belong to a group called DPP4 Inhibitors.
How it works: It works by increasing Insulin secretion and also by decreasing sugar production by Liver.

Type 2 Diabetes Patients Who Lost Weight Soon After Diagnosis Had Better Control

People diagnosed with type 2 diabetes who lose excess weight soon after their diagnosis are up to twice as likely to maintain control of their disease than those who do not lose weight or who gain weight, according to a new study. The study is published in online in Diabetes Care, the journal of the American Diabetes Association.
Even if they regain the weight, as most in this study did, the benefits remain, the researchers found.
People who lose (excess) weight are more likely to attain their blood sugar and blood pressure goals than people who gain weight or maintain a stable weight.
When a patient is newly diagnosed with type 2 diabetes, he/she might already have lost some weight, but may still be over-weight for their height. If they try to control blood sugar with medications alone(especially medicines that increase secretion of Insulin), they will gain weight. So, if an already over-weight patient gains weight on treatment for diabetes, the chances of them attaining target treatment goals is remote.
If vigorous exercise and dieting along with Insulin sensitisers like Metformin are used, the patients may continue to loose weight while attaining normal blood sugar levels. In the long run, such patients attain treatment goals more often, as per the study.

So in management of type 2 diabetes in over-weight patients, the most important treatment is life style modification with low-carb diet and exercise.