My Doctor Online The Permanente Medical Group

Types

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The main types of diabetes are:

• Type 1 diabetes. In this type of diabetes, the pancreas does not produce insulin, and therefore insulin is needed. Type 1 diabetes results from the immune system destroying insulin-producing cells (called beta cells) in the pancreas. Type 1 diabetes is less common and usually develops in childhood or young adulthood.
• Type 2 diabetes. The body is resistant to insulin. Over time, the pancreas does not produce enough insulin. This type of diabetes usually begins in adults; however, children can also develop type 2 diabetes, especially if they are overweight and inactive. Type 2 diabetes often runs in families.
• Gestational diabetes. This condition can develop in pregnant women, although the mother's blood sugar usually returns to normal after pregnancy. The hormones produced during pregnancy cause insulin resistance. If you have gestational diabetes during pregnancy, you have a greater chance of developing diabetes later in life and may require yearly blood sugar tests to look for this.

Prior to developing type 2 diabetes, many people have an elevated blood sugar level that we call prediabetes. With prediabetes, fasting blood glucose (sugar) is slightly elevated but not high enough to be considered diabetes. Having prediabetes means you are more likely to develop type 2 diabetes in the future. However, by losing weight and being more physically active, you can prevent or delay diabetes from developing.

Risk Factors

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The more risk factors that describe you, the greater chance you have of developing prediabetes and type 2 diabetes. Risk factors for developing this type of diabetes include:

• Being overweight.
• Having a family history of the disease: Your parent, brother, or sister has type 2 diabetes.
• Belonging to certain ethnic groups, such as Native American, Latino, African American, or Asian/Pacific Islander, who are at increased risk.
• Giving birth to a baby weighing more than 9 pounds.
• Gaining too much weight during pregnancy.
• Having diabetes during a pregnancy (gestational diabetes).
• Having prediabetes.
• Having high blood pressure.
• Having low levels of high-density lipoprotein (HDL) cholesterol (35 mg/dL or less) or high triglycerides (greater than 250 mg/dL).
• Being a woman with polycystic ovarian syndrome (PCOS).

Symptoms and Complications

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Many people with diabetes do not have any symptoms. If you do experience symptoms of high blood sugar levels, they may include:

• Extreme tiredness.
• Extreme thirst.
• Frequent urination, especially at night.
• Blurry vision or a change in vision.
• Increased hunger.
• Unintentional weight loss.
• Sores or cuts that heal slowly.
• Numbness or tingling in your feet.
• Frequent infections of skin, gums, bladder, or vagina.

Women who develop gestational diabetes usually have no symptoms. We will check you for gestational diabetes during your pregnancy.

Complications of Diabetes

Untreated or uncontrolled diabetes can damage several parts of the body and can lead to very serious additional health problems. Any part of the body can be affected. Some of the major ones are:

• Eye damage causing loss of vision or blindness.
• Nerve damage causing loss of sensation and chronic pain.
• Kidney damage causing a rise in blood pressure and kidney failure.
• Stomach issues causing chronic nausea and difficulty digesting food.
• Blood vessel damage causing circulation problems, such as stroke, heart attacks, and/or difficulty walking and pain in the feet.
  

Diagnosis

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If you have symptoms of diabetes, we recommend getting a blood test for fasting blood sugar (glucose). Depending on your age, weight, and other risk factors, we recommend a fasting blood glucose test at least every 5 years. We may recommend the fasting blood glucose test every year if you have these risk factors:

• High blood pressure or high cholesterol.
• Prediabetes.
• Diabetes during pregnancy (gestational diabetes) or birth of a baby weighing more than 9 pounds.

Before this blood test, you will need to fast overnight for 12 hours. Your test result is reported in milligrams of sugar (glucose) per deciliter of blood (mg/dL).

If the first blood test is high, we may ask you to have another fasting blood test on a different day to confirm the diagnosis.

Alternatively, you may have a non-fasting blood test for a Hemoglobin A1C and estimated average glucose (eAG), which measures your average blood sugar over the past 2-3 months. A Hemoglobin of 6.5 or over is diagnostic of diabetes.

Routine Monitoring Tests

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Our goal for treatment is to keep your blood sugar, blood pressure, and lipids (cholesterol and triglycerides) as close to normal as possible. Studies have shown that controlling these reduces the chance of developing complications like heart attack and stroke. We will prescribe tests to monitor your levels. If your results are frequently above the target ranges, we will adjust your treatment plan. In addition, we may conduct other tests such as an eye and feet exam, a retinal screen, and a microalbumin analysis to test for kidney function.

If you have gestational diabetes, you may need to test your blood sugar as often as 4 times a day during your pregnancy to reduce the risk of health problems for you and your baby.

Hemoglobin A1c and eAG (blood sugar)

Hemoglobin A1c and estimated average glucose (eAG) is a blood test that measures your average blood sugar during the past 2 to 3 months. This test helps us understand how well we are able to keep your diabetes under control. We recommend a hemoglobin A1c and eAG blood test at least every year, and possibly more often if we are adjusting your treatment plan.

Talk with us about your personal target for A1c and eAG. Typical ranges are:

Blood pressure

For most people with diabetes, the target blood pressure is 139/89 or less. Lower blood pressure means less stress on your heart and blood vessels, eyes, and kidneys. Ask us about the blood pressure target that is best for you.

Lipids (cholesterol and triglycerides)

Lower LDL cholesterol and triglyceride (blood fat) levels reduce your risk for hardening of the arteries, heart attack, and stroke. Your test results are reported in milligrams per deciliter of blood (mg/dL). Target ranges for most people with diabetes:

For some people with diabetes and heart disease, we aim for LDL cholesterol less than 70 mg/dL. Talk with us about your lipid targets.

Treatments

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In addition to eating a healthy diet and exercising, most people with diabetes benefit from medication that helps keep blood sugar, blood pressure, and/or cholesterol levels in the target ranges. If you are pregnant, planning to become pregnant, or are at risk for pregnancy, it’s very important that you talk to us. Controlling blood sugars early in pregnancy helps prevent birth defects.

Blood sugar medications

The type of medication that we prescribe depends on your specific condition. We often start with a low dose of pills or insulin and ask you to check your blood sugar with a blood glucose meter. If your blood sugar stays above your target range, we will recommend increasing the dose, adding another oral medication, or adding insulin. If your blood sugar is frequently below target (hypoglycemia), we will discuss changes in your treatment. Types of medication include:

• Insulin for type 1 diabetes. Insulin injections are essential throughout your lifetime since your body does not produce insulin. Oral medications are not an effective treatment for type 1 diabetes.
• Medications or insulin for type 2 diabetes. There are several types of pills that we can use separately or in combination to help control your blood sugar. Insulin is an important, safe, and effective choice for many people with type 2 diabetes.
• Medications for gestational diabetes. Some types of gestational diabetes can be controlled by following a specific diet. If your blood sugars cannot be controlled by diet alone, then you may need to take a pill or do insulin injections.

Medications to Prevent Complications

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Studies have shown that certain medications can reduce the risk of developing diabetes complications. Because of their protective benefit, we often recommend these medications even if your blood pressure and lipids are in the target ranges. Depending on your age and medical conditions, common types of preventive medications may include:

• Aspirin. Low-dose aspirin reduces risk for heart attack and stroke by decreasing the chance of a sudden blockage in an artery.
• ACE inhibitors (angiotensin converting enzyme inhibitors) or ARBs (angiotensin receptor blockers). These specialized blood pressure medications protect your kidneys and reduce the chance of having a heart attack or stroke.
• Statins. These decrease inflammation inside the arteries, reducing the chance of a heart attack or stroke.

Diabetes medications and pregnancy

Some diabetes medications should not be taken by women trying to get pregnant or who are at risk for pregnancy, because they can cause birth defects. If you have diabetes and want to get pregnant, please talk to us. It is best to have your diabetes under good control before trying to get pregnant. Diabetes can complicate your pregnancy and create risks for your own health and the health of your baby. If you are a woman of childbearing age (15 to 49) and are not planning to get pregnant, you must use a highly effective form of birth control if you are taking certain medications for diabetes or medications to prevent diabetes complications (such as ACE inhibitors or ARBs).

Lifestyle Changes and Management

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Lifestyle habits make a big difference in successfully managing your blood sugar, staying healthy, and preventing complications. Healthy lifestyle habits may mean you need less medication, have more energy, and feel better overall. Healthy habits for people with type 1 and type 2 diabetes include:

• Maintaining a healthy weight.
• Being physically active on most days.
• Eating healthy foods.
• Managing stress and depression.
• Monitoring your blood sugar.
• Quitting smoking.
• Taking care of your feet.

Making changes in your daily habits can be challenging. We recommend learning about managing diabetes and making changes one step at a time. Many people find it helpful to enroll in diabetes classes or join a support group for people with diabetes. It is also important to ask for support from friends and family members.

Eating Healthy and Maintaining a Healthy Weight

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Healthy eating and maintaining a healthy weight are important ways to manage blood sugar, blood pressure, and lipids (cholesterol and triglycerides). You do not need to eat special diet foods. You can eat the same healthy foods as everyone else in your family. With all types of diabetes, including gestational diabetes, it is important to pay attention to:

How much you eat. Eat portions that are right for your weight and activity level. Eating too much leads to weight gain and higher blood sugar levels. Eating too little means you will not get enough energy from your food.

When you eat. Eat on a regular basis to prevent overeating and control blood sugar. Skipping or delaying meals can cause blood sugar to drop too low. Many people find it helpful to eat a meal or healthy snack at least every 4 to 5 hours.

What you eat. Choose a variety of foods from all food groups: vegetables, fruit, whole grains, lean protein foods, and nonfat or low-fat dairy products.

Being Physically Active on Most Days

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We recommend gradually working up to 30 minutes or more of physical activity on most days, at a comfortable pace for you. Being physically active helps control your blood sugar, blood pressure, and lipids. It can also reduce stress and improve your mood, give you more energy, and reduce your chance of heart disease and stroke. If you are pregnant, being active can help control your blood sugars.

If you are just beginning to exercise, talk with us about activity that is right for your fitness level and health condition. Here are some tips for being physically active:

• Do something you enjoy.
• Start out slowly, for 5 to 10 minutes each day, and gradually increase your activity.
• Listen to your body. Stop right away if you feel dizzy, short of breath, sick, or in pain.
• Stay hydrated by drinking water before, during, and after you exercise.
• Wear shoes and socks that fit well.
• Make exercise a part of your daily schedule.
• For variety, try different activities.

If you have type 1 diabetes and your blood sugar is above 250 mg/dL, check your urine for ketones (a sign that your body does not have enough insulin). You can check for ketones at home by testing your own urine using ketostix that we prescribe for you. If there are moderate or high ketones in your urine, do not exercise. Contact us right away to discuss your treatment.

Managing blood sugar while being physically active

If you have type 1 diabetes, before you exercise, check your blood sugar and eat a carbohydrate snack if necessary. While you are exercising, watch for symptoms of low blood sugar (hypoglycemia). Carry a fast-acting sugar source with you, like glucose tablets or gel, or fruit juice. You may also consider wearing a MedicAlert bracelet than can identify you in an emergency as a person with diabetes.

Self-Monitoring

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You can keep yourself healthy by monitoring (checking) your own blood sugar, blood pressure, and feet. We recommend you keep a log of this information.

Check your blood sugar. It is important to know your blood sugar targets. We will discuss your personal targets and how often to check your blood sugar. For many people, the blood sugar targets are:

• Before a meal: 70 to 130 mg/dL.
• 2 hours after a meal: less than 180 mg/dL.
• Bedtime: 100 to 140 mg/dL.

We may modify these targets to fit your lifestyle and health goals. If you are pregnant, we will talk with you about what your target blood sugars should be.

Monitor your blood pressure. If you have high blood pressure, you can periodically check your own blood pressure with an automated blood pressure monitor. Let us know if your blood pressure is frequently outside your target range, so we may adjust your treatment plan.

Take care of your feet. Foot injuries or infections are more common with diabetes. Taking care of your feet daily helps prevent problems. By checking your feet daily, you are more likely to notice problems early so we can start treatment right away.

Managing Stress

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Stress has many effects on the body, including increasing blood sugar and blood pressure. People who are stressed often struggle with lifestyle habits like healthy eating, exercising, checking blood sugar, and remembering to take medications. Many people notice higher blood sugar levels when they are stressed or angry.

Though most people feel stressed at times, ongoing stress can get in the way of managing diabetes. Learning and practicing methods to cope with stress can help you manage diabetes and enjoy life. Some ways to cope with stress include:

• Deep breathing.
• Being physically active.
• Muscle relaxation.
• Meditation.
• Getting support from family or friends.
• Making time for activities you enjoy.

Coping with feelings and mood

Your feelings can affect your blood sugar, and having diabetes can affect mood. Depression is more common in people with diabetes, although we do not know why. Let us know if you frequently feel sad, angry, irritable, or hopeless. These may be signs of depression. The good news is there are behavioral treatments and medications to help you feel better.

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Prevention

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Even when you have risk factors for diabetes, studies show you can delay or prevent prediabetes or type 2 diabetes by:

Being physically active on most days. We recommend gradually working up to 30 to 60 minutes of activity every day. Physical activity decreases insulin resistance, which leads to diabetes. Studies show that walking for 30 minutes 3 times per week reduces the chance of developing diabetes.

Losing weight if you are overweight. Studies show losing 5 to 7 percent of your weight reduces the chance of developing diabetes. For example, if you weigh 200 pounds, losing 10 to 15 pounds can make a difference.

Eating a healthy diet. Eat fewer calories by eating less fat and fatty foods and choosing smaller portions. Include a variety of vegetables, fruit, and whole grains in your diet. Limit your intake of sugary foods and alcohol.

Your Care with Me

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We urge you to call if your blood sugar gets:

• Very low (typically under 70 mg/dL or a target we have set for you).
• Very high (typically over 300 mg/dL or a target we have set for you). 

And especially if you have symptoms such as:

• Dizziness.
• Cold sweats.
• Shortness of breath.
• Seizures related to low blood sugar.
• Excessive thirst and/or urination. 

If you are pregnant and your blood sugars get very low (hypoglycemia), call 911.

As part of your routine care, I will order lab tests to screen for diabetes at the appropriate time, based on your risk factors. If you have prediabetes, you can enroll in the prediabetes class without a referral for more information and support.

If we determine that you have diabetes, I will work with you to help manage it. We have a comprehensive program to help you live well with diabetes and maintain your health. I will refer you to a Diabetes Education class. You will be prescribed a glucose monitor, and you or your family will be trained to use it. We have online tools and classes to help you with physical activity, healthy nutrition, smoking cessation, and weight management.

I will likely prescribe medication. As we continue to monitor your blood sugar levels, blood pressure, and cholesterol levels, we will send you for follow-up tests and make adjustments as needed.

If you have difficulty getting your blood sugar under control, I may recommend that you work closely with a Diabetes Care Manager to help you achieve ideal blood sugar, blood pressure, and cholesterol levels. If you have diabetes and you are working with a Care Manager, you may call him or her directly. If you are interested in a referral to this program, please contact me.

Diabetes and Pregnancy

If we know about your diabetes when you become pregnant, I may help you enroll in the Kaiser Regional Perinatal Nursing Services Program. They have someone on call at all times, and you should call them for advice: 1-800-439-8376.

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You can connect with me in a variety of ways, depending on the situation and what is most convenient for you at the time. I am available online, by telephone, or in person.

• For nonurgent questions or concerns, you can e-mail me using this site. You can also book an appointment online to see me in person.
• If your concerns are immediate, or you simply prefer to use the telephone, please call our Appointment and Advice line, which is available 24 hours a day, 7 days a week. Our advice nurses can give you immediate advice, and our telephone staff can send me a message or book an appointment for you. 

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How We Coordinate Your Care

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Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system which allows all of the doctors and clinicians involved in your care to stay current on your health status and to collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you come to an office visit

• At the beginning of your visit, you will receive information about when you are due for your next test, screening, or immunization.  We can discuss and schedule any preventive tests that you need. 
• At the end of your visit, you may receive a document called the “After Visit Summary” that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed, or if you just want to recheck your vital signs and weight. You can also view it online under Past Visits.
• To help you prepare for your visit, please see additional details under Office Visit. 

If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments as needed. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you and I will send the prescription electronically in advance of your arrival at the pharmacy.

If refills are needed in the future, you can:

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
• Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.

If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures we will schedule an appointment with the radiology department. When the results are ready I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to a specialist

My specialty colleagues are readily available to assist me if I need additional advice about your condition. In some cases, I may contact them during your visit, so we can discuss your care together. If we decide you need a specialty appointment after that discussion, we can often schedule it the same day or soon thereafter.

If you are due for preventive screenings or tests

As part of our commitment to prevention, additional members of our health care team may contact you to come in for a visit or test.  We will contact you if you are overdue for cancer screenings or conditions which may require monitoring.

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Convenient Resources for You

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My goal is to provide high quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available 24/7 so that you can access and manage your care where and when it is most convenient. From my home page you can:

Manage your care securely

• View and compose secure e-mail messages.
• Manage your prescriptions and schedule appointments.
• View your past visits and test results.
• View your preventive services to see whether you are due for a routine screening or updated immunization.

Learn more about your condition

• Read about causes, symptoms, treatments and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Stay healthy

• Locate health education classes and support groups offered at our medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

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