On behalf of the South Dakota Department of Health Diabetes Prevention & Control Program, I the occurrence of diabetes and its complications. …

Managing Cystic Fibrosis Related Diabetes CFRD I

Managing Cystic Fibrosis-Related Diabetes CFRD
An Instruction Guide for Patients Families
3rd Edition

DANA S HARDIN, MD University of Texas Southwestern Medical School Dallas, Texas CAROL BRUNZELL, RD, CDE Fairview-University Medical Center, Minneapolis, Minnesota KATHLEEN SCHISSEL, RD Fairview-University Medical Center, Minneapolis, Minnesota TERRI SCHINDLER, RD, MS Childrens Hospital Medical Center, Cincinnati, Ohio ANTOINETTE MORAN, MD University of Minnesota, Minneapolis, Minnesota

Address Content-Oriented Correspondence to: Dana S Hardin, MD Associate Professor of Pediatrics, Division of Endocrinology Clinical Medical Director of Childrens Endocrinology University of Texas Southwestern Medical Center 55323 Harry Hines Blvd Dallas, Texas 75390-9063 danahardin@utsouthwesternedu Address All Other Correspondence to: Cystic Fibrosis Foundation 6931 Arlington Road Bethesda, Maryland 20814 800 FIGHT CF info@cfforg

Table of Contents
Introduction ________________________________________________________________ 5 Chapter 1 Chapter 2 What is Cystic Fibrosis-Related Diabetes CFRD?
__________________ 7 Medical Treatment of CFRD ______________________________________ 9
Why treat high blood sugar levels in CFRD? What are the goals for blood sugar levels? Insulin — What does it do? — Types of insulin: short-acting vs longer-acting — Storage and handling of insulin — How often is insulin given? — How to give insulin — When does the body need extra insulin? Oral agents Insulin pumps

Chapter 3

Blood Sugar Testing _____________________________________________ 17
This chapter reviews blood sugar testing It is designed to help you understand why your blood sugar is tested at home and to learn how and when to test it

Chapter 4

Tests Used to Diagnose CFRD ____________________________________ 21
There are several different tests which can be used to diagnose CFRD This chapter reviews each method

Chapter 5

Medical Tests and Clinical Examinations Used in the Management of CFRD _______________________________ 23
This chapter reviews the current recommendations for management of CFRD

I Table of Contents

Chapter 6

Nutrition and CFRD _____________________________________________ 25
Importance of calories in CF Food groups Carbohydrate counting Alcohol
ingestion Delayed meals Artificial sweeteners

Chapter 7

Low Blood Sugar Hypoglycemia ________________________________ 37
This chapter reviews the symptoms, causes and treatment of low blood sugar

Chapter 8

Sick Day Management __________________________________________ 41
When you are sick, maintaining good blood sugar control becomes a greater challenge This chapter will help you learn how to manage your blood sugar when you are sick

Chapter 9

Exercise ________________________________________________________ 43
Exercise is important for your physical well-being The effect of exercise on CFRD is reviewed in this chapter

Chapter 10 CFRD Without Fasting Hyperglycemia and Other Types of Abnormal Glucose Tolerance Found in CF _________________________ 45
People with CF can have several types of abnormal glucose tolerance These are defined differently than CFRD Diagnostic criterion and management recommendations are reviewed in this chapter

Chapter 11 Your Caregivers Role in the Management of CFRD ________________ 47
This chapter reviews the members of the diabetes care team and provides suggestions for your role on the team

Chapter 12 Food Lists: Carbohydrate Units in Common
Food Items _____________ 49
This chapter provides a handy reference of the carbohydrate content of all your favorite foods It includes an area for you to create your own personal food list It also includes a sample meal plan, and a place for you and your dietitian to develop your personal meal plan

Glossary ____________________________________________________________________ 67
Throughout the text, words are highlighted in bold These words are defined in this glossary as a handy reference The glossary is organized alphabetically

Cystic Fibrosis Foundation ________________________________________________ 71
4

Managing Cystic Fibrosis Related Diabetes CFRD I

Introduction
If you are reading this manual, you or someone you love has probably been diagnosed with cystic fibrosisrelated diabetes CFRD This instruction guide is intended to supplement information provided by diabetes caregivers and pulmonologists Each chapter discusses different topics important for CFRD management At the beginning of each chapter are educational goals to help you focus on the important points Although there are several handbooks for people with other forms of diabetes, there has been no widely available
manual specifically tailored for people who have both cystic fibrosis and diabetes The Cystic Fibrosis Foundation, and the authors, hope this guide will fill this need and be helpful to you Full support to produce this document was provided by the Cystic Fibrosis Foundation You may be feeling very stressed by having an additional diagnosis like diabetes You may even feel hopeless because you believe diabetes is the last straw We understand these feelings and want to encourage you to learn as much as possible about CFRD, so you will have a better sense of control of your diabetes management Despite your CFRD, you should be able to do all the things you want to do, including eating the foods you like Although we have incorporated all that is currently known about CFRD into this manual, there is still much that we do not know The Cystic Fibrosis Foundation plans to revise this guide every few years to provide the most current information to you In the United States, blood sugar levels are reported as milligrams per deciliter mg/dl However, in Canada and in Europe, blood sugar levels are reported as millimoles per liter mmol/L Both values are included throughout this document It is the
shared goal of the authors and the Cystic Fibrosis Foundation that this handbook will help you and your family to better understand the unique nature of CFRD, so that you and your care providers can better manage this disease

Managing Cystic Fibrosis Related Diabetes CFRD I

Notes

What is Cystic FibrosisRelated Diabetes CFRD?
EDUCATIONAL GOALS
At the end of this chapter, you should be able to:
I I I I I

Recognize that CFRD is a common problem, especially in adults; Understand how the body normally uses insulin to metabolize food; Recognize differences between CFRD and type 1 or type 2 diabetes; Recognize the causes of CFRD; Understand the symptoms of CFRD

CFRD is a Common Problem
Diabetes is extremely common in people with CF, especially as they get older One study found that up to 75 percent of adults with CF have some form of glucose intolerance and 15 percent have frank CFRD

What is Diabetes?
Diabetes is an abnormal condition resulting in weight loss and other problems, such as lack of energy Normally when you eat, food breaks down into sugar, fat and protein Sugar enters your bloodstream and blood sugar levels rise The increase in blood sugar signals the pancreas
to secrete insulin Insulin works by helping protein, fat and sugar leave the blood and enter the cells where they are used for energy People with diabetes either do not have enough insulin, or do not respond to insulin normally; thus insulin is not available to help sugar leave the bloodstream and enter cells Therefore, people with diabetes do not efficiently convert food into energy If you have CF and diabetes, then you have a unique type of diabetes which is called cystic fibrosis-related diabetes CFRD The reason that there is a special name for CFRD is because this disease is not the same as diabetes found in people who do not have CF It is important for you, your family and your caregivers to understand that the diagnosis and treatment of CFRD is not exactly like the diagnosis and management of other types of diabetes

How CF-Related Diabetes Relates To Non CF Diabetes
The most common types of diabetes are called type 1 and type 2 diabetes CFRD has features of both type 1 and type 2 diabetes Type 1 diabetes, formerly called insulin-dependent or juvenile onset diabetes, is the type of diabetes that is most often found in childhood People who have type 1 diabetes are not able to
make any insulin, and must take insulin to stay alive This is why type 1 diabetes is sometimes called insulin-dependent diabetes If someone with type 1 diabetes misses insulin doses, he/she becomes very sick and develops ketoacidosis a life-threatening alteration in the blood acidity Type 2 diabetes, formerly called non-insulin dependent or adult onset diabetes, is caused by lack of normal response to insulin This type of diabetes occurs most often in people who are older than forty and who are overweight People with type 2 diabetes generally do not develop ketoacidosis, but they can become very sick when their blood sugar level is too high People with type 2 diabetes do not always require insulin to manage their diabetes 7

I Chapter 1 / What is Cystic Fibrosis Related Diabetes CFRD?

Some may take pills, and others may be treated with insulin Weight loss diets are recommended for most of these people, and some may be treated only with diet and exercise

Causes of CFRD
CFRD has some features of both of these types of diabetes, but it is a separate condition As in type 1 diabetes, the CF pancreas does not make enough insulin Thus people with CF have insulin deficiency This is
probably because of pancreatic scarring due to thickened secretions Most people with CF make less insulin than normal, however, not everyone with cystic fibrosis develops diabetes If you have CF, another reason you can develop diabetes is because of insulin resistance Insulin resistance means that your body does not use insulin normally, thus more insulin is required to metabolize food The combination of insulin deficiency and insulin resistance can cause people with CF to develop diabetes more frequently than the general population One reason that you may have insulin resistance is because of chronic underlying infection, even when you are not acutely ill Another cause of insulin resistance is higher than normal levels of a hormone called cortisol This hormone is a steroid and is made in the adrenal glands Our bodies make higher than normal cortisol levels in response to stress High cortisol levels can interfere with insulin action Cortisol levels can also increase from steroid-containing medications called corticosteroids At times these medicines are necessary for treatment of lung disease When such medicines are used, they can temporarily worsen your blood sugar control In
people with CF who do not already have diabetes, use of corticosteroids can temporarily cause diabetes CFRD can occur only some of the time intermittent CFRD, or can occur at all times chronic CFRD If you have intermittent CFRD you may only need to take insulin during infections, or with steroid treatment If you have chronic CFRD, you require insulin treatment at all times to prevent unacceptably high blood sugar levels Although CFRD is different than type 1 or type 2 diabetes, the development of diabetes-induced complications is similar in all types of diabetes These complications include eye, kidney, circulation and nerve problems The complications from diabetes are caused by continuous high blood sugar levels over several years The goal of diabetes therapy is to maintain blood sugar in a range as close to normal as possible This goal is shared by people with all forms of diabetes and helps prevent development of complications from diabetes

Symptoms of CFRD
Common symptoms of diabetes, such as frequent urination polyuria and frequent drinking polydipsia, are caused by high blood sugar levels hyperglycemia These symptoms may not be recognized in CF People with CF often drink a
lot of fluids because of dry mouth, and thus urinate more often than normal Other symptoms of CFRD include excessive fatigue, weight loss or difficulty maintaining weight, and unexplained worsening of pulmonary function Because these symptoms can also be associated with infection and lung disease, diabetes may not be recognized unless specific tests are done to look for it Unlike people with type 1 diabetes, people with CF usually do not develop ketoacidosis Anytime you have unexplained weight loss, or difficulty gaining weight, your CF Foundation-accredited care center should do tests to look for diabetes If you already have diabetes and you are having problems with your weight, you need to review your diabetes management with your diabetes physician Diagnosis and management of CFRD should be coordinated with your CF healthcare needs Contact your local Cystic Fibrosis Foundation care center with questions about your concerns in developing diabetes You can locate the nearest care center by accessing the CF Foundation Web site, wwwcfforg/locationshtm or by calling 800 FIGHT CF 8

Medical Treatment of CFRD
EDUCATIONAL GOALS
At the end of this chapter, you should be able to:
I I I
I

Understand the role of insulin in the metabolism of nutrients in food; Understand the effect of insulin deficiency in CF; Understand the different types of insulin and how they work; Understand the oral agents and why they are not commonly used to treat CFRD;

At the present time, the only medication which has been proven to be effective for treatment of CFRD is insulin Therefore, it is important for you to learn how insulin works and learn about the different types of insulin

What is Insulin?
Insulin is a hormone, which lowers blood sugar levels It is made in the pancreas by special cells, called beta cells These cells are scattered throughout the pancreas in the islets of Langerhans Production of insulin is one of the endocrine functions of the pancreas Another part of the pancreas, called the exocrine pancreas, makes digestive enzymes which are secreted into the intestine to help digest food Most people with CF have damage to their entire pancreas and do not make enough digestive enzymes, thus they must take enzyme supplements People with CF who do not require enzyme supplementation do not usually develop CFRD

What Insulin Does
Insulin helps the cells of your body take
up the nutrients that you eat to be used for energy and growth Food is made up of carbohydrates sugars and starches, protein and fat Insulin has specific actions on each of these food groups Carbohydrates are converted to sugar for the bodys immediate energy needs Insulin allows the sugar to pass from the bloodstream into the cells where it is burned for energy The body cannot turn sugar into energy without insulin If insulin is not available, sugar builds up in the blood until it spills into the urine This loss of sugar in the urine causes the diabetic symptoms of polyuria urinating frequently and polydipsia drinking frequently Muscle tissue is made up mostly of protein Insulin allows the cells of the body to take up the building blocks of protein amino acids to build up muscle tissue If there is not enough insulin, protein breakdown and muscle loss occurs Loss of muscle can affect your breathing because respiratory function depends on good muscle strength Finally, insulin allows dietary fat to be stored in the body as body fat Without enough insulin, the bodys fat stores become depleted and weight loss occurs People with CF have decreased production of insulin When your insulin
production becomes very low, CFRD develops, and you need to be treated At this time, insulin is the only medication proven by research to be effective for the treatment of CFRD Insulin can only be given by injections In the past, insulin came from the pancreas of cows and pigs However, now most people with diabetes use human insulin This insulin does not actually come from humans, but has the same genetic makeup as human insulin It is produced by using complicated genetic engineering There are no known advantages of one brand of insulin over another brand 9

I Chapter 2 / Medical Treatment of CFRD

Types of Insulin
Several companies make many different types of insulin Insulin types are grouped by how long they last in the body The two broad classes of insulin are short-acting, such as Regular, Lys-Pro Humalog, and Aspart Novolog, and longer-acting types of insulin, such as NPH, Lente, Ultralente, and Glargine insulin Insulin action when it peaks in activity, and how long it lasts may vary from person to person There is also some variability from one day to the next in the same person Rapid-Acting Insulins — Humalog and Novalog insulin have more rapid onset of activity 15-25
minutes and have peak activity in 30 to 90 minutes They are generally gone from the body after two to four hours, but can last as long as five hours They can be given five-15 minutes before the meal Either of these may be right for you if you do not know how much you will eat until you begin eating, if you exercise following a meal, if you do not like to snack, or if you have problems with low blood glucose levels in between meals Short-Acting Insulin — Regular human insulin begins to act approximately 30 minutes after being injected It has its peak effect two to three hours after the injection and lasts six to eight hours There may be variability in these times from person to person Regular insulin should be given at least one-half hour before eating so that it is working as your food is digested If you eat frequent snacks, regular insulin may be helpful because one injection can cover a meal and a snack Intermediate-Acting Insulins — NPH insulin is made with zinc and a protein, called protamine These compounds allow NPH insulin to be absorbed by the body more slowly Human NPH has its peak activity six to eight hours after injection and lasts an average of 13 hours However, the
peak and the duration of activity may vary from person to person Lente insulin has a peak action that occurs in seven-15 hours and can last as long as 18 hours Long-Acting Insulins — Ultralente insulin lasts about 18 hours, and, for some people, up to 24 hours It acts primarily as a background, or basal, insulin because it has only a small peak in activity which occurs at about 10 hours Glargine Lantus is called a basal insulin, because one dose provides constant, even background insulin for about 24 hours without any peak Basal insulin does not provide the extra insulin needed to cover food, so people who take Glargine still need to cover the carbohydrates in their diet with rapid-acting insulin Glargine cannot be mixed in the same syringe with other insulins Many CF patients only require short-acting insulin before meals and snacks However, long-acting insulin at bedtime is useful if you have high blood sugar levels before breakfast Long-acting insulin may be given in the morning to cover late afternoon snacks Generally your physician will know to add this if your before supper blood sugar is consistently high

INSULIN PREPARATIONS
Insulin Preparations Regular Humalog/Novolog
NPH Lente Ultralente Glargine 10 Onset hrs 05 to 1 025 1 to 15 1 to 25 4 to 8 2 to 4 Peak hrs 2 to 3 05 to 15 6 to 8 7 to 15 10 to 13 none Duration hrs 6-8 3-5 12-18 12-18 12-24 24

Managing Cystic Fibrosis Related Diabetes CFRD I

General Principles of Insulin Therapy
Background Insulin — Everyone needs a small amount of insulin at all times These low levels of insulin are often called background or basal insulin The pancreas works to make this insulin People with type 1 diabetes do not have the ability to make background insulin This is one reason that they become so sick when they do not receive insulin injections Most people with CF make insulin, they just make less insulin than people without CF who do not have diabetes Many people with CFRD do not require injections of long-acting insulin because they make background insulin Meal Coverage — A normal pancreas secretes insulin as a bolus to cover the meal you are eating Short-acting insulin is given before meals to mimic this extra insulin bolus Generally, the best way to judge a pre-meal insulin dose is to account for the carbohydrate content of the meal This will be discussed in more detail in the chapter on dietary
management Chapter 6 Correction — If your blood glucose is too high, you can add short-acting insulin to your usual insulin dose to correct it Generally one unit of short-acting insulin will lower your glucose level approximately 50 mg/ dl Work with your healthcare providers to determine your actual correction dose

How Often is Insulin Given?
Most people with CFRD require two or more injections of insulin per day to control blood sugar levels In general, the more often a person with diabetes takes insulin, the better the blood sugar control will be, and the more flexible the persons schedule can be in terms of when and what they eat People with very consistent eating habits can sometimes be effectively treated with just two shots per day, by mixing long and short-acting insulin together, and giving the dose before breakfast and supper However, this regimen may not work well in people with CFRD who have irregular eating habits, or who require flexibility in what and when they eat Many people with CFRD report problems with low blood sugar on this regimen Multiple injections per day can allow you to eat as much as you want, whenever you want, and still achieve excellent control of
your blood glucose levels Most people with CFRD have trouble with high blood sugar levels after meals However, your blood sugar may be completely normal when you have not eaten for four or more hours Thus many people with CFRD need only to be given short-acting insulin before each meal Long-acting insulin is added only when necessary to prevent high blood sugar in the morning, or to cover afternoon snacks Our goal is to give insulin so that its peak occurs when sugar from your meal is absorbed into your blood stream Your insulin type, and the time it is given, should be timed with your schedule of eating, activity, and sleeping It is important that you provide your caregiver with as much information as possible about your schedule The best blood sugar control can only be achieved if insulin shots fit your individual routine 11

I Chapter 2 / Medical Treatment of CFRD

Some people with CF may have high blood sugar levels only during night-time nasogastric or gastrostomy drip feeding also called milk drips or tube feedings If this is the only time you have problems with hyperglycemia, you may be given one injection of longer-acting insulin, or a combination of longer-acting plus
short-acting insulin, at the start of the feeding

Times When You May Need More Insulin
When any person becomes acutely ill, his or her insulin needs increase People with CF are not an exception Although people without diabetes can make more insulin in their pancreas when they are sick, people with CFRD cannot meet their increased insulin needs, and their blood sugar increases It is important to recognize that blood sugar readings may increase during illness Adequate dosing of insulin during illness will help prevent weight loss during illness, and will ensure a quicker recovery It is also important to recognize that sudden high blood sugar levels may indicate that the body is stressed High blood sugar levels may be the first sign that a little cold is really a more serious infection requiring more aggressive treatment Always notify your physician if your blood sugar levels suddenly become high

Storage and Handling of Insulin
Unopened bottles of insulin should be stored in the refrigerator Once opened, a bottle of insulin is good at room temperature for one month, or longer, if kept in the refrigerator Many people like to inject room temperature insulin because cold insulin may
sting To warm the insulin, you may roll the bottle between your hands for one to two minutes before withdrawing insulin from the bottle Alcohol wipes should be used to clean the top of the insulin bottle before insulin is withdrawn Regular, Humalog and Novolog insulin are clear in appearance and should be discarded if they become cloudy NPH, Lente, and Ultralente insulin are cloudy in appearance Any bottle of insulin which appears clumpy should be discarded If Regular, Humalog or Novolog insulin appear cloudy, they should also be discarded Insulin should be discarded if it freezes or if it is exposed to extremely hot temperatures greater than 85 Fahrenheit This can happen if insulin is left in a car or in the sun Insulin in cartridges, for use with insulin injection pens, should be stored in the refrigerator until they are loaded into the pen Once loaded into the pen, insulin cartridges containing Regular or Humalog insulin are good for twenty-eight days Insulin cartridges which contain NPH insulin are good for one week Insulin injection devices containing insulin should be stored at room temperature and should never be left in a hot environment, for example, the glove box of the
car

How Insulin is Given
Syringe and Needles — Insulin can be given using a syringe with a needle Insulin syringes measure insulin as units per cubic centimeter cc All types of insulin marketed in the US contain 100 units of insulin per cc U-100 insulin Standard insulin syringes hold either 3/ 10cc 30 units, 1/2cc 50 units or 1cc 100 units The 3/10 cc syringes have larger distances between the unit lines and are thus easier to use when measuring small doses of insulin 30 units or less Most likely, this is the size of insulin syringe you will use Needles come in different widths Needles are sized such that the largest number is associated with the smallest width needle For example, a thirty-one gauge needle is the smallest needle made, while a twenty gauge needle is very large Most insulin syringe needles are 28-30 gauge Needles may also come in different lengths Many people prefer a short needle such as 1/4 inch It is important for you to remind your diabetes physician to specifically prescribe short needles if you prefer using them 12

Managing Cystic Fibrosis Related Diabetes CFRD I

Injection Devices — Several different companies make insulin injection devices These devices
are generally about the size of a ballpoint pen and have a very small needle which is used for giving insulin Insulin is stored in a cartridge inside of the pen Some pens are meant to be reused and have disposable cartridges of insulin With these pens, you simply change the cartridge when insulin runs out Other pens are disposable and are simply thrown away when the insulin in the cartridge is gone Insulin cartridges for the pen can contain different types, or different mixes, of insulin Similarly, disposable insulin pens are available containing different types of insulin Your diabetes physician can help you determine the type of insulin best suited for your needs Insulin Injector Insulin injection devices can improve the convenience of administering insulin They can be carried easily in your purse or your pocket and are a very manageable way of taking insulin An insulin injection device may be especially useful to you if you take only short-acting insulin before meals These devices can easily be carried into restaurants

Insulin Pumps — Instead of taking insulin by injections, some people with diabetes use insulin pumps also called Continuous Subcutaneous Insulin Infusion or
CSII A pump delivers insulin through an infusion set a thin short plastic tubing which is inserted into the skin using a tiny needle Once the tubing is in place, clear tape is placed over the site and the needle is removed The infusion set is generally changed every two to three days The pump is connected to the infusion set and is programmed to deliver a continuous dose of insulin, called a basal dose, throughout the day Larger doses of insulin are given with meals or snacks; this is called a bolus dose The pump offers the advantage of excellent control over blood sugar without the need to give multiple daily shots It has been especially helpful in people who enjoy large snacks outside of meal times, and for anyone who is frustrated by taking multiple injections However, any person who uses the pump should check his or her blood sugar levels four times per day If you are not committed to checking your blood sugar levels at least this often, a pump may not the best choice of insulin administration for you If you enjoy eating meals and snacks at varied times, the pump may be the best way for you to have control over your blood sugar levels They have been used successfully in people
with CFRD Your diabetes caregiver can provide you with a video and written materials to help you become better acquainted with this exciting option for insulin delivery

I Chapter 2 / Medical Treatment of CFRD

How to Give an Insulin Injection with a Syringe
Before giving an insulin injection, always check the insulin bottle to be sure you are giving yourself the right type of insulin and that it has not expired a Many people like to roll the bottle of insulin between the palms of their hands for a minute or two in order to warm the insulin Some people feel that cold insulin stings b Be sure to wipe the top of the insulin bottle with alcohol before you insert the needle into the bottle c When you use both long- and short-acting insulin at one time, always withdraw the short-acting insulin in-to your syringe before you withdraw the longacting insulin d Once you withdraw the proper amount of insulin, you should clean the place on your skin with an alcohol wipe e before inserting the needle f

Check for correct insulin a

Roll insulin bottle to warm b

Clean top with alcohol wipe c

Withdrawing insulin d

Clean skin with alcohol wipe e

Inject insulin f

Managing Cystic
Fibrosis Related Diabetes CFRD I

Where Insulin is Given
Insulin can be given in several places, including the thigh, back of the arm and the abdomen The best place for you will probably be where you have the most fat underneath the skin The needle should be inserted just under the skin and into fat It may be helpful for you to pinch up a fold of skin and fat before inserting the needle You should try to pick a new place to give your insulin each time also called rotating the injection site The illustration below shows some good places to give insulin

Insulin Injection Sites

Oral agents
Although many people with CFRD wish they could take pills to treat their diabetes, at this time insulin is the only medical therapy recommended by the CF Foundation for treatment of CFRD The reason pills were not recommended by the 1998 Consensus Conference on CFRD was due to the lack of research studies documenting the usefulness or safety of a pill in treating CFRD However, several small studies have been published now and your physician may recommend a pill for you in certain situations There are two major types of oral agents Those which increase insulin secretion, and those which increase
insulin sensitivity Oral hypoglycemic agents, such as glipizide and glyburide increase insulin secretion One commonly reported side-effect of these drugs in people with CF is low blood sugar Drugs in the replaniglide class also work to increase insulin secretion, however, they have less reported side-effects of hypoglycemia Drugs which increase insulin sensitivity, such as glucophage, also decrease glucose output from the liver These drugs carry some risk of lactic acidosis, thus research trials are needed before they are used in CF Recently, several companies have developed oral agents which both stimulate insulin secretion and improve insulin sensitivity Studies are needed to determine whether they could be used to treat CFRD

Blood Sugar Testing
EDUCATIONAL GOALS
The goals of this chapter include:
I I I I

Increasing your awareness of why it is important to measure blood sugar levels; Increasing your understanding of how to measure blood sugar levels; Improving your understanding of when to measure blood sugar levels; Helping you learn the acceptable range for your blood sugar levels

Introduction to Home Glucose Monitoring
People with diabetes need to check their own
blood sugar levels at home so that adjustments in their insulin dose can be made Good blood sugar control is important for preventing complications and improving health Home glucose monitors, called meters, have given people with diabetes, and their families, the ability to check blood sugar levels quickly and accurately Meters have changed diabetes management more than anything else in the past 20 years People with diabetes need to measure their blood sugar levels at home using a meter This is called self monitoring of blood glucose SMBG Self monitoring of blood glucose provides information which can help you and your physician adjust your insulin dosage so that you can achieve good blood sugar levels

Why Do Self Monitoring of Blood Glucose SMBG?
There are many reasons why measuring blood sugar at home is important, including:
I

Improving Diabetes Control — Studies have clearly shown that checking blood sugar daily, and using the results wisely, result in improved blood sugar control Improved blood sugar control results in improved body weight and decreases your chance of developing diabetic eye and kidney complications Safety — This is an important reason to test blood sugar
levels Checking the blood sugar may help prevent the development of dangerously low blood sugar levels by allowing you to recognize a downward trend in blood sugar before symptoms occur Low blood sugar symptoms can occur when the blood sugar falls rapidly for example from 300 to 150 mg/dl or 166 to 83 mmol/L, or when the blood sugar is truly below the normal safe range A blood sugar test at the time of feeling low will help determine whether the symptoms are due to a rapid fall in glucose, or are due to seriously low blood sugar We consider a truly low blood sugar level to be below 60 mg/dl 32 mmol/L, or in a preschooler, below 70 mg/dl 39 mmol/L Glucose should be given if the blood sugar is low, but is not needed if the symptoms are due to a rapid fall in sugar

I Chapter 3 / Blood Sugar Testing
I

Improved Nutritional Status — High blood sugar levels indicate that your body is not using the food you eat effectively and can cause you to lose weight or have trouble maintaining your weight Good blood sugar control will improve your nutritional status and will help you gain weight Managing Illness — During illness, you will probably need extra insulin This is because insulin
doesnt work well when your body is stressed Frequent blood glucose monitoring during illness will help you know when you need more insulin Keeping up with insulin needs during illness will help you maintain your body weight instead of losing weight when you are sick Blood Sugar Testing Gives You a Sense of Control Over Your Diabetes — Knowing your blood sugar, and adjusting your insulin to meet your bodys needs, gives you control over your diabetes You will probably feel better knowing your blood sugar levels, so that you can see how well you are managing your diabetes Adjusting the Insulin Dosage Pattern Management — When blood sugar levels are checked regularly and the results recorded, patterns of low or high blood sugar at certain times of day can be seen This information can be used to help you and your physician adjust the insulin dose between appointments If you take short-acting insulin before meals, you can use the blood sugar level along with your amount of food and planned exercise to decide how much insulin to take The only accurate way to measure blood sugar levels at home is with a glucose meter Studies have shown that you cannot accurately guess your blood sugar
levels based on how you feel

SUGGESTED BLOOD SUGAR LEVELS Age years Before Eating No food for 2 hours mg/dl
5 to 12 12 and above 80 to 180 80 to 120

Bedtime before bedtime snack mg/dl
100 to 160 100 to 140
I I

mmol/L
44 to 100 44 to 67

mmol/L
55 to 78 55 to 78
I I

If your blood sugar level is less than 100 mg/dl 55 mmol/L, add one carbohydrate unit or 15 grams of total carbohydrates see nutrition section, to your bedtime snack If your blood sugar level is less than 60 mg/dl 33 mmol/L you should add one carbohydrate unit to your bedtime snack and should recheck your blood sugar between midnight and two am If this happens more than once within a week, either reduce your dinner short-acting insulin or call your diabetes care provider for advice

Managing Cystic Fibrosis Related Diabetes CFRD I

When to Check Blood Sugar
Most physicians recommend that you check your blood sugar three to four times per day to help you determine how much insulin you need Most people with diabetes check their blood sugar before breakfast, before lunch, after school or before supper, and before their bedtime snack You should always check your blood sugar when you first wake up in
the morning One important difference between CFRD and other types of diabetes is that your post-meal blood sugar levels may be much higher than blood sugar levels from times when you have not eaten For this reason, you may be asked to check your blood sugar two hours after eating a meal, instead of before eating If you take long-acting insulin in the evening, check your blood sugar in the middle of the night once every two to three weeks, to make sure that low blood sugar does not occur while you are sleeping If you receive night-time enteral feedings sometimes called milk drips or tube feeding, you should check your blood sugar one to two times per week in the middle of the feeding If you receive intermittent bolus feedings, you should check your blood sugar two hours after the bolus A blood sugar level greater than 200 in the middle of a night-time enteral feeding, or two hours after a bolus, suggests a need for more insulin Several times per week you should check your blood sugar two hours after your largest meal a post-prandial blood sugar The blood sugar reading two hours after a meal should be less than 200 mg/dl Check with your diabetes care team for what your personal goal
should be If it is higher than 200 mg/dl on several occasions, you need more short-acting insulin before your meal The more blood sugar levels you check, the more information you and the diabetes care provider will have for making the right decisions regarding your diabetes management

How To Do Self Monitoring of Blood Glucose
Finger Sticks — Checking your blood sugar requires that you obtain a drop of blood by pricking a small hole in your finger with a device called a lancet A lancet is a spring loaded device with a needle specially made for gently obtaining blood from your finger tip There are many good brands on the market which will help you obtain a good drop of blood without having to poke your finger too deeply Before using a lancet, your hands should be washed with warm water to increase blood flow and to make sure they are clean Washing your hands also helps remove any trace of sugar on the finger and helps prevent a falsely elevated reading Occasionally, when you are away from home eg, camping, picnics, it is necessary to use alcohol to clean your finger Under usual circumstances, however, alcohol, is not recommended because it dries out the fingertips It is often
helpful to place the finger you will use on a table top Use the side of the finger, rather than the fleshy pad on the fingertip, because it may hurt less After pricking your finger, if the drop is not coming easily, hold your hand down at your side to increase blood flow to your finger Alternate the fingers you use for testing so your fingers dont become sore

Lancet used for checking blood sugar
19

1
2
3

I Chapter 3 / Blood Sugar Testing

Blood Sugar Meters — There are many meters on the market Each meter differs in the procedure necessary for use Each brand of meter has test strips which are made to go with the meter It is important to use the test strips appropriate for the meter and to follow company instructions for coding, cleaning, and checking the accuracy of your meter It is also important that the test strips be kept in their bottle until use so that readings are accurate Do not use generic or out-of-date test strips

Common Problems Causing Inaccurate Blood Sugar Test Results
Finger is not clean and dry Not following directions specific to the meter Meter parts are dirty eg, with dried blood Codes on strips and meter are not matched Too small a drop of blood on
pad Test strips are past expiration date or have not been properly stored Keeping good records and bringing the results to clinic visits, allows you and the diabetes team to work together more effectively to achieve good diabetes management Recording Results — Always record your results in a book even if your meter has a memory Look for patterns in blood sugar readings at specific times of day which may signal a need to change the insulin dose Recording blood sugar in a record book also allows you to note any special circumstances which might account for that blood sugar For example, next to a low blood sugar reading you might note I did not eat enough or I exercised more than usual

Summary
Good blood sugar control is important to your overall health Your blood sugar level is best measured by a glucose meter You should write down the time of the test, the date, how you feel, circumstances that may affect your blood sugar and the blood sugar value These results, and the meter, should be brought to clinic appointments If the results are consistently outside of the desired range, the insulin dose should be changed You can call, mail, or fax the test results to your diabetes care
provider Your physician can recommend changes in insulin, or you can make some changes yourself The longer you have CFRD, the more comfortable you will feel making adjustments in your insulin dose Problems should be reported before the next scheduled appointment Although the use of blood sugar testing adds extra time and expense to CFRD management, it is very important Good diabetes control can only occur through the use of blood sugar testing It is necessary for the whole family to be supportive in this effort In many states it is the law that insurance companies have to pay for diabetes supplies The local American Diabetes Association ADA can provide information about the laws specific for each state

Tests Used to Diagnose CFRD
EDUCATIONAL GOALS
At the end of this chapter, you should be able to:
I

Be familiar with the different tests used to diagnose CFRD

Tests Used to Diagnose CFRD
Casual Blood Glucose Levels — A casual blood glucose level is one that is drawn without paying attention to the time of day, or to when a meal was last eaten If this level is less than 126 mg/dl 70 mmol, it is unlikely that a person has diabetes If this level is greater than or equal to 200
mg/dl 111 mmol, it means the person likely has diabetes Glucose levels between 126 and 200 mg/dl 70-111 mmol are in a gray zone and indicate the need for more testing The Cystic Fibrosis Foundation recommends that people with CF have a casual blood glucose level drawn at least once a year Generally, this is done at your birthday visit The 1998 CF Foundation Consensus Conference developed guidelines for clinicians to follow once they have measured your casual blood glucose They are summarized below Oral Glucose Tolerance Test — The oral glucose tolerance test OGTT is sometimes recommended when CFRD is suspected A patient must be fasting nothing to eat or drink for 12 hours before this test is done To do an OGTT, blood is drawn to measure your baseline glucose level Then you will be asked to drink glucose in a syrupy liquid called a Glucola Your blood sugar will be re-measured two hours later Sometimes blood sugar is also measured at one hour and three hours, as well as at two hours The blood sugar level obtained in response to Glucola sometimes referred to as a glucose load determines whether or not a person has diabetes Any person who has a blood sugar level greater than or equal
to 200 mg/dl 111mmol at two hours following this glucose load has diabetes If the blood sugar drawn at baseline is greater than 126 mg/dl 70mmol, you have CFRD with fasting hyperglycemia, and insulin treatment should be prescribed If the blood sugar drawn at baseline is less than 126 mg/dl, and the blood sugar two hours after drinking Glucola is greater than 200 mg/dl, you have CFRD without fasting hyperglycemia Insulin treatment may be needed, but it is not always needed, with this type of CFRD Hemoglobin A1C — This test is not useful for making a new diagnosis of CFRD It is used to monitor long term blood sugar control in patients with known diabetes This will be discussed in greater detail under diabetes management

I Chapter 5 / Tests Used to Diagnose CFRD

Summary of 1998 Cystic Fibrosis Foundation Consensus Conference Guidelines:
Results of Casual Blood Glucose Level 1 If your casual blood glucose is less than 126 mg/dl 70mmol, no further testing needs to be done for one year, unless symptoms of diabetes develop 2 If your casual blood glucose is 126-199 mg/dl 70mmol, a fasting blood glucose, done in the morning before breakfast, should be measured If your fasting blood
glucose is less that 126 mg/dl 70mmol, no further testing needs to be done for one year, unless symptoms are present If your fasting blood glucose is greater than 126 mg/dl 70mmol, another fasting blood glucose should be checked Some physicians may recommend an oral glucose tolerance test instead of obtaining a second fasting blood glucose If the second fasting blood glucose level is higher than 126 mg/dl, you will require insulin treatment 3 If the casual blood glucose is greater than 200 mg/dl 111mmol, it is likely that you have diabetes Fasting blood sugar levels must be measured to determine if fasting hyperglycemia is present If you have fasting hyperglycemia, you should be treated with insulin

Summary
There are multiple ways your physician can diagnose CFRD These include: 1 A fasting blood sugar greater than 126 mg/dl 70mmol on two or more occasions By definition this is CFRD with fasting hyperglycemia 2 A casual glucose greater than 200 mg/dl 111mmol on two or more occasions, with symptoms of diabetes 3 A two hour glucose level greater than 200 mg/dl 111mmol during an oral glucose tolerance test OGTT It is important to know whether or not you have CFRD with or without
fasting hyperglycemia This can be done with an OGTT or by a fasting blood sugar See Chapter 10 for a discussion of the different types of CFRD and glucose intolerance

Medical Tests and Clinical Examinations Used in the Management of CFRD
EDUCATIONAL GOALS
At the end of this chapter, you should:
I I

Be familiar with the tests used for diabetes management; Understand routine management of CFRD

Tests Used for Management of CFRD
Hemoglobin A1C glycosylated hemoglobin — New red blood cells have a life span of about three months in normal healthy people Hemoglobin A1C tells how much sugar is stuck to your red blood cells Thus hemoglobin A1C tells how high your blood sugar levels have been for the previous three months and provides a useful indication to the physician about long-term blood sugar control The hemoglobin A1C can be done at the time of a clinic visit and you do not have to be fasting Although each clinic has its own normal values, in general the desired hemoglobin A1C for adults is less than seven percent Urine Microalbumin — Diabetes can be associated with kidney disease, so it is important for your physician to look for it The amount of protein albumin in your
urine is a good indication about the overall health of your kidneys At the time of diagnosis with CFRD, and at least one time per year, you will be asked to provide a urine sample from which protein will be measured a spot urine check If the amount of protein is higher than normal in this sample, you will collect your urine for 24 hours The amount of albumin can be accurately quantified from this 24 hour sample, and if too high, indicates that you have kidney disease If you have kidney disease, there are medications available to treat it Urine Sugar Monitoring — Urine can be tested for sugar; however, this is not accurate for either diagnosis or management of diabetes The blood sugar level at which sugar spills into the urine varies between persons, and sometimes from one time of day to another in the same person Testing urine sugar should never be done as replacement for self-monitoring of blood glucose Urine Ketone Testing — Ketones are products made by the body when fat is used for energy instead of sugar When ketones are present, they can be detected in the urine Although you may know people with diabetes who monitor their urine for ketones, in general you will not have to
check your urine for ketones Although the reasons are not completely understood, people with CFRD generally do not develop a large amount of ketones, and therefore do not need to test their urine Lipid Profile — Serum lipids include cholesterol and triglyceride Elevation of fasting cholesterol and triglyceride levels can indicate risk for heart disease and stroke These are often referred to as the macrovascular complications of diabetes People with type 1 and type 2 diabetes often have higher than normal risk for the development of these complications Thus lipid profiles are routinely measured in these patients At this time, people with CFRD are believed to be at low risk for the development of macrovascular complications, and in general, do not need to have routine lipid profile measurements At this time, you will probably not receive routine screening unless you have a strong family history of stroke and heart disease As we learn more about CFRD, this recommendation may change 23

I Chapter 4 / Medical Tests Clinical Examinations Used in the Management of CFRD

Other Management Tools
Visits with the Diabetes Team — Every three to four months, you should be seen by the diabetes
team At this time they will review your diet, your blood sugar control and insulin doses, and you will have a physical examination These visits are an important part of your diabetes management One goal of these visits is to maximize your medical therapy and dietary intake to prevent future problems The physical examination will be especially designed to examine your insulin injection sites, to review your neurologic status and to examine your eyes You should point out any new wounds, or wounds which have not healed normally, to your physician so they can be examined Visits with the diabetes care team should occur in addition to your routine care for management of CF at your CF Foundation-accredited care center Annual Ophthalmology Visits — Diabetes can cause a type of eye disease called retinopathy This eye disease can initially cause blurred vision, and eventually can lead to loss of eyesight Most people with diabetes do not develop retinopathy for at least five years after diagnosis However previous studies in people with CFRD suggest that retinopathy develops earlier than in people with other types of diabetes You will need to see an ophthalmologist eye physician once per year
to be certain that you have not developed retinopathy If retinopathy occurs, the ophthalmologist can provide treatment for it

Nutrition and CFRD
EDUCATIONAL GOALS
At the end of this chapter you should be able to:
I I I

Understand your unique nutritional needs to help you achieve and maintain a healthy body weight; Understand the effect of dietary carbohydrates on blood sugar; Understand how to handle delayed meals and alcohol, and to learn the role of artificial sweeteners

Importance of a Healthy Diet
Maintaining a healthy body weight is one of the most important steps you can take to ensure good health With type 1 or type 2 diabetes, people are normally advised to eat a low-fat, low-salt, and often times low-calorie diet However, people with CF have different dietary needs With CFRD, you still need to eat your usual high-calorie, highprotein, high-fat, high-salt diet to help you achieve and maintain a healthy body weight In addition, keeping your blood sugar at near-normal levels will help you to maintain your weight, and ensure good health You can manage your blood sugar successfully by balancing your food, insulin, and physical activity A healthy diet consists of
eating a wide variety of foods from all food groups Added fats and sweets provide a valuable source of needed calories as well All foods are healthy, and when consumed in appropriate amounts, can help you maintain a healthy body weight The only difference now that you have CFRD, is that you need to learn how to measure or count the foods that affect your blood sugar the most, to help control your blood sugar The Six Major Food Groups 1 Grains 2 Fruits 3 Vegetables 4 Meats 5 Dairy 6 Fats To help you understand how to do this, it is important to know how food affects blood sugar Food can be categorized into six major food groups containing six different nutrients: carbohydrates, protein, fat, vitamins, minerals and water Carbohydrates, protein and fat provide energy calories Foods that contain carbohydrates affect blood sugar the most because they are metabolized into blood sugar by the body Foods that are made up primarily of protein and fat have much less of an effect on blood sugar The graphs on the following page show how carbohydrates, protein, and fat affect blood sugar 25

I Chapter 6 / Nutrition CFRD

Nutrient Effects on Blood Sugar
Meal Blood Sugar Meal
Meal

carbohydrates

protein

fat

The above illustration helps explain how different nutrients affect your blood sugar Carbohydrates have the most affect on blood sugar levels Protein and fats really have little influence on your blood sugar readings However, fats can slow the absorption of carbohydrates from the intestine, and therefore have an indirect affect on blood sugar levels

Carbohydrates
Since carbohydrates have the greatest impact on blood sugar, the main way to control blood sugar with diet is to control the amount of carbohydrates you eat during meals and snacks This does not mean that high-carbohydrate foods should be avoided They contain important nutrients and are the bodys main source of energy Carbohydrates are metabolized into sugar which is then used as fuel for all body functions The insulin you take works to help your body use the energy or calories that carbohydrates provide along with protein and fat and keep your blood sugar at acceptable levels Food groups which contain carbohydrates include: Grains bread, rice, pasta, and cereal; fruits fresh fruit, canned and dried fruit, and fruit juice; starchy vegetables potatoes, corn, peas, and winter squash;
milk and yogurt; legumes; desserts; sweetened beverages and snack foods The two main types of carbohydrates found in these different foods are referred to as sugars and starches Both types of carbohydrates in foods affect blood sugar equally when eaten in similar amounts Foods that are high in fiber have no special effect on blood sugar By checking your blood sugar and paying attention to what kinds and how much carbohydrates you eat during meals and snacks, you will eventually learn how different combinations of foods affect your blood sugar levels It is important that foods containing carbohydrates be eaten at times when there is enough insulin in your body to help convert them into energy If you are on a fixed insulin dose two or three injections per day, using the same dose each time, you will be better able to manage your blood sugar by eating a consistent amount of carbohydrates throughout the day, spread into three meals and three snacks With this regimen it is also important to eat at about the same times each day People who are willing to take four or more injections of short-acting insulin per day, or people using an insulin pump, have the greatest flexibility in deciding
when to eat and how much to eat If you desire more flexibility, your physician or diabetes educator nurse or dietitian can help you learn how to adjust your short-acting insulin depending on how many carbohydrates you plan on eating during meals and/or snacks This method is called carbohydrate counting and allows a great deal of flexibility in what you eat You and your dietitian can determine how many carbohydrates should be eaten for each meal and snack based on your usual eating habits This will be stated as how many carbohydrate units or grams of carbohydrates you can eat at each meal and snack See Chapter 12 for more information on counting carbohydrates There are other methods available to help you plan meals and snacks as well The exchange lists is another common method Talk to your dietitian to see which method may work best for you 26

Managing Cystic Fibrosis Related Diabetes CFRD I

What is a Carbohydrate Unit?
When carbohydrate counting, it is important to understand that foods that contain carbohydrates can be broken down into carbohydrate units, or carbohydrate choices One reason for this is that many physicians prefer to prescribe insulin based on the amount of
carbohydrates a person typically consumes at meals and snacks For example, one unit of regular insulin may cover approximately 10-15 grams of total carbohydrates about one carbohydrate unit, but this varies from person to person and depends on several other factors as well Food labels can provide you with valuable information about the carbohydrate content of the foods you eat One carbohydrate unit equals about 12-15 grams of total carbohydrates in any particular food item To calculate carbohydrate units, divide the grams of total carbohydrates by 15 to determine how many carbohydrate units are in the food the grams of sugar in the food item are included in this number Note: dietary fiber is not digestible Therefore, if a food item contains more than five grams of fiber, you can subtract this from the grams of total carbohydrates to determine the actual grams of carbohydrates in that food item See the example below

Look at the food label in this example The serving size on the label is listed as a half of a cup All of the nutrient values listed below the serving size are based on a half of a cup of this food item Therefore, the total carbohydrate content in a half of a cup is 13
grams So, a half of a cup of this food item equals approximately one carbohydrate unit If you plan on eating more than the listed serving size, for example, you plan to eat one cup of the food item then you must multiply the information on the label accordingly In this example, multiply by two Some people prefer to use the carbohydrate units method, others prefer to use only grams of carbohydrates You can discuss this with your dietitian to decide which may work best for you The following is based on the nutrition facts on the label: Two servings one cup 26 total grams of carbohydrates - 6 grams of dietary fiber 20 grams of carbohydrates 15 carbohydrate units

Nutrition Facts
Serving Size 1/2 cup 90g Servings Per Container 4 Amount Per Serving Calories 100 Calories from Fat 30
Daily Value

Total Fat 3g Saturated Fat 0g Cholesterol 0mg Sodium 300mg Total Carbohydrates 13g Dietary Fiber 3g Sugars 3g Protein 3g

5 0 0 13 4 12

I Chapter 6 / Nutrition CFRD

Meal Using Carbohydrate Units
An example of seven carbohydrate units converted from grams of total carbohydrates for breakfast is as follows: 8 ounces whole milk 1 cup sweetened dry cereal 1 large banana 2 slices toast
margarine or butter 2 fried eggs TOTAL 13 28 27 32 0 0 grams grams grams grams grams grams 1 2 2 2 0 0 carbohydrate carbohydrate carbohydrate carbohydrate carbohydrate carbohydrate unit units units units units units

100 grams

7 carbohydrate units

Remember: 1 carbohydrate unit 15 total grams of carbohydrates in the food item

Daily Meal Plan Using Carbohydrate Units
An example of a meal plan for someone who needs about 3,000 calories per day may have this pattern of carbohydrate units for meals and snacks In addition, daily meat, vegetable and fat servings would be included along with the carbohydrate foods for a well-balanced diet Breakfast AM Snack Lunch PM Snack Dinner Bedtime Snack 6-7 carbohydrate units 1-2 carbohydrate units 6-7 carbohydrate units 1-2 carbohydrate units 6-7 carbohydrate units 1-2 carbohydrate units

If you are on fixed doses of insulin with two to three daily injections, the goal is to eat consistent amounts of carbohydrates at each meal and snack In addition, try to eat at about the same times each day It is important to eat a well-balanced diet composed of a variety of foods daily It is not necessary to avoid high carbohydrate foods, or eat the
same types of food Basing your diet on carbohydrate units gives you flexibility and helps you to control your sugar levels along with medication and physical activity Your personal meal plan will be determined by you and your registered dietitian based on your usual eating habits If you desire more flexibility within your meal plan, talk to your physician, dietitian or diabetes nurse educator about insulin adjustment and establishment of a carbohydrates to insulin ratio Refer to Chapter 12 to review your individual meal plan with the help of your dietitian

Using a Carbohydrate Insulin Ratio for Insulin Administration
If you desire more flexibility within your meal plan, talk to your physician, dietitian or diabetes nurse educator about administration of insulin based on a carbohydrate to insulin ration This method of insulin dosing allows the greatest flexibility to your diet To use this method, you must first understand how to count carbohydrates Rapid-acting or short-acting insulin is then dosed before a meal based on the carbohydrates to be eaten in the meal Generally, the ratio is started as one unit of short- or rapid-acting insulin for every 15 grams of carbohydrates This
dose is then adjusted by evaluating the blood sugar response This method of insulin administration allows the greatest dietary freedom In our experience, many patients are able to count carbohydrates and enjoy using this method of insulin administration 28

Managing Cystic Fibrosis Related Diabetes CFRD I

THE FOOD GUIDE PYRAMID

Fats, Sweets use fats liberally for added calories

Milk minimum 3-4 servings 1 cup milk 1 cup yogurt

Meat, Fish, Poultry, Eggs Legumes, Nuts 3 or more servings 3 ounces cooked meat, fish, poultry 2-3 ounces cheese 1 egg 2 tbsp peanut butter 1/2 cup legumes

Non-Starchy Vegetables 3 or more servings 1/2 cup cooked vegetables 1 cup raw vegetables /2 cup vegetable juice
1

Fruits 2 or more servings 1 piece fresh fruit 1/2 cup canned fruit 1/2 cup fruit juice 1/4 cup dried fruit

Grains, Beans, Starchy Vegetables 6 or more servings per day 1 slice bread 1/2 cup pasta cooked cereal or bulgar 1/2 bagel, eng muffin bun or pita 1 small dinner roll 1/3 cup rice 1 small tortilla 1/2 cup corn, peas potatoes or legumes 1 cup winter squash 3/4 cup dry cereal 4-6 crackers 1/3 cup sweet potato

I Chapter 6 / Nutrition CFRD

Good
Nutrition
The traditional food guide pyramid shows us that a healthy diet consists of eating a wide variety of grains, fruits, vegetables, meats and dairy products Added fats and sugars can be used to increase total calories in your diet The traditional food guide pyramid shows fat at the top to coincide with the recommendation that fats be used sparingly Remember, fats are an important calorie source for you and it is important that you use fats liberally to increase your calorie intake
I

Use the food guide pyramid to plan a healthy diet Your dietitian can help you determine the number of servings right for you

Protein
Protein does not have much of an impact on your blood sugar levels Yet, it is very important for you to eat enough protein for good health Protein is used by the body to build, repair, and maintain muscle and other body tissues Protein is found in greatest amounts in meat, poultry, fish, eggs, cheese, milk, yogurt, legumes, nuts, and meat substitutes See the carbohydrate counting section for more informatio n on protein

Meat and Meat Substitutes
Meats and meat substitutes contain various amounts of fat Try to choose higher-fat meats and cheeses most often Use
high-fat cooking methods such as frying, deep-frying, and sautéing to add extra calories Lower Fat USDA Select or Choice Beef round, sirloin, flank, tenderloin, lean ground beef, roast Lean Pork fresh and boiled ham, canadian bacon, tenderloin, chops Poultry Without Skin chicken, turkey, cornish game hen Fish fresh and frozen fish, crab, shrimp, lobster, clams, tuna, shrimp, lobster, tuna in water, sardines, oysters, herring, salmon Wild Game venison, buffalo, ostrich, duck, pheasant, goose [no skin], rabbit Low-fat Cheeses cottage cheese, fat-free or low-fat cheese products, grated Parmesan, part-skim cheeses such as ricotta and mozzarella Tofu, tempeh, soy products, egg substitutes, low-fat deli meats 30 Higher Fat USDA Prime Cuts ribs, corned beef, prime rib, hot dogs, regular ground beef Spareribs, ground pork, sausage, chorizo, pickled pigs feet Fried poultry, poultry with skin, ground poultry Fried Fish Crab Cakes Tuna, shrimp or lobster salad Leaving skin on adds more fat High-fat Cheeses regular full-fat cheeses; cheddar, Swiss, Colby, Monterey Jack, American, etc High-fat Deli Meats bologna, pastrami, salami, etc, eggs, peanut butter

Managing Cystic
Fibrosis Related Diabetes CFRD I

Fat
Most people with type 1 and type 2 diabetes and most Americans as well are advised to eat a low-fat diet to help prevent obesity, atherosclerosis, and heart disease These recommendations do not apply to you Because you have CF, you are less likely to develop heart disease or other diseases related to a high dietary fat intake Dietary fat is an important part of your diet as it provides an excellent source of calories and important vitamins as well The enzymes that you receive when you eat help your body to absorb the nutrients and calories which fat provides Even with the enzymes, you may still end up losing or malabsorbing some of the fat you eat Thats why you need a high-fat diet to help you maintain your weight Make sure your enzyme doses are adjusted properly, so you can get the most nutritional benefit from your food Fats are found in oils, margarine, butter, mayonnaise, salad dressings, nuts and seeds, cream, cream cheese, sour cream, shortening, and other high-fat foods Fat does not have a significant effect on blood sugar However, it does slow absorption from the intestines and therefore has an indirect effect on the blood sugar The
more fat in your food, the later your blood sugar may peak Fat is high in calories Therefore, if you are trying to gain weight, you would benefit from choosing foods that are high in fat Try to eat a variety of added fats from the following lists:

Monounsaturated
Olive oil Peanut oil Canola oil Margarine mayonnaise2 Avocados Black and green olives Almonds, cashews Peanuts, pecans Sesame seeds1 Tahini
1

Polyunsaturated
Margarine
2

Saturated
Butter, lard, shortening Bacon, salt pork Fatback Chitterlings Coconut Cream, any variety Cream cheese Sour cream Coconut oil, palm oil

Mayonnaise2 Salad dressing1 Corn oil Soybean oil Sunflower oil Safflower oil Walnuts Pumpkin seeds Sunflower seeds
1

Palm kernel oil

Peanut butter1
1 2

These foods may contain some carbohydrates Depends on brand Check labels carefully

Vegetables
Vegetables are an important part of a well-balanced diet Try to include a minimum of three servings each day The serving size for a vegetable is typically:
I

1/2 cup of cooked vegetables or vegetable juice, or 1 cup of raw, leafy vegetables

Non-starchy vegetables contain approximately five grams of carbohydrates per serving Since vegetables are low in calories,
try frying them or adding cheese sauce, butter, margarine, or dips to add extra calories Starchy vegetables such as corn, peas, winter squash and potatoes are found in the starch group because they contain more carbohydrates See Food Lists — Chapter 12

I Chapter 6 / Nutrition CFRD

Salt, Vitamins and Minerals
Eating extra sodium salt and salty foods is recommended for people with CF You still need to eat a high-salt diet just as you did before you developed CFRD You lose lots of salt every day in your perspiration, and that salt needs to be replaced from table salt and salty foods in your diet Salt can be added during cooking or at the table Convenience foods snack items, canned and packaged foods, and processed meats and cheeses, condiments ketchup, mustard, soy sauce, pickles, olives, etc and restaurant and fast foods tend to be very high in sodium Adding table salt is also a good way to add sodium You need at least 4,000 milligrams of sodium each day One teaspoon of table salt contains approximately 2,300 milligrams Check your food labels for the sodium content to help you choose high-sodium foods Also, eating a wide variety of foods from all of the food groups, in
addition to taking your multivitamin pills each day, will help you to obtain all the vitamins and minerals you need

Water
Water is a nutrient which is often overlooked It is an important nutrient which is necessary for good health Try to drink at least 64 ounces eight fluid measuring cups of some type of non-caffeinated fluid each day to replace water which is lost with rapid breathing and sweat

Free Foods
Free foods are defined as any food that contains less than 20 calories, or less than five grams of carbohydrates, per serving Be careful to watch the portion size, or simply count it as a carbohydrate unit if the serving size you plan to eat adds up to a carbohydrate unit for example three to four servings eaten at one time Free foods are low in calories, so it is important not to eat too many of them You need plenty of calories each day to maintain a healthy body weight Beverages Bouillon or broth Carbonated or mineral water Coffee Club soda Diet soft drinks Tea Sugar-free Tonic Water Sugar-Free Gelatin Gum Sugar Substitutes: Aspartame Acesulfame K Saccharin Sucralose Condiments BBQ Sauce Catsup Horseradish Lemon and lime juice Mustard Relish Pickles Salsa Soy sauce Tabasco
Taco sauce Teriyaki sauce Vinegar Spices and Herbs All spices and herbs

Managing Cystic Fibrosis Related Diabetes CFRD I

Nutritional Supplements
At times you may experience a decrease in your appetite, noticeable weight loss, or difficulty gaining weight Drinking nutritional supplements during these times can provide you with a valuable source of calories to help you reach your healthy body weight and improve your nutritional status These can be incorporated into your daily meal plan using the carbohydrates information provided below The calories will vary widely, and you may need a particular type of supplement depending upon your nutritional needs Talk with your physician and your dietitian to determine which one is best for you If you use a different type of supplement not listed here, ask your dietitian to help you calculate the carbohydrate content of the supplement Supplement Choice BoostTM Boost PlusTM Calories PlusTM 3 scoops mixed with water 3 scoops mixed with whole milk 3 scoops mixed with half half CitroteinTM EnsureTM Ensure PlusTM Carnation Instant Breakfast TM 1 pkt mixed with 8 ounces half half Sugar-free Carnation Instant Breakfast TM 1 pkt mixed with 8
ounces half half Nutren 10TM Nutren 15TM Nutren 20TM Polycose powder PulmocareTM RespalorTM Resource Fruit BeverageTM ScandishakeTM 1 pkg mixed with 8 ounces whole milk Sportshake TM Chocolate SportshakeTM vanilla, strawberry Typical Serving Size 8 ounces 1 can 8 ounces 1 can 1 serving 1 serving 1 serving
1

Carb Units in Typical Serving 2 1/2 3 3 3 1 /2 3 1 /2 2 2 3 2 1 /2

/3 cup powder

8 ounces 1 can 8 ounces 1 can 1 serving

1 serving

845 ounces 845 ounces 845 ounces 3 tbsp 8 ounces 8 ounces 8 ounces 1 serving 7 1/2 ounces 7 1/2 ounces

2 3 3 1 1 1/2 2 2 1/2 5 3 2 1 /2 33

I Chapter 6 / Nutrition CFRD

Insulin Coverage of Nutritional Supplements
When persons with CFRD use diet supplements, they need to cover the carbohydrate units with insulin just as they do for other food Some people receive several cans of supplement overnight by gastrostomy or nasogastric tube Generally, a single injection of combined Regular plus NPH insulin given before the drip feeding will cover the whole drip feeding Checking some glucose values two to three hours into the feeding and when it ends will help fine-tune the insulin dose

Special Considerations
Delayed Meals Timing of meals and
snacks is important when you are taking insulin When possible, try to eat all of your meals and snacks on time in conjunction with the time-action of your insulin dose This will help you to avoid low blood sugar If your meal is delayed for some reason and you have already taken your insulin, eat or drink something with 15-30 grams of carbohydrates while you wait for your meal Ideally, try not to delay meals for longer than one hour If your meal is delayed, check your blood glucose more often to avoid low blood sugar Use of Alcoholic Beverages You should check with your physician to see if drinking alcohol is appropriate for you It is important to never drink alcohol on an empty stomach when taking insulin or other medication for your diabetes because of the risk of low blood sugar If you plan on drinking alcohol, it is important to understand the affect alcohol has on blood sugar If you are not careful, alcohol can cause blood sugar to go either too high from sugary drinks mixed with alcohol, or dangerously low Normally when you are not drinking alcohol, your liver releases glucose sugar into your bloodstream to prevent your blood sugar from dropping too low When you drink alcohol,
your liver is busy breaking down the alcohol and therefore releases less glucose into the bloodstream This puts you at risk for hypoglycemia, especially if you are drinking on an empty stomach Furthermore, signs of alcohol intoxication are very similar to symptoms of low blood sugar, also called hypoglycemia see Chapter 7 — Hypoglycemia If your judgment is impaired from alcohol, you may not be able to treat your low blood sugar adequately, and/or those around you may not realize that you are experiencing hypoglycemia This can be a medical emergency For safe use of alcohol, review the following guidelines: 1 Always check with your physician to determine if any amount of alcohol is safe for you 2 Wear diabetes identification at all times when drinking alcohol 3 It is safest to drink alcohol only when your blood sugar levels are well-controlled 4 To prevent hypoglycemia, alcohol should be consumed only with food, never alone 5 One alcoholic beverage for women, and two alcoholic beverages for men are generally considered safe One alcoholic beverage is defined as: 12 ounces of beer 4-5 ounces of wine 15 ounces of distilled spirits, cordials, or liqueurs 6 Check your blood sugar
after drinking alcohol to determine your individual response to alcohol 7 Your other CF medications may interact with alcohol, check with your physician about medications and alcohol 34

Managing Cystic Fibrosis Related Diabetes CFRD I

Use of Artificial Sweeteners Artificial sweeteners are considered safe to use on a daily basis Four artificial sweeteners have been approved by the Food and Drug Administration for use in the United States: aspartame, acesulfame-K, saccharin, and sucralose The acceptable daily intake ADI for aspartame is 50 milligrams per kilogram of body weight 1 kilogram 22 pounds This amount includes a 100-fold safety factor The average daily intake of these sweeteners for people with diabetes is approximately 2-4 milligrams per kilogram of body weight Therefore, typical intakes are considered safe and are well below the acceptable daily intake It is important to read nutrition labels for the carbohydrate content of foods which contain artificial sweeteners because individual food items may contain other sources of carbohydrates like sugar-free yogurt which contains milk, and therefore must be calculated as part of your total carbohydrate intake Many food items
containing these artificial sweeteners are low in calories Because you have CF and need a lot of calories, you may be better off eating the regular, rather than the dietetic or low-calorie version of the food item The exception to this is regular soda Excessive intake of regular soda may cause high blood sugar because of the high carbohydrate content of soda One 12 ounce can of regular soda contains approximately 3 carbohydrate units or 40-45 grams of total carbohydrates In addition, regular soda contributes no beneficial nutrients for good health One can of diet soda contains approximately 170 milligrams of aspartame Therefore, an average adult weighing approximately 150 pounds would need to consume 20 twelve-ounce cans of soda or 97 packets of tabletop sweetener to reach the acceptable daily intake For all foods, use moderation and good sense when selecting individual food items Sugar Alcohols Sugar alcohols are another type of low-calorie sugar substitute Sorbitol, Mannitol and Xylitol are examples of sugar-substitutes Excessive amounts of these sweetners can cause diarrhea Use these with caution and remember that you need to eat a lot of calories, so use these only in
moderation

Notes

Low Blood Sugar Hypoglycemia
EDUCATION GOALS
When you have finished reviewing this chapter, you should be able to:
I I

Recognize the common signs of low blood sugar hypoglycemia; Know how to treat low blood sugar

What is Hypoglycemia?
Low blood sugar is called hypoglycemia Blood sugar levels less than 60 mg/dl are abnormally low, and can be dangerous Blood sugar this low, generally, does not occur unless a person is taking insulin People who are taking insulin shots can have dangerously low blood sugar levels Low blood sugar develops quickly, and must be treated immediately Early treatment helps prevent more severe symptoms Thus, when you are newly diagnosed, it is very important that you, your family, friends, and co-workers learn the signs and symptoms of hypoglycemia and how to treat it

Symptoms of Low Blood Sugar
The body gives a warning when low blood sugar is developing DIFFERENT PEOPLE GET DIFFERENT WARNINGS The following symptoms are common signals of hypoglycemia: Hunger Upset stomach nausea Shakiness — your hands or body may feel shaky Sweatiness — you may sweat more than usual often a cold sweat Color — your face may become pale
or red Weakness Headache Confusion — you may feel or look spaced out or appear dazed Anxiety Drowsiness Double vision Behavior changes — changes in behavior are quite common; you may cry, act drunk or act angry You may not recognize your own behavior when you have low blood sugar, so it is important to listen to comments from your family and friends

I Chapter 7 / Low Blood Sugar Hypoglycemia

These symptoms are usually the result of prolonged hypoglycemia Loss of consciousness Seizures, also called convulsions

Causes of Low Blood Sugar
Low blood sugar occurs when your body doesnt have enough sugar to burn for energy and the level of sugar in the blood falls too low The fall in blood sugar triggers the release of special hormones, called counter-regulatory hormones, which help your body correct low blood sugar These hormones also cause the symptoms of low blood sugar Dangerously low blood sugar levels generally only occur if you are taking insulin Low blood sugar associated with insulin use is often called an insulin reaction, or just a reaction Frequent causes of low blood sugar when you are taking insulin are listed below: Meals and snacks that are late or
missed; Extra exercise that burns more sugar than usual; An insulin dose that is too high; More rapid absorption of insulin after an injection, which could occur if a shot was administered into the muscle instead of just under the skin, or because of exercise; Lack of warning symptoms that the blood sugar is low for example when you are asleep; Making a mistake in the drawing up of the insulin dose either drawing up too much insulin or mixing insulin types

Recognizing Low Blood Sugar
It is important for anyone taking insulin to recognize low blood sugar early so that it does not progress to severe symptoms The common warning symptoms, listed above, vary from person to person These warning symptoms usually occur when blood sugar levels are not yet low enough for you to lose consciousness The early signs of hypoglycemia are due to the release of a hormone called adrenaline Adrenaline is also called the fight or flight hormone because most people produce it when they are excited or scared It causes shakiness, sweating, dilated pupils, rapid heart rate, and other symptoms If you feel these symptoms, you should check your blood sugar level If your blood sugar is less than 60
mg/dl, you need to be treated quickly with carbohydrates as described below

Low Blood Sugar in CF Patients Without Diabetes
People with CF who are not treated with insulin may have mildly low blood sugar levels and feel symptoms of hypoglycemia similar to those as previously described These symptoms occur because insulin secretion is not regulated correctly While mildly low blood sugar can be uncomfortable, it is not dangerous Your blood sugar should never drop dangerously low unless you are taking insulin People not taking insulin who experience the symptoms of low blood sugar can prevent these symptoms by eating small, frequent meals containing carbohydrates every two to three hours Although food intake adequately prevents hypoglycemia, you may also wish to try a product containing uncooked starch Several cookie-like bars are commercially available such as Nite Bite BarsTM These uncooked starch bars should not be used to treat severely low blood sugar blood sugar 60 mg/dl, because they will not raise your blood sugar quickly Always treat an acutely low blood sugar with a simple sugar as outlined in the following section

Managing Cystic Fibrosis Related Diabetes CFRD
I

Treatment of Hypoglycemia
The best treatment for severely low blood sugar is to eat or drink a quick acting sugar source If your blood sugar is less than 70 mg/dl, you should take 15 grams of carbohydrates If your blood sugar is less than 50 mg/dl, you should take 30 grams of carbohydrates Examples of 15 grams of carbohydrates include: three to four glucose tablets; half a cup of regular soda, juice or lemonade; one cup milk; one tablespoon of sugar or honey; or one piece of a medium-sized fruit If you are taking insulin, you should always carry glucose tablets in your purse, pocket, on your person, or in a backpack Use glucose tablets for those times when you feel low, but dont have time to test, or when no other sugar source is available It is not safe to feed anyone who is unconscious because the person is likely to choke If your blood sugar is so low that you lose consciousness, or are unable to drink, someone else can treat you with glucagon Glucagon is a hormone which squeezes extra sugar out of the liver and raises the blood sugar level It must be given as a shot Someone who lives with you should know how to give glucagon and you should have it available Glucagon can
cause nausea and vomiting for up to six hours after it is given Even if the package is unopened, glucagon expires after one year Periodically check the expiration date on your glucagon and replace it when necessary You should always wear an identification bracelet or necklace stating that you have diabetes This is the first thing that emergency personnel look for, and it tells them that a patient might need glucagon or intravenous sugar It is also very important that you include your CF diagnosis on your identification bracelet

Hypoglycemia and Driving
People with diabetes are not restricted from driving; however, if you are taking insulin, you need to do everything possible to prevent yourself from developing hypoglycemia while you are driving Several suggestions for preventing hypoglycemia include: Check your blood sugar before you drive and never drive if your blood sugar is less than 75 mg/dl; Eat a snack before you drive; If you are on a long trip, pack plenty of snacks; If you feel jittery or shaky, pull over and check your blood sugar; if it is low, eat a snack; Dont take your insulin on an empty stomach before driving to a restaurant, instead take your insulin once
you arrive Keep glucose tablets in your car

Notes

Sick Day Management
EDUCATIONAL GOALS
When you have finished reviewing this chapter, you should be able to:
I

Understand how to manage your diabetes on days when you are too sick to eat your normal diet

Introduction
When you are unable to tolerate your usual foods, controlling your blood sugar can be difficult Your blood sugar usually rises when you are ill or have an infection You are also more likely to become dehydrated if you have a fever, vomiting or diarrhea, and high blood sugar It is very important for you to notify your diabetes team when you are having difficulty with vomiting, or when your appetite decreases significantly

Helpful Guidelines to Manage Sick Days
The following guidelines will help you to manage your blood sugar when you are unable to follow your usual eating pattern while sick 1 Check your blood sugar frequently, every four to six hours is recommended while blood sugar is elevated 2 Notify your physician that your blood sugar is higher than usual 3 Continue your usual dose of insulin, unless your physician recommends a change 4 Drink liquids if solids are not well tolerated Replace 15 grams
of carbohydrates from solids with 15 grams of carbohydrates from liquids 5 Sip a minimum of eight-12 ounces of fluid every hour, alternating fluids containing carbohydrates juice, milk, supplements, soda with fluids which do not contain carbohydrates water, sugar-free beverages 6 Even if your blood sugar is not high, you need to call your physician if you are unable to eat normally for more than 24 hours Other reasons to call include diarrhea or vomiting which last longer than six hours 7 Most people with CFRD do not develop ketones in large amounts, so you may not have been asked to check your urine for ketones If your diabetes caregiver has instructed you to check your urine for ketones, then you need to check even more often when you are sick You should call your physician if urine ketones are moderate or large 8 Keep in mind that you need to pay special attention to your CF treatments when you are sick Even though you may not feel like using your inhalers and administering your chest percussion, it is important that you continue these routines 9 Notify your pulmonary team or primary care physician when you have a fever 10 Remember that blood sugar levels which are higher than
normal may indicate the beginning of a more serious illness Always notify your CF Foundation-accredited care center and your diabetes team if your blood sugar is running higher than normal for longer than two days 41

Notes

Exercise
EDUCATIONAL GOALS
After reading this chapter, you should be able to:
I I

Understand the benefits of exercise for diabetes management; Understand the precautions needed to prevent problems with exercise

Benefits of Exercise
Regular exercise is good for you for many reasons It can improve your diabetes by making your body more responsive to insulin Exercise can also strengthen your lungs and help you feel healthier Finally, exercise is a natural antidepressant These are just a few of the benefits CF patients will achieve from regular exercise

Precautions
Exercise may cause low blood sugar hypoglycemia because sugar gets used for energy by exercising muscles Most people with CFRD can exercise safely as long as precautionary measures are taken Here are some guidelines: Try to avoid injecting insulin into the areas of the body you will be exercising Check your blood sugar before, during and after exercise so you can determine your blood sugar
patterns If your blood sugar is less than 100 before exercise, eat a snack before you begin Carry a source of carbohydrates like glucose tablets in case you need it Your insulin dose may need to be adjusted to match your activity level Even if your blood sugar is greater than 100, eating an extra carbohydrate snack before exercising is advisable You may need an extra 15-30 grams or more of carbohydrates for each hour of intense or prolonged exercise It is important to remember that the blood sugar lowering effect of exercise can last as long as 12 to 24 hours, and therefore an extra bedtime snack may need to be eaten on days when exercise has been unusually vigorous It is always good to record exercise in the comments section of blood sugar records so that your physician will know if a low blood sugar is the result of exercise

Notes

CFRD Without Fasting Hyperglycemia and Other Types of Abnormal Glucose Tolerance Found in CF
EDUCATIONAL GOALS
This chapter will help you to:
I I

Understand the different types of glucose tolerance found in people with CF; Recognize current treatment guidelines for each type of glucose tolerance

A blood sugar level measured when you
have not eaten any food for 10-12 hours is called a fasting blood glucose, abbreviated FBG This value should normally be less than 126 mg/dl A blood sugar level checked two hours after eating a meal is called a postprandial glucose level Normally, a blood sugar level two hours after eating should be less than 140 mg/dl In Chapter 5, we reviewed different ways to diagnose CFRD One of the diagnostic tests reviewed was the OGTT However, CFRD with fasting hyperglycemia can be diagnosed in several ways reviewed in Chapter 5 The other types of abnormal glucose tolerance described in this chapter must be diagnosed by an OGTT Each of these categories of glucose tolerance require different management

CFRD With Fasting Hyperglycemia
Throughout this manual you have been reading about CFRD with fasting hyperglycemia In this type of diabetes, both the fasting blood sugar and the postprandial blood sugar are higher than normal People with this type of CFRD are the most likely to have classic symptoms of diabetes This type of diabetes should always be treated

CFRD Without Fasting Hyperglycemia
People with normal fasting blood glucose 126 mg/dl, 70mmol, but with a blood sugar greater than 200
mg/dl 111mmol two hours following an oral glucose load have CFRD without fasting hyperglycemia This is a milder form of diabetes In general, these people dont have the classic symptoms of diabetes such as polyuria and polydipsia If you have CFRD without fasting hyperglycemia, you need to measure your blood sugar levels at home self-monitoring of blood glucose — SMBG before meals one day per week You will need insulin in the future if fasting hyperglycemia develops You are at very high risk for needing insulin when you are acutely sick or being treated with corticosteroids You may also be asked to measure your blood sugar two hours after a meal, several times per week Your physician may ask you to take insulin if your postmeal glucose is routinely greater than 200 mg/dl Try to minimize drinking excessive mounts of sweetened beverages like soda Try to eat more frequent meals and snacks throughout the day with consistent amounts of carbohydrates Although your physician may not routinely place you on insulin, you may be given a trial of insulin therapy for the following reasons: Failure to gain or maintain weight Decline in pulmonary function Acute illness Excessive fatigue The
recommendations for treating this type of diabetes may soon change The latest evidence suggests that prevention of post-meal elevation of blood sugar may play an important role in the prevention of diabetes complications 45

I Chapter 10 / CFRD Without Fasting Hyperglycemia Other Types of Abnormal Glucose Tolerance Found in CF

Intermittent Diabetes
Some people with CF may develop diabetes only when they are acutely ill, or when taking oral or intravenous steroids If you are one of these people, it is important that you are treated with insulin during this time so you do not lose an excessive amount of weight during an illness Insulin may be stopped following the acute illness Intermittent diabetes can occur with or without fasting hyperglycemia You will need a yearly oral glucose tolerance test to follow your clinical course You need to be aware that once you have developed intermittent diabetes, you are likely to develop it again You will need to be screened for diabetes when you are acutely sick

Impaired Glucose Tolerance
People with normal fasting blood glucose 126 mg/dl, 70mmol, but a blood sugar of 141-199 mg/dl 78-111mmol two hours following an oral glucose load, have
impaired glucose tolerance Thirty to forty percent of people with CF have impaired glucose tolerance IGT This means that their blood glucose levels may be higher than normal, but not as high as in CFRD If you have impaired glucose tolerance you may develop diabetes in the future Impaired glucose tolerance can only be diagnosed by oral glucose tolerance testing, and if you have IGT, you should be screened yearly with an OGTT You should be tested earlier if diabeteslike symptoms develop You should also be screened when you are acutely ill to be sure you do not develop intermittent CFRD Try to avoid drinking excessive amounts of sweetened beverages like soda Try to eat more frequent meals and snacks throughout the day with consistent amounts of carbohydrates

Diabetes and Pregnancy
In general, women with CF are at high risk for development of diabetes during pregnancy Diabetes which develops only during pregnancy is called gestational diabetes Women with CF should have an oral glucose tolerance test at the end of the first trimester of pregnancy Please note that this recommendation represents earlier screening than is typically done for pregnant women Insulin should be started at the
first sign of diabetes in order to preserve both the babys and the mothers health Women with CF who already have diabetes before becoming pregnant, should discuss potential pregnancy with their physician They should have good blood sugar control before becoming pregnant They also need to be especially careful about monitoring their blood sugar levels and taking enough insulin during pregnancy When a woman becomes pregnant, the amount of insulin she needs increases, especially during the second and third trimester It is very important for the health of the baby that blood sugar levels be normal throughout the pregnancy Any woman with CF who becomes pregnant should be treated by a high-risk obstetrician If she has diabetes before becoming pregnant, or develops gestational diabetes, she should also see an endocrinologist Good blood sugar control and adequate nutrition are especially important during pregnancy Poor blood sugar control or poor nutritional status can negatively affect both mother and baby Although women with gestational diabetes who do not have CF are generally managed by decreasing the amount of carbohydrates in their diet, this management plan is not appropriate for a
woman with both CF and gestational diabetes In general, insulin is the treatment of choice because it promotes weight gain for both the mother and the baby Cutting back on nutrition is never a good choice in CF This is especially true during pregnancy, when nutritional needs are even higher If you have any questions or concerns, discuss them with both your diabetes and CF Foundation-accredited care center teams

Your Caregivers Role in CFRD
EDUCATIONAL GOALS
After reading this chapter, you should be able to:
I

Understand that you and your caregivers are part of a healthcare team; with a common goal of improving your blood sugar control and your overall health

Members of the Diabetes Team
Although you may have developed a very strong relationship with your pulmonologist, you may not have become acquainted with an endocrinologist An endocrinologist is a physician with special training in the treatment of diabetes and other diseases of hormone producing glands If you have CFRD or glucose intolerance, you should see an endocrinologist as well as your pulmonologist The endocrinologist will design a treatment plan to meet your needs and maintain your health Most
endocrinologists work with a certified diabetes educator CDE, generally a nurse or a dietitian who has special training in the management of diabetes Although you may feel most comfortable with the nurse and the dietitian who usually works with your pulmonologist, it is important that you develop a good relationship with your diabetes educators Diabetes educators can help you to manage your diabetes by spending extra time teaching you about blood sugar control, insulin dosing, and diabetes management Diabetes educators are especially helpful in teaching you to recognize when insulin doses need to be changed Other members of the diabetes healthcare team include a social worker or psychologist It is possible that you may not meet all of the diabetes healthcare team because you may continue to use the dietitian and social worker provided by the pulmonary clinic Your endocrinologist and pulmonologist need to be in close communication regarding management of your diabetes The pulmonologist, endocrinologist, pulmonary nurse, endocrine nurse/diabetes educator, the dietitian and the social worker at your CF care center and diabetes clinic should represent a healthcare team which is very
responsive to the unique needs of your CFRD The most important role you have as part of the team is to communicate your schedule when you wake up, when you go to bed, what time you eat meals, and what time you eat snacks to the rest of your diabetes team You also need to tell your team about your other medications, your physical activity and your feelings Good communication allows your healthcare team to tailor diabetes treatment to your individual schedule and makes it easier for you to follow the recommendations It is always easier for the healthcare team to develop a diabetes management plan for you if you follow similar routines most of the time You can help obtain good blood sugar management by developing a routine which works best with your schedule If you are in school or work, separate plans can be made for school/work days and weekend days Remember, you are the most important member of your diabetes healthcare team You need to communicate your needs to the rest of the healthcare team so that they can help you obtain good diabetes management

Notes

Food Lists: Carbohydrate Units in Common Food Items
EDUCATION GOALS
The goal of this chapter is to:
I

Provide
easy reference for carbohydrate content in commonly eaten foods

Carbohydrate Counting
As you have learned in Chapter 6, carbohydrates are the main food group which affect your blood sugar For this reason, it is important to learn how to measure or count the carbohydrates in foods to help you to control your blood sugar The following section contains lists of common foods and their carbohydrate content in carbohydrate units We have also included some common household measurements and portion sizes This information will help you as you make your personal meal plan All foods listed represent ready-to-eat portions It is a good idea to review this section with a registered dietitian to help you determine a reasonable meal plan and distribution of carbohydrates for you, based on your usual eating patterns At the end of this section, there is a blank meal plan which can be filled out by you and your dietitian If you do not have a dietitian, ask your physician to refer you to a registered dietitian in your area who is familiar with both diabetes and cystic fibrosis

Common Household Measurements
3 teaspoons tsp 1 tablespoon Tbsp 4 Tbsp cup 2 fluid ounces 8 Tbsp cup 4 fluid ounces
16 Tbsp 1 cup 8 fluid ounces 1 cup pint 2 cups 1 pint 1 ounce 30 grams dry weight

Estimating Portion Sizes
These handy tips will help you estimate portion size: 3 ounces cooked meat/protein a deck of cards, or the size of a womens palm 1 ounce cheese 4 stacked dice cup casserole, grain, or vegetable covers about of a standard size dinner plate cup fruit the size of a tennis ball

I Chapter 12 / Food Lists: Carbohydrate Units in Common Food Items

Food Lists
As you read these lists, an asterisk placed behind the listed food item denotes higher fat foods Try to choose these foods more often to help you get the extra calories that you need

Breads
Food Choice Bread Breadsticks soft Challah Cornbread Croutons Dinner Roll Foccocia bread French bread Hot dog/hamburger bun Lefse Matzoh Pita small Pita large Taco shell Tortilla corn or flour Tortilla flour Stuffing Wheat pilaf/bulgur
Denotes foods that are higher in fat

Typical Serving Size 1 slice 1 oz 1 - 6 stick 1 ounce 4 cube
1

Carb Units in Typical Serving 1 1 1 2 1 1 2 1 2 1 1 2 3 1 1 2 1 /2 1 1 /2 1

/2 cup

1 roll 1 wedge 1 - 1-ounce slice 1 bun 1 plain
3

/4 ounce

1 1 2 hard shells 1 - 6 inch 1 - 10 inch
1
1

/2 cup /2 cup

Managing Cystic Fibrosis Related Diabetes CFRD I

Pasta, Grains and Other Side Dishes
Food Choice Barley Chow mein noodles Couscous Kasha/buckwheat Pasta Pasta side dish packaged Rice, white, brown or wild Rice-a-RoniTM Rice pilaf Typical Serving Size
1 1 1 1 1 1 1 1 1

Carb Units in Typical Serving 1 1/2 1 1 1 1 1 1/2 1 1/2 1 1/2 1 1 /2

/2 cup /2 cup /2 cup /2 cup /2 cup /2 cup /2 cup /2 cup /2 cup

Breakfast Items
Food Choice Regular bagel Large bagel Biscuit Bran cereals, flaked Cooked cereals oatmeal Cereal, dry unsweetened Cereal, dry, sweetened Croissant Danish small Cake doughnut Frosted or glazed doughnut French toast English muffin
Denotes foods that are higher in fat

Typical Serving Size 1 1 1 medium 1 cup 1 cup
3

Carb Units in Typical Serving 2-3 4-5 1 2 1/2 - 3 2 1 2 2 2 1 1 /2 2 1 2

/4 cup

1 cup 1 1 1 1 1 slice 1 muffin

I Chapter 12 / Food Lists: Carbohydrate Units in Common Food Items

Breakfast Items
Food Choice Grits Hash browns Muffin Giant muffin Pancake Scone Sweet roll Waffle

Continued

Typical Serving Size
1

Carb Units in Typical Serving 1 2 2-3 5-6 1 3 2-3 1

/2 cup

1 cup 1 medium 1 giant 2 pancakes 4 1 1 1 small
waffle

Starchy Vegetables Legumes
Food Choice Beans, peas, lentils cooked Baked beans Corn Corn on the cob French fries Small order: Peas Plantain Potato, baked 1 small Potato, mashed Potato, sweet Potato pancakes Potato salad Potato side dish, packaged Squash, winter Tater tots
Denotes foods that are higher in fat

Typical Serving Size 1 cup
1 1

Carb Units in Typical Serving 2 2 1 1 1-2 1 1 1 1 1 1/2 1 1 1 1/2
1

/2 cup /2 cup

1 medium 16-25
1 1

/2 cup /2 cup

3 ounce
1 1

/2 cup /2 cup

1 medium
1 1 1 1

/2 cup /2 cup /2 cup /2 cup

Managing Cystic Fibrosis Related Diabetes CFRD I

Crackers, Chips Popcorn
Food Choice GoldfishTM crackers Graham crackers Popcorn Popcorn, microwave Potato chips Pretzels Rice cakes RitzTM crackers Saltine crackers Tortilla chips TriscuitTM crackers Wheat crackers Wheat ThinsTM Typical Serving Size
1

Carb Units in Typical Serving
1

/2 cup

3 small squares 3 cups 1 bag 12 - 18 chips 1 oz
3

1 1 3-4 1 1 1 1 1 1 2 1 2

/4oz handful

2 large cakes 8 crackers 6 crackers 6 - 12 1 oz 10 crackers 4 - 6 crackers 1 oz 24 crackers

Condiments and Spreads
Food Choice Honey, sugar jelly, jam Peanut butter Syrup pancake Syrup pancake,
sugar-free Syrup pancake light
Denotes foods that are higher in fat

Typical Serving Size 1 tablespoon 2 tablespoons
1 1 1

Carb Units in Typical Serving 1
1

/4 cup /4 cup /4 cup

3-4 0-1 2

I Chapter 12 / Food Lists: Carbohydrate Units in Common Food Items

Beverages
Food Choice Cappuccino espresso, foamed milk Cocoa, hot Iced tea, bottled, sweetened Latte espresso, steamed milk Lemonade, punch, Kool-Aid Mocha espresso, chocolate, milk Soda, regular Sports drink Typical Serving Size 1 cup 1 packet 16 ounces 1 cup 1 cup 1 cup 1 can 1 cup Carb Units in Typical Serving
1

1-2 4 1 2 2-3 3 1

Milk, Milk Substitutes, Yogurt
Food Choice Milk; 2, whole Chocolate milk Rice milk Soy milk Yogurt, plain Yogurt, fruit Yogurt, fruit with NutraSweetTM Typical Serving Size 1 cup 1 cup 1 cup 1 - 11/2 cup 1 cup 1 cup 1 cup Carb Units in Typical Serving 1 2 2
1

1 2-3 1

Fresh, Frozen Canned Fruit
Food Choice Typical Serving Size 1 cup
1

Carb Units in Typical Serving 1 1 1 1

Fresh fruit pieces berries, melon, and papaya only Other fresh fruit Fresh fruit, raw Canned fruits or fruit sauces in natural juice
Denotes foods that are higher in fat

/2 cup

1 medium piece
1

/2
cup

Managing Cystic Fibrosis Related Diabetes CFRD I

Fresh, Frozen Canned Fruit
Food Choice Banana large Grapefruit Grapes Raisins Other dried fruit Typical Serving Size 1
1

Continued

Carb Units in Typical Serving 2 1 1 2 1

15
1 1

/4 cup

Fruit Juices
Food Choice Apple, grapefruit, orange, pineapple Cranberry, grape, prune Bottled juice Typical Serving Size
1

Carb Units in Typical Serving 1 1 4

/2 cup 4 ounces /3 cup about 3 ounces

16 ounces

Combination Foods
Food Choice Mexican Regular taco Burrito Quesadilla Fajita Refried beans Italian Spaghetti with meat sauce Spaghetti sauce from jar Pizza-thin crust restaurant Pizza-thick crust restaurant Manicotti
Denotes foods that are higher in fat

Typical Serving Size

Carb Units in Typical Serving

1 taco 1 burrito 1 entree size 1 fajita
1

1-2 3-4 3 2-3 1-2

/2 cup

1 cup
1

2 1 1/2 1 1/2 2 2 55

/2 cup

1 medium slice 1 medium slice 2 pieces

I Chapter 12 / Food Lists: Carbohydrate Units in Common Food Items

Food Choice Italian continued Fettucini alfredo Lasagna Pesto with pasta Ravioli Tortellini Asian/Indian Basmati, jasmine rice Chow mein no rice Egg rolls Fried rice Lo mein Mock duck/wheat gluten
Naan

Typical Serving Size

Carb Units in Typical Serving

1 cup 8 ounces 1 cup 1 cup 1 cup

2 2 2 3 3

1 cup 2 cups 1 large 1 cup 2 cups
3 1

3 1 1 3 4 1 2
1

/4 cup

/2 of 8 x 2 piece

Stir fry meat and vegetables only Sweet and sour chicken no rice Wonton plain Mid-Eastern Falafel sandwich Gyros sandwich Hummus Tabouli
Denotes foods that are higher in fat

1 cup 1 cup 5

2 1

1 whole pita 1 sandwich
1 1

4-5 3 1 1

/3 cup /2 cup

Managing Cystic Fibrosis Related Diabetes CFRD I

Food Choice American Casserole with meat and noodles Cold cut sub Corn dog Grilled cheese sandwich

Typical Serving Size 1 cup 6 inch 1 1 sandwich 1 sandwich 1 cup 1 pie 1 cup 1 sandwich

Carb Units in Typical Serving 2 3 1 2 2 2-3 2 1/2 - 3 2 2 1 /2

Hamburger or hot dog on bun Macaroni cheese Pot pie SpaghettiOs with meatballs Veggie burger on bun Southern/Creole Hominy Hoppin John Red beans rice Shrimp creole Succotash Soup Bean with bacon soup Chicken noodle soup Chili Cream of broccoli soup Minestrone soup Miso paste New England clam chowder Tomato soup Vegetable soup
Denotes foods that are higher in fat

3 2

/4 cup /3 cup

1-2 1-2 4 1-2 1

1 cup 1 cup
1

/2 cup

1 cup 1 cup 1 cup 1 cup 1
cup 3 tbsp 1 cup 1 cup 1 cup

1
1

2
1

1 1 1 1
1

I Chapter 12 / Food Lists: Carbohydrate Units in Common Food Items

Fast Foods
Food Choice ArbysTM Arby-Q Reg Roast Beef Beefn Cheddar Roast Chicken Club Grilled Chicken Deluxe French fries Curly fries Burger KingTM Whopper Whopper/Cheese Whopper Jr BK Big Fish BK Broiler French fries Onion rings Apple pie Dairy QueenTM Single hamburger Hot dog Vanilla cone Frozen yogurt cone Chocolate dipped cone Dilly bar Mr Misty Chocolate sundae Chocolate malt
Denotes foods that are higher in fat

Typical Serving Size

Carb Units in Typical Serving

1 sandwich 1 sandwich 1 sandwich 1 sandwich 1 sandwich 1 order 1 order

3 2 2 1/2 2 1/2 3 1 1/2 2 1/2

1 sandwich 1 sandwich 1 sandwich 1 sandwich Medium order Regular 1 pie

3 2 4 3 3 3 3

1 sandwich 1 hot dog 1 medium cone 1 medium cone 1 medium cone 1 bar 1 medium 1 medium sundae 1 small malt

2 1 1/2 3 1/2 4 4 1 1/2 5 5 7 1/2

Managing Cystic Fibrosis Related Diabetes CFRD I

Food Choice Dairy QueenTM Chocolate shake Banana split Oreo blizzard Peanut Buster Parfait

Typical Serving Size 1 medium shake 1 split 1 medium blizzard 1 sundae

Carb Units in Typical Serving 8 1/2 6
1/2 6 1/2 6 1/2

Kentucky Fried ChickenTM Original recipe Wing Breast Drumstick BBQ baked beans Biscuit Coleslaw Corn bread Mashed potatoes McDonaldsTM Breakfast danish Biscuit with sausage Egg McMuffin Hotcakes with syrup English muffin Hash browns Hamburger Cheeseburger Quarter Pounder Big Mac Filet-O-Fish Crispy Chicken Deluxe Chicken McNuggets
Denotes foods that are higher in fat

1 piece 1 piece 1 piece 1 order 1 1 order 1 1 order

1
1

2 1 1 /2 1 1 1 /2 1

1 danish 1 sandwich 1 sandwich 1 order 1 muffin 1 order 1 burger 1 burger 1 burger 1 burger 1 sandwich 1 sandwich 6 pieces

3 1 /2 2 2 6 1 /2 2 1 2 2 1 /2 2 1 /2 3 3 3 1 59

I Chapter 12 / Food Lists: Carbohydrate Units in Common Food Items

Food Choice McDonaldsTM cont Small fries Vanilla shake Regular sundae Apple/cherry pie McDonaldland cookies Chocolate chip cookies Pizza HutTM Pan Pizza Thinn Crispy Personal Pan pizza WendysTM Cheeseburger Grilled chicken sandwich Chili Plain baked potato Frosty

Typical Serving Size

Carb Units in Typical Serving

1 order 1 shake 1 sundae 1 pie 1 box 1 box

2 4 3 1/2 - 4 2 1/2 2 1/2 3

2 medium slices 2 medium slices Whole pizza

4 3 4 1/2

1 burger 1 sandwich 1 serving 1
potato Medium drink

2 2 1/2 1 1/2 5 5

Desserts Sweets
Food Choice Popsicle Pudding pop Ice cream Ice cream bar Ice cream sandwich Sherbet Frozen yogurt
Denotes foods that are higher in fat

Typical Serving Size 1 popsicle 1 pop
1

Carb Units in Typical Serving 1 1 1 1-2 1-2 2 1 1/2

/2 cup

1 bar 1 sandwich
1 1

/2 cup /2 cup

Managing Cystic Fibrosis Related Diabetes CFRD I

Food Choice Pudding/Gelatin Instant regular pudding Gelatin Candy Chocolate bar Gummy bears Jelly beans Junior MintsTM M MsTM Peanut M MsTM SkittlesTM SnickersTM Sucker, lollipop TwixTM TwizzlersTM Baked Goods Angel food cake Apple crisp Banana bread Brownie Cake frosting Cheesecake, plain Cheesecake, fruit topping Cream pie Dessert bar Fruit pie Strawberry shortcake
Denotes foods that are higher in fat

Typical Serving Size

Carb Units in Typical Serving

/2 cup

2 3

1 cup

1 bar 16 pieces 15 pieces reg box 16 mints reg pkg 24 pieces reg pkg 20 pieces reg pkg 40 pieces 1 bar 2 reg pkg-2 bars 3 pieces

2 2 1 2 2 2 4 2 1/2 1 2 1/2 2

Medium slice Medium piece Medium slice Medium square Medium piece Medium slice Medium slice
1

2 3-4 2 2 3-4 2 3 1-2 2-3 3-4 3-4

/8 pie

1 bar
1

/8 pie

Medium
piece

I Chapter 12 / Food Lists: Carbohydrate Units in Common Food Items

Food Choice Cookies Animal crackers Chips AhoyTM Creme wafer cookies Fig Newtons Fortune cookies Fruit Roll-Up Ginger snaps Granola bar plain Granola bar fruit filled Homemade cookie Pepperidge FarmTM gourmet cookie Pepperidge FarmTM fruit cookies Rice Krispie bar Sandwich creme cookies Shortbread cookies Vanilla wafers
Denotes foods that are higher in fat

Typical Serving Size 16 pieces 3 cookies 2 cookies 3 cookies 2 cookies 1 roll 4 snaps 1 bar 1 bar 1 cookie 1 cookie 2 cookies 1 bar 3 cookies 3 5 cookies

Carb Units in Typical Serving 2 2 1 2 1 1 1 1 - 1 1/2 2 1 1/2 - 2 1 1 1/2 1-2 1 1 /2 1 1

Managing Cystic Fibrosis Related Diabetes CFRD I

Your Meal Plan
Time Carbohydrate Units Carbohydrate Grams

Breakfast

__________

AM Snack

__________

Lunch

__________

PM Snack

__________

Dinner

__________

Evening Snack

__________

Recommended amount of added fat per day _________

Recommended amount of meat, poultry, fish, cheese, or eggs per day _________

Recommended amount of vegetables per day _________

Remember: One
carbohydrate unit equals about 15 grams of total carbohydrates

I Chapter 12 / Food Lists: Carbohydrate Units in Common Food Items

Sample Menu
Breakfast: Morning Snack:

Lunch:

Afternoon Snack:

Dinner:

Evening Snack:

Managing Cystic Fibrosis Related Diabetes CFRD I

Your Favorites
Food Choice Typical Serving Size Carb Units in Typical Serving Size

Notes

Managing Cystic Fibrosis Related Diabetes CFRD I

Glossary
American Diabetes Association ADA — A national organization of health professionals committed to teaching the public about all forms of diabetes This organization is a good resource for health information and legal information pertaining to diabetes They can be reached at: 1660 Duke Street, Alexandria, VA 22314, 800 232-3472, or wwwdiabetesorg Aspart Insulin — See Novolog insulin Beta Cells — Special cells in the pancreas which make insulin Carbohydrates — Carbohydrates are the preferred source of energy for the body There are two types: simple commonly called sugar and complex often called starch Carbohydrates are the main food group which affect blood sugar They provide four calories per gram Carbohydrate Counting — A method of quantifying
carbohydrate intake This, combined with flexible insulin dosing, allows the most flexibility in your eating schedule Carbohydrate Unit — This is a method for measuring the amount of carbohydrates in food One carbohydrate unit is equal to 12-15 grams of carbohydrates Casual Blood Glucose — A blood sugar taken without respect to time of day or meal ingestion Certified Diabetes Educator CDE — A CDE is a healthcare professional physician, nurse or dietitian who has received special accreditation for their knowledge about teaching patients how to manage diabetes To obtain this certification, the healthcare professional must work in the field of diabetes education for at least two years and must pass a special examination CFRD with Fasting Hyperglycemia — This type of CF related diabetes always requires medical treatment Patients who have this type of CFRD are the most likely patients to display classic symptoms of diabetes In this type of diabetes, the fasting blood sugar level is higher than 126 mg/dl and the blood sugar two hours after glucose load is higher than 200 mg/dl CFRD without Fasting Hyperglycemia — This is a type of CF related diabetes which may not always require
treatment In this type of diabetes, the fasting blood sugar level is normal, but the blood sugar level two hours after glucose is greater than 200 mg/dl Your diabetes caregiver will determine whether or not you should be treated with insulin Chronic CFRD — CFRD that does not go away Continuous Subcutaneous Insulin Infusion CSII — This is the method of giving insulin by a constant infusion from an insulin pump Diabetes — The lack of insulin or the lack of the bodys ability to use insulin Diabetes Team — This team of healthcare professionals has special training and knowledge about diabetes management Members of the diabetes team include the physician usually an endocrinologist, a nurse, a dietitian and a social worker As the person with diabetes, you are the most important member of the diabetes team Dietary Fat — Fat is the major source of energy for the body because it has the most calories nine per gram Fat can also be stored as body fat to be used for fuel when we do not eat enough Fat is important because it carries essential fat-soluble vitamins vitamins A, D, E and K Fat in food helps provide flavor Endocrine Pancreas — The part of the pancreas which makes hormones One
of these hormones is insulin Exocrine Pancreas — The part of the pancreas which makes digestive enzymes Endocrinologist — A physician with special training in the diagnosis and management of diseases caused by hormone abnormalities, including diabetes 67

I Glossary

Fasting Blood Glucose — A fasting blood glucose is a blood sugar level taken after a person has not eaten any food or drank any fluids containing sugar for at least 10 hours A fasting blood glucose should normally be less than 126 mg/dl If it is higher, it could indicate the presence of diabetes Gestational Diabetes — Diabetes which occurs only during pregnancy It is caused by decreased insulin secretion and insulin resistance CF women are especially prone to this type of diabetes Glargine Insulin — See Lantus insulin Glipizide — An oral hypoglycemic agent which stimulates insulin secretion Glucagon — This hormone increases glucose release from the liver It is given as an injection and should be used to treat hypoglycemia in an unconscious person Glucose Intolerance — When the body has difficulty turning sugar into energy that the body can use Glucose Meters — Home glucose monitors Many brands are currently
marketed Glyburide — An oral hypoglycemic agent which stimulates insulin secretion Glycosylated Hemoglobin — See hemoglobin A1C Hemoglobin A1C — This is a measurement of glucose control for approximately three months before the test It gives the diabetes team an indication of how your blood sugar is between glucose monitoring This is not a useful diagnostic test for CFRD Humalog Insulin — A rapid-acting insulin with onset of 10-15 minutes This insulin generally is gone in twothree hours It is manufactured by Eli Lilly and Company and the generic name is Lys-Pro Hyperglycemia — High blood sugar levels 300 mg/dl in adults Hypoglycemia — Low blood sugar levels 60 mg/dl in adults Impaired Glucose Tolerance — Blood sugar levels that are higher than normal following a glucose load, 140 but less than 200 This diagnosis must be made using an oral glucose tolerance test Insulin Injection Devices — These pen-like devices provide a convenient method for giving and transporting insulin One such device is the Novopen made by Novo-Nordisk Other pens include the Pen-let manufactured by Becton-Dickinson B-D and a disposable pen made by Eli Lilly Insulin Pump — See continuous subcutaneous
insulin infusion Insulin Resistance — Lack of normal response to insulins metabolic actions Insulin resistance can be caused by certain hormones and by other changes which occur during acute illness Intermittent CFRD — This type of CFRD occurs only occasionally, especially during illness It can be associated with or without fasting hyperglycemia Treatment may be necessary when blood sugar is high Juvenile Diabetes Research Foundation International — The mission of the Juvenile Diabetes Research Foundation is to find a cure for diabetes and its complications through the support of research The Juvenile Diabetes Research Foundation is the worlds leading nonprofit, nongovernmental funded organization of diabetes research For more information contact: Shira M Kandel, Manager of Public Information, 120 Wall Street, 19th floor, New York, NY 10005, Phone-212 479-7508, Fax-212 785-9595 wwwjdfrorg Ketones — Ketones are products made by the body when fat is used for energy instead of sugar Lancet — A device used to prick your finger to obtain a small drop of blood Lantus Insulin — This is a basal insulin which has no peak and lasts approximately 24 hours It may not be mixed with other
types of insulin This insulin is manufactured by Aventis and the generic name is Glargine Lente Insulin — This is an intermediate-acting insulin with peak activity in 8-12 hours It lasts up to 22 hours 68

Managing Cystic Fibrosis Related Diabetes CFRD I

Lys-Pro Insulin — See Humalog insulin Metformin — A pill which is used to treat type 2 diabetes It promotes sensitivity to insulin Metformin should only be used to treat CFRD as part of a research protocol at the time of this writing Novolog Insulin — A rapid-acting insulin with onset of 10-15 minutes This insulin is generally gone in twothree hours It is manufactured by Novo-Nordisk and the generic name is Aspart NPH Insulin — This is an intermediate-acting insulin with peak activity in 4-6 hours Although its average length of action is 8-12 hours, it can last as long as 20 hours It is made by multiple manufacturers Oral Glucose Tolerance Test OGTT — This is a test used to diagnose diabetes A glucose containing solution is given and blood sugar response is measured hourly for either 2 or 3 hours Oral Hypoglycemic Agents — These are pills used to treat type 2 diabetes They promote insulin release from the pancreas They
should only be used to treat CFRD as part of a research protocol Postprandial glucose level — A blood sugar level checked two hours after a meal Protein — Protein is comprised of amino acids also called the building blocks of protein Amino acids are classified as essential and nonessential The essential amino acids cannot be made by the body and therefore must be obtained by eating certain foods Animal sources of protein, such as meats, poultry, fish, eggs and dairy products are complete protein sources because they contain all of the essential amino acids Plant proteins are incomplete because they do not contain all of the essential amino acids The functions of protein include maintenance, growth and repair of body tissues Protein also helps to regulate the immune system and other body processes Protein provides four calories per gram Regular Insulin — This short acting insulin has its peak activity in 2 to 4 hours and lasts for 6 to 8 hours Multiple manufacturers make this type of insulin and all brands have equal effectiveness Repaglinide — An oral agent which increases insulin secretion The trade name is Prandin Retinopathy — Eye disease caused by long-term high blood
sugar levels Every adult with diabetes should be screened for this type of eye disease once per year Self Monitoring of Blood Glucose SMBG — Using a blood sugar meter to measure blood sugar levels SMBG allows you and your diabetes caregiver to better adjust insulin to meet your daily schedule Troglitazone — A pill used to treat type 2 diabetes, which promotes sensitivity to insulin It should only be used to treat CFRD as part of a research protocol Type 1 Diabetes — Also called insulin dependent diabetes This type of diabetes generally presents itself during childhood It is caused by lack of insulin and is associated with life-threatening illness when insulin is not taken Type 2 Diabetes — Also called non-insulin dependent diabetes This type of diabetes generally occurs in adults over 40 and is associated with obesity It is caused by resistance to insulins biological effects Uncooked Starch Bars — These can be eaten to prevent symptoms of low blood sugar They are not rapid acting and therefore cannot be used to treat acutely low blood sugar They are commercially available as Nite Bite Bars Ultralente Insulin — This is a long-acting insulin which does not have a specific peak
in activity and generally lasts 20-24 hours It is manufactured by Eli Lilly and Company

Notes

Cystic Fibrosis Foundation
The mission of the Cystic Fibrosis Foundation is to assure the development of the means to cure and control cystic fibrosis CF, and to improve the quality of life for those who have the disease The CF Foundation pursues this mission via four major avenues:
I I I I

Medical Care; Research; Public Policy; Education

Medical Care
Medical care that is unique to CF is available through more than 200 CF Foundation-accredited care centers, affiliate programs, and adult CF care programs throughout the country The success of the comprehensive care center approach is shown by the increased life span for those with CF — now extending into the early 30s When the CF Foundation was created by a dedicated group of parents in 1955, most individuals rarely lived to attend school CF Services, Inc, a wholly-owned subsidiary of the CF Foundation, offers CF medications at the lowest possible cost through a mail-order service Pharmacy staff also function as advocates for the rights and interests of its customers by going to bat with insurance companies

Research
The CF
Foundation supports research in several ways A network of CF Foundation research centers, located at leading universities and medical schools around the country, is devoted to studying CF Scientists at these centers work together, sharing ideas and information to move the research ahead When CF Foundation-supported scientists found the CF gene in 1989, it started research to turn this knowledge into the cure for CF CF gene therapy trials began in 1993 Early CF gene therapy clinical trials gathered vital information about the safety and potential of this new technology CF scientists are leading the whole field of gene therapy In fact, more people with CF have received gene therapy than those with all other genetic diseases The first phase of study has shown that CF gene therapy corrects CF cells for a short time Scientists are now focusing their work on finding ways to deliver genes into the cells, and be turned on to express the normal protein Rapid strides are being made through many new approaches At the same time, the CF Foundation supports finding other types of treatments Clinical studies are looking at mucus-thinning drugs, for example, and a new strategy called protein
repair In protein repair, drugs are given to help the defective protein made by the CF gene Another new area of research is finding ways to replace or restore function of natural antibiotics that should be working on the outside of CF cells to prevent infections For information about CF Foundation-supported clinical trials, call 800 FIGHT CF, or visit wwwcfforg 71

I Cystic Fibrosis Foundation

Ideas for new drugs most often come from the labs of CF Foundation-supported scientists who make discoveries about the disease The speed at which these discoveries are changed into therapies has been accelerated through the Therapeutics Development Program This program provides matching awards as reasons for biotechnology companies to explore promising CF drugs Another part of the program is a set of CF care centers selected by the CF Foundation to form the Therapeutics Development Network These sites carry out Phase I and II clinical studies in patients on new CF drugs The opportunities for new drugs to be created have never been greater and now the program is in place to evaluate many CF drugs The CF Foundation has many research grants These grants range from student traineeships to
research awards for veteran scientists Through its ground-breaking approaches to CF research, the CF Foundation has created a time of new goals being achieved and optimism for those fighting CF Every day brings us one step closer to finding a cure

Public Policy
The primary legislative aims of the CF Foundation include: working to have enough money for CF research through its partner, the National Institutes of Health; reducing the barriers to healthcare faced by many people with CF, including continued access to the CF Foundation-accredited care centers; and improving educational and career opportunities for people with CF Through its public policy goals, the CF Foundation gives information to government agencies and legislators on the national, state, and local levels to encourage them to devote resources toward fighting CF For example, the CF Foundations Public Policy Alliance was created in 1996 as a grassroots network to educate legislators and explain the major issues confronting individuals with CF and their families by representing the CF community on Capitol Hill Contact the CF Foundation for more information

Education
Education is a priority for the CF Foundation at both
the consumer and the healthcare profession For people with CF, their families and the general public, the CF Foundation has Commitment, a national newsletter, and consumer fact sheets, which cover the latest in CF research and methods to pay for care Medical videos on the latest about gene therapy or other news about CF science are offered at no charge For up-to-the-minute news about CF research and CF Foundation activities, check out the CF Foundations Web site at: wwwcfforg The CF Foundation also supports the training of medical students and residents at CF Foundation-accredited care centers and sponsors conferences on CF for scientists and the CF care center teams If you would like more information about the CF Foundation or its programs, or to reach a local chapter, contact: Cystic Fibrosis Foundation 6931 Arlington Road Bethesda, Maryland 20814 301 951-4422 800 FIGHT CF wwwcfforg info@cfforg

del.icio.us:On behalf of the South Dakota Department of Health Diabetes Prevention & Control Program, I the occurrence of diabetes and its complications. ...

digg:On behalf of the South Dakota Department of Health Diabetes Prevention & Control Program, I the occurrence of diabetes and its complications. ...

spurl:On behalf of the South Dakota Department of Health Diabetes Prevention & Control Program, I the occurrence of diabetes and its complications. ...

newsvine:On behalf of the South Dakota Department of Health Diabetes Prevention & Control Program, I the occurrence of diabetes and its complications. ...

blinklist:On behalf of the South Dakota Department of Health Diabetes Prevention & Control Program, I the occurrence of diabetes and its complications. ...

furl:On behalf of the South Dakota Department of Health Diabetes Prevention & Control Program, I the occurrence of diabetes and its complications. ...

reddit:On behalf of the South Dakota Department of Health Diabetes Prevention & Control Program, I the occurrence of diabetes and its complications. ...

fark:On behalf of the South Dakota Department of Health Diabetes Prevention & Control Program, I the occurrence of diabetes and its complications. ...

Y!:On behalf of the South Dakota Department of Health Diabetes Prevention & Control Program, I the occurrence of diabetes and its complications. ...

Diabetes Treatments

On behalf of the South Dakota Department of Health Diabetes Prevention & Control Program, I the occurrence of diabetes and its complications. …

Recent Diabetes Treatments Articles

Categories