The Autoimmune Connection: Essential Information for Women on Diagnosis, Treatment, and Getting On With Your Life (26 page)

Hemoglobin A1C
is a test now used to diagnose diabetes as well as to monitor blood sugar control.
Hemoglobin
, a protein inside red blood cells that carries oxygen to the body, also links up (
glycates
) with glucose in the bloodstream. The higher your blood glucose, the more hemoglobin is glycated, says the ADA. Measuring the percentage of A1C provides an average of blood glucose over two to three months. An A1C level of 6.5 percent or greater is among the revised diagnostic ADA criteria for diabetes.
¹
For treatment monitoring purposes; A1C testing is typically done two to four times a year.

Fasting plasma glucose (FPG)
is a second blood test for diagnosing type 1 diabetes. The day before the test, your doctor will ask you not to eat for 8 to 10 hours. The next morning, a sample of your blood will be taken and the glucose level measured. Normally, your glucose would be 100 milligrams per deciliter (mg/dL) of blood after not eating for that many hours.
But if you have diabetes, your glucose will be 126 mg/dl or over, according to the ADA criteria. Levels in between are considered
impaired fasting glucose
and indicate a high risk of developing diabetes.

Postprandial glucose (PPG)
may be an earlier indication of impending diabetes than an FPG for some patients. Postprandial glucose is the level seen two hours after eating. In this test you’re given oral glucose after an overnight fast. If postprandial glucose is over 200, then you have diabetes. If it’s between 140 and 200, you have
impaired glucose tolerance
, or
prediabetes
.

Urinalysis
(for
ketones
,
protein
, and
sediment
from red or white blood cells) is also done. The presence of ketones in the urine can indicate the beginnings of ketoacidosis. (It can also just mean that you haven’t eaten for a long time.) Protein in the urine and sediment are signs of kidney dysfunction.

eGFR (estimated glomerular filtration rate)
tells how well your kidneys are working. It’s a number based on results of a blood test for
creatinine
, a waste product of muscles. Healthy kidneys filter creatinine out of your blood. An eGFR is calculated from a blood creatinine level, your age, race, gender, and other factors. A normal eGFR is 60 or above; if the rate is lower, your kidneys aren’t functioning properly. An eGFR is also used to diagnose
chronic kidney disease (CKD)
.

Since one out of every 100 with type 1 diabetes will develop Graves’ disease, and one in 20 will develop
Hashimoto’s thyroiditis
, your doctor will likely order a test to measure
thyroid stimulating hormone (TSH)
.

You and your immediate family also run a high risk (approximately one in 20) of developing
celiac disease
. Many people with celiac are asymptomatic, and if the condition goes untreated it can lead to anemia, bone loss, and even cancer. Diagnosing it early can help prevent those problems (see
page 270
).

Measuring the level of vitamin B
₁₂
and folic acid in your blood helps to diagnose
pernicious anemia
. One in 50 adults with type 1 diabetes also develops this autoimmune disease, in which the stomach is unable to absorb vitamin B
₁₂
; telltale symptoms include anemia and weakness. Testing for autoantibodies against the
parietal cells
in the stomach lining indicates autoimmune disease; low plasma B
₁₂
indicates malabsorption.

There are a number of tests for EPI, among them stool tests to measure the pancreatic enzymes
trypsin
and
elastase
, and a blood test for
trypsinogen (immunoreactive trypsin)
another enzyme reduced in pancreatic sufficiency. (For more details on testing for EPI, see
page 202
.)
¹⁰

The ADA recommends repeating all diagnostic tests to rule out lab errors and confirm a diagnosis, unless classic symptoms of diabetes are present.
¹

Mary Kay’s story continues:

When I was first diagnosed with diabetes, I had to mix two kinds of insulin in my morning injection, one was long-acting and the other was fast-acting. I also needed to eat breakfast. I was never a breakfast eater, and you need to eat approximately four hours after your first injection. My appetite has always been zero first thing in the morning, and it sort of grows during the day. Now on a different insulin regimen things are a bit easier with eating. Everyone thinks it must be hard or painful to give yourself shots, because we all remember those painful immunizations we got as kids. But it’s really not like that at all. In fact, I don’t really feel the injections; they have these itty-bitty fine needles now. The most difficult part for me is the constant paying attention to eating and what you are consuming. I mean, diabetes makes you eat a healthy diet. And you can certainly lead a normal life with it. . . . . But it means never going anywhere without candy bars or fruit in your purse, in case your blood sugar gets too low, and never skipping meals. And always making sure if you’ve taken your insulin. It’s been many years, and I can often tell when my glucose is low. I can feel the symptoms of hypoglycemia before it really gets bad. For me, it feels very much like a hot flash. And I have such a rapid metabolism I never seem to get enough calories.

How much insulin you need depends on your glucose level, and that requires testing blood glucose throughout the day (see
page 208
).

After you eat, the body normally releases just enough insulin to process glucose; with a schedule of insulin injections timed before meals, you can mimic the normal release of insulin. If you’re eating three meals a day (and one or two snacks), you might use a short-acting insulin just before each meal, and intermediate- or long-acting insulin once or twice a day to maintain a basic-level (
basal
) insulin.

Your body may respond better to a particular type of insulin, or a combination of insulin preparations, depending on how quickly they work, when they peak, and how long they last. The most commonly used preparations are human insulins produced by genetic engineering, which act just like natural insulin. Some are faster-acting than others.

There are four basic types of insulin
¹²
:

• Rapid-acting insulin
  begins to work about 15 minutes after injection, peaks in about 1 hour, and continues to work for 2 to 4 hours. These include:
  Insulin glulisine (Apidra)
  ,
  insulin lispro (Humalog)
  , and
  insulin aspart (NovoLog)
  .
  
• Regular or short-acting insulin
  usually reaches the bloodstream within 30 minutes after injection, peaks anywhere from 2 to 3 hours after injection, and is effective for approximately 3 to 6 hours. These include:
  Humulin R
  ,
  Novolin R
  .
  
• Intermediate-acting insulin
  generally reaches the bloodstream about 2 to 4 hours after injection, peaks 4 to 12 hours later, and is effective for about 12 to 18 hours. There are currently two:
  Humulin N
  and
  Novolin N
  .
  
• Long-acting insulin
  reaches the bloodstream several hours after injection and tends to lower glucose levels fairly evenly over a 24-hour period. The two long-acting insulins are
  insulin detemir (Levemir)
  and
  insulin glargine (Lantus, Toujeo)
  .
  

Instead of a syringe that must be filled from a separate vial, insulin these days often comes in a “pen,” either a prefilled injector or a pen that uses an insulin cartridge. You dial the insulin dose on the pen and inject your insulin through a small needle. Cartridges and prefilled insulin pens contain a single type of insulin, so if you use two forms of insulin you’ll need an injection from each device.

Insulin works fastest when injected in the abdomen, the ADA says, and gets into the blood a little more slowly from the upper arms and slower still from the thighs and buttocks. For best results, especially with mealtime insulin, inject it in the same general
area
each time—but not in the same exact
spot
, which may cause fatty deposits or hard lumps to develop. For example, injecting your before-breakfast insulin in the abdomen and your before-supper insulin in the leg each day gives more similar blood glucose results.

There’s now a rapid-acting inhaled human insulin powder,
Afrezza
.
¹³
Afrezza is used in combination with long-acting insulin. It’s not recommended for treating diabetic ketoacidosis. Afrezza is inhaled at the beginning of each meal.

“If a woman is eating a low-fat diet, which many women do, she’ll do much better with short-acting insulins or insulin analogues in combination with a long-acting insulin like Lantus. However, if you go out to dinner and eat higher-fat items, like pizza, then these insulins don’t work as well,” says Dr. Levy. Taking several injections of fast-acting insulin can give you more flexibility in planning meals (you can take a little extra to cover a second helping of pasta, for example).

Some women prefer to wear insulin pumps that can be programmed to release different doses of insulin at different times of the day. “The only issue for some women is body image; you have to wear a pump 24 hours a day, seven days a week, and some women don’t feel comfortable with that,” says Dr. Levy. Insulin pumps can be useful in pregnancy, when blood sugars can be erratic, she adds.

Pumps can be programmed to deliver insulin as steady, continuous “basal” dose or as a surge or “bolus” dose around mealtime to control the rise in glucose after you eat. The pump is attached to a flexible plastic catheter with a small needle at the end. As with an insulin injection, the needle is inserted into the fatty tissue under the skin, then you tape it in place. A recent study from Sweden suggests that patients using insulin pumps may have better long-term outcomes compared with people taking insulin injections.
¹⁴

However, insulin therapy is a highly individualized process that should be worked out with a specially trained healthcare provider, such as a certified diabetes educator. They can also help you learn when and how and where to give yourself injections or how to use an insulin pump. (An indispensable reference to help you manage insulin treatment is the
American Diabetes Association Complete Guide to Diabetes
, see
Appendix B
for more information.)

Pregnancy and oral estrogens can also affect blood glucose and the amount of insulin you need, so you may need more frequent glucose testing if you’ve just begun taking oral contraceptives or hormone replacement. Illness and stress can also affect glucose, requiring adjustments in insulin.

You need to match the amount of insulin you take with the amount of food you eat (which raises glucose) and the amount of exercise you get (which lowers glucose). But even if you ate the same amount of food each day and exercised the same amount daily, your need for insulin could still fluctuate, so self-monitoring of glucose is vital.

Studies show that three or four injections of insulin a day give the best blood glucose control and can prevent or delay the eye, kidney, and nerve damage caused by diabetes, according to the ADA.

If your goal is keeping glucose levels as close to normal as possible, you may need to test up to five times a day. The standard times to self-test are before breakfast, lunch, and dinner (and before eating a larger snack), one to two hours after eating, and before bedtime. According to new guidelines set by the ADA,
¹
acceptable blood glucose ranges are 80 to 120 milligrams per deciliter of blood (mg/dl) before meals and 100 to 140 mg/dl before bedtime. People without diabetes generally have a glucose level of less than 110 mg/dl before meals, and under 120 mg/dl before going to bed, but you may not be able to achieve those levels.

Glucose home monitoring is usually done with a disposable
lancet
device; you prick a finger to produce a drop of blood and apply it to a specially treated piece of paper or to a handheld glucose meter.

You can also keep track of blood sugar with a monitor (
MiniMed Continuous Glucose Monitoring System
), which your doctor can order for you.

However you test, you should keep track of the results in a small notebook. The patterns you see (for example, a rise in glucose after eating certain foods, or during the premenstrual period) can help you make adjustments in your insulin intake.

Monitoring your glucose and preventing problems like ketoacidosis may get easier in the future with new technology now being tested.

In the past, women with diabetes were told to avoid sugary foods because they would send blood glucose soaring. But updated dietary guidelines from the American Diabetes Association (ADA) say it’s OK to have sweets occasionally—as long as your blood sugar levels are well controlled.

According to the revised guidelines, issued in 2014, it’s not so important what kind of carbohydrates you eat, but that you keep an eye on your total carbohydrate intake. However, you are advised to eat more nutritious carbohydrates, like fruits, vegetables, and complex carbohydrates like whole grains, which are digested more slowly and don’t cause spikes in glucose. Cut sodium to less than 2,300 milligrams a day, limit artery-clogging saturated fat, and eat more fiber (25 to 20 grams a day).
¹⁵

“I let my patients eat what they want as long as they can appropriately cover it with insulin and exercise,” remarks Dr. Levy. “As long as you eat a healthful diet, there are no limitations if you don’t have problems with weight or cholesterol. But you really need to be careful to balance your carbohydrate intake.”

People with type 1 diabetes may process protein faster, but because most of us eat 50 percent more protein than we need (15 to 20 percent of our daily calories), you won’t suffer protein deficiency. If you follow a vegetarian diet, be sure to include plant proteins (like beans, nuts, sweet potatoes, and avocado) to avoid deficiency.

Calorie-free sweeteners approved by the FDA—including
saccharine
(
Sweet’N Low
,
Sugar Twin
),
aspartame
(
NutraSweet
,
Equal
), sucralose (
Splenda
), and
stevia/rebaudioside
(
Truvia
,
Pure Via
)—can safely be used by people with diabetes. Apart from the natural sugar (
free fructose
) in fruits, which may aid glycemic control, the ADA advises avoiding foods and beverages with
fructose
added as a sweetener.
¹⁰

Alcohol can trigger both high and low blood sugar, depending on the amount that’s consumed and whether it’s taken with food. It can also raise blood pressure. But moderate alcohol consumption is not harmful, so follow the standard recommendation for women of one or fewer drinks per day (one drink is considered to be 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of spirits).

The ADA guidelines stress that regular exercise is as important as diet to maintain normal blood sugar. In fact, moderate exercise can lower blood sugar to the extent that you may even need less insulin. Exercise can also help raise “good” high density lipoprotein (HDL) cholesterol and lower blood pressure, which can lessen the risk of cardiovascular complications, notes Dr. Levy.

Intensive diabetes care means a solid education in controlling glucose; balancing diet, exercise, and insulin; and the support of an active healthcare team (including a diabetes nurse specialist, a dietitian, and a physician) to provide regular follow-up.

Your care team can also help reduce your risk of heart attack and stroke. Your goals are to keep blood pressure below 130 mm Hg systolic and less than 80 mm Hg (diastolic, the resting rate) and maintain a
low density lipoprotein (LDL)
cholesterol under 100 mg/dl, an HDL above 50 mg/dl, and triglycerides below 150 mg/dL. Your A1C should be below 7 percent, according to the ADA.
¹

Women who develop high blood pressure or kidney disease will need medications to control those conditions, such as
angiotensin-converting enzyme (ACE) inhibitors
. If retinopathy develops, there are treatments to coagulate leaky blood vessels and prevent vision loss with laser therapy.

The one time sugar
does
come in handy is during an episode of hypoglycemia, or low blood glucose. This can occur if you don’t take enough insulin, skip a meal or a snack, eat a meal unusually late, or drink alcohol on an empty stomach. You can also suffer low blood sugar if you exercise too vigorously (it can even occur during sex). Even if you’re doing everything right, you can still have an episode of hypoglycemia, since the body may not always use insulin consistently; hypoglycemia is also more common during pregnancy. Warning signs can occur at any time—even waking you up from a sound sleep (sometimes you may have a nightmare due to the effects of low blood sugar on the brain).

The first thing to do when those symptoms hit is to test your glucose—hypoglycemia is generally considered to be a glucose level of 50 mg/dl or under, but some women can have symptoms with slightly higher levels. If glucose is low, eat something containing sugar. It’s a good idea to carry things like hard candy to help raise your glucose quickly if needed; you can also carry glucose tablets, available in most drugstores. Something as simple as a half cup of orange juice or a handful of raisins (both of which contain 10 to 15 grams of carbohydrates) can raise your blood sugar and head off a more serious reaction, such as seizures or loss of consciousness. After you’ve eaten, wait 15 to 20 minutes and then retest. Sometimes, you may need a second snack to get your blood glucose back to where it should be. Even if you don’t have your test kit with you, treat hypoglycemia immediately.

After you’ve had diabetes for a number of years, it’s not unusual to lose the ability to feel the early warning signs, and you may suffer from more severe episodes. Hypoglycemia unawareness can also occur during pregnancy. This is another reason why testing is crucial.

Mary Kay’s story continues:

I was diagnosed with thyroid disease many years ago during a routine wellness exam, and I have been taking a very low dose of Synthroid ever since. My doctor said it was “borderline” hypothyroidism. There was no history of diabetes in my family or other autoimmune diseases; no arthritis, no thyroid disease. When they were searching for the cause of my lung nodules in 1984, I was tested for lupus and for rheumatoid arthritis, and all those tests were negative. But here I am with thyroid disease and diabetes. And my brother has had the same lung nodules I had . . . but he hasn’t had a diagnosis of sarcoid. They only found the lung nodules by accident with a routine x-ray. He was also diagnosed with gout, and that’s a form of arthritis. So it’s possible that there is some genetic component.