Gusto ko lang po maglabas ng personal na opinion regarding sa issue ni Rosanna Roces at ni Cristy Fermin.
From PEP.com
Headline sa isang tabloid ngayong araw, February 19, ang balitang hinuli diumano ng mga tauhan ng Philippine Drug Enforcement Agency (PDEA) ang aktres na si Rosanna Roces.
Ito ay nakasulat sa kolum ng batikang entertaimment columnist na si Cristy Fermin, ang "Most Wanted," sa Bulgar.
Ayon kay Cristy, kasama raw ni Rosanna ang ilang kaibigan nang mahuli ng mga operatiba dahil sa “paulit-ulit nang report na nakararating sa kanilang opisina tungkol sa pagdodroga ng magaling pa namang aktres.”
Dagdag pang impormasyon ng impormante ni Cristy, kasalukuyan daw nakakulong si Osang at mga kasama nito, at “no bail recommended” sa kanila.
Ito naman ang sagot ni Cristy Feemin ( GMA news)
Depensa naman ni Fermin, isang linggo na raw niyang hawak ang impormasyon at hiningan niya ng pahayag si Rossana sa isyu pero hindi raw ito sumasagot ang sa kaniyang mga tawag at text. -- FRJ, GMA news
HIndi ba ito nagpapakita lang isang irresponsableng pamamahayag?
Kung isang linggo na na hawak niya ang information, bakit hindi siya nagtanong sa PDEA tulad ng ginawa ng PEP.com? tumawag sila sa PDEA para iconfirm kung tama ang balita at naconfirm na hindi tutuo!
Minsan mahirap mapagkatiwalaan ang mga ganitong klaseng writer/reporter. TSK TSK TSK.
Wala po akong personal na attachment kina Rosanna at Cristy.
Personal na opinion lang
Kitchen Design Plans, Tips on Small Kitchen Designs
The kitchen is often the focal point of any house, as well as a place for cooking and eating it is often a meeting place where the whole family gather. Therefore it is important to have a kitchen that is both functional and pleasant to be in. If you thought that it was too difficult to design your own kitchen, then think again. There are many different kitchen design plans and with a few tips you can have the kitchen that you have always wanted.
SMALL KITCHEN DESIGNS
If you have a small room for a kitchen it may at first seem to be very difficult when you want to design your own kitchen to your personal preferences. But remember that a functional kitchen does not rely just on the kitchen floor design, where everything has to fit into tight corners to make the most of the available space.
One simple but effective idea is to put an island in or near the centre of the room. These provide great storage as well a convenient and handy workspace. Kitchen island designs automatically create more space, as they are usually placed in the centre of the kitchen it also gives you easy access all the way around.
With a little thought you could even incorporate something like a breakfast bar as part of your kitchen island design. And don’t forget that you are not just limited to a square or rectangle for your kitchen island, it could be round or oval or any shape that will fit into your kitchen floor design.
As well as the actual design there are also many kitchen appliances available these days that come in smaller sizes, especially designed for the smaller kitchen. Things like refrigerators are available that are only twenty four inches deep as apposed to the usual thirty inch deep models. And don’t forget things like microwave ovens that will fit easily onto a worktop below overhead cabinets.
Also think about hanging your pots and pans on a rack over your kitchen island. This not only makes them more accessible and easier to get at when needed but will also drastically cut down on the amount of cupboard space that they take up. And its not just pots and pans that can be hung on racks, you can also hang up things like cooking utensils, oven gloves, and anything else that you use often. This way you don’t have to go searching through cluttered drawers just to find one item.
Lighting is another important part of the décor to think about when you design your own kitchen. With the proper kind of lighting it can create the illusion of a bigger room. There are lots of different types of lighting available these days, so you no longer have to put up with a fluorescent strip light or glaring 100 watt bulbs. The simple use of dimmer switches can give you a greater flexibility for different lighting moods.
These are just some of the basic tips for small kitchen designs. When you come to design your own kitchen make sure you think it through properly so you get exactly what you want. Whether you want an old world kitchen design, or if you are after a great island kitchen design, remember that its your kitchen so its worth getting it right, as its you who will be using it.
About Author
Click here for great tips on kitchen design http://www.buytryreview.com/recommends/kitchendesignplans
For further articles please visit Floweradvisor lifestyle.
There are a wide range of topics to read about:
Furniture, Home Builders, Home Decorators, Home Mortgage, Interior Design, Kitchens, New Home, Real Estate Investment, Refinance Home
by phlip
The kitchen is often the focal point of any house, as well as a place for cooking and eating it is often a meeting place where the whole family gather. Therefore it is important to have a kitchen that is both functional and pleasant to be in. If you thought that it was too difficult to design your own kitchen, then think again. There are many different kitchen design plans and with a few tips you can have the kitchen that you have always wanted.
SMALL KITCHEN DESIGNS
If you have a small room for a kitchen it may at first seem to be very difficult when you want to design your own kitchen to your personal preferences. But remember that a functional kitchen does not rely just on the kitchen floor design, where everything has to fit into tight corners to make the most of the available space.
One simple but effective idea is to put an island in or near the centre of the room. These provide great storage as well a convenient and handy workspace. Kitchen island designs automatically create more space, as they are usually placed in the centre of the kitchen it also gives you easy access all the way around.
With a little thought you could even incorporate something like a breakfast bar as part of your kitchen island design. And don’t forget that you are not just limited to a square or rectangle for your kitchen island, it could be round or oval or any shape that will fit into your kitchen floor design.
As well as the actual design there are also many kitchen appliances available these days that come in smaller sizes, especially designed for the smaller kitchen. Things like refrigerators are available that are only twenty four inches deep as apposed to the usual thirty inch deep models. And don’t forget things like microwave ovens that will fit easily onto a worktop below overhead cabinets.
Also think about hanging your pots and pans on a rack over your kitchen island. This not only makes them more accessible and easier to get at when needed but will also drastically cut down on the amount of cupboard space that they take up. And its not just pots and pans that can be hung on racks, you can also hang up things like cooking utensils, oven gloves, and anything else that you use often. This way you don’t have to go searching through cluttered drawers just to find one item.
Lighting is another important part of the décor to think about when you design your own kitchen. With the proper kind of lighting it can create the illusion of a bigger room. There are lots of different types of lighting available these days, so you no longer have to put up with a fluorescent strip light or glaring 100 watt bulbs. The simple use of dimmer switches can give you a greater flexibility for different lighting moods.
These are just some of the basic tips for small kitchen designs. When you come to design your own kitchen make sure you think it through properly so you get exactly what you want. Whether you want an old world kitchen design, or if you are after a great island kitchen design, remember that its your kitchen so its worth getting it right, as its you who will be using it.
About Author
Click here for great tips on kitchen design http://www.buytryreview.com/recommends/kitchendesignplans
For further articles please visit Floweradvisor lifestyle.
There are a wide range of topics to read about:
Furniture, Home Builders, Home Decorators, Home Mortgage, Interior Design, Kitchens, New Home, Real Estate Investment, Refinance Home
by phlip
Sex Relieves Stress
1. Sex Relieves Stress
A big health benefit of sex is lower blood pressure and overall stress reduction, according to researchers from Scotland who reported their findings in the journal Biological Psychology. They studied 24 women and 22 men who kept records of their sexual activity. Then the researchers subjected them to stressful situations — such as speaking in public and doing verbal arithmetic — and noted their blood pressure response to stress.
Those who had Inte*cou*se had better responses to stress than those who engaged in other sexual behaviors or abstained.
Another study published in the same journal found that frequent Inte*cou*se was associated with lower diastolic blood pressure in cohabiting participants. Yet other research found a link between partner hugs and lower blood pressure in women.
2. Sex Boosts Immunity
Good sexual health may mean better physical health. Having sex once or twice a week has been linked with higher levels of an antibody called immunoglobulin A or IgA, which can protect you from getting colds and other infections. Scientists at Wilkes University in Wilkes-Barre, Pa., took samples of saliva, which contain IgA, from 112 college students who reported the frequency of sex they had.
Those in the "frequent" group — once or twice a week — had higher levels of IgA than those in the other three groups — who reported being abstinent, having sex less than once a week, or having it very often, three or more times weekly.
3. Sex Burns Calories
Thirty minutes of sex burns 85 calories or more. It may not sound like much, but it adds up: 42 half-hour sessions will burn 3,570 calories, more than enough to lose a pound. Doubling up, you could drop that pound in 21 hour-long sessions.
"Sex is a great mode of exercise," says Patti Britton, PhD, a Los Angeles sexologist and president of the American Association of Sexuality Educators and Therapists. It takes work, from both a physical and psychological perspective, to do it well, she says.
4. Sex Improves Cardiovascular Health
While some older folks may worry that the efforts expended during sex could cause a stroke, that's not so, according to researchers from England. In a study published in the Journal of Epidemiology and Community Health, scientists found frequency of sex was not associated with stroke in the 914 men they followed for 20 years.
And the heart health benefits of sex don't end there. The researchers also found that having sex twice or more a week reduced the risk of fatal heart attack by half for the men, compared with those who had sex less than once a month.
5. Sex Boosts Self-Esteem
Boosting self-esteem was one of 237 reasons people have sex, collected by University of Texas researchers and published in the Archives of Sexual Behavior.
That finding makes sense to Gina Ogden, PhD, a sex therapist and marriage and family therapist in Cambridge, Mass., although she finds that those who already have self-esteem say they sometimes have sex to feel even better. "One of the reasons people say they have sex is to feel good about themselves," she tells WebMD. "Great sex begins with self-esteem, and it raises it. If the sex is loving, connected, and what you want, it raises it."
6. Sex Improves Intimacy
Having sex and orgasms increases levels of the hormone oxytocin, the so-called love hormone, which helps us bond and build trust. Researchers from the University of Pittsburgh and the University of North Carolina evaluated 59 premenopausal women before and after warm contact with their husbands and partners ending with hugs. Tey found that the more contact, the higher the oxytocin levels.
"Oxytocin allows us to feel the urge to nurture and to bond," Britton says.
Higher oxytocin has also been linked with a feeling of generosity. So if you're feeling suddenly more generous toward your partner than usual, credit the love hormone.
7. Sex Reduces Pain
As the hormone oxytocin surges, endorphins increase, and pain declines. So if your headache, arthritis pain, or PMS symptoms seem to improve after sex, you can thank those higher oxytocin levels.
In a study published in the Bulletin of Experimental Biology and Medicine, 48 volunteers who inhaled oxytocin vapor and then had their fingers pricked lowered their pain threshold by more than half.
8. Sex Reduces Prostate Cancer Risk
Frequent ejaculations, especially in 20-something men, may reduce the risk of prostate cancer later in life, Australian researchers reported in the British Journal of Urology International. When they followed men diagnosed with prostate cancer and those without, they found no association of prostate cancer with the number of sexual partners as the men reached their 30s, 40s, and 50s.
But they found men who had five or more ejaculations weekly while in their 20s reduced their risk of getting prostate cancer later by a third.
Another study, reported in the Journal of the American Medical Association, found that frequent ejaculations, 21 or more a month, were linked to lower prostate cancer risk in older men, as well, compared with less frequent ejaculations of four to seven monthly.
9. Sex Strengthens Pelvic Floor Muscles
For women, doing a few pelvic floor muscle exercises known as Kegels during sex offers a couple of benefits. You will enjoy more pleasure, and you'll also strengthen the area and help to minimize the risk of incontinence later in life.
To do a basic Kegel exercise, tighten the muscles of your pelvic floor, as if you're trying to stop the flow of urine. Count to three, then release.
10. Sex Helps You Sleep Better
The oxytocin released during orgasm also promotes sleep, according to research.
And getting enough sleep has been linked with a host of other good things, such as maintaining a healthy weight and blood pressure. Something to think about, especially if you've been wondering why your guy can be active one minute and snoring the next.
A big health benefit of sex is lower blood pressure and overall stress reduction, according to researchers from Scotland who reported their findings in the journal Biological Psychology. They studied 24 women and 22 men who kept records of their sexual activity. Then the researchers subjected them to stressful situations — such as speaking in public and doing verbal arithmetic — and noted their blood pressure response to stress.
Those who had Inte*cou*se had better responses to stress than those who engaged in other sexual behaviors or abstained.
Another study published in the same journal found that frequent Inte*cou*se was associated with lower diastolic blood pressure in cohabiting participants. Yet other research found a link between partner hugs and lower blood pressure in women.
2. Sex Boosts Immunity
Good sexual health may mean better physical health. Having sex once or twice a week has been linked with higher levels of an antibody called immunoglobulin A or IgA, which can protect you from getting colds and other infections. Scientists at Wilkes University in Wilkes-Barre, Pa., took samples of saliva, which contain IgA, from 112 college students who reported the frequency of sex they had.
Those in the "frequent" group — once or twice a week — had higher levels of IgA than those in the other three groups — who reported being abstinent, having sex less than once a week, or having it very often, three or more times weekly.
3. Sex Burns Calories
Thirty minutes of sex burns 85 calories or more. It may not sound like much, but it adds up: 42 half-hour sessions will burn 3,570 calories, more than enough to lose a pound. Doubling up, you could drop that pound in 21 hour-long sessions.
"Sex is a great mode of exercise," says Patti Britton, PhD, a Los Angeles sexologist and president of the American Association of Sexuality Educators and Therapists. It takes work, from both a physical and psychological perspective, to do it well, she says.
4. Sex Improves Cardiovascular Health
While some older folks may worry that the efforts expended during sex could cause a stroke, that's not so, according to researchers from England. In a study published in the Journal of Epidemiology and Community Health, scientists found frequency of sex was not associated with stroke in the 914 men they followed for 20 years.
And the heart health benefits of sex don't end there. The researchers also found that having sex twice or more a week reduced the risk of fatal heart attack by half for the men, compared with those who had sex less than once a month.
5. Sex Boosts Self-Esteem
Boosting self-esteem was one of 237 reasons people have sex, collected by University of Texas researchers and published in the Archives of Sexual Behavior.
That finding makes sense to Gina Ogden, PhD, a sex therapist and marriage and family therapist in Cambridge, Mass., although she finds that those who already have self-esteem say they sometimes have sex to feel even better. "One of the reasons people say they have sex is to feel good about themselves," she tells WebMD. "Great sex begins with self-esteem, and it raises it. If the sex is loving, connected, and what you want, it raises it."
6. Sex Improves Intimacy
Having sex and orgasms increases levels of the hormone oxytocin, the so-called love hormone, which helps us bond and build trust. Researchers from the University of Pittsburgh and the University of North Carolina evaluated 59 premenopausal women before and after warm contact with their husbands and partners ending with hugs. Tey found that the more contact, the higher the oxytocin levels.
"Oxytocin allows us to feel the urge to nurture and to bond," Britton says.
Higher oxytocin has also been linked with a feeling of generosity. So if you're feeling suddenly more generous toward your partner than usual, credit the love hormone.
7. Sex Reduces Pain
As the hormone oxytocin surges, endorphins increase, and pain declines. So if your headache, arthritis pain, or PMS symptoms seem to improve after sex, you can thank those higher oxytocin levels.
In a study published in the Bulletin of Experimental Biology and Medicine, 48 volunteers who inhaled oxytocin vapor and then had their fingers pricked lowered their pain threshold by more than half.
8. Sex Reduces Prostate Cancer Risk
Frequent ejaculations, especially in 20-something men, may reduce the risk of prostate cancer later in life, Australian researchers reported in the British Journal of Urology International. When they followed men diagnosed with prostate cancer and those without, they found no association of prostate cancer with the number of sexual partners as the men reached their 30s, 40s, and 50s.
But they found men who had five or more ejaculations weekly while in their 20s reduced their risk of getting prostate cancer later by a third.
Another study, reported in the Journal of the American Medical Association, found that frequent ejaculations, 21 or more a month, were linked to lower prostate cancer risk in older men, as well, compared with less frequent ejaculations of four to seven monthly.
9. Sex Strengthens Pelvic Floor Muscles
For women, doing a few pelvic floor muscle exercises known as Kegels during sex offers a couple of benefits. You will enjoy more pleasure, and you'll also strengthen the area and help to minimize the risk of incontinence later in life.
To do a basic Kegel exercise, tighten the muscles of your pelvic floor, as if you're trying to stop the flow of urine. Count to three, then release.
10. Sex Helps You Sleep Better
The oxytocin released during orgasm also promotes sleep, according to research.
And getting enough sleep has been linked with a host of other good things, such as maintaining a healthy weight and blood pressure. Something to think about, especially if you've been wondering why your guy can be active one minute and snoring the next.
Food as Medicine
Food as Medicine
HEADACHE? EAT FISH!
Eat plenty of fish -- fish oil helps prevent headaches.
So does ginger, which reduces inflammation and pain.
HAY FEVER? EAT YOGURT!
Eat lots of yogurt before pollen season.
Also-eat honey from your area (local region) daily.
TO PREVENT STROKE DRINK TEA!
Prevent build-up of fatty deposits on artery walls with regular
doses of tea. (actually, tea suppresses appetite and keeps the pounds
from invading....Green tea is great for our immune system)!
INSOMNIA (CAN'T SLEEP?) HONEY!
Use honey as a tranquilizer and sedative.
ASTHMA? EAT ONIONS!!!!
Eating onions helps ease constriction of bronchial tubes. (onion
packs place on chest helped the respiratory ailments and actually
made breathing better).
ARTHRITIS? EAT FISH, TOO!!
Salmon, tuna, mackerel and sardines actually prevent arthritis. (fish
has omega oils, good for our immune system)
UPSET STOMACH? BANANAS - GINGER!!!!!
Bananas will settle an upset stomach.
Ginger will cure morning sickness and nausea.
BLADDER INFECTION? DRINK CRANBERRY JUICE!!!!
High-acid cranberry juice controls harmful bacteria.
BONE PROBLEMS? EAT PINEAPPLE!!!
Bone fractures and osteoporosis can be prevented by the manganese in
pineapple.
MEMORY PROBLEMS? EAT OYSTERS!
Oysters help improve your mental functioning by supplying
much-needed zinc.
COLDS? EAT GARLIC!
Clear up that stuffy head with garlic. (remember, garlic lowers
cholesterol, too.)
COUGHING? USE RED PEPPERS!!
A substance similar to that found in the cough syrups is found in hot
red pepper. Use red (cayenne) pepper with caution-it can irritate
your tummy.
BREAST CANCER? EAT Wheat, bran and cabbage
Helps to maintain estrogen at healthy levels.
LUNG CANCER? EAT DARK GREEN AND ORANGE AND VEGGIES!!!
A good antidote is beta carotene, a form of Vitamin A found in dark
green and orange vegetables.
ULCERS? EAT CABBAGE ALSO!!!
Cabbage contains chemicals that help heal both gastric and duodenal
ulcers.
DIARRHEA? EAT APPLES!
Grate an apple with its skin, let it turn brown and eat it to cure
this condition. (Bananas are good for this ailment)
CLOGGED ARTERIES? EAT AVOCADO!
Mono unsaturated fat in avocados lowers cholesterol.
HIGH BLOOD PRESSURE? EAT CELERY AND OLIVE OIL!!!
Olive oil has been shown to lower blood pressure.
Celery contains a chemical that lowers pressure too.
BLOOD SUGAR IMBALANCE? EAT BROCCOLI AND PEANUTS!!!
The chromium in broccoli and peanuts helps regulate insulin and
blood sugar.
Kiwi: Tiny but mighty. This is a good source of potassium,
magnesium, Vitamin E & fibre. It's Vitamin C content is twice that of
an orange.
Apple: An apple a day keeps the doctor away? Although an apple has a
low Vitamin C content, it has antioxidants & flavonoids which
enhances the activity of Vitamin C thereby helping to lower the risks
of colon cancer, heart attack & stroke.
Strawberry: Protective fruit. Strawberries have the highest total
antioxidant power among major fruits & protects the body from cancer
causing, blood vessels clogging free radicals. (Actually, any berry
is good for you..they're high in anti-oxidants and they actually keep
us young.........blueberries are the best and very versatile in the
health field........they get rid of all the free-radicals that invade
our bodies)
Orange: Sweetest medicine. Taking 2 - 4 oranges a day may help keep
colds away, lower cholesterol, prevent & dissolve kidney stones as
well as lessen the risk of colon cancer.
Watermelon: Coolest Thirst Quencher. Composed of 92% water, it is
also packed with a giant dose of glutathione which helps boost our
immune system. They are also a key source of lycopene - the cancer
fighting oxidant. Other nutrients
Found in watermelon are Vitamin C & Potassium. (watermelon also has
natural substances [natural SPF sources] that keep our skin healthy,
protecting our skin from those darn UV rays)
Guava & Papaya: Top awards for Vitamin C. They are the clear winners
for their high Vitamin C content. Guava is also rich in fibre which
helps prevent constipation.
Papaya is rich in carotene, this is good for your eyes. (also good
for gas and indigestion)
Tomatoes are very good as a preventative measure for men, keeps
those prostrate problems from invading their bodies......GOOD AS
MEDICINE.
HEADACHE? EAT FISH!
Eat plenty of fish -- fish oil helps prevent headaches.
So does ginger, which reduces inflammation and pain.
HAY FEVER? EAT YOGURT!
Eat lots of yogurt before pollen season.
Also-eat honey from your area (local region) daily.
TO PREVENT STROKE DRINK TEA!
Prevent build-up of fatty deposits on artery walls with regular
doses of tea. (actually, tea suppresses appetite and keeps the pounds
from invading....Green tea is great for our immune system)!
INSOMNIA (CAN'T SLEEP?) HONEY!
Use honey as a tranquilizer and sedative.
ASTHMA? EAT ONIONS!!!!
Eating onions helps ease constriction of bronchial tubes. (onion
packs place on chest helped the respiratory ailments and actually
made breathing better).
ARTHRITIS? EAT FISH, TOO!!
Salmon, tuna, mackerel and sardines actually prevent arthritis. (fish
has omega oils, good for our immune system)
UPSET STOMACH? BANANAS - GINGER!!!!!
Bananas will settle an upset stomach.
Ginger will cure morning sickness and nausea.
BLADDER INFECTION? DRINK CRANBERRY JUICE!!!!
High-acid cranberry juice controls harmful bacteria.
BONE PROBLEMS? EAT PINEAPPLE!!!
Bone fractures and osteoporosis can be prevented by the manganese in
pineapple.
MEMORY PROBLEMS? EAT OYSTERS!
Oysters help improve your mental functioning by supplying
much-needed zinc.
COLDS? EAT GARLIC!
Clear up that stuffy head with garlic. (remember, garlic lowers
cholesterol, too.)
COUGHING? USE RED PEPPERS!!
A substance similar to that found in the cough syrups is found in hot
red pepper. Use red (cayenne) pepper with caution-it can irritate
your tummy.
BREAST CANCER? EAT Wheat, bran and cabbage
Helps to maintain estrogen at healthy levels.
LUNG CANCER? EAT DARK GREEN AND ORANGE AND VEGGIES!!!
A good antidote is beta carotene, a form of Vitamin A found in dark
green and orange vegetables.
ULCERS? EAT CABBAGE ALSO!!!
Cabbage contains chemicals that help heal both gastric and duodenal
ulcers.
DIARRHEA? EAT APPLES!
Grate an apple with its skin, let it turn brown and eat it to cure
this condition. (Bananas are good for this ailment)
CLOGGED ARTERIES? EAT AVOCADO!
Mono unsaturated fat in avocados lowers cholesterol.
HIGH BLOOD PRESSURE? EAT CELERY AND OLIVE OIL!!!
Olive oil has been shown to lower blood pressure.
Celery contains a chemical that lowers pressure too.
BLOOD SUGAR IMBALANCE? EAT BROCCOLI AND PEANUTS!!!
The chromium in broccoli and peanuts helps regulate insulin and
blood sugar.
Kiwi: Tiny but mighty. This is a good source of potassium,
magnesium, Vitamin E & fibre. It's Vitamin C content is twice that of
an orange.
Apple: An apple a day keeps the doctor away? Although an apple has a
low Vitamin C content, it has antioxidants & flavonoids which
enhances the activity of Vitamin C thereby helping to lower the risks
of colon cancer, heart attack & stroke.
Strawberry: Protective fruit. Strawberries have the highest total
antioxidant power among major fruits & protects the body from cancer
causing, blood vessels clogging free radicals. (Actually, any berry
is good for you..they're high in anti-oxidants and they actually keep
us young.........blueberries are the best and very versatile in the
health field........they get rid of all the free-radicals that invade
our bodies)
Orange: Sweetest medicine. Taking 2 - 4 oranges a day may help keep
colds away, lower cholesterol, prevent & dissolve kidney stones as
well as lessen the risk of colon cancer.
Watermelon: Coolest Thirst Quencher. Composed of 92% water, it is
also packed with a giant dose of glutathione which helps boost our
immune system. They are also a key source of lycopene - the cancer
fighting oxidant. Other nutrients
Found in watermelon are Vitamin C & Potassium. (watermelon also has
natural substances [natural SPF sources] that keep our skin healthy,
protecting our skin from those darn UV rays)
Guava & Papaya: Top awards for Vitamin C. They are the clear winners
for their high Vitamin C content. Guava is also rich in fibre which
helps prevent constipation.
Papaya is rich in carotene, this is good for your eyes. (also good
for gas and indigestion)
Tomatoes are very good as a preventative measure for men, keeps
those prostrate problems from invading their bodies......GOOD AS
MEDICINE.
The 90/10 Principle
The 90/10 Principle
We can all learn from this. Most of us are â€oeReactionariesâ. If we try
to reflect and stay calm we could probably avoid most of our stresses in
life.
The 90/10 Principle By Steven Covey
Author of bestseller The 7 Habits of Highly Effective People) Discover
the 90/10 Principle. It will change your life (at least the way you
react to situations). What is this principle? 10% of life is made up of
what happens to you. 90% of life is decided by how you react. What does
this mean?
We really have no control over 10% of what happens to us. We cannot stop
the car from breaking down. The plane will be late arriving, which
throws our whole schedule off. A driver may cut us off in traffic. We
have no control over this 10%. The other 90% is different. You
determine the other 90%.
How? By your reaction. You cannot control a red light. However, you can
control your reaction. Do not let people fool you; YOU can control how
you react.
Let us use an example: You are eating breakfast with your family. Your
daughter knocks over a cup of coffee onto your business shirt.
You have no control over what just happened. What happens next will be
determined by how you react. You curse. You harshly scold your daughter
for knocking the cup over.
She breaks down in tears. After scolding her, you turn to your spouse
and criticize her for placing the cup too close to the edge of the
table. A short verbal battle follows. You storm upstairs and change your
shirt. Back downstairs, you find your daughter has been too busy crying
to finish breakfast and get ready for school. She misses the bus. Your
spouse must leave immediately for work.
You rush to the car and drive your daughter to school. Because you are
late, you drive 40 miles an hour in a 30 mph speed limit zone. After a
15-minute delay and throwing $60 traffic fine away, you arrive at
school. Your daughter runs into the building without saying goodbye.
After arriving at the office 20 minutes late, you find you forgot your
briefcase. Your day has started terrible.
As it continues, it seems to get worse and worse. You look forward to
coming home. When you arrive home, you find small wedge in your
relationship with your spouse and daughter.
Why? Because of how you reacted in the morning. Why did you have a bad
day?
A. Did the coffee cause it?
B. Did your daughter cause it?
C. Did the policeman cause it?
D. Did you cause it?
The answer is "D".
You had no control over what happened with the coffee. How you reacted
in those 5 seconds is what caused your bad day.
Here is what could have and should have happened. Coffee splashes over
you. Your daughter is about to cry. You gently say, "Its ok honey, you
just need to be more careful next time".
Grabbing a towel, you rush upstairs. After grabbing a new shirt and your
briefcase, you come back down in time to look through the window and see
your child getting on the bus. She turns and waves. You arrive 5 minutes
early and cheerfully greet the staff. Your boss comments on how good the
day you are having.
Notice the difference?
Two different scenarios. Both started the same. Both ended different.
Why? Because of how you REACTED.
You really do not have any control over 10% of what happens. The other
90% was determined by your reaction.
Here are some ways to apply the 90/10 principle.
If someone says something negative about you, do not be a sponge. Let
the attack roll off like water on glass. You do not have to let the
negative comment affect you! React properly and it will not ruin your
day. A wrong reaction could result in losing a friend, being fired,
getting stressed out etc.
How do you react if someone cuts you off in traffic?
Do you lose your temper?
Pound on the steering wheel? (A friend of mine had the Steering wheel
fall off)
Do you curse?
Does your blood pressure skyrocket?
Do you try to bump them?
WHO CARES if you arrive ten seconds later at work? Why let the cars ruin
your drive. Remember the 90/10 principle, and do not worry about it.
You are told you lost your job. Why lose sleep and get irritated? It
will work out. Use your worrying energy and time into finding another
job.
The plane is late; it is going to mangle your schedule for the day. Why
take out your frustration on the flight attendant? She has no control
over what is going on. Use your time to study, get to know the other
passenger.
Why are you stressed out? It will just make things worse. Now you know
the 90/10 principle. Apply it and you will be amazed at the results. You
will lose nothing if you try it. The 90/10 principle is incredible. Very few know and apply this
principle.
The result? Millions of people are suffering from undeserved stress,
trials, problems and heartache.
We all must understand and apply the 90/10 principle.
It CAN change your life!
This transmission is intended only for use by the intended recipient(s).
If you are not an intended recipient you should not read, disclose,
copy, circulate or in any other way use the information contained in
this transmission. The information contained in this transmission may be
confidential and/or privileged. If you have received this transmission
in error, please notify the sender immediately and delete this
transmission including any attachments.
We can all learn from this. Most of us are â€oeReactionariesâ. If we try
to reflect and stay calm we could probably avoid most of our stresses in
life.
The 90/10 Principle By Steven Covey
Author of bestseller The 7 Habits of Highly Effective People) Discover
the 90/10 Principle. It will change your life (at least the way you
react to situations). What is this principle? 10% of life is made up of
what happens to you. 90% of life is decided by how you react. What does
this mean?
We really have no control over 10% of what happens to us. We cannot stop
the car from breaking down. The plane will be late arriving, which
throws our whole schedule off. A driver may cut us off in traffic. We
have no control over this 10%. The other 90% is different. You
determine the other 90%.
How? By your reaction. You cannot control a red light. However, you can
control your reaction. Do not let people fool you; YOU can control how
you react.
Let us use an example: You are eating breakfast with your family. Your
daughter knocks over a cup of coffee onto your business shirt.
You have no control over what just happened. What happens next will be
determined by how you react. You curse. You harshly scold your daughter
for knocking the cup over.
She breaks down in tears. After scolding her, you turn to your spouse
and criticize her for placing the cup too close to the edge of the
table. A short verbal battle follows. You storm upstairs and change your
shirt. Back downstairs, you find your daughter has been too busy crying
to finish breakfast and get ready for school. She misses the bus. Your
spouse must leave immediately for work.
You rush to the car and drive your daughter to school. Because you are
late, you drive 40 miles an hour in a 30 mph speed limit zone. After a
15-minute delay and throwing $60 traffic fine away, you arrive at
school. Your daughter runs into the building without saying goodbye.
After arriving at the office 20 minutes late, you find you forgot your
briefcase. Your day has started terrible.
As it continues, it seems to get worse and worse. You look forward to
coming home. When you arrive home, you find small wedge in your
relationship with your spouse and daughter.
Why? Because of how you reacted in the morning. Why did you have a bad
day?
A. Did the coffee cause it?
B. Did your daughter cause it?
C. Did the policeman cause it?
D. Did you cause it?
The answer is "D".
You had no control over what happened with the coffee. How you reacted
in those 5 seconds is what caused your bad day.
Here is what could have and should have happened. Coffee splashes over
you. Your daughter is about to cry. You gently say, "Its ok honey, you
just need to be more careful next time".
Grabbing a towel, you rush upstairs. After grabbing a new shirt and your
briefcase, you come back down in time to look through the window and see
your child getting on the bus. She turns and waves. You arrive 5 minutes
early and cheerfully greet the staff. Your boss comments on how good the
day you are having.
Notice the difference?
Two different scenarios. Both started the same. Both ended different.
Why? Because of how you REACTED.
You really do not have any control over 10% of what happens. The other
90% was determined by your reaction.
Here are some ways to apply the 90/10 principle.
If someone says something negative about you, do not be a sponge. Let
the attack roll off like water on glass. You do not have to let the
negative comment affect you! React properly and it will not ruin your
day. A wrong reaction could result in losing a friend, being fired,
getting stressed out etc.
How do you react if someone cuts you off in traffic?
Do you lose your temper?
Pound on the steering wheel? (A friend of mine had the Steering wheel
fall off)
Do you curse?
Does your blood pressure skyrocket?
Do you try to bump them?
WHO CARES if you arrive ten seconds later at work? Why let the cars ruin
your drive. Remember the 90/10 principle, and do not worry about it.
You are told you lost your job. Why lose sleep and get irritated? It
will work out. Use your worrying energy and time into finding another
job.
The plane is late; it is going to mangle your schedule for the day. Why
take out your frustration on the flight attendant? She has no control
over what is going on. Use your time to study, get to know the other
passenger.
Why are you stressed out? It will just make things worse. Now you know
the 90/10 principle. Apply it and you will be amazed at the results. You
will lose nothing if you try it. The 90/10 principle is incredible. Very few know and apply this
principle.
The result? Millions of people are suffering from undeserved stress,
trials, problems and heartache.
We all must understand and apply the 90/10 principle.
It CAN change your life!
This transmission is intended only for use by the intended recipient(s).
If you are not an intended recipient you should not read, disclose,
copy, circulate or in any other way use the information contained in
this transmission. The information contained in this transmission may be
confidential and/or privileged. If you have received this transmission
in error, please notify the sender immediately and delete this
transmission including any attachments.
Top 20 signs that a movie is GAWANG PINOY
Top 20 signs that a movie is GAWANG PINOY:
1. Sasayaw sa likod ng puno ng buko pag nasa beach yung scene. Alternate
pa yung mga ulo nila.
2. Yung kontrabida yayakap sa bida, sabay taas ng kilay at ngingisi.
3. Ang pancit, nagdadala ng malas. Uuwi ang bida na may dalang pancit sa
kanyang nanay na si Anita Linda. Tatawagin nito ang mga bata
para kumain, at kakamustahin ng bida ang pag-aaral habang kumakain ng
pancit. Biglang may titigil na sasakyan sa harap ng bahay at pauulanan
ng baril ang pamilya! Mamamatay si Anita Linda, at sisigaw ang bida ng
"Inaaay!" at mangangakong ipaghihiganti ito. Moral lesson: Ang pancit,
nakakamatay.
4. Pag may magkaribal na babae, yung mabait diretcho ang buhok at may
bangs. Yung salbahe, laging kulot.
5. Sa pinoy action movies, ang bida hindi nauubusan ng bala.
6. Sa pinoy action movies, kapag tumakbo ang bida, sa lupa lahat ang
tama ng bala ng kalaban.
7. Kapag may angry mob na pupunta sa bahaykubo ng manananggal, si Vangie
Labalan ang laging lider.
8. Alam mong moment of truth na ng bida kapag sinabi na niya yung title
ng pelikula.
9. Ang tawag ng kontrabida sa mga goons niya, "Mga bata."
10. Yung nakababatang kapatid ng bida habang naglalaro ng bola,
mabibitawan at mapupunta sa gitna ng kalsada. Tapos may darating na
sasakyan, tapos itutulak siya ng bida. Yung bida naman ang nasa gita ng
kalsada. Biglang may sasakyang darating. Ang bida, ico-cross lang niya
arms niya covering his face tapos sisigaw yung kapatd ng 'kuyaaa!'. Next
scene nasa ospital na sila. Simula na ng drama.
11. Kapag bakbakan, hindi nasasaktan ang bida, pero umaaray siya pag
ginagamot na siya ng leading lady, at kasunod na ang love scene.
12. Kapag may sinabi ng kontrabida ang masama niyang planosa bida, ang
sasabihin ng bida: "hayop ka!"
13. Ang bidang babae, pag katulong ang role, siguradong magiging anak ng
amo niya sa ending.
14. Ang nanay ng mayaman laging may pamaypay na pangmayaman, at ang
nanay ng mahirap laging naka duster.
15. Ang hideout ng kontrabida, parating mansion na may chicks sa pool.
16. Ang mga bida sa drama, pag nakatanggap ng masamang balita, laging
may pinto sa likod nila para puwede silang sumandal habang nagsa-slide
dahan-dahan pababa, tapos todo iyak with matching uhog.
17. Pag di nahuli ng mga goons ang bida, sasabihin ng boss sa kanila,
"Mga inutil!"
18. Laging nakakapulot ng baril na may bala ang bida kapag kinakailangan
niya.
19. Laging mas maganda ang yayang bida kesa sa kontrabidang anak ng amo
niya.
20. Pag ang ending ng movie ay song and dance number sa beach o resort,
ang huling frame, tatalon ang buong cast...sabay freeze.
1. Sasayaw sa likod ng puno ng buko pag nasa beach yung scene. Alternate
pa yung mga ulo nila.
2. Yung kontrabida yayakap sa bida, sabay taas ng kilay at ngingisi.
3. Ang pancit, nagdadala ng malas. Uuwi ang bida na may dalang pancit sa
kanyang nanay na si Anita Linda. Tatawagin nito ang mga bata
para kumain, at kakamustahin ng bida ang pag-aaral habang kumakain ng
pancit. Biglang may titigil na sasakyan sa harap ng bahay at pauulanan
ng baril ang pamilya! Mamamatay si Anita Linda, at sisigaw ang bida ng
"Inaaay!" at mangangakong ipaghihiganti ito. Moral lesson: Ang pancit,
nakakamatay.
4. Pag may magkaribal na babae, yung mabait diretcho ang buhok at may
bangs. Yung salbahe, laging kulot.
5. Sa pinoy action movies, ang bida hindi nauubusan ng bala.
6. Sa pinoy action movies, kapag tumakbo ang bida, sa lupa lahat ang
tama ng bala ng kalaban.
7. Kapag may angry mob na pupunta sa bahaykubo ng manananggal, si Vangie
Labalan ang laging lider.
8. Alam mong moment of truth na ng bida kapag sinabi na niya yung title
ng pelikula.
9. Ang tawag ng kontrabida sa mga goons niya, "Mga bata."
10. Yung nakababatang kapatid ng bida habang naglalaro ng bola,
mabibitawan at mapupunta sa gitna ng kalsada. Tapos may darating na
sasakyan, tapos itutulak siya ng bida. Yung bida naman ang nasa gita ng
kalsada. Biglang may sasakyang darating. Ang bida, ico-cross lang niya
arms niya covering his face tapos sisigaw yung kapatd ng 'kuyaaa!'. Next
scene nasa ospital na sila. Simula na ng drama.
11. Kapag bakbakan, hindi nasasaktan ang bida, pero umaaray siya pag
ginagamot na siya ng leading lady, at kasunod na ang love scene.
12. Kapag may sinabi ng kontrabida ang masama niyang planosa bida, ang
sasabihin ng bida: "hayop ka!"
13. Ang bidang babae, pag katulong ang role, siguradong magiging anak ng
amo niya sa ending.
14. Ang nanay ng mayaman laging may pamaypay na pangmayaman, at ang
nanay ng mahirap laging naka duster.
15. Ang hideout ng kontrabida, parating mansion na may chicks sa pool.
16. Ang mga bida sa drama, pag nakatanggap ng masamang balita, laging
may pinto sa likod nila para puwede silang sumandal habang nagsa-slide
dahan-dahan pababa, tapos todo iyak with matching uhog.
17. Pag di nahuli ng mga goons ang bida, sasabihin ng boss sa kanila,
"Mga inutil!"
18. Laging nakakapulot ng baril na may bala ang bida kapag kinakailangan
niya.
19. Laging mas maganda ang yayang bida kesa sa kontrabidang anak ng amo
niya.
20. Pag ang ending ng movie ay song and dance number sa beach o resort,
ang huling frame, tatalon ang buong cast...sabay freeze.
Tips for getting a contractor, materials & what to avoid
Tips for getting a contractor,
materials & what to avoid
Written by R. Locsin
Before even canvassing for a contractor, you should know exactly what you want. This will not only help the contractor quote, but give you total control of your project.
1. What is your time-frame?
2. Make a list of specific things you want (Cut and paste pictures from magazines of things you want in your construction)
3. Set a maximum budget and a contingency fund (If you have set your maximum budget, you may declare this amount to the contractor less 30%, as your buffer or contingency fund should things go unplanned)
4. Make a rough sketch of your desired floor plan.
5. Without considering budget, what are the things you want?
6. Considering your budget, what are the things you could let go?
7. Pay a small fee to an Engineer, Architect or better yet a Project Manager to get his/her professional opinion on the contract your about to sign.
Be aware of contractors who:
1. Those who quote prices before seeing the job.
2. Knock on the door because they happen to be in your area doing some other work and can give you a "special price".
3. Demand more than 40% deposit "to buy materials". Reputable contractors maintain charge accounts with their suppliers and large deposit is not necessary.
4. Will not supply you with a detailed written contract specifying what they say and what they will do.
5. They don’t have a permanent address nor have stayed in a permanent office in the past year. Chances are, these are bogus contractors or worst, they’ve just changed their name and location to avoid previous project disasters.
6. The lowest price is not always the best price. Check works they have recently done in the past.
7. Contractors who gives you low rates but uses inferior materials.
Materials you should not scrimp on:
1. Tiles – Never buy cheap tiles. It may look nice but its luster will disappear in few months and cracks easily. You can never go wrong with branded tiles.
2. Steel gauge in your foundation. When strong earthquakes happen, your house can actually collapse.
3. Exterior paint – Be sure that your paint are all-weather when painting the exterior.
4. Wire gauge – Your investment could literary turn to ashes with sub-standard wires.
5. Water proofing compounds – Always get the brand your contractor recommends
6. Wall paper quality – If you cannot afford quality wall paper, settle with ordinary paint. You will only be peeling away your money within the next year.
7. Cement – In most third world countries, there are unscrupulous cement supplier that actually repacks cement mixed with clay. These produce brittle cement work that eventually chips off or caves in.
Look for warning signs such as (a) Cheap pricing, (b) delivered by a truck that has no company logo or signage that it came from a legitimate supplier and (c) observe curing time - Quality cement hardens quickly while adulterated ones take time.
Remember!
Check for at least three contractors to bid. Asking for referrals is a good way to decide. Lastly, never sign a contract on the first few meetings with the contractor, even though you’ve gained confidence with this contractor. Excitement to start your construction may get on the way of right- thinking.
You may reproduce this article with the following credits – R. Locsin, www,constructionphils.com
materials & what to avoid
Written by R. Locsin
Before even canvassing for a contractor, you should know exactly what you want. This will not only help the contractor quote, but give you total control of your project.
1. What is your time-frame?
2. Make a list of specific things you want (Cut and paste pictures from magazines of things you want in your construction)
3. Set a maximum budget and a contingency fund (If you have set your maximum budget, you may declare this amount to the contractor less 30%, as your buffer or contingency fund should things go unplanned)
4. Make a rough sketch of your desired floor plan.
5. Without considering budget, what are the things you want?
6. Considering your budget, what are the things you could let go?
7. Pay a small fee to an Engineer, Architect or better yet a Project Manager to get his/her professional opinion on the contract your about to sign.
Be aware of contractors who:
1. Those who quote prices before seeing the job.
2. Knock on the door because they happen to be in your area doing some other work and can give you a "special price".
3. Demand more than 40% deposit "to buy materials". Reputable contractors maintain charge accounts with their suppliers and large deposit is not necessary.
4. Will not supply you with a detailed written contract specifying what they say and what they will do.
5. They don’t have a permanent address nor have stayed in a permanent office in the past year. Chances are, these are bogus contractors or worst, they’ve just changed their name and location to avoid previous project disasters.
6. The lowest price is not always the best price. Check works they have recently done in the past.
7. Contractors who gives you low rates but uses inferior materials.
Materials you should not scrimp on:
1. Tiles – Never buy cheap tiles. It may look nice but its luster will disappear in few months and cracks easily. You can never go wrong with branded tiles.
2. Steel gauge in your foundation. When strong earthquakes happen, your house can actually collapse.
3. Exterior paint – Be sure that your paint are all-weather when painting the exterior.
4. Wire gauge – Your investment could literary turn to ashes with sub-standard wires.
5. Water proofing compounds – Always get the brand your contractor recommends
6. Wall paper quality – If you cannot afford quality wall paper, settle with ordinary paint. You will only be peeling away your money within the next year.
7. Cement – In most third world countries, there are unscrupulous cement supplier that actually repacks cement mixed with clay. These produce brittle cement work that eventually chips off or caves in.
Look for warning signs such as (a) Cheap pricing, (b) delivered by a truck that has no company logo or signage that it came from a legitimate supplier and (c) observe curing time - Quality cement hardens quickly while adulterated ones take time.
Remember!
Check for at least three contractors to bid. Asking for referrals is a good way to decide. Lastly, never sign a contract on the first few meetings with the contractor, even though you’ve gained confidence with this contractor. Excitement to start your construction may get on the way of right- thinking.
You may reproduce this article with the following credits – R. Locsin, www,constructionphils.com
Reasons for sleeping and waking up early :
Reasons for sleeping and waking up early :
Evening at 9 - 11pm: is the time for eliminating
unnecessary/ toxic chemicals (detoxification) from the
antibody system (lymph nodes). This time duration
should be spent by relaxing or listening to music. If
during this time a housewife is still not in a relaxed
state such as washing the dishes or monitoring
children doing their homework, this will have a
negative impact on health.
Evening at 11pm - 1am: is the detoxification process
in the liver, and ideally should be done in a deep
sleep state.
Early morning 1 - 3am: detoxification process in the
gall, also ideally done in a deep sleep state.
Early morning 3 - 5am: detoxification in the lungs.
Therefore there will sometimes be a severe cough for
cough sufferers during this time. Since the
detoxification process had reached the respiratory
tract, there is no need to take cough medicine so as
not to interfere with toxin removal process.
Morning 5 - 7am: detoxification in the colon, you
should empty your bowel.
Morning 7 - 9am: absorption of nutrients in the small
intestine, you should be having breakfast at this
time. Breakfast should be earlier, before 6:30am, for
those who are sick. Breakfast before 7:30am is very
beneficial to those wanting to stay fit .
Those who always skip breakfast, they should change
their habits, and it is still better to eat breakfast
late until 9 - 10am rather than no meal at all.
Sleeping so late and waking up too late will disrupt
the process of removing unnecessary chemicals. Aside
from that, midnight to 4:00 am is the time when the
bone marrow produces blood. Therefore, have a good
sleep and don't sleep late.
The top five cancer-causing foods are:
Hot dogs - Because they are high in nitrates. The
Cancer Prevention Coalition advises that children eat
no more than 12 hot dogs a month. If you can't live
without hot dogs, buy those made without sodium
nitrate.
Processed meats and bacon Also high in the same sodium
nitrates found in hot dogs, bacon, and other processed
meats raise the risk of heart disease. The saturated
fat in bacon also contributes to cancer.
Doughnuts Doughnuts are cancer-causing double trouble.
First, they are made with white flour, sugar, and
hydrogenated oils, then fried at high temperatures.
Doughnuts, says Adams , may be the worst food you can
possibly eat to raise your risk of cancer.
French fries Like dough nuts, French fries are made
with hydrogenated oils and then fried at high
temperatures. They also contain cancer- causing acryl
amides which occur during the frying process. They
should be called cancer fries, not French fries, said
Adams .
Chips, crackers, and cookies All are usually made with
white flour and sugar. Even the ones whose labels
claim to be free of trans-fats generally contain small
amounts of trans-fats.
BRAIN DAMAGING HABITS
No Breakfast People who do not take breakfast are
going to have a lower blood sugar level. This leads to
an insufficient supply of nutrients to the brain
causing brain degeneration.
Overeating It causes hardening of the brain arteries,
leading to a decrease in mental power.
Smoking It causes multiple brain shrinkage and may
lead to Alzheimer disease.
High Sugar consumption Too much sugar will interrupt
the absorption of proteins and nutrients causing
malnutrition and may interfere with brain development.
Air Pollution The brain is the largest oxygen consumer
in our body. Inhaling polluted air decreases the
supply of oxygen to the brain, bringing about a
decrease in brain efficiency.
Sleep Deprivation Sleep allows our brain to rest. Long
term deprivation from sleep will accelerate the death
of brain cells.
Head covered while sleeping Sleeping with the head
covered increases the concentration of carbon dioxide
and decrease concentration of oxygen that may lead to
brain damaging effects.
Working your brain during illness Working hard or
studying with sickness may lead to a decrease in
effectiveness of the brain as well as damage the
brain.
Lacking in stimulating thoughts Thinking is the best
way to train our brain, lacking in brain stimulation
thoughts may cause brain shrinkage.
Talking Rarely Intellectual conversations will promote
the efficiency of the brain.
The main causes of liver damage are:
Sleeping too late and waking up too late.
Not urinating in the morning.
Too much eating.
Skipping breakfast.
Consuming too much medication.
Consuming too much preservatives, additives, food
coloring, and artificial sweetener.
Consuming unhealthy cooking oil. As much as possible
reduce cooking oil use when frying, which includes
even the best cooking oils like olive oil. Do not
consume fried foods when you are tired, except if the
body is very fit.
Consuming overly done foods also add to the burden of
liver. Veggies should be eaten raw or cooked 3-5
parts. Fried veggies should be finished in one
sitting, do not store.
We should prevent this without necessarily spending
more. We just have to adopt a good daily lifestyle and
eating habits. Maintaining good eating habits
according to schedule / time and condition are very
important for our bodies to absorb the proper
nutrients and get rid of unnecessary chemicals.
DO TAKE CARE ABOUT YOUR HEALTH.
Evening at 9 - 11pm: is the time for eliminating
unnecessary/ toxic chemicals (detoxification) from the
antibody system (lymph nodes). This time duration
should be spent by relaxing or listening to music. If
during this time a housewife is still not in a relaxed
state such as washing the dishes or monitoring
children doing their homework, this will have a
negative impact on health.
Evening at 11pm - 1am: is the detoxification process
in the liver, and ideally should be done in a deep
sleep state.
Early morning 1 - 3am: detoxification process in the
gall, also ideally done in a deep sleep state.
Early morning 3 - 5am: detoxification in the lungs.
Therefore there will sometimes be a severe cough for
cough sufferers during this time. Since the
detoxification process had reached the respiratory
tract, there is no need to take cough medicine so as
not to interfere with toxin removal process.
Morning 5 - 7am: detoxification in the colon, you
should empty your bowel.
Morning 7 - 9am: absorption of nutrients in the small
intestine, you should be having breakfast at this
time. Breakfast should be earlier, before 6:30am, for
those who are sick. Breakfast before 7:30am is very
beneficial to those wanting to stay fit .
Those who always skip breakfast, they should change
their habits, and it is still better to eat breakfast
late until 9 - 10am rather than no meal at all.
Sleeping so late and waking up too late will disrupt
the process of removing unnecessary chemicals. Aside
from that, midnight to 4:00 am is the time when the
bone marrow produces blood. Therefore, have a good
sleep and don't sleep late.
The top five cancer-causing foods are:
Hot dogs - Because they are high in nitrates. The
Cancer Prevention Coalition advises that children eat
no more than 12 hot dogs a month. If you can't live
without hot dogs, buy those made without sodium
nitrate.
Processed meats and bacon Also high in the same sodium
nitrates found in hot dogs, bacon, and other processed
meats raise the risk of heart disease. The saturated
fat in bacon also contributes to cancer.
Doughnuts Doughnuts are cancer-causing double trouble.
First, they are made with white flour, sugar, and
hydrogenated oils, then fried at high temperatures.
Doughnuts, says Adams , may be the worst food you can
possibly eat to raise your risk of cancer.
French fries Like dough nuts, French fries are made
with hydrogenated oils and then fried at high
temperatures. They also contain cancer- causing acryl
amides which occur during the frying process. They
should be called cancer fries, not French fries, said
Adams .
Chips, crackers, and cookies All are usually made with
white flour and sugar. Even the ones whose labels
claim to be free of trans-fats generally contain small
amounts of trans-fats.
BRAIN DAMAGING HABITS
No Breakfast People who do not take breakfast are
going to have a lower blood sugar level. This leads to
an insufficient supply of nutrients to the brain
causing brain degeneration.
Overeating It causes hardening of the brain arteries,
leading to a decrease in mental power.
Smoking It causes multiple brain shrinkage and may
lead to Alzheimer disease.
High Sugar consumption Too much sugar will interrupt
the absorption of proteins and nutrients causing
malnutrition and may interfere with brain development.
Air Pollution The brain is the largest oxygen consumer
in our body. Inhaling polluted air decreases the
supply of oxygen to the brain, bringing about a
decrease in brain efficiency.
Sleep Deprivation Sleep allows our brain to rest. Long
term deprivation from sleep will accelerate the death
of brain cells.
Head covered while sleeping Sleeping with the head
covered increases the concentration of carbon dioxide
and decrease concentration of oxygen that may lead to
brain damaging effects.
Working your brain during illness Working hard or
studying with sickness may lead to a decrease in
effectiveness of the brain as well as damage the
brain.
Lacking in stimulating thoughts Thinking is the best
way to train our brain, lacking in brain stimulation
thoughts may cause brain shrinkage.
Talking Rarely Intellectual conversations will promote
the efficiency of the brain.
The main causes of liver damage are:
Sleeping too late and waking up too late.
Not urinating in the morning.
Too much eating.
Skipping breakfast.
Consuming too much medication.
Consuming too much preservatives, additives, food
coloring, and artificial sweetener.
Consuming unhealthy cooking oil. As much as possible
reduce cooking oil use when frying, which includes
even the best cooking oils like olive oil. Do not
consume fried foods when you are tired, except if the
body is very fit.
Consuming overly done foods also add to the burden of
liver. Veggies should be eaten raw or cooked 3-5
parts. Fried veggies should be finished in one
sitting, do not store.
We should prevent this without necessarily spending
more. We just have to adopt a good daily lifestyle and
eating habits. Maintaining good eating habits
according to schedule / time and condition are very
important for our bodies to absorb the proper
nutrients and get rid of unnecessary chemicals.
DO TAKE CARE ABOUT YOUR HEALTH.
Mistakes made by start up micro businesses
In my work life, I come in contact with a lot of start up micro businesses and have discovered some of the mistakes they have made. Fortunately, we have the opportunity to learn from them, and hopefully avoid the same mistakes ourselves.
Here is a collection of mistakes made by start up micro businesses that I have seen firsthand. I hope by sharing them, you can avoid them on your solo journey.
1 Making decisions based upon advice you heard at the pub rather than paying for, listening to and acting upon specialist advice.
2 Advertising beyond your business’s capacity to serve.
Providing discounted or free work for friends/families/charities and not leveraging off it.
3 As discussed in the article on five tips for naming your business splurging on branded stationery, and then changing the business name, structure or contact details and the stationery has to be thrown away.
4 Designing a website with no contact details, and pages which do not link pack to the home page.
5 Incorrect contact details on anything!
6 Not understanding property insurance – what is insured and under which policy? Check with your insurer as sometimes home insurance will extend to the home office, however you will need to let them know about it.
7 Focusing on the parts of the business that you enjoy to the neglect of the parts of the business that don’t interest you.
8 Purchasing software when similar freeware is available to download from the internet.
9 Using a spam filter that treats potential new customers email as junk.
Delaying issuing invoices because you are too busy earning money and have no time to bill clients.
10 Not chasing payment of invoices in a timely manner and continuing to work for a client when payment is overdue.
11 Registering for GST, and all the paperwork that comes with it, before it was economically necessary to.
12 Confusing your bookkeeping records by not having a dedicated business account, or by paying for personal expenses through the business.
For better of worse, those were just a few mistakes made by start up micro businesses in the journey of growing their business. What mistakes did you make in your first year in business?
Heather Smith, an MYOB Certified Consultant and Specialist Trainer, provides business management software solutions which generate accurate and timely financial information that the business owner can use and understand.
Here is a collection of mistakes made by start up micro businesses that I have seen firsthand. I hope by sharing them, you can avoid them on your solo journey.
1 Making decisions based upon advice you heard at the pub rather than paying for, listening to and acting upon specialist advice.
2 Advertising beyond your business’s capacity to serve.
Providing discounted or free work for friends/families/charities and not leveraging off it.
3 As discussed in the article on five tips for naming your business splurging on branded stationery, and then changing the business name, structure or contact details and the stationery has to be thrown away.
4 Designing a website with no contact details, and pages which do not link pack to the home page.
5 Incorrect contact details on anything!
6 Not understanding property insurance – what is insured and under which policy? Check with your insurer as sometimes home insurance will extend to the home office, however you will need to let them know about it.
7 Focusing on the parts of the business that you enjoy to the neglect of the parts of the business that don’t interest you.
8 Purchasing software when similar freeware is available to download from the internet.
9 Using a spam filter that treats potential new customers email as junk.
Delaying issuing invoices because you are too busy earning money and have no time to bill clients.
10 Not chasing payment of invoices in a timely manner and continuing to work for a client when payment is overdue.
11 Registering for GST, and all the paperwork that comes with it, before it was economically necessary to.
12 Confusing your bookkeeping records by not having a dedicated business account, or by paying for personal expenses through the business.
For better of worse, those were just a few mistakes made by start up micro businesses in the journey of growing their business. What mistakes did you make in your first year in business?
Heather Smith, an MYOB Certified Consultant and Specialist Trainer, provides business management software solutions which generate accurate and timely financial information that the business owner can use and understand.
15 Secrets of Great interviewing
Interviewing is the most important part of selecting the right candidate to work for you.
Here are some quick tips on how to interview successfully this week......
Interview tip 1 - Don't be like most interviewers!
Prepare well in advance for the interview.
Go over the all the employees' CV's and try not to be like most interviewers who make up their minds about a candidate in the first 4 to 5 minutes ---- and then spend the rest of the interview asking questions merely to confirm their initial assessment.
Try to keep an open mind. Remember most interviewees are very nervous at the beginning of the interview.
Interview tip 2
Dress professionally on the day of the interview. Your conduct will reflect on your company, and will leave an impression in the mind of the interviewee.
Interview tip 3
If the interviewee has some disability such as hearing problems or the use of a wheelchair, prepare appropriate accommodation before the interview.
Interview tip 4
At the start of the interview, introduce yourself to the candidate in a friendly manner. Make her feel at ease from the very start of the interview. And try to be aware of what is called the 'Primacy-regency effect'.
This is where most interviewers remember, what happens at the beginning and the end of the interview, but tend to forget what happens in the middle. Is that you?
Interview tip 5
Be fully informed about the needs of your company and the job responsibilities the person occupying that position will have. This way you will know what to look for when you are interviewing applicants.
Interview tip 6
Pay close attention to the interviewee's body language. Does he appear confident? Does he make good eye contact during the interview?
Interview tip 7
Listen carefully and attentively to what the interviewee is saying. Your listening skills can help you detect things you may otherwise miss. Does the candidate really believe what he is saying?
Interview tip 8
Are you aware of what career psychologists call the 'Halo Effect' - and how it might affect your judgment?
If the candidate before the candidate you are interviewing was very good -- or very bad, this can radically influence your rating and perception of the candidate you are presently interviewing. This is the 'halo effect'.
It's like having to give a speech in a wedding - just AFTER the best speaker in the room has spoken. Your speech may be very good but people will subconsciously judge it against what they have just heard. As an interviewer try to beware of this.
Interview tip 9
Tell the interviewee what she can expect from the job. Let her know what your company does and what her job responsibilities may be. Does she seem fazed or excited by this responsibility?
Interview tip 10
Find out about the candidate's goals or aims in life to make sure they are compatible with the goals of your company. This can also tell you whether the candidate will feel fulfilled and happy at his work environment.
Interview tip 11
Ask open-ended, behavioral-based questions to get the candidate talking and reveal his or her true character.
Extensive research supports behavioral interviewing questions (i.e. using past performance as a reliable indicator of future performance) as the most effective interviewing technique available to evaluate suitable applicants - so use plenty of them. ( If you want to hire the right person you MUST ask these questions)
Interview tip 12
Make sure the interviewee has all the necessary technical skills required. If something is not clear from his resume this is your only chance to get it clarified.
Interview tip 13
Always ask about previous work experience. This can often be an excellent indicator of the applicant's future job performance. Also it can let you know if the employee has the skills that you need.
Interview tip 14
Avoid making snap judgments on the candidate. Have an open mind throughout the interview.
Interview tip 15
Be aware of illegal questions. This way you will be less likely to discriminate on the basis of such factors as age, etc.
Susan O'Neill, Chief Interview Advisor
At long last, a Software Program to help you create a great interview!
Hiring the right people is crucial to the success of every organization - and as interviewers the onus and pressure of hiring falls totally on YOU.
Here are some quick tips on how to interview successfully this week......
Interview tip 1 - Don't be like most interviewers!
Prepare well in advance for the interview.
Go over the all the employees' CV's and try not to be like most interviewers who make up their minds about a candidate in the first 4 to 5 minutes ---- and then spend the rest of the interview asking questions merely to confirm their initial assessment.
Try to keep an open mind. Remember most interviewees are very nervous at the beginning of the interview.
Interview tip 2
Dress professionally on the day of the interview. Your conduct will reflect on your company, and will leave an impression in the mind of the interviewee.
Interview tip 3
If the interviewee has some disability such as hearing problems or the use of a wheelchair, prepare appropriate accommodation before the interview.
Interview tip 4
At the start of the interview, introduce yourself to the candidate in a friendly manner. Make her feel at ease from the very start of the interview. And try to be aware of what is called the 'Primacy-regency effect'.
This is where most interviewers remember, what happens at the beginning and the end of the interview, but tend to forget what happens in the middle. Is that you?
Interview tip 5
Be fully informed about the needs of your company and the job responsibilities the person occupying that position will have. This way you will know what to look for when you are interviewing applicants.
Interview tip 6
Pay close attention to the interviewee's body language. Does he appear confident? Does he make good eye contact during the interview?
Interview tip 7
Listen carefully and attentively to what the interviewee is saying. Your listening skills can help you detect things you may otherwise miss. Does the candidate really believe what he is saying?
Interview tip 8
Are you aware of what career psychologists call the 'Halo Effect' - and how it might affect your judgment?
If the candidate before the candidate you are interviewing was very good -- or very bad, this can radically influence your rating and perception of the candidate you are presently interviewing. This is the 'halo effect'.
It's like having to give a speech in a wedding - just AFTER the best speaker in the room has spoken. Your speech may be very good but people will subconsciously judge it against what they have just heard. As an interviewer try to beware of this.
Interview tip 9
Tell the interviewee what she can expect from the job. Let her know what your company does and what her job responsibilities may be. Does she seem fazed or excited by this responsibility?
Interview tip 10
Find out about the candidate's goals or aims in life to make sure they are compatible with the goals of your company. This can also tell you whether the candidate will feel fulfilled and happy at his work environment.
Interview tip 11
Ask open-ended, behavioral-based questions to get the candidate talking and reveal his or her true character.
Extensive research supports behavioral interviewing questions (i.e. using past performance as a reliable indicator of future performance) as the most effective interviewing technique available to evaluate suitable applicants - so use plenty of them. ( If you want to hire the right person you MUST ask these questions)
Interview tip 12
Make sure the interviewee has all the necessary technical skills required. If something is not clear from his resume this is your only chance to get it clarified.
Interview tip 13
Always ask about previous work experience. This can often be an excellent indicator of the applicant's future job performance. Also it can let you know if the employee has the skills that you need.
Interview tip 14
Avoid making snap judgments on the candidate. Have an open mind throughout the interview.
Interview tip 15
Be aware of illegal questions. This way you will be less likely to discriminate on the basis of such factors as age, etc.
Susan O'Neill, Chief Interview Advisor
At long last, a Software Program to help you create a great interview!
Hiring the right people is crucial to the success of every organization - and as interviewers the onus and pressure of hiring falls totally on YOU.
Lechon Manok Recipe and Gravy
What does Andok’s, Baliwag’s and Sr. Pedro’s have in common? Yes, they’re just a few who had very successful selling lechon manok — one of Filipino’s all-time favorite dish, be it “ulam” for ordinary days, holidays or special occasions. You don’t really need a big capital here, just start a few pieces of chicken and a small place for grilling, and you’re off to a good start. Who knows, you could be the next lechon king. Here are several recipes I searched from the internet.
RECIPE #1
Ingredients
• 1 whole chicken
• 3 tablespoons of brown or white sugar
• 1 cup soy sauce
• 1 head garlic, minced
• 1 onion, finely chopped
• 3 tablespoons of calamansi juice or lemon juice
• 1/2 cup of sprite, 7up or beer
• 2 cups of tanglad (lemon grass) for stuffing
• 1 teaspoon ground black pepper
Directions
1. Marinate the whole chicken in soy sauce, calamansi juice, minced garlic, chopped onions, soda or beer, sugar and pepper.
2. Let stand marinate in the refrigerator for 1 to 3 hours.
3. Stuff the chicken cavity with tanglad (lemon grass).
4. Cook chicken on grill or in oven until golden brown
RECIPE #2 (from Nestle)
Ingredients
• 1 kg whole chicken
Marinade:
• 2 tbsp calamansi juice
• salt and pepper to taste
• 2 tbsp Maggi Savor, Classic
• tamarind or tanglad leaves for stuffing
Liver Sauce:
• 3 whole chicken liver
• 4 cloves garlic minced
• 1/2 medium onion diced
• 2 tbsp cooking oil
• 2 tsp cooking oil
• 1 11g MAGGI Chicken Broth Cube
• salt and pepper to taste
• 2 tbsp vinegar
• 1 bay leaf
• 2 tbsp breadcrumbs
• 1 tsp brown sugar or to taste
Procedure
1. Rub chicken with calamansi juice, salt, pepper and MAGGI Savor. Let stand for at least four hours, turning occasionally to marinate evenly. Drain and reserve marinade.
2. Stuff chicken with tanglad or tamarind leaves and roast in an oven, turbo or over hot charcoal. Add cooking oil to marinade and use this to brush chicken every now and then as it cooks.
3. Prepare sauce. Pound together or put on a blender chicken liver, half of the garlic and the onion. If using a blender, add a little water or broth to make a paste. Set aside.
4. Heat oil and saute remaining garlic and onion. Stir in liver mixture, MAGGI Chicken Broth Cubes and seasonings.
5. Add vinegar and bay leaf. Simmer for 2 min. Stir in breadcrumbs; add sugar and a little more water or broth to reach the desired consistency. Adjust seasonings to obtain the desired balance of sweet and sour taste.
6. Cut up chicken into serving portions and serve with liver sauce.
RECIPE #3 Using Native Chicken
Mga Sangkap:
• 1 matabang inahing manok
• 1 itlog na nilaga
• 1 longganisa (bilbao)
• ½ kilo atay ng baboy
• 2 kalamansi
• 1 kutsarang toyo
• kaunting paminta
• kaunting mantikilya
Paraan
Patayin ang isang inahing manok na mataba at alisan ng lamang loob. Kung malinis na ang manok ay ilagay sa loob ang lahat ng kahalong nababanggit sa itaas. Pagkatapos ay tahiing mabuti upang huwag sumabog ang dahon ng sampalok. Magpabaga ng maraming matitigas na kahoy at kung handa na ay litsunin na ang manok sa uling na gaya ng ginagawa sa paglilitson ng baboy. Gamitin ang mantika na pambasa sa katawan ng manok. Kung luto na’y hanguin.
Ganito naman ang paggawa ng sarsa para sa litsong manok. Lutuin sa baga ang atay at saka bayuhin sa almires. Magpabango ng bawang sa mantika at dito ilalagay ang harina o biskotsong dinurog at isang kutsarang asukal. Sabawan ng kalahating tasang tubig at timplahan ng asin at suka. Kung luto na ay hanguin at ihaing kasama ang manok. Lagyan ng kaunting paminta.
GRAVY RECIPE
Follow these three easy steps on how to make an instant and an all-purpose homemade, but healthy
Gravy:
Ingredients:
• 1 small carrot, peeled and chopped into rough 1/2-inch pieces (about 1/3 cup)
• 1 small rib celery, chopped into rough 1/2-inch piece (about ½ cup)
• 1 small onion, chopped into rough 1/2-inch pieces (about ¾ cup)
• 3 tablespoons unsalted butter
• ¼ cup unbleached all-purpose flour
• 2 cups low-sodium chicken broth
• 2 cups low-sodium beef broth
• 1 bay leaf
• ¼ teaspoon dried thyme
• 5 whole black peppercorns
• Table salt and ground black pepper
Steps:
1. For bout five 1-second beatings, pound the carrot till it is broken into roughly ¼-inch pieces. When carrot is broken, add celery and onion; pound vegetables till turned into 1/8-inch kaput pieces.
2. In a large saucepan, heat butter on a medium-high temperature; when the foam subsides, add vegetables. Stir continuously until it is cooked, softened and browned for about seven minutes. Slowly reduce heat. Stir the flour for about five minutes till it is golden browned and attained its yummy scent. Constantly beat with gradual pouring of broths and wait till it heats up. When it is boiled, cream-off any foam that shapes on its surface. Add bay leaf, thyme and peppercorns. Simmer and stir once in a while for about 20-25 minutes. Wait till it is thickened and reduced to 3 cups.
3. Strain gravy and get the fine-mesh texture into clean saucepan, press the solids to extract; discard solids. Adjust the seasonings with salt and pepper. Serve it hot.
source: dyaryoboy.com, pinoywebsights.com, nestle.com.ph, sme.com.ph
RECIPE #1
Ingredients
• 1 whole chicken
• 3 tablespoons of brown or white sugar
• 1 cup soy sauce
• 1 head garlic, minced
• 1 onion, finely chopped
• 3 tablespoons of calamansi juice or lemon juice
• 1/2 cup of sprite, 7up or beer
• 2 cups of tanglad (lemon grass) for stuffing
• 1 teaspoon ground black pepper
Directions
1. Marinate the whole chicken in soy sauce, calamansi juice, minced garlic, chopped onions, soda or beer, sugar and pepper.
2. Let stand marinate in the refrigerator for 1 to 3 hours.
3. Stuff the chicken cavity with tanglad (lemon grass).
4. Cook chicken on grill or in oven until golden brown
RECIPE #2 (from Nestle)
Ingredients
• 1 kg whole chicken
Marinade:
• 2 tbsp calamansi juice
• salt and pepper to taste
• 2 tbsp Maggi Savor, Classic
• tamarind or tanglad leaves for stuffing
Liver Sauce:
• 3 whole chicken liver
• 4 cloves garlic minced
• 1/2 medium onion diced
• 2 tbsp cooking oil
• 2 tsp cooking oil
• 1 11g MAGGI Chicken Broth Cube
• salt and pepper to taste
• 2 tbsp vinegar
• 1 bay leaf
• 2 tbsp breadcrumbs
• 1 tsp brown sugar or to taste
Procedure
1. Rub chicken with calamansi juice, salt, pepper and MAGGI Savor. Let stand for at least four hours, turning occasionally to marinate evenly. Drain and reserve marinade.
2. Stuff chicken with tanglad or tamarind leaves and roast in an oven, turbo or over hot charcoal. Add cooking oil to marinade and use this to brush chicken every now and then as it cooks.
3. Prepare sauce. Pound together or put on a blender chicken liver, half of the garlic and the onion. If using a blender, add a little water or broth to make a paste. Set aside.
4. Heat oil and saute remaining garlic and onion. Stir in liver mixture, MAGGI Chicken Broth Cubes and seasonings.
5. Add vinegar and bay leaf. Simmer for 2 min. Stir in breadcrumbs; add sugar and a little more water or broth to reach the desired consistency. Adjust seasonings to obtain the desired balance of sweet and sour taste.
6. Cut up chicken into serving portions and serve with liver sauce.
RECIPE #3 Using Native Chicken
Mga Sangkap:
• 1 matabang inahing manok
• 1 itlog na nilaga
• 1 longganisa (bilbao)
• ½ kilo atay ng baboy
• 2 kalamansi
• 1 kutsarang toyo
• kaunting paminta
• kaunting mantikilya
Paraan
Patayin ang isang inahing manok na mataba at alisan ng lamang loob. Kung malinis na ang manok ay ilagay sa loob ang lahat ng kahalong nababanggit sa itaas. Pagkatapos ay tahiing mabuti upang huwag sumabog ang dahon ng sampalok. Magpabaga ng maraming matitigas na kahoy at kung handa na ay litsunin na ang manok sa uling na gaya ng ginagawa sa paglilitson ng baboy. Gamitin ang mantika na pambasa sa katawan ng manok. Kung luto na’y hanguin.
Ganito naman ang paggawa ng sarsa para sa litsong manok. Lutuin sa baga ang atay at saka bayuhin sa almires. Magpabango ng bawang sa mantika at dito ilalagay ang harina o biskotsong dinurog at isang kutsarang asukal. Sabawan ng kalahating tasang tubig at timplahan ng asin at suka. Kung luto na ay hanguin at ihaing kasama ang manok. Lagyan ng kaunting paminta.
GRAVY RECIPE
Follow these three easy steps on how to make an instant and an all-purpose homemade, but healthy
Gravy:
Ingredients:
• 1 small carrot, peeled and chopped into rough 1/2-inch pieces (about 1/3 cup)
• 1 small rib celery, chopped into rough 1/2-inch piece (about ½ cup)
• 1 small onion, chopped into rough 1/2-inch pieces (about ¾ cup)
• 3 tablespoons unsalted butter
• ¼ cup unbleached all-purpose flour
• 2 cups low-sodium chicken broth
• 2 cups low-sodium beef broth
• 1 bay leaf
• ¼ teaspoon dried thyme
• 5 whole black peppercorns
• Table salt and ground black pepper
Steps:
1. For bout five 1-second beatings, pound the carrot till it is broken into roughly ¼-inch pieces. When carrot is broken, add celery and onion; pound vegetables till turned into 1/8-inch kaput pieces.
2. In a large saucepan, heat butter on a medium-high temperature; when the foam subsides, add vegetables. Stir continuously until it is cooked, softened and browned for about seven minutes. Slowly reduce heat. Stir the flour for about five minutes till it is golden browned and attained its yummy scent. Constantly beat with gradual pouring of broths and wait till it heats up. When it is boiled, cream-off any foam that shapes on its surface. Add bay leaf, thyme and peppercorns. Simmer and stir once in a while for about 20-25 minutes. Wait till it is thickened and reduced to 3 cups.
3. Strain gravy and get the fine-mesh texture into clean saucepan, press the solids to extract; discard solids. Adjust the seasonings with salt and pepper. Serve it hot.
source: dyaryoboy.com, pinoywebsights.com, nestle.com.ph, sme.com.ph
Start Saving Money...Now!
by: Mike Collins
Could you use more money? Of course, who couldn't?
Whether you are overwhelmed with bills and expenses or just looking to save some extra cash for a nice family vacation, you basically have just two choices:
1. Make more money.
2. Lower your bills.
Making more money is easier said than done. Most people only get a salary increase that barely covers inflation and the increased cost of living. Add in the increased cost of healthcare, and many people actually have less money in their paycheck!
You can get a promotion and earn more, but that can take time. And in this day and age of massive layoffs, how secure do you feel at work?
You can find a new job that pays more, or get a second job. But take it from someone who has worked part-time jobs to get by…it’s exhausting, and you’ll have to say goodbye to a lot of your free time.
Lowering your bills is less likely to cause major strife in your life. Cutting your expenses and finding ways to save money is not as difficult as you might think. All it takes is a little thought, creativity, and perspective.
Sit down and take an honest look at where your money is going. You are likely to be surprised. Most people throw money down the drain everyday, often without even realizing it. Ask yourself these questions...
Did I really get the best price for the blouse I am wearing?
Could I have paid less for that new car in my driveway?
Am I going to be able to retire when I am ready or will I have to keep working until I die?
Hopefully, your answers were yes, no, and yes. If not, you probably lost out on an opportunity to save money.
Learning how to save money and achieve financial security is a skill that not everyone learns. After all, it is not something that is taught in schools. Here are some ideas to get you thinking about how you can improve your financial situation…
Set your priorities. Decide what is important to you. Do you want to retire early? Afford a bigger house? Go on a dream vacation? Set those goals, and keep them in mind whenever you’re about to spend. Before you drop $5 on a latte, consider whether or not it is worth putting off your dream.
Think about how you can lower your bills:
If you own your own home, can you refinance your mortgage at a lower interest rate? Even though interest rates are starting to creep back up, they are still at historic lows. You could save hundreds of dollars by refinancing.
How about your credit cards? If you are paying a high interest rate, you can transfer your balance to a card with a lower rate and save big money. Many cards now offer 0% introductory offers for a year or more! Transfer the balance and then pay off as much as possible before the 0% offer ends. Just be sure not to run up a big balance again.
Keep an eye on your credit report. So much depends on your credit score. How would you know if there is a problem or mistake on it? You should keep a close eye on it at all times. If you notice something is inaccurate, get it corrected immediately.
Could you use more money? Of course, who couldn't?
Whether you are overwhelmed with bills and expenses or just looking to save some extra cash for a nice family vacation, you basically have just two choices:
1. Make more money.
2. Lower your bills.
Making more money is easier said than done. Most people only get a salary increase that barely covers inflation and the increased cost of living. Add in the increased cost of healthcare, and many people actually have less money in their paycheck!
You can get a promotion and earn more, but that can take time. And in this day and age of massive layoffs, how secure do you feel at work?
You can find a new job that pays more, or get a second job. But take it from someone who has worked part-time jobs to get by…it’s exhausting, and you’ll have to say goodbye to a lot of your free time.
Lowering your bills is less likely to cause major strife in your life. Cutting your expenses and finding ways to save money is not as difficult as you might think. All it takes is a little thought, creativity, and perspective.
Sit down and take an honest look at where your money is going. You are likely to be surprised. Most people throw money down the drain everyday, often without even realizing it. Ask yourself these questions...
Did I really get the best price for the blouse I am wearing?
Could I have paid less for that new car in my driveway?
Am I going to be able to retire when I am ready or will I have to keep working until I die?
Hopefully, your answers were yes, no, and yes. If not, you probably lost out on an opportunity to save money.
Learning how to save money and achieve financial security is a skill that not everyone learns. After all, it is not something that is taught in schools. Here are some ideas to get you thinking about how you can improve your financial situation…
Set your priorities. Decide what is important to you. Do you want to retire early? Afford a bigger house? Go on a dream vacation? Set those goals, and keep them in mind whenever you’re about to spend. Before you drop $5 on a latte, consider whether or not it is worth putting off your dream.
Think about how you can lower your bills:
If you own your own home, can you refinance your mortgage at a lower interest rate? Even though interest rates are starting to creep back up, they are still at historic lows. You could save hundreds of dollars by refinancing.
How about your credit cards? If you are paying a high interest rate, you can transfer your balance to a card with a lower rate and save big money. Many cards now offer 0% introductory offers for a year or more! Transfer the balance and then pay off as much as possible before the 0% offer ends. Just be sure not to run up a big balance again.
Keep an eye on your credit report. So much depends on your credit score. How would you know if there is a problem or mistake on it? You should keep a close eye on it at all times. If you notice something is inaccurate, get it corrected immediately.
How is diabetes treated?
How is diabetes treated?
Diabetes At A Glance
• Diabetes is a chronic condition associated with abnormally high levels of sugar (glucose) in the blood.
• Insulin produced by the pancreas lowers blood glucose.
• Absence or insufficient production of insulin causes diabetes.
• The two types of diabetes are referred to as type 1 (insulin dependent) and type 2 (non-insulin dependent).
• Symptoms of diabetes include increased urine output, thirst and hunger as well as fatigue.
• Diabetes is diagnosed by blood sugar (glucose) testing.
• The major complications of diabetes are both acute and chronic.
o Acutely: dangerously elevated blood sugar, abnormally low blood sugar due to diabetes medications may occur.
o Chronically: disease of the blood vessels (both small and large) which can damage the eye, kidneys, nerves, and heart may occur
• Diabetes treatment depends on the type and severity of the diabetes. Type 1 diabetes is treated with insulin, exercise, and a diabetic diet. Type 2 diabetes is first treated with weight reduction, a diabetic diet, and exercise. When these measures fail to control the elevated blood sugars, oral medications are used. If oral medications are still insufficient, insulin medications are considered.
Last Editorial Review: 12/5/2006
Diabetes Treatment
Medical Author: Ruchi Mathur, MD
Medical Editor: William C. Shiel, Jr., MD, FACP, FACR and Jay W. Marks, MD
• How is diabetes treated?
• Medications for type 2 diabetes
• Sulfonylureas
• Meglitinides – (Prandin and Starlix)
• Medications that decrease the amount of glucose produced by the liver
• Medications that increase the sensitivity of cells to insulin (Actos and Avandia)
• Medications that decrease the absorption of carbohydrates from the intestine (Precose)
• New medications that effect glycemic control (Symlin and Byetta)
• DPP–IV inhibitors
• Combination medications
• Treatment of diabetes with insulin
• Different methods of delivering insulin
• Pre–filled insulin pens
• Insulin pump
• Inhaled Insulin
• Intranasal, Transderm
• The future of pancreas transplantation
• Diabetes main article including causes, symptoms, complications, and diagnosis
How is diabetes treated?
The major goal in treating diabetes is to minimize any elevation of blood sugar (glucose) without causing abnormally low levels of blood sugar. Type 1 diabetes is treated with insulin, exercise, and a diabetic diet. Type 2 diabetes is treated first with weight reduction, a diabetic diet, and exercise. When these measures fail to control the elevated blood sugars, oral medications are used. If oral medications are still insufficient, treatment with insulin is considered.
Adherence to a diabetic diet is an important aspect of controlling elevated blood sugar in patients with diabetes. The American Diabetes Association (ADA) has provided guidelines for a diabetic diet. The ADA diet is a balanced, nutritious diet that is low in fat, cholesterol, and simple sugars. The total daily calories are evenly divided into three meals. In the past two years, the ADA has lifted the absolute ban on simple sugars. Small amounts of simple sugars are allowed when consumed with a complex meal. For more, please read the Diabetic Diet article.
Weight reduction and exercise are important treatments for diabetes. Weight reduction and exercise increase the body's sensitivity to insulin, thus helping to control blood sugar elevations. For more, please read the Weight Loss and Fitness articles.
Medications for type 2 diabetes
WARNING: All the information below applies to patients who are not pregnant or breastfeeding. At present the only recommended way of controlling diabetes in women who are pregnant or breastfeeding is by diet, exercise and insulin therapy. You should speak with your doctor if you are taking these medications and are considering becoming pregnant or if you have become pregnant while taking these medications.
Based on what is known, medications for type 2 diabetes are designed to:
1. Increase the insulin output by the pancreas.
2. Decrease the amount of glucose released from the liver.
3. Increase the sensitivity (response) of cells to insulin.
4. Decrease the absorption of carbohydrates from the intestine.
5. Slow emptying of the stomach to delay the presentation of carbohydrates for digestion and absorption in the small intestine.
When selecting therapy for type 2 diabetes, consideration should be given to:
1. The magnitude of change in blood sugar control that each medication will provide.
2. Other coexisting medical conditions (high blood pressure, high cholesterol, etc.)
3. Adverse effects of the therapy
4. Contraindications to therapy
5. Issues that may affect compliance (timing of medication, frequency of dosing)
6. Cost to the patient and the healthcare system
It's important to remember that if a drug can provide more than one benefit (lower blood sugar and have a beneficial effect on cholesterol, for example), it should be preferred. It's also important to bear in mind that the cost of drug therapy is relatively small compared to the cost of managing the long–term complications associated with poorly controlled diabetes.
Varying combinations of medications also are used to correct abnormally elevated levels of blood glucose in diabetes. As the list of medications continues to expand, treatment options for type 2 diabetes can be better tailored to meet an individuals needs. Not every patient with type 2 diabetes will benefit from every drug, and not every drug is suitable for each patient. Patients with type 2 diabetes should work closely with their physicians to achieve an approach that provides the greatest benefits while minimizing risks.
Patients with diabetes should never forget the importance of diet and exercise. The control of diabetes starts with a healthy lifestyle regardless of what medications are being used.
Medications that increase the insulin output by the pancreas – sulfonylureas and meglitinides
Sulfonylureas
Historically, increasing insulin output by the pancreas has been the major area targeted by medications used to treat type 2 diabetes. Medications that increase the output of insulin belong to a class of drugs called sulfonylureas. Sulfonylureas primarily lower blood glucose levels by increasing the release of insulin from the pancreas. Older generations of these drugs include chlorpropamide and tolbutamide, while newer drugs include glyburide (DiaBeta), glipizide (Glucotrol), and glimepiride (Amaryl). These drugs are effective in rapidly lowering blood sugar but run the risk of causing hypoglycemia (abnormally low and dangerous levels of blood sugar). In addition, they are sulfa–containing drugs and should be avoided by patients who are allergic to sulfa .
Meglitinides – repaglinide (Prandin) and nateglinide (Starlix)
The class of drugs known as meglitinides is relatively new. Meglitinides also work on the pancreas to promote insulin secretion. Unlike sulfonylureas that bind to receptors on the insulin producing cells, meglitinides work through a separate potassium based channel on the cell surface. Unlike the sulfonylureas which last longer in the body, repaglinide (Prandin) and nateglinide (Starlix) are very short acting, with peak effects within one hour. For this reason, they are given up to three times a day just before meals. Since these drugs also increase circulating insulin levels, they may cause hypoglycemia, but the literature suggests this is less frequent than the hypoglycemia seen with sulfonylureas.
Prandin
In a three month study, repaglinide (Prandin) dropped fasting blood glucose values by 61 mg/dL and post meal blood glucose values by 100 mg/dL. Because Prandin is short acting and given before meals, it is particularly beneficial in lowering blood glucose after meals and does not tend to lower fasting glucose levels to the same degree. Prandin has been used in combination with other medications, such as metformin (Glucophage), with impressive results. In 83 patients with type 2 diabetes, blood sugar control improved significantly with the addition of Prandin to Glucophage.
Prandin interacts with other medications. Therefore, the doctor must be aware of all other medications a patient is taking before prescribing Prandin. The usual starting dose is 0.5mg before each meal and can be increased to 4mg. The maximum daily dose is 16mg. Prandin is used with caution in people with kidney or liver abnormalities. Since Prandin increases insulin levels, it has the risk of causing abnormally low blood sugars. Blood sugars that remain severely low can result in sweating, tremors, confusion, and may lead to coma and seizure. In addition, the use of Prandin has been associated with headaches, muscle and joint aches, along with sinus infections in some individuals. This drug should not be used in pregnancy or by nursing mothers. The dose may need to be adjusted in older people, since the elderly may metabolize (eliminate) medications at a slower rate. For more, please read the drug information on repaglinide (Prandin).
Starlix
Nateglinide (Starlix) has essentially the same profile of side effects and interactions as Prandin. The major benefit of Starlix is that the starting dose of 120mg does not need to be adjusted upward, but rather remains constant. These medications are also relatively safe to use in people with impaired kidney function. For more, please read the drug information on nateglinide (Starlix).
Medications that decrease the amount of glucose produced by the liver
A class of drugs called biguanides has been used for many years in Europe and Canada. In 1994, the FDA approved the use of the biguanide metformin (Glucophage) for the treatment of type 2 diabetes in the U.S. Glucophage is unique in its ability to decrease glucose production by the liver. Briefly, because metformin does not increase insulin levels, when used alone, it does not usually cause hypoglycemia. In addition, metformin has an effect whereby it tends to suppress appetite, which may be beneficial in diabetics who tend to be overweight. Metformin may be used by itself or together with other oral drugs or insulin. It should not be used in patients with kidney impairment and should be used with caution in those with liver impairment. The older biguanides that preceded metformin were associated with a serious condition called lactic acidosis, a dangerous acid build up in the blood resulting from accumulation of the drug and its breakdown products. While metformin is safer in this regard, it is recommended that the drug be discontinued for 24 hours before any procedure involving the intravenous injection of dyes (such as for some x–ray studies of the kidney) or surgery is performed. The dyes may impair kidney function and cause a build up of the drug in the blood. Metformin can be restarted after these procedures once the patient is urinating normally.
Medications that increase the sensitivity of cells to insulin
The class of drugs known as thiazolidinediones lowers blood glucose by improving target cell response to insulin (that is, increasing the sensitivity of the cells to insulin). Troglitazone (Rezulin) was the first of this class in the U.S. Because of severe toxic liver effects, troglitazone has been taken off the market. Sister compounds are now available with a better safety profile. These drugs include pioglitazone (Actos) and rosiglitazone (Avandia).
Pioglitazone (Actos) and rosiglitazone (Avandia) are thiazolidinediones approved for use in the U.S. While they are sister compounds to Rezulin, extensive studies have failed to show that they are associated with any liver problems. Both Avandia and Actos act by increasing the sensitivity (responsiveness) of cells to insulin. They improve the sensitivity of muscle and fat cells to insulin. These drugs have been effective in lowering blood sugars in patients with type 2 diabetes, Actos and Avandia act within one hour of administration and are taken once daily. It is important to note that it takes up to six weeks to see a drop in blood glucose levels with these drugs and up to 12 weeks to see a maximum benefit. Actos and Avandia have been approved as first line therapy in diabetes and for use in combination with other drugs. Both drugs may be used in patients taking other oral drugs as well as those using insulin.
While reported liver problems with these agents are mild (and reversible with discontinuation of the drug), most physicians choose to follow an earlier recommendation to do blood tests to detect liver injury every two months or so during the first year of therapy. Recently this recommendation has been removed. If at any point the liver tests increase to three times the normal upper limit, the drug should be stopped.
The most important contraindications to these medications include any type of liver disease, and heart failure. Fluid retention can be of particular concern in patients with signs or symptoms of heart failure and in those with ejection fractions of less than 40% which indicates poor function of the heart. While the reports are three to eight pounds, clinical experience shows up to 12–15 pounds of weight gain can occur. Usually the majority of this is fluid, but an absolute body weight gain can also occur. This is likely to be dose–dependent and, therefore, the increases in weight may be greater with higher doses of drug. Weight gain is more pronounced in patients who are also taking insulin. In general, the ankle swelling and puffiness due to the accumulation of fluid can be controlled with the addition of a diuretic such as spironolactone (Aldactone) — (furosemide (Lasix) does not work as well) — or by reducing the dose. On occasion, patients may be symptomatic enough from fluid retention to warrant withdrawal of the drug. Some recent studies have suggested an association between pioglitazone and rosiglitazone and untoward cardiac events, for example, heart attacks, though this association is controversial. Regardless of the controversy, it is well established that pioglitazone and rosiglitazone should be avoided in patients with symptomatic heart failure or heart failure.
Another newer concern is an association of treatment with a small increase in the frequency of fractures of the distal long bones of the arms and legs. At present, this does not translate into fractures of the hip and spine, which would be clinically more worrisome. More data is needed to make a definitive statement about cause and effect at this time.
As an aside, Actos and Avandia have an added benefit of changing cholesterol patterns in diabetes. HDL (or good cholesterol) increases with these medications, and triglycerides often decrease. While there is some controversy regarding what happens to bad cholesterol (LDL) levels, there is a suggestion that Actos may be superior in changing lipid profiles than Avandia. In this population of diabetics that is already at an increased risk for heart disease, an improvement in cholesterol profile is beneficial. As more and more data becomes available, there is mounting evidence that this class of drugs may provide direct benefits to the heart and large blood vessels and may actually be valuable in preventing the progression of diabetes in high–risk individuals by reducing inflammation and by decreasing clotting factors. As time goes on, I have no doubt that the uses for this class of medications will expand. For more, please read the drug information on pioglitazone (Actos) and rosiglitazone (Avandia).
Medications that decrease the absorption of carbohydrates from the intestine
Before being absorbed into the bloodstream, carbohydrates must be broken down into smaller sugar particles, such as glucose, by enzymes in the small intestine. One of the enzymes involved in breaking down carbohydrates is called alpha glucosidase. By inhibiting this enzyme, carbohydrates are not broken down as efficiently and glucose absorption is delayed.
Precose
The name of the alpha glucosidase inhibitor available in the U.S. is acarbose (Precose). In clinical trials with over 700 patients, the use of Precose was associated with a reduction in hemoglobin A1c values (a well known measurement of average blood sugars over the preceding three months) that was significantly greater than the use of placebo (no treatment). However, as a single agent, Precose is not as effective as the other medications for diabetes. Since Precose works in the intestine, its effects are additive to diabetic medications that work at other sites, such as sulfonylureas. Clinical studies have shown statistically better control of blood glucose in patients treated with Precose and a sulfonylurea compared to the sulfonylurea alone. Precose is currently used alone or in combination with a sulfonylurea.
Precose is taken three times a day at the beginning of meals. The dosage varies from 25 to 100mg with each meal. The maximum recommended dose is 100mg three times a day. At doses greater than this, reversible abnormalities in liver tests may be seen. Because of its mechanism of action, Precose has significant gastrointestinal side effects. Abdominal pain, diarrhea, and gas are common and are seen in up to 75% of patients taking Precose. For this reason, Precose is administered using a low initial dose that is increased over weeks depending on the patient's tolerance. Most of the gastrointestinal symptoms tend to subside over the course of a few weeks although some patients report persistent problems. For more information, please read the drug information on acarbose (Precose).
New medications that effect glycemic control
Symlin (pramlintide)
Symlin is the first in a new class of injectable, anti–hyperglycemic medications for use in patients with type 2 or type 1 diabetes treated with insulin. Pramlintide, the active ingredient in Symlin, is a synthetic analog of human amylin, a naturally occurring neuroendocrine hormone synthesized by pancreatic beta cells that helps control glucose control after meals. Amylin, similar to insulin, is absent or deficient in patients with diabetes. When used with insulin, this compound can improve glycemic control and has additional benefits that cannot be realized with insulin alone.
According to published data, Symlin reduces post meal blood sugar peaks, reduces glucose fluctuations throughout the day, enhances satiety (the sensation of fullness) leading to potential weight loss, and lowers mealtime insulin requirements. Studies have shown it improves A1C beyond the effect of insulin alone.
Symlin is taken just prior to meals, three times a day. It is given in injection form and is used for:
• Type 2 diabetes, as an additional treatment in patients who use mealtime insulin therapy and have failed to achieve desired glucose control despite optimal insulin therapy, with or without a concurrent sulfonylurea agent and/or metformin.
• Type 1 diabetes, as an additional treatment in patients who use mealtime insulin therapy and who have failed to achieve desired glucose control despite optimal insulin therapy.
Symlin is considered a therapy option in patients with insulin–using type 2 or type 1 diabetes, that are unable to achieve adequate glycemic control despite individualized insulin management. Insulin–using patients with type 2 diabetes may also be taking a concurrent sulfonylurea agent and/or metformin.
The major side effect of Symlin is nausea, and this can be reduced with a slow, steady, increase in dose. The other major side effect is hypoglycemia (dangerously low levels of blood sugar). To avoid this, the dose of mealtime insulin should be cut in half when starting Symlin. Of note is the degree of weight loss seen with Symlin therapy. Studies for up to six months show weight loss of greater than six pounds more than placebo (inactive pills). For more, please read the drug information on pramlintide (Symlin).
Byetta (exenatide)
Byetta (exenatide) is a new medication on the market that has it's origins in an interesting place––the Gila monster's saliva. Scientists studying this small lizard noted it could go a long time without eating. They found a substance in it's saliva that slowed stomach emptying, thus making the lizard feel fuller longer. This substance was similar in nature to a gut hormone found in humans known as GLP–1. GLP–1 is broken down in the body by an enzyme called DPP–IV. So, if you could make a substance like GLP–1 that was not so easy to breakdown, this would have potential benefit; thus, the studies began. Ultimately, after modifying this hormone, exenatide (with the trade name Byetta) was developed. Byetta is the first in a new class of drugs for the treatment of type 2 diabetes called incretin mimetics. Byetta has been shown to have many of the same effects on sugar regulation as GLP–1, so it mimics the body's natural physiology for self–regulating blood sugar. Namely, it slows the release of glucose from the liver, slows stomach emptying thereby regulating delivery of nutrients to the intestine for absorption, and works centrally in the brain to regulate hunger.
Byetta is indicated as additional therapy to improve control of blood sugars in patients with type 2 diabetes who are taking metformin, a sulfonylurea, or a combination of metformin and a sulfonylurea but who have not achieved adequate sugar control. It enhances the way the insulin producing beta cells in the pancreas work. Insulin secretion increases only when blood sugars are high and decreases as blood sugars approach normal. In addition to enhancing the normal physiology of the beta cell, Byetta suppresses glucose release from the liver, slows stomach emptying and the absorption of nutrients including carbohydrate, and reduces intake of food.
Just like Symlin, Byetta is given by injection, but it is given twice a day (usually before breakfast and dinner meals). It comes in a disposable pen form and is available in two doses. The goal is to start with the lower dose for a month or so and then move up to the higher dose if needed and if tolerated. Similar to Symlin, the main side effect is nausea, most likely due to its effects on stomach emptying. This medication is temperature sensitive and it was recommended that the pens be stored at 36–46 degrees F. Recently, this has changed, with a recommendation that unopened pens be refrigerated, and once opened, the pens can be left at room temperature. The risk of hypoglycemia is still a possibility with Byetta, especially when used in combination with sulfonylureas. Your physician may choose to decrease the dose of some of your other medications when initially evaluating how you respond to Byetta.
Similar to Symlin, weight reduction is seen with Byetta in the majority of patients. This makes it particularly suitable for the typical patient with type 2 diabetes who is also overweight. For more, please read the drug information pamphlet on exenatide (Byetta).
A longer acting from of Byetta is currently being considered for approval by the FDA. This would allow for the same benefits (and side effects) without need for such frequent injections.
DPP–IV inhibitors
GLP–1 in the body is broken down by an enzyme called DPP IV. Logically, you can either make a synthetic GLP–1 that is not broken down by this enzyme (for example, Byetta) OR you could try to stop the enzyme that breaks down the GLP–1 your body already makes. Hence, the new class of drugs called DPP IV inhibitors. They do just that, that is, they inhibit this enzyme from breaking down GLP–1. This allows GLP–1 already in the blood to circulate longer. There are a number of companies working on this class of drug and the FDA just approved the first drug in this class made by Merck and called Januvia. Januvia can be used in combination with certain other medications and must be dose adjusted in patients with poor kidney function. For more, please read the Januvia pamplet.
These drugs have essentially the same side effect profile as Byetta; however, they are in pill form. While Byetta has a significant weight loss profile, DPP–IV inhibitors so far have had no effect on weight.
Combination medications
Glyburide/metformin (Glucovance), rosiglitazone/metformin (Avandamet), glipizide/metformin (Metaglip), and pioglitazone/metformin (Actosplusmet) are four relatively new combination pills that are on the market to treat diabetes.
• Glucovance combines glyburide with metformin in varying doses.
• Avandamet is a combination of varying doses of Avandia and metformin.
• Actosplusmet is a combination of varying doses of pioglitazone and metformin.
• Metaglip is a combination pill containing glipizide and metformin in varying strengths.
The benefit to these combination drugs is that there are fewer pills to take, hopefully leading to better compliance. While they work well, I personally like to give patients individual medications until I know what doses are working, and then switch to a combination pill once the patient has been stable on the doses of individual medications for a period of time.
Treatment of diabetes with insulin
Insulin is the mainstay of treatment for patients with type 1 diabetes. Insulin is also important in type 2 diabetes when blood glucose levels cannot be controlled by diet, weight loss, exercise, and oral medications.
Ideally, insulin should be administered in a manner that mimics the natural pattern of insulin secretion by a healthy pancreas; however, the complex pattern of insulin secretion by the pancreas is difficult to duplicate. Still, adequate blood glucose control can be achieved with careful attention to diet, regular exercise, home blood glucose monitoring, and multiple insulin injections throughout the day. For more, please see the Diabetes and Home Care Monitoring article.
In the past, the insulin was being derived from animal sources, particularly cows and pigs. Not only was there a problem with enough supply of insulin to meet the demand, but beef and pork insulin also had specific problems. Originating from animals, these types of insulin caused immune reactions in some people. Patients would become intolerant or resistant to animal insulin. With the acceleration of scientific research in the latter half of the twentieth century, beef and pork insulin were replaced by human insulin. In 1977, the gene for human insulin was cloned, and through modern technology, manufactured human insulin was made available. Human insulin is now widely used.
Insulin now comes in a variety of preparations that differ in the amount of time following injection until they begin to work and the duration of their action. Because of these differences, combinations of insulin are often used to allow for a more tailored regimen of blood sugar control. The table below lists the most common types of insulin currently in use in the U.S. and their specific properties.
Name of Insulin Onset of Action Peak Effect After Injection
Humalog and Novolog//Very Short Acting 5–15 minutes 30–60 minutes
Regular/Short Acting 30 minutes 2–5 hours
NPH/Intermediate Acting 1–2.5 hours 8–14 hours
Lente/Intermediate Acting 1–2.5 hours 8–12 hours
Ultra Lente/Long Acting 4–6 hours 10–18 hours
Lantus 2–3 hours Stable from 2–3 hours to @20 hours
Detemir 3–4 hours Dose dependent (longer acting at higher doses)
Combinations – 75/25, 70/30, 50/50 30 minutes 7–12 hours
For example, a patient may take an injection of Lantus in the morning and evening to provide a baseline of insulin throughout a 24–hour period. In addition, the same patient may take an injection of Humalog just before meals to cover the increase in carbohydrate load after eating.
Different methods of delivering insulin
Not only is the variety of insulin preparations growing, so are the methods for administering insulin.
Pre–filled insulin pens
In the past, insulin was available only in an injectable form that involved carrying syringes (which a few decades ago were made of glass and required sterilization), needles, vials of insulin, and alcohol swabs. Needless to say, patients often found it difficult to take multiple shots each day, and, as a result, good blood sugar control was often compromised. Many pharmaceutical companies are now offering discreet and convenient methods of delivering insulin.
Both Novo Nordisk and Lily have an insulin pen delivery system. This system is similar to an ink cartridge in a fountain pen. A small pen–sized device holds an insulin cartridge (usually containing 300 units). Cartridges are available in the most widely used insulin formulations, such as those listed in the table above. The amount of insulin to be injected is dialed in by turning the bottom of the pen until the required number of units is seen in the dose–viewing window. The tip of the pen consists of a needle that is replaced with each injection. A release mechanism allows the needle to penetrate just under the skin and deliver the required amount of insulin. The cartridges and needles are disposed of when finished and new ones simply are inserted. In many cases, the entire pen is disposed of. These insulin delivery devices are less cumbersome than traditional methods.
Insulin pump
The most recently available advance in insulin delivery is the insulin pump. In the U. S., MiniMed, Deltec and Disetronic market the insulin pump. An insulin pump is composed of a pump reservoir similar to that of an insulin cartridge, a battery–operated pump, and a computer chip that allows the user to control the exact amount of insulin being delivered. Currently, pumps on the market are about the size of a pager or beeper. The pump is attached to a thin plastic tube (an infusion set) that has a cannula (like a needle but soft) at the end through which insulin passes. This cannula is inserted under the skin, usually on the abdomen. The cannula is changed every two days. The tubing can be disconnected from the pump while showering or swimming. The pump is used for continuous insulin delivery, 24 hours a day. The amount of insulin is programmed and is administered at a constant rate (basal rate). Often, the amount of insulin needed over the course of 24 hours varies depending on factors like exercise, activity level, and sleep. The insulin pump allows for the user to program many different basal rates to allow for this variation in lifestyle. In addition, the user can program the pump to deliver additional insulin during meals to cover the excess demands for insulin caused by the ingestion of carbohydrates with the meal.
Over 50,000 people worldwide are using an insulin pump. This number is growing dramatically as these devices become smaller and more user–friendly. Insulin pumps allow for tight blood sugar control and lifestyle flexibility while minimizing the effects of low blood sugar (hypoglycemia). At present, the pump is the closest device on the market to an artificial pancreas. More recently, newer models of the pump have been developed that do not require a tubing, in fact - the insulin delivery device is placed directly on the skin and any adjustments needed for insulin delivery are made through a PDA like device that must be kept within a 6 foot range of the insulin delivery device, and can be worn in a pocket, kept in a purse, or on a tabletop when working.
Probably the most exciting innovation in pump technology is the ability to use the pump in tandem with newer glucose sensing technology. Glucose sensors have improved dramatically in the last few years, and are an option for patients to gain further insight into their patterns of glucose response to tailor a more individual treatment regimen. The newest generation of sensors allows for a real time glucose value to be given to the patient. The implantable sensor communicates wirelessly with a pager-sized device that has a screen. The device is kept in proximity to the sensor to allow for transfer of data, however, it can be a few feet away and still receive transmitted information. Depending on the model, the screen displays the blood glucose reading, a thread of readings over time, and a potential rate of change in the glucose values. The sensors can be programmed to produce a "beep" if blood sugars are in a range that is selected as too high or too low. Some can provide a warning beep if the drop in blood sugar is occurring too quickly.
To take things one step further, there is one particular sensor that is new to the market that is designed to communicate directly with the insulin pump. While the pump does not yet respond directly to information from the sensor, it does "request" a response from the patient if there is a need for adjustments according to the patterns it is programmed to detect. The ultimate goal of this technology is to "close the loop" by continuously sensing what the body needs, and then responding by providing the appropriate dose of insulin. While this technology is a few more years in the making, the strides in this direction continue to grow.
Inhaled Insulin
Inhaled insulin, marketed by Pfizer in 2006, was approved by the FDA. This inhaled form of insulin is called Exubera. The insulin is packaged in dry blister packs that are inserted into an inhalation device. This device lances the powder packs allowing the insulin to enter a chamber that has a mouth piece through which the user can inhale the insulin. Exubera has a peak of action similar to Humalog (rapid acting), and a duration of action similar to regular insulin (short acting). It can be combined with oral medication in patients with type 2 diabetes or used alone. In patients with type 1 diabetes the insulin should be combined with a longer acting basal insulin such as glargine.
The side effect profile of inhaled insulin is similar to other insulins, and the user must be aware of hypoglycemia. In addition, since the insulin is absorbed through the lungs, there was initial concern regarding lung function. While there is a slight decrease in lung function with the initial use of Exubera, this stabilizes quickly and returns to baseline of aged matched controls when the Exubera is discontinued. Since this is still a new product, it is recommended that any patient starting on inhaled insulin have lung function tests done prior to starting treatment. If baseline values of FEV1 (a measure of lung function) are < 70%, Exubera is not given. After six months of use lung function tests are performed again; if deterioration is noted, Exubera is discontinued.
Exubera is not to be used in regular or intermittent smokers and patients requiring very small doses of insulin. Nevertheless, in the right population, this is a great option.
Note: Unfortunately, acceptance of Exubera was poor over the year or so it was available since it's launch in 2006. Recently in October 2007, the company Pfizer decided not to sell the product anymore. Part of this issue was the time required to teach the device and the uniqueness of the format of delivery. While no major medical concerns were noted with it's use, it simply has not been accepted by patients and doctors. Perhaps we will see this modality come back in a new easier to use incarnation.
Intranasal, Transdermal
Other routes for the delivery of insulin have also been tried. Intranasal insulin delivery was thought to be promising. However, this method was associated with poor absorption and nasal irritation. Transdermal insulin (skin patch delivery) has also yielded disappointing results to date. Insulin in pill form is also not yet effective since the digestive enzymes in the gut break it down.
The future of pancreas transplantation
Ultimately, the goal in the management of type 1 diabetes is to provide insulin therapy in a manner that mimics the natural pancreas. Perhaps the closest therapy available at this time is a transplant of the pancreas. Several approaches to pancreatic transplantation are currently being studied, including the whole pancreas and isolated islet cells (these groups of cells contain beta cells that are responsible for insulin production). Data available from 1995 indicates that almost 8,000 patients underwent pancreatic transplantation. Most patients undergo pancreatic transplantation at the time of kidney transplantation for diabetic kidney disease.
Transplantation is not without risk. Both the surgery itself and the immunosuppression that must occur afterward pose significant risks to the patient. For these reasons, the kidney and pancreas are usually transplanted at the same time. At present, there is disagreement about whole pancreas transplantation in patients not currently requiring kidney transplantation. The issue of whether the benefits outweigh the risks in these patients is under debate. There is also a chance that diabetes will occur in the transplanted pancreas. Selectively transplanting islet cells is an interesting alternative to whole pancreas transplantation. However, the concern over rejection remains. Attempts to disguise the islet cells in tissues that the body won't reject (for example, by surrounding the islet cells by the patient's own cells and then implanting them) are underway. In addition, researchers are exploring artificial barriers that can surround the islet cells, provide protection against rejection, and still allow insulin to enter the bloodstream.
A Final Word
These last few years have been an exciting time in diabetes care. Many agents for the treatment of type 2 diabetes are under development and the options for insulin therapy continue to grow and methods for insulin delivery continue to become more refined. While research continues to expand in these areas, one thing remains constant. Achieving the best blood sugar control possible remains the ultimate goal in both type 1 and type 2 diabetes. We now know, beyond a doubt, that good blood sugar control minimizes the long–term complications of diabetes, including blindness, nerve damage, and kidney damage. Finally, a healthy lifestyle can do nothing bad...it should remain the cornerstone of management for diabetes.
Diabetes At A Glance
• Diabetes is a chronic condition associated with abnormally high levels of sugar (glucose) in the blood.
• Insulin produced by the pancreas lowers blood glucose.
• Absence or insufficient production of insulin causes diabetes.
• The two types of diabetes are referred to as type 1 (insulin dependent) and type 2 (non-insulin dependent).
• Symptoms of diabetes include increased urine output, thirst and hunger as well as fatigue.
• Diabetes is diagnosed by blood sugar (glucose) testing.
• The major complications of diabetes are both acute and chronic.
o Acutely: dangerously elevated blood sugar, abnormally low blood sugar due to diabetes medications may occur.
o Chronically: disease of the blood vessels (both small and large) which can damage the eye, kidneys, nerves, and heart may occur
• Diabetes treatment depends on the type and severity of the diabetes. Type 1 diabetes is treated with insulin, exercise, and a diabetic diet. Type 2 diabetes is first treated with weight reduction, a diabetic diet, and exercise. When these measures fail to control the elevated blood sugars, oral medications are used. If oral medications are still insufficient, insulin medications are considered.
Last Editorial Review: 12/5/2006
Diabetes Treatment
Medical Author: Ruchi Mathur, MD
Medical Editor: William C. Shiel, Jr., MD, FACP, FACR and Jay W. Marks, MD
• How is diabetes treated?
• Medications for type 2 diabetes
• Sulfonylureas
• Meglitinides – (Prandin and Starlix)
• Medications that decrease the amount of glucose produced by the liver
• Medications that increase the sensitivity of cells to insulin (Actos and Avandia)
• Medications that decrease the absorption of carbohydrates from the intestine (Precose)
• New medications that effect glycemic control (Symlin and Byetta)
• DPP–IV inhibitors
• Combination medications
• Treatment of diabetes with insulin
• Different methods of delivering insulin
• Pre–filled insulin pens
• Insulin pump
• Inhaled Insulin
• Intranasal, Transderm
• The future of pancreas transplantation
• Diabetes main article including causes, symptoms, complications, and diagnosis
How is diabetes treated?
The major goal in treating diabetes is to minimize any elevation of blood sugar (glucose) without causing abnormally low levels of blood sugar. Type 1 diabetes is treated with insulin, exercise, and a diabetic diet. Type 2 diabetes is treated first with weight reduction, a diabetic diet, and exercise. When these measures fail to control the elevated blood sugars, oral medications are used. If oral medications are still insufficient, treatment with insulin is considered.
Adherence to a diabetic diet is an important aspect of controlling elevated blood sugar in patients with diabetes. The American Diabetes Association (ADA) has provided guidelines for a diabetic diet. The ADA diet is a balanced, nutritious diet that is low in fat, cholesterol, and simple sugars. The total daily calories are evenly divided into three meals. In the past two years, the ADA has lifted the absolute ban on simple sugars. Small amounts of simple sugars are allowed when consumed with a complex meal. For more, please read the Diabetic Diet article.
Weight reduction and exercise are important treatments for diabetes. Weight reduction and exercise increase the body's sensitivity to insulin, thus helping to control blood sugar elevations. For more, please read the Weight Loss and Fitness articles.
Medications for type 2 diabetes
WARNING: All the information below applies to patients who are not pregnant or breastfeeding. At present the only recommended way of controlling diabetes in women who are pregnant or breastfeeding is by diet, exercise and insulin therapy. You should speak with your doctor if you are taking these medications and are considering becoming pregnant or if you have become pregnant while taking these medications.
Based on what is known, medications for type 2 diabetes are designed to:
1. Increase the insulin output by the pancreas.
2. Decrease the amount of glucose released from the liver.
3. Increase the sensitivity (response) of cells to insulin.
4. Decrease the absorption of carbohydrates from the intestine.
5. Slow emptying of the stomach to delay the presentation of carbohydrates for digestion and absorption in the small intestine.
When selecting therapy for type 2 diabetes, consideration should be given to:
1. The magnitude of change in blood sugar control that each medication will provide.
2. Other coexisting medical conditions (high blood pressure, high cholesterol, etc.)
3. Adverse effects of the therapy
4. Contraindications to therapy
5. Issues that may affect compliance (timing of medication, frequency of dosing)
6. Cost to the patient and the healthcare system
It's important to remember that if a drug can provide more than one benefit (lower blood sugar and have a beneficial effect on cholesterol, for example), it should be preferred. It's also important to bear in mind that the cost of drug therapy is relatively small compared to the cost of managing the long–term complications associated with poorly controlled diabetes.
Varying combinations of medications also are used to correct abnormally elevated levels of blood glucose in diabetes. As the list of medications continues to expand, treatment options for type 2 diabetes can be better tailored to meet an individuals needs. Not every patient with type 2 diabetes will benefit from every drug, and not every drug is suitable for each patient. Patients with type 2 diabetes should work closely with their physicians to achieve an approach that provides the greatest benefits while minimizing risks.
Patients with diabetes should never forget the importance of diet and exercise. The control of diabetes starts with a healthy lifestyle regardless of what medications are being used.
Medications that increase the insulin output by the pancreas – sulfonylureas and meglitinides
Sulfonylureas
Historically, increasing insulin output by the pancreas has been the major area targeted by medications used to treat type 2 diabetes. Medications that increase the output of insulin belong to a class of drugs called sulfonylureas. Sulfonylureas primarily lower blood glucose levels by increasing the release of insulin from the pancreas. Older generations of these drugs include chlorpropamide and tolbutamide, while newer drugs include glyburide (DiaBeta), glipizide (Glucotrol), and glimepiride (Amaryl). These drugs are effective in rapidly lowering blood sugar but run the risk of causing hypoglycemia (abnormally low and dangerous levels of blood sugar). In addition, they are sulfa–containing drugs and should be avoided by patients who are allergic to sulfa .
Meglitinides – repaglinide (Prandin) and nateglinide (Starlix)
The class of drugs known as meglitinides is relatively new. Meglitinides also work on the pancreas to promote insulin secretion. Unlike sulfonylureas that bind to receptors on the insulin producing cells, meglitinides work through a separate potassium based channel on the cell surface. Unlike the sulfonylureas which last longer in the body, repaglinide (Prandin) and nateglinide (Starlix) are very short acting, with peak effects within one hour. For this reason, they are given up to three times a day just before meals. Since these drugs also increase circulating insulin levels, they may cause hypoglycemia, but the literature suggests this is less frequent than the hypoglycemia seen with sulfonylureas.
Prandin
In a three month study, repaglinide (Prandin) dropped fasting blood glucose values by 61 mg/dL and post meal blood glucose values by 100 mg/dL. Because Prandin is short acting and given before meals, it is particularly beneficial in lowering blood glucose after meals and does not tend to lower fasting glucose levels to the same degree. Prandin has been used in combination with other medications, such as metformin (Glucophage), with impressive results. In 83 patients with type 2 diabetes, blood sugar control improved significantly with the addition of Prandin to Glucophage.
Prandin interacts with other medications. Therefore, the doctor must be aware of all other medications a patient is taking before prescribing Prandin. The usual starting dose is 0.5mg before each meal and can be increased to 4mg. The maximum daily dose is 16mg. Prandin is used with caution in people with kidney or liver abnormalities. Since Prandin increases insulin levels, it has the risk of causing abnormally low blood sugars. Blood sugars that remain severely low can result in sweating, tremors, confusion, and may lead to coma and seizure. In addition, the use of Prandin has been associated with headaches, muscle and joint aches, along with sinus infections in some individuals. This drug should not be used in pregnancy or by nursing mothers. The dose may need to be adjusted in older people, since the elderly may metabolize (eliminate) medications at a slower rate. For more, please read the drug information on repaglinide (Prandin).
Starlix
Nateglinide (Starlix) has essentially the same profile of side effects and interactions as Prandin. The major benefit of Starlix is that the starting dose of 120mg does not need to be adjusted upward, but rather remains constant. These medications are also relatively safe to use in people with impaired kidney function. For more, please read the drug information on nateglinide (Starlix).
Medications that decrease the amount of glucose produced by the liver
A class of drugs called biguanides has been used for many years in Europe and Canada. In 1994, the FDA approved the use of the biguanide metformin (Glucophage) for the treatment of type 2 diabetes in the U.S. Glucophage is unique in its ability to decrease glucose production by the liver. Briefly, because metformin does not increase insulin levels, when used alone, it does not usually cause hypoglycemia. In addition, metformin has an effect whereby it tends to suppress appetite, which may be beneficial in diabetics who tend to be overweight. Metformin may be used by itself or together with other oral drugs or insulin. It should not be used in patients with kidney impairment and should be used with caution in those with liver impairment. The older biguanides that preceded metformin were associated with a serious condition called lactic acidosis, a dangerous acid build up in the blood resulting from accumulation of the drug and its breakdown products. While metformin is safer in this regard, it is recommended that the drug be discontinued for 24 hours before any procedure involving the intravenous injection of dyes (such as for some x–ray studies of the kidney) or surgery is performed. The dyes may impair kidney function and cause a build up of the drug in the blood. Metformin can be restarted after these procedures once the patient is urinating normally.
Medications that increase the sensitivity of cells to insulin
The class of drugs known as thiazolidinediones lowers blood glucose by improving target cell response to insulin (that is, increasing the sensitivity of the cells to insulin). Troglitazone (Rezulin) was the first of this class in the U.S. Because of severe toxic liver effects, troglitazone has been taken off the market. Sister compounds are now available with a better safety profile. These drugs include pioglitazone (Actos) and rosiglitazone (Avandia).
Pioglitazone (Actos) and rosiglitazone (Avandia) are thiazolidinediones approved for use in the U.S. While they are sister compounds to Rezulin, extensive studies have failed to show that they are associated with any liver problems. Both Avandia and Actos act by increasing the sensitivity (responsiveness) of cells to insulin. They improve the sensitivity of muscle and fat cells to insulin. These drugs have been effective in lowering blood sugars in patients with type 2 diabetes, Actos and Avandia act within one hour of administration and are taken once daily. It is important to note that it takes up to six weeks to see a drop in blood glucose levels with these drugs and up to 12 weeks to see a maximum benefit. Actos and Avandia have been approved as first line therapy in diabetes and for use in combination with other drugs. Both drugs may be used in patients taking other oral drugs as well as those using insulin.
While reported liver problems with these agents are mild (and reversible with discontinuation of the drug), most physicians choose to follow an earlier recommendation to do blood tests to detect liver injury every two months or so during the first year of therapy. Recently this recommendation has been removed. If at any point the liver tests increase to three times the normal upper limit, the drug should be stopped.
The most important contraindications to these medications include any type of liver disease, and heart failure. Fluid retention can be of particular concern in patients with signs or symptoms of heart failure and in those with ejection fractions of less than 40% which indicates poor function of the heart. While the reports are three to eight pounds, clinical experience shows up to 12–15 pounds of weight gain can occur. Usually the majority of this is fluid, but an absolute body weight gain can also occur. This is likely to be dose–dependent and, therefore, the increases in weight may be greater with higher doses of drug. Weight gain is more pronounced in patients who are also taking insulin. In general, the ankle swelling and puffiness due to the accumulation of fluid can be controlled with the addition of a diuretic such as spironolactone (Aldactone) — (furosemide (Lasix) does not work as well) — or by reducing the dose. On occasion, patients may be symptomatic enough from fluid retention to warrant withdrawal of the drug. Some recent studies have suggested an association between pioglitazone and rosiglitazone and untoward cardiac events, for example, heart attacks, though this association is controversial. Regardless of the controversy, it is well established that pioglitazone and rosiglitazone should be avoided in patients with symptomatic heart failure or heart failure.
Another newer concern is an association of treatment with a small increase in the frequency of fractures of the distal long bones of the arms and legs. At present, this does not translate into fractures of the hip and spine, which would be clinically more worrisome. More data is needed to make a definitive statement about cause and effect at this time.
As an aside, Actos and Avandia have an added benefit of changing cholesterol patterns in diabetes. HDL (or good cholesterol) increases with these medications, and triglycerides often decrease. While there is some controversy regarding what happens to bad cholesterol (LDL) levels, there is a suggestion that Actos may be superior in changing lipid profiles than Avandia. In this population of diabetics that is already at an increased risk for heart disease, an improvement in cholesterol profile is beneficial. As more and more data becomes available, there is mounting evidence that this class of drugs may provide direct benefits to the heart and large blood vessels and may actually be valuable in preventing the progression of diabetes in high–risk individuals by reducing inflammation and by decreasing clotting factors. As time goes on, I have no doubt that the uses for this class of medications will expand. For more, please read the drug information on pioglitazone (Actos) and rosiglitazone (Avandia).
Medications that decrease the absorption of carbohydrates from the intestine
Before being absorbed into the bloodstream, carbohydrates must be broken down into smaller sugar particles, such as glucose, by enzymes in the small intestine. One of the enzymes involved in breaking down carbohydrates is called alpha glucosidase. By inhibiting this enzyme, carbohydrates are not broken down as efficiently and glucose absorption is delayed.
Precose
The name of the alpha glucosidase inhibitor available in the U.S. is acarbose (Precose). In clinical trials with over 700 patients, the use of Precose was associated with a reduction in hemoglobin A1c values (a well known measurement of average blood sugars over the preceding three months) that was significantly greater than the use of placebo (no treatment). However, as a single agent, Precose is not as effective as the other medications for diabetes. Since Precose works in the intestine, its effects are additive to diabetic medications that work at other sites, such as sulfonylureas. Clinical studies have shown statistically better control of blood glucose in patients treated with Precose and a sulfonylurea compared to the sulfonylurea alone. Precose is currently used alone or in combination with a sulfonylurea.
Precose is taken three times a day at the beginning of meals. The dosage varies from 25 to 100mg with each meal. The maximum recommended dose is 100mg three times a day. At doses greater than this, reversible abnormalities in liver tests may be seen. Because of its mechanism of action, Precose has significant gastrointestinal side effects. Abdominal pain, diarrhea, and gas are common and are seen in up to 75% of patients taking Precose. For this reason, Precose is administered using a low initial dose that is increased over weeks depending on the patient's tolerance. Most of the gastrointestinal symptoms tend to subside over the course of a few weeks although some patients report persistent problems. For more information, please read the drug information on acarbose (Precose).
New medications that effect glycemic control
Symlin (pramlintide)
Symlin is the first in a new class of injectable, anti–hyperglycemic medications for use in patients with type 2 or type 1 diabetes treated with insulin. Pramlintide, the active ingredient in Symlin, is a synthetic analog of human amylin, a naturally occurring neuroendocrine hormone synthesized by pancreatic beta cells that helps control glucose control after meals. Amylin, similar to insulin, is absent or deficient in patients with diabetes. When used with insulin, this compound can improve glycemic control and has additional benefits that cannot be realized with insulin alone.
According to published data, Symlin reduces post meal blood sugar peaks, reduces glucose fluctuations throughout the day, enhances satiety (the sensation of fullness) leading to potential weight loss, and lowers mealtime insulin requirements. Studies have shown it improves A1C beyond the effect of insulin alone.
Symlin is taken just prior to meals, three times a day. It is given in injection form and is used for:
• Type 2 diabetes, as an additional treatment in patients who use mealtime insulin therapy and have failed to achieve desired glucose control despite optimal insulin therapy, with or without a concurrent sulfonylurea agent and/or metformin.
• Type 1 diabetes, as an additional treatment in patients who use mealtime insulin therapy and who have failed to achieve desired glucose control despite optimal insulin therapy.
Symlin is considered a therapy option in patients with insulin–using type 2 or type 1 diabetes, that are unable to achieve adequate glycemic control despite individualized insulin management. Insulin–using patients with type 2 diabetes may also be taking a concurrent sulfonylurea agent and/or metformin.
The major side effect of Symlin is nausea, and this can be reduced with a slow, steady, increase in dose. The other major side effect is hypoglycemia (dangerously low levels of blood sugar). To avoid this, the dose of mealtime insulin should be cut in half when starting Symlin. Of note is the degree of weight loss seen with Symlin therapy. Studies for up to six months show weight loss of greater than six pounds more than placebo (inactive pills). For more, please read the drug information on pramlintide (Symlin).
Byetta (exenatide)
Byetta (exenatide) is a new medication on the market that has it's origins in an interesting place––the Gila monster's saliva. Scientists studying this small lizard noted it could go a long time without eating. They found a substance in it's saliva that slowed stomach emptying, thus making the lizard feel fuller longer. This substance was similar in nature to a gut hormone found in humans known as GLP–1. GLP–1 is broken down in the body by an enzyme called DPP–IV. So, if you could make a substance like GLP–1 that was not so easy to breakdown, this would have potential benefit; thus, the studies began. Ultimately, after modifying this hormone, exenatide (with the trade name Byetta) was developed. Byetta is the first in a new class of drugs for the treatment of type 2 diabetes called incretin mimetics. Byetta has been shown to have many of the same effects on sugar regulation as GLP–1, so it mimics the body's natural physiology for self–regulating blood sugar. Namely, it slows the release of glucose from the liver, slows stomach emptying thereby regulating delivery of nutrients to the intestine for absorption, and works centrally in the brain to regulate hunger.
Byetta is indicated as additional therapy to improve control of blood sugars in patients with type 2 diabetes who are taking metformin, a sulfonylurea, or a combination of metformin and a sulfonylurea but who have not achieved adequate sugar control. It enhances the way the insulin producing beta cells in the pancreas work. Insulin secretion increases only when blood sugars are high and decreases as blood sugars approach normal. In addition to enhancing the normal physiology of the beta cell, Byetta suppresses glucose release from the liver, slows stomach emptying and the absorption of nutrients including carbohydrate, and reduces intake of food.
Just like Symlin, Byetta is given by injection, but it is given twice a day (usually before breakfast and dinner meals). It comes in a disposable pen form and is available in two doses. The goal is to start with the lower dose for a month or so and then move up to the higher dose if needed and if tolerated. Similar to Symlin, the main side effect is nausea, most likely due to its effects on stomach emptying. This medication is temperature sensitive and it was recommended that the pens be stored at 36–46 degrees F. Recently, this has changed, with a recommendation that unopened pens be refrigerated, and once opened, the pens can be left at room temperature. The risk of hypoglycemia is still a possibility with Byetta, especially when used in combination with sulfonylureas. Your physician may choose to decrease the dose of some of your other medications when initially evaluating how you respond to Byetta.
Similar to Symlin, weight reduction is seen with Byetta in the majority of patients. This makes it particularly suitable for the typical patient with type 2 diabetes who is also overweight. For more, please read the drug information pamphlet on exenatide (Byetta).
A longer acting from of Byetta is currently being considered for approval by the FDA. This would allow for the same benefits (and side effects) without need for such frequent injections.
DPP–IV inhibitors
GLP–1 in the body is broken down by an enzyme called DPP IV. Logically, you can either make a synthetic GLP–1 that is not broken down by this enzyme (for example, Byetta) OR you could try to stop the enzyme that breaks down the GLP–1 your body already makes. Hence, the new class of drugs called DPP IV inhibitors. They do just that, that is, they inhibit this enzyme from breaking down GLP–1. This allows GLP–1 already in the blood to circulate longer. There are a number of companies working on this class of drug and the FDA just approved the first drug in this class made by Merck and called Januvia. Januvia can be used in combination with certain other medications and must be dose adjusted in patients with poor kidney function. For more, please read the Januvia pamplet.
These drugs have essentially the same side effect profile as Byetta; however, they are in pill form. While Byetta has a significant weight loss profile, DPP–IV inhibitors so far have had no effect on weight.
Combination medications
Glyburide/metformin (Glucovance), rosiglitazone/metformin (Avandamet), glipizide/metformin (Metaglip), and pioglitazone/metformin (Actosplusmet) are four relatively new combination pills that are on the market to treat diabetes.
• Glucovance combines glyburide with metformin in varying doses.
• Avandamet is a combination of varying doses of Avandia and metformin.
• Actosplusmet is a combination of varying doses of pioglitazone and metformin.
• Metaglip is a combination pill containing glipizide and metformin in varying strengths.
The benefit to these combination drugs is that there are fewer pills to take, hopefully leading to better compliance. While they work well, I personally like to give patients individual medications until I know what doses are working, and then switch to a combination pill once the patient has been stable on the doses of individual medications for a period of time.
Treatment of diabetes with insulin
Insulin is the mainstay of treatment for patients with type 1 diabetes. Insulin is also important in type 2 diabetes when blood glucose levels cannot be controlled by diet, weight loss, exercise, and oral medications.
Ideally, insulin should be administered in a manner that mimics the natural pattern of insulin secretion by a healthy pancreas; however, the complex pattern of insulin secretion by the pancreas is difficult to duplicate. Still, adequate blood glucose control can be achieved with careful attention to diet, regular exercise, home blood glucose monitoring, and multiple insulin injections throughout the day. For more, please see the Diabetes and Home Care Monitoring article.
In the past, the insulin was being derived from animal sources, particularly cows and pigs. Not only was there a problem with enough supply of insulin to meet the demand, but beef and pork insulin also had specific problems. Originating from animals, these types of insulin caused immune reactions in some people. Patients would become intolerant or resistant to animal insulin. With the acceleration of scientific research in the latter half of the twentieth century, beef and pork insulin were replaced by human insulin. In 1977, the gene for human insulin was cloned, and through modern technology, manufactured human insulin was made available. Human insulin is now widely used.
Insulin now comes in a variety of preparations that differ in the amount of time following injection until they begin to work and the duration of their action. Because of these differences, combinations of insulin are often used to allow for a more tailored regimen of blood sugar control. The table below lists the most common types of insulin currently in use in the U.S. and their specific properties.
Name of Insulin Onset of Action Peak Effect After Injection
Humalog and Novolog//Very Short Acting 5–15 minutes 30–60 minutes
Regular/Short Acting 30 minutes 2–5 hours
NPH/Intermediate Acting 1–2.5 hours 8–14 hours
Lente/Intermediate Acting 1–2.5 hours 8–12 hours
Ultra Lente/Long Acting 4–6 hours 10–18 hours
Lantus 2–3 hours Stable from 2–3 hours to @20 hours
Detemir 3–4 hours Dose dependent (longer acting at higher doses)
Combinations – 75/25, 70/30, 50/50 30 minutes 7–12 hours
For example, a patient may take an injection of Lantus in the morning and evening to provide a baseline of insulin throughout a 24–hour period. In addition, the same patient may take an injection of Humalog just before meals to cover the increase in carbohydrate load after eating.
Different methods of delivering insulin
Not only is the variety of insulin preparations growing, so are the methods for administering insulin.
Pre–filled insulin pens
In the past, insulin was available only in an injectable form that involved carrying syringes (which a few decades ago were made of glass and required sterilization), needles, vials of insulin, and alcohol swabs. Needless to say, patients often found it difficult to take multiple shots each day, and, as a result, good blood sugar control was often compromised. Many pharmaceutical companies are now offering discreet and convenient methods of delivering insulin.
Both Novo Nordisk and Lily have an insulin pen delivery system. This system is similar to an ink cartridge in a fountain pen. A small pen–sized device holds an insulin cartridge (usually containing 300 units). Cartridges are available in the most widely used insulin formulations, such as those listed in the table above. The amount of insulin to be injected is dialed in by turning the bottom of the pen until the required number of units is seen in the dose–viewing window. The tip of the pen consists of a needle that is replaced with each injection. A release mechanism allows the needle to penetrate just under the skin and deliver the required amount of insulin. The cartridges and needles are disposed of when finished and new ones simply are inserted. In many cases, the entire pen is disposed of. These insulin delivery devices are less cumbersome than traditional methods.
Insulin pump
The most recently available advance in insulin delivery is the insulin pump. In the U. S., MiniMed, Deltec and Disetronic market the insulin pump. An insulin pump is composed of a pump reservoir similar to that of an insulin cartridge, a battery–operated pump, and a computer chip that allows the user to control the exact amount of insulin being delivered. Currently, pumps on the market are about the size of a pager or beeper. The pump is attached to a thin plastic tube (an infusion set) that has a cannula (like a needle but soft) at the end through which insulin passes. This cannula is inserted under the skin, usually on the abdomen. The cannula is changed every two days. The tubing can be disconnected from the pump while showering or swimming. The pump is used for continuous insulin delivery, 24 hours a day. The amount of insulin is programmed and is administered at a constant rate (basal rate). Often, the amount of insulin needed over the course of 24 hours varies depending on factors like exercise, activity level, and sleep. The insulin pump allows for the user to program many different basal rates to allow for this variation in lifestyle. In addition, the user can program the pump to deliver additional insulin during meals to cover the excess demands for insulin caused by the ingestion of carbohydrates with the meal.
Over 50,000 people worldwide are using an insulin pump. This number is growing dramatically as these devices become smaller and more user–friendly. Insulin pumps allow for tight blood sugar control and lifestyle flexibility while minimizing the effects of low blood sugar (hypoglycemia). At present, the pump is the closest device on the market to an artificial pancreas. More recently, newer models of the pump have been developed that do not require a tubing, in fact - the insulin delivery device is placed directly on the skin and any adjustments needed for insulin delivery are made through a PDA like device that must be kept within a 6 foot range of the insulin delivery device, and can be worn in a pocket, kept in a purse, or on a tabletop when working.
Probably the most exciting innovation in pump technology is the ability to use the pump in tandem with newer glucose sensing technology. Glucose sensors have improved dramatically in the last few years, and are an option for patients to gain further insight into their patterns of glucose response to tailor a more individual treatment regimen. The newest generation of sensors allows for a real time glucose value to be given to the patient. The implantable sensor communicates wirelessly with a pager-sized device that has a screen. The device is kept in proximity to the sensor to allow for transfer of data, however, it can be a few feet away and still receive transmitted information. Depending on the model, the screen displays the blood glucose reading, a thread of readings over time, and a potential rate of change in the glucose values. The sensors can be programmed to produce a "beep" if blood sugars are in a range that is selected as too high or too low. Some can provide a warning beep if the drop in blood sugar is occurring too quickly.
To take things one step further, there is one particular sensor that is new to the market that is designed to communicate directly with the insulin pump. While the pump does not yet respond directly to information from the sensor, it does "request" a response from the patient if there is a need for adjustments according to the patterns it is programmed to detect. The ultimate goal of this technology is to "close the loop" by continuously sensing what the body needs, and then responding by providing the appropriate dose of insulin. While this technology is a few more years in the making, the strides in this direction continue to grow.
Inhaled Insulin
Inhaled insulin, marketed by Pfizer in 2006, was approved by the FDA. This inhaled form of insulin is called Exubera. The insulin is packaged in dry blister packs that are inserted into an inhalation device. This device lances the powder packs allowing the insulin to enter a chamber that has a mouth piece through which the user can inhale the insulin. Exubera has a peak of action similar to Humalog (rapid acting), and a duration of action similar to regular insulin (short acting). It can be combined with oral medication in patients with type 2 diabetes or used alone. In patients with type 1 diabetes the insulin should be combined with a longer acting basal insulin such as glargine.
The side effect profile of inhaled insulin is similar to other insulins, and the user must be aware of hypoglycemia. In addition, since the insulin is absorbed through the lungs, there was initial concern regarding lung function. While there is a slight decrease in lung function with the initial use of Exubera, this stabilizes quickly and returns to baseline of aged matched controls when the Exubera is discontinued. Since this is still a new product, it is recommended that any patient starting on inhaled insulin have lung function tests done prior to starting treatment. If baseline values of FEV1 (a measure of lung function) are < 70%, Exubera is not given. After six months of use lung function tests are performed again; if deterioration is noted, Exubera is discontinued.
Exubera is not to be used in regular or intermittent smokers and patients requiring very small doses of insulin. Nevertheless, in the right population, this is a great option.
Note: Unfortunately, acceptance of Exubera was poor over the year or so it was available since it's launch in 2006. Recently in October 2007, the company Pfizer decided not to sell the product anymore. Part of this issue was the time required to teach the device and the uniqueness of the format of delivery. While no major medical concerns were noted with it's use, it simply has not been accepted by patients and doctors. Perhaps we will see this modality come back in a new easier to use incarnation.
Intranasal, Transdermal
Other routes for the delivery of insulin have also been tried. Intranasal insulin delivery was thought to be promising. However, this method was associated with poor absorption and nasal irritation. Transdermal insulin (skin patch delivery) has also yielded disappointing results to date. Insulin in pill form is also not yet effective since the digestive enzymes in the gut break it down.
The future of pancreas transplantation
Ultimately, the goal in the management of type 1 diabetes is to provide insulin therapy in a manner that mimics the natural pancreas. Perhaps the closest therapy available at this time is a transplant of the pancreas. Several approaches to pancreatic transplantation are currently being studied, including the whole pancreas and isolated islet cells (these groups of cells contain beta cells that are responsible for insulin production). Data available from 1995 indicates that almost 8,000 patients underwent pancreatic transplantation. Most patients undergo pancreatic transplantation at the time of kidney transplantation for diabetic kidney disease.
Transplantation is not without risk. Both the surgery itself and the immunosuppression that must occur afterward pose significant risks to the patient. For these reasons, the kidney and pancreas are usually transplanted at the same time. At present, there is disagreement about whole pancreas transplantation in patients not currently requiring kidney transplantation. The issue of whether the benefits outweigh the risks in these patients is under debate. There is also a chance that diabetes will occur in the transplanted pancreas. Selectively transplanting islet cells is an interesting alternative to whole pancreas transplantation. However, the concern over rejection remains. Attempts to disguise the islet cells in tissues that the body won't reject (for example, by surrounding the islet cells by the patient's own cells and then implanting them) are underway. In addition, researchers are exploring artificial barriers that can surround the islet cells, provide protection against rejection, and still allow insulin to enter the bloodstream.
A Final Word
These last few years have been an exciting time in diabetes care. Many agents for the treatment of type 2 diabetes are under development and the options for insulin therapy continue to grow and methods for insulin delivery continue to become more refined. While research continues to expand in these areas, one thing remains constant. Achieving the best blood sugar control possible remains the ultimate goal in both type 1 and type 2 diabetes. We now know, beyond a doubt, that good blood sugar control minimizes the long–term complications of diabetes, including blindness, nerve damage, and kidney damage. Finally, a healthy lifestyle can do nothing bad...it should remain the cornerstone of management for diabetes.
Diabetes Mellitus
Diabetes Mellitus
Medical Author: Ruchi Mathur, MD
Medical Editor: William C. Shiel, Jr., MD, FACP, FACR
• What is diabetes?
• What is the impact of diabetes?
• What causes diabetes?
• What are the different types of diabetes?
• What are diabetes symptoms?
• How is diabetes diagnosed?
• Why is blood sugar checked at home?
• What are the acute complications of diabetes?
• What are the chronic complications of diabetes?
• What can be done to slow diabetes complications?
• How is diabetes treated?
• Diabetes At A Glance
• Related Diabetes articles:
Diabetes Health Center - on WebMD
• Read what your doctor is reading:
Diabetes - on Medscape
What is diabetes?
Diabetes mellitus is a group of metabolic diseases characterized by high blood sugar (glucose) levels, which result from defects in insulin secretion, or action, or both. Diabetes mellitus, commonly referred to as diabetes (as it will be in this article) was first identified as a disease associated with “sweet urine," and excessive muscle loss in the ancient world. Elevated levels of blood glucose (hyperglycemia) lead to spillage of glucose into the urine, hence the term sweet urine. Normally, blood glucose levels are tightly controlled by insulin, a hormone produced by the pancreas. Insulin lowers the blood glucose level. When the blood glucose elevates (for example, after eating food), insulin is released from the pancreas to normalize the glucose level. In patients with diabetes, the absence or insufficient production of insulin causes hyperglycemia. Diabetes is a chronic medical condition, meaning that although it can be controlled, it lasts a lifetime.
What is the impact of diabetes?
Over time, diabetes can lead to blindness, kidney failure, and nerve damage. These types of damage are the result of damage to small vessels, referred to as microvascular disease. Diabetes is also an important factor in accelerating the hardening and narrowing of the arteries (atherosclerosis), leading to strokes, coronary heart disease, and other large blood vessel diseases. This is referred to as macrovascular disease. Diabetes affects approximately 17 million people (about 8% of the population) in the United States. In addition, an estimated additional 12 million people in the United States have diabetes and don't even know it. From an economic perspective, the total annual cost of diabetes in 1997 was estimated to be 98 billion dollars in the United States. The per capita cost resulting from diabetes in 1997 amounted to $10,071.00; while healthcare costs for people without diabetes incurred a per capita cost of $2,699.00. During this same year, 13.9 million days of hospital stay were attributed to diabetes, while 30.3 million physician office visits were diabetes related. Remember, these numbers reflect only the population in the United States. Globally, the statistics are staggering.
Diabetes is the third leading cause of death in the United States after heart disease and cancer.
What causes diabetes?
Insufficient production of insulin (either absolutely or relative to the body's needs), production of defective insulin (which is uncommon), or the inability of cells to use insulin properly and efficiently leads to hyperglycemia and diabetes. This latter condition affects mostly the cells of muscle and fat tissues, and results in a condition known as "insulin resistance." This is the primary problem in type 2 diabetes. The absolute lack of insulin, usually secondary to a destructive process affecting the insulin producing beta cells in the pancreas, is the main disorder in type 1 diabetes. In type 2 diabetes, there also is a steady decline of beta cells that adds to the process of elevated blood sugars. For more, please read the Insulin Resistance article. Essentially, if someone is resistant to insulin, the body can, to some degree, increase production of insulin and overcome the level of resistance. After time, if production decreases and insulin cannot be released as vigorously, hyperglycemia develops.
Glucose is a simple sugar found in food. Glucose is an essential nutrient that provides energy for the proper functioning of the body cells. Carbohydrates are broken down in the small intestine and the glucose in digested food is then absorbed by the intestinal cells into the bloodstream, and is carried by the bloodstream to all the cells in the body where it is utilized. However, glucose cannot enter the cells alone and needs insulin to aid in its transport into the cells. Without insulin, the cells become starved of glucose energy despite the presence of abundant glucose in the bloodstream. In certain types of diabetes, the cells' inability to utilize glucose gives rise to the ironic situation of "starvation in the midst of plenty". The abundant, unutilized glucose is wastefully excreted in the urine.
Insulin is a hormone that is produced by specialized cells (beta cells) of the pancreas. (The pancreas is a deep-seated organ in the abdomen located behind the stomach.) In addition to helping glucose enter the cells, insulin is also important in tightly regulating the level of glucose in the blood. After a meal, the blood glucose level rises. In response to the increased glucose level, the pancreas normally releases more insulin into the bloodstream to help glucose enter the cells and lower blood glucose levels after a meal. When the blood glucose levels are lowered, the insulin release from the pancreas is turned down. It is important to note that even in the fasting state there is a low steady release of insulin than fluctuates a bit and helps to maintain a steady blood sugar level during fasting. In normal individuals, such a regulatory system helps to keep blood glucose levels in a tightly controlled range. As outlined above, in patients with diabetes, the insulin is either absent, relatively insufficient for the body's needs, or not used properly by the body. All of these factors cause elevated levels of blood glucose (hyperglycemia).
What are the different types of diabetes?
There are two major types of diabetes, called type 1 and type 2. Type 1 diabetes was also called insulin dependent diabetes mellitus (IDDM), or juvenile onset diabetes mellitus. In type 1 diabetes, the pancreas undergoes an autoimmune attack by the body itself, and is rendered incapable of making insulin. Abnormal antibodies have been found in the majority of patients with type 1 diabetes. Antibodies are proteins in the blood that are part of the body's immune system. The patient with type 1 diabetes must rely on insulin medication for survival.
In autoimmune diseases, such as type 1 diabetes, the immune system mistakenly manufactures antibodies and inflammatory cells that are directed against and cause damage to patients' own body tissues. In persons with type 1 diabetes, the beta cells of the pancreas, which are responsible for insulin production, are attacked by the misdirected immune system. It is believed that the tendency to develop abnormal antibodies in type 1 diabetes is, in part, genetically inherited, though the details are not fully understood. Exposure to certain viral infections (mumps and Coxsackie viruses) or other environmental toxins may serve to trigger abnormal antibody responses that cause damage to the pancreas cells where insulin is made. These antibodies can be measured in the majority of patients, and may help determine which individuals are at risk for developing type 1 diabetes.
At present, the American Diabetes Association does not recommend general screening of the population for type 1 diabetes, though screening of high risk individuals, such as those with a first degree relative (sibling or parent) with type 1 diabetes should be encouraged. Type 1 diabetes tends to occur in young, lean individuals, usually before 30 years of age, however, older patients do present with this form of diabetes on occasion. This subgroup is referred to as latent autoimmune diabetes in adults (LADA). LADA is a slow, progressive form of type 1 diabetes. Of all the patients with diabetes, only approximately 10% of the patients have type 1 diabetes and the remaining 90% have type 2 diabetes.
Type 2 diabetes was also referred to as non-insulin dependent diabetes mellitus (NIDDM), or adult onset diabetes mellitus (AODM). In type 2 diabetes, patients can still produce insulin, but do so relatively inadequately for their body's needs, particularly in the face of insulin resistance as discussed above. In many cases this actually means the pancreas produces larger than normal quantities of insulin. A major feature of type 2 diabetes is a lack of sensitivity to insulin by the cells of the body (particularly fat and muscle cells). In addition to the problems with an increase in insulin resistance, the release of insulin by the pancreas may also be defective and suboptimal. In fact, there is a known steady decline in beta cell production of insulin in type 2 diabetes that contributes to worsening glucose control. (This is a major factor for many patients with type 2 diabetes who ultimately require insulin therapy.) Finally, the liver in these patients continues to produce glucose through a process called gluconeogenesis despite elevated glucose levels. The control of gluconeogenesis becomes compromised.
While it is said that type 2 diabetes occurs mostly in individuals over 30 years old and the incidence increases with age, we are seeing an alarming number patients with type 2 diabetes who are barely in their teen years. In fact, for the first time in the history of humans, type 2 diabetes is now more common than type 1 diabetes in childhood. Most of these cases are a direct result of poor eating habits, higher body weight, and lack of exercise.
While there is a strong genetic component to developing this form of diabetes, there are other risk factors - the most significant of which is obesity. There is a direct relationship between the degree of obesity and the risk of developing type 2 diabetes, and this holds true in children as well as adults. It is estimated that the chance to develop diabetes doubles for every 20% increase over desirable body weight.
Regarding age, data shows that for each decade after 40 years of age regardless of weight there is an increase in incidence of diabetes. The prevalence of diabetes in persons 65 to 74 years of age is nearly 20%. Type 2 diabetes is also more common in certain ethnic groups. Compared with a 6% prevalence in Caucasians, the prevalence in African Americans and Asian Americans is estimated to be 10%, in Hispanics 15%, and in certain Native American communities 20% to 50%. Finally, diabetes occurs much more frequently in women with a prior history of diabetes that develops during pregnancy (gestational diabetes - see below).
Diabetes can occur temporarily during pregnancy. Significant hormonal changes during pregnancy can lead to blood sugar elevation in genetically predisposed individuals. Blood sugar elevation during pregnancy is called gestational diabetes. Gestational diabetes usually resolves once the baby is born. However, 25-50% of women with gestational diabetes will eventually develop Type 2 diabetes later in life, especially in those who require insulin during pregnancy and those who remain overweight after their delivery. Patients with gestational diabetes are usually asked to undergo an oral glucose tolerance test about 6 weeks after giving birth to determine if their diabetes has persisted beyond the pregnancy, or if any evidence (such as impaired glucose tolerance) is present that may be a clue to the patient's future risk for developing diabetes.
"Secondary" diabetes refers to elevated blood sugar levels from another medical condition. Secondary diabetes may develop when the pancreatic tissue responsible for the production of insulin is destroyed by disease, such as chronic pancreatitis (inflammation of the pancreas by toxins like excessive alcohol), trauma, or surgical removal of the pancreas. Diabetes can also result from other hormonal disturbances, such as excessive growth hormone production (acromegaly) and Cushing's syndrome. In acromegaly, a pituitary gland tumor at the base of the brain causes excessive production of growth hormone, leading to hyperglycemia. In Cushing's syndrome, the adrenal glands produce an excess of cortisol, which promotes blood sugar elevation.
In addition, certain medications may worsen diabetes control, or "unmask" latent diabetes. This is seen most commonly when steroid medications (such as prednisone) are taken and also with medications used in the treatment of HIV infection (AIDS).
What are diabetes symptoms?
The early symptoms of untreated diabetes are related to elevated blood sugar levels, and loss of glucose in the urine. High amounts of glucose in the urine can cause increased urine output and lead to dehydration. Dehydration causes increased thirst and water consumption. The inability of insulin to perform normally has effects on protein, fat and carbohydrate metabolism. Insulin is an anabolic hormone, that is, one that encourages storage of fat and protein. A relative or absolute insulin deficiency eventually leads to weight loss despite an increase in appetite. Some untreated diabetes patients also complain of fatigue, nausea and vomiting. Patients with diabetes are prone to developing infections of the bladder, skin, and vaginal areas. Fluctuations in blood glucose levels can lead to blurred vision. Extremely elevated glucose levels can lead to lethargy and coma.
How is diabetes diagnosed?
The fasting blood glucose (sugar) test is the preferred way to diagnose diabetes. It is easy to perform and convenient. After the person has fasted overnight (at least 8 hours), a single sample of blood is drawn and sent to the laboratory for analysis. This can also be done accurately in a doctor's office using a glucose meter.
Normal fasting plasma glucose levels are less than 100 milligrams per deciliter (mg/dl). Fasting plasma glucose levels of more than 126 mg/dl on two or more tests on different days indicate diabetes. A random blood glucose test can also be used to diagnose diabetes A blood glucose level of 200 mg/dl or higher indicates diabetes.
When fasting blood glucose stays above 100mg/dl, but in the range of 100-126mg/dl, this is known as impaired fasting glucose (IFG). While patients with IFG do not have the diagnosis of diabetes, this condition carries with it its own risks and concerns, and is addressed elsewhere.
The oral glucose tolerance test
Though not routinely used anymore, the oral glucose tolerance test (OGTT) is a gold standard for making the diagnosis of type 2 diabetes. It is still commonly used for diagnosing gestational diabetes. With an oral glucose tolerance test, the person fasts overnight (at least eight but not more than 16 hours). Then first, the fasting plasma glucose is tested. After this test, the person receives 75 grams of glucose (100 grams for pregnant women). There are several methods employed by obstetricians to do this test, but the one described here is standard. Usually, the glucose is in a sweet-tasting liquid that the person drinks. Blood samples are taken at specific intervals to measure the blood glucose.
For the test to give reliable results, the person must be in good health (not have any other illnesses, not even a cold). Also, the person should be normally active (not lying down, for example, as an inpatient in a hospital) and should not be taking medicines that could affect the blood glucose. For three days before the test, the person should have eaten a diet high in carbohydrates (150- 200 grams per day). The morning of the test, the person should not smoke or drink coffee.
The classic oral glucose tolerance test measures blood glucose levels five times over a period of three hours. Some physicians simply get a baseline blood sample followed by a sample two hours after drinking the glucose solution. In a person without diabetes, the glucose levels rise and then fall quickly. In someone with diabetes, glucose levels rise higher than normal and fail to come back down as fast.
People with glucose levels between normal and diabetic have impaired glucose tolerance (IGT). People with impaired glucose tolerance do not have diabetes, but are at high risk for progressing to diabetes. Each year, 1-5% of people whose test results show impaired glucose tolerance actually eventually develop diabetes. Weight loss and exercise may help people with impaired glucose tolerance return their glucose levels to normal. In addition, some physicians advocate the use of medications, such as metformin (Glucophage), to help prevent/delay the onset of overt diabetes. Recent studies have shown that impaired glucose tolerance itself may be a risk factor for the development of heart disease. In the medical community, most physicians are now understanding that impaired glucose tolerance is nor simply a precursor of diabetes, but is its own clinical disease entity that requires treatment and monitoring.
Evaluating the results of the oral glucose tolerance test
Glucose tolerance tests may lead to one of the following diagnoses:
• Normal response: A person is said to have a normal response when the 2-hour glucose level is less than 140 mg/dl, and all values between 0 and 2 hours are less than 200 mg/dl.
• Impaired glucose tolerance: A person is said to have impaired glucose tolerance when the fasting plasma glucose is less than 126 mg/dl and the 2-hour glucose level is between 140 and 199 mg/dl.
• Diabetes: A person has diabetes when two diagnostic tests done on different days show that the blood glucose level is high.
• Gestational diabetes: A woman has gestational diabetes when she has any two of the following: a 100g OGTT, a fasting plasma glucose of more than 95 mg/dl, a 1-hour glucose level of more than 180 mg/dl, a 2-hour glucose level of more than 155 mg/dl, or a 3-hour glucose level of more than 140 mg/dl.
Why is blood sugar checked at home?
Home blood sugar (glucose) testing is an important part of controlling blood sugar. One important goal of diabetes treatment is to keep the blood glucose levels near the normal range of 70 to 120 mg/dl before meals and under 140 mg/dl at two hours after eating. Blood glucose levels are usually tested before and after meals, and at bedtime. The blood sugar level is typically determined by pricking a fingertip with a lancing device and applying the blood to a glucose meter, which reads the value. There are many meters on the market, for example, Accu-Check Advantage, One Touch Ultra, Sure Step and Freestyle. Each meter has its own advantages and disadvantages (some use less blood, some have a larger digital readout, some take a shorter time to give you results, etc). The test results are then used to help patients make adjustments in medications, diets, and physical activities.
There are some interesting developments in blood glucose monitoring. Currently, at least three continuous glucose sensors are being considered for approval in the United States (Dexcom, Medtronic and Navigator). The new continuous glucose sensor systems involve an implantable cannula placed just under the skin in the abdomen or in the arm. This cannula allows for frequent sampling of blood glucose levels. Attached to this is a transmitter that sends the data to a pager-like device. This device has a visual screen that allows the wearer to see, not only the current glucose reading, but also the graphic trends. In some devices, the rate of change of blood sugar is also shown. There are alarms for low and high sugar levels. Certain models will alarm if the rate of change indicates the wearer is at risk for dropping or rising blood glucose too rapidly. The Medtronic version is specifically designed to interface with their insulin pumps. However, at this time the patient still must manually approve any insulin dose (the pump cannot blindly respond to the glucose information it receives, it can only give a calculated suggestion as to whether the wearer should give insulin, and if so, how much). All of these devices need to be correlated to fingersticks for a few hours before they can function independently. The devices can then provide readings for 3-5 days.
Diabetes experts feel that these blood glucose monitoring devices give patients a significant amount of independence to manage their disease process; and they are a great tool for education as well. It is also important to remember that these devices can be used intermittently with fingersticks. For example, a well-controlled patient with diabetes can rely on fingerstick glucose checks a few times a day and do well. If they become ill, if they decide to embark on a new exercise regimen, if they change their diet and so on, they can use the sensor to supplement their fingerstick regimen, providing more information on how they are responding to new lifestyle changes or stressors. This kind of system takes us one step closer to closing the loop, and to the development of an artifical pancreas that senses insulin requirements based on glucose levels and the body's needs and releases insulin accordingly - the ultimate goal.
Hemoglobin A1c (A1c)
To explain what an A1c is, think in simple terms. Sugar sticks, and when it's around for a long time, it's harder to get it off. In the body, sugar sticks too, particularly to proteins. The red blood cells that circulate in the body live for about three months before they die off. When sugar sticks to these cells, it gives us an idea of how much sugar is around for the preceding three months. In most labs, the normal range is 4-5.9 %. In poorly controlled diabetes, its 8.0% or above, and in well controlled patients it's less than 7.0% (optimal is <6.5%). The benefits of measuring A1c is that is gives a more reasonable and stable view of what's happening over the course of time (three months), and the value does not bounce as much as finger stick blood sugar measurements. There is a direct correlation between A1c levels and average blood sugar levels as follows.
While there are no guidelines to use A1c as a screening tool, it gives a physician a good idea that someone is diabetic if the value is elevated. Right now, it is used as a standard tool to determine blood sugar control in patients known to have diabetes.
A1c(%) Mean blood sugar (mg/dl)
6 135
7 170
8 205
9 240
10 275
11 310
12 345
The American Diabetes Association currently recommends an A1c goal of less than 7.0%. Other Groups such as the American Association of Clinical Endocrinologists feel that an A1c of < 6.5% should be the goal.
Of interest, studies have shown that there is about a 10% decrease in relative risk for microvascular disease for every 1 % reduction in A1c. So, if a patient starts off with an A1c of 10.7 and drops to 8.2, though there are not yet at goal, they have managed to decrease their risk of microvascular complications by about 20%. The closer to normal the A1c, the lower the absolute risk for microvascular complications. Data also suggests that the risk of macrovascular disease decreases by about 24% for every 1% reduction in A1c values.
It should be mentioned here that there are a number of conditions in which an A1c value may not be accurate. For example, with significant anemia, the red blood cell count is low, and thus the A1c is falsely low as is similarly in cases of sickle cell disease and other hemoglobinopathies. For more, please read the Hemoglobin A1c article.
What are the acute complications of diabetes?
1. Severely elevated blood sugar levels due to an actual lack of insulin or a relative deficiency of insulin.
2. Abnormally low blood sugar levels due to too much insulin or other glucose-lowering medications.
Insulin is vital to patients with type 1 diabetes - they cannot live with out a source of exogenous insulin. Without insulin, patients with type 1 diabetes develop severely elevated blood sugar levels. This leads to increased urine glucose, which in turn leads to excessive loss of fluid and electrolytes in the urine. Lack of insulin also causes the inability to store fat and protein along with breakdown of existing fat and protein stores. This dysregulation, results in the process of ketosis and the release of ketones into the blood. Ketones turn the blood acidic, a condition called diabetic ketoacidosis (DKA). Symptoms of diabetic ketoacidosis include nausea, vomiting, and abdominal pain. Without prompt medical treatment, patients with diabetic ketoacidosis can rapidly go into shock, coma, and even death.
Diabetic ketoacidosis can be caused by infections, stress, or trauma all which may increase insulin requirements. In addition, missing doses of insulin is also an obvious risk factor for developing diabetic ketoacidosis. Urgent treatment of diabetic ketoacidosis involves the intravenous administration of fluid, electrolytes, and insulin, usually in a hospital intensive care unit. Dehydration can be very severe, and it is not unusual to need to replace 6-7 liters of fluid when a person presents in diabetic ketoacidosis. Antibiotics are given for infections. With treatment, abnormal blood sugar levels, ketone production, acidosis, and dehydration can be reversed rapidly, and patients can recover remarkably well.
In patients with type 2 diabetes, stress, infection, and medications (such as corticosteroids) can also lead to severely elevated blood sugar levels. Accompanied by dehydration, severe blood sugar elevation in patients with type 2 diabetes can lead to an increase in blood osmolality (hyperosmolar state). This condition can lead to coma (hyperosmolar coma). A hyperosmolar coma usually occurs in elderly patients with type 2 diabetes. Like diabetic ketoacidosis, a hyperosmolar coma is a medical emergency. Immediate treatment with intravenous fluid and insulin is important in reversing the hyperosmolar state. Unlike patients with type 1 diabetes, patients with type 2 diabetes do not generally develop ketoacidosis solely on the basis of their diabetes. Since in general, type 2 diabetes occurs in an older population, concomitant medical conditions are more likely to exist, and these patients may actually be sicker overall. The complication and death rates from hyperosmolar coma is thus higher than in DKA.
Hypoglycemia means abnormally low blood sugar (glucose). In patients with diabetes, the most common cause of low blood sugar is excessive use of insulin or other glucose-lowering medications, to lower the blood sugar level in diabetic patients in the presence of a delayed or absent meal. When low blood sugar levels occur because of too much insulin, it is called an insulin reaction. Sometimes, low blood sugar can be the result of an insufficient caloric intake or sudden excessive physical exertion.
Blood glucose is essential for the proper functioning of brain cells. Therefore, low blood sugar can lead to central nervous system symptoms such as dizziness, confusion, weakness, and tremors. The actual level of blood sugar at which these symptoms occur varies with each person, but usually it occurs when blood sugars are less than 65 mg/dl. Untreated, severely low blood sugar levels can lead to coma, seizures, and, in the worse case scenario, irreversible brain death. At this point, the brain is suffering from a lack of sugar, and this usually occurs somewhere around levels of <40 mg/dl.
The treatment of low blood sugar consists of administering a quickly absorbed glucose source. These include glucose containing drinks, such as orange juice, soft drinks (not sugar-free), or glucose tablets in doses of 15-20 grams at a time (for example, the equivalent of half a glass of juice). Even cake frosting applied inside the cheeks can work in a pinch if patient cooperation is difficult. If the individual becomes unconscious, glucagon can be given by intramuscular injection.
Glucagon causes the release of glucose from the liver (i.e., it promotes gluconeogenesis). Glucagon can be lifesaving and every patient with diabetes who has a history of hypoglycemia (particularly those on insulin) should have a glucagon kit. Families and friends of those with diabetes need to be taught how to administer glucagon, since obviously the patients will not be able to do it themselves in an emergency situation. Another lifesaving device that should be mentioned is very simple; a medic alert bracelet should be worn by all patients with diabetes.
For more, please read the Hypoglycemia article.
What are the chronic complications of diabetes?
These diabetes complications are related to blood vessel diseases and are generally classified into small vessel disease, such as those involving the eyes, kidneys and nerves (microvascular disease), and large vessel disease involving the heart and blood vessels (macrovascular disease). Diabetes accelerates hardening of the arteries (atherosclerosis) of the larger blood vessels, leading to coronary heart disease (angina or heart attack), strokes, and pain in the lower extremities because of lack of blood supply (claudication). For more information, please read the following articles: Stroke, Angina, and Heart Attack.
Eye Complications
The major eye complication of diabetes is called diabetic retinopathy. Diabetic retinopathy occurs in patients who have had diabetes for at least five years. Diseased small blood vessels in the back of the eye cause the leakage of protein and blood in the retina. Disease in these blood vessels also causes the formation of small aneurysms (microaneurysms), and new but brittle blood vessels (neovascularization). Spontaneous bleeding from the new and brittle blood vessels can lead to retinal scarring and retinal detachment, thus impairing vision.
To treat diabetic retinopathy a laser is used to destroy and prevent the recurrence of the development of these small aneurysms and brittle blood vessels. Approximately 50% of patients with diabetes will develop some degree of diabetic retinopathy after 10 years of diabetes, and 80% of diabetics have retinopathy after 15 years of the disease. Poor control of blood sugar and blood pressure further aggravates eye disease in diabetes. For more, please read the Diabetic Eye Disease article.
Cataracts and glaucoma are also more common among diabetics. It is also important to note that since the lens of the eye lets water through, if blood sugar concentrations vary a lot, the lens of the eye will shrink and swell with fluid accordingly. As a result, blurry vision is very common in poorly controlled diabetes. Patients are usually discouraged from getting a new eyeglass prescription until their blood sugar is controlled. This allows for a more accurate assessment of what kind of glasses prescription is required.
Kidney damage
Kidney damage from diabetes is called diabetic nephropathy. The onset of kidney disease and its progression is extremely variable. Initially, diseased small blood vessels in the kidneys cause the leakage of protein in the urine. Later on, the kidneys lose their ability to cleanse and filter blood. The accumulation of toxic waste products in the blood leads to the need for dialysis. Dialysis involves using a machine that serves the function of the kidney by filtering and cleaning the blood. In patients who do not want to undergo chronic dialysis, kidney transplantation can be considered. For more about dialysis, please read the Kidney Dialysis article.
The progression of nephropathy in patients can be significantly slowed by controlling high blood pressure, and by aggressively treating high blood sugar levels. Angiotensin converting enzyme inhibitors (ACE inhibitors) or angiotensin receptor blockers (ARBs) used in treating high blood pressure may also benefit kidney disease in diabetic patients.
Nerve damage
Nerve damage in diabetes is called diabetic neuropathy and is also caused by disease of small blood vessels. In essence, the blood flow to the nerves is limited, leaving the nerves without blood flow, and they get damaged or die as a result (a term known as ischemia). Symptoms of diabetic nerve damage include numbness, burning, and aching of the feet and lower extremities. When the nerve disease causes a complete loss of sensation in the feet, patients may not be aware of injuries to the feet, and fail to properly protect them. Shoes or other protection should be worn as much as possible. Seemingly minor skin injuries should be attended to promptly to avoid serious infections. Because of poor blood circulation, diabetic foot injuries may not heal. Sometimes, minor foot injuries can lead to serious infection, ulcers, and even gangrene, necessitating surgical amputation of toes, feet, and other infected parts.
Diabetic nerve damage can affect the nerves that are important for penile erection, causing erectile dysfunction (ED, impotence). Erectile dysfunction can also be caused by poor blood flow to the penis from diabetic blood vessel disease.
Diabetic neuropathy can also affect nerves to the stomach and intestines, causing nausea, weight loss, diarrhea, and other symptoms of gastroparesis (delayed emptying of food contents from the stomach into the intestines, due to ineffective contraction of the stomach muscles).
The pain of diabetic nerve damage may respond to traditional treatments with gabapentin (Neurontin), phenytoin (Dilantin), carbamazepine (Tegretol), desipramine (Norpraminine), amitriptyline (Elavil), or with topically-applied capsaicin (an extract of pepper). Neurontin, Dilantin and Tegretol are medications that are traditionally used in the treatment of seizure disorders. Elavil and Norpraminine are medications that are traditionally used for depression. While many of these medications are not FDA indicated specifically for the treatment of diabetes related nerve pain, they are used by physicians commonly. The pain of diabetic nerve damage may also improve with better blood sugar control, though unfortunately blood glucose control and the course of neuropathy do not always go hand in hand. Newer medications for nerve pain have recently come to market in the US. Pregabalin (Lyrica) which has an indication for diabetic neuropathic pain and duloxetine (Cymbalta) are newer agents used in the treatment of diabetic neuropathy. For more, please read the Diabetic Neuropathy article.
What can be done to slow diabetes complications?
Findings from the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS) have clearly shown that aggressive and intensive control of elevated levels of blood sugar in patients with type 1 and type 2 diabetes decreases the complications of nephropathy, neuropathy, retinopathy, and may reduce the occurrence and severity of large blood vessel diseases. Aggressive control with intensive therapy means achieving fasting glucose levels between 70-120 mg/dl; glucose levels of less than 160 mg/dl after meals; and a near normal hemoglobin A1C levels (see below).
Studies in type 1 patients have shown that in intensively treated patients, diabetic eye disease decreased by 76%, kidney disease decreased by 54%, and nerve disease decreased by 60%. More recently the EDIC trial has shown that type 1 diabetes is also associated with increased heart disease, similar to type 2 diabetes. However, the price for aggressive blood sugar control is a two to three fold increase in the incidence of abnormally low blood sugar levels (caused by the diabetes medications). For this reason, tight control of diabetes to achieve glucose levels between 70-120 mg/dl is not recommended for children under 13 years of age, patients with severe recurrent hypoglycemia, patients unaware of their hypoglycemia, and patients with far advanced diabetes complications. To achieve optimal glucose control without an undue risk of abnormally lowering blood sugar levels, patients with type 1 diabetes must monitor their blood glucose at least four times a day and administer insulin at least three times per day. In patients with type 2 diabetes, aggressive blood sugar control has similar beneficial effects on the eyes, kidneys, nerves and blood vessels.
Medical Author: Ruchi Mathur, MD
Medical Editor: William C. Shiel, Jr., MD, FACP, FACR
• What is diabetes?
• What is the impact of diabetes?
• What causes diabetes?
• What are the different types of diabetes?
• What are diabetes symptoms?
• How is diabetes diagnosed?
• Why is blood sugar checked at home?
• What are the acute complications of diabetes?
• What are the chronic complications of diabetes?
• What can be done to slow diabetes complications?
• How is diabetes treated?
• Diabetes At A Glance
• Related Diabetes articles:
Diabetes Health Center - on WebMD
• Read what your doctor is reading:
Diabetes - on Medscape
What is diabetes?
Diabetes mellitus is a group of metabolic diseases characterized by high blood sugar (glucose) levels, which result from defects in insulin secretion, or action, or both. Diabetes mellitus, commonly referred to as diabetes (as it will be in this article) was first identified as a disease associated with “sweet urine," and excessive muscle loss in the ancient world. Elevated levels of blood glucose (hyperglycemia) lead to spillage of glucose into the urine, hence the term sweet urine. Normally, blood glucose levels are tightly controlled by insulin, a hormone produced by the pancreas. Insulin lowers the blood glucose level. When the blood glucose elevates (for example, after eating food), insulin is released from the pancreas to normalize the glucose level. In patients with diabetes, the absence or insufficient production of insulin causes hyperglycemia. Diabetes is a chronic medical condition, meaning that although it can be controlled, it lasts a lifetime.
What is the impact of diabetes?
Over time, diabetes can lead to blindness, kidney failure, and nerve damage. These types of damage are the result of damage to small vessels, referred to as microvascular disease. Diabetes is also an important factor in accelerating the hardening and narrowing of the arteries (atherosclerosis), leading to strokes, coronary heart disease, and other large blood vessel diseases. This is referred to as macrovascular disease. Diabetes affects approximately 17 million people (about 8% of the population) in the United States. In addition, an estimated additional 12 million people in the United States have diabetes and don't even know it. From an economic perspective, the total annual cost of diabetes in 1997 was estimated to be 98 billion dollars in the United States. The per capita cost resulting from diabetes in 1997 amounted to $10,071.00; while healthcare costs for people without diabetes incurred a per capita cost of $2,699.00. During this same year, 13.9 million days of hospital stay were attributed to diabetes, while 30.3 million physician office visits were diabetes related. Remember, these numbers reflect only the population in the United States. Globally, the statistics are staggering.
Diabetes is the third leading cause of death in the United States after heart disease and cancer.
What causes diabetes?
Insufficient production of insulin (either absolutely or relative to the body's needs), production of defective insulin (which is uncommon), or the inability of cells to use insulin properly and efficiently leads to hyperglycemia and diabetes. This latter condition affects mostly the cells of muscle and fat tissues, and results in a condition known as "insulin resistance." This is the primary problem in type 2 diabetes. The absolute lack of insulin, usually secondary to a destructive process affecting the insulin producing beta cells in the pancreas, is the main disorder in type 1 diabetes. In type 2 diabetes, there also is a steady decline of beta cells that adds to the process of elevated blood sugars. For more, please read the Insulin Resistance article. Essentially, if someone is resistant to insulin, the body can, to some degree, increase production of insulin and overcome the level of resistance. After time, if production decreases and insulin cannot be released as vigorously, hyperglycemia develops.
Glucose is a simple sugar found in food. Glucose is an essential nutrient that provides energy for the proper functioning of the body cells. Carbohydrates are broken down in the small intestine and the glucose in digested food is then absorbed by the intestinal cells into the bloodstream, and is carried by the bloodstream to all the cells in the body where it is utilized. However, glucose cannot enter the cells alone and needs insulin to aid in its transport into the cells. Without insulin, the cells become starved of glucose energy despite the presence of abundant glucose in the bloodstream. In certain types of diabetes, the cells' inability to utilize glucose gives rise to the ironic situation of "starvation in the midst of plenty". The abundant, unutilized glucose is wastefully excreted in the urine.
Insulin is a hormone that is produced by specialized cells (beta cells) of the pancreas. (The pancreas is a deep-seated organ in the abdomen located behind the stomach.) In addition to helping glucose enter the cells, insulin is also important in tightly regulating the level of glucose in the blood. After a meal, the blood glucose level rises. In response to the increased glucose level, the pancreas normally releases more insulin into the bloodstream to help glucose enter the cells and lower blood glucose levels after a meal. When the blood glucose levels are lowered, the insulin release from the pancreas is turned down. It is important to note that even in the fasting state there is a low steady release of insulin than fluctuates a bit and helps to maintain a steady blood sugar level during fasting. In normal individuals, such a regulatory system helps to keep blood glucose levels in a tightly controlled range. As outlined above, in patients with diabetes, the insulin is either absent, relatively insufficient for the body's needs, or not used properly by the body. All of these factors cause elevated levels of blood glucose (hyperglycemia).
What are the different types of diabetes?
There are two major types of diabetes, called type 1 and type 2. Type 1 diabetes was also called insulin dependent diabetes mellitus (IDDM), or juvenile onset diabetes mellitus. In type 1 diabetes, the pancreas undergoes an autoimmune attack by the body itself, and is rendered incapable of making insulin. Abnormal antibodies have been found in the majority of patients with type 1 diabetes. Antibodies are proteins in the blood that are part of the body's immune system. The patient with type 1 diabetes must rely on insulin medication for survival.
In autoimmune diseases, such as type 1 diabetes, the immune system mistakenly manufactures antibodies and inflammatory cells that are directed against and cause damage to patients' own body tissues. In persons with type 1 diabetes, the beta cells of the pancreas, which are responsible for insulin production, are attacked by the misdirected immune system. It is believed that the tendency to develop abnormal antibodies in type 1 diabetes is, in part, genetically inherited, though the details are not fully understood. Exposure to certain viral infections (mumps and Coxsackie viruses) or other environmental toxins may serve to trigger abnormal antibody responses that cause damage to the pancreas cells where insulin is made. These antibodies can be measured in the majority of patients, and may help determine which individuals are at risk for developing type 1 diabetes.
At present, the American Diabetes Association does not recommend general screening of the population for type 1 diabetes, though screening of high risk individuals, such as those with a first degree relative (sibling or parent) with type 1 diabetes should be encouraged. Type 1 diabetes tends to occur in young, lean individuals, usually before 30 years of age, however, older patients do present with this form of diabetes on occasion. This subgroup is referred to as latent autoimmune diabetes in adults (LADA). LADA is a slow, progressive form of type 1 diabetes. Of all the patients with diabetes, only approximately 10% of the patients have type 1 diabetes and the remaining 90% have type 2 diabetes.
Type 2 diabetes was also referred to as non-insulin dependent diabetes mellitus (NIDDM), or adult onset diabetes mellitus (AODM). In type 2 diabetes, patients can still produce insulin, but do so relatively inadequately for their body's needs, particularly in the face of insulin resistance as discussed above. In many cases this actually means the pancreas produces larger than normal quantities of insulin. A major feature of type 2 diabetes is a lack of sensitivity to insulin by the cells of the body (particularly fat and muscle cells). In addition to the problems with an increase in insulin resistance, the release of insulin by the pancreas may also be defective and suboptimal. In fact, there is a known steady decline in beta cell production of insulin in type 2 diabetes that contributes to worsening glucose control. (This is a major factor for many patients with type 2 diabetes who ultimately require insulin therapy.) Finally, the liver in these patients continues to produce glucose through a process called gluconeogenesis despite elevated glucose levels. The control of gluconeogenesis becomes compromised.
While it is said that type 2 diabetes occurs mostly in individuals over 30 years old and the incidence increases with age, we are seeing an alarming number patients with type 2 diabetes who are barely in their teen years. In fact, for the first time in the history of humans, type 2 diabetes is now more common than type 1 diabetes in childhood. Most of these cases are a direct result of poor eating habits, higher body weight, and lack of exercise.
While there is a strong genetic component to developing this form of diabetes, there are other risk factors - the most significant of which is obesity. There is a direct relationship between the degree of obesity and the risk of developing type 2 diabetes, and this holds true in children as well as adults. It is estimated that the chance to develop diabetes doubles for every 20% increase over desirable body weight.
Regarding age, data shows that for each decade after 40 years of age regardless of weight there is an increase in incidence of diabetes. The prevalence of diabetes in persons 65 to 74 years of age is nearly 20%. Type 2 diabetes is also more common in certain ethnic groups. Compared with a 6% prevalence in Caucasians, the prevalence in African Americans and Asian Americans is estimated to be 10%, in Hispanics 15%, and in certain Native American communities 20% to 50%. Finally, diabetes occurs much more frequently in women with a prior history of diabetes that develops during pregnancy (gestational diabetes - see below).
Diabetes can occur temporarily during pregnancy. Significant hormonal changes during pregnancy can lead to blood sugar elevation in genetically predisposed individuals. Blood sugar elevation during pregnancy is called gestational diabetes. Gestational diabetes usually resolves once the baby is born. However, 25-50% of women with gestational diabetes will eventually develop Type 2 diabetes later in life, especially in those who require insulin during pregnancy and those who remain overweight after their delivery. Patients with gestational diabetes are usually asked to undergo an oral glucose tolerance test about 6 weeks after giving birth to determine if their diabetes has persisted beyond the pregnancy, or if any evidence (such as impaired glucose tolerance) is present that may be a clue to the patient's future risk for developing diabetes.
"Secondary" diabetes refers to elevated blood sugar levels from another medical condition. Secondary diabetes may develop when the pancreatic tissue responsible for the production of insulin is destroyed by disease, such as chronic pancreatitis (inflammation of the pancreas by toxins like excessive alcohol), trauma, or surgical removal of the pancreas. Diabetes can also result from other hormonal disturbances, such as excessive growth hormone production (acromegaly) and Cushing's syndrome. In acromegaly, a pituitary gland tumor at the base of the brain causes excessive production of growth hormone, leading to hyperglycemia. In Cushing's syndrome, the adrenal glands produce an excess of cortisol, which promotes blood sugar elevation.
In addition, certain medications may worsen diabetes control, or "unmask" latent diabetes. This is seen most commonly when steroid medications (such as prednisone) are taken and also with medications used in the treatment of HIV infection (AIDS).
What are diabetes symptoms?
The early symptoms of untreated diabetes are related to elevated blood sugar levels, and loss of glucose in the urine. High amounts of glucose in the urine can cause increased urine output and lead to dehydration. Dehydration causes increased thirst and water consumption. The inability of insulin to perform normally has effects on protein, fat and carbohydrate metabolism. Insulin is an anabolic hormone, that is, one that encourages storage of fat and protein. A relative or absolute insulin deficiency eventually leads to weight loss despite an increase in appetite. Some untreated diabetes patients also complain of fatigue, nausea and vomiting. Patients with diabetes are prone to developing infections of the bladder, skin, and vaginal areas. Fluctuations in blood glucose levels can lead to blurred vision. Extremely elevated glucose levels can lead to lethargy and coma.
How is diabetes diagnosed?
The fasting blood glucose (sugar) test is the preferred way to diagnose diabetes. It is easy to perform and convenient. After the person has fasted overnight (at least 8 hours), a single sample of blood is drawn and sent to the laboratory for analysis. This can also be done accurately in a doctor's office using a glucose meter.
Normal fasting plasma glucose levels are less than 100 milligrams per deciliter (mg/dl). Fasting plasma glucose levels of more than 126 mg/dl on two or more tests on different days indicate diabetes. A random blood glucose test can also be used to diagnose diabetes A blood glucose level of 200 mg/dl or higher indicates diabetes.
When fasting blood glucose stays above 100mg/dl, but in the range of 100-126mg/dl, this is known as impaired fasting glucose (IFG). While patients with IFG do not have the diagnosis of diabetes, this condition carries with it its own risks and concerns, and is addressed elsewhere.
The oral glucose tolerance test
Though not routinely used anymore, the oral glucose tolerance test (OGTT) is a gold standard for making the diagnosis of type 2 diabetes. It is still commonly used for diagnosing gestational diabetes. With an oral glucose tolerance test, the person fasts overnight (at least eight but not more than 16 hours). Then first, the fasting plasma glucose is tested. After this test, the person receives 75 grams of glucose (100 grams for pregnant women). There are several methods employed by obstetricians to do this test, but the one described here is standard. Usually, the glucose is in a sweet-tasting liquid that the person drinks. Blood samples are taken at specific intervals to measure the blood glucose.
For the test to give reliable results, the person must be in good health (not have any other illnesses, not even a cold). Also, the person should be normally active (not lying down, for example, as an inpatient in a hospital) and should not be taking medicines that could affect the blood glucose. For three days before the test, the person should have eaten a diet high in carbohydrates (150- 200 grams per day). The morning of the test, the person should not smoke or drink coffee.
The classic oral glucose tolerance test measures blood glucose levels five times over a period of three hours. Some physicians simply get a baseline blood sample followed by a sample two hours after drinking the glucose solution. In a person without diabetes, the glucose levels rise and then fall quickly. In someone with diabetes, glucose levels rise higher than normal and fail to come back down as fast.
People with glucose levels between normal and diabetic have impaired glucose tolerance (IGT). People with impaired glucose tolerance do not have diabetes, but are at high risk for progressing to diabetes. Each year, 1-5% of people whose test results show impaired glucose tolerance actually eventually develop diabetes. Weight loss and exercise may help people with impaired glucose tolerance return their glucose levels to normal. In addition, some physicians advocate the use of medications, such as metformin (Glucophage), to help prevent/delay the onset of overt diabetes. Recent studies have shown that impaired glucose tolerance itself may be a risk factor for the development of heart disease. In the medical community, most physicians are now understanding that impaired glucose tolerance is nor simply a precursor of diabetes, but is its own clinical disease entity that requires treatment and monitoring.
Evaluating the results of the oral glucose tolerance test
Glucose tolerance tests may lead to one of the following diagnoses:
• Normal response: A person is said to have a normal response when the 2-hour glucose level is less than 140 mg/dl, and all values between 0 and 2 hours are less than 200 mg/dl.
• Impaired glucose tolerance: A person is said to have impaired glucose tolerance when the fasting plasma glucose is less than 126 mg/dl and the 2-hour glucose level is between 140 and 199 mg/dl.
• Diabetes: A person has diabetes when two diagnostic tests done on different days show that the blood glucose level is high.
• Gestational diabetes: A woman has gestational diabetes when she has any two of the following: a 100g OGTT, a fasting plasma glucose of more than 95 mg/dl, a 1-hour glucose level of more than 180 mg/dl, a 2-hour glucose level of more than 155 mg/dl, or a 3-hour glucose level of more than 140 mg/dl.
Why is blood sugar checked at home?
Home blood sugar (glucose) testing is an important part of controlling blood sugar. One important goal of diabetes treatment is to keep the blood glucose levels near the normal range of 70 to 120 mg/dl before meals and under 140 mg/dl at two hours after eating. Blood glucose levels are usually tested before and after meals, and at bedtime. The blood sugar level is typically determined by pricking a fingertip with a lancing device and applying the blood to a glucose meter, which reads the value. There are many meters on the market, for example, Accu-Check Advantage, One Touch Ultra, Sure Step and Freestyle. Each meter has its own advantages and disadvantages (some use less blood, some have a larger digital readout, some take a shorter time to give you results, etc). The test results are then used to help patients make adjustments in medications, diets, and physical activities.
There are some interesting developments in blood glucose monitoring. Currently, at least three continuous glucose sensors are being considered for approval in the United States (Dexcom, Medtronic and Navigator). The new continuous glucose sensor systems involve an implantable cannula placed just under the skin in the abdomen or in the arm. This cannula allows for frequent sampling of blood glucose levels. Attached to this is a transmitter that sends the data to a pager-like device. This device has a visual screen that allows the wearer to see, not only the current glucose reading, but also the graphic trends. In some devices, the rate of change of blood sugar is also shown. There are alarms for low and high sugar levels. Certain models will alarm if the rate of change indicates the wearer is at risk for dropping or rising blood glucose too rapidly. The Medtronic version is specifically designed to interface with their insulin pumps. However, at this time the patient still must manually approve any insulin dose (the pump cannot blindly respond to the glucose information it receives, it can only give a calculated suggestion as to whether the wearer should give insulin, and if so, how much). All of these devices need to be correlated to fingersticks for a few hours before they can function independently. The devices can then provide readings for 3-5 days.
Diabetes experts feel that these blood glucose monitoring devices give patients a significant amount of independence to manage their disease process; and they are a great tool for education as well. It is also important to remember that these devices can be used intermittently with fingersticks. For example, a well-controlled patient with diabetes can rely on fingerstick glucose checks a few times a day and do well. If they become ill, if they decide to embark on a new exercise regimen, if they change their diet and so on, they can use the sensor to supplement their fingerstick regimen, providing more information on how they are responding to new lifestyle changes or stressors. This kind of system takes us one step closer to closing the loop, and to the development of an artifical pancreas that senses insulin requirements based on glucose levels and the body's needs and releases insulin accordingly - the ultimate goal.
Hemoglobin A1c (A1c)
To explain what an A1c is, think in simple terms. Sugar sticks, and when it's around for a long time, it's harder to get it off. In the body, sugar sticks too, particularly to proteins. The red blood cells that circulate in the body live for about three months before they die off. When sugar sticks to these cells, it gives us an idea of how much sugar is around for the preceding three months. In most labs, the normal range is 4-5.9 %. In poorly controlled diabetes, its 8.0% or above, and in well controlled patients it's less than 7.0% (optimal is <6.5%). The benefits of measuring A1c is that is gives a more reasonable and stable view of what's happening over the course of time (three months), and the value does not bounce as much as finger stick blood sugar measurements. There is a direct correlation between A1c levels and average blood sugar levels as follows.
While there are no guidelines to use A1c as a screening tool, it gives a physician a good idea that someone is diabetic if the value is elevated. Right now, it is used as a standard tool to determine blood sugar control in patients known to have diabetes.
A1c(%) Mean blood sugar (mg/dl)
6 135
7 170
8 205
9 240
10 275
11 310
12 345
The American Diabetes Association currently recommends an A1c goal of less than 7.0%. Other Groups such as the American Association of Clinical Endocrinologists feel that an A1c of < 6.5% should be the goal.
Of interest, studies have shown that there is about a 10% decrease in relative risk for microvascular disease for every 1 % reduction in A1c. So, if a patient starts off with an A1c of 10.7 and drops to 8.2, though there are not yet at goal, they have managed to decrease their risk of microvascular complications by about 20%. The closer to normal the A1c, the lower the absolute risk for microvascular complications. Data also suggests that the risk of macrovascular disease decreases by about 24% for every 1% reduction in A1c values.
It should be mentioned here that there are a number of conditions in which an A1c value may not be accurate. For example, with significant anemia, the red blood cell count is low, and thus the A1c is falsely low as is similarly in cases of sickle cell disease and other hemoglobinopathies. For more, please read the Hemoglobin A1c article.
What are the acute complications of diabetes?
1. Severely elevated blood sugar levels due to an actual lack of insulin or a relative deficiency of insulin.
2. Abnormally low blood sugar levels due to too much insulin or other glucose-lowering medications.
Insulin is vital to patients with type 1 diabetes - they cannot live with out a source of exogenous insulin. Without insulin, patients with type 1 diabetes develop severely elevated blood sugar levels. This leads to increased urine glucose, which in turn leads to excessive loss of fluid and electrolytes in the urine. Lack of insulin also causes the inability to store fat and protein along with breakdown of existing fat and protein stores. This dysregulation, results in the process of ketosis and the release of ketones into the blood. Ketones turn the blood acidic, a condition called diabetic ketoacidosis (DKA). Symptoms of diabetic ketoacidosis include nausea, vomiting, and abdominal pain. Without prompt medical treatment, patients with diabetic ketoacidosis can rapidly go into shock, coma, and even death.
Diabetic ketoacidosis can be caused by infections, stress, or trauma all which may increase insulin requirements. In addition, missing doses of insulin is also an obvious risk factor for developing diabetic ketoacidosis. Urgent treatment of diabetic ketoacidosis involves the intravenous administration of fluid, electrolytes, and insulin, usually in a hospital intensive care unit. Dehydration can be very severe, and it is not unusual to need to replace 6-7 liters of fluid when a person presents in diabetic ketoacidosis. Antibiotics are given for infections. With treatment, abnormal blood sugar levels, ketone production, acidosis, and dehydration can be reversed rapidly, and patients can recover remarkably well.
In patients with type 2 diabetes, stress, infection, and medications (such as corticosteroids) can also lead to severely elevated blood sugar levels. Accompanied by dehydration, severe blood sugar elevation in patients with type 2 diabetes can lead to an increase in blood osmolality (hyperosmolar state). This condition can lead to coma (hyperosmolar coma). A hyperosmolar coma usually occurs in elderly patients with type 2 diabetes. Like diabetic ketoacidosis, a hyperosmolar coma is a medical emergency. Immediate treatment with intravenous fluid and insulin is important in reversing the hyperosmolar state. Unlike patients with type 1 diabetes, patients with type 2 diabetes do not generally develop ketoacidosis solely on the basis of their diabetes. Since in general, type 2 diabetes occurs in an older population, concomitant medical conditions are more likely to exist, and these patients may actually be sicker overall. The complication and death rates from hyperosmolar coma is thus higher than in DKA.
Hypoglycemia means abnormally low blood sugar (glucose). In patients with diabetes, the most common cause of low blood sugar is excessive use of insulin or other glucose-lowering medications, to lower the blood sugar level in diabetic patients in the presence of a delayed or absent meal. When low blood sugar levels occur because of too much insulin, it is called an insulin reaction. Sometimes, low blood sugar can be the result of an insufficient caloric intake or sudden excessive physical exertion.
Blood glucose is essential for the proper functioning of brain cells. Therefore, low blood sugar can lead to central nervous system symptoms such as dizziness, confusion, weakness, and tremors. The actual level of blood sugar at which these symptoms occur varies with each person, but usually it occurs when blood sugars are less than 65 mg/dl. Untreated, severely low blood sugar levels can lead to coma, seizures, and, in the worse case scenario, irreversible brain death. At this point, the brain is suffering from a lack of sugar, and this usually occurs somewhere around levels of <40 mg/dl.
The treatment of low blood sugar consists of administering a quickly absorbed glucose source. These include glucose containing drinks, such as orange juice, soft drinks (not sugar-free), or glucose tablets in doses of 15-20 grams at a time (for example, the equivalent of half a glass of juice). Even cake frosting applied inside the cheeks can work in a pinch if patient cooperation is difficult. If the individual becomes unconscious, glucagon can be given by intramuscular injection.
Glucagon causes the release of glucose from the liver (i.e., it promotes gluconeogenesis). Glucagon can be lifesaving and every patient with diabetes who has a history of hypoglycemia (particularly those on insulin) should have a glucagon kit. Families and friends of those with diabetes need to be taught how to administer glucagon, since obviously the patients will not be able to do it themselves in an emergency situation. Another lifesaving device that should be mentioned is very simple; a medic alert bracelet should be worn by all patients with diabetes.
For more, please read the Hypoglycemia article.
What are the chronic complications of diabetes?
These diabetes complications are related to blood vessel diseases and are generally classified into small vessel disease, such as those involving the eyes, kidneys and nerves (microvascular disease), and large vessel disease involving the heart and blood vessels (macrovascular disease). Diabetes accelerates hardening of the arteries (atherosclerosis) of the larger blood vessels, leading to coronary heart disease (angina or heart attack), strokes, and pain in the lower extremities because of lack of blood supply (claudication). For more information, please read the following articles: Stroke, Angina, and Heart Attack.
Eye Complications
The major eye complication of diabetes is called diabetic retinopathy. Diabetic retinopathy occurs in patients who have had diabetes for at least five years. Diseased small blood vessels in the back of the eye cause the leakage of protein and blood in the retina. Disease in these blood vessels also causes the formation of small aneurysms (microaneurysms), and new but brittle blood vessels (neovascularization). Spontaneous bleeding from the new and brittle blood vessels can lead to retinal scarring and retinal detachment, thus impairing vision.
To treat diabetic retinopathy a laser is used to destroy and prevent the recurrence of the development of these small aneurysms and brittle blood vessels. Approximately 50% of patients with diabetes will develop some degree of diabetic retinopathy after 10 years of diabetes, and 80% of diabetics have retinopathy after 15 years of the disease. Poor control of blood sugar and blood pressure further aggravates eye disease in diabetes. For more, please read the Diabetic Eye Disease article.
Cataracts and glaucoma are also more common among diabetics. It is also important to note that since the lens of the eye lets water through, if blood sugar concentrations vary a lot, the lens of the eye will shrink and swell with fluid accordingly. As a result, blurry vision is very common in poorly controlled diabetes. Patients are usually discouraged from getting a new eyeglass prescription until their blood sugar is controlled. This allows for a more accurate assessment of what kind of glasses prescription is required.
Kidney damage
Kidney damage from diabetes is called diabetic nephropathy. The onset of kidney disease and its progression is extremely variable. Initially, diseased small blood vessels in the kidneys cause the leakage of protein in the urine. Later on, the kidneys lose their ability to cleanse and filter blood. The accumulation of toxic waste products in the blood leads to the need for dialysis. Dialysis involves using a machine that serves the function of the kidney by filtering and cleaning the blood. In patients who do not want to undergo chronic dialysis, kidney transplantation can be considered. For more about dialysis, please read the Kidney Dialysis article.
The progression of nephropathy in patients can be significantly slowed by controlling high blood pressure, and by aggressively treating high blood sugar levels. Angiotensin converting enzyme inhibitors (ACE inhibitors) or angiotensin receptor blockers (ARBs) used in treating high blood pressure may also benefit kidney disease in diabetic patients.
Nerve damage
Nerve damage in diabetes is called diabetic neuropathy and is also caused by disease of small blood vessels. In essence, the blood flow to the nerves is limited, leaving the nerves without blood flow, and they get damaged or die as a result (a term known as ischemia). Symptoms of diabetic nerve damage include numbness, burning, and aching of the feet and lower extremities. When the nerve disease causes a complete loss of sensation in the feet, patients may not be aware of injuries to the feet, and fail to properly protect them. Shoes or other protection should be worn as much as possible. Seemingly minor skin injuries should be attended to promptly to avoid serious infections. Because of poor blood circulation, diabetic foot injuries may not heal. Sometimes, minor foot injuries can lead to serious infection, ulcers, and even gangrene, necessitating surgical amputation of toes, feet, and other infected parts.
Diabetic nerve damage can affect the nerves that are important for penile erection, causing erectile dysfunction (ED, impotence). Erectile dysfunction can also be caused by poor blood flow to the penis from diabetic blood vessel disease.
Diabetic neuropathy can also affect nerves to the stomach and intestines, causing nausea, weight loss, diarrhea, and other symptoms of gastroparesis (delayed emptying of food contents from the stomach into the intestines, due to ineffective contraction of the stomach muscles).
The pain of diabetic nerve damage may respond to traditional treatments with gabapentin (Neurontin), phenytoin (Dilantin), carbamazepine (Tegretol), desipramine (Norpraminine), amitriptyline (Elavil), or with topically-applied capsaicin (an extract of pepper). Neurontin, Dilantin and Tegretol are medications that are traditionally used in the treatment of seizure disorders. Elavil and Norpraminine are medications that are traditionally used for depression. While many of these medications are not FDA indicated specifically for the treatment of diabetes related nerve pain, they are used by physicians commonly. The pain of diabetic nerve damage may also improve with better blood sugar control, though unfortunately blood glucose control and the course of neuropathy do not always go hand in hand. Newer medications for nerve pain have recently come to market in the US. Pregabalin (Lyrica) which has an indication for diabetic neuropathic pain and duloxetine (Cymbalta) are newer agents used in the treatment of diabetic neuropathy. For more, please read the Diabetic Neuropathy article.
What can be done to slow diabetes complications?
Findings from the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS) have clearly shown that aggressive and intensive control of elevated levels of blood sugar in patients with type 1 and type 2 diabetes decreases the complications of nephropathy, neuropathy, retinopathy, and may reduce the occurrence and severity of large blood vessel diseases. Aggressive control with intensive therapy means achieving fasting glucose levels between 70-120 mg/dl; glucose levels of less than 160 mg/dl after meals; and a near normal hemoglobin A1C levels (see below).
Studies in type 1 patients have shown that in intensively treated patients, diabetic eye disease decreased by 76%, kidney disease decreased by 54%, and nerve disease decreased by 60%. More recently the EDIC trial has shown that type 1 diabetes is also associated with increased heart disease, similar to type 2 diabetes. However, the price for aggressive blood sugar control is a two to three fold increase in the incidence of abnormally low blood sugar levels (caused by the diabetes medications). For this reason, tight control of diabetes to achieve glucose levels between 70-120 mg/dl is not recommended for children under 13 years of age, patients with severe recurrent hypoglycemia, patients unaware of their hypoglycemia, and patients with far advanced diabetes complications. To achieve optimal glucose control without an undue risk of abnormally lowering blood sugar levels, patients with type 1 diabetes must monitor their blood glucose at least four times a day and administer insulin at least three times per day. In patients with type 2 diabetes, aggressive blood sugar control has similar beneficial effects on the eyes, kidneys, nerves and blood vessels.
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