If the A1C test isn’t available, or if you have certain conditions that can make the A1C test inaccurate — such as if you’re pregnant or have an uncommon form of hemoglobin (known as a hemoglobin variant) — your doctor may use the following tests to diagnose diabetes:
If you receive a diagnosis of diabetes, your doctor will also run blood tests to check for autoantibodies that are common in type 1 diabetes. These tests help your doctor distinguish between type 1 and type 2 diabetes. The presence of ketones — byproducts from the breakdown of fat — in your urine also suggests type 1 diabetes, rather than type 2.
Once you’ve been diagnosed with type 1 diabetes, you’ll regularly visit your doctor to help you with your diabetes management. During these visits, the doctor will check your A1C levels. Your target A1C goal may vary depending on your age and various other factors, but the American Diabetes Association generally recommends that A1C levels be below 7 percent, which translates to an estimated average glucose of 154 mg/dL (8.5 mmol/L).
Compared with repeated daily blood sugar tests, A1C testing better indicates how well your diabetes treatment plan is working. An elevated A1C level may signal the need for a change in your insulin regimen, meal plan or both.
People who are meeting their A1C goals and who are confident in their diabetes management are generally seen twice a year by their endocrinologists. People who are having trouble reaching their A1C goals are usually seen every three months.
In addition to the A1C test, the doctor will also take blood and urine samples periodically to check your cholesterol levels, thyroid function, liver function and kidney function. The doctor will also examine you to assess your blood pressure, and he or she will check the sites where you test your blood sugar and deliver insulin.
- Taking insulin
- Carbohydrate counting
- Frequent blood sugar monitoring
- Eating healthy foods
- Exercising regularly and maintaining a healthy weight
The goal is to keep your blood sugar level as close to normal as possible to delay or prevent complications. Although there are exceptions, generally, the goal is to keep your daytime blood sugar levels before meals between 70 and 130 mg/dL (3.9 to 7.2 mmol/L) and your after meal numbers no higher than 180 mg/dL (10 mmol/L) two hours after eating.
Good diabetes management can be overwhelming, especially when you’re first diagnosed. Take it one day at a time. And remember that you’re not alone. You’ll work closely with your diabetes treatment team to keep your blood sugar level as close to normal as possible.
Insulin and other medications
Anyone who has type 1 diabetes needs lifelong insulin therapy. After the diagnosis, there may be a “honeymoon” period, during which blood sugar is controlled with little or no insulin. However, this phase doesn’t last.
Types of insulin are many and include:
- Rapid-acting insulin
- Long-acting insulin
- Intermediate options
Examples are regular insulin (Humulin 70/30, Novolin 70/30, others), insulin isophane (Humulin N, Novolin N), insulin glulisine (Apidra), insulin lispro (Humalog) and insulin aspart (Novolog). Long-acting insulins include glargine (Lantus) and detemir (Levemir).
Insulin can’t be taken orally to lower blood sugar because stomach enzymes interfere with insulin’s action. Therefore, it must be given either through injections or an insulin pump.
- Injections. You can use a fine needle and syringe or an insulin pen to inject insulin under your skin. Insulin pens look similar to ink pens, and are available in disposable or refillable varieties. Needles are available in a variety of sizes, so you can find one that’s most comfortable for you.If you choose injections, you’ll likely need a mixture of insulin types to use throughout the day and night. Multiple daily injections that include a combination of a long-acting insulin, such as Lantus or Levemir combined with a rapid-acting insulin, such as Apidra, Humolog or Novolog, more closely mimic the body’s normal use of insulin than older insulin regimens that only required one or two shots a day. Three or more insulin injections a day has been shown to improve blood sugar levels.
- An insulin pump — a device about the size of a cellphone worn on the outside of your body. A tube connects a reservoir of insulin to a catheter that’s inserted under the skin of your abdomen. This type of pump can be worn in a variety of ways, such as on your waistband, in your pocket, or with specially designed pump belts.There’s also a wireless pump option. You wear a pod that houses the insulin reservoir on your body that has a tiny catheter that’s inserted under your skin. The insulin pod can be worn on your abdomen, lower back, or on a leg or an arm. The programming is done with a wireless device that communicates with the pod.
Pumps are programmed to dispense specific amounts of rapid-acting insulin automatically. This steady dose of insulin is known as your basal rate, and it replaces whatever long-acting insulin you were using.
When you eat, you program the pump with the amount of carbohydrates you’re eating and your current blood sugar, and it will give you what’s called a “bolus” dose of insulin to cover your meal and to correct your blood sugar if it’s elevated. Some research has found that in some people an insulin pump can be more effective at controlling blood sugar levels than injections. But many people achieve good blood sugar levels with injections, too.
An emerging treatment approach, not yet available, is closed-loop insulin delivery, also known as the artificial pancreas. It links a continuous glucose monitor to an insulin pump. The device automatically delivers the correct amount of insulin when the monitor indicates the need for it. There are a number of different versions of the artificial pancreas, and clinical trials have had encouraging results. More research needs to be done before a fully functional artificial pancreas can receive regulatory approval.
The first step toward an artificial pancreas was approved in 2013. Combining a continuous glucose monitor with an insulin pump, this system stops insulin delivery when blood sugar levels drop too low. Studies on the device found that it could prevent low blood sugar levels overnight without significantly increasing morning blood sugar levels.
Additional medications also may be prescribed for people with type 1 diabetes, such as:
- Pramlintide (Symlin). An injection of this medication before you eat can slow the movement of food through your stomach to curb the sharp increase in blood sugar that occurs after meals.
- High blood pressure medications. Your doctor may prescribe medications known as angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), because these medications also can help keep your kidneys healthy. These medications are recommended for people with diabetes that have blood pressures above 140/80 millimeters of mercury (mm Hg).
- Aspirin. Your doctor may recommend you take baby or regular aspirin daily to protect your heart.
- Cholesterol-lowering drugs. Your doctor may not wait until your cholesterol is elevated before he or she prescribes cholesterol-lowering agents known as statins. Cholesterol guidelines tend to be more aggressive for people with diabetes because of the elevated risk of heart disease. The American Diabetes Association recommends that low-density lipoprotein (LDL, or “bad”) cholesterol be below 100 mg/dL (2.6 mmol/L), and if you already have heart disease, your LDL goal is below 70 mg/dL (1.8 mmol/L). Your high-density lipoprotein (HDL, or “good”) cholesterol is recommended to be over 50 mg/dL (1.3 mmol/L) in women and over 40 mg/dL (1 mmol/L) in men. Triglycerides, another type of blood fat, are ideal when they’re less than 150 mg/dL (1.7 mmol/L).
Blood sugar monitoring
Depending on what type of insulin therapy you select or require — twice daily injections, multiple daily injections or insulin pump — you may need to check and record your blood sugar level at least four times a day, and generally more often. The American Diabetes Association recommends testing blood sugar levels before meals and snacks, before bed, before exercising or driving, and if you suspect you have low blood sugar. Careful monitoring is the only way to make sure that your blood sugar level remains within your target range. Be sure to wash your hands before checking your blood sugar levels.
Even if you take insulin and eat on a rigid schedule, the amount of sugar in your blood can change unpredictably. With help from your diabetes treatment team, you’ll learn how your blood sugar level changes in response to food, activity, illness, medications, stress, hormonal changes and alcohol.
Continuous glucose monitoring (CGM) is the newest way to monitor blood sugar levels, and may be especially helpful for preventing hypoglycemia. Plus, when used by people older than 25, the devices have been shown to lower A1C.
Continuous glucose monitors attach to the body using a fine needle just under the skin that checks blood glucose level every few minutes. CGM isn’t yet considered as accurate as standard blood sugar monitoring, so it’s not considered a replacement method for keeping track of blood sugar, but an additional tool for some people.
Healthy eating and monitoring carbohydrates
Contrary to popular perception, there’s no such thing as a diabetes diet. However, it’s important to center your diet on nutritious, low-fat, high-fiber foods such as:
- Whole grains
Your dietitian will recommend that you eat fewer animal products and refined carbohydrates, such as white bread and sweets. This healthy eating plan is recommended for everyone, even people without diabetes.
You’ll need to learn how to count the amount of carbohydrates in the foods you eat so that you can give yourself enough insulin to properly metabolize those carbohydrates. A registered dietitian can help you create a meal plan that fits your health goals, food preferences and lifestyle.
Everyone needs regular aerobic exercise, and people who have type 1 diabetes are no exception. But get your doctor’s OK to exercise first. Then choose activities you enjoy, such as walking, swimming and biking. Make physical activity part of your daily routine. Aim for at least 30 minutes of aerobic exercise most days of the week. The goal for children is at least an hour of activity a day. Flexibility and strength training exercises are important, too. If you haven’t been active for a while, start slowly and build up gradually.
Remember that physical activity lowers blood sugar, often for long after you’re done working out. If you begin a new activity, check your blood sugar level more often than usual until you know how that activity affects your blood sugar levels. You might need to adjust your meal plan or insulin doses to compensate for the increased activity. If you use an insulin pump, you can set a temporary basal rate to keep your blood sugar from dropping. Ask your doctor or diabetes educator to show you how.
Certain life circumstances call for different considerations.
- Driving. Hypoglycemia can occur at any time, even when you’re driving. It’s a good idea to check your blood sugar anytime you’re getting behind the wheel. If it’s below 70 mg/dL (3.9 mmol/L), have a snack and then retest again in 15 minutes to make sure it has risen to a safe level. Low blood sugar makes it hard to concentrate or to react as rapidly as you might need to when you’re driving.
- Working. In the past, people with type 1 diabetes were often refused certain jobs because they had diabetes. Fortunately, advances in diabetes management and anti-discrimination laws have made such blanket bans largely a thing of the past.However, type 1 diabetes can pose some challenges in the workplace. For example, if you work in a job that involves driving or operating heavy machinery, hypoglycemia could pose a serious risk to you and those around you. You may need to work with your doctor and your employer to ensure that certain accommodations are made, such as your having a quick break for blood sugar testing and fast access to food and drink anytime, so you can properly manage your diabetes and prevent low blood sugar levels. There are federal and state laws in place that require employers to make reasonable accommodations for people with diabetes.
- Being pregnant. Because the risk of pregnancy complications is higher for women with type 1 diabetes, experts recommend that women have a preconception evaluation and that A1C readings should be less than 7 percent before you attempt to get pregnant. Some drugs, such as high blood pressure medications and cholesterol-lowering medications, may need to be stopped before pregnancy.The risk of birth defects is increased for women with type 1 diabetes, particularly when diabetes is poorly controlled during the first six to eight weeks of pregnancy, so planning your pregnancy is key. Careful management of your diabetes during pregnancy can decrease your risk of complications.
- Being older. As long as you’re still active and have normal cognitive abilities, your diabetes management goals will likely be the same as they were when you were younger. But for those who are frail, sick or have cognitive deficits, tight control of blood sugar may not be practical. If you’re caring for a loved one with type 1 diabetes, ask his or her doctor what the new diabetes goals should be.
- Pancreas transplant. With a successful pancreas transplant, you would no longer need insulin. But pancreas transplants aren’t always successful — and the procedure poses serious risks. You would need a lifetime of potent immune-suppressing drugs to prevent organ rejection. These drugs can have serious side effects, including a high risk of infection and organ injury. Because the side effects can be more dangerous than the diabetes itself, pancreas transplants are generally reserved for those with very difficult-to-manage diabetes, or for people who also need a kidney transplant.
- Islet cell transplantation. Researchers are experimenting with islet cell transplantation, which provides new insulin-producing cells from a donor pancreas. Although this experimental procedure has met with problems in the past, new techniques and better drugs to prevent islet cell rejection may improve its future chance for success.Islet cell transplantation still requires the use of immune-suppressing medications. And just as it did with its own natural islet cells, the body often destroys transplanted islet cells, making the time off injected insulin short-lived. Additionally, a sufficient supply of islet cells isn’t available for this treatment to become more widespread.
Researchers are working on ways to expand the number of available islets, as well as find ways to protect islets from the immune system. Some ideas that may soon be in clinical trials include encapsulating the individual islet cells, or housing the islet cells in a device that would shield them from the immune cells, but still allow in oxygen and a blood supply.
- Stem cell transplant. In a 2007 study, a small number of people newly diagnosed with type 1 diabetes were able to stop using insulin for up to five years after being treated with stem cells made from their own blood. Although stem cell transplants — which involve shutting down the immune system and then building it up again — can be risky, the technique may one day provide an additional treatment option for type 1 diabetes.
Signs of trouble
Despite your best efforts, sometimes problems will arise. Certain short-term complications of type 1 diabetes, such as hypoglycemia, require immediate care.
Low blood sugar (hypoglycemia). This occurs when your blood sugar level drops below your target range. Ask your doctor what’s considered a low blood sugar level for you. Blood sugar levels can drop for many reasons, including skipping a meal, getting more physical activity than normal or injecting too much insulin.
Learn the symptoms of low blood sugar, and test your blood sugar if you think your blood sugar levels are dropping. When in doubt, always do a blood sugar test. Early signs and symptoms of low blood sugar include:
- Dizziness or lightheadedness
- Rapid or irregular heart rate
- Blurred vision
Later signs and symptoms of low blood sugar, which can sometimes be mistaken for alcohol intoxication in teens and adults include:
- Behavior changes, sometimes dramatic
- Poor coordination
If you develop hypoglycemia during the night, you might wake with sweat-soaked pajamas or a headache. Due to a natural rebound effect, nighttime hypoglycemia might cause an unusually high blood sugar reading first thing in the morning.
If you have a low blood sugar reading:
- Have 15 to 20 grams of a fast-acting carbohydrate, such as fruit juice, glucose tablets, hard candy, regular (not diet) soda or another source of sugar. Foods with added fat, such as chocolate or ice cream, don’t raise blood sugar as quickly because fat slows down the absorption of the sugar.
- Retest your blood sugar in about 15 minutes to make sure it’s normal.
- If it’s still low, have another 15 to 20 grams of carbohydrate from juice, candy, glucose tablets or other source of sugar, and retest in another 15 minutes.
- Repeat until you get a normal reading.
- Eat a mixed food source, such as peanut butter and crackers, to help stabilize your blood sugar.
If a blood glucose meter isn’t readily available, treat for low blood sugar anyway if you have symptoms of hypoglycemia, and then test as soon as possible.
Always carry a source of fast-acting sugar with you. Left untreated, low blood sugar will cause you to lose consciousness. If this occurs, you may need an emergency injection of glucagon — a hormone that stimulates the release of sugar into the blood. Be sure you always have a glucagon emergency kit available — at home, at work, when you’re out — and make sure it hasn’t expired.
Hypoglycemia unawareness. Some people may lose the ability to sense that their blood sugar levels are getting low, because they’ve developed a condition known as hypoglycemia unawareness. With hypoglycemia unawareness, the body no longer reacts to a low blood sugar level with symptoms such as lightheadedness or headaches. The more you experience low blood sugars, the more likely you are to develop hypoglycemia unawareness. The good news is that if you can avoid having a hypoglycemic episode for several weeks, you may start to become more aware of impending lows.
High blood sugar (hyperglycemia). Your blood sugar can rise for many reasons, including eating too much, eating the wrong types of foods, not taking enough insulin or illness.
- Frequent urination
- Increased thirst
- Blurred vision
- Difficulty concentrating
If you suspect hyperglycemia, check your blood sugar. You might need to adjust your meal plan or medications. If your blood sugar is higher than your target range, you’ll likely need to administer a “correction” using an insulin shot or through an insulin pump. A correction is an additional dose of insulin that should bring your blood sugar back into the normal range. High blood sugar levels don’t come down as quickly as they go up. Ask your doctor how long to wait until you recheck. If you use an insulin pump, random high blood sugar readings may mean you need to change the pump site.
If you have a blood sugar reading above 240 mg/dL (13.3 mmol/L), test for ketones using a urine test stick. Don’t exercise if your blood sugar level is above 240 mg/dL or if ketones are present. If only a trace or small amounts of ketones are present, drink extra fluids to flush out the ketones.
If your blood sugar is persistently above 300 mg/dL (16.7 mmol/L), despite taking appropriate correction doses of insulin, call your doctor or seek emergency care.
Increased ketones in your urine (diabetic ketoacidosis). If your cells are starved for energy, your body may begin to break down fat — producing toxic acids known as ketones. Diabetic ketoacidosis is a life-threatening emergency.
Signs and symptoms of this serious condition include:
- Abdominal pain
- A sweet, fruity smell on your breath
- Weight loss
If you suspect ketoacidosis, check your urine for excess ketones with an over-the-counter ketones test kit. If you have large amounts of ketones in your urine, call your doctor right away or seek emergency care. Also, call your doctor if you have vomited more than once and you have ketones in your urine.
Lifestyle and home remedies
Following your diabetes treatment plan requires round-the-clock care, which can be frustrating at times. But realize that your efforts are worthwhile. Careful management of type 1 diabetes can reduce your risk of serious — even life-threatening — complications. Consider these tips:
- Make a commitment to managing your diabetes. Take your medications as recommended. Learn all you can about type 1 diabetes. Make healthy eating and physical activity part of your daily routine. Establish a relationship with a diabetes educator, and ask your diabetes treatment team for help when you need it.
- Identify yourself. Wear a tag or bracelet that says you have diabetes. Keep a glucagon kit nearby in case of a low blood sugar emergency — and make sure your friends and loved ones know how to use it.
- Schedule a yearly physical exam and regular eye exams.Your regular diabetes checkups aren’t meant to replace yearly physicals or routine eye exams. During the physical, your doctor will look for any diabetes-related complications, as well as screen for other medical problems. Your eye care specialist will check for signs of retinal damage, cataracts and glaucoma.
- Keep your immunizations up to date. High blood sugar can weaken your immune system. Get a flu shot every year. Your doctor will likely recommend the pneumonia vaccine, as well.The Centers for Disease Control and Prevention (CDC) also recommends hepatitis B vaccination if you haven’t previously been vaccinated against hepatitis B and you’re an adult ages 19 to 59 with type 1 or type 2 diabetes. The CDC advises vaccination as soon as possible after diagnosis with type 1 or type 2 diabetes. If you’re age 60 or older and have diabetes and haven’t previously received the vaccine, talk to your doctor about whether it’s right for you.
- Pay attention to your feet. Wash your feet daily in lukewarm water. Dry them gently, especially between the toes. Moisturize your feet with lotion. Check your feet every day for blisters, cuts, sores, redness or swelling. Consult your doctor if you have a sore or other foot problem that doesn’t heal.
- Keep your blood pressure and cholesterol under control.Eating healthy foods and exercising regularly can go a long way toward controlling high blood pressure and cholesterol. Medication may be needed, too.
- If you smoke or use other forms of tobacco, ask your doctor to help you quit. Smoking increases your risk of diabetes complications, including heart attack, stroke, nerve damage and kidney disease. In fact, smokers who have diabetes are three times more likely to die prematurely than are nonsmokers who have diabetes, according to the American Diabetes Association. Talk to your doctor about ways to stop smoking or to stop using other types of tobacco.
- If you drink alcohol, do so responsibly. Alcohol can cause either high or low blood sugar, depending on how much you drink and if you eat at the same time. If you choose to drink, do so only in moderation and always with a meal. And be sure to check your blood sugar levels before going to sleep.
- Take stress seriously. The hormones your body may produce in response to prolonged stress may prevent insulin from working properly, which can stress and frustrate you even more.Take a step back and set some limits. Prioritize your tasks. Learn relaxation techniques. Get plenty of sleep.
Coping and support
Living with type 1 diabetes isn’t easy. Diabetes management requires a lot of time and effort, especially in the beginning.
Diabetes can affect your emotions both directly and indirectly. Poorly controlled blood sugar can directly affect your emotions by causing behavior changes, such as irritability. Diabetes may also make you feel different from other people. And there may be times you feel resentful that you always have to incorporate diabetes planning in everything you do.
People with diabetes have an increased risk of depression and diabetes-related distress, which may be why many diabetes specialists regularly include a social worker or psychologist as part of their diabetes care team.
You may find that talking to other people with type 1 diabetes is helpful. Support groups are available both online and in person. Support groups aren’t for everyone, but they can be good sources of information. Group members often know about the latest treatments and tend to share their own experiences or helpful information, such as where to find carbohydrate counts for your favorite takeout restaurant.
If you’re interested in a support group, your doctor may be able to recommend one in your area. Or you can visit the websites of the American Diabetes Association (ADA) or the Juvenile Diabetes Research Foundation (JDRF) for support group information and to check out local activities for people with type 1 diabetes. You can also reach the ADA at 800-DIABETES (800-342-2383) or JDRF at 800-533-CURE (800-533-2873).
There’s no known way to prevent type 1 diabetes. But researchers are working on preventing the disease or further destruction of the islet cells in people who are newly diagnosed. Ask your doctor if you might be eligible for one of these clinical trials, but carefully weigh the risks and benefits of any treatment available in a trial.
You can find more information on the types of research being done from TrialNet, a collaboration of diabetes researchers. TrialNet is also conducting a natural history study to check for diabetes genes in parents, children and siblings of people with type 1 diabetes.