Yes. Since the A1c test reveals what your average blood sugar has been for the last 3 months or so, your doctor is right to be concerned by a high value. At high A1c numbers, your blood is thick, like honey or corn syrup and this can damage several body systems. But like you, most people feel just fine while this trouble is going on. Lowering your A1c into a healthier range – many experts recommend 6 1/2% or less –would be a big step toward assuring a healthy future with diabetes. You may not feel a whole lot different physically, but your eyes, heart and blood vessels will definitely notice the difference. You can learn more about other goals of control for diabetes in the Diabetes Myth Book.

Probably. But first, check your blood sugar when you start feeling bad. If your blood sugars are going too low (below about 70mg/dl (3.8mmol)) on your new medicine, take some quick-acting carbohydrate like fruit juice to treat the low. Then contact your doctor – your new medicine dose may need adjusting. But chances are you will find your blood sugars are actually normal to high. It's most likely that you're feeling weak and shaky because your body had grown accustomed to running higher sugars. This can cause it to interpret your more normal blood sugars as "low." It will take a while – probably a few weeks – to re-educate your body. Until then, just tell yourself that yucky feeling is a sign you're getting better.

Congratulations! You have accomplished a lot and you are definitely headed in the right direction. But please don't stop the new medicine. That would be like taking off your glasses because you can see perfectly through them. It's the combination of that new medicine, the older medicines, your food choices and so on that's resulting in better blood sugars. Pat yourself on the back and keep going! For best health, the closer you can get to normal blood sugars, the better.

A1c is an average of all blood sugars, day and night, 24/7. So if your blood sugar is fine when you check in the morning but you still have a high A1c, it means that your blood sugars are high at times you're NOT checking. The most likely place is after meals. Try checking before and about 2 hours after meals for a while. Your blood sugar should rise only about 40-60mg/dl (2-3mmol) each time you eat. And the actual value will ideally average below about 140 – 160 mg/dl (7.8 – 8.9 mmol). Your high A1c suggests that it's probably going up more than that.

There are several approaches that can improve this problem. The best choice for you depends on what medicines you're taking and how much you're eating. One option is to eat fewer carbohydrates. This makes most sense if you're eating quite a bit of carbohydrate at the meals you're checking. But if you're eating reasonably (say around 45-60 grams of carbohydrate or less) and your blood sugars are still rising too much after meals, your medicines need to be reviewed. A different type or dose will probably be needed to give you control after meals. And that will also bring down a high A1c.

Most experts don't believe that diabetes causes depression. But it IS more common in people who have diabetes than it is in people who don't. Researchers believe that depression may be something like high blood pressure for people with diabetes: that they travel together, with both conditions triggered by some other factor. But it's also clear that both the burden of living with diabetes and high blood sugar itself can make an existing depression worse. If you're not already getting treatment for your depression, please see your doctor soon. Good treatments are available.

Here a couple of things that can help you find your motivation and keep it strong over time. First, get clear about why you want to stay in control. Is it to prevent complications, to worry less, to avoid lows, to stop falling asleep after lunch or even to stop getting up three times a night to pee? When you figure out your reasons, remind yourself of them when you start getting worn out. In other words, stay focused on what you're working for. Another way to fight occasional burnout is to feel more effective. So learn all you can about exactly how your actions affect your diabetes. Become the world's expert on your own diabetes and pat yourself on the back often for all you do. Finally, accept that sometimes you may just need a break. By accepting that fact, you may find it easier to get back in the swing of things after taking an occasional "diabetes vacation."

The Bottom Line: Having a frightening personal experience like yours often leaves people thinking that there's nothing they can do to avoid complications. The feeling is very real and understandable, but it's not based on what actually happens to most people with diabetes. Kidney disease actually affects only a small percentage of people with diabetes. And you can greatly reduce your own risk with three specific steps:

• Control your blood sugar, shooting for a hemoglobin A1c of 6 1/2 - 7% or less. Kidney disease is caused, not by diabetes itself, but by uncontrolled diabetes.
• Get yearly checks for microalbumin in your urine. This test can find very early changes in kidney function that can be successfully treated with certain medicines. This stops the progression to kidney failure.
• Control your blood pressure. The goal for people with diabetes is less than 130/80, but for optimal kidney protection, some experts recommend using less than 120/80 as your goal.

The Bigger Picture: Having a frightening personal experience like yours often leaves people thinking that there's nothing they can do to avoid complications. The feeling is very real and understandable, but it's not based on what actually happens to most people with diabetes. Maybe some facts will help decrease your anxiety.

• First, just having diabetes does not cause kidney failure, heart disease or any of the other health problems often associated with it. These things are caused by uncontrolled diabetes. So, getting your blood sugars under control is your strongest protection against having the sorts of problems your mother did.
• Second, problems like kidney failure develop over a long period of time. And although you can't FEEL them until they become pretty serious, there are simple tests your doctor can and should do every year to find any developing problems at an early, treatable stage. So be sure to check that your doctor is doing kidney tests each year for microalbumin in your urine. If he finds it, ask about starting either an angiotensin converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB). These medicines have a strong protective effect on the kidney.
• Finally, make sure your blood pressure is also well-controlled. The goal for people with diabetes is less than 130/80, but for optimal kidney protection, some experts recommend using less than 120/80 as your goal.

With these three actions, you will be doing a great deal to assure a long future free of kidney problems.

Feeling isolated and alone with diabetes IS pretty common. Here are some things you can try that may improve things. First, find some folks who DO understand – perhaps friends who also have diabetes, people in a diabetes support group, or members of your diabetes team – to whom you can talk about your diabetes. It feels good to be able to talk to people who really "get it." Then, see if you can improve understanding among your loved ones. You might share a book with them – like Diabetes Myths, Misconceptions and Big Fat Lies! or Diabetes: Myth or Truth? Ask them to read it so you can all be on the same page in your understanding of diabetes. Also, offer to answer their questions about what you're doing and why. A better understanding of diabetes may improve their appreciation for your situation. And hearing from you that you want their understanding may be a wake up call.

It would be great if controlling diabetes was as simple as staying away from sweets, but it just isn't. Blood sugar control requires you to do something from the outside that your body used to be able to do automatically on the inside: keep food and insulin in perfect balance. Many foods – not just sweets – affect your need for insulin. So it's important to learn how to manage all carbohydrates (starches and sugars) – the ones in healthier foods such as grains and fruit as well as the ones in candies and cakes. Coupled with the right medicines, that will give you the power to work out the best balance for you.

The main thing in foods that raises after-meal blood sugar is carbohydrate. MANY traditional breakfast choices – fruit, cereal, milk, yogurt, toast – are high carbohydrate foods. To find what will work best for you, try checking before and after breakfast for a few days. Keep track of what you eat as well as your blood sugars. You should be able to eat at least 45 grams of carbohydrate without having your blood sugars rise more than 40-60mg/dl (2-3mmol) after eating. If you are eating less carbohydrate than that but still having high after-meal numbers, see your team about reviewing your medicines. You might also try adding some protein and fat to your breakfast carbs to flatten out the after-meal blood sugar. For example, add an egg or a piece of meat instead of having just toast. Or try some peanut butter with that morning banana.

No. There is no food that you absolutely must – or must not – eat to control diabetes. Vegetables, however, have some great advantages. They provide lots of fiber and many nutrients important to overall health – like vitamin A, antioxidants, and phytochemicals – that increase resistance to disease, slow aging and so on. These nutrients are also available from fruits, but fruits have a lot more carbohydrate and so must be managed more carefully by those who have diabetes. Low carb veggies – like lettuce, greens, tomatoes, broccoli, spinach and so on – are filling and healthful and have very little ability to raise blood sugar. So while you certainly don't HAVE to eat veggies, it might be worth finding some to add to your diet to improve overall nutrition.

Absolutely. Everyone in the family has a similar need for good food – a variety of foods, more fruits and veggies, heart healthy fats, moderate protein servings, good sources of vitamin D and calcium – and so on. All that's different for you is to understand how to manage the effect that your choices – mostly the carbohydrate-containing foods – have on your blood sugar. To do this, you need to know which foods have carbohydrate, how much carbohydrate is in the amount you eat, and what happens to your blood sugar when you eat that amount.

Pizza is definitely "the gift that keeps on giving" when it comes to blood sugar. Most pizzas are high in BOTH carbohydrate and fat. The fat slows down the rate at which the carbohydrate is digested and absorbed, pushing your highest blood sugars out several hours after you've finished eating. To make matters, worse, that big demand may come at a time when your own insulin levels are low, resulting in a more exaggerated rise in blood sugar. Getting thin crust instead of thick to reduce the carb load may help. So might cutting out the extra cheese, sausage, pepperoni and other higher fat add-ons. If you use an insulin pump, you may be able to solve the problem by giving your meal bolus as "extended," "dual-wave," or "square wave." Testing before and after will show which, if any, of these options helps bring down that morning "pizza gift."

She told you that because you are more than your diabetes. Humans need carbohydrates – and, in fact, if you don't eat carbs, your body will go to great lengths to MAKE them from the protein you consume. The system just runs better if you give it what it needs from the start. In addition to our need for carbohydrate as a fuel, we also need many nutrients that are found in carbohydrate foods. Some of them – vitamin C, antioxidants, phytochemicals, fiber, carotene, and others – are ONLY found in healthy carbohydrate foods such as grains, fruits and vegetables. If you're having trouble controlling your blood sugars when eating reasonable amounts of carbohydrate foods, it's a sign that your medicines may need adjusting – that you're not making enough insulin on your own to cover healthy meals. Some medicine choices can help you make more of your own insulin or use it better. Or in some cases, insulin itself may need to be added to your treatment to make both a healthy food intake and glucose control possible.

We strongly disagree. The choices you make every day about what to eat, whether to take your medicine, go for a walk and so on are what determine your blood sugar. YOU need the information from checking to see what's working or what's not. That's no different whether your insulin is coming fro your body or from a syringe. Monitoring is YOUR tool to learn how your diabetes works and how to manage it in your real life.

It's pretty disappointing to do all that work and then not get any benefit from it. But in reality, the best person to use the numbers is you, not your doctor! If you gather your numbers before and after eating, first thing in the morning and at bedtime, before and after exercise, they provide invaluable insight into how your diabetes works and how your choices are affecting it. You can see the numbers in context – that is, together with details about what you ate, whether you took your medicine or not, and whether you were sick or under stress. When a doctor looks at numbers weeks or months later and without that context, he or she really isn't seeing the whole picture. Learn what your numbers mean and use them to improve things BEWTEEN doctor visits. Don't wait for help that may or may not come at your next medical visit.

Blood sugar rises when we eat. And it can rise too high when there is not a good match between the food eaten and the amount of insulin available to use it. Checking after meals lets you see if that match is working or not. You may discover that different foods, or amounts of food always result in a blood sugar higher than what you're trying to achieve. That allows you to change your food choices or the amounts you're eating to improve things. Or you may see that your blood sugars after meals are very high even when you eat very little. Pass that information along to your team. It means you need a change in medicines or doses to support your own efforts.

The mere act of checking blood sugar doesn't change a thing, except maybe to make you frightened or frustrated! Try checking in a way that gives the numbers real value. Think of a problem you're having – maybe high blood sugars after breakfast, falling asleep after lunch every day, or whatever – and begin by gathering information around that specific situation. Look at where your blood sugars start and end and what you're doing in between. Maybe you'll see something you can fix right away – like cutting down carbs at breakfast or setting up a reminder to take your lunchtime insulin. Or maybe you won't have an answer yourself. In that case, take what you've learned to your team and ask them what they suggest. In other words, don't just collect numbers, ACT on them. That's how to make them valuable.

I'm afraid that there is no sure-fire way for people with type 2 diabetes to avoid insulin. Early in the disease, there are several medicines that work WITH your body's insulin production to control blood sugar. But as time goes by, people with Type 2 make less and less insulin. At some point, many people are simply unable to control blood sugars any longer without adding insulin to their treatment. This is not a failure or the result of anything you did wrong. It's just the natural history of Type 2 diabetes. When the time comes, don't let fear stop you from doing the one thing that can control your blood sugar.

Metformin is a great and inexpensive medicine for Type 2 diabetes and probably worth trying again. Having some stomach upset for a while after starting it is expected. But some people had severe symptoms in the past, often because their dose was increased too quickly. To give yourself the best chance of getting the benefits of metformin this time without the downside, ask your doctor to "start low and move slow." So for example, start with just one 500 mg tablet with the evening meal. Since supper is a bigger meal for most people, this helps cut down the stomach-related side effects. Then don't add another tablet, usually at breakfast, until all the side effects have passed – no queasiness, no diarrhea. Increase the dose one tablet at a time as slowly as necessary till you reach the full therapeutic dose of 2000 mg. If you still have stomach upset after going through this process, ask your doctor about other medicines that do some of the same things as metformin, such as exenatide.

Indeed! These insulins contain 70% intermediate-acting insulin, which has a long peak that lasts pretty much all afternoon. If your blood sugars are at all close to target and you don't have an afternoon snack, that peak puts you at risk for low blood sugar. Your options include either having a snack (or two) every afternoon or talking to your team about using a flat background insulin like glargine (Lantus) with meal insulin so you don't have such a high risk for lows in the afternoon. That would mean more shots, but would also give you greater flexibility and less risk for lows. It would probably make better after-meal blood sugar control more likely as well.

Type 2 diabetes is complicated. Several things go wrong with your ability to control blood sugar levels. Chances are that each of the pills you're taking treats a different one of those problems. And right now, there isn't one medication that can do all that. More pills that result in better blood sugar control is just good therapy. But if you're taking all those pills and NOT achieving the level of control you want, you and your team need to look for another option.

Make an appointment with your doctor. Diabetes changes over time, not because of anything you are doing, but simply because that's the normal course of the condition. Treatment needs to change periodically to keep up with the changes. One good way to prepare for the visit with your doctor is to keep a Discovery Record (see pages 78 and 79 in Diabetes Myths, Misconceptions and Big Fat Lies! or Diabetes: Myth or Truth?) for a few days. Include your medicine doses and when you are taking them, what you are eating and the blood sugars before and after meals. Include any physical activity and the blood sugars before and after that. For one thing, this record will clearly show your doctor you are serious about taking care of your diabetes. For another, it will show exactly where the problems in control are happening: are all the blood sugars high? Or maybe they're only high in the morning. Or the problem is only happening after larger meals. Each of those patterns would require a different action to see improvement.

The best way to get your questions answered during a medical visit is to be prepared. Think about how things are going and what concerns you. Then write down your questions and take the list with you. Also, if your question is about some specific problem in control, gather information about what's happening and take that with you too. For just the last 3 or 4 days before the visit, gather blood sugars before and after meals and at bedtime. Write down what you're eating. Keep track of your medicines and whether you missed any doses. Write down exercise, stress, illness – anything that contributes to the numbers you're finding. That information should make it possible for you and the doctor to understand and solve most problems. Here are two other things that can make your visit more productive. When the doctor walks in, say specifically what you're there about. Set the agenda right away. Also, take off your shoes and socks before the doctor gets to the room. Your feet need to be check at every medical visit – and bare feet are the best way to make sure that happens!

Use the Discovery Record in the Diabetes Myth Book to gather complete information for three or four days before your next visit. By showing food intake together with the blood sugars that follow, you may be able to demonstrate to your dietitian both your commitment to taking care of your diabetes and the facts of what's going on. If she still seems to be doubtful, ask her about it. Consider saying something like, "I feel as though you have questions about my records. Is that right? What are they?"

Often when loved ones nag folks with diabetes about their self-care – Why are you eating that? What was your blood sugar? Did you take your insulin? – it's because they're concerned or frightened and don't know how else to express it. See if this helps. First, let your wife know what you think about her nagging. Maybe something like, "I know you're concerned about my diabetes and trying to help, but what you're doing now isn't working for me. I feel criticized and watched when you make comments." And explain what you WOULD see as supportive. Give her a tangible way to help and the nagging may decrease.

It makes sense to be worried. Diabetes is serious. You don't want bad things to happen to someone you love. And, of course, anything that happens to your spouse affects you as well. But how you express that concern can make a big difference in both your relationship and what your spouse does about his diabetes. If it comes out as nagging, it's likely to cause more problems than it solves. So tell him how you feel. Perhaps say something like, "I'm worried about your diabetes. I don't want anything bad to happen to you. But I'm afraid that my concern may come across as nagging or criticism. Does it ever feel that way to you?" That should start a good conversation. You might also acknowledge how hard diabetes is and offer to help. Ask him what sort of help he wants. That should give you a positive way to express your concern.

Ask. Be clear about what will FEEL like support to you and then ask for it. Some of the kinds of things people find helpful are having someone to go on walks with, someone to help plan meals, someone to talk to or confide in, and someone to do an insulin shot or blood test once in a while. Whatever help means to you, people who care about you will probably be glad you asked. Most people feel great when they get to help someone they care about.

Run! And make sure they do too! Diabetes is increasing everywhere as people have become less active. The most powerful tool we have to prevent it is to be more active – like our ancestors were. As recently as two generations ago, when life was still physically hard for many people, populations in which diabetes is now very common had NO diabetes at all. Food was scarce and daily life was hard. So get up off the couch and take your kids with you. Walking, hiking, doing yard work or home maintenance, riding bicycles - anything active is great. Also pay attention to the family's overall nutrition. Better foods – leaner meats, more fruits and veggies, eating whole grains, fewer sweets – those are all helpful as well.