JAMA ; 20 Colberg SR, Sigal RJ, Yardley JE, et al. Diabetes Care ;39 11 Sigal RJ, Kenny GP, Boulé NG, et al. Effects of aerobic training, resistance training, or both on glycemic control in type 2 diabetes: a randomized trial.

Ann Intern Med ; 6 Bohn B, Herbst A, Pfeifer M, et al. Impact of Physical Activity on Glycemic Control and Prevalence of Cardiovascular Risk Factors in Adults With Type 1 Diabetes: A Cross-sectional Multicenter Study of 18, Patients.

Diabetes Care ;38 8 Pongrac Barlovic D, Harjutsalo V, Groop PH. Exercise and nutrition in type 1 diabetes: Insights from the FinnDiane cohort.

Front Endocrinol Lausanne ; Shorey S, Ng ED, Law EC, Wong JCM, Loke KY, Tam WWS. Physical Activity and Nutrition Interventions for Type 1 Diabetes: A Meta-analysis.

Pediatrics ; 3 :e Dean PG, Kukla A, Stegall MD, et al : Pancreas transplantation. BMJ , Rickels MR, Robertson RP : Pancreatic islet transplantation in humans: Recent progress and future directions. Endocr Rev 40 2 —, The goal of diabetes treatment is control of hyperglycemia to relieve symptoms and prevent complications while minimizing hypoglycemic episodes.

Diabetes mellitus control can be monitored by measuring blood levels of. These goals may be adjusted to be less strict for patients in whom strict glucose control may be inadvisable, such as.

Patients who experience repeated episodes of hypoglycemia Hypoglycemia Hypoglycemia, or low plasma glucose level can result in sympathetic nervous system stimulation and central nervous system dysfunction.

In patients with diabetes who take insulin or antihyperglycemic read more , especially those who do not develop symptoms of hypoglycemia hypoglycemia unawareness. Patients who cannot communicate the presence of hypoglycemia symptoms eg, young children, patients with dementia.

Potential candidates for tighter glycemic control include. Glucose levels are typically determined by home monitoring Special Populations and Settings Diabetes mellitus is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia.

read more of capillary blood glucose eg, from a fingerstick or continuous glucose monitoring. Most patients with type 1 diabetes benefit from testing at least 4 times a day 1 Monitoring references Diabetes mellitus is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia.

More frequent self-monitoring is recommended when blood glucose levels are suboptimal or when there are changes in the medication regimen.

HbA1C levels measured in venous plasma are monitored every 3 months or, for patients with consistently good control, every 6 months. Fingerstick glucose monitors measure capillary blood glucose. Many different glucose meters are available. Nearly all require test strips and a means for pricking the skin and obtaining a blood sample.

Choice among devices is usually based on patient preferences for features such as time to results usually 5 to 30 seconds , size of display panel large screens may benefit patients with poor eyesight , voice readout for those with visual impairment , and smartphone app connectivity 2 Monitoring references Diabetes mellitus is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia.

Continuous glucose monitoring CGM systems estimate capillary blood glucose from interstitial glucose detected by a subcutaneous sensor. They can either provide glucose measurements continuously real-time CGM or intermittently when scanned with a device intermittently scanned CGM.

CGMs provide real-time glucose data including an alarm to warn of hypoglycemia, hyperglycemia, or rapidly changing glucose levels. Although CGMs have less stringent accuracy requirements than capillary blood glucose monitors, they allow users and clinicians to assess for patterns of hyperglycemia and hypoglycemia that are not identified with fingerstick glucose monitoring.

Use of CGMs has been shown to increase patients' time in target range TIR and decrease HbA1C 3, 4, 5 Monitoring references Diabetes mellitus is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia. Use of CGMs is recommended for all patients who are treated with intensive insulin therapy and can use the devices safely 6 Monitoring references Diabetes mellitus is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia.

As with all glycemic targets, CGM targets should be individualized depending on age, comorbidities, and risk of hypoglycemia. CGM systems can be integrated with insulin pumps to provide real-time adjustment of insulin doses based on blood glucose levels. Such systems, known as automated insulin delivery AID systems or hybrid closed-loop systems, are expensive; however, they are recommended for all patients who take multiple daily injections of insulin and have been shown to lower HbA1C levels and decrease hypoglycemia 6, 9, 10 Monitoring references Diabetes mellitus is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia.

They are becoming more commonly used, and some versions do not require daily fingerstick glucose testing to calibrate the glucose monitor. They are especially useful in patients with type 1 diabetes and for those with hypoglycemia unawareness or nocturnal hypoglycemia.

Some CGM sensors can be used for up to 2 weeks before they need to be replaced. Clinicians can review the recorded data to determine whether the patient is experiencing undetected hyperglycemia or hypoglycemia. HbA1C levels reflect glucose control over the preceding 3 months and hence assess control between physician visits.

HbA1C should be assessed quarterly in patients with type 1 diabetes and at least twice a year in patients with type 2 diabetes when plasma glucose appears stable and more frequently when control is uncertain.

Home testing kits are available but are used infrequently. Control suggested by HbA1C values sometimes appears to differ from that suggested by daily glucose readings because of falsely elevated or normal HbA1C values. False elevations of HbA1C may occur with low red blood cell turnover as occurs with iron, folate, or vitamin B12 deficiency anemia , high-dose aspirin , and high blood alcohol concentrations.

Falsely normal HbA1C values occur with increased red blood cell turnover, as occurs with hemolytic anemias Overview of Hemolytic Anemia At the end of their normal life span about days , red blood cells RBCs are removed from the circulation. Hemolysis is defined as premature destruction and hence a shortened RBC life span read more and hemoglobinopathies Overview of Hemoglobinopathies Hemoglobinopathies are genetic disorders affecting the structure or production of the hemoglobin molecule.

Hemoglobin molecules consist of polypeptide chains whose chemical structure is genetically read more eg, HbS disease, HbC disease , or during treatment of deficiency anemias.

In patients with cirrhosis Cirrhosis Cirrhosis is a late stage of hepatic fibrosis that has resulted in widespread distortion of normal hepatic architecture. Cirrhosis is characterized by regenerative nodules surrounded by dense read more or chronic kidney disease stages 4 and 5 Stages of chronic kidney disease Chronic kidney disease CKD is long-standing, progressive deterioration of renal function.

Symptoms develop slowly and in advanced stages include anorexia, nausea, vomiting, stomatitis, dysgeusia read more , correlation between HbA1C and glycemic levels is poor, and HbA1C can be falsely decreased in these patients.

Pregnancy also falsely decreases HbA1C values. Fructosamine, which is mostly glycosylated albumin but also comprises other glycosylated proteins, reflects glucose control in the previous 1 to 2 weeks.

Fructosamine monitoring may be used during intensive treatment of diabetes and for patients with hemoglobin variants or high red blood cell turnover which cause false HbA1C results , but it is mainly used in research settings.

Urine glucose monitoring is too inaccurate to be recommended. Diabetes Care 44 11 —, Domingo-Lopez DA, Lattanzi G, H J Schreiber L, et al. Medical devices, smart drug delivery, wearables and technology for the treatment of Diabetes Mellitus.

Adv Drug Deliv Rev ; Beck RW, Riddlesworth T, Ruedy K, et al. Effect of Continuous Glucose Monitoring on Glycemic Control in Adults With Type 1 Diabetes Using Insulin Injections: The DIAMOND Randomized Clinical Trial. JAMA ; 4 Olafsdottir AF, Polonsky W, Bolinder J, et al. A Randomized Clinical Trial of the Effect of Continuous Glucose Monitoring on Nocturnal Hypoglycemia, Daytime Hypoglycemia, Glycemic Variability, and Hypoglycemia Confidence in Persons with Type 1 Diabetes Treated with Multiple Daily Insulin Injections GOLD Diabetes Technol Ther ;20 4 Vigersky RA, Fonda SJ, Chellappa M, Walker MS, Ehrhardt NM.

Short- and long-term effects of real-time continuous glucose monitoring in patients with type 2 diabetes. Diabetes Care ;35 1 Grunberger G, Sherr J, Allende M, et al.

American Association of Clinical Endocrinology Clinical Practice Guideline: The Use of Advanced Technology in the Management of Persons With Diabetes Mellitus. Endocr Pract ;27 6 Battelino T, Danne T, Bergenstal RM, et al : Clinical targets for continuous glucose monitoring data interpretation: Recommendations from the international consensus on time in range.

Diabetes Care 42 8 —, Brown SA, Kovatchev BP, Raghinaru D, et al. Six-Month Randomized, Multicenter Trial of Closed-Loop Control in Type 1 Diabetes.

N Engl J Med ; 18 Tauschmann M, Thabit H, Bally L, et al. Closed-loop insulin delivery in suboptimally controlled type 1 diabetes: a multicentre, week randomised trial [published correction appears in Lancet Oct 13; ]. Diabetes care requires careful adjustment for patient factors, including those related to age and lifestyle, comorbid conditions, and need for treatment of other acute or chronic conditions.

The term brittle diabetes has been used to refer to patients who have dramatic, recurrent swings in glucose levels, often for no apparent reason. Labile plasma glucose levels are more likely to occur in patients with type 1 diabetes because endogenous insulin production is almost completely absent, and in some patients, counter-regulatory response to hypoglycemia is impaired.

Other causes of labile plasma glucose levels include occult infection, gastroparesis which leads to erratic absorption of dietary carbohydrates , and endocrine disorders eg, Addison disease Addison Disease Addison disease is an insidious, usually progressive hypofunctioning of the adrenal cortex.

It causes various symptoms, including hypotension and hyperpigmentation, and can lead to adrenal crisis Patients with chronic difficulty maintaining acceptable glucose levels should be evaluated for situational factors that affect glucose control. Such factors include inadequate patient education or understanding that leads to errors in insulin administration, inappropriate food choices, and psychosocial stress that expresses itself in erratic patterns of medication use and food intake.

The initial approach is to thoroughly review self-care techniques, including insulin preparation and injection and glucose testing. Increased frequency of self-testing may reveal previously unrecognized patterns and provides the patient with helpful feedback.

A thorough dietary history, including timing of meals, should be taken to identify potential contributions to poor control. Underlying disorders should be ruled out by physical examination and appropriate laboratory tests.

For some insulin -treated patients, changing to a more intensive regimen that allows for frequent dose adjustments based on glucose testing is helpful. Continuous glucose monitoring with alarms and sensor-augmented or hybrid closed-loop insulin pump therapy are useful tools in individuals who fluctuate between hypoglycemia and hyperglycemia.

Diabetes in children Diabetes Mellitus in Children and Adolescents Diabetes mellitus involves absence of insulin secretion type 1 or peripheral insulin resistance type 2 , causing hyperglycemia. read more is discussed in more detail elsewhere.

Children with type 1 diabetes require physiologic insulin replacement as do adults, and similar treatment regimens, including insulin pumps Insulin pumps General treatment of diabetes mellitus for all patients involves lifestyle changes, including diet and exercise.

read more , are used. However, the risk of hypoglycemia, because of unpredictable meal and activity patterns and limited ability to report hypoglycemic symptoms, may require modification of treatment goals.

Most young children can be taught to actively participate in their own care, including glucose testing and insulin injections. School personnel and other caregivers must be informed about the disease and instructed about the detection and treatment of hypoglycemic episodes.

Monitoring for microvascular complications Monitoring for complications of diabetes Diabetes mellitus is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia. read more can generally be deferred until after puberty.

Children with type 2 diabetes require the same attention to diet and weight control and recognition and management of dyslipidemia and hypertension as do adults.

Most children with type 2 diabetes have obesity, so lifestyle modification is the cornerstone of therapy. Medication therapy may also be indicated. Diabetes in adolescents Diabetes Mellitus in Children and Adolescents Diabetes mellitus involves absence of insulin secretion type 1 or peripheral insulin resistance type 2 , causing hyperglycemia.

Glucose control typically deteriorates as children with diabetes enter adolescence. Multiple factors contribute, including. Pubertal and insulin -induced weight gain.

Hormonal changes that decrease insulin sensitivity. Psychosocial factors that lead to insulin nonadherence eg, mood and anxiety disorders, hectic schedules, irregular meals, family conflict. read more that lead to insulin omission as a means of controlling weight.

For these reasons, some adolescents experience recurrent episodes of hyperglycemia, diabetic ketoacidosis Diabetic Ketoacidosis DKA Diabetic ketoacidosis DKA is an acute metabolic complication of diabetes characterized by hyperglycemia, hyperketonemia, and metabolic acidosis.

read more , and hypoglycemia requiring emergency department visits and hospitalization. Treatment often involves intensive medical supervision combined with psychosocial interventions eg, mentoring or support groups , individual or family therapy, and psychopharmacology when indicated.

Patient education is important so that adolescents can safely enjoy the freedoms of early adulthood. Rather than judging personal choices and behaviors, clinicians must continually reinforce the need for careful glycemic control, especially frequent glucose monitoring and use of frequent, low-dose, fast-acting insulins as needed.

Diabetes mellitus may be a primary reason for hospitalization or may accompany other illnesses that require inpatient care. All patients with diabetic ketoacidosis Diabetic Ketoacidosis DKA Diabetic ketoacidosis DKA is an acute metabolic complication of diabetes characterized by hyperglycemia, hyperketonemia, and metabolic acidosis.

read more , hyperosmolar hyperglycemic state Hyperosmolar Hyperglycemic State HHS Hyperosmolar hyperglycemic state is a metabolic complication of diabetes mellitus characterized by severe hyperglycemia, extreme dehydration, hyperosmolar plasma, and altered consciousness read more , or prolonged or severe hypoglycemia Hypoglycemia Hypoglycemia, or low plasma glucose level can result in sympathetic nervous system stimulation and central nervous system dysfunction.

read more should be hospitalized. Patients with hypoglycemia induced by sulfonylureas, poorly controlled hyperglycemia, or acute worsening of diabetic complications may benefit from brief hospitalization. Children and adolescents with new-onset diabetes Diabetes Mellitus in Children and Adolescents Diabetes mellitus involves absence of insulin secretion type 1 or peripheral insulin resistance type 2 , causing hyperglycemia.

read more may also benefit from hospitalization. Control may worsen on discharge when insulin regimens developed in controlled inpatient settings prove inadequate to the uncontrolled conditions outside the hospital. In patients with newly diagnosed diabetes, insulin doses used in the inpatient setting are often too high and can cause hypoglycemia if not adjusted when discharged from the hospital.

When other illnesses mandate hospitalization, some patients can continue on their home diabetes treatment regimens. However, glucose control often proves difficult, and it is often neglected when other diseases are more acute. Restricted physical activity and acute illness worsen hyperglycemia in some patients, whereas dietary restrictions and symptoms that accompany illness eg, nausea, vomiting, diarrhea, anorexia precipitate hypoglycemia in others—especially when antihyperglycemic medication doses remain unchanged.

In addition, it may be difficult to control glucose adequately in patients who are hospitalized because usual routines eg, timing of meals, medications, and procedures are inflexibly timed relative to diabetes treatment regimens.

In patients who are hospitalized, oral antihyperglycemic medications often need to be stopped. Metformin can cause lactic acidosis Lactic Acidosis Lactic acidosis is a high anion gap metabolic acidosis due to elevated blood lactate.

Lactic acidosis results from overproduction of lactate, decreased metabolism of lactate, or both. See also read more in patients with renal insufficiency and has to be stopped if contrast agents need to be given.

Therefore, metformin is withheld in all but the most stable patients who are hospitalized. Sulfonylureas can cause hypoglycemia and should also be stopped. Most inpatients can be appropriately treated with basal insulin without or with supplemental short-acting insulin.

Dipeptidyl peptidase-4 inhibitors are relatively safe, even in patients with kidney disease, and they may also be used for postprandial glucose lowering. Sliding-scale insulin should not be the only intervention to correct hyperglycemia; it is reactive rather than proactive, and it leads to poor glycemic control compared to basal-bolus insulin.

Longer-acting insulins should be adjusted to prevent hyperglycemia rather than just using short-acting insulins to correct it. Inpatient hyperglycemia is associated with increased infection rate and mortality. Critical illness causes insulin resistance and hyperglycemia even in patients without known diabetes mellitus.

Such stress-induced hyperglycemia is associated with poor outcomes, including increased mortality. Previously, glucose target levels were lower; however, it appears that the less stringent targets as described above may be sufficient to prevent adverse outcomes.

The physiologic stress of surgery can increase plasma glucose in patients with diabetes and induce diabetic ketoacidosis Diabetic Ketoacidosis DKA Diabetic ketoacidosis DKA is an acute metabolic complication of diabetes characterized by hyperglycemia, hyperketonemia, and metabolic acidosis.

read more in those with type 1 diabetes. For shorter procedures, subcutaneous insulin can be used. During and after surgery, plasma glucose and ketones if hyperglycemia suggests the need should be measured at least every 2 hours. This approach may also be used for insulin -treated patients with type 2 diabetes, but frequent measurement of ketones may be omitted.

Some physicians prefer to withhold subcutaneous or inhaled insulin on the day of surgery and to give insulin by IV infusion. For patients undergoing a long procedure or major surgery, a continuous insulin infusion is preferable, especially since insulin requirements can increase because of the stress of surgery.

IV insulin infusion can be given at the same time as intravenous dextrose solution to maintain blood glucose. The insulin doses are adjusted in 5-unit increments. This approach is not used at many institutions because of the frequent remixing and changing of bags needed to adjust to the patient's level of glycemia.

A more common approach in the United States is to infuse insulin and dextrose separately. The insulin rate may need to be decreased for patients with more insulin -sensitive type 1 diabetes and increased for patients with more insulin -resistant type 2 diabetes.

Ten percent dextrose may also be used. It is important, especially in patients with type 1 diabetes, to continue insulin infusion to avoid development of diabetes ketoacidosis. Insulin adsorption onto IV tubing can lead to inconsistent effects, which can be minimized by preflushing the IV tubing with insulin solution.

Insulin infusion is continued through recovery, with insulin dose adjusted based on the plasma glucose levels obtained in the recovery room and at 1- to 2-hour intervals thereafter. Most patients with type 2 diabetes who are treated only with oral antihyperglycemic medications maintain acceptable glucose levels when fasting and may not require insulin in the perioperative period.

Most oral medications, including sulfonylureas and metformin , should be withheld on the day of surgery, and plasma glucose levels should be measured preoperatively and postoperatively and every 6 hours while patients receive IV fluids.

Oral medications may be resumed when patients are able to eat, but metformin should be withheld until normal renal function is confirmed 48 hours after surgery. People at high risk of type 1 diabetes eg, siblings and children of people with type 1 diabetes can be tested for the presence of islet cell or anti-glutamic acid decarboxylase antibodies, which precede onset of clinical disease 1 Screening reference Diabetes mellitus is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia.

Gestational diabetes mellitus Diabetes Mellitus in Pregnancy Pregnancy makes glycemic control more difficult in preexisting type 1 insulin-dependent and type 2 non—insulin-dependent diabetes but does not appear to exacerbate diabetic retinopathy, Hypertension with no known cause primary; formerly, essential Dyslipidemia Dyslipidemia Dyslipidemia is elevation of plasma cholesterol, triglycerides TGs , or both, or a low high-density lipoprotein cholesterol HDL-C level that contributes to the development of atherosclerosis Polycystic ovary syndrome Polycystic Ovary Syndrome PCOS Polycystic ovary syndrome is a clinical syndrome typically characterized by anovulation or oligo-ovulation, signs of androgen excess eg, hirsutism, acne , and multiple ovarian cysts in the Steatotic liver disease Metabolic Dysfunction—Associated Liver Disease MASLD Steatotic liver disease is due to excessive accumulation of lipid in hepatocytes.

Metabolic dysfunction—associated liver disease MASLD includes simple fatty infiltration a benign condition read more formerly fatty liver disease.

Sims EK, Besser REJ, Dayan C, et al. Screening for Type 1 Diabetes in the General Population: A Status Report and Perspective. Show references Abdul-Ghani M, et al. Insulin resistance and hyperinsulinemia: The egg and the chicken. Jameson JL, et al. The metabolic syndrome. In: Harrison's Manual of Medicine.

McGraw Hill; Accessed Nov. Merck Manual Professional Version. Vella A. Noninsulinoma pancreatogenous hypoglycemia syndrome. Products and Services Assortment of Health Products from Mayo Clinic Store A Book: The Essential Diabetes Book.

See also A1C test Acanthosis nigricans Amputation and diabetes Atkins Diet Bariatric surgery Caffeine: Does it affect blood sugar? Can medicine help prevent diabetic macular edema?

CBD safety Diabetes foods: Can I substitute honey for sugar? Diabetes prevention: 5 tips for taking control Medications for type 2 diabetes Types of diabetic neuropathy Does keeping a proper blood sugar level prevent diabetic macular edema and other eye problems?

Prickly pear cactus Endoscopic sleeve gastroplasty Endoscopic Sleeve Gastroplasty Gastric Sleeve Exercise and chronic disease Fasting diet: Can it improve my heart health? Fatigue Frequent urination Gastric bypass Roux-en-Y Gastric Bypass Complications Gastric bypass diet Gastric Bypass Surgery: One Patient's Journey GLP-1 agonists: Diabetes drugs and weight loss Glucose tolerance test Weight-loss surgery What is insulin resistance?

A Mayo Clinic expert explains Intermittent fasting Kidney disease FAQs Living with diabetic macular edema Low-glycemic index diet Reducing your risks of diabetic macular edema Screening for diabetic macular edema: How often?

Spotting symptoms of diabetic macular edema Symptom Checker Type 2 diabetes Unexplained weight loss Biliopancreatic diversion with duodenal switch Weight Loss Surgery Options What is diabetic macular edema?

Show more related content. Mayo Clinic Press Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. Mayo Clinic on Incontinence - Mayo Clinic Press Mayo Clinic on Incontinence The Essential Diabetes Book - Mayo Clinic Press The Essential Diabetes Book Mayo Clinic on Hearing and Balance - Mayo Clinic Press Mayo Clinic on Hearing and Balance FREE Mayo Clinic Diet Assessment - Mayo Clinic Press FREE Mayo Clinic Diet Assessment Mayo Clinic Health Letter - FREE book - Mayo Clinic Press Mayo Clinic Health Letter - FREE book.

FAQ Home Hyperinsulinemia Is it diabetes. Show the heart some love! Give Today. Help us advance cardiovascular medicine. Find a doctor. Explore careers. Sign up for free e-newsletters. This can be done at commercial laboratories and should be considered in any child suspected to have congenital HI.

Contact us for more information on where to have this testing performed. There are two options for treatment of congenital HI, medical therapy and surgical intervention.

About 50 percent of children respond to medical therapy, while the other half require surgery for a partial or near total pancreatectomy. We are now tracking and compiling data on the long-term outlook for children with congenital hyperinsulinism. With focal hyperinsulinism, View this video with a transcript.

Congenital Hyperinsulinism. Contact Us Online. There are several forms of HI: Diazoxide-Responsive and Diazoxide-Unresponsive Diffuse KATP HI : In diffuse KATP HI, potassium channels named KATP channels in the beta cell, which help regulate insulin secretion, do not work properly.

Focal KATP HI : For children with a KATP defect who have focal congenital HI, only an isolated or focal area of the pancreas is abnormal; the remainder of the pancreas is normal. GDH-HI : In GDH-HI, excess insulin secretion causes low blood glucose with fasting or when the child eats protein.

This form also causes higher ammonia levels and, in some people, may cause seizures. Glucokinase HI : In glucokinase HI, the beta cells are not able to turn off insulin secretion when the blood glucose is too low. HNF1a-HI and HNF4a-HI : These are rare forms of HI that progress to diabetes in adolescence and adulthood.

Exercise-induced HI : In this rare form of HI, exercise triggers insulin release, which results in low blood sugars SCHAD-HI : SCHAD-HI is a type of HI caused by a very rare disorder of fatty acid metabolism.

UCP2-HI : UCP-2 HI is rare form of congenital HI that seems to be transient, meaning it is not a permanent condition, and eventually resolves over time.