Uncontrolled diabetes is life-threatening. It is important for you or a loved one who has been diagnosed with type 2 diabetes to check your sugar levels on a regular basis. I have often been told, “It’s okay, I drink diet soda.” I can’t emphasize enough that this is not sufficient. Although some people have difficulty checking their blood sugar, there are new devices that don’t require you to draw blood, are even easier to use and are more acceptable for use on Shabbat.

• What are the symptoms of diabetes?

○ Although some people have the classic symptoms of increased urination, increased thirst, blurry vision and weight loss, many people, especially those with type 2 diabetes, do not have any specific symptoms.

• How do I know if I have diabetes?

○ Your doctor can do a blood test—a fasting glucose level and a hemoglobin A1C (HbA1C). The HbA1C measures the average glucose in the blood over the past three months. If the glucose is at least 126 mg/dL or the HbA1C is at least 6.5 percent then you have diabetes.

• How is diabetes treated?

○ Type 1 diabetes is characterized by insulin deficiency, and is often treated with multiple daily injections of insulin. Generally people with type 1 diabetes are on two types of insulin, one that is long acting and lasts the entire day, and one that is rapid acting, which is taken before meals. Another option is to use an insulin pump that is constantly infusing rapid-acting insulin and can give extra doses when you eat.

○ Type 2 diabetes treatment is more variable. Some people can control their diabetes with a low-carb diet, exercise and weight loss alone; some take pills daily; some use non-insulin injections daily or weekly; some need one or multiple daily injections of insulin.

• How do I know if my diabetes is controlled?

○ Without testing your blood sugar levels or HbA1C it is impossible to know if your diabetes is controlled. Many people mistakenly think that avoiding sugary foods and taking their medications is enough to ensure good control of type 2 diabetes.

○ Your HbA1C should be measured every 3-6 months. The American Diabetes Association recommends to keep the HbA1C at least under 7 percent for most adults. However, for an elderly person or someone with many other medical problems, your doctor might recommend a higher HbA1C target.

○ Testing your own blood sugar levels to make sure they are in range is also important. Self-monitoring of blood glucose multiple times a day is imperative for anyone who is taking insulin. It is necessary to avoid hypoglycemia (low blood sugar) and identify when you are having hyperglycemia (high blood sugar). Insulin doses can be adjusted to hopefully avoid extremely high or low glucose numbers.

• But I take (some of) my diabetes medications and I feel fine. Why do I need to make sure my diabetes numbers are perfect? It’s not causing me any problems.

○ It’s not causing you any problems yet…There’s a reason why diabetes is called the silent killer. Uncontrolled diabetes causes retinopathy—damage to the tiny blood vessels in the back of the eye (retina); nephropathy—damage to the function of the kidney; and neuropathy—nerve damage, which most commonly causes tingling, pain or numbness of the feet. Diabetes can lead to blindness, end-stage kidney disease requiring dialysis and foot ulcers that do not heal and necessitate amputation.

○ Fortunately, the complications of diabetes develop slowly over time, often occurring many years after the initial diagnosis of diabetes. The longer the diabetes is poorly controlled, the faster the complications develop. You might be unknowingly in the process of developing irreversible complications from diabetes. Now is the time to start controlling your diabetes before it gets worse.

• How can I find out if I have complications from diabetes?

○ An eye doctor can examine your retina for retinopathy. A simple blood and urine test can tell if you have the beginnings of diabetic kidney disease. A foot exam can diagnose neuropathy.

○ Diabetes also causes heart disease, including heart attacks. Although there is no specific screening test that is recommended to all patients to identify heart disease, it is important for everyone with diabetes to follow up with their doctor regularly to see if there are cardiac tests that would be helpful in their situation. They should also make sure their cholesterol and blood pressure levels are controlled as well.

• I know it is biblically prohibited to draw blood on Shabbat and don’t want to violate the laws of Shabbat by checking my blood sugar. Additionally, I don’t like pricking my finger to check my blood sugar all the time. Is there any way to check my glucose without drawing blood?

○ I encourage you to ask your rabbi about what you should or should not do on Shabbat with regard to taking care of your health. Your rabbi might advise that you are halachically obligated (not just allowed) to check your blood sugar with your regular lancing device and glucose meter, but that you should do so with a shinui (irregular or awkward way of performing a normally prohibited activity).

○ For those who need to check their sugars many times throughout the day, there are continuous glucose monitors (from Dexcom and Medtronic) available that can tell you what your glucose level is at any time, requiring you to prick your finger and calibrate them only a few times a day. They can also alert you if the glucose is going dangerously low or very high and are very helpful for people who have had problems with hypoglycemia in the past.

○ There is a new device called the FreeStyle Libre system that became available in the US in December 2017 that is much less halachically problematic for Shabbat. It can tell you what your glucose reading is without measuring your blood. The sensor, which is about the size of a quarter, sticks to your upper arm painlessly with a thin filament under the skin. You then take the reader (the size of a small cell phone), press a button and place it over your sensor to give you a glucose reading. The sensor can function and stay in your arm for up to 10 days, thereby avoiding the necessity to prick your finger (unless the device indicates that a fingerstick is necessary) so it would not necessarily involve drawing blood on Shabbat.

○ I have no vested interest in this product, but I think its ease of use (a small child can be taught how to use it, although it’s only approved for ages 18 and older) is a huge benefit and will help people check their sugars and control their diabetes in ways that they were previously unable to do. For Hilchot Shabbat purposes it is also preferable as it does not necessarily involve drawing blood (but you should still ask your rabbi in any case).

○ If this system is something that you think will help you take better care of your diabetes, I encourage you to reach out to your endocrinologist for a prescription and to your insurance provider to find out about the out-of-pocket costs.

By Lena Shalem, MD

 Lena Shalem, MD, is a board certified endocrinologist with Summit Medical Group. Her practice is located in Teaneck, NJ. Office number 201-836-5655.