Q: How do I lower my blood sugar when it goes over 200 mg/dl? I have  type 2 diabetes.

A: An excellent question, but a complicated one to answer. Your doctor or nurse educator should be contacted whenever your blood sugar runs consistently higher than 250 mg/dl for more than two days. When a person with type 2 diabetes encounters a high blood sugar, the strategy used to bring it down will vary from individual to individual. This is because of differences in treatment involving diet, exercise, and medication. It will also depend upon the guidelines for glucose control that you and your doctor have mutually agreed upon.

When high blood sugars do occur, there are a number of strategies that can be employed to lower the glucose level back down to a normal range. These might include:

1) Eating less food at the next meal, eliminating a snack, and/or eating foods with a lower glycemic index.

A general rule of thumb to follow is to eliminate 15 grams of carbohydrate (the amount in one starch exchange, one fruit exchange, or one cup of skim milk exchange), which will lower blood glucose by 30 mg/dl. If you test your blood sugar at 182 mg/dl before a meal or snack, then eliminate one starch and one cup of milk at the next meal to bring the glucose value close to 120 mg/dl as a baseline. Although people with diabetes will respond differently to this adjustment, it provides a basic guideline to start with.

For persons with type 2 diabetes who are overweight, the loss of only five to 10 percent of total weight can dramatically improve blood glucose values. Consequently, just cutting calories moderately can achieve better blood glucose control.

Lastly, choosing foods with a lower glycemic index, that is, foods that do not raise blood sugar as quickly or dramatically, can help to bring blood glucose back into a normal range. Some examples of foods with a low glycemic index are dried beans and lentils.

To test the glycemic effect of a food on your system, you will need to do more frequent monitoring. For example, you may want to compare the effect of brown rice versus baked potato by eating equivalent carbohydrate amounts of these foods at dinner and comparing your blood glucose response two hours later. The exact effect will vary from person to person.

2) Increasing activity or incorporating more exercise.

Persons with type 2 diabetes generally respond to increased exercise with a lowered blood glucose value. Simple exercise, such as walking 20 minutes or more per day, can effectively improve glucose tolerance and induce weight loss. Proper exercise can actually be effective enough to lower or completely eliminate the need for medication altogether.

3) Increasing medications, changing medications, and/or administering them more frequently.

Although this is certainly an option, it makes more sense to first address the problem of elevated blood glucose by exercise and cutting back on food. These measures are less costly and have fewer side effects. If they aren't effective, however, a medication change may be indicated. If you are on the minimal dose of oral agents, your doctor might raise the dose or split it into morning and evening doses.

This could also be true for those using insulin. Taking more shots per day does not mean that your diabetes is worse. It may even bring more flexibility into your lifestyle. In fact, a rule of thumb for those on insulin (check with your doctor first before making these adjustments) is to take one unit of regular insulin to lower blood glucose 30 mg/dl. If your blood sugar is 191 mg/dl before a meal, an extra three units of insulin will bring the glucose down about 100 mg/dl.

It is important to note that this rule may change for people who exercise regularly because it will take less insulin to achieve the desired effect. It may also change for those who become ill  because they are more insulin-resistant and may need more insulin to achieve the desired effect. The effectiveness of insulin is also dramatically decreased by high blood sugar levels.

4) Using relaxation techniques and behavioral management.

Relaxation exercises, including deep breathing and audio tapes that guide you through deep muscle relaxation, can reduce stress and help you deal more effectively with it. Tapes are available specifically designed to create images of healthiness in diabetic individuals and encourage visualization of improved glucose control. Behavioral management techniques also increase one's overall sense of control over life and self-efficacy, so that diabetes becomes a state of "wellness in the midst of illness." When you are relaxed and in control, your blood glucose values can improve.

5) Treating identified illness and/or infections.

Illness and infection causes a rise in adrenergic hormones, which increase the production of glucose in the body. This extra surge of glucose is part of the healing process, but can upset glucose control. Thus, continuing to take medications despite poor appetite is vital. You may temporarily require more medication during periods of extended illness. Ask your doctor for instructions on dealing with illness.

6) Monitoring on a more frequent basis and/or monitoring other parameters.

When your blood glucose values exceed the target ranges established by you and your doctor, monitoring should be done every two hours until your blood glucose returns to normal. This gives you an opportunity to treat and adjust blood glucose as soon as possible, rather than waiting until your next doctor visit or next meal (which might be four or five hours later). It also tells you whether or not what you are doing is helping to bring the blood glucose down. Another step to take if your blood sugar is over 250 mg/dl would be ketone checks (done by urine dip stick or via a fingerstick to measure betahydroxybutyrate, an acid). Testing ketones hourly until they disappear is recommended.

7) Increasing consumption of sugar-free fluids.

Often, poor hydration accounts for the concentration of sugar in the blood. All people (with diabetes or not) should drink two to three quarts of sugar-free fluids per day. When glucose is elevated, drinking helps to dilute it. Also, drinking fluids is filling, decreasing the possibility of overeating.

People with heart disease who take diuretics and those with renal (kidney) complications may need to be on restricted fluids. Check with your doctor and/or dietitian if you fall into these special categories.

To combat high blood sugars, the most important strategy is prevention. Prevention of high blood sugars is usually possible with frequent and consistent monitoring. If you have awareness of your usual glucose response patterns to foods and exercise, it will be easier to plan out your day and prevent fluctuations in your blood sugar.