Patient guide

1.0. Before anything else

Most endocrine patients arrive with a single number: TSH, fasting glucose, HbA1c, or vitamin D. A number alone is not enough. The doctor needs to know the conditions under which it was measured and which medications you take. If your papers are in order, the first visit is more productive.

This guide is a general checklist. Ask a few things where you book the appointment: how the appointment is booked, which documents are needed, and whether any special preparation is required. This page does not describe the process of any particular office or center.

1.1. Gather these

• Previous lab results, with the date and the unit. A number without a unit and date is of little use. If you have several tests from different months, bring all of them, not just the latest.
• Imaging reports: thyroid ultrasound, bone density, MRI, CT. If you have the disc or the images, bring them along. A report without the images is also enough, and the doctor will say whether they are needed.
• A list of all your medications: name, form, and schedule. NIDDK and NHS both say to mention all medications, including over-the-counter drugs, herbal products, vitamins, and supplements. Do not forget hair and nail supplements that contain biotin.
• Steroid pills or injections, even if it was some time ago. NHS writes that long-term steroid use has side effects such as diabetes, high blood pressure, osteoporosis, and Cushing’s syndrome.
• Your glucose log if you have a home glucose meter. CDC writes that you should record each reading along with anything that may have affected it, and bring it to your care team. If you have a continuous sensor, bring its report.
• Family history: diabetes, thyroid or autoimmune disease, osteoporosis, thyroid cancer.
• Pregnancy or plans for pregnancy, and any recent pregnancy. NIDDK and NHS say this matters in thyroid disease and diabetes.
• A list of your questions, because they are easy to forget during the visit.

1.2. What does the doctor usually ask?

NHS writes that in thyroid disease the doctor asks about symptoms, a family history of thyroid and autoimmune disease, and recent pregnancy, and may feel the neck to check for thyroid swelling. Questions like these usually come up too:

• When did it start, and was it gradual or sudden?
• What makes it worse or better?
• How are your sleep, weight, appetite, mood, and energy?
• Periods and fertility, for women.
• Current and past medications.

If you do not know when weight loss or gain, period changes, or other symptoms began, make a guess and say that it is a guess.

1.3. Which tests may be requested?

Depending on your complaint, the doctor may request tests like these:

• Thyroid hormones (TSH and T4). NHS and NIDDK list them for diagnosing an underactive or overactive thyroid.
• Fasting glucose or HbA1c.
• Sometimes imaging, such as a thyroid ultrasound.

NIDDK writes that symptoms alone cannot give a definite diagnosis and that tests are needed. For preparation details, see the guide “Preparing for lab tests.”

1.4. What should you not do before the visit?

• Do not stop your medication or change the dose on your own. MedlinePlus writes to tell the doctor what you take, but not to stop any of it without asking. Do not stop thyroid pills, insulin, or steroids without the doctor.
• Biotin: NHS says biotin may interfere with thyroid tests. If you take it, ask the doctor or the lab before the test.
• Do not guess about fasting. For fasting glucose, NIDDK lists at least 8 hours of fasting, but some tests do not require fasting. Ask at the place where you have the test done.

1.5. Who should come with me?

If you tend to forget, or medical language is hard for you, bring someone with you. After the visit, ask the doctor to write down or repeat the plan: which test, when, and under what circumstances to call sooner.

1.6. After the visit

• Write down the result and the plan, and keep new lab results in the same folder.
• If a medication was started, NIDDK says that for thyroid pills the test is usually repeated six to eight weeks later. Do not forget the follow-up.
• If you notice a new symptom or a side effect from a medication, do not wait for the next appointment. Call. For urgent situations, see the guide “When should I call right away?”

2.0. Before anything else

The exact preparation is given by the lab that takes the sample, because methods differ. This guide is only a general explanation. If you take any medication, do not stop it without asking.

2.1. Which tests require fasting?

NIDDK lists these:

• Fasting plasma glucose (FPG): Do not eat or drink anything for at least 8 hours, except sips of water. A morning sample is more reliable.
• Oral glucose tolerance test (OGTT): At least 8 hours of fasting. A fasting sample, then a sugar solution to drink, and a second sample two hours later.
• HbA1c: Fasting is not required. It can be done at any time of day. It shows the average glucose over roughly the past three months.
• Random glucose: Fasting is not required, and it is used together with symptoms.

Other tests, including blood lipids and vitamin D, have their own preparation, and the source we opened for this page does not list them. Ask the lab.

2.2. The thyroid test

MedlinePlus writes that no special preparation is needed for TSH. A few points:

• Time of day: TSH levels change during the day, and MedlinePlus considers early morning better.
• Medications: Tell the doctor and the lab about all your medications. MedlinePlus writes that some medications, such as amiodarone, lithium, potassium iodide, and steroids, may need a short pause. That decision belongs to the doctor. Do not stop them yourself.
• Thyroid pill before the test: The sources we opened for this page give no clear ruling on whether the morning pill should be taken before the blood draw. Ask the doctor or the lab that takes the sample, and repeat the same routine every time, so the results can be compared with each other.
• A recent severe illness: The NHS lab writes that an acute illness can make the result misleading and that the test is better done about three months afterward. If you recently had a serious illness, say so.
• After a medication change: The same lab lists waiting at least two months before retesting, and NIDDK lists 6 to 8 weeks after starting thyroid pills. The doctor sets the interval.

2.3. Biotin and testing

Biotin (vitamin B7) is common in hair, skin, and nail supplements. NHS and MedlinePlus both write that biotin can interfere with thyroid test results, so tell the doctor before any test. For high doses, the NHS lab writes that the sample should be taken at least 8 hours after the last dose. If you take biotin:

• Tell the doctor or the lab before the test.
• Do not decide on your own to stop it a few days earlier and then interpret the result. The doctor will say whether a pause is needed.
• Name the supplement, because biotin may not appear on the label as such and may be inside a multivitamin or a “hair and nails” product.

2.4. “Is my number normal or not?”

• The normal range differs from one lab to another. The NHS lab gives 0.27 to 4.2 for adult TSH, and MedlinePlus gives 0.4 to 4.8. Both say the range depends on the lab’s method. Always compare your number with the range on that same report.
• Pregnancy: The TSH range differs in each trimester of pregnancy (NHS lab). Tell the lab if you are pregnant.
• Children: The range is based on age.
• A1C is not always reliable. NIDDK writes that in some anemias, thalassemia, severe iron-deficiency anemia, kidney failure or liver disease, blood disorders, and in the second and third trimesters of pregnancy, the result may be misleading. If your A1C does not match your glucose readings, the doctor should ask why.
• One number is not enough. NIDDK writes that doctors usually repeat the test to confirm diabetes.

For interpreting TSH, see the article “What Does a TSH Number Mean?”

2.5. Test day

• Water: In fasting tests, NIDDK allows sips of water.
• Medication: Take any medication the doctor has told you to take. If the doctor has not said, ask before the test whether to take your pill that day.
• Bring with you: Your list of medications and supplements, and previous results with date and unit.
• After the test: Keep a copy of the result.

3.0. First things first

The CDC writes that checking blood sugar is the most important thing you can do to manage diabetes, because food, medicine and activity each move your glucose. But your doctor sets your target and how often to check. If you take insulin or another medicine, do not raise or lower it yourself based on a glucose number, unless you are following a plan you wrote with your care team.

3.1. How do I measure my glucose?

The CDC lists these steps for a fingerstick meter:

1. Make sure the meter is charged and ready.
2. Wash your hands with warm water and soap and dry them well.
3. Massage or shake your hand so blood flows to the finger.
4. Prick the tip of your finger with a lancet and put a drop of blood on the strip.
5. Insert the strip into the meter. The number appears in a few seconds.
6. Write the number down, along with anything that might have affected it.
7. Throw away the lancet and strip.
8. Never share lancets or monitoring supplies with anyone, even family.

Cold hands make it harder to get blood, so warm your hands first. Keep strips in a closed container, away from moisture, heat and cold. Teach a family member to use the meter, for times when you are not well enough to check yourself.

3.2. What is the target?

For most adults with diabetes who are not pregnant, the CDC lists these ranges:

• Before a meal: 80 to 130 mg/dL.
• One to two hours after a meal: less than 180.

The CDC stresses that the target varies with age, health and treatment plan. NIDDK also writes that the target changes during pregnancy. So ask your doctor for your own number.

3.3. How often and when?

The CDC says your doctor decides when and how often. NIDDK writes that even if you have a continuous sensor, you still need a fingerstick in these cases: you doubt the sensor reading, your insulin dose is changing, or the sensor alerts you. Some sensors also need fingerstick calibration.

3.4. A logbook or an app

Write down each number along with anything that might have affected it: food, exercise, illness, medicine. The CDC says to look for patterns and bring them to your care team so they can adjust the plan. If your meter has memory or connects to a phone, that is enough. Otherwise, use a paper logbook.

An A1C test is also needed alongside home monitoring. The CDC writes that if you have diabetes, it should be done at least twice a year.

3.5. Continuous sensor or fingerstick?

NIDDK writes that a continuous glucose monitor (CGM) estimates the glucose in the fluid between cells every few minutes, through a sensor under the skin, usually on the abdomen or arm, and sends the number to a phone, pump or receiver. Types: real-time, intermittently scanned, and downloaded at a clinic. Disposable sensors are replaced every 7 to 14 days. The cost is higher and insurance coverage varies. It has high and low glucose alerts, and the response to them should follow your treatment plan. Your doctor decides whether you need one and which type. This page does not say whether sensors or sensor services are available at any particular center.

3.6. What is low blood sugar?

NIDDK writes that for many people with diabetes it means glucose below 70 mg/dL, but your care team can set a different threshold for you. The CDC calls below 55 severe. At that level the 15-15 rule may not work and the person may not be able to check or treat their own glucose, so someone else has to help.

Who is at higher risk? NIDDK says people who take insulin or certain other diabetes medicines, people with type 1, people age 65 and older, people who have had lows before, and people with kidney disease, heart disease or cognitive impairment.

Causes: insulin or some pills, skipping or delaying a meal, more physical activity than usual (the effect can last up to 24 hours), alcohol without food, an illness that reduces eating, and fasting while taking medicine.

Symptoms: the NHS and NIDDK list shakiness, sweating, hunger, dizziness, anxiety or irritability, a pounding heart, tiredness, blurred vision, headache, confusion and tingling lips. A low can also happen during sleep: waking up tired or confused, sheets soaked with sweat, nightmares. A severe low can lead to seizures or loss of consciousness.

3.7. How do I treat a mild low?

This section is for someone who is awake and able to swallow. If you have symptoms of a low, or your glucose is low, treat it right away. If you cannot check your glucose, take the symptoms seriously and treat them (NHS). The CDC writes the 15-15 rule and NIDDK writes 15 to 20 grams of fast-acting carbohydrate:

1. Eat 15 to 20 grams of fast-acting carbohydrate. Examples: 3 to 4 glucose tablets, half a cup of juice or regular soda (not diet), one tablespoon of sugar, honey or syrup, or one tube of glucose gel.
2. Wait 15 minutes and check your glucose again.
3. If it is still low, repeat.
4. Once your glucose is back in the target range, eat a balanced snack or a meal with protein and carbohydrate. NIDDK says to have a snack if your next meal is more than an hour away.

NIDDK writes that people who take medicines that slow the digestion of carbohydrate should use glucose tablets or gel, because other foods act too slowly. If you have kidney disease, avoid orange juice because it has a lot of potassium; apple or grape juice is a better choice (NIDDK). The CDC says small children may need less than 15 grams, and you should ask the doctor. If your lows are frequent, happen at night, or you do not feel the symptoms, tell your doctor (NHS).

3.8. A severe low

The CDC writes that injectable glucagon is the best treatment for a severe low. NIDDK says it comes as an injection or a nasal spray. It needs a prescription, so ask your doctor whether you need it.

• Teach the people around you: the signs of a low, how to check glucose, and where glucagon is kept and how to use it. The CDC says a person with a severe low may not be awake or able to help themselves.
• If the person is unconscious, has a seizure or cannot swallow: give nothing by mouth and lay the person in the recovery position, on their side (NHS). If glucagon is available and you know how to use it, give it right away.
• Call 115: right away if there is no glucagon or you do not know how to use it, and immediately after giving it if you do (NIDDK and CDC). The NHS calls for emergency help when there is no glucagon, when there is no recovery within 10 minutes, or when the person has been drinking alcohol. We give the more cautious rule here.
• Once the person is awake and able to swallow: give fast-acting sugar and then longer-lasting carbohydrate with protein (CDC). Stay with them until they have fully recovered (NHS).
• NIDDK says to carry a medical alert card or bracelet.

115 is Iran’s emergency number and does not work abroad. For the full list, see the guide “When should I call right away?”

3.9. Preventing lows

NIDDK writes these:

• Check your glucose regularly with the meter. If you have frequent lows or do not feel the symptoms, a continuous sensor with alerts may help.
• Eat regular meals and snacks with enough carbohydrate, and carry a fast sugar source.
• Check your glucose before, during and after exercise, and ask your care team how to adjust medicine or food.
• Drink alcohol with food.
• Ask your care team which of your medicines can cause lows and how to adjust the plan.

NIDDK warns that repeated lows can cause “hypoglycemia unawareness,” meaning you do not feel the symptoms until your glucose is very low. Fear of lows also sometimes leads patients to stop their medicine, and their glucose then rises. Do not do this, and share your fear with your doctor.

4.0. First things first

This guide is general information. Your care team writes your insulin type, amount, injection times and sick-day plan, and everyone is different. Never stop insulin on your own, especially in type 1 diabetes. The NHS also writes that even if you are not eating, you should not skip an injection, and you should check what your care team has told you.

4.1. What is insulin and who needs it?

NIDDK writes that insulin is a hormone made by the pancreas.

• Type 1: The body does not make insulin, so injections are essential. Usually several times a day, including with meals.
• Type 2: Some people are controlled with lifestyle changes alone. Many need medicine and sometimes insulin, and the need may grow over time. Sometimes it is temporary, for example during pregnancy or a hospital stay.
• Gestational diabetes: If food and activity are not enough, insulin comes up. NIDDK writes that insulin is safe in pregnancy.

Types of insulin differ in how soon they start, when they peak and how long they last: rapid-acting, short-acting, intermediate-acting, long-acting and mixed. The doctor decides the type and schedule. Ways to take it: syringe, pen, pump and, in some cases, inhaled powder (NIDDK).

The main side effect of insulin is low blood sugar. NIDDK says weight gain is also possible. How to treat a low is covered in the guide “Checking Glucose at Home and Recognizing Low Blood Sugar.”

4.2. Storing insulin

The American Diabetes Association and the NHS write these:

• Spare, unopened: In the refrigerator, away from the freezer section and the cooling element. If it freezes, throw it away.
• In use: Many doctors suggest room temperature, because cold insulin sometimes stings. The American Diabetes Association says it lasts about a month at room temperature. The NHS writes that an open cartridge can stay at room temperature for 4 or 6 weeks, depending on the brand. Check the leaflet that comes with the medicine, or ask the pharmacist.
• Heat and light: Keep insulin away from extreme heat, extreme cold and direct sunlight. Do not leave it on a car dashboard.
• Before injecting: Let cold insulin come to room temperature (NHS).
• Checking: Do not use insulin past its expiration date. If you see particles, discoloration, or crystals and clumps, do not use it. An unopened vial can be returned to the pharmacy (American Diabetes Association).
• Supply: The NHS says the doctor or nurse usually recommends a one- to two-month supply, with at least one spare cartridge or vial.
• Syringes and needles: Never share a syringe or pen with anyone. The American Diabetes Association writes to talk with your doctor or nurse before reusing a syringe. Do not reuse if you are sick, have a wound on your hand, or have a weakened defense against infection. Put needles in a sturdy, puncture-proof container, and do not put the container in recycling.

Travel: The NHS writes to bring extra insulin, keep it in your carry-on bag, carry a letter from your doctor or diabetes team, and tell the airline before the flight if you have a pump or sensor. If you use a cool bag, keep the insulin away from the ice so it does not freeze. If you cross several time zones, ask your doctor how to adjust the schedule.

4.3. Sick days

When you are sick, glucose rises and you may not want or be able to eat. Three sources give these points:

• CDC: Keep taking your insulin and diabetes pills as usual. The sick-day steps apply even if your glucose is in range.
• American Diabetes Association: Agree in advance with your care team on a plan for illness. Some medicines or routines may change.
• NHS (about ketoacidosis): Keep taking insulin even when you are not eating, and do not skip an injection.

The takeaway: without a plan from your doctor, do not lower or raise the dose, and do not stop insulin. If you have no plan, call on the very first day of illness. The NHS also writes that in type 2 diabetes, if you have vomiting, diarrhea or fever, you should contact your care team. They may pause a medicine temporarily, but do not do it yourself.

4.3.1. What should I monitor?

• Glucose: The CDC says to check every 4 hours and write it down. Your doctor may ask you to check more often.
• Ketones: The CDC says if you are sick or your glucose is 250 mg/dL or higher, also check your urine for ketones. The American Diabetes Association writes every four to six hours when you are sick. For blood ketones the NHS gives these: below 0.6 is normal, 0.6 to 1.5 slightly high (recheck after two hours, and call your team right then if you feel unwell), 1.6 to 3 at risk (call your team right then), above 3 high, meaning possible ketoacidosis and an emergency. For a urine strip, the NHS treats above 2+ as high and an emergency. The NHS adds that these numbers are a guide and your care team will tell you yours.
• Fluids: The CDC says to drink enough to avoid dehydration. The American Diabetes Association says if you cannot keep water down, sip every 15 minutes.
• Food: The CDC writes to eat your usual food as far as you can. If you cannot, about 50 grams of carbohydrate every 4 hours, for example one and a half cups of juice or unsweetened applesauce.
• Fever and weight: Check your temperature morning and evening and weigh yourself every day (CDC).
• Over-the-counter medicines: The American Diabetes Association says to ask your care team which cold and flu medicines are safe, because some raise glucose or interact with your medicines.

4.3.2. When should I call the doctor?

The American Diabetes Association writes to call if you have vomiting or diarrhea more than three times in 24 hours, or a fever above 101 degrees Fahrenheit (about 38.3 degrees Celsius) that lasts 24 hours.

Take ketones in the urine seriously. The CDC says that if there are ketones in your urine, you should call the doctor right away and will probably need hospital treatment. The same page also puts urine ketones on its emergency room list. So call right then, and if you cannot reach the doctor straight away, do not wait: go to the emergency room.

4.3.3. When should I go to the emergency room?

The CDC lists these:

• Shortness of breath.
• Ketones in the urine, if you cannot reach the doctor straight away, the strip shows above 2+ (NHS), or you feel unwell.
• Being unable to keep fluids down for more than 4 hours, or food for more than 24 hours.
• Losing 5 pounds (about 2.3 kg) or more during the illness.
• Severe vomiting or diarrhea for more than 6 hours.
• Glucose below 60 mg/dL. If you are awake and able to swallow, take fast-acting sugar right away.
• Fever above 101 degrees Fahrenheit for 24 hours, if your doctor has not given you a different plan.

For ketoacidosis, the CDC also lists glucose of 300 or higher that does not come down, fruity-smelling breath, and vomiting with inability to drink. If you are tired or confused, send someone else to call or take you. Do not drive yourself.

4.4. Ketoacidosis and the hyperosmolar state

Ketoacidosis (DKA): The CDC and NHS write that when insulin is low, the body burns fat and ketones rise. It is more common in type 1 but can also happen in type 2. Symptoms: thirst and frequent urination, abdominal pain, nausea and vomiting, fast and deep breathing, fruity-smelling breath, drowsiness and confusion, blurred vision. The NHS writes that symptoms usually develop over 24 hours, and sometimes faster. Triggers: illness, a missed or insufficient insulin dose, a pump blockage, stroke, injury, alcohol and some medicines such as cortisone and diuretics. The CDC considers it a medical emergency.

Hyperosmolar hyperglycemic state (HHS): MedlinePlus writes that it is most common in uncontrolled type 2 diabetes. Glucose becomes very high with severe dehydration, and ketones are usually absent. Symptoms worsen over days or weeks: thirst and frequent urination, then weakness, nausea, dry mouth, fever, confusion, seizures and coma. It is an emergency. Prevention: controlling diabetes, recognizing dehydration and infection, a sick-day plan, and keeping three months of medicine so it does not run out.

For both, call 115 (Iran’s emergency number, not valid abroad) and bring your medicines. Do not drive yourself (NHS).

4.5. What if I cannot reach my care team?

Go to the emergency room of the nearest hospital, bring your medicines and your medicine list, and say that you have diabetes.

5.0. Before anything else

This guide is for someone who has diabetes and wants to decide about fasting in Ramadan. The decision about whether to fast is made by your doctor and you together before the month begins. This page neither prescribes nor forbids fasting, and it cannot replace an individual assessment. For the religious ruling on fasting during illness, ask your own religious authority.

IDF-DAR (the International Diabetes Federation and the “Diabetes and Ramadan” alliance) has a detailed guideline that grades the risk for people with diabetes who fast. We could not open its full text, and what you read here comes from two journal articles and one hospital guide that explain it. If your doctor uses it, ask the doctor to assess your risk.

5.1. Why ask early?

Johns Hopkins Aramco writes to book an appointment six to eight weeks before Ramadan. The doctor assesses your glucose control, your medications, your past fasting experience, and your risk. About the IDF-DAR tool, PMC writes that the assessment is done about six weeks before the month and repeated every year. There is no need to wait until the last week.

Risk assessment: The IDF-DAR tool treats a score of 0 to 3 as low risk, 3.5 to 6 as moderate, and above 6 as high risk. Scores go up in half points, so no value falls between 3 and 3.5. The score is built from things like the type and duration of diabetes, HbA1c, a history of low blood sugar, recent ketoacidosis or hyperosmolar state, kidney function, heart and vascular disease, pregnancy, frailty and cognitive impairment, medications, and previous fasting experience. The article writes that physicians are advised to discourage fasting for patients at moderate and high risk, but that discussion and shared decision-making matter, because many people fast anyway.

5.2. Who is usually not advised to fast?

Johns Hopkins Aramco writes that people at very high and high risk are usually not advised to fast. They include:

• Type 1 diabetes
• Uncontrolled type 2 diabetes
• Pregnant women with diabetes
• People who have had severe low blood sugar in the past three months

The same page says that someone with well-controlled type 2 diabetes and no major complications may be able to fast with medication adjustments and monitoring. Only the doctor decides on medication changes.

5.3. Risks of fasting

The PMC article describes the risks this way:

• Low blood sugar: Documented, especially with insulin or a sulfonylurea. NIDDK also lists fasting while taking a glucose-lowering medication as one of the causes of low blood sugar.
• High blood sugar: Documented, and sometimes accompanied by overeating or missed medication.
• Ketoacidosis and hyperosmolar state: The evidence is mixed. CDC lists illness and missed insulin as triggers of ketoacidosis.
• Dehydration: Documented, and made worse by heat and long fasts.
• Clots: This link is debated and has not been firmly established.

5.4. When should you break the fast?

Johns Hopkins Aramco writes to break the fast and get help from the doctor in these situations:

• Glucose below 70 mg/dL (3.9 mmol/L)
• Glucose above 300 mg/dL
• Symptoms of low or high blood sugar
• Dehydration, fever, diarrhea, or an acute illness

The same page says that breaking the fast in these situations is permitted and necessary. For low blood sugar, treat it with the same 15-15 rule and fast-acting glucose (see the guide “Checking Glucose at Home and Recognizing Low Blood Sugar”).

Checking your glucose does not break the fast. Johns Hopkins Aramco writes that religious scholars have permitted fingerstick checks and glucose sensors. So do not wait to check. If you feel unwell, check right then.

Call the doctor right away if you have repeated low or high readings, dehydration that does not improve with drinking fluids, a new symptom of a complication, or you are not sure whether continuing is safe. For the signs of ketoacidosis (severe thirst, vomiting, rapid breathing, fruity breath, drowsiness), see the guide “When should I call right away?” In Iran, call 115 (Iran’s emergency number, not valid abroad).

5.5. Medication and insulin

• Do not change your medication yourself. Johns Hopkins Aramco writes that any medication change must be approved by a medical team. The timing and amount of medications usually change in Ramadan and differ for each person.
• Do not stop insulin, especially in type 1. Do not fast without a plan from the doctor, and do not skip insulin.
• If you take a medication that can cause low blood sugar (such as insulin or some pills), ask what to do at suhoor, at iftar, and in between.

5.6. Fluids and food

Johns Hopkins Aramco lists these:

• Fluids: Drink plenty at suhoor, and drink enough fluids from iftar until suhoor too.
• Suhoor: Slowly digested carbohydrates such as whole grains, oats, barley, and legumes, together with a protein such as eggs, yogurt, or cheese. Eat close to the dawn call to prayer so the fasting period is shorter.
• Iftar: Start with dates and water. Do not eat quickly or a lot. Prefer grilled or baked food to fried, add vegetables, and cut back on sweets and sweet drinks.
• Overall: Two main meals and one light snack.

Plan your exact diet with the doctor or a dietitian.

5.7. If I cannot or do not want to fast

Talk to the doctor and see what is possible in your situation. If you decide to fast, raise it with the doctor before the month and take monitoring seriously throughout the month.

6.0. Before anything else

Most of the time, an endocrine problem can be looked into at a regular appointment. But there are a few situations in which you should not wait. This list does not cover every case and does not replace seeing a doctor. If you are worried or unsure, call. It is better to call needlessly than too late.

In Iran, the emergency number is 115 (it does not work abroad). If you feel very unwell, do not drive yourself. Take the medications you use with you and say that you have an endocrine condition or diabetes.

There are three categories. The first means call 115 right now, the second means the same day, and the third means this week with a doctor.

6.1. Call 115 right now

If you have any of these, or someone next to you does, call. Do not wait for your own doctor’s reply or for your appointment to arrive.

6.1.1. Severe low blood sugar

NIDDK writes that severe low blood sugar is dangerous and must be treated immediately. Signs: loss of consciousness, a seizure, being unable to swallow, or not responding normally (NHS). In this situation, do these in order:

• Do not give anything by mouth, because the person cannot swallow safely (NHS).
• Lay the person in the recovery position, on their side (NHS).
• If glucagon has been prescribed and you know how to use it, give it right away.
• Call 115: right away if there is no glucagon or you do not know how to use it, and immediately after giving it if you do (NIDDK and CDC).
• Stay with the person. Once they are awake and able to swallow, give fast-acting sugar and then longer-lasting carbohydrate with protein (NHS and CDC).

The NHS calls for emergency help when there is no glucagon, when there is no recovery within 10 minutes, or when the person has been drinking alcohol. We give the more cautious rule here.

For how to treat mild low blood sugar, see the guide “Checking Glucose at Home and Recognizing Low Blood Sugar.”

6.1.2. Signs of ketoacidosis (DKA)

CDC calls it a serious and potentially deadly complication of diabetes. It is more common in type 1, but it can also happen in type 2. Signs (CDC and NHS): severe thirst and frequent urination, nausea and vomiting, abdominal pain, fast and deep breathing, dry mouth and skin, fruity-smelling breath, headache, muscle cramps and aches, severe fatigue, drowsiness, and confusion.

CDC lists these as reasons for immediate care: glucose that stays at 300 mg/dL or higher, fruity breath, vomiting with inability to keep food or fluids down, shortness of breath, several symptoms together, or high ketones. NHS says to treat blood ketones above 3 mmol/L or urine ketones above 2+ as an emergency, and if you have symptoms but do not know your ketones, still treat it as an emergency. The same applies if you have not had diabetes before and have these symptoms. For sick days, CDC also gives these reasons to go to the emergency room: being unable to keep fluids down for more than 4 hours, and severe vomiting or diarrhea for more than 6 hours.

Call 115 or ask someone to take you to the emergency room. Do not drive yourself, and bring your medications (NHS). Do not stop insulin, even if you are not eating (NHS).

For checking urine or blood ketones, see the testing steps in the guide “Insulin, Storage and Sick Days.”

6.1.3. Hyperosmolar state (HHS)

MedlinePlus writes that it happens mostly in uncontrolled type 2 diabetes. Glucose rises very high, the body becomes severely dehydrated, and ketones are usually absent. Symptoms worsen over days to weeks: thirst and frequent urination, then weakness, nausea, dry mouth, fever, confusion, seizures, and coma. Triggers: infection, stroke, recent surgery, medications, or running out of diabetes medication. It is an emergency: go to the emergency room or call 115 (Iran’s emergency number, not valid abroad).

6.1.4. Adrenal crisis

NHS calls adrenal crisis the most serious complication of Addison’s disease and a medical emergency. An infection, an accident or injury, or surgery can trigger it, and the symptoms get worse very quickly. NIDDK lists suddenly stopping steroid medication as a cause of adrenal insufficiency, so this warning also applies to someone who has taken steroids for a long time. Signs: fast heartbeat, severe dizziness, severe pain in the abdomen or side, muscle weakness or cramps, persistent headache, nausea and vomiting, confusion or drowsiness, seizures, or loss of consciousness. In this situation:

• If you have an emergency steroid injection and have been taught to use it, give it right away.
• Call 115 even if you have given the injection (NHS).
• Tell the emergency team that you take steroids and show your steroid emergency card (NHS).

Do not suddenly stop steroid pills or steroid medication. NHS writes that stopping suddenly can cause severe fatigue, nausea and vomiting, and dizziness.

6.1.5. Thyroid storm

If you have an overactive thyroid and these signs suddenly appear, call 115. MedlinePlus calls thyroid storm a rare, life-threatening condition, and NHS describes it as a sudden flare-up of symptoms. Signs: restlessness, confusion or a change in alertness, fever, a fast and pounding heartbeat, tremor, sweating, diarrhea, and bulging eyes. It happens in uncontrolled overactive thyroid after a major stress such as an infection, an injury or a heart attack, and rarely after radioactive iodine treatment, even a week or more later. It is often treated in the intensive care unit.

6.1.6. Very low or high calcium

• Low calcium: NHS writes that tingling, cramps, and muscle spasms are signs of low calcium. Confusion, an irregular heartbeat, and seizures are more serious signs. If a seizure is the first one, lasts longer than usual, or continues for more than 5 minutes, call 115 and do not drive yourself. NHS writes that very low calcium can cause seizures and serious heart problems and must be treated in hospital, so go to the emergency room for confusion or an irregular heartbeat too. After neck or thyroid surgery, also tell the surgical team about these signs.
• High calcium: MedlinePlus writes that many people have no symptoms, but some may have nausea, vomiting, constipation, thirst and frequent urination, muscle weakness, and confusion. Severe cases with symptoms are usually admitted to the hospital. If you have confusion, vomiting, or severe thirst with high calcium or an overactive parathyroid, go to the emergency room. (NIDDK lists confusion and vomiting among the more severe signs of an overactive parathyroid.)

6.1.7. Other situations

• Myxedema coma (very severe underactive thyroid): Rare and mostly in older adults. NHS calls it a hospital emergency.
• Severe shortness of breath or swelling of the throat or tongue after taking a thyroid pill: NHS lists this as a serious allergic reaction (anaphylaxis). Call 115.
• Shortness of breath with a lump at the front of the neck: NHS gives an urgent appointment for difficulty breathing. If the shortness of breath is severe or getting worse, do not wait for an appointment: go to the emergency room.
• A sudden, severe headache with vision changes, nausea or vomiting in someone with a pituitary tumor: MedlinePlus writes that the pressure symptoms of a tumor rarely come on suddenly and severely (pituitary apoplexy). Go to the emergency room.
• Severe pain after a fall in someone who has or may have osteoporosis: NHS says it is an emergency, and do not drive yourself.

6.2. Call your doctor or care center the same day

• High glucose that does not come down with the usual plan, even if your ketones are normal (NHS).
• Call now, not at the end of the day: blood ketones of 1.6 to 3 mmol/L, even if you feel well, or 0.6 to 1.5 with feeling ill (NHS). The same applies to ketones in the urine, and if you cannot reach the doctor straight away, go to the emergency room (CDC).
• Vomiting or diarrhea more than three times in 24 hours, or a fever above 101 degrees Fahrenheit (about 38.3 degrees Celsius) for 24 hours, in a person with diabetes (American Diabetes Association). If severe vomiting or diarrhea lasts more than 6 hours, or you cannot keep fluids down, see section 6.1.2.
• Constant thirst, frequent urination, severe fatigue, and unexplained weight loss that have just started: NHS writes to get an urgent appointment with a doctor or call a telephone advice service.
• Repeated or nighttime low blood sugar, or not feeling the signs of a low (NHS).
• A side effect of an antithyroid medication: NIDDK writes that if you develop fatigue or weakness, vague abdominal pain, loss of appetite, a rash or easy bruising, yellowing of the skin or eyes, a persistent sore throat, or fever and chills, tell a doctor right away.
• Pregnancy: If you become pregnant while living with thyroid disease or diabetes, NIDDK says to contact the doctor as soon as you find out.
• Becoming ill while taking steroid pills or cortisol replacement. NHS writes that the dose of the medication may need to be higher during illness. Only the doctor decides this.
• A new symptom after neck surgery.

6.3. Book an appointment this week

• A new lump at the front of the neck, hoarseness, or difficulty swallowing that does not get better (NHS).
• Back pain that does not improve after a few weeks, a stooped back, or loss of height (NHS).
• A fast heartbeat, tremor, and weight loss with a big appetite (NHS and NIDDK).
• Irregular or stopped periods, or milk discharge without pregnancy.
• Unexplained headache or vision problems.
• Chronic symptoms that have gotten worse.

6.4. If you cannot reach your own doctor

Go to the emergency room of the nearest hospital and say that you have diabetes or an endocrine condition. Take your medication list with you: insulin, thyroid pills, steroids, biotin, or supplements. If you do not have a reserve of medication or glucagon, ask the doctor or the pharmacy before it runs out.