Diabetes

Hope is on the horizon

Diabetes is a disorder in which the basic human fuel-- blood sugar (glucose)-- remains too high. It also involves insulin, the body's "thermostat" for blood sugar levels.

There are two major kinds of diabetes. In type 1, the body has a profound shortage of insulin because the cells in the pancreas which make it have been destroyed. In type 2, the pancreas produces less insulin than you need, and your body resists its action so that it cannot deliver glucose to the cells. Type 2 also happens when the pancreas does not make enough insulin.

Unfortunately, diabetes is an extensive, chronic disease. Its complications can run the gamut from gangrene to vision loss. But its treatment is equally far-reaching, involving long-term vigilance against the dangers associated with the condition. Breakthroughs in treatment methods have made living with diabetes more convenient and manageable. People with this condition can perform much of their own care. And in the past two decades, life expectancy for people with diabetes has increased dramatically.

If you have diabetes, you need to take charge of your health. You have a treatable condition and an enjoyable future ahead of you. And there's hope on the horizon for even more breakthroughs.

Pronunciation

dye-uh-BEE-teez

Abbreviation of Condition

  • IDDM: insulin-dependent diabetes mellitus (type 1)
  • NIDDM: non-insulin-dependent diabetes mellitus (type 2)

Synonyms

For type 1 diabetes:

  • Juvenile-onset diabetes
  • Brittle diabetes
  • Insulin-dependent diabetes mellitus

For type 2 diabetes:

  • Adult-onset diabetes mellitus
  • Non-insulin-dependent diabetes mellitus
  • Nonketiotic diabetes mellitus

Detailed Description

Diabetes, or diabetes mellitus, is a disorder in which your body's blood sugar (glucose) level remains too high and causes problems. It involves the hormone insulin, which normally allows your body's cells to use the glucose as fuel. Diabetes occurs when your body either does not produce enough insulin or when it resists the hormone's action, or both.

Your body cannot use food directly. It needs to digest the food and convert it into glucose for the cells to use it. Insulin is the "messenger" for the blood's sugar (glucose) level. It promotes delivery of glucose from the blood into the cells of the body, where the sugar fuels the biological functions of the cells. Without insulin, the body does not have proper access to its basic source of energy.

If you are one of the millions of people who have diabetes, your body has trouble with the process of insulin regulating blood sugar. Your pancreas may not produce insulin at all; it may produce inadequate amounts of the hormone to carry the necessary amounts of fuel to your cells; and/or your body may resist insulin's activity. In any case, too much glucose remains in the bloodstream and not enough makes its way into the cells.

For people without diabetes, glucose levels go up and down slightly throughout the day, rising after a meal (120 to 140 mg/dL) and then returning to normal (70 to 100 mg/dL) in a few hours. But people with diabetes often register blood sugar levels above 160 mg/dL and even over 200 mg/dL.

In the short term, low glucose levels cause fatigue and weakness. The tissues and muscles don't receive sufficient energy. High blood sugar also triggers a harmful chain of events. It can cause frequent infections, impotence, chronic vaginitis, nerve conditions, eye damage, kidney damage, and heart disease.

The two main types of diabetes are:

  • Type 1. Also called insulin-dependent diabetes mellitus (IDDM). People with type 1 diabetes depend upon insulin injections because their bodies have stopped producing insulin. One of every 10 people with diabetes has type 1 diabetes. Most people with type 1 diabetes are diagnosed during childhood or adolescence and need to take insulin for life. Though the exact cause of type 1 diabetes remains unknown, recent findings suggest it relates to an immune system problem. About 85% of people with type 1 diabetes have antibodies to the insulin-producing cells of the pancreas. This suggests that it is the body's own immune system that injures the pancreas. Symptoms can include abnormally high thirst or hunger, frequent urination, fatigue, weakness, irritability, nausea, and weight loss despite increased hunger.
  • Type 2. Also referred to as non-insulin-dependent diabetes mellitus (NIDDM). Formerly, it was called adult-onset diabetes. Type 2 diabetes is marked by too little insulin and insulin that is ineffective. The typical person with type 2 diabetes is an older, overweight individual who has developed the disease over a period of years. Nine of every 10 diabetes cases are type 2. Sometimes, people with type 2 can treat their condition through weight loss, diet, and exercise, restoring their blood sugar levels to normal. If further treatment is needed, a doctor may prescribe oral medications that lower blood sugar levels (hypoglycemic agents). When oral medication doesn't work, the doctor may prescribe insulin injections.

Other types of diabetes include:

  • Gestational diabetes: impairment of glucose tolerance during pregnancy
  • Secondary diabetes mellitus: caused by medication or illness
  • Malnutrition-related diabetes: observed mainly in developing countries

If you have diabetes, the problems don't just begin and end with your metabolism. You need to be aware of a variety of other issues to care properly for your body. Tendencies toward infection, vision trouble, sexual dysfunction, and pregnancy problems can arise. You may find yourself chasing a number of seemingly random clues. Unfortunately, they all add up to elevated sugar levels and demand extra attention.

Characteristics of Diabetes

Type 1 diabetes has the following characteristics:

  • Younger age of onset (usually but not always before age 25)

  • Common among those with lean body mass

  • Sudden onset

  • Little or no natural insulin in bloodstream
  • Can also involve ketoacidosis, a very serious metabolic event with extreme dehydration, more acidic blood, and severe loss of body salts (electrolytes)
  • Lifelong insulin treatment required
  • Frequent urination (polyuria)
  • Abnormally high thirst (polydipsia)
  • Abnormally high hunger (polyphagia)
  • Other symptoms including fatigue, weakness, irritability, nausea, and weight loss despite raised hunger
  • Linked with autoimmune disease

Type 2 diabetes has the following characteristics:

  • Older age of onset (usually but not always after age 40)
  • Gradual onset (weeks to months)
  • Common among overweight individuals
  • Natural insulin in blood can be low, normal, or high
  • Usually have insulin resistance
  • Frequent urination (polyuria)
  • Abnormally high thirst (polydipsia)
  • Abnormally high hunger (polyphagia)
  • Other symptoms including fatigue, dry skin, skin infections, slow wound healing, blurred vision, and tingling or itching in the feet
  • Tends to run in families

How Common Is Diabetes?

Current estimates suggest that 12 million to 15 million Americans have diabetes, although about half are undiagnosed. Approximately 700,000 new cases appear annually. As many as 150,000 deaths are attributable to diabetes each year, and another 300,000 to 400,000 deaths may have diabetes as a leading factor.

For type 1 diabetes, the average onset happens between ages 8 and 12. The average age of onset for girls is about one year before onset in boys. After adolescence, the incidence of type 1 diabetes declines rapidly. For type 1 diabetes, the sex ratio appears equal. In type 2 diabetes, the incidence in females is higher than in males.

What You Can Expect

In type 1 diabetes, in the first few months after diabetes begins, you may experience a relative improvement referred to as the "honeymoon phase." During this period, people with type 1 diabetes will handle carbohydrates (sugars) better and may need less insulin. Overall, though, insulin injections will be required throughout life. Without insulin injections to control blood sugar levels, people with diabetes are prone to ketoacidosis (a very serious metabolic event) and other long-term complications such as vision loss, kidney disease, atherosclerosis, high blood pressure, heart disease, impaired digestion, vascular disease, gangrene, and nerve problems. According to medical evidence, with consistent good control of blood sugar levels, you can prevent development or progression of these complications.

People with type 2 diabetes have similar possibilities for complications. As with type 1 diabetes, you can decrease your risk of complications if you practice good control of your blood sugar levels. Diet and activity changes can help with glucose control. In type 2 diabetes, the cells in the pancreas which make insulin may eventually be lost. If that happens, you will need insulin injections.

Established Causes

No one knows what causes diabetes.

Theoretical Causes

It is thought that the inherited form of type 1 diabetes causes an alteration in the immune system that places the beta cells at risk for damage. Beta cells are the insulin-producing cells of the pancreas. Some researchers believe that the following factors can trigger the genetic tendency to develop this immune process:

  • Viruses (mumps, hepatitis, coxsackievirus)
  • Diet
  • Environmental toxins

For type 2 diabetes, it is theorized that a genetic predisposition to the disease may exist.

Risk Factors

Risk factors for diabetes include the following:

  • Pregnancy (causing gestational diabetes or diabetes during pregnancy)
  • Predisposition to autoimmune disorders
  • Hormone syndromes that interfere with insulin (acromegaly, Cushing's syndrome)
  • Diseases affecting the pancreas
  • Obesity (more than 25% over ideal body weight)
  • Having a first-degree relative with either type of diabetes

Symptoms

The signs and symptoms common to both type 1 and type 2 diabetes include:

  • High blood glucose
  • Excessive urination (polyuria)
  • Excessive thirst and hunger (polydipsia and polyphagia)
  • Fatigue and lethargy
  • Blurry vision
  • Frequent infections

Signs and symptoms more common to type 1 diabetes:

  • Weight loss despite high appetite
  • Failure to grow
  • Abdominal pain
  • Low blood pressure and rapid pulse (signs of dehydration)

Signs and symptoms more common to type 2 diabetes:

  • Skin infections
  • Tingling in the feet
  • Itching

In diabetic ketoacidosis, a severe systemic disturbance more common in type 1 diabetes, the following symptoms may appear:

  • Drowsiness
  • Dehydration (low blood pressure and rapid pulse, dry skin and tongue)
  • Nausea and vomiting
  • Smell of acetone on the breath (similar to nail-polish remover)

How Is Diabetes Diagnosed?

Your doctor will discuss your medical history and perform a physical exam, which will often include lab tests. In addition to symptoms, your doctor will take family history into account. If you are an older person suspected of having diabetes, your doctor will need to ask you numerous questions to reveal possible symptoms that may indicate complications of diabetes.

Lab tests

Laboratory diagnostic tests include measurement or analysis of the following:

  • Blood glucose
  • Electrolytes
  • Venous pH
  • CBC (complete blood count)
  • Glycosylated hemoglobin (indicates average plasma glucose levels for the last 1.5 to 3 months)
  • Islet cell antibodies
  • Thyroid function tests and thyroid antibodies
  • Urine for glucose (glycosuria) and ketones
  • Kidney function tests (BUN and creatinine)
  • Lipid profile

To confirm a suspected diagnosis, doctors perform a variety of tests that measure glucose levels. These include:

  • Fasting plasma glucose test. This test entails not eating or drinking anything except water for 12 hours prior to the test. Two or more glucose levels of higher than 140 mg/dL confirm diabetes.
  • Random plasma glucose test. This test measures your blood glucose levels without fasting. If it registers 200 mg/dL or higher and you are have excessive urination or thirst, intense appetite, weight loss, or fatigue, this test will confirm a diagnosis of diabetes.
  • Oral glucose tolerance test. This test evaluates your body's response to glucose. This test requires a 12-hour fast for accurate results. Avoid anything that may mislead the test results, including alcohol, caffeine, vigorous exercise, or smoking. The lab technicians will give you a sweet, syrupy solution. Drink the entire thing. If your blood glucose levels exceed 200 mg/dL within the first two hours, you have diabetes. This test can take up as long as five hours with repeated blood draws.

Goals of Treatment

While there is currently no known cure for diabetes, it can be treated with close management of diet, exercise, and medication-- either oral drugs or injected insulin. Treatment goals include keeping glucose levels within normal range, controlling the symptoms of hypoglycemic and hyperglycemic states, preventing the acute and long-term complications associated with this condition, and improving your overall quality of life. For children, treatment also aims to allow for normal growth.

Treatment Overview

Current treatments and self-management tools for diabetes offer much tighter control than those of the past did. Medical knowledge and more sophisticated self-blood-testing and insulin delivery systems have made tremendous progress in helping people with diabetes maintain appropriate blood sugar levels. Secondary diseases developing from unstable glucose levels, which jeopardize the heart and circulatory system, can be avoided with tight control.

Still, treatment of this condition through such lifestyle modifications as weight control, exercise, and diet is equally important. The most crucial component of managing diabetes is selfcare. Learning as much as possible about the disease and its complications will go a long way toward helping you successfully manage your diabetes.

Type 1 diabetes

Your doctor will prescribe you insulin to regulate your blood sugar levels. It comes in short-acting, intermediate-acting, or long-acting forms. Each has its peculiarities and tactics that you will need to finesse. Your doctor will coach you on how to test your blood-sugar levels and inject your insulin. But remember a few pointers:

  • If you're taking two different kinds of insulin (perhaps a short- and long-acting combination), ask your doctor to teach you how to mix them.
  • Rotate injection sites.
  • Always make sure the syringe is compatible with the insulin dose.
  • Report any of these responses to your doctor: breathing problems; systemic itching, especially redness, swelling, stinging, or itching at the site of your injections; and repetitive or extreme hypoglycemic or hyperglycemic episodes.
  • If you experience a severe hypoglycemic episode and someone needs to administer glucagon, be aware that nausea and vomiting may occur after taking this corrective medication. If you have difficulty breathing, develop a rash, or don't respond to glucagon, call your doctor immediately.

If you have type 1 diabetes, you should be monitored every three months to check for normal growth and development, and overall blood sugar control. Daily monitoring should occur at home with home blood glucose tests. Because your body is always growing and changing, annual assessments should be made on serum lipids, thyroid functions, and normal growth requirements.

Type 2 diabetes

You will generally be treated through diet and exercise. Occasionally, people with type 2 diabetes will be prescribed insulin injections and need to follow the suggestions above. Your doctor may also prescribe oral medications.

If you are going through a period of stress in your life, you may need to increase your oral medications. Avoid alcohol when taking these drugs -- the combination may cause nausea, vomiting, and sweating, or a full-blown hypoglycemic episode. Call your doctor if you have any of the following while taking these drugs: epigastric fullness, facial flushing, headache, heartburn, nausea, rash, vomiting, or jaundice.

For people with type 2 diabetes, the severity of the condition usually determines the frequency of follow-up care. Your doctor should examine your feet for ulcers, arterial insufficiency, and neuropathy. You will also need an eye exam and renal function assessment at diagnosis. In cases of type 1 diabetes, five years after diagnosis eye exams should be done annually, as should assessments of renal functions.

Drug therapy

Drugs most commonly prescribed

For type 1 and some forms of type 2 diabetes, injectable insulin is available in different forms. These vary in their speed and length of action, and include:

Commonly used oral drugs for type 2 diabetes include:

New Drugs in Development

  • Thiazolidinedione derivatives
    • Ciglitazone
    • Englitazone

Other approaches under investigation include:

  • Insulin skin patches
  • Oral and nasal forms of insulin doses
  • Islet-cell transplants that won't cause immunosuppression

Self-management

You can combat the problems associated with diabetes by being aware of the following:

  • People with diabetes are prone to skin infections due to impaired circulation. If you have severe nerve damage, care for your skin and feet very carefully and watch for signs of limited circulation (swelling, pallor, numbness, tingling, or hair loss). Dry thoroughly between your toes -- people with diabetes are 20 times more likely to develop gangrene than people without the disease are.
  • Don't use a hot-water bottle or heating pad if you have severe nerve damage; with reduced sensitivity, you may not feel it getting too hot and you could burn yourself.
  • Get your eyes examined regularly, as you are more inclined to develop retinopathy and vision loss.
  • Be aware that illness may change your blood sugar levels.
  • Men with diabetes who have vascular disease and/or nerve damage may experience impotence; discuss this issue with your doctor if you have a particular concern about your sexual functioning.
  • Women with diabetes have a greater risk of delivering babies with birth defects; it is crucial that you regulate your blood sugar levels before conception. Speak with a doctor who cares for women of childbearing age who have diabetes.
  • Plan ahead if you are traveling. Take plenty of medication and plot a blueprint for your insulin schedule if you are traveling across time zones.
  • Wearing a Medic-Alert bracelet or necklace is important. By alerting emergency personnel to your condition, you may help them save your life.
  • Report such infection signs as a burning sensation, pain, or difficulty urinating to your doctor.
  • People with diabetes are more prone to dental problems. Brush your teeth after eating, floss daily, and see your dentist regularly.
  • Know the signs of hypoglycemia. If you have mistakenly given yourself too much insulin or medication, you will begin to feel the effects of a low blood sugar crisis. If you notice that you are beginning to feel weak and anxious, or have a headache, vision changes, and start to sweat, use sugar or have someone prepared in advance to deliver glucagon.
  • Diabetic ketoacidosis is an emergency; signs include deep and rapid breathing, excessive thirst and urination, weight loss, nausea, vomiting, fatigue, and breath that smells like nail-polish remover. In the absence of sufficient insulin, the body cannot use sugar for energy and eventually begins to use fat and muscle as a source of energy. Contact your doctor immediately and go to the nearest emergency room.

Healthcare Professionals Who May Be Involved in Treatment

Many types of physicians may participate in treating your diabetes. They include the following:

  • Family physicians
  • Internists
  • Geriatricians
  • Pediatricians
  • Clinical endocrinologists
  • Neurologists
  • Nephrologists
  • Optometrists
  • Ophthalmologists
  • Vascular surgeons
  • Podiatrists

Activity & Diet Recommendations

Activity

Regular aerobic exercise will help you maintain more stable blood sugar levels. It provides the following benefits:

  • Increases insulin sensitivity and consequently lower insulin needs
  • Improves glucose tolerance
  • Reduces total serum cholesterol and triglyceride levels
  • Promotes weight loss in people who are overweight

Aerobic (cardiovascular) exercise is better than anaerobic (intense, muscle-building) exercise if you have diabetes, so stick to activities like walking, running, cycling, or swimming.

Diet

Tight monitoring and dietary controls are crucial if you have diabetes. You need to regulate what you eat so you can maintain appropriate glucose levels. Regulating blood sugar levels takes planning. Eat small, light meals frequently throughout the day. The diet of choice is high in fiber, protein, and complex carbohydrates and low in refined sugars. Experts recommend that people with diabetes limit cholesterol intake to 300 mg daily. They also recommend that total calorie intake represent about 10% to 20% from lean protein, such as fish, chicken, or veal, and no more than 10% each of saturated fat and polyunsaturated fat.

The timing of meals can be very important, too. In general, small, and frequent meals throughout the day-- rather than one or two big meals-- may help keep blood sugar steady. If you are using insulin, the timing of meals is especially important. Take into account the peak action of insulin during the day. When insulin is being used, missed meals may cause a serious episode of low blood sugar (hypoglycemia).

Some suggestions for planning your diet:

Fiber. The indigestible residues of fruits and vegetables especially benefit people with diabetes and hypoglycemia. Fibers from wheat, legumes, oat bran, nuts, seeds, psyllium-seed husks, pears, apples, and most vegetables help sustain even blood-sugar levels. Eat about 50 grams of fiber per day. You can get it by choosing the most natural form of a food possible. For example, instead of drinking apple juice, eat an apple.

Protein. Diets high in protein can help stabilize blood sugar levels. By providing calories with a low glycemic index, protein tends to produce much less of an insulin response than do carbohydrates. For instance, nuts (high in protein) have a glycemic index of 13, whereas corn flakes have an index of 80. These are both measured against glucose, which has an index of 100. Choose low-fat proteins such as chicken, fish, or veal instead of red meat.

Chromium. Interest has been growing in this trace mineral for its insulin-regulating properties. Discuss the possibility of using supplemental chromium with your physician.

Alcohol. Avoid it. It interferes with normal glucose utilization and pumps up insulin levels in people who have natural insulin available to them. Additionally, it sets up a hypoglycemic spiral where you crave more sugar-rich foods in a misguided effort to save the dropping blood sugar levels. Acute and chronic alcohol abuse provokes hypoglycemia. In the long run, it can even lead to diabetes by provoking insulin resistance. But if you are going to drink it, limit your intake and never drink on an empty stomach.

Possible Complications

Complications may occur for people with undiagnosed diabetes or people who know they have diabetes but aren't diligent about managing their treatment.

Possible complications due to both type 1 and type 2 diabetes include the following:

  • Neuropathy
  • Retinopathy
  • Nephropathy
  • Cardiovascular disease, including heart attack and stroke
  • Foot problems
  • Excess weight gain
  • Hypoglycemia
  • Coronary artery disease
  • Cerebral artery disease
  • Microvascular disease related to the eye, kidneys, and nerves
  • Cataracts
  • Glaucoma
  • Circulation problems
  • Charcot's joint
  • Diseases related to the eye, kidneys, and nerves, including blindness

Quality of Life

Diabetes is one of the most challenging of all chronic diseases to manage. The balance between too much and too little blood sugar controls many body functions and an error or mistiming can mean the difference between life and death. Ultimately, you are responsible for monitoring your own diet, medication, and exercise routine so that everything stays in balance.

The good news is that it's now possible to maintain a balanced glucose level. Medical knowledge and more sophisticated insulin delivery systems have made tremendous progress in maintaining appropriate blood sugar levels. Secondary diseases developing from unstable glucose levels, which jeopardize the heart and circulatory system, can be avoided with tight control. Consequently, life expectancy for people with diabetes has increased over the past two decades.

Considerations for Women

Women with type 2 diabetes have a higher risk of developing cardiovascular disease than other women. Consistent and strict control of blood glucose is especially important to prevent complications.

Pregnancy

Since high blood sugar can jeopardize fetal development in the very beginning stages of life, make sure you plan your pregnancy in advance and manage your blood sugar levels at the time of conception. Since having diabetes can make pregnancy more risky for both the mother and baby, it is best to seek advice from a doctor experienced with both pregnancy and diabetes.

Pregnant women who have risk factors associated with diabetes should closely monitor blood glucose level for the development of gestational diabetes.

Oral medications regulating blood sugar levels -- sulfonylurea and metformin - (glucophage) are not routinely recommended during pregnancy.

Nursing mothers

Oral hypoglycemic drugs used to regulate blood sugar levels are not usually recommended for nursing mothers. Insulin dosages may need adjustment because breastfeeding has a tendency to reduce insulin needs.

Considerations for Children and Adolescents

Most people with type 1, insulin-dependent diabetes are diagnosed as children. In the past 10 years, the disease has become more common in children under age 5. Type 2 diabetes is more rare in children, but is occurring more frequently in teenagers.

Get a MedicAlert bracelet or pendant for your child and make sure he or she wears it. Call your child's doctor at the first sign of any infection. Strict adherence to treatment programs is necessary so that the child does not develop further complications. Maintaining stable blood sugar levels is crucial to good health.

Poor diabetes control can eventually lead to cardiovascular disease, renal disease, eye disease, and life-threatening consequences from high or low blood sugar.

Have your child's medical program reviewed periodically to meet his or her growing and changing needs. When changes in physical activity and caloric needs develop during growth spurts, weight changes, and age increases, contact your doctor for advice about updating your treatment program.

Considerations for the Elderly

Type 2 diabetes affects a large portion of the elderly population and often contributes to other conditions such as heart disease, blindness, kidney failure, and infection in lower limbs.

Older people with diabetes may not need as much medication as their younger counterparts. Lower starting dosages are often prescribed in an effort to avoid hypoglycemia. Long-acting oral medications and long-acting insulin should be avoided for the same reason.

* Parke-Davis voluntarily discontinued the manufacture of this product on March 21, 2000.

Supplements

  • Vitamin E. Many studies show the value of vitamin E in treating type 2 diabetes. For example, Louisiana State University researchers gave 35 people with diabetes vitamin E (100 IU/day) for three months. Their blood sugar levels fell significantly. [1]
  • Chromium. Chromium is necessary for insulin synthesis and blood-sugar control. USDA researchers told 180 people with type 2 diabetes to continue taking their medications plus one of three supplement regimens: a placebo, a low dose of chromium picolinate (200 mcg/day), or a high dose of chromium picolinate (1,000 mcg/day). Both chromium groups experienced significant decreases in blood sugar and cholesterol. The high-dose group enjoyed the greatest benefit. [2]

Herbs

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