Diabetes Basics

Basics of diabetes

Diabetes is a condition caused by lack of a chemical in the body (a hormone) called insulin. There are two major forms of diabetes. In type 1 diabetes eventually no insulin is produced and individuals require insulin injections for survival. It used to be thought this only presented in children, but it is now clear this can occur at any age.

The other more common form of diabetes called type 2 diabetes occurs due to the body's resistance to the effects of insulin in addition to an insufficient quantity of insulin. However, in this type of diabetes there is usually some insulin produced.

For both types of diabetes, blood glucose levels are elevated. Furthermore, people with diabetes are prone to certain complications not seen in those without diabetes. These complications involve the eye (retinopathy), kidney (nephropathy) and nerves (neuropathy). People with diabetes also get early hardening of the arteries (atherosclerosis), leading to early heart attacks and strokes. The good news for people with diabetes is that with proper care all of these problems can be avoided.

Immediate medical attention

Uncontrolled diabetes presents with frequent thirst and urination. Over time, patients will become dehydrated as the glucose is "spilling" over into the urine. If insulin deficiency is severe enough, fat stores are used for energy as glucose cannot get into cells. This problem is much more common with type 1 diabetes and is called "ketoacidosis". It can be diagnosed at home with a simple urine test. When significant ketones are found in the urine, it is important to be in touch with a physician immediately.

There are other conditions that require immediate attention. Blurry vision in someone with known diabetic eye disease or someone with a long history of diabetes may mean there was bleeding in the back of the eye. This may require treatment by an eye doctor. An infection on the bottom of the foot is a common problem that needs immediate attention too. When people with long-standing diabetes experience heart disease, they often do not get the typical chest pain (angina) that occurs in those people without diabetes. Often their symptoms of heart disease presents with shortness of breath with minimal exertion. This should also prompt a call to a physician.

Swelling (edema) of the ankles is another common symptom that may be a sign of a serious problem. For example, new swelling in the ankles may suggest that large quantities of protein are being lost in the urine--the first problem noted with kidney disease. Swelling may also be seen with early heart failure, a common problem in people with diabetes. Alternatively, swelling may be due to a non-serious condition such as a side effect of a new medication or even a clue that the veins which take blood back to the heart are not working as well as they could be. Therefore, anytime new swelling is noted it should be reported to your physician.

Facts and myths

Diabetes does not "skip" generations. However, we don't understand the exact reasons why some people get diabetes and others don't.

A common misconception is that if children eat too much candy they will "catch" diabetes. Although we are seeing more type 2 diabetes in young people, this misconception refers to type 1 diabetes and is not true.

For people with diabetes, many feel that occasional blood glucose levels over 200 mg/dL will have long-term consequences. This is not true at all as it is common for glucose levels to rise above this level in almost everyone with diabetes.

There are also many misconceptions regarding food. One common one is that fresh fruit is "healthy" because it is "natural". While this may be true, fruit is also very effective at causing the blood glucose to rise quickly. Fruit juices are the most common problem here. Many people also don't realize how much milk causes blood glucose to rise. Finally, there are many misunderstandings regarding the glucose effects of alcohol. Depending on the type of alcohol consumed and the amount of food consumed, blood glucose can actually go DOWN when drinking so this needs to be done with caution.

There is also a common misunderstanding about exercise. While it is true that exercise usually results in lower blood glucose levels, if a person with type 1 diabetes exercises without sufficient insulin in the bloodstream (for example, more than 12 hours after the last shot of NPH insulin), the blood glucose can actually go UP! In fact exercise at this time period can actually lead to ketoacidosis. Therefore, for people with type 1 diabetes, great attention is required balancing blood glucose levels and exercise. Since high blood glucose often occurs when insulin levels in the blood are low, the usual recommendation is to wait until the blood sugar is below 250 mg/dL before participating in strenuous exercise.

Prognosis

Diabetes needs to be considered a very serious condition. It is the 7th leading cause of death in the United States and over 15 million American have diabetes. It is a chronic condition for which we have no cure. About 2/3 of people with diabetes die of heart disease. It is the leading cause of adult blindness, the leading cause of kidney failure and the leading cause of lower extremity amputation. It is also the second most common chronic condition seen by American doctors.

Although diabetes is a serious and chronic condition, early diagnosis and proper patient self-management can reduce and possibly eliminate the majority of the chronic complications. Meticulous control of blood glucose (HbA1c below 7% which would correlate to an average blood glucose below 150 mg/dL), good blood pressure control (below 130/80), low LDL (low density lipoprotein) cholesterol levels (below 100 mg/dL), one daily aspirin (either adult or children's) and daily foot inspection can make a major impact on improving one's risk for all diabetes-related problems.

Lethality

Diabetes can be deadly. Acute complications (such as low blood glucose, also called hypoglycemia) resulting in death are rare. More often people with diabetes die of a chronic problem such as heart attack or stroke.

Pain

High blood glucose levels do not cause pain. However, having high glucose levels for many years can lead to nerve damage in the feet (called neuropathy), which can be painful. It is estimated that 25% of newly diagnosed patients with type 2 diabetes have pain or numbness in their feet from neuropathy.

Other complications related to many years of high blood glucose levels can cause pain. For example, people with diabetes are more at risk for carpal tunnel syndrome, which is a common condition in the general population. With this problem, a large nerve going to the hand is squeezed causing pain in the hand. Often surgery is required to fix this. People with diabetes are also more at risk for certain infections that may be painful. Some examples include infections of the skin (cellulitis and abscess) and even the kidney.

There is also an uncommon condition often referred to as "diabetic amyotrophy" which presents with muscle wasting of the thighs, weight loss and severe pain. These patients often appear to have cancer. This condition is most common for men with type 2 diabetes in their 50s and 60s and usually resolves spontaneously in 12 to 18 months. There are no specific treatments for this.

Debilitation

Diabetes can be debilitating and there are many reasons for this.

It is not uncommon for people with diabetes to experience advanced neuropathy to the point that he or she cannot walk.

Diabetes can also be debilitating in that people with it have an increased risk of stroke.

Other complications such as heart disease, sight impairment and the need for kidney dialysis would all be considered debilitating.

The good news is that all of these can be prevented if treatment is started early and aggressively. This treatment includes meticulous control of blood glucose (average glucose below 150 mg/dL), blood pressure (below 130/80), LDL cholesterol (bad cholesterol below 100 mg/dL), daily aspirin and smoking cessation. Research also has shown that one particular type of blood pressure medication called ACE (angiotensin converting enzyme) inhibitors has an additional protective effect on complications besides lowering blood pressure. ACE inhibitors appear to stabilize or even reverse diabetic kidney disease if it is caught early enough. These drugs also have been found useful for people who have had heart attacks or have heart failure. One study even showed these drugs reduced the risk of heart attack or stroke by 25%! Finally, there is a growing body of research suggesting ACE inhibitors may protect against diabetic eye disease.

Comfort

Diabetes usually does not cause discomfort. In fact, one of the biggest public health problems in America is that there are over 5 million Americans who have asymptomatic diabetes and do not know it. The most common reason for any discomfort is the neuropathy noted above. Another common reason people have discomfort is from the finger sticks to measure blood glucose. Fortunately, this technology is quickly improving so that discomfort is minimal.

Curability

Diabetes is currently not curable. Type 1 diabetes is defined as no requirement for insulin with normal blood sugars. Scientists are working on this so that the cells that make insulin ("islets") may be able to be transplanted to result in a cure. To date, these experiments are not quite ready and are still in the research phases. For type 2 diabetes, there is no "cure" but often it can be treated early in its course with a strict diet, exercise and weight loss. However, it is rare for the diabetes to "disappear" even with these measures. The main focus of research now is to prevent both types of diabetes.

Fertility and pregnancy

The topic of diabetes and pregnancy is complicated. Women with diabetes can have a normal pregnancy but the blood sugar levels need to be NORMAL before conception. Each pregnancy needs to be planned. Furthermore, patients with type 2 diabetes need to be off all of their pills and using insulin before conception. If these rules are followed, the pregnancy can be uncomplicated although many women tend to have large babies. Furthermore, if the diabetes is complicated with eye or kidney problems before conception, the mother may have more problems with these complications during the pregnancy. Women with diabetes need to be managed by a team of providers experienced with these high-risk pregnancies.

Independence

In the vast majority of cases, patients with diabetes should have no problems with independence.

Mobility

Again in the vast majority of cases, diabetes should have no impact on someone's ability to move about. The exceptions to this are those people who suffer from advanced neuropathy or vascular disease. A complication involving the foot, such as a foot ulcer or amputation can impact one's ability to move around. Visual problems also will impact one's ability to move about.

Daily activities

For the vast majority of people with diabetes, there should be no alterations of daily living. For most people, however, small amounts of time should be reserved for self-management. This would include time for home blood glucose monitoring (although our current meters take as little as 5 seconds!) and extra time to ensure the proper medication is received.

Exercise is encouraged for people with diabetes, although for those over the age of 40 years old, it is recommended a stress test is performed to rule out early heart disease.

For people who take insulin, "shift work" (working different shifts including the "graveyard shift") can be a challenge. You should talk to your doctor about the best way to manage your insulin, if this pertains to you.

Energy

Extremes in blood glucose levels can cause fatigue. Although it is difficult to give exact levels since it differs with the person, many people note fatigue when the blood glucose exceeds 400 mg/dL. Although hypoglycemia often presents with a tremor, fast heart rate, and sweating, it may be noted only as fatigue. This often occurs when the blood glucose drops below 60 mg/dL.

Unfortunately, many people have no symptoms or may note they were fatigued after they are diagnosed with diabetes and treated for it. The vast majority of people once treated, note no problems with fatigue.

Diet

Over the years, there have been many changes to the proper diet for people with diabetes. It is first important to note that the diet for people with diabetes has to be individualized based on a variety of issues such as:

• the type of diabetes
• the ethnicity of the patient
• the presence or absence of kidney disease
• the presence or absence of obesity
• the presence or absence of heart disease or high cholesterol levels
• the amount of physical activity planned and
• age.

If a pregnancy is planned or one is pregnant and has diabetes, the diet will also need adjustment for this.

In general, it is recommended that one eats a low-fat diet with less than 10% of the calories coming from saturated fat. For people with high levels of LDL-cholesterol (the "bad" cholesterol), the January 2002 guidelines from the ADA suggest only 7% of total calories from saturated fat.

The most confusion about diet for people with diabetes has to do with carbohydrates which are the types of foods most quickly broken down to glucose (such as breads, potatoes, pasta, fruit and simple sugar). Research has clearly shown that table sugar (sucrose) does not increase blood sugar any more than breads, pasta or other carbohydrates AS LONG AS THE SAME NUMBER OF CALORIES ARE CONSUMED. For example, putting table sugar into coffee (about 15 grams of carbohydrate) would not change blood glucose any more than 1 piece of bread (about 15 grams of carbohydrate). Therefore, simple sugars ("sweets") do not need to be restricted by people with diabetes but rather need to be substituted for other carbohydrate sources. For people using insulin, it is much easier since additional insulin can be administered to "cover" additional carbohydrate. This is where a nutritionist can be extremely helpful so that the exact amount of insulin needed to cover the carbohydrates can be determined. Typical ranges are one unit of insulin (lispro aspart or regular) may cover anywhere from 5 to 20 grams of carbohydrate.

Relationships

The interactions between relationships and diabetes are greatly underappreciated.

For children, relationships with friends and teachers can be profound. Adolescence is often a difficult time anyway and diabetes can affect relationships with peers, members of the opposite sex, parents and teachers. All of these relationships can be quite complicated. Many in this age group often try to hide their diabetes which can also result in problems (for example, someone with diabetes gets hypoglycemic and no one in the group knows the person has diabetes).

Communication becomes particularly important for people in their early adult years as issues pertaining to marriage and family planning are discussed. It is critical that concerns be discussed in the open with the assistance from a health care provider with understanding about the disease.

For older adults, the impact of both the daily living of diabetes and its complications becomes even more important. Again one needs to talk to a healthcare provider knowledgeable about diabetes to explore its complications and how it affects everything from work performance to driving or sexual function.

Everyone living with an individual who has diabetes needs to have some knowledge about how to treat emergencies (hypoglycemia). Finally, psychological support can be extremely effective for many individuals due to the extreme challenges this condition presents for many individuals.

Incidence

For type 2 diabetes which is the most common form, the gene or genes responsible have not yet been identified. Certainly, obese individuals are more at risk. For reasons not entirely understood, many of the ethnic minorities in the US have a disproportionate risk of type 2 diabetes: African Americans, American Indians, Hispanic Americans and Asian Americans all have a high risk for type 2 diabetes. Recently, there has been an epidemic of type 2 diabetes in young adults and even adolescents. Obesity has been the primary reason for this. Other risks for type 2 diabetes include a history of gestational diabetes (diabetes during pregnancy), hypertension (high blood pressure), a family history of type 2 diabetes, a sedentary lifestyle and high triglyceride levels (a type of blood fat). One exciting research study showed that by strict diet and exercise, someone with a high risk of getting type 2 diabetes can reduce that risk by 58%.

Type 1 diabetes is a completely different disease. We are now learning more about the genetic risks and can also predict who will get the disease by measuring "antibodies" which are markers in the blood for type 1 diabetes. We don't understand why some people get this and others don't but there are appears to be an environmental insult (perhaps a virus) that attacks the cells in the pancreas which makes insulin. Although type 1 diabetes often presents in childhood we now know it can occur at any age.

Acquisition

For type 2 diabetes, besides having a genetic predisposition, most people are also obese especially those less than 60 years of age. It is also clear that not everyone who is obese gets diabetes as a additional genetic risk must be present.

For type 1 diabetes, besides having a genetic risk, there appears to be an environmental "trigger", most likely a virus which seems to cause the body to attack the cells in the pancreas that makes insulin.

Genetics

As noted above, genetics plays a large role for both type 1 and type 2 diabetes.

The majority of people with type 2 diabetes have a family member with the disease. If an identical twin gets type 2 diabetes, the risk for the second twin to get it exceeds 95%. For type 1 diabetes, the risk of a school-age child to get the disease is only 0.3%. However, if the mother has type 1 diabetes, the risk of the child getting it is 2-3% while the father gives a 5-6% risk to the child. No one knows why the father gives a greater risk to the offspring. If one identical twin has type 1 diabetes, the risk of the other twin getting it is only about 35%. So there are obviously huge differences between the genetics of type 1 and type 2 diabetes.

Communicability

Neither type 1 nor type 2 diabetes appears to be contagious.

Lifestyle risk factors

For type 1 diabetes, there are no known risks for acquiring the disease although a recent study from Europe suggested that ingesting cod liver oil may prevent type 1 diabetes in children. Much more research on this topic is now needed.

For type 2 diabetes, obesity is a major risk factor and as noted above, weight loss with diet and exercise can reduce the risk of developing type 2 diabetes by 58% over a 3-year period.

Injury & trauma risk factors

Neither type 1 nor type 2 diabetes can result from injury or trauma. However, a more rare form of diabetes called "pancreatic diabetes occurs when injury or surgical removal of the pancreas occurs. Since insulin is made in the pancreas, the lack of a functioning pancreas leads to insulin deficiency and diabetes.

Prevention

The prevention of both type 1 and type 2 diabetes are major research goals.

Animal studies and early human studies in children suggested that low doses of insulin could prevent type 1 diabetes in high-risk children. A large study funded by the U.S. government presented in summer 2001 showed that insulin did not prevent type 1 diabetes, at least in the doses of insulin used in the study. Studies are now underway to see if other therapies may be of benefit for high-risk individuals.

For type 2 diabetes, the Diabetes Prevention Program was announced in August of 2001. This study showed that for high-risk people with "impaired glucose tolerance" (a two hour blood glucose between 140 and 200 mg/dL after a sugary drink), a strict diet and vigorous exercise, mostly walking, could reduce the risk of type 2 diabetes by 58%. Another group in this study received the drug metformin (glucophage) and even without additional diet or exercise, their risk of diabetes was reduced by 31%. It is now expected that there will be new public health policies directing doctors and their patients as we try to translate this research to clinical practice.

Anatomy

Diabetes can affect almost every organ in some way or another. There appears to be several ways high glucose levels attach to tissues, and since the blood flows throughout the body, the effects of the high glucose can be seen everywhere.

The most common sites include the eyes, the nerves, the kidney, the heart, the blood vessels, the skin, the joints, the liver, the stomach and even the brain.

Initial symptoms

Many patients with type 2 diabetes have no symptoms or signs. Others realize they were fatigued after they were treated. The most common symptom however is frequent urination and thirst. Blurry vision, yeast infections in women and numb feet are also often seen.

Type 1 diabetes usually presents in a more dramatic fashion: frequent urination, thirst, weight loss (often severe) and hunger are all common. If blood glucose levels are high enough and ketoacidosis is present, the presentation may include coma although this is less common now than in the past.

Symptoms

High glucose levels "spill" into the urine, resulting in water following the glucose. This results in the frequent urination and thirst. If insulin levels are too low in the blood, fat is burned for energy and this may result in the ketones, a byproduct of the fat metabolism. High ketones in the blood, called ketoacidosis, is a life threatening condition which usually only occurs in type 1 diabetes. With this, one may develop stupor or coma. Often there is a fruity breath that can be smelled by family members.

As noted above, type 2 diabetes may have no symptoms at all, but at the very least, usually has a much less dramatic presentation.

For both type 1 and type 2 diabetes, if it is well controlled there should be no symptoms. For those requiring insulin therapy, the most common symptom is low blood glucose (hypoglycemia). The presenting symptom of this usually relates to a surge of epinephrine (adrenalin). These symptoms include a fast heart rate, tremor and increased anxiety. Other symptoms include a cold sweat and hunger. For more severe hypoglycemia, one can see blurry vision, nausea and mental confusion. Often family members pick up on these more subtle symptoms before the patient does. If some type of food is not eaten, the symptoms may progress to extreme lethargy or seizures (convulsions). Hypoglycemia is the major side effect of superb glucose control, but the risk can be dramatically reduced with frequent home blood glucose monitoring and a complete understanding of how the different insulins work (the timing of their "peaks"). Strategies to minimize the risk of hypoglycemia, especially in the middle of the night should be discussed frequently with a health care team.

Progression

The symptoms of high blood glucose (frequent urination and thirst) do not change over time. Unfortunately, many people with diabetes lose many of their symptoms of low blood glucose (hypoglycemia), which means they must be aware of the more subtle clues of low blood glucose and more frequent home blood glucose monitoring may be indicated.

Also if complications of diabetes occur over time, these may result in new symptoms. As noted above, this may involve swelling of the feet (edema) for kidney disease or heart failure, blurry vision for eye disease which could include bleeding of the retina (retinopathy) or cataract formation. Neuropathy may have many different symptoms: pain or tingling of the feet, numbness of the feet, sweating with eating any types of foods, nausea and feeling "full" after eating a small amount of food (this is called gastroparesis), and dizziness with standing (called orthostasis). If any of these occur, they should be discussed with a health care provider.

Perhaps the most important point is the LACK of symptoms accompanying heart disease for many people with diabetes. People without diabetes often get chest pain ("angina"), which indicates that there is a blockage in one of the arteries leading to the heart. People with diabetes often have no symptoms or any warning that they have these blockages, and many people with diabetes have heart attacks with no symptoms at all. Others get shortness of breath with minimal exertion as their only symptom of heart disease. For these reasons, the American Diabetes Association recommends regular stress testing for high risk individuals for heart disease. Again, this should be discussed in detail with a health care provider.

Secondary effects

Much of the discussion above relates to the effects of blood glucose (sugar) on the various organs of the body: the eyes, the kidneys, the nerves and the vascular system, including the heart and all of the blood vessels. However, many other effects of diabetes also need to be considered.

For example, people with diabetes have an increased risk for depression and anxiety disorders. Some of this is directly related to the diabetes (depression due to the diabetes or one of the complications), whereas for others, the depression would have been present anyway. Importantly, those that are depressed have a much more difficult time taking care of their diabetes with self-management skills. Often after the depression is controlled with either medication or counseling, the diabetes control improves. There is recent research also noting that depression may be a risk factor for heart disease, similar to high cholesterol levels or smoking. Much more research on this last point is needed.

Other secondary effects are numerous. For example, diabetes can cause a variety of different skin lesions. It can also cause joint problems, so that the joints are not as mobile as usual. With poorly controlled diabetes, blood fats (triglycerides in particular) may rise to very high levels. Sexual dysfunction is common both in men and in women. High blood sugars increase the risk of infection, especially urinary tract infections and yeast infections in women. People with frequent hypoglycemia resulting in loss of consciousness or seizures may have difficulty with thought processing. Although this is not a complete list, it should be clear that diabetes has many secondary effects!

Conditions with similar symptoms

In considering the symptoms of high blood glucose (hyperglycemia) only, there are only a few conditions with similar symptoms. Urinary tract infections in women may be associated with frequent urination, but these types of infections usually also result in pain with urination and thirst. A more rare condition called diabetes insipidus results when a hormone (chemical) from the pituitary gland called vasopressin is absent. Without vasopressin, one can also get frequent urination and thirst similar to what is seen with high blood glucose from diabetes mellitus (the word mellitus means "sweet" or "honey"). The combination of thirst, frequent urination and weight loss is uncommon except with diabetes (mellitus).

For low blood glucose (hypoglycemia), which may be common in patients with type 1 diabetes who are striving for near-normal blood sugar levels, there are a variety of symptoms that can be similar to other conditions. Anxiety and hyperthyroidism (high thyroid hormone levels) are seen when adrenalin (epinephrine) levels rise in response to the hypoglycemia. More concerning are the symptoms which occur when the brain does not receive enough glucose. These symptoms include forgetfulness, confusion, nausea, seizure disorders and personality changes. Hypoglycemia usually resolves quickly after eating something that is absorbed quickly (glucose tablet orange juice) and with the use of home blood glucose monitoring, it should be an easy diagnosis to make.

Causes

No one knows the cause of type 1 diabetes. Clearly, one must have a genetic risk and scientists are now identifying the genetic markers. Not everyone with a genetic risk gets type 1 diabetes, however, as there also must be an environmental risk. The exact environmental insult is not clear but may be a virus and likely is different for different people. It is interesting that 90% of people with type 1 diabetes have no family history, although the genetic risk needs to be present for the disease to occur.

For type 2 diabetes, genetics appear to have a more important role as the disease usually occurs within families. Ethnic minorities (African Americans, Asian Americans, Hispanics and Native Americans) are at a particularly high risk. Our population's trend toward a sedentary lifestyle and higher fat foods have resulted in more obesity which appears to be the main reason we are seeing more type 2 diabetes. However, not everyone who is obese gets type 2 diabetes, which speaks for the need of a genetic risk to get this disease.

Effects

High blood glucose (sugar) has an impact on almost every tissue and organ in the body. Scientists have noted three possible ways this may occur, and current research is determining if there are drugs that oppose the effects of the high glucose levels after the damage is done. It is clear, however, that the best therapy is to prevent the damage before it occurs by taking meticulous care to avoid excessive high blood glucose levels. Research has shown that the complications of diabetes, particularly those that involve the eyes, kidneys and nerves can be avoided by maintaining the average blood glucose level below 150 mg/dL which will be below a HbA1c level below 7%. The HbA1c a test which provides an average of your blood glucose control for the past 3 months should be done 4 times each year if you take insulin twice yearly, if your diabetes is well-controlled on medication or diet alone.

Diagnosis

Diabetes can be diagnosed only with a blood glucose level performed in a laboratory, not a fingerstick glucose level at home or a HbA1c level. To diagnose diabetes, one must have either a fasting blood glucose level (no food for 10 hours) of 126 mg/dL on two occasions or a random blood glucose of 200 mg/dL on two occasions, with the symptoms (thirst and frequent urination) seen with high glucose levels. Oral glucose tolerance tests can also be done but are not routinely recommended except during pregnancy.

The American Diabetes Association suggests people without symptoms but with risks for type 2 diabetes be screened (usually with a fasting blood glucose) every three years. This would include:

• all Americans over the age of 45 years
• any woman with diabetes during pregnancy or a baby born over 9 pounds
• anyone obese with a sedentary lifestyle
• anyone with high blood pressure and
• anyone with a family history.

For people less than 45 years old, the frequency of screening is not clear but is something you should discuss with your physician.

Effects

The blood glucose test is like any blood test and may cause a small amount of discomfort. The bigger issue is usually the shock the patient and their family have after the diagnosis is made. This is particularly an issue for type 1 diabetes where there is usually no family history. There are so many misconceptions about diabetes that the major issue for the first few weeks after diagnosis is teaching the patient and the family about the treatments and overall good outcomes, if the condition is treated aggressively.

Health care team

Almost all health care professionals have experience in diagnosing diabetes because it is so common. Primary care physicians diagnose it most frequently, both with patients with and without symptoms. Eye doctors also diagnose it often as some patients complain of blurry vision as their first symptom. Diabetes is also often noted by emergency room doctors, podiatrists (early nerve damage in the feet), cardiologists, vascular surgeons and nutritionists (patients seeking advice for weight loss).

Finding a doctor

Doctors with expertise in diabetes are called endocrinologists, although in the United States not all endocrinologists specialize in diabetes. Endocrinologists who have a special interest or expertise in diabetes are called diabetologists. So in the U.S., all diabetologists are endocrinologists but not all endocrinologists are diabetologists. This varies by country.

If one is looking for an expert in diabetes, the Yellow Pages is a good place to start. Again first look under "Diabetologist" and then "Endocrinologist". The local American Diabetes Association can also provide names of their professional members. Most communities have patient-care symposiums and support groups which are often good sources of information. If this is not convenient, other health care professionals are a good source of information. Nurses and nutritionists often know who is up-to-date with the latest in diabetes therapy. Finally, some smaller communities may not have an endocrinologist but may have a well-versed primary care physician who is more knowledgeable about diabetes than other physicians in that community. Often word-of-mouth is the best way to find these individuals.

Treatment

The treatment of diabetes is usually a complex program involving a specific diet, a specific exercise prescription and medication(s). These treatments are most effective when carried out with a team of health care providers knowledgeable in the care of people with diabetes. As opposed to high blood pressure, asthma and even high cholesterol, with diabetes self-management is the fundamental key to success. Many other conditions can result in good outcomes by taking a medication at the appropriate times. With diabetes, so much more is required since everything from stress, depression, food, exercise, other illness and a host of other factors effect blood glucose levels. Learning about all of these factors and knowing what to do when blood glucose levels are above or below target can take quite a bit of time. The rewards, however, are great.

Patients who do best are those who measure their blood glucose frequently, pay attention to which factors affect blood sugar and try to avoid anything that causes a disruption in diabetes control in the future. No one is always successful in keeping blood glucose in the "normal" range, and it must always be remembered that there is no such thing as being "perfect" if you have diabetes. Fluctuations in blood glucose will occur no matter how careful you are.

Self-management

For a person with diabetes, self-management skills are the key to success. Although eating at the same time each day the same amount of food, exercising everyday and taking the medication exactly as prescribed may be helpful, doing all of these things perfectly for the rest of one's life is not realistic. Rather the goal of therapy is to know what to do when the daily routine is disrupted: such as a late dinner, a ten-mile bike ride that was not planned or a birthday celebration with cake and other goodies. Certain life situations also require self-management expertise--acute illness such as nausea and vomiting (gastroenteritis), surgery, pregnancy and menopause all have their own challenges for people with diabetes. It is beyond the scope of this essay to deal with the daily complexities for everyone with diabetes, but especially for those on insulin and those with type 1 diabetes, more training will be required.

Health care team

Ideally, it would be best if an entire team of health care professionals were available for everyone with diabetes. This is not always possible, but at the very least all of these people should be available for consultation if needed. These team members include:

• Physician: Often an endocrinologist but may be a general internist or family practice physician. In the U.S., endocrinologists see a very small number of the adults with diabetes due to the small number of specialists and large number of patients with diabetes.
• Nurse Specialist: Usually a registered nurse with special expertise in diabetes care. All providers but especially nurses and nutritionists may be certified in diabetes education (CDE). A CDE ensures you are receiving up-to-date information about diabetes care and education.
• Nutritionist: In the opinion of many, the most important person on the team. A nutritionist with a CDE is an expert about the two most important factors of blood glucose control: food and medications. Current nutrition therapy has become quite sophisticated, but outstanding nutritionists can simplify the information especially for those learning how to match food with insulin.
• Mental Health Professionals: Both psychologists (using mostly counseling techniques) and psychiatrists (doctors who can also prescribe drugs) should be available as any mental health disorder can affect diabetes control.
• Pharmacist: Due to the complexity of medications with diabetes, the pharmacist has become a critical member of the team.
• Podiatrist: A doctor with special expertise in disorders of the feet common for people with diabetes.

Pain and fatigue

If controlled well, diabetes will not cause pain or fatigue. Poorly controlled diabetes will result in these symptoms and will resolve with proper treatment. For patients with type 2 diabetes, fatigue will often improve if insulin is started and blood glucose improves.

For most people, these symptoms mean another problem is present. For those with type 1 diabetes, the most common condition is hypothyroidism. It is estimated that 10-20% of people with type 1 diabetes develop some type of thyroid problem.

Exercise and therapy

Exercise is a key component of a treatment plan for anyone with diabetes. For those with type 2 diabetes, exercise improves insulin's effect on the muscle and will result in blood glucose lowering. For many newly diagnosed individuals, a regular exercise program with proper diet can result in the need for no further therapy. However, if your HbA1c remains above 7% diet and exercise alone will not be sufficient.

For those on insulin, especially those with type 1 diabetes, exercise needs to be planned to prevent problems with hypoglycemia. Exercise will result in a lowering of blood glucose and either additional carbohydrate or less insulin will be required. More frequent home blood glucose monitoring may be required. This is a large topic beyond the scope of this essay and should be discussed in detail with your healthcare team.

Medications

For type 2 diabetes, there are 4 classes of medications:

• Insulin secretagogues (for example glyburide, glipizide, repaglinide, glimiperide to name a few)--These agents increase stimulate the pancreas to make more insulin.
• Biguanides--There is only one available metformin. This drug makes the liver more sensitive to insulin. It lowers HbA1c levels 1.5-2% similar to that of insulin secretagugues.
• Alpha-glucosidase inhibitors (acarbose and miglitol)--These drugs slow down the absorption of carbohydrate.
• Thiazolidinediones (also called "glitazones") (pioglitazone, rosiglitazone)--These drugs result in insulin becoming more sensitive at the muscle.

Insulin is used for both type 1 and type 2 diabetes. Insulin can be classified as basal (or background) insulin or mealtime (or prandial) insulin. In general, the basal insulins are the long-acting and intermediate-acting insulins and the mealtime insulins are the short-acting and rapid-acting insulins.

Long acting:

• Glargine: no peak, lasts 24 hours
• Ultralente: broad peak 10-16 hours, lasts 20-24 hours

Intermediate acting:

• NPH: peaks 5-8 hours, lasts 12-16 hours
• Lente: similar to NPH

Short-acting

• Regular: peaks 2-3 hours, lasts 6-8 hours

Rapid-acting

• Lispro: peaks 1 hour, lasts 4-5 hours
• Aspart: peaks 1 hour, lasts 4-5 hours

Surgery

People with diabetes have more frequent surgery than those without. However only rarely do we use surgery to actually TREAT diabetes. This occurs with either a kidney-pancreas transplant, or more rarely, a pancreas transplant by itself. Pancreas transplants are only done for those with type 1 diabetes. For those who do not need a kidney transplant, pancreas transplants may be considered if frequent life-threatening hypoglycemia is occurring. In the near future, we hope that islet cell transplants will become available. Islets are the tiny cells in the pancreas that make insulin.

Social impacts

There are a variety of important social impacts of the management and treatment programs for diabetes. Much of this depends on the age of the patient. For children, it is critical for teachers and other adults to be familiar with routine diabetes care but particularly the treatment of mild hypoglycemia. For teens, social issues become more complicated but it is important for at least some friends to be aware of the diabetes. For young adults, other issues pertaining to one's job dating situations and overall comfort level with sharing information about diabetes become important points. Many sensitive issues, particularly regarding family planning questions, regarding sexual issues, and the effects of diabetes on mental health will require discussion with a health care provider knowledgeable about these topics as they relate to diabetes. For older adults, many of these same issues are present, but now it is common for patients to also address the social impact of the various complications of diabetes. This is obviously a complicated topic that deserves a great amount of attention from a provider with understanding of the impact of all of the elements of diabetes on someone's life.

Long-term management

Ongoing monitoring can be divided into two major categories.

First, monitoring for the diabetes itself needs to be considered. Although this is usually done with two major mechanisms, other important tests are occasionally needed. Home blood glucose monitoring is the standard for assessing diabetes control at home. Although there is still controversy as to how often someone with type 2 diabetes who does not take insulin should measure their blood glucose, all patients who take insulin should monitor on a regular basis both to assess any patterns in glucose levels but also to make changes at the time if the glucose level is too high or too low.

The other way diabetes is monitored is with HbA1c described above. This test allows both patients and their physicians to assess overall blood glucose control during the past 3 months. The goal for the majority of people should be a HbA1c below 7%, which would be an average blood glucose level of 150 mg/dL.

Monitoring also needs to include assessment of complications. Current recommendations include:

• a yearly dilated eye exam to exam the retina
• a yearly test for kidney disease with protein (or microalbumin) from a urine test
• a yearly lipid panel with the primary goal to maintain LDL cholesterol below 100 mg/dL
• at least a yearly comprehensive foot exam to assess risks for foot ulcer and
• regular blood pressure measurements with a goal to maintain a blood pressure below 130/80.

Unproven remedies

There are numerous misconceptions about treatments for diabetes but the most common ones involve insulin therapy.

First, some people think that starting insulin therapy will lead to blindness or some other major problem. The thinking here occurs often due to the fact a relative or friend had a similar problem just after starting insulin. In truth, insulin has been shown to PREVENT these problems and there is no cause and effect relationship between the timing of insulin therapy and the start of a complication.

The other problem is that many people feel they can avoid insulin if they "behave" and are careful with the diet. The reality is that over time insulin secretion normally diminishes, so that no matter what is done with pills, diet and exercise, the only way to maintain the goal of a HbA1c of less than 7% will be with insulin therapy. Insulin is not dangerous if used correctly. Furthermore, the vast majority of patients don't complain about insulin use once they start. A more common complaint regards the finger pokes for home glucose monitoring.

It needs to be emphasized: the goal of therapy is to bring the blood glucose levels down to the target range. Having the primary goal of avoiding insulin will eventually lead to a poor outcome.

Strategies for coping

Different people find different ways to cope with diabetes. Some people find it helpful to join a support group. This can be found in most communities by calling the local American Diabetes Association office. Others prefer to volunteer at hospitals, diabetes clinics, or camps for children with diabetes. For others, coping mechanisms require talking to a professional, such as a psychologist. For everyone, it is important to relate feelings to both your family and your physician.

Asking for help

There are many options for help in coping with diabetes. Support groups, healthcare professionals and clergy can all be of assistance. Often simply finding someone with experience living with diabetes can be quite helpful. The American Diabetes Association is a good resource and they have a variety of books dealing with this topic. The books can be found at www.diabetes.org.

In many communities, the clinical nurse specialist (CDE) is the most knowledgeable about what resources are available for a particular location.

Work

Coping with diabetes at work has similarities to coping with it at home. Of course, much of this depends on the type of work one does. People with "desk jobs" who get very little physical activity at work would do best by taking advantage of walking steps instead of riding the elevator or intentionally parking further away than necessary. Even this moderate amount of additional exercise can improve glucose levels and for many improve stress.

For people who take insulin, it is important your supervisor knows you need to eat at specific times. If this is not possible, you can discuss with your physician different strategies to avoid problems. With the newer insulins, there are many ways to be creative about this. For everyone with diabetes, it is important not to "hide" your diabetes from your co-workers. This is especially true if you take insulin.

Some people have difficulty discussing their diabetes with others. Occasionally, this is such a problem that self-management tasks are not performed (blood sugar testing, for example). These fears need to be addressed and occasionally require the help of a psychologist.

Family and friends

Another important but complicated topic is the effect of diabetes on different types of relationships.

For children, diabetes can affect their relationships with parents, siblings and friends. Kids often feel "different" and this can create significant problems--occasionally resulting in behavior changes. It is important for parents to make sure their child with diabetes does not feel "different." The most important example is to make sure a different type of food is not served to the child with diabetes compared to the rest of the family. Everyone should be served the same food.

In teens with diabetes, issues pertaining to dating are often a concern. Both girls and boys often have difficulty in dealing with their diabetes when confronted with the opposite sex. Again the key is for the family to be supportive of an open discussion of any concerns that the teen may have. This may include discussions about the effects of alcohol on diabetes control.

Diabetes can affect relationships in adults as well. Issues can be just as complicated: relationships at work, at church and at the golf course can all be affected by diabetes. Many of these problems are due to others being uneducated about diabetes. Explaining to others about diabetes can be the most important solution to problems that may arise.

Adaptive aids

There are a variety of different "adaptive aids" to help with the various aspects of diabetes. Perhaps the most common one is the use of the specialized shoes to protect the feet in people with severe peripheral neuropathy. Feelings of sensation in the feet are lost and special protective shoes can protect these feet from developing an ulcer. These ulcers often become infected and cause many problems, but the special shoes can assist in preventing this. Similarly, the use of "orthotics" for the feet help to redistribute the weight so that areas that are prone to callus formation have a better opportunity to heal.

There are a variety of new aids for actual blood glucose management. Home blood glucose meters have become quite simple to use, requiring small amounts of blood. Several meters can use blood from the arm or thigh, so there is no more pain from the fingersticks which tend to cause more pain. We are also using more sophisticated software systems to download the meters to help assess trends in blood glucose readings. This is particularly helpful for people who test frequently and most of the meter software can be purchased directly from the company for your PC.

Insulin pump use continues to grow. In the US, there are over 120 000 people using pumps and this is also growing in people with type 2 diabetes. The pump delivers small amounts of fast-acting insulin--usually lispro (Humalog) or aspart (Novolog)-- continuously around-the-clock and a "bolus" of insulin is infused by pressing a button before a meal. The amount of insulin to infuse is based on the blood glucose reading at the time and the amount of anticipated carbohydrate intake. Obviously, exercise also has an influence in how much insulin to administer. In our experience at the University of Washington with pumps for 107 patients for a time period of 3 years, we saw a 74% reduction in hypoglycemia.

Stress

Stress can have a major impact on blood glucose control as it causes an elevation of adrenalin (also called epinephrine), in addition to other hormones. Adrenalin makes one more resistant to the effects of insulin, so no matter if you have type 1 or type 2 diabetes, stress can raise the blood glucose levels. One recent study showed that if one can relieve stress, the HbA1c can decrease on average by 0.5%.

The best strategy for relieving stress is to learn how to avoid the emotional upset that may occur. This is easier said then done, as it takes time to change the way one reacts to stress. For some people, getting exercise works well. This is particularly helpful for people with diabetes as the exercise directly works against insulin resistance. For many, it also makes the stress less bothersome.

For others, the main problem is lack of sleep--the stress keeps people awake, and the next day, the stressed-out person has difficulty functioning due to lack of sleep. It would be important to discuss this with your physician as there are safe medications that could be used for a short period of time to help with this problem. For people with type 2 diabetes, there is a higher rate of sleep apnea (due to obesity). If you snore and are exhausted during the day, also ask your doctor about this possibility.

For many with overwhelming stress, it may be best to discuss with your physician. Divorce, loss of a loved one, loss of a job are all major "stressor events" which may require more formal treatment either by discussing with a psychologist or with anti-anxiety medication.

Resources

There are a variety of important resources for people with diabetes. The largest American organization is the American Diabetes Association (ADA). Based in Alexandria, Virginia, the ADA funds diabetes research, has extensive education programs for patients with diabetes and health-care professionals, and manages camps for children with diabetes. They have a monthly journal "Diabetes Forecast" and a regular e-newsletter for important updates in relevant news. The ADA can be reached at 1-800-DIABETES or www.diabetes.org.

Other important resources include:

• Juvenile Diabetes Research Foundation: 1-800-533-CURE or jdf.org. The JDRF is the world's leading nonprofit, nongovernmental funder of diabetes research. JDRF is the only major diabetes organization focused exclusively on research.
• Taking Control of Your Diabetes: www.tcoyd.org. A nonprofit organization started by Dr. Steven Edelman at the University of California in San Diego, this group strives to motivate and improve the lives of everyone with diabetes. The programs this group runs are tremendous and if one comes close to you, please make time to attend!
• American Association of Diabetes Educators: http://www.diabeteseducator.org/
• The Diabetes Mall: www.diabetesnet.com. Provides reviews of all of the latest research and new products.
• The Diabetes Monitor: www.diabetesmonitor.com. "Monitors everything about diabetes in cyberspace."
• Diabetes Self-Management: www.diabetesselfmanagement.com. Comprehensive journal regarding all aspects of diabetes care.
• Diabetes Interview: www.diabetesworld.com. An excellent newspaper.

Condition research

For both type 1 and type 2 diabetes, research is focusing both on prevention and cure. Another major focus of research is improvements in current therapies.

For type 1 diabetes, a large study asking if small doses of insulin could prevent type 1 diabetes in high-risk individuals showed this strategy did not work. Scientists are now looking at other strategies, perhaps an "immunization". For example, a group from Israel showed that injecting a small protein could slow the progression of diabetes in newly diagnosed individuals with type 1 diabetes. More research on this is anxiously awaited. As far as a cure in concerned, some progress has been made with islet cell (the cells that make insulin) transplants. Newer ways to prevent rejection of the transplanted tissue are now being studied.

For type 2 diabetes, a large prevention study showed that intense diet and exercise could reduce the risk of diabetes by 59% in high-risk people. The drug metformin could also reduce this risk but by only 31%. This makes sense since weight loss and metformin also improve insulin resistance, one of the main mechanisms for type 2 diabetes.

Research has also resulted in an explosion of new drugs and technologies for the treatment of diabetes. This explosion shows no sign of a slow-down as we expect more new pharmaceutical agents to be released over the next five years. This will include new classes of oral agents to improve both insulin resistance and insulin secretion in type 2 diabetes and new insulins for those both with type 1 and type 2 diabetes. It is also hoped there will be better weight-loss drugs as our understanding of obesity improves. It is also likely glucose sensors will become more often used as telemetry-based glucose sensors should be available by 2003. This would allow a sensor placed under the skin to relay "real-time" blood glucose readings to you on a monitor you could wear on your belt or like a watch. Another development, the "Glucowatch" by Cygnus, will work similar to this and should be available in the near future. It is hoped that the sensors will progress to the point they can be attached to an implantable pump and thus work like a normal pancreas.

Non-surgical research

The study of exercise and its effects on blood glucose is one of the earliest types of diabetes research. Dietary research also continues to evolve especially as we learn more about heart and kidney disease. There have been tremendous advances in our understanding in dietary recommendations as mentioned above.

There is also better understanding on the impact of anxiety and depression on the impact of diabetes. People with diabetes tend to have more mental health challenges than those without diabetes and effective management of these often tends to improve diabetes care. For example, some people when stressed or depressed tend to eat more. Others find it difficult to measure their blood glucose during these times. Treating any mental health problems often makes diabetes management easier.

Since diabetes is treated surgically only in a very small minority of patients, treatment programs are based on many other factors: appropriate diet, regular exercise and a variety of medications which often includes insulin. As opposed to many other conditions, diabetes is a chronic medical condition that first and foremost requires active patient participation to result in good outcomes (blood glucose control).

Surgical research

At the current time, the possibility of programming cells with new genes to produce insulin or perhaps stem cells (early types of cells which can "differentiate or transform into islet cells, the cells that make insulin) is a goal of many scientists. Of course, there are both technical and political barriers with this type of research. Nevertheless, diabetes, especially type 1 diabetes, is a condition for which gene therapy or stem cell research could produce a breakthrough advance.

Summary of diabetes basics

The five most important facts about diabetes are as follows:

• Diabetes is not one disease but rather is at least two diseases grouped as type 1 and type 2 diabetes. In actuality, there are many other types of diabetes, but the vast majority can be classified into these two types. Type 1 diabetes which usually presents in children or teens can present at any age. It is caused by the body destroying the cells in the pancreas that make insulin (the B-cells of the islets), and therefore insulin is required for survival. In type 2 diabetes which affects Hispanics, Blacks, Asians and American Indians more frequently, one must have both a resistance to the effects of insulin (so more insulin is required to maintain a normal glucose) and some degree of insulin deficiency. People with type 2 diabetes are usually (but not always) overweight and often have other risk factors for a heart attack or stroke including high blood pressure and dyslipidemia (high triglycerides low HDL cholesterol). People with type 2 diabetes often have their disease for years before they are diagnosed which is why the American Diabetes Association recommends screening for all high-risk individuals which would include everyone over 45 years of age, people with a strong family history of type 2 diabetes, and women who had diabetes during a pregnancy (gestational diabetes).

• Control of blood glucose for both type 1 and type 2 diabetes can reduce the risks of complications especially those involving the eyes (retinopathy), the kidney (nephropathy) and the nerves (neuropathy). The American Diabetes Association recommends maintaining the HbA1c below 7% which would be an average blood glucose of 150 mg/dL.

• Treatment of blood pressure below 130/80 and LDL-cholesterol ("bad cholesterol") below 100 mg/dL has been shown to prolong life in people with diabetes. For the blood pressure, there are advantages to using the class of drugs called ACE inhibitors. Also a daily aspirin has been shown to reduce risks of a heart attack.

• People with diabetes should have the following tests performed on a regular basis by their doctor:

  • a dilated eye exam each year to assess for diabetic retinopathy (the leading cause of adult blindness in the U.S.)
  • a yearly assessment for urine albumin or urine protein which is the first sign of diabetic kidney disease (nephropathy which is the leading cause of kidney dialysis or transplant in the U.S.)
  • a yearly measurement of cholesterol levels
  • Two HbA1c levels measured each year if you are well controlled, not receiving insulin, and four per year if you are receiving insulin.
  • have a yearly comprehensive foot exam by your doctor, assessing for the presence of neuropathy and vascular disease (the leading cause of lower extremity amputation in the U.S.).
  • consider some type of heart stress testing if you have diabetes and any other risk factors for a heart attack. Although 2/3 of people with diabetes die from heart disease it often presents without any symptoms and testing for it early may lead to finding a problem before it leads to a heart attack.

• If despite following the physician's advice, a person with diabetes still cannot meet the specific HbA1c blood pressure or cholesterol goals noted above, or the physician refuses to perform the standards of care from the ADA outlined above (they can also be read at www.diabetes.org), he or she might consider getting a second opinion or finding another physician. Doctors specializing in diabetes are called endocrinologists and it may be wise to consider seeing an endocrinologist if this situation occurs.