Diabetes

Diabetes is a condition in which the body can't regulate the amount of glucose, or sugar, in the blood. Insulin, a hormone produced by the pancreas, is like a key that opens the cells in your body to accept glucose and provide you with energy. With diabetes, the pancreas either loses its ability to make enough insulin or cells can't use insulin properly.

Diabetes affects about 18 million people in the United States, slightly more than 6 percent of the population. One-third of all people who have diabetes are unaware they have the condition. Another estimated 16 million people in the United States have a condition called prediabetes. Their blood sugar levels are higher than normal, but not high enough to be diagnosed with type 2 diabetes.

Although it's most common in older adults, diabetes is one of the most prevalent chronic diseases for American children.


Types of diabetes
There are two major forms of diabetes, type 1 and type 2.
Type 1 diabetes, formerly called insulin-dependent diabetes mellitus (IDDM), is an autoimmune disorder in which the body's immune system destroys the insulin-producing cells of the pancreas. With type 1 diabetes, the pancreas releases either little or no insulin. About 5 to 10 percent of people who have diabetes have type 1 diabetes. Although the condition can develop at any age, it's most common in children and young adults, typically developing suddenly before age 30. Genetic and environmental factors may also play a role in the development of type 1 diabetes. Currently, type 1 diabetes can only be effectively managed with doses of insulin.

Type 2 diabetes, formerly called non-insulin-dependent diabetes mellitus (NIDDM), is caused by a lack of insulin production or the inability of the cells to use insulin properly. This is known as insulin resistance. About 90 to 95 percent of people who have diabetes have type 2 diabetes. It usually develops after age 40, especially for people who are overweight. However, it can also develop in overweight children. Possibly an inherited condition, type 2 diabetes typically develops gradually and symptoms may go unrecognized for many months.

Most children who have diabetes have type 1 diabetes. However, in the past 10 years there's been an increase in the number of children developing type 2 diabetes. Adolescents who are obese are at particularly high risk.


Prediabetes
A condition known as prediabetes increases the risk of developing type 2 diabetes. Again, this condition exists when you have a blood sugar level between the normal range and the diabetic range. It may occur in two forms: impaired fasting glucose (IFG) and impaired glucose tolerance (IGT). IFG means you have a fasting blood sugar of 100 to 125 mg/dL. IGT is when you have a blood sugar level of 140 to 199 mg/dL two hours after drinking a sugar solution (also known as an oral glucose tolerance test).

Associated factors
Risk factors for prediabetes and diabetes include:
Age: The risk increases as you get older.

Weight: The risk increases when you're overweight, defined as a body mass index of 25 or higher.

Blood pressure: The risk increases with blood pressure of 140/90 mm/Hg or higher.

Cholesterol: The risk increases with HDL cholesterol less than 40mg/dL for men or 50mg/dL for women and triglycerides of 250mg/dL or higher.

Family history: The risk increases with a family history of diabetes, especially a parent or sibling who has diabetes.

Race/ethnicity: The risk for type 2 diabetes is higher for people who have an African American, American Indian, Asian American, Pacific Islander, Hispanic American or Latino heritage.

History of gestational diabetes: The risk is higher for women who developed gestational diabetes during pregnancy or delivered a baby weighing more than 9 pounds.

Lifestyle: The risk is higher for those with an inactive lifestyle, defined as exercising less than three times a week.

Associated conditions
Hyperglycemia is a condition in which your body doesn't produce enough insulin or is unable to utilize glucose, which causes you to develop high blood sugar. Other factors that may raise blood sugar levels include stress, growth, menstruation, and the use of birth control pills, steroids and other medications.
A condition known as glycosuria occurs when the concentration of sugar in the blood reaches a certain level and "spills" into the urine.

Hypoglycemia develops when your blood sugar level is too low, often due to too much insulin, alcohol, certain medications, not enough food or too much exercise. Hypoglycemia can be dangerous if not properly treated. (Warning signs are listed below.)

Ketoacidosis is a medical emergency that may develop in people who have uncontrolled type 1 diabetes. When the body doesn't have enough insulin, it's unable to move sugar into the cells for energy. Instead, the body breaks down its store of fat to get energy. This process, called ketosis, produces an excessive accumulation of ketones (the end product of fat metabolism) in the blood and tissues. Ketoacidosis can develop if you miss doses of insulin or have an infection or serious illness, since the body's stress response to an illness can raise blood sugar levels. This condition is especially dangerous for children because it increases the risk of developing swelling in the brain.

A condition known as hyperosmolar hyperglycemic nonketotic coma (HHNC) can also be caused by an infection or serious illness. HHNC can develop in people who have type 2 diabetes and is more common in elderly adults. With HHNC, blood sugar levels get very high. The body tries to get rid of the excess sugar by passing it into the urine. Urination increases at first, which can lead to dehydration. The dehydration can get worse if your fluid intake is poor because you feel ill. HHNC can progress to a coma, and in some cases, it may be fatal.


Signs/symptoms
Common symptoms of diabetes, which often go undiagnosed, may include:
increased thirst
frequent urination
weight loss despite an increase in appetite
extreme fatigue
blurred vision
irritability
frequent infections
slow healing of wounds
For children, diabetes is sometimes detected through a routine blood test. Or, in addition to any of the symptoms listed above, children may experience:

nausea
symptoms that mimic the flu
atypical bedwetting

Emergency symptoms
The following emergency symptoms require immediate medical attention.
Symptoms of hypoglycemia (low blood sugar) can develop suddenly. Initial symptoms may include:

weakness
shakiness or tremors
dizziness
sweating
pale, cold and clammy skin
irritability or nervousness
hunger
heart palpitations or rapid heartbeat
tingling of hands or feet
Moderate to severe symptoms of hypoglycemia may include:

headache
fainting (or feeling near faint)
difficulty concentrating or confusion
emotional changes or unusual behavior patterns such as stubbornness or uncoorperativeness (may resemble a state of intoxication)
slurred speech
poor coordination or staggering gait
fatigue or drowsiness
visual disturbances
coma
possibly seizures, particularly in children
Ketoacidosis may appear gradually. Symptoms, some of which are also considered general symptoms of diabetes, may include:

increased thirst and urination
hot, dry skin or flushed face
deep, rapid or labored breathing
nausea or vomiting
abdominal pain
slightly sweet-smelling breath (You may notice a fruity odor.)
constant fatigue
confusion
Symptoms of HHNC may also appear gradually and may include:

increased or extreme thirst
nausea
visual disturbances
weakness
drowsiness or lethargy
confusion or hallucinations
convulsions or seizures
coma
Again, any of these emergency symptoms require immediate medical attention. If you're helping someone who's experiencing these symptoms but are unsure what type of reaction it is, call 911 or contact your local emergency services provider. While you're requesting help, give the person a quick source of sugar (such as 4 to 6 ounces of orange juice, three glucose tablets or five to six pieces of hard candy) if he or she is awake.

If a loved one has diabetes, especially a child, it's important to learn how to recognize and respond to severe hypoglycemia. Often, a prescription medication called Glucagon can be injected to raise blood sugar. Be sure you understand how and when to use this medication.


Diagnosis
To detect diabetes, you may need a variety of blood tests. These tests are usually done after you've fasted for a certain amount of time. An initial diagnosis is often based on classic symptoms and a random blood glucose level of 200 mg/dl or higher. (For comparison, normal blood glucose levels after an overnight fast are 70 to 99 mg/dl.) Diagnosis can also be based on:
two fasting blood sugar levels of 126 mg/dl or higher
two readings of 200 or higher after eating a meal
one fasting reading of 126 or higher AND one reading of 200 or higher after eating a meal
Levels of thyroid hormone are often checked as well because diabetes increases the risk of developing thyroid disease.


Treatment
The goal of diabetes treatment is to keep your blood sugar level within a normal range, as recommended by your doctor. Treatment plans often focus on the factors described below.

Diet
A healthful diet can help you achieve and maintain a reasonable weight, as well as maintain healthy blood sugar levels. If you're overweight and have type 2 diabetes, weight loss alone may be beneficial. Along with your doctor, a registered dietitian or certified diabetes educator can be a resource for diet instruction and meal planning. Learning to make healthy choices for meals and snacks will be especially important for children and adolescents taking insulin. Family involvement is crucial to make sure meal plans are followed and regular meals are available.
Here are some general tips:

Eat at about the same time every day -- don't skip meals.
It may also be helpful to eat about the same amount of food every day.
Choose a variety of foods from the basic food groups.
Limit the amount of pure sugar in your diet. Make sure you read food labels carefully.
Learn how certain foods affect your blood sugar level.
You may also want to contact the American Diabetes Association and the American Dietetic Association. The American Diabetes Association offers a booklet titled "Exchange Lists for Meal Planning" to help you learn how to use exchanges. You can find it on their Web site -- www.diabetes.org -- or request a copy by calling (800) 342-2383.


Exercise
For adults who have mild to moderate diabetes, regular exercise can lower blood sugar and increase circulation. Regular exercise may also decrease the risk of heart disease. It's important to choose a form of exercise you enjoy. And, of course, consult your doctor before beginning an exercise program or participating in a group sport. Since hypoglycemia can develop quickly during exercise, always carry a high-carbohydrate food item. If you have type 1 diabetes, eating a light carbohydrate snack and drinking a glass of skim milk 30 minutes before you exercise may help prevent low blood sugar, but discuss this with your doctor.
For children, regular exercise is also an important part of the treatment plan. Physical activity can help your child maintain a healthy weight and control his or her blood sugar. If your child has type 1 diabetes, his or her doctor will provide an individualized plan to help prevent hypoglycemia (low blood sugar) during physical activity. Make sure your child's blood sugar is in a healthy range before exercise, and keep in mind that less insulin or extra food may be needed after a period of physical activity.

At any age, it's a good idea to wear an emergency identification tag and inform friends, teachers, coaches, co-workers and others of your condition.


Medication
If you have type 2 diabetes and diet or lifestyle changes are unsuccessful, you may need an oral hypoglycemic medication. Taken by mouth, these medications work in a variety of ways and differ in duration, potency and dosage. There are currently five main groups of oral medications used to treat diabetes.
Sulfonylureas (Diabinese, Glucotrol, Amaryl or Micronase, for example) are the oldest group of oral medications. They stimulate the pancreas to make more insulin.

Meglitinides (Prandin or Starlix, for example) stimulate your pancreas to make more insulin. These short-acting medications are taken at the start of a meal and may help prevent elevated blood sugar after a meal.

Biguanides such as metformin (Glucophage, for example) work mostly by decreasing the amount of glucose the liver makes, but also by making cells more sensitive to insulin so glucose can be absorbed.

Thiazolidinediones (Actos or Avandia, for example) decrease insulin resistance by making the body's cells more sensitive to insulin and reducing the amount of glucose made by the liver.

Alpha glucosidase inhibitors (Precose or Glyset, for example) slow the body's digestion of carbohydrates, delaying absorption of glucose from the intestines.
If your blood sugar levels can't be controlled with oral hypoglycemic medications, you may need to combine them with insulin injections or take insulin on its own. It's essential to use the correct amount of insulin, as prescribed by your doctor. Periodic dosage adjustments may be needed. Whether you're taking insulin, oral agents or managing your diabetes through your diet, you'll need to test your blood sugar with a home glucose monitor as often as four or more times a day (see details below).

If you have vision problems or other difficulties, ask your doctor about special medical equipment (such as prisms and magnifiers) to help you read the numbers on the syringe. A voice glucose monitor may also be an option. Of course, your doctor, nurse or diabetes educator can help you understand how to take your medications or give yourself insulin injections.


At-home glucose monitoring
There are many brands of glucose meters available for at-home monitoring. To ensure proper readings, learn how to properly use and care for the equipment. Here are some general recommendations:
Follow the instructions carefully, including how to check the meter for accuracy against a control strip, as well as store the meter and testing products. Consult your doctor, pharmacist or the manufacturer if you have any questions.

Don't mix and match brands of equipment or test products, and check the expiration dates on test strip bottles and solutions. Follow directions on calibrating your machine with each new vial of strips.

Take your readings regularly, as recommended by your doctor. Keep a record of your glucose results to share with your doctor, including notes on what you've eaten. Generally, blood glucose readings should be 70 to 120mg/dL before eating, and 80 to 150 mg/dL two hours after eating.

Consult your doctor promptly if your readings are abnormal.
Two new devices for monitoring blood sugar trends have been approved by the U.S. Food and Drug Administration (FDA). The GlucoWatch is a noninvasive device worn like a wristwatch. It measures glucose from tiny amounts of fluid pulled from the skin. It may be used by both children and adults. The MiniMed Continuous Glucose Monitoring System uses a very small tube inserted under the skin to remove fluid and measure glucose. Both systems must be used in combination with fingerstick glucose testing. They're not intended to replace fingerstick testing, but rather record trends in blood sugar.

Another recent advance combines a glucose monitor with wireless technology to send information to an insulin pump. The glucose monitor automatically calculates the proper dose of insulin based on the blood sugar reading and sends that information to the insulin pump. The pump then delivers the insulin to your bloodstream.


Surgery
A pancreas transplant may be considered for a small number of people who have diabetes. It's often done at the same time as a kidney transplant. For people who have type 1 diabetes, an experimental procedure to transplant insulin-producing cells may be an option. The procedure has had limited success, but research continues. As with any transplant surgery, immunosuppressive medications must be taken for life to prevent rejection of the transplanted organ(s).

Preventive health maintenance
Foot care
When you have diabetes, regular preventive foot care is essential. Consider the following self-care measures.

Wear properly fitting shoes, and avoid going barefoot.

Buy shoes toward the end of the day when your feet will be slightly more swollen. The shoes should be comfortable right away. They should not require any "breaking in."

Change your socks daily, and regularly rotate the shoes you wear.

Bathe your feet every day, making sure to dry them well. Check your feet and the area between your toes for blisters, sores, pressure areas or changes in skin color.

Don't use a heating pad or hot water bottle to warm cold feet. Wear socks instead.

Avoid garters and hosiery with tight bands that could impair circulation.

Avoid extremes in temperature.

Don't use medication or strong antiseptics on your feet without consulting your doctor.
Other lifestyle measures
If you smoke, quit. Smoking impairs circulation, which could increase the risk of diabetes-related complications.


Follow-up care
As an adult, it's essential to take daily responsibility for managing your condition. Children will need the help of their families. Coping with diabetes can be difficult, especially for adolescents and school-aged children who don't want to feel different from their peers. If you or your child need help meeting the challenges of daily life with diabetes, it may help to consult a mental health professional.
Keeping your blood sugar as close to normal can significantly decrease the risk of complications. Inform all health care professionals involved in your care of any problems you may experience, especially in the specific situations outlined above. Even when you feel well, keep scheduled appointments with your doctor. Children who have type 1 diabetes will need to see their doctors frequently, at least every three months.

Your doctor may recommend periodic hemoglobin A1C blood tests (also called glycosylated hemoglobin or glycohemoglobin tests). These tests will help your doctor determine how well your blood sugar has been controlled over the last few months. The goal is to have a result less than 7 percent (for adults) or 8 percent (for children). A reading of 4 to 6 percent is optimal. A change in your treatment plan will be considered if your result is more than 8 percent. Hemoglobin A1C results compared to blood sugar readings are:

6 percent -- 120
7 percent -- 150
8 percent -- 180
9 percent -- 210
10 percent -- 240
11 percent -- 270
12 percent -- 300
13 percent -- 330


To detect complications early, your doctor will monitor the results of annual eye exams, urine tests, leg and foot exams, blood pressure and cholesterol measurements, and electrocardiograms (recordings of the electrical activity of the heart). In some cases, stress tests (a method of evaluating cardiovascular fitness) may also be recommended. Talk with your doctor about an annual flu shot and the need for a pneumococcal vaccine.

In addition to the emergency symptoms described above, inform your doctor if you:

develop a fever
have frequent diarrhea or vomiting
have blood sugar levels in an inadequate range
are injured or have any break in the skin
have any signs of wound infection, such as increased redness, swelling, pain or tenderness, pus drainage, an area that's warm to the touch or has red streaks coming from it, or you feel ill
In some cases, medication may be prescribed to help prevent serious problems during illness, such as dehydration, ketosis or hypoglycemia. For example, the medication promethazine, which is a suppository used to treat vomiting, can be given to young children who're susceptible to viral illnesses accompanied by vomiting.


Complications
Poorly controlled diabetes can lead to serious, long-term complications. For example, routinely high blood sugar can cause:
atherosclerosis (hardening of the arteries), which can lead to heart disease, heart attacks, stroke or gangrene (tissue death) requiring amputation
diabetic retinopathy (impaired vision or blindness)
diabetic nephropathy (kidney disease or failure)
neuropathy (any disease of the nerves), which can cause pain, numbness, tingling or loss of feeling in the extremities, and erectile dysfunction (impotence) for men
gastrointestinal problems, such as delayed stomach emptying and diarrhea
gum disease
To emphasize the importance of controlling diabetes, one large long-term study of people with type 1 diabetes who maintained almost normal blood glucose levels reported a delayed onset of diabetes-related complications, as well as an immense slowing of complications related to atherosclerosis and neuropathy. Another large study in type 2 patients showed similar results.

Finally, the U.S. Preventive Services Task Force recommends that adults who have high blood pressure or high cholesterol be tested for type 2 diabetes to help decrease the risk for cardiovascular disease. Up to 65 percent of Americans who have diabetes die from heart disease and stroke.


Pregnancy-specific information
If you have diabetes and become pregnant, you face a greater risk of developing serious complications during pregnancy unless you keep your blood sugar tightly controlled. If your blood sugar is higher than normal when the baby is born, the excess sugar will be passed on to your infant and may cause medical complications. To reduce the risk of complications, careful prepregnancy planning and prenatal care are essential. Keep in mind that pregnant women can't take oral hypoglycemic medication. If your blood sugar isn't controlled through diet, your doctor will prescribe insulin.
When diabetes develops during pregnancy, it's known as gestational diabetes. In this case, the placenta makes hormones that change the way insulin works in your body. Although blood sugar control usually returns to normal after delivery, gestational diabetes increases the risk of developing type 2 diabetes in the future.


Senior-specific information
Type 2 diabetes is common in elderly adults. In fact, slightly more than 20 percent of people age 65 and older are estimated to have diabetes. Especially for older adults, diabetes can lead to complications such as kidney disease, amputations, blindness and diseases related to hardening of the arteries, including heart attack and stroke.

Prevention
Today, type 1 diabetes isn't preventable. Researchers are studying ways to suppress the autoimmune responses that destroy the insulin-producing cells of the pancreas, as well as identify who's at risk for type 1 diabetes.
You may be able to delay or even prevent type 2 diabetes by eating healthfully, losing excess pounds and exercising. Remember to consult your doctor before beginning an exercise program or participating in a group sport. If you're at risk for type 2 diabetes, have your blood sugar measured every one to two years. The role of oral diabetes medication in the prevention of diabetes is controversial and not currently recommended.