Diabetes Basics.
Last updated Thursday, February 10, 2005
Prognosis and impactsPrognosis 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 carpel 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, a 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.
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