Diabetes Demystified

What is diabetes?

Diabetes mellitus is a group of metabolic diseases characterized by high blood sugar levels that result from defects in insulin secretion, or action, or both. Diabetes mellitus, commonly referred to as diabetes was first identified as a disease associated with “sweet urine,” and excessive muscle loss in the ancient world. Elevated levels of blood glucose (hyperglycemia) lead to spillage of glucose into the urine, hence the term sweet urine.

Normally blood glucose levels are tightly controlled by insulin, a hormone produced by the pancreas. Insulin lowers the blood glucose level. When the blood glucose elevates (for example, after eating food), insulin is released from the pancreas to normalize the glucose level. In patients with diabetes, the absence or insufficient production of insulin causes hyperglycemia. Diabetes is a chronic medical condition, meaning that although it can be controlled, it lasts a lifetime.

What causes diabetes?

Insufficient production of insulin, production of defective insulin (which is uncommon), or the inability of cells to use insulin properly and efficiently leads to hyperglycemia and diabetes. Glucose is a simple sugar found in food. Glucose is an essential nutrient that provides energy for the proper functioning of the body cells. Carbohydrates are broken down in the small intestine and the glucose in digested food is then absorbed by the intestinal cells into the bloodstream, and is carried by the bloodstream to all the cells in the body where it is utilized. However, glucose cannot enter the cells alone and needs insulin to aid in its transport into the cells. Without insulin, the cells become starved of glucose energy despite the presence of abundant glucose in the bloodstream. In certain types of diabetes, the cells’ inability to utilize glucose gives rise to the ironic situation of “starvation in the midst of plenty”. The abundant, unutilized glucose is wastefully excreted in the urine.

Insulin is a hormone that is produced by specialized cells (beta cells) of the pancreas. In addition to helping glucose enter the cells, insulin is also important in tightly regulating the level of glucose in the blood. After a meal, the blood glucose level rises. In response to the increased glucose level, the pancreas normally releases more insulin into the bloodstream to help glucose enter the cells and lower blood glucose levels after a meal. When the blood glucose levels are lowered, the insulin released from the pancreas is turned down. In normal individuals, such a regulatory system helps to keep blood glucose levels in a tightly controlled range. In patients with diabetes, the insulin is either absent, relatively insufficient for the body’s needs, or not used properly by the body. All of these factors cause elevated levels of blood glucose (hyperglycemia).

What are the different types of diabetes?

There are two major types of diabetes, called type 1 and type 2. Type 1 diabetes was also called insulin dependent diabetes mellitus (IDDM), or juvenile onset diabetes mellitus. In type 1 diabetes, the pancreas undergoes an autoimmune attack by the body itself, and is rendered incapable of making insulin. The patient with type 1 diabetes must rely on insulin medication for survival.

Type 2 diabetes was also referred to as non-insulin dependent diabetes mellitus (NIDDM), or adult onset diabetes mellitus (AODM). In type 2 diabetes, patients can still produce insulin, but do so relatively inadequately for their body’s needs. In many cases this actually means the pancreas produces larger than normal quantities of insulin. A major feature of type 2 diabetes is a lack of sensitivity to insulin by the cells of the body (particularly fat and muscle cells).

While it is said that type 2 diabetes occurs mostly in individuals over 30 years old and the incidence increases with age, we are seeing an alarming number patients with type 2 diabetes who are barely in their teen years. In fact, for the first time in the history of humans, type 2 diabetes is now more common than type 1 diabetes in childhood. Most of these cases are a direct result of poor eating habits, higher body weight, and lack of exercise.

While there is a strong genetic component to developing this form of diabetes, there are other risk factors – the most significant of which is obesity. There is a direct relationship between the degree of obesity and the risk of developing type 2 diabetes, and this holds true in children as well as adults. It is estimated that the chance to develop diabetes doubles for every 20% increase over desirable body weight.

What are diabetes symptoms?

  • Excessive urination
  • Unquenchable thirst
  • Fatigue, nausea and vomiting
  • Infections of the bladder, skin, and vaginal areas.
  • Numbness in hands, legs or feet.
  • Blurred vision
  • Dry, itchy skin

How is diabetes diagnosed?

The fasting blood glucose test (sugar) is the preferred way to diagnose diabetes. It is easy to perform and convenient. After the person has fasted overnight (at least 8 hours), a single sample of blood is drawn and sent to the laboratory for analysis. This can also be done accurately in a doctor’s office using a glucose meter.

Normal fasting plasma glucose levels are less than 100 milligrams per deciliter (mg/dl) (5.6mmol/l)

Fasting plasma glucose levels of more than 126 mg/dl (7mmol/l) on two or more tests on different days indicate diabetes.

A random blood glucose test can also be used to diagnose diabetes. A blood glucose level of 200 mg/dl (11.1mmol/l) or higher indicates diabetes.

What are the acute complications of diabetes?

Hyperglycemic Hyperosmolar Non-Ketotic Syndrome (HHNS). Occurs in patients with type 2 diabetes. Usually occurs when patients are ill or stressed. Symptoms include frequent urination, drowsiness, lethargy, and decreased intake of fluids. HHNS is not typically associated with nausea, vomiting, or abdominal pain.

Hypoglycemia (low blood sugar (glucose)). In patients with diabetes, the most common cause of low blood sugar is excessive use of insulin or other glucose-lowering medications, to lower the blood sugar level in diabetic patients in the presence of a delayed or absent meal. When low blood sugar levels occur because of too much insulin, it is called an insulin reaction. Sometimes, low blood sugar can be the result of an insufficient caloric intake or sudden excessive physical exertion. Blood glucose is essential for the proper functioning of brain cells. Therefore, low blood sugar can lead to central nervous symptoms such as dizziness, confusion, weakness and tremors.

What are the chronic complications of diabetes?

These diabetes complications are related to blood vessel diseases and are generally classified into small vessel disease, such as those involving the eyes, kidneys and nerves ,and large vessel disease involving the heart and blood vessels .Diabetes accelerates hardening of the arteries (atherosclerosis) of the larger blood vessels, leading to coronary heart disease, angina or heart attack, strokes, and pain in the lower extremities because of lack of blood supply.

Eye Complications

The major eye complication of diabetes is called diabetic retinopathy. Diabetic retinopathy occurs in patients who have had diabetes for at least five years. Diseased small blood vessels in the back of the eye cause the leakage of protein and blood in the retina. Disease in these blood vessels also causes the formation of small aneurysms , and new but brittle blood vessels. Spontaneous bleeding from the new and brittle blood vessels can lead to retinal scarring and retinal detachment, thus impairing vision.

To treat diabetic retinopathy a laser is used to destroy and prevent the recurrence of the development of these small aneurysms and brittle blood vessels. Approximately 50% of patients with diabetes will develop some degree of diabetic retinopathy after 10 years of diabetes, and 80% of diabetics have retinopathy after 15 years of the disease. Poor control of blood sugar and blood pressure further aggravates eye disease in diabetes.

Cataracts and glaucoma are also more common among diabetics. It is also important to note that since the lens of the eye lets water through, if blood sugar concentrations vary a lot, the lens of the eye will shrink and swell with fluid accordingly. As a result, blurry vision is very common in poorly controlled diabetes. Patients are usually discouraged from getting a new eyeglass prescription until their blood sugar is controlled. This allows for a more accurate assessment of what kind of glasses prescription is required.

Kidney damage

Kidney damage from diabetes is called diabetic nephropathy. The onset of kidney disease and its progression is extremely variable. Initially, diseased small blood vessels in the kidneys cause the leakage of protein in the urine. Later on, the kidneys lose their ability to cleanse and filter blood. The accumulation of toxic waste products in the blood leads to the need for dialysis. Dialysis involves using a machine that serves the function of the kidney by filtering and cleaning the blood. In patients who do not want to undergo chronic dialysis, kidney transplantation can be considered.

The progression of nephropathy in patients can be significantly slowed by controlling high blood pressure, and by aggressively treating high blood sugar levels. Angiotensin converting enzyme inhibitors (ACE inhibitors) or angiotensin receptor blockers (ARBs) used in treating high blood pressure may also benefit kidney disease in diabetic patients.

Nerve damage

Nerve damage from diabetes is called diabetic neuropathy and is also caused by disease of small blood vessels. In essence, the blood flow to the nerves is limited, leaving the nerves without blood flow, and they get damaged or die as a result (a term known as ischemia). Symptoms of diabetic nerve damage include numbness, burning, and aching of the feet and lower extremities. When the nerve disease causes a complete loss of sensation in the feet, patients may not be aware of injuries to the feet, and fail to properly protect them. Shoes or other protection should be worn as much as possible. Seemingly minor skin injuries should be attended to promptly to avoid serious infections. Because of poor blood circulation, diabetic foot injuries may not heal. Sometimes, minor foot injuries can lead to serious infection, ulcers, and even gangrene, necessitating surgical amputation of toes, feet, and other infected parts.

Diabetic nerve damage can affect the nerves that are important for penile erection, causing erectile dysfunction (ED, impotence). Erectile dysfunction can also be caused by poor blood flow to the penis from diabetic blood vessel disease.

Diabetic neuropathy can also affect nerves to the stomach and intestines, causing nausea, weight loss, diarrhea, and other symptoms of gastroparesis (delayed emptying of food contents from the stomach into the intestines, due to ineffective contraction of the stomach muscles).

The pain of diabetic nerve damage may respond to traditional treatments with gabapentin (Neurontin), phenytoin (Dilantin) or carbamazapine (Tegretol) with topically applied capsaicin (an extract of pepper).

Gabapentin (Neurontin), phenytoin (Dilantin), and carbamazepine (Tegretol) are medications that are traditionally used in the treatment of seizure disorders.

The pain of diabetic nerve damage may also improve with better blood sugar control, though unfortunately blood glucose control and the course of neuropathy do not always go hand in hand. Newer medications for nerve pain have recently come to market .Pregabalin (Lyrica) which has an indication for diabetic neuropathic pain and duloxetine (Cymbalta) are newer agents used in the treatment of diabetic neuropathy.

Diabetes management: How lifestyle, daily routine affect blood sugar

Above all, stay positive. The good habits you adopt today can help you enjoy an active, healthy life with diabetes.

Diabetes management requires awareness. Know what makes your blood sugar level rise and fall — and how to control these day-to-day factors.

When it comes to diabetes management, blood sugar control is often the central theme. After all, keeping your blood sugar level within your target range can help you live a long and healthy life with diabetes. But do you know what makes your blood sugar level rise and fall? The list is sometimes surprising.

Food

What to do:

Be consistent. Your blood sugar level is highest an hour or two after you eat, and then begins to fall. But this predictable pattern can work to your advantage. Simply eating about the same amount of food at about the same time every day can help you control your blood sugar level.

Even out your CARBS. Carbohydrates have a bigger effect on your blood sugar level than does protein or fat. Eating about the same amount of carbohydrates at each meal or snack will help keep your blood sugar level steady throughout the day.

Coordinate your meals and medication. Too little food in comparison to your diabetes medications — especially insulin — may result in dangerously low blood sugar (hypoglycemia). Too much food may cause your blood sugar level to climb too high (hyperglycemia). Your diabetes health care team can help you strike a balance.

Exercise

Physical activity is another important part of your diabetes management plan. When you exercise, your muscles use sugar (glucose) for energy. Regular physical activity also improves your body’s response to insulin. These factors work together to lower your blood sugar level. The more strenuous your workout, the longer the effect lasts. But even light activities — such as housework, gardening or being on your feet for extended periods — can lower your blood sugar level.

What to do:

Get doctor’s OK to exercise. This is especially important if you’ve been inactive and plan to start exercising regularly.

Adjust your diabetes treatment plan as needed. If you take insulin, you may need to adjust your insulin dose before exercising or wait a few hours to exercise after injecting insulin. Or your doctor may suggest other changes to your diabetes treatment plan.

Exercise good judgement. Check your blood sugar level before, during and after exercise, especially if you take insulin or medications that can cause low blood sugar. Drink plenty of fluids while you work out. Stop exercising if you experience any warning signs, such as severe shortness of breath, dizziness or chest pain.

Medication

Insulin and other diabetes medications are designed to lower your blood sugar level. But the effectiveness of these medications depends on the timing and size of the dose. And any medications you take for conditions other than diabetes can affect your blood sugar level, too.

What to do:
Store insulin properly – Insulin that’s improperly stored or past its expiration date may not be effective.

Report problems to your doctor. If your diabetes medications cause your blood sugar level to drop too low, the dosage or timing may need to be adjusted.

Be cautious with new medications. If you’re considering an over-the-counter medication or your doctor prescribes a new drug to treat another condition — such as high blood pressure or high cholesterol — ask your doctor or pharmacist if the medication may affect your blood sugar level. Sometimes an alternate medication may be recommended.

Monitoring you blood glucose levels.

Everyone with diabetes should test their blood sugar, or glucose, levels regularly. Knowing your blood sugar levels allows you to alter your diabetes management strategy if your levels aren’t near your target blood sugar.

Traditional Home Blood Sugar Monitoring. The traditional method of testing your blood sugar involves pricking your finger with a lancet (a small, sharp needle), putting a drop of blood on a test strip and then placing the strip into a meter that displays your blood sugar level. Meters vary in features, readability (with larger displays or spoken instructions for the visually impaired), portability, speed, size, and cost. Current devices provide results in less than 15 seconds and can store this information for future use. These meters can also calculate an average blood sugar level over a period of time. Some meters also feature software kits that retrieve information from the meter and display graphs and charts of your past test results. Blood sugar testing is usually recommended before meals, after meals, and at bedtime. Frequency and timing of blood sugar measurements should be individualized. Your health care provider will tell you when and how often you should check your blood sugar.

The chart below gives you an idea of where your blood sugar level should be throughout the day. Your ideal blood sugar range may be different from another person’s and will change throughout the day.

Time of TestIdeal for Adults With Diabetes
Before meals70-130 mg/dl (3.9-7.2mmol/l)
After mealsLess than 180 mg/dl (10mmol/l)
*Source: American Diabetes Association, 2009

Hemoglobin A1c test

The hemoglobin A1c test — also called HbA1c, glycated hemoglobin test, or glycohemoglobin — is an important blood test used to determine how well your diabetes is being controlled. Hemoglobin A1c provides an average of your blood sugar control over a six to 12 week period and is used in conjunction with home blood sugar monitoring to make adjustments in your diabetes medicines.

Lifestyle Changes for Diabetics.

Make a commitment to managing your diabetes. Learn all you can about diabetes. Make healthy eating and physical activity part of your daily routine. Establish a relationship with a diabetes educator, and ask your diabetes treatment team for help when you need it.

Take care of your teeth. Diabetes may leave you prone to gum infections. Brush and floss your teeth at least twice a day. And if you have type 1 or type 2 diabetes, schedule dental exams at least twice a year. Consult your dentist right away if your gums bleed or look red or swollen.

Identify yourself. Wear a tag or bracelet that says you have diabetes. Keep a glucagon kit nearby in case of a low blood sugar emergency — and make sure your friends and loved ones know how to use it.

Schedule a yearly physical and regular eye exams. Your regular diabetes checkups aren’t meant to replace yearly physicals or routine eye exams. During the physical, your doctor will look for any diabetes-related complications, as well as screen for other medical problems. Your eye care specialist will check for signs of retinal damage, cataracts and glaucoma.

Keep your immunizations up-to-date. High blood sugar can weaken your immune system. Get a flu shot every year, and get a tetanus booster shot every 10 years. Your doctor may recommend the pneumonia vaccine or other immunizations as well.

Pay attention to your feet. Wash your feet daily in lukewarm water. Dry them gently, especially between the toes. Moisturize with lotion, but not between the toes. Check your feet every day for blisters, cuts, sores, redness or swelling. Consult your doctor if you have a sore or other foot problem that doesn’t start to heal within a few days.

Keep your blood pressure and cholesterol under control. Eating healthy foods and exercising regularly can go a long way toward controlling high blood pressure and cholesterol. Medication may be needed, too.

If you smoke or use other types of tobacco, ask your doctor to help you quit. Smoking increases your risk of various diabetes complications, including heart attack, stroke, nerve damage and kidney disease. In fact, smokers who have diabetes are three times more likely to die of cardiovascular disease than are nonsmokers who have diabetes, according to the American Diabetes Association. Talk to your doctor about ways to stop smoking or to stop using other types of tobacco.

If you drink alcohol, do so responsibly. Alcohol can cause either high or low blood sugar, depending on how much you drink and if you eat at the same time. If you choose to drink, do so only in moderation and always with a meal. Remember to include the calories from any alcohol you drink in your daily calorie count.

Take stress seriously. If you’re stressed, it’s easy to abandon your usual diabetes management routine. The hormones your body may produce in response to prolonged stress may prevent insulin from working properly, which only makes matters worse. To take control, set limits. Prioritize your tasks. Learn relaxation techniques. Get plenty of sleep.

Above all, stay positive. The good habits you adopt today can help you enjoy an active, healthy life with diabetes.