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Diabetes

Overview

More than 4 million UK citizens are thought to have diabetes, a disease characterized by too much sugar in the bloodstream. Almost 1 million of them, however, have not yet been diagnosed with the disease. If you have diabetes, you will want to learn as much as you can about how to take care of yourself. The better you eat and the more you exercise and keep your weight down, the more likely you will be able to lead a full and healthy life.

Diabetes occurs when the pancreas, a gland behind the stomach, does not produce enough of the hormone insulin. Insulin is necessary to carry sugar from the bloodstream into the cells. Once inside the cells, sugar is converted into energy for immediate use or stored for the future. That energy fuels all our bodily functions and rids the body of waste products. This process is known as metabolism.

Here is what normally happens during normal metabolism:

During and just after a meal, the body digests food into its “basic building blocks.” In this way, the body breaks down carbohydrates (starches) into sugar. Glucose is the primary form of sugar the body needs for energy.
After the meal, glucose is absorbed into the blood.
The rise in blood glucose tells the pancreas to make insulin, which goes out into the bloodstream. About 10 minutes after a meal, insulin is at its highest level.
Insulin helps the glucose enter the body's cells. The glucose either is used right away for energy or stored in the liver and muscles for future use.
About two to four hours after eating a meal, the body returns to low levels of blood glucose and starts using stored glucose for energy.

Here is what normally happens during normal metabolism:

The pancreas is unable to produce enough insulin or the body is resistant to the action of insulin.
Without enough insulin to move sugar from the bloodstream into the cells, the blood glucose level rises too high.
As blood glucose rises, extra glucose passes into the urine and out of the body before the body gets the energy it needs every day.
The body reacts to a prolonged sugar imbalance and, eventually, the person may develop major health problems. This is why it is important to get tested for diabetes and begin treatment as soon as possible.

There are two types of diabetes: type 1 and type 2. Type 1 diabetes is the more severe form as far as glucose is concerned. People with type 1 diabetes must take insulin every day because their bodies make very little or no insulin. Symptoms of type 1 diabetes can come on suddenly. This form of the disease is commonly seen in children and used to be called insulin-dependent diabetes or juvenile diabetes, although it may occur at any age. Type 2 diabetes is the most common form of the disease, affecting 90 to 95 percent of people with diabetes. In type 2 diabetes, the body is resistant to the action of insulin, meaning it cannot use insulin properly, so it cannot carry sugar into the cells. Although the body makes some insulin, it is not enough to overcome this resistance. Being overweight adds to insulin resistance. Therefore, as more children and adults become overweight, many more are developing type 2 diabetes.

People with type 2 diabetes often can control the condition with a healthy lifestyle, which includes exercise and diet that lead to a return to normal body weight. Many may need medications, however. These medications can either improve insulin secretion by the pancreas or decrease insulin resistance. Some individuals may also need to take insulin. In type 2 diabetes, the ability of the pancreas to make insulin slowly gets worse over time. This is why lifestyle changes may be sufficient shortly after diabetes develops, but eventually medications and even insulin may be needed to keep blood sugar under control. If the disease is in the early stage, an individual may not experience any diabetes symptoms. If you suspect you may have diabetes, you should see a doctor. Symptoms of diabetes include fatigue, weight loss, blurred vision, excessive thirst, and excessive urination. You are more likely to develop diabetes if you are overweight, have a family history of diabetes, or have a history of diabetes during pregnancy. If any of these apply to you, you should get tested for diabetes. Other groups more likely to have the disease are people over 45 years of age and non-Caucasians. Signs of diabetes should not be ignored.

A doctor will do various tests to measure a person's blood glucose level and his or her ability to tolerate glucose. Getting blood glucose levels under control is necessary to prevent the complications of diabetes. Both types of diabetes can cause dangerous complications if not controlled. Uncontrolled diabetes can cause blindness, heart disease, strokes and kidney failure. Decreased blood flow to the limbs may eventually lead to amputation. People with diabetes may also experience life-threatening reactions to extremely low or high blood sugar levels.

Due to the possible serious consequences of uncontrolled diabetes, people with the disease must manage their treatment carefully. Endocrinologists and diabetes specialist physicians are trained to help patients manage this condition. People with diabetes may also need to see eye doctors (ophthalmologists), foot doctors (podiatrists), and dietitians to round out their care. Only with proper attention can people with diabetes live a normal life, but with this care, they should be in control of their disease rather than the other way around.

Signs and Symptoms

Type 1 Diabetes

People with type 1 diabetes may have noticeable early symptoms that often come on suddenly. Symptoms of type 1 diabetes may include:

Increased thirst
Increased urination
Constant hunger
Weight loss
Blurred vision
Fatigue, or a feeling of being tired

Type 2 Diabetes

Type 2 diabetes may occur without any symptoms, or symptoms may develop gradually. Symptoms may include:

Frequent yeast infections e.g thrush
Very slow healing of wounds or sores
Nausea
Fatigue, or a feeling of being tired
Increased urination
Increased thirst
Weight loss
Blurred vision

If you have these symptoms of diabetes, please see your doctor for testing.

Treatment of Diabetes

All people with diabetes need to control their condition with proper diet and exercise. This is critical to the successful control of the blood sugar levels. They also may need to measure their glucose regularly and take oral medications or insulin injections to keep blood sugar levels under control.

Type 1 Diabetes: People with type 1 diabetes must take insulin, which is the hormone they lack. Most people take several insulin injections every day or use an insulin pump—a device worn outside the body that pumps insulin through a flexible tube to a small needle inserted under the skin. The pump can be set to give small amounts of short-acting insulin continuously through the day and additional doses before meals.

If you take insulin for type 1 diabetes, you should:

Take your insulin daily, as directed. Take your insulin even if you do not feel well or are sick. If you have any questions, contact your doctor immediately.
Discuss the time you eat and the amount of food you eat with your physician and dietitian so that your insulin regimen can be adjusted appropriately.
Eat regularly scheduled meals. Never skip meals, especially if you have taken an insulin injection, because your blood sugar may drop too low.
Monitor your blood glucose levels regularly, as your doctor recommends.

Types of Insulin

Different types of insulin are classified by how fast they work and how long they work in the body.

Mealtime (or “bolus”) insulin. Bolus insulin is given before meals to control the rise of blood glucose levels after eating. It is usually used in combination with basal insulin.

Rapid-acting (e.g. lispro, aspart) starts to work in 15 minutes and works for 3 to 5 hours.
Short-acting (regular insulin) starts to work in 30 to 60 minutes and works for 5 to 8 hours.

Basal insulin. Basal insulin controls blood sugar levels between meals and throughout the night. It is usually given once or twice daily and can be used alone or in combination with oral medications or bolus insulin.

Intermediate-acting (NPH) starts to work in 1 to 3 hours and works for 12 to 16 hours.
Long-acting (glargine, detemir) starts to work in 1 hour and works for 20 to 26 hours.

Pre-mixed insulin. A pre-mixed combination of bolus and intermediate-acting insulin controls blood sugar levels after and between meals. It is usually given twice daily before breakfast and dinner. Pre-mixed insulin can start to work as quickly as 15 minutes or may take 30 to 60 minutes, depending on the type of bolus insulin in the mixture. It works for 10 to 16 hours and can be used alone or with oral medications.

The type of insulin your doctor prescribes will depend on which type of diabetes you have, your lifestyle (e.g., foods you eat, how much you exercise), your age, your body’s response to insulin, and how often you are able or willing to check your blood sugar and to give yourself injections.

Type 2 Diabetes: Most people with type 2 diabetes can be treated with diet and exercise and oral antidiabetic agents. Some people may need insulin injections one or more times each day to control their diabetes. If you take oral agents or insulin for diabetes, you should:

Know how often to take your medication and stick to the schedule.
Remember that your medication may not lower blood sugar if you do not eat correctly or do not do regular exercise.
Know that you may need to start using insulin if your other medication does not lower your blood sugar sufficiently.
Try to lose some weight if you are overweight. Even a small amount of weight loss can help to lower your blood sugar. You may even be able to stop taking medication if you lose weight.

Oral Medications

Different types of oral anti-diabetic agents work in different ways. They can be used alone or in combination with other agents or insulin. The most common types of oral anti-diabetic drugs are:

Biguandes (metformin). Metformin is the most common anti-diabetic agent used to treat diabetes. It decreases the amount of glucose produced by the liver and helps the body respond better to insulin. People with kidney or liver failure cannot use metformin.

Sulphonylureas (e.g. gliclizide, glimepiride). Sulfonylureas increase the amount of insulin produced by the pancreas, which in turn lowers blood sugar levels. Nateglinide and repaglinide are similar to sulfonylureas but are short-acting and must be taken with each meal.

Thiazolidinediones (e.g. pioglitazone, rosiglitazone). Thiazolidinediones help the body respond better to insulin. A major side effect is heart failure in some people.

DPP-4 inhibitors (e.g. sitagliptin, saxagliptin). DPP-4 inhibitors increase insulin secretion and lower the release of glucagon, a hormone that raises blood sugar, by the pancreas.

In addition to oral medications, two injectable antidiabetic agents (exenatide and pramlintide acetate) help control blood sugar levels. These medications help the pancreas produce insulin more efficiently. They may also lead to a decrease in appetite and weight loss.

Keeping your glucose levels close to normal will greatly lower your chances of developing long-term complications. If you already have complications, keeping your glucose levels close to normal will greatly slow the progression of these complications.

Even if you take very good care of yourself, sometimes you may have high blood sugar, called hyperglycemia, or low blood sugar, called hypoglycemia.

If your blood sugar is high (hyperglycemia):

You may need to urinate often and have increased thirst.
Exercising may help lower your blood sugar level. If your blood sugar is very high (over 14 mmol/L), however, exercise may not help. Avoid exercise if your blood sugar is more than 16 mmol/L, and do not take insulin to lower your blood sugar so you can exercise.
If you have type 1 diabetes or if you develop an illness that results in an increase in your blood glucose, you should check your blood or urine for ketones. High ketones can mean that there is not enough insulin to move glucose from your bloodstream into your cells and your body starts breaking down fat for energy. Ketones form when stored fat is burned and you are dehydrated. This can happen, for example, if you have the flu or another illness. You can keep a test kit for ketones in your home and workplace.
If eating and exercise do not help you control your high blood sugar, contact your doctor about a better way to manage your blood sugar. Often this means a change in oral medication, or you may need to start using insulin or increase your dose.

If your blood sugar is low (hypoglycemia):

You probably have an imbalance between the amount of food you have eaten, the amount of exercise you have done, and the amount of medication (especially insulin) you have taken.
You may have symptoms like shakiness, dizziness, confusion, inability to concentrate, hunger, paleness, or headache.
Raise your blood sugar immediately with a glass of fruit juice, some sweets, or three glucose tablets (available at pharmacies).
Wait 15 minutes or so and then test yourself again. If your blood sugar is still low, repeat the sugar treatment again (juice, sweets etc.).
If your blood glucose remains low so that you cannot help yourself, someone should give you an injection of glucagon. Injectable glucagon is a prescription drug that helps to raise blood sugar. If you do not have glucagon, someone should bring you to the nearest A/E room for help.
If you take insulin and are prone to hypoglycemic reactions, you should always have glucagon on hand, and train a relative or co-workers how or when to inject you with it, should you become unconscious.
If you are beginning to feel dizzy or weak with the symptoms of low blood sugar while you are driving, pull to the side of the road immediately. Treat the reaction with sugar. Do not begin to drive again until you are completely back to normal

Living with Diabetes

If you are living with diabetes, lifestyle is an important element of your care. It is extremely important that you eat a good balance of foods every day and exercise regularly. Managing your disease also means taking medicine, if necessary, and testing your blood sugar levels each day.

Diet:

Diabetes does not require special foods. A healthy, balanced diet can come from everyday foods. If you have diabetes, you should:

Choose foods that are low in fat and salt.
Choose foods that are high in fibre (such as beans, vegetables and fruit).
Remember to eat foods from all food groups: milk and milk products; lean meat, chicken, turkey, fish, beans, cheese, and eggs; bread, cereal, rice, noodles, and potatoes; and fruits and vegetables.
Lose weight by reducing the amount of food you eat. If you have type 2 diabetes, weight loss will make your diabetes easier to control.

Your doctor can refer you to a dietitian who can help you plan meals that include the right foods, and recipes that taste great and are good for you.

Alcohol:

If your diabetes is under control and you do not have high blood pressure or nerve damage, you may drink alcohol in moderation. Keep in mind that if you drink alcohol while taking insulin or other diabetes medication, you risk low blood sugar. The liver slows its release of glucose until it first clears the alcohol.

If you drink alcohol, limit yourself to one drink a day if you are a woman and two drinks a day if you are a man. Never drink alcohol on an empty stomach.

Smoking:

Smoking greatly increases your risk of heart disease and blood vessel disease — two of the major complications of diabetes. Stopping smoking is the single best thing you can do to decrease your chances of developing heart or blood vessel disease.

Exercise and Activity:

Always see a doctor before starting an exercise program. Your doctor may have good ideas about types of exercise that would be best for you. Exercise is very important for people with diabetes because it does the following:

Helps insulin work better to lower blood sugar
Helps keep weight down, which also improves the condition
Is good for the heart, blood vessels, and lungs
Gives you more energy

Be aware that exercise affects your body's need for sugar. When you exercise, be sure to do the following:

Have a snack with you in case you get low blood sugar
Wear a tag or carry a card that says you have diabetes
Eat a snack, such as milk or an apple, if it has been more than an hour since you have eaten
Avoid exercising if your blood sugar is over 16 mmol/L.
Do not take insulin to lower your blood sugar before exercising. This may result in severe low blood sugar.

If you have heart disease or risk factors for heart disease, such as advanced age, high cholesterol, increased protein in your urine, high blood pressure, or poor diabetes control, check with your doctor about whether or not you need a cardiac evaluation before beginning an exercise regimen which may include a CT scan of your heart arteries to determine if you have any ‘furring up’.

If you have nerve damage to your feet, be careful to wear well-fitting shoes and socks to avoid blisters. You should discuss your exercise regimen with your physician and/or podiatrist.

Medications and Monitoring:

Taking your medicines and monitoring your blood sugar are also part of managing your diabetes. If you need to take medicine, be sure to take it as directed. Do not change your dosage or how often you take your medication unless you have been instructed to do so by your physician. Take it as prescribed and on time every day. Be careful not to skip doses of insulin or other medications. Test your blood for sugar as directed by your doctor. Some people only test once a day. Those who take insulin or multiple medications may need to test four or more times a day. Talk to your doctor about how often you should test your blood sugar.

To test your blood, you will need test strips and a lancet to pierce your finger or forearm for a blood drop. You will simply prick your finger or forearm, get a drop of blood, and place it on the end of the strip. After a short time, place the strip in your glucose meter and get an exact number for your blood sugar.

People with type 1 diabetes may also want to buy urine or blood test strips to detect ketones—substances your body forms when you do not have enough insulin and your blood glucose levels are high. This usually happens when you are sick. You may need to test for ketones when you have a blood sugar reading of more than 14 mmol/L before you eat. If you have a positive ketone test when you take a blood or urine test, call your doctor immediately. This may indicate a developing condition called diabetic ketoacidosis, a serious condition that can cause death if left untreated.

Finally, you should see your doctor for a hemoglobin A1c (HbA1c)test every three to six months. This blood test gives your doctor a picture of your average blood sugar levels over the past three months. Ask your doctor if you have questions about your HbA1c test results. You should have a normal result if most of your blood sugar levels are near 7-8 mmol/l.

Managing your diabetes may take some planning. Ask your doctor how to best prepare for the following situations, which may require extra insulin or even changes to your regular dose of medication:

When you are sick
If you are planning a pregnancy or become pregnant
When you are travelling
When you are at school or at work
When you are exercising

Associated Conditions

People with diabetes of both types commonly develop high blood pressure, or hypertension, and high cholesterol levels. These conditions may also require specific medications to achieve normal blood pressure and cholesterol levels.

When these levels are not controlled, they increase the risk for ‘furring up’ (atherosclerosis of the large blood vessels, which can cause heart attacks and strokes and lead to amputations. It is critical to control these conditions, as well as the diabetes.

Many of the lifestyle changes you may make to control your diabetes, such as diet and exercise, will also help control your blood pressure and cholesterol. Other changes may also be needed as well, such as lowering the salt and fats in your diet.

If you are diagnosed with diabetes, the first thing you should do is to find a physician, specifically an endocrinologist, to help you manage your condition. Find a doctor who will listen to you and answer your questions. Make a commitment to yourself to get educated and to make the lifestyle changes needed to maintain good health despite the challenges of diabetes. An experienced and sympathetic doctor, the right medication, a good diet, and exercise will go a long way in ensuring your well-being for many years to come.