Diabetes is one of the most important medical problems in our culture today. It is more than just high sugars. It is a disease that involves nearly every body system. Diabetes contributes to many causes of death and suffering. Much has been learned about the various forms of diabetes. To gain control over this disease, diabetics and their loved-ones should learn as much about it as possible.
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What is Diabetes?
We consume energy, store energy and burn energy. At the most basic level, diabetes is a disease that alters the way we store and use energy. Energy comes in the form of carbohydrates ("carbs"), fats and proteins (see the Nutrition Page ). Carbohydrates circulate in our blood stream as glucose (sugar). Fats circulate as triglycerides. After eating, these energy forms enter the bloodstream. If they are not burned right away, they are stored (proteins usually are not burned, but are used to make structures, like muscle and enzymes).
After a meal, the levels of these energy forms rise in the blood. In order to store or burn them, we need a "key" to let them into our cells. This key is insulin. Without properly functioning insulin, glucose (sugar) and triglycerides (fat) cannot be let into the cells. Since they cannot be used properly, their levels rise in the bloodstream. Hence, diabetics have high sugars and tend to have high triglyceride levels (proteins can be used without insulin). These high levels, among other problems, lead to the devastating complications (see below).
Types of Diabetes
There are two main types of diabetes. Type 1 and Type 2 diabetes have some things in common, but are really 2 different diseases. Gestational Diabetes is really a form of Type 2 Diabetes.
Type 1 Diabetes occurs when the insulin-producing cells of the pancreas (islet cells) are destroyed. This seems to be due to an immune system reaction, possibly during an infection. Type 1 Diabetes tends to occur in children and young adults, leading to the term "childhood onset diabetes". Type 1 diabetics must use insulin to survive. Without insulin therapy, the body cannot use any energy. Untreated, this eventually can lead to a build-up of acid in the blood (ketones), coma and death. With insulin therapy, the acids usually do not build up. However, the higher than normal sugars in poorly treated diabetes will cause damage to the small blood vessels and nerves. This damage leads to the many complications.
People with Type 1 Diabetes must monitor their sugars carefully and adjust their insulin dosage accordingly. This is best done with close communication with the doctor. Exercise and Diet are extremely important.
Type 2 Diabetes occurs when the body becomes unable to use its insulin properly. The pancreas cells are not destroyed in Type 2. The origin of Type 2 Diabetes is a bit complicated. Some people are more prone than others due to genetics. If your parents or siblings have Type 2 Diabetes, then consider yourself at risk. Obesity and sedentary lifestyle increases the risk. Even without a family history, if one becomes obese enough, Type 2 Diabetes will develop.
The main culprits in Type 2 Diabetes are the fat cells (adipocytes). Specifically, belly fat cells are the issue. It turns out that our fat cells help regulate insulin function. When we eat, insulin rises so that our energy can be put into either muscles or fat (again, see the Nutrition Page for details). If the muscles are not used much, most of our food energy is put into the fat cells. Fat cells can store a lot of energy. Eventually, fat cells become too big. They become sick and produce inflammation. Under such conditions, our insulin cannot work properly. The sugar and triglyceride levels then rise, just like in Type 1 diabetes. However, unlike Type 1 Diabetes, there still is at least some insulin function. Except for extreme circumstances, this prevents the build up of acids and the diabetic comas seen in untreated Type 1 Diabetes.
The high sugars, high triglycerides and high levels of inflammation damage the heart, blood vessels, kidneys and nervous system. Type 2 diabetes is such a huge risk factor for heart disease that a type 2 diabetic has the same 7 year risk of heart attack as the non-diabetic who has already had a heart attack (20%). It is one of the main reasons for kidney failure, amputations and blindness.
Type 2 Diabetes can usually be prevented. We must strive to keep the fat cells healthy. This is accomplished by avoiding excess calories, eating a healthy balance of foods, and by regularly burning energy in the muscles and the fat cells through exercise.
Click these links for more on Preventing Type 2 Diabetes.
Symptoms of Diabetes
Symptoms of both types can be similar. They are the result of high sugars and the inability to use energy.
Symptoms typically include increased fatigue, hunger, thirst and urination. There is usually unexplained weight loss despite increased hunger and eating.
Type 1 diabetics typically develop symptoms rapidly and progress to being very ill. Type 2 diabetics develop symptoms very slowly may not even be aware that the disease is present.
Complications of Diabetes
Type 1 diabetes is screened for with urine tests at the yearly physical exam. However, it is usually diagnosed with blood tests after the patient develops symptoms.
Type 2 diabetes is usually diagnosed on routine blood or urine tests during the routing yearly exam. If a high random sugar is found, then a fasting blood sugar is usually measured. A fasting sugar level over 126 is diagnostic.
Type 1 diabetics are trained to monitor their blood sugars several times a day with a glucose meter. They also should learn to check their urine for "ketones" (acids) with chemically treated dipsticks.
Type 2 diabetics should also check their sugars with a meter, however they typically do not need to check as frequently unless they have a complicated treatment plan. Some Type 2 diabetics need only to check their own sugars once in a while or when ill. If insulin is used for treatment, more frequent checks are helpful. The doctor will indicate how often sugars should be checked.
Hemoglobin A1C (Hgb A1C) is a blood test that all diabetics should have every 3 to 6 months. This is a very important number. It indicates the average sugar levels from the preceding 3 months. If you are a diabetic, you should always know your last Hgb A1C number. It is like a "score". Non-diabetics typically have Hgb A1C levels below 6%. The primary goal for all diabetics is to maintain level of 7% or less. Levels higher than 7% indicate poorer control. Levels over 9% indicate very poor control.
Urine tests should be done at the doctor's office every 6 to 12 months to check for early kidney disease. Diabetic kidney disease is indicated by abnormal amounts of protein in the urine.
Blood Pressure must be controlled. High blood pressure is another major risk factor for heart and kidney disease. It is extra important to monitor the blood pressure and treat it if high, preferably with an "ACE inhibitor" or an "Angiotensin Receptor Inhibitor" medication to decrease the risk of diabetic kidney disease (see below).
Cholesterol must be monitored and controlled as well. The "bad" cholesterol, called LDL, should be less than 100 or, alternatively, less than 70 if possible. This will lower the risk of heart attack and other complications.
Eye exams should be done at least yearly by an eye doctor (ophthalmologist). Diabetic eye disease ("retinopathy") can be picked up early and treated with laser before blindness sets in.
Foot exams should be done daily at home. Diabetics should look at their feet regularly (after or before a shower). The feet should be inspected for breaks in the skin, foot ulcers and toenail abnormalities. At the doctor's office, the feet should be examined at least once a year. The feet will be checked for nerve damage ("neuropathy"), skin break down, ulcers and blood-flow problems. Regular exams by a podiatrist are also recommended. Click on this link for more information on Diabetic Foot Care (PDF).
Remember, abdominal fat is the cause of Type 2 diabetes. We need these fat cells functioning properly. The way to keep them healthy is to keep the waist line down through a healthy lifestyle of good nutrition and regular exercise. In some cases, weight-loss surgery ("bariatric surgery") will be recommended. Please see our Weight Management Page for more details.
Good eating habits are essential for all of us, particularly for diabetics. The "diabetic diet" is really just a very healthy, balanced diet designed to help us manage energy and promote health. Meal planning is important.
Please see our Nutrition Page for details on a healthy diet. One potential option for additional control is to evaluate foods based on their Glycemic Index. Foods lower on this index tend to require less insulin and produce smaller blood sugar spikes.
Click this link for lots of information on Nutrition from the American Diabetes Association.
Regular exercise is extremely important. This is as important as diet. Exercise is like a medication in that it produces healthy changes in how we use and store energy. It is the best medication that we have for diabetes. A good rule of thumb is 2 1/2 hours a week of moderately intense exercise (that is "to a sweat"). This can be 20 minutes a day, or 30 minutes 5 days a week.
Exercise is the only time that our cells can use sugar energy from the blood without insulin. Therefore, it lowers blood sugar. With regular exercise, the muscle energy stores increase, and the fat energy stores decrease. By regularly calling on the fat cells for energy, the "sick" fat cells can become healthy again. This leads to a decrease in the insulin resistance described above. As the insulin starts to work better, we can store and use sugar and triglycerides better. This also leads to lower blood sugar, triglycerides and inflammation. Exercise lowers the risk of complications, such as heart attacks.
For more on the details and benefits of exercise, see our Exercise and Fitness Page.
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Other Routine Care
Vaccines should be up to date. Uncontrolled diabetes makes it harder to fight infection. Also, infections tend to worsen diabetes control. If you have diabetes, please talk to your doctor and make sure that you are up to date. These include the usual vaccine schedule from childhood, a tetanus booster every 10 years, a yearly flu shot in the Fall, and likely a pneumonia shot every 5 to 10 years.
There are a number of ways to correct the many problems that diabetes causes. For some Type 2 diabetics, good nutrition, exercise and weight control may be enough to control the diabetes. However, most need medication.
Click this link for information on the types of medications that can be used to treat diabetes.
Click this link for more information on Insulin Therapy.
Besides these, most diabetics will be advised to use:
- an aspirin a day (81 mg will likely be fine) to reduce the risk of heart attack
- an "ACE Inhibitor" or an "Angiotensin Receptor Blocker" to reduce the risk of kidney failure
- a cholesterol medication such as a "statin" to further reduce the risk of heart disease, heart attack, and arterial disease
Some diabetes medications (insulin and sulfanylureas) can cause the blood sugar to drop to dangerous levels.
Please click this link for more information on Hypoglycemia