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According to the American Diabetes Association 23.6 million people in the United States have diabetes and the number will increase significantly over the next 20 years. Disturbingly, 24% of those with diabetes are unaware of their diagnosis (1).
Diabetes, a disease associated with high blood sugar levels due to a decreased amount of insulin or an inability of the body to use insulin, is a serious disease, which affects many body systems. Insulin, a hormone produced by the pancreas, helps transport sugar into cells where it can be used for energy. Diabetes increases your risk for heart disease, stroke, heart failure, kidney failure and blindness. Diabetes decreases quality of life and shortens your life span.
Types: There are two main types of diabetes. Type I usually occurs in younger individuals and accounts for about 10% of the cases. It occurs after cells of the pancreas that produce insulin are destroyed and the body cannot produce insulin. Type II diabetes occurs mostly in adults. It occurs because the body’s cells are insensitive to the action of insulin. The body has a decreased ability to get the blood sugar into the cells, consequently the blood sugar rises. In response to the cells not getting enough sugar, the body produces more insulin. Therefore, the individual with diabetes type II has high levels of blood sugar and increased levels of insulin (at least early in the disease). As the disease progresses the pancreas loses its ability to produce insulin.
Pre-diabetes is a condition associated with elevated blood sugars but levels are not high enough to be classified as diabetes. Pre-diabetes increases the risk for developing diabetes. If you have been diagnosed with pre-diabetes focusing on a healthy lifestyle, including exercise, proper nutrition and weight control, will help to prevent progression to diabetes.
Bonus: How to Work with Your Doctor to Manage Your Diabetes
Risk Factors
Many factors increase the risk of diabetes. Family history, meaning a parent or sibling also having the disease, is a major risk factor. Scientists believe there is a strong genetic component to diabetes but only a few genes have been documented as a direct cause of diabetes.
Obesity, especially fat in the abdomen, is another risk factor. Individuals who carry excessive weight in the legs and hips are at less risk for diabetes than those who have large amounts of abdominal fat. Obesity is defined as having a body mass index greater than thirty. Body mass index is determined by dividing the weight in kilograms by your height in meters squared (see example in Table 8).
Physical inactivity is another risk factor for diabetes but body mass index is a greater risk factor for developing diabetes than physical inactivity. (For females) having a baby that weighs more than nine pounds also puts you at risk for developing diabetes.
Table 8: Body Mass Index
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Chris, a 68-year-old man, weighs 200 pounds or 90 kilograms and is 5 feet and 9 inches or 1.75 meters To determine his body mass index use the following formula Weight in kilograms/((Height in meters) x (Height in meters)) 90.9/(1.75x1.75)=29.7 Chris has a body mass index of 29.7, which places him in the overweight category. Interpretation of Body Mass Index Less than 18.5 Underweight 18.6 – 24.9 Normal 25-29.9 Overweight Over 30 Obese |
Complications
Diabetes is associated with many complications, which occur mainly because of increased insulin levels and increased blood sugars. There are two broad categories of complications in diabetes which experts term microvascular and macrovascular. Macrovascular complications: Macrovascular complications include heart disease, diseases of the blood vessels in the legs and cerebrovascular disease (stroke). High levels of sugar and resistance to insulin damage the blood vessels walls leading to disease.
Heart and vascular disease is very common in patients with diabetes and it needs to be monitored for carefully. Due to damaged nerves in diabetes, many diabetic have silent heart disease, which is heart disease without any symptoms and is associated with heart attacks that are unrecognized. It is therefore important to be vigilant about monitoring for heart disease in diabetics.
Controlling risk factors in diabetics is essential in reducing macrovascular complications, including controlling blood pressure and high cholesterol. In addition to controlling for cardiovascular risk factors, heart and vascular disease should be monitored for carefully. This can be accomplished by a good physical exam by your physician and certain diagnostic tests, such as stress tests.
Microvascular complications: Microvascular complications, include retinopathy (eye disease), nephropathy (kidney disease) and neuropathy (nerve disease). These are diseases of the small blood vessels and associated with high sugar levels. The best way to decrease the risk of these complications is to control blood sugar levels.
Retinopathy: Retinopathy is a disease of the eyes that leads to blindness. It is critical to have annual eye exams with an eye doctor and control blood sugars to reduce the risk of this disease.
Nephropathy: Nephropathy, or destruction of the kidney, may advance to end stage renal disease and dialysis. Diabetics should be screened annually with a urine test to look for protein, which is an early sign that diabetes is doing damage to the kidney. Again, controlling the blood sugar is essential in preventing this complication. Medicines called angiotensin converting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARBS) are two medicines that have been shown to protect the kidneys from nephropathy.
Neuropathy: This is disease of the nerves in your body. The most common presentation of neuropathy is peripheral neuropathy where high sugar levels damage nerves in the arms and legs causing burning pain and decreased sensation. Other nerves that can be affected are the stomach nerves resulting in nausea and vomiting as the stomach is unable to push the food through. As with other microvascular complications, the most important factor in preventing neuropathy is controlling blood sugars.
Other Compilations
Erectile dysfunction (ED) is a common complication of diabetes. In diabetes, the majority of causes of ED are from dysfunction of the nerves and blood vessels in the pelvis. High levels of blood sugar damage the nerves in the groin and the vessels supplying blood to the penis. Without stimulation from the nervous system and adequate blood flow to the groin, the body is unable to get an erection.
Non-healing wounds, especially on the legs, are common in diabetics and occur for a number of reasons. High sugar levels provide an environment in which wounds do not heal well. In addition, diabetic commonly have poor blood flow to the extremities. Blood flow, which supplies oxygen, is crucial to wound healing.
The wounds sometimes go unnoticed for a period of time because damage to the nervous system prevents the patient from feeling the injury. Consequently, by the time the wound is recognized it has advanced beyond a simple cut or scrape, making it harder to treat. Diabetics should look at their feet everyday to catch any scrapes or cuts early before they advance to a more severe wound.
Amputation: Wounds that do not heal have the potential to spreads to the bone resulting in a severe infection called gangrene. Gangrene may result in death to bone tissue. It often requires amputation or the infection will spread through out the body and death will ensue.
Other potential complications of diabetes include: congestive heart failure and memory loss.
Signs and Symptoms
Type II diabetes is typically present for years before it is diagnosed. The diagnosis of diabetes is often found on routine blood work and not related to any specific complaint. When symptoms are present they are usually related to the increased amount of sugar in the body. The most common symptoms include: urinating frequently, eating a lot of food and having excessive thirst. Other symptoms include blurred vision, frequent infections, wounds that do not heal and fatigue.
Table 9: Signs and Symptoms of Diabetes
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Often none Urinating frequently Eating a lot Drinking a lot Blurred vision Fatigue Sores that heal slowly Frequent infections |
Diagnosis
Typically, by the time diabetes is diagnosed the disease has been present for many years. This leaves a large window of time for complications of the disease to damage the body. Simple screening tests are available to diagnosis diabetes, which not only diagnosis the disease early but can reduce the number of complications that diabetes imparts on the body. It is therefore important to do screenings to catch the disease early.
There are three ways a doctor makes the diagnosis of diabetes. Each way to diagnosis diabetes involves taking blood and confirming the results on a separate occasion. The three ways to diagnosis the disease include:
- Fasting blood sugar greater than 126 mg/dl on two occasions.
- Blood sugar greater than 200 mg/dl after eating 75 grams of glucose on two occasions.
- Signs and symptoms of diabetes with a random blood sugar over 200 on two occasions.
Pre-diabetes is diagnosed when:
- Fasting blood sugar is between 100-125 mg/dl or
- The blood sugar is between 140-200 mg/dl after eating 75 grams of glucose.
It is important to have pre-diabetes diagnosed because this disease is a precursor to diabetes. If you have risk factors for diabetes it is important to be tested early and often to detect diabetes or pre-diabetes. Those with risk factors for diabetes should be tested every one to three years for diabetes and pre-diabetes. If one of these conditions are picked up then treatment, usually with aggressive lifestyle modifications, is initiated.
Treatment Goals
The goals in treating type II diabetes include:
- Eliminating symptoms
- Preventing complications
- Controlling blood sugars
- Controlling other risk factors
Eliminating symptoms: The primary way to eliminate symptoms is to control blood sugar. This can be done with diet, exercise and a variety of medications.
Preventing complications: Preventing complications is accomplished through controlling blood sugars and other risk factors associated with diabetes.
Controlling blood sugar: This is a primary responsibility of the diabetic who practices health care responsibility. One should check blood sugar levels at various times through out the day. Keeping good records lets you and your health care provider know if you are treating your disease optimally. Readings should be recorded so the results can be shared with your health care provider. The blood sugar tracking sheet should be used to monitor blood sugar readings and results should be reported to your doctor at each visit.
It is essential that you get readings at different times of the day. The standard recommendation includes checking blood sugars before meals and before bed, but this prescription is not most advantageous. Diabetics often have problems controlling blood sugars after they eat. Some patients notice they have blood sugars before meals that fall in the recommended range but have readings after eating food that are far from ideal. Therefore, diabetics should obtain readings before each meal and two hours after each meal. It is also important to monitor before bed blood sugars. It is not necessary to check your blood sugars seven times a day but you should vary the times. Patients who have good blood sugar control might only check their blood sugar one time a day or one time a week but should vary the time. Someone with poor control of their diabetes should check blood sugar four times a day at various times (see Table 11). Talk to your health care provider about how often and when you should check your blood sugars. Table 10: Goals for Blood Sugar for the Diabetic
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Fasting blood sugar between 80-120 mg/dl. Before bed reading of 100-140 mg/dl Two hours after a meal reading of less than 150 mg/dl |
Table 11: Examples of a Prescription for Blood Sugar Monitoring
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John is a 52-year-old male with good control of his blood sugar John should check is blood sugar one time a day as follows:
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Mary is a 66-year-old female with fair control of her blood sugar Mary should check her blood sugar two times a day as follows:
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Jeff is a 70-year-old male with poor control of his sugar Jeff should check is blood sugar four times a day as follows:
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Your health care provider will also obtain a reading called an glycosylated hemoglobin (HbA1C). This is a reading that looks at how well your blood sugar has been controlled over the last 2-3 months. Most professionals would recommend a goal of less than 7.0 %. This correlates with an average blood sugar reading of less than 150 mg/dl (some health care providers even recommend a lower reading). Keeping the HbA1C down significantly reduces the number of complications that you will suffer.
Other goals
To prevent macrovascular complications it is important not only to control blood sugars, but control other risk factors. Controlling blood pressure is essential in preventing complications of the disease. Most professionals agree that your blood pressure should be controlled to a reading below 130/80 mm Hg. It is generally agreed that using a blood pressure medicine called an angiotensin converting enzyme inhibitor (ACE-I) is the best medicine to use to control blood pressure in the diabetic. Other medicines such as angiotensin receptor blockers and calcium channel blockers are also recommended in diabetes.
High cholesterol should also be controlled to prevent many of the long-term complications of diabetes. High cholesterol levels increase the risk of death. The low-density lipoprotein (LDL) or bad cholesterol is the most important number to manage. The main target is to control the LDL cholesterol to less than 100 mg/dl with high-risk patients having targets of less than 70 mg/dl.
Diabetics are often afflicted with low high-density lipoproteins (HDL) or good cholesterol and high triglycerides. Secondary goals in treating cholesterol in diabetics include increasing the HDL cholesterol and reducing triglycerides.
A variety of methods are available to control cholesterol including lifestyle changes and medications. Lifestyle changes that can be used to treat abnormal cholesterol include exercise, weight loss and dietary changes. Dietary changes that raise cholesterol include reducing saturated fats and increasing monounsaturated fats in the diet.
Many medications are available to treat abnormal cholesterol. Diabetics may benefit from the class of drugs called the statins, which include drugs such as atorvastatin (Lipitor), simvastatin (Zocor) and Fluvastatin (Lescol), to reduce the risk of heart and vascular disease. Niacin is another popular medicine used to treat abnormal cholesterol but caution needs to be used in diabetics as this drug can increase blood sugar.
Aspirin: Aspirin therapy reduces the risk of heart disease. It is recommended to use low dose aspirin in those with diabetes that are at risk for heart disease. Those with a bleeding disorders including bleeding ulcers need to use aspirin with caution.
Treatment
Often the first step in treating diabetes is to make lifestyle changes. Lifestyle changes include diet, exercise, and smoking cessation.
Diet: Weight loss is essential to controlling diabetes. People who can lose as little as 10 pounds can significantly reduce the need for diabetic medicine. Eating well-balanced meals with portions spread out evenly help maintain blood sugar levels. Diets should include a variety of foods including vegetables, fruits, whole grains, low-fat dairy products and lean meats.
Diets high in simple sugars such as juice, white bread and candy result in large rises in blood sugar and should be eaten in limited quantities. Everybody responds differently to different foods. One way to tell if you can eat certain foods is to check your blood sugar one to two hours after eating the food to assess the effect it has on your blood sugar. If eating a handful of jellybeans causes your blood sugar to skyrocket to 350 mg/dl it is not the best food to use as a snack.
Exercise: Exercise can help people with diabetes in a variety of ways. It aids in weight loss, which can help control diabetes. Exercise - specifically aerobic exercise such as walking, biking and swimming - improves insulin sensitivity. This means that after exercise your cells are better able to use insulin, which lowers blood sugar readings. This effect lasts up to 48 hours after an exercise session so exercise should be performed at least every other day to derive benefits of improved insulin sensitivity.
Exercise reduces the risk of death and disability. Diabetes increases risk for heart disease and stroke and the addition of exercise reduces the risk of heart disease and stroke. Exercise also improves cholesterol and blood pressure.
Medications
When lifestyle changes are unable to adequately manage diabetes, drug therapy is added. Multiple classes of drugs treat diabetes including: sulfonylureas, meglitinides, biguanides, thiazolidinediones, alpha-glucosidase inhibitors, dipeptidyl peptidase IV inhibitors, incretin mimetics and insulin. These drugs work in different ways to lower blood sugar levels.
Sulfonylureas
Sulfonylureas, including glipizide (Glucotrol), glyburide (Micronase, Diabeta, Glynase), and glimepiride (Amaryl), help the body make insulin. These drugs work best in those who are not overweight and are taken one to two times a day, before meals.
All sulfonylurea drugs have similar effects on blood glucose levels, but they differ in side effects, how often they are taken, and interactions with other drugs. Sulfonylureas typically lower the HbA1C by 1-2 points. This means that if your HbA1C is 10.2%, after being on this drug for a few months your level would drop to 8.2 – 9.2%. So, the addition of this drug alone will not get you to the goal of less than 7.0%. Common side effects include low blood sugar, weight gain and increased risk for sunburn.
Thiazolidinediones (TZD)
Rosiglitazone (Avandia) and pioglitazone (Actos) are the two thiazolidinediones. These drugs help the body use insulin more effectively and decrease the amount of blood sugar that the liver makes. TZDs have been shown to reduce the HbA1C by 1.0 to 1.5% when used alone. These drugs may reduce the risk of heart disease, but there is no hard data to prove this. This reduction of heart disease may be secondary to improvements in cholesterol and reduction of blood clots.
TZDs increase HDL cholesterol, lower triglycerides and increase the LDL cholesterol. The increase in LDL cholesterol may not have negative impacts on the health. There are two types of LDL cholesterol: a large fluffy type and a small and dense type. Standard laboratory evaluations do not differentiate between the two types of cholesterol, but the small dense type is much more detrimental to health.
TZDs do not increase the small dense LDL cholesterol, and therefore are not, theoretically, detrimental to cardiovascular health. TZDs have been shown to increase the large fluffy type of LDL cholesterol. Since the standard cholesterol laboratory report does not differentiate between the two types of LDL cholesterol, the lab report will just show an increase in LDL cholesterol. There is limited long-term data on this class of drugs, but it is believed that the increase in LDL cholesterol is not detrimental to health.
Most of the cardiovascular benefit of TZDs is theoretical. TZDs may actually be harmful. The FDA recently placed a warning that there is a potential for heart attack and heart related deaths with the use of rosiglitazone.
Side effects of these drugs include: fluid retention, weight gain, headache, sinusitis, muscle aches, increase low-density lipoprotein levels and elevated liver enzymes (not common). Caution must be used in those with heart failure as this drug can increase the risk of developing heart failure.
Biguanides
Metformin (Glucophage) is a biguanide. Biguanides lower blood glucose levels by decreasing the amount of sugar that the liver produces and improves the cell’s ability to use insulin more effectively. This class is highly recommended in those who are overweight.
This class shows similar efficacy to the TZDs with drops in HbA1C of 1-1.5%. The main side effects include stomach upset, weight loss, diarrhea and gas. Those with congestive heart failure, kidney failure or those over the age of 75 need to be carefully monitored when using this drug.
Alpha-glucosidase inhibitors
Acarbose (Precose) and miglitol (Glyset) are alpha-glucosidase inhibitors. They block the breakdown of sugar in the stomach and therefore lower the amount that gets into the blood, thereby attenuating the rise in blood sugar after a meal. Meglitinides are effective at lowering the blood sugar after meals by about 50 mg/dl and when used regularly they lower HbA1C 0.5 to 1.0%. These drugs should be given 30 minutes before a meal. Common side effects include bloating, gas and abdominal pain.
Meglitinides
This class of drugs lowers blood sugar by stimulating the pancreas to release insulin. They are short acting medicines and are taken 30 minutes prior to eating. Meglitinides are effective at lowing blood sugars after meals about 60 mg/dl and when used regularly they lower HbA1C 0.5 to 1.0%. The drugs in this class include: Repaglinide (Prandin) and Nateglinide (Starlix). The side effects include low blood sugar, back pain, flu symptoms and dizziness.Dipeptidyl peptidase IV inhibitors
These are the newest oral drugs available for the management of diabetes, gaining FDA approval in 2006. There is one drug in this class called Januvia. They are dosed once a day. Common side effects include: runny nose, headache and rash.
Incretin-mimetic
Incretin mimetics are another new class of medications, but they are injectable. They are given twice a day and they modulate multiple hormonal pathways. They are easier to use then insulin as there are only two separate doses, as opposed to many different insulin doses.
Insulin
Many different types of insulin exist. There are long acting, short acting and medium acting types of insulin. They are titrated upward until your health care provider is satisfied that your blood sugar is well controlled. Insulin is often added to a the above medicines, to enhance control of blood sugar. There is some concern about the use of insulin with TZDs as this may increase the risk of swelling and heart failure. Common side effects include: low blood sugar and pain at the injection site.
Treatment points
Treating diabetes is a very complicated process. It is important that you take responsibility to assure that all of the proper monitoring is executed. Here are some key points about the treatment of diabetes.
- Control of blood sugar worsens overtime and your health care provider may need to add more than one medicine. If your blood sugar is controlled at the present time don’t assume that it will always be controlled. Be diligent and continue to monitor your blood sugar.
- Keep good records of your blood sugars to help your health care provider adjust your medicines and monitor your disease. These records not only help your health care provider, but they can help you understand what foods negatively affect your blood sugar.
- Develop a regular exercise program
- Become involved in a diabetic education group
- Monitor blood pressure to assure that you are at goal
- Talk to your health care provider about medicines that are recommended for diabetics: aspirin, angiotensin converting enzyme inhibitors, angiotensin receptor blockers and cholesterol pills called statins.
- Assure you are getting an annul eye exam.
- Assure you urine is checked annually for protein.
- Know your HbA1C and make sure it is being checked 2-4 times a year.
Health Care Responsibility
- Understand the questions below.
- Track your blood sugars on a schedule that you and your doctor agree on using the blood sugar tracking sheet.
- Diabetes is a disease with many complications, make sure that all preventative testing is taking place. Use the diabetes flow sheet to help you track the testing necessary to remain healthy with diabetes. There should be no gaps on this form – if there is – talk to your doctor.
Questions you should be able to answer. If not, ask your health care provider.
What type of diabetes do I have? The two most common types of diabetes are Type 1 and Type 2. Type 2 is much more common and the most likely diagnosis if diabetes was diagnosed after age 40.
How did you diagnose my disease?
How often should I check my blood sugar? This can vary from person to person. Some can benefit from checking their blood sugars 4 times a day while some need 1-2 times a day or 1-2 times week. Talk to your health care provider.
Should I attend classes for diabetes management? Classes are provided that teach the diabetic how to self-manage his or her disease. Diabetes is a very dangerous and complicated disease, each patients needs to understand it to help manage it properly. These classes are a great start in helping each diabetic partner with the doctor in managing diabetes.
How often should I get my HbA1C checked? This can vary from 2-4 times a year. Well controlled patients should have it checked every six months while people with poor control should have it checked every three months. It is recommended you obtain a reading less than 7%.
Should I have an Electrocardiogram (EKG)? Most diabetics should have at least one baseline EKG. Diabetics have high rates of silent heart attacks. Having a baseline EKG allows physicians to know if you have had any changes to your EKG, which may indicate if you have had a heart attack.
How often should I have a dilated eye exam? It is recommended that you have an annual dilated eye exam.
Is my cholesterol at goal? You should have your cholesterol monitored. Optimal cholesterol can significantly reduce your chances for developing heart disease. The most important number to evaluate is your LDL cholesterol, which should be less than 100 mg/dl and in some people less than 70 mg/dl. Your HDL cholesterol should be greater than 40 mg/dl. Triglycerides should be less than 150 mg/dl.
Should I be on a pill to control my blood cholesterol? Statins are potent cholesterol lowering medicines, which has been shown to be very effective in diabetics.
Do I have protein in my urine? You should have an annual evaluation for protein in your urine. This is an early indicator of kidney failure. If you do have protein in your urine you should be on an ACE-I or ARB.
Should I be exercising? Do I need a stress test prior to exercise? Most people should be exercising. Some individuals need to use precautions so it is essential you talk to your health care provider prior to starting a program. Most diabetics should have an exercise stress test before engaging in an exercise program.
Do I need to be medicines or insulin to manage my disease? There are multiple medicines to treat diabetes and each class of medicine has benefits and risks. Talk to your doctor about which medicine is best for you.
What are the side effects of my medicines? Talk to your doctor about the common side effects of the medicines you are on?
Should I be on an aspirin? Most diabetics should be on an aspirin unless there is a contraindication. People who have an allergy to aspirin or a history of bleeding may not be a candidate for an aspirin.
Should I have my feet evaluated by a podiatrist? Most diabetics should have their feet looked at on a regular basis for any wounds, nerve damage or peripheral vascular disease.
Should I have a pneumococcal vaccine? Flu vaccine? Most diabetics should have a pneumococcal vaccine once than have it repeated after the age of 65 and an annual flu vaccine unless there is a contraindication.
References
American Diabetes Association. Diabetes Statistics. http://www.diabetes.org/diabetes-statistics.jsp. Accessed on 6/02/09
- Diabetes is a disease with many complications, make sure that all preventative testing is taking place. Use the diabetes flow sheet to help you track the testing necessary to remain healthy with diabetes. There should be no gaps on this form – if there is – talk to your doctor.
