Noninsulin-Dependent Diabetes --------------------------------------------------------------------- --- This etext is about noninsulin-dependent diabetes. The word "diabetes" in this epub refers to noninsulin-dependent diabetes unless otherwise specified. --------------------------------------------------------------------- --- Table of Contents •Introduction •What is Diabetes? •Symptoms •What Causes Noninsulin-Dependent Diabetes? •Who Develops Noninsulin-Dependent Diabetes? •Diagnosing Diabetes •Treating Diabetes •Diabetes Diet •Alcoholic Beverages •Exercise •Oral Medications •Insulin •Checking Blood Glucose Levels •Diabetes Complications •Special Situations •Dealing with Diabetes •Finding Help •Printed Information •Resources on Diabetes Introduction Of the estimated 13 to 14 million people in the United States with diabetes, between 90 and 95 percent have noninsulin-dependent or type II diabetes. Formerly called adult-onset, this form of diabetes usually begins in adults over age 40, and is most common after age 55. Nearly half of people with diabetes don't know it because the symptoms often develop gradually and are hard to identify at first. The person may feel tired or ill without knowing why. Diabetes can cause problems that damage the heart, blood vessels, eyes, kidneys, and nerves. Although there is no cure for diabetes yet, daily treatment helps control blood sugar, and may reduce the risk of complications. Under a doctor's supervision, treatment usually involves a combination of weight loss, exercise and medication. This hypertext document isn't a guide to treatment and it doesn't replace the advice of a doctor. It's one of many sources of extra information about diabetes. Local diabetes groups and clinics sponsor meetings and educational programs about diabetes that also can be helpful. At the end of this book is a list of groups that have information on diabetes programs. --------------------------------------------------------------------- --- Points to Remember •Only a doctor can treat diabetes. •Treatment usually involves weight loss, exercise and medication. •Daily treatment helps control diabetes and may reduce the risk of complications. --------------------------------------------------------------------- --- What is Diabetes? The two types of diabetes, insulin-dependent and noninsulin-dependent, are different disorders. While the causes, short-term effects, and treatments for the two types differ, both can cause the same long-term health problems. Both types also affect the body's ability to use digested food for energy. Diabetes doesn't interfere with digestion, but it does prevent the body from using an important product of digestion, glucose (commonly known as sugar), for energy. After a meal the digestive system breaks some food down into glucose. The blood carries the glucose or sugar throughout the body, causing blood glucose levels to rise. In response to this rise the hormone insulin is released into the bloodstream to signal the body tissues to metabolize or burn the glucose for fuel, causing blood glucose levels to return to normal. A gland called the pancreas, found just behind the stomach, makes insulin. Glucose the body doesn't use right away goes to the liver, muscle or fat for storage. In someone with diabetes, this process doesn't work correctly. In people with insulin-dependent diabetes, the pancreas doesn't produce insulin. This condition usually begins in childhood and is also known as type I (formerly called juvenile-onset) diabetes. People with this kind of diabetes must have daily insulin injections to survive. In people with noninsulin-dependent diabetes the pancreas usually produces some insulin, but the body's tissue don't respond very well to the insulin signal and, therefore, don't metabolize the glucose properly, a condition called insulin resistance. Insulin resistance is an important factor in noninsulin-dependent diabetes. --------------------------------------------------------------------- --- Points to Remember •Diabetes interferes with the body's use of food for energy. •While noninsulin-dependent diabetes are different disorders, they can cause the same complications. --------------------------------------------------------------------- --- Symptoms The symptoms of diabetes may begin gradually and can be hard to identify at first. They may include fatigue, a sick feeling, frequent urination, especially at night, and excessive thirst. When there is extra glucose in blood, one way the body gets rid of it is through frequent urination. This loss of fluids causes extreme thirst. Other symptoms may include sudden weight loss, blurred vision, and slow healing of skin, gum and urinary tract infections. Women may notice genital itching. A doctor also may suspect a patient has diabetes if the person has health problems related to diabetes. For instance, heart disease, changes in vision, numbness in the feet and legs or sores that are slow to heal, may prompt a doctor to check for diabetes. These symptoms do not mean a person has diabetes, but anyone who has these problems should see a doctor. --------------------------------------------------------------------- --- Points to Remember •The symptoms of diabetes can develop gradually and may be hard to identify at first. •Symptoms may include feeling tired or ill, excessive thirst, frequent urination, sudden weight loss, blurred vision, slow healing of infections, and genital itching. --------------------------------------------------------------------- --- What Causes Noninsulin-Dependent Diabetes? There is no simple answer to what causes noninsulin-dependent diabetes. While eating sugar, for example, doesn't cause diabetes, eating large amounts of sugar and other rich, fatty foods, can cause weight gain. Most people who develop diabetes are overweight. Scientists do not fully understand why obesity increases someone's chances of developing diabetes, but they believe obesity is a major factor leading to noninsulin-dependentdiabetes. Current research should help explain why the disorder occurs and why obesity is such an important risk factor. A major cause of diabetes is insulin resistance. Scientists are still searching for the causes of insulin resistance, but they have identified two possibilities. The first could be a defect in insulin receptors on cells. Like an appliance that needs to be plugged into an electrical outlet, insulin has to bind to a receptor to function. Several things can go wrong with receptors. There may not be enough receptors for insulin to bind to, or a defect in the receptors may prevent insulin from binding. A second possible cause involves the process that occurs after insulin plugs into the receptor. Insulin may bind to the receptor, but the cells don't read the signal to metabolize the glucose. Scientists are studying cells to see why this might happen. --------------------------------------------------------------------- --- Points to Remember •In people with noninsulin-dependent diabetes, insulin doesn't lower blood sugar, a condition called insulin resistance. •Obesity is a risk factor for diabetes. --------------------------------------------------------------------- --- Who Develops Noninsulin-Dependent Diabetes? Age, sex, weight, physical activity, diet, lifestyle, and family health history all affect someone's chances of developing diabetes. The chances that someone will develop diabetes increase if the person's parents or siblings have the disease. Experts now know that diabetes is more common in African Americans, Hispanics, Native Americans and Native Hawaiians than whites. They believe this is the result of both heredity and environmental factors, such as diet and lifestyle. The highest rate of diabetes in the world is in an Arizona community of American Indians called the Pimas. While the chances of developing diabetes increase with age, gender isn't a risk factor, although African American women are more likely to develop diabetes than African American men. While people can't change family history, age, or race, it is possible to control weight and physical fitness. A doctor can decide if someone is at risk for developing diabetes and offer advice on reducing that risk. --------------------------------------------------------------------- --- Points to Remember •The following factors increase someone's chances of developing diabetes: obesity, family history of diabetes, and advancing age. --------------------------------------------------------------------- --- Diagnosing Diabetes A doctor can diagnose diabetes by checking for symptoms such as excessive thirst and frequent urination and by testing for glucose in blood or urine. When blood glucose rises above a certain point, the kidneys pass the extra glucose in the urine. However, a urine test alone is not sufficient to diagnose diabetes. A second method for testing glucose is a blood test usually done in the morning before breakfast (fasting glucose test) or after a meal (postprandial glucose test). The oral glucose tolerance test is a second type of blood test used to check for diabetes. Sometimes it can detect diabetes when a simple blood test does not. In this test, blood glucose is measured before and after a person has consumed a thick, sweet drink of glucose and other sugars. Normally, the glucose in a person's blood rises quickly after the drink and then falls gradually again as insulin signals the body to metabolize the glucose. In someone with diabetes, blood glucose rises and remains high after consumption of the liquid. A doctor can decide, based on these tests and a physical exam, whether someone has diabetes. If a blood test is borderline abnormal, the doctor may want to monitor the person's blood glucose regularly. If a person is overweight, he or she probably will be advised to lose weight. The doctor also may monitor the patient's heart, since diabetes increases the risk of heart disease. --------------------------------------------------------------------- --- Points to Remember A doctor will diagnose diabetes by looking for four kinds of evidence: •risk factors like exercise weight and a family history of diabetes •symptoms such as thirst and frequent urination •complications like heart trouble •signs of excess glucose or sugar in blood and urine tests. --------------------------------------------------------------------- --- Treating Diabetes The goals of diabetes treatment are to keep blood glucose within normal range and to prevent long-term complications. Why control blood glucose? In the first place, diabetes can cause short-term effects: some are unpleasant and some are dangerous. These include thirst, frequent urination, weakness, lack of ability to concentrate, loss of coordination, and blurred vision. Loss of consciousness is possible with very high or low blood sugar levels, but is more of a danger in insulin-dependent than in noninsulin-dependent diabetes. In the second place, the long-term complications of diabetes may result from many years of high blood glucose. Research is under way to find out if this is true and to learn if careful control can help prevent complications. Meanwhile, most doctors feel that if people with diabetes keep their blood glucose levels under control, they will reduce the risk of complications. In 1986, a National Institutes of Health panel of experts recommended that the best treatment for noninsulin-dependent diabetes is a diet that helps the person maintain normal weight. In people who are overweight, losing weight is the one treatment that is clearly effective in controlling diabetes. In some people, exercise can help keep weight and diabetes under control. However, when diet and exercise alone can't control diabetes, two other kinds of treatment are available: oral diabetes medications and insulin. The treatment a doctor suggests depends on the person's age, lifestyle, and the severity of the diabetes. --------------------------------------------------------------------- --- Points to Remember •Diabetes treatment can reduce symptoms, like thirst and weakness, and the chances of long-term problems, like heart and eye disease. •If treatment with diet and exercise isn't effective, a doctor may prescribe oral medications or insulin. •There is no known cure for diabetes; daily treatment must continue throughout a person's lifetime. --------------------------------------------------------------------- --- Diabetes Diet The proper diet is critical to diabetes treatment. It can help someone with diabetes: •Achieve and maintain desirable weight. Many people with diabetes can control their blood glucose by losing weight and keeping it off. •Maintain normal blood glucose levels. •Prevent heart and blood vessel diseases, conditions that tend to occur in people with diabetes. A doctor will usually prescribe diet as part of diabetes treatment. A dietitian or nutritionist can recommend a diet that is healthy, but also interesting and easy to follow. No one has to be limited to a preprinted, standard diet. Someone with diabetes can get assistance in the following ways: •A doctor can recommend a local nutritionist or dietitian. •The local American Diabetes Association, American Heart Association, and American Dietetic Association can provide names of qualified dietitians or nutritionists and information about diet planning. •Local diabetes centers at large medical clinics, hospitals, or medical universities usually have dietitians and nutritionists on staff. The guidelines for diabetes diet planning include the following: •Many experts, including the American Diabetes Association, recommend that 50 to 60 percent of daily calories come from carbohydrates, 12 to 20 percent from protein, and no more than 30 percent from fat. •Spacing meals throughout the day, instead of eating heavy meals once or twice a day, can help a person avoid extremely high or low blood glucose levels. •With few exceptions, the best way to lose weight is gradually: one or two pounds a week. Strict diets must never be undertaken without the supervision of a doctor. •People with diabetes have twice the risk of developing heart disease as those without diabetes, and high blood cholesterol levels raise the risk of heart disease. Losing weight and reducing intake of saturated fats and cholesterol, in favor of unsaturated and monounsaturated fats, can help lower blood cholesterol. For example, meats and dairy products are major sources of saturated fats, which should be avoided; most vegetable oils are high in unsaturated fats, which are fine in limited amounts; and olive oil is a good source of monounsaturated fat, the healthiest type of fat. Liver and other organ meats and egg yolks are particularly high in cholesterol. A doctor or nutritionist can advise someone on this aspect of diet. Studies show that foods with fiber, such as fruits, vegetables, peas, beans, and whole-grain breads and cereals may help lower blood glucose. However, it seems that a person must eat much more fiber than the average American now consumes to get this benefit. A doctor or nutritionist can advise someone about adding fiber to a diet. Exchange lists are useful in planning a diabetes diet. They place foods with similar nutrients and calories into groups. With the help of a nutritionist, the person plans the number of servings from each exchange list that he or she should eat throughout the day. Diets that use exchange lists offer more choices than preprinted diets. More information on exchange lists is available from nutritionists and from the American Diabetes Association. Continuing research may lead to new approaches to diabetes diets. Because one goal of a diabetes diet is to maintain normal blood glucose levels, it would be helpful to have reliable information on the effects of foods on blood glucose. For example, foods that are rich in carbohydrates, like breads, cereals, fruits, and vegetables break down into glucose during digestion, causing blood glucose to rise. However, scientists don't know how each of these carbohydrates affect blood glucose levels. Research is also under way to learn whether foods with sugar raise blood glucose higher than foods with starch. Experts do know that cooked foods raise blood glucose higher than raw, unpeeled foods. A person with diabetes can ask a doctor or nutritionist about using this kind of information in diet planning. Alcoholic Beverages Most people with diabetes can drink alcohol safely if they drink in moderation (one or two drinks occasionally), because in higher quantities alcohol can cause health problems: •Alcohol has calories without the vitamins, minerals, and other nutrients that are essential for maintaining good health. A doctor can discuss whether it's safe for an individual with diabetes to drink. People who are trying to lose weight need to account for the calories in alcohol in diet planning. A dietitian also can provide information about the sugar and alcohol content of various alcoholic drinks. •Alcohol on an empty stomach can cause low blood glucose or hypoglycemia. Hypoglycemia is a particular risk in people who use oral medications or insulin for diabetes. It can cause shaking, dizziness, and collapse. People who don't know someone has diabetes may mistake these symptoms for drunkenness and neglect to seek medical help. •Oral diabetes medications-tolbutamide and chlorpropamide-can cause dizziness, flushing, and nausea when combined with alcohol. A doctor can advise patients on the safety of drinking when taking these and other diabetes medications. •Frequent, heavy drinking can cause liver damage over time. Because the liver stores and releases glucose, blood glucose levels may be more difficult to control in a person with liver damage from alcohol. •Frequent heavy drinking also can raise the levels of fats in blood, increasing the risk of heart disease. --------------------------------------------------------------------- --- A thorough physical exam by a doctor is essential before starting an exercise program. --------------------------------------------------------------------- --- Points to Remember •A diabetes diet should do three things; achieve ideal weight, maintain normal blood glucose levels, and limit foods that contribute to hear disease. •A nutritionist or dietitian can help plan a diabetes diet. --------------------------------------------------------------------- --- Exercise Exercise has many benefits, and for someone with diabetes regular exercise combined with a good diet can help control diabetes. Exercise not only burns calories, which can help with weight reduction, but it also can improve the body's response to the hormone insulin. As a result, following a regular exercise program can make oral diabetes medications and insulin more effective and can help control blood glucose levels. Exercise also reduces some risk factors for heart disease. For example, exercise can lower fat and cholesterol levels in bloods which increase heart disease risk. It also can lower blood pressure and increase production of a cholesterol, called HDL, that protects against heart disease. However, infrequent, strenuous exercise can strain muscles and the circulatory system and can increase the risk of a heart attack during exercise. A doctor can decide how much exercise is safe for an individual. The doctor will consider how well controlled a person's diabetes is, the condition of the heart and circulatory system, and whether complications require that the person avoid certain types of activity. Walking is great exercise, especially for an inactive person, and it's easy to do. A person can start off walking for 15 or 20 minutes, three or four times a week, and gradually increase the speed or distance of the walks. The purpose of a good exercise program is to find an enjoyable activity and do it regularly. Doing strenuous exercise for six months and then stopping isn't as effective. People taking oral drugs or insulin need to remember that strenuous exercise can cause dangerously low blood glucose and they should carry a food or drink high in sugar for medical emergencies. Signs of hypoglycemia include hunger, nervousness, shakiness, weakness, sweating, headache, and blurred vision. As a precaution, a person with diabetes should wear an identification bracelet or necklace to alert a stranger that the wearer has diabetes and may need special medical help in an emergency. A doctor may advise someone with high blood pressure or other complications to avoid exercises that raise blood pressure. For example, lifting heavy objects and exercises that strain the upper body raise blood pressure. People with diabetes who have lost sensitivity in their feet also can enjoy exercise. They should choose shoes carefully and check their feet regularly for breaks in skin that could lead to infection. Swimming or bicycling can be easier on the feet than running. --------------------------------------------------------------------- --- Points to Remember •Exercise has three major benefits; it burns calories, improves the body's response to insulin, and reduces risk factors for heart disease. •An exercise program should be started slowly and with the advice of a doctor. --------------------------------------------------------------------- --- Oral Medications Oral diabetes medicines, or oral hypoglycemics, can lower blood glucose in people who have diabetes, but are able to make some insulin. They are an option if diet and exercise don't work. Oral diabetes medications are not insulin and are not a substitute for diet and exercise. Although experts don't understand exactly how each oral medicine works, they know that they increase insulin production and affect how insulin lowers blood glucose. These medications are most effective in people who developed diabetes after age 40, have had diabetes less than 5 years, are normal weight, and have never received insulin or have taken only 40 units or less of insulin a day. Pregnant and nursing women shouldn't take oral medications because their effect on the fetus and newborn is unknown, and because insulin provides better control of diabetes during pregnancy. There is also some question about whether oral diabetes medications increase the risk of a heart attack. Experts disagree on this point and many people with noninsulin-dependent diabetes use oral medicines safely and effectively. The Food and Drug Administration (FDA), the agency of the Federal Government that approves medications for use in this country, requires that oral diabetes medicines carry a warning concerning the increased risk of heart attack. Whether someone uses a medication depends on its benefits and risks, something a doctor can help the patient decide. Six FDA-approved oral diabetes medications are now on the market. Their generic names are tolbutamide, chlorpropamide, tolazamide, acetohexamide, glyburide, and glipizide. The generic name refers to the chemical that gives each medicine its particular effect. Some of these medications are made by more than one pharmaceutical company and have more than one brand name. All six are different types of one class of medication, called sulfonylureas, but each affects metabolism differently. A doctor will choose a patient's medication based on the person's general health, the amount his or her blood glucose needs to be lowered, the person's eating habits, and the medicine's side effects. The purpose of oral medications is to lower blood glucose. Therefore, the person taking them must eat regular meals and engage in only light to moderate exercise, to prevent blood glucose from dipping too low. Medications taken for other health problems, including illness, also can lower blood sugar and may react with the diabetes medicine. Therefore, a doctor needs to know all the medications a person is taking to prevent a harmful interaction. Lowering blood sugar too much can cause hypoglycemia with symptoms such as headache, weakness, shakiness, and if the condition is severe enough, collapse. Oral diabetes medications usually don't cause side effects. However, a few people do experience nausea, skin rashes, headache, either water retention or diuresis (increased urination), and sensitivity to direct sunlight. These effects should gradually subside, but a person should see a doctor if they persist. For reasons that aren't always clear, sometimes oral diabetes medications don't help the person for whom they're prescribed. Investigations are under way to learn why this happens. --------------------------------------------------------------------- --- Points to Remember •Oral diabetes medications may be used when diet and exercise alone don't control diabetes. •Oral diabetes medicines aren't a substitute for diet and exercise. --------------------------------------------------------------------- --- Insulin Like oral diabetes medications, insulin is an alternative for some people with noninsulin-dependent diabetes who can't control their blood glucose levels with diet and exercise. In special situations, such as surgery and pregnancy, insulin is a temporary but important means of controlling blood glucose. A section of this booklet called "special situations" discusses insulin use during pregnancy and surgery. Sometimes it's unclear whether insulin or oral medications are more effective in controlling blood glucose; therefore, a doctor will consider a person's weight, age, and the severity of the diabetes before prescribing a medicine. Experts do know that weight control is essential for insulin to be effective. A doctor is likely to prescribe insulin if diet, exercise, or oral medications don't work, or if someone has a bad reaction to oral medicines. A person also may have to take insulin if his or her blood glucose fluctuates a great deal and is difficult to control. A doctor will instruct a person with diabetes on how to purchase, mix, and inject insulin. Various types of insulin are available that differ in purity, concentration, and how quickly they work. They also are made differently. In the past, all commercially available insulin came from the pancreas glands of cows and pigs. Today, human insulin is available in two forms: one uses genetic engineering and the other involves chemically changing pork insulin into human insulin. The best sources of information on insulin are the company that makes it and a doctor. --------------------------------------------------------------------- --- Points to Remember •Insulin may be used when diet, exercise, or oral medications don't control diabetes. •Weight control is important when taking insulin. •Insulin is taken in special situations such as surgery and pregnancy. --------------------------------------------------------------------- --- Checking Blood Glucose Levels When a person's body is operating normally, it automatically checks the level of glucose in blood. If the level is too high or too low, the body will adjust the sugar level to return it to normal. This system operates in much the same way that cruise control adjusts the speed of a car. With diabetes, the body doesn't do the job of controlling blood glucose automatically. To make up for this, someone with diabetes has to check blood sugar regularly and adjust treatment accordingly. A doctor can measure blood glucose during an office visit. However, levels change from hour to hour and someone who visits the doctor only every few weeks won't know what his or her blood glucose is daily. Do-it-yourself tests enable people with diabetes to check their blood sugar daily. The easiest test someone can do at home is a urine test. When the level of glucose in blood rises above normal, the kidneys eliminate the excess glucose in urine. Glucose in urine, therefore, reflects an excess of glucose in blood. Urine testing is easy. Tablets or paper strips are dipped in urine. The color change that occurs indicates whether blood glucose is too high. However, urine testing is not completely accurate because the reading reflects the level of blood glucose a few hours earlier. In addition, not everyone's kidneys are the same. Even when the amount of glucose in two people's urine is the same, their sugar levels may be different. Certain drugs and vitamin C also can affect the accuracy of urine tests. It's more accurate to measure blood glucose directly. Kits are available that allow people with diabetes to test their blood glucose at home. The test involves pricking a finger to draw a drop of blood. A spring-operated "lancet" does this automatically. The drop of blood is placed on a strip of specially coated plastic or into a small machine that "reads" how much glucose is in the blood. A doctor may suggest that someone test his or her blood glucose several times a day. Self blood glucose monitoring can show how the body responds to meals, exercise, stress, and diabetes treatment. Another test that measures the effectiveness of treatment is a "glycosylated hemoglobin" test. It measures the glucose that has become attached to hemoglobin, the molecule in red blood cells that gives blood its red color. Over time, hemoglobin absorbs glucose, according to its concentration in blood. Once glucose is absorbed by hemoglobin it remains there until the blood cells die and new ones replace them. With the "glycosylated hemoglobin" test, a doctor can tell whether blood glucose has been very high over the last few months. --------------------------------------------------------------------- --- Points to Remember •Testing blood glucose levels regularly can show whether treatment is working. --------------------------------------------------------------------- --- Diabetes Complications A key goal of diabetes treatment is to prevent complications because, over time, diabetes can damage the heart, blood vessels, eyes, kidneys, and nerves, although the person may not know damage is taking place. It's important to diagnose and treat diabetes early, because it can cause damage even before it makes someone feel ill. How diabetes causes long-term problems is unclear. However, changes in the small blood vessels and nerves are common. These changes may be the first step toward many problems that diabetes causes. Scientists can't predict who among people with diabetes will develop complications, but complications are most likely to occur in someone who has had diabetes for many years. However, because a person can have diabetes without knowing it, a complication may be the first sign. Heart Disease Heart disease is the most common life-threatening disease linked to diabetes, and experts say diabetes doubles a person's risk of developing heart disease. In heart disease, deposits of fat and cholesterol build-up in the arteries that supply the heart with blood. If this buildup blocks blood from getting to the heart, a potentially fatal heart attack can occur. Other risk factors include hypertension or high blood pressure, obesity, high amounts of fats and cholesterol in blood, and cigarette smoking. Eliminating these risk factors, along with treating diabetes, can reduce the risk of heart disease. The American Heart Association has literature that explains what heart disease is and how to prevent it. The association's address is in the resources section of this hypertext. Kidney Disease People with diabetes are also more likely to develop kidney disease than other people. The kidneys filter waste products from the blood and excrete them in the form of urine, maintaining proper fluid balance in the body. While people can live without one kidney, those without both must have special treatment, called dialysis. Most people with diabetes will never develop kidney disease, but proper diabetes treatment can further reduce the risk. High blood pressure also can add to the risk of kidney disease. Therefore, regular blood pressure checks and early treatment of the disorder can help prevent kidney disease. Urinary tract infections are also a cause of kidney problems. Diabetes can affect the nerves that control the bladder, making it difficult for a person to empty his or her bladder completely. Bacteria can form in the unemptied bladder and the tubes leading from it, eventually causing infection. The symptoms of a urinary tract infection include frequent, painful urination, blood in the urine, and pain in the lower abdomen and back. Without prompt examination and treatment by a doctor, the infection can reach the kidneys, causing pain, fever, and possibly kidney damage. A doctor may prescribe antibiotics to treat the infection and may suggest that the person drink large amounts of water. Kidney problems are one cause of water retention, or edema, a condition in which fluid collects in the body, causing swelling, often in the legs and hands. A doctor can decide if swelling or water retention relates to kidney function. A nephrologist, a doctor specially trained to diagnose and treat kidney problems, can identify the cause of problems and recommend ways to reduce the risk of kidney disease. Eye Problems Diabetes can affect the eyes in several ways. Frequently, the effects are temporary and can be corrected with better diabetes control. However, long-term diabetes can cause changes in the eyes that threaten vision. Stable blood glucose levels and yearly eye examinations can help reduce the risk of serious eye damage. Blurred vision is one effect diabetes can have on the eyes. The reason may be that changing levels of glucose in blood also can affect the balance of fluid in the lens of the eye, which works like a flexible camera lens to focus images. If the lens absorbs more water than normal and swells, its focusing power changes. Diabetes also may affect the function of nerves that control eyesight, causing blurred vision. Cataract and glaucoma are eye diseases that occur more frequently in people with diabetes. Cataract is a clouding of the normally clear lens of the eye. Glaucoma is a condition in which pressure within the eye can damage the optic nerve that transmits visual images to the brain. Early diagnosis and treatment of cataract and glaucoma can reduce the severity of these disorders. Diabetic Retinopathy Retinopathy, a disease of the retina, the light sensing tissue at the back of the eye, is a common concern among people with diabetes. Diabetic retinopathy damages the tiny vessels that supply the retina with blood. The blood vessels may swell and leak fluid. When retinopathy is more severe, new blood vessels may grow from the back of the eye and bleed into the clear gel that fills the eye, the vitreous. While most people with diabetes may never develop serious eye problems, people who have had diabetes for 25 years are more likely to develop retinopathy. Experts think high blood pressure may contribute to diabetic retinopathy, and that smoking can cause the condition to worsen. If someone experiences blurred vision that lasts longer than a day or so, sudden loss of vision in either eye, or black spots, lines, or flashing lights in the field of vision, a doctor should be alerted right away. Treatment for diabetic retinopathy can help prevent loss of vision and can sometimes restore vision lost because of the disease. A yearly eye examination with dilated pupils makes it possible for an ophthalmologist, an eye doctor, to notice changes before the illness becomes harder to treat. Scientists are testing new means of treating diabetic retinopathy. For more information on eye complications of diabetes and the treatment of these conditions, see the resource list at the end of this hypertext document. Legs and Feet Leg and foot problems can arise in people with diabetes due to changes in blood vessels and nerves in these areas. Peripheral vascular disease is a condition in which blood vessels become narrowed by fatty deposits, reducing blood supply to the legs and feet. Diabetes also can dull the sensitivity of nerves. Someone with this condition, called peripheral neuropathy, might not notice a sore spot caused by tight shoes or pressure from walking. If ignored, the sore can become infected, and because blood circulation is poor, the area may take longer to heal. Proper foot care and regular visits to a doctor can prevent foot and leg sores and ensure that any that do appear don't become infected and painful. Helpful measures include inspecting the feet daily for cuts or sore spots. Blisters and sore spots are not as likely when shoes fit well and socks or stockings aren't tight. A doctor also may suggest washing feet daily, with warm, not hot water; filing thick calluses; and using lotions that keep the feet from getting too dry. Shoe inserts or special shoes can be used to prevent pressure on the foot. Diabetic neuropathy, or nerve disease, dulls the nerves and can be extremely painful. A person with neuropathy also may be depressed. Scientists aren't sure whether the depression is an effect of neuropathy, or if it's simply a response to pain. Treatment, aimed at relieving pain and depression, may include aspirin and other pain-killing drugs. Any sore on the foot or leg, whether or not it's painful, requires a doctor's immediate attention. Treatment can help sores heal and prevent new ones from developing. Problems with the feet and legs can cause life-threatening problems that require amputation-surgical removal of limbs if not treated early. Other Effects of Diabetic Neuropathy Nerves provide muscle tone and feeling and help control functions like digestion and blood pressure. Diabetes can cause changes in these nerves and the functions they control. These changes are most frequent in people who have had other complications of diabetes, like problems with their feet. Someone who has had diabetes for some years and has other complications, may find that spells of indigestion or diarrhea are common. A doctor may prescribe drugs to relieve these symptoms. Diabetes also can affect the nerves that control penile erection in men, which can cause impotence that shows up gradually, without any loss of desire for sex. A doctor can find out whether impotence is the result of physical changes, such as diabetes, or emotional changes, and suggest treatment or counseling. Skin and Oral Infections People with diabetes are more likely to develop infections, like boils and ulcers, than the average person. Women with diabetes may develop vaginal infections more often than other women. Checking for infections, treating them early, and following a doctor's advice can help ensure that infections are mild and infrequent. Infections also can affect the teeth and gums, making people with diabetes more susceptible to periodontal disease, an inflammation of tissue surrounding and supporting the teeth. An important cause of periodontal disease is bacterial growth on the teeth and gums. Treating diabetes and following a dentist's advice on dental care can help prevent periodontal disease. Emergencies Very high blood glucose levels cause symptoms that are hard to ignore: frequent urination and excessive thirst. However, in someone who is elderly or in poor health these symptoms may go unnoticed. Without treatment, a person with high blood glucose or hyperglycemia can lose fluids, become weak, confused, and even unconscious. Breathing will be shallow and the pulse rapid. The person's lips and tongue will be dry, and his or her hands and feet will be cool. A doctor should be called immediately. The opposite of high blood glucose, very low blood glucose or hypoglycemia, is also dangerous. Hypoglycemia can occur when someone hasn't eaten enough to balance the effects of insulin or oral medicine. Prolonged, strenuous exercise in someone taking oral diabetes drugs or insulin also can cause hypoglycemia, as can alcohol. Someone whose blood glucose has become too low may feel nervous, shaky, and weak. The person may sweat, feel hungry, and have a headache. Severe hypoglycemia can cause loss of consciousness. A person with hypoglycemia who begins to feel weak and shaky should eat or drink something with sugar in it immediately, like orange juice. If the person is unconscious, he or she should be taken to a hospital emergency room right away. An identification bracelet or necklace that states that the wearer has diabetes will let friends know that these symptoms are a warning of illness that requires urgent medical help. This etext is about noninsulin-dependent diabetes. The word "diabetes" in the text of this booklet refers to noninsulin-dependent diabetes unless otherwise specified. --------------------------------------------------------------------- --- Points to Remember •Diabetes can cause long-term complications such as heart, kidney, eye, and nerve disease. •Careful treatment of diabetes and checking for signs of complications can lower the chances that someone will be troubled by these conditions. •An identification bracelet or necklace stating that the wearer has diabetes can help ensure that friends or strangers won't ignore symptoms that signal a medical emergency. --------------------------------------------------------------------- --- Special Situations Surgery Surgery is stressful, both physically and mentally. It can raise blood glucose levels even in someone who is careful about control. To make sure that surgery and recovery are successful for someone with diabetes, a doctor will test blood glucose and keep it under careful control, usually with insulin. Careful control makes it possible for someone with diabetes to have surgery with little or no more risk than someone without diabetes. To plan a safe and successful surgery, the surgeon and attending physicians must know that the person they're treating has diabetes. While tests done before surgery can detect diabetes, the patient should inform the doctor of his or her condition. A surgical team also will evaluate the possible effect of complications of diabetes, such as heart or kidney problems. Pregnancy Bearing a child places extra demands on a woman's body. Diabetes makes it more difficult for her body to adjust to these demands and it can cause problems for both mother and baby. Some woman may develop a form of diabetes during pregnancy called gestational diabetes. Gestational diabetes develops most frequently in the middle and later months of pregnancy, after the time of greatest risk for birth defects. Although this kind of diabetes often disappears after the baby's birth, treatment is necessary during pregnancy to make sure the diabetes doesn't harm the mother or fetus. A woman who knows she has diabetes should keep her condition under control before she becomes pregnant, so that her diabetes won't increase the risk of birth defects. A woman whose diabetes isn't well controlled may have an unusually large baby. Diabetes also increases the risk of premature birth and problems in the baby, such as breathing difficulties, low blood sugar and occasionally, death. Blood glucose monitoring and treatment with insulin can ensure that a baby born to a mother with diabetes will be healthy. Oral diabetes drugs aren't given during pregnancy because the effects of these drugs on the unborn baby aren't known. By following the advice of a doctor trained to treat gestational diabetes, the mother can make sure her blood glucose is normal and her baby is well nourished. Approximately half of women with gestational diabetes will no longer have abnormal blood glucose tests shortly after giving birth. However, many women with gestational diabetes will develop noninsulin-dependent diabetes later in their lives. Regular check-ups can ensure that if a woman does develop diabetes later, it will be diagnosed and treated early. --------------------------------------------------------------------- --- Drinking fluids during illness is especially important for someone with diabetes. --------------------------------------------------------------------- --- Is Diabetes Hereditary? Scientists estimate that the child of a parent with noninsulin-dependent diabetes has approximately a 10 to 15 percent chance of developing noninsulin-dependent diabetes. If both parents have diabetes, the child's risk of having the disease increases. The child's health habits throughout his or her life will affect the risk of developing diabetes. Obesity, for example, may increase the risk of diabetes or cause it to occur earlier in life. Noninsulin-dependent diabetes in a parent has no effect on the chances that his or her child will have insulin-dependent diabetes, the more severe form of diabetes. Stress and Illness One way the body responds to stress is to increase the level of blood glucose. In a person with diabetes, stress may increase the need for treatment to lower blood glucose levels. Illnesses such as colds and flu are forms of physical stress that a doctor can treat. The doctor will advise the person to drink plenty of fluids. When blood glucose is high, the body gets rid of glucose through urine, and this fluid needs to be replaced. If nausea makes eating or taking oral diabetes drugs a problem, a doctor should be consulted. Not eating can increase the risk of low blood glucose, while stopping oral medications or insulin during illness can lead to very high blood glucose. A doctor may prescribe insulin temporarily for someone with diabetes who can't take medicine by mouth. Great thirst, rapid weight loss, high fever, or very high urine or blood glucose are signs that blood sugar is out of control. If a person has these symptoms, a doctor should be called immediately. Like illness, stress that results from losses or conflicts at home or on the job can affect diabetes control. Urine and blood glucose checks can be clues to the effects of stress. If someone finds that stress is making diabetes control difficult, a doctor can advise treatment and suggest sources of help. --------------------------------------------------------------------- --- Points to Remember •Special situations such as pregnancy, surgery, and illness call for extra careful diabetes control. •Special control may require the use of insulin, even in people who don't normally use insulin. --------------------------------------------------------------------- --- Dealing with Diabetes Good diabetes care requires a daily effort to follow a diet, stay active, and take medicine when necessary. Talking to people who have diabetes or who treat diabetes may be helpful for someone who needs emotional support. The list of organizations at the back of this hypertext document can help patients find discussion groups or counselors familiar with diabetes. It's very important for people with diabetes to understand how to stay healthy, follow a proper diet, exercise, and be aware of changes in their bodies. People with diabetes can live long, healthy lives if they take care of themselves. --------------------------------------------------------------------- --- Points to Remember •Good diabetes care is a daily responsibility. •Local diabetes organizations offer programs to people with diabetes can share experiences and support. •The good health care urged for people with diabetes is beneficial to anyone who wishes to stay healthy. --------------------------------------------------------------------- --- Finding Help A person with diabetes is responsible for his or her daily care and a doctor is the best source of information on that care. A doctor in family practice or internal medicine can diagnose and treat diabetes, and may refer the patient to a doctor who specializes in treating diabetes. "Endocrinologists" and "diabetologists" are doctors with advanced training and experience in diabetes treatment. The local chapters of the American Diabetes Association or the Juvenile diabetes Foundation have lists of doctors who specialize in diabetes. Another alternative is to contract a university-based medical center. Those centers may have special diabetes clinics or may be able to suggest diabetes doctors who practice in the community. --------------------------------------------------------------------- --- Points to Remember: •Medical guidance is available from a variety of sources such as diabetes groups, local medical societies and hospitals, and diabetes clinics. --------------------------------------------------------------------- --- Printed Information While information in books and magazines can't replace a doctor's personal advice, it can provide a clear explanation of diabetes and treatment. The American Diabetes Association and Juvenile Diabetes Foundation have brochures about diabetes and diabetes treatment. These publications are for people without a medical background. The addresses of these organizations are in the resources section at the end of this etext. Brochures and books about diabetes also are available from public libraries and bookstores. Local chapters of the American Diabetes Association, hospitals, and medical centers frequently sponsor educational programs on diabetes and diabetes treatment. Information about diabetes programs is also available from a doctor's office, a local hospital or health department, or a local diabetes organization. --------------------------------------------------------------------- --- Points to Remember: •Information on diabetes is available from local bookstores, libraries, and local diabetes programs and groups. --------------------------------------------------------------------- --- Resources on Diabetes Agency for Health Care Policy and Research (AHCPR) Medical Treatment Effectiveness Program 2101 East Jefferson Avenue Rockville, MD 20852 (301) 227-8364 Division of Information and Publications The Agency supports grant and contract research on the relationship between the use of medical services and procedures and patient outcomes. --------------------------------------------------------------------- --- American Association of Diabetes Educators (AADE) 444 N. Michigan Avenue Suite 1240 Chicago, IL 60611 (312) 644-2233 or 1-800-338-3633 The AADE is a multidisciplinary organization, with state and regional chapters, for health professionals involved in diabetes education. It sponsors continuing education programs on both beginning and advanced levels and a certification program for diabetes educators, and provides grants, scholarships, and awards for educational research and teaching activities. The AADE publishes a monthly journal, curriculum guides, consensus statements, self-study programs, and other resources for diabetes educators. --------------------------------------------------------------------- --- American Diabetes Association National Service Center 1660 Duke Street P.O. Box 25757 Alexandria, VA 22313 (703) 549-1500 or 1-800-232-3472 A private, voluntary organization that fosters public awareness of diabetes and supports and promotes diabetes research. It publishes information on many aspects of diabetes, and local affiliates sponsor community programs. Local affiliates can be found in the telephone directory or through the national office. --------------------------------------------------------------------- --- American Dietetic Association 430 North Michigan Avenue Chicago, IL 60611 (312) 822-0330 A professional organization that can help someone find a nutritionist in the community. --------------------------------------------------------------------- --- American Heart Association 7320 Greenville Avenue Dallas, TX 75231 1-800-242-1793 A private, voluntary organization that has literature on heart disease and how to prevent it. Contact the local affiliate of the American Heart Association listed in telephone directories. --------------------------------------------------------------------- --- Centers for Disease Control (CDC) National Center for Chronic Disease Prevention and Health Promotion 1600 Clifton Road The Rodes Building MS K-13 Atlanta, GA 30333 Technical Information Services Branch (404) 488-5080 The CDC is an agency of the Federal Government that has information on the surveillance al prevention of diabetes for health care professionals and people with diabetes. --------------------------------------------------------------------- --- Juvenile Diabetes Foundation International 432 Park Avenue, South New York, NY 10016 (212) 889-7575 or 1-800-223-1138 A private, voluntary organization with an interest in type I or insulin-dependent diabetes. Local affiliates are found across the country. It also has information on noninsulin-dependent diabetes. --------------------------------------------------------------------- --- National Diabetes Information Clearinghouse 1 Information Way Bethesda, MD 20892-3560 The National Diabetes Information Clearinghouse has a variety of publications for distribution to the public and to health professionals. The clearinghouse is a program of the National Institute of Diabetes and Digestive and Kidney Diseases, a component of the National Institutes of Health, leading the Federal Government's research on diabetes. --------------------------------------------------------------------- --- National Eye Health Education Program National Eye Institute National Institutes of Health Box 20/20 Bethesda, MD 20892 (301) 496-5248 Information about how diabetes affects the eyes is available from the National Eye Institute, a component of the Federal Government's National Institutes of Health. --------------------------------------------------------------------- --- National Heart, Lung, and Blood Institute Building 31, Room 4A21 National Institutes of Health Bethesda, MD 20892 (301) 496-4236 Information on heart disease is available from this component of the Federal Government's National Institutes of Health. --------------------------------------------------------------------- --- NIH Publication No. 92-241 September 1992 --------------------------------------------------------------------- --- [Back to Diabetes Information]