DIABETES

WHAT IS IT?

Diabetes is a disease that affects the way your body handles blood glucose. Insulin, a hormone produced by the pancreas, signals glucose entry into cells so that it can be used as a source of fuel. In diabetes, the body ignores this signal resulting in high levels of blood glucose (“blood sugar”).

High blood glucose damages nerves and blood vessels leading to a variety of complications including stroke, kidney disease, blindness and amputation. Importantly, diabetes doubles a person’s risk for cardiovascular disease.

There are three major types of diabetes:

·         Type 1 diabetes occurs when the body stops producing insulin altogether; about 10% of individuals in the U.S. have this type of diabetes

·         Type 2 diabetes is the most common form and occurs when the body is resistant to the effects of insulin (called insulin resistance) and the pancreas is unable to keep up with the increased demand for insulin.  In type 2 diabetes your body does not respond appropriately to the insulin signal.

·         Gestational diabetes is a form of glucose intolerance that occurs during pregnancy. Gestational diabetes occurs more frequently among African Americans, Hispanic/Latino Americans, and Native Americans. It’s also more common among obese women and women with a family history of diabetes. Treatment to reduce high glucose levels during pregnancy may be required to avoid complications that could harm the baby. While most women with gestational diabetes return to normal after pregnancy, about 5-10% are immediately diagnosed with diabetes, usually type 2. Women who develop gestational diabetes have a 40-60% chance of developing diabetes within 10 years of the pregnancy.

When fasting blood glucose is higher than normal (normal = less than 100 mg/dl), but not high enough to be diagnosed as diabetes (diabetes = higher than 126 mg/dl on 2 occasions), it’s called prediabetes. About 57 million people in the U.S. have prediabetes that may start damaging the body long before it becomes full-blown diabetes.  (see Signs and Symptoms for more information.)

This article focuses on Type 2 Diabetes unless otherwise noted.

Key Facts

·         Progression from prediabetes to diabetes is not inevitable.

·         Diabetes develops when the body stops producing or processing insulin correctly, resulting in high levels of blood glucose (“blood sugar”).

·         Diabetes complications can damage the eyes, feet, kidneys, heart, skin, and nerves.

·         A healthy lifestyle, especially diet and exercise, combined with diligent monitoring of blood glucose levels and adherence to medication helps control diabetes, reduces risk, and increase longevity.

·         Conversely, individuals who don’t take prescribed medications, do not monitor what they eat, and get little exercise are much more likely to develop complications and severe diseases as they age.

What’s New?

As of 2008, the American Diabetes Association suggests that all overweight adults with at least one additional risk factor for type 2 diabetes be tested for prediabetes and also recommends that everyone over 45 years or older should be tested for diabetes even if they do not have any other risk factors. The U.S. Centers for Disease Control states that progression to diabetes is not inevitable among people with prediabetes. Thus, it’s important to know if you have prediabetes and make lifestyle changes, including diet modification, weight loss and exercise, which will slow or halt the progression towards diabetes.

Diabetes By the Numbers

According to the U.S. Department of Health and Human Services, Centers for Disease

Control and Prevention:

·         23.6 million people have diabetes

·         Of that number, 11.5 million are women and 12 million are men

·         The largest age group with diabetes is people 60 years or older (approximately 12.2 million people)

·         Over the past 10 years, there has been a 62% increase in diabetes cases in the U.S.

·         Diabetes disproportionately affects Hispanics in the United States and Puerto Rico. Hispanics were twice as likely to have diabetes as were non-Hispanic whites of similar age (9.8% versus 5.0%).

·         Non-Hispanic blacks aged 20 years or older are at high risk, too; 3.7 million non-Hispanic blacks (14.7%) have diabetes.

·         Approximately 57 million people in the U.S. have pre-diabetes.

Causes

The actual cause of type 2 diabetes is unclear; however, most experts believe that both genetics and lifestyle or environmental factors contribute to its development. There is a strong hereditary link for type 2 diabetes. If you have relatives with type 2 diabetes, especially “first-degree” relatives such as a parent or sibling, you have a much greater risk of developing diabetes.

Risk Factors for Type 2 Diabetes:

·         Obesity — excessive body weight, especially if the weight centers around the stomach (producing what is called an “apple” shape and often called central obesity). An adult is considered obese if his or her body mass index (BMI), which is calculated using height and weight, is 30 or higher. (Use the CardioSmart BMI Calculator to find out your BMI.)

·         Age — over 45 years

·         Physical inactivity

·         Ethnic ancestry — people whose family background is either Alaska native, Native American, African American, Hispanic/Latino, Asian American, or Pacific Islander have a higher risk of developing diabetes

·         High blood pressure (hypertension) — greater than or equal to 140/90 mm Hg

·         Abnormal cholesterol levels — high-density liproprotein (HDL) cholesterol lower

than 35 mg/dl or triglycerides higher than 250 mg/dl

·         Impaired glucose tolerance (IGT) — defined as a 2-hour glucose level of 140-199 mg/dl using an oral glucose tolerance test (OGTT), which is a raised glucose level that does not qualify as type 2 diabetes but is higher than normal. Impaired fasting glucose is 100-125 mg/dl

·         Metabolic syndrome — a combination of medical disorders (IGT, central obesity, elevated triglycerides, lowered HDL, and high blood pressure) that increases risk of cardiovascular disease as well as diabetes

·         History of cardiovascular disease especially if you have heart failure or heart attack

Additional risk factors for women include diabetes during pregnancy, giving birth to at least one baby weighing more than 9 pounds, and polycystic ovary syndrome (PCOS). 

Signs and Symptoms

·         Excessive thirst (leading to increased fluid intake)

·         Increased appetite

·         Increased urination (sometimes as often as every hour)

·         Unusual weight loss or gain

·         Fatigue

·         Nausea, perhaps vomiting

·         Blurred vision

·         In women, frequent vaginal infections

·         In men and women, yeast infections

·         Dry mouth

·         Slow-healing sores or cuts

·         Itching skin, especially in the groin or vaginal area

·         Altered mental state; decreased concentration and decreased coordination.

The first three (excessive thirst, increased appetite and increased urination) are considered the “classical triad” of diabetes symptoms.  Symptoms tend to develop slowly over time. Also, symptoms may be subtle or not appear at all. Many of these symptoms occur when the glucose concentration in the blood is high.

Long term poorly controlled diabetes can also relate to  long term conditions such as coronary artery disease, cerebral vascular disease and heart muscle disease, to name just a few. Increased levels of glucose cause different problems in different parts of the body. For example, chronically high blood glucose can literally change the shape of the lenses of the eyes, leading to vision changes and blurriness. Other common complications of diabetes can cause damage to heart, kidneys, feet, skin, and nerves. (see complications of Diabetes)

Treatment

A healthy lifestyle is the cornerstone for treating diabetes. This includes a consistent, well balanced diet; exercise; limited alcohol; and a smoking cessation program if you smoke. While a healthy lifestyle may not cure diabetes, it will help you manage the disease, control blood glucose levels, reduce your risk of potentially deadly complications, and reduce your dependence on medication. 

Diet 

Most people with diabetes should follow a meal plan tailored to your individual needs. Consultation with your physician or diabetes educator is recommended. A person’s meal plan should take into account not only target glucose levels, (tested before and after meals) but also calorie and nutrition needs, lifestyle and activity level, and the foods a person likes to eat. A meal plan must take into consideration medications, too, because this may impact when you should eat a meal or snack.

Overall, carbohydrates have the biggest impact on blood glucose. It is recommended that you consult with a diabetic educator about carbohydrate counting in your diet plan.

However, some experts have developed a new pyramid that puts into perspective the wealth of research conducted during the last 15 years that has reshaped the definition of healthy eating. This new approach classifies carbohydrates based on how quickly and how high they boost blood sugar compared to pure glucose. For example, the starch in white bread and French-fried potatoes is converted to blood sugar nearly as fast as pure glucose. Conversely, many whole grain breads and cereals are digested more slowly, causing a lower and gentler change in blood sugar.

Recently, one of the world’s most highly studied regional diets, the “Mediterranean Diet,” has been shown to reduce the incidence of type 2 diabetes. Based on the traditional foods of some of the countries on the Mediterranean Sea, such as Italy, Greece, and Crete, research suggests that it has offers major health benefits, particularly in terms of fasting blood glucose and insulin levels compared to other types of popular diets. The Mediterranean Diet is rich in olive oil, plant-based foods (fruits, vegetables, and legumes), and fiber, moderate consumption of dairy products (mostly as cheese and yogurt), and moderate to high consumption of fish but low consumption of meat and meat products.

Exercise 

While physical activity is not the cure for every disease and condition, it helps with weight management ,stress reduction, and glucose uptake— critical in diabetes — and it reduces the risk of suffering adverse events such as cardiovascular disease. Physical activity does not have to be strenuous workouts or marathon training — about 120 minutes a week of brisk walking will help most people with diabetes. Experts recommend at least 30 minutes of physical activity a day which can be split up across the day (such as 3 10-minute walks).

Walking and other aerobic activities (e.g., swimming, dancing, playing tennis) increase heart and breathing rates and build muscle. Strength training helps build muscle and strengthens bones and may make simple activities of daily life easier, such as carrying groceries or picking up a child. Stretching or flexibility exercises improve movement and protect you from injury, especially when used as a warm up before activity.

Even if a workout is not on your schedule for the day, increased activity should be. That means taking stairs instead of an elevator or parking the car farther from a building rather than as close as possible. Walking or bicycling instead of always driving provides benefits, too. Even activities around the house, such as raking leaves or vacuuming, can help increase your activity level and provide health benefits.

You can use a pedometer, which counts the number of steps you take each day, to help you stay on target with your activity during the day. An average person is considered active when they take 10,000 or more steps every day.  

Alcohol

Alcohol contains calories but few if any nutrients. When consumed on an empty stomach, alcohol can cause blood glucose levels to fall too low and raise blood fats. Questions about alcohol use and diabetes have been a concern for many years. Alcohol abuse causes chronic inflammation of the pancreas and is one cause of diabetes.

Research suggests that high alcohol intake (more than 14 drinks per week) increases the risk of developing diabetes among middle-aged men. However, moderate levels (considered less than 2 drinks for men and 1 drink for women per day) of alcohol consumption do not increase risk of type 2 diabetes in either middle-aged men or women. What if you already have diabetes? Once again, the key is moderation: using what’s called a “systematic review,” investigators evaluated data from 32 studies and learned that moderate alcohol consumption is associated with a decreased incidence of heart disease in persons with diabetes. If you do not drink alcohol, there is no evidence to suggest you should start drinking!  However, if you drink alcohol and are either at risk of diabetes or have diabetes, talk to your doctor or dietitian about your alcohol intake.

Smoking Cessation

While the overall dangers of smoking are well known, some effects are especially problematic for people with diabetes. Smoking raises blood glucose levels. Smokers with diabetes are more likely to get nerve damage and kidney disease. Smoking damages and constricts blood vessels, which can worsen foot ulcers and increase the risk of infections that often occur in people with diabetes. What’s more, smoking aggravates other risk factors that are particularly harmful if you have diabetes, such as increasing cholesterol levels and raising blood pressure. Most people know smoking is harmful to their health — but it is even more damaging in people with diabetes and every effort should be made to quit.

Medications

If a healthy diet and physical activity are not enough to control blood glucose levels, medication may be necessary. There are a variety of drugs available for treating type 2 diabetes and the choice depends on the type of diabetes you have, your schedule, and other health conditions you may have. Because medications have different mechanisms of action, you may be prescribed more than one medication (also known as combination therapy).

The main classes of oral diabetes drugs differ in how they work in the body. Some increase insulin production or secretion, some slow absorption of glucose, others decrease the amount of glucose produced by the liver, while still others reverse insulin resistance by improving sensitivity of insulin receptors in muscle, liver, and fat cells. There are newer agents in research and development that impact other systems as well; for example, one agent helps control glucose levels after eating by suppressing gastric (stomach) emptying.

Insulin

Many patients with type 2 diabetes will need to include insulin in addition to oral medications because their bodies are no longer able to produce the hormone. Diabetes is a progressive disease, so it is common to need supplemental insulin after having diabetes for a length of time or during times of stress.

Complications

Just as there are risk factors that heighten your chance of developing diabetes, the presence of diabetes in turn can lead to an increased risk of developing several other diseases and conditions. Chronic elevation of blood glucose levels can damage blood vessels and nerves, leading to complications such as:

    coronary artery disease 

·         cerebral vascular disease

    heart muscle disease (diabetic cardiomyopathy) and eventually heart failure 

    peripheral artery disease (affecting kidneys, blood flow to the limbs, and other “peripheral” blood vessels) 

    stroke  and transient ischemic attacks (“mini-strokes”)

·         diabetic neuropathy (pain or loss of feeling in the extremities, which can lead to ulcerations and infections)

·         diabetic retinopathy (which leads to vision loss)

·         diabetic nephropathy (kidney damage)

An Acute complication that demands immediate attention is hypoglycemia — various diabetes treatments can produce abnormally low blood glucose levels (hypoglycemia), that can lead to an inadequate supply of glucose as fuel to the brain, causing feelings of dread and panic. Include the more common feelings: sudden hunger, weakness, sweating, rapid heartbeat, shaking.  (No single glucose value serves to define hypoglycemia for all people and purposes.but the most common level to begin with symptoms is in the 70s) Untreated hypoglycemia can lead to unconsciousness and eventually coma, seizures, brain damage, and even death. Hypoglycemia can often be treated by consuming sugary foods or drinks that restore more normal glucose levels (recommended 15 gm of rapidly absorbing carbohydrate).

Living With Diabetes

Staying true to a healthy lifestyle, especially diet and exercise, combined with diligent monitoring of blood glucose levels and adherence to medication requirements, helps control diabetes, reduces risk, and increases longevity. Good control of diabetes will require regular trips to a health care provider (such as a physician’s office,  a dietician, or a diabetes consultant) where staff that can monitor the effectiveness of medical therapy and adjust as needed as well optimize their lifestyle choices. It also helps to have a supportive network of family, friends, and other caregivers.

Conversely, individuals who do not take prescribed medications, do not monitor what they eat, and do not engage in any physical activity — in short, patients who abandon responsibility for their disease — are much more likely to develop complications and severe diseases as they age. Moreover, insulin production in the body decreases naturally over time, leading to a higher rate of diabetes in older people and greater challenges for those who already have diabetes.

If you become hospitalized, you may be switched from oral medications to insulin during your hospital stay; that is so your blood glucose levels can be more tightly controlled. Oral medications will likely be prescribed again at hospital discharge, but the types of medication may change after your medications, diet, and lifestyle are all reviewed during your hospitalization. (If your diabetes was the precipitating factor for hospitalization, chances are high that the medical therapy received at discharge will be different from the therapy you were on when admitted.)

People with diabetes also are encouraged to have a “sick day plan” at home that reminds them what do when blood glucose levels are too high or too low, and what to do when you experience symptoms that may be related to your diabetes. As part of this plan, you should assemble a sick day box that has everything from antacids and pain relievers to hard candy and crackers to combat different problems you are likely to face from time to time.  Meet with your provider or diabetes educator to develop your own plan.

Prevention

Both primary prevention (as described above in Treatment) of diabetes and the prevention of recurrent diabetic episodes or complications (secondary prevention) revolve around controlling blood glucose levels. If you are at high risk of developing diabetes (based on the risk factors noted above), then the keys to prevention include a healthy diet, weight loss or maintaining ideal weight, and regular physical activity. These lifestyle factors can slow or even prevent the development of diabetes because they help restore insulin sensitivity in the body.  Even if you already have diabetes, you will prevent additional problems and benefit tremendously from a healthier lifestyle — even a modest 10 to 15 pound weight loss can contribute to restoring insulin sensitivity, especially when the weight is lost from abdominal fat deposits. Healthier lifestyles also may reduce the need for medication.

1,200 to 1,600 Calories Plan

Have about 1,200 to 1,600 calories a day if you are a

·         • small woman who exercises

·         • small or medium-sized woman who wants to lose weight

·         • medium-sized woman who does not exercise much 

Choose this many servings from these food groups to have

1,200 to 1,600 calories a day:

·         • 6 starches

·         • 3 vegetables

·         • 2 fruits

·         • 2 milks

·         • 4 to 6 ounces meat and meat substitutes

·         • up to 3 fats

1,600 to 2,000 Calories Plan

Have about 1,600 to 2,000 calories a day if you are a

·         • large woman who wants to lose weight

·         • small man at a healthy weight

·         • medium-sized man who does not exercise much

Choose this many servings from these food groups to have 1,600 to 2,000 calories a day:

·         • 8 starches

·         • 4 vegetables

·         • 3 fruits

·         • 2 milks

·         • 4 to 6 ounces meat and meat substitutes

·         • up to 4 fats

Have about 2,000 to 2,400 calories a day if you are a

·         • medium-sized or large man who exercises a lot or has a physically active job

·         • large man at a healthy weight

·         • medium-sized or large woman who exercises a lot or has a physically active job 

·         • 10 starches

·         • 4 vegetables

·         • 4 fruits

·         • 2 milks

·         • 5 to 7 ounces meat and meat substitutes

·         • up to 5 fats

Talk with your diabetes teacher about how to make a meal plan that fits the way you usually eat, your daily routine, and your diabetes medicines. Then make your own plan.

Measuring Your Food

To make sure your food servings are the right size, you can use

·         • measuring cups

·         • measuring spoons

·         • a food scale

Also, the Nutrition Facts label on food packages tells you how much of that food is in one serving.

Alcoholic Drinks

Alcoholic drinks have calories but no nutrients. If you have alcoholic drinks on an empty stomach, they can make your blood glucose level go too low. Alcoholic drinks also can raise your blood fats. If you want to have alcoholic drinks, talk with your doctor or diabetes teacher about how much to have.