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 Diabetes |
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WHAT IS DIABETES ? The human body consists of millions of units, called cells that require energy for everything from physical activities to thinking. As abstract as the word energy may seem, consider for a moment the following daily chores of life that are dependent on energy: getting out of your bed in the morning, brushing your teeth, thinking about your day ahead, jogging, breathing, and many other daily tasks we do not even think about as we perform them. The energy your body needs to accomplish these and many other activities comes from the food you eat. After you have had a meal, your body's digestive system breaks down the carbohydrate portion of the meal into a fuel called glucose or simply sugar. The sugar then passes from the intestine into the bloodstream, where it is transported by the blood to all the cells of the body for use, either for energy production or it gets stored for later use. Before the sugar (glucose) gets into the various cells of the body, a hormone called insulin is needed to facilitate the process. Under normal circumstances, this process happens without a hitch through the tight regulatory systems our body has in place. Usually, after you have had a meal, body sensors detect rising levels of sugar in the blood, and signals are sent to the pancreas, a gland that lies behind the stomach. The pancreas then releases insulin in response to this sugar load. The insulin travels through the blood stream to the cells where it functions like a key at the receptor (entry point) on the surface of the body cells, letting glucose into the cells. Thus, without insulin (the key), the cells "doors" remain closed and glucose does not enter the cell, instead it builds up in the bloodstream. It is this build up of glucose in the bloodstream - sometimes referred to as high blood sugar or hyperglycemia - that causes diabetes. The hallmark of diabetes is thus abnormally high blood sugar (glucose) - hyperglycemia. Hyper means "high" and glycemia means "glucose in blood". It is this excess glucose in the blood that primarily leads to all the manifestations and complications of diabetes. For instance, when the sugar level in your blood reaches a certain level, the excess glucose flows out from the kidneys (two organs that filter our blood) into the urine. The glucose draws a lot of body water with it, which causes you to urinate frequently and pass large amount of urine. By losing so much water from the body, you become thirsty and may even lose weight - all signs and symptoms of diabetes. TYPES OF DIABETES
DIAGNOSING
DIABETES Normal glucose level is considered fasting blood glucose (FBG) less than 110 mg/dl. Impaired fasting glucose (IFG) is a new category that describes those individuals in whom FBG is 110 mg/dl or greater but less than the diagnostic cut-off point of 126 mg/dl. It is very important to recognize this group of people because we now know that these individuals are at risk of developing diabetes (in fact, may be pre-diabetic), and more importantly, they are at increased risk for heart diseases and hypertension when compared to individuals with normal blood sugar. For this reasons, such individuals should be closely monitored. Experts say that these new screening policies could help unmask 2 million cases of diabetics in this country alone. The guidelines recommend screening for diabetes in people without symptoms that are 45 years of age and older and repeating the test every 3 years if the results are normal. Testing should begin earlier and be repeated more frequently for those at higher risk. If these new guidelines are followed by both healthcare providers and consumers, the black community, being one of the groups at higher risk, stands to gain a lot from the implementation of the new guidelines. This latter statement is borne out of the fact that one in ten black Americans - three million in all - have diabetes, and half don't even realize it. It is hoped that with the new guidelines, treatment will start sooner rather than later and hopefully, some of the serious complications of the disease can be avoided or be delayed. Screening aside, there are signs and symptoms that are commonly seen in diabetic patients that should call for testing for diabetes when any person presents with them. In other words, even if you have undergone diabetes screening in the past, the presence of any of the symptoms listed requires that you be checked again for diabetes. The signs and symptoms of diabetes
include:
WHO GETS DIABETES?
- Any individual aged 30 or more
even if they have no symptoms. Type 2 diabetes most commonly occurs in people over 30
years of age. It is recommended that diabetes testing be done in this group and if normal,
repeated at 3-year intervals.
The ADA believes that if appropriately applied, these new screening strategies, coupled with the lowering of the diagnostic criteria for diabetes, will facilitate earlier diagnosis and intervention, and perhaps, prevent or delay diabetes complications. Although every group will benefit from these new screening strategies, the African-American community appears to have the most to gain, considering the havoc diabetes is wreaking on their health. IMPACT OF DIABETES
ON AFRICAN-AMERICAN HEALTH COMPLICATIONS OF
DIABETES
It is believed that these four factors are able to encourage the development of diabetic complications through their effects in inducing the following biological changes:
Once you have one or more of these biological changes, all the body organs get affected in one way or another because we are dealing with blood flow and nerves that traverse the entire body. Essentially, no body organ is spared from the ravages of diabetes - starting from the brain to the toes. The most disabling complications are discussed below:
LIVING WITH
DIABETES The truth remains however, that countless number of people before you have been able to arm themselves with information and take control of their diabetes rather than the diabetes controlling them. And you can do it. So make a commitment to yourself now to start dealing with diabetes rather than it dealing with you. To live with diabetes requires that you stay informed about diabetes. The guide to living with diabetes should include, but not be limited to the following; Don't be blind to diabetes, Stay informed - You must make a personal commitment to understand this disease to the best of your ability, and use that information to create a healthy lifestyle. This information can come from your local library, healthcare professionals, diabetes support groups, reliable Internet sites, etc. When in doubt ask your diabetes doctor. Choosing the right partner (i.e. a good Diabetes Doctor) - You should take this as seriously as choosing a life partner. If you really think about it, that's what you are doing - you are choosing a partner to help you manage a condition you are live with every moment of your life. You have to be an active participant in your diabetes management. The doctor's role is to provide the guide. A good diabetes doctor should:
Keeping an eye on diabetes so it doesn't take your eyes away from you: Under normal circumstances, our body has in-built sensors that help regulate our blood sugar. Thus, when it is too high, processes are put in place to bring it to normal levels, and when it is low, the body attempts to bring up the level of sugar in our blood. Unfortunately, when you have diabetes, this built in mechanism does not work optimally. Therefore it becomes your responsibility to check your blood sugar regularly and adjust treatment accordingly. The whole idea of monitoring is to ensure that your blood sugar is neither too high nor too low. You certainly do not want your blood sugar to be too low, because that can instantly kill you, much quicker than high blood sugar will. It is therefore imperative that once you have been diagnosed with diabetes, you should arm yourself with a blood-glucose monitoring kit, which you can buy over the counter at grocery stores and pharmacies. You should buy a kit that is easy for you to use. When in doubt, take it to your healthcare provider to teach you how to use it correctly. These kits are able to tell you the level of glucose (sugar) in your blood at the exact time you are running the test. Initially, until your blood sugar is brought under control, you may have to do the tests several times a day. It is important to keep an accurate record of these values since your healthcare provider will need them to facilitate your diabetes management. Once your blood sugar is brought under control, you may only have to check it a few times each week. It is a very good idea to have another family member learn how to check your blood sugar, so he or she can help you in times of emergency. By regularly monitoring your blood sugar, you and your doctor can see how it responds to treatment, physical exercise, and meals. That information guides both of you on treatment choices you have to make to keep your blood sugar under control. Keeping your sugar under control is really what diabetes management is all about. Besides, that's what minimizes diabetic complications. Don't let diabetes get to you,
deal with it Hypoglycemia Hypoglycemia also called "low blood sugar", is a serious medical emergency. The symptoms and signs are the result of your blood glucose level dropping to dangerously low levels, usually below 70 mg/dl (3.9 mmol/L). Because diabetes medications generally work by lowering the level of glucose in your blood, there is always a risk of overshooting. Usually hypoglycemia is seen in the setting of taking too much of your glucose-lowering pills or insulin shots. It may also occur if you have taken the usual dose of your medicine but do not eat enough, delay or miss a meal, or if you exercise too much. It is extremely important that diabetic patients and their family members be aware of the signs and symptoms of hypoglycemia and how to treat it promptly. The reason for this is that hypoglycemia can kill or leave the brain permanently damaged. When the blood sugar level drops to low levels for a given individual, it triggers a sort of adrenaline response characterized by: tremulousness, irritability, nervousness, inability to focus, confusion, jitteriness, feeling of faint, weakness, hunger, rapid heartbeat, sweating, headache, irrational behavior, and possible seizures. If it progresses, the brain's activity may be suppressed that drowsiness and sometimes coma can ensue. When any of these is happening to a diabetic patient, action is required immediately to bring the blood sugar level up. In fact, the rule of the thumb in clinical practice is that when in doubt, assume low blood sugar is the problem and direct your treatment towards raising the blood sugar. Things you can do to elevate the blood sugar in this situation will include drinking or eating something that is rich in sugar such as cola, orange juice, sugar cubes. You really want to get sugar into the bloodstream as soon as possible. In circumstances where the patient is unable to treat this hypoglycemia because they are unconscious, confused or physically unable to, family members should learn how to recognize and treat the condition. Long-term complications of diabetes - Most of the long-term complications of diabetes have been discussed earlier. The key to preventing them lies in being aware of them and knowing factors that promote their occurrence or early onset. Equally relevant is making sure you and your healthcare providers have put in place strategies to detect them early and treat promptly when they occur. Heart disease and Stroke - These are two serious conditions that are known to be long term complications of uncontrolled diabetes. Diabetes doubles your risk for developing blockage of the arteries of the heart and the brain. You can reduce your risk for this by keeping your blood sugar levels normal, adequate control of blood pressure, maintaining your ideal body weight, regular exercise, avoidance of cigarette smoking and making sure your cholesterol levels are at recommended levels. Currently, the high blood pressure goal for adults with diabetes is less than 130/85 mmHg. In contrast, the treatment goal for high blood pressure in most individuals without other medical problems is less than 140/90. There are also recommended end points for cholesterol management in diabetic patients that need to be adhered to. Kidney disease - It is
estimated that most diabetics will, after about 20 years or so, have some degree of kidney
damage, which sometimes can lead to being dialysis dependent. This damage results from
narrowing of the blood vessels that carry blood to the kidney, thus reducing the kidney's
ability to filter out and remove wastes from our blood. Diabetes is also known to increase
one's risk of urinary tract infections and these infections can potentially harm the
kidney. To reduce this damage to the kidney in diabetic patients, it is extremely
important that urinary tract infections are treated promptly, and blood sugar and blood
pressure are kept at recommended levels. Smoking must be avoided. Some drugs that have the
potential to harm the kidney need to be used with caution. Always check with your doctor
and local pharmacists prior to taking any medications. Luckily, we now have two groups of
blood pressure medicines: angiotensin-converting enzyme (ACE) inhibitors and
angiotensin-receptor blockers (ARBs) that are believed to prevent or reduce kidney damage
in people with diabetes. All diabetics with high blood pressure should be on one or both
of these medications. If you are not, you need to find out why. Other precautionary measures for the kidney of the diabetic include monitoring the function of the kidney, one strategy involves blood tests and a yearly check of a protein (microalbumin) level in the urine. Poor circulation and Nerve damage - Diabetes can cause narrowing of blood vessels anywhere in the body. When the feet and legs' blood vessels are the ones affected, the condition is called peripheral vascular disease (PVD), commonly referred to as "poor circulation". When you also have nerve damage to these extremities, you have a set up for disaster. First, there is reduced feeling from the nerve damage, hence with cuts patients do not feel the pain and remain unaware of the sore area. Then infection sets in, and since you already have reduced blood flow to the area, this slows the healing process. An infection that does not heal can cause the tissue to die and in some cases may require amputation of the dead part of the foot or leg to save the rest of the extremity. Key ways to prevent this serious complication in diabetic patient include:
Exercise - This is one of the
most important aspects of diabetes management, particularly in the prevention and
treatment of type 2 diabetes. Research done at the University of Pennsylvania has shown,
that regular exercise reduces the risk of developing diabetes in middle-aged men by as
much as 41 percent. These findings are believed to be equally true for women. For
individuals with a family history of diabetes but who do not have the disease, regular
exercise can delay the onset or reduce their chances of developing type 2 diabetes. If you
already have diabetes, there are other beneficial effects of exercise towards helping
control your blood sugar. These effects include: Diet - Adhering to a recommended diet is really the first step to control in diabetes management. In any diabetes treatment program, the most important component is nutrition. In fact, for some people with type 2 diabetes, regular exercise with proper meal planning may well be all that is needed to control their blood sugar. This is especially true for those individuals who are overweight or obese. Most people who develop type 2 diabetes are overweight or obese. Overweight is defined as having a body mass index (BMI) of 25 to 29.9, while obesity is a BMI of 30 or greater. BMI is calculated using one's weight in kilograms divided by height in meters squared. In fact, the correlation between BMI and risk for developing diabetes has become so strong that BMI of 27 or greater is considered one of the risk factors that will require screening for diabetes even in individuals without symptoms. Put another way, BMI of 27 or greater is a pre-diabetic state especially if there is a family history of diabetes. From the foregoing, it is clear that if you are overweight, losing weight is the single most cost-effective way to reduce your risk of developing diabetes, and managing the disease if you have it. Your doctor or dietician can help you develop a diet that's right for you. The role of dieticians in diabetes management cannot be overstated. Make sure you consult one periodically to stay in line with the nutritional aspect of your diabetes management. Immunization guidelines for diabetes patients - It is said that prevention is better than cure. Diabetes epitomizes a diseases where prevention is far more effective than any cure. Diabetes left uncontrolled creates a favorable medium in our body for infections to thrive. In fact, unexplained recurrent infection warrants a screen for diabetes. It then follows that all diabetes patients should make sure they are adequately immunized against infections with recommended vaccines. For kids, it appears this is happening satisfactorily in the United States. For adults, it is a different story altogether. Because of the higher risk of infection in diabetics, coupled with their dysfunctional immune defense system, unless there is a contraindication, it is mandatory that the following immunizations (shots) be administered:
TREATMENT OPTIONS FOR DIABETES In the last decade or so, the management of diabetes has gained a lot from research and clinical trials that have improved our ability to control diabetes and hopefully prevent or delay the onset of dreaded diabetes complications. First, we now have blood tests such as Hemoglobin A1c (HbA1c) that enable us have a better idea of how well we are controlling the blood glucose over a period of time. Prior to this test, all we had was just the glucose level in the blood that simply tells you what the level is at the moment of testing. We now know that it is the long term accumulation of excess glucose in the blood that leads to most of the complications of diabetes. So indeed, the new marker (HbA1c) that measures glucose control over a much longer period of time, is a welcome revolution in the treatment of diabetic patients. Secondly, we now have a broader choice of medications for controlling blood sugar. Not too long ago, all we had were two classes of medications; insulin shots and a group of pills called sulfonylureas. Now we have six classes of medications for treating diabetes, so that leaves us with better chances of controlling the blood glucose. Despite the availability of these additional classes of medications, daily insulin injection remain the primary treatment option for type 1 diabetes. In contrast, for type 2 diabetes, diet and exercise still remain the cornerstones of therapy. Diabetes management for type 2 diabetes should consist of multiple interventions that include weight reduction if body mass index (BMI) is 25 or more, medical nutrition therapy (MNT), regular exercise and use of medications when these first three approaches have failed. It is very important that all type 2 diabetes patients recognize and appreciate the possibility of controlling their blood glucose (i.e. their disease) without medications. This means that unless the fasting blood glucose at onset of disease is very high, it is unwise to initiate medications in type 2 patients without giving these three approaches a chance to control the blood glucose. Most experts recommend 3 months as the time limit for assessing the success or failure of this "non-medication" approach to diabetes management in type 2 disease. It must be mentioned that in using these various approaches and setting a time limit, treatment goals need to be established. Patients and all healthcare professionals (diabetes educators, dieticians, physicians, nurses etc) involved in the care of the patients should clearly be aware of these goals. The goals need to be revisited and be discussed with the patient and close family members when appropriate. The game plan is to make the patient an active participant in his/her care and every other person else a consultant. In other words, the patients take charge of their health. The treatment goals should be adhered to religiously and when not being met, attempts need to be made to address all the components of diabetes management. In it's most recent position statement on standards of medical care, the ADA set treatment goals that apply to the general diabetic population. These goals should be used as guidelines for the care of diabetes patients. These goals reflect evidence-based medicine that we now believe, has a chance to ensure that diabetic patients live healthy lives while keeping complications away. Goals for blood sugar control in diabetes patients:
From American Diabetes Association As stated earlier, medications should be considered if target blood glucose levels are not achieved within 3 months. Although we have six classes of diabetic medications, if you look at their mechanisms of action, there are four major groupings, and the discussion below aims to classify the medicines based on the mechanisms rather than by name. We do not intend to favor one group over another, therefore we will identify the six classes for knowledge sake and list a few examples purely for illustrative purposes only. · Insulin · Insulin secretion stimulators · Insulin sensitizers · Carbohydrate absorption delaying agents Insulin - Whereas the other of diabetic medications are pills, insulin is administered as an injection (shot). There are several different formulations which differ principally in their duration of action. There is the quick acting but short duration form called regular insulin. It is commonly referred to as "R" insulin. This is the only form of insulin used in very high blood glucose level emergencies. An example is Humulin R. There are the intermediate to long acting insulin formulations, commonly referred to as "N" insulin. These are slow in onset of action, but effects last much longer than the regular insulin. Examples include NPH insulin, and Humulin N. We also have insulin preparations are of in combinations of "R" and "N". An Example is Humulin 70/30, which has 70% long acting insulin ("N) and the other 30% is regular insulin ("R"). Insulin action has earlier been described - it acts as the key that unlocks the receptor (door) on the surface of cells to enable glucose enter the cells from the bloodstream. Insulin secretion stimulators - This group of medicines basically reduces blood glucose level through their effect on the pancreas (the organ that manufactures and stores insulin). Their chief mode of action is to stimulate the pancreas to release insulin into the blood stream. Therefore, you have to possess a functioning pancreas for them to work. Patients with type 1 diabetes who have no significant pancreatic function do not benefit from this group of drugs. This statement also applies to people who have lost their pancreas due to cancer, alcohol, unintended surgical removal etc. There are two classes of oral medications that fall into this group:
Carbohydrate absorption delaying agents - This group is very unique in their action. They work by slowing the rate of absorption of glucose. In other words, instead of absorbing say two slices of bread over an hour, these agents might delay or slow the process to say 4 hours, hence limiting the peaks in blood glucose levels after a carbohydrate meal. The main problems with these agents are diarrhea, flatulence and abdominal pain. However, starting with small doses and gradually going up on the dose under physician supervision can minimize these side effects. An example of this class of drugs is Precose (acarbose). Sometimes your physician may have to combine these classes of medications to achieve the desired goals of therapy. The important message remains that your active participation in your care, staying informed about your disease and working together with your healthcare providers is the best way to optimize your diabetic care. BHO TEN COMMANDMENTS FOR DIABETIC PATIENTS RESOURCES FOR DIABETES PATIENTS |
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