$Unique_ID{BRK01757}
$Pretitle{}
$Title{Diabetes and You, part II}
$Subject{Diabetes metabolic metabolism metabolisms diabetics diabetic kidney
kidneys failure carbohydrates starches sugars food foods glucose Blood sugar
insulin ketones ketoacidosis mellitus insulin-dependent noninsulin dependent
pancreas autoimmune hormone injections injection hypoglycemic Diet circulation
Eye Kidney Dental Gestational Pregnancy insulins ketone hyperglycemic
hypoglycemics hypoglycemia pre-eclampsia dm}
$Volume{Y-0}
$Log{
Location and Function of the Endocrine Glands*0002901.scf
The Islets of Langerhans*0002905.scf
Structure of the Pancreas*0009801.scf
Diabetes Mellitus*0009802.scf
The Functions of Insulin*0009803.scf
Diseases of the Pancreas*0016001.scf
Anatomy of the Pancreas*0016601.scf
Glossary*0174301.tid}

Copyright (c) 1991-92,1993   Tribune Media Services, Inc.


Health Update

by Dr. Allan Bruckheim

Diabetes and You, part II


------------------------------------------------------------------------------

Diet in diabetes

     Diet is a cornerstone of controlling diabetes.  More than half of all
adult diabetics manage their diabetes with diet rather than insulin or oral
hypoglycemic agents.
     A doctor or dietitian will go over a diet and sample meal plans with the
patient.  They will help the patient determine his or her best weight,
consider any special dietary needs (such as pregnancy or food allergies) and
calculate how much carbohydrate, protein and fat should be taken in daily.
     Carbohydrates are an important part of a diabetic's diet.  There are two
types of carbohydrates--simple and complex.  Simple carbohydrates include
sugar, candy, pastries and cakes, and these usually raise blood sugar levels
very quickly.  Complex carbohydrates include vegetables, dried beans and peas,
grains, breads and cereals, and these raise blood sugar levels gradually over
a longer period of time.  Complex carbohydrates usually contain more
nutrients, minerals and fiber than do simple carbohydrates, but simple
carbohydrates can give blood sugar a quick lift to help stave off an insulin
reaction.  Both forms of carbohydrates have their place in a diabetic's diet.
     Many diabetics must limit their fat intake as well as their intake of
cholesterol and salt.  Eating too much fat and cholesterol are linked to heart
disease.  This may mean they have to cut out or limit eating eggs, dairy foods
and red meats.
     Special consideration must be given to planning medications, mealtimes
and exercise so that wide swings in blood-sugar levels are avoided.  An
insulin-dependent diabetic should plan to eat foods that are heavy in
carbohydrates at a time when they coincide with the peak effectiveness of the
insulin he or she uses.  This will vary with the type and amounts of insulin
being used.
     To help diabetics in planning their meals, the American Diabetes
Association has created lists of equivalent foods called exchange lists. These
are nutritional guidelines that can be used every day to help diabetics choose
what to eat.  A serving of any food on a given exchange list can be
substituted for a serving of any other food on that list.  The lists can help
diabetics with daily meal plans.  They'll learn to include foods from the six
exchange lists in their daily diet.
     A diabetic can have an occasional alcoholic drink, but too much alcohol
can cause problems.  Alcoholic beverages are empty calories and can contribute
to weight problems.  Alcohol can lower blood-sugar levels which can bring on
hypoglycemia.  This is especially likely to happen if alcohol is taken on an
empty stomach.  Excessive drinking causes additional problems for diabetics,
because it raises blood-fat levels and can damage the liver.

Exercise and diabetes

     If diet is a cornerstone of controlling diabetes, exercise is the brick
on top of the cornerstone.  Many people can control their diabetes with diet
and exercise alone.
     Regular exercise helps improve the way the body responds to insulin,
either injected insulin or natural.  A diabetic using insulin who starts a
program of regular exercise may be able to lower the amounts he or she needs.
Exercise also burns calories, which is one way to lose weight.
     Insulin-dependent diabetics must consider their exercise program when
giving themselves insulin.  It may be necessary for them to reduce the amount
of insulin they take before a period of extended exercise so that they avoid
an insulin reaction.  They may not need to adjust their insulin dose or
schedule for shorter periods of exercise.  Diabetics who run or play tennis
also may want to carry small candies around with them in case their
blood-sugar levels fall too low.
     A patient should discuss with his or her doctor the desire to start an
exercise program.  It is a good idea to start any exercise program gradually
and build it up over time.
     Diabetics who have lost any sensitivity in their feet, which is a
complication of diabetes, should make sure the athletic shoes fit well.  Shoes
and socks should be checked carefully and the feet should be examined daily
for blisters or breaks in the skin.  If running or walking are too hard on the
feet, swimming or bicycling are good alternatives.
     Some diabetics who can control their condition with diet and exercise may
find they need insulin when they have a cold or infection.

Self-monitoring

     Controlling diabetes means keeping blood-sugar levels as close to normal
as possible.  Most diabetics usually can tell when their blood-sugar levels
are too low or too high, but this is not the best way to keep track of them.
The best way to determine blood sugar levels is through careful and continual
monitoring.
     There are two common forms of blood-sugar monitoring.  The older method
is testing the levels of sugar in the urine.  Urine also can be tested for
levels of ketones, a byproduct of fat breakdown, in the urine.  High levels of
ketones in urine indicate that fat is being broken down and the body is not
getting enough insulin.
     Urine testing is simple and usually is done in the morning before
breakfast.  The patient takes a sample of urine in a clean container and uses
one of several testing products.  These products may be strips of tape or
paper or sticks that have chemicals impregnated in them.  The test product is
dipped into the urine.  After waiting the proper amount of time, the patient
then checks the tape or stick for a color change and compares it to the color
chart on the product package.  Different products turn different colors,
indicating the levels of sugar or presence of ketones in the urine.  If
directions on the package are followed carefully, the patient should get the
right results from the urine test.
     For many years, urine testing was the only way diabetics could keep track
of their blood sugar.  Many diabetics still use urine testing safely and take
good care of themselves.
     The best way to monitor blood-sugar levels is to test blood directly.  In
the past few years, small monitoring devices have been perfected that allow a
diabetic to test blood-sugar levels at home quickly, easily and reasonably
economically.  Blood monitoring has the advantage of allowing a patient to
test blood sugar several times a day, giving the whole pattern of how his or
her body responds to diet, exercise and insulin or drugs.  The information is
accurate and instantaneous.
     Blood testing is rather simple and only takes a drop of blood.  The
patient pricks a finger with a sterilized pin or lancet to get a drop of
blood.  The drop is placed on a special, chemically treated strip of paper.
The strip is processed according to directions and a color change will occur.
The strip then can be compared to a color-coded chart or, more frequently, it
is placed into a special monitor that analyzes the change and gives an
accurate readout of the blood-sugar level.
     The disadvantage of blood monitoring is that the monitoring devices are
expensive.  Health insurance plans are starting to pick up the costs of
monitoring equipment, but some may only cover a portion.

Heart and circulatory problems

     In addition to lack of control over blood-sugar levels, many diabetics
also have problems with high blood pressure and blood cholesterol and fat
levels.  This combination leads to angiopathy, or disease of the blood
vessels.  Very small blood vessels, both veins and arteries, become thick and
weak.  They may leak, and blood flows more slowly in these affected vessels.
Larger blood vessels start developing atherosclerosis; they clog up with fat
and blood clots, which hampers the flow of blood.  If the clots break loose
and travel to the brain, a stroke can occur.  If the clogged blood vessel
supplies the heart, a heart attack can occur when blood circulation to it is
interrupted.
     The impaired blood flow means poor circulation, notably in the feet and
lower legs.  Poor circulation is compounded by neuropathy, damage to the
nerves caused by diabetes.  A cut on the foot may become infected before it is
even noticed.  If circulation is cut off to any body part for too long--or if
an infection is left to fester--the part becomes gangrenous and must be
amputated.
     Diabetics must take care of their feet properly to avoid the problems
lack of circulation can cause.  They must get into the habit of checking their
feet carefully every day for cuts and blisters and keep them clean.  They must
make sure their shoes and socks fit well and do not rub.  Toenails should be
cut short and straight across.
     Because circulation can be a problem for diabetics, those diabetics who
smoke must stop.  Smoking impairs the circulation further and it is an insult
to the body that can be avoided.

Eye problems

     Diabetes destroys vision by interfering with the function of the retina,
the inside layer of the back of the eye.  The retina is a delicate piece of
tissue that receives light focused on it by the lens and sends the message to
the brain.
     Many tiny blood vessels run through the retina.  Retinopathy occurs when
these tiny blood vessels weaken, break and start to leak blood into the inside
of the eye.  Vision becomes clouded.  These vessels also may start to overgrow
or proliferate within the retina and further reduce vision.
     Most people who have had diabetes longer than 10 years start to show some
signs of diabetic retinopathy.  After 15 years, almost all diabetics show some
changes.  These changes may not mean any vision is lost, but enough serious
changes in the retina can lead to loss of vision.
     A doctor--or an ophthalmologist, a medical doctor who specializes in eye
care--will check the diabetic's eyes carefully every year or two.  This
checkup will include an examination of the retina.
     If changes in the retina develop, several treatments can stop them from
progressing.  Laser beams can be used to coagulate abnormal blood vessels
within the retina.  This seals them and prevents them from bleeding.  Laser
photocoagulation should be done before any serious loss of vision occurs,
because it will only halt further loss.  The procedure cannot reverse the loss
of vision.  If bleeding already has caused the fluid within the eye to become
clouded, this fluid can be removed and replaced in a procedure called
vitrectomy.  Vitrectomy can return some vision that has been lost, but not all
of it.
     Diabetes also appears to be a risk factor in developing cataracts, or
clouding of the eye's lenses.  Cataracts can reduce or blur vision to the
point where the clouded lens must be removed surgically.

Kidney problems

     Diabetes also causes nephropathy or damage to the kidneys, the organs
that remove waste from the body.  Kidney damage is most likely to occur in
people who have had diabetes for several years.
     High blood pressure is a risk factor in diabetic nephropathy.  If a
patient's blood pressure is high, the doctor may suggest cutting down on the
amount of salt eaten or may prescribe blood pressure medications.
     Another risk factor for nephropathy is kidney and urinary tract
infections.  Patients who feel they have to urinate all the time or who notice
a burning sensation when urinating should tell their doctors.  These are
symptoms of a urinary tract infection.
     If a patient's kidneys fail--a condition called end-stage renal
disease--he or she will have to have dialysis, which is a method of removing
wastes from the blood.  Dialysis must be performed several times a week in
order for the patient to remain healthy.  Diabetics whose kidneys have failed
can undergo kidney transplantation, where they get a healthy kidney from a
relative or from someone who has died.

Dental problems

     Diabetics are prone to tooth and gum problems that stem from infections
of the gum called periodontitis.  People with diabetes must take close care of
their teeth and mouth to avoid infections and possible loss of teeth.  Because
periodontal disease can cause damage to the jawbones in addition to tooth
loss, dentures will not fit well.  Even the best-fitting dentures are not a
good substitute for natural teeth.
     Good dental hygiene habits must be developed.  Teeth should be brushed
with a soft-bristle brush, and teeth should be flossed carefully.  A patient
who notices any bleeding from the gums or while brushing the teeth should see
a dentist.

Surgery

     Diabetes increases the risks of any kind of surgery.  It has been said
that one out of every two diabetics will need surgery at some time during
their lives.
     Surgery is a stress on the body.  It changes blood-glucose levels and
interferes with insulin absorption.  In most cases, blood-sugar levels go up
during surgery, which means that, unless insulin levels are lowered before and
during the operation, hypoglycemia can occur.  Another possible consequence of
surgery, especially in insulin-dependent diabetics, is ketoacidosis.
     A diabetic is admitted to the hospital the day before surgery and his or
her condition is assessed.  If necessary, blood-sugar levels are corrected
within a few hours and surgery is performed.
     A patient may be asked to modify his or her insulin dosage and the type
of insulin used a few days before surgery.  If hypoglycemic agents are used,
they may be switched to another type.  These regimen changes are done to
prevent the stress of surgery from sending blood-sugar levels out of control.
While the patient is in the hospital, blood sugar will be monitored
frequently.
     During surgery, insulin will be administered, if needed.  The need for
insulin depends on what type of operation is being done, how long it lasts and
the condition and type of diabetes of the patient.  In a minor procedure,
insulin may not be needed.
     After surgery, the insulin or oral drug regimen may be changed again.  A
patient who was taking oral drugs and who cannot swallow or eat after surgery
may be switched to insulin until he or she is allowed to eat again.  The
patient will be put back onto oral medications, or the insulin regimen will
stabilize, as the body heals.
     Emergency surgery poses more of a problem because the conditions that
demand surgical correction can precipitate ketoacidosis.  The symptoms of
ketoacidosis--abdominal cramps and nausea--may be confused with appendicitis
or abdominal injury, or interpreted as developing complications.  Surgery may
have to be delayed for several hours until blood-sugar levels are stabilized
with insulin, and the situation can be clarified.
     The surgeon must know about the patient's diabetes.  An emergency is
another reason it is wise for diabetics to wear medical identification
bracelets and carry wallet cards identifying them as such.

Gestational diabetes

     Some women may find out they have diabetes during a pregnancy.  This is
known as gestational diabetes and goes away after the delivery.  However, a
woman who has had gestational diabetes is more likely to get
noninsulin-dependent diabetes in later years.
     Gestational diabetes occurs when the hormones made up by the placenta
(the tissue of the afterbirth that supplies blood to the baby) interfere with
the way insulin works in the mother's body.  For some women, they may have
been mildly diabetic already and the pregnancy increases their blood-sugar
levels.
     Obese women are more likely to become diabetic during pregnancy, as are
women with relatives who are diabetic and women older than 25.  Gestational
diabetes can bring on several complications during pregnancy, including
preeclampsia (high blood pressure during pregnancy), so gestational diabetes
can be detected early.  This form of diabetes can be controlled with diet,
exercise and, in some cases, insulin injections.

Pregnancy and diabetes

     Up to 95 percent of babies born to diabetic women are healthy.  A
diabetic woman must have a good partnership with her doctor before, during and
after her pregnancy.  Diabetes should be under tight control throughout this
time, especially during the early days, when the baby is starting to develop.
     Pregnant women with diabetes are at an increased risk for ketoacidosis,
hypoglycemia or hypertension.  These problems increase their chances of having
a complicated delivery, a baby with medical problems or a lasting complication
such as kidney, nerve or eye damage.  The major risks to the baby are
premature birth, birth defects, larger-than-average size, jaundice or
breathing difficulties at birth.
     A woman with nonnsulin-dependent diabetes who uses oral hypoglycemic
agents may be switched to insulin for the duration of her pregnancy.  Insulin
gives tighter control over blood-sugar levels and is known to be completely
safe for use during pregnancy, because it is a natural body hormone.  Oral
hypoglycemic drugs have side effects and while they may not cause problems
during pregnancy, it is not known whether they are completely safe.

Diabetes and sex

     Some men who have diabetes suffer occasional impotence, the inability to
achieve or maintain an erection.  Some studies say that impotence occurs in
between 10 percent and 50 percent of all diabetic men.
     Diabetes can cause fatigue, loss of energy and physical weakness, which
are certainly not conducive to sexual relations.
     Impotence also can be a result of neuropathy or angiopathy.  An erection
depends on both nerve signals and blood supply to the penis.  If either one is
interrupted, an erection will not occur.
     Diabetic women also may undergo changes that interfere with their
sexuality.  Many diabetic women suffer vaginal infections or a shortage of
vaginal lubrication that can cause irritation and make intercourse
uncomfortable.
     An impotent man can consider using either an external brace or a
surgically implanted prosthesis.  A diabetic woman can have vaginal infections
treated and use a lubricant such as KY jelly.

Diabetes in children

     Because small children cannot take care of themselves, the family must
play a role in caring for a child, administering insulin and making sure that
the child's blood-sugar levels stay within normal levels.
     A child with diabetes has a chronic condition and must be treated
differently, but this does not mean he or she is an invalid.  The best way for
a family to cope with diabetes in a child is to do so with a minimum of fuss.
Understanding diabetes is an important first step.  The best way to control
diabetes is to learn to live with it.
     Parents of a diabetic must learn to cope with caring for their child and
with teaching the child how to deal with diabetes.  The child's food intake,
exercise and insulin dosages must be carefully balanced.  It can be difficult
to tell whether a preschool child is having an insulin reaction or is just in
a bad mood, but most parents quickly learn to deal with it all.
     A parent also must cope with occasional blood-sugar levels that are high
or low.  Even the best-regulated insulin dosage and schedule will not control
blood sugar perfectly in a child, and occasional high readings do not mean
that the child is cheating on diet.  As the child grows, and especially during
adolescence, there will be times when diabetes is more difficult to control,
no matter how closely he or she follows doctor's orders.

Diabetes in the elderly

     In many elderly, noninsulin-dependent diabetes can be treated with diet
and exercise alone.
     Diabetes in the elderly often is linked to increased weight and loss of
lean body tissue.  Plus, the elderly diabetic may not be getting a nutritional
diet or enough exercise.
     The elderly should worry more about certain diabetic complications,
notably atherosclerosis (fatty clogging of arteries) and poor circulation.
Because they may have difficulty in caring for their feet, they are at greater
risk of developing infections and gangrene.

The future of diabetes treatment

     Researchers are learning more daily about the causes of diabetes.  Other
studies are looking for ways to prevent diabetes or reduce its complications.
Still other research is aimed at perfecting methods of administering insulin
and monitoring blood-sugar levels.
     Work is under way to investigate why the immune system attacks beta cells
in the pancreas.  If this process can be controlled, diabetes could be
prevented.  Immune-suppression drugs are being studied as one way to stop the
immune system from attacking beta cells.
     Another promising line of investigation is the work being done on
transplanting either a whole pancreas or just the beta cells that make
insulin.

Obtaining help

     There are many resources that offer literature, printed information and
personal advice from trained professionals and volunteers.  Here is a listing
of just a few, that may lead to others, all useful in expanding one's
knowledge and helping one to deal effectively with this disease.

     American Diabetes Association, National Service Center, 1660 Duke St.,
P.O. Box 25757, Alexandria, Va. 22313; (800) 232-3472.
     American Dietetic Association, 430 N. Michigan Ave., Chicago, Ill. 60611;
(312) 822-0330.
     American Heart Association, 7272 Greenville Ave., Dallas, Texas 75231;
(214) 373-6300.
     Juvenile Diabetes Foundation International, 432 Park Ave. S., New York,
N.Y. 10016; (212) 889-7575.
     National Diabetes Information Clearinghouse, Box NDIC, Bethesda, Md.
20892.
     National Eye Institute, Building 31, Room 6A32, National Institutes of
Health, Bethesda, Md. 20892; (301) 496-5248.
     National Heart, Lung, and Blood Institute, Building 31, Room 4A21,
National lnstitutes of Health, Bethesda, Md. 20892; (301) 496-4236.

A final word

     Nothing remains the same in this world, and medicine is no exception.
Many research projects are in operation as of this writing that could
dramatically change our understanding of diabetes and our manner of treating
this chronic illness.

------------------------------------------------------------------------------
(Research by Valerie De Benedette, Consulting Editor Robert De Marco, M.D.)

----------------

The material contained here is "FOR INFORMATION ONLY" and should not replace
the counsel and advice of your personal physician.  Promptly consulting your
doctor is the best path to a quick and successful resolution of any medical
problem.