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Diabetes and Its Treatment

19.09.2012

Summary

Diabetes is a malfunction of the body's glucose regulation. The disease can lead to kidney disease, damage to the retina leading to blindness, nerve damage, foot ulcers, hardening of the arteries, heart disease, and bacterial or fungal infections. Three out of four diabetics die of heart disease related to their diabetes. Doctors tend to prescribe pills, instead of insisting on weight loss or dietary changes. And sadly, many patients find it easier to take a pill, than to change their eating habits. Below, you can read about diabetes treatments, ranking them from most hazardous to safest.

What Is Diabetes?

Diabetes (diabetes mellitus) is a malfunction of the body's system that regulates glucose. Normally, sweets and starches (carbohydrates) are broken down in the intestines to simple sugars, mostly glucose. Glucose then circulates in the blood and enters cells all over the body where it is either stored or burned to produce energy. Insulin is a hormone made in the pancreas and released into the bloodstream. It enables some of the body's organs to take sugar from the bloodstream and use it for energy. When there isn't enough insulin, or when cells have too few receptors that recognize insulin, sugar is not removed from the bloodstream and high levels accumulate. High blood sugar stems from a defect in insulin production or a defect in insulin action or both. Diabetes can lead to kidney disease, damage to the retina leading to blindness, nerve damage, foot ulcers, hardening of the arteries, heart disease, and bacterial or fungal infections. Three out of four diabetics die of cardiovascular (heart and blood vessel) disease related to their diabetes, and two of those three deaths are from heart disease.

Insulin-dependent Diabetes Mellitus, (IDDM,Type-1)

A small fraction of all diabetics have IDDM and require insulin to live. With insulin, many live to an old age. Although this type of diabetes most commonly appears in childhood or adolescence, the term "juvenile-onset" is misleading. IDDM can first occur in much older patients as well. Therefore, physicians often refer to this type of diabetes in non-age-restricted terms as IDDM, or type-1 diabetes. In type-1 diabetes, the pancreas cannot produce insulin. When a diabetic eats carbohydrates, their blood sugar rises sharply. This is because without insulin, glucose moves into the cells very slowly. Therefore, while a diabetic's blood contains concentrations of sugar, the cells are not able to absorb the glucose properly. Deprived of glucose, the cells may be forced to burn fat at an abnormally fast rate, a process that in turn floods the body with substances called ketones. This can lead to a condition known as ketoacidosis. Symptoms of ketoacidosis include vomiting, weakness, stomach pain, dehydration, and very low blood pressure. Untreated, it may even lead to coma and death.

Treatment

To prevent toxic levels of ketones from accumulating in the blood, a type-1 diabetic needs insulin injections daily. By adhering strictly to the American Diabetes Association's diet, a type-1 diabetic can attempt regulate the amount and type of sugar taken into the body at various times throughout the day. The type-1 diabetic needs both insulin injections and a regimented diet to live.

Non-insulin-dependent Diabetes Mellitus (NIDDM,Type-2)

Of the millions of older Americans who have diabetes, 85 to 90%a have type-2 diabetes. The vast majority of these people are obese, averaging about 50% over their ideal body weight. Type-2 diabetics have a hereditary tendency toward diabetes which is magnified when they become overweight. The symptoms of adult onset diabetes involve, at the worst, increased urination, excessive eating and drinking, and perhaps occasional dizziness. Because of the vagueness of the symptoms, type-2 diabetes can often only be diagnosed with blood tests. The many long-term complications of diabetes make this disease the sixth leading cause of death in this country.

Like their type-1 counterparts, type-2 diabetics cannot remove sugar from the blood at a normal rate, but partly for a different reason. Type-2 diabetics do not respond normally to insulin (this is called "insulin resistance"); they require much larger amounts of insulin than do non-diabetics in order to control blood glucose. This resistance to insulin appears to be hereditary. Type-2 diabetics can make insulin, but not as much as can non-diabetics. This combination of increased insulin requirements and limited insulin secretion leads to the loss of control of blood glucose.

Obesity itself causes insulin resistance. Thus, type-2 diabetics who are overweight have even higher needs for insulin than do those who are not. Weight loss is the cornerstone of treatment for type-2 diabetics who are overweight: losing the excess weight makes the body more sensitive to insulin, and the amount of insulin produced will have much greater effects. Physically and psychologically, the benefits of a low calorie diet are achieved early (often within days) when patients are still overweight.'

Treatment

There are three kinds of medical treatment of type-2 diabetes: diet, oral hypoglycemic pills (anti-diabetes drugs taken by mouth), or insulin injections, alone or in combination. Below is a ranking of treatments from most hazardous to safest. Diabetes pills, although the easiest therapy to follow, actually undermine the purpose of treating diabetes because they may increase your chances of dying from cardiovascular disease. The University Group Diabetes Program (UGDP) study, a study done on insulin and the antidiabetes drugs tolbutamide-a member of the sulfonylurea group of drugs-and phenformin (banned from the market-a biguanide drug, and a first cousin to metformin (GLUCOPHAGE)-failed to prove that diabetes pills prevent the long-term complications of diabetes, such as heart disease, kidney disease, and blindness. Moreover, it is probable that these drugs cause premature deaths from cardiovascular disease.

Unlike insulin, oral hypoglycemics are only somewhat effective in lowering blood sugar. They fail to adequately control blood sugar in 20 to 40% of patients. But even if they work at first, they may fail later in as many as 30% of patients per year. After the UGDP report was released, two clinics that stopped using the sulfonyl urea oral hypoglycemics found no change in blood sugar in about one-third to one-half of patients after stopping the drug, indicating that these people did not need to be on the drug in the first place.' The remaining patients were able to lower their blood sugar with diet alone or diet plus insulin. These results suggest that a majority of the people who take the sulfonylurea oral hypoglycemics could get along with mild dietary changes and not risk premature cardiovascular death.

Two oral hypoglycemics pose additional problems for older people. Chlorpropamide (DIABINESE) may cause life-threatening, long-lasting periods of low blood sugar. It may also cause difficulty breathing, drowsiness, muscle cramps, seizures, swelling of face, hands, or ankles, and unconsciousness, water retention, or weakness that could be life-threatening to people who have congestive heart failure or cirrhosis of the liver.' For these reasons, the World Health Organization recommends that chlorpropamide not be used by people 60 years and older. Acetohexamide (DYMELOR) is eliminated from the body predominantly by the kidneys. Since kidney function decreases steadily with age, there is a possibility that toxic amounts of this drug may accumulate in older people.

Chlorpropamide and acetohexamide should not be used in older people and probably should be avoided at any age. Other diabetes pills should only be used by people whose diabetes is not controlled by diet and who cannot inject insulin. Below is an informed consent statement containing information that Public Citizen's Health Research Group believes all patients should receive and sign before they are prescribed diabetes pills. Insulin, like the diabetes pills, alters only the symptoms of the disease without treating the cause. In too large a dose, it may cause trembling, hunger, weakness, and irritability symptoms of low blood sugar that can progress to insulin shock. Unlike the diabetes pills, however, insulin has not been shown to increase your chance of cardiovascular disease, but does carry a risk of severe hypoglycemia (low blood sugar).

It is very important that you understand the correct use of the needle and syringe and instructions that come in the insulin package. Ask for help if you are not sure about any part of your treatment. Your doctor or the diabetes nurse-educator at your hospital can help you. Improper cleansing or infection technique may cause skin problems. Tell your doctor if you are having skin problems or difficulty injecting insulin. Disposable syringes and needles are meant to be used only once. United States Pharmacopeia medical panels do not recommend reusing them. However, if you do reuse them, the syringe and needle must be used for only one person. After each use, wipe the needle with alcohol and replace the cap. These needles should definitely not be used more than a few times. Glass syringes need to be sterilized each time they are used.

Insulin should be refrigerated but not frozen. It can be kept at room temperature for a month, but it is better to keep it in the refrigerator. Do not expose it to hot temperatures or sunlight. Insulin is available in a wide variety of preparations. Some last longer than others local allergy is more common with the less pure, older insulins and may be recognized by a hard, red, itching area at the injection site. You should be using a human insulin rather than the older animal insulins. Some people experience more serious allergic reactions (skin rash, swelling, stomach upset, difficulty breathing, and very rarely, low blood pressure or even death). Call your doctor immediately if you think you may be experiencing an allergic reaction.

Diet is the safest, most effective treatment available for the vast majority of adult-onset diabetics. More than 90% of type-2 diabetics are overweight. In many cases, blood sugar levels return to normal and symptoms go away when the diabetic loses enough, weight.

Since a large proportion of diabetics can be treated by diet alone, why are so many people taking pills? There are three reasons: drug companies, doctors, and patients. When the oral hypoglycemic agents became available, they were intended to serve as substitutes for insulin in the few adult-onset diabetics who needed diet plus insulin to control their diabetes. Instead, the pills became substitutes for the diet. With the availability of oral drugs, experts stopped stressing the role of diet in controlling the disease, mostly in those very people whose diabetes could have been controlled by an appropriate diet.

Doctors find it easier to prescribe a pill than to prod and nag patients into losing weight. Some assume that older people won't change their diet or lose weight. Doctors may not even suggest a trial weight loss period, but simply begin treatment by prescribing an oral hypoglycemic pill. Patients, who receive complex diet instructions from their physician and are referred to a dietitian for instructions on weighing food portions and memorizing food choices, often find it easier to take a pill than to change eating habits. However, it is foolhardy to increase the already present risk of heart and blood vessel disease for the convenience of popping a pill, when proper instruction, limited dietary changes, and a little encouragement can help you to reach optimal weight, better health, and improved control of blood sugar. Below are some suggestions for successful weight loss, guidelines for developing a healthier diet, and details of some of the common pitfalls that cause people to become discouraged and discontinue dietary therapy for diabetes.

Diets that are very complicated or very different from what you are used to are hard to follow. The American Diabetes Association (ADA) diet is a highly structured plan based on exchange lists. Although it serves its purpose of regulating calorie and sugar intake quite well, the ADA diet may be difficult for older people to use. Successful use of this diet requires considerable time spent planning meal patterns and food portions. Older people often have trouble with this diet because the food lists are long and complicated and require considerable memorization. The amount of patience and manual dexterity necessary to properly weigh and measure foods may prove difficult, especially for older people. Furthermore, rigid control, such as that provided by the ADA diet, is not always necessary in type-2 diabetics. Often more gradual dietary change will reduce weight and lower blood sugar.

See if your doctor or a dietitian can help you plan an easy-to-follow diet that will help to control your diabetes. The diet for a type-2 diabetic is based on the same nutritional principles as for a non-diabetic. Special foods ("dietetic") and unbalanced fad diets are unnecessary and sometimes dangerous. The basic plan should be to avoid sugar and instead eat a diet high in starch and fiber. Many people are already eating a diet that is partly appropriate for diabetics. Only small changes may be needed. Eat fewer simple sugars. Instead of soft drinks, snack foods, and cookies, substitute water, and raw foods, especially vegetables. To reduce your risk of atherosclerosis (hardening of the blood vessels) do the Metabolic Typing test to confirm what foods will be your optimal diet that will keep your inflammation and resulting cholesterol low. A regular exercise program is recommended for people who have diabetes. Exercise helps to lower blood sugar and to reduce weight. It does not have to be strenuous; walking and especially rebounding is often the best form of exercise. Some complications of diabetes can limit your ability to exercise. Make sure you have picked a form of exercise that is safe for you.

Health Care for Diabetics

Because diabetes is such a complex disease, your overall health and your response to treatment need to be checked periodically. Schedule regular appointments with your doctor. Most diabetics, even those treated by diet alone, should use one of the many devices currently available to test blood glucose at home at least once a day. This will let you know how well controlled your blood sugar is and will tell you if it is getting out of control. You should rotate the time of measurement (before breakfast one day, before lunch the next day, before supper the next, at bedtime the next, and then back to breakfast); this way you will know what happens to your blood sugar throughout the day. Write down your measurements and show them to your doctor at each visit (your doctor should make a copy for your medical record).

Also, at least two or three times a year your doctor should order a blood test called "hemoglobin Ale" or "glycosylated hemoglobin." This will tell your doctor how well your blood sugar has been controlled during the previous two to three months. If this test indicates that your blood sugar has been more than just slightly elevated, your doctor should consider changes in your treatment. Foot care is a particular problem for diabetics. Between appointments be sure to check your feet regularly for sores, infections, and ulcers. These need prompt medical attention. Use cotton socks and wear well-fitted shoes. Diabetic eye disease is one of the major causes of blindness in our country. Schedule an appointment with an ophthalmologist, (an eye doctor with an MD) degree), at least every 12 months.

A number of drugs may raise blood sugar as an adverse effect. The most common are clonidine, corticosteroids, diuretics, gemfabrozil, narcotics, progesterone, and theophylline. If you are taking one of these drugs, ask your doctor whether you still need the medicine or if there is an alternative. Older people should not use chlorpropamide or acetohexamide.


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