Diabetes is a condition caused by lack of a chemical in the body (a hormone) called insulin. There are two major forms of diabetes. In type 1 diabetes, eventually no insulin is produced and individuals require insulin injections for survival. It used to be thought this only presented in children but it is now clear this can occur at any age.

The other, more common form of diabetes, called type 2 diabetes, occurs due to the body's resistance to the effects of insulin in addition to an insufficient quantity of insulin. However, in this type of diabetes there is usually some insulin produced.

For both types of diabetes blood glucose levels are elevated. Furthermore, people with diabetes are prone to certain complications not seen in those without diabetes. These complications involve the eye (retinopathy), kidney (nephropathy), and nerves (neuropathy). People with diabetes also get early hardening of the arteries (atherosclerosis), leading to early heart attacks and strokes. The good news for people with diabetes is that with proper care, all of these problems can be avoided.

Immediate medical attention

Uncontrolled diabetes presents with frequent thirst and urination. Over time patients will become dehydrated as the glucose is "spilling" over into the urine. If insulin deficiency is severe enough, fat stores are used for energy as glucose cannot get into cells. This problem is much more common with type 1 diabetes and is called "ketoacidosis". It can be diagnosed at home with a simple urine test. When significant ketones are found in the urine it is important to be in touch with a physician immediately.

There are other conditions that require immediate attention. Blurry vision in someone with known diabetic eye disease or someone with a long history of diabetes may mean there was bleeding in the back of the eye. This may require treatment by an eye doctor. An infection on the bottom of the foot is a common problem that needs immediate attention too. When people with long-standing diabetes experience heart disease, they often do not get the typical chest pain (angina) that occurs in those people without diabetes. Often their symptoms of heart disease presents with shortness of breath with minimal exertion. This should also prompt a call to a physician.

Swelling (edema) of the ankles is another common symptom that may be a sign of a serious problem. For example, new swelling in the ankles may suggest that large quantities of protein are being lost in the urine--the first problem noted with kidney disease. Swelling may also be seen with early heart failure, a common problem in people with diabetes. Alternatively, swelling may be due to a non-serious condition, such as a side effect of a new medication or even a clue that the veins which take blood back to the heart are not working as well as they could be. Therefore, anytime new swelling is noted it should be reported to your physician.

Facts and myths

Diabetes does not "skip" generations. However, we don't understand the exact reasons why some people get diabetes and others don't.

A common misconception is that if children eat too much candy they will "catch" diabetes. Although we are seeing more type 2 diabetes in young people, this misconception refers to type 1 diabetes and is not true.

For people with diabetes, many feel that occasional blood glucose levels over 200 mg/dL will have long-term consequences. This is not true at all as it is common for glucose levels to rise above this level in almost everyone with diabetes.

There are also many misconceptions regarding food. One common one is that fresh fruit is "healthy" because it is "natural". While this may be true, fruit is also very effective at causing the blood glucose to rise quickly. Fruit juices are the most common problem here. Many people also don't realize how much milk causes blood glucose to rise. Finally, there are many misunderstandings regarding the glucose effects of alcohol. Depending on the type of alcohol consumed and the amount of food consumed, blood glucose can actually go DOWN when drinking so this needs to be done with caution.

There is also a common misunderstanding about exercise. While it is true that exercise usually results in lower blood glucose levels, if a person with type 1 diabetes exercises without sufficient insulin in the bloodstream (for example, more than 12 hours after the last shot of NPH insulin) the blood glucose can actually go UP! In fact exercise at this time period can actually lead to ketoacidosis. Therefore, for people with type 1 diabetes great attention is required balancing blood glucose levels and exercise. Since high blood glucose often occurs when insulin levels in the blood are low, the usual recommendation is to wait until the blood sugar is below 250 mg/dL before participating in strenuous exercise.

Diabetes needs to be considered a very serious condition. It is the 7th leading cause of death in the United States and over 15 million American have diabetes. It is a chronic condition for which we have no cure. About 2/3 of people with diabetes die of heart disease. It is the leading cause of adult blindness, the leading cause of kidney failure, and the leading cause of lower extremity amputation. It is also the second most common chronic condition seen by American doctors.

Although diabetes is a serious and chronic condition, early diagnosis and proper patient self-management can reduce and possibly eliminate the majority of the chronic complications. Meticulous control of blood glucose (HbA1c below 7% which would correlate to an average blood glucose below 150 mg/dL), good blood pressure control (below 130/80), low LDL (low density lipoprotein) cholesterol levels (below 100 mg/dL), one daily aspirin (either adult or children's), and daily foot inspection can make a major impact on improving one's risk for all diabetes-related problems.

Lethality

Diabetes can be deadly. Acute complications (such as low blood glucose, also called hypoglycemia) resulting in death are rare. More often, people with diabetes die of a chronic problem such as heart attack or stroke.

Pain

High blood glucose levels do not cause pain. However, having high glucose levels for many years can lead to nerve damage in the feet (called neuropathy), which can be painful. It is estimated that 25% of newly diagnosed patients with type 2 diabetes have pain or numbness in their feet from neuropathy.

Other complications related to many years of high blood glucose levels can cause pain. For example, people with diabetes are more at risk for carpel tunnel syndrome  which is a common condition in the general population. With this problem a large nerve going to the hand is squeezed causing pain in the hand. Often, surgery is required to fix this. People with diabetes are also more at risk for certain infections that may be painful. Some examples include infections of the skin (cellulitis and abscess) and even the kidney.

There is also an uncommon condition often referred to as "diabetic amyotrophy" which presents with muscle wasting of the thighs, weight loss, and severe pain. These patients often appear to have cancer. This condition is most common for men with type 2 diabetes in their 50s and 60s and usually resolves spontaneously in 12 to 18 months. There are no specific treatments for this.

Debilitation

Diabetes can be debilitating, and there are many reasons for this.

It is not uncommon for people with diabetes to experience advanced neuropathy to the point that he or she cannot walk.

Diabetes can also be debilitating in that people with it have an increased risk of stroke.

Other complications such as heart disease, sight impairment, and the need for kidney dialysis would all be considered debilitating.

The good news is that all of these can be prevented if treatment is started early and aggressively. This treatment includes meticulous control of blood glucose (average glucose below 150 mg/dL), blood pressure (below 130/80), LDL cholesterol (bad cholesterol below 100 mg/dL), daily aspirin, and smoking cessation. Research also has shown that one particular type of blood pressure medication, called ACE (angiotensin converting enzyme) inhibitors, has an additional protective effect on complications besides lowering blood pressure. ACE inhibitors appear to stabilize or even reverse diabetic kidney disease if it is caught early enough. These drugs also have been found useful for people who have had heart attacks or have heart failure. One study even showed these drugs reduced the risk of heart attack or stroke by 25%! Finally, there is a growing body of research suggesting ACE inhibitors may protect against diabetic eye disease.

Comfort

Diabetes usually does not cause discomfort. In fact, one of the biggest public health problems in America is that there are over 5 million Americans who have asymptomatic diabetes and do not know it. The most common reason for any discomfort is the neuropathy noted above. Another common reason people have discomfort is from the finger sticks to measure blood glucose. Fortunately, this technology is quickly improving so that discomfort is minimal.

Curability

Diabetes is currently not curable. Type 1 diabetes is defined as no requirement for insulin with normal blood sugars. Scientists are working on this so that the cells that make insulin ("islets") may be able to be transplanted to result in a cure. To date these experiments are not quite ready and are still in the research phases. For type 2 diabetes, there is no "cure" but often it can be treated early in its course with a strict diet, exercise, and weight loss. However, it is rare for the diabetes to "disappear" even with these measures. The main focus of research now is to prevent both types of diabetes.

Fertility and pregnancy

The topic of diabetes and pregnancy is complicated. Women with diabetes can have a normal pregnancy but the blood sugar levels need to be NORMAL before conception. Each pregnancy needs to be planned. Furthermore, patients with type 2 diabetes need to be off all of their pills and using insulin before conception. If these rules are followed, the pregnancy can be uncomplicated, although many women tend to have large babies. Furthermore, if the diabetes is complicated with eye or kidney problems before conception the mother may have more problems with these complications during the pregnancy. Women with diabetes need to be managed by a team of providers experienced with these high-risk pregnancies.

Independence

In the vast majority of cases patients with diabetes should have no problems with independence.

Mobility

Again, in the vast majority of cases, diabetes should have no impact on someone's ability to move about. The exceptions to this are those people who suffer from advanced neuropathy or vascular disease. A complication involving the foot, such as a foot ulcer or amputation can impact one's ability to move around. Visual problems also will impact one's ability to move about.

Daily activities

For the vast majority of people with diabetes, there should be no alterations of daily living. For most people however, small amounts of time should be reserved for self-management. This would include time for home blood glucose monitoring (although our current meters take as little as 5 seconds!) and extra time to ensure the proper medication is received.

Exercise is encouraged for people with diabetes, although for those over the age of 40 years old it is recommended a stress test is performed to rule out early heart disease.

For people who take insulin, "shift work" (working different shifts including the "graveyard shift") can be a challenge. You should talk to your doctor about the best way to manage your insulin if this pertains to you.

Energy

Extremes in blood glucose levels can cause fatigue. Although it is difficult to give exact levels since it differs with the person, many people note fatigue when the blood glucose exceeds 400 mg/dL. Although hypoglycemia often presents with a tremor, fast heart rate, a sweating, it may be noted only as fatigue. This often occurs when the blood glucose drops below 60 mg/dL.

Unfortunately, many people have no symptoms or may note they were fatigued after they are diagnosed with diabetes and treated for it. The vast majority of people, once treated, note no problems with fatigue.

Diet

Over the years, there have been many changes to the proper diet for people with diabetes. It is first important to note that the diet for people with diabetes has to be individualized based on a variety of issues, such as:

• the type of diabetes,
• the ethnicity of the patient,
• the presence or absence of kidney disease,
• the presence or absence of obesity,
• the presence or absence of heart disease or high cholesterol levels,
• the amount of physical activity planned, and
• age.

If a pregnancy is planned or one is pregnant and has diabetes the diet will also need adjustment for this.

In general, it is recommended that one eats a low-fat diet with less than 10% of the calories coming from saturated fat. For people with high levels of LDL-cholesterol (the "bad" cholesterol) the January 2002 guidelines from the ADA suggest only 7% of total calories from saturated fat.

The most confusion about diet for people with diabetes has to do with carbohydrates, which are the types of foods most quickly broken down to glucose (such as breads, potatoes, pasta, fruit, and simple sugar). Research has clearly shown that table sugar (sucrose) does not increase blood sugar any more than breads, pasta or other carbohydrates AS LONG AS THE SAME NUMBER OF CALORIES ARE CONSUMED. For example, putting table sugar into coffee (about 15 grams of carbohydrate) would not change blood glucose any more than 1 piece of bread (about 15 grams of carbohydrate). Therefore, simple sugars ("sweets") do not need to be restricted by people with diabetes, but rather need to be substituted for other carbohydrate sources. For people using insulin, it is much easier since additional insulin can be administered to "cover" additional carbohydrate. This is where a nutritionist can be extremely helpful so that the exact amount of insulin needed to cover the carbohydrates can be determined. Typical ranges are one unit of insulin (lispro, aspart, or regular) may cover anywhere from 5 to 20 grams of carbohydrate.

Relationships

The interactions between relationships and diabetes are greatly underappreciated.

For children, relationships with friends and teachers can be profound. Adolescence is often a difficult time anyway, and diabetes can affect relationships with peers, members of the opposite sex, parents, and teachers. All of these relationships can be quite complicated. Many in this age group often try to hide their diabetes, which can also result in problems (for example, someone with diabetes gets hypoglycemic and no one in the group knows the person has diabetes).

Communication becomes particularly important for people in their early adult years, as issues pertaining to marriage and family planning are discussed. It is critical that concerns be discussed in the open with the assistance from a health care provider with understanding about the disease.

For older adults, the impact of both the daily living of diabetes and its complications becomes even more important. Again, one needs to talk to a healthcare provider knowledgeable about diabetes to explore its complications and how it affects everything from work performance to driving or sexual function.

Everyone living with an individual who has diabetes needs to have some knowledge about how to treat emergencies (hypoglycemia). Finally, psychological support can be extremely effective for many individuals due to the extreme challenges this condition presents for many individuals