Diabetes (Type 1 and Type 2)

Diabetes (Type 1 and Type 2) Quick Overview

  • Diabetes is a condition characterized by the body's inability to regulate glucose (sugar) levels in blood.
  • In type 1 diabetes, the body does not produce enough insulin.
  • People with type 2 diabetes can produce insulin, but the body is not able to use the insulin effectively.
  • Symptoms of both type 1 and type 2 diabetes include
  • The cause of type 1 diabetes is an autoimmune reaction. Combinations of genetic risk factors and unhealthy lifestyle choices cause type 2 diabetes.
  • The main diagnostic test for diabetes is measurement of the blood glucose level.
  • Changes in lifestyle and diet may be adequate to control some cases of type 2 diabetes. Others with type 2 diabetes require medications. Insulin is essential treatment for type 1 diabetes.
  • No effective approach yet exists to prevent type 1 diabetes. Prevention of type 2 diabetes can be accomplished in some cases by
    • maintaining a healthy weight,
    • exercising,
    • sustaining a healthy lifestyle.
  • Prediabetes is a condition that can occur before development of type 2 diabetes.
  • Complications of any type of diabetes include damage to blood vessels, leading to heart disease or kidney disease. Damage to blood vessels in the eye can result in vision problems including blindness. Nerve damage can occur, leading to diabetic neuropathy.

What Is Diabetes?

Diabetes mellitus (DM) is a set of related diseases in which the body cannot regulate the amount of sugar (specifically, glucose) in the blood.

The blood delivers glucose to provide the body with energy to perform all daily activities.

  • The liver converts the food a person eats into glucose. The glucose is then released into the bloodstream from the liver between meals.
  • In a healthy person, several hormones tightly regulate the blood glucose level, primarily insulin. Insulin is produced by the pancreas, a small organ between the stomach and liver. The pancreas also releases other important enzymes directly into the gut to help digest food.
  • Insulin allows glucose to move out of the blood into cells throughout the body, where it is used for fuel.
  • People with diabetes either do not produce enough insulin (type 1 diabetes), cannot use insulin properly (type 2 diabetes), or both (various forms of diabetes).
  • In diabetic patients, glucose cannot move efficiently from the blood into cells, so blood glucose levels remain high. This not only starves all the cells, which need the glucose for fuel, but also harms certain organs and tissues exposed to the high glucose levels over time.

What Are the Types of Diabetes?

Type 1 diabetes (T1D): The body stops producing insulin or produces too little insulin to regulate blood glucose level.

  • Type 1 diabetes affects about 10% of all people with diabetes in the United States.
  • Type 1 diabetes is typically diagnosed during childhood or adolescence. It used to be referred to as juvenile-onset diabetes or insulin-dependent diabetes mellitus.
  • Insulin deficiency can occur at any age due to destruction of the pancreas by alcohol, disease, or removal by surgery.
  • Type 1 diabetes also results from progressive failure of the pancreatic beta cells, the only cell type that produces significant amounts of insulin.
  • People with type 1 diabetes require daily insulin treatment to sustain life.

Type 2 diabetes (T2D): Although the pancreas still secretes insulin, the body of someone with type 2 diabetes is partially or completely incapable of responding to insulin. This is often referred to as insulin resistance. The pancreas tries to overcome this resistance by secreting more and more insulin. People with insulin resistance develop type 2 diabetes when they fail to secrete enough insulin to cope with their body's demands.

  • At least 90% of adult individuals with diabetes have type 2 diabetes.
  • Type 2 diabetes is typically diagnosed during adulthood, usually after age 45 years. It was once called adult-onset diabetes mellitus, or non-insulin-dependent diabetes mellitus. These names are no longer used because type 2 diabetes does occur in young people, and some people with type 2 diabetes require insulin therapy.
  • Type 2 diabetes is usually controlled with diet, weight loss, exercise, and/or oral medications. However, more than half of all people with type 2 diabetes require insulin to control their blood sugar levels at some point during the course of their illness.

Gestational diabetes (GDM) is a form of diabetes that occurs during the second half of pregnancy.

  • Although gestational diabetes typically resolves after delivery of a baby, a woman who develops gestational diabetes is more likely than other women to develop type 2 diabetes later in life.
  • Women with gestational diabetes are more likely to have large babies.

Metabolic syndrome (also referred to as syndrome X) is a set of abnormalities in which insulin-resistant diabetes (type 2 diabetes) is almost always present along with hypertension (high blood pressure), high fat levels in the blood (increased serum lipids, predominant elevation of LDL cholesterol, decreased HDL cholesterol, and elevated triglycerides), central obesity, and abnormalities in blood clotting and inflammatory responses. A high rate of cardiovascular disease is associated with metabolic syndrome.

Prediabetes is a common condition related to diabetes. In people with prediabetes, the blood sugar level is higher than normal but not yet high enough to be considered diagnostic of diabetes.

  • Prediabetes increases a person's risk of developing type 2 diabetes, heart disease, or stroke.
  • Prediabetes can typically be reversed (without insulin or medication) by lifestyle changes, such as losing a modest amount of weight and increasing physical activity levels. Weight loss can prevent, or at least delay, the onset of type 2 diabetes.
  • An international expert committee of the American Diabetes Association redefined the criteria for prediabetes, lowering the blood sugar level cut-off point for prediabetes. Approximately 20% more adults are now believed to have this condition and may develop diabetes within 10 years unless they change to healthier lifestyles, such as exercising more and maintaining a healthy weight.

About 17 million Americans (6.2% of adults in North America) are believed to have diabetes. It has been estimated that about one-third of adults with diabetes do not know they have diabetes.

  • About 1 million new cases of diabetes are diagnosed occur each year, and diabetes is the direct or indirect cause of at least 200,000 deaths each year.
  • The incidences of type 1 diabetes and type 2 diabetes are increasing rapidly. This is due to many factors, but the most significant reasons for type 2 diabetes are the increasing incidence of obesity associated with sedentary lifestyles.
Non-starchy vegetables make up a large portion of the diet of those with type 2 diabetes.

Type 2 Diabetes Diet

A healthy eating plan is an essential part of any diabetes treatment plan, but there is no one recommended "diabetic diet" for everyone. An individual nutrition plan will depend on many things, including underlying health and level of physical activity, the types of medication(s) being taken, and personal preference. Most people with type 2 diabetes find that having a fairly regular schedule for meals and snacks is helpful. Eating a variety of foods and watching portion sizes is also recommended.

Examples of meal planning tools that some people with type 2 diabetes like to use include

  • the plate method,
  • carbohydrate counting, or the
  • glycemic index.

What Are the Causes of Diabetes?

Type 1 diabetes: Type 1 diabetes is an autoimmune disease. The body's immune system specifically attacks the cells in the pancreas that produce insulin.

  • A predisposition to develop type 1 diabetes may run in families, but genetic causes (a positive family history) are much more common for type 2 diabetes.
  • Environmental factors, including common and unavoidable viral infections, may also contribute to type 1 diabetes.
  • Type 1 diabetes is most common among people of non-Hispanic, Northern European descent (especially Finland and Sardinia), followed by African Americans, and Hispanic Americans. It is relatively rare among people of Asian descent.
  • Type 1 diabetes is slightly more common in men than in women.

Type 2 diabetes: Type 2 diabetes has strong genetic links, so type 2 diabetes tends to run in families. Several genes have been linked to type 2 diabetes, and many are under study related to type 2 diabetes. Risk factors for developing type 2 diabetes include the following:

  • High blood pressure
  • High triglyceride (fat) levels in the blood
  • Gestational diabetes or giving birth to a baby weighing more than 9 pounds
  • High-fat diet
  • High alcohol intake
  • Sedentary lifestyle
  • Obesity or being overweight
  • Ethnicity, particularly when a close relative had type 2 diabetes or gestational diabetes. Certain groups (such as African Americans, Native Americans, Hispanic Americans, and Japanese Americans) have a greater risk of developing type 2 diabetes than non-Hispanic whites.
  • Aging: Increasing age is a significant risk factor for type 2 diabetes. Risk begins to rise significantly at about age 45 years, and rises considerably after age 65 years.

What Are Diabetes Symptoms and Signs?

Symptoms of type 1 diabetes are often dramatic and come on very suddenly.

  • Type 1 diabetes is usually recognized in childhood or early adolescence, often in association with an injury or illness (such as a virus or urinary tract infection).
  • The extra stress can cause diabetic ketoacidosis (DKA).
    • Symptoms of ketoacidosis include nausea and vomiting. Dehydration and often-serious disturbances in blood levels of potassium and other factors follow.
    • Without treatment, ketoacidosis can lead to coma and death.

Symptoms of type 2 diabetes are often subtle and may be attributed to aging or obesity.

  • A person may have type 2 diabetes for many years without knowing it.
  • People with type 2 diabetes can develop the hyperglycemic hyperosmolar nonketotic syndrome.
  • Type 2 diabetes can be precipitated by steroids and stress.
  • If not properly treated, type 2 diabetes can lead to complications such as blindness, kidney failure, heart disease, and nerve damage.

Common symptoms of both type 1 and type 2 diabetes include:

  • Fatigue, or feeling constantly tired: In diabetes, the body is inefficient and sometimes unable to use glucose for fuel. The body switches over to metabolizing fat, partially or completely, as a fuel source. This process requires the body to use more energy. The end result is feeling fatigued or constantly tired.
  • Unexplained weight loss: People with diabetes are unable to process many of the calories in the foods they eat. Thus, they may lose weight even though they eat an apparently appropriate or even an excessive amount of food. Losing sugar and water in the urine and the accompanying dehydration also contributes to weight loss.
  • Excessive thirst (polydipsia): A person with diabetes develops high blood sugar levels, which overwhelms the kidney's ability to reabsorb the sugar as the blood is filtered to make urine. Excessive urine is made as the kidney spills the excess sugar. The body tries to counteract this by sending a signal to the brain to dilute the blood, which translates into thirst. The body encourages more water consumption to dilute the high blood sugar back to normal levels and to compensate for the water lost by excessive urination.
  • Excessive urination (polyuria): Another way the body tries to rid the body of the extra sugar in the blood is to excrete it in the urine. This can also lead to dehydration because a large amount of water is necessary to excrete the sugar.
  • Excessive eating (polyphagia): If the body is able, it will secrete more insulin in order to try to manage the excessive blood sugar levels. With type 2 diabetes, the body resists the action of insulin. One function of insulin is to stimulate hunger. Therefore, higher insulin levels lead to increased hunger. Despite eating more, the diabetic person may gain very little weight and may even lose weight.
  • Poor wound healing: High blood sugar levels prevent white blood cells, which are important in defending the body against bacteria and also in cleaning up dead tissue and cells, from functioning normally. When these cells do not function properly, wounds take much longer to heal and become infected more frequently. Long-standing diabetes also is associated with thickening of blood vessels, which prevents good circulation, including the delivery of enough oxygen and other nutrients to body tissues.
  • Infections: Certain infections -- such as frequent yeast infections of the genitals, dental infections, skin infections, and frequent urinary tract infections -- may result from suppression of the immune system by diabetes and by the presence of glucose in the tissues, which allows bacteria to grow. These infections can also be an indicator of poor blood sugar control in a person known to have diabetes.
  • Altered mental status: Agitation, unexplained irritability, inattention, extreme lethargy, or confusion can all be signs of very high blood sugar, ketoacidosis, hyperosmolar hyperglycemia nonketotic syndrome, or hypoglycemia (low sugar). Thus, any of these in a diabetic patient merit the immediate assessment of blood glucose. Call your health-care professional or 911 for immediate attention by a medical professional.
  • Blurry vision: Blurry vision is not specific for diabetes but is frequently present with high blood sugar levels.

When Should Someone Seek Medical Care for Type 1 or Type 2 Diabetes?

If a person has diabetes and experiences any of the following, call a health-care professional:

  • Experiencing diabetes symptoms, since this may mean that the person's blood sugar level is not being controlled despite treatment.
  • When tested, blood sugar levels are consistently high (more than 200 mg/dL). Persistently high blood sugar levels are the root cause of all of the complications of diabetes.
  • The patient's blood sugar level is often low (less than 70 mg/dL), called hypoglycemia. This may mean that the diabetes management strategy is too aggressive. It also may be a sign of infection or other stress on the body's organs, such as kidney failure, liver failure, adrenal gland failure, or the concomitant use of certain medications.
  • An injury to the foot or leg, no matter how minor: Even the tiniest cut or blister can become very serious in a person with diabetes. Early diagnosis and treatment of problems with the feet and lower extremities, along with regular diabetic foot care, are critical in preserving the function of the legs and preventing amputation.
  • Low-grade fever (less than 101.5 F or 38.6 C): Fever is one sign of infection. Many common infections can potentially be more dangerous for diabetic patients than for other people. Note any symptoms that may indicate where the infection is located, such as painful urination, redness or swelling of the skin, abdominal pain, chest pain, or cough.
  • Nausea or vomiting but can keep liquids down.: The health-care professional may adjust medications while the patient is sick. The health-care professional will probably recommend an urgent office visit or a visit to the emergency department. Persistent nausea and vomiting can be a sign of diabetic ketoacidosis (DKA), a potentially life-threatening condition, as well as several other serious illnesses.
  • Small sore(s) (ulcer) on the foot or leg: Any non-healing sore or ulcer on the feet or legs of someone with diabetes needs to be seen by a medical professional right away. A sore less than 1 inch across, not draining pus, and not exposing deep tissue or bone, can safely be evaluated by a health-care professional, as long as the patient does not have fever and their blood sugar levels are under control.

When you call a health-care professional, tell them that you are concerned because you or someone you know has diabetes.

  • The patient will probably be referred to a nurse who will ask questions and initially recommend what to do.
  • Be prepared for this conversation. Have handy by the phone a list of all medications and nutritional supplements, medical problems, allergies to medicines, and a blood sugar diary.
  • The nurse may need any or all of this information to decide both the urgency of the patient's condition and how best to treat the problem.

Diabetes Emergencies

The following situations can become medical emergencies (911) and warrant an immediate visit to a hospital emergency department.

  • The person with a severe diabetic complication should travel to the emergency department by car or ambulance.
  • A companion should go along to speak for the person if the person is unable to speak for himself or herself with the emergency-care professional.
  • Always bring a list of medical problems, medications, nutritional supplements, allergies to medications, and the person's blood sugar diary to the emergency department. This information will help the emergency care professional diagnose the problem and treat it appropriately.

The following are signs and symptoms of diabetic complications that warrant emergency care.

  • Altered mental status: Lethargy, agitation, forgetfulness, or just strange behavior can be a sign of very low or very high blood sugar levels. If a person with diabetes has an altered mental status,
    • try giving them some fruit juice (about 6 ounces) or cake icing if the person is awake enough to swallow normally without choking. Avoid giving things such as hard candy that can lodge in the throat. The health-care professional can prescribe glucose wafers or gels that melt under the tongue.
    • does not wake up and behave normally within about 15 minutes, call 911.
    • If not a known diabetic, these symptoms can be signs of stroke, drug intoxication, alcohol intoxication, oxygen starvation, and other serious medical conditions. Call 911 immediately.
  • Nausea or vomiting: If the patient is known to have diabetes and cannot keep food, medications, or fluids down at all, they may have diabetic ketoacidosis, hyperosmolar hyperglycemic nonketotic syndrome, or another complication of diabetes. If the person
    • has not already taken the latest insulin dose or oral diabetes medicine, do not take it without talking to a medical professional.
    • already has low blood sugar levels, taking additional insulin or medication will drive the blood sugar level down even further, possibly to dangerous levels.
  • Fever above 101.5 F (38.6 C): If the primary health-care professional cannot see the patient right away, seek emergency care for a person with diabetes with a high fever. Note any other symptoms such as cough, painful urination, abdominal pain, or chest pain.
  • High blood sugar level: If the patient's blood sugar level is above 400 mg/dL, and the primary health-care professional cannot see them right away, go to the closest emergency department. Very high blood sugar levels can be a sign of diabetic ketoacidosis or hyperosmolar hyperglycemic nonketotic syndrome, depending on the type of diabetes. Both conditions can be fatal if not treated promptly.
  • Large sores or ulcers on the feet or legs: If the person has diabetes, a nonhealing sore larger than 1 inch in diameter can be a sign of a potentially limb-threatening infection.
    • Other signs and symptoms that merit immediate care are exposed bone or deep tissue wound, large areas of surrounding redness and warmth, swelling, and severe pain in the foot or leg.
    • If left untreated, such a sore may ultimately require amputation of the limb.
  • Cuts or lacerations: Any cut penetrating all the layers of skin, especially on the legs, is a potential danger to a person with diabetes. Although important to anyone's recovery, proper wound care is especially important in diabetic people to assure proper wound healing.
  • Chest pain: If the person has diabetes, take very seriously any pain in the chest or arms (particularly in the middle of the chest or along the left side), and seek medical attention immediately.
    • People with diabetes are more likely than nondiabetic people to have a heart attack, with or without experiencing chest pain.
    • Irregular heartbeats and unexplained shortness of breath may also be signs of heart attack.
  • Severe abdominal pain: Depending on the location, this can be a sign of heart attack, abdominal aortic aneurysm (dangerous widening of the large artery in the abdomen), diabetic ketoacidosis, or interrupted blood flow to the bowels.
    • All of these are more common in people with diabetes than in the general population, and they are potentially life-threatening.
    • People with diabetes also get other common causes of severe abdominal pain such as appendicitis, perforated ulcer, inflammation and infection of the gallbladder, kidney stones, and bowel obstruction.
    • Severe pain anywhere in the body is a signal for timely medical attention.

What Tests Do Health-Care Professionals Use to Diagnose Diabetes?

Doctors use common tests to diagnose diabetes and also to monitor blood sugar control in diabetes.

The health-care professional will take a history including information about the patient's symptoms, risk factors for diabetes, past medical problems, current medications, allergies to medications, family history of diabetes, or other medical problems such as high cholesterol or heart disease, and personal habits and lifestyle.

A number of laboratory tests can confirm the diagnosis of diabetes.

Finger stick blood glucose: This rapid screening test may be performed anywhere, including community-based screening programs.

  • Although not as accurate as testing blood in a hospital laboratory, a finger stick blood glucose test is easy to perform, and the result is available quickly.
  • The test involves sticking the patient's finger for a blood sample, which is then placed on a strip that has been inserted into a machine that reads the blood sugar level. These machines are only accurate to within about 10%-20% of true laboratory values.
  • Finger stick blood glucose values tend to be most inaccurate at very high or very low levels, so abnormally low or high results should be confirmed by repeat testing. Finger stick is the way most people with diabetes monitor their blood sugar levels at home.

Fasting plasma glucose: The patient will be asked to eat or drink nothing for eight hours before having blood drawn (usually first thing in the morning). If the blood glucose level is greater than or equal to 126 mg/dL (without eating anything) at any age, they probably have diabetes.

  • If the result is abnormal, the fasting plasma glucose test may be repeated on a different day to confirm the result. Or the patient may undergo an oral glucose tolerance test or a glycosylated hemoglobin test (often called "hemoglobin A1c") as a confirmatory test.
  • If fasting plasma glucose level is greater than 100 but less than 126 mg/dL, then the patient has what is called impaired fasting glucose, or IFG. This is considered to be prediabetes. These patients do not have diabetes, but they are at high risk of developing diabetes in the near future.

Oral glucose tolerance test: This test involves drawing blood for a fasting plasma glucose test, then drawing blood for a second glucose test at two hours after drinking a specific sweet drink (containing up to 75 grams of sugar).

  • If the blood sugar level after the sugar drink rises over or equal to 200 mg/dL, the patient has diabetes.
  • If the blood glucose level is between 140 and 199 mg/dL, then the patient has impaired glucose tolerance (IGT), also a prediabetic condition.

Glycosylated hemoglobin or hemoglobin A1c: This test measures how high the blood sugar levels have been over approximately the last 120 days (the average life span of the red blood cells on which the test is based).

  • Excess blood glucose hooks itself on to the hemoglobin in red blood cells and stays there for the remaining life of the red blood cell.
  • The percentage of hemoglobin that has had excess blood sugar attached to it can be measured in the blood. The test involves having a small amount of blood drawn or by finger stick.
  • The hemoglobin A1c test is the best measurement of blood sugar control in people known to have diabetes. The normal value is under 6%. Hemoglobin A1c levels of 7% or less indicate good glucose control. A result of 8% or higher indicates that blood sugar levels are too high, too often.
  • The hemoglobin A1c test is the best test for diabetes follow-up care. Although less than ideal for diagnosing diabetes, hemoglobin A1c above 6% is highly suggestive of diabetes. Generally, another confirmatory test would be needed to diagnose diabetes.
  • The hemoglobin A1c test is usually measured about every three to six months for people with diabetes, although it may be done more frequently for people who are having difficulty achieving and maintaining good blood sugar control.
  • This test is not used for people who do not have diabetes or are not at increased risk of diabetes.
  • Normal values may vary from laboratory to laboratory, although an effort is under way to standardize how measurements are performed.

What Are Treatment Options for Diabetes?

Various treatments exist for diabetes. Type 1 diabetes is treated with insulin (by multiple daily injections or pump), diabetic diet, and other lifestyle modifications. Type 2 diabetes is generally treated with diabetic diet, lifestyle changes such as moderate to vigorous exercise, and medication(s).

Are There Home Remedies (Diet, Exercise, and Glucose Monitoring) for Diabetes?

If a person has diabetes, healthful lifestyle choices in diet, exercise, sleep, and other habits will help improve glycemic (blood sugar) control and prevent or minimize complications from diabetes.

Diabetes diet: A healthy diet is key to controlling blood sugar levels and preventing diabetes complications.

  • If the patient is obese and has had difficulty losing weight on their own, talk to a health-care professional. He or she can recommend a dietitian or a weight-modification program to help the patient reach a goal.
  • Eat a consistent, well-balanced diet that is high in fiber, low in saturated fat, and low in concentrated sweets.
  • A consistent diet that includes roughly the same number of calories at about the same times of day helps the health-care professional prescribe the correct dose of medication or insulin.
  • A healthy diet also helps to keep blood sugar at a relatively even level and avoids excessively low or high blood sugar levels, which can be dangerous and even life-threatening.

Exercise: Regular exercise, in any form, can help reduce the risk of developing diabetes. Activity can also reduce the risk of developing complications of diabetes such as heart disease, stroke, kidney failure, blindness, and leg ulcers.

  • As little as 20 minutes of walking three times a week has a proven beneficial effect. Any exercise is beneficial. No matter how easy or how long, some exercise is better than no exercise.
  • If the patient has complications of diabetes (such as eye, kidney, or nerve problems), they may be limited both in type of exercise and amount of exercise they can safely do without worsening their condition. Consult with your health-care professional before starting any exercise program.

Alcohol use: Moderate or eliminate consumption of alcohol. Try to have no more than seven alcoholic drinks in a week, and never more than two drinks in an evening. One drink is considered 1.5 ounces of liquor, 6 ounces of wine, or 12 ounces of beer. Excessive alcohol use is a known risk factor for type 2 diabetes. Alcohol consumption can cause low or high blood sugar levels, nerve pain (neuritis), and an increase in triglycerides.

Smoking: If the patient has diabetes, and smokes cigarettes or use any other form of tobacco, they are dramatically raising their risks for nearly all of the complications from diabetes. Smoking damages blood vessels and contributes to heart disease, stroke, and poor circulation in the limbs. If a person needs help to quit tobacco use, talk to a health-care professional.

Self-monitored blood glucose: Check blood sugar levels frequently, at least before meals and at bedtime, then record the results in a logbook.

  • This log should also include the doses and times for insulin or oral medications, when and what the patient ate, when and for how long they exercised, and any significant events of the day such as high or low blood sugar levels and how they treated the problem. Many mobile applications ("apps") now exist to help with such logging.
  • Simple equipment now exists to make testing blood sugar levels less painful and more convenient. The daily blood sugar diary is invaluable both to self-management and to the health-care professional evaluating how the patient is responding to medications, diet, and exercise during treatment.
  • Medicare now pays for diabetic testing supplies, as do many private insurers and Medicaid.

What Are Medical Treatments for Diabetes?

Treatment of diabetes is highly individualized, depending on the type of diabetes, whether the patient has other active medical problems, whether the patient has complications from diabetes, and the age and general health of the patient at time of diagnosis.

  • A health-care professional will set goals for lifestyle changes, blood sugar control, and treatment.
  • Together, the patient and the health-care professional will formulate a plan to help meet those goals.

Education about diabetes and its treatment is essential in all types of diabetes.

  • When the patient is first diagnosed with diabetes, the diabetes care team will spend a lot of time educating the patient, teaching them about their condition, treatment, and tools to care for themselves on a daily basis.
  • The diabetes care team includes the health-care professional and his or her staff. It may include specialists in foot care, neurology, kidney diseases, and eye diseases. A professional dietitian and a diabetes educator are usually part of the team.

The health-care team will encounter the patient at appropriate intervals to monitor their progress and evaluate goals.

Type 1 diabetes

Treatment of type 1 diabetes involves multiple daily injections of insulin, usually a combination of short-acting insulin (for example, lispro [Humalog] or aspart [NovoLog]) and a long-acting insulin (for example, NPH, Lente, glargine [Lantus], detemir [Levemir]).

  • Insulin must be given as an injection just under the skin. If taken by mouth, insulin would be destroyed in the stomach before it could get into the blood where it is needed.
  • Most people with type 1 diabetes give these injections to themselves. Even if someone else usually gives the patient injections, it is important that the patient knows how to do it in case the other person is unavailable.
  • A trained professional will show the patient how to store and inject the insulin. Usually this is a nurse who works with the health-care professional or a diabetes educator.
  • Insulin is usually given as three or four injections per day, generally around mealtimes. Dosage is individualized and is tailored to the patient's specific needs by the health-care professional. Longer-acting insulin formulations are typically administered once or twice each day.
  • Some people have their insulin administered by continuous infusion pumps to provide adequate blood-glucose control. Supplemental mealtime insulin is programmed into the pump by the individual as recommended by his or her health-care professionals.
  • It is very important to eat after the taking insulin, as the insulin will lower blood sugar regardless of whether the person has eaten. If insulin is taken without eating, the result may be hypoglycemia. This is called an insulin reaction.
  • There is an adjustment period while the patient learns how insulin affects them and how to time their meals and exercise with insulin injections to keep blood sugar levels as even as possible.
  • Keeping accurate records of blood sugar levels and insulin dosages is crucial for the patient's diabetes management.
  • Eating a consistent, healthy diet appropriate for the patient's size and weight is essential to control blood-sugar levels.

Type 2 diabetes

Depending on how elevated the patient's blood sugar was at diagnosis of type 2 diabetes, they may be given a chance to lower blood sugar levels through lifestyle changes, without medication.

  • For obese patients with type 2 diabetes, the best approach is to lose weight and begin an exercise program under the supervision of a physician.
  • This course will generally be tried for three to six months, then blood sugar and glycosylated hemoglobin will be rechecked. If they remain high, the patient will be started on an oral medication to help control blood sugar levels, usually a sulfonylurea or biguanide (metformin [Glucophage]).
  • Even while on medication, it is still important to eat a healthy diet, lose weight if they are overweight, and engage in moderate to vigorous physical activity as often as possible.
  • The health-care professional will initially monitor the patient's progress on medication carefully. It is important to receive the right dose of the right medication, in order to regulate blood sugar levels in the recommended range with the fewest side effects.
  • The doctor may decide to combine different medications to achieve blood sugar levels control.
  • Gradually, even people with type 2 diabetes may require insulin injections to control their blood sugar levels.
  • It is becoming more common for people with type 2 diabetes to take a combination of oral medication and insulin injections to control blood sugar levels.

What Medications Treat Diabetes?

Many different types of medications are available to help lower blood sugar levels in people with type 2 diabetes. Each type works in a different way. It is very common to combine two or more types to get the best effect with fewest side effects.

  • Sulfonylureas: These drugs stimulate the pancreas to make more insulin.
  • Biguanides: These agents decrease the amount of glucose produced by the liver.
  • Alpha-glucosidase inhibitors: These agents slow absorption of the starches a person eats. This slows down the rise of glucose after meals.
  • Thiazolidinediones: These agents increase sensitivity to insulin but are restricted in the U.S. market.
  • Meglitinides: These agents stimulate the pancreas to make more insulin.
  • D-phenylalanine derivatives: These agents stimulate the pancreas to produce more insulin more quickly.
  • Sodium-glucose co-transporter 1 (SGLT2) inhibitors: Approved in 2013, cenagliflozin (Invokana) the first drug of this class blocks reabsorption of glucose by the kidney, leading to increased glucose excretion and reduction of blood sugar levels. Urinary tract infections are more common with this treatment due to higher sugar levels in the urine.
  • Amylin synthetic derivatives: Amylin is a naturally occurring hormone secreted by the pancreas along with insulin. An amylin derivative, such as pramlintide (Symlin), can help control blood sugar when insulin alone does not. Pramlintide is administered as a subcutaneous injection along with insulin and helps achieve lower blood sugar levels after meals, helps reduce fluctuation of blood sugar levels throughout the day, and improves hemoglobin A1c levels.
  • Incretin mimetics: Incretin mimetics promote insulin secretion by the pancreas. They mimic other natural actions that lower blood sugar level. Exenatide (Byetta) was the first incretin mimetic agent approved in the United States. It is indicated for type 2 diabetes in addition to metformin (Glucophage) or a sulfonylurea when these agents alone cannot control blood sugar level.
  • Insulins: Synthetic human insulin is now the only type of insulin available in the United States. It is less likely to cause allergic reactions than animal-derived varieties of insulin used in the past. The type of insulin chosen to customize treatment for an individual is based on the goal of providing optimal blood sugar control. Different types of insulin are available and categorized according to their times of action onset and duration. Commercially prepared mixtures of insulin may also be used to provide constant (basal) control and immediate control.

What Are Complications of Diabetes?

Both type 1 and type 2 diabetes lead to high blood sugar levels, called hyperglycemia. Over a long period of time, hyperglycemia damages the retina of the eye, blood vessels of the kidneys and other organs, and the nerves.

  • Damage to the retina from diabetes (diabetic retinopathy) is the leading cause of blindness.
  • Damage to the kidneys from diabetes (diabetic nephropathy) is the leading cause of kidney failure.
  • Damage to the nerves from diabetes (diabetic neuropathy) is a leading cause of foot wounds and ulcers, which frequently lead to foot and leg amputations.
  • Damage to the nerves in the autonomic nervous system can lead to paralysis of the stomach (gastroparesis), chronic diarrhea, and an inability to control heart rate and blood pressure during postural changes.
  • Diabetes accelerates atherosclerosis, (the formation of fatty plaques inside the arteries), which can lead to blockages or a clot (thrombus). Such changes can then lead to heart attack, stroke, and decreased circulation in the arms and legs (peripheral vascular disease).
  • Diabetes predisposes people to elevated blood pressure, high levels of cholesterol and triglycerides. Both independently and together with hyperglycemia, these conditions increase the risk of heart disease, kidney disease, and other blood vessel complications.

Diabetes can contribute to a number of acute (coming on suddenly rather than developing slowly over time) medical problems.

  • Many infections are associated with diabetes. Infections are frequently more dangerous in someone with diabetes because the body's normal ability to fight infections is impaired. To compound the problem, infections may worsen glucose control, which further delays recovery from infection.
  • Hypoglycemia or low blood sugar occurs intermittently in most people with diabetes. It can result from taking too much diabetes medication or insulin (sometimes called an insulin reaction), missing a meal, exercising more than usual, drinking too much alcohol, or taking certain medications for other conditions. It is very important to recognize hypoglycemia and be prepared to treat it at all times. Headache, feeling dizzy, poor concentration, tremor of the hands, and sweating are common symptoms of hypoglycemia. A person can faint or have a seizure if his or her blood sugar level becomes too low.
  • Diabetic ketoacidosis (DKA) is a serious condition in which uncontrolled hyperglycemia (usually due to complete lack of insulin or a relative deficiency of insulin) over time creates a buildup of ketones (acidic waste products) in the blood. High levels of ketones can be very harmful. This typically happens to people with type 1 diabetes who do not have good blood glucose control. Diabetic ketoacidosis can be precipitated by infection, stress, trauma, missing medications like insulin, or medical emergencies such as a stroke and heart attack.
  • Hyperosmolar hyperglycemic nonketotic syndrome is a serious condition in which the blood sugar level gets very high. The body tries to get rid of the excess blood sugar by eliminating it in the urine. This increases the amount of urine significantly, and often leads to dehydration so severe that it can cause seizures, coma, and even death. This syndrome typically occurs in people with type 2 diabetes who are not controlling their blood sugar levels, who have become dehydrated, or who have stress, injury, stroke, or are taking certain medications, like steroids.

Diagnosing Complications of Diabetes

A person with diabetes should be checked regularly for early signs of diabetic complications. A health-care professional can order some of these tests. For other tests, the patient should be referred to a specialist.

  • The patient should have their eyes checked at least once a year by an eye specialist (ophthalmologist) to screen for diabetic retinopathy, a leading cause of blindness.
  • The patient's urine should be checked for protein (microalbumin) on a regular basis, at least one to two times per year. Protein in the urine is an early sign of diabetic nephropathy, a leading cause of kidney failure.
  • Sensation in the legs should be checked regularly using a tuning fork or a monofilament device. Diabetic neuropathy is a leading cause of lower extremity ulcers in individuals with diabetes, which frequently lead to amputation of the feet or legs.
  • The health-care professional should check the feet and lower legs of the patient at every visit for cuts, scrapes, blisters, or other lesions that could become infected. Adults with diabetes should check the soles of their feet and their legs daily with a hand-held mirror, either by themselves or with the assistance of a relative or caretaker.
  • The patient should be screened regularly for conditions that may contribute to heart disease, such as high blood pressure and high cholesterol.

Diabetes Follow-up

Treatment

  • Follow the health-care professional's treatment recommendations.
  • Keep records of blood sugar levels as often as recommended by the health-care professional and the diabetes care team, including the times the levels were checked, when and how much insulin or medication was taken, when and what was eaten, and when and for how long the patient exercised.
  • Call the health-care professional if the patient has any problems with their treatment or symptoms that suggest poor glucose control.
  • Glucagon should always be available for emergency use by the patient or patient's support in case of seizure or unconsciousness related to hypoglycemia.
  • People with diabetes should always wear a medical identification tag that identifies their diagnosis and shows contact information for their health-care provider.

Education

  • Attend diabetes education classes at the local hospital. The more educated the patient and their family are about the disease, the better they are likely to do.
  • If the patient takes insulin, they should see the health-care professional about every three months or more often. For other people with diabetes, every three to six months is generally adequate, unless they are having complications.
  • Recognize low blood sugar levels and know how to treat them.
  • The patient and their family should be taught how to recognize the signs and symptoms of low blood sugar levels. The patient should have a clear plan for treating low blood sugar levels and know when to call 911. Mild symptoms include confusion and sweating. Moreover, these symptoms can progress to lethargy, agitation (sometimes with violent, jerking motions), or even seizures.

Is It Possible to Prevent Diabetes?

It is not yet known how to prevent type 1 diabetes. Type 2 diabetes, however, can be prevented in some cases.

  • Control weight to normal or near-normal levels by eating a healthy low-fat, high-fiber diet.
  • Regular exercise is essential to prevention of type 2 diabetes.
  • Keep alcohol consumption low.
  • Quit smoking.
  • If a person has high blood fat levels (such as high cholesterol) or high blood pressure, take all medications as directed.
  • Lifestyle modifications and/or certain medications can be used in people with prediabetes to prevent progression to diabetes. Prediabetes can be diagnosed by checking fasting glucose and two hours after ingesting up to 75 grams of glucose (dosing is based on the weight of the patient).

If you or someone you know already has diabetes, focus on preventing complications, which can cause serious disabilities such as blindness, kidney failure requiring dialysis, amputation, or even death.

  • Tight glucose control: The single best thing a person with diabetes can do is to keep their blood sugar level within the suggested range every day. The only way to do this is through a combination of regular blood sugar checks, a balanced diet (low in simple sugars and fat, and high in complex carbohydrates and fiber), a high degree of personal motivation, and appropriate medical treatment. Consult a nutritionist or check with a doctor with questions in regard to diet.
  • Quit smoking.
  • Maintain a healthy weight.
  • Increase physical activity levels. Aim for moderately vigorous physical activity for at least 30 minutes every day.
  • Drink an adequate amount of water and avoid consuming too much salt.
  • Take care of the skin. Keep it supple and hydrated to avoid sores and cracks that can become severely infected.
  • Brush and floss the teeth every day. See a dentist regularly to prevent gum disease.
  • The feet should be washed and examined daily, including the soles, looking for small cuts, sores, or blisters that may cause problems later. The toenails should be filed rather than cut to avoid damaging the surrounding skin. A specialist in foot care (podiatrist) may be necessary to help care for the feet.

What Is the Prognosis of Diabetes?

Diabetes is a leading cause of death in all industrialized nations. Overall, the risk of premature death of people with diabetes is twice that of people who do not have diabetes. Prognosis depends on the type of diabetes, degree of blood sugar control, and development of complications.

Type 1 diabetes

About 15% of people with type 1 diabetes die before age 40 years, which is about 20 times the rate of that age group in the general population.

  • The most common causes of death in type 1 diabetes are diabetic ketoacidosis, kidney failure, and heart disease.
  • The good news is that prognosis can be improved with good blood-sugar control. Maintaining tight blood sugar control has been proven to prevent, slow the progression of, and even improve established complications of type 1 diabetes.

Type 2 diabetes

The life expectancy of people who are diagnosed with type 2 diabetes during their 40s decreases by five to 10 years because of the disease.

  • Heart disease is the leading cause of death for people with type 2 diabetes.
  • Excellent glycemic control, tight blood pressure control, and keeping the "bad" cholesterol (LDL) level at the recommended level below 100 mg/dL (or lower, particularly if other risk factors for cardiovascular disease are present) and the "good" (HDL) cholesterol as high as possible. When indicated, use of aspirin can prevent, slow the progression of, and improve established complications in diabetes.

What Types of Health-Care Providers Treat Diabetes?

Most primary-care providers have experience managing diabetes, including internists, gynecologists, and family practitioners. Specialists in diabetes care are called endocrinologists or diabetologists. You can locate the endocrinologist(s) in your area using the "Find an Endocrinologist" search engine online at the Hormone Health Network (http://www.hormone.org). You can locate a pediatric endocrinologist for diabetic youth using the "Find a Doctor" search engine of the Pediatric Endocrine Society (http://www.pedsendo.org/patients_families/find_a_doctor/index.cfm).

Are There Support Groups and Counseling for People With Diabetes?

You may wish to join a support group with other people to share your experiences. The American Diabetes Association and Hormone Health Network are excellent resources. Your health-care provider will have information about local groups in your area. The following groups also provide support:

American Association of Diabetes Educators
100 W Monroe, Suite 400
Chicago, IL 60603
(800) 338-3633

American Dietetic Association
120 South Riverside Plaza, Suite 2000
Chicago, IL 60606-6995
(800) 877-1600

National Diabetes Education Program
One Diabetes Way
Bethesda, MD 20814-9692
(800) 438-5383
[email protected]

Hormone Health Network
1-800-HORMONE
2055 L Street NW, Suite 600
Washington DC 20036
[email protected]

Reviewed on 11/17/2017
Sources: References

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