Diabetes

Signs and Symptoms

Type 1: Type 1 diabetes can occur at any age, but usually starts in people younger than 30. Symptoms are usually severe and occur rapidly. They include:

• Increased thirst
• Increased urination
• Weight loss despite increased appetite
• Nausea
• Vomiting
• Abdominal pain
• Fatigue
• Absence of menstruation

Type 2: People with type 2 diabetes often have no symptoms, and their condition is detected only when a routine exam reveals high levels of glucose in their blood. Occasionally, however, a person with type 2 diabetes may experience symptoms listed below, which tend to appear slowly over time:

• Numbness or burning sensation of the feet, ankles, and legs
• Blurred or poor vision
• Impotence
• Fatigue
• Poor wound healing

In some cases, symptoms may mimic type 1 diabetes and appear more abruptly, such as:

• Excessive urination and thirst
• Yeast infections
• Whole body itching
• Coma. In severe cases, high blood glucose may affect water distribution in brain cells, causing a state of deep unconsciousness, or coma.

Causes

Both type 1 and type 2 diabetes are caused by the absence, insufficient production, or lack of response by cells in the body to the hormone insulin. Insulin is a key regulator of the body's metabolism. After meals, food is digested in the stomach and intestines. Sugar (glucose) molecules are absorbed directly into the bloodstream, and blood glucose levels rise. Under normal circumstances, the rise in blood glucose levels signals specific cells in the pancreas, called beta cells, to secrete insulin into the bloodstream. Insulin, in turn, enables glucose to enter cells in the body that may be burned for energy or stored for future use.

In type 1 diabetes, the beta cells of the pancreas produce little or no insulin, the hormone that allows glucose to enter body cells. Once glucose enters a cell, it is used as fuel. Without adequate insulin, glucose builds up in the bloodstream instead of going into the cells. The body is unable to use this glucose for energy despite high levels in the bloodstream, leading to increased hunger.

In addition, the high levels of glucose in the blood cause the patient to urinate more, which leads to excessive thirst. Within 5 to 10 years after diagnosis, the insulin-producing beta cells of the pancreas are completely destroyed, and no more insulin is produced.

The exact cause of type 1 diabetes is not known. Each year more than 13,000 young people are diagnosed with type 1 diabetes. New cases are less common among adults older than 20.

Type 2 diabetes usually develops in older, overweight individuals who become resistant to the effects of insulin over time. When type 2 diabetes is diagnosed, the pancreas is usually producing enough insulin but, for unknown reasons, the body cannot use the insulin effectively. This is called insulin resistance. This means that the insulin produced by your pancreas cannot connect with fat and muscle cells to let glucose inside and produce energy. This causes hyperglycemia (high blood glucose). To compensate, the pancreas produces more insulin. The cells sense this flood of insulin and become even more resistant, resulting in a vicious cycle of high glucose levels and often high insulin levels.

Inflammation is also common among those with type 2 diabetes. Inflammatory markers (chemicals in the body that lead to inflammation), such as interleukin-6 (Il-6) and C-reactive protein, have been found to be increased in those with type 2 diabetes.

Type 2 diabetes usually occurs gradually. Most people with type 2 diabetes are overweight at the time of diagnosis. However, the disease can also develop in lean people, especially the elderly.

Risk Factors

Type 1 diabetes

• Family history of type 1 diabetes
• Mother who had pre-eclampsia (a condition characterized by a sharp increase in blood pressure during the third trimester of pregnancy)
• Family history of autoimmune diseases, including Hashimoto's thyroiditis, Graves disease, myasthenia gravis, Addison disease, or pernicious anemia
• Viral infections during infancy, including mumps, rubella, and coxsackie
• Child of an older mother
• Northern European or Mediterranean descent
• Lack of breastfeeding and consumption of cow's milk during infancy (although the theory is controversial and not widely accepted)

Type 2 diabetes

• Family history of type 2 diabetes (one quarter to one third of all individuals with type 2 diabetes have a family history of the condition)
• Age older than 45 years
• Excess body fat, particularly around the waist
• Sedentary lifestyle and high-fat, high-calorie diet
• Abnormal levels of cholesterol or triglycerides in the blood
• High blood pressure
• History of gestational diabetes or polycystic ovarian syndrome (a hormonal disorder that causes women to have irregular or no menstruation)
• African American, Hispanic American, or Native American (particularly Pima tribe in Arizona) descent
• Low birth weight or a mother's malnutrition in pregnancy (this may cause metabolic disturbances in a fetus that lead to diabetes later in the child's life)
• Depression is associated with a 60% increased risk of type 2 diabetes

Diagnosis

According to the American Diabetes Association, all pregnant women should be screened for gestational diabetes during their third trimester. People who are 45 years or older should have their blood glucose levels checked every 3 years. Those who have a high risk of developing diabetes (such as people with a family history of the disease) should be tested more often.

Different types of tests are used to diagnose diabetes: Random plasma glucose level, fasting plasma glucose level, and oral glucose tolerance test.

If the fasting glucose level is 100 to 125 mg/dL, the individual has a form of pre-diabetes called impaired fasting glucose (IFG), meaning that the individual is more likely to develop type 2 diabetes but does not have the condition yet. A level of 126 mg/dL or above, confirmed by repeating the test on another day, means that the individual has diabetes.

Other diagnostic tests for diabetes include fructosamine testing and hemoglobin A1c. The American Diabetes Association (ADA) recommends A1c as the best test to find out if an individual's blood sugar is under control over time. The test should be performed every 3 months for insulin-treated patients, during treatment changes, or when blood glucose is elevated. For stable patients on oral agents, health care professionals recommended testing A1c at least twice per year. The ADA currently recommends an A1c goal of less than 7%. Studies have reported that there is a 10% decrease in relative risk of microvascular complications (injuries to the small blood vessels throughout the body), such as diabetic nephropathy (kidney disease) or diabetic neuropathy (nerve damage), for every 1% reduction in hemoglobin A1c. Many nutritionally-oriented physicians look for a much lower A1c as the goal for their patients.

People with diabetes must closely monitor their blood sugar and see their doctor regularly. Self monitoring of blood glucose is done by checking the glucose content of a drop of blood. Regular testing tells you how well diet, medication, and exercise are working together to control your diabetes. Dieticians can also be an integral part of care.

Preventive Care

Type 1 diabetes

There is no proven way to prevent type 1 diabetes. However, research conducted in Finland suggests that adequate amounts of vitamin D, particularly in the first year of life, may decrease one's chances of developing type 1 diabetes within the first 30 years of life. In northern Finland (where the annual exposure to sunlight is very limited) researchers followed 10,000 infants for up to 30 years. Those given at least 2,000 IU of vitamin D per day (generally from cod liver oil) for the first year of life were significantly less likely to develop type 1 diabetes over 30 years than infants who were given less than that. Other studies have confirmed that doses of 2,000 IU or higher of vitamin D may have a strong protective effect against type 1 diabetes. For this reason, caretakers of infants and children at increased risk for type 1 diabetes might wish to consider supplementation. Experts suggest supplementing these individuals at the high end of current U.S. recommendations for vitamin D, which is 200 to 1,000 IU.

Type 2 diabetes

Considerable evidence from population based studies suggests that type 2 diabetes is highly preventable, particularly through exercise and weight management. Individuals who are physically inactive or overweight are much more likely to develop type 2 diabetes. Similarly, people who move from a non-Westernized country to a Westernized country (such as the United States, where more people are overweight and live sedentary lives) increase their risk for type 2 diabetes. Studies suggest that you do not need vigorous physical activity to lower your risk of diabetes; moderate, regular exercise, such as walking for 30 minutes most days of the week, is enough. In general, lifestyle changes recommended to treat diabetes may help prevent the condition as well.

Treatment Approach

The goal of diabetes treatment is to achieve and maintain healthy blood glucose levels. A major study called the Diabetes Control and Complications Trial (DCCT) found that people with diabetes who kept their blood glucose levels close to normal reduced their risk of developing major complications from the condition.

People with diabetes can use the following therapies to help manage their blood glucose levels and to prevent complications:

• Lifestyle changes, such as a well-balanced diet and regular exercise
• Medications, particularly insulin for individuals with type 1 diabetes and some people with type 2 diabetes
• Supplements, including fiber and chromium
• Relaxation techniques
• Acupuncture for pain from nerve damage
• Bariatric surgery, for people who are overweight and obese to help manage blood glucose levels

Lifestyle

People with diabetes can improve significantly from lifestyle changes, particularly diet and exercise. People with type 2 diabetes may even eliminate the need for medications when they make appropriate lifestyle changes.

Diet

The ADA recommends that people with diabetes consume a healthy, low-fat diet, rich in grains, fruits, and vegetables. A healthy diet typically includes 10 to 20% of daily calories from protein, such as poultry, fish, dairy, and vegetable sources. People with diabetes who also have kidney disease should work with their health care providers to limit protein intake to 10% of daily calories. A low-fat diet typically includes 30% or less of daily calories from fat, less than 10% from saturated fats and up to 10% from polyunsaturated fats (such as fats from fish).

Carbohydrates tend to have the greatest effect on blood glucose. The balance between the amount of carbohydrate eaten and the available insulin determines how much the blood glucose level goes up after meals or snacks. To help control blood glucose, people should watch how many carbohydrate servings they eat each day. Foods that contain a high amount of carbohydrates include grains, pasta, and rice; breads, crackers, and cereals; starchy vegetables, including potatoes, corn, peas, and winter squash; legumes such as beans, peas, and lentils; fruits and fruit juices; milk and yogurt; and sweets and desserts. Non-starchy vegetables, such as spinach, kale, broccoli, salad greens, and green beans, are very low in carbohydrates. Carbohydrate counting can ensure that the right amount of carbohydrate is eaten at each meal and snack. A dietitian can help each person work out a dietary plan that is right for them.

In addition, weight loss should be part of the plan for those with type 2 diabetes. Moderate weight loss (achieved by reducing calories by 250 to 500 per day and exercising regularly) controls not only blood sugars, but also blood pressure and cholesterol. People with diabetes who eat healthy, well-balanced diets do not need to take extra vitamins or minerals to treat their condition.

Exercise

Exercise plays an important role in both the prevention and management of diabetes because it lowers blood sugar and helps insulin work more efficiently in the body. Exercise also enhances cardiovascular fitness by improving blood flow and increasing the heart's pumping power, promoting weight loss and lowering blood pressure. However, exercise has the most value when it's done regularly, at least 3 to 4 sessions per week for 30 to 60 minutes per session. As little as 20 minutes of walking, 3 times a week, has a proven beneficial effect. People with type 2 diabetes who exercise regularly have been shown to lose weight and gain better control over their blood pressure, thereby reducing their risk for cardiovascular disease (a major complication of diabetes). Studies have also shown that people with type 1 diabetes who exercise regularly reduce their need for insulin injections.

Despite the benefits of exercise, many people have difficulty sticking with an exercise program for a long period of time. Health care providers can help develop suitable routines, as well as strategies that may improve adherence to such routines. Anyone with long-standing diabetes should have a thorough screening before starting an exercise program and receive careful monitoring from a doctor.

Medications

Medications for diabetes must always be used in combination with lifestyle changes, particularly diet and exercise, to improve the symptoms of diabetes. Medications include insulin, oral sulfonylureas (like glimepiride, glyburide, and tolazamide), biguanides (Metformin), alpha-glucosidase inhibitors (such as acarbose), thiazolidinediones (such as rosiglitazone) and meglitinides (including repaglinide and nateglinide). A new agent in the fight against diabetes, exenatide (Byetta), is an injectable drug that reduces the level of sugar (glucose) in the blood. In clinical studies, patients treated with exenatide achieved lower blood glucose levels and lost weight. Exenatide was approved by the U.S. Food and Drug Administration in May 2005. Several other agents are under investigation including sodium-glucose co-transporter 2 inhibitors, G-protein-coupled receptor agonists, and the balanced dual perpexisome proliferator-activated receptor agents.

Nutrition and Dietary Supplements

Considerable research has been conducted on the relationship between diabetes and specific nutrients and dietary supplements. Dietary supplements may increase the effects of blood sugar-lowering medications, including insulin. When considering the use of supplements or making dietary changes, be sure to discuss these changes with your health care provider to ensure safety and appropriateness.

Supplements with Blood Sugar Lowering Effects

Chromium. Found in a variety of foods and supplements, including liver, brewer's yeast, cheese, meats, fish, fruits, vegetables, and whole grains, chromium appears to enhance the body's sensitivity to insulin. Researchers believe that chromium helps insulin pull glucose from the bloodstream into the cells for energy. The benefit of chromium supplements for diabetes has been studied and debated for years. While some studies show no beneficial effects of chromium use for people with diabetes, other studies have shown that chromium supplements may reduce blood glucose levels in individuals with type 2 diabetes and reduce the need for insulin in those with type 1 diabetes. Most Americans get at least 50 mcg of chromium in their diets each day. The National Research Council estimates that intakes of 50 to 200 mcg per day are safe and effective. Clinical studies showing improved blood sugar control for those with diabetes have used doses of chromium picolinate ranging from 200 to 1,000 mcg per day. However, until human studies of long-term safety are conducted with higher doses, it is best to use 200 mcg or less per day. Chromium may interact negatively with insulin and thyroid medicines. Speak with your doctor if you have a history of kidney or liver disease, or are being treated for a psychiatric disorder.

Magnesium. Several clinical studies have demonstrated a strong association between low levels of magnesium in the blood and type 2 diabetes. However, researchers are still unclear about the cause and effect in that association. They are investigating whether low magnesium levels worsen blood sugar control in people with type 2 diabetes or whether diabetes causes magnesium deficiencies. Some experts believe that low magnesium levels worsen blood sugar control and that foods rich in magnesium (such as whole grains, green leafy vegetables, bananas, legumes, nuts, and seeds) or magnesium supplements may promote healthy blood glucose levels. At least one small study suggests that taking magnesium supplements may improve the action of insulin and decrease blood sugar levels, particularly in the elderly. People with severe heart disease or kidney disease should not take magnesium supplements. People with diabetes should talk with their health care provider about whether it is safe and appropriate to take magnesium supplements. Magnesium can interact with some medications. Magnesium may lower blood pressure and cardiac output, and potentially interact with some cardiac medications. Excess magnesium can cause diarrhea.

Fiber. Studies suggest that a high-fiber diet may help:

• Prevent development of type 2 diabetes
• Lower average glucose and insulin levels in people who already have type 2 diabetes
• Improve cholesterol and triglyceride levels in those with diabetes

In a large-scale study of nurses in the United States, women who consumed the most whole grain foods in their diets were nearly 40% less likely to develop diabetes than women who consumed the least. People with irritable bowel syndrome, inflammatory bowel disease, or other digestive issues should speak with their doctor before adding fiber to their diet.

Studies have also shown that cholesterol levels improved in people with type 2 diabetes after they took supplements of a soluble fiber known as psyllium (Plantago psyllium).

Beta-glucan is a soluble fiber derived from the cell walls of algae, bacteria, fungi, yeast, and plants. It is commonly used for its cholesterol-lowering effects. There are several human trials supporting the use of beta-glucan for glycemic (blood sugar) control.

Vanadium. Vanadium is an essential trace mineral present in the soil and in many foods. It appears to mimic the action of insulin and, in a number of human studies, vanadyl sulfate (a form of vanadium) has increased insulin sensitivity in those with type 2 diabetes. Animal studies and some small human studies also suggest that vanadium may lower blood glucose to normal levels (reducing the need for insulin) in people with diabetes. One preliminary clinical study found that people with diabetes using insulin who were given vanadium were able to lower their dose of insulin. Vanadium may slow blood clotting, so people who take blood-thinning medication such as warfarin (Coumadin) and aspirin should check with their doctor before adding vanadium supplements to their regimen. People with a history of kidney issues should speak with their doctor before using vanadium supplements.

Melatonin. Melatonin is a natural hormone secreted in the brain. Studies link low melatonin secretion with an increased risk of developing type 2 diabetes. Melatonin can cause sleepiness and potentially interact with some psychiatric medications and medications used to treat insomnia.

Antioxidants

Antioxidants such as beta-carotene and vitamin C are scavengers of free radicals, unstable and potentially damaging molecules generated by normal chemical reactions in the body. Free radicals are unstable because they lack one electron. In an attempt to replace this missing electron, the free radical molecules react with neighboring molecules in a process called oxidation. Some studies suggest that people with diabetes have elevated levels of free radicals and lower levels of antioxidants. Preliminary clinical studies show that the following antioxidants may improve diabetes (by returning blood glucose levels to the normal range) and reduce the risk of associated complications:

• Vitamin E
• Selenium
• Zinc
• Quercetin

Two additional substances that show preliminary evidence to possibly help control blood sugar include:

• Biotin (a B-complex vitamin). Possibly helpful for type 2 diabetes; brewer's yeast is a good source of biotin.
• Vitamin B6. Possibly helpful for both type 1 and type 2 diabetes.

Supplements with Cardiovascular Effects

Since insulin resistance is often associated with cardiovascular disease, people with diabetes may benefit from nutrients that help manage elevated blood lipid levels, high blood pressure, or heart failure. Although the following supplements have been shown to improve cardiovascular health, there is some concern that they may raise blood glucose levels, and they may interact with certain medications. People with diabetes interested in trying the following supplements should first consult with their health care providers:

• Coenzyme Q10 (CoQ10)
• Niacin
• Omega-3 fatty acids

Although clinical studies have not shown that either CoQ10 or omega-3 fatty acid supplements raise blood sugar levels, people with diabetes should discuss the safety and appropriateness of using these, or any supplements, with their health care provider or pharmacist, particularly if they are taking other medications. CoQ10 can potentially increase the clotting tendency of blood while omega-3 fatty acids can potentially decrease it. Niacin in certain amounts can potentially damage the liver. Work with your physician to find the types and amounts of supplements that are right for you.

In addition, the following antioxidants have been shown to improve cholesterol levels in people with type 2 diabetes. Work with your doctor to see if these are appropriate for you as they can potentially interact with other medications and may potentially worsen other medical conditions:

• Beta-carotene
• Vitamin C (1000 mg per day)
• Vitamin E (800 IU per day)

Several clinical studies have also found that elevated manganese levels may help protect against LDL oxidation (a process that contributes to the development of plaque in the arteries).

Herbs

People have long used plant-based medicines in the treatment of diabetes. For instance, the plant extract guanidine, which lowers blood glucose, prompted the development and use of biguanides, a commonly used oral medication for diabetes. Other herbs may have a role in the management or prevention of diabetes. Always talk to your health care provider about any herbs you consider using. Some herbs may interact with medications and some may lower your blood sugar. When combined with blood sugar-lowering medications, some herbs can bring your blood sugar to a dangerously low level.

Herbs that may have a role in the management or prevention of diabetes include:

• Bitter melon (Momordica charantia). Bitter melon has traditionally been used as a remedy for lowering blood glucose in patients with diabetes. Preliminary clinical studies have indicated that bitter melon may decrease serum glucose levels. Bitter melon can be extremely dangerous to take when pregnant.
• Fenugreek seeds (Trigonella foenum graecum). Fenugreek seeds, a spice found in many curry preparations, are high in fiber and have been shown to regulate glucose and improve lipid levels in both animals and humans. In two small studies of people with either type 1 or type 2 diabetes, fenugreek seed powder lowered blood glucose and improved levels of blood cholesterol and triglycerides, among other beneficial effects. Fenugreek may interact with blood-thinning medications, such as warfarin (Coumadin).
• Gymnema (Gymnema sylvestre). Preliminary human research reports that gymnema may be beneficial in patients with type 1 or type 2 diabetes when it is added to diabetes drugs being taken by mouth or to insulin. Gymnema may alter the ability to detect sweet tastes.
• Cinnamon (Cinnamomum zeylanicum). In a clinical study of 60 people with type 2 diabetes, intake of 1, 3, or 6 grams of cinnamon per day reduced glucose, triglyceride, LDL cholesterol, and total cholesterol levels. Other clinical studies have found similar results. As a result, experts claim that cinnamon may play an important role in regulating blood sugar in people with diabetes.
• American ginseng (Panax quinquefolium). Although both Asian (Panax ginseng) and American (Panax quinquefolium) ginseng appear to lower blood glucose levels, only American ginseng has been studied scientifically. Several clinical studies report a blood sugar-lowering effect of American ginseng (Panax quinquefolium) in individuals with type 2 diabetes, both on fasting blood glucose and on postprandial glucose levels. One clinical study found that people with type 2 diabetes who take American ginseng before or together with a glucose meal experience a reduction in glucose levels after they consume the meal. American ginseng may not be appropriate for people with autoimmune disease, and may interact with several medications, including blood-thinning medications, such as warfarin (Coumadin), among others. People with a history of hormone-sensitive cancers should only use ginseng under the guidance of their physician.

Acupuncture

Some researchers speculate that acupuncture may trigger the release of natural painkillers and reduce the debilitating symptoms of a complication of diabetes known as neuropathy (nerve damage). In one clinical study of people with diabetes suffering from chronic, painful neuropathy, acupuncture reduced pain and improved sleep in 77% of the participants and eliminated the need for pain medications in 32% of the participants. Given these findings, acupuncture may be a reasonable option for people with diabetes who have neuropathy, and either find no symptom relief, or develop side effects from conventional drug treatment.

Mind-Body Medicine

Stressful life events can worsen diabetes in several ways. For example, stress stimulates the nervous and endocrine systems in ways that increase blood glucose levels and disrupt healthful behaviors (increasing the chances that an individual may consume excess calories and limit his or her physical activity, a pattern that leads to elevated blood glucose).

It makes sense then to consider stress management as part of the treatment and prevention of diabetes. Clinical studies have reported that people with diabetes who participate in biofeedback sessions (a technique that increases awareness and control of the body's response to stress) are more likely to reach target blood glucose levels than those who do not receive biofeedback. Although other studies have produced conflicting results, researchers and clinicians agree that long-term stress is likely to worsen diabetes and that biofeedback, tai chi, yoga, and other forms of relaxation may help motivate people with diabetes to change their habits to manage their condition.

Other Considerations

Pregnancy

Women of child-bearing age who have diabetes should consult an endocrine specialist about the benefits of managing glucose levels before trying to conceive.

About 4% of all pregnant women in the United States are diagnosed with gestational diabetes. Risk factors for developing diabetes while pregnant include:

• Modest weight gain prior to pregnancy (11 to 22 pounds or more)
• Family history of diabetes
• Tobacco use
• African American, Hispanic American, or Asian ancestry
• Age older than 50 at conception

Normalizing glucose levels in women with gestational diabetes reduces their risk of complications, such as having an overweight baby, birth trauma, or the need for cesarean section. If the mother's glucose levels are uncontrolled, an infant can be stillborn or suffer from complications, including defects of the brain or central nervous system, an abnormally large body or organs, heart or kidney abnormalities, asphyxia, respiratory distress, and heart failure.

If dietary restrictions fail to improve glucose levels, a woman with gestational diabetes may need insulin. Women should not take oral diabetes medications during pregnancy. Women who develop gestational diabetes may experience the condition again in subsequent pregnancies. Gestational diabetes also increases the risk for developing type 2 diabetes later in life.

Depressive symptoms are associated with an increased risk of diabetes. The association cannot be explained by the use of antidepressant drugs or being overweight. Depression is an important risk factor for diabetes.

Prognosis and Complications

People who maintain tight control over their blood glucose levels can prevent or delay the development of long-term complications from diabetes. Type 1 diabetes generally has more complications than type 2 diabetes.

Long-term complications of diabetes may include:

• Heart disease and stroke
• Vision loss and blindness
• Kidney disease
• Neuropathy (nerve damage)
• Foot ulcers and infections
• Skin problems, including bruising, dryness, itching, hair loss, warts, gangrene (tissue death), and skin ulcers
• Cognitive impairment

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