For the past week or so, I have been struggling with maintaining my blood sugars. As a diabetic, that should be one of my biggest priorities, but I must admit that most of the time it is easy to ignore the disease. It has been called "the silent killer" because as far as diseases go, by the time that you begin to notice the symptoms, it is generally too late. You are already a full blown diabetic. As for me, my diabetes was not discovered until 2000, but I had been noticing symptoms for over a decade. I had seen several doctors during that time, and asked about the discoloration of my legs, the problems sleeping, et cetera, but it was generally dismissed. It was not until I went in demanding that I be tested because my brother made me promise to do so that a doctor took me seriously.
Diabetes comes in many forms, and for the record, it is not limited to human beings. Our cats and dogs also can suffer from the disease. It can be hereditary, but it is not contagious. (I was actually asked that by a child once.)
The two basic forms of Diabetes are broken down into different types. I will simply cut and paste here, because I really have other things I want to write about this morning.
DIABETES INSIPIDUS: This is also called Water Diabetes
Diabetes Insipidus (DI) is a disorder in which there is an abnormal increase in urine output, fluid intake and often thirst. It causes symptoms such as urinary frequency, nocturia (frequent awakening at night to urinate) or enuresis (involuntary urination during sleep or "bedwetting"). Urine output is increased because it is not concentrated normally. Consequently, instead of being a yellow color, the urine is pale, colorless or watery in appearance and the measured concentration (osmolality or specific gravity) is low. *Diabetes Insipidus is not the same as diabetes mellitus ("sugar" diabetes). Diabetes Insipidus resembles diabetes mellitus because the symptoms of both diseases are increased urination and thirst. However, in every other respect, including the causes and treatment of the disorders, the diseases are completely unrelated. Sometimes diabetes insipidus is referred to as "water" diabetes to distinguish it from the more common diabetes mellitus or "sugar" diabetes.
*Diabetes Insipidus is divided into four types, each of which has a different cause and must be treated differently. The most common type of DI is caused by a lack of vasopressin, a hormone that normally acts upon the kidney to reduce urine output by increasing the concentration of the urine. This type of DI is usually due to the destruction of the back or "posterior" part of the pituitary gland where vasopressin is normally produced. Hence, it is commonly called pituitary DI. It is also known as central or neurogenic DI. The posterior pituitary can be destroyed by a variety of underlying diseases including tumors, infections, head injuries, infiltrations, and various inheritable defects. The latter can be recognized by the onset of the DI in early childhood and a family history of parents, siblings or other relatives with the same disorder. Nearly half the time, however, pituitary DI is "idiopathic" (that is, no cause can be found despite a thorough search including magnetic resonance imaging or MRI of the brain) and the underlying cause(s) is (are) still unknown. Pituitary DI is usually permanent and cannot be cured but the signs and symptoms (i.e. constant thirst, drinking and urination) can be largely or completely eliminated by treatment with various drugs including a modified from of vasopressin known as desmopressin or DDAVP. Because pituitary DI is sometimes associated with abnormalities in other pituitary hormones, tests and sometimes treatments for these other abnormalities are also needed.
*Occasionally, a lack of vasopressin can also develop during pregnancy if the pituitary is slightly damaged and/or the placenta destroys the hormone too rapidly. This second type of vasopressin deficiency is called gestagenic or gestational DI and is also treatable with DDAVP but, in this case, the deficiency and the DI often disappear 4 to 6 weeks after delivery at which time the DDAVP treatment can usually be stopped. Often, however, the signs and symptoms of DI recur with subsequent pregnancies.
*The third type of DI is caused by an inability of the kidneys to respond to the "antidiuretic effect" of normal amounts of vasopressin. This type of DI is usually referred to as nephrogenic DI and can result from a variety of drugs or kidney diseases including heritable genetic defects. It cannot be treated with DDAVP and, depending on the cause, may or may not be curable by eliminating the offending drug or disease. The heritable form, for example, lasts for life and cannot be cured at present. However, there are treatments that can partially relieve the signs and symptoms of nephrogenic DI.
*The fourth form of DI occurs when vasopressin is suppressed by excessive intake of fluids. The latter is usually referred to as primary polydipsia and is most often caused by an abnormality in the part of the brain that regulates thirst. This subtype is called dipsogenic DI and is difficult to differentiate from pituitary DI particularly since the two disorders can result form many of the same brain diseases. The only sure way to tell them apart is to measure vasopressin during a stimulus such as fluid deprivation or to observe the effects of DDAVP treatment. In dipsogenic DI, DDAVP also eliminates the excessive urination but, unlike pituitary DI, it does not completely eliminate the increased thirst and fluid intake. Thus, it also results in water intoxication, a condition associated with symptoms such as headache, loss of appetite, lethargy and nausea and signs such as an abnormally large decrease in the plasma sodium concentration (hyponatremia). Because of this and the current lack of a way to correct the underlying abnormality in thirst, dipsogenic DI cannot be treated at present, although the most troubling symptoms, nocturia, can be safely relieved by taking small doses of DDAVP at bedtime. The other subtype of primary polydipsia is due not to abnormal thirst but to psychosomatic causes and is often referred to as pyschogenic polydipsia. It cannot be treated at present.
QUESTIONS YOU MAY HAVE
What is considered "excessive" urination? What is considered "excessive thirst?
An adult who urinates more than 50mL/kg body weight per 2 hours is generally considered to have a higher than normal output. Loosely translated, 50mL/kg is about 3.5 quarts per day for a 150-lb. adult. an adult who drinks more than 4 quarts (1 gallon) or approximately 12 glasses (144 oz) of beverages per day would have a higher than normal intake.
Does pituitary diabetes insipidus cause any problems other than increased urination, thirst and drinking? Does it shorten one's life span?
As far as we know, pituitary or nephrogenic DI does not cause any other disabilities or health risks provided there is no interference with the ability to replace the loss fluid. If water intake is impaired - for example, by loss of consciousness or by separation from an abundant supply of drinkable water - there is a very grave risk of severe dehydration that could lead to serious brain damage or even death. Treatment reduces this risk because it reduces the rate of water loss and thereby lengthens the time one can go without drinking. However, it does not eliminate the risk altogether because there is always the possibility that the medication will be lost or run out. For this reason, it is important to always carry an adequate supply of medication and be careful about getting in a situation where a good supply of drinking water is not available - for example ocean sailing or hiking in the mountains or desert.
Dipsogenic DI or pyschogenic polydipsia does not carry the risk of dehydration but may result in serious overhydration (water intoxication) if DDAVP or other drugs such as thiazide diuretics are taken or if certain acute diseases such as influenza develop. Therefore, it is important to know if these disorders are present so that the offending drugs can be avoided or the appropriate tests and countermeasures can be applied as soon as a disease or ailment like influenza develops.
If I have pituitary or nephrogenic DI and the symptoms don't bother me, why should I take treatment?
The principle reason is to reduce the risk of severe dehydration and provide greater freedom to participate in activates in which it is difficult, if not impossible to drink and urinate frequently.
Apart from taking DDAVP or other antidiuretic medication, is there anything else I should do?
Yes, you should wear a MedicAlert bracelet and/or carry a MedicAlert card in your wallet so that if you have a medical emergency even a doctor who does not know you will recognize immediately your need for special treatment.
DIABETES MELLITUS: This is also called Sugar Diabetes
Diabetes is a life-long disease marked by high levels of sugar in the blood. It can be caused by too little insulin (a hormone produced by the pancreas to regulate blood sugar), resistance to insulin, or both.
Causes, incidence, and risk factors
To understand diabetes, it is important to first understand the normal process of food metabolism. Several things happen when food is digested:
- A sugar called glucose enters the bloodstream. Glucose is a source of fuel for the body.
- An organ called the pancreas makes insulin. The role of insulin is to move glucose from the bloodstream into muscle, fat, and liver cells, where it can be used as fuel.
People with diabetes have high blood glucose. This is because their pancreas does not make enough insulin or their muscle, fat, and liver cells do not respond to insulin normally, or both.
There are three major types of diabetes:
- Type 1 diabetes is usually diagnosed in childhood. The body makes little or no insulin, and daily injections of insulin are required to sustain life. Without proper daily management, medical emergencies can arise.
- Type 2 diabetes is far more common than type 1 and makes up 90% or more of all cases of diabetes. It usually occurs in adulthood. Here, the pancreas does not make enough insulin to keep blood glucose levels normal, often because the body does not respond well to the insulin. Many people with type 2 diabetes do not know they have it, although it is a serious condition. Type 2 diabetes is becoming more common due to the growing number of older Americans, increasing obesity, and failure to exercise.
- Gestational diabetes is high blood glucose that develops at any time during pregnancy in a person who does not have diabetes.
Diabetes affects about 18 million Americans. There are many risk factors for diabetes, including:
- A parent, brother, or sister with diabetes
- Obesity
- Age greater than 45 years
- Some ethnic groups (particularly African-Americans and Hispanic Americans)
- Gestational diabetes or delivering a baby weighing more than 9 pounds
- High blood pressure
- High blood levels of triglycerides (a type of fat molecule)
- High blood cholesterol level
The American Diabetes Association recommends that all adults be screened for diabetes at least every three years. A person at high risk should be screened more often.
Symptoms
High blood levels of glucose can cause several problems, including frequent urination, excessive thirst, hunger, fatigue, weight loss, and blurry vision. However, because type 2 diabetes develops slowly, some people with high blood sugar experience no symptoms at all.
Symptoms of type 1 diabetes:
Symptoms of type 2 diabetes:
- Increased thirst
- Increased urination
- Increased appetite
- Fatigue
- Blurred vision
- Slow-healing infections
- Impotence in men
Signs and tests
A urine analysis may be used to look for glucose and ketones from the breakdown of fat. However, a urine test alone does not diagnose diabetes. The following blood glucose tests are used to diagnose diabetes:
- Fasting blood glucose level -- diabetes is diagnosed if higher than 126 mg/dL on two occasions. Levels between 100 and 126 mg/dl are referred to as impaired fasting glucose or pre-diabetes. These levels are considered to be risk factors for type 2 diabetes and its complications.
- Random (non-fasting) blood glucose level -- diabetes is suspected if higher than 200 mg/dL and accompanied by the classic symptoms of increased thirst, urination, and fatigue. (This test must be confirmed with a fasting blood glucose test.)
- Oral glucose tolerance test -- diabetes is diagnosed if glucose level is higher than 200 mg/dL after 2 hours (This test is used more for type 2 diabetes.)
Patients with type 1 diabetes usually develop symptoms over a short period of time, and the condition is often diagnosed in an emergency setting. In addition to having high glucose levels, acutely ill type 1 diabetics have high levels of ketones.
Ketones are produced by the breakdown of fat and muscle, and they are toxic at high levels. Ketones in the blood cause a condition called "acidosis" (low blood pH). Urine testing detects both glucose and ketones in the urine. Blood glucose levels are also high.
Treatment
There is no cure for diabetes. The immediate goals are to stabilize your blood sugar and eliminate the symptoms of high blood sugar. The long-term goals of treatment are to prolong life, relieve symptoms, and prevent long-term complications such as heart disease and kidney failure.
LEARN THESE SKILLS
Basic diabetes management skills will help prevent the need for emergency care. These skills include:
- How to recognize and treat low blood sugar (hypoglycemia) and high blood sugar (hyperglycemia)
- What to eat and when
- How to take insulin or oral medication
- How to test and record blood glucose
- How to test urine for ketones (type 1 diabetes only)
- How to adjust insulin and/or food intake when changing exercise and eating habits
- How to handle sick days
- Where to buy diabetes supplies and how to store them
After you learn the basics of diabetes care, learn how the disease can cause long-term health problems and the best ways to prevent these problems. People with diabetes need to review and update their knowledge, because new research and improved ways to treat diabetes are constantly being developed.
WHAT TO EAT
You should work closely with your health care provider to learn how much fat, protein, and carbohydrates you need in your diet. Your specific meal plans need to be tailored to your food habits and preferences. People with type 1 diabetes should eat at about the same times each day and try to be consistent with the types of food they choose. This helps to prevent blood sugars from becoming extremely high or low. Type 2 diabetics should follow a well-balanced and low-fat diet.
A registered dietician can be very helpful in planning dietary needs.
Weight management is important to achieving control of diabetes. Some people with type 2 diabetes can stop medications after losing excess weight, although the diabetes is still present.
HOW TO TAKE INSULIN OR ORAL MEDICATION
Medications to treat diabetes include insulin and glucose-lowering pills, called oral hypoglycemic agents. The bodies of people with type 1 diabetes cannot make their own insulin, so daily insulin injections are required. The bodies of people with type 2 diabetes make insulin but cannot use it effectively.
Insulin is not available in oral form. It is delivered by injections that are generally required one to four times per day. Some people use an insulin pump, which is worn at all times and delivers a steady flow of insulin throughout the day.
Insulin preparations differ in how quickly they start to work and how long they remain active. Sometimes different types of insulin are mixed together in a single injection. The types of insulin to use, the doses required, and the number of daily injections are chosen by a health care professional trained to provide diabetes care.
People who need insulin are taught to give themselves injections by their health care providers or diabetes educators.
Unlike type 1 diabetes, type 2 diabetes may respond to treatment with exercise, diet, and/or oral medications. There are several oral hypoglycemic agents that lower blood glucose in type 2 diabetes. They fall into one of three groups:
Most type 2 diabetics will require more than one medication for good blood sugar control within three years of starting their first medication. Different groups of oral medications may be combined, or insulin and oral medications may be used together.
Some people with type 2 diabetes find they no longer need medication if they lose weight and increase activity, because when their ideal weight is reached, their own insulin and a careful diet can control their blood glucose levels.
Oral hypoglycemic agents are not known to be safe for use in pregnancy; women who have type 2 diabetes and take these medications may be switched to insulin during pregnancy and while breast-feeding.
Gestational diabetes is treated with diet and insulin.
SELF-TESTING
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.
The results of the test can be used to adjust meals, activity, or medications to keep blood sugar levels in an appropriate range. Testing provides valuable information for the health care provider and identifies high and low blood sugar levels before serious problems develop.
The American Diabetes Association recommends that premeal blood sugar levels fall in the range of 80 to 120 mg/dL and bedtime blood levels fall in the range of 100 to 140 mg/dL. Your doctor may adjust this depending on your circumstances.
You should also ask your doctor how often to check your hemoglobin A1c (HbA1c) level. The HbA1c is a measure of average blood glucose during the previous two to three months. It is a very helpful way to monitor a patient's overall response to diabetes treatment over time. A person without diabetes has an HbA1c around 5%. People with diabetes should try to keep it below 7%.
Ketone testing is another test that is used in type 1 diabetes. Ketones build up in the blood when there is not enough insulin in people with type 1 diabetes, eventually "spilling over" into the urine. The ketone test is done on a urine sample. High levels of blood ketones may result in a serious condition called ketoacidosis. Ketone testing is usually done at the following times:
- When the blood sugar is higher than 240 mg/dL
- During acute illness (for example, pneumonia, heart attack, or stroke)
- When nausea or vomiting occur
- During pregnancy
EXERCISE
Regular exercise is especially important for people with diabetes. It helps with blood sugar control, weight loss, and high blood pressure. People with diabetes who exercise are less likely to experience a heart attack or stroke than diabetics who do not exercise regularly. You should be evaluated by your physician before starting an exercise program.
Here are some exercise considerations:
- Choose an enjoyable physical activity that is appropriate for your current fitness level.
- Exercise every day, and at the same time of day, if possible.
- Monitor blood glucose levels before and after exercise.
- Carry food that contains a fast-acting carbohydrate in case you become hypoglycemic during or after exercise.
- Carry a diabetes identification card and a mobile phone or change for a payphone in case of emergency.
- Drink extra fluids that do not contain sugar before, during, and after exercise.
Changes in exercise intensity or duration may require changes in diet or medication dose to keep blood sugar levels from going too high or low.
FOOT CARE
People with diabetes are prone to foot problems because of the likelihood of damage to blood vessels and nerves and a decreased ability to fight infection. Problems with blood flow and damage to nerves may cause an injury to the foot to go unnoticed until infection develops. Death of skin and other tissue can occur.
If left untreated, the affected foot may need to be amputated. Diabetes is the most common condition leading to amputations.
To prevent injury to the feet, people with diabetes should adopt a daily routine of checking and caring for the feet as follows:
- Check your feet every day, and report sores or changes and signs of infection.
- Wash your feet every day with lukewarm water and mild soap, and dry them thoroughly.
- Soften dry skin with lotion or petroleum jelly.
- Protect feet with comfortable, well-fitting shoes.
- Exercise daily to promote good circulation.
- See a podiatrist for foot problems or to have corns or calluses removed.
- Remove shoes and socks during a visit to your health care provider and remind him or her to examine your feet.
- Stop smoking, which hinders blood flow to the feet.
Expectations (prognosis)
The risks of long-term complications from diabetes can be reduced.
The Diabetes Control and Complications Trial (DCCT) studied the effects of tight blood sugar control on complications in type 1 diabetes. Patients treated for tight blood glucose control had an average HbA1c of approximately 7%, while patients treated less aggressively had an average HbA1c of about 9%. At the end of the study, the tight blood glucose group had dramatically fewer cases of kidney disease, eye disease, and nervous system disease than the less-aggressively treated patients.
In the United Kingdom Prospective Diabetes Study (UKPDS), researchers followed nearly 4,000 people with type 2 diabetes for 10 years. The study monitored how tight control of blood glucose (HbA1c of 7% or less) and blood pressure (less than 144 over less than 82) could protect a person from the long-term complications of diabetes.
This study found dramatically lower rates of kidney, eye, and nervous system complications in patients with tight control of blood glucose. In addition, there was a significant drop in all diabetes-related deaths, including lower risks of heart attack and stroke. Tight control of blood pressure was also found to lower the risks of heart disease and stroke.
The results of the DCCT and the UKPDS dramatically demonstrate that good blood glucose and blood pressure control, many of the complications of diabetes can be prevented.
Complications
Emergency complications include diabetic hyperglycemic hyperosmolar coma.
Long-term complications include:
Calling your health care provider
Go to the emergency room or call the local emergency number (such as 911) if symptoms of ketoacidosis occur:
Go to the emergency room or call the local emergency number if symptoms of extremely low blood sugar (hypoglycemic coma or severe insulin reaction) occur:
Prevention
Maintaining an ideal body weight and an active lifestyle may prevent the onset of type 2 diabetes. Currently there is no way to prevent type 1 diabetes.
