The CDC Diabetes Surveillance System collects, analyzes, and disseminates data on diabetes and its complications. This public health surveillance (disease tracking) of diabetes is viewed by the CDC as critical to:

• Increase recognition of the disease
• Identify high-risk groups
• Develop strategies to reduce the economic and human cost of this disease
• Formulate health care policy
• Evaluate progress in disease prevention and control.

Diabetes is becoming more common in the United States. Based upon the survey results of the CDC and the American Diabetes Association (ADA) an estimated 20 millions Americans have diabetes with 14 million having already been diagnosed and another 6 million are unaware that they have the disease.

The CDC reported that from 1980 through 2003, the number of Americans with diabetes more than doubled (from 5.8 million to 13.8 million). Between 1996 and 1997 an unusually large increase occurred in the number of people with diagnosed diabetes. Part of this increase is likely due to changes in the survey used to measure diagnosed diabetes. In 1997 the National Health Institute (NHI) survey was redesigned, and two changes may have affected trends. First, the diabetes question was changed and all sampled adults were asked whether a health professional had ever told them they had diabetes. Second, proxy respondents (i.e., household members responding for absent adult members) who tend to under report disease were no longer used in the survey.

The American Diabetes Association (ADA) estimates are in a similar range as the CDC. The ADA reports that there are 20.8 million people in the United States, or 7% of the population, who have diabetes. While an estimated 14.6 million have been diagnosed with diabetes, unfortunately, 6.2 million people (or nearly one-third) are unaware that they have the disease.

Number (in Millions) of Persons with Diagnosed Diabetes, U.S, 1980-2003
(Source: CDC National Center for Chronic Disease Prevention and Health Promotion

From 1980 through 2003, the prevalence of diagnosed diabetes increased in all age groups. In general, throughout the time period, people aged 65-74 years had the highest prevalence, followed by people aged 75 or older, people aged 45-64 years, and people less than 45 years of age. In 2003, the prevalence of diagnosed diabetes among people aged 65-74 (17.3%) was approximately 14 times that of people less than 45 years of age (1.2%). As the detailed tables show, people aged 65 years or older account for almost 40% of the population with diabetes.

Prevalence of Diagnosed Diabetes by Age, U.S., 1980-2003
(Source: CDC National Center for Chronic Disease Prevention and Health Promotion)

From 1980 to 1998, the age-adjusted prevalence of diagnosed diabetes for men and women was similar. However, in 1999, the prevalence for males began to increase at a faster rate than that of females. From 1980 to 2003, the age-adjusted prevalence of diagnosed diabetes increased 50% for men and 37% for women.

Trends show that minority populations are disproportionately affected by diabetes. From 1980 through 2003, the age-adjusted prevalence of diagnosed diabetes increased among all sex-race groups examined. From 1980 through 2003, the age-adjusted prevalence of diagnosed diabetes was higher among blacks than whites and highest among black females. During this time period, age-adjusted prevalence increased 101% among white males, 57% among white females, 73% among black males and 56% among black females. From 1997 through 2003, age-adjusted prevalence of diagnosed diabetes among Hispanics was similar to that of black males.

Age-Adjusted Prevalence of Diagnosed Diabetes by Race/Ethnicity and Sex, U.S, 1980-2003
(Source: CDC National Center for Chronic Disease Prevention and Health Promotion)

According to the CDC, diabetes was the sixth leading cause of death listed on U.S. death certificates in 2002. This ranking is based on the 73,249 death certificates in which diabetes was listed as the underlying cause of death. According to death certificate reports, diabetes contributed to a total of 224,092 deaths.

However diabetes is likely to be underreported as a cause of death. Studies have found that only about 35% to 40% of decedents with diabetes had it listed anywhere on the death certificate and only about 10% to 15% had it listed as the underlying cause of death. Overall, the risk for death among people with diabetes is about twice that of people without diabetes of similar age.

Mortality Due to Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is an acute complication of diabetes that can lead to coma and death. From 1980 to 2001, the CDC reported that the number of deaths with DKA as the underlying cause was relatively stable. In 1980 there were 1,772 deaths due to DKA and in 2001 there were 1,871 deaths due to DKA.

Trends show that black males are disproportionately affected by diabetic ketoacidosis (DKA) mortality. From 1980 through 2001, age-adjusted death rates for DKA as underlying cause of death per 100,000 diabetic population was highest among black males and lowest among white females. In 2001, the DKA death rate for black males (56.5 per 100,000 diabetic population) was more than 3.5 times higher than that for white females (15.3 per 100,000 diabetic population) and about 2.5 times that for white males (21.7 per 100,000 diabetic population) and black females (22.6 per 100,000 diabetic population).

The CDC estimated that the annual cost of diabetes in the United States in 2002 was in the annual range of $264 billion:

• Total (direct and indirect): $132 billion
• Direct medical costs: $92 billion
• Indirect costs: $40 billion (disability, work loss, premature mortality)

These estimates of the economic cost of supported the findings a study by the Lewin Group, Inc., for the American Diabetes Association and are 2002 estimates of both the direct (cost of medical care and services) and indirect costs (costs of short-term and permanent disability and of premature death) attributable to diabetes.

Diabetes also has a negative impact upon the general health condition. In 2003, the CDC found that 33.6% of U.S. adults with diabetes reported at least one day of poor mental health in the past 30 days; 53.9% reported at least one day of poor physical health; and 62.8% reported at least one day of either poor mental or physical health. Also, 32.6% of adults with diabetes were unable to perform their usual activities at least one day in the past month due to either poor mental or physical health.

Diabetes ABC's

An important concept that has is used by organizations such as the ADA, CDC and the National Institute of Health, is to "Manage the ABCs of Diabetes."

(A) is for A1C. This test shows average blood sugar for the past 2 to 3 months. An A1C test can help monitor how well the treatment plan is working. The ADA recommends that an A1C test be completed twice a year.

(B) is for Blood Pressure. The American College of Physicians has made the following important recommendations.

• Blood Pressure control must be a priority if the person has hypertension and type 2 diabetes.
• Blood pressure should be checked with each visit to the doctor and the goal should be a reading of no more than 135/80.
• Thiazide diurectics or ACE inhibiorts are types of medication that the doctor might prescribe to control blood pressure.

(C) is for Cholosterol. Colesterol numbers tell the amount of fat in the blood. HDL cholesterol helps protect the heart. LDL cholesterol can clog arteries and lead to heart disease. Triglycerides are another kind of blood fat the can affect the risk of heart attack or stroke. The ADA recommends that cholesterol be checked at least once a year.

This section provides messages that a health care provider should discuss with people with diabetes.

Promote the ABCs - A1C, Blood Pressure, and Cholesterol - It is important to control risk factors for cardiovascular disease. Ask persons with diabetes if they understand the ABCs.

• Advise them that controlling the ABCs can prevent complications of diabetes and reduce the risk for heart attack and stroke.
• Ask if they know their ABC goals and how to manage them. They should work with their health care team to determine both long- and short-term goals for each ABC.
• Explain that poor control of the ABCs can lead to problems in foot, eye, and oral health but that screening and team care can prevent complications.

Promote a Healthy Lifestyle - Diabetes can be controlled through a healthy lifestyle. Describe ways this can be accomplished.

• Weight. Advise people with diabetes to aim for a healthy weight.
• Diet. Encourage meal planning that includes a variety of foods and controls portion sizes and snacks. Increasing fiber and limiting saturated fats and salts will help control blood glucose, blood pressure, and cholesterol.
• Physical activity. Advise people with diabetes that moderate physical activity (such as walking) can help control the ABCs and prevent complications.
• Self management. Ask people with diabetes to identify their high priority concerns. Prompt them to plan for challenging situations and set short-term achievable goals. Compliment them on any steps taken toward these goals. See "Self-Management Support" in the previous section.
• Tobacco. Ask about tobacco use. Encourage people with diabetes to avoid smoking and using smokeless tobacco products. People who use tobacco are at greater risk for stroke; heart, kidney, and eye diseases; nerve damage; and lower-extremity complications.

Weight loss helps people with diabetes in two important ways.

• First, it lowers insulin resistance. This allows the bodies natural insulin (in people with type 2 diabetes) to do a better job lowering blood glucose levels. If they take a diabetes medicine, losing weight lowers blood glucose and may allow them to reduce the amount they are taking, or quit taking it altogether.
• Second, it improves blood fat and blood pressure levels. People with diabetes are about twice as likely to get cardiovascular disease as most people. Lowering blood fats and blood pressure is a way to reduce that risk.

Experts say most people with diabetes should try to keep their blood glucose level as close as possible to the level of someone who doesn't have diabetes. The closer to normal the blood glucose is, the lower the chances are of developing damage to the eyes, kidneys, and nerves.

The National Institute of Diabetes and Digestive and Kidney Diseases recommend that the following four things be done every day to lower high blood glucose:

• Follow the meal plan.
• Be physically active.
• Take their diabetes medicine.
• Check their blood glucose.

Blood glucose that's too high or too low can make the person very sick. Here are some recommendations on how to handle these emergencies from the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.

If the blood glucose level stays over 180, it may be too high. It means the person don't have enough insulin in their body. High blood glucose can happen if they miss taking their diabetes medicine, eat too much, or don't get enough exercise. Sometimes, the medicines they take for other problems cause high blood glucose.

Having an infection or being sick or under stress can also make the blood glucose too high. That's why it's very important to check the blood glucose and keep taking the insulin or diabetes pills when they are sick.

A symptom of high blood glucose levels is if they are very thirsty and tired, have blurry vision, and have to go to the bathroom often. Very high blood glucose may also make them feel sick to their stomach.

Hypoglycemia happens if the blood glucose drops too low. It can come on fast. It's caused by taking too much diabetes medicine, missing a meal, delaying a meal, exercising more than usual, or drinking alcoholic beverages. Sometimes, medicines taken for other health problems can cause blood glucose to drop.

Hypoglycemia can make a person feel weak, confused, irritable, hungry, or tired. They may sweat a lot or get a headache. They may feel shaky. If their blood glucose drops lower, they could pass out or have a seizure.

If a person have any of these symptoms, they should check their blood glucose. If the level is 70 or below, the National Institute of Health advises that the person should have one of the following right away:

• 2 or 3 glucose tablets
• 1/2 cup (4 ounces) of any fruit juice
• A piece of fruit or a small box of raisins
• 1 cup (8 ounces) of milk
• 1/2 cup (4 ounces) of a regular (not diet) soft drink
• 5 or 6 pieces of hard candy
• 1 or 2 teaspoons of sugar or honey

After 15 minutes, they should check their blood glucose again to make sure their level is 70 or above. Repeat these steps as needed. Once their blood glucose is stable, if it will be at least an hour before their next meal, have a snack.

If they take insulin or a diabetes pill that can cause hypoglycemia, they should always carry food for emergencies. It's a good idea also to wear a medical identification bracelet or necklace.

If they take insulin, they should keep a glucagon kit at home and also at a few other places where they go often. Glucagon is given as an injection with a syringe and quickly raises blood glucose. They should also show their family, friends, and co-workers on how to give them a glucagon injection if they pass out because of hypoglycemia.

They can prevent hypoglycemia by eating regular meals, taking their diabetes medicine, and checking their blood glucose often. Checking will tell them whether their glucose level is going down. They can then take steps, like drinking fruit juice, to raise their blood glucose.

Hyperglycemia can be a serious problem if it is not treated it. Hyperglycemia is a major cause of many of the complications that happen to people who have diabetes. For this reason, it's important to know what hyperglycemia is, what its symptoms are, and how to treat it.

glucose happens when the body has too little, or not enough, insulin or when the body can't use insulin properly.

A number of things can cause hyperglycemia. For example, with type 1 diabetes, they may not have given themselves enough insulin. With type 2 diabetes, the body may have enough insulin, but it is not as effective as it should be.

The problem could be that they ate more than planned or exercised less than planned. The stress of an illness, such as a cold or flu, could also be the cause. Other stresses, such as family conflicts or school or dating problems, could also cause hyperglycemia.

The signs and symptoms include: high blood glucose, high levels of sugar in the urine, frequent urination, and increased thirst.

Part of managing diabetes is checking the blood glucose often. If hyperglycemia is not treated, a condition called ketoacidosis (diabetic coma) could occur. Ketoacidosis develops when your body doesn't have enough insulin. Without insulin, your body can't use glucose for fuel. So, your body breaks down fats to use for energy.

When the body breaks down fats, waste products called ketones are produced. The body cannot tolerate large amounts of ketones and will try to get rid of them through the urine. Unfortunately, the body cannot release all the ketones and they build up in your blood. This can lead to ketoacidosis.

Ketoacidosis is life-threatening and needs immediate treatment. Symptoms include:

• Shortness of breath
• Breath that smells fruity
• Nausea and vomiting
• A very dry mouth

Often, blood glucose levels can be lowered by exercising. However, if the blood glucose is above 240 mg/dl, the ADA advises that they check their urine for ketones. If they have ketones, it is advised that they do NOT exercise.

Exercising when ketones are present may make the blood glucose level go even higher. Cutting down on the amount of food they eat might also help. This may require changes to the meal plan. If exercise and dietary changes don't work, their doctor may change the amount of medication or insulin or possibly the timing of when they take it.

Of all the all of the foods, carbohydrates (Carbs) have the most effect on the blood sugar. Counting the carbs or exchanges in the meal should also be used to ensure that the insulin and exercise are on target.

Carbohydrates include starches and sugar foods such as fruit, bread, potatoes, pasta, milk, and sweets. The American Dietetic Association recommends that eating the same amount of carbs each day can help the person reach their A1C goals.

Cholesterol is a fatlike substance that serves several useful functions. The liver makes cholesterol, and we get some from our diet. Cholesterol travels around the body in tiny clumps of fat and protein called lipoproteins. Low-density lipoproteins (LDL) carry cholesterol where it is needed. High-density lipoproteins (HDL) carry leftover cholesterol back to the liver.

When cholesterol levels are high, LDL dumps it in arteries, where it builds up in hard lumps called plaques. For good blood flow, blood vessels need to be flexible and free of plaques. Cholesterol buildup in arteries makes them rigid ("hardening of the arteries") and narrower. The result: high blood pressure, blood clots, even heart attacks and strokes. Luckily, HDL carts away from arteries some of the cholesterol LDL leaves there. For these reasons, it's healthiest to have low LDL cholesterol levels and high HDL cholesterol levels.

Diabetes can upset the balance between HDL and LDL levels:

• People with diabetes tend to have LDL particles that stick to arteries and damage their walls more easily.
• Glucose (a type of sugar) latches onto lipoproteins. Sugar-coated LDL remains in the blood-stream longer and may lead to plaques.
• People with diabetes tend to have low HDL and high triglyceride (another kind of blood fat) levels, both of which boost the risk of heart and artery disease.

As a result, in people with diabetes:

• Heart disease occurs earlier.
• Heart disease is two to four times as common.
• Heart disease is more often fatal.

The design and content of a diabetes patient education program can have a significant impact on their interest in learning. There are many methods used to disseminate information. Historically, the compliance-based approach has been used to improve adherence to the treatment plan established by health care professionals. This model places the health care provider as the director of the client's medical care and assumes the provider knows what is best for the patient. Clients are expected to conform to the practitioner's directions. The ultimate goal is to optimize glucose control to prevent complications. This approach may be more suitable for newly diagnosed or poorly informed patients.

The empowerment model serves to guide patients in making informed decisions about their diabetes management. This approach assumes that patients have the right and the responsibility to be the primary decision-makers in their health care. The health care provider acts as technical resource in the decision making process. There is a sense of partnership between the client and health care provider. This model can work well with the client who is self-directed and motivated.

These approaches can be alternated or modified to individualize its use. Considerations may include the patient's level of comprehension and experience in making complex, long-term decisions.

A patient's past experience can affect their readiness to learn. If they have a relative who managed their diabetes poorly with resultant complications, they may transfer that poor experience to their own situation. Also, if they feel no ill effects from hyperglycemia, they may be inclined to not treat their glucose management seriously. Their level of social support can affect their interest in learning. Those with greater support from family and friends are more likely to manage better. Other areas that can affect readiness to learn include: current ability to care for themselves, preferred style of learning (verbal, written, active participation), psychological stability, stress level, cultural influences, ability to read, language barriers, visual acuity, hearing loss, and dexterity.

Adult learners are usually self-directed and are more likely to participate in a process that is relevant. Adults focus on problem-solving rather than learning the information for fact gathering. Learning is maximized when the process is active rather than passive. A non-judgmental approach is recommended to gain the patient's trust so that the health care providers and the patient may work as a team.

The National Institutes of Health have developed the following targets for the daily management of diabetes.

Glucose: Everyone's blood has some glucose in it. In people who don't have diabetes, the normal range is about 70 to 120. Blood glucose goes up after eating, but returns to the normal range 1 or 2 hours later. According to the National Institutes of Health and the Centers for Disease Control and Prevention, the target glucose range for most people using whole blood is:

• 80 to 120 before meals and 100 to 140 at bedtime.
• 90 to 130 before meals and 110 to 150 at bedtime.

Blood Pressure: High blood pressure makes the heart work too hard. This leads to strokes and other problems such as kidney disease. Blood pressure should be checked at every doctors visit or the person may need to check it themselves. According to the National Institutes of Health and the Centers for Disease Control and Prevention, the target blood pressure for most people with diabetes is:

• Less than 130/80.

Cholesterol: LDL is the "bad cholesterol" that builds up in the blood vessels. It causes the vessels to narrow and harden, which can lead to a heart attack. The LDL cholesterol should be checked at least once a year. According to the National Institutes of Health and the Centers for Disease Control and Prevention, the target LDL cholesterol for most people with diabetes is:

• Less than 100.

Following a healthy diet is one of the best things that can do for the heart. The ADA has established that a meal plan to improve the cholesterol levels should, according to the guidelines set by the National Cholesterol Education Program Adult Treatment Panel (ATP III), include:

• Cutting intake of saturated fats (found mostly in meat, milk and eggs) to less than 7 percent of calories.
• Decreasing cholesterol intake to less than 200 mg per day.
• Limiting trans fats (found in shortening, packaged foods and many margarines).
• Keeping total fat intake between 25 and 35 percent of calories.
• Eating more fiber. Total fiber should add up to 20 to 30 grams a day.
• Adding plant stanols and sterols to the diet. These are found in the cholesterol-lowering spreads Benecol, Take Control, Smart Balance Plus and in the dietary supplement Benecol SoftGels.

In addition, other changes in eating habits may help cholesterol levels.

• Eat smaller, more frequent meals throughout the day, which research has linked to lower total and LDL cholesterol levels.
• Consider drinking small amounts of alcohol, because alcohol raises HDL levels. However, if they don't drink now, don't start.

The National Diabetes Information Clearinghouse published the following form for each person to use as part of their diabetes plan. It should be completed in conjunction with the health care team to set the blood glucose target levels. This should be completed when the person's blood glucose is checked with a meter. (This form is also developed using the ABC approach to managing diabetes.)

According to the CDC diabetes prevention is proven and possible.

• Type 1 Diabetes - Researchers are making progress in identifying the exact genetics and "triggers" that predispose some individuals to develop type 1diabetes, but prevention remains elusive.
• Type 2 Diabetes -Regular physical activity can significantly reduce the risk of developing type 2 diabetes. Studies show that people at high risk for type 2 diabetes can prevent or delay the onset of the disease by losing 5 to 7 percent of their body weight. This can be done by eating healthier and getting 30 minutes of physical activity 5 days a week. Type 2 diabetes appears to be associated with obesity.

Persons with diabetes are at increased risk for serious health complications. Prevention care practices have been shown to be effective in reducing both the incidence and progression of diabetes-related complications.

In 2004, the CDC reported that the following rates of preventive care "Practices with Diabetes" in the United States:

• 68.6% of adults with diabetes in 42 states reported receiving a dilated-eye examination within the last year, 59.8% reported self-monitoring their blood glucose at least once per day,
• 67.7% reported receiving a foot examination within the last year,
• 90.1% reported seeing a doctor in the last year for their diabetes,
• 65.8% reported examining their feet on a daily basis,
• 71.9% reported having their A1C tested at least twice in the past year,
• 53.7% reported ever having attended a diabetes self-management class,
• 56.8% reported receiving an influenza vaccination within the last year, and 50.3% reported ever receiving a pneumococcal vaccine.

Rates of Preventive Care Practices per 100 Adults with Diabetes, U.S., 2004
(Source: CDC National Center for Chronic Disease Prevention and Health Promotion)

In response to the growing health burden of diabetes, the US Department of Health and Human Services is pursing three activities: prevent diabetes; cure diabetes; and improve the quality of care of people with diabetes to prevent devastating complications.

Both the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC) are involved in prevention activities. The NIH reports that it is involved in research to cure both type 1 and type 2 diabetes, especially type 1. CDC focuses most of its programs on being sure that the proven science is put into daily practice for people with diabetes. The basic idea is that if all the important research and science are not applied meaningfully in the daily lives of people with diabetes, then the research is, in essence, wasted.

Several approaches to "cure" diabetes are being pursued:

• Pancreas transplantation
• Islet cell transplantation (islet cells produce insulin)
• Artificial pancreas development
• Genetic manipulation (fat or muscle cells that don't normally make insulin have a human insulin gene inserted - then these "pseudo" islet cells are transplanted into people with type 1 diabetes).

Each of these approaches still creates issues that have to be overcome, such as preventing immune rejection; finding an adequate number of insulin cells; keeping cells alive; and others. But progress is being made in all areas.

The pancreas, an organ about the size of a hand, is located behind the lower part of the stomach. It makes insulin and enzymes that help the body digest and use food. Spread all over the pancreas are clusters of cells called the islets of Langerhans. Islets are made up of two types of cells: alpha cells, which make glucagon, a hormone that raises the level of glucose (sugar) in the blood, and beta cells, which make insulin.

Insulin is a hormone that helps the body use glucose for energy. If the beta cells do not produce enough insulin, diabetes will develop. In type 1 diabetes, the insulin shortage is caused by an autoimmune process in which the body's immune system destroys the beta cells.

In an experimental procedure called islet transplantation, islets are taken from a donor pancreas and transferred into another person. Once implanted, the beta cells in these islets begin to make and release insulin. Researchers hope that islet transplantation will help people with type 1 diabetes live without daily injections of insulin.

The National Institutes of Health has reported that scientists have made many advances in islet transplantation in recent years. Since reporting their findings in the June 2000 issue of the New England Journal of Medicine, researchers at the University of Alberta in Edmonton, Canada, have continued to use a procedure called the Edmonton protocol to transplant pancreatic islets into people with type 1 diabetes. A multicenter clinical trial of the Edmonton protocol for islet transplantation is currently under way, and results will be announced in several years. According to the Immune Tolerance Network (ITN), as of June 2003, about 50 percent of the patients have remained insulin-free up to 1 year after receiving a transplant. A clinical trial of the Edmonton protocol is also being conducted by the ITN, funded by the National Institutes of Health and the Juvenile Diabetes Research Foundation International

Researchers use specialized enzymes to remove islets from the pancreas of a deceased donor. Because the islets are fragile, transplantation occurs soon after they are removed.

During the transplant, the surgeon uses ultrasound to guide placement of a small plastic tube (catheter) through the upper abdomen and into the liver. The islets are then injected through the catheter into the liver. The patient will receive a local anesthetic. If a patient cannot tolerate local anesthesia, the surgeon may use general anesthesia and do the transplant through a small incision. Possible risks include bleeding or blood clots.

It takes time for the cells to attach to new blood vessels and begin releasing insulin. The doctor will order many tests to check blood glucose levels after the transplant, and insulin may be needed until control is achieved.

The goal of islet transplantation is to infuse enough islets to control the blood glucose level without insulin injections. For an average-size person (70 kg), a typical transplant requires about 1 million islets, extracted from two donor pancreases. Because good control of blood glucose can slow or prevent the progression of complications associated with diabetes, such as nerve or eye damage, a successful transplant may reduce the risk of these complications. But a transplant recipient will need to take immunosuppressive drugs that stop the immune system from rejecting the transplanted islets.

Researchers are trying to find new approaches that will allow successful transplantation without the use of immunosuppressive drugs, thus eliminating the side effects that may accompany their long-term use. Rejection is the biggest problem with any transplant. The immune system is programmed to destroy bacteria, viruses, and tissue it recognizes as "foreign," including transplanted islets. Immunosuppressive drugs are needed to keep the transplanted islets functioning.

The Edmonton protocol uses a combination of immunosuppressive drugs, also called antirejection drugs, including dacliximab (Zenapax), sirolimus (Rapamune), and tacrolimus (Prograf). Dacliximab is given intravenously right after the transplant and then discontinued. Sirolimus and tacrolimus, the two main drugs that keep the immune system from destroying the transplanted islets, must be taken for life.

These drugs have significant side effects and their long-term effects are still not known. Immediate side effects of immunosuppressive drugs may include mouth sores and gastrointestinal problems, such as stomach upset or diarrhea. Patients may also have increased blood cholesterol levels, decreased white blood cell counts, decreased kidney function, and increased susceptibility to bacterial and viral infections. Taking immunosuppressive drugs increases the risk of tumors and cancer as well.

Researchers do not fully know what long-term effects this procedure may have. Also, although the early results of the Edmonton protocol are very encouraging, more research is needed to answer questions about how long the islets will survive and how often the transplantation procedure will be successful.

A major obstacle to widespread use of islet transplantation will be the shortage of islet cells. The supply available from deceased donors will be enough for only a small percentage of those with type 1 diabetes. However, researchers are pursuing avenues for alternative sources, such as creating islet cells from other types of cells. New technologies could then be employed to grow islet cells in the laboratory.

Medical Nutrition Therapy (MNT) is one of the most stressed upon as well as most challenging treatment modalities in the management of diabetes. It is an integral part of a successful management plan.

Nutrition management utilizing MNT requires an individualized approach. It involves an assessment of the patient's needs, and a recommendation of a management plan tailoring to each patient's lifestyle and treatment goal. The American Diabetes Association has developed the following position statement of Nutrition recommendations and principles for people with diabetes mellitus.

1. Achieve and maintain near-normal blood glucose levels.
2. Achieve optimal blood lipid levels.
3. Provide appropriate calories.
4. Prevent, delay, or treat nutrition-related factors or complications such as hypoglycemia, short-term illness, exercise-related problems, renal disease, autonomic neuropathy, hypertension, and cardiovascular disease.
5. Improve or maintain overall health through optimal nutrition.

A diabetes meal plan is a guide that says how much and what kinds of food are selected to eat at meals and snack times. A good meal plan should fit in with the persons schedule and eating habits. The right meal plan will help them improve their blood glucose, blood pressure, and cholesterol numbers and also help keep their weight on track. Whether they need to lose weight or stay where they are, the meal plan can help. People with diabetes have to take extra care to make sure that their food is balanced with insulin and oral medications, and exercise to help manage their blood glucose levels.

A healthy diet is a way of eating that that reduces risk for complications such as heart disease and stroke. Healthy eating includes eating a wide variety of foods including vegetables, whole grains, fruits, non-fat dairy products, beans, and lean meats, poultry and fish. There is no one perfect food so including a variety of different foods and watching portion sizes is essential to maintaining a healthy diet. Also, it is recommended that choices are made from each food group to provide the highest quality nutrients. Pick foods rich in vitamins, minerals and fiber over those that are processed.

The ADA and the American College of Physicians (ACP) have developed a guide for making wise food choices. Healthy food choices are vital to controlling blood sugar, blood pressure, and cholesterol. The general guidelines in developing the meal plan are to choose a variety of foods, and to have less fat and salt intake.

The starting point in developing the meal planning is to divide the plate into 4 sections. The ADA and the ACP recommend that foods are grouped into the following sections:

• Fill one-quarter of the plate with grains or other starches. Choices include breads, tortillas, rice, pasta, dried bean, corn, peas, potatoes, and yam.
• Cover one-quarter of the plate with fish, meat, poultry, or other protein sources. Grill or broil meats, and trim fat and skin.
• The remaining one-half can be used to add color to the plate. Choose a mix of nonstarch vegetables, such as salad, broccoli, cabbage, carrots, and cauliflower.

Additional meal planning considerations include:

• Add a piece of fruit or a roll to finish the meal.
• Reduce salt by eating fresh vegetables instead of canned. Also, try using half the sale a receipt calls for.
• Season with herbs or lemon instead of salt and butter.
• Use canola or olive oil instead of butter or lard.
• Split sweets and treats with a friend or family member. Or save the rest for another day.

Alcohol has calories but no nutrients. Drinking alcohol on an empty stomach can make the blood glucose level too low. Alcohol also can raise the blood fats. For those who drink alcohol, it needs to be included in the meal plan.

The Diabetes Food Pyramid divides food into six groups. These groups or sections on the pyramid vary in size. The largest group -- grains, beans, and starchy vegetables -- is on the bottom. This means that more servings of grains, beans, and starchy vegetables should be eaten than of any of the other foods. The smallest group -- fats, sweets, and alcohol -- is at the top of the pyramid. This serves as a reminder to eat very few servings from these food groups.

(Source: National Institutes of Health)

The Diabetes Food Pyramid gives a range of servings. If a person followed the minimum number of servings in each group, they would eat about 1600 calories and if they eat at the upper end of the range, it would be about 2800 calories. Most women, would eat at the lower end of the range and many men would eat in the middle to high end of the range if they are very active. The exact number of servings need depends on the diabetes goals, calorie and nutrition needs, lifestyle, and the foods they like to eat. Divide the number of servings they should eat among the meals and snacks they eat each day.

On April 19, 2005 the United States Department of Agriculture (USDA) released a new food guidance system replacing the former Food Guide Pyramid. The new system, called "MyPyramid," provides a set of tools based on caloric requirements to help Americans make healthy food choices.

However, the Diabetes Food Pyramid is a little different than the USDA Food Guide Pyramid because it groups foods based on their carbohydrate and protein content instead of their classification as a food. To have about the same carbohydrate content in each serving, the portion sizes are a little different too. For example: potatoes and other starchy vegetables in the grains, beans and starchy vegetables group can be eaten instead of the vegetables group. Cheese is in the meat group instead of the milk group. A serving of pasta or rice is 1/3 cup in the Diabetes Food Pyramid and ½ cup in the USDA pyramid. Fruit juice is ½ cup in the Diabetes Food Pyramid and ¾ cup in the USDA pyramid. This difference is to make the carbohydrate about the same in all the servings listed.

Following is a description of each group and the recommended range of servings of each group developed by the American Diabetes Association.

1. Grains and Starches - At the base of the pyramid are bread, cereal, rice, and pasta. These foods contain mostly carbohydrates. The foods in this group are made mostly of grains, such as wheat, rye, and oats. Starchy vegetables like potatoes, peas, and corn also belong to this group, along with dry beans such as black eyed peas and pinto beans. Starchy vegetables and beans are in this group because they have about as much carbohydrate in one serving as a slice of bread. So, count them as carbohydrates for the meal plan.

Choose 6-11 servings per day. Remember, not many people would eat the maximum number of servings. Most people are toward the lower end of the range. Serving sizes are:

• 1 slice of bread
• ¼ of a bagel (1 ounce)
• ½ an English muffin or pita bread
• 1, 6 inch tortilla
• ¾ cup dry cereal
• ½ cup cooked cereal
• ½ cup potato, yam, peas, corn, or cooked beans
• 1 cup winter squash
• 1/3 cup of rice or pasta

2. Vegetables - All vegetables are naturally low in fat and good choices to include often in meals or have them as a low calorie snack. Vegetables are full of vitamins, minerals and fiber. This group includes spinach, chicory, sorrel, Swiss chard, broccoli, cabbage, bok choy, brussels sprouts, cauliflower, and kale, carrots, tomatoes, cucumbers, and lettuce. Starchy vegetables such as potatoes, corn, peas, and lima beans are counted in the starch and grain group for diabetes meal planning.

Choose at least 3-5 servings per day. A serving is:

• 1 cup raw
• ½ cup cooked

3. Fruit - The next layer of the pyramid is fruits, which also contain carbohydrates. They have plenty of vitamins, minerals, and fiber. This group includes blackberries, cantaloupe, strawberries, oranges, apples, bananas, peaches, pears, apricots, and grapes.

Choose 2-4 servings per day. A serving is:

• ½ cup canned fruit
• 1 small fresh fruit
• 2 tbs dried fruit
• 1 cup of melon or raspberries
• 1 ¼ cup of whole strawberries

4. Milk - Milk products contain a lot of protein and calcium as well as many other vitamins. Choose non-fat or low-fat dairy products for the great taste and nutrition without the saturated fat.

Choose 2-3 servings per day. A serving is:

• 1 cup non-fat or low-fat milk
• 1 cup of yogurt

5. Meat and Meat Substitutes - The meat group includes beef, chicken, turkey, fish, eggs, tofu, dried beans, cheese, cottage cheese and peanut butter. Meat and meat substitutes are great sources of protein and many vitamins and minerals. Choose from lean meats, poultry and fish and cut all the visible fat off meat. Keep portion sizes small. Three ounces is about the size of a deck of cards and only need 4-6 ounces are needed for the whole day

Choose 4-6 oz per day divided between meals. Equal to 1 oz of meat:

• ¼ cup cottage cheese
• 1 egg
• 1 Tbsp peanut butter
• ½ cup tofu

6. Fats, Sweets, and Alcohol

Things like potato chips, candy, cookies, cakes, crackers, and fried foods contain a lot of fat or sugar. They aren't as nutritious as vegetables or grains. Keep servings small and save them for a special treat!

Serving sizes include:

• ½ cup ice cream
• 1 small cupcake or muffin
• 2 small cookies

The National Institute of Health has developed the following Diabetes Food Planning Chart. This can be useful in determining the individuals daily quantity of foods required within each of the food groups.

Meal Plan Calories

The National Institutes of Health has developed the following recommend that meal plans based upon the following calorie targets.

1,200 to 1,600 calories a day if they are:

• a small woman who exercises
• a small or medium woman who wants to lose weight
• a medium woman who does not exercise much

1,600 to 2,000 calories a day if they are:

• a large woman who wants to lose weight
• a small man at a healthy weight
• a medium man who does not exercise much
• a medium to large man who wants to lose weight

2,000 to 2,400 calories a day if they are:

• a medium to large man who does a lot of exercise or has a physically active job
• a large man at a healthy weight
• a large woman who exercises a lot or has a physically active job

Daily Meal Plan

The following chart was produced by the CDC to serve as personal guide for planning the meals and snacks for one day.

Exchange Meal Plan

Another way to plan meals is to use exchanges. This system divides types of foods into six exchange lists. The lists are very much like the groups used in the food pyramid: starch/bread, meat and meat substitutes, vegetables, fruit, milk, and fat. The serving sizes of the foods on each list have similar amounts of calories, protein, carbohydrate, and fat content. Any food on the list can be "exchanged" for any other food on the same list.

The exchange meal plan is a food program that balances the amounts of carbohydrate eaten each day. Althought carbohydrates (carbs) supply energy for the body, they also affect blood sugar more than any other nutrient. The main goal of this food plan is to balance insulin with the carbohydrates that are eaten. This plan helps them decide what type of food to eat, how much and when to eat.

It is easier to manage blood sugar if a consistent amount of carbohydrates are eaten at each meal. Carbohydrates come from the starch, milk, and fruit lists. Based on the daily calorie requirements, the exchanges can be determined at each meal. The meal plan helps set a consistent amount of carbohydrates as well as eat a variety of other healthy foods that are consumed with each meal. It will also make food choices that fit with the persons lifestyle, culture, likes and dislikes and goals.

For example, if they need 1500 calories a day, the exchange meal plan might look like this:

The numbers tell how many items can be picked from each food list. Notice that the carbohydrates (starch, fruit, milk) are equal for breakfast, lunch, and dinner and that they are also included in snacks.

The following menu might be chosen based on the above plan.

• Breakfast: 3/4 cup of cereal (1 starch), 1 cup skim of milk (1 milk), 1/2 banana (1 fruit), grapefruit juice (1 fruit)
• Morning snack: small apple (1 fruit)
• Lunch: Hot dog bun (2 starch), hot dog (1 meat, 1 fat), 1 cup milk (1 milk), orange (1 fruit)
• Afternoon snack: fruit roll-up (1 fruit), 1 1/2 graham crackers (1 starch)
• Dinner: 2 ounces of chicken breast (2 meat), 1/2 cup pasta (1 starch), green beans (1 vegetable), bread with butter (1 starch, 1 fat), glass of skim milk (1 milk).
• Bedtime snack: 1 string cheese (1 meat) and 6 saltine crackers (1 starch)

The next day, they can choose a completely different menu using the exchange lists. For example, instead of having cereal, they could choose toast from the starch list.

Sugary foods (brownies, sugar, ice cream, cookies, and honey) are on a list called the "other carbohydrates" list. If they choose to eat a food from the "other carbohydrates" list, they can exchange it for a starch, fruit, or milk exchange. For example, they may plan to eat cereal, milk, a banana, and grapefruit juice for breakfast. If they want to add sugar to their cereal, they can trade one of the carbohydrate items from breakfast, such as the banana, for the sugar.

Examples of types of food in each exchange list are as follows:

Carbohydrates

• Starch List: One starch exchange contains about 15 grams of carbohydrate and 3 grams of protein (80 calories). Examples of items on this list include bread, cereals, grains, starchy vegetables, crackers, and beans.
• Fruit List: One fruit exchange contains about 15 grams of carbohydrate (60 calories) and has essentially no fat or protein. Items on the fruit list include fruits and fruit juice.
• Milk List: One milk exchange contains about 8 grams of protein, 12 grams of carbohydrate with a trace of fat (90 calories). Items on the milk list include different varieties of milk and yogurt.
• Other Carbohydrates List: One "other carbohydrate" exchange has 15 grams of carbohydrate Many of these foods count as a carbohydrate exchange and one or more fat exchanges. This list contains cakes, cookies, ice cream, potato chips, and other foods with carbohydrates.
• Vegetable List: One-half cup of most vegetables (cooked or raw) has about 5 grams of carbohydrate and 2 grams of protein (25 calories) and is considered 1 exchange. Raw lettuce may be eaten in larger quantities, but regular salad dressing usually equals 1 fat exchange. Some vegetables are higher in carbohydrate and are counted as1 starch exchange.

Meats and Meat Substitutes

Meats are divided into very lean, lean, medium-fat, and high-fat meats. High-fat meats may raise the cholesterol level and increase the risk for heart disease.

• Very Lean List: One exchange equals 7 grams of protein and 0 to 1 gram of fat (35 calories). Examples include skinless chicken or turkey, fresh fish, fat-free cheese, and egg whites.
• Lean List: One exchange equals 7 grams of protein and 3 grams of fat (55 calories). Examples include lean pork, lean beef, and cottage cheese.
• Medium-Fat List: One exchange equals 7 grams of protein and 5 grams of fat (75 calories). Examples include ground beef, eggs, and tofu.
• High-Fat List: One exchange equals 7 grams of protein and 8 grams of fat (100 calories). This group includes items such as fried fish, hot dogs, spare ribs, peanut butter, and most cheeses.

Fats

Fats include oils, butter, nuts, bacon, cream cheese, and other fatty foods. A fat exchange is equal to 5 grams of fat and 45 calories. Fats are divided into three lists: monounsaturated fats, polyunsaturated fats, and saturated fats. Saturated fats are the "bad" fats that are linked with raising cholesterol levels and heart disease.

Free Foods

A free food contains less than 20 calories or less than 5 grams of carbohydrate per serving. If they eat 3 servings a day or less, they do not need to count these foods. Examples of free foods include sugar-free gelatin, diet soft drinks, catsup, soy sauce, and spices.

Combination Foods

Many foods are mixed together. A dietitian can help determine out how many exchanges to count for foods such as casseroles. For example, a cup of lasagna would equal 2 carbohydrate exchanges and 2 medium-fat meat exchanges.

The CDC recommends that the food servings selected are the right size by using:

• Measuring cups
• Measuring spoons
• A food scale

Also, the Nutrition Facts label on food packages tells how much of that food is in one serving.

Weigh or measure foods to make sure they eat the right amounts.

These tips will help choose the right serving sizes.

• Measure a serving size of dry cereal or hot cereal, pasta, or rice and pour it into a bowl or plate. The next time they eat that food, use the same bowl or plate and fill it to the same level.
• For one serving of milk, measure 1 cup and pour it into a glass. See how high it fills the glass. Always drink milk out of that size glass.
• Meat weighs more before it's cooked. For example, 4 ounces of raw meat will weigh about 3 ounces after cooking. For meat with a bone, like a pork chop or chicken leg, cook 5 ounces raw to get 3 ounces cooked.
• One serving of meat or meat substitute is about the size and thickness of the palm of the hand or a deck of cards.
• A small fist is equal to about 1/2 cup of fruit, vegetables, or starches like rice.
• A small fist is equal to 1 small piece of fresh fruit.
• A thumb is equal to about 1 ounce of meat or cheese.
• The tip of a thumb is equal to about 1 teaspoon.

Treatment

In all of the following recommended diabetes treatment, the CDC recommends healthy eating as one of the key solutions. Their specific recommendation for the treatment of Type 1 and 2 diabetes are:

• Type 1 Diabetes - Healthy eating, physical activity, and insulin injections are the basic therapies for type 1 diabetes. The amount of insulin taken must be balanced with food intake and daily activities. Blood glucose levels must be closely monitored through frequent blood glucose testing.
• Type 2 Diabetes - Healthy eating, physical activity, and blood glucose testing are the basic therapies for type 2 diabetes. In addition, many people with type 2 diabetes require oral medication, insulin, or both to control their blood glucose levels.

People with diabetes must take responsibility for their day-to-day care, and keep blood glucose levels from going too low or too high.

In 2003, 11.6 million adults with diabetes reported taking some type of medication for their diabetes (i.e., either insulin or oral medications, or both) and 2.1 million did not report diabetes medication use. Of the adults taking diabetes medication, 7.8 million reported taking only oral medication, 2.1 million reported taking only insulin, and 1.7 million reported taking both insulin and oral medication.

Those with diabetes need insulin if the body has stopped making insulin or if it doesn't make enough. Everyone with type 1 diabetes needs insulin, and many people with type 2 diabetes do too.

Insulin can't be taken as a pill. The person must give themselves shots every day or use an insulin pump. An insulin pump is a small machine that connects to narrow tubing, ending with a needle just under the skin near the abdomen. Insulin is delivered through the needle.

It is advised that extra insulin be kept in refrigerator in case they break the bottle they are using. Insulin can not be kept in the freezer or in hot places like the glove compartment of the car. Also, keep it away from bright light. Too much heat, cold, or bright light can damage insulin.

If they use a whole bottle of insulin within a month, they can keep that bottle at room temperature. If the whole bottle of insulin is not used within one month, then it should be store in the refrigerator.

If the body makes insulin, but the insulin doesn't lower the person's blood glucose, they may need diabetes pills. Some pills are taken once a day, and others are taken more often. Diabetes pills don't lower blood glucose all by themselves and it is important that a meal plan be followed. Being active will also help to lower the blood glucose.

Sometimes, people who take diabetes pills may need insulin shots for a while. If the person gets sick or have surgery, the diabetes pills may no longer work to lower their blood glucose.

It is possible that they may be able to stop taking diabetes pills if they lose weight. Losing 10 or 15 pounds can sometimes help the person to reach their target blood glucose level.

A person may need to check their urine if they are sick or if their blood glucose is over 240. A urine test will tell them if they have ketones in their urine. The body makes ketones when there isn't enough insulin in their blood. Ketones can make them very sick. If the person has a moderate or large amounts of ketones, along with high blood glucose levels, when they do a urine test they may have a serious condition called ketoacidosis. If it isn't treated, it can cause death. Signs of ketoacidosis are vomiting, weakness, fast breathing, and a sweet smell on the breath. Ketoacidosis is more likely to develop in people with type 1 diabetes. Strips for testing ketones can be purchased at a drug store.

Many people with type 2 diabetes don't need insulin or diabetes pills. They can take care of their diabetes by using a meal plan and exercising regularly.

Exercise is an important part of staying healthy and controlling blood glucose. Physical activity should be safe and enjoyable, so they should talk with their doctor about what types of exercise are right for them. What they eat and when also depend on how much they exercise.

Whatever kind of exercise they do, here are some special things that people with diabetes need to remember:

• Take care of the feet. Make sure shoes fit properly and socks stay clean and dry. They should check their feet for redness or sores after exercising. They should their doctor if they have sores that do not heal.
• Drink about 2 cups of water before exercising, about every 20 minutes during exercise, and after they finish, even if they don't feel thirsty.
• Warm up and cool down for 5 to 10 minutes before and after exercising. For example, walk slowly at first, then walk faster. Finish up by walking slowly again.
• Test blood glucose before and after exercising. Do not exercise if the fasting blood glucose level is above 300. Eat a small snack if blood glucose is below 100.
• Know the signs of low blood glucose (hypoglycemia) and how to treat it.

During pregnancy there are many changes that take place in the mother's metabolism a rise in insulin resistance is one of these changes.

The placenta supplies a growing fetus with nutrients and produces a variety of hormones to maintain the pregnancy. Some of these hormones, such as human placental lactogen, have a blocking effect on insulin that usually begins 20 to 24 weeks into the pregnancy. The contra-insulin effect of placental hormones leads to higher levels of maternal blood glucose after eating (post-prandial levels) that may aid fetal growth.

Normally, the mother's beta cells can produce additional insulin to overcome the insulin resistance of pregnancy. As the placenta grows, more hormones are produced, and insulin resistance becomes greater. When the mother's production of insulin is not enough to overcome the effect of the placental hormones, gestational diabetes mellitus (GDM) results. GDM is defined as "carbohydrate intolerance of varying degrees of severity with onset or first recognition during pregnancy". GDM complicates 7% of all pregnancies in the United States and is more common in populations with a higher rate of type 2 diabetes mellitus, such as African Americans, Asian Americans, Hispanic Americans, and Native Americans).

The main complications of GDM are increased fetal size, which may complicate delivery, and hypoglycemia in the baby immediately after delivery. Women with GDM generally have normal blood sugar levels during the critical first trimester (before the 13th week) of pregnancy. This is in contrast to patients with type 1 diabetes, where hyperglycemia in this period may cause congenital birth defects.

After a positive screening test, the diagnosis of GDM is made by a glucose tolerance test. In this test, a sugary drink is given, and a series of blood tests are taken at set time intervals. If hyperglycemia is detected, treatment begins with a change in diet and an increase in exercise. If these lifestyle changes fail to control blood glucose levels, insulin therapy is started.

Women with pre-existing diabetes require higher doses of insulin during pregnancy because of the increase in insulin resistance. If their diabetes is usually controlled using oral hypoglycemic agents, they are usually transferred to insulin to enable better glucose control and because the safety of most hypoglycemic agents has not been studied in pregnancy.

GDM can disappear within hours of giving birth, depending on individual factors such as beta cell function and predisposing factors such as obesity. However, a significant portion of women go on to develop type 2 diabetes. Because GDM and type 2 diabetes both feature insulin resistance and share risk factors such as obesity, it is possible that these two conditions may also share diabetes susceptibility genes.

To evaluate an individuals risk for gestational diabetes, they can check each item that applies to them. It is recommended that they speak with their doctor about their risk at their first prenatal visit. The following form was developed by the National Institute of Diabetes and Digestive and Kidney Diseases .

The National Center for Complementary and Alternative Medicine, part of the National Institutes of Health, defines complementary and alternative medicine as a "group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine."

Complementary medicine is used with conventional therapy, whereas alternative medicine is used instead of conventional medicine.

Some people with diabetes use complementary or alternative therapies to treat diabetes. Although some of these therapies may be effective, others can be ineffective or even harmful. Patients who use complementary and alternative medicine need to let their health care providers know what they are doing.

Some complementary and alternative medicine therapies are discussed below.

Acupuncture - procedure in which a practitioner inserts needles into designated points on the skin. Some scientists believe that acupuncture triggers the release of the body's natural painkillers. Acupuncture has been shown to offer relief from chronic pain. Acupuncture is sometimes used by people with neuropathy, the painful nerve damage of diabetes.

Biofeedback - a technique that helps a person become more aware of and learn to deal with the body's response to pain. This alternative therapy emphasizes relaxation and stress-reduction techniques. Guided imagery is a relaxation technique that some professionals who use biofeedback do. With guided imagery, a person thinks of peaceful mental images, such as ocean waves. A person may also include the images of controlling or curing a chronic disease, such as diabetes. People using this technique believe their condition can be eased with these positive images.

Chromium - The benefit of added chromium for diabetes has been studied and debated for several years. Several studies report that chromium supplementation may improve diabetes control. Chromium is needed to make glucose tolerance factor, which helps insulin improve its action. Because of insufficient information on the use of chromium to treat diabetes, no recommendations for supplementation yet exist.

Ginseng - Several types of plants are referred to as ginseng but most studies of ginseng and diabetes have used American ginseng. Those studies have shown some glucose-lowering effects in fasting and post-prandial (after meal) blood glucose levels as well as in A1C levels (average blood glucose levels over a 3-month period). However, larger and more long-term studies are needed before general recommendations for use of ginseng can be made. Researchers also have determined that the amount of glucose-lowering compound in ginseng plants varies widely.

Magnesium - Although the relationship between magnesium and diabetes has been studied for decades, it is not yet fully understood. Studies suggest that a deficiency in magnesium may worsen blood glucose control in type 2 diabetes. Scientists believe that a deficiency of magnesium interrupts insulin secretion in the pancreas and increases insulin resistance in the body's tissues. Evidence suggests that a deficiency of magnesium may contribute to certain diabetes complications. A recent analysis showed that people with higher dietary intakes of magnesium (through consumption of whole grains, nuts, and green leafy vegetables) had a decreased risk of type 2 diabetes.

Vanadium - Vanadium is a compound found in tiny amounts in plants and animals. Early studies showed that vanadium normalized blood glucose levels in animals with type 1 and type 2 diabetes. A recent study found that when people with diabetes were given vanadium, they developed a modest increase in insulin sensitivity and were able to decrease their insulin requirements. Currently researchers want to understand how vanadium works in the body, discover potential side effects, and establish safe dosages.

The rate of beta cell destruction in type 1 diabetes is quite variable--rapid in some individuals (mainly infants and children) and slow in others (mainly adults). Children and adolescents may present with ketoacidosis as the first indication of the disease. Others may have modest fasting hyperglycemia that rapidly changes to severe hyperglycemia and/or ketoacidosis in the presence of infection or other stress.

Most children and adolescents diagnosed with type 2 diabetes are overweight or obese, insulin resistant, and have a family history of type 2 diabetes. They also may have physical signs of insulin resistance such as acanthosis nigricans. Diabetes complications such as microalbuminuria and the presence of cardiovascular risk factors such as abnormal cholesterol and high blood pressure have been observed among teenage Pima Indians and in other pediatric populations in the United States.

The basic elements of type 1 diabetes management are insulin administration, nutrition management, physical activity, blood glucose testing, and the avoidance of hypoglycemia. Algorithms are used for insulin dosing based on blood glucose level and food intake.

Children receiving fixed insulin doses of intermediate- and rapid-acting insulins must have food given at the time of peak action of the insulin. Children receiving a long-acting insulin analogue or using an insulin pump receive a rapid-acting insulin analogue just before a meal, with the amount of pre-meal insulin based on carbohydrate content of the meal using an insulin:carbohydrate ratio and a sliding scale for hyperglycemia. Further adjustment of insulin or food intake may be made based on anticipation of special circumstances such as increased exercise. Children on these regimens are expected to check their blood glucose levels routinely before meals and at bedtime.

Management of type 2 diabetes involves nutrition management, increased physical activity, and blood glucose testing. If this is not sufficient to normalize blood glucose levels, oral anti-diabetes medication and/or insulin therapy are used as well. The only oral agent approved for use in children and adolescents is metformin.

There is no single recipe to manage diabetes that fits all children. Blood glucose targets, frequency of blood glucose testing, type, dose and frequency of insulin, use of insulin injections or a pump, and details of nutrition management, all may vary among individuals. The family and diabetes care team determine the regimen that best suits each child's individual characteristics and circumstances.

To control diabetes and prevent complications, blood glucose levels must be managed as close to a "normal" range as is safely possible (70 to 100 mg/dl before eating). Families should work with their health care team to set target blood glucose levels appropriate for the child.

The American Diabetes Association has developed recommendations for blood glucose goals for young people with type 1 diabetes. Although there are no national recommendations for children with type 2 diabetes, it may be reasonable to use the values in the following table as a guide.

Blood Glucose Goals for Young People

Causes of hyperglycemia include forgetting to take medications on time, eating too much, and getting too little exercise. Being ill also can raise blood glucose levels. Over time, hyperglycemia can cause damage to the eyes, kidneys, nerves, blood vessels, gums, and teeth.

Concurrent illnesses are more frequent in young children. Sick-day management rules, including assessment for ketosis with every illness, must be established for children with type 1 diabetes. Families need to be taught what to do for vomiting and for ketosis to prevent severe hyperglycemia and ketoacidosis.

The following recommendations are based on the American Diabetes Association's standards of Medical Care.

Retinopathy. Although retinopathy most commonly occurs after the onset of puberty and after 5-10 years of diabetes duration, it has been reported in prepubertal children and with diabetes duration of only 1-2 years. Referrals should be made to eye care professionals with expertise in diabetic retinopathy, an understanding of the risk for retinopathy in the pediatric population, as well as experience in counseling the pediatric patient and family on the importance of early prevention/intervention. The first ophthalmologic examination should be obtained once the child is 10 years of age or older and has had diabetes for 3-5 years. After the initial examination, annual routine follow-up is generally recommended. Less frequent examinations may be acceptable on the advice of an eye care professional.

Nephropathy. To reduce the risk and/or slow the progression of nephropathy, optimize glucose and blood pressure control. Annual screening for microalbuminuria should be initiated once the child is 10 years of age and has had diabetes for 5 years. Screening may be done with a random spot urine sample analyzed for microalbumin-to-creatinine ratio. Confirmed, persistently elevated microalbumin levels should be treated with an ACE inhibitor, titrated to normalization of microalbumin excretion if possible.

Neuropathy. Although it is unclear whether foot examinations are important in children and adolescents, annual foot examinations are painless, inexpensive, and provide an opportunity for education about foot care. The risk for foot complications is increased in people who have had diabetes over 10 years.

Lipids. In children older than 2 years of age with a family history of total cholesterol over 240 mg/dl, or a CVD event before age 55, or if family history is unknown, perform a lipid profile after diagnosis of diabetes and when glucose control has been established. If family history is not a concern, then perform a lipid profile at puberty. Based on data obtained from studies in adults, having diabetes is equivalent to having had a heart attack, making diabetes a key risk factor for future cardiovascular disease.

Pubertal children should have a lipid profile at the time of diagnosis after glucose control has been established. If lipid values fall within the accepted risk levels (LDL less than 100 mg/dl), repeat lipid profile every 5 years.

The goal for LDL-cholesterol in children and adolescents with diabetes is less than 100 mg/dl (2.60 mmol/l). If the LDL-cholesterol is greater than 100 mg/dl, the child should be treated with an exercise plan and a Step 2 American Heart Association diet. If, after 6 months of diet and exercise, the LDL-C level remains above 160 mg/dl, pharmacologic agents should be given. If, the LDL-C is between 130 and 160 mg/dl, pharmacologic therapy should be considered. Statins are the agents of choice. Weight loss, increased physical activity, and improvement in glycemic control often result in improvements in lipid levels.

Blood pressure. Careful control of hypertension in children is critical. Hypertension in childhood is defined as an average systolic or diastolic blood pressure > 95 th percentile for age, sex, and height measured on at least three separate days.

CE inhibitors are the agents of choice in children with microalbuminuria. They have beneficial effects on slowing progression or preventing diabetic nephropathy.

Because most newly diagnosed cases of type 1 diabetes occur in individuals younger than 18 years of age, and more children and teens are now getting type 2 diabetes, care of this group requires integration of diabetes management with the complicated physical and emotional growth needs of children, adolescents, and their families, as well as with their emerging autonomy and independence.

Diabetes care for children should be provided by a team that can deal with these special medical, educational, nutritional, and behavioral issues. The team usually consists of a physician, diabetes educator, dietitian, social worker or psychologist, along with the patient and family. Children should be seen by the team at diagnosis and in follow-up, as agreed upon by the primary care provider and the diabetes team. The following schedule of care is based on the American Diabetes Association's Standards of Medical Care, published in 2005.

At Diagnosis:

• Establish the goals of care and required treatment.
• Check lipids in children with a significant family history. In children with no significant family history, check lipids at puberty and if normal, repeat profile every 5 years
• Begin diabetes self-management education about healthy eating habits, daily physical activity, and insulin/medication administration, and self-monitoring of blood glucose levels if appropriate. A solid educational base is needed so that the individual and family can become increasingly independent in self-management of diabetes. Diabetes educators play an important role in this aspect of management.
• Provide nutritional therapy by an individual experienced with the nutritional needs of the growing child and the behavioral issues that have an impact on adolescent diets.
• Conduct a psychosocial assessment to identify emotional and behavioral disorders.

Each Quarterly Visit - Most young people with diabetes are seen by the health care team every 3 months. At each visit, the following should be monitored or examined:

• A1C, an indicator of average blood glucose control
• Growth (height and weight)
• BMI
• Blood pressure
• Injection sites
• Self-testing blood glucose records
• Psychosocial assessment

Annually:

• Evaluate nutrition therapy
• Provide ophthalmologic examination (less often on the advice of an eye care professional) The first ophthalmologic examination should be obtained once the child is age 10 or older and has had diabetes for 3 to 5 years.
• Check for microalbuminuria (once the child is 10 years old and has had diabetes for 5 years)
• Perform thyroid function test (for children with type 1 diabetes)
• Administer influenza vaccination
• Examine feet.

The health care provider team, in partnership with the young person with diabetes and caregivers, can develop a personal diabetes plan for the child that puts a daily schedule in place to keep diabetes under control. The plan shows the child how to follow a healthy meal plan, get regular physical activity, check blood glucose levels, take insulin or oral medication as prescribed, and manage hyperglycemia and hypoglycemia.

Follow a healthy meal plan - Young people with diabetes need to follow a meal plan developed by a registered dietitian, diabetes educator, or physician. For children with type 1 diabetes, the meal plan must ensure proper nutrition for growth. For children with type 2, the meal plan should outline appropriate changes in eating habits that lead to better energy balance and reduce or prevent obesity. A meal plan also helps keep blood glucose levels in the target range.

Children or adolescents and their families can learn how different types of food -- especially carbohydrates such as breads, pasta, and rice -- can affect blood glucose levels. Portion sizes, the right amount of calories for the child's age, and ideas for healthy food choices at meal and snack time also should be discussed including reduction in soda and juice consumption. Family support for following the meal plan and setting up regular meal times is a key to success, especially if the child or teen is taking insulin.

Children with diabetes need regular physical activity, ideally a total of 60 minutes each day. Exercise helps to lower blood glucose levels, especially in children and adolescents with type 2 diabetes. Exercise is also a good way to help children control their weight. In children with type 1 diabetes, the most common problem encountered during exercise is hypoglycemia. If possible, a child or a teen should check blood glucose levels before beginning a game or a sport. If blood glucose levels are too low, the child should not exercise until the low blood glucose level has been treated.

Check blood glucose levels regularly - Young people with diabetes should know the acceptable range for their blood glucose. Children, particularly those using insulin should check blood glucose values regularly with a blood glucose meter, preferably one with a built-in memory. A health care team member can teach a child how to use a blood glucose meter properly and how often to use it. Children should keep a journal or other records of blood glucose results to discuss with their health care team. This information helps providers make any needed changes to the child's or teen's personal diabetes plan.

Take all diabetes medication as prescribed - Parents, caregivers, school nurses, and others can help a child or teen learn how to take medications as prescribed. For type 1 diabetes, a child or teen takes insulin at prescribed times each day via multiple injections or an insulin pump. Some young people with type 2 diabetes need oral medication or insulin or both. In any case, it is important to stress that all medication should be balanced with food and activity every day.

Maturity-onset diabetes of the young (MODY) is a rare form of diabetes in children that is caused by a single gene defect that results in faulty insulin secretion. MODY is defined by its early onset (usually before age 25), absence of ketosis, and autosomal dominant inheritance. Thus each child of a parent with MODY has a 50 percent chance of inheriting the same type of diabetes. MODY is thought to account for 2 to 5 percent of all cases of diabetes and often goes unrecognized. Treatment of MODY varies. Some children respond to diet therapy, exercise, and/or oral anti-diabetes medications that enhance insulin release. Others may require insulin therapy.

Diabetes presents unique issues for young people with the disease. Simple things, such as going to a birthday party, playing sports, or staying overnight with friends, need careful planning. Checking blood glucose, making correct food choices, and taking insulin or oral medication can make school-age children feel "different" from their classmates and this can be particularly bothersome for teens.

Heart Health Factors

The American Dietetic Association lists many factors that can affect cholesterol and triglyceride levels and thus affect the heart's health.

• Several medicines can worsen cholesterol levels. These include widely used drugs such as thiazide diuretics (a kind of water pill), oral estrogens (such as in birth control pills) and some beta-blockers (a class of blood pressure drugs).
• Smoking can lower HDL cholesterol levels.
• Although small amounts of alcohol help HDL cholesterol levels, greater amounts can increase triglycerides.
• Several illnesses affect cholesterol levels, including liver disease and hypothyroidism (low levels of thyroid hormones).

In addition to unhealthy cholesterol levels, several other conditions raise the risk of heart disease.

• High levels of a lipoprotein called lipoprotein(a)
• High blood pressure
• A family history of heart disease
• An inactive lifestyle
• Obesity
• Smoking
• High homocysteine levels. Homocysteine is produced when the body digests proteins. The homocysteine level can be lowered by avoiding coffee made without a filter (such as French press) and getting plenty of folate and vitamins B-6 and B-12.
• Infection with chlamydia. The common bacterium Chlamydia pneumoniae causes flulike symptoms and sometimes pneumonia. It appears that chlamydia bacteria can leave the lungs and infect blood vessels, making them more prone to deposits of cholesterol.

In addition, some evidence points to poor blood glucose management and long-term emotional stress as factors that contribute to heart disease.

Sometimes diet and exercise aren't enough to bring cholesterol back to normal, and drug therapy is also needed. ADA has set the following guidelines for how doctors should treat lipid problems. The highest priority is usually to get LDL cholesterol levels below 100 mg/dl. The first drug to try is one of the "statins." "Statins" are a class of drugs that lowers the level of cholesterol in the blood by reducing the production of cholesterol by the liver. Statins block the enzyme in the liver that is responsible for making cholesterol.

These are:

• Atorvastatin (Lipitor)
• Fluvastatin (Lescol)
• Lovastatin (Mevacor, Altocor)
• Pravastatin (Pravachol)
• Rosuvastatin (Crestor)
• Simvastatin (Zocor)

Side effects of statins are usually mild. The most common side effects are muscle and stomach pain. Also, statins can raise the levels of some liver enzymes, so people need to have liver tests when they start taking statins.

Simvastatin lowers the risk of stroke and heart attack in people with diabetes even when they have normal LDL cholesterol levels. Some researchers suggest statins should be considered for such people at high risk for heart disease, even if their cholesterol is normal.

If statins can't be used or if they don't work, the second-choice drug is one of the bile-acid binding resins. These drugs are:

• Cholestyramine (Prevalite, Questran Light)
• Colesevelam (Welchol)
• Colestipol (Colestid)

Side effects include upset stomach and constipation. Also, bile-acid binding resins can interfere with the body's ability to absorb other drugs they may be taking.

People with type 2 diabetes often have too high triglyceride levels. Therefore, some people need a drug to lower triglycerides in addition to (or instead of) an LDL cholesterol-lowering drug. The first drug to try is one of the fibric acid derivatives, which are:

• Fenofibrate (TriCor)
• Gemfibrozil (Lopid)

The most common side effects are heartburn and stomach pain. Other side effects are diarrhea, skin rash, muscle pain and gallstones.

The second-choice drug for triglycerides is nicotinic acid. Because nicotinic acid can complicate blood glucose control, it is recommended for use at low doses (less than 2 grams per day). The three prescription brands are:

• Niacor (the immediate-release form, which is preferred for people with diabetes)
• Niaspan (the extended-release form, which may be tolerated better)
• Advicor (Niaspan combined with lovastatin)

In addition to its effects on blood glucose, nicotinic acid can cause skin flushing, gout, upset stomach, tiredness and diarrhea.

Ezetimibe (Zetia) is a new drug that reduces LDL cholesterol. It can be used alone or with a statin. Some people may not be able to take certain cholesterol- or triglyceride-lowering drugs. A drug may not be suitable for someone because of other health problems, another drug he or she is already taking or personal habits (such as being a heavy drinker).

Nerve Disorders

Diabetic neuropathies are a family of nerve disorders caused by diabetes. People with diabetes can, over time, have damage to nerves throughout the body. Neuropathies lead to numbness and sometimes pain and weakness in the hands, arms, feet, and legs. Problems may also occur in every organ system, including the digestive tract, heart, and sex organs. People with diabetes can develop nerve problems at any time, but the longer a person has diabetes, the greater the risk.

An estimated 50 percent of those with diabetes have some form of neuropathy, but not all with neuropathy have symptoms. The highest rates of neuropathy are among people who have had the disease for at least 25 years.

Diabetic neuropathy also appears to be more common in people who have had problems controlling their blood glucose levels, in those with high levels of blood fat and blood pressure, in overweight people, and in people over the age of 40. The most common type is peripheral neuropathy, also called distal symmetric neuropathy, which affects the arms and legs.

The causes are probably different for different varieties of diabetic neuropathy. Researchers are studying the effect of glucose on nerves to find out exactly how prolonged exposure to high glucose causes neuropathy. Nerve damage is likely due to a combination of factors:

• Metabolic factors, such as high blood glucose, long duration of diabetes, possibly low levels of insulin, and abnormal blood fat levels
• Neurovascular factors, leading to damage to the blood vessels that carry oxygen and nutrients to the nerves
• Autoimmune factors that cause inflammation in nerves
• Mechanical injury to nerves, such as carpal tunnel syndrome
• Inherited traits that increase susceptibility to nerve disease
• Lifestyle factors such as smoking or alcohol use

Symptoms depend on the type of neuropathy and which nerves are affected. Some people have no symptoms at all. For others, numbness, tingling, or pain in the feet is often the first sign. A person can experience both pain and numbness. Often, symptoms are minor at first, and since most nerve damage occurs over several years, mild cases may go unnoticed for a long time. Symptoms may involve the sensory or motor nervous system, as well as the involuntary (autonomic) nervous system. In some people, mainly those with focal neuropathy, the onset of pain may be sudden and severe.

Symptoms may include:

• Numbness, tingling, or pain in the toes, feet, legs, hands, arms, and fingers
• Wasting of the muscles of the feet or hands
• Indigestion, nausea, or vomiting
• Diarrhea or constipation
• Dizziness or faintness due to a drop in postural blood pressure
• Problems with urination
• Erectile dysfunction (impotence) or vaginal dryness
• Weakness

In addition, the following symptoms are not due to neuropathy but nevertheless often accompany it:

• Weight loss
• Depression

Diabetic neuropathies can be classified as peripheral, autonomic, proximal, and focal. Each affects different parts of the body in different ways.

• Peripheral neuropathy causes either pain or loss of feeling in the toes, feet, legs, hands, and arms.
• Autonomic neuropathy causes changes in digestion, bowel and bladder function, sexual response, and perspiration. It can also affect the nerves that serve the heart and control blood pressure. Autonomic neuropathy can also cause hypoglycemia (low blood sugar) unawareness, a condition in which people no longer experience the warning signs of hypoglycemia.
• Proximal neuropathy causes pain in the thighs, hips, or buttocks and leads to weakness in the legs
• Focal neuropathy results in the sudden weakness of one nerve, or a group of nerves, causing muscle weakness or pain. Any nerve in the body may be affected.

Neuropathy affects the nerves throughout the body can this includes:

Peripheral Neuropathy
• Toes
• Feet
• Legs
• Hands
• Arms

Autonomic Neuropathy
• Heart and blood vessels
• Digestive system
• Urinary tract
• Sex organs
• Sweat glands
• Eyes

Proximal Neuropathy
• Thighs
• Hips
• Buttocks

Focal Neuropathy
• Eyes
• Facial muscles
• Ears
• Pelvis and lower back
• Thighs
• Abdomen

This type of neuropathy damages nerves in the arms and legs. The feet and legs are likely to be affected before the hands and arms. Many people with diabetes have signs of neuropathy upon examination but have no symptoms at all. Symptoms of peripheral neuropathy may include:

• Numbness or insensitivity to pain or temperature
• A tingling, burning, or prickling sensation
• Sharp pains or cramps
• Extreme sensitivity to touch, even a light touch
• Loss of balance and coordination

These symptoms are often worse at night.

Peripheral neuropathy may also cause muscle weakness and loss of reflexes, especially at the ankle, leading to changes in gait (walking). Foot deformities, such as hammertoes and the collapse of the midfoot, may occur. Blisters and sores may appear on numb areas of the foot because pressure or injury goes unnoticed. If foot injuries are not treated promptly, the infection may spread to the bone, and the foot may then have to be amputated. Some experts estimate that half of all such amputations are preventable if minor problems are caught and treated in time.

Autonomic neuropathy affects the nerves that control the heart, regulate blood pressure, and control blood glucose levels. It also affects other internal organs, causing problems with digestion, respiratory function, urination, sexual response, and vision. In addition, the system that restores blood glucose levels to normal after a hypoglycemic episode may be affected, resulting in loss of the warning signs of hypoglycemia such as sweating and palpitations.

Normally, symptoms such as shakiness occur as blood glucose levels drop below 70 mg/dL. In people with autonomic neuropathy, symptoms may not occur, making hypoglycemia difficult to recognize. However, other problems can also cause hypoglycemia unawareness so this does not always indicate nerve damage.

The heart and circulatory system are part of the cardiovascular system, which controls blood circulation. Damage to nerves in the cardiovascular system interferes with the body's ability to adjust blood pressure and heart rate. As a result, blood pressure may drop sharply after sitting or standing, causing a person to feel light-headed-or even to faint. Damage to the nerves that control heart rate can mean that it stays high, instead of rising and falling in response to normal body functions and exercise.

Digestive System - Nerve damage to the digestive system most commonly causes constipation. Damage can also cause the stomach to empty too slowly, a condition called gastroparesis. Severe gastroparesis can lead to persistent nausea and vomiting, bloating, and loss of appetite. Gastroparesis can make blood glucose levels fluctuate widely as well, due to abnormal food digestion.

Nerve damage to the esophagus may make swallowing difficult, while nerve damage to the bowels can cause constipation alternating with frequent, uncontrolled diarrhea, especially at night. Problems with the digestive system may lead to weight loss.

Urinary Tract and Sex Organs - Autonomic neuropathy most often affects the organs that control urination and sexual function. Nerve damage can prevent the bladder from emptying completely, allowing bacteria to grow in the bladder and kidneys and causing urinary tract infections. When the nerves of the bladder are damaged, urinary incontinence may result because a person may not be able to sense when the bladder is full or control the muscles that release urine.

Neuropathy can also gradually decrease sexual response in men and women, although the sex drive is unchanged. A man may be unable to have erections or may reach sexual climax without ejaculating normally. A woman may have difficulty with lubrication, arousal, or orgasm.

Sweat Glands - Autonomic neuropathy can affect the nerves that control sweating. When nerve damage prevents the sweat glands from working properly, the body cannot regulate its temperature properly. Nerve damage can also cause profuse sweating at night or while eating.

Eyes - Finally, autonomic neuropathy can affect the pupils of the eyes, making them less responsive to changes in light. As a result, a person may not be able to see well when the light is turned on in a dark room or may have trouble driving at night.

Proximal neuropathy, sometimes called lumbosacral plexus neuropathy, femoral neuropathy, or diabetic amyotrophy, starts with pain in either the thighs, hips, buttocks, or legs, usually on one side of the body. This type of neuropathy is more common in those with type 2 diabetes and in older people. It causes weakness in the legs, manifested by an inability to go from a sitting to a standing position without help. Treatment for weakness or pain is usually needed. The length of the recovery period varies, depending on the type of nerve damage.

Occasionally, diabetic neuropathy appears suddenly and affects specific nerves, most often in the head, torso, or leg. Focal neuropathy may cause:

• Inability to focus the eye
• Double vision
• Aching behind one eye
• Paralysis on one side of the face (Bell's palsy)
• Severe pain in the lower back or pelvis
• Pain in the front of a thigh
• Pain in the chest, stomach, or flank
• Pain on the outside of the shin or inside the foot
• Chest or abdominal pain that is sometimes mistaken for heart disease, heart attack, or appendicitis

People with diabetes also tend to develop nerve compressions, also called entrapment syndromes. One of the most common is carpal tunnel syndrome, which causes numbness and tingling of the hand and sometimes muscle weakness or pain