Complications of Diabetes in the United States

Diabetes can cause serious health complications including heart disease, blindness, kidney failure, and lower-extremity amputations. Diabetes is the sixth leading cause of death in the United States

The National Institute of Health has identified some of the complications that can arise from diabetes:⁸

• In 2004, heart disease was noted on 68 percent of diabetes-related death certificates among people aged 65 years or older.
• In 2004, stroke was noted on 16 percent of diabetes-related death certificates among people aged 65 years or older.
• Adults with diabetes have heart disease death rates about two to four times higher than adults without diabetes.
• The risk for stroke is two to four times higher among people with diabetes.

• In 2003 to 2004, 75 percent of adults with self-reported diabetes had blood pressure greater than or equal to 130/80 millimeters of mercury (mm Hg) or used prescription medications for hypertension.

• Diabetes is the leading cause of new cases of blindness among adults aged 20 to 74 years.
• Diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each year.

• Diabetes is the leading cause of kidney failure, accounting for 44 percent of new cases in 2005.
• In 2005, 46,739 people with diabetes began treatment for end-stage kidney disease in the United States and Puerto Rico.
• In 2005, a total of 178,689 people with end-stage kidney disease due to diabetes were living on chronic dialysis or with a kidney transplant in the United States and Puerto Rico.

• About 60 to 70 percent of people with diabetes have mild to severe forms of nervous system damage. The results of such damage include impaired sensation or pain in the feet or hands, slowed digestion of food in the stomach, carpal tunnel syndrome, erectile dysfunction, or other nerve problems.
• Almost 30 percent of people with diabetes aged 40 years or older have impaired sensation in the feet-for example, at least one area that lacks feeling.
• Severe forms of diabetic nerve disease are a major contributing cause of lower-extremity amputations.

• More than 60 percent of nontraumatic lower-limb amputations occur in people with diabetes.
• In 2004, about 71,000 nontraumatic lower-limb amputations were performed in people with diabetes.

• Periodontal, or gum, disease is more common in people with diabetes. Among young adults, those with diabetes have about twice the risk of those without diabetes.
• Persons with poorly controlled diabetes (A1C > 9 percent) were nearly three times more likely to have severe periodontitis than those without diabetes.
• Almost one-third of people with diabetes have severe periodontal disease with loss of attachment of the gums to the teeth measuring 5 millimeters or more.

• Poorly controlled diabetes before conception and during the first trimester of pregnancy among women with type 1 diabetes can cause major birth defects in 5 to 10 percent of pregnancies and spontaneous abortions in 15 to 20 percent of pregnancies.
• Poorly controlled diabetes during the second and third trimesters of pregnancy can result in excessively large babies, posing a risk to both mother and child.

• Uncontrolled diabetes often leads to biochemical imbalances that can cause acute life-threatening events, such as diabetic ketoacidosis and hyperosmolar, or nonketotic, coma.
• People with diabetes are more susceptible to many other illnesses and, once they acquire these illnesses, often have worse prognoses. For example, they are more likely to die with pneumonia or influenza than people who do not have diabetes.
• Persons with diabetes aged 60 years or older are two to three times more likely to report an inability to walk a quarter of a mile, climb stairs, do housework, or use a mobility aid compared with persons without diabetes in the same age group.

Diabetes can affect many parts of the body and can lead to serious complications such as blindness, kidney damage, and lower-limb amputations. Working together, people with diabetes, their support network, and their health care providers can reduce the occurrence of these and other diabetes complications by controlling the levels of blood glucose, blood pressure, and blood lipids and by receiving other preventive care practices in a timely manner.⁹

• Studies in the United States and abroad have found that improved glycemic control benefits people with either type 1 or type 2 diabetes. In general, every percentage point drop in A1C blood test results-for example, from 8.0 to 7.0 percent-can reduce the risk of microvascular complications-eye, kidney, and nerve diseases-by 40 percent.
• In patients with type 1 diabetes, intensive insulin therapy has long-term beneficial effects on the risk of cardiovascular disease.

• Blood pressure control reduces the risk of cardiovascular disease-heart disease or stroke-among persons with diabetes by 33 to 50 percent, and the risk of microvascular complications-eye, kidney, and nerve diseases-by approximately 33 percent.
• In general, for every 10 mm Hg reduction in systolic blood pressure, the risk for any complication related to diabetes is reduced by 12 percent.

• Improved control of LDL cholesterol can reduce cardiovascular complications by 20 to 50 percent.

• Detecting and treating diabetic eye disease with laser therapy can reduce the development of severe vision loss by an estimated 50 to 60 percent.
• Comprehensive foot care programs can reduce amputation rates by 45 to 85 percent.
• Detecting and treating early diabetic kidney disease by lowering blood pressure can reduce the decline in kidney function by 30 to 70 percent. Treatment with angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are more effective in reducing the decline in kidney function than other blood pressure lowering drugs.
• In addition to lowering blood pressure, ARBs reduce proteinuria, a risk factor for developing kidney disease, by 35 percent-similar to the reduction achieved by ACE inhibitors.

Health Care Team

The CDC recommends that people with diabetes should see a health care provider who will monitor their diabetes control and help them learn to manage their diabetes. In addition, the health care team people with diabetes may see are endocrinologists, who may specialize in diabetes care; ophthalmologists for eye examinations; podiatrists for routine foot care; and dietitians and diabetes educators who teach the skills needed for daily diabetes management.

Diabetes Prevalence

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:¹⁰

• 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.

According to the CDC's the prevalence of diagnosed and undiagnosed diabetes in the United States in 2007, was for all ages a total of 23.6 million people-7.8 percent of the population.

• Diagnosed: 17.9 million people
• Undiagnosed: 5.7 million people
• Prevalence of Diagnosed and Undiagnosed Diabetes among People Aged 20 Years or Older, United States, 2007
• Age 20 years or older: 23.5 million, or 10.7 percent, of all people in this age group have diabetes.
• Age 60 years or older: 12.2 million, or 23.1 percent, of all people in this age group have diabetes.
• Men: 12.0 million, or 11.2 percent, of all men aged 20 years or older have diabetes.
• Women: 11.5 million, or 10.2 percent, of all women aged 20 years or older have diabetes.
• Non-Hispanic whites: 14.9 million, or 9.8 percent, of all non-Hispanic whites aged 20 years or older have diabetes.
• Non-Hispanic blacks: 3.7 million, or 14.7 percent, of all non-Hispanic blacks aged 20 years or older have diabetes.

About 186,300 people younger than 20 years have diabetes-type 1 or type 2. This represents 0.2 percent of all people in this age group. Estimates of undiagnosed diabetes are unavailable for this age group.

Sufficient data are not available to derive prevalence estimates of both diagnosed and undiagnosed diabetes for all minority populations. For example, national survey data cannot provide reliable estimates for the Native Hawaiian and other Pacific Islander population. However, national estimates of diagnosed diabetes for certain minority groups are available from national survey data and from the IHS user population database, which includes data for approximately 1.4 million American Indians and Alaska Natives in the United States who receive health care from the IHS. Because most minority populations are younger and tend to develop diabetes at earlier ages than the non-Hispanic white population, it is important to control for population age differences when making race and ethnic comparisons.

• " Data from the 2005 IHS user population database indicate that 14.2 percent of the American Indians and Alaska Natives aged 20 years or older who received care from IHS had diagnosed diabetes. After adjusting for population age differences, 16.5 percent of the total adult population served by IHS had diagnosed diabetes, with rates varying by region from 6.0 percent among Alaska Native adults to 29.3 percent among American Indian adults in southern Arizona.

• " After adjusting for population age differences, 2004 to 2006 national survey data for people aged 20 years or older indicate that 6.6 percent of non-Hispanic whites, 7.5 percent of Asian Americans, 10.4 percent of Hispanics, and 11.8 percent of non-Hispanic blacks had diagnosed diabetes. Among Hispanics, rates were 8.2 percent for Cubans, 11.9 percent for Mexican Americans, and 12.6 percent for Puerto Ricans.

Incidence of Diagnosed Diabetes among People Aged 20 Years or Older

A total of 1.6 million new cases of diabetes were diagnosed in people aged 20 years or older in 2007.

Deaths among People with Diabetes

Diabetes was the seventh leading cause of death listed on U.S. death certificates in 2006. This ranking is based on the 72,507 death certificates in 2006 in which diabetes was listed as the underlying cause of death. According to death certificate reports, diabetes contributed to a total of 233,619 deaths in 2005, the latest year for which data on contributing causes of death are available.

Diabetes is likely to be underreported as a cause of death. Studies have found that only about 35 to 40 percent of decedents with diabetes had it listed anywhere on the death certificate and only about 10 to 15 percent 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.

Estimated Diabetes Costs

The American Dietetic Association estimates that the total direct and indirect total annual cost of diabetes in the US is $174 billion in 2007. Medical expenditures totaled $116 billion and were comprised of $27 billion for diabetes care, $58 billion for chronic diabetes-related complications, and $31 billion for excess general medical costs. Indirect costs resulting from increased absenteeism, reduced productivity, disease-related unemployment disability, and loss of productive capacity due to early mortality totaled $58 billion. This is an increase of $42 billion since 2002. This 32% increase means the dollar amount has risen over $8 billion more each year.

The direct medical costs are $116 billion. After adjusting for population age and sex differences, average medical expenditures among people with diagnosed diabetes were 2.3 times higher than what expenditures would be in the absence of diabetes.¹¹

• The 2007 per capita annual costs of health care for people with diabetes is $11,744 a year, of which $6,649 (57%) is attributed to diabetes.
• One out of every five health care dollars is spent caring for someone with diagnosed diabetes, while one in ten health care dollars is attributed to diabetes.

Medical Expenditures Attributed to Diabetes

Medical expenditures are estimated at $116 billion, including $27 billion for care to directly treat diabetes, $58 billion to treat diabetes-related chronic complications, and $31 billion in excess general medical costs.

• People with diagnosed diabetes, on average, have medical expenditures that are approximately 2.3 times higher than those without diabetes. Diagnosed diabetes patients account for 5.8 percent of the total U.S. population.
• $58.3 billion was spent on inpatient hospital care and $9.9 billion on physician's office visits directly attributed to diabetes.
• Diabetes-related hospitalizations totaled 24.3 million days in 2007, an increase of 7.4 million from the 16.9 million days in 2002. The average cost for a hospital inpatient day due to diabetes is $1,853 and $2,281 due to diabetes-related chronic complications, including neurological, peripheral vascular, cardiovascular, renal, metabolic, and ophthalmic complications.

Indirect Costs of Diabetes

The indirect cost of diabetes was estimated to be $58 billion in 2007. In 2007, diabetes accounted for 15 million work days absent, 120 million work days with reduced performance, 6 million reduced productivity days for those not in the workforce, and an additional 107 million work days lost due to unemployment disability attributed to diabetes.

• Diabetes caused 445,000 cases of unemployment disability in 2007.
• The value of lost productivity due to premature death related to diabetes is $26.9 billion.

Causes for Diabetes Increased Cost

The increase in the cost of diabetes reflects three causes:

1. 1the growth in diabetes prevalence;
2. medical costs rising faster than general inflation; and
3. improvements made in the methods and data sources influencing cost estimates.

The actual national burden of diabetes likely exceeds the $174 billion estimate because it omits the social cost of intangibles such as pain and suffering, care provided by non-paid caregivers, excess medical costs associated with undiagnosed diabetes, and diabetes-attributed costs for health care expenditures categories not studied.

According to CDC, in 2007 23.6 million Americans had diabetes, with nearly a third undiagnosed. Another 57 million have pre-diabetes, and are likely to have the disease if they do not alter their living habits. The 23.6 million represents a 13.5% increase from the 20.8 million in 2005. Many factors contribute to this rise, including higher prevalence of overweight and obesity, changes in diagnostic criteria, improved or enhanced detection, decreasing mortality, a growing elderly population, and growth in minority populations in whom the prevalence and incidence of diabetes are increasing.

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.¹²

• 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:¹³

• 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.¹⁴

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.¹⁵

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.¹⁶

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.)¹⁷

According to the CDC diabetes prevention is proven and possible.¹⁸

• 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:¹⁹

• 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.

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:²⁰

• 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.²¹

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:²²

• 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.²³

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.²⁴

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:²⁵

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.

Treating Diabetes

Diabetes can lead to serious complications, such as blindness, kidney damage, cardiovascular disease, and lower-limb amputations, but people with diabetes can lower the occurrence of these and other diabetes complications by controlling blood glucose, blood pressure, and blood lipids.²⁶

• Many people with type 2 diabetes can control their blood glucose by following a healthy meal plan and exercise program, losing excess weight, and taking oral medication. Some people with type 2 diabetes may also need insulin to control their blood glucose.
• To survive, people with type 1 diabetes must have insulin delivered by injection or a pump.
• Among adults with diagnosed diabetes-type 1 or type 2-14 percent take insulin only, 13 percent take both insulin and oral medication, 57 percent take oral medication only, and 16 percent do not take either insulin or oral medication. Medications for each individual with diabetes will often change over the course of the disease.
• Self-management education or training is a key step in improving health outcomes and quality of life. It focuses on self-care behaviors, such as healthy eating, being active, and monitoring blood glucose. It is a collaborative process in which diabetes educators help people with or at risk for diabetes gain the knowledge and problem-solving and coping skills needed to successfully self-manage the disease and its related conditions.
• Many people with diabetes also need to take medications to control their cholesterol and blood pressure. The following chart shows the use of insulin or oral medications to treat diabetes.

From 1997 to 2006, the number of adults with diabetes only taking pill(s) and the number taking both insulin and pill(s) approximately doubled. In contrast, the number of adults only using insulin remained stable. In 2006, about 14 million adults with diabetes reported taking either pill(s), or insulin, or both medications and 2.7 million not taking any medication.

Age-Adjusted Percentage Using Any Diabetes Medication Among Adults with Diabetes

From 1997 to 2006, trends in the crude and age-adjusted percentage of adults with diabetes taking any medication (either pill(s) or insulin or both) were similar and showed little change. In 2006, of adults with diabetes took diabetes medication is 84%.

Percentage Using Any Diabetes Medication Among Adults with Diabetes by Age

From 1997 to 2006, adults with diabetes aged 18-44 years had a lower percentage of any diabetes medication use (either pill(s) or insulin or both) than the older age groups. During this time period, no consistent trend was observed within each age group. In 2006, about 72% of adults with diabetes aged 18-44 years took any diabetes medication for diabetes, followed by 85% of those aged 45-64 years, 89% of those aged 65-74 years, and 87% of those aged 75 years and older.

Age-Adjusted Percentage Using Any Diabetes Medication Among Adults with Diabetes, by Race/Ethnicity

From 1997 to 2006, no trend was observed within each race/ethnicity group for the age-adjusted percentage of any diabetes medication use (either pill(s) or insulin or both) among adults with diabetes. However, during this period, using any diabetes medication was highest among blacks. In 2006, the age-adjusted percentage of any diabetes medication use among adults with diabetes was about 78% for white, 84% for black and 79% for Hispanics.

Gestational Diabetes

Pregnant women who have never had diabetes before but who have high blood sugar (glucose) levels during pregnancy are said to have gestational diabetes. Gestational diabetes affects about 4% of all pregnant women - about 135,000 cases of gestational diabetes in the United States each year.

It is not known what causes gestational diabetes, but there are some clues. The placenta supports the baby as it grows. Hormones from the placenta help the baby develop. But these hormones also block the action of the mother's insulin in her body. This problem is called insulin resistance. Insulin resistance makes it hard for the mother's body to use insulin. She may need up to three times as much insulin.

Gestational diabetes starts when the body is not able to make and use all the insulin it needs for pregnancy. Without enough insulin, glucose cannot leave the blood and be changed to energy. Glucose builds up in the blood to high levels. This is called hyperglycemia.

Gestational diabetes affects the mother in late pregnancy, after the baby's body has been formed, but while the baby is busy growing. Because of this, gestational diabetes does not cause the kinds of birth defects sometimes seen in babies whose mothers had diabetes before pregnancy.

However, untreated or poorly controlled gestational diabetes can hurt the baby. The pancreas works overtime to produce insulin, but the insulin does not lower the blood glucose levels. Although insulin does not cross the placenta, glucose and other nutrients do. Extra blood glucose goes through the placenta, giving the baby high blood glucose levels. This causes the baby's pancreas to make extra insulin to get rid of the blood glucose. Since the baby is getting more energy than it needs to grow and develop, the extra energy is stored as fat.

This can lead to macrosomia, or a "fat" baby. Babies with macrosomia face health problems of their own, including damage to their shoulders during birth. Because of the extra insulin made by the baby's pancreas, newborns may have very low blood glucose levels at birth and are also at higher risk for breathing problems. Babies with excess insulin become children who are at risk for obesity and adults who are at risk for type 2 diabetes.

Treating gestational diabetes

Treatment for gestational diabetes aims to keep blood glucose levels equal to those of pregnant women who don't have gestational diabetes. Treatment for gestational diabetes always includes special meal plans and scheduled physical activity. It may also include daily blood glucose testing and insulin injections. Treatment for gestational diabetes helps lower the risk of a cesarean section birth that very large babies may require.

Gestational diabetes usually goes away after pregnancy, however the chances are 2 in 3 that it will return in future pregnancies. In a few women, however, pregnancy uncovers type 1 or type 2 diabetes. It is hard to tell whether these women have gestational diabetes or have just started showing their diabetes during pregnancy. These women will need to continue diabetes treatment after pregnancy.

Many women who have gestational diabetes go on to develop type 2 diabetes years later. There seems to be a link between the tendency to have gestational diabetes and type 2 diabetes. Gestational diabetes and type 2 diabetes both involve insulin resistance. Certain basic lifestyle changes may help prevent diabetes after gestational diabetes.

Pregnancy and Preexisting Diabetes

About 1 in 100 women of childbearing age has diabetes before pregnancy. Pregnancy is considered risky for women with diabetes because of the increased risk of miscarriage, stillbirth and birth defects. However, with good preconception care and careful monitoring of their blood sugar, most women with preexisting diabetes can look forward to healthy pregnancies and healthy babies.²⁷

It is important for women with preexisting diabetes to see a health care provider before trying to get pregnaat and to establish good blood sugar control before, during and after pregnancy. Women who take oral medications to control blood sugar will need to switch to insulin before conceiving and during pregnancy. A multivitamin and folic acid before conception and during early pregnancy can help prevent serious birth defects of the brain and spinal cord.

Women with poorly controlled diabetes in the early weeks of pregnancy are two to four times more likely than women without diabetes to have a baby with a serious birth defect, such as a heart defect or a neural tube defect. They also have an increased risk of miscarriage and stillbirth as well as increased risk of having a very large baby (10 pounds or more), which makes vaginal delivery more difficult and puts the baby at risk for injuries during birth.

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.²⁸

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.

Children with Diabetes

Diabetes is one of the most common diseases in school-aged children. According to the National Diabetes Fact Sheet, about 186,300 young people in the US under age 20 had diabetes in 2007. This represents 0.2% of all people in this age group.²⁹¹

Based on data from 2002-2003, the SEARCH for Diabetes in Youth study reported that approximately 15,000 US youth under 20 years of age are diagnosed annually with type 1 diabetes, while 3,700 are newly diagnosed with type 2 diabetes. Type 2 diabetes is rare in children younger than 10 years of age, regardless of race or ethnicity. After 10 years of age, type 2 diabetes becomes increasingly common, especially in minority populations, representing 14.9% of newly diagnosed cases of diabetes in non-Hispanic whites, 46.1% in Hispanic youth, 57.8% in African Americans, 69.7 % in Asian/Pacific Islanders, and 86.2% in American Indian youth.

Results from the 2005-2006 National Health and Nutrition Examination Survey (NHANES), using measured heights and weights, indicate that an estimated 16-17 percent of children and adolescents ages 2-19 years had a BMI greater than or equal to 95th percentile of the age- and sex-specific BMI- about double the number of two decades ago. Overweight in youth contributes to the increasing numbers of young people who have type 2 diabetes.

Type 1 Diabetes

Type 1 diabetes is an autoimmune disease in which the immune system destroys the insulin-producing beta cells of the pancreas that help regulate blood glucose levels. Type 1 diabetes mostly has an acute onset, with children and adolescents usually able to pinpoint when symptoms began. Onset can occur at any age, but it most often occurs in children and young adults.

Since the pancreas can no longer produce insulin, people with type 1 diabetes are required to take insulin daily, either by injection or via an insulin pump. Other methods to deliver insulin are being investigated. Children with type 1 diabetes are at risk for long-term complications (damage to the cardiovascular system, kidneys, eyes, nerves, blood vessels, skin, gums, and teeth).

Type 1 diabetes accounts for 5 to 10 percent of all diagnosed cases of diabetes, but is the leading cause of diabetes in children of all ages, and in those less than 10 years of age, type 1 accounts for almost all diabetes. A diabetes management plan for young people includes insulin therapy, self-monitoring of blood glucose, healthy eating, and physical activity. The plan is designed to ensure proper growth and prevention of hypoglycemia. New management strategies are helping children with type 1 diabetes live long and healthy lives.

Symptoms

The immunologic process that leads to type 1 diabetes can begin years before the symptoms of type 1 diabetes develop. Symptoms become apparent when most of the beta-cell population is destroyed and develop over a short period of time. Early symptoms, which are mainly due to hyperglycemia, include increased thirst and urination, constant hunger, weight loss, and blurred vision. Children also may feel very tired.

As insulin deficiency worsens, ketoacids (formed from the breakdown of fat) build up in the blood and are excreted in the urine and breath. They cause the feeling of shortness of breath and abdominal pain, vomiting and worsening dehydration. Elevation of blood glucose, acidosis and dehydration comprise the condition known as diabetic ketoacidosis or DKA. If diabetes is not diagnosed and treated with insulin at this point, the individual can lapse into a life-threatening diabetic coma. Often, children with vomiting are mistakenly diagnosed as having gastroenteritis. New-onset diabetes can be differentiated from a GI infection by the frequent urination that accompanies continued vomiting, as opposed to decreased urination due to dehydration if the vomiting is caused by a GI "bug."

Risk Factors

Type 2 Diabetes

Symptoms

Type 2 diabetes usually develops slowly and insidiously in children. Symptoms may be similar to those of type 1 diabetes. A child or teen can feel very tired, thirsty, or nauseated and have to urinate often. Other symptoms may include weight loss, blurred vision, frequent infections, and slow healing of wounds or sores. Some children or adolescents with type 2 diabetes may show no symptoms at all when they are diagnosed, and others may present with vaginal yeast infection or burning on urination due to yeast infection. Some children may have extreme elevation of the blood glucose level associated with severe dehydration and coma. Therefore, it is important for health care providers to identify and test children or teens who are at high risk for the disease.

Maturity-onset Diabetes of the Young

Maturity-onset diabetes of the young (MODY), due to one of six gene defects, 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.3 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.3 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.

Secondary Diabetes

Diabetes can occur in children with other diseases such as cystic fibrosis or those using glucocorticoid drugs. These causes may account for one to five percent of all diagnosed cases of diabetes.

Prevalence of Diabetes in Youth

Diabetes is one of the most common diseases in school-aged children. According to the National Diabetes Fact Sheet, about 186,300 young people in the US under age 20 had diabetes in 2007. This represents 0.2% of all people in this age group.

Based on data from 2002-2003, the SEARCH for Diabetes in Youth study reported that approximately 15,000 US youth under 20 years of age are diagnosed annually with type 1 diabetes, while 3,700 are newly diagnosed with type 2 diabetes. Type 2 diabetes is rare in children younger than 10 years of age, regardless of race or ethnicity. After 10 years of age, type 2 diabetes becomes increasingly common, especially in minority populations, representing 14.9% of newly diagnosed cases of diabetes in non-Hispanic whites, 46.1% in Hispanic youth, 57.8% in African Americans, 69.7 % in Asian/Pacific Islanders, and 86.2% in American Indian youth.

Results from the 2005-2006 National Health and Nutrition Examination Survey (NHANES), using measured heights and weights, indicate that an estimated 16-17 percent of children and adolescents ages 2-19 years had a BMI greater than or equal to 95th percentile of the age- and sex-specific BMI- about double the number of two decades ago. Overweight in youth contributes to the increasing numbers of young people who have type 2 diabetes. The Centers for Disease Control and Prevention (CDC) BMI and growth curves calculate body fatness in children.³⁰

Identifying and Testing Children with Diabetes

Type 1 diabetes

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 older adolescents and adults). Children and adolescents may present with ketoacidosis as the first indication of type 1 diabetes. Others may have post-meal hyperglycemia, or modest fasting hyperglycemia that rapidly progresses to severe hyperglycemia and/or ketoacidosis in the presence of infection or other stress.

As type 1 diabetes is caused by immune destruction of the insulin-producing beta cells, antibodies against proteins in the islets are found in children and adolescents months to years before the onset of diabetes. The presence of these antibodies, GAD-65, ICA, IAA and IA-2, have formed the basis for trials predicting who will develop diabetes and for recruiting high risk children and adults for prevention trials. Individuals with high titer antibodies and those with more than one antibody are more likely to develop type 1 diabetes. In addition, young age and being a first degree relative of someone with type 1 diabetes place children at high risk. In general, 70 percent of people with new-onset diabetes will have a positive antibody if only one antibody is tested, whereas 90 percent will have at least one antibody when all four are measured.

Type 2 diabetes

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 Indians7 and in other pediatric populations in the United States8-10 and are often present at disease onset.

Undiagnosed type 2 diabetes in children and adolescents may place these young people at early risk for cardiovascular disease; however, no data are available to define the scope of this problem. In adults, up to 25% of individuals who have type 2 diabetes are undiagnosed and at risk for microvascular and macrovascular complications of diabetes.11 It is important, therefore, for health care providers to consider testing for diabetes in high risk or symptomatic children. Note that adult screening programs identify more people with diabetes than do equivalent screening programs in youth.

Current testing criteria and diabetes risk factors to help identify type 2 diabetes in children before the onset of complications were developed in 2000 by the American Academy of Pediatrics and the American Diabetes Association.

Testing Criteria

Overweight (BMI 85th to 94th percentile) or obese (BMI >95th percentile) for age and gender; weight for height >85th percentile; or weight >120 percent of ideal for height

Any two of the following risk factors:

1. 1. Family history of type 2 diabetes in first- or second-degree relative
2. American Indian, African American, Hispanic/Latino, Asian American, or Pacific Islander heritage
3. 2. Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovarian syndrome)
4. Age to begin testing--10 years old or at onset of puberty if puberty occurs earlier Frequency of testing--every 2 years
5. Test to use--fasting plasma glucose

Clinical judgment should be used to perform testing in children and adolescents who do not meet the above criteria.

Treatment Strategies

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 meals, with the amount of pre-meal insulin based on carbohydrate content of the meal using an insulin:carbohydrate ratio and a correction scale for hyperglycemia. Further adjustment of insulin or food intake may be made based on anticipation of special circumstances such as increased exercise and intercurrent illness. 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, glucose-lowering medication and/or insulin therapy are used as well. There are a variety of different diabetes medications, some that are taken orally, and some taken by injection (or via a subcutaneous pump), such as insulin. Youth with type 2 diabetes may take one or more different glucose-lowering medications. Glucose lowering medications differ by their mechanism of actions. Overall, they can enhance endogenous insulin secretion, inhibit excessive hepatic glucose production, enhance insulin sensitivity in muscle and adipose tissue, inhibit gastrointestinal carbohydrate absorption, delay gastric emptying, inhibit glucagon secretion, and enhance satiety. The most frequently used oral glucose-lowering medication in children and adolescents is metformin. Glimperide is also approved for children eight years of age and older. All aspects of the regimen are individualized.

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 with a syringe or a pen or pump, use of oral glucose-lowering medication 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.

Blood Glucose Goals

To control diabetes and prevent complications, blood glucose levels in children with type 1 diabetes should be managed as indicated in Table 1. Families should work with their health care team to set target blood glucose levels appropriate for the child. 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.

Optimal plasma blood glucose and A1C goals for type 1 diabetes by age group are:

* A lower goal (<7.0) is reasonable if it can be achieved without excessive hypoglycemia.

Key concepts in setting glycemic goals:

• " Goals should be individualized and lower goals may be reasonable based on benefit: risk assessment.
• " Blood glucose goals should be higher than those listed above in children with frequent hypoglycemia or hypoglycemia unawareness.
• " Postprandial blood glucose values should be measured when there is a disparity between preprandial blood glucose values and A1C levels.

Diabetes treatment can sometimes cause blood glucose levels to drop too low, with resultant hypoglycemia. Taking too much insulin, missing a meal or snack, or strenuous exercising may cause hypoglycemia. In addition, hypoglycemia can occur when there has been no apparent cause. A child can become irritable, shaky, or confused. When blood glucose levels fall very low, loss of consciousness or seizures may develop.

When hypoglycemia is recognized, the child should drink or eat a concentrated sugar to quickly raise the blood glucose to greater than 70 mg/dl. Once the blood glucose is over 70 mg/dl, the child can eat food containing protein to maintain blood glucose levels in the normal range. Hypoglycemia occurring during the night should be treated with a concentrated sugar to achieve a BG of 80- 100 mg/dL before giving a protein-containing food. The concentrated sugar will cause resolution of symptoms quickly, avoiding over-treatment of "lows." If the child is unable to eat or drink, a glucose gel may be administered to the buccal mucosa of the cheek; however, in the face of an altered level of consciousness or if the child cannot cooperate, glucagon or IV glucose should be administered.

Glycemic goals may need to be modified to take into account the fact that most children younger than 6 or 7 years of age have a form of "hypoglycemic unawareness." They lack the cognitive capacity to recognize and respond to hypoglycemic symptoms and may be at greater risk for hypoglycemia.

Hyperglycemia

Monitoring Complications and Reducing CVD Risk

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. For children with type 1 diabetes, 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. In type 2 diabetes, the initial examination should be shortly after diagnosis. In type 1 and type 2 diabetes, 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. For children with type 1 diabetes, annual screening for microalbuminuria should be initiated once the child is 10 years of age and has had diabetes for 5 years. In type 2 diabetes, annual screening should be initiated at diagnosis. 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</p>

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-cholesterol less than 100 mg/dl), repeat the 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-cholesterol level remains above 160 mg/dl, pharmacologic agents should be given. If, the LDL-cholesterol 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 >95th percentile for age, sex, and height measured on at least three separate days.³¹

ACE inhibitors are the agents of choice for the treatment of hypertension in children with co-existing microalbuminuria. They have beneficial effects on slowing progression or preventing diabetic nephropathy.

Health Care Team

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 consideration of teens' emerging autonomy and independence.

Diabetes care for children and teens 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.

At Diagnosis, establish the goals of care and required treatment. 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.
• Check lipids in children with a significant family history*
• Check for microalbumin in type 2 diabetes.
• Provide ophthalmologic examination shortly after diagnosis in type 2 diabetes.
• * In children with no significant family history, check lipids at puberty after glucose control has been established and if normal, repeat profile every 5 years (see section on lipids for more information).

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)*
• 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 first ophthalmologic examination should be obtained once the child is age 10 or older and has had type 1 diabetes for 3 to 5 years. For children with type 2 diabetes, the first examination should be shortly after diagnosis.

Helping Children and Adolescents Manage Diabetes

The health care professional team, in partnership with the young person with diabetes and parents or other caregivers, needs to develop a personal diabetes management plan and daily schedule. The plan helps the child or teen 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 activity level, 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.

Get regular physical activity

Children with diabetes need regular physical activity, ideally a total of 60 minutes each day. Physical activity helps to lower blood glucose levels and increase insulin sensitivity, especially in children and adolescents with type 2 diabetes. Physical activity is also a good way to help children control their weight. In children with type 1 diabetes, the most common problem encountered during physical activity 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 be physically active until the low blood glucose level has been treated.

Check blood glucose levels regularly

Continuous Glucose Sensing Systems

After many years of research, continuous glucose sensing systems are becoming available for young people and adults with type 1 diabetes. All continuous glucose sensing systems have the same basic components: a sensor that is placed underneath the skin, a small transmitter worn on the body that connects to the sensor, and a hand-held cell-phone sized receiver that displays the current glucose levels and trends. Some systems integrate the receiver into an insulin pump, thereby reducing the number of extra components that need to be carried.

By having more glucose values available, users are able to see trends and better understand the effects of different foods, exercise, stress, and illness. Receivers sound an alarm when the person's glucose level drops below or goes above a certain pre-set level and in some systems when the projected glucose level will be high or low in 10 or 20 minutes, giving users a chance to prevent low blood glucose with early treatment. As insurance companies begin to approve coverage for continuous glucose sensors, more and more young people with type 1 diabetes are likely to benefit from them.

Take all diabetes medication as prescribed

Special Issues

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.

For any child or teen with diabetes, learning to cope with the disease is a big task. Dealing with a chronic illness such as diabetes may cause emotional and behavioral challenges, sometimes leading to depression. Talking to a social worker or psychologist may help young people and their families learn to adjust to the lifestyle changes needed to stay healthy.

Family Support

Managing diabetes in children and adolescents is most effective when the entire family gets involved. Diabetes education should involve family members. Families can be encouraged to share concerns with physicians, diabetes educators, dietitians, and other health care providers to get their help in the day-to-day management of diabetes. Extended family members, teachers, school nurses, counselors, coaches, day care providers, and other resources in the community can provide information, support, guidance, and help with coping skills. These individuals also may be knowledgeable about resources for health education, financial services, social services, mental health counseling, transportation, and home visits.

Diabetes is stressful for both the children and their families. Parents should be alert for signs of depression or eating disorders or insulin omission to lose weight and seek appropriate treatment. While all parents should talk to their children about avoiding tobacco, alcohol, and other drugs, this is particularly important for children with diabetes. Smoking and diabetes each independently increase the risk of cardiovascular disease and people with diabetes who smoke have a greatly increased risk of heart disease and circulatory problems. Binge drinking can cause hyperglycemia acutely, followed by an increased risk of hypoglycemia. The symptoms of intoxication are very similar to the symptoms of hypoglycemia, and thus, may result in delay of treatment of hypoglycemia with potentially disastrous consequences.

Transition to Independence

Children with diabetes--depending on their age and level of maturity--will learn to take over much of their care. Most school-age children can recognize symptoms of hypoglycemia and monitor blood glucose levels. They also participate in nutrition decisions. They often can give their own insulin injections but may not be able to draw up the dose accurately in a syringe until a developmental age of 11 to 12 years.

Adolescents often have the motor and cognitive skills to perform all diabetes-related tasks and determine insulin doses based on blood glucose levels and food intake. This is a time, however, when peer acceptance is important, risk-taking behaviors common, and rebellion against authority is part of teens' search for independence. Thus, adolescents must be supervised in their diabetes tasks and allowed gradual independence with the understanding that the independence will be continued only if they adhere to the diabetes regimen and succeed in maintaining reasonable metabolic control. During mid-adolescence, the family and health care team should stress to teens the importance of checking blood glucose levels prior to driving a car to avoid hypoglycemia while driving.

Diabetes at School

NDEP's School Guide educates and informs school personnel about diabetes, how it is managed, and how each member of the school staff can help meet the needs of students with the disease. School principals, administrators, nurses, teachers, coaches, bus drivers, health care, and lunchroom staff all play a role in helping students with diabetes succeed.

Several Federal and some state laws provide protections to children with disabilities, including diabetes. These laws help ensure that all students with diabetes are educated in a medically safe environment and have the same access to educational opportunities as their peers-in public and some private schools. Students with diabetes are entitled to accommodations and modifications necessary for them to stay healthy at school. Accommodations may need to be made in the classroom, with physical education, on field trips, and/or for after-school activities.

Written plans outlining each student's diabetes management help students, their families, school staff, and the student's health care providers know what is expected of them. These expectations should be laid out in written documents, such as a:

Diabetes Medical Management Plan, developed by the student's personal health care team and family Quick Reference Emergency Plan, which describes how to recognize hypoglycemia and hyperglycemia and what to do as soon as signs or symptoms of these conditions are observed Education plans, such as the Section 504 Plan or Individualized Education Program (IEP)

Care Plan or Individual Health Plan generated by the school nurse

The school nurse is the most appropriate person to coordinate care for students with diabetes. Each student with diabetes should have a written plan, developed by the school nurse, incorporating physician orders, parent requests, and tailored to the specific developmental, physical, cognitive, and skill ability of the child. The nurse will conduct a nursing assessment of the student and develop a nursing care plan, taking into consideration the child's cognitive, emotional, and physical status as well as the medical orders contained in the Diabetes Medical Management Plan. A team approach to developing the care plan, involving the student, parent, health care provider, key school personnel, and school nurse, is the most effective way to ensure safe and effective diabetes management during the school day.

The nursing care plan would also identify school employees assigned to provide care to an individual student, under the direction of the school nurse, when allowed by state nurse practice acts. The school nurse is responsible for training, monitoring, and supervising these school personnel. The school nurse will promote and encourage independence and self-care consistent with the student's ability, skill, maturity, and developmental level.

Camps and Support Groups

Local peer groups and camps for children and teens with diabetes can provide positive role models and group activities. Peer encouragement often helps children perform diabetes-related tasks that they had been afraid to do previously and encourages independence in diabetes management. Talking with other children who have diabetes helps young people feel less isolated and less alone in having to deal with the demands of diabetes. They have the opportunity to discuss issues they share in common that others in their peer group can't understand, and they can share solutions to problems that they have encountered. Often, these programs challenge children physically and teach them how to deal with increased exercise, reinforcing the fact that diabetes should not limit them in their ability to perform strenuous physical activity.³²

Prevention Strategies for Type 2 Diabetes

For children and teens at risk, health care professionals can encourage, support, and educate the entire family to make lifestyle changes that may delay -- or lower the risk for -- the onset of type 2 diabetes. Such lifestyle changes include keeping at a healthy weight and staying active. New research findings will help determine effective ways to lower risk factors in high risk children.

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. Other nerves susceptible to entrapment may cause pain on the outside of the shin or the inside of the foot.

The best way to prevent neuropathy is to keep blood glucose levels as close to the normal range as possible and maintaining safe blood glucose levels protects nerves throughout the body.

Neuropathy is diagnosed on the basis of symptoms and a physical exam. During the exam, the doctor may check blood pressure and heart rate, muscle strength, reflexes, and sensitivity to position, vibration, temperature, or a light touch.

The doctor may also do other tests to help determine the type and extent of nerve damage.³³

• A comprehensive foot exam assesses skin, circulation, and sensation. The test can be done during a routine office visit. To assess protective sensation or feeling in the foot, a nylon monofilament (similar to a bristle on a hairbrush) attached to a wand is used to touch the foot. Those who cannot sense pressure from the monofilament have lost protective sensation and are at risk for developing foot sores that may not heal properly. Other tests include checking reflexes and assessing vibration perception, which is more sensitive than touch pressure.
• Nerve conduction studies check the transmission of electrical current through a nerve. With this test, an image of the nerve conducting an electrical signal is projected onto a screen. Nerve impulses that seem slower or weaker than usual indicate possible damage. This test allows the doctor to assess the condition of all the nerves in the arms and legs.
• Electromyography (EMG) shows how well muscles respond to electrical signals transmitted by nearby nerves. The electrical activity of the muscle is displayed on a screen. A response that is slower or weaker than usual suggests damage to the nerve or muscle. This test is often done at the same time as nerve conduction studies.
• Quantitative sensory testing (QST) uses the response to stimuli, such as pressure, vibration, and temperature, to check for neuropathy. QST is increasingly used to recognize sensation loss and excessive irritability of nerves.
• A check of heart rate variability shows how the heart responds to deep breathing and to changes in blood pressure and posture.
• Ultrasound uses sound waves to produce an image of internal organs. An ultrasound of the bladder and other parts of the urinary tract, for example, can show how these organs preserve a normal structure and whether the bladder empties completely after urination.
• Nerve or skin biopsy involves removing a sample of nerve or skin tissue for examination by microscope. This test is most often used in research settings.

The first step is to bring blood glucose levels within the normal range to prevent further nerve damage. Blood glucose monitoring, meal planning, exercise, and oral drugs or insulin injections are needed to control blood glucose levels. Although symptoms may get worse when blood glucose is first brought under control, over time, maintaining lower blood glucose levels helps lessen neuropathic symptoms. Importantly, good blood glucose control may also help prevent or delay the onset of further problems.

Additional treatment depends on the type of nerve problem and symptom, as described in the following sections.

People with neuropathy need to take special care of their feet. The nerves to the feet are the longest in the body and are the ones most often affected by neuropathy. Loss of sensation in the feet means that sores or injuries may not be noticed and may become ulcerated or infected. Circulation problems also increase the risk of foot ulcers.

More than half of all lower limb amputations in the United States occur in people with diabetes-86,000 amputations per year. Doctors estimate that nearly half of the amputations caused by neuropathy and poor circulation could have been prevented by careful foot care. The recommended steps to follow are:

• Clean feet daily, using warm-not hot-water and a mild soap. Avoid soaking the feet. Dry them with a soft towel; dry carefully between the toes.
• Inspect feet and toes every day for cuts, blisters, redness, swelling, calluses, or other problems. Use a mirror (laying a mirror on the floor works well) or get help from someone else if they cannot see the bottoms of the feet.
• Moisturize feet with lotion, but avoid getting it between the toes.
• After a bath or shower, file corns and calluses gently with a pumice stone.
• Each week or when needed, cut toenails to the shape of the toes and file the edges with an emery board.
• Always wear shoes or slippers to protect feet from injuries. Prevent skin irritation by wearing thick, soft, seamless socks.
• Wear shoes that fit well and allow the toes to move. Break in new shoes gradually by wearing them for only an hour at a time at first.
• Before putting shoes on, look them over carefully and feel the insides with the hand to make sure they have no tears, sharp edges, or objects in them that might injure the feet.
• If thye need help taking care of their feet, they should make an appointment to see a foot doctor (podiatrist).

Pain Relief

To relieve pain, burning, tingling, or numbness, the doctor may suggest aspirin, acetaminophen, or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. (People with renal disease should use NSAIDs only under a doctor's supervision.) A topical cream called capsaicin is another option. Tricyclic antidepressant medications such as amitriptyline, imipramine, and nortriptyline, or anticonvulsant medications such as carbamazepine or gabapentin may relieve pain in some people. Codeine may be prescribed for a short time to relieve severe pain. Also, mexiletine, used to regulate heartbeat, has been effective in treating pain in several clinical trials.

Other pain treatments include transcutaneous electronic nerve stimulation (TENS), which uses small amounts of electricity to block pain signals, as well as hypnosis, relaxation training, biofeedback, and acupuncture.

Walking regularly or using elastic stockings may also help leg pain.

To relieve mild symptoms of gastroparesis-indigestion, belching, nausea, or vomiting-doctors suggest eating small, frequent meals, avoiding fats, and eating less fiber. When symptoms are severe, the doctor may prescribe erythromycin to speed digestion, metoclopramide to speed digestion and help relieve nausea, or other drugs to help regulate digestion or reduce stomach acid secretion.

To relieve diarrhea or other bowel problems, the doctor may prescribe an antibiotic such as tetracycline, or other medications as appropriate.

Sitting or standing slowly may help prevent the light-headedness, dizziness, or fainting associated with blood pressure and circulation problems. Raising the head of the bed or wearing elastic stockings may also help. Some people may benefit from increased salt in the diet and treatment with salt-retaining hormones. Others may benefit from high blood pressure medications. Physical therapy can help when muscle weakness or loss of coordination is a problem.

To clear up a urinary tract infection, the doctor will probably prescribe an antibiotic. Drinking plenty of fluids will help prevent another infection. People who have incontinence should try to urinate at regular intervals (every 3 hours, for example) since they may not be able to tell when their bladder is full.

To treat erectile dysfunction in men, the doctor will first do tests to rule out a hormonal cause. Several methods are available to treat erectile dysfunction caused by neuropathy, including taking oral drugs, using a mechanical vacuum device, or injecting a drug called a vasodilator into the penis before sex. The vacuum and vasodilator raise blood flow to the penis, making it easier to have and maintain an erection. Another option is to surgically implant an inflatable or semirigid device in the penis. A constriction ring or penile sling may be helpful.

Vaginal lubricants may be useful for women when neuropathy causes vaginal dryness. To treat problems with arousal and orgasm, the doctor may refer the woman to a gynecologist.

• Diabetic neuropathies are nerve disorders caused by many of the abnormalities common to diabetes, such as high blood glucose.
• Neuropathy can affect nerves throughout the body, causing numbness and sometimes pain in the hands, arms, feet, or legs, and problems with the digestive tract, heart, and sex organs.
• Treatment first involves bringing blood glucose levels within the normal range. Good blood glucose control may help prevent or delay the onset of further problems.
• Foot care is another important part of treatment. People with neuropathy need to inspect their feet daily for any injuries. Untreated injuries increase the risk of infected foot sores and amputation.
• Treatment also includes pain relief and other medications as needed, depending on the type of nerve damage.
• Smoking significantly increases the risk of foot problems and amputation. If they smoke, it is advised that they ask their health care provider for help in quitting.

The following Glossary was developed by the National Center for Chronic Disease Prevention and Health Promotion.

A1C-A test that sums up how much glucose has been sticking to part of the hemoglobin during the past 3-4 months. Hemoglobin is a substance in the red blood cells that supplies oxygen to the cells of the body.

ACE inhibitor-A type of drug used to lower blood pressure. Studies indicate that it may also help prevent or slow the progression of kidney disease in people with diabetes. ACE is an acronym for angiotensin-converting enzyme.

Autoimmune process-A process where the body's immune system attacks and destroys body tissue that it mistakes for foreign matter.

beta cells-Cells that make insulin. Beta cells are found in areas of the pancreas called the Islets of Langerhans.

bladder-A hollow organ that urine drains into from the kidneys. From the bladder, urine leaves the body.

blood glucose-The main sugar that the body makes from the food we eat. Glucose is carried through the bloodstream to provide energy to all of the body's living cells. The cells cannot use glucose without the help of insulin.

blood pressure-The force of the blood against the artery walls. Two levels of blood pressure are measured: the highest, or systolic, occurs when the heart pumps blood into the blood vessels, and the lowest, or diastolic, occurs when the heart rests.

blood sugar-See blood glucose.

calluses-Thick, hardened areas of the skin, generally on the foot, caused by friction or pressure. Calluses can lead to other problems, including serious infection and even gangrene.

carbohydrate-One of three main groups of foods in the diet that provide calories and energy. (Protein and fat are the others.) Carbohydrates are mainly sugars (simple carbohydrates) and starches (complex carbohydrates, found in bread, pasta, beans) that the body breaks down into glucose.

cholesterol-A substance similar to fat that is found in the blood, muscles, liver, brain, and other body tissues. The body produces and needs some cholesterol. However, too much cholesterol can make fats stick to the walls of the arteries and cause a disease that decreases or stops circulation.

corns-A thickening of the skin of the feet or hands, usually caused by pressure against the skin.

diabetes-The short name for the disease called diabetes mellitus. Diabetes results when the body cannot use blood glucose as energy because of having too little insulin or being unable to use insulin. See also type 1 diabetes, type 2 diabetes, and gestational diabetes.

diabetes pills-Pills or capsules that are taken by mouth to help lower the blood glucose level. These pills may work for people whose bodies are still making insulin.

diabetic eye disease-A disease of the small blood vessels of the retina of the eye in people with diabetes. In this disease, the vessels swell and leak liquid into the retina, blurring the vision and sometimes leading to blindness.

diabetic ketoacidosis-High blood glucose with the presence of ketones in the urine and bloodstream, often caused by taking too little insulin or during illness.

diabetic kidney disease-Damage to the cells or blood vessels of the kidney.

diabetic nerve damage-Damage to the nerves of a person with diabetes. Nerve damage may affect the feet and hands, as well as major organs.

dialysis-A method for removing waste from the blood when the kidneys can no longer do the job.

diphtheria-An acute, contagious disease that causes fever and problems for the heart and nervous system.

EKG-A test that measures the heart's action. Also called an electrocardiogram.

flu-An infection caused by the "flu" (short for "influenza") virus. The flu is a contagious viral illness that strikes quickly and severely. Signs include high fever, chills, body aches, runny nose, sore throat, and headache.

food exchanges-A way to help people stay on special food plans by letting them replace items from one food group with items from another group.

gestational diabetes-A type of diabetes that can occur in pregnant women who have not been known to have diabetes before. Although gestational diabetes usually subsides after pregnancy, many women who've had gestational diabetes develop type 2 diabetes later in life.

gingivitis-A swelling and soreness of the gums that, without treatment, can cause serious gum problems and disease.

glucagon-A hormone that raises the blood glucose level. When someone with diabetes has a very low blood glucose level, a glucagon injection can help raise the blood glucose quickly.

glucose-A sugar in our blood and a source of energy for our bodies.

heart attack-Damage to the heart muscle caused when the blood vessels supplying the muscle are blocked, such as when the blood vessels are clogged with fats (a condition sometimes called hardening of the arteries).

HDL (or high-density lipoprotein)-A combined protein and fatlike substance. Low in cholesterol, it usually passes freely through the arteries. Sometimes called "good cholesterol."

high blood glucose-A condition that occurs in people with diabetes when their blood glucose levels are too high. Symptoms include having to urinate often, being very thirsty, and losing weight.

high blood pressure-A condition where the blood circulates through the arteries with too much force. High blood pressure tires the heart, harms the arteries, and increases the risk of heart attack, stroke, and kidney problems.

hormone-A chemical that special cells in the body release to help other cells work. For example, insulin is a hormone made in the pancreas to help the body use glucose as energy.

hyperglycemia-See high blood glucose.

hypertension-See high blood pressure.

hypoglycemia-See low blood glucose.

immunization-Sometimes called vaccination; a shot or injection that protects a person from getting an illness by making the person "immune" to it.

impotence-A condition where the penis does not become or stay hard enough for sex. Some men who have had diabetes a long time become impotent if their nerves or blood vessels have become damaged.

influenza-See flu.

inject-To force a liquid into the body with a needle and syringe.

insulin-A hormone that helps the body use blood glucose for energy. The beta cells of the pancreas make insulin. When people with diabetes can't make enough insulin, they may have to inject it from another source.

insulin-dependent diabetes-See type 1 diabetes.

ketones-Chemical substances that the body makes when it doesn't have enough insulin in the blood. When ketones build up in the body for a long time, serious illness or coma can result.

kidneys-Twin organs found in the lower part of the back. The kidneys purify the blood of all waste and harmful material. They also control the level of some helpful chemical substances in the blood.

laser surgery-Surgery that uses a strong ray of special light, called a laser, to treat damaged parts of the body. Laser surgery can help treat some diabetic eye diseases.

low blood glucose-A condition that occurs in people with diabetes when their blood glucose levels are too low. Symptoms include feeling anxious or confused, feeling numb in the arms and hands, and shaking or feeling dizzy.

LDL (or low-density lipoprotein)-A combined protein and fatlike substance. Rich in cholesterol, it tends to stick to the walls in the arteries. Sometimes called "bad cholesterol."

meal plan-A guide to help people get the proper amount of calories, carbohydrates, proteins, and fats in their diet. See also food exchanges.

microalbumin-A protein found in blood plasma and urine. The presence of microalbumin in the urine can be a sign of kidney disease.

nephropathy-See diabetic kidney disease.

neuropathy-See diabetic nerve damage.

non-insulin-dependent diabetes-See type 2 diabetes.

pancreas-An organ in the body that makes insulin so that the body can use glucose for energy. The pancreas also makes enzymes that help the body digest food.

periodontitis-A gum disease in which the gums shrink away from the teeth. Without treatment, it can lead to tooth loss.

plaque-A film of mucus that traps bacteria on the surface of the teeth. Plaque can be removed with daily brushing and flossing of teeth.

pumice stone-A special foot care tool used to gently file calluses as instructed by the health care team.

retinopathy-See diabetic eye disease.

risk factors-Traits that make it more likely that a person will get an illness. For example, a risk factor for getting type 2 diabetes is having a family history of diabetes.

self-monitoring blood glucose-A way for people with diabetes to find out how much glucose is in their blood. A drop of blood from the fingertip is placed on a special coated strip of paper that "reads" (often through an electronic meter) the amount of glucose in the blood.

stroke-Damage to a part of the brain that happens when the blood vessels supplying that part are blocked, such as when the blood vessels are clogged with fats (a condition sometimes called hardening of the arteries).

support group-A group of people who share a similar problem or concern. The people in the group help one another by sharing experiences, knowledge, and information.

type 1 diabetes-A condition in which the pancreas makes so little insulin that the body can't use blood glucose as energy. Type 1 diabetes most often occurs in people younger than age 30 and must be controlled with daily insulin injections.

type 2 diabetes-A condition in which the body either makes too little insulin or can't use the insulin it makes to use blood glucose as energy. Type 2 diabetes most often occurs in people older than age 40 and can often be controlled through meal plans and physical activity plans. Some people with type 2 diabetes have to take diabetes pills or insulin.

ulcer-A break or deep sore in the skin. Germs can enter an ulcer and may be hard to heal.

urea-One of the chief waste products of the body. When the body breaks down food, it uses what it needs and throws the rest away as waste. The kidneys flush the waste from the body in the form of urea, which is in the urine.

vaccination-A shot given to protect against a disease.

vitrectomy-An operation to remove the blood that sometimes collects at the back of the eyes when a person has eye disease.

yeast infection-A vaginal infection that is usually caused by a fungus. Women who have this infection may feel itching, burning when urinating, and pain, and some women have a vaginal discharge. Yeast infections occur more frequently in women with diabetes.