About Diabetes

Diabetes is a high sugar (glucose) level in your blood. It is often diagnosed in people without symptoms, but classic symptoms are feeling very thirsty, urinating frequently, and losing weight despite eating high quantities of food.

Your doctor can diagnose diabetes with a blood test. If a fasting (no food for over eight hours) sugar in your doctor’s office is greater than 126, random sugar greater than 200, or average blood sugar over three months (hemoglobin A1c) is greater than 6.5%, this may suggest the diagnosis of diabetes. Your doctor will likely repeat the blood test to confirm the diagnosis.

What problems can a high blood sugar cause? High sugar levels can damage body organs and cause tissue damage. As a result, complications can occur such as nerve damage, heart attacks, strokes, peripheral vascular disease (causing leg pain and ulcers in the feet), cataracts, loss of vision and kidney damage. High sugar passes through the kidneys and causes an increased volume of urine, which can lead to increased thirst. Although the sugar is high in the blood, it cannot be used for energy by the body, which is the reason that people with poorly controlled diabetes may lose weight ("starvation in the midst of plenty").

Why do diabetics have an elevated fasting morning blood sugar if they have not been eating all night? The rise in sugar after meals comes primarily from the carbohydrates in the diet. However, the fasting blood sugar (the glucose level which is measured in the morning before breakfast, after an overnight fast) comes from the liver. The liver stores sugar in the form of starch (glycogen). The liver normally releases sugar (which becomes available when the starch is broken down in the liver) during the night to prevent the blood sugar from going too low during sleep. However, just like a diabetic cannot control the rise in blood sugar after meals, a person with diabetes cannot control the rise in sugar, which occurs at night from sugar released from the liver. There are medications (pills or insulin) to control the rise in sugar after meals and the release of sugar from the liver.


Diabetes-Related Conditions

What other conditions affect people with diabetes? People with Type 2 diabetes are often (but not always) overweight, and can have other co-existing conditions such as high blood pressure (“hypertension”) and high cholesterol. These conditions can lead to strokes, heart attacks and peripheral vascular disease. The combination of suboptimally controlled diabetes, along with poorly controlled hypertension and high cholesterol, greatly increases the risk of vascular damage and the complications previously mentioned. Cigarette smoking, which is also associated with vascular damage can lead to many complications, even worse for people with diabetes.


Prevention

Implementing physical activity into your daily routine can help prevent or delay type 2 diabetes among adults at high risk of developing diabetes. Developing a lifestyle that incorporates healthy eating and nutritional choices can help prevent type 2 diabetes and manage prediabetes.

What is prediabetes? Prediabetes is defined as a fasting blood sugar between 100 mg/dl and 126 mg/dl, or a random blood sugar between 140 mg/ dl and 200 mg/dl or hemoglobin A1c above the normal range (usually 5.7%-5.8% and less than 6.5%). Although diabetes can appear without warning, most people go through a stage of prediabetes or "impaired glucose tolerance" prior to developing overt diabetes. The good news is that people with prediabetes can reduce the likelihood of developing diabetes with initiation of a low-carbohydrate diet and increasing physical activity.

Who is at risk of developing diabetes? People with a family history of diabetes are at an increased risk of developing diabetes in the future, however there are many people without a family history who also develop diabetes. The association of being overweight and developing diabetes is well known. Other risk factors such as infection, some endocrine disorders, and certain medications such as steroids have been associated with high blood sugar. People who get diabetes under the conditions mentioned above are likely "predisposed” to diabetes. Pregnancy can be associated with the development of diabetes ( a condition called gestational diabetes), however the sugar often returns to normal after delivery. Factors that may increase your risk of developing diabetes include the following:

  1. You are 45 or older
  2. You are overweight
  3. You eat an unhealthy diet
  4. You have a parent, brother or sister with diabetes
  5. Your family background is African American, American Indian, Asian American, Pacific Islander or Hispanic American/Latino
  6. You have had gestational diabetes
  7. You have given birth to at least one baby weighing more than 9 pounds
  8. You have high blood pressure
  9. Your cholesterol levels are higher than normal
  10. You do not get enough physical activity

Treatment

People with diabetes should learn to count carbohydrates in their food as carbohydrates contribute to high blood sugar. Physical activity is essential to diabetes treatment, because muscles that are regularly exercised consume sugar more efficiently than muscles that are inactive. Your doctor may suggest you monitor your finger-stick sugar levels at home with a machine that can measure your sugar (a glucometer). Good control is a fasting blood sugar between 80 and 110 and, 2 hours after a meal ,blood sugar less than 140, The frequency of monitoring depends on your level of control and if you are on insulin and may range from a few times per week to a four to six times per day. Discuss with your doctor if you should monitor your sugar levels and how often.

What kind of medications are used to treat diabetes? Type 1 diabetes, which usually presents in childhood (although can occur less commonly later in life), is caused by a lack of insulin. Therefore, people with type 1 diabetes need to administer insulin due to the absence of their own insulin production

Type 2 diabetes, which is usually present in adulthood, but is being seen more commonly in overweight children, is caused by resistance to the action of insulin. If physical activity and proper nutrition do not adequately control the blood sugar, medication is needed. The choice of medicine depends on what is causing the diabetes. For example, medications can be used to increase the production of insulin from the pancreas, decrease sugar production from the liver, or make the body more sensitive to insulin. Some diabetic medications have a favorable weight profile and can help you lose weight (in combination with diet and physical activity), and this should be kept in mind when deciding on the course of treatment.

Why do some people with type 2 diabetes need to take insulin if they can already make insulin? Sugar can be harmful to many organs in the body, including the pancreas, which is the organ that produces insulin. If a person has long-standing, poorly controlled diabetes with a chronic elevation of the blood sugar, the pancreas cells which make insulin become partially destroyed. As a result, there is a deficiency in insulin and it is important to take insulin as a supplement to other diabetes medications. If the pancreas is making very low amounts of insulin, insulin may be used instead of pills (like a person with type 1 diabetes). Your doctor can perform and check a blood test to help determine if your pancreas is producing insulin.

What is new in the treatment of diabetes? For people with diabetes who are insulin-dependent, insulin pumps are available instead of injections. Insulin pumps can be paired with continuous glucose monitoring systems that can read the blood frequently. The coupling of glucose sensors with pumps will eventually allow for an “artificial pancreas”. In the meantime, glucose data from glucose sensors allows programming of insulin pumps to dose the appropriate amount of insulin." Researchers are looking into ways to regenerate the cells in the pancreas that make insulin. Easier-to-use medications will allow the transplantation of insulin-producing cells to become more common than it is now. Certain drugs called incretins and Amylin (already available) work in complex ways to make the body respond better to the insulin that is available. Alternative ways of taking insulin have been developed (inhaled insulin) or are in development.

How can a person with diabetes know that everything is under control? Monitoring the sugar level at home with a glucometer, as well as following a low-carbohydrate, portion-controlled diet and engaging in regular physical activity, is important. At the physician’s office, a blood test called a hemoglobin A1c (“A1c”) should be done. This test reflects the control of sugar over several months. A normal level is <5.7; a diabetic should aim for less than < 6.5 (in special cases such as in older people or people at high risk for having very low sugar levels, a higher level may be acceptable). Ask your physician what your goal blood glucose levels and A1c should be. The urine should be checked to see if there are small amounts of protein called microalbumin present, which can indicate early kidney disease. If there is microalbumin in the urine, your doctor will likely start a blood pressure medication to protect the kidneys. As part of the office visit, a lipid (cholesterol) panel should be checked, in addition to blood pressure measurement, eye exam and foot exam with a simple nerve function test, called the monofilament test.

In summary, with dietary and lifestyle modifications, medications if necessary, and close monitoring by your physician, you can live and thrive with diabetes.

References Rhoda H. Cobin, MD, MACE; Michael González-Campoy, MD, PhD, FACE; and Carol S. Guber, MS. A Guide to Managing Diabetes. 2007. American Association of Clinical Endocrinologists.