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Life After Cancer A Roadmap for Cancer Survivors

Diabetes Mellitus
Robert J. Rushakoff, MD, FACP

Introduction
Types Of Diabetes
Complications of Diabetes
Treatment of Diabetes
Prevention of Diabetes
Summary


Introduction
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Diabetes mellitus is a chronic disease that can affect the entire body. Two major problems occur with diabetes. First, the body is not able to store and use sugar (glucose) appropriately, and this leads to high levels of glucose in the blood (hyperglycemia). Second, as a result of the hyperglycemia, complications of diabetes may occur - eye disease, kidney disease, nerve disease, and atherosclerosis or heart disease and strokes.

In the past decade, large studies in both the United States and Europe have shown conclusively that with good control of the blood glucose levels (lowering the glucose level to nearly normal), the risk of developing the complications of diabetes can be dramatically reduced. In addition, these studies have also shown that by lowering cholesterol and blood pressure levels, the risk of heart disease and stroke can also be reduced. Thus now, more than ever before, it is clear that control of diabetes and its associated conditions is of primary importance and will lead to a healthier longer life.

Prevention of diabetes in the first place would, of course, keep these devastating complications from ever occurring. Strategies for prevention of diabetes and treatment options are discussed below.

How do we know if you have diabetes? You may have symptoms of high blood sugar. These are:
Excessive thirst
Frequent urination
Fatigue
Itching
Numbness

By current criteria, if you have these symptoms and have a random blood sugar level that is high, (generally over 200 mg/dl) then you have diabetes. If you do not have any symptoms, and your fasting blood sugar is over 126 mg/dl on two different days, then you also have diabetes. Fasting blood sugar levels considered normal fall between 70 and 100 mg/dl.


Types Of Diabetes
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There are two major types of diabetes: Type 1 diabetes (previously called Insulin Dependent Diabetes Mellitus (IDDM) or juvenile onset diabetes) and Type 2 diabetes (previously called Noninsulin Dependent Diabetes Mellitus (NIDDM) or maturity or adult onset diabetes).

In type 1 diabetes, the insulin-producing cells of the pancreas are destroyed slowly, it is believed by an autoimmune process, and eventually not enough insulin can be made to maintain normal glucose levels. Thus lifelong insulin use is required in order to survive. Although most people who develop this type of diabetes do so before age 30, it can occur at any age. About 5% of all people with diabetes have type 1 diabetes.

Most people with type 2 diabetes develop it after the age of 40, though it also may occur at any age. In fact, there is now an epidemic of type 2 diabetes in teenagers. These individuals are genetically at risk for this type of diabetes, but now actually have the disease early secondary to obesity. In type 2 diabetes, insulin is initially produced in large quantities, but the insulin does not work properly and glucose levels increase. Most people with this type of diabetes are overweight. While diet and exercise remain an important base for all treatment of type 2 diabetes, most people will require multiple medications to control their glucose levels unless they lose weight. In addition, as the disease progresses, insulin levels decrease and to successfully treat type 2 diabetes, insulin will generally be required.


Complications of Diabetes
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With the treatment of diabetes as described below, it is generally relatively easy to control blood sugar levels in a range that will allow you to feel normal. Unfortunately this degree of control has not been good enough to decrease the risk of developing complications. Recall that 50% of people with diabetes do not even know that they have the disease. It is not unusual for people to have already advanced complications from the diabetes even before they realize they have the disease. The complications include:
Retinopathy is the eye disease in diabetes which damages the blood vessels on the retina (inside back wall) of the eye. These blood vessels can leak fluid or blood, and lead to diminished vision or blindness.
Nephropathy is the kidney disease from diabetes. People who develop this complication initially have increasing amounts of protein which leak into the kidneys and urine reducing the ability of the kidneys to filter the blood which can decrease to the point that dialysis or a kidney transplant is needed.
Neuropathy, or nerve damage, occasionally can cause severe burning pain to occur, especially in the feet. More commonly, there may be a tingling, numbness or even complete loss of sensation in the feet and sometimes in the hands. The loss of sensation can be extremely dangerous as trauma to the feet will go unrecognized and even a minor injury can lead to ulcer formation and amputation.
Cardiovascular disease in diabetics also is associated with an increased risk of heart attacks and strokes. Studies have shown that people with type 2 diabetes, but not a known history of heart disease, have the same risk of a heart attack as a person without diabetes who has already had a heart attack! Another condition, claudication (walking or climbing stairs may lead to extreme calf pain that resolves when the movement is stopped) is from blocked arteries in the legs.

Reducing the risk of developing these complications has been the major goal in controlling diabetes. In the past there was controversy as to whether improving one's glucose levels would actually decrease the risk for complications. In a recent medical study, the group with excellent glucose control had a 50-70% reduction in risk of developing the complications of diabetes, and a similar reduction in progression. Thus, for all people with diabetes the goal is to keep blood glucose as close to normal as possible.

When diabetics aggressively control their blood pressure and cholesterol levels, the risk of cardiovascular disease also decreases dramatically.


Treatment of Diabetes
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In people with type 1 diabetes, the cornerstone of treatment remains insulin injections.

In type 2 diabetes, some individuals will initially obtain control of blood sugar with diet modification, weight loss and exercise. The diet utilized is similar to the healthy diet described earlier in this booklet. The main alteration is that highly concentrated sugars are avoided, i.e. fruit juices, large quantities of fruit, etc. Exercise is of equal importance. The exercise must be almost daily for at least 30 minutes in order to help achieve significant lowering of blood glucose levels.

Unfortunately, many people are unable to meet the dietary and exercise recommendations. Diet is often difficult to modify with aging. In addition, exercise may be difficult secondary to other medical conditions such as osteoarthritis or heart disease. In addition, the natural history of type 2 diabetes shows that less insulin is made over time. For most patients, medications are generally required early, and often multiple medications with different mechanisms of action are utilized.

There are several oral medications used to treat type 2 diabetes. Some of these medications increase the ability of the pancreas to produce insulin; others help the insulin work better. For most people the weak link is insulin production and we now understand that no matter what treatment has been used, there is a slow decrease in insulin production. So for most people with type 2 diabetes, insulin treatment will be required at some point. Insulin is needed to control the glucoses and prevent complications that will be more likely to occur if the insulin is not taken.


Prevention of Diabetes
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Type 1 diabetes is an autoimmune disease. This means that if individuals at risk can be identified then alteration of the immune system may be able to prevent the destruction of the insulin producing cells of the pancreas. Stem-cell bone marrow transplants to normalize the immune system are being tried experimentally.

As 95% of people who develop diabetes have type 2 diabetes, prevention of this type of diabetes certainly will have a major impact. Those who exercise have a much lower chance of developing diabetes than those who do not exercise.

Proper diet can also help prevent the onset of type 2 diabetes. The standard American diet was recently evaluated in a very large study in the United States, the Diabetes Prevention Program (DPP) - 3200 people at high risk for developing diabetes were divided into groups. Those in the lifestyle intervention group received intensive counseling on effective diet, exercise, and behavior modification, and reduced their risk of developing diabetes by 58%. This finding was true across all participating ethnic groups and for both men and women. Lifestyle changes worked particularly well for participants aged 60 and older, reducing their risk by 71%.

Thus for type 2 diabetes, the current best treatment is preventing the onset in the first place with an improved healthy diet and exercise.


Summary
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Diabetes is a common, chronic disease. It can lead to eye disease, kidney disease, and nerve damage, and is a risk factor for cardiovascular disease. Most people with diabetes are overweight and have type 2 diabetes. Although excellent control of blood sugar levels can decrease the risk of the above complications, prevention of this type of diabetes through lifelong diet modifications and exercise remains the best option for a healthy life.
Facts from The National Institutes of Health
Diabetes is the fifth leading cause of death in U.S. (224,000 deaths each year).
1 in 3 babies born today (and 1 in 2 non-whites) will develop diabetes.
By 2050 there will be 1,000,000 diabetic related deaths yearly.
Diabetes is the leading cause of blindness, kidney failure, and non-traumatic leg amputations.


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First appeared January 6, 2008; updated August 2, 2008