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Copyright (c) 1991   Tribune Media Services, Inc.


Health Update

by Dr. Allan Bruckheim

Diabetes and you


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     Diabetes is a chronic metabolic disease that can be treated, but, as yet,
it cannot be cured.  Before the 1920's, diabetics usually died soon after the
diagnosis of their disease.  Diabetes can be controlled, however.  The more
than 11 million people in the United States with diabetes can live long lives,
hold productive jobs, marry and have children.
     Despite this seeming normality, it must be remembered that diabetes can
have serious complications.  It is the third leading cause of death in this
country, following only heart disease and cancer.  It kills 300,000 people per
year.  It is the leading cause of blindness (5,000 cases per year) in the
United States.  It causes one-quarter of all cases of kidney failure.  It can
lead to heart disease, stroke, gangrene and nerve damage.  And it is on the
rise, with a 6 percent increase in new cases diagnosed each year.
     Diabetes can lead to complications, but with care and proper treatment,
most can be avoided or minimized.  The Centers for Disease Control now says
that between 50 percent and 85 percent of acute and chronic complications
caused by diabetes can be prevented or treated with early diagnosis of
diabetes and careful monitoring.  People with diabetes must incorporate
several precautions against their disease into their daily lives.  They must
watch what they eat and at what times, they must keep a close eye on their
overall health, they must test their blood or urine daily, and they may have
to take medications or injections.  Because of this, diabetics learn to take
an active role in their own treatment.

What is diabetes?

     Essentially, diabetes is the body's inability to use the energy normally
derived from food.  The process by which food is converted into energy or into
components of the body is known as metabolism.
     In a healthy person, the intestines break down carbohydrates (starches
and sugars) in food into glucose--a type of sugar--which is the body's chief
source of fuel.  "Blood sugar" is glucose and is carried by the blood
throughout the body to the cells, which either use it immediately for energy
or store it away for future use.  But it cannot get into the cells by itself.
For glucose to get into the cells, a special hormone called insulin must be
present.
     Insulin is just one of the many hormones the body uses daily.  It is made
within the pancreas, the large gland just beneath the stomach, in special beta
cells within segments of the pancreas known as the Islets of Langerhans.  Beta
cells normally react to high blood levels of glucose by making more insulin.
     Blood-sugar levels in a healthy person rise and fall in response to many
factors.  Certain things such as a recent sugary or starchy meal of emotional
stress can make the level rise, while exercise and fasting can make it fall.
The pancreas keeps regulating the level of blood sugar to make sure that it
meets the body's needs.
     In a diabetic, everything is working except the insulin.  The intestines
break carbohydrates down into glucose.  The blood carries glucose to the
cells, but the cells cannot take in the glucose.  In some diabetics, there is
not enough insulin, while in others, insulin is present, but it does not work
properly.  Unused glucose starts to build up in the bloodstream at the same
time the body starts starving for energy.  When the blood becomes saturated
with glucose, the glucose spills into the urine and the body must produce more
urine, and a diabetic must urinate more frequently to get rid of it.  Fatigue
sets in and the body turns to fat stores for energy.
     Severe, out-of-control diabetes is an emergency.  When the body does not
have enough insulin, or its need for insulin increases suddenly, it starts
breaking down fat for energy.  When fat breaks down in large quantities,
chemicals called ketones are released and build up in the blood, and a
condition called diabetic ketoacidosis develops.
     A diabetic in ketoacidosis may suffer nausea, vomiting and start
breathing deeply and rapidly.  He or she may have a very fruity odor on the
breath, which is caused by acetone, a ketone that can be expelled by the
lungs.  If ketoacidosis is not treated promptly, the person can become
comatose and die.
     The full name for diabetes is diabetes mellitus, Greek for the
"honey-urine disease," because the urine of an untreated diabetic has so much
sugar in it that it is sweet.  Another disease, called diabetes insipidus, has
some similar symptoms to diabetes mellitus, but it is a completely different
disease.

The types of diabetes

     There are two main types of diabetes mellitus:  insulin-dependent and
non-insulin dependent.  These used to be referred to as juvenile-onset
diabetes and maturity-onset diabetes, respectively, but the names were changed
because not everyone who is diagnosed as having juvenile diabetes is a child
and some children have maturity-onset diabetes.  To add to the confusion, some
people with non-insulin-dependent diabetes do use insulin to control their
disease, but most do not.
     The two types of diabetes mellitus are in many ways very different
diseases, and even within these two types of diabetes, there are variations.
Insulin-dependent and non-insulin-dependent diabetes both result in the same
problem:  the inability to properly control blood sugar.  They also can result
in similar long-term side effects.

Insulin-dependent diabetes

     Insulin-dependent diabetes is the less common form of the two major types
of diabetes.  Only about 10 percent of all diabetics are insulin-dependent.
Other names for this kind of diabetes are Type I diabetes and ketosis-prone
diabetes.
     An insulin-dependent diabetic has a pancreas that is not making insulin
or not making enough of it.  Researchers now believe that this type of
diabetes is an autoimmune disease, that is, a disease caused by an
over-reactive immune system.  Although much is still unknown, medical
scientists now think that some triggering factor confuses the body's defense
system into attacking the beta cells of the pancreas and killing them.  This
autoimmune reaction may be triggered by a virus or by several viral
infections.
     Heredity and environment are other factors in the development of
insulin-dependent diabetes.  According to researchers, an immune system that
will over-react and attack the beta cells is an inherited characteristic, but
this over-reaction still must be turned on by a triggering factor such as a
virus,
     White people who trace their heritage to Northern Europe have a higher
incidence of insulin-dependent diabetes, but it is rarely seen in Orientals.
Blacks and certain American Indian tribes have a high incidence of
non-insulin-dependent diabetes.
     The autoimmune destruction of the beta cells does not happen overnight. A
person can get by quite well with less than a full amount of beta cells making
insulin, but at some point, enough cells are destroyed so that a sufficient
amount of insulin is no longer produced and the symptoms of diabetes start to
appear.
     One subtype of insulin-dependent diabetes is secondary or acquired
diabetes.  It is caused by the surgical removal of the pancreas, either
because of pancreatic cancer or after an injury.
     Symptoms of insulin-dependent diabetes come on relatively quickly.  The
warning signs include frequent urination, extreme thirst, continuous hunger,
weight loss, irritability and fatigue.  Urination and thirst are caused by the
body's need to rid itself of glucose building up in the bloodstream.  Hunger
and fatigue are felt because, even though the body is getting enough food, it
cannot get enough energy out of that food.  Weight loss occurs when the body
must turn to stored energy, and fat is burned off.
     An insulin-dependent diabetic must have regular injections of insulin in
order to survive.  In addition to insulin, diet and exercise must be carefully
regulated in order to maintain good blood-sugar control.

Non-insulin-dependent diabetes

     As the name implies, non-insulin-dependent diabetes means a form of
diabetes where the patient does not have to depend on insulin.  Nine out of 10
diabetics in the United States have non-insulin-dependent diabetes, also known
as Type II diabetes.  Although most people with non-insulin-dependent diabetes
are adults, the disease can occur at any age.
     In non-insulin-dependent diabetes, the pancreas is producing insulin,
although it may not be doing so at normal levels.  Although insulin is
present, blood-glucose levels are still abnormal because something is causing
the body to resist the insulin.
     The cause of this insulin resistance or insulin antagonism is unknown.
Insulin must be able to plug into individual cells to work at sites on the
cell called receptors.  One possible cause of insulin resistance is that the
insulin receptors are impaired.  Another possibility is that even after the
insulin plugs into the receptor site, the cell does not respond to the
insulin.
     Of people who are diagnosed as having this form or diabetes, 80 percent
are overweight.  Some people who are obese have high insulin levels, yet are
insensitive to insulin.  In an obese person, it appears that cells have fewer
insulin receptor sites.  While a fat person's body may be turning out two or
three times the insulin that a lean person's body is making, it is not working
well.  If the overweight diabetic loses weight, often his or her blood-glucose
levels will return to normal.
     Non-insulin-dependent diabetes also can run in families, but again
environment plays a role.  This is one reason why any doctor giving a physical
always asks if there is a family history of diabetes.  Because obesity is also
a factor, it can be difficult to tell if diabetes is due to an inherited
propensity or because the members of a family tend to eat alike and all may be
overweight.
     Symptoms of non-insulin-dependent diabetes come on much more slowly than
do those of insulin-dependent-diabetes.  Symptoms may include frequent
urination, thirst, hunger, fatigue, irritability, and also may include
drowsiness, blurred vision, tingling or numbness in the hands and feet, or
itching.  Another important symptom of non-insulin-dependent diabetes is
recurring or slow-to-heal cuts and sores.  A woman may have recurrent urinary
or vaginal infections.
     Non-insulin-dependent diabetics often can control their condition through
diet and exercise alone, especially with a well-balanced reducing diet that
helps them shed extra pounds.  Other diabetics may need a combination of diet,
exercise and medications.  Medications for this type of diabetes include a
class of drugs called oral hypoglycemic agents that help non-insulin-dependent
diabetics use blood glucose better.
     In some cases, insulin is needed to help treat non-insulin-dependent
diabetes.  The difference is that, for this version of the disease, insulin is
not a requirement.  Many people may need insulin before diet and exercise can
bring their diabetes under control.

How diabetes is diagnosed

     Doctors use urine and blood tests to check for diabetes.  In both, they
are checking glucose levels.  Glucose in the urine can be a sign of diabetes,
although it is not always so.  The doctor also may give a complete physical to
check the heart, eyes and kidneys.
     In the blood, a certain level of glucose is normal.  Usually, the test is
done on blood drawn before breakfast in the morning, and it is called a
"fasting glucose test."  If blood is drawn after a meal, it is a "postprandial
glucose test."
     If a doctor wants to double-check the blood tests, he or she may ask the
patient to take an oral glucose tolerance test, which can detect diabetes even
when a regular blood test will not.  For this test, the patient's blood is
taken and then the patient drinks a liquid with a known amount of glucose in
it.  This is very sweet, but not unpleasant.  More blood samples will be taken
during the hours after drinking the glucose.  Comparing the samples will show
how the body responds to an increase in blood glucose.
     Normally, blood-glucose levels will rise after the drink and then fall
gradually as the pancreas sends out insulin to cope with it.  A diabetic's
blood-glucose level may stay high after the glucose drink or it may fall very
slowly.

Insulin

     Insulin is a natural hormone made in the pancreas of healthy people. Many
diabetics need injections of insulin regularly in order to control their
blood-sugar levels.
     A diabetic who uses insulin may need to have an injection once, twice or
several times a day.  Two diabetics may have extremely different injection
schedules, dosage amounts and even different types of insulin.  It is very
important that diabetics test their blood or urine frequently to make sure
their insulin regimen is working.
     Injected insulin is a replacement for the insulin that a diabetic's
pancreas is not making and it works the same way as normal insulin to lower
blood sugar.  However, injections of insulin do not respond to the body's
needs the way the pancreas responds.  When a healthy body needs to lower
blood-sugar levels, the pancreas can churn out as much insulin as is needed.
When blood-sugar levels fall low, the pancreas stops sending out insulin.
     An injection of insulin will lower blood sugar whether or not it needs to
be lowered.  In other words, if a diabetic takes an insulin injection and then
skips a meal, the insulin will keep on lowering blood sugar even though it
drops below normal and an insulin reaction or insulin shock occurs.  Only by
careful scheduling of injections, meals and exercise, can a diabetic control
blood-sugar levels.
     Insulin is sold in pharmacies as a liquid in vials, and in most states, a
prescription is not needed.  However, hypodermic needles--which are
prescription products--are necessary.  Insulin must be injected.  It is not
effective if swallowed, because it is a protein that is digested by the
stomach and intestines.
     An insulin injection is subcutaneous, that is, the insulin is deposited
just under the skin, rather than into a vein or muscle tissue.  The insulin
spreads from the subcutaneous tissue into the rest of the body quickly.
     Newly diagnosed diabetics who must use insulin are taught how to inject
themselves and where.  Injecting insulin is a relatively simple procedure,
and, even though it is not pleasant, most diabetics get used to it.  New
extra-fine needles that cut down on the discomfort are widely available. There
are also devices that use a jet spray to administer insulin right through the
skin without a needle, but these are expensive.
     The areas of the body that can be used for insulin injections include the
outer side of the upper arm, the stomach (except for a small area around the
navel), the buttocks, the outer area of the hips and the thighs.  A diabetic
soon learns to rotate injection sites.  No site should be used for two
injections in a row.
     The doctor gives the patient a little map of the body that can help mark
injection sites that have been used.  A diabetic should never inject insulin
less than a half-inch from a site injected recently.  Repeated injections in
one site can cause lumps or fat to collect or depressions in the skin to
appear.
     Insulin is absorbed slower from certain injection sites.  Usually
absorption in the thighs is slower than in the abdomen, and slower yet in the
arms.  This difference in absorption rates can result in erratic blood-sugar
control unless it is taken into account.

How to administer insulin

     A diabetic should have all the materials ready before giving himself or
herself a shot of insulin.  Needed are a vial of insulin, a fresh disposable
hypodermic syringe, some clean cotton balls and a bottle of rubbing alcohol.
     The first step is to take the metal protective top off of the vial to
expose the rubber stopper, without removing the stopper itself.  The next step
is to turn the vial upside down and roll it gently between the hands.  The
vial should not be shaken, because that causes bubbles that may throw off the
measurement later.  Then the top of the rubber stopper is wiped with cotton
dipped in alcohol.  This cleans and sterilizes the top.  The vial then can be
put to one side.
     Next, the hypodermic syringe wrapper is opened, with caution not to touch
the needle.  The syringe plunger is pulled down so that it is at the number
for the patient's dosage of insulin and the needle is inserted into the
insulin vial.  The plunger is pressed down to expel air into the vial (this
makes getting insulin out of the vial easier) and is pulled back up to the
right amount.  The needle is removed from the vial and the syringe is set down
so that the needle touches nothing.
     The patient finds his or her injection site and wipes it with cotton and
alcohol.  Then the patient pinches up the skin at the site with one hand and
picks up the syringe like a pencil with the other.  The needle is pushed
quickly through the skin at a 90-degree angle.  The plunger is pushed down to
empty it and the needle is removed from the skin.  The site should be wiped
with alcohol again.

Types of insulin

     Insulin comes from three basic sources.  Natural insulin is collected
from the pancreases of cattle and pigs.  Pork or beef insulin is similar to
human insulin and is highly purified to remove impurities.  Semi-synthetic
insulin is animal insulin that has been treated to be more like human insulin.
Synthetic insulin is human insulin that has been manufactured through genetic
engineering.
     Insulins can be rapid-, intermediate- or long acting, depending on how
fast they take action inside the body and how long they last.  For instance, a
rapid-acting insulin (also known as regular or Semilente) can start acting
within an hour of an injection, have its peak effectiveness in two to three
hours after the injection and last for six to eight hours.  An
intermediate-acting insulin (NPH or Lente) can take effect within two to three
hours, have a peak effect within 12 hours and have worn off up to 24 hours
later.  Long-acting insulin (PZI or Ultralente) may start to work in four to
six hours, have a peak effect 14 to 24 hours after injection and last up to 36
hours.
     A patient may be told to use different insulins at different times during
the day so that his or her blood sugar is always under control.  Mixtures of
regular- and intermediate-acting insulins are available or a doctor will tell
the patient how to mix different types of insulin to get the best effect.
     Many years ago, when insulin from pork and cattle pancreases first was
being purified, allergic reactions were more common.  Now, all insulin is very
pure, but some people who use beef or pork insulin may have allergic reaction
to it.  Patients with any itching, redness or swelling at the site of an
injection, at any time, should tell their doctors.  They may need to be
switched to either synthetic or semi-synthetic insulin.

Insulin reactions

     An insulin reaction is an emergency and it needs prompt recognition and
proper attention.  The patient and everyone in his or her family must learn
the symptoms of insulin reaction and what to do about it.
     The warning signs of an insulin reaction include irritability, sweating,
paleness, rapid heartbeat, extreme hunger, weakness, faintness, inability to
concentrate, blurred vision, loss of coordination and mental confusion.  Some
people get headaches, feel nauseous, cry during a reaction, or feel symptoms
not on this list and unique to them.
     Because of the patient's confusion and unsteadiness, it is easy for
strangers to think that a diabetic having an insulin reaction is drunk or on
drugs.  This is one reason it is wise for a patient to wear a medical
identification bracelet and carry a wallet card that identifies him or her as
a diabetic.
     The most important thing a diabetic do during a reaction is to eat
something to counteract the low blood sugar.  A glass of milk or orange juice
or even swallowing a packet of plain white sugar work well for most people.  A
diabetic who uses insulin must always carry a supply of quick-acting
sugar--such as candy, sugar packets or special glucose tablets--at all times
to use during an insulin reaction.
     If the reaction is not treated, unconsciousness sets in quickly, and two
things can be done.  A drug called glucagon, if readily available, can be
injected into the buttock.  Glucagon is another hormone created by the
pancreas and it raises blood-sugar levels.  If glucagon is not available, a
finger-full of honey, maple syrup or corn syrup can be rubbed on the inside of
the unconscious person's cheek.  If the person does not respond, an ambulance
should be called immediately.
     After recovering from an insulin reaction, the person should eat
something that is digested slowly, such as a sandwich or a piece of fruit.
This will prevent the high insulin levels from causing another insulin
reaction after the sugar or glucagon has worn off.
     Preventing insulin reactions is as important as knowing how to treat
them.  People who test their blood-glucose levels several times a day usually
don't have reactions because they give themselves appropriate amounts of
insulin or eat a snack to avoid them.
     A diabetic may find it necessary to eat a snack at certain times of the
day to prevent reactions.  He or she may need extra carbohydrates before
exercising and will learn from experience how much is needed.  Eating a snack
before bedtime is also wise to prevent nighttime insulin reactions.

Oral hypoglycemic agents

     Many people with diabetes use medications called oral hypoglycemic
agents, which act to lower blood-sugar levels.  These are an option if diet
and exercise fail to control diabetes, but cannot be used for
insulin-dependent diabetes, except in a small number of cases.  They are not a
substitute for proper diet and exercise.  Hypoglycemic drugs belong to a group
of chemicals known as sulfanylureas.
     Oral hypoglycemic drugs are not oral forms of insulin.  Insulin cannot be
put into tablet or capsule form because it is digested in the intestines.
     No one is exactly sure how oral hypoglycemic agents work to lower blood
sugar.  Apparently, they increase the levels of insulin put out by the
pancreas, but they also seem to decrease resistance to insulin in the body's
cells.  These drugs may do this by increasing the number of insulin receptors
in the cells.
     Oral hypoglycemic agents are most likely to be useful for people who are
diagnosed as having diabetes after age 40 and who are at normal weight or
close to it.  They are most useful for less severe cases of
non-insulin-dependent diabetes.
     Some studies show that oral hypoglycemic drugs may increase a person's
risk of a heart attack.  However, there is some disagreement on this matter. A
doctor will discuss the risks and benefits of these drugs before he or she
prescribes them.
     Six hypoglycemic agents are approved for sale and although they have
similar actions, they are not identical.  One may be more effective than
another for a given patient.  A doctor may try the patient out on one drug and
switch to another if the first is not effective.  Some diabetics find that no
hypoglycemic agent works for them and they must use insulin.
     The six brands of hypoglycemic agents (some are available generically)
and their generic names are:  Orinase (tolbutamide), Diabinase
(chlorpropamide), Dymelor (acetohexamide), Tolinase (tolazamide) Micronase,
Diabeta (glyburide) and Glucotrol (glibizide).
     Oral hypoglycemic agents can cause nausea, skin rashes, water retention
or increased urination.  Some people may become more sensitive to sunlight and
burn more easily.  Most of these side effects decrease over time.  Patients
bothered by them should talk to their doctors.
     Diabetics who take oral hypoglycemics must carefully space their meals
and snacks so that their blood sugar does not fall too low.

Diet in diabetes

     Diet is a cornerstone of controlling diabetes.  More than half of all
adult diabetics manage their diabetes with diet rather than insulin or oral
hypoglycemic agents.
     A doctor or dietitian will go over a diet and sample meal plans with the
patient.  They will help the patient determine his or her best weight,
consider any special dietary needs (such as pregnancy or food allergies) and
calculate how much carbohydrate, protein and fat should be taken in daily.
     Carbohydrates are an important part of a diabetic's diet.  There are two
types of carbohydrates--simple and complex.  Simple carbohydrates include
sugar, candy, pastries and cakes, and these usually raise blood sugar levels
very quickly.  Complex carbohydrates include vegetables, dried beans and peas,
grains, breads and cereals, and these raise blood sugar levels gradually over
a longer period of time.  Complex carbohydrates usually contain more
nutrients, minerals and fiber than do simple carbohydrates, but simple
carbohydrates can give blood sugar a quick lift to help stave off an insulin
reaction.  Both forms of carbohydrates have their place in a diabetic's diet.
     Many diabetics must limit their fat intake as well as their intake of
cholesterol and salt.  Eating too much fat and cholesterol are linked to heart
disease.  This may mean they have to cut out or limit eating eggs, dairy foods
and red meats.
     Special consideration must be given to planning medications, mealtimes
and exercise so that wide swings in blood-sugar levels are avoided.  An
insulin-dependent diabetic should plan to eat foods that are heavy in
carbohydrates at a time when they coincide with the peak effectiveness of the
insulin he or she uses.  This will vary with the type and amounts of insulin
being used.
     To help diabetics in planning their meals, the American Diabetes
Association has created lists of equivalent foods called exchange lists. These
are nutritional guidelines that can be used every day to help diabetics choose
what to eat.  A serving of any food on a given exchange list can be
substituted for a serving of any other food on that list.  The lists can help
diabetics with daily meal plans.  They'll learn to include foods from the six
exchange lists in their daily diet.
     A diabetic can have an occasional alcoholic drink, but too much alcohol
can cause problems.  Alcoholic beverages are empty calories and can contribute
to weight problems.  Alcohol can lower blood-sugar levels which can bring on
hypoglycemia.  This is especially likely to happen if alcohol is taken on an
empty stomach.  Excessive drinking causes additional problems for diabetics,
because it raises blood-fat levels and can damage the liver.

Exercise and diabetes

     If diet is a cornerstone of controlling diabetes, exercise is the brick
on top of the cornerstone.  Many people can control their diabetes with diet
and exercise alone.
     Regular exercise helps improve the way the body responds to insulin,
either injected insulin or natural.  A diabetic using insulin who starts a
program of regular exercise may be able to lower the amounts he or she needs.
Exercise also burns calories, which is one way to lose weight.
     Insulin-dependent diabetics must consider their exercise program when
giving themselves insulin.  It may be necessary for them to reduce the amount
of insulin they take before a period of extended exercise so that they avoid
an insulin reaction.  They may not need to adjust their insulin dose or
schedule for shorter periods of exercise.  Diabetics who run or play tennis
also may want to carry small candies around with them in case their
blood-sugar levels fall too low.
     A patient should discuss with his or her doctor the desire to start an
exercise program.  It is a good idea to start any exercise program gradually
and build it up over time.
     Diabetics who have lost any sensitivity in their feet, which is a
complication of diabetes, should make sure the athletic shoes fit well.  Shoes
and socks should be checked carefully and the feet should be examined daily
for blisters or breaks in the skin.  If running or walking are too hard on the
feet, swimming or bicycling are good alternatives.
     Some diabetics who can control their condition with diet and exercise may
find they need insulin when they have a cold or infection.

Self-monitoring

     Controlling diabetes means keeping blood-sugar levels as close to normal
as possible.  Most diabetics usually can tell when their blood-sugar levels
are too low or too high, but this is not the best way to keep track of them.
The best way to determine blood sugar levels is through careful and continual
monitoring.
     There are two common forms of blood-sugar monitoring.  The older method
is testing the levels of sugar in the urine.  Urine also can be tested for
levels of ketones, a byproduct of fat breakdown, in the urine.  High levels of
ketones in urine indicate that fat is being broken down and the body is not
getting enough insulin.
     Urine testing is simple and usually is done in the morning before
breakfast.  The patient takes a sample of urine in a clean container and uses
one of several testing products.  These products may be strips of tape or
paper or sticks that have chemicals impregnated in them.  The test product is
dipped into the urine.  After waiting the proper amount of time, the patient
then checks the tape or stick for a color change and compares it to the color
chart on the product package.  Different products turn different colors,
indicating the levels of sugar or presence of ketones in the urine.  If
directions on the package are followed carefully, the patient should get the
right results from the urine test.
     For many years, urine testing was the only way diabetics could keep track
of their blood sugar.  Many diabetics still use urine testing safely and take
good care of themselves.
     The best way to monitor blood-sugar levels is to test blood directly.  In
the past few years, small monitoring devices have been perfected that allow a
diabetic to test blood-sugar levels at home quickly, easily and reasonably
economically.  Blood monitoring has the advantage of allowing a patient to
test blood sugar several times a day, giving the whole pattern of how his or
her body responds to diet, exercise and insulin or drugs.  The information is
accurate and instantaneous.
     Blood testing is rather simple and only takes a drop of blood.  The
patient pricks a finger with a sterilized pin or lancet to get a drop of
blood.  The drop is placed on a special, chemically treated strip of paper.
The strip is processed according to directions and a color change will occur.
The strip then can be compared to a color-coded chart or, more frequently, it
is placed into a special monitor that analyzes the change and gives an
accurate read-out of the blood-sugar level.
     The disadvantage of blood monitoring is that the monitoring devices are
expensive.  Health insurance plans are starting to pick up the costs of
monitoring equipment, but some may only cover a portion.

Heart and circulatory problems

     In addition to lack of control over blood-sugar levels, many diabetics
also have problems with high blood pressure and blood cholesterol and fat
levels.  This combination leads to angiopathy, or disease of the blood
vessels.  Very small blood vessels, both veins and arteries, become thick and
weak.  They may leak, and blood flows more slowly in these affected vessels.
Larger blood vessels start developing atherosclerosis; they clog up with fat
and blood clots, which hampers the flow of blood.  If the clots break loose
and travel to the brain, a stroke can occur.  If the clogged blood vessel
supplies the heart, a heart attack can occur when blood circulation to it is
interrupted.
     The impaired blood flow means poor circulation, notably in the feet and
lower legs.  Poor circulation is compounded by neuropathy, damage to the
nerves caused by diabetes.  A cut on the foot may become infected before it is
even noticed.  If circulation is cut off to any body part for too long--or if
an infection is left to fester--the part becomes gangrenous and must be
amputated.
     Diabetics must take care of their feet properly to avoid the problems
lack of circulation can cause.  They must get into the habit of checking their
feet carefully every day for cuts and blisters and keep them clean.  They must
make sure their shoes and socks fit well and do not rub.  Toenails should be
cut short and straight across.
     Because circulation can be a problem for diabetics, those diabetics who
smoke must stop.  Smoking impairs the circulation further and it is an insult
to the body that can be avoided.

Eye problems

     Diabetes destroys vision by interfering with the function of the retina,
the inside layer of the back of the eye.  The retina is a delicate piece of
tissue that receives light focused on it by the lens and sends the message to
the brain.
     Many tiny blood vessels run through the retina.  Retinopathy occurs when
these tiny blood vessels weaken, break and start to leak blood into the inside
of the eye.  Vision becomes clouded.  These vessels also may start to overgrow
or proliferate within the retina and further reduce vision.
     Most people who have had diabetes longer than 10 years start to show some
signs of diabetic retinopathy.  After 15 years, almost all diabetics show some
changes.  These changes may not mean any vision is lost, but enough serious
changes in the retina can lead to loss of vision.
     A doctor--or an ophthalmologist, a medical doctor who specializes in eye
care--will check the diabetic's eyes carefully every year or two.  This
checkup will include an examination of the retina.
     If changes in the retina develop, several treatments can stop them from
progressing.  Laser beams can be used to coagulate abnormal blood vessels
within the retina.  This seals them and prevents them from bleeding.  Laser
photocoagulation should be done before any serious loss of vision occurs,
because it will only halt further loss.  The procedure cannot reverse the loss
of vision.  If bleeding already has caused the fluid within the eye to become
clouded, this fluid can be removed and replaced in a procedure called
vitrectomy.  Vitrectomy can return some vision that has been lost, but not all
of it.
     Diabetes also appears to be a risk factor in developing cataracts, or
clouding of the eye's lenses.  Cataracts can reduce or blur vision to the
point where the clouded lens must be removed surgically.

Kidney problems

     Diabetes also causes nephropathy or damage to the kidneys, the organs
that remove waste from the body.  Kidney damage is most likely to occur in
people who have had diabetes for several years.
     High blood pressure is a risk factor in diabetic nephropathy.  If a
patient's blood pressure is high, the doctor may suggest cutting down on the
amount of salt eaten or may prescribe blood pressure medications.
     Another risk factor for nephropathy is kidney and urinary tract
infections.  Patients who feel they have to urinate all the time or who notice
a burning sensation when urinating should tell their doctors.  These are
symptoms of a urinary tract infection.
     If a patient's kidneys fail--a condition called end-stage renal
disease--he or she will have to have dialysis, which is a method of removing
wastes from the blood.  Dialysis must be performed several times a week in
order for the patient to remain healthy.  Diabetics whose kidneys have failed
can undergo kidney transplantation, where they get a healthy kidney from a
relative or from someone who has died.

Dental problems

     Diabetics are prone to tooth and gum problems that stem from infections
of the gum called periodontitis.  People with diabetes must take close care of
their teeth and mouth to avoid infections and possible loss of teeth.  Because
periodontal disease can cause damage to the jawbones in addition to tooth
loss, dentures will not fit well.  Even the best-fitting dentures are not a
good substitute for natural teeth.
     Good dental hygiene habits must be developed.  Teeth should be brushed
with a soft-bristle brush, and teeth should be flossed carefully.  A patient
who notices any bleeding from the gums or while brushing the teeth should see
a dentist.

Surgery

     Diabetes increases the risks of any kind of surgery.  It has been said
that one out of every two diabetics will need surgery at some time during
their lives.
     Surgery is a stress on the body.  It changes blood-glucose levels and
interferes with insulin absorption.  In most cases, blood-sugar levels go up
during surgery, which means that, unless insulin levels are lowered before and
during the operation, hypoglycemia can occur.  Another possible consequence of
surgery, especially in insulin-dependent diabetics, is ketoacidosis.
     A diabetic is admitted to the hospital the day before surgery and his or
her condition is assessed.  If necessary, blood-sugar levels are corrected
within a few hours and surgery is performed.
     A patient may be asked to modify his or her insulin dosage and the type
of insulin used a few days before surgery.  If hypoglycemic agents are used,
they may be switched to another type.  These regimen changes are done to
prevent the stress of surgery from sending blood-sugar levels out of control.
While the patient is in the hospital, blood sugar will be monitored
frequently.
     During surgery, insulin will be administered, if needed.  The need for
insulin depends on what type of operation is being done, how long it lasts and
the condition and type of diabetes of the patient.  In a minor procedure,
insulin may not be needed.
     After surgery, the insulin or oral drug regimen may be changed again.  A
patient who was taking oral drugs and who cannot swallow or eat after surgery
may be switched to insulin until he or she is allowed to eat again.  The
patient will be put back onto oral medications, or the insulin regimen will
stabilize, as the body heals.
     Emergency surgery poses more of a problem because the conditions that
demand surgical correction can precipitate ketoacidosis.  The symptoms of
ketoacidosis--abdominal cramps and nausea--may be confused with appendicitis
or abdominal injury, or interpreted as developing complications.  Surgery may
have to be delayed for several hours until blood-sugar levels are stabilized
with insulin, and the situation can be clarified.
     The surgeon must know about the patient's diabetes.  An emergency is
another reason it is wise for diabetics to wear medical identification
bracelets and carry wallet cards identifying them as such.

Gestational diabetes

     Some women may find out they have diabetes during a pregnancy.  This is
known as gestational diabetes and goes away after the delivery.  However, a
woman who has had gestational diabetes is more likely to get
non-insulin-dependent diabetes in later years.
     Gestational diabetes occurs when the hormones made up by the placenta
(the tissue of the afterbirth that supplies blood to the baby) interfere with
the way insulin works in the mother's body.  For some women, they may have
been mildly diabetic already and the pregnancy increases their blood-sugar
levels.
     Obese women are more likely to become diabetic during pregnancy, as are
women with relatives who are diabetic and women older than 25.  Gestational
diabetes can bring on several complications during pregnancy, including
pre-eclampsia (high blood pressure during pregnancy), so gestational diabetes
can be detected early.  This form of diabetes can be controlled with diet,
exercise and, in some cases, insulin injections.

Pregnancy and diabetes

     Up to 95 percent of babies born to diabetic women are healthy.  A
diabetic woman must have a good partnership with her doctor before, during and
after her pregnancy.  Diabetes should be under tight control throughout this
time, especially during the early days, when the baby is starting to develop.
     Pregnant women with diabetes are at an increased risk for ketoacidosis,
hypoglycemia or hypertension.  These problems increase their chances of having
a complicated delivery, a baby with medical problems or a lasting complication
such as kidney, nerve or eye damage.  The major risks to the baby are
premature birth, birth defects, larger-than-average size, jaundice or
breathing difficulties at birth.
     A woman with non-insulin-dependent diabetes who uses oral hypoglycemic
agents may be switched to insulin for the duration of her pregnancy.  Insulin
gives tighter control over blood-sugar levels and is known to be completely
safe for use during pregnancy, because it is a natural body hormone.  Oral
hypoglycemic drugs have side effects and while they may not cause problems
during pregnancy, it is not known whether they are completely safe.

Diabetes and sex

     Some men who have diabetes suffer occasional impotence, the inability to
achieve or maintain an erection.  Some studies say that impotence occurs in
between 10 percent and 50 percent of all diabetic men.
     Diabetes can cause fatigue, loss of energy and physical weakness, which
are certainly not conducive to sexual relations.
     Impotence also can be a result of neuropathy or angiopathy.  An erection
depends on both nerve signals and blood supply to the penis.  If either one is
interrupted, an erection will not occur.
     Diabetic women also may undergo changes that interfere with their
sexuality.  Many diabetic women suffer vaginal infections or a shortage of
vaginal lubrication that can cause irritation and make intercourse
uncomfortable.
     An impotent man can consider using either an external brace or a
surgically implanted prosthesis.  A diabetic woman can have vaginal infections
treated and use a lubricant such as KY jelly.

Diabetes in children

     Because small children cannot take care of themselves, the family must
play a role in caring for a child, administering insulin and making sure that
the child's blood-sugar levels stay within normal levels.
     A child with diabetes has a chronic condition and must be treated
differently, but this does not mean he or she is an invalid.  The best way for
a family to cope with diabetes in a child is to do so with a minimum of fuss.
Understanding diabetes is an important first step.  The best way to control
diabetes is to learn to live with it.
     Parents of a diabetic must learn to cope with caring for their child and
with teaching the child how to deal with diabetes.  The child's food intake,
exercise and insulin dosages must be carefully balanced.  It can be difficult
to tell whether a preschool child is having an insulin reaction or is just in
a bad mood, but most parents quickly learn to deal with it all.
     A parent also must cope with occasional blood-sugar levels that are high
or low.  Even the best-regulated insulin dosage and schedule will not control
blood sugar perfectly in a child, and occasional high readings do not mean
that the child is cheating on diet.  As the child grows, and especially during
adolescence, there will be times when diabetes is more difficult to control,
no matter how closely he or she follows doctor's orders.

Diabetes in the elderly

     In many elderly, non-insulin-dependent diabetes can be treated with diet
and exercise alone.
     Diabetes in the elderly often is linked to increased weight and loss of
lean body tissue.  Plus, the elderly diabetic may not be getting a nutritional
diet or enough exercise.
     The elderly should worry more about certain diabetic complications,
notably atherosclerosis (fatty clogging of arteries) and poor circulation.
Because they may have difficulty in caring for their feet, they are at greater
risk of developing infections and gangrene.

The future of diabetes treatment

     Researchers are learning more daily about the causes of diabetes.  Other
studies are looking for ways to prevent diabetes or reduce its complications.
Still other research is aimed at perfecting methods of administering insulin
and monitoring blood-sugar levels.
     Work is under way to investigate why the immune system attacks beta cells
in the pancreas.  If this process can be controlled, diabetes could be
prevented.  Immune-suppression drugs are being studied as one way to stop the
immune system from attacking beta cells.
     Another promising line of investigation is the work being done on
transplanting either a whole pancreas or just the beta cells that make
insulin.

Obtaining help

     There are many resources that offer literature, printed information and
personal advice from trained professionals and volunteers.  Here is a listing
of just a few, that may lead to others, all useful in expanding one's
knowledge and helping one to deal effectively with this disease.

     American Diabetes Association, National Service Center, 1660 Duke St.,
P.O. Box 25757, Alexandria, Va. 22313; (703) 549-1500.
     American Dietetic Association, 430 N. Michigan Ave., Chicago, Ill. 60611;
(312) 822-0330.
     American Heart Association, 7320 Greenville Ave., Dallas, Texas 75231.
     Juvenile Diabetes Foundation International, 432 Park Ave. S., New York,
N.Y. 10016; (212) 889-7575.
     National Diabetes Information Clearinghouse, Box NDIC, Bethesda, Md.
20892.
     National Eye Institute, Building 31, Room 6A32, National lnstitutes of
Health, Bethesda, Md. 20892.
     National Heart, Lung, and Blood Institute, Building 31, Room 4A21,
National lnstitutes of Health, Bethesda, Md. 20892; (301) 496-4236.

A final word

     Nothing remains the same in this world, and medicine is no exception.
Many research projects are in operation as of this writing that could
dramatically change our understanding of diabetes and our manner of treating
this chronic illness.


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(Research by Valerie De Benedette, Consulting Editor Robert De Marco, M.D.)
ÿ
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The material contained here is "FOR INFORMATION ONLY" and should not replace 
the counsel and advice of your personal physician.  Promptly consulting your 
doctor is the best path to a quick and successful resolution of any medical 
problem.
