Pennington Nutrition Series, Diabetes

Pennington Nutrition Series

2006. No. 3

Healthier lives through education in nutrition and preventive medicine

Complications of Diabetes Diabetes is a chronic disease that requires lifetime treatment by a physician. The physician will monitor blood glucose and insulin levels, check for development of complications and treat symptoms as needed. Potential Diabetes Complications • • • •

Heart disease Kidney disease/Kidney transplantation Eye complications Diabetic Neuropathy and nerve damage

• • • •

Foot Complications Skin Complications Gastroparesis Depression

Heart Disease

Coronary artery disease is caused by a narrowing or blocking of the blood vessels to the heart. It is the most common form of heart disease. The blood vessels to the heart are important because the blood flowing through them carries oxygen and other necessary materials. Unfortunately, these blood vessels can become partially or totally blocked by fatty deposits. A heart attack occurs when the blood supply to the heart is reduced or cut off. Having diabetes means that there is an increased likelihood of having coronary artery disease, a heart attack or stroke. Luckily, there are steps that can be taken to prevent heart disease or reduce the chances of having another heart attack. The risk can be reduced by keeping the ABCs of diabetes on target through wise food choices, physical activity and/or medication. “The ABCs” “A” is for A1C

A1C is the blood glucose check “with a memory.” It determines average blood glucose control over the past 2 to 3 months. The American Diabetes Association (ADA) recommends an A1C below 7.

“B” is for blood pressure

Blood pressure (BP) numbers tell the force of blood inside the blood vessels. With a high blood pressure, this means that the heart is having to work harder than it should. The ADA recommends a BP below 130/80.

“C” is for cholesterol

Cholesterol numbers tell you the amount of fat in the blood. Some kinds, such as HDL, help protect the heart. Other kinds, such as LDL, can clog the blood vessels, leading to heart disease. Triglycerides are another kind of blood fat that can raise the risk for heart disease.

Kidney Function

The kidneys’ role is to remove waste products from the blood. Inside the kidneys are millions of tiny blood vessels (capillaries) that act as filters. Digestion of proteins creates waste products that need to be removed. Normally, as blood flows through the small capillaries, tiny molecules (waste products) flow through the holes with water to make urine for removal from the body. Useful substances, such as protein and red blood cells are too big to pass through the filter and they remain in the blood. High levels of blood sugar (from poorly controlled diabetes) can make the kidneys work too hard, putting extra stress on them. After years of damage, the kidneys start to leak and useful protein leaks in the urine. Having a small amount of protein in the urine is known as microalbuminuria. When kidney disease is diagnosed early (during microalbuminuria), there are several treatments that may keep the kidney disease from getting worse. However, when kidney disease is caught later, end-stage renal disease (ESRD) usually follows. Facts about Diabetes & Kidney Disease •

10-21% of all people with diabetes have nephropathy (kidney disease).

•

Approximately 43% of new cases of ESRD are attributed to diabetes.

•

The risk of ESRD is 12 times higher in people with type 1 diabetes than in those with type 2.

•

In the US, the incidence of ESRD in people with diabetes is more than 4 times higher in African Americans, 4 to 6 times higher in Mexican Americans and 6 times higher in Native Americans than the remaining population of diabetic patients.

With time, the stress of overwork causes the kidneys to lose their filtering ability. Waste products begin to build up in the blood. Finally, the kidneys fail. ESRD is a very serious condition requiring either a kidney transplant or regular visits to a dialysis clinic where blood is filtered by a machine which contains an artificial kidney.

Not everyone with diabetes will develop kidney disease. Factors that influence kidney disease development include: genetics, blood pressure, and blood sugar control. Of course, genetics are beyond our control. On the other hand, blood pressure and blood sugar levels can be improved with diet and exercise. By doing this, the risk for kidney disease is reduced.

Eye Complications

Cataracts

People with diabetes have a higher risk of blindness than people without diabetes. Most people with diabetes have nothing more than minor eye disorders. With minor and major problems, treatments must begin immediately to avoid loss of eyesight.

With cataracts, the eye’s clear lens clouds, blocking light. For mild cataracts, one may need to wear sunglasses more often, and use glarecontrol lenses in eyeglasses. For cataracts that interfere greatly with vision, doctors generally remove the lens of the eye, replacing it with a new transplanted lens.

Glaucoma

Glaucoma occurs when pressure builds up in the eye. The pressure pinches the blood vessels carrying blood to the retina and the optic nerve. Vision is gradually lost because the retina and nerve are damaged. The risk for glaucoma increases with age and duration of diabetes. People with diabetes are 40% more likely to suffer from glaucoma than are people without diabetes. Luckily, there are several effective treatments for glaucoma. For some, drugs are used to reduce the pressure in the eye, and for others, surgery is an option.

Individuals with diabetes are: • • •

60% more likely to develop cataracts Likely to get cataracts at a younger age Likely to have problems if removal of the lens is necessary due to the beginning stages of glaucoma

Retinopathy

Diabetic retinopathy is a general term for all disorders of the retina caused by diabetes. There are two major types of retinopathy: nonproliferative and proliferative. Nonproliferative is the more common, milder form. It usually has no effect on vision and needs no treatment. Yearly monitoring is important, however, to make sure the condition is not getting any worse. Proliferative retinopathy is a much more serious condition. With proliferative retinopathy, blood vessels are so damaged that they close off. In response, new vessels begin growing in the retina. These vessels are weak and can leak blood, blocking vision. This condition is known as vitreous hemorrhage. A more serious condition that can occur with proliferative retinopathy is retinal detachment.

Almost everyone with type 1 diabetes will eventually develop nonproliferative retinopathy. Luckily, the retinopathy that destroys vision, proliferative retinopathy, is far less common.

Diabetic Neuropathy & Nerve Damage

It is important to:

About half of all people with diabetes have some form of nerve damage. Nerve damage from diabetes is referred to as diabetic neuropathy. It is more common in those who have had the disease for many years. Keeping blood glucose levels on target, can help prevent or delay nerve damage.

• • • •

• •

Report all possible signs of diabetic neuropathy Get treatment immediately at the onset of problems. Take good care of the feet, checking them every day. Lack of pain sensation may lead to foot injury. Protect the feet. Wear shoes and socks that fit well and wear them at all times. Use warm water to wash the feet and dry them carefully. Purchase special shoes if they are needed. Medicare may cover the cost of the shoes. It is important to be careful when exercising. Some activities are not safe for individuals with neuropathy.

Calluses

Foot Complications •

Skin Changes

•

Calluses

•

Foot Ulcers

•

Poor Circulation

•

Amputation

Skin Changes

Diabetes can cause feet to be very dry at times. This is because the nerves that control the oil and moisture in the foot are no longer working. After bathing, feet need to be dried well. Use petroleum jelly, unscented hand cream, or a similar product to seal in extra moisture. It is important not to put oils or creams between toes, since extra moisture can lead to infection.

Calluses occur more often and build up faster in the diabetic. Too much callus build up may mean that therapeutic shoes and inserts are required. Calluses, if not trimmed, get very thick and can break down and turn into ulcers (open sores). It is important not to self treat calluses. This can lead to infection. Your healthcare provider should do this for you.

Foot Ulcers

Even though some ulcers do not hurt, every ulcer should be seen by the health care provider immediately. Neglecting ulcers can result in infections, which can lead to potential loss of a limb. Keeping off the feet, when there are problems, is very important. Walking on an ulcer can make it get larger and force the infection deeper into the foot.

Poor Circulation

Amputation

Poor blood flow can make the foot less able to fight infection and heal. There are things that can be done to improve circulation: stop smoking, keep blood pressure and cholesterol in check. Also, exercise is good for poor circulation because it stimulates blood flow in the legs and feet. Exercise is a good idea for individuals who currently do not have any open sores on the foot. Proper shoes are essential.

Skin Complications •

Bacterial infections

•

Fungal infections

•

Itching

•

Diabetic Dermopathy

•

Atherosclerosis

•

Allergic Reactions

•

Diabetic Blisters

•

Eruptive Xanthomatosis

•

Digital Sclerosis

•

Disseminated Granuloma Annulare

•

Acanthosis Nigricans

People with diabetes are far more likely to have a foot or leg amputated than anyone else. This is because many people with diabetes have artery disease, which reduces blood flow to the feet. Also, individuals with diabetes usually have nerve damage, which reduces sensation. These two problems combined make an individual much more likely to get ulcers and infection that may potentially lead to amputation. Luckily, most amputations are preventable with regular and proper footwear. Two of the most important factors in reducing the likelihood of amputation is to always follow your health care provider’s advice when caring for foot problems and to stop smoking! Smoking affects small blood vessels by decreasing their blood flow to the feet and delays the healing of wounds.

Bacterial Infections

There are several kinds of bacterial infections that can occur in individuals with diabetes. Styes are infections of the glands of the eyelid. Boils are infections of the hair follicles. Carbuncles are deep infections in the skin and the tissue underneath. Inflamed tissues are usually hot, swollen, red and painful. Today, there are antibiotics that can be used to treat such infections.

Stye

Fungal Infections

Candida albicans is a yeast-like fungus which is often responsible for fungal infections in individuals with diabetes. Common fungal infections include: jock itch, athlete’s foot, ringworm, and vaginal infections. If you suspect a yeast or fungal infection, contact your health care provider. He/she can prescribe medication to treat it.

Athlete’s foot

Itching

Diabetic Dermopathy

Localized itching is often caused by diabetes. Itching can be caused by a yeast infection, dry skin, or poor circulation. When poor circulation is the cause, the itchiest regions are often the lower parts of the legs. Limiting the frequency of bathing, particularly when humidity is low, using mild soap with moisturizer, and applying skin cream after bathing may help resolve the issue.

Diabetic Dermopathy refers to changes in the small blood vessels caused by diabetes. Dermopathy looks like light brown, scaly patches, often mistaken for age spots. The disorder most often occurs on the front of both legs. The patches do not hurt, open up or itch. Dermopathy is harmless and does not require treatment.

Allergic Reactions

Skin reactions can occur in response to medications, such as insulin or diabetes pills. If you think you are having a reaction to a medication, contact your doctor immediately. Be on the lookout for rashes, depressions, or bumps around the sites where insulin is injected.

Atherosclerosis refers to the thickening of arteries. People with diabetes tend to get atherosclerosis at a younger age. As atherosclerosis narrows blood vessels, skin changes occur. Skin becomes hairless, thin, cool, and shiny. Because blood carries the infection-fighting white cells, affected legs tend to heal slowly when the skin is injured. Diabetic Blisters

Diabetic blisters occur rarely in individuals with diabetes. When they do occur, they are typically found on the backs of fingers, hands, toes, feet, or on the legs or forearms. They are sometimes large and resemble burn blisters. They are painless and often heal themselves within 3 weeks. The only treatment is to bring blood sugar levels under control.

Eruptive Xanthomatosis

Eruptive Xanthomatosis is a condition caused when diabetes is out of control. It consists of firm, yellow, pea-like enlargements in the skin. The disorder usually occurs in young men with type 1 diabetes. Like diabetic blisters, these bumps disappear when diabetes control is restored.

Atherosclerosis

Digital Sclerosis

Digital Sclerosis consists of tight, thick, waxy skin on the back of the hands. The finger joints become stiff and can no longer move the way they should. Rarely, knees, ankles or elbows also get stiff. Digital sclerosis happens to about 1/3 of all people with type 1 diabetes. The only treatment is to bring blood sugar levels under control.

Disseminated Granuloma Annulare

Acanthosis Nigricans

This condition consists of sharply defined ring-shaped or arc-shaped raised areas on the skin. Rashes most often occur on parts of the body far from the trunk (i.e., ears or fingers), but sometimes the raised areas occur on the trunk. Contact your doctor if you see rashes like these. Certain drugs can help clear up the condition.

Acanthosis Nigricans is a condition in which tan or brown raised areas appear on the sides of the neck, armpits, and groin. It usually strikes people who are overweight. The best treatment is to lose weight. Some creams can also help the spots look better.

Gastroparesis & Diabetes

Occurs when the nerves to the stomach are damaged or stop working. In this condition, the muscles of the stomach and intestines do not work normally, and the movement of food is slowed or stopped. Signs & Symptoms • • • • • • • • • •

Heartburn Nausea Vomiting of undigested food An early feeling of fullness when eating Weight loss Abdominal bloating Erratic blood glucose levels Lack of appetite Gastroesophageal reflux Spasms of the stomach wall

Gastroparesis can worsen diabetes by making it harder to manage blood glucose. Food staying in the stomach too long can: •

Cause problems such as bacterial overgrowth due to fermentation

•

Harden into solid masses called bezoars that may cause nausea, vomiting, and obstruction of the stomach

The most important treatment goal for diabetes-related gastroparesis is to manage blood glucose levels through the use of: Insulin

May need to take more often and after meals for best results.

Medication

There are several available drugs that can be used to treat gastroparesis. Different drugs or combinations of drugs may need to be tried before finding the most effective treatment.

Meal and food changes

This can help control your gastroparesis. Your doctor or dietitian will give you specific recommendations.

Feeding tube

If other approaches do not work, surgery may be required. A feeding tube allows for the insertion of nutrients directly into the small intestine, bypassing the stomach altogether .

Bezoars can be dangerous if they block the passage of food into the small intestine.

Depression

If you are feeling symptoms of depression, don't keep it bottled up. Talk to your doctor. There may be a physical cause for your depression. Diabetes that is in poor control can cause symptoms that look like depression: • • •

High or low blood sugar during the day can make you feel tired or anxious Low blood sugar levels can also lead to hunger and eating too much High blood sugar in the night can lead to frequent urination and then feeling tired throughout the next day

The Pennington Biomedical Research Center is a worldrenowned nutrition research center. Pennington Nutrition Series, Number 3, 2006 3/06 Authors: Heli Roy, PhD, RD Shanna Lundy, BS Division of Education Phillip Brantley, PhD, Director Pennington Biomedical Research Center Claude Bouchard, PhD, Executive Director

All information was obtained from the American Diabetes Association

Available at: http://www.diabetes.org

Mission: To promote healthier lives through research and education in nutrition and preventative medicine. The Pennington Center has six priorities in research: 1. Clinical Obesity Research 2. Experimental Obesity 3. Functional Foods 4. Health and Performance Enhancement 5. Nutrition and Chronic Diseases 6. Nutrition and the Brain The research fostered by these divisions can have a profound impact on healthy living and on the prevention of common chronic diseases, such as heart disease, cancer, diabetes, hypertension and osteoporosis. The Division of Education provides education and information to the scientific community and the public about research findings, training programs and research areas, and coordinates educational events for the public on various health issues. We invite people of all ages and backgrounds to participate in the exciting research studies being conducted at the Pennington Center in Baton Rouge, Louisiana. If you would like to take part, visit the clinical trials web page at www.pbrc.edu or call (225) 763-2597. Visit our Web Site: www.pbrc.edu

Pennington Nutrition Series

2006. No. 4

Healthier lives through education in nutrition and preventive medicine

Metabolic Syndrome The metabolic syndrome is a clustering of conditions that can occur together in an individual. These conditions can increase the risk for heart disease, stroke and diabetes. A commitment to a lifestyle change can delay these conditions. Overview

Metabolic syndrome is not a disease, but rather a cluster of disorders, including: • • • •

High blood pressure High insulin levels Excess body weight Abnormal cholesterol levels

Each of these disorders is by itself a risk factor for other diseases. In combination, however, these disorders dramatically boost the chances of developing potentially life-threatening illnesses, such as diabetes, heart disease or stroke. Conditions associated with the Metabolic Syndrome:

The syndrome is closely related to a generalized metabolic disorder called insulin resistance, in which the body can’t use insulin efficiently. Metabolic syndrome has been called by many names, including: • •

The risk to your health increases with an increasing number of components you have.

•

Syndrome X The deadly quartet Insulin Resistance Syndrome

Prevalence • • •

•

Metabolic syndrome affects as many as one in four American adults (25%) For adults over the age of 40, this percentage jumps to 40% There has been an increase in metabolic syndrome prevalence by 61% over the past decade Rates differ among races and gender

Risk Factors Age

♦

The prevalence of metabolic syndrome increases with age, affecting less than 10% of people in their 20s and 40% of people in their 60s.

Race

♦

Metabolic syndrome is generally more common among blacks and Mexican Americans than among Caucasians.

Obesity

♦

A body mass index (BMI) greater than 25 increases the risk of developing metabolic syndrome. Abdominal obesity does as well. Abdominal obesity refers to having an apple shape rather than a pear.

♦

History of Diabetes

♦

Having a family history of type 2 diabetes or diabetes during pregnancy (gestational diabetes) increase the risk for developing metabolic syndrome.

Other diseases

♦

A diagnosis of hypertension, cardiovascular disease (CVD) or polycystic ovary syndrome (a hormonal disorder in which a woman’s body produces an excess of male hormones) also increases the risk for metabolic syndrome.

Having at least one feature of metabolic syndrome, such as high blood pressure, high cholesterol or an apple-shaped body, may indicate the presence of the condition. It is important to talk with a physician about testing for other components of the syndrome and developing a plan to avoid the development of serious diseases.

Apple

Pear

Diagnosing Metabolic Syndrome According to the National Cholesterol Education Program (NCEP), you have metabolic syndrome if you have 3 or more of the following: •

Waist circumference Greater than 35 inches in women and 40 inches in men (abdominal obesity)

•

Triglycerides Levels of 150 milligrams per deciliter (mg/dl) or higher

•

Blood pressure 130/85 mm Hg or higher

•

Fasting Blood Glucose Level of 110 mg/dl or higher

•

High-density lipoprotein cholesterol Lower than 50 mg/dl in women and 40 mg/dl in men

Prevention If you have only one or two components of metabolic syndrome— or better yet, none at all, then you can make the following lifestyle changes now to prevent the onset of the syndrome •

Commit to a healthy life This includes eating plenty of fruits and vegetables, choosing lean cuts of white meat and fish over red meat, avoiding processed or deep-fried dinners, and eliminating table salt by experimenting with other herbs and spices.

•

Get moving It is important to stay active. We should get at least 30 minutes of moderately strenuous activity on most days of the week.

•

Schedule regular check-ups It is important to schedule regular check-ups on blood pressure, cholesterol and blood sugar levels. Early detection of problems can allow you to make additional lifestyle modifications early on.

Treatment There are medications to control the syndrome that include:

The primary goal of treatment is to prevent: • • •

Type 2 diabetes Heart attack Stroke

The primary goal of therapy is to prevent the development of insulin resistance. To achieve this goal, the preferred method is an aggressive regimen of self-care strategies focusing on diet and exercise. The following are routinely monitored to ensure that lifestyle modifications are working: • • • •

Weight Blood glucose Cholesterol Blood pressure

Pennington Nutrition Series, Number 4, 2006 3/06 Authors: Heli Roy, PhD, RD Shanna Lundy, BS Division of Education Phillip Brantley, PhD, Director Pennington Biomedical Research Center Claude Bouchard, PhD, Executive Director http://www.mayoclinic.com http://americanheart.org

Weight loss drugs

Along with diet and exercise, it may sometimes be necessary to prescribe weight loss drugs at times.

Insulin sensitizers

Drugs prescribed to diabetics to help decrease insulin resistance may be helpful.

Aspirin

Prescribed to reduce the risk of heart attack.

Medications to Diuretics, angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers and beta lower blood blockers all work to lower blood pressure. pressure Medications to Medications such as niacin, statins and fibrates can help improve cholesterol in several different ways. regulate cholesterol

The Pennington Biomedical Research Center is a world-renowned nutrition research center. Mission: To promote healthier lives through research and education in nutrition and preventative medicine. The Pennington Center has six priorities in research: 1. Clinical Obesity Research 2. Experimental Obesity 3. Functional Foods 4. Health and Performance Enhancement 5. Nutrition and Chronic Diseases 6. Nutrition and the Brain The research fostered by these divisions can have a profound impact on healthy living and on the prevention of common chronic diseases, such as heart disease, cancer, diabetes, hypertension and osteoporosis. The Division of Education provides education and information to the scientific community and the public about research findings, training programs and research areas, and coordinates educational events for the public on various health issues. We invite people of all ages and backgrounds to participate in the exciting research studies being conducted at the Pennington Center in Baton Rouge, Louisiana. If you would like to take part, visit the clinical trials web page at www.pbrc.edu or call (225) 763-2597. Visit our Web Site: www.pbrc.edu

Pennington Nutrition Series

2006. No. 1

Healthier lives through education in nutrition and preventive medicine

Type 1 Diabetes Overview

Type 1 Diabetes (DM) is usually diagnosed in children and young adults. It was previously referred to as “Juvenile Diabetes.” In this type of diabetes, the body is not able to produce insulin. Insulin is required by the body to use sugar, in the form of glucose. Glucose is the basic fuel for cells. Insulin’s role is to take the glucose from the blood and carry it into cells where it can be used to provide energy for the body to do work.

About Insulin

Insulin cannot be taken in a pill form trough the mouth. If it were to be consumed this way, it would be broken down during digestion just like normal proteins in your food. Insulin must be injected into the fat under the skin in order for it to get into the bloodstream.

Insulin is a hormone made by the beta cells of the pancreas. With each meal consumed, beta cells release insulin in order for the body to be able to use or store the glucose it gets from foods. With Type 1 Diabetics, however, the pancreas is no longer able to make insulin. The beta cells have been destroyed. Insulin shots are thus required in order for the body to use the glucose coming from meals.

Characteristics of Insulin

There are three characteristics of insulin: •

Onset: is the length of time before insulin reaches the bloodstream and begins lowering blood glucose.

•

Peaktime: is the time during which insulin is at maximum strength in being able to lower blood glucose.

•

Duration: is how long insulin continues to lower blood glucose.

The Four Types •

Rapid-acting insulin

•

Intermediate-acting insulin

•

Regular or short-acting insulin

•

Long-acting insulin

Rapid-acting •

Onset: Begins to work in about 5 minutes

•

Peaktime: Peak is about 1 hour

•

Duration: Continues to work for about 2-4 hours

Regular/short-acting •

Onset: Reaches the bloodstream within 30 minutes after injection

•

Peaktime: Peaks anywhere from 2-3 hours after injection

•

Duration: Effective for approximately 3-6 hours

Intermediate-acting •

Onset: Reaches the bloodstream about 2-4 hours after injection

•

Peaktime: Peaks 4-12 hours later

•

Duration: Effective for about 12 to 18 hours

Long-acting •

Onset: Reaches the bloodstream 6-10 hours after injection

•

Duration: Usually effective for 20-24 hours

•

There is also a very long-acting insulin, known as glargine, which starts to lower blood glucose levels about one hour after injection and keeps working evenly for 24 hours after injection.

Fine-Tuning Blood Glucose levels

Premixed Insulin

Premixed insulin is also an option for individuals with Type 1 Diabetes. It is helpful for individuals who have trouble drawing up insulin out of two bottles or for individuals who have difficulty in reading the correct directions and dosages. Information on Storage of Insulin •

Manufacturers recommend storing insulin in the refrigerator; however, injecting cold insulin sometimes makes the injection more painful.

•

You can store insulin to be used immediately at room temperature.

•

Insulin stored at room temperature will last for approximately 1 month.

•

If purchasing several bottles at once, keep one at room temperature to be used immediately. Store the remaining bottles in the refrigerator so that they will keep longer.

There are many factors that influence blood glucose levels, including: •

What you eat

•

How much and when you exercise

•

Where you inject your insulin

•

When you take your insulin injections

•

Illness

•

Stress

Information on Storage of Insulin • • • • •

Do not store insulin near extreme heat or extreme cold. Never store in the freezer, direct sunlight, or in the glove compartment of a car. Check the expiration date. This is especially important for a larger batch. Make sure that the insulin looks normal before drawing it into the syringe. If there is any discoloration, particles, “frosting” or crystals in the solution, do not use it. Return the unopened bottle to a pharmacy for an exchange and/or refund.

Conditions that can arise from Type 1 DM •

Hypoglycemia

•

Hyperglycemia

•

Ketoacidosis

Symptoms of Hypoglycemia •

Shakiness

—HYPOGLYCEMIA—

•

Dizziness

Hypoglycemia is a condition that occurs due to low blood glucose. It happens from time to time in everyone with diabetes. It is sometimes referred to as an “insulin reaction.” It must always be treated immediately.

•

Sweating

•

Hunger

•

Pale skin color

•

Sudden moodiness or behavior changes, such as crying for no apparent reason

•

Clumsy or jerky movements

•

Seizure

•

Difficulty paying attention or confusion

•

Tingling sensations around the mouth

Establish a schedule for checking blood glucose levels as directed by a physician. • Blood glucose should be checked if there are any symptoms of hypoglycemia present. • The presence of low blood glucose level requires immediate treatment. • If you are unable to check your blood glucose, a good rule of thumb is: •

“When in doubt, treat”

Treatment Should Be Immediate

If hypoglycemia is not treated immediately, it can result in a loss of consciousness. Loss of consciousness requires immediate treatment such as injection of glucagon or emergency treatment at the hospital. Glucagon, like insulin, is injected but serves a different purpose. Glucagon helps to raise blood glucose levels. A physician can prescribe glucagon and give directions on its use.

How to Treat Hypoglycemia

The fastest way to raise blood glucose and treat hypoglycemia is with some form of sugar. Any of the following would work: • • •

3 glucose tablets 1/2 cup of fruit juice 5-6 pieces of hard candy

—HYPERGLYCEMIA— Potential Causes of Hyperglycemia

Hyperglycemia is a technical term for high blood glucose. It can be a serious problem if not treated. Hyperglycemia can happen when the body has too little, or not enough insulin, or when the body is not able to use insulin properly. Blood glucose levels can be reduced by exercising. However, if the blood glucose level is above 240 mg/dl, check the urine for ketones. If there are ketones present, then exercise is not recommended. In addition, cutting down on the amount of food may help. If exercise and changes in diet do not help, then talk with a physician about either changing the amount of insulin or the timing of the injections.

•

Eating more than planned

•

Exercising less than planned

•

Stress of an illness, such as the cold or flu

•

Other stresses, such as family conflicts or dating problems

Ketones are acids that build up in the blood. They appear in the urine when the body doesn't have enough insulin. Ketones can poison the body. They are an indicator that the diabetes is getting out of control. Ketones are present in high amounts in a condition known as Ketoacidosis.

Potential Causes of Hypoglycemia —KETOACIDOSIS—

Ketoacidosis results from a failure to treat hyperglycemia. It rarely occurs in individuals with Type 2 DM. It is a very serious condition that can lead to diabetic coma, or even death. Treatment for this condition usually takes place in a hospital. You can prevent the condition by learning what the warning signs are and by checking your blood and urine regularly.

•

Thirst or a very dry mouth

•

Frequent urination

•

High blood glucose levels

•

High levels of ketones in the urine

•

Constantly feeling tired

•

Dry or flushed skin

•

Nausea, vomiting, or abdominal pain

•

Shortness of breath

•

Difficulty paying attention

Possible Causes of Ketoacidosis •

Not getting enough insulin: The dose was not enough or perhaps the body needed more insulin than usual because of illness. Without sufficient insulin, the body begins to break down fat for energy.

•

Not enough food: During illness, appetite and food intake is reduced and this may result in high ketone levels. Skipping meals can also lead to ketoacidosis.

•

An insulin reaction: When blood glucose levels fall too low, the body must use fat for energy. If testing shows high ketones in the morning, its likely that the person may have had an insulin reaction while asleep.

Who Should Check?

The ADA recommends blood glucose checks if you have diabetes and are: • • • • •

•

Taking insulin or diabetes pills On intensive insulin therapy Pregnant Having a hard time controlling your blood glucose levels Having severe low blood glucose levels or ketones from high blood glucose levels Having low blood glucose levels without the usual warning signs

Pennington Nutrition Series, Number 1, 2006 3/06

Authors: Heli Roy, PhD, RD Shanna Lundy, BS

Division of Education Phillip Brantley, PhD, Director Pennington Biomedical Research Center Claude Bouchard, PhD, Executive Director

http://www.diabetes.org

Ketoacidosis is dangerous and serious. If you have any of the mentioned symptoms, contact your health care provider immediately or go to the nearest emergency room. An important note: NEVER exercise when urine test shows ketones and the blood glucose is high. This combination can mean that the diabetes is out of control.

The Pennington Biomedical Research Center is a world– renowned nutrition research center. Mission: To promote healthier lives through research and education in nutrition and preventative medicine. The Pennington Center has six priorities in research: 1. Clinical Obesity Research 2. Experimental Obesity 3. Functional Foods 4. Health and Performance Enhancement 5. Nutrition and Chronic Diseases 6. Nutrition and the Brain The research fostered by these divisions can have a profound impact on healthy living and on the prevention of common chronic diseases, such as heart disease, cancer, diabetes, hypertension and osteoporosis. The Division of Education provides education and information to the scientific community and the public about research findings, training programs and research areas, and coordinates educational events for the public on various health issues. We invite people of all ages and backgrounds to participate in the exciting research studies being conducted at the Pennington Center in Baton Rouge, Louisiana. If you would like to take part, visit the clinical trials web page at www.pbrc.edu or call (225) 763-2597. Visit our Web Site: www.pbrc.edu

Pennington Nutrition Series Healthier lives through education in nutrition and preventive medicine

2006. No. 2

Type 2 Diabetes Type 2 Diabetes Type 2 is the most common form of diabetes. In this form, the body does not produce enough insulin or the cells ignore the insulin that is produced. Insulin is required by the body in order to use sugar. Insulin takes the sugar from the blood into the cells. When glucose builds up in the blood instead of going into the cells, it can cause some problems: • •

In the short-term, your cells may be starved for energy In time, high blood glucose may damage your eyes, kidneys, nerves or heart

About Insulin •

•

•

Inside the pancreas, beta cells make the hormone insulin. Beta cells release insulin to help the body use or store blood glucose from food. In individuals with Type 1 diabetes, the pancreas no longer makes insulin. The beta cells have been destroyed and insulin shots are the only way to keep blood glucose levels down. Individuals with Type 2 diabetes make insulin, but their bodies don't respond well to it. Most people with Type 2 diabetes can control their condition through diet and exercise. Only a small amount of people need diabetes pills or insulin shots to help their bodies use glucose.

Although diabetes occurs in people of all ages and races, some groups have a higher risk for developing type 2 diabetes (DM) than others. Examples include: • • • • •

African Americans Latinos Native Americans Asian American/Pacific Islanders Aged population

Type 2 Diabetes

Conditions that can arise from Type 2 DM • • •

Hypoglycemia Hyperglycemia Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)

Symptoms of Hypoglycemia • •

—HYPOGLYCEMIA—

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Hypoglycemia, or low blood glucose (sugar) is a problem that happens from time to time in everyone who has diabetes. It is sometimes referred to as “insulin reaction.” Although it may be unavoidable at times, it is important to recognize and treat it immediately before symptoms worsen.

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You should check your blood glucose level according to the schedule you work out with your doctor. In addition, you should check your blood glucose any time you feel low blood glucose coming on. If you check and observe a low blood glucose level, then treat for hypoglycemia quickly. A good rule if you are unable to check your blood glucose is:

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Shakiness Dizziness Sweating Hunger Headache Pale skin color Sudden moodiness or behavior changes, such as crying for no apparent reason Clumsy or jerky movements Seizure Difficulty paying attention or confusion Tingling sensations around the mouth

Treating Hypoglycemia

The quickest way to raise your blood glucose and treat hypoglycemia is with some form of sugar, such as: • • •

3 glucose tablets 1/2 cup of fruit juice 5-6 pieces of hard candy

“When in doubt, treat”

If hypoglycemia is not treated quickly enough, you could pass out. If you pass out, immediate treatment will be required, such as an injection of glucagon or emergency treatment at a hospital. Glucagon, like insulin, is injected but serves a different purpose. Glucagon works to raise your blood glucose. Your doctor can prescribe glucagon and tell you how to use it.

—HYPERGLYCEMIA—

Type 2 Diabetes Potential Causes of Hyperglycemia

Hyperglycemia is the technical term for high blood glucose. It happens when the body has too little, or not enough, insulin or when the body can’t use insulin properly.

It is important to monitor blood glucose levels frequently. If hyperglycemia is detected, treatment should begin immediately. Failing to treat hyperglycemia could lead to a condition called ketoacidosis. Ketoacidosis occurs when the body doesn't have enough insulin. Without insulin, the body cant use glucose for fuel, so it is left breaking down fats for energy.

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Eating more than planned Exercising less than planned The stress of illness, such as a cold or flu Other stresses, such as family conflicts or dating problems

Symptoms of Hyperglycemia • • • •

High blood glucose High levels of sugar in the urine Frequent urination Increased thirst

Symptoms of Ketosis • • • •

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

Waste products (ketones) are generated as your body breaks down fats. Large amounts of ketones cannot be tolerated by the body. So, your body will try to excrete these ketones through the urine. However, not all will be able to be excreted, and the rest is left to build up in the blood. This buildup is what leads to ketosis.

How to Treat Hyperglycemia

Exercise is often effective in lowering blood glucose levels. However, if your blood glucose is above 240 mg/dl, check your urine for ketones. If they are present, do NOT exercise. This can actually lead to higher blood glucose levels than prior to beginning the exercise. You will need to work with your doctor on finding the best way to lower your blood glucose level.

Warning Signs of HHNS Type 2 Diabetes

—HYPEROSMOLAR HYPERGLYCEMIC NONKETOTIC SYNDROME—

HHNS is a serious condition most frequently seen in older persons. It can occur in both type 1 and type 2 diabetes, although it is most commonly seen in type 2. HHNS is usually brought on by something else, such as an illness or infection.

Blood glucose level over 600 mg/dl Dry, parched mouth Extreme thirst

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(which may gradually disappear)

Warm, dry skin that does not sweat High fever

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(>101 degrees Fahrenheit)

Sleepiness or confusion Loss of vision Hallucinations

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(seeing/hearing things that aren't there)

In HHNS, your blood sugar levels rise. Your body tries to rid itself of excess sugar by passing it through the urine. Initially, a lot of urine is produced and you have to go to the bathroom often. With time, you may not have to go as often and the urine can become very dark. You may be very thirsty. Even if you are not thirsty, it is very important to consume a lot of liquids to prevent dehydration. If HHNS continues, severe dehydration can potentially lead to seizures, coma or even death.

Weakness on one side of the body

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To Prevent HHNS • •

Check your blood glucose regularly Speak with your doctor about how often you should check your blood glucose and what your target range should be

Importance of Monitoring Blood Glucose •

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Keeping your blood glucose in your target range can help prevent or delay the start of diabetes complications, such as nerve, eye, kidney and blood vessel damage. Once an individual learns that he/she has diabetes, it is important to work with your health care team to create a diabetes care plan. The plan aims to balance the foods you eat with exercise, and possibly, with diabetes pills or insulin. There are two types of checks that you can do to help keep track of how your plan is working: — Blood glucose checks — Urine ketone checks

Urine Checks Type 2 Diabetes

Blood Glucose Monitoring Checks

This is the main tool you have to check diabetes control. The check can tell you your blood glucose level at any one time. Keeping a log of results is important. You can present this log to your healthcare provider. The log provides the healthcare provider with a good picture of your body’s response to your diabetes care plan. It will allow for your doctor to make changes if necessary.

Urine checks are not as accurate as blood glucose checks. They should not be done to test for glucose levels unless blood testing is impossible. A urine check for ketones, however, is another matter. This is an important check when your diabetes is out of control or when you are sick. Everyone with diabetes should know how to check their urine for ketones.

Experts feel that anyone with diabetes can benefit from checking their blood glucose. The American Diabetes Association recommends blood glucose checks if you have diabetes and are: • • • • •

Taking insulin or diabetes pills On intensive insulin therapy Pregnant Having a hard time controlling your blood glucose levels Having severe low blood glucose levels or ketones from high blood glucose levels

When You Should Test For Ketones

Ask your doctor or nurse when to check for ketones. You may be advised to check for ketones when: • • • • • • • • •

Your blood glucose is more than 300 mg/dl You feel nauseated, are vomiting, or have abdominal pain You are sick (example— with the cold or the flu) You feel tired all the time You are thirsty or have a very dry mouth Your skin is flushed You have a hard time breathing Your breath smells “fruity” You feel confused or “in a fog”

Tight Control and Diabetes

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Losing weight is one way to achieve tight control. By shedding excess pounds, you may be able to bring your glucose levels down to normal. Your doctor should work with you to find an eating and exercise plan right for you.

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Exercising is another way to achieve tight control. Even without a weight loss, exercise proves beneficial with blood glucose control. It allows for your cells to take glucose out of the blood.

Type 2 Diabetes

The benefit of tight control of blood glucose can be in the prevention or slower progression of many complications of diabetes, giving you extra years of healthy, active life. However, tight control is not for everyone and it involves hard work. Much of the previous research on the benefits of tight control and diabetes has involved type 1 diabetes. But doctors believe that tight control can also prevent complications in people with type 2 diabetes as well. Most people with type 2 diabetes do not take insulin, so it may not be apparent how such tight control could occur in these individuals. Tight Control– Not Recommended For: • • •

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Children The elderly Some individuals who already have complications, such as individuals with end-stage kidney disease or severe vision loss Some individuals with diseases, such as coronary artery disease or vascular disease Individuals with hypoglycemia unawareness

Pennington Nutrition Series, Number 2, 2006 Authors: Heli Roy, PhD, RD Shanna Lundy, BS Division of Education Phillip Brantley, PhD, Director Pennington Biomedical Research Center Claude Bouchard, PhD, Executive Director 3/06

American Diabetes Association

The Pennington Biomedical Research Center is a world– renowned nutrition research center. Mission: To promote healthier lives through research and education in nutrition and preventative medicine. The Pennington Center has six priorities in research: 1. Clinical Obesity Research 2. Experimental Obesity 3. Functional Foods 4. Health and Performance Enhancement 5. Nutrition and Chronic Diseases 6. Nutrition and the Brain The research fostered by these divisions can have a profound impact on healthy living and on the prevention of common chronic diseases, such as heart disease, cancer, diabetes, hypertension and osteoporosis. The Division of Education provides education and information to the scientific community and the public about research findings, training programs and research areas, and coordinates educational events for the public on various health issues. We invite people of all ages and backgrounds to participate in the exciting research studies being conducted at the Pennington Center in Baton Rouge, Louisiana. If you would like to take part, visit the clinical trials web page at www.pbrc.edu or call (225) 763-2597. Visit our Web Site: www.pbrc.edu