The word diabetes comes from a Greek expression meaning syphon. It refers to the large amounts of urine and the excessive thirst which often occurs in newly diagnosed or seriously uncontrolled diabetes.

These symptoms are due to a build-up of glucose (sugar) in the blood which then overflows into the urine. However, there may be no symptoms at all for many years.

As the glucose level rises higher, the lens of the eye may alter its shape, producing blurring of vision. When sugar overflows into the urine (where it can be easily tested), it draws water with it and produces more urine. This runs down the body's fluid reserves and creates thirst. The loss of essential chemicals into the urine can cause cramps, tiredness and weakness, together with weight loss.

If the fluid loss is severe, dehydration, and even coma can occur. High glucose levels in the blood prevent the body's defence against infection, particularly of the skin, urine and lungs. It may be a severe or chronic infection which first alerts the doctor that you have diabetes.

In some countries, tuberculosis is the first sign of diabetes. Sometimes, your type of diabetes may be picked up by a screening program on a blood or urine test.

What is the latest thinking on the ideal blood sugar level and how, and how often should people with diabetes monitor their condition? 

Blood sugar, or more properly, blood glucose, targets for people with diabetes must be individualised - what is right for one person may not be right for another, or even for the same person at a different time in his/her life.  

Ideally, everyone would have a blood glucose level that was the same as that of the non-diabetic  - between 4 and 6 mmol/l before meals and less than 11 mmol/l at any time. Some people with diabetes can achieve this, although it can be difficult if a person has no insulin of their own.

Injected insulin cannot precisely mimic the action of insulin produced by a healthy pancreas, especially in terms of the time over which it acts, and no-one ever gets it exactly right all the time!  Notwithstanding, as an aim, pre-meal blood glucose levels of between 4 and 7 mmol/l are desirable, with slightly higher levels 11/2 hours after meals (5 to 9 mmol/l) and before a bedtime snack (7 to 9 or even 11 mmol/l), to guard against low blood glucose (hypoglycaemia) in the night.

The lower end to the glucose aim is as important as the upper - blood glucose levels lower than normal can be as problematic as those that are too high, for different reasons. (NB the quoted aims are not necessarily appropriate for pregnant women, who should seek individual advice).

Such strict blood glucose control may not always be appropriate, for example, in the very young, in people who cannot measure their own blood glucose often enough to make it safe, or in people with advanced diabetic complications or problems with hypoglycaemia.

Everyone needs to keep their blood glucose levels out of the range that cause symptoms (excess urination, thirst, tendency to infection and thrush, tiredness and weight loss) or that cause (as a result of treatment) low blood glucose (hypoglycaemia). But we now have good evidence that the closer one can get to the targets above, the lower the risk of the long term complications of diabetes and if the above targets can be achieved, most of the time, it is a good thing. 

Everyone with diabetes, except perhaps those with other life threatening illness, should have a measure of long-term blood glucose control made once every 3 - 6 months. The glycosylated haemoglobin (or HbA1c) reflects blood glucose levels over about 3 months. A near normal value means less risk of long term complications.

If the glycosylated haemoglobin result is acceptable, a patient on diet, exercise and perhaps metformin tablets, may monitor day to day by ensuring that his/her urine is free from glucose, perhaps once or twice a day at different times. Someone on medication that can lower blood glucose below normal will probably want to be using home blood tests, as only these will reveal the blood glucose level at the time, and the possibility of hypoglycaemia. For someone aiming for tight control, to reduce the risk of long term diabetic complications, 4 tests a day (or sometimes even more) are desirable. 

An annual check for the early complications of diabetes and the risk factors for complications, such as high blood pressure, is mandatory for every person with diabetes.
 

Diabetes increases the risk of stroke and heart attack - what lifestyle implications does this have? 

Recent trials have shown that good blood glucose control and very good blood pressure control (often involving treatment of minor degrees of blood pressure that would not be treated in a person without diabetes) can substantially reduce the risk of stroke and heart disease in diabetes.

Having normal blood fat levels (cholesterol and triglyceride) is important and, of course, not being a smoker. All this involves sensible healthy diet patterns and plenty of exercise. People on insulin may find they need to eat more regularly and reproducibly than they would wish, to keep blood glucose levels normal but not too low. Eating extra or taking extra exercise may require temporary adjustment of treatment. 

Exercise matters.  One does not need to become an Olympic athlete, but the couch potato who slowly builds up to 30 minutes brisk walking a day - or even every other day - will be doing himself much good! People with diabetes do need to take care of their feet however, and some will have problems of the circulation or heart. It is sensible to discuss your exercise plans with your diabetes health care professional before starting.
What about cholesterol and high blood pressure?

Diabetes increases the risk of heart attacks, stroke and circulatory problems, so additional risk factors such as high cholesterol and high blood pressure are treated aggressively, using the treatment aims normally kept for people who have already had a heart attack or stroke.

It is a case for "the lower the better" for both blood pressure and cholesterol - and for blood triglyceride, another blood fat implicated in diabetic heart disease. Medication may be needed to achieve the best possible control of blood pressure and blood fat but a diet low in salt, excess alcohol and animal fat helps.

What are the latest theories on the causes of diabetes?

Type 1 or insulin dependent diabetes results from the total destruction of the insulin-producing cells of the pancreas. This is usually an autoimmune process. This means that the body has ceased to recognise the cells as belonging to it - it "sees" them as foreign and destroys them, just as it would destroy a foreign tissue such as a graft, an infecting organism or a cancer cell. What triggers the process is not known but it is probably different in different people.

Type 2 or non-insulin dependent diabetes is a group of diseases, all ending in the body being resistant to the actions of insulin and unable to make enough insulin to compensate for this. Again, a genetic predisposition is required but an unhealthy life style can precipitate the disease itself. Insufficient exercise, and a diet that is high in calories, simple carbohydrates and fat and encourages obesity are contributing to the present "epidemic" of diabetes in the world - a predicted doubling of the number of people with diabetes by the year 2010.

Does diabetes run in families?

Yes. For Type 1 diabetes, the risk of diabetes in other members of a family where one person has diabetes is 5 -10% if a brother or sister has the disease, 4-6% if the father is diabetic and 2 - 3% if diabetes is present in the mother. For children of families with Type 2 diabetes, the risk of developing diabetes 10-15% (vs perhaps 5% in the background population), with a 20-30% risk of having abnormal blood sugar handling that may progress to diabetes. This risk can be reduced by significantly by adopting a healthy lifestyle of more exercise and healthy eating.

Are there any exciting developments on the horizon?

This question deserves a web site of its own! There are many areas in which knowledge is increasing that may help people with diabetes. Current research looks at ways of preventing diabetes in people at risk.

For people with diabetes already, new ways of glucose monitoring, new drugs and new ways of giving insulin are on their way. A device to warn of low blood sugar is eagerly awaited and much work is going into ways of monitoring blood glucose painlessly and continuously, perhaps eventually linking measurements to an insulin delivery system.

Perhaps the most exciting news of recent years is the clear demonstration that people can help themselves to a healthier life, with proof that improving diabetes control and controlling blood pressure can make a real difference to the risk of long term complications and even life span. Currently available drugs to lower blood pressure can reduce the risk of heart trouble in people with diabetes and simple things such as careful review of all patients with diabetes on a regular basis already allows us to prevent  much of the visual loss and limb loss and kidney failure that was such a terrible burden for people with diabetes.

What about pancreas transplants?

Pancreas transplantation is really only suitable for Type 1 diabetes. Because of the toxic nature of the drugs used to maintain a graft, for most people, a new pancreas is really only an option when they need to be on immunosuppression for other reasons - such as needing  a new kidney. However, the techniques have improved rapidly and most operations result in an insulin-independence, at least for the life of the graft.

A few patients with very unstable diabetes have received pancreas tranplants alone but the success rate is lower. Much work is being done to make immunosuppression safer so that pancreas tranplantation could become more widely used, but there will always be limitations on the availability of donors. Separating out the cells of the pancreas that make insulin (islet transplantation), growing or making them are attractive ideas in development.

Could you explain the advantages of a flexible multi-dose insulin regimen as used by people with insulin pens?

Insulin pens can be used by anyone and do not necessarily imply a flexible regimen. Nor do you need a pen to have a flexible regimen! Pens are simply a more convenient way to take ordinary insulins. For Type 1 diabetes, two daily injections are the minimum with which it is possible to achieve anything approaching appropriate replacement of absent insulin. The term "multiple injection regimen" is used for treatment plans that include at least three injections a day. Such regimens are not always very flexible!

Two types of insulin replacement are needed in diabetes - a background of insulin, provided continuously, to control the body's own tendency to make glucose and allow resting muscle and fat access to the blood glucose, and bursts of insulin, often called boluses, to raise blood insulin levels at mealtimes to allow the body to use and store the glucose taken in the meal. Injected insulin either works quickly after being taken or its action is prolonged and delayed. All insulin regimens use combinations of these different insulins to provide background and mealtime insulin replacement.

In a multiple dose regimen, you would take one or two daily injections of a prolonged action insulin to provide a background to which you then add injections of quick acting insulin for meals. If successful, you may then have some flexibility of the timing of meals and their size - as you are taking the quick acting insulin for the meal close to the time you want to eat, you can adjust the dose there and then. Total flexibility is difficult to achieve - many of these regimens depend on the slow wane of the quick acting insulin to contribute to the background replacement between meals, and skipping a dose altogether may result in loss of control.

For the same reason, snacking after meals is often still necessary between meals, although this may be less of a concern with the very new very fast acting insulin analogues, which are often used with two or three injections of background insulin. A few people replace the background insulins with a continuous, low dose flow of insulin from a special pump worn in their clothes but this requires careful monitoring and adjusting.

One of the most important parts of these multiple injection regimens is the splitting of the evening insulin doses - taking a quick acting bolus before the evening meal and the delayed acting insulin separately at bedtime, often at lower dose, instead of taking both together before the evening meal. This makes the overnight control of blood glucose easier and safer, with less chance of running out of insulin before breakfast next day and less chance of too much insulin in the middle of the night.

Any change in insulin therapy needs to be designed for the individual patient and changes must be carefully monitored. Any significant change should be discussed with your diabetes health-care provider.

Can my GP manage my diabetes or should I be seen every so often by a specialist?

Where you obtain your professional support for managing your diabetes will depend on who you are, who your doctors are, what type of diabetes you have and whether you have trouble achieving proper control.

What matters is that your health care provider is trained in providing diabetes care and is interested in diabetes! The doctor should be working with you to ensure that you are feeling well, that your risks of long term complications of diabetes are minimised and that any complications that may occur are detected early enough for them to be treated and controlled. Often that means the doctor finding problems for you, before you notice anything. Regular checks are essential.

People with Type 2 diabetes especially are often managed by their GPs and his/her practice staff. Many GPs run special clinics for their diabetic patients. This can be entirely appropriate and beneficial, as your GP should know a lot about you. Wherever your diabetes care is provided, it should include regular checks of your blood glucose control (is your glycated haemoglobin where you want it? are you having too  many hypos?) and at least annual checks of your blood pressure, feet, eyes and kidney function, with regular checks of blood cholesterol and triglyceride too. If any of these are not right, they should be checked (and treated) more often.

You should have access to advice on home monitoring, diet, personal health care, exercise etc. through the service provided. If you are unable to achieve the desired levels of control of blood glucose, blood pressure etc, with your GP, you should be referred on for specialist advice. You may also need the help of a specialist if you develop any problems as a result of your diabetes.

Some GPs will ask for specialist help in transferring patients who have been on tablet therapy to insulin or ask for specialist help in teaching you about your diabetes, as Hospital clinics are multidisciplinary and have access to specialist nurse educators, dietitians trained in diabetes manangement and podiatrists, all in one place.

For similar reasons, some GPs like diabetic patients to be seen at least once in a specialist service, for the discussion and setting of treatment goals but many GPs will do this themselves. A few GPs will have interests outside diabetes and may ask the local specialist service to see all their diabetic patients, but this is increasingly unusual.

People with Type 1 diabetes, particularly children and young people; women with any type of diabetes wanting to become pregnant and people with advanced diabetic complications need specialist care. Any person who is having trouble controlling their diabetes appropriately (for example, someone having trouble with hypoglycaemia or someone not achieving the treatment goals they wish) should have access to specialist advice.

 In all cases, it is important that good communications are maintained between such Hospital Clinics and your GP, so that everyone knows what needs doing and what has to be done.

Do you know of any complementary therapy or supplement that can help treat diabetes or reduce the risk of long term complications?

Type 1 diabetes needs insulin therapy and nothing can replace that. The same is also true of late Type 2 diabetes, where the body's own pancreas has ceased to work. There have been suggestions that some minerals such as chromium or magnesium may help improve insulin action but none have stood up to rigorous evaluation. Mineral or vitamin supplementation is only indicated in cases of proven deficiency. 

In Type 2 diabetes, where insulin resistance plays a role, life style issues are very important and it is possible that some natural plant remedies may be able to help. If such remedies are effective, they are also capable of producing side effects! I am not personally familiar with any effective complementary therapies that lower blood glucose consistently.

Stress can worsen diabetic control as the body's stress response has anti-insulin effects. Complementary therapies that aid relaxation can help, usually in conjunction with conventional therapies. Where a complication such as neuropathy has caused pain, pain relieving therapies such as acupuncture may help, although care must be taken in applying any therapy to the feet because of the risk of injury and infection.

There are no known agents that reduce risk of complications directly, although some  of vitamins and other agents that reduce oxidation of body tissues are being tested. There is no evidence to date that allows us to recommend any of these trial agents.   

Conventional medicines are also sought that might reduce diabetic complications - these are usually drugs designed to interfere in the pathways by which the complications arise. None of these have yet proved very successful but the search continues.

Medpages Medical Reference from: www.surgerydoor.co.uk

Last Updated: 28/1/2009
This information is not intended to replace the advice of a doctor. Disclaimer