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Diabetes


Diabetes is a life-long condition marked by abnormally high levels of sugar (glucose) in the blood. People with diabetes either do not produce enough insulin — a hormone that is needed to convert sugar, starches and other food into energy needed for daily life — or cannot use the insulin that their bodies produce. As a result, glucose builds up in the bloodstream. If left untreated, diabetes can lead to blindness, kidney disease, nerve disease, heart disease, and stroke.

According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), 18.2 million Americans — more than 6% of the population — have diabetes.

Although an estimated 13 million people have been diagnosed with the disease, 5.2 million are not aware that they have the disease. It is the sixth leading cause of death in the United States and it affects men and women of all ages, races, and income levels.

There are two major types of diabetes:

  • Type 1 — Also known as juvenile or insulin-dependent diabetes), type 1 diabetes occurs when the pancreas produces too little insulin to regulate blood sugar levels appropriately. It is usually diagnosed in childhood.
  • Type 2 — This form is far more common than type 1 and makes up 90% or more of all cases of diabetes. It usually occurs in adulthood. It occurs when the pancreas does not make enough insulin to keep blood glucose levels normal. Many people with type 2 diabetes do not know they have it, although it is a serious condition. Type 2 diabetes is becoming more common due to the growing number of older Americans, increasing obesity, and failure to exercise.

Gestational diabetes is high blood glucose that develops at any time during pregnancy in a person who does not have diabetes. Four percent of all pregnant women develop gestational diabetes. Although it usually disappears after delivery, the mother is at increased risk of developing type 2 diabetes later in life.

Diabetes may also be associated with genetic syndromes, surgery, drugs, malnutrition, infections, and other illnesses.


Signs and Symptoms

Type 1: Type 1 diabetes can occur at any age, but it usually starts in people younger than 30. Symptoms are usually severe and occur rapidly. They include:

  • increased thirst
  • increased urination
  • weight loss despite increased appetite
  • nausea
  • vomiting
  • abdominal pain
  • fatigue
  • absence of menstruation

Type 2: People with type 2 diabetes often have no symptoms, and their condition is detected only when a routine exam reveals high levels of glucose in their blood. Occasionally, however, a person with type 2 diabetes may experience symptoms listed below, which tend to appear slowly over time:

  • Numbness or burning sensation of the feet, ankles, and legs
  • Blurred or poor vision
  • Impotence
  • Fatigue
  • Poor wound healing 

In some cases, symptoms may mimic type 1 diabetes and appear more abruptly:

  • Excessive urination and thirst
  • Yeast infections
  • Whole body itching
  • Coma — in severe cases, high blood glucose may affect water distribution in brain cells, causing a state of deep unconsciousness, or coma.

Causes

Both type 1 and type 2 diabetes are caused by the absence, insufficient production, or lack of response by cells in the body to the hormone insulin. Insulin is a key regulator of the body's metabolism. After meals,  food is digested in the stomach and intestines. Sugar (glucose) molecules are absorbed directly into the bloodstream, and blood glucose levels rise. Under normal circumstances, the rise in blood glucose levels signals specific cells in the pancreas — called beta cells — to secrete insulin into the bloodstream. Insulin, in turn, enables glucose to enter cells in the body that may be burned for energy or stored for future use.

In type 1 diabetes, the beta cells of the pancreas produce little or no insulin, the hormone that allows glucose to enter body cells. Once glucose enters a cell, it is used as fuel. Without adequate insulin, glucose builds up in the bloodstream instead of going into the cells. The body is unable to use this glucose for energy despite high levels in the bloodstream, leading to increased hunger.

In addition, the high levels of glucose in the blood cause the patient to urinate more, which leads to excessive thirst. Within 5 to 10 years after diagnosis, the insulin-producing beta cells of the pancreas are completely destroyed, and no more insulin is produced.

The exact cause of type 1 diabetes is not known. Type 1 diabetes accounts for 3% of all new cases of diabetes each year. There is 1 new case per every 7,000 children per year. New cases are less common among adults older than 20.

Type 2 diabetes usually develops in older, overweight individuals who become resistant to the effects of insulin over time. When type 2 diabetes is diagnosed, the pancreas is usually producing enough insulin but, for unknown reasons, the body cannot use the insulin effectively. This is called insulin resistance. This means that the insulin produced by your pancreas cannot connect with fat and muscle cells to let glucose inside and produce energy. This causes hyperglycemia (high blood glucose). To compensate, the pancreas produces more insulin. The cells sense this flood of insulin and become even more resistant, resulting in a vicious cycle of high glucose levels and often  high insulin levels.

Type 2 diabetes usually occurs gradually. Most people with type 2 diabetes are overweight at the time of diagnosis. However, the disease can also develop in lean people, especially the elderly.


Risk Factors

Type 1

  • Family history of type 1 diabetes
  • Mother who had preeclampsia (a condition characterized by a sharp increase in
  • blood pressure during the third trimester of pregnancy)
  • Family history of autoimmune diseases, including Hashimoto's thyroiditis, Graves' disease, myasthenia gravis, Addison's disease, or pernicious anemia
  • Viral infections during infancy including mumps, rubella, and coxsackie
  • Child of an older mother
  • Northern European or Mediterranean descent
  • Consumption of cow's milk during infancy (this idea is controversial)

Type 2

  • Family history of type 2 diabetes (one-quarter to one-third of all individuals with type 2 diabetes have a family history of the condition)
  • Age older than 45 years
  • Excess body fat, particularly around the waist
  • Sedentary lifestyle and high-fat, high-calorie diet
  • Abnormal levels of cholesterol or trigylcerides in the blood [We don’t use and/or, just use or]
  • High blood pressure
  • History of gestational diabetes or polycystic ovary syndrome (a hormonal disorder that causes women to have irregular or no menstruation)
  • African American, Hispanic American or Native American (particularly Pima tribe in Arizona) descent
  • Low birth weight and/or a mother's malnutrition in pregnancy (this may cause metabolic disturbances in a fetus that lead to diabetes later in the child's life)

Diagnosis

According to the American Diabetes Association, all pregnant women should be screened for gestational diabetes during their third trimester, People who are 45 years or older should have their blood glucose levels checked every 3 years. Those who have a high risk of developing diabetes (such as people with a family history of the disease) should be tested more often.

Different types of tests are used to diagnose diabetes: Random plasma glucose level, fasting plasma glucose level, and oral glucose tolerance test.

Diabetes is suspected if the random test shows a blood glucose level higher than 200 mg/dL and the patient also has symptoms of increased thirst, urination, and fatigue. Diabetes is diagnosed if the fasting blood glucose test is higher than 126 mg/dL on 2 occasions or if glucose level is higher than 200 mg/dL after a glucose tolerance test.

People with diabetes require routine doctor’s visits and must closely monitor their blood sugar. Self-monitoring of blood glucose is done by checking the glucose content of a drop of blood. Regular testing tells you how well diet, medication, and exercise are working together to control your diabetes. Dieticians can also be an integral part of care.


Preventive Care

Type 1

There is currently no proven way to prevent Type 1 diabetes. However, research conducted in Finland suggests that adequate amounts of vitamin D, particularly in the first year of life, may decrease one's chances of developing type 1 diabetes within the first 30 years of life. In northern Finland (where the annual exposure to sunlight is very limited) researchers followed 10,000 infants for up to 30 years. Those given at least 2,000 IU of vitamin D per day (generally from cod liver oil) for the first year of life were significantly less likely to develop type 1 diabetes over a 30-year time course than infants who were given less than that. Other studies have confirmed that doses of 2,000 IU of vitamin D and higher may have a strong protective effect against type 1 diabetes. For this reason, caretakers of infants and children at increased risk for type 1 diabetes might wish to consider supplementation. Experts suggest supplementing these individuals at the high end of current U.S. recommendations for vitamin D, which is between 200 and 1,000 IU.

Type 2

Considerable evidence from population-based studies suggests that type 2 diabetes is highly preventable — particularly through exercise and weight management. Individuals who are physically inactive or overweight are much more likely to develop type 2 diabetes. Similarly, people who move from a non-Westernized country to a Westernized country (such as the United States where more people are overweight and live sedentary lives), increase their risk for type 2 diabetes. Studies suggest that you do not need vigorous physical activity to lower your risk of diabetes; moderate, regular exercise such as walking for 30 minutes most days of the week, is enough. In general, lifestyle changes recommended to treat diabetes may help prevent the condition as well.  


Treatment Approach

The goal of diabetes treatment is to achieve and maintain a healthy blood glucose levels. A major study called the Diabetes Control and Complications Trial (DCCT) found that people with diabetes who kept their blood glucose levels close to normal reduced their risk of developing major complications from the condition.

People with diabetes can use the following therapies to help manage their blood glucose levels and to prevent complications:

  • Lifestyle changes, such as a well-balanced diet and regular exercise
  • Medications, particularly insulin for individuals with type 1 diabetes and some people with type 2 diabetes
  • Supplements, including fiber and chromium
  • Relaxation techniques
  • Acupuncture for pain from nerve damage

Lifestyle

People with diabetes can improve significantly from lifestyle changes — particularly diet and exercise. People with type 2 diabetes may even eliminate the need for medications when they make appropriate lifestyle changes.

Diet

The American Diabetes Association (ADA) recommends that people with diabetes consume a healthy, low-fat diet, rich in grains, fruits, and vegetables. A healthy diet typically includes 10% to 20% of daily calories from protein such as poultry, fish, dairy, and vegetable sources. People with diabetes who also have kidney disease should work with their healthcare practitioners to limit protein intake to 10% of daily calories. A low-fat diet typically includes 30% or less of daily calories from fat — less than 10% from saturated fats and up to 10% from polyunsaturated fats (such as fats from fish). In addition, weight loss should be part of the plan for those with type 2 diabetes. Moderate weight loss (achieved by reducing calories by 250 to 500 per day and exercising regularly) not only controls blood sugars but blood pressure and cholesterol as well. People with diabetes who eat healthy, well-balanced diets will not need to take extra vitamins or minerals to treat their condition.

Exercise

Exercise plays an important role in controlling diabetes because it lowers blood sugar and helps insulin work more efficiently in the body. Exercise also enhances cardiovascular fitness by improving blood flow and increasing the heart's pumping power, promoting weight loss, and lowering blood pressure. However, exercise has the most value when it’s done regularly — at least three to four sessions per week for 30 to 60 minutes per session. People with type 2 diabetes who exercise regularly have been shown to lose weight and gain better control over their blood pressure, thereby reducing their risk for cardiovascular disease (a major complication of diabetes). Studies have also shown that people with type 1 diabetes who regularly exercise reduce their need for insulin injections.

Despite the benefits of exercise, many people have difficulty sticking with an exercise program for a long period of time. Healthcare practitioners can help develop suitable routines as well as strategies that may improve adherence to such routines. Anyone with long-standing diabetes should undergo a thorough screening before beginning an exercise program and should receive careful monitoring from a physician.

Medications

Medications for diabetes must always be used in combination with lifestyle changes, particularly diet and exercise, to improve the symptoms of diabetes. Medications include insulin, oral sulfonylureas (like glimepiride, glyburide, and tolazamide), biguanides (Metformin), alpha-glucosidase inhibitors (such as acarbose), thiazolidinediones (such as rosiglitazone) and meglitinides (including repaglinide and nateglinide).

Nutrition and Dietary Supplements

In addition to the basic dietary guidelines mentioned in the Lifestyle section, further dietary options may be available for people with diabetes. Considerable research has been conducted on the relationship between diabetes and specific nutrients and dietary supplements. Whenever considering the use of supplements or making dietary changes, be sure to discuss these changes with your healthcare provider to ensure safety and appropriateness.

Supplements with Glucose-Lowering Effects

Chromium . Found in a variety of foods and supplements, including liver, brewer's yeast, cheese, meats, fish, fruits, vegetables, and whole grains, chromium appears to enhance the body's sensitivity to insulin. Researchers believe that chromium helps insulin pull glucose from the bloodstream into the cells for energy. The benefit of chromium supplements for diabetes has been studied and debated for a number of years. While some studies show no beneficial effects of chromium use for people with diabetes, other studies have shown that chromium supplements may reduce blood glucose levels in individuals with type 2 diabetes and reduce the need for insulin in those with type 1 diabetes. Most Americans obtain at least 50 mcg of chromium in their diets each day. The National Research Council estimates that intakes of 50 to 200 mcg per day are safe and effective. Studies showing improved blood sugar control for those with diabetes have used doses of chromium picolinate ranging from 200 to 1,000 mcg per day. However, until studies of long-term safety are conducted with higher doses, it is best to use 200 mcg or less per day.

Magnesium . Several studies have demonstrated a strong association between low levels of magnesium in the blood and type 2 diabetes. However, researchers are still unclear about which is the cause and which is the effect. They are investigating whether low magnesium levels worsen blood sugar control in people with type 2 diabetes or whether diabetes causes magnesium deficiencies. Some experts believe that low magnesium levels worsen blood sugar control and that foods rich in magnesium (such as whole grains, green leafy vegetables, bananas, legumes, nuts, and seeds) or magnesium supplements may promote healthy blood glucose levels. At least one small study suggests that taking magnesium supplements may improve the action of insulin and decrease blood sugar levels, particularly in the elderly. People with severe heart disease or kidney disease should not take magnesium supplements. People with diabetes should discuss whether it’s safe and appropriate to take magnesium supplements with a healthcare provider.

Fiber . Studies suggest that a high-fiber diet may help:

  • Prevent development of type 2 diabetes
  • Lower average glucose and insulin levels in people who already have type 2 diabetes
  • Improve cholesterol and triglyceride levels in those with diabetes

In a large-scale study of nurses in the United States, women who consumed the most whole grain foods in their diets were nearly 40% less likely to develop diabetes than women who consumed the least.

Studies have also shown that cholesterol levels improved in people with type 2 diabetes after they took supplements of a soluble fiber known as psyllium (Plantago psyllium).

Vanadium . Vanadium is an essential trace mineral present in the soil and in many foods. It appears to mimic the action of insulin and, in a number of human studies, vanadyl sulfate (a form of vanadium) has increased insulin sensitivity in those with type 2 diabetes. Animal studies and some small human studies also suggest that vanadium may lower blood glucose to normal levels (reducing the need for insulin) in people with diabetes. One preliminary study found that people with diabetes using insulin who were given vanadium were able to lower their dose of insulin. However, because the long-term safety of vanadium has not been established, this is not a recommended therapy at this time.

Antioxidants  

Antioxidants such as beta-carotene and vitamin C are scavengers of free radicals — unstable and potentially damaging molecules generated by normal chemical reactions in the body. Free radicals are unstable because they lack one electron. In an attempt to replace this missing electron, the free radical molecules react with neighboring molecules in a process called oxidation. Some studies suggest that people with diabetes have elevated levels of free radicals and lower levels of antioxidants. Preliminary studies show that the following antioxidants may improve symptoms of diabetes (by returning blood glucose levels to the normal range) and reduce the risk of associated complications:

  • Vitamin E
  • Selenium
  • Zinc

Two additional substances that show preliminary evidence to possibly help control blood sugar include:

  • Biotin (a B-complex vitamin) — helpful for type 2 diabetes; brewer's yeast is a good source of biotin
  • Vitamin B6 — helpful for both type 1 and type 2 diabetes

Supplements with Cardiovascular Effects

Because insulin resistance is often associated with cardiovascular disease, people with diabetes may benefit from nutrients that help manage elevated blood lipid levels, high blood pressure, or congestive heart failure. Although the following supplements have been shown to improve cardiovascular health, there is some concern that they may raise blood glucose levels. People with diabetes interested in trying the following supplements should first consult with their healthcare providers:

  • Coenzyme Q10 (CoQ10)
  • Niacin
  • Omega-3 Fatty acids

Although recent studies have not shown that either CoQ10 or omega-3 fatty acid supplements raise blood sugar levels, people with diabetes should discuss the safety and appropriateness of using these, or any supplements, with their physician.

In addition, the following antioxidants have been shown to improve cholesterol levels in people with type 2 diabetes:

  • Beta-carotene
  • Vitamin C (1000 mg per day)
  • Vitamin E (800 IU per day)

At least one study has also found that elevated manganese levels may help protect against LDL oxidation (a process that contributes to the development of plaque in the arteries).

Supplements that May Reduce Complications of Diabetes

More than one-third of all people with diabetes develop a painful condition known as diabetic neuropathy (nerve damage). Some researchers speculate that elevated levels of free radicals, which can cause damage to nerves and blood vessels, may cause this condition. Studies suggest that the following antioxidant supplements may improve nerve communication in damaged areas and reduce the symptoms of diabetic neuropathy:

  • Alpha-lipoic acid
  • Gamma-linolenic acid (evening primrose oil (Oenothera biennis) is a rich source)

Herbs

People have long used plant-based medicines have long been used in the treatment of diabetes. For instance, the plant extract guanidine, which lowers blood glucose, prompted the development and use of biguanides, a commonly used oral medication for diabetes. Other herbs may have a role in the management or prevention of diabetes. These include:

Aloe (Aloe vera). Studies suggest that aloe vera taken orally might help reduce blood glucose in people who have type 2 diabetes. In a few studies, women with diabetes who received aloe vera juice experienced significant reductions in blood glucose levels compared to women who received placebo, or “dummy pill.” Although more research is needed to determine the safety and effectiveness of aloe in the treatment of diabetes, it seems possible that the herb may prove to be a useful addition to the diet, exercise, and medication program for people with type 2 diabetes.

Fenugreek seeds (Trigonella foenum graecum). Fenugreek seeds, a spice found in many curry preparations, are high in fiber and have been shown to regulate glucose and improve lipid levels in both animals and humans. In two small studies of people with either type 1 or type 2 diabetes, fenugreek seed powder lowered blood glucose and improved levels of blood cholesterol and trigylcerides, among other beneficial effects.

Cinnamon . In a study of 60 people with type 2 diabetes, intake of 1, 3, or 6 grams of cinnamon per day reduced glucose, triglyceride, LDL cholesterol and total cholesterol. As a result, experts claim that cinnamon may play an important role in regulating blood sugar in people with diabetes.

American ginseng (Panax quinquefolium). Although both Asian ( Panax ginseng ) and American ( Panax quinquefolium ) appear to lower blood glucose levels, only American ginseng has been studied scientifically. One study found that people with type 2 diabetes who take American ginseng before or together with a glucose meal experience a reduction in glucose levels after they consume the meal.

Other Herbs  

Numerous other herbs have been used traditionally to regulate glucose levels in the body. Although preliminary research is promising, more studies are needed to determine whether the following herbs are safe and effective for the treatment of diabetes:

  • Onion (Allium cepa)
  • Garlic (Allium sativum)
  • Andrographis (Andrographis paniculata)
  • Green tea (Camellia sinensis)
  • Indian cluster bean (Cyamopsis tetgonolobus)
  • Gurmar (Gymnema sylvestre)
  • Bitter melon or karela (Momordica charantia) 
  • Tinospora gulancha (Tinospora cordifolia) 
  • Bilberry (Vaccinium myrtillus)

Acupuncture

Some researchers speculate that acupuncture may trigger the release of natural painkillers and reduce the debilitating symptoms of a complication of diabetes known as neuropathy (nerve damage). In one study of people with diabetes suffering from chronic, painful neuropathy, acupuncture reduced pain and improved sleep in 77% of the participants and eliminated the need for pain medications in 32% of the participants. Given these findings, acupuncture may be a reasonable option for people with diabetes who have neuropathy and either find no symptom relief or develop side effects from conventional drug treatment.

Mind/Body Medicine

Stressful life events can worsen diabetes in several ways. For example, stress stimulates the nervous and endocrine systems in ways that increase blood glucose levels and disrupts healthful behaviors (increasing the chances that an individual may consume a high level of calories and limit his or her physical activity — a pattern that leads to elevated blood glucose).

It makes sense, then, to consider stress management as part of the treatment and prevention of diabetes. Studies have shown that people with diabetes who participate in biofeedback sessions (a technique that increases awareness of and control of the body's response to stress) are more likely to reach target blood glucose levels than those who do not receive biofeedback. Although other studies have produced results that contradict this, researchers and clinicians agree that long-term stress is likely to worsen diabetes and that biofeedback, tai chi, yoga, and other forms of relaxation may help motivate people with diabetes to change their habits in order to manage their condition.


Other Considerations

Pregnancy

Women of child-bearing age who have diabetes should consult an endocrine specialist about the benefits of managing glucose levels before trying to conceive.

Approximately 4% of all pregnant women in the United States are diagnosed with gestational diabetes. Risk factors for developing diabetes while pregnant include:

  • Modest weight gain prior to pregnancy (11 to 22 pounds or more)
  • Family history of diabetes
  • Tobacco use
  • African, Hispanic-American, or Asian ancestry
  • Age older than 50 at conception

Normalizing glucose levels in women with gestational diabetes reduces their risk of complications, such as having an overweight baby, birth trauma, or the need for cesarean section. If the mother's glucose levels are uncontrolled, an infant can be stillborn or suffer from any number of complications, including defects of the brain or central nervous system, an abnormally large body or organs, heart or kidney abnormalities, asphyxia, respiratory distress, and congestive heart failure.

If dietary restrictions fail to improve glucose levels, a woman with gestational diabetes may need insulin. Women should not take oral diabetes medications during pregnancy. Women who develop gestational diabetes may experience the condition again in subsequent pregnancies. Gestational diabetes also increases the risk for developing type 2 diabetes.

Prognosis and Complications

People who maintain tight control over their blood glucose levels can prevent or delay the development of long-term complications from diabetes. Type 1 diabetes generally has more complications than type 2 diabetes.

Long-term complications of diabetes may include:

  • Heart disease and stroke
  • Vision loss and blindness
  • Kidney disease
  • Neuropathy (nerve damage)
  • Foot ulcers and infections
  • Skin problems, including bruising, dryness, itching, hair loss, warts, gangrene (tissue death), and skin ulcers

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  • Review Date: 9/21/2005
  • Reviewed By: A.D.A.M. editorial, previously reviewed by: Robert A. Anderson, MD, President , American Board of Holistic Medicine, East Wenatchee, WA; Ruth Debusk, RD, PhD, Editor, Nutrition in Complementary Care, Tallahassee, FL; R. Lynn Shumake, PD, Director, Alternative Medicine Apothecary, Blue Mountain Apothecary & Healing Arts, University of Maryland Medical Center, Glenwood, MD.
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