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Diabetes Complications can be Prevented

Every 21 seconds, someone is diagnosed with diabetes. That means every 21 seconds, you have a reason to walk more, to eat balanced, nutritious meals, to take a good look at your life, and make changes for the better. But if and when you are diagnosed, you simply can’t wait for the next shoe to drop. Action must be taken to protect yourself from further falling subject to various complications.

A Very Present Danger
An online survey conducted by the American Diabetes Association (ADA) in 2008 asked pollers what they feared the most. Among the results, 16 percent feared being in a plane crash, 13 percent couldn’t bear the thought of being bitten by a snake, 5 percent feared being struck by lightning, and 4 percent said the bite of a shark was their greatest fear. The fear of contracting an illness or disease? Just four percent.

“Unfortunately, people don’t seem to take diabetes seriously and they don’t seem to realize that diabetes – if left untreated or poorly treated – can be a very scary disease,” said Ann Albright, PhD, RD, President, Health Care & Education, American Diabetes Association. “We don’tlike to unnecessarily scare people, but the findings from this survey are alarming because diabetes is more deadly than these other fears and Americans are more likely to have a personal experience with diabetes than shark attacks or snake bites.”

Also worthy of note are the kinds of diseases respondents feared. When asked specifically about diseases, 49 percent reported a fear of cancer, while only 3 percent cited diabetes. In contrast, about 6 percent of adults have been diagnosed with cancer while a greater 1 in every 10 adults reports having been diagnosed with diabetes.

Perhaps the reason why many fear accidents or animal attacks is because the impact is seen more immediately. But lightning strikes, shark and snake bites, or plane crashes don’t compare to diabetes. In reality, the consequences of mismanaged diabetes are equally severe – including loss of limbs and even death. In fact, commercial aviation accidents accounted for 491 deaths in 20072, whereas diabetes contributed to 233,619 deaths in 2005.

Diabetes mellitus increases your risk for many serious health problems like heart attack or stroke. It also puts patients at risk for developing serious complications such as kidney disease, blindness, and amputation yet only one-fourth of people with diabetes know it. But there’s good news – with the correct treatment and recommended lifestyle changes you will be able to delay’or prevent altogether the outbreak of complications.

Complications Overview
First, what causes these complications? “Most patients think only blood glucose levels are the most important,” says Dr. Mary Ann Lim-Abrahan, an endocrinologist at UP-PGH. “The physician or caregiver should always emphasize other risk factors, such as hypertension, obesity, smoking, excessive alcohol intake, lack of physical activity and abnormalities in lipids and target the treatment goals set by the different organizations/associations.”

Right off the bat, you should already know that smoking is dangerous to your health. It hurts your lungs and heart, it lowers the amount of oxygen that gets to your organs, raises your bad cholesterol, and raises your blood pressure – all terrible effects to add on to your already increased risk of heart attack and stroke. Quit now, it’s better for you and those around you in more ways than you may know. And if you must drink, as social drinking is such a pervasive part of our society, limit your intake to a two-drink maximum and preferably with a meal or healthy snack.

Diabetes complications can be divided into two categories: acute and chronic. Acute complications, more immediately serious, though less common – diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar non-ketotic syndrome (HHNS) – usually will lead to hospitalization. To cover them briefly, DKA is caused primarily by inadequate insulin along with an intercurrent illness such as pneumonia, influenza, gastroenteritis, or a urinary tract infection. Symptoms will include nausea or vomiting, abdominal pain, drowsiness or lethargy, deep or rapid breathing, increased thirst or dehydration, and fruity-smelling breath. If you or your family members notice symptoms suggestive of DKA or if your blood sugar is above 300, call your doctor immediately. Before the introduction of insulin therapy in the 1920s, it was almost universally fatal.

HHNS, on the other hand, is usually precipitated by infection, heart attack, stroke, or another acute illness. It most often occurs in patients with type 2 diabetes, the elderly, and happens during times of great stress or illness along with blood sugars typically greater than 500. Symptoms similar to DKA include frequent urination, drowsiness, and a decreased intake of fluids but it is typically not associated with nausea, vomiting, or abdominal pain. If not immediately brought to the attention of your doctor, HHNS could cause coma or death. You must be especially prudent about monitoring your levels and educating yourself when experiencing these symptoms, as either HHNS or DKA can occur at any time over the course of having diabetes.

“For acute complications,” confirms Dr. Abrahan, “not missing medications; being particularly careful (monitor glucose) when acutely ill, i.e., throat infections, lung infections, skin infections, as they can precipitate acute complications. Drinking lots of fluids and, of course, letting your doctor know, so that adjustments in medications can take place.”

Then we have chronic complications which are responsible for most illness and death associated with diabetes. Chronic complications include cardiovascular (heart disease, peripheral vascular disease, stroke), eye (diabetic retinopathy, cataracts, glaucoma), nerve damage, and kidney damage. According to the Centers for Disease Control, some numbers associated with these complications include 1) heart disease accounting for 68% of diabetes-related death certificates among people aged 65 years or older in 2004; 2) diabetic retinopathy causing 12,000 to 24,000 new cases of blindness each year; 3) diabetes as the leading cause of kidney failure at 44% of new cases in 2005; and 4) 60% – 70% of people with diabetes having mild to severe forms of nervous system damage.

On a Microvascular Level
You don’t need to know exactly how your eyes work to know that losing your eyesight can be nothing short of devastating. Diabetics are more likely than non-diabetics to suffer from glaucoma by 40 percent and cataracts, by 60 percent, according to the American Diabetic Association (ADA). The longer a patient has had diabetes, and the older they are, the more common glaucoma is. It occurs when pressure builds up in the anterior chamber of the eye, which most often, is caused by the slowdown of drainage in the aqueous humor. This pressure pinches the blood vessels that carry blood to the retina and optic nerve gradually causing vision loss because of nerve damage.

Glaucoma treatment aims to reduce intraocular pressure by improving the aqueous outflow or reducing its production. The first line of treatment often is the prescription of medicated eyedrops. Be absolutely sure to follow your doctor’s instructions because improper dosage may lead to increased optic nerve damage including side effects unrelated to your eyes by virtue of the eyedrops being absorbed by your bloodstream. If you are unable to tolerate eyedrops or oral medications (typically carbonic anhydrase inhibitors), surgery may be required. This is usually the last resort because, although they can be effectively treated, more complications such as infection, abnormally high or low pressure in the eye, and in rare cases, loss of vision, may even occur. Unfortunately, glaucoma can’t be totally cured nor its damages completely reversed so it is best to consult your doctor immediately if you begin to feel frequent pain in your eye or notice blurred vision. Swift action and regular checkups and treatments can help prevent total visual loss in those with very early glaucoma.

As mentioned above, while many people without diabetes get cataracts, people with diabetes are at greater risk of developing this clouding of the lens. Those with diabetes also tend to develop cataracts at a younger age than those without diabetes. To help deal with mild cataracts, you may need to wear sunglasses more often or avoid looking at bright television or computer screens for extended periods of time. Though treatment for cataracts is fairly simple and surgery, when needed, is almost always successful, it is still best tobring this issue up immediately with your doctor as it could lead to glaucoma and eventual vision loss.

Disorders of the retina caused by diabetes can be categorized under nonproliferative (also known as background retinopathy) and proliferative retinopathy. Together, they are responsible for about 10,000 cases of blindness ever year in the US alone. The less serious but more common form of the two, nonproliferative retinopathy, is characterized by the ballooning or forming of pouches by the capillaries in the back of the eye. The severity can be measured in three stages — mild, moderate, and severe — depending on how blocked the vessels become. Nonproliferative retinopathy typically does not cause vision loss at this stage though the control of passage by substances between the blood and the retina is lost as capillary walls swell. Fluid can then leak into the macula, the part of the eye where focusing occurs, and causes blurred vision as it fills up with fluid. This condition, called macular edema, must be treated before it worsens.

If nonproliferative retinopathy and an ensuing case of macular edema are left untreated, the eyes may, over several years, progress into proliferative retinopathy. Blood vessels begin growing in the retina in an effort to aid the ones that have become completely blocked off. Instead of reversing the damage, the new and still weak vessels can leak blood into the eye in a condition called vitreous hemorrhaging. Scar tissue that grows as an effect of these new blood vessels, eventually shrink causing a distortion in the retina even pulling it completely out of place — called retinal detachment.

The scary thing is, almost everyone with type 1 diabetes will have nonproliferative retinopathy, according to the ADA. Sadly, because usually no symptoms present, most people with it never know the damage done to their retina until it’s too late. The good news is, proliferative retinopathy, the more dangerous form, is far less common. Regardless, it is tremendously important for diabetics to have their eyes regularly examined by an eye care professional. In the mean time, several factors to continue to keep tabs on are: blood sugar control, blood pressure levels, how long you’ve had diabetes, and whether your family has a history of diabetes.

Diabetes can also cause nephropathy, more commonly known as kidney disease. High blood sugar can overwork the kidneys whose millions of tiny blood cells act as filters, removing waste products from the blood stream. Diabetic with high levels of blood sugar puts their kidneys under extra stress by having to filter more blood than someone who maintains good or target levels. Before long, the kidneys begin to leak from being overworked and useful proteins get lost in the blood. This condition of small amounts of protein in the urine is called microalbuminuria. The fact that the symptoms of kidney disease are not entirely specific only makes a diagnosis all the more difficult, given that the failing capillaries work overtime to sustain the kidneys keeping any symptoms from showing until the function is almost all gone.

Loss of sleep, poor appetite, upset stomach, weakness, and difficulty concentrating are often the first signs of kidney disease but are so general they are shrugged off for being ailments all on their own. Needless to say, once even trace amounts of protein are found in the urine, it is important to start treatments right away before macroalbuminuria (or having large amounts of protein in the urine) develops. If the problem goes untreated, kidney failure, or end-stage renal disease (ESRD), usually follows. Having your kidneys fail is very serious, requiring a kidney transplant or being put on dialysis (a machine that filters your blood).

So without any symptoms to look out for, having a good system in place to properly manage your blood sugar will give you a step up over kidney disease. Research by the American Diabetes Association has shown that tight blood sugar control reduces the risk of microalbuminuria by one third, cuts macroalbuminuria from progressing by half, and even reversing its early stages all together. Blood pressure also has an exponential effect on the rate at which nephropathy progresses – just a mild rise in blood pressure can quickly make kidney disease worse. Regular visits to your doctor will also help identify whether you have a case of microalbuminuria for which they may prescribe blood pressure lowering medication or angiotensin-converting enzyme (ACE) inhibitors. Still, fail-safe actions you can take to combat any of these microvascular complications include losing weight, eating less salty foods, avoiding alcohol and tobacco, and getting regular exercise.

Unlike the symptoms of nephropathy, neuropathic sufferers feel burning, tingling, or electrical sensations in the arms and hands, and especially, the legs. This most common form of neuropathy, called chronic sensorimotor distal symmetric polyneuropathy is often experienced worst during the nighttime. The precise nature of injury to the peripheral nerves from hyperglycemia is not known but is recognized by the ADA as “the presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes after the exclusion of other causes.” It is likely, however, to be related to mechanisms such as polyol accumulation, injury from AGEs (advanced glycation end products), and oxidative stress.

Untreated infections on your feet can lead to amputation. Be sure to include foot exams as a regular check during your visits to the doctor so any injuries, sores, blisters or other problems may be treated. Every year, schedule a complete foot exam where the skin on your feet, its muscles and bones, and the blood flow can be assessed. Numbness can also be checked by a number of ways including touching a tuning fork to your feet to see if you can feel it vibrating.

As key with the other complications, making sure to keep your blood glucose levels within your target range will help manage the pain and lessen the symptoms. Medications to target the relief of pain and burning sensations, along with numbness and tingling, are available for problems caused by conditions other than nerve damage and have been found to work quite well. Learn how to check your feet on your own. Use a mirror to see the bottoms of your feet and feel for hot or cold spots, bumps, or dry skin. Also check for sores, cuts or breaks in the skin, calluses, swelling, red areas, blisters, ingrown toenails, and toenail infections. Make sure you aren’t forcing your feet into tight shoes but instead are wearing comfortable socks and shoes. Buy special shoes if needed. Wash your feet in warm water and dry them carefully afterward.

What You Can Do
Chronic complications cover a wide gamut of illnesses but there are common denominators for taking action to keep all of them from happening to you. These are basic admonitions your doctor has probably already given you – take your medications as prescribed, monitor your blood sugars closely, follow a sensible diet, don’t skip meals, exercise regularly, and see your doctor to expertly monitor for complications.

“The global risk factor control to target goals results in a 50 percent reduction in diabetic complications,” adds Dr. Abrahan also a professor at the University of the Philippines College of Medicine’s Endocrine Section. “This includes decreasing HbA1c (glycated hemoglobin) to less than 6.5, blood pressure to less than 130/80, LDL cholesterol to less than 100, triglycerides to less than 150 mg/dL, and raising HDL to greater than 45 for men and 50 for women, together with the use of an anti-platelet and the use of an ACE-I, or ARB in patients who present with microalbuminuria.”

This means eating more nutritionally and exercising regularly. To put it in implementable terms, “Decrease total caloric intake,” advices Dr. Abrahan. “Gradually take off 30% of total calories. Redistribute the remaining total calories so that one gets more fruits and vegetables, and less of meat and oils, and simple carbohydrates. A very simple way is to get meal serving once (no refills) and arrange the food on theplate so that 1/2 of plate is covered by fruits and vegetable, 1/4 by rice (steamed) and 1/4 by protein (meat, fish, chicken, pork or beef), roughly measuring the equivalent size of a deck of cards.”

Being mindful of what and when you eat works doubly for those with diabetes. Not only are you able to keep track of the calories and in turn, the blood glucose you target for each meal, but you also put a limit on the amount of food you intake which then helps prevent full fat cells from releasing hormones that cause inflammation and block the body’s insulin receptors.

Proper dieting cannot do it all on its own, however. Losing weight also plays a crucial role in diabetes complications prevention. For men, if you have 40 or more inches around the waist, you have 12 times the risk of developing diabetes than if you had a 35 inch waist. For women, the numbers are 37 and 32.5 inches, respectively. The simplest way to prevent the progression of diabetes is exercise. “Walking is good exercise,” reminds Dr. Abrahan, “a total of at least 150 minutes per week. One way to increase activity is to walk or pace when on cell/portable phones, taking 15 minute breaks from the computer and walking around if one cannot make time to go to the gym or participate in a more formal form of exercise. When riding a vehicle, one can stop some distance from their destination and walk the rest of the way either to work or upon entering a gated community.”

Other experts agree that knowing when to take complication-specific measures are best to detect these complications early on. Having annual eye exams, for instance, to combat diabetic retinopathy could mean the difference betweenkeeping your eyesight and completely going blind. The earlier the problems are detected and treated, the better the outcome a patient is likely to have. This goes for foot complications that result from nerve damage or neuropathy, as well. Ulcers, skin changes, and poor blood flow can result from the loss of feeling in your feet because you may have a foot injury or blister and not even know it. These can then lead to more serious complications. Avoid putting oils and creams between your toes as the extra moisture can lead to infection and break down of skin.

In summary, one cannot be too careful when it comes to proper management of diabetes and its complications. We know people all across the world and across the street struggle with this serious issue. But the tools are right before us all the time. Eat a nutritious, balanced diet, exercise on a deliberate and consistent basis, and be educated about monitoring levels and identifying areas for improvement. With a positive outlook and a realization that you can take control of your condition, you have nothing to fear.

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