Introduction

Lipids are the building blocks of the fats and fatty substances found in animals and plants. They
are microscopic layered spheres of oil, which, in animals, are composed mainly of cholesterol,
triglycerides, proteins (called lipoproteins), and phospholipids (molecules made up of phosphoric
acid, fatty acids, and nitrogen). Lipids do not dissolve in water and are stored in the body to
serve as sources of energy.
Cholesterol
Cholesterol is present in all animal cells and in animal-based foods (not in plants). n spite of its
bad press, cholesterol is an essential nutrient necessary for many functions, including!
"epairing cell membranes
#anufacturing vitamin $ in the skin
%roducing hormones, such as estrogen and testosterone
%ossibly helping cell connections in the brain that are important for learning and memory
"egardless of these benefits, when cholesterol levels rise in the blood, they can have dangerous
conse&uences, depending on the type of cholesterol. 'lthough the body ac&uires some
cholesterol through diet, about two-thirds is manufactured in the liver, its production stimulated
by saturated fat. (aturated fats are found in animal products (meat, egg yolks, high-fat dairy
products) and tropical plant oils (palm, coconut)..
(aturated fats are found predominantly in animal products, such as meat and dairy products, and
are strongly associated with higher cholesterol levels. Tropical oils -- such as palm, palm kernel,
coconut, and cocoa butter -- are also high in saturated fats.
Triglycerides
Triglycerides are composed of fatty acid molecules. They are the basic chemicals contained in
fats in both animals and plants.
Lipoproteins
Lipoproteins are protein spheres that transport cholesterol, triglyceride, or other lipid molecules
through the bloodstream. #ost of the vascular effects of cholesterol and triglyceride actually
depend on lipoproteins.
Lipoproteins are categori)ed into five types according to si)e and density. They can be further
defined by whether they carry cholesterol or triglycerides.
Cholesterol-Carrying Lipoproteins. These are the lipoproteins commonly referred to as
cholesterol.
Low density lipoproteins (L$L). (*ften called +bad+ cholesterol.)
,igh-density lipoproteins (,$L), the smallest and most dense. (*ften called +good+
cholesterol.)
Triglyceride-Carrying Lipoproteins.
ntermediate density lipoproteins ($L). They tend to carry triglycerides.
-ery low density lipoproteins (-L$L). These tend to carry triglycerides.
Chylomicrons (largest in si)e and lowest in density).
Effects of Lipoproteins and Triglycerides on Heart Disease
Low Density Lipoproteins (LDL), the "Bad"Cholesterol. The main villain in the cholesterol story
is low-density lipoprotein (L$L). ,eart disease is is less likely to occur among people with the
lowest L$L levels. Lowering L$L is the primary goal of cholesterol drug and lifestyle therapy.
Low-density lipoprotein (L$L) transports about ./0 of the blood1s cholesterol to the body1s
cells. t is normally harmless. ,owever, if it is e2posed to a process called o2idation, L$L can
penetrate and interact dangerously with the walls of the artery, producing a harmful
inflammatory response. *2idation is a natural process in the body that occurs from chemical
combinations with unstable molecules. These molecules are known as o2ygen-free radicals or
o2idants.
n response to o2idi)ed L$L, the body releases various immune factors aimed at protecting the
damaged arterial walls. 3nfortunately, in e2cessive &uantities they cause inflammation and
promote further in4ury to the areas they target.
High Density Lipoproteins (HDL), the "Good" Cholesterol. ,igh density lipoprotein (,$L)
appears to benefit the body in two ways!
t removes cholesterol from the walls of the arteries and returns it to the liver for disposal
from the body.
t helps prevent o2idation of L$L. ,$L actually appears to have its own antio2idant
properties.
t might fight inflammation.
,$L helps keep arteries open and reduces the risk for heart attack. ,igh levels of ,$L (above
56 mg7dL) may be nearly as protective for the heart as low levels of L$L. ,$L levels below 86
mg7dL are associated with an increased risk of heart disease.
Triglycerides. Triglycerides interact with ,$L cholesterol in such a way that ,$L levels fall as
triglyceride levels rise. ,igh triglycerides may pose other dangers, regardless of cholesterol
levels. 9or e2ample, they may be associated with blood clots that form and block the arteries.
,igh triglyceride levels are also associated with the inflammatory response -- the harmful effect
of an overactive immune system that can cause considerable damage to cells and tissues,
including the arteries.
Cholesterol and Triglycerides Goals
Total cholesterol count includes measurements of L$L, ,$L, and triglycerides. The following
chart summari)es all lipid goals for adults.
Cholesterol Goals for Adults
Total
Cholesterol
Goals
LDL Goals HDL Goals Triglyceride
Goals
Less than :66
mg7dL is
desirable.
;etween :66
and :<= is
borderline.
*ver :86 is
high.
7 !g"dL is considered an important goal for
very high-risk patients (recent heart attack>
current active or unstable cardiovascular or
cerebrovascular disease> or two multiple risk
factors as defined below.)
Below # !g"dL is optimal for everyone. t
should be the goal for high-risk people,
including those with e2isting heart disease,
diabetes, or two or more risk factors for heart
disease> .6 mg7dL is an even better goal for
Levels above 86
mg7dL are
desirable> levels
above 56 mg7dL
are optimal.
;elow ?/6
mg7dL is
normal.
?/6 - ?== is
borderline
high.
:66 - 8== is
high.
these individuals.
#$ !g"dL or below for people with two or
more risk factors> ?66 mg7dL is an optimal
goal.
#% !g"dL or &elow for people at less risk
(one or )ero risk factors)> ?<6 mg7dL is an
optimal goal.
'nything a&o(e #%!g"dL is high, with levels
above ?=6 being very high. L$L levels over
?=6 often re&uire medication even with no
other cardiac risk factors present.
*ver /66 is
very high.
"isk factors for heart disease include a family history of early heart problems before age // for
men (before age 5/ for women), smoking, high blood pressure, diabetes, being older (over 8/ for
men and // for women), and having ,$L levels below </ mg7dL. %eople with two or more of
these risk factors may have a ?6-year risk of heart attack that e2ceeds :60, and may therefore
need to aim for L$L levels of ?66 mg7dL or below.
Cholesterol Goals )or Children. n :66., the 'merican ,eart 'ssociation established general
L$L goals for children. L$L goals are ?=6 mg7dL or less for children with no additional heart
disease risk factors and ?56 mg7dL or less for children with additional risk factors (such as
family history of high cholesterol, heart disease, and diabetes).
Risk Factors
3nhealthy cholesterol levels (low ,$L, high L$L, and high triglycerides) increase the risk for
heart disease and heart attack. (ome risk factors for cholesterol can be controlled (diet, e2ercise,
weight) while others cannot (age, gender, and family history).
Age and Gender
9rom puberty on, men tend to have lower ,$L (@goodA cholesterol) levels than women. *ne
reason is that the female se2 hormone estrogen is associated with higher ,$L levels. ;ecause of
this, premenopausal women generally have lower rates of heart disease than men. 'fter
menopause, as estrogen levels decline, women catch up in their rates of heart disease.
Throughout the menopausal years, ,$L levels decrease and L$L (@badA cholesterol) and
triglyceride levels increase. 9or men, L$L and triglyceride levels also rise as they age and the
risks for heart disease increase as well. (There is some evidence that high triglyceride levels
carry more risks for women than men.) ,eart disease is the main cause of death for both men and
women.
Children and 'dolescents. Children who have abnormal cholesterol levels are at increased risk of
developing heart disease later in life. ,owever, it is difficult to distinguish @normalA cholesterol
levels in children. Cholesterol levels tend to naturally rise sharply until puberty, decrease sharply,
and then rise again.
Genetic Factors and Family History
Benetics play a ma4or role in determining a person1s blood cholesterol levels. (Children from
families with a history of premature heart disease should be tested for cholesterol levels after
they are : years old.) Benes may influence whether a person has low ,$L levels, high L$L
levels, high triglycerides, or high levels of other lipoproteins, such as lipoprotein(a).
nherited cholesterol disorders include!
9amilial hypercholesterolemia is a genetic disorder that causes high cholesterol levels,
particularly L$L, and premature heart disease. t occurs in as many as ? in /66 people.
9amilial lipoprotein lipase deficiency is a very rare disorder that causes depletion of
lipoprotein lipase. This is an en)yme that appears to be important in the removal of
lipoproteins that are rich in triglycerides. %eople who are deficient in it have high levels
of cholesterol and fat in their blood.
Lifestyle Factors
Diet. The primary dietary elements that lead to unhealthy cholesterol include saturated fats
(found mainly in red meat, egg yolks, and high-fat dairy products) and trans fatty acids (found in
fried foods and some commercial baked food products). (hellfish is also high in dietary
cholesterol.
*eight. ;eing overweight or obese increases the risks for unhealthy cholesterol levels.
+,ercise. Lack of e2ercise can contribute to weight gain, decreases in ,$L levels, and increases
in L$L and total cholesterol levels.
-!o.ing. (moking reduces ,$L cholesterol and promotes build-up of fatty deposits in the
coronary arteries.
!esity" #eta!olic $yndrome" and Type % Dia!etes
n the 3.(., obesity is at epidemic levels in all age groups. The effect of obesity on cholesterol
levels is comple2. *verweight individuals tend to have high triglyceride and L$L levels and low
,$L levels. This combination is a risk factor for heart disease. *besity also causes other effects
(such as high blood pressure and an increase in inflammation) that pose ma4or risks to the heart.
*besity is particularly dangerous when it is one of the components of the metabolic syndrome.
The syndrome consists of obesity marked by abdominal fat, unhealthy cholesterol levels, high
blood pressure, and insulin resistance. #etabolic syndrome is a pre-diabetic condition that is
significantly associated with heart disease and higher mortality rates from all causes. #any
doctors recommend that patients with metabolic syndrome should be aggressively treated with
high-dose statin therapy to lower L$L levels.
*besity is also strongly associated with type : diabetes, which itself poses a significant risk for
high cholesterol levels and heart disease.
Children who are overweight are at higher risk for high triglycerides and low ,$L, which may
be directly related to later unhealthy cholesterol levels. Childhood L$L levels and body mass
inde2 (;#) are strongly associated with cardiovascular risk during adulthood. *verweight and
obese children who have high cholesterol should also get tested for high blood pressure, diabetes,
and other conditions associated with metabolic syndrome.
C9or more information, see /n-Depth 0eport D56! $iabetes type :.E
ther #edical Conditions
High Blood 1ress2re. ,igh blood pressure (hypertension) contributes to the thickening of the
heartFs blood vessel walls, which can worsen atherosclerosis (accumulated deposits of
cholesterol in the blood vessels.) ,igh blood pressure, high cholesterol, and diabetes all work
together to increase the risk for developing heart disease. C9or more information, see /n-Depth
0eport D?8! ,igh blood pressure.E
Hypothyroidis!. Low thyroid levels (hypothyroidism) are associated with higher risk for high
total and L$L cholesterol and triglycerides. Treating the thyroid condition can significantly
reduce cholesterol levels. "esearch is mi2ed on whether mild hypothyroidism (subclinical
hypothyroidism) is associated with unhealthy cholesterol levels. C9or more information, see /n-
Depth 0eport 3$4! ,ypothyroidism.E
,ypothyroidism is a decreased activity of the thyroid gland which may affect all body functions.
n this condition, the rate of metabolism slows, causing mental and physical sluggishness. The
most severe form of hypothyroidism is my2edema, which is a medical emergency.
1olycystic 5(arian -yndro!e. Gomen with this endocrine disorder may have increased risks for
high triglyceride and low ,$L levels. This risk may be due to the higher levels of the male
hormone testosterone associated with this disease.
'n accumulation of incompletely developed follicles in the ovaries is seen in polycystic ovarian
disease. The condition may be characteri)ed by irregular menstrual cycles, absent periods,
multiple cysts on the ovaries and infertility.
6idney Disease. Hidney disease increases the risk of heart disease.
ther Risk Factors
7edications. Certain medications such as specific antisei)ure drugs, corticosteroids, and
isotretinoin ('ccutane) may increase lipid levels.
Complications
Heart Disease
'therosclerosis is a common disorder of the arteries. 9at, cholesterol, and other substances
collect in the walls of arteries. Larger accumulations are called atheromas or pla&ue and can
damage artery walls and block blood flow. (everely restricted blood flow in the heart muscle
leads to symptoms such as chest pain.
3nhealthy cholesterol, particularly low-density lipoprotein (L$L) cholesterol, forms a fatty
substance called pla&ue, which builds up on the arterial walls of the heart. (maller pla&ues
remain soft, but older, larger pla&ues tend to develop fibrous caps with calcium deposits.
Click the icon to see an image of the developmental process of atherosclerosis.
The long-term result is atherosclerosis, commonly called hardening of the arteries. The heart is
endangered in two ways by this process!
Iventually these calcified and inelastic arteries become narrower (a condition known as
stenosis). 's this process continues, blood flow slows and prevents sufficient o2ygen-rich
blood from reaching the heart. This condition leads to angina (chest pain) and, in severe
cases, to heart attack.

' heart attack or acute myocardial infarction (#) occurs when one of the arteries that
supplies the heart muscle becomes blocked. ;lockage may be caused by spasm of the
artery or by atherosclerosis with acute clot formation. The blockage results in damaged
tissue and a permanent loss of contraction of this portion of the heart muscle.
Click the icon to see an image of a heart attack.
(maller unstable pla&ues may rupture, triggering the formation blood clots on their
surface. The blood clots block the arteries and are important causes of heart attack.
Cholesterol: Stroke, Brain Function
This process is accelerated and enhanced by other risk factors, including high blood pressure,
smoking, obesity, diabetes, and a sedentary lifestyle. Ghen more than one of these risk factors is
present, the risk is compounded.
Coronary 'rtery Disease. The end result of atherosclerosis is coronary artery disease. Coronary
artery disease, commonly known as heart disease, is the leading cause of death in the 3.(.
(tudies consistently report a higher risk for death from heart disease with high total cholesterol
levels (:66 mg7dL and higher). The higher the cholesterol, the greater the risk. *n average, every
time a person1s total cholesterol level drops by a point, the risk of heart disease drops by :0.
C9or more information, see /n-Depth 0eports D6<! Coronary artery disease.E
&eripheral Artery Disease
%eripheral artery disease (%'$) is caused by the buildup of pla&ue in the feet, legs, hands, and
arms. t most often occurs in the legs. %'$ is associated with atherosclerosis. The risk for %'$
increases by / - ?60 with every ?6 mg7dL increase in total cholesterol levels. Lower levels of
,$L and high triglyceride levels also increase the risk for %'$. C9or more information, see /n-
Depth 0eport D?6:! %eripheral artery disease.E
$troke
,aving ade&uate levels of ,$L may be the most important lipid-related factor for preventing
ische!ic stroke, a type of stroke caused by blockage of the arteries that carry blood to the brain.
,$L may even reduce the risk for he!orrhagic stroke, a much less common type of stroke
caused by bleeding in the brain that is associated with low overall cholesterol levels.
The build-up of pla&ue in the internal carotid artery may lead to narrowing and irregularity of the
artery1s lumen, preventing proper blood flow to the brain. #ore commonly, as the narrowing
worsens, pieces of pla&ue in the internal carotid artery can break free, travel to the brain, and
block blood vessels that supply blood to the brain. This leads to stroke, with possible paralysis or
other deficits.
The effects of high total cholesterol and L$L levels on ischemic stroke are less clear. (ome
research suggests that the risk for ischemic stroke increases when total cholesterol is above :J6
mg7dL. *ther studies suggest that high cholesterol poses a risk for stroke only when specific
proteins associated with inflammation are present. C9or more information, see /n-Depth 0eport
D8/! (troke.E
$ymptoms
There are no warning signs for high L$L and other unhealthy cholesterol levels. Ghen
symptoms finally occur, they usually take the form of angina (chest pain) or heart attack in
response to the buildup of atherosclerotic pla&ue in the heart arteries.
'therosclerosis is a disease of the arteries in which fatty material is deposited in the vessel wall,
resulting in narrowing and eventual impairment of blood flow. (everely restricted blood flow in
the arteries to the heart muscle leads to symptoms such as chest pain. 'therosclerosis shows no
symptoms until a complication occurs.
Diagnosis
;lood tests can easily measure cholesterol levels. ' blood test for cholesterol should include the
entire lipoprotein profile! L$L, total cholesterol, ,$L, and triglycerides. t is very difficult to
measure L$L levels by themselves, but L$L levels can be reliably calculated using total
cholesterol and ,$L levels.
To obtain a reliable cholesterol reading, doctors advise!
'void strenuous e2ercise for :8 hours before the test.
$o not eat or drink anything but water for ?: hours beforehand.
f the test results are abnormal, a second test should be performed between ? week and :
months after the first test.
$creening Guidelines
%eriodic cholesterol testing is recommended in all adults, but the ma4or national guidelines differ
on the age to start testing.
"ecommended starting ages are between :6 - </ for men and :6 - 8/ for women.
'dults with normal cholesterol levels do not need to have the test repeated for / years
unless changes occur in lifestyle (including weight gain and diet).
'dults with a history of elevated cholesterol, diabetes, kidney problems, heart disease,
and other conditions re&uire more fre&uent testing.
(creening with a fasting lipid profile is recommended for children who!
,ave risk factors such as a family history of high cholesterol, and history of heart attacks
before age // for men and before age 5/ for women. (creening should begin as early as
age : and no later than age ?6.
're obese (above J/th percentile for weight) or who have diabetes. f the childFs
cholesterol level tests normal, retesting is recommended in < - / years.
%atients already being treated for high cholesterol should be checked every : - 5 months.
Treatment
Lifestyle changes (such as diet, weight control, e2ercise, and smoking cessation) are the first line
of defense for treating unhealthy cholesterol levels. f levels still remain high, drug treatment is
an effective ne2t step. ,owever, while statins have been shown to slow the rate of atherosclerotic
progression, they have not yet been shown to reverse heart disease.
"educing L$L (@badA cholesterol) and total cholesterol levels, while at the same time boosting
,$L (@goodA cholesterol) levels, can prevent heart attacks and death in all people (with or
without heart disease). "educing L$L is the primary goal of most cholesterol therapy.
Cholesterol-lowering medications are used along with healthy lifestyle habits, not in place of
them. Lowering cholesterol levels with lifestyle changes and drug treatment has been shown to
decrease the risk of heart attacks and other complications of atherosclerosis.
The Kational Cholesterol Iducation %rogramFs (KCI%) clinical practice guidelines set treatment
goals for L$L levels based on a patient1s risk factors for heart disease. The risk factors include!
,aving a first-degree female relative diagnosed with heart disease before age 5/ or a
first-degree male relative diagnosed before age //
;eing male and over age 8/ or female and over age //
Cigarette smoking
$iabetes
,igh blood pressure
#etabolic syndrome (risk factors associated with obesity such as low ,$L levels and
high triglycerides)
Two or more of these risk factors increases by :60 the chance of having a heart attack within ?6
years.
The L$L cholesterol level is one of the most important factors in determining whether a patient
needs cholesterol therapy and whether the treatment is working properly. n particular, guidelines
emphasi)e lower L$L levels and earlier treatment for people with coronary artery disease, or
other forms of atherosclerosis, and diabetes. (9or a table of Cholesterol Boals for 'dults, see
/ntrod2ction section of this report.)
Type 1 Diabetes - diabetes mellitus,
juvenile diabetes
Introduction
The two ma4or forms of diabetes are type ?, previously called insulin-dependent diabetes
mellitus ($$#) or 4uvenile-onset diabetes, and type :, previously called non-insulin-dependent
diabetes mellitus (K$$#) or maturity-onset diabetes.
Insulin
;oth type ? and type : diabetes share one central feature! elevated blood sugar (gl2cose) levels
due to absolute or relative insufficiencies of ins2lin, a hormone produced by the pancreas. nsulin
is a key regulator of the body1s metabolism. t works in the following way!
$uring and immediately after a meal, digestion breaks carbohydrates down into sugar
molecules (of which gl2cose is one) and proteins into a!ino acids.
"ight after the meal, glucose and amino acids are absorbed directly into the bloodstream,
and blood glucose levels rise sharply. (Blucose levels after a meal are called postprandial
levels.)
The rise in blood glucose levels signals important cells in the pancreas, called &eta cells,
to secrete insulin, which pours into the bloodstream. Githin :6 minutes after a meal
insulin rises to its peak level.
nsulin enables glucose to enter cells in the body, particularly muscle and liver cells.
,ere, insulin and other hormones direct whether glucose will be burned for energy or
stored for future use.
Ghen insulin levels are high, the liver stops producing glucose and stores it in other
forms until the body needs it again.
's blood glucose levels reach their peak, the pancreas reduces the production of insulin.
'bout : - 8 hours after a meal both blood glucose and insulin are at low levels, with
insulin being slightly higher. The blood glucose levels are then referred to as )asting
&lood gl2cose concentrations.
The pancreas is located behind the liver and stomach. n addition to secreting digestive en)ymes,
the pancreas secretes the hormones insulin and glucagon into the bloodstream. The release of
insulin into the blood lowers the level of blood glucose (simple sugars from food) by enhancing
glucose to enter the body cells, where it is metaboli)ed. f blood glucose levels get too low, the
pancreas secretes glucagon to stimulate the release of glucose from the liver.
Type ' Dia!etes
n type ? diabetes, the pancreas does not produce insulin. *nset is usually in childhood or
adolescence. Type ? diabetes is considered an autoimmune disorder that involves!
;eta cells in the pancreas that produce insulin are gradually destroyed. Iventually insulin
deficiency is absolute.
Githout insulin to move glucose into cells, blood glucose levels become e2cessively
high, a condition known as hyperglycemia.
;ecause the body cannot utili)e the sugar, it spills over into the urine and is lost.
Geakness, weight loss, fre&uent urination, and e2cessive hunger and thirst are among the
initial symptoms.
%atients with type ? diabetes need to take daily insulin for survival.
Type % Dia!etes
Type : diabetes is the most common form of diabetes, accounting for =6 - =/0 of cases. n type
: diabetes, the body does not respond properly to insulin, a condition known as insulin
resistance.
Gestational Dia!etes
Bestational diabetes is a form of type : diabetes, usually temporary, that appears during
pregnancy. t usually develops during the third trimester of pregnancy. 'fter delivery, blood
sugar (glucose) levels generally return to normal, although some women go on to develop type :
diabetes.
Bestational diabetes is not the same as the situation for women who have type ? or type :
diabetes before their pregnancy.
Causes
Autoimmune Response
Type ? diabetes is considered a progressive a2toi!!2ne disease, in which the beta cells that
produce insulin are slowly destroyed by the body1s own immune system. t is unknown what first
starts this process, but evidence suggests that both a genetic predisposition and environmental
factors, such as a viral infection, are involved.
slets of Langerhans contain beta cells and are located within the pancreas. ;eta cells produce
insulin which is needed to metaboli)e glucose within the body.
Genetic Factors
"esearchers have found at least ?J genetic locations, labeled $$#? - $$#?J, which are
related to type ? diabetes. The $$#? region contains the ,L' genes that encode proteins
called ma4or histocompatibility comple2. The genes in this region affect the immune response.
*ther chromosomes and genes continue to be identified.
#ost people who develop type ? diabetes, however, do not have a family history of the disease.
The odds of inheriting the disease are only ?60 if a first-degree relative has diabetes and, even in
identical twins, one twin has only a <<0 chance of having type ? diabetes if the other twin has it.
Children are more likely to inherit the disease from a father with type ? diabetes than from a
mother with the disorder.
Benetic factors cannot fully e2plain the development of diabetes. *ver the past 86 years, a ma4or
increase in the incidence of type ? diabetes has been reported in certain Iuropean countries, and
the incidence has tripled in the 3.(.
(iruses
(ome research suggests that viral infections may trigger the disease in genetically susceptible
individuals.
'mong the viruses under scrutiny are enteric viruses, which attack the intestinal tract. Co2sackie
viruses are a family of enteric viruses of particular interest. Ipidemics of Co2sackie virus, as
well as mumps and congenital rubella, have been associated with type ? diabetes.
Risk Factors
Type ? diabetes is much less common than type : diabetes, consisting of only / - ?60 of all
cases of diabetes. Kevertheless, like type : diabetes, new cases of type ? diabetes have been
rising over the past few decades. Ghile type : diabetes has been increasing among 'frican-
'merican and ,ispanic adolescents, the highest rates of type ? diabetes are found among
Caucasian youth.
Type ? diabetes can occur at any age but usually appears between infancy and the late <6s, most
typically in childhood or adolescence. #ales and females are e&ually at risk. (tudies report the
following may be risk factors for developing type ? diabetes!
;eing ill in early infancy
,aving a parent with type ? diabetes (the risk is greater if a father has the condition)
,aving an older mother
,aving a mother who had preeclampsia during pregnancy
,aving other autoimmune disorders such as Brave1s disease, ,ashimoto1s thyroiditis (a
form of hypothyroidism), 'ddison1s disease, multiple sclerosis (#(), or pernicious
anemia
$ymptoms
The process that destroys the insulin-producing beta cells can be long and invisible. 't the point
when insulin production bottoms out, however, type ? diabetes usually appears suddenly and
progresses &uickly. Garning signs of type ? diabetes include!
9re&uent urination (in children, a recurrence of bed-wetting after toilet training has been
completed)
3nusual thirst, especially for sweet, cold drinks
I2treme hunger
(udden, sometimes dramatic, weight loss
Geakness
I2treme fatigue
;lurred vision or other changes in eyesight
rritability
Kausea and vomiting
Children with type ? diabetes may also be restless, apathetic, and have trouble functioning at
school. n severe cases, diabetic coma may be the first sign of type ? diabetes.
Complications
Type ? diabetes increases the risk for many serious health complications. ,owever, during the
past several decades, the rate of serious complications among people with diabetes has been
decreasing, and more patients are living longer and healthier lives. There are two important
approaches to preventing complications from type ? diabetes!
Bood control of blood glucose and keeping glycosylated hemoglobin ('?C) levels below
or around .0. This approach can help prevent complications due to vascular (blood
vessel) abnormalities and nerve damage (neuropathy) that can cause ma4or damage to
organs, including the eyes, kidneys, and heart.
#anaging risk factors for heart disease. ;lood glucose control helps the heart, but it is
also very important that people with diabetes control blood pressure, cholesterol levels,
and other factors associated with heart disease.
Dia!etic )etoacidosis
$iabetic ketoacidosis ($H') is a life-threatening complication caused by a complete (or almost
complete) lack of insulin. n $H', the body produces abnormally high levels of blood acids
called ketones. Hetones are byproducts of fat breakdown that build up in the blood and appear in
the urine. They are produced when the body burns fat instead of glucose for energy. The buildup
of ketones in the body is called ketoacidosis. I2treme stages of diabetic ketoacidosis can lead to
coma and death.
9or some people, $H' may be the first sign that someone has diabetes. n type ? diabetes, it
usually occurs when a patient is not compliant with insulin therapy or intentionally reduces
insulin doses in order to lose weight. t can also be triggered by a severe illness or infection.
(ymptoms and complications include!
Thirst and dry mouth
9re&uent urination
9atigue
$ry warm skin
Kausea and vomiting and stomach pain
$eep and rapid breathing sometimes with fre&uent sighing
9ruity breath odor
Confusion and decreased consciousness
Cerebral edema, or brain swelling, is a rare but very dangerous complication that can
result in coma, brain damage, or death.
*ther serious complications from $H' include aspiration pneumonia and adult
respiratory distress syndrome.
Life-saving treatment uses rapid replacement of fluids with a salt (saline) solution followed by
low-dose insulin and potassium replacement.
Hetoacidosis is a serious condition of glucose build-up in the blood and urine. ' simple urine test
can determine if high ketone levels are present.
Hyperglycemic Hyperosmolar *onketonic $yndrome +HH*$,
,yperglycemic hyperosmolar nonketonic syndrome (,,K() is a serious complication of
diabetes that involves a cycle of increasing blood sugar levels and dehydration, without ketones.
,,K( usually occurs with type : diabetes, but it can also occur with type ? diabetes. t is often
triggered by a serious infection or another severe illness, or by medications that lower glucose
tolerance or increase fluid loss (especially in people who are not drinking enough fluids).
(ymptoms of ,,K( include high blood sugar levels, dry mouth, e2treme thirst, dry skin, and
high fever. ,,K( can lead to loss of consciousness, sei)ures, coma, and death.
Hypoglycemia
Tight blood sugar (glucose) control increases the risk of low blood sugar (hypoglycemia).
,ypoglycemia occurs if blood glucose levels fall below normal. t is generally defined as a blood
sugar below .6 mg7dL, although this level may not necessarily cause symptoms in all patients.
nsufficient intake of food and e2cess e2ercise or alcohol intake may cause hypoglycemia.
3sually the condition is manageable, but, occasionally, it can be severe or even life threatening,
particularly if the patient fails to recogni)e the symptoms, especially while continuing to take
insulin or other hypoglycemic drugs. ;eta-blocking medications, which are often prescribed for
high blood pressure and heart disease, can mask symptoms of hypoglycemia.
0is. 8actors )or -e(ere Hypoglyce!ia. (pecific risk factors for severe hypoglycemia include!
%atients attempting tight control of blood glucose and '?C levels
Long-term diabetes
%atients who do not comply with treatment
nfections such as gastroenteritis or respiratory illnesses
Hypoglyce!ia 2nawareness. ,ypoglycemia unawareness is a condition in which people become
accustomed to hypoglycemic symptoms. They may no longer notice the signs of hypoglycemia
until they become more severe. t affects about :/0 of patients who use insulin, nearly always
people with type ? diabetes. n such cases, hypoglycemia appears suddenly, without warning,
and can escalate to a severe level. Iven a single recent episode of hypoglycemia may make it
more difficult to detect the ne2t episode. Gith vigilant monitoring and by rigorously avoiding
low blood glucose levels, patients can often regain the ability to sense the symptoms. ,owever,
even very careful testing may fail to detect a problem, particularly one that occurs during sleep.
-y!pto!s. #ild symptoms usually occur at moderately low and easily correctable levels of
blood glucose. They include!
(weating
Trembling
,unger
"apid heartbeat
(everely low blood glucose levels can cause neurologic symptoms, such as!
Confusion
Geakness
$isorientation
Combativeness
n rare and worst cases, coma, sei)ure, and death
C9or information on preventing hypoglycemia or managing an attack, see Ho!e 7anage!ent
section of this report.E
Heart Disease and $troke
%atients with type ? diabetes are ?6 times more at risk for heart disease than healthy patients.
,eart attacks account for 560 of deaths in patients with diabetes, while strokes account for :/0
of such deaths. $iabetes affects the heart in many ways!
;oth type ? and : diabetes accelerate the progression of atherosclerosis (hardening of the
arteries). $iabetes is often associated with low ,$L (+good+ cholesterol) and high
triglycerides. This can lead to coronary artery disease, heart attack, or stroke.
n type ? diabetes, high blood pressure (hypertension) usually develops if the kidneys
become damaged. ,igh blood pressure is another ma4or cause of heart attack, stroke, and
heart failure. Children with diabetes are also at risk for hypertension.
mpaired nerve function (neuropathy) associated with diabetes also causes heart
abnormalities.
'therosclerosis is a disease of the arteries in which fatty material is deposited in the vessel wall,
resulting in narrowing and eventual impairment of blood flow. (everely restricted blood flow in
the arteries to the heart muscle leads to symptoms such as chest pain. 'therosclerosis shows no
symptoms until a complication occurs.
The kidneys are responsible for removing wastes from the body, regulating electrolyte balance
and blood pressure, and stimulating the production of red blood cells.
Click the icon to see an image of the kidney.
)idney Damage +*ephropathy,
Hidney disease (nephropathy) is a very serious complication of diabetes. Gith this condition, the
tiny filters in the kidney (called glomeruli) become damaged and leak protein into the urine.
*ver time this can lead to kidney failure. 3rine tests showing microalbuminuria (small amounts
of protein in the urine) are important markers for kidney damage.
$iabetic nephropathy is the leading cause of end-stage renal disease (I("$). %atients with
I("$ have ?< times the risk of death compared to other patients with type ? diabetes. f the
kidneys fail, dialysis or transplantation is re&uired. (ymptoms of kidney failure may include
swelling in the feet and ankles, itching, fatigue, and pale skin color. The outlook of end-stage
renal disease has greatly improved during the last four decades for patients with type ? diabetes,
and fewer people with type ? diabetes are developing I("$.
*europathy
$iabetes reduces or distorts nerve function, causing a condition called neuropathy. Keuropathy
refers to a group of disorders that affect nerves. The two main types of neuropathy are!
1eripheral (affects nerves in the toes, feet, legs, hand, and arms)
'2tono!ic (affects nerves that help regulate digestive, bowel, bladder, heart, and se2ual
function)
%eripheral neuropathy particularly affects sensation. t is a common complication for nearly half
of people who have lived with type ? or type : diabetes for more than :/ years. The most serious
conse&uences of neuropathy occur in the legs and feet and pose a risk for ulcers and, in unusually
severe cases, amputation. %eripheral neuropathy usually starts in the fingers and toes and moves
up to the arms and legs (called a stocking-glove distribution). (ymptoms include!
Tingling
Geakness
;urning sensations
Loss of the sense of warm or cold
Kumbness (if the nerves are severely damaged, the patient may be unaware that a blister
or minor wound has become infected)
$eep pain
'utonomic neuropathy can cause!
$igestive problems (constipation, diarrhea, nausea, and vomiting)
;ladder infections and incontinence
Irectile dysfunction
,eart problems. Keuropathy may mask angina, the warning chest pain for heart disease
and heart attack. %atients with diabetes should be aware of other warning signs of a heart
attack, including sudden fatigue, sweating, shortness of breath, nausea, and vomiting.
"apid heart rates
Lightheadedness when standing up (orthostatic hypotension)
$iabetic gastroparesis is a type of neuropathy that affects the digestive track. t is triggered by
high blood sugar, which over time can damage the vagus nerve. The result of this damage is that
the digestive system takes too long at time to move and empty food. 3ndigested food and the
delay in stomach emptying can cause blood glucose levels to rise, and make diabetes more
difficult to control. (ymptoms of gastroparesis include heartburn, nausea, abdominal bloating,
feeling full after eating only a small amount of food, and vomiting of undigested food several
hours after a meal.
;lood sugar control is an essential component in the treatment for neuropathy. (tudies show that
tight control of blood glucose levels delays the onset and slows progression of neuropathy. ,eart
disease risk factors may increase the likelihood of developing neuropathy. Lowering
triglycerides, losing weight, reducing blood pressure, and &uitting smoking may help prevent the
onset of neuropathy.
Foot -lcers and Amputations
'bout ?/0 of patients with diabetes e2perience serious foot problems. They are the leading
cause of hospitali)ations for these patients. The conse&uences of both poor circulation and
peripheral neuropathy make this a common and serious problem for all patients with diabetes.
$iabetes is responsible for more than half of all lower limb amputations performed in the 3.(.
#ost amputations start with foot ulcers.
%eople with diabetes who are overweight, smokers, and have a long history of diabetes tend to be
at most risk. %eople who have the disease for more than :6 years and are insulin-dependent are at
the highest risk. "elated conditions that put people at risk include peripheral neuropathy,
peripheral artery disease, foot deformities, and a history of ulcers. C9or more information, see /n-
Depth 0eport D?6:! %eripheral artery disease and intermittent claudication.E
9oot ulcers usually develop from infections, such as those resulting from blood vessel in4ury.
Kumbness from nerve damage, which is common in diabetes, compounds the danger since the
patient may not be aware of in4uries. 'bout one-third of foot ulcers occur on the big toe.
Charcot 8oot. Charcot foot or Charcot 4oint (medically referred to as neuropathic arthropathy) is
a degenerative condition that affects the bones and 4oints in the feet. t is associated with the
nerve damage that occurs with neuropathy. Iarly changes appear similar to an infection, with the
foot becoming swollen, red, and warm. Bradually, the affected foot can become deformed. The
bones may crack, splinter, and erode, and the 4oints may shift, change shape, and become
unstable. t typically develops in people who have neuropathy to the e2tent that they cannot feel
sensation in the foot and are not aware of an e2isting in4ury. nstead of resting an in4ured foot or
seeking medical help, the patient often continues normal activity, causing further damage.
Retinopathy and Eye Complications
$iabetes accounts for thousands of new cases of blindness annually and is the leading cause of
new cases of blindness in adults ages :6 - .8. The most common eye disorder in diabetes is
retinopathy. %eople with diabetes are also at higher risk for developing cataracts and certain
types of glaucoma. C9or more information, see /n-Depth 0eport D:5! Cataracts and /n-Depth
0eport D:/! Blaucoma.E
"etinopathy is a condition in which the retina becomes damaged. t generally occurs in one or
two phases!
Click the icon to see an image of diabetic retinopathy.
The early and more common type of this disorder is called nonproli)erati(e or
&ac.gro2nd retinopathy. The blood vessels in the retina are abnormally weakened. They
rupture and leak, and wa2y areas may form. f these processes affect the central portion
of the retina, swelling may occur, causing reduced or blurred vision.
f the capillaries become blocked and blood flow is cut off, soft, +woolly+ areas may
develop in the retina1s nerve layer. These woolly areas may signal the development of
proli)erati(e retinopathy. n this more severe condition, new abnormal blood vessels form
and grow on the surface of the retina. They may spread into the cavity of the eye or bleed
into the back of the eye. #a4or hemorrhage or retinal detachment can result, causing
severe visual loss or blindness. The sensation of seeing flashing lights may indicate
retinal detachment.
Click the icon to see an animation on diabetic retinopathy.
Infections
0espiratory /n)ections. %eople with diabetes face a higher risk for influen)a and its
complications, including pneumonia. Iveryone with diabetes should have annual influen)a
vaccinations and a vaccination against pneumococcal pneumonia.
9rinary Tract /n)ections. Gomen with diabetes face a significantly higher risk for urinary tract
infections, which are likely to be more complicated and difficult to treat than in the general
population.
Depression
$iabetes doubles the risk for depression. $epression, in turn, may increase the risk for
hyperglycemia and complications of diabetes.
steoporosis
Type ? diabetes is associated with slightly reduced bone density, putting patients at risk for
osteoporosis and possibly fractures.
ther Complications
$iabetes increases the risk for other conditions, including!
,earing loss
%eriodontal disease
Carpal tunnel syndrome and other nerve entrapment syndromes
Konalcoholic fatty liver disease, also called nonalcoholic steatohepatitis (K'(,)> a
particular danger for people who are obese
$pecific Complications in .omen
$iabetes can cause specific complications in women. Gomen with diabetes have an increased
risk of recurrent yeast infections. n terms of se2ual health, diabetes may cause decreased vaginal
lubrication, which can lead to pain or discomfort during intercourse.
Gomen with diabetes should also be aware that certain types of medication can affect their blood
glucose levels. 9or e2ample, birth control pills can raise blood glucose levels. Long-term use
(more than : years) of birth control pills may increase the risk of health complications.
Dia&etes and 1regnancy. %regnancy in a patient with e2isting diabetes can increase the risk for
birth defects. (tudies indicate that high blood sugar levels (hyperglycemia) can affect the
developing fetus during the critical first 5 weeks of organ development. Therefore, it is important
that women with pre-e2isting diabetes (both type ? and type :) who are planning on becoming
pregnant strive to maintain good glucose control for < - 5 months before pregnancy.
t is also important for women to closely monitor their blood sugar levels during pregnancy. 9or
women with type ? diabetes, pregnancy can affect their insulin dosing needs. nsulin dosing may
also need to be ad4usted during and following delivery. C9or more information, see @Treatment of
$iabetes $uring %regnancyA in Treat!ent o) Co!plications section of this report.E
Dia&etes and 7enopa2se. The changes in estrogen and other hormonal levels that occur during
perimenopause can cause ma4or fluctuations in blood glucose levels. Gomen with diabetes also
face an increased risk of premature menopause, which can lead to higher risk of heart disease.
$pecific &ro!lems for Adolescents /ith Type ' Dia!etes
Lac. o) Blood Gl2cose Control. Control of blood glucose levels is generally very poor in
adolescents and young adults. 'dolescents with diabetes are at higher risk than adults for
ketoacidosis resulting from noncompliance. Loung people who do not control glucose are also at
high risk for permanent damage in small vessels, such as those in the eyes.
+ating Disorders. 3p to a third of young women with type ? diabetes have eating disorders and
under-use insulin to lose weight. 'nore2ia and bulimia pose significant health risks in any young
person, but they can be especially dangerous for people with diabetes.
Diagnosis
There are three tests that can diagnose diabetes!
9asting plasma glucose (9%B)
*ral glucose tolerance test (*BTT)
,emglobin '?C ('?C)
Fasting &lasma Glucose Test
The fasting plasma glucose (9%B) test has been the standard test for diagnosing diabetes. t is a
simple blood test taken after J hours of fasting.
9%B levels indicate!
Kormal. ?66 mg7dL (or /./ mmol7L) or below.
%re-$iabetes. (' risk factor for type : diabetes)! ;etween ?66 - ?:/ mg7dL (/./ - ..6
mmol7L).
$iabetes.?:5 mg7dL (..6 mmol7L) or higher
The 9%B test is not always reliable, so a repeat test is recommended if the initial test suggests the
presence of diabetes, or if the tests are normal in people who have symptoms or risk factors for
diabetes. Gidespread screening of patients to identify those at higher risk for diabetes type ? is
not recommended.
ral Glucose Tolerance Test
The oral glucose tolerance test (*BTT) is more comple2 than the 9%B and may overdiagnose
diabetes in people who do not have it. (ome doctors recommend it as a follow-up after 9%B, if
the latter test results are normal but the patient has symptoms or risk factors of diabetes. The test
uses the following procedures!
t first uses an 9%B test.
' blood test is then taken : hours later after drinking a special glucose solution.
*BTT levels indicate!
Kormal. ?86 mg7dL or below.
%re-$iabetes. ;etween ?86 - ?== mg7dL.
$iabetes. :66 mg7dL or higher.
%atients who have the 9%B and *BTT tests must not eat for at least J hours prior to the test.
The oral glucose tolerance test is used to diagnose diabetes. The first portion of the test involves
drinking a special glucose solution. ;lood is then taken several hours later to test for the level of
glucose in the blood. %atients with diabetes will have higher than normal levels of glucose in
their blood.
Hemoglo!in A'C Test
This test e2amines blood levels of glycosylated hemoglobin, also known as hemoglobin '?C
(,b'?c). The results are given in percentages and indicate a personFs average blood glucose
levels over the past : - < months. (The 9%B and *BTT show a personFs glucose level for only
the time of the test.) The '?C test is not affected by recent food intake so patients do not need to
fast to prepare for it.
n :6?6, the 'merican $iabetes 'ssociation advised that the '?C test can be used as another
option for diagnosing diabetes.
'?C levels indicate!
Kormal. Less than /.. percent.
%re-$iabetes. ;etween /.. - 5.8 percent.
$iabetes. 5./ percent or higher.
'?C tests are also used to help patients with diabetes monitor how well they are keeping their
blood glucose levels under control. 9or patients with diabetes, '?C is measured periodically
every : - < months, or at least twice a year. Ghile finger prick self-testing provides information
on blood glucose for that day, the '?C test shows how well blood sugar has been controlled over
the past several months.
n general, most adult patients with diabetes should aim for '?C levels below or around .0.
Lour doctor may ad4ust this goal depending on your individual health profile.
Boal '?C levels for children are!
;etween ../ - J./0 for children under age 5 years
Less than J0 for children age 5 - ?: years
Less than ../0 for children age ?< - ?= years
(chedule for '?C #onitoring!
Ivery 5 months if diabetes is well controlled
Ivery < months if not well controlled
The 'merican $iabetes 'ssociation recommends that results from the '?C test be used
as to calculate estimated 'verage Blucose (e'B). I'B is a relatively new term that
patients may see on lab results from their '?C tests. t converts the '?C percentages into
the same mg7dL units that patients are familiar with from their daily home blood glucose
tests. 9or e2ample, an '?C of .0 is e&ual to an e'B of ?/8 mg7dL. The e'B
terminology can help patients better interpret the results of their '?C tests, and make it
easier to correlate '?C with results from home blood glucose monitoring.
Autoanti!ody Tests
Type ? diabetes is characteri)ed by the presence of a variety of antibodies that attack the
islet cells. These antibodies are referred to as autoantibodies because they attack the
body1s own cells -- not a foreign invader. ;lood tests for these autoantibodies can help
differentiate between type ? and type : diabetes.
$creening Tests for Complications
-creening Tests )or Heart Disease. 'll patients with diabetes should be tested for high
blood pressure (hypertension) and unhealthy cholesterol and lipid levels and given an
electrocardiogram. *ther tests may be needed in patients with signs of heart disease.
Click the icon to see an image of an ICB.
-creening Tests )or 6idney Da!age. The earliest manifestation of kidney disease is
microalbuminuria, in which tiny amounts of a protein called albumin are found in the
urine. #icroalbuminuria is also a marker for other complications involving blood vessel
abnormalities, including heart attack and stroke.
%eople with diabetes should have an annual microalbuminuria urine test. %atients should
also have their blood creatinine tested at least once a year. Creatinine is a waste product
that is removed from the blood by the kidneys. ,igh levels of creatinine may indicate
kidney damage. ' doctor uses the results from a creatinine blood test to calculate the
glomerular filtration rate (B9"). The B9" is an indicator of kidney function> it estimates
how well the kidneys are cleaning the blood.
-creening )or 0etinopathy. The 'merican $iabetes 'ssociation recommends that patients
with type ? diabetes have an annual comprehensive eye e2am, with dilation, to check for
signs of retina disease (retinopathy). %atients at low risk may need e2ams only every : - <
years. n addition to a comprehensive eye e2am, fundus photography may be used as a
screening tool. 9undus photography uses a special type of camera to take images of the
back of the eye.
-creening )or :e2ropathy. 'll patients should be screened for nerve damage
(neuropathy), including a comprehensive foot e2am. %atients who lose sensation in their
feet should have a foot e2am every < - 5 months to check for ulcers or infections.
-creening )or Thyroid '&nor!alities. Thyroid function tests should be performed.
Lifestyle Changes
Bood nutrition and regular e2ercise can help prevent or manage medical complications of
diabetes (such as heart disease and stroke), and help patients live longer and healthier lives.
Diet
There is no single diabetes diet. %atients should meet with a professional dietitian to plan an
individuali)ed diet within the general guidelines that takes into consideration their own health
needs.
,ealthy eating habits, along with good control of blood glucose, are the basic goals, and several
good dietary methods are available to meet them. Beneral dietary guidelines for diabetes
recommend!
Carbohydrates should provide 8/ - 5/0 of total daily calories. The type and amount of
carbohydrate are both important. ;est choices are vegetables, fruits, beans, and whole
grains. These foods are also high in fiber. %atients with diabetes should monitor their
carbohydrate intake either through carbohydrate counting or meal planning e2change
lists.
9ats should provide :/ - </0 of daily calories. #onounsaturated (olive, peanut, and
canola oils> avocados> and nuts) and omega-< polyunsaturated (fish, fla2seed oil, and
walnuts) fats are the best types. Limit saturated fat (red meat, butter) to less than .0 of
daily calories. Choose nonfat or low-fat dairy instead of whole milk products. Limit
trans-fats (hydrogenated fat found in snack foods, fried foods, and commercially baked
goods) to less than ?0 of total calories.
%rotein should provide ?: - :60 of daily calories, although this may vary depending on a
patientFs individual health re&uirements. %atients with kidney disease should limit protein
intake to less than ?60 of calories. 9ish, soy, and poultry are better protein choices than
red meat.
(odium (salt) intake should be limited to ?,/66 mg7day or less. "educing sodium can
help lower blood pressure and decrease the risk of heart disease.
C9or more information, see /n-Depth 0eport D8:! $iabetes diet.E
Healthy .eight Control
Geight gain is a potential side effect of intense diabetic control with insulin. ;eing overweight
can increase the risk for health problems. *n the other hand, studies suggest that more than one-
third of women with diabetes omit or underuse insulin in order to lose weight. Iating disorders
are especially dangerous in patients with diabetes and can increase the risk for diabetic
ketoacidosis. Hetoacidosis is a significant complication of insulin depletion and can be life
threatening.
E0ercise
'erobic e2ercise has significant and particular benefits for people with type ? diabetes. t
increases sensitivity to insulin, lowers blood pressure, improves cholesterol levels, and decreases
body fat. ;ecause glucose levels swing dramatically during workouts, people with type ?
diabetes need to take certain precautions!
#onitor glucose levels carefully before, during, and after workouts.
'void e2ercise if glucose levels are above <66 mg7dL or under ?66 mg7dL.
To avoid hypoglycemia, patients should in4ect insulin in sites away from the muscles they
use the most during e2ercise.
;efore e2ercising, avoid alcohol and if possible certain drugs, including beta blockers,
which make it difficult to recogni)e symptoms of hypoglycemia.
nsulin-dependent athletes may need to decrease insulin doses or take in more
carbohydrates, especially in the form of pre-e2ercise snacks. (kim milk is particularly
helpful. They should also drink plenty of fluids.
Bood, protective footwear is essential to help avoid in4uries and wounds to the feet.
'void resistance or high impact e2ercises. They can strain weakened blood vessels in the eyes of
patients with retinopathy. ,igh-impact e2ercise may also in4ure blood vessels in the feet.
;ecause patients with diabetes may have silent heart disease, they should always check with
their doctors before undertaking vigorous e2ercise.
.arning on Dietary $upplements
-arious fraudulent products are often sold on the nternet as @curesA or treatments for diabetes.
These dietary supplements have not been studied or approved. The 3( 9ood and $rug
'dministration (9$') and 9ederal Trade Commission (9TC) warn patients with diabetes not to
be duped by bogus and unproven remedies.
Treatment
nsulin is essential for strict control of blood glucose levels in type ? diabetes. Bood blood
glucose control is the best way to prevent ma4or complications in type ? diabetes, including those
that affect the kidneys, eyes, nerve pathways, and blood vessels. ntensive insulin treatment in
early diabetes may even help preserve any residual insulin secretion for at least : years.
There are, however, some significant problems with intensive insulin therapy!
There is a greater risk for low blood sugar (hypoglycemia).
#any patients e2perience significant weight gain from insulin administration, which may
have adverse effects on blood pressure and cholesterol levels. t is important to manage
heart disease risk factors that might develop as a result of insulin treatment.
' diet plan that compensates for insulin administration and supplies healthy foods is e2tremely
important. C9or more information, see /n-Depth 0eport D8:! $iabetes diet.E %ancreas
transplantation may eventually be considered for patients who cannot control glucose levels
without fre&uent episodes of severe hypoglycemia.
Regimens for Intensi1e Insulin Treatment
The goal of intensive insulin therapy is to keep blood glucose levels as close to normal as
possible.
Glucose Goals for &atients /ith Dia!etes
*ormal Goal
;lood glucose levels before meals Less than ?66
mg7dL
.6 - ?<6 mg7dL for adults
?66 - ?J6 mg7dL for children under age 5
=6 - ?J6 mg7dL for children 5 - ?: years
old
=6 - ?<6 mg7dL for children ?< - ?= years
old
;edtime blood glucose levels Less than ?:6
mg7dL
Less than ?J6 mg7dL for adults
??6 - :66 mg7dL for children under age 5
?66 - ?J5 mg7dL for children 5 - ?: years
old
=6 - ?/6 mg7dL for children ?< - ?= years
old
Blycosylated hemoglobin ('?C)
levels
Less than /..0 Less than or around .0
#a4or source! -tandards o) 7edical Care /n Dia&etes -- ;##, 'merican $iabetes 'ssociation.
(tandard insulin therapy usually consists of one or two daily insulin in4ections, one daily blood
sugar test, and visits to the health care team every < months. 9or strictly controlling blood
glucose, however, intensive management is re&uired. The regimen is complicated although newer
insulin forms may make it easier.
There are two components to insulin administration!
;asal insulin administration. The &asal component of the treatment attempts to provide a
steady amount of background insulin throughout the day. ;asal insulin levels maintain
regular blood glucose needs. nsulin glargine now offers the most consistent insulin
activity level, but other intermediate and long-acting forms may be beneficial when
administered twice a day. (hort-acting insulin delivered continuously using a pump is
proving to a very good way to provide basal rates of insulin.
#ealtime insulin administration. #eals re&uire a boost (a bolus) of insulin to regulate the
sudden rise in glucose levels after a meal.
n achieving insulin control the patient must also take other steps!
The patient should perform four or more blood glucose tests during the day.
%atients should coordinate insulin administration with calorie intake. n general, they
should eat three meals each day at regular intervals. (nacks are often necessary.
nsulin re&uirements vary depending on many non-nutritional situations during the day,
including e2ercise and sleep. %eople are at increased risk for low blood sugar during
e2ercise. (ome patients e2perience a sudden rise in blood glucose levels in the morning --
the so-called +dawn phenomenon.+
The patient must also maintain a good diet plan and should visit the health care team of
doctors, nurses, and dietitians once a month.
;ecause of the higher risk for hypoglycemia in children, doctors recommend that intensive
treatment be used very cautiously in children under ?< and not at all in very young children.
Types of Insulin
nsulin cannot be taken orally because the body1s digestive 4uices destroy it. n4ections of insulin
under the skin ensure that it is absorbed slowly by the body for a long-lasting effect. The timing
and fre&uency of insulin in4ections depend upon a number of factors!
The duration of insulin action. nsulin is available in several forms, including! standard,
intermediate, long-acting, and rapid-acting.
'mount and type of food eaten. ngestion of food makes the blood glucose level rise.
'lcohol lowers levels.
The person1s level of physical activity. I2ercise lowers glucose levels.
8ast-'cting /ns2lin. nsulin lispro (,umalog) and insulin aspart (Kovo "apid, Kovolog) lower
blood sugar very &uickly, usually within / minutes after in4ection. nsulin peaks in about 8 hours
and continues to work for about 8 more hours. This rapid action reduces the risk for
hypoglycemic events after eating (postprandial hypoglycemia). *ptimal timing for administering
this insulin is about ?/ minutes before a meal, but it can also be taken immediately after a meal
(but within <6 minutes). 9ast-acting insulins may be especially useful for meals with high
carbohydrates.
0eg2lar /ns2lin. "egular insulin begins to act <6 minutes after in4ection, reaches its peak at : - 8
hours, and lasts about 5 hours. "egular insulin may be administered before a meal and may be
better for high-fat meals.
/nter!ediate /ns2lin. K%, (Keutral %rotamine ,agedorn) insulin has been the standard
intermediate form. t works within : - 8 hours, peaks 8 - ?: hours later, and lasts up to ?J hours.
Lente (insulin )inc) is another intermediate insulin that peaks 8 - ?: hours and lasts up to ?J
hours.
Long-'cting (9ltralente) /ns2lin. Long-acting insulins, such as insulin glargine (Lantus), are
released slowly. Long-acting insulin peaks at ?6 hours and lasts up to :6 hours. "esearchers are
studying new types of long-acting insulins including one called degludec that re&uires in4ections
only three times a week.
Co!&inations. "egimens generally include combinations of short and longer-acting insulins to
help match the natural cycle. 9or e2ample, one approach in patients who are intensively
controlling their glucose levels uses < in4ections of insulin, which includes a mi2ture of regular
insulin and K%, at dinner. 'nother approach uses 8 in4ections, including a separate short-acting
form at dinner and K%, at bedtime, which may pose a lower risk for nighttime hypoglycemia
than the <-in4ection regimen.
/ns2lin 1ens. nsulin pens, which contain cartridges of insulin, have been available for some
time. 3ntil recently, they were fairly complicated and difficult to use. Kewer, prefilled pens
(,umulin %en, ,umalog) are disposable and allow the patient to dial in the correct amount.
Insulin &umps
'n insulin pump can improve blood glucose control and &uality of life with fewer hypoglycemic
episodes than multiple in4ections. The pumps correct for the @dawn phenomenonA (sudden rise of
blood glucose in the morning) and allow &uick reductions for specific situations, such as
e2ercise. #any different brands are available.
The typical pump is about the si)e of a beeper and has a digital display. (ome are worn
e2ternally and are programmed to deliver insulin through a catheter in the skin or the abdomen.
They generally use rapid-acting insulin, the most predictable type. They work by administering a
small amount of insulin continuously (the basal rate) and a higher dose (a bolus dose) when food
is eaten.
'lthough learning to use the pump can be complicated at first, most patients find over time that
the devices are fairly easy to use. 'dults, adolescents, and school children use insulin pumps and
even very young children (ages : - . years) may be able to successfully use them.
The catheter at the end of the insulin pump is inserted through a needle into the abdominal fat of
a person with diabetes. $osage instructions are entered into the pump1s small computer, and the
appropriate amount of insulin is then in4ected into the body in a calculated, controlled manner.
To achieve good blood sugar control, patients and parents of children must undergo some
training. The patient and doctor must determine the amount of insulin used -- it is not
automatically calculated. This re&uires an initial learning period, including understanding insulin
needs over the course of the day and in different situations and knowledge of carbohydrate
counting. 9re&uent blood testing is very important, particularly during the training period.
nsulin pumps are more e2pensive than insulin shots and occasionally have some complications,
such as blockage in the device or skin irritation at the infusion site. n spite of early reports of a
higher risk for ketoacidosis with pumps, more recent studies have found no higher risk.
$upplementary Drugs for Hyperglycemia
%ramlintide ((ymlin) is an in4ectable drug that is used to help control postprandial
hyperglycemia, the sudden increase in blood sugar after a meal. %ramlintide is in4ected before
meals and can help lower blood sugar levels in the < hours after meals. %ramlintide is used in
addition to insulin for patients who take insulin regularly but still need better blood sugar control.
%ramlintide and insulin are the only two drugs approved for treatment of type ? diabetes.
%ramlintide is a synthetic form of amylin, a hormone that is related to insulin. (ide effects may
include nausea, vomiting, abdominal pain, headache, fatigue, and di))iness. %atients with type ?
diabetes have an increased risk of severe low blood sugar (hypoglycemia) that may occur within
< hours following a pramlintide in4ection. This drug should not be used if patients have trouble
knowing when their blood sugar is low or have slow stomach emptying (gastroparesis).
High 2lood &ressure and Heart Disease
'll patients with diabetes and high blood pressure should adopt lifestyle changes. These include
weight reduction (when needed), following the $ietary 'pproaches to (top ,ypertension
($'(,) diet, smoking cessation, limiting alcohol intake, and limiting salt intake to no more than
?,/66 mg of sodium per day.
High Blood 1ress2re Control. %atients should aim for blood pressure levels of less than ?<67J6
mm ,g (systolic7diastolic).
%atients with diabetes and high blood pressure need an individuali)ed approach to drug
treatment, based on their particular health profile. $o)ens of anti-hypertensive drugs are
available. The most beneficial fall into the following categories
$iuretics rid the body of e2tra sodium (salt) and water. There are three main types of
diuretics! %otassium-sparing, thia)ide, and loop.
'ngiotensin-converting en)yme ('CI) inhibitors reduce the production of angiotensin, a
chemical that causes arteries to narrow.
'ngiotensin-receptor blockers ('";s) block angiotensin.
;eta blockers block the effects of adrenaline and ease the heartFs pumping action.
Calcium-channel blockers (CC;s) decrease the contractions of the heart and widen blood
vessels. Like 'CI inhibitors and '";s, certain calcium channel blockers (diltia)em and
verapamil) can reduce urine protein loss caused by diabetic kidneys.
Kearly all patients who have diabetes and high blood pressure should take an 'CI inhibitor (or
'";) as part of their regimen for treating their hypertension. These drugs help prevent kidney
damage. C9or more information, see /n-Depth 0eport D?8! ,igh blood pressure.E
/!pro(ing Cholesterol and Lipid Le(els. 'bnormal cholesterol and lipid levels are common in
diabetes. ,igh L$L (@badA) cholesterol should always be lowered, but people with diabetes also
often have additional harmful imbalances, including low ,$L (@goodA) cholesterol and high
triglycerides.
High 2lood &ressure and Heart Disease
'll patients with diabetes and high blood pressure should adopt lifestyle changes. These include
weight reduction (when needed), following the $ietary 'pproaches to (top ,ypertension
($'(,) diet, smoking cessation, limiting alcohol intake, and limiting salt intake to no more than
?,/66 mg of sodium per day.
High Blood 1ress2re Control. %atients should aim for blood pressure levels of less than ?<67J6
mm ,g (systolic7diastolic).
%atients with diabetes and high blood pressure need an individuali)ed approach to drug
treatment, based on their particular health profile. $o)ens of anti-hypertensive drugs are
available. The most beneficial fall into the following categories
$iuretics rid the body of e2tra sodium (salt) and water. There are three main types of
diuretics! %otassium-sparing, thia)ide, and loop.
'ngiotensin-converting en)yme ('CI) inhibitors reduce the production of angiotensin, a
chemical that causes arteries to narrow.
'ngiotensin-receptor blockers ('";s) block angiotensin.
;eta blockers block the effects of adrenaline and ease the heartFs pumping action.
Calcium-channel blockers (CC;s) decrease the contractions of the heart and widen blood
vessels. Like 'CI inhibitors and '";s, certain calcium channel blockers (diltia)em and
verapamil) can reduce urine protein loss caused by diabetic kidneys.
Kearly all patients who have diabetes and high blood pressure should take an 'CI inhibitor (or
'";) as part of their regimen for treating their hypertension. These drugs help prevent kidney
damage. C9or more information, see /n-Depth 0eport D?8! ,igh blood pressure.E
/!pro(ing Cholesterol and Lipid Le(els. 'bnormal cholesterol and lipid levels are common in
diabetes. ,igh L$L (@badA) cholesterol should always be lowered, but people with diabetes also
often have additional harmful imbalances, including low ,$L (@goodA) cholesterol and high
triglycerides.
'dult patients should aim for L$L levels below ?66 mg7dL, ,$L levels over /6 mg7dL, and
triglyceride levels below ?/6 mg7dL. %atients with diabetes and e2isting heart disease should
strive for even lower L$L levels> the 'merican $iabetes 'ssociation recommends L$L levels
below .6 mg7dL for these patients.
Children should be treated for L$L cholesterol above ?56 mg7dL, or above ?<6 mg7dL if they
have other cardiovascular risk factors.
9or medications, statins are the best cholesterol-lowering drugs. They include atorvastatin
(Lipitor), lovastatin (#evacor and generics), pravastatin (%ravachol), simvastatin (Mocor and
generics), fluvastatin (Lescol), rosuvastatin (Crestor), and pitavastatin (Livalo). These drugs are
very effective for lowering L$L cholesterol levels.
The primary safety concern with statins has involved myopathy, an uncommon condition that can
cause muscle damage and, in some cases, muscle and 4oint pain. ' specific myopathy called
rhabdomyolysis can lead to kidney failure. %eople with diabetes and risk factors for myopathy
should be monitored for muscle symptoms.
'lthough lowering L$L cholesterol is beneficial, statins are not as effective as other medications
-- such as niacin and fibrates -- in addressing ,$L and triglyceride imbalances. Combining a
statin with one of these drugs may be helpful for people with diabetes who have heart disease,
low ,$L, and near-normal L$L levels. 'lthough combinations of statins and fibrates or niacin
increase the risk of myopathy, both combinations are considered safe if used with e2tra care.
9ibrates, such as gemfibro)il (Lopid) and fenofibrate (Tricor), are usually the second choice after
statins. Kiacin has the most favorable effect on raising ,$L and lowering triglycerides of all the
cholesterol drugs. ,owever, some patients who take high-dose niacin can e2perience increased
blood glucose levels. #oderate doses of niacin can control lipids without causing serious blood
glucose problems. C9or more information, see /n-Depth 0eport D:<! Cholesterol.E
'spirin )or Heart Disease 1re(ention. 9or patients with diabetes who are at increased risk for
heart problems, taking a daily aspirin can reduce the risk for blood clotting and may help protect
against heart attacks. (There is not enough evidence to indicate that aspirin prevention is helpful
for patients at lower risk.) The recommended dose is ./ - ?5: mg7day. 'spirin as primary
prevention is recommended for men who are older than age /6 or women who are older than age
56 who have at least one additional heart risk factor. These risk factor include a family history of
heart disease, high blood pressure, smoking, unhealthy cholesterol levels, or e2cessive urine
levels of the protein albumin (albuminuria). Talk to your doctor, particularly if you are at risk for
gastrointestinal bleeding and ulcers.
Treatment of Retinopathy
%atients with severe diabetic retinopathy or macular edema (swelling of the retina) should see an
eye specialist who is e2perienced in the management and treatment of diabetic retinopathy. *nce
damage to the eye develops, laser or photocoagulation eye surgery may be needed. Laser surgery
can help reduce vision loss in high-risk patients.
Treatment of Foot -lcers
'bout a third of foot ulcers will heal within :6 weeks with good wound care treatments. (ome
treatments are as follows!
'ntibiotics are generally given. n some cases, hospitali)ation and intravenous antibiotics
for up to :J days may be needed for severe foot ulcers.
n virtually all cases, wound care re&uires debridement, which is the removal of in4ured
tissue until only healthy tissue remains. $ebridement may be accomplished using
chemical (en)ymes), surgical, or mechanical (irrigation) means.
,ydrogels (such as Ku-Bel) may help soothe and heal ulcers.
9elted foam may be helpful in healing ulcers on the sole of the foot. 9elted foam uses a
multi-layered foam pad over the bottom of the foot with an opening over the ulcer.
5ther Treat!ents )or 8oot 9lcers. $octors are also using or investigating other treatments to
heal ulcers. These include!
'dministering hyperbaric o2ygen (o2ygen given at high pressure) is showing promise in
promoting healing. t is generally reserved for patients with severe, full thickness diabetic
foot ulcers that have not responded to other treatments, particularly when gangrene or an
abscess is present.
Total-contact casting (TCC) uses a cast that is designed to match the e2act contour of the
foot and distribute weight along the entire length of the foot. t is usually changed
weekly. t may be helpful for ulcer healing and for Charcot foot. 'lthough it is very
effective in healing ulcers, recurrence is common.
Treatment of *europathy
' number of different drugs are used for peripheral neuropathy pain relief! They include!
Konprescription analgesics, such as aspirin, acetaminophen, and non-steroidal anti-
inflammatory drugs (K('$s). (%atients with stomach or kidney problems should check
with their doctors before using these drugs.)
%rescription painkillers, such as tramadol (3ltram). Tramadol is a drug that is similar to
opioids. t can help relieve pain but has significant side effects, including nausea,
constipation, and headache.
Topical medications, particularly capsaicin (the active ingredient in hot peppers), are
applied to the skin to relieve minor local pain. ' /0 lidocaine patch has also shown good
results in clinical trials.
Tricyclic antidepressants, such as amitriptyline (Ilavil) or do2epin ((ine&uan), are
effective in reducing pain from neuropathy in many patients. ' combination of do2epin
and capsaicin (applied to the skin) may also be helpful. 3nfortunately, tricyclics may
cause heart rhythm problems, so patients at risk need to be monitored carefully.
$ulo2etine (Cymbalta), a serotonin and norepinephrine reuptake inhibitor, is approved
for treatment of pain associated with diabetic peripheral neuropathy.
'nti-sei)ure drugs used for peripheral neuropathy pain relief include gabapentin
(Keurontin), pregabalin (Lyrica), carbama)epine (Tegretol), and valproate ($epakote).
'lthough not proven to be beneficial, patients may also try transcutaneous electrostimulation
(TIK(), a treatment that involves administering mild electrical pulses to painful areas.
'lternative treatments -- such as hypnosis, biofeedback, rela2ation techni&ues, and acupuncture
-- have also been reported to help some patients manage pain. $octors also recommend lifestyle
measures, such as walking and wearing elastic stockings.
Treat!ents )or 5ther Co!plications o) :e2ropathy. Keuropathy also impacts other functions,
and treatments are needed to reduce their effects. f diabetes affects the nerves in the autonomic
nervous system, then abnormalities of blood pressure control and bowel and bladder function
may occur. Irythromycin, domperidone (#otilium), or metoclopramide ("eglan) may be used to
relieve delayed stomach emptying caused by neuropathy (diabetic gastroparesis). %atients need
to watch their nutrition if the problem is severe.
Irectile dysfunction is also associated with neuropathy. (tudies indicate that phosphodiesterase
type / (%$I-/) drugs, such as sildenafil (-iagra), vardenafil (Levitra), and tadalafil (Cialis), are
safe and effective, at least in the short term, for many patients with diabetes. Typical side effects
are minimal but may include headache, flushing, and upper respiratory tract and flu-like
symptoms. %atients who take nitrate medications for heart disease cannot use %$I-/ drugs.
Treatment of )idney &ro!lems
Tight control of blood sugar and blood pressure is essential for preventing the onset of kidney
disease. (trict control of these two conditions produces a reduction in new cases of nephropathy
and a delay in progression of the disease.
'CI inhibitors are the best class of blood pressure medications for delaying kidney disease and
slowing disease progression in patients with type ? diabetes. 'ngiotensin-receptor blockers
('";s) are also very helpful.
9or patients with diabetes who have microalbuminuria, the 'merican $iabetes
'ssociation strongly recommends 'CI inhibitors or '";s. #icroalbuminuria is an
accumulation of protein in the blood, which can signal the onset of kidney disease
(nephropathy).
Kearly all patients who have diabetes and high blood pressure should take an 'CI
inhibitor (or '";) as part of their regimen for treating their hypertension
' doctor may recommend a low-protein diet for patients whose kidney disease is progressing
despite tight blood sugar and blood pressure control. %rotein-restricted diets can help slow
disease progression and delay the onset of end-stage renal disease (kidney failure). ,owever,
patients with end-stage renal disease who are on dialysis generally need higher amounts of
protein. C9or more information, see /n-Depth 0eport D8:! $iabetes diet.E
'ne!ia. 'nemia is a common complication of end-stage kidney disease. %atients on dialysis
usually need in4ections of erythropoiesis-stimulating drugs to increase red blood cell counts and
control anemia. ,owever, these drugs -- darbepoetin alfa ('ranesp) and epoetin alfa (Ipogen and
%rocrit) -- can increase the risk of blood clots, stroke, heart attack, and heart failure in patients
with end-stage kidney disease when they are given at higher than recommended doses.
The 9$' recommends that patients with end-stage kidney disease who receive erythropoiesis-
stimulating drugs should!
#aintain hemoglobin levels between ?6 - ?: g7dL.
"eceive fre&uent blood tests to monitor hemoglobin levels.
Contact their doctors if they e2perience such symptoms as shortness of breath, pain,
swelling in the legs, or increases in blood pressure.
C9or more information, see /n-Depth 0eport D/.! 'nemia.E
Treatment of Dia!etes During &regnancy
(ome recommendations for preventing pregnancy complications include!
ntensive blood sugar control during pregnancy can reduce the risk for health
complications for both mothers and babies. $octors recommend that pregnant women
with pre-e2isting diabetes monitor their blood sugar levels up to J times daily. This
includes checking your blood glucose before each meal, ? - : hours after a meal, at
bedtime, and possibly during the night.
nsulin needs increase during the pregnancy, especially during the last < months. Lour
doctor may recommend increasing your insulin dosage during this time.
Consult a registered dietician to help ad4ust your food plan during pregnancy.
Low-impact aerobic e2ercise during pregnancy can lower glucose levels. ('ll pregnant
women, particularly those with diabetes, should check with their doctors before
embarking on a rigorous e2ercise regimen. This is especially important for women with
eye, kidney, or high blood pressure or other heart problems.)
To prevent birth defects that affect the heart and nervous system, women with diabetes
should take a higher dose of folic acid from the time of conception up to week ?: of
pregnancy. They should also be checked for any heart problems.
Gomen with diabetes should have an eye e2amination during pregnancy and up to a year
afterward.
Home #anagement
#onitoring Glucose +2lood $ugar, Le1els
;oth low blood sugar (hypoglycemia) and high blood sugar (hyperglycemia) are of concern for
patients who take insulin. t is important, therefore, to carefully monitor blood glucose levels. n
general, patients with type ? diabetes need to take readings four or more times a day. %atients
should aim for the following measurements!
%re-meal glucose levels of .6 - ?<6 mg7dL
%ost-meal glucose levels of less than ?J6 mg7dL
$ifferent goals may be re&uired for specific individuals, including pregnant women, very old and
very young people, and those with accompanying serious medical conditions.
8inger-1ric. Test. ' typical blood sugar test includes the following!
' drop of blood is obtained by pricking the finger.
The blood is then applied to a chemically treated strip.
#onitors read and provide results.
,ome monitors are about ?6 - ?/0 less accurate than laboratory monitors, and many do not meet
the standards of the 'merican $iabetes 'ssociation. #ost doctors believe, however, that they are
accurate enough to indicate when blood sugar is too low.
To monitor the amount of glucose within the blood a person with diabetes should test their blood
regularly. The procedure is &uite simple and can often be done at home.
(ome simple procedures may improve accuracy!
Testing the meter once a month.
"ecalibrating it whenever a new packet of strips is used.
3sing fresh strips> outdated strips may not provide accurate results.
Heeping the meter clean.
%eriodically comparing the meter results with the results from a laboratory.
Continuous Glucose #onitoring $ystems
Continuous glucose monitoring systems (CB#s) use a needle-like sensor inserted under the skin
of the abdomen to monitor glucose levels every / minutes. $epending on the system, C#Bs
measure glucose levels for <- . days and sound an alarm if glucose levels are too high or low.
These devices are used in addition to traditional fingerstick test kits and glucose meters but do
not replace them.
-rine Tests
3rine tests are useful for detecting the presence of ketones. These tests should always be
performed during illness or stressful situations, when diabetes is likely to go out of control. The
patient should also undergo yearly urine tests for microalbuminuria (small amounts of protein in
the urine), a risk factor for future kidney disease.
&re1enting Hypoglycemia
The following tips may help avoid hypoglycemia or prepare for attacks.
;edtime snacks are advisable if blood glucose levels are below ?J6 mg7dL (?6 mmol7L).
%rotein snacks may be best.
(ome research has suggested that children (particularly thin children) are at higher risk
for hypoglycemia because the in4ection goes into muscle tissue. %inching the skin so that
only fat (and not muscle) tissue is gathered or using shorter needles may help.
-arious insulin regimens are available that can reduce the risk. 9or e2ample, taking a
fast-acting insulin (insulin lispro) before the evening meal may be particularly helpful in
preventing hypoglycemia at bedtime or during the night.
%atients who intensively control their blood sugar should monitor blood levels as often as
possible, four times or more per day. This is particularly important for patients with
hypoglycemia unawareness.
n adults, it is particularly critical to monitor blood glucose levels before driving, when
hypoglycemia can be very ha)ardous.
%atients who are at risk for hypoglycemia should always carry hard candy, 4uice, sugar
packets, or commercially available glucose substitutes.
%atients at high risk for severe hypoglycemia, and their family members, should consider
having on hand a glucagon emergency kit. The kit is available by prescription and
contains an in4ection of glucagon, a hormone that helps to &uickly raise blood glucose
levels.
9amily and friends should be aware of the symptoms and be prepared!
f the patient is helpless (but not unconscious), family or friends should administer three
to five pieces of hard candy, two to three packets of sugar, half a cup (four ounces) of
fruit 4uice, or a commercially available glucose solution.
f there is inade&uate response within ?/ minutes, the patient should receive additional
sugar by mouth and may need emergency medical treatment, possibly including an
intravenous glucose solution.
9amily members and friends can learn to in4ect glucagon (see above).
mer!ency treatment
Blucagon is a fast-acting hormone used to raise blood glucose levels &uickly. t is administered
by in4ection in cases where a person with diabetes has symptoms of hypoglycemia -- such as
confusion, sei)ures, or unconsciousness -- that have not responded to treatment with glucose
(sugar).
"eview $ate! ?:7::7:6?6
"eviewed ;y! ,arvey (imon, #$, Iditor-in-Chief> 'ssociate %rofessor of #edicine, ,arvard
#edical (chool> %hysician, #assachusetts Beneral ,ospital.
A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation
HealthCare Commission (www.urac.org.
Click the icon to see an e2ample of a glucagon kit.
%atients with type ? diabetes should always wear a medical alert $ bracelet or necklace that
states that they have diabetes and take insulin.
Foot Care
7eas2res to 1re(ent 8oot 9lcers. %reventive foot care can significantly reduce the risk of ulcers
and amputation. (ome tips for preventing problems include!
%atients should inspect their feet daily and watch for changes in color or te2ture, odor,
and firm or hardened areas, which may indicate infection and potential ulcers.
Ghen washing the feet, the water should be warm (not hot) and the feet and areas
between the toes should be thoroughly dried afterward. Check water temperature with the
hand or a thermometer before stepping in.
'pply moisturi)ers, but K*T between the toes.
Bently use pumice to remove corns and calluses (patients should not use medicated pads
or try to shave the corns or calluses themselves).
Trim toenails short and file the edges to avoid cutting ad4acent toes.
Gell-fitting footwear is very important. %eople should be sure the shoe is wide enough.
%atients should also avoid high heels, sandals, thongs, and going barefoot. (hoes with a
rocker sole reduce pressure under the heel and front of the foot and may be particularly
helpful. Custom-molded boots increase the surface area over which foot pressure is
distributed. This reduces stress on the ulcers and allows them to heal.
Change shoes often during the day.
Gear socks, particularly with e2tra padding (which can be specially purchased).
%atients should avoid tight stockings or any clothing that constricts the legs and feet.
Consult a specialist in foot care for any problems.

%eople with diabetes are prone to foot problems because the disease can cause damage to
the blood vessels and nerves, which may result in decreased ability to sense an in4ury to
the foot. The circulation is also altered, so that the diabetic cannot efficiently fight
infection or heal wounds.
Click the icon to see an image of foot inspection.
Transplantation &rocedures
Islet3Cell Transplantation
"esearchers are investigating islet-cell transplantation as a way to help patients to come off
insulin or reduce their use of it. #ost research in recent years has focused on an islet-
transplantation procedure called the Idmonton protocol.
This procedure has only been used in clinical trials, but it has helped some patients with severe
type ? diabetes to become free of insulin in4ections. ,owever, many of these insulin-independent
patients needed to resume insulin in4ections within : years. "esearchers are continuing to work
on refining the Idmonton protocol so that its benefits can be more sustainable and long lasting.
' ma4or obstacle for the islet cell transplantation is the need for two or more donor pancreases to
supply sufficient islet cells. 3nfortunately, there are not enough pancreases available to make this
procedure feasible for even ?0 of patients. "esearchers are looking for alternative approaches,
including the use of umbilical cord cells, embryonic or adult stem cells, bone marrow
transplantation, and other types of cellular therapies. These studies are still in very early stages,
but researchers predict that there will be ma4or advances in these fields in the coming years.
rgan Transplantation
Ghole pancreas transplants and double transplants of pancreases and kidneys are proving to have
a good long-term success rate for some patients with type ? diabetes. The operations help to
prevent further kidney damage, and long-term studies indicate that they may even eventually
reverse some e2isting damage. There is some evidence that heart disease and diabetic neuropathy
improve after pancreas transplantation (although not retinopathy).
,owever, organ transplantation can have significant surgical and postsurgical complications. n
addition, patients need to take immunosuppressive drugs on a lifelong basis following a
transplant. $octors generally recommend transplants in cases of end-stage kidney failure or
when diabetes poses more of a threat to the patient1s life than the transplant itself.
3ncontrolled diabetes causes damage to many tissues of the body, including the kidneys. Hidney
damage caused by diabetes most often involves thickening and hardening of the internal kidney
structures. (trict blood glucose control may delay the progression of kidney disease in type ? and
type : diabetics.