Diabetes is a chronic ailment, characterized by an increased sugar level in the blood.

It is caused due to abnormal metabolism of the hormone insulin, which is secreted by the beta cells of the pancreas. Insulin regulates the metabolic process of sugar in the body. It induces the body cells to take up glucose from the blood, for using it as a source of energy. This function of insulin is disturbed in a diabetic patient. Hence, sugar remains in the blood, resulting in high blood glucose level (hyperglycemia) and associated symptoms. Three Types of Diabetes It is estimated that about 8.3 percent Americans have diabetes. In fact, it is identified as one of the leading causes of death, after cancer and heart disease. Diabetes is classified into three major types, depending upon the etiology, viz. type 1 diabetes, type 2 diabetes and gestational diabetes. While the health effects accompanied with high blood sugar remain the same, actual symptoms differ slightly according the type of diabetes. Hence, to get a better understanding about the same, a brief explanation about the three diabetes types is given below. Type 1 Diabetes About 10-15 percent of diabetes patients are diagnosed with this type. Type 1 diabetes is caused due to damage of beta cells of the pancreas, which results in little or no production of insulin. Previously, it was thought to affect only children and hence, it is referred to as juvenile diabetes or childhood diabetes. Since a patient of type 1 diabetes requires insulin injections daily, it is also known as insulin-dependent diabetes. Type 2 Diabetes In contrary to the type 1 diabetes, type 2 diabetes is known as insulin-independent diabetes or adult-onset diabetes. It is the most common type of diabetes, accounting to about 85-90 percent of all the cases. In this diabetes type, either the body cells do not respond properly to insulin (though hormone secretion is normal) or there is insufficient insulin. It is often associated with obesity and a less active lifestyle. Gestational Diabetes This form of diabetes is similar to type 2 diabetes, but occurs exclusively in pregnant women. Also known as carbohydrate intolerance, it is caused either due to hormonal changes or shortage of insulin during pregnancy. Usually, the sugar level becomes normal or near normal after the birth of the baby. In case, the symptoms persist then there is a high chance of developing type 2 diabetes in a later period. Early Signs and Symptoms of Diabetes A few symptoms of diabetes are manifested in the early stage (or prediabetes phase). Hence, about one-third of people who have diabetes remain unaware of the high blood sugar level. When early signs of diabetes are present, they are often confused with symptoms of other health problems. Let's look into some of the warming signs of diabetes. A common sign exhibited in the early stages of type 1 and type 2 diabetes is frequent urination (polyuria). Since the glucose in the blood increases above the normal level, filtration by kidneys is incomplete. This also hampers water absorption by the kidneys, resulting in frequent urination. Due to increase in the frequency of urination, the body losses excessive fluid. Ultimately, dehydration occurs, causingincreased thirst (polydipsia). If one is

drinking more fluid than the usual amount, and the number of urination is increased, either type 1 or type 2 diabetes is suspected. Another warning sign of type 1 and type 2 diabetes is increased appetite. One of the functions of insulin is stimulating hunger. Since, the body starts secreting more insulin to lower glucose level in the bloodstream, it is obvious to experience increased hunger (polyphagia). A patient who is in the prediabetes stage suffers from unusual weight loss, even without trying. This is caused due to excessive loss of sugar in the urine. The body starts using muscular proteins and fats as its source of energy, resulting in weight loss. This symptom is typical of type 1 diabetes. In a person with prediabetes, excess sugar is found in the blood and not in the cells. As the body cells are deprived of the main energy source - glucose, the patient feels increased fatigue at most of the time. Physical ability is lowered and the patient gets tired very easily. Vision problem is reported in patients of type 2 diabetes. Increase in the blood sugar levels leads to change in the shape of the eye lenses. Over time, this results in poor focusing power and blurred vision in patients. A type 2 diabetic patient suffers from frequent yeast and skin infections. Unchecked high sugar brings about damage to the nerves, causing neuropathy symptoms (numbness in the extremities). In addition, cuts and wounds take longer period to heal. It has been found that the immune system of a diabetic patient is low, as compared to a healthy person. This may be due to presence of elevated glucose in the blood, which in turn hampers the proper functioning of white blood cells (leucocytes). Thus, overall defense mechanism of the body gets disturbed and the person experiences frequent yeast infection, skin infection, accompanied with slow healing of bruises. As far as early signs of gestational diabetes are concerned, it seldom produces notable signs. The expecting mother rarely feels polyuria and polydipsia. In case, a person experiences any of the above mentioned warning signs, he/she should go for blood glucose test right away. Seeking advice from a health specialist for proper diagnosis is necessary. Doing so will help in delaying the onset or even control this chronic ailment. The doctor may suggest lifestyle changes and diet modification to keep the blood sugar level under control. Remember that an untreated diabetes can lead to serious health problems such as diabetic retinopathy (eye disease), diabetic neuropathy (nerve damage), kidney disease and kidney failure. Impotency in men and vaginal dryness in women afflicted with type 2 diabetes are also not uncommon. Along with changes in the lifestyle and diet, regular checking of blood sugar is a must. This helps in confirming, whether the treatment approaches are working or not.

The classical symptoms of diabetes are polyuria (frequent urination), polydipsia (increased thirst) and polyphagia (increased hunger). Symptoms may develop rapidly (weeks or months) in type 1 diabetes while in type 2 diabetes they usually develop much more slowly and may be subtle or absent. Prolonged high blood glucose causes glucose absorption, which leads to changes in the shape of the lenses of the eyes, resulting in vision changes; sustained sensible glucose control usually returns the lens to its original shape. Blurred vision is a common complaint leading to a diabetes diagnosis; type 1 should always be suspected in cases of rapid vision change, whereas with type 2 change is generally more gradual, but should still be suspected. People (usually with type 1 diabetes) may also present with diabetic ketoacidosis, a state of metabolic dysregulation characterized by the smell of acetone; a rapid, deep breathing known as Kussmaul breathing; nausea; vomiting and abdominal pain; and an altered states of consciousness. A rarer but equally severe possibility is hyperosmolar nonketotic state, which is more common in type 2 diabetes and is mainly the result of dehydration. Often, the patient has been drinking extreme amounts of sugar-containing drinks, leading to a vicious circle in regard to the water loss. A number of skin rashes can occur in diabetes that are collectively known as diabetic dermadromes. Nursing Care Plan for Diabetes Mellitus Assessment

Family Health History Are there families who suffer from illnesses such as client ? Patient Health History and Previous Treatment How long suffered from DM client, how to handle, get what kind of insulin therapy, how to take the medicine whether regular or not, what is done to cope with illness clients. Activity / Rest: Tired, weak, hard Moves / walking, muscle cramps, decreased muscle tone. Circulation Is there a history of hypertension, AMI, claudication, numbness, tingling in the extremities, ulcers on the feet long healing time, tachycardia, changes in blood pressure Ego Integrity Stress, anxiety Elimination Changes in the pattern of urination (polyuria, nocturia, anuria), diarrhea Food / Fluids Anorexia, nausea, vomiting, do not follow the diet, weight loss, thirst, the use of diuretics.

Neurosensori Dizziness, headache, numbness, muscle weakness numbness, paraesthesia, visual disturbances. Pain / Leisure Abdominal strain, pain (is / weight) Respiratory Cough with or without purulent sputum Security Dry skin, itching, skin ulcer.

Nursing Diagnosis and Nursing Intervention Fluid volume deficient related to osmotic diuresis from hyperglycemia Planning After 8 hours of nursing interventions, the patient will demonstrate adequate hydration. Intervention

Monitor orthostatic blood pressure changes. Rational : Hypovolemia may be manifested by hypotension and tachycardia. Assess peripheral pulses, capillary refill, skin turgor, and mucous membrane. Rational : Indicators of level of dehydration, adequacy of circulating volume. Monitor respiratory pattern like Kussmauls respirations and acetone breath. Rational : Lungs remove carbonic acid through respirations, producing a compensatory respiratory alkalosis for ketoacidosis. Monitor input and output. Note urine specific gravity. Rational : Provides ongoing estimate of volume replacement needs, kidney function, and effectiveness of therapy. Promote comfortable environment. Cover patient with light sheets. Rational : Avoids overheating, which could promote further fluid loss. Monitor temperature, skin color and moisture. Rational : Fever, chills, and diaphoresis are common with infectious process; fever with flushed, dry skin may reflect dehydration.

Type 2 diabetes can cause serious health complications. That's why is very important to know how to spot type 2 diabetes symptoms. Even prediabetes can increase the chance of heart disease just like type 1 or type 2 diabetes. Talk to your doctor about preventive measures you can take now to reduce the chance of type 2 diabetes and heart disease. The symptoms of type 2 diabetes due to high blood sugar may include:

Increased thirst Increased hunger (especially after eating) Dry mouth Frequent urination Unexplained weight loss (even though you are eating and feel hungry) Fatigue (weak, tired feeling) Blurred vision Headaches Loss of consciousness (rare) Contact your health care provider if you have any type 2 diabetes symptoms or if you have further questions about type 2 diabetes. It's important to get diabetes testing and start a treatment plan early to prevent serious diabetes complications. Type 2 diabetes is usually not diagnosed until health complications have occurred. Most often, there are no diabetes symptoms or a very gradual development of the above symptoms of type 2 diabetes. In fact, about a third of all people who have type 2 diabetes don't know they have it. Other symptoms of type 2 diabetes may include:

Slow-healing sores or cuts Itching of the skin (usually around the vaginal or groin area) Frequent yeast infections Recent weight gain Velvety dark skin changes of the neck, armpit, and groin, called acanthosis nigricans Numbness and tingling of the hands and feet Decreased vision Impotency

The signs and symptoms of type 1 diabetes often appear after a flu-like illness and gradually intensify over the course of a few weeks. Typical symptom may include:

Increased thirst and frequent urination. This diabetes symptom is common with type 1 diabetes, excess sugar (glucose) builds up in your bloodstream. A high level of blood glucose pulls water from your body's tissues, making you thirsty. As a result, a symptom of thirst or you drink more fluids and urinate

more. The excess sugar in your bloodstream passes through your kidneys and leaves your body in your urine. Extreme hunger. Another diabetes symptom of type 1 diabetes is extreme hunger. Because of inability to produce insulin, the hormone necessary for glucose to enter cells and fuel their functions leaves your muscles and organs energy depleted. A symptom of hunger makes you feel like eating more until your stomach is full, but the hunger persists because, without insulin, the glucose produced from dietary carbohydrates never reaches your body's energystarved tissues. Weight loss. Despite eating a lot to relieve their constant hunger, another diabetes symptom of people with type 1 diabetes is rapid lose of weight. That's because the body's cells are deprived of glucose and energy, as glucose is lost into the urine. Without the energy glucose supplies, cells die at an increased rate before they can divide and replace themselves. Muscle tissues and fat stores shrink, and body weight declines. Blurred vision. Another diabetes symptom is blurred vision. A high level of blood glucose pulls fluid from all your tissues, including the lenses of your eyes. The decrease in fluid affects your ability to focus. Fatigue. A diabetes symptom that occures when your cells are deprived of glucose, you become tired and irritable.

Type 2 diabetes has the same symptom as that of type 1 diabetes but may include these symptom

Slow-healing sores or frequent infections. This diabetes symptom affects your body's ability to heal and fight infection. Bladder and vaginal infections can be a particular problem for women. Nerve damage (neuropathy) . This diabetes symptom is due to excess sugar in your blood that can damage the small blood vessels to your nerves. Symptom may include tingling and loss of sensation in your hands and feet, as well as burning pain in your arms, hands, legs and feet Red, swollen, tender gums . This diabetes symptom is due to the infection in your gums and in the bones that hold your teeth in place. Your gums may pull away from your teeth, your teeth may become loose, or you may develop sores or pockets of pus in your gums especially if you have a gum infection before diabetes develops.

Nursing Diagnosis: Imbalanced Nutrition Less Than Body Requirements May be related to:

Insulin deficiency (decreased uptake and utilization of glucose by the tissues, resulting in increased protein/fat metabolism)

Decreased oral intake: anorexia, nausea, gastric fullness, abdominal pain; altered consciousness Hypermetabolic state: release of stress hormones (e.g., epinephrine, cortisol, and growth hormone), infectious process Possibly evidenced by:

Increased urinary output, dilute urine Reported inadequate food intake, lack of interest in food Recent weight loss; weakness, fatigue, poor muscle tone Diarrhea Increased ketones (end product of fat metabolism) Desired Outcomes: Ingest appropriate amounts of calories/nutrients. Display usual energy level. Demonstrate stabilized weight or gain toward usual/desired range with normal laboratory values. Nursing Interventions Weigh daily or as indicated. Ascertain patients dietary program and usual pattern; compare with recent intake. Auscultate bowel sounds. Note reports of abdominal pain/bloating, nausea, vomiting of undigested food. Maintain nothing by mouth (NPO) status as indicated. Rationale Assesses adequacy of nutritional intake (absorption and utilization). Identifies deficits and deviations from therapeutic needs. Hyperglycemia and fluid and electrolyte disturbances can decrease gastric motility/function (distension or ileus), affecting choice of interventions. Note: Long-term difficulties with decreased gastric emptying and poor intestinal motility suggest autonomic neuropathies affecting the GI tract and requiring symptomatic treatment. Provide liquids containing nutrients and electrolytes as soon as patient can tolerate oral fluids; progress to more solid food as tolerated. Identify food preferences, including ethnic/cultural needs. If patients food preferences can be incorporated into the meal plan, cooperation with dietary requirements may be facilitated Oral route is preferred when patient is alert and bowel function is restored.

after discharge. Include SO in meal planning as indicated. Promotes sense of involvement; provides information for SO to understand nutritional needs of patient. Note:Various methods available or dietary planning include exchange list, point system, glycemic index, or preselected menus. Observe for signs of hypoglycemia, e.g., changes in level of consciousness, cool/clammy skin, rapid pulse, hunger, irritability, anxiety, headache, lightheadedness, shakiness. Once carbohydrate metabolism resumes (blood glucose level reduced) and as insulin is being given, hypoglycemia can occur. If patient is comatose, hypoglycemia may occur without notable change in level of consciousness (LOC). This potentially life-threatening emergency should be assessed and treated quickly per protocol. Note: Type 1 diabetics of long standing may not display usual signs of hypoglycemia because normal response to low blood sugarmay be diminished. Perform fingerstick glucose testing. Bedside analysis of serum glucose is more accurate (displays current levels) than monitoring urine sugar, which is not sensitive enough to detect fluctuations in serum levels and can be affected by patients individual renal threshold or the presence of urinary retention/renal failure. Note: Some studies have found that a urine glucose of 20% may be correlated to a blood glucose of 140360 mg/dL. Administer regular insulin by intermittent or continuous IV method, e.g., IV bolus followed by a continuous drip via pump of approximately 5 10 U/hr so that glucose is reduced by 50 mg/dL/hr. Regular insulin has a rapid onset and thus quickly helps move glucose into cells. The IV route is the initial route of choice because absorption from subcutaneous tissues may be erratic. Many believe the continuous method is the optimal way to facilitate transition to

carbohydrate metabolism and reduce incidence of hypoglycemia. Administer glucose solutions, e.g., dextrose and half-normal saline. Glucose solutions may be added after insulin and fluids have brought the blood glucose to approximately 400 mg/dL. As carbohydrate metabolism approaches normal, care must be taken to avoid hypoglycemia. Provide diet of approximately 60% carbohydrates, 20% proteins, 20% fats in designated number of meals/snacks. Complex carbohydrates (e.g., corn, peas, carrots, broccoli, dried beans, oats, apples) decrease glucose levels/insulin needs, reduce serum cholesterol levels, and promote satiation. Food intake is scheduled according to specific insulin characteristics (e.g., peak effect) and individual patient response. Note:A snack at bedtime (hs) of complex carbohydrates is especially important (if insulin is given in divided doses) to prevent hypoglycemia during sleep and potential Somogyi response. < Administer other medications as indicated, e.g., metoclopramide (Reglan); tetracycline. May be useful in treating symptoms related to autonomic neuropathies affecting GI tract, thus enhancing oral intake and absorption of nutrients.

PHYSICAL DEVELOPMENT PHYSICAL CHANGES Guidepost 2: What physical changes generally occur during the middle years, and what is their psychological impact? Although some physiological changes result from aging and genetic makeup, behavior and lifestyle can affect their timing and extent. Most middle-aged adults compensate well for gradual, minor declines in sensory and psychomotor abilities, including such age-related conditions as presbyopia and presbycusis, increases in myopia, and loss of endurance due to slowing of basal metabolism. Losses in bone density and vital capacity are common.

Menopause occurs, on average, at about age 51, following the physiological changes of perimenopause. Attitudes toward menopause, and symptoms experienced, may depend on personal characteristics, past experiences, and cultural attitudes. Although men can continue to father children until late in life, many middle-aged men experience a decline in fertility and in frequency of orgasm. Sexual activity generally diminishes only slightly and gradually, and the quality of sexual relations may improve. Among women, sexual dysfunction decreases with age; in men, it is just the opposite. A large proportion of middle-aged men experience erectile dysfunction. Sexual dysfunction can have physical causes but also may be related to health, lifestyle, and emotional well-being. The "double standard of aging" causes women to seem less desirable as they lose their youthful appearance. For both men and women, anxiety about getting older is heightened in a society that places a premium on youth.

HEALTH Guidepost 3: What factors affect health at midlife? Most middle-aged people are healthy and have no functional limitations. Diet, exercise, alcohol use, and smoking affect present and future health. Preventive care is important. Hypertension is a major health problem beginning in midlife. AIDS tends to be more severe in older people because of weakened immune functioning. Leading causes of death in middle age are cancer, heart disease, liver disease, and stroke. Diabetes also is a major cause of death. Low income is associated with poorer health, in part because of lack of insurance. African Americans' elevated health risks may be due to a combination of hereditary factors, lifestyle factors, poverty, and stress caused by discrimination. Postmenopausal women become more susceptible to heart disease and bone loss leading to osteoporosis. Chances of developing breast cancer also increase with age, and routine mammography is recommended for beginning at age 40. About one in three U.S. women has a hysterectomy by age 60, usually because of uterine fibroids, abnormal uterine bleeding, or endometriosis. Many experts believe this procedure is overused. Hormone replacement therapy (HRT) is often prescribed for symptoms related to menopause, but there is mounting evidence that its risks may outweigh its benefits in long-term use. Alternative treatments are being tested. Personality and negative emotionality can affect health. Stress is related to a variety of physical and psychological problems. An accumulation of minor, everyday stressors can be more harmful than major life changes. Everyday hassles tend to decrease with age, perhaps because people learn strategies for managing stress. Causes of occupational stress include work overload, interpersonal conflict, sexual harassment, a combination of high pressure and low control, and inability to "unwind." Continual stress may lead to burnout. Unemployment creates psychological as well as financial stress. Physical and psychological effects may depend on coping resources.

COGNITIVE DEVELOPMENT MEASURING COGNITIVE ABILITIES IN MIDDLE AGE

Guidepost 4: What cognitive gains and losses occur during middle age? The Seattle Longitudinal Study found that most basic mental abilities peak during middle age. Fluid intelligence declines earlier than crystallized intelligence.

THE DISTINCTIVENESS OF ADULT COGNITION Guidepost 5: Do mature adults think differently than younger people do? Some theorists propose that cognition takes distinctive forms at midlife. Advances in expertise, or specialized knowledge have been attributed to encapsulation of fluid abilities within a person's chosen field. Expertise also depends on the social context. Postformal thought seems especially useful in situations calling for integrative thinking. The ability to solve practical problems is strong, and may peak, at midlife.

CREATIVITY Guidepost 6: What accounts for creative achievement, and how does it change with age? Creative performance depends on personal attributes and environmental forces, as well as cognitive abilities. Creativity is not strongly related to intelligence. However, according to Sternberg, the insightful, analytic, and practical aspects of intelligence play a part in creative performance. An age-related decline appears in both psychometric tests of divergent thinking and actual creative output, but peak ages for output vary by occupation. Losses in productivity with age may be offset by gains in quality.

WORK AND EDUCATION: ARE AGE-BASED ROLES OBSOLETE? Guidepost 7: How have work patterns changed, and how does work contribute to cognitive development? A shift from age-differentiated to age-integrated roles appears to be occurring in response to longer life and social change. Ginzberg's theory, based on more recent changes in work life, describes two basic career paths: stability and change. Complex work may improve cognitive flexibility. Changes in the workplace may make work more meaningful and cognitively challenging for many people.

Guidepost 8: What is the value of education for mature learners? Many adults go to college at a nontraditional age or participate in continuing education. Adults go to school chiefly to improve work-related skills and knowledge or to prepare for a change of career. Mature adults have special educational needs and strengths.

Geriatric conditions develop in middle-aged adults with diabetes.

Cigolle CT, Lee PG, Langa KM, Lee YY, Tian Z, Blaum CS.

Source
Department of Family Medicine, University of Michigan, 300 N. Ingalls, Ann Arbor, MI 48109-2007, USA. ccigolle@umich.edu

Abstract
BACKGROUND: Geriatric conditions, collections of symptoms common in older adults and not necessarily associated with a specific disease, increase in prevalence with advancing age. These conditions are important contributors to the complex health status of older adults. Diabetes mellitus is known to co-occur with geriatric conditions in older adults and has been implicated in the pathogenesis of some conditions. OBJECTIVE: To investigate the prevalence and incidence of geriatric conditions in middle-aged and olderaged adults with diabetes. DESIGN: Secondary analysis of nationally-representative, longitudinal health interview survey data (Health and Retirement Study waves 2004 and 2006). PARTICIPANTS: Respondents 51 years and older in 2004 (n=18,908). MAIN MEASURES: Diabetes mellitus. Eight geriatric conditions: cognitive impairment, falls, incontinence, low body mass index, dizziness, vision impairment, hearing impairment, pain. KEY RESULTS: Adults with diabetes, compared to those without, had increased prevalence and increased incidence of geriatric conditions across the age spectrum (p< 0.01 for each age group from 5154 years old to 75-79 years old). Differences between adults with and without diabetes were most marked in middle-age. Diabetes was associated with the two-year cumulative incidence of acquiring new geriatric conditions (odds ratio, 95% confidence interval: 1.8, 1.6-2.0). A diabetesage interaction was discovered: as age increased, the association of diabetes with new geriatric conditions decreased. CONCLUSIONS: Middle-aged, as well as older-aged, adults with diabetes are at increased risk for the development of geriatric conditions, which contribute substantially to their morbidity and functional impairment. Our findings suggest that adults with diabetes should be monitored for the development of these conditions beginning at a younger age than previously thought.

Health: Age 4565

Health during middle age is typically good to excellent. In fact, American middle adults are quite healthy, especially those who are college-educated, wealthier (with an annual income over $35,000), and white. The most common health problems experienced during middle age are arthritis, asthma, bronchitis, coronary heart disease, diabetes, genitourinary disorders, hypertension (high blood pressure), mental disorders, and strokes (cerebrovascular accidents). AIDS has also become an increasingly frequent health problem in this age group.

Stress, or the internal sense that one's resources to cope with demands will soon be depleted, is present in all age groups, although it seems to be unavoidable during middle age. Middle adults are faced with stressors, such as the challenges of raising a family, paying their mortgages, facing layoffs at the office, learning to use technology that is continually changing, or dealing with chronic health ailments. All stressful events need not be negative (distressors), however. Psychiatrists Holmes and Rahe note that positive events (eustressors), such as marriage, vacations, holidays, and winning the lottery, can be just stressful as negative ones. They also indicated that the higher a person's stress levels, including the number of good or bad stresses being experienced, the more likely that person is to develop an illness within two years. Resistance to stress, known as hardiness, varies from person to person. Hardiness is probably due to a combination of a person's cognitive appraisal, or interpretation, of the stresses, the degree to which he or she feels in control of the stresses, and his or her personality type and behavioral patterns. Some people, such as easygoing type B's, seem less bothered by stress and are thus better equipped physically to handle both negative and positive stresses than are other personality types, such as type A's, or more anxious people. Most everyone considers death during middle age as being a premature occurrence. Even so, the death rate doubles during each decade after 35, and unlike death in adolescence and young adulthood, death during middle

adulthood is more often the result of natural causes than accidents. Socioeconomic status and race also have an impact on health and death. Typically, less educated, urban, and poorer minorities have the worst health, frequently due to limited access to necessary medical care. The death rate for middle-aged black Americans is nearly twice that of their white counterparts. Perhaps the place where stress is most keenly felt during middle age is at work. Middle adults may feel that their competence is in question because of their age, or middle adults may feel pressured to compete with younger workers. Research indicates that age has less to do with predicting job success than do tests of physical and mental abilities. The most common sources of stress in the workplace include forced career changes, lack of expected progress (including promotions and raises), lack of creative input into decision making, monotonous work, lack of challenging work, inadequate pay, feelings of being underutilized, unclear procedures and job descriptions, conflicts with the boss or supervisor, lack of quality vacation time,workaholism (addiction to work), and sexual harassment. Long-term job stress can eventually result in burnout, a state of mental exhaustion characterized by feelings of helplessness and loss of control, as well as the inability to cope with or complete assigned work. Short of resigning, interventions to prevent burnout include using standard stress- reduction techniques, such as meditation or exercise, and taking longer breaks at work and longer vacations from work. Most middle adults can be categorized as either successful in a stable career chosen during young adulthood or ready for a new career. Career changes are sometimes the result of reevaluation, or a midcareer reassessment, which can certainly be stressful. Such reexamination of one's vocation can come about for many reasons, such as feeling trapped in a career or even wanting to make more money. One recent trend, however, is for middle adults to leave highpaying professions to take on more humanitarian roles, such as ministers, social workers, or counselors. The greatest source of job stress is unemployment, especially when termination comes suddenly. Besides wrestling with issues of self-esteem, unemployed workers must also deal with the financial hardship brought about by loss of income. As may be expected, unemployed persons who have

alternative financial resources and who also cognitively reframe their situations tend to cope better than those who do not.

Adult Diabetes Adult onset diabetes is the most common form manifested in 90% of all diabetes cases. Unlike childhood diabetes, adult type or Type 2 diabetes is usually triggered more by diet than anything else. Symptoms may not appear until middle age in most patients. Many people find that they have actually had the disease for a prolonged period of time before actual diagnosis. The onset occurs as the body creates insulin rejection which in turn causes patients to gain weight, sustain organ damage and develop hypertension. Most of us could develop adult diabetes and since the disease is correlated with diet and exercise, many people have control over prevention. Since prevention or treatment is directly related to diet and exercise, it is sometimes difficult for those at risk to incorporate lifestyle changes easily. Most sufferers develop adult diabetes later in life and have subsequently acquired lifetime habits of eating poorly and exercising very little. In order to control Type 2, a patient needs to change his or her lifestyle. The best medicine for adult onset diabetes is preventive care through proper care of the eyes, skin, and feet. Type 2 puts patients at risk for blindness, poor circulation and other serious conditions. Liver, kidney and heart damage can also result from the ravages of the disease. It is a serious matter to take control as soon as a person is diagnosed. Type 2 is considered a very serious health condition by many health insurance companies and patients with certain types can have a very difficult time in finding health insurance coverage after the onset. The health costs can be astronomical to insurance companies and patients alike if the disease soars out of control. Some serious developments can occur in some cases where a patient ends up having a foot amputated or experiences a heart attack or stroke. However, adult onset diabetes can be controlled and managed well if a patient is diligent to follow medical advice. Unfortunately, however, since diet and lack of exercise for many years in some patients are major reasons whyadult diabetes occurred, old habits are hard to break. The spouse and family members should extend caring support to patients and assist them in breaking these habits. A lifestyle developed over 40 or 50 years is very hard to change, but much easier if those around a patient provide loving support and encouragement regarding diet and exercise. If a patient who has Type 2 smokes or drinks, the medical community highly recommends that the patient stop these harmful habits. Tobacco and alcohol consumption is a factor in exacerbating Type 2

so it is critical that a patient stop these habits in order to control the disease. A patient must make a new lifestyle a priority to take care of him or herself in order to achieve maximum control of the disease. Healthy meal planning for anyone who has adult onset diabetes is necessary in order to stabilize the insulin malfunction in the body. There are many sources online that offer a large selection of articles and books that can assist an adult diabetes patient in developing the best strategies for food consumption and exercise. Doctors and dietitians can also offer patients with information in structuring meals that keep insulin levels, control cholesterol and keep blood pressure normalized. Meal planning needs to be done in order to plan around schedules so that anyone who has Type 2 can be prepared wherever he or she goes. Planning for main meals as well as snacks in conjunction with medications are necessary in order to keep patients stabilized. Many sources offer recipes and food alternatives for a change in life style eating patterns that are necessary. Anyone who has Type 2 can plan ahead and develop weekly menus. Preparation is the key to maintaining good control of the disease since leveling out the blood glucose level is so important. There are also online sources that can assist patients in dealing with the stress and depression associated with long term illnesses especially if there is difficulty in getting the illness under control. The psychological drain of chronic illnesses can complicate the illness even further for patients. That is why it is so important that family members rally around adult onset diabetes patients in order to encourage and support them physically, emotionally and spiritually. Patients need to pray and seek God for strength. "It is God that girdeth me with strength, and maketh my way perfect" (Psalm 18:32). Some patients are pleased to learn that in time, if they adhere to the planned health program, diabetes can sometimes disappear. This is especially possible in borderline cases that have developed from poor eating habits. When a change in lifestyle is implemented, there is a good chance that adult diabetes can be controlled and perhaps alleviated altogether.