Juvenile Diabetes

Juvenile diabetes is an autoimmune disorder which can be due to environmental trigger or virus, which hampers the function of beta cell. Once the beta cells are destroyed the body is unable to produce insulin. It is also believed that Type 1 diabetes results from an infectious or toxic insult to a child, whose immune system is predisposed to develop an aggressive autoimmune response either against molecules of the B cell or against altered pancreatic B antigens, resembling a viral protein. A child with diabetic siblings is more prone to develop juvenile diabetes than the child from a totally unaffected family. It is considered to be a more hereditary problem than excess eating or being obese. Pancreas produces the exact amount of insulin, to breakdown the sugar produced in the body. The juvenile diabetic lack the production of insulin so, sugar builds up high in the blood, overflows into the urine and passes from the body unused. It is estimated that about 10-15% in United States are suffering with juvenile diabetes. Approximately 35 American children are diagnosed with juvenile diabetes every day.

Symptoms of Juvenile Diabetes

Juvenile Diabetes Cure

Diagnosis of Juvenile Diabetes

Obesity and Diabetes

Diabetes is spreading worldwide as an epidemic. Diabetes is a disorder in which the body cells fail to take up glucose from the blood. Wasting of tissues is seen as glucose-starved cells are forced to consume their own proteins. Diabetes is the cause of blindness, kidney failure and amputation in adults. Individuals with diabetes lack the ability to use the hormone insulin.

As we start eating food, our body starts producing insulin. The insulin signal attaches to a special receptor on the cell surface, to make the cell turn-on its own glucose transporting machinery. It had been observed that type 2 diabetics have normal or even elevated levels of insulin in their body with normal insulin receptor, but due to some unknown reason the binding of insulin to the cell receptors does not starts the glucose transporting machinery, which it is supposed to do. Special proteins called IRS (insulin receptor substrate) are inside the cell. In type 2 diabetes something is interfering with the action of the IRS protein and it is also estimated that about 80% of those who develop type 2 diabetes are obese. When insulin attaches to the receptor protein, the receptor responds by adding a chemical called a phosphate group onto the IRS molecules by which the IRS molecules turn into action. Once activated, they start variety of processes, including an enzyme that turns on the glucose transporter machinery.

Overweight and obesity are both labels for series of weight, greater than what is generally considered healthy for an individual. BMI ranges for children and teens above a normal weight have different labels (at risk of overweight and overweight). Excess body weight is implicated as a risk factor for many disorders including heart disease, cancer, diabetes, female infertility, prostate enlargement, uterine fibroids, gallstone and gestational diabetes etc. The location of fat deposits in the body leads to different risks associated with it. Increased abdominal fat can be estimated by waist size.

Dozens of controlled clinical trials had been carried out to determine the fasting insulin levels and effect of weight loss on fasting blood glucose. They found:

• Weight loss produced by lifestyle modification declines blood glucose levels and HbA1c in type 2 diabetics.
• Glucose tolerance in overweight individuals will improve due to decrease in abdominal fat with impaired glucose tolerance.
• Glucose tolerance improves in overweight individuals due to increased cardio respiratory fitness with impaired glucose tolerance or diabetes.

Diabetic Weight Loss

Hypoglycemia

Glucose is an important fuel for the body to produce energy. The glucose used by the body as a fuel is released from the metabolism of carbohydrates. After meal, glucose starts producing and it is circulated to different body cells through the circulating blood. The cells require insulin to take up glucose inside the membrane and generate energy. When there is inadequate production of insulin, glucose metabolism is slowed down and less glucose is circulated in the blood. This condition is termed as Hypoglycemia. It happens to every diabetic patient from time to time and the severity differs from case to case. Although you are taking good care of diabetes, hypoglycemia may result as it is mostly an insulin reaction which in turn depends on number of factors at a time. As blood sugar begins to fall the counter regulatory hormone like glucagon, another hormone stimulates break down of glycogen and releases glucose, causing blood glucose level to rise. For diabetes, glucagon response to hypoglycemia is impaired, which makes it tough for the body to revert back the normal blood glucose level. Hypoglycemia can occur in people with diabetes who take certain medications to keep their blood glucose levels in control. Hypoglycemia is mild and it can be easily treated by drinking or eating something with carbohydrate. But left untreated, hypoglycemia can lead to loss of consciousness. Although it can happen suddenly, hypoglycemia can usually be treated quickly, bringing your blood glucose level back to normal. Hypoglycemia is a problem for every diabetic so it is important to learn its causes, signs, symptoms, diagnosis and prevention in order to cope up with it as soon as possible.

Hypoglycemia Symptoms

Causes of Hypoglycemia

Treating Hypoglycemia

Diabetic Ketoacidosis

Diabetic Ketoacidosis is a condition in which the body cells are unable to get glucose for producing energy. It is a state of absolute or relative insulin deficiency aggravated by hyperglycemia, dehydration, and acidosis-producing derangements in intermediary metabolism. Due to insufficiency of insulin, the cells cannot use glucose. To avoid starvation the body begins to break down fat, for energy. The constant break down of fat, releases fatty acids and ketone bodies causing chemical imbalance (metabolic imbalance) called Diabetic Ketoacidosis. Diabetic Ketoacidosis (DKA) and its Pathophysiology In the absence of insulin, an anabolic hormone the cells of muscle, liver and other body parts are unable to take up glucose. Counter regulatory hormones, such as glucagon, growth hormone, and catecholamine; boosts triglyceride breakdown into free fatty acids and gluconeogenesis. Beta-oxidation of these free fatty acids leads production of ketone bodies. Metabolism in DKA shifts from carbohydrate metabolism to fat breakdown. Diabetic Ketoacidosis include a metabolic acidosis as the ketone bodies, produced by beta-oxidation of free fatty acids to deplete extra cellular and cellular acid buffers. The hyperglycemia-induced osmotic diuresis depletes sodium, potassium, phosphates, and water (i.e.10% of total body fluids). Moderate or large amounts of ketones in your urine are dangerous. They upset the chemical balance of the blood. Following are the reasons for moderate or large amounts of ketones in the body: Insufficiency of insulin (inborn error) Due to improper injection Body does not produce insulin (flu or any infection) Body needs more insulin No enough food or skipping of meals When blood glucose levels fall too low

Diabetic Ketoacidosis Symptoms

Diabetic Ketoacidosis Causes

Diagnosis of Ketoacidosis

Diabetic Ketoacidosis Treatment

Prevention

Glycosuria

Clinical diagnosis of the diabetes require some of the laboratory tests, glycosuria (finding glucose in the urine) is one of the significant test for detecting frank diabetes. Those who are non diabetic, for them glycosuria can occur for the short term due to emotional stress, pain, hyperthyroidism, alimentary hyperglycemia or meningitis. It can also occur when there is insufficiency of insulin and if a substantial amount of food with high sugar is consumed.

Glycosuria is a condition in which glucose or simple sugar is detected in the urine despite of normal blood sugar level. The normally functioning kidneys absorb and reabsorb the extra blood sugar till renal threshold, with the help of millions of micro tubules – Nephron (filtering unit of kidney). The renal threshold is a concentration level above which all simple sugar is not absorbed in the blood, hence extra glucose is excreted by the kidneys in the urine. Renal threshold of normal kidney is around 10mmol/L. In few cases, when drugs are being used for a longer span of time, it may alter the threshold level of kidney. The amount of glucose not reabsorbed by the kidneys is usually less than 0.1%. Adults excrete about 65 mg of glucose per day. The relationship between glycosuria and the renal threshold are explained in the diagram given below.

In renal glycosuria glucose is abnormally eliminated in the urine due to improper action of the nephron.

The renal glycosuria occurs only when there are abnormally functioning kidneys, due some dent in the kidneys or as an autosomal recessive trait.

Glycosuria Causes

Diabetes and Insulin

The failure to make insulin or insufficiency of insulin is termed as Diabetes mellitus. Insulin is a natural hormone which controls the level of the sugar glucose in the blood. Insulin allows cells to use glucose for energy. Cells cannot utilize glucose without insulin. Excess glucose builds up in the bloodstream, increasing the risk of diabetes. Glucose is the body's primary source of fuel. Insulin enables the body cells to take glucose from the bloodstream. The cells might use glucose for production of energy if required, or it is sent to the liver to preserve it, in the form of glycogen. Functions of Insulin In addition to its role of regulating glucose metabolism, insulin also Stimulates lipogenesis Diminishes lipolysis Increases amino acid transport into cells Modulates transcription Altering the cell content of numerous mRNAs Stimulates growth DNA synthesis Cell replication

Structure of Insulin

Insulin Synthesis

Types of Insulin

Insulin Regimens

Diabetes Insulin Classification

Diabetes and Insulin Analogs

Insulin Injection Devices

Diabetes Treatment and Insulin Problems

Diabetes Diet

Diet plays a significant role in controlling the diabetes. The diabetic diet may be used alone or else in combination with insulin doses or with oral hypoglycemic drugs. Main objective of diabetic diet is to maintain ideal body weight, by providing adequate nutrition along with normal blood sugar levels in blood. The diet plan for a diabetic is based on height, weight, age, sex, physical activity and nature of diabetes. While planning diet, the dietician has to consider complications such as high blood pressure, high cholesterol levels. With respect to the above factors, a dietician will assess calories to be given, like scheming the carbohydrates, proteins, fats, type of carbohydrate, amount of fiber and so on. Exchange meal plan is a diet program which balances the amount of carbohydrate that we intake per day. Glucose is a sugar released from carbohydrate so if we want to control blood sugar we have to limit the consumption of simple carbohydrate. Carbohydrate foods are given as value per portion, known as the exchange. This plan helps us to decide on the type of food to be taken, the amount of food and also the time to eat. You can plan for more flexible meal as you get more knowledge about the diet of a diabetic, may be like the counting carbohydrate meal plan or constant carbohydrate. But there is no common diet that works for everyone. Nor is there any particular diet that works perfectly for any diabetic over a long period. While planning diabetes diet we should adhere to certain important factors, they are as follows: Fiber should be at least 40 gm / day Instead of 3 heavy meals, we should go for 4-5 small mid intervals Replace bakery products and fast foods by simple whole cooked cereals, and don't eat carbohydrates 2 hours before bedtime Consume fresh fruit and vegetables at least 5 exchange/ day Diabetics must always need to take care of thier diet and also about the food they eat. Care has to be taken because all foods contain not only carbohydrate, but also some energy value. Protein and fat available in the food are converted to glucose in the body. This glucose has some effect on the blood sugar level which has to be taken care. Furthermore there is no need that you have to eat only bland boring diet. Instead you have to eat more fruits, vegetables and whole grains. It means that to select foods that are high in nutrition and low in calories and fat.

Diabetes Care

Diabetic Diet Dos

Diabetic Diet Donts

Diabetes Complications

Once we have crossed the reversible stage of prediabetes and enter diabetes stage certain changes start developing in our body. These changes occur due to high blood sugar with instability in the hormones as well as blood vessels and nerves. When these changes become permanent in the body it develops into serious Diabetes Complications and body indicates these changes by steady symptoms. Symptoms of the Diabetes Complications Diabetic retinopathy shows symptoms of pain in your eyes and may even result in loss of vision. Renal (kidney) disease shows symptoms of swelling (edema) in the feet and legs. It then passes over total body and as the disease progresses, blood pressure also increases. Tingling, burning, numbness, tightness, shooting or stabbing pain in the hands, feet or other parts of your body, especially at night. Digestive problems also occur if, the nerves controlling internal organs gets damaged (autonomic neuropathy). You may have scanty or profuse sweating, difficulty of sensing when your bladder is full, when there is a low blood sugar, increased sexual problems, weakness, dizziness, and fainting. Chest pain (angina) or shortness of breath dizziness or light headache, shoulder or stomach pain, fast heartbeat. You might not show any symptoms until having a heart attack or stroke. When alarming symptoms given by the body are ignored and the same status is maintained, it starts damaging body organs, such as heart, kidney, eye, feet, and skin. The physiology for each and every affected organ is explained one by one.

Diabetic Retinopathy

Diabetic Neuropathy

Diabetes Skin Care

Diabetic Nephropathy

Heart Disease and Stroke

Outlook

Diabetes is a leading cause of death in all industrialized nations. Overall, the risk of premature death of people with diabetes is twice that of people who do not have diabetes. Prognosis depends on the type of diabetes, degree of blood sugar control, and development of complications.

Type 1 diabetes

About 15% of people with type 1 diabetes die before age 40 years, which is about 20 times the rate of that age group in the general population.

• The most common causes of death in type 1 diabetes are diabetic ketoacidosis, kidney failure, and heart disease.
  
  
• The good news is that prognosis can be improved with good blood sugar control. Maintaining tight blood sugar control has been proven to prevent, slow the progression of, and even improve established complications of type 1 diabetes.

Type 2 diabetes

The life expectancy of people who are diagnosed with type 2 diabetes in their 40s decreases by 5-10 years because of the disease.

• Heart disease is the leading cause of death for people with type 2 diabetes.
  
  
• Excellent glycemic control, tight blood pressure control, and keeping the bad cholesterol level at the recommended level of 100 mg/dL or lower and the good cholesterol as high as possible. Use of aspirin when indicated can prevent, slow the progression of, and improve established complications in diabetes.

Prevention

We do not yet know of a way to prevent type 1 diabetes. Type 2 diabetes, however, can be prevented in some cases.

• Control weight to normal or near-normal levels by eating a healthy low-fat, high-fiber diet.
  
  
• Regular exercise is crucial to the prevention of type 2 diabetes.
  
  
• Keep alcohol consumption low.
  
  
• Quit smoking.
  
  
• If you have high blood fat levels (such as high cholesterol) or high blood pressure, take your medication as directed.
  
  
• Lifestyle modification and/or certain medications can be used in people with prediabetes to prevent progression to diabetes. Prediabetes can be diagnosed by checking fasting glucose and 2 hours after ingesting 75 grams of glucose.

If you already have diabetes, your focus should be on preventing the complications, which can cause serious disabilities such as blindness, kidney failure requiring dialysis, amputation, or even death.

• Tight glucose control: The single best thing you can do is to keep your blood sugar level within the suggested range every day. The only way to do this is through a combination of regular blood sugar checks, a balanced diet low in simple sugars and fat and high in complex carbohydrates and fiber, and appropriate medical treatment. Please consult a nutritionist or check with your doctor about questions that you may have regarding diet.
  
  
• Quit smoking
  
  
• Maintain a healthy weight
  
  
• Increase your physical activity. Aim for moderately vigorous physical activity for at least 30 minutes every day.
  
  
• Drink an adequate amount of water and avoid taking too much salt.
  
  
• Take care of your skin. Keep it supple and hydrated to avoid sores and cracks that can become severely infected.
  
  
• Brush and floss your teeth every day. See your dentist regularly to prevent gum disease.
  
  
• Wash and examine your feet every day, looking for small cuts, sores, or blisters that may cause problems later. You should file rather than cut your toenails to avoid damaging the surrounding skin. You may need to see a specialist in foot care (podiatrist) to help you care for your feet.

Next Steps

Follow-up

Treatment: Follow your health care provider's treatment recommendations. Keep daily records of your blood sugar levels, the times you checked the levels, when and how much insulin or medication you took, when and what you ate, and when and for how long you exercised. Call your health care provider if you have any problems with your treatment or symptoms that suggest poor glucose control.

Education: Attend diabetes education classes at your local hospital. The more educated you are about your disease, the better you are likely to do.

Regular visits to your primary care provider: If you are on insulin, you should see your health care provider about every 3 months or more often. For other diabetics, every 3-6 months is generally adequate, unless you are having problems.

Recognize low blood sugar levels and know how to treat them: You and your family should be taught how to recognize the signs and symptoms of low blood sugar levels. You should have a clear plan for treating low blood sugar levels and when to call 911. Mild symptoms include confusion and sweating. These symptoms progress to lethargy, agitation (sometimes with violent, jerking motions), or even seizures.

Medications

Many different types of medications are available to help lower blood sugar levels in type 2 diabetes. Each type works in a different way. It is very common to combine 2 or more types to get the best effect with fewest side effects.

• Sulfonylureas: These drugs stimulate your pancreas to make more insulin.
  
  
• Biguanides: These agents decrease the amount of glucose produced by your liver.
  
  
• Alpha-glucosidase inhibitors: These agents slow absorption of the starches you eat. This slows down glucose production.
  
  
• Thiazolidinediones: These agents increase your sensitivity to insulin.
  
  
• Meglitinides: These agents stimulated the pancreas to make more insulin.
  
  
• D-phenylalanine derivatives: These agents stimulate your pancreas to produce more insulin more quickly.
  
  
• Amylin synthetic derivatives: Amylin is a naturally occurring hormone secreted by the pancreas along with insulin. An amylin derivative, such as pramlintide (Symlin), is indicated when blood sugar control is not achieved despite optimal insulin therapy. Pramlintide is administered as a subcutaneous injection along with insulin and helps achieve lower blood sugar levels after meals, helps reduce fluctuation of blood sugar levels throughout the day, and improves hemoglobin A1C levels.
  
  
• Incretin mimetics: Incretin mimetics promote insulin secretion by the pancreas and mimic other blood sugar level lowering actions that naturally occur in the body. Exenatide (Byetta) is the first incretin mimetic agent approved in the United States. It is indicated for diabetes mellitus type 2 in addition to metformin or a sulfonylurea when these agents have not attained blood sugar level control alone.
  
  
• Insulins: Human insulin is the only type of insulin available in the United States; it is less likely to cause allergic reactions than animal-derived varieties of insulin. The type of insulin chosen to customize treatment for an individual is based on the goal of providing optimal blood sugar control. Different types of insulin are available and categorized according to their times of action onset and duration. Commercially prepared mixtures of some insulins may also be used to provide constant (basal) control and immediate control.
  • Rapid-acting insulins
    • Regular insulin (Humulin R, Novolin R)
      
      
    • Insulin lispro (Humalog)
      
      
    • Insulin aspart (Novolog)
      
      
    • Insulin glulisine (Apidra)
      
      
    • Prompt insulin zinc (Semilente, slightly slower acting)
      
      
    • Inhaled insulin (Exubera)
      
  • Intermediate-acting insulins
    • Isophane insulin, neutral protamine Hagedorn (NPH) (Humulin N, Novolin N)
      
      
    • Insulin zinc (Lente)
      
  • Long-acting insulins
    • Extended insulin zinc insulin (Ultralente)
      
      
    • Insulin glargine (Lantus)
      
      
    • Insulin detemir (Levemir)

Medical Treatment

The treatment of diabetes is highly individualized, depending on the type of diabetes, whether you have other active medical problems, whether you have complications of diabetes, and your age and general health at time of diagnosis.

• Your health care provider will set goals for lifestyle changes, blood sugar control, and treatment.
  
  
• Together, you will devise a plan to help you meet those goals.

Education about diabetes and its treatment is essential in all types of diabetes.

• When you are first diagnosed with diabetes, your diabetes care team will spend a lot of time with you, teaching you about your condition, your treatment, and everything you need to know to care for yourself on a daily basis.
  
  
• Your diabetes care team includes your health care provider and his or her staff. It may include specialists in foot care, neurology, kidney diseases, and eye diseases. A professional dietitian and a diabetes educator also may be part of the team.

Your care team will see you at appropriate intervals to monitor your progress with your goals.

Type 1 diabetes

Treatment of diabetes almost always involves the daily injection of insulin, usually a combination of short-acting insulin such as regular or Lispro or Aspart insulin and a longer acting insulin such as NPH, lente, glargine, detemir, or ultralente insulins.

• Insulin must be given as an injection. If taken by mouth, insulin would be destroyed in the stomach before it could get into the blood where it is needed.
  
  
• Most people with type 1 diabetes give these injections to themselves. Even if someone else usually gives you your injections, it is important that you know how to do it in case the other person is not available.
  
  
• A trained professional will show you how to store and inject the insulin. Usually this is a nurse who works with the health care provider or a diabetes educator.
  
  
• Insulin is usually given in 2 or 3 injections per day, generally around mealtimes. Dosage is individual and is tailored by the health care provider. Longer acting insulins are typically administered 1 or 2 times per day.
  
  
• Some people have their insulin administered by continuous infusion pumps to provide adequate blood glucose control. Supplemental mealtime insulin is programed into the pump by the individual as recommended by his or her health care provider.
  
• It is very important to eat if you have taken insulin, as the insulin will lower your blood sugar regardless of whether you have eaten. If you take insulin without eating, you could have hypoglycemia. This is called an insulin reaction.
  
  
• There is an adjustment period while you learn how insulin affects you and how to time your mealtimes and exercise times with your insulin injections to keep your blood sugar level as even as possible.
  
  
• Keeping accurate records of your blood sugar levels and insulin dosages is crucial in helping your health care provider take care of your diabetes.
  
  
• Eating a consistent, healthy diet appropriate for your size and weight is essential in controlling your blood sugar level.

Type 2 diabetes

Depending on how elevated your blood sugar and glycosylated hemoglobin are at the time of your diagnosis, you may be given a chance to lower your blood sugar level without medication.

• The best way to do this is to lose weight if you are obese and begin an exercise program.
  
  
• This will generally be tried for 3-6 months, and then your blood sugar and glycosylated hemoglobin will be rechecked. If they remain high, you will be started on an oral medication, usually a sulfonylurea or biguanide (Metformin), to help control your blood sugar level.
  
  
• Even if you are on medication, it is still important to eat a healthy diet, lose weight if you are overweight, and engage in moderate physical activity as often as possible.
  
  
• Your health care provider will monitor your progress on medication very carefully at first. It is important to get just the right dose of the right medication to get your blood sugar level in the recommended range with the fewest side effects.
  
  
• Your doctor may decide to combine two types of medications to get your blood sugar level under control.
  
  
• Gradually, even people with type 2 diabetes may require insulin injections to control their blood sugar levels.
  
  
• It is becoming more common for people with type 2 diabetes to take a combination of oral medication and insulin injections to control blood sugar levels.

Diabetes Treatment

Self-Care at Home

If you have diabetes, you would be wise to make healthful lifestyle choices in diet, exercise, and other health habits. These will help to improve glycemic (blood sugar) control and prevent or minimize complications of diabetes.

Diet: A healthy diet is key to controlling blood sugar levels and preventing diabetes complications.

• If you are obese and have had difficulty losing weight on your own, talk to your health care provider. He or she can recommend a dietitian or a weight modification program to help you reach your goal.
  
  
• Eat a consistent, well-balanced diet that is high in fiber, low in saturated fat, and low in concentrated sweets.
  
  
• A consistent diet that includes roughly the same number of calories at about the same times of day helps your health care provider prescribe the correct dose of medication or insulin.
  
  
• It will also help to keep your blood sugar at a relatively even level and avoid excessively low or high blood sugar levels, which can be dangerous and even life threatening.

Exercise: Regular exercise, in any form, can help reduce the risk of developing diabetes. Activity can also reduce the risk of developing complications of diabetes such as heart disease, stroke, kidney failure, blindness, and leg ulcers.

• As little as 20 minutes of walking 3 times a week has a proven beneficial effect. Any exercise is beneficial; no matter how light or how long, some exercise is better than no exercise.
  
  
• If you have complications of diabetes (eye, kidney, or nerve problems), you may be limited both in type of exercise and amount of exercise you can safely do without worsening your condition. Consult with your health care provider before starting any exercise program.

Alcohol use: Moderate or eliminate your consumption of alcohol. Try to have no more than 7 alcoholic drinks in a week and never more than 2-3 in an evening. One drink is considered 1.5 ounces of liquor, 6 ounces of wine, or 12 ounces of beer. Excessive alcohol use is a known risk factor for type 2 diabetes. Alcohol consumption can cause low or high blood sugar levels, nerve pain called neuritis, and increase in triglycerides, which is a type of fat in our blood.

Smoking: If you have diabetes, and you smoke cigarettes or use any other form of tobacco, you are raising your risks markedly for nearly all of the complications of diabetes. Smoking damages blood vessels and contributes to heart disease, stroke, and poor circulation in the limbs. If you need help quitting, talk to your health care provider.

Self-monitored blood glucose: Check your blood sugar levels frequently, at least before meals and at bedtime, and record the results in a logbook.

• This log should also include your insulin or oral medication doses and times, when and what you ate, when and for how long you exercised, and any significant events of the day such as high or low blood sugar levels and how you treated the problem.
  
  
• Better equipment now available makes testing your blood sugar levels less painful and less complicated than ever. Your daily blood sugar diary is invaluable to your health care provider in seeing how you are responding to medications, diet, and exercise in the treatment of your diabetes.
  
  
• Medicare now pays for diabetic testing supplies, as do many private insurers and Medicaid.

Exams and Tests

Doctors use special tests in diagnosing diabetes and also in monitoring blood sugar level control in known diabetics.

If you are having symptoms but are not known to have diabetes, your evaluation should always begin with a thorough medical interview and physical examination. Your health care provider asks you about your symptoms, risk factors for diabetes, past medical problems, medications you are taking, allergies to medications, family history of diabetes or other medical problems such as high cholesterol or heart disease, and habits and lifestyle.

A number of lab tests are available to confirm the diagnosis of diabetes.

Fingerstick blood glucose: This is a rapid screening test that may be performed at a medical office or at a hospital emergency department.

• A fingerstick blood glucose test is not as accurate as testing your blood in the laboratory but is easy to perform, and the result is available right away.
  
  
• The test involves sticking your finger for a blood sample, which is then placed on a strip. The strip goes into a machine that reads the blood sugar level. These machines are only accurate to within about 10% of actual laboratory values.
  
  
• Fingerstick blood glucose values may be inaccurate at very high or very low levels, so this test is only a preliminary screening study. This is the way most diabetics monitor their blood sugar levels at home.

Fasting plasma glucose: You will be asked to eat or drink nothing for 8 hours before having your blood drawn (usually first thing in the morning). If the blood glucose level is greater than or equal to 126 mg/dL without eating anything, you probably have diabetes.

• If the result is abnormal, the fasting plasma glucose test may be repeated on a different day to confirm the result, or you may undergo an oral glucose tolerance test or a glycosylated hemoglobin test (often nicknamed "hemoglobin A1c") as a confirmatory test.
  
  
• If your fasting plasma glucose level is greater than 100 but less than 126 mg/dL, then you have what is called impaired fasting glucose or IFG. This is a prediabetes condition. You do not have diabetes, but you are at high risk of developing diabetes in the near future.

Oral glucose tolerance test: This test involves drawing blood for a fasting plasma glucose test and then drawing blood for a second test 2 hours after you drink a very sweet drink containing 75 grams of sugar.

• If the blood sugar level after the sugar drink is greater than or equal to 200 mg/dL, you are probably diabetic.
  
  
• If the blood glucose level is between 140 and 199, then you probably have impaired glucose tolerance, which is also a prediabetic condition.

Glycosylated hemoglobin or hemoglobin A1c: This test is a measurement of how high your blood sugar level has been over about the last 120 days—the lifespan of a red blood cell.

• Excess blood glucose hooks on to the hemoglobin in red blood cells and stays there for the life of the red blood cell, which is approximately 90 days.
  
  
• The percentage of hemoglobin that has had excess blood sugar attached to it can be measured in the blood. The test involves having a small amount of blood drawn.
  
  
• A hemoglobin A1c test is the best measurement of blood sugar control in people known to have diabetes. A hemoglobin A1c result of 7% or less is considered to indicate good glucose control. A result of 8% or greater is considered to indicate that your blood sugar level is too high too much of the time.
  
  
• The hemoglobin A1c test is also beginning to be used as a diagnostic test for diabetes. A hemoglobin A1c result greater than 6.1% is highly suggestive of diabetes. Generally, a confirmatory test would be needed before diagnosing diabetes.
  
  
• The hemoglobin A1c test is generally measured about every 3-6 months for people with known diabetes, although it may be done more frequently for people who are having difficulty achieving and maintaining good blood sugar control.
  
  
• This test is not used for people who do not have diabetes or are not at increased risk of diabetes.
  
  
• Normal values may vary from lab to lab, although an effort is under way to standardize how measurements are performed.

Diagnosing complications of diabetes

If you have diabetes, you should be checked regularly for early signs of diabetes complications. Your health care provider can do some of these checks; for others, you should be referred to a specialist.

• You should have your eyes checked at least once a year by an eye specialist (ophthalmologist) to screen for diabetic retinopathy, a leading cause of blindness.
  
  
• Your urine should be checked for protein (microalbumin) on a regular basis, at least 1-2 times per year. Protein in the urine is an early sign of diabetic nephropathy, a leading cause of kidney failure.
  
  
• Sensation in your legs should be checked regularly using a tuning fork or a monofilament device. Diabetic neuropathy is a leading cause in diabetic lower extremity ulcers, which frequently lead to amputation of the feet or legs.
  
  
• Your health care provider should check your feet and lower legs at every visit for cuts, scrapes, blisters, or other lesions that could become infected.
  
  
• You should be screened regularly for conditions that may contribute to heart disease, such as high blood pressure and high cholesterol.

When to Seek Medical Care

If you are not known to have diabetes but are having any symptoms that suggest diabetes or concern you in any way, make an appointment to see your health care provider as soon as possible. When you make the appointment, tell the operator that you are concerned about diabetes. He or she may make arrangements for blood sugar testing before your appointment.

If you are known to have diabetes, call your health care provider right away if any of the following apply:

• You are experiencing diabetes symptoms. This may mean that your blood sugar level is not being controlled despite treatment.
  
  
• Your blood sugar levels, when you test them, are consistently high (more than 200 mg/dL). Persistently high blood sugar levels are the root cause of all of the complications of diabetes.
  
  
• Your blood sugar level is often low (less than 60 mg/dL). This may mean that your management strategy is too aggressive. It also may be a sign of infection or other stress on your system such as kidney failure, liver failure, adrenal gland failure, or the concomitant use of certain medications.
  
  
• You have an injury to your foot or leg, no matter how minor. Even the tiniest cut or blister can become very serious in a person with diabetes. Early diagnosis and treatment of problems with the feet and lower extremities, along with regular diabetic foot care, are critical in preserving the function of your legs and preventing amputation.
  
  
• You have a low-grade fever (less than 101.5°F). Fever is a sign of infection. If you have diabetes, many common infections can potentially be more dangerous for you than for other people. Note any symptoms, such as painful urination, redness or swelling of the skin, abdominal pain, chest pain, or cough, that may indicate where your infection is located.
  
  
• You are nauseated or vomiting but can keep liquids down. Your health care provider may adjust your medications while you are sick and will probably recommend an urgent office visit or a visit to the emergency department. Persistent nausea and vomiting can be a sign of diabetic ketoacidosis, a potentially life-threatening condition, as well as several other serious illnesses.
  
  
• You have a small sore (ulcer) on your foot or leg. Any nonhealing sore or ulcer on the feet or legs of someone with diabetes needs to be seen by a medical professional right away. A sore less than 1 inch across, not draining pus, and not exposing deep tissue or bone can safely be evaluated in your health care provider's office as long as you do not have fever and your blood sugar levels are in control.

When you call your health care provider, tell the operator that you have diabetes and are concerned.

• You will probably be referred to a nurse who will ask questions and make a recommendation about what to do.
  
  
• Be prepared for this conversation. Have a list of your medications, medical problems, allergies to medicines, and your blood sugar diary handy by the phone.
  
  
• The nurse may need any or all of this information to decide both the urgency of your condition and how best to recommend treatment for your problem.

Diabetic emergencies

The following situations can become 911 medical emergencies and warrant an immediate visit to a hospital emergency department.

• The person with a severe diabetic complication may travel to the emergency department by car or ambulance.
  
  
• A companion should go along to speak for the person if the person is not able to speak for himself or herself with the emergency care provider.
  
  
• Bring a list of medical problems, medications, allergies to medications, and the blood sugar diary to the emergency department. This information will help the emergency care provider diagnose the problem and treat it appropriately.

The following are signs and symptoms of diabetic complications that warrant emergency care.

• Altered mental status: Lethargy, agitation, forgetfulness, or just strange behavior can be a sign of very low or very high blood sugar levels.
  
  
  • If the person is a known diabetic, try giving him or her some fruit juice (about 6 ounces) if the person is awake enough to swallow normally without choking. Avoid giving things such as hard candy that can lodge in the throat. Your health care provider can prescribe glucose wafers that melt under the tongue.
    
    
  • If the person does not wake up and behave normally within about 15 minutes, call 911.
    
    
  • If the person is not a known diabetic, these symptoms can be signs of stroke, drug intoxication, alcohol intoxication, oxygen starvation, and other serious medical conditions. Call 911 immediately.
  
  
• Nausea or vomiting: If you are known to have diabetes and cannot keep food, medications, or fluids down at all, you may have diabetic ketoacidosis, hyperosmolar hyperglycemic nonketotic syndrome, or another complication of diabetes.
  
  
  • If you have not already taken the latest insulin dose or oral diabetes medicine, do not take it without talking to a medical professional.
    
    
  • If you already have low blood sugar levels, taking additional insulin or medication will drive your blood sugar level down even further, possibly to dangerous levels.
  
  
• Fever of more than 101.5°F: If your primary health care provider cannot see you right away, you should seek emergency care for a high fever if you are diabetic. Note any other symptoms such as cough, painful urination, and abdominal pain or chest pain.
  
  
• High blood sugar level: Your blood sugar level is more than 400 mg/dL, and your primary care provider cannot see you right away. Very high blood sugar levels can be a sign of diabetic ketoacidosis or hyperosmolar hyperglycemic nonketotic syndrome, depending on the type of diabetes you have. Both of these conditions can be fatal if not treated promptly.
  
  
• Large sores or ulcers on the feet or legs: If you have diabetes, a nonhealing sore larger than 1 inch in diameter can be a sign of a potentially limb-threatening infection.
  
  
  • Other signs and symptoms that merit immediate care are exposed bone or deep tissue in the wound, large areas of surrounding redness and warmth, swelling, and severe pain in the foot or leg.
    
    
  • If left untreated, such a sore may ultimately require amputation of the limb.
  
  
• Cuts or lacerations: Any cut penetrating all the layers of skin, especially on the legs, is a potential danger to a person with diabetes. Proper wound care, although important to anyone's recovery, is especially important in diabetes to assure good wound healing.
  
  
• Chest pain: If you are diabetic, take very seriously any pain in your chest, particularly in the middle or on the left side, and seek medical attention immediately.
  
  
  • People with diabetes are more likely than nondiabetic people to have a heart attack, with or without experiencing chest pain.
    
    
  • Irregular heartbeats and unexplained shortness of breath may also be signs of heart attack.
  
  
• Severe abdominal pain: Depending on the location, this can be a sign of heart attack, abdominal aortic aneurysm (widening of the large artery in the abdomen), diabetic ketoacidosis, or interrupted blood flow to the bowels.
  
  
  • All of these are more common in people with diabetes than in the general population and are potentially life threatening.
    
    
  • Diabetics also get other common causes of severe abdominal pain such as appendicitis, perforated ulcer, inflammation and infection of the gallbladder, kidney stones, and bowel obstruction.
    
    
  • Severe pain anywhere in the body is a signal for timely medical attention.

Diabetes Symptoms

Symptoms of type 1 diabetes are often dramatic and come on very suddenly.

• Type 1 diabetes is usually recognized in childhood or early adolescence, often in association with an illness (such as a virus) or injury.
  
  
• The extra stress can cause diabetic ketoacidosis.
  
  
• Symptoms of ketoacidosis include nausea and vomiting. Dehydration and often-serious disturbances in blood levels of potassium follow.
  
  
• Without treatment, ketoacidosis can lead to coma and death.

Symptoms of type 2 diabetes are often subtle and may be attributed to aging or obesity.

• A person may have type 2 diabetes for many years without knowing it.
  
  
• People with type 2 diabetes can develop hyperglycemic hyperosmolar nonketotic syndrome.
  
  
• Type 2 diabetes can be precipitated by steroids and stress.
  
  
• If not properly treated, type 2 diabetes can lead to complications like blindness, kidney failure, heart disease, and nerve damage.

Common symptoms of both major types of diabetes

• Fatigue: In diabetes, the body is inefficient and sometimes unable to use glucose for fuel. The body switches over to metabolizing fat, partially or completely, as a fuel source. This process requires the body to use more energy. The end result is feeling fatigued or constantly tired.
  
  
• Unexplained weight loss: People with diabetes are unable to process many of the calories in the foods they eat. Thus, they may lose weight even though they eat an apparently appropriate or even excessive amount of food. Losing sugar and water in the urine and the accompanying dehydration also contributes to weight loss.
  
  
• Excessive thirst (polydipsia): A person with diabetes develops high blood sugar levels. The body tries to counteract this by sending a signal to the brain to dilute the blood, which translates into thirst. The body encourages more water consumption to dilute the high blood sugar back to normal levels and to compensate for the water lost by excessive urination.
  
  
• Excessive urination (polyuria): Another way the body tries to get rid of the extra sugar in the blood is to excrete it in the urine. This can also lead to dehydration because excreting the sugar carries a large amount of water out of the body along with it.
  
  
• Excessive eating (polyphagia): If the body is able, it will secrete more insulin in order to try to deal with the excessive blood sugar levels. Also the body is resistant to the action of insulin in type 2 diabetes. One of the functions of insulin is to stimulate hunger. Therefore, higher insulin levels lead to increased hunger and eating. Despite increased caloric intake, the person may gain very little weight and may even lose weight.
  
  
• Poor wound healing: High blood sugar levels prevent white blood cells, which are important in defending the body against bacteria and also in cleaning up dead tissue and cells, from functioning normally. When these cells do not function properly, wounds take much longer to heal and become infected more frequently. Also, long-standing diabetes is associated with thickening of blood vessels, which prevents good circulation and our body tissues from getting enough oxygen and other nutrients.
  
  
• Infections: Certain infection syndromes, such as frequent yeast infections of the genitals, skin infections, and frequent urinary tract infections, may result from suppression of the immune system by diabetes and by the presence of glucose in the tissues, which allows bacteria to grow well. They can also be an indicator of poor blood sugar control in a person known to have diabetes.
  
  
• Altered mental status: Agitation, unexplained irritability, inattention, extreme lethargy, or confusion can all be signs of very high blood sugar, ketoacidosis, or hyperosmolar hyperglycemia nonketotic syndrome or hypoglycemia (low sugar). Thus, any of these merit the immediate attention of a medical professional. Call your health care provider or 911.
  
  
• Blurry vision: Blurry vision is not specific for diabetes but is frequently present with high blood sugar levels.

Diabetes Causes

Type 1 diabetes is believed to be an autoimmune disease. The body's immune system attacks the cells in the pancreas that produce insulin.

• A predisposition to develop type 1 diabetes may run in families but much less so than for type 2.
  
  
• Environmental factors, such as certain types of viral infections, may also contribute.
  
  
• Type 1 diabetes is most common in people of non-Hispanic white persons of Northern European descent, followed by African Americans and Hispanic Americans. It is relatively rare in those of Asian descent.
  
  
• Type 1 diabetes is slightly more common in men than in women.

Type 2 diabetes: Type 2 diabetes is believed to have a strong genetic link, meaning that it tends to run in families. Several genes are being studied that may be related to the cause of type 2 diabetes. Risk factors for developing type 2 diabetes include the following:

• High blood pressure
  
  
• High blood triglyceride (fat) levels
  
  
• Gestational diabetes or giving birth to a baby weighing more than 9 pounds
  
  
• High-fat diet
  
  
• High alcohol intake
  
  
• Sedentary lifestyle
  
  
• Obesity or being overweight
  
  
• Ethnicity: Certain groups, such as African Americans, Native Americans, Hispanic Americans, and Japanese Americans, have a greater risk of developing type 2 diabetes than non-Hispanic whites.
  
  
• Aging: Increasing age is a significant risk factor for type 2 diabetes. Risk begins to rise significantly at about age 45 years, and rises considerably after age 65 years.

What factors increase my risk for type 2 diabetes?

To find out your risk, check each item that applies to you.

• I am 45 or older.
  
  
• I am overweight or obese (see the body mass index [BMI] in table 4).
  
  
• I have a parent, brother, or sister with diabetes.
  
  
• My family background is African American, American Indian, Asian American, Pacific Islander, or Hispanic American/Latino.
  
  
• I have had gestational diabetes, or I gave birth to at least one baby weighing more than 9 pounds.
  
  
• My blood pressure is 140/90 or higher, or I have been told that I have high blood pressure.
  
  
• My cholesterol levels are not normal. My HDL cholesterol ("good" cholesterol) is 35 or lower, or my triglyceride level is 250 or higher.
  
  
• I am fairly inactive. I exercise fewer than three times a week.

Checking My Weight

BMI is a measure used to evaluate body weight relative to height. You can use BMI to find out whether you are underweight, normal weight, overweight, or obese. Use table 4 to find your BMI.

• Find your height in the left-hand column.
• Move across in the same row to the number closest to your weight.

The number at the top of that column is your BMI. Check the word above your BMI to see whether you are normal weight, overweight, or obese. If you are overweight or obese, talk with your doctor about ways to lose weight to reduce your risk of diabetes or pre-diabetes.

How are diabetes and pre-diabetes diagnosed?

The following tests are used for diagnosis:

• A fasting plasma glucose test measures your blood glucose after you have gone at least 8 hours without eating. This test is used to detect diabetes or pre-diabetes.
  
  
• An oral glucose tolerance test measures your blood glucose after you have gone at least 8 hours without eating and 2 hours after you drink a glucose-containing beverage. This test can be used to diagnose diabetes or pre-diabetes.
  
  
• In a random plasma glucose test, your doctor checks your blood glucose without regard to when you ate your last meal. This test, along with an assessment of symptoms, is used to diagnose diabetes but not pre-diabetes.

Positive test results should be confirmed by repeating the fasting plasma glucose test or the oral glucose tolerance test on a different day.

Fasting Plasma Glucose (FPG) Test

The FPG is the preferred test for diagnosing diabetes due to convenience and is most reliable when done in the morning. Results and their meaning are shown in table 1. If your fasting glucose level is 100 to 125 mg/dL, you have a form of pre-diabetes called impaired fasting glucose (IFG), meaning that you are more likely to develop type 2 diabetes but do not have it yet. A level of 126 mg/dL or above, confirmed by repeating the test on another day, means that you have diabetes.

Table 1. Fasting Plasma Glucose Test

Plasma Glucose Result (mg/dL)	Diagnosis
99 and below	Normal
100 to 125	Pre-diabetes (impaired fasting glucose)
126 and above	Diabetes*

Oral Glucose Tolerance Test (OGTT)

Research has shown that the OGTT is more sensitive than the FPG test for diagnosing pre-diabetes, but it is less convenient to administer. The OGTT requires you to fast for at least 8 hours before the test. Your plasma glucose is measured immediately before and 2 hours after you drink a liquid containing 75 grams of glucose dissolved in water. Results and what they mean are shown in table 2. If your blood glucose level is between 140 and 199 mg/dL 2 hours after drinking the liquid, you have a form of pre-diabetes called impaired glucose tolerance or IGT, meaning that you are more likely to develop type 2 diabetes but do not have it yet. A 2-hour glucose level of 200 mg/dL or above, confirmed by repeating the test on another day, means that you have diabetes.

Table 2. Oral Glucose Tolerance Test

2-Hour Plasma Glucose Result (mg/dL)	Diagnosis
139 and below	Normal
140 to 199	Pre-diabetes (impaired glucose tolerance)
200 and above	Diabetes*

Table 3. Gestational Diabetes: Above-Normal
Results for the Oral Glucose Tolerance Test

When	Plasma Glucose Result (mg/dL)
Fasting	95 or higher
At 1 hour	180 or higher
At 2 hours	155 or higher
At 3 hours	140 or higher

Random Plasma Glucose Test

A random blood glucose level of 200 mg/dL or more, plus presence of the following symptoms, can mean that you have diabetes:

• increased urination
• increased thirst
• unexplained weight loss

Other symptoms include fatigue, blurred vision, increased hunger, and sores that do not heal. Your doctor will check your blood glucose level on another day using the FPG or the OGTT to confirm the diagnosis.

What is pre-diabetes?

In pre-diabetes, blood glucose levels are higher than normal but not high enough to be characterized as diabetes. However, many people with pre-diabetes develop type 2 diabetes within 10 years. Pre-diabetes also increases the risk of heart disease and stroke. With modest weight loss and moderate physical activity, people with pre-diabetes can delay or prevent type 2 diabetes.

Types of Diabetes

The three main types of diabetes are type 1, type 2, and gestational diabetes.

• Type 1 diabetes, formerly called juvenile diabetes, is usually first diagnosed in children, teenagers, or young adults. In this form of diabetes, the beta cells of the pancreas no longer make insulin because the body's immune system has attacked and destroyed them.
  
  
• Type 2 diabetes, formerly called adult-onset diabetes, is the most common form. People can develop it at any age, even during childhood. This form of diabetes usually begins with insulin resistance, a condition in which muscle, liver, and fat cells do not use insulin properly. At first, the pancreas keeps up with the added demand by producing more insulin. In time, however, it loses the ability to secrete enough insulin in response to meals.
  
  
• Gestational diabetes develops in some women during the late stages of pregnancy. Although this form of diabetes usually goes away after the baby is born, a woman who has had it is more likely to develop type 2 diabetes later in life. Gestational diabetes is caused by the hormones of pregnancy or by a shortage of insulin.
  

What if I already have diabetes?

If you already have diabetes, you can lessen your chance of developing kidney disease by keeping your blood sugar under control. Some ways to do this are to:

• Check your blood sugar often.
• Ask your doctor about a blood test called “hemoglobin A1C.” This tests how your normal blood sugars have been over the past 2 or 3 months. It is a kind of “report card” for your blood sugar.
• Follow your doctor’s advice about insulin injections, medicines, diet and exercise.

You can also reduce your risk for kidney failure if you:

• Monitor your blood pressure. If your blood pressure is high, talk to your doctor about taking an ACE inhibitor.
• Have your doctor check your urine for protein.
• Ask your doctor to calculate your eGFR (estimated glomerular filtration rate). This number is based on the creatinine level in your blood, as well as your age, sex and race.

What can I do to prevent diabetes?

Healthy eating and exercise habits are the best way to prevent diabetes. These are also great ways to help keep diabetes in control if you already have it.

To eat healthy, pick foods that are nutrient-rich. This means that they have many vitamins, but not much fat or sugar. When it comes to foods that are high in sugar, like ice cream or cookies, make sure that you are not overeating. You can still eat these foods, but eat them in moderation.

Exercising three or four times a week is another way to lower your risk of developing diabetes. For example, you might go for walks, run, bike, swim, join a local sports team or try a dance class. The key here is to start small and find something that you enjoy.

How will I know if I have diabetes?

Diabetes often has no symptoms or warning signs. The only way to be sure is to have your blood tested for glucose (blood sugar). If symptoms do appear, they might include:

• Feeling tired
• Feeling irritable
• Urinating more than normal
• Being very thirsty
• Being very hungry
• Unexplained weight loss
• Blurred vision

If you are experiencing some of these symptoms or think that you might be at risk for diabetes, be sure to talk to your doctor about getting tested.

Who is at risk?

Anyone can develop diabetes, but some people are more at risk than others. You are at greater risk for diabetes if you:

• Are over 45 years old.
• Are overweight.
• Are African American, Hispanic/Latino, Asian, Pacific Islander or American Indian.
• Have a family history of diabetes.
• Have high cholesterol.
• Have had gestational diabetes during pregnancy.
• Have given birth to a baby that weighed more than 9 lbs.
• Exercise less than 3 times a week.

While you cannot change some of these factors, you can change others. For example, you cannot change your age, but you can exercise more often. These kinds of changes will help reduce your risk of developing diabetes.

What is diabetes

Diabetes happens when the body cannot make or use insulin correctly. Insulin is a hormone that turns the sugars in the foods we eat into energy. When a person has diabetes, too much sugar stays in the blood. This can damage different parts of the body, including the heart, blood vessels, eyes, nerves and kidneys. There are a few different types of diabetes:

Type 1: The body cannot make insulin. It is also called “juvenile diabetes”.
Type 2: The body cannot use the insulin that it makes, or the insulin that it makes does not work correctly.
Gestational: Diabetes during pregnancy.

The good news is that diabetes can often be prevented by healthy habits like a good diet and exercise. If someone already has diabetes, he or she can learn to control it and reduce the risk of complications.