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Sympton&diagnosis in diabet
Diabetes Symptoms       

The four "classic" symptoms of diabetes are:

 

  • Increased thirst
  • Increased urination
  • Feeling very hungry
  • Weight loss in spite of increased eating
Here is why these symptoms happen.
Every cell in the body needs energy in order to live. People get their energy by converting the food they eat into fats and sugar (glucose). This glucose travels in the bloodstream as a component of normal blood. Individual cells then remove some of that glucose from the blood to use for energy. The substance that allows the cells to take glucose from the blood is a protein called 'insulin'.
Insulin is created by beta cells that are located in the pancreas. The pancreas is an organ located next to the stomach.
  • When glucose in the blood increases, the beta cells release insulin into the bloodstream, which distributes it to the cells in the body.
  • The insulin attaches itself to proteins on the cell surface, and allows glucose to move from the blood into the cell, where it is converted into energy.
A person with type 2 or gestational diabetes either cannot produce enough insulin, or they are "insulin insensitive", which means that their body can't use insulin properly. A person with type 1 diabetes produces little or no insulin.
Without enough insulin, the cells in the body do not have a way to use the glucose that is in the bloodstream, so the cells 'starve' while the glucose level in the blood rises.
In response to a lack of energy in the cells, the brain sends out signals that tell the person to eat more. Meanwhile, other cells in the body try to obtain energy by asking the body to break down fat and muscle protein. The liver can convert the muscle protein into glucose. A vicious cycle happens: more glucose is being created, but it cannot be turned into energy because there is not enough insulin to transfer the glucose into the cells of the body.
When too much glucose is in the blood, it 'leaks' into the urine. The urine of healthy people does not contain sugar. In diabetes, sugar in the urine draws water to it just like a dry sponge draws water. The person produces large amounts of urine because of all this water. All of that urination makes the person thirsty, so they drink excessively.
These responses to a lack of insulin lead people with diabetes to show the four classic symptoms of diabetes: they lose weight in spite of an increased appetite, drink excessively, and urinate excessively.
Diabetes Diagnosis
Your doctor will perform tests to confirm if you have diabetes. These 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 are confirmed by your doctor, by repeating the fasting plasma glucose test or the oral glucose tolerance test on a different day.

Fasting Plasma Glucose (FPG) Test
Because of ease of use, acceptability to patients and lower cost, the FPG is the preferred diagnostic test.  Fasting is defined as no caloric intake for at least 8 hours.
  • 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 somewhat 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.

Oral Glucose Tolerance Test (OGTT)
The OGTT requires you to fast for at least eight hours before the test. Your plasma glucose is measured immediately before, at intermediate times, and two hours after you drink a liquid containing 75 grams of glucose dissolved in water.
  • If your blood glucose level is between 140 and 199 mg/dL two 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 two-hour glucose level of 200 mg/dL or above, confirmed by repeating the test on another day, means that you have diabetes.

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.
Complications of Diabetes
When you were first diagnosed, you probably wondered how diabetes could cause problems in so many parts of the body. The reason is that diabetes damages nerves and blood vessels, and these are found everywhere in the body.
Diabetes complications fall into three general categories:
1. Nerve Damage (Neuropathy, pronounced Noo-RAW-pah-thee).
Diabetic neuropathies are a family of nerve disorders that lead to numbness and sometimes pain and weakness in the hands, arms, feet and legs. Neuropathy can also cause problems in your digestive system, heart, and sex organs.
Around 50% of people with diabetes have some degree of nerve damage, but not everyone experiences physical symptoms. Neuropathies are more common in people who have had diabetes for at least 25 years, who are overweight, have poor blood glucose control, and have high blood pressure. The most common type is peripheral neuropathy, which affects the arms and legs. This type of nerve damage causes numbness in the feet. This increases the chance of foot injuries, which, if left untreated, can lead to amputation.
2. Damage to large blood vessels (called Macrovascular disease)
High blood glucose causes hardening of the arteries (atherosclerosis), which can lead to a heart attack, stroke or poor circulation in the feet.
Heart disease is the leading cause of diabetes-related death. Adults with diabetes have heart disease death rates about 2 to 4 times higher than adults without diabetes. The risk of stroke is also 2 to 4 times greater for people with diabetes.
3. Damage to small blood vessels such as capillaries (called Microvascular disease)
High blood glucose also thickens capillary walls, makes blood stickier and can cause small blood vessels to 'leak'. Together, these effects reduce blood circulation to the skin, arms, legs, and feet. They can also change the circulation to the eyes and kidneys. Reduced capillary blood flow may cause some brown patches on the legs.
With good blood glucose control, many of these complications can be lessened. Your first priority should be to achieve HbA1c levels of 7% or less. Research has shown that for every 1% that you reduce your HbA1c level, the risk of heart attack drops by 14%, the risk of microvascular disease falls by 37% and the risk of peripheral vascular disease drops by 43%. Each additional 1% drop in your HbA1c score reduces the risk of complications even more.
If you already have a diabetes complication, take heart. Treatments are available for many diabetes-related problems. Ask your doctor if there are treatments that might be right for you.
Diabetes Requires Total Body Care
Doctors now believe that diabetes is not just a blood glucose problem. It is a complicated metabolic disorder that is closely associated with heart disease. Studies show that most people with diabetes also have high blood pressure and/or high cholesterol.
Research is underway to help us better understand causes and effects. For now, we know that if you have high cholesterol and high blood pressure, they will need to be treated as seriously as your high blood glucose. That means your doctor may ask you to take some other medications along with your diabetes pills.
That's why the American Diabetes Association's 2007 Standards for Diabetes Care look at the whole body. The chart below highlights the ADA's recommendations to healthcare professionals who treat people with diabetes.
Factor
Goals for adults with diabetes mellitus
Comments
 
Blood glucose control
Goals for non-pregnant patients:

Pre-meal plasma glucose: 90-130 mg/dL

Peak post-meal plasma glucose: less than 180 mg/dL

A1c Level less than 7%
People with type 1 diabetes and pregnant women taking insulin should test their blood glucose three times or more per day.




Test A1c twice a year in patients who are meeting treatment goals, and every 3 months in patients whose therapy has changed or who are not meeting their blood glucose goals.
 
Blood pressure
Systolic blood pressure less than 130

Diastolic blood pressure less than 80
Check blood pressure at every routine visit.

Orthostatic measurement of blood pressure should be performed to check for the presence of autonomic neuropathy.
 
Lipids
LDL cholesterol less than 100 mg/dL

Triglycerides: less than 150 mg/dL

HDL cholesterol more than 40 mg/dL for men, and more than 50 mg/dL for women
Adults: test for lipid disorders at least once a year, more often if necessary to meet goals.

Children less than 2 years old: Perform a lipid profile after diagnosis. Check every 5 years.
 
Coronary heart disease (CHD)
Goal: reduce hardening of the arteries that can lead to heart attack or stroke.
Assess the person's cardiovascular risk factors and perform an exercise test at least annually.

Refer people with symptoms to a cardiologist.
 
Aspirin therapy
75-162 mg/day
Use aspirin therapy in all adult patients with diabetes and cardiovascular disease.

Consider aspirin therapy for patients over 40 years who have diabetes and one or more cardiovascular risk factors.
No aspirin therapy to people who:
  • Are younger than 21 years due to Reye's syndrome.
  • Are allergic to aspirin
  • Have bleeding tendency or recent gastrointestinal bleeding
  • Receive anticoagulant therapy
  • Have clinically active hepatic disease
 
Kidney care
Albumin secretion: Less than 30 µg/mg, spot collection
Perform annual test for presence of microalbumininuria in all people with type 1 diabetes more than 5 years, and in all type 2 diabetes patients starting at diagnosis.
 
Foot care
Goal: prevent ulcers and other injuries that can lead to amputation.
Perform an annual comprehensive foot exam.

Perform a visual inspection at every routine visit.
 
Eye care
Goal: prevent or minimize diabetic retinopathy, which can lead to blindness.
Type 1: schedule an initial dilated and comprehensive eye exam by an ophthalmologist or optometrist 3-5 years after diagnosis, then once a year.

Type 2: schedule comprehensive eye exam right after diagnosis, then once a year.
 
Neuropathy
Goal is to prevent or minimize nerve damage that can lead to loss of feeling in the feet, digestive disorders, bladder dysfunction or heart function.

Aim for stable blood glucose control and avoid extreme blood glucose fluctuations.
All patients should be screened for distal symmetric polyneuropathy (DPN) at diagnosis and at least annually thereafter, using simple clinical tests.
Screen for autonomic neuropathy at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes.
Lifestyle
Goal is to reduce other risk factors such as diet, weight, smoking and alcohol use.
These can worsen the complications of diabetes.
People with diabetes should receive nutrition education, a regular exercise program, annual flu shots, and at least one lifetime pneumonia vaccine.
People who smoke are advised to quit.
 
Vision Complications
Early detection of eye problems will allow for more effective treatment and could halt the progression of further damage to your vision. Diabetes can lead to serious eye problems including blurred vision, diabetic retinopathy, cataracts, and glaucoma. Keeping your blood sugar within your target range is one of the best ways to prevent eye complications. And it's a good idea to be proactive in preserving your eyesight by visiting your eye doctor yearly for a full exam.
Retinopathy
Retinopathy is a serious eye disease associated with diabetes. Treatments are available, and the most successful are usually applied during the early phases of the condition. You should see your ophthalmologist every year to be checked for the two types of retinopathy: non-proliferative and proliferative.
Non-proliferative retinopathy is a mild form of retinopathy which may slightly decrease vision. Abnormalities are limited to the retina and usually will only seriously interfere with vision if they involve the macula (the area of the retina that gives us the sharpest vision). The earlier this type of retinopathy is discovered, the more successful the treatment. If left untreated, it can progress to proliferative retinopathy.
Proliferative retinopathy is a more serious condition in which new blood vessels branch out in and around the retina. These new blood vessels are very thin and fragile; they easily break and cause bleeding in the fluid-filled center of the eye. Serious diabetic eye disease may also lead to swelling of the retina. Either one may lead to blindness.
Early Cataracts
People with diabetes are at risk for developing cataracts at an earlier age than people without diabetes. A cataract is a cloud over your eye's lens, usually caused by a thickening of the tissue in the lens. As a result, light cannot be focused properly on your retina and vision becomes cloudy. This condition may be corrected by a surgery in which the lens is removed and a plastic lens is inserted in its place.
Glaucoma
People with diabetes are at risk for developing glaucoma at an earlier age than people without diabetes. Glaucoma is a condition caused by the buildup of pressure in the eye that can, over time, damage the optic nerve. The first symptom of glaucoma may be loss of vision from the sides of the eyes. Glaucoma can be treated by an eye doctor with special daily eye drops that lower the pressure in the eyes. Laser surgery is another alternative to reducing eye pressure. It is essential that you have your eye pressure measured by an ophthalmologist or other doctor every year.
Be sure to schedule yearly eye exams, which should be performed by an opthamologist who has been trained to look at the back of the eye. During your exam, ask the doctor to check for signs of diabetic retinopathy, cataracts, and glaucoma.
Smart Tips: Proper Eye Care
In between your annual visits, you should call your doctor if you experience any of the following signs of eye disease: 
  • Blurry vision 
  • Double vision 
  • Difficulty reading 
  • Pain or pressure in one or both eyes 
  • Rings, flashing light, or blank spots 
  • Spots or "floaters" appearing in your field of vision 
  • Decreased peripheral vision 
  • Bleeding in your eye 

If you have diabetes and you become pregnant, consult with your eye doctor within the first three months to check for retinopathy. Tight diabetes control during pregnancy can affect existing retinopathy.

And finally, if you smoke, here is another reason to quit. Smoking narrows the small blood vessels in your eyes and will affect circulation.
Eye Disease Simulations
 
Normal Vision
Scene as it might be viewed by a person with normal vision
National Eye Institute,
National Institutes of Health
 
 
Severe Diabetic Retinopathy
Scene as it might be viewed by a person with severe diabetic retinopathy
National Eye Institute,
National Institutes of Health
 
 
Cataracts
Scene as it might be viewed by a person with cataracts
National Eye Institute,
National Institutes of Health
 
 
Glaucoma
Scene as it might be viewed by a person with glaucoma
National Eye Institute,
National Institutes of Health
 
Heart Disease and Stroke
Heart disease and stroke are the leading causes of early death in people with diabetes. At least 65% of people with diabetes die from one of these two conditions. Heart attacks and stroke result from the same blood circulation problems. You can lower your risk by controlling your blood glucose, lowering your blood pressure and cholesterol, and not smoking.
How Diabetes Affects Blood Circulation
High blood glucose leads to poor circulation, blood clots and high blood pressure, which are at the root of heart disease and stroke.
1. Reduced blood flow; high blood pressure
People with diabetes tend to have high levels of LDL (bad) cholesterol, low levels of HDL (good) cholesterol, and high triglyceride levels. These can lead to atherosclerosis, sometimes called "hardening of the arteries". This condition happens when fatty deposits, cholesterol and other substances build up on artery walls.
This buildup, called plaque, reduces the flow of blood to the heart, brain and kidneys, and increases blood pressure. High blood glucose causes artery walls to stiffen, which also increases blood pressure.
2. Blood Clots More Easily
High blood glucose makes the blood "sticky" so it coagulates more easily. It can also cause small blood vessels to 'leak'. Together, these factors can cause blood clots to occur.
Sometimes plaque in an artery breaks off and causes blood clots to form. These clots can block the blood flow right where they are. When this happens in a blood vessel that feeds the heart, the result is a heart attack. When a clot blocks a blood vessel that feeds the brain, the result is a stroke.
Traveling clots called emboli can also cause blockages in other parts of the body, such as the legs.
SMART TIPS: MAINTAINING GOOD CIRCULATION
People with diabetes have such a high risk of heart disease and stroke that the American Diabetes Association and the American College of Cardiology have joined forces. They are running a campaign called the ABC's of Diabetes. The ABC's reflect the fact that blood pressure and cholesterol are as important as blood glucose in keeping your circulation system healthy:
A stands for A1c test, a measure of blood glucose levels
B stands for blood pressure
C stands for cholesterol, especially the bad LDL cholesterol
To prevent the cardiovascular complications of diabetes,  
  • Keep your blood glucose at the target set by your doctor. The American Diabetes Association recommends an A1c level less than 7% for most people. The American Association of Clinical Endocrinologists and the European Association for the Study of Diabetes prefer to set the A1c goal at 6.5%. Ask your doctor what A1c target is right for you.
  • Keep your blood pressure at 130/80 or less. Some people can achieve this through diet and exercise alone. Other people may require medication. Your doctor will advise you what steps you should take.
  • Keep your LDL (bad) cholesterol at 100 mg/dL or less. A value above 130 usually needs to be treated with medication.
  • If you smoke, quit.
 
Kidney Complications
The kidneys filter waste products from the blood. The filtering is done by small structures (called "glomeruli") that are similar to blood vessels. In healthy kidneys, the glomeruli filter waste products from the blood but keep protein inside the body, where it can be used to keep you healthy. Filtered blood leaves the kidney and goes back into the bloodstream.
High blood glucose and high blood pressure can damage the glomeruli. If damaged, they are not able to do their filtering job as well, so protein leaks out of the kidneys into the urine. If left untreated, large amounts of protein are lost in the urine. Eventually the kidneys are so damaged that they stop working altogether.
Kidney failure from diabetes happens so slowly that you may not feel sick for many years. About 30% of people with Type 1 diabetes, and 10-40% of those with Type 2 diabetes will develop this kidney disease, which is called diabetic nephropathy.
Symptoms of Kidney Disease
The earliest clinical sign of kidney disease is when the kidneys leak small amounts of a protein called albumin into the urine. Some people experience weight gain and swollen ankles, and more frequent urination at night.
As the kidney damage gets worse, more protein is leaked into the urine. This is called proteinuria. More and more wastes build up in the blood, too. The person may feel nauseous, weak and tired from anemia. They may lose their appetite or suffer leg cramps.

Prevention and Treatment
You can avoid kidney disease or slow down its progress by keeping your blood glucose at normal levels and treating high blood pressure. Your doctor may check for early signs of kidney disease with a test for excess protein in the urine, called microalbuminurea.

If you have high blood pressure, your doctor or a kidney specialist called a nephrologist may prescribe ACE inhibitors or similar medications to control your blood pressure and prevent future kidney damage. If you have a small amount of protein in the urine you may also be put on a low-protein diet.

If your kidneys fail, the nephrologist will choose from three possible treatments:
  • Hemodialysis. In this process, your blood flows through a tube from your arm to a machine that filters out the waste products and extra fluid. The clean blood flows back into your arm. Hemodialysis is usually done in an outpatient center. It can sometimes be done at home.
  • Peritoneal dialysis. In this approach, your abdomen is filled with a special fluid. The fluid collects waste products and extra water from your blood. Then the fluid is drained and discarded. This type of dialysis can be done at home.
  • Kidney transplant. In this major surgery, one of your failed kidneys is replaced with a healthy kidney from a close family member, friend, or someone you do not know. The new kidney must be a good match for your body.
  
SMART TIPS FOR KIDNEY CARE 
  • Keep your blood glucose in the target zone.
  • Keep your blood pressure under control.
  • Follow a healthy eating plan.
  • Ask your doctor to do a microalbuminurea test to check kidney function at least once a year.
  • If you have kidney damage, discuss all over-the-counter and prescription medications with your doctor before taking them. Check the labels of all medications (especially pain relievers) and ask your doctor if the label indicates that they might cause kidney damage.
  • See your doctor right away if you think you may have a bladder or kidney infection. Urinary tract infections are more common in people with diabetes. Symptoms include: 

    • Pain or burning when urinating
    • Cloudy or reddish urine 
    • A need to urinate often
    • Fever or shakiness
    • Back pain or pain on your side below your ribs
Foot Complications
There are two effects of diabetes that can be damaging to your feet.
  • Blood flow to the legs and feet is reduced.
  • The neuropathy (nerve damage) that results from high blood glucose levels may reduce the sense of feeling in the legs and feet.
Do you have high risk feet?
Your healthcare team will determine if your feet are at low risk or high risk of developing serious problems in the future.

A high risk foot has one or more of the following conditions:
  • Loss of protective sensation so you cannot feel a foot injury
  • Poor blood circulation (doctors call it absent pedal pulses)
  • Foot deformity
  • History of foot ulcer
  • Prior amputation
You can help to prevent ulcers and other foot problems by controlling other risk factors, such as smoking, drinking alcohol, high cholesterol, and high blood glucose.

Be sure to take special care of your feet and examine them often. Check visually for cuts and sores every day, because you may not feel them. Good foot care will help you to avoid serious infections, as well as reduce the risk of diabetes-related amputation by 50 percent.
Signs that might help you to recognize potential problems include:
  • Hammer toes, especially with redness at the top
  • High arch
  • Calluses

Smart Tips: Keeping Feet in Top Condition
  • Check your feet and toes daily. Look for any cuts, corns, blisters, bruises, bumps, or infections. You can use a mirror or ask someone else to examine them for you.
  • If you have an injury or sore and notice that it is not healing well, contact your doctor immediately.
  • Wear shoes that fit you well. New shoes should be worn for only one hour at a time to break them in and avoid sores and blisters.
  • Do not cross your legs while sitting - it reduces circulation.
  • Wash your feet daily and dry them thoroughly, especially between the toes. Use warm water (not hot) and mild soap. Do not soak your feet.
  • Never go barefoot, especially on the beach, hot sand, or rocks.
  • Moisturize your feet (except for the skin in between your toes).
  • See a specialist who can provide you with corrective shoes or inserts.
  • Cut your toenails straight across and smooth them. If you have difficulty cutting your toenails, you should see a podiatrist who can do it for you.
  • Use a pumice stone to slough away dead skin.
  • Avoid harsh chemicals such as wart or corn removers.
Visual Foot Inspection
Careful inspection of the diabetic foot on a regular basis is one of the easiest and most effective ways to prevent foot complications.

All people with diabetes should have an annual foot inspection performed by a doctor, nurse, or other trained healthcare professional.

The purpose of the inspection is to identify early warnings signs of nerve damage or minor injuries that could lead to ulcers down the road. If any problems are found, the patient is referred to a podiatrist who will perform a detailed foot exam.
Elements of the Foot Inspection
  1. Inspect the foot between the toes, and from toe to heel. Examine the skin for injury, calluses, blisters, cracks, ulcers or other unusual conditions. These are possible entry points for infection. 
  2. Look for thin, fragile, shiny and hairless skin. These are signs of reduced blood flow to the foot.
  3. Feel the temperature of the feet. Are they too hot? Too dry? Decreased sweating and dryness could be signs of nerve damage in the skin. 
  4. Remove any nail polish. Inspect the nails for length, thickening, ingrown corners, and fungal infection. 
  5. Inspect the socks or hose for blood or other discharge that indicates an open wound in the foot. 
  6. Examine the shoes for torn linings, abnormal wear, breathable material and proper fit. Check for foreign objects in the shoes. 
  7. If any new foot abnormality is found, schedule the patient for a detailed foot exam by a specialist.
Visual Foot Inspection
Careful inspection of the diabetic foot on a regular basis is one of the easiest and most effective ways to prevent foot complications.

All people with diabetes should have an annual foot inspection performed by a doctor, nurse, or other trained healthcare professional.
The purpose of the inspection is to identify early warnings signs of nerve damage or minor injuries that could lead to ulcers down the road. If any problems are found, the patient is referred to a podiatrist who will perform a detailed foot exam.
Elements of the Foot Inspection
  1. Inspect the foot between the toes, and from toe to heel. Examine the skin for injury, calluses, blisters, cracks, ulcers or other unusual conditions. These are possible entry points for infection. 
  2. Look for thin, fragile, shiny and hairless skin. These are signs of reduced blood flow to the foot.
  3. Feel the temperature of the feet. Are they too hot? Too dry? Decreased sweating and dryness could be signs of nerve damage in the skin. 
  4. Remove any nail polish. Inspect the nails for length, thickening, ingrown corners, and fungal infection. 
  5. Inspect the socks or hose for blood or other discharge that indicates an open wound in the foot. 
  6. Examine the shoes for torn linings, abnormal wear, breathable material and proper fit. Check for foreign objects in the shoes. 
  7. If any new foot abnormality is found, schedule the patient for a detailed foot exam by a specialist.
Detailed Foot Exam
The detailed foot exam is typically performed in a podiatrist office. It doesn't take long, and it doesn't hurt.
Elements of the Foot Exam
The podiatrist will look at your medical history to see if you have diabetes complications such as nerve damage, eye disease, heart disease, kidney disease, blood circulation problems, and previous foot problems or amputations. You'll be asked whether you smoke, and what your most recent A1c test result was.
You will be asked questions about your feet, such as
  • Do you currently have a foot ulcer or have you ever had one?
  • When you walk, do you feel pain in your calf muscles that goes away after you rest?
  • Any change in your foot since the last exam?
  • Any shoe problems?
  • Any blood or discharge in your socks or hose?
Next, the podiatrist will perform the detailed foot exam:
  • Check skin, hair and nail condition. The podiatrist uses a foot diagram like the one on this page, marking the location of any problems such as a callous, ulcer, cracks, etc.
  • Note foot deformities, such as misshapen toes, bunions, Charcot foot, foot drop, or prominent metatarsal heads.
  • Check the pedal pulse (blood pressure) in both feet.
  • Push a thin nylon wire (monofilament) into the bottom of the toes and the soles of the feet to see how well you can feel the sensation. These spots are shown in the diagram on the right.
  • Check your shoes to see if they are appropriate, or if you need inserts or corrective footwear.
 
Based on tests, the podiatrist will categorize your feet as low risk or high risk. A lack of protective sensation combined with foot deformities can lead to stresses on the feet that result in ulcers, infection, and ultimately, amputation. This would be a high risk foot.
The doctor will show you how to care for your feet. If necessary the podiatrist will prescribe special shoes.
If follow-up by other specialists is indicated, the podiatrist will refer you to them. Lastly, the podiatrist will schedule a date for a follow-up visit.
Foot Facts
Did you know...
  1. The 52 bones in your two feet make up about one fourth of all the bones in your body.
  2. The average person takes 8,000 to 10,000 steps a day. Those cover several miles, and they all add up to about 115,000 miles in a lifetime --- more than four times the circumference of the Earth. 
  3. Women have about four times as many foot problems as men. Lifelong wearing of high heels is often a factor. 
  4. Each year about 5% of the US population has foot infections such as athlete's foot, other fungal infections, and warts. 
  5. There are approximately 250,000 sweat glands in a pair of feet, and they excrete as much as half a pint of moisture each day. 
  6. Medicare covers therapeutic footware such as depth-inlay shoes, custom-molded shoes, and shoe inserts for people with diabetes who qualify under Medicare Part B. 
  7. During their lifetime, 15% of people with diabetes will experience a foot ulcer. Between 14% and 24% of the people with a foot ulcer will require amputation. 
  8. Each year, more than 86,000 amputations are performed on people with diabetes. 
  9. Around half of these lower extremity amputations might be prevented by easy foot care steps. These are:
  • Early identification of the high-risk foot
  • Early diagnosis of foot problems
  • Early specialist care to prevent foot problems from getting worse
  • Proper care of your feet and shoes
Pregnancy Complications
If you have diabetes, with some advance planning you can generally have a successful pregnancy and a healthy baby. The most important step you can take is to keep your blood glucose tightly controlled and your A1c on target for several months before the baby is even conceived. 

Risks to the Fetus
Low blood glucose generally does not cause health problems for your baby. However, even an occasional episode of high blood glucose can affect your baby. The first trimester is a critical time for your developing baby's health.
  • During the first three months of pregnancy, there is a higher risk of miscarriage. If the mother has high blood glucose, the fetus may develop breathing problems at birth or deformities of the spine, skeleton, kidneys, heart and circulatory system.
  • In months four through nine, the major risks are an overly large baby (called Macrosomia) or a stillbirth. About one third of babies born to mothers with diabetes have Macrosomia. Aside from their large size, these babies are otherwise generally healthy.
Risks to the Mother

During pregnancy, you may face three diabetes-related health risks:
  • Vision and kidney complications.  Vision problems due to retinopathy can sometimes worsen during pregnancy. In addition, some women experience high blood pressure by the third trimester of pregnancy. High blood pressure can lead to kidney damage. Keeping your blood glucose under tight control before and during pregnancy can help prevent these complications. 
  • Childbirth problems. If your baby is larger than normal, your doctor may ask you to give birth a little earlier or to have a cesarean delivery. This is because a very large baby can be bigger than the actual birth canal, so a standard childbirth approach might cause injury to you and your baby.
  • Hypoglycemia. If you are trying to keep your blood glucose in tight control, you may sometimes have hypoglycemia. Although low blood glucose does not harm your developing baby, repeated hypoglycemia episodes might create health problems for you.
Smart Tips for Pregnancy
  1. Plan for the pregnancy. Keep your blood glucose close to normal before and during the pregnancy to protect your health and the baby's well being. Your blood glucose and A1c should be within target for a number of months before you try to conceive.

    The American Diabetes Association recommends that women achieve the following stable blood glucose levels:

    • Plasma glucose 80-110 mg/dL before meals
    • Plasma glucose less than 155 mg/dL 2 hours after meals
    • During the preconception period and the first trimester, obtain the lowest A1c test level possible without undue risk of hypoglycemia in the mother.
  2. During pregnancy, your doctor may want to check your A1c level more often. Your A1c goal may also be set to less than 6%. Women with type 1 diabetes may need to test and inject three or more times a day in order to achieve this goal. The good news: today's thin lancets, syringes and insulin pen needles make it easier to test and inject with less pain.
  3. You will need to visit the doctor and have ultrasound tests more often than nondiabetic women do. These check-ups will help to ensure a healthy pregnancy.
Skin Conditions
Some people with diabetes may experience minor skin conditions. These conditions may be annoying, but most of them are not harmful to your health. By testing and injecting often to keep your blood glucose within target, you can also help to prevent skin problems.
 
Diabetes-related skin conditions include:

Dry skin. High blood glucose increases fluid loss, which dries out the skin. Dry skin can crack, allowing bacteria and germs to enter and cause infections.

Thickening of the skin, especially of the hands, due to changes in skin collagen. There is no clinical importance to this, other than its association with diabetes.

Yellowing of the nails, palms of the hands and soles of the feet. This is believed to occur because sugar molecules in the bloodstream attach to proteins. This yellowing is not a health concern.

Facial blush, redness around the nails and brown spots on legs. These are caused by thickened capillary walls and increased 'viscosity' (coagulation) of the blood.

Yeast infections. These tend to occur in moist areas where skin touches skin, such as the space between the fingers or the genital area.

Fungal infections under the nails
. The nails become yellow and thicker. They may also crack. This type of infection needs to be treated with medication prescribed by your doctor.
 Smart Tips for Avoiding Skin Problems
  • Keep your blood sugar in your target zone
  • Wash with mild soaps and shampoos, and rinse and dry your entire body thoroughly
  • Use talcum powder in armpit and groin areas
  • Do not take very hot baths or showers
  • Moisturize your skin daily
  • Drink plenty of fluids to keep your skin hydrated
  • Treat cuts right away. Wash minor cuts with soap and water; use antibiotic ointment only if your doctor recommends it. See your doctor immediately for any major cuts or burns.
  • Do not use feminine hygiene sprays
  • Check your feet daily
Dental Complications
People with diabetes may experience tooth and gum problems because of high blood sugar in the saliva, which promotes the growth of bacteria in the mouth and could lead to gum disease. Have your teeth and gums checked twice a year and inform your dentist of your diabetes.

Recognizing Symptoms of Dental Problems

See your dentist if you experience one or more of the following symptoms:
  • Red, sore, or swollen gums
  • Bleeding gums
  • Gums pulling away from the teeth making them appear "longer"
  • Loose or sensitive teeth
  • Bad breath
  • A bite that feels different
  • Dentures that do not fit well
Communicating with Your Dentist

Here are a few topics to discuss with your dentist:
  • Tell your dentist that you have diabetes.
  • If your dentist tells you about a problem, take care of it right away.
  • If you are having specific dental work done, ask your dentist if any special procedures should be followed in regards to your medication or meals.
SMART TIPS: GOOD DENTAL HEALTH
  • Keep your blood sugar within your target zone.
  • Brush your teeth after each meal or snack with a soft toothbrush.
  • Floss your teeth after each meal or snack by using a sawing motion between the teeth and scraping from the base upwards.
  • If you wear false teeth, keep them clean.
  • Talk to your dental hygienist about proper tooth and gum care.
  • Let your dentist know you have diabetes prior to any dental work.
Depression
It is not uncommon to experience depression if you have diabetes. Take comfort that you are not alone and that the condition can be successfully treated. Some research suggests that depression can be a trigger for the onset of Type 2 diabetes because both involve imbalances in the same hormones. Fortunately, there are therapies and medications available to help.
The common symptoms of depression include:
  • Feeling sad or empty for two weeks or more  
  • Less interest or pleasure from activities you previously enjoyed
  • Significant weight loss or weight gain  
  • Irregular sleep patterns nearly every day
  • Feeling "slowed down" or having no energy  
  • Feelings of worthlessness or inappropriate guilt
  • Difficulty concentrating nearly every day  
  • Recurrent thoughts of death or suicide
You can combat the symptoms of depression through stress management techniques and relaxation methods. A local diabetes support group is a great way to share your thoughts. Family and friends can also offer help and understanding in dealing with your mood disorder.

If you and your doctor feel that your depression has lasted longer than usual and is more than you can handle with family and community support, you should discuss other options such as counseling or medication.

Do not let depression keep you from following you daily diabetes regimen, diet and exercise. Controlling your blood sugar levels is your best bet for keeping in top physical and mental health. Stick with your winning plan!

 

       Continuance Subject

Diabetes Symptoms       

The four "classic" symptoms of diabetes are:

 

  • Increased thirst
  • Increased urination
  • Feeling very hungry
  • Weight loss in spite of increased eating
Here is why these symptoms happen.
Every cell in the body needs energy in order to live. People get their energy by converting the food they eat into fats and sugar (glucose). This glucose travels in the bloodstream as a component of normal blood. Individual cells then remove some of that glucose from the blood to use for energy. The substance that allows the cells to take glucose from the blood is a protein called 'insulin'.
Insulin is created by beta cells that are located in the pancreas. The pancreas is an organ located next to the stomach.
  • When glucose in the blood increases, the beta cells release insulin into the bloodstream, which distributes it to the cells in the body.
  • The insulin attaches itself to proteins on the cell surface, and allows glucose to move from the blood into the cell, where it is converted into energy.
A person with type 2 or gestational diabetes either cannot produce enough insulin, or they are "insulin insensitive", which means that their body can't use insulin properly. A person with type 1 diabetes produces little or no insulin.
Without enough insulin, the cells in the body do not have a way to use the glucose that is in the bloodstream, so the cells 'starve' while the glucose level in the blood rises.
In response to a lack of energy in the cells, the brain sends out signals that tell the person to eat more. Meanwhile, other cells in the body try to obtain energy by asking the body to break down fat and muscle protein. The liver can convert the muscle protein into glucose. A vicious cycle happens: more glucose is being created, but it cannot be turned into energy because there is not enough insulin to transfer the glucose into the cells of the body.
When too much glucose is in the blood, it 'leaks' into the urine. The urine of healthy people does not contain sugar. In diabetes, sugar in the urine draws water to it just like a dry sponge draws water. The person produces large amounts of urine because of all this water. All of that urination makes the person thirsty, so they drink excessively.
These responses to a lack of insulin lead people with diabetes to show the four classic symptoms of diabetes: they lose weight in spite of an increased appetite, drink excessively, and urinate excessively.
Diabetes Diagnosis
Your doctor will perform tests to confirm if you have diabetes. These 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 are confirmed by your doctor, by repeating the fasting plasma glucose test or the oral glucose tolerance test on a different day.

Fasting Plasma Glucose (FPG) Test
Because of ease of use, acceptability to patients and lower cost, the FPG is the preferred diagnostic test.  Fasting is defined as no caloric intake for at least 8 hours.
  • 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 somewhat 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.

Oral Glucose Tolerance Test (OGTT)
The OGTT requires you to fast for at least eight hours before the test. Your plasma glucose is measured immediately before, at intermediate times, and two hours after you drink a liquid containing 75 grams of glucose dissolved in water.
  • If your blood glucose level is between 140 and 199 mg/dL two 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 two-hour glucose level of 200 mg/dL or above, confirmed by repeating the test on another day, means that you have diabetes.

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.
Complications of Diabetes
When you were first diagnosed, you probably wondered how diabetes could cause problems in so many parts of the body. The reason is that diabetes damages nerves and blood vessels, and these are found everywhere in the body.
Diabetes complications fall into three general categories:
1. Nerve Damage (Neuropathy, pronounced Noo-RAW-pah-thee).
Diabetic neuropathies are a family of nerve disorders that lead to numbness and sometimes pain and weakness in the hands, arms, feet and legs. Neuropathy can also cause problems in your digestive system, heart, and sex organs.
Around 50% of people with diabetes have some degree of nerve damage, but not everyone experiences physical symptoms. Neuropathies are more common in people who have had diabetes for at least 25 years, who are overweight, have poor blood glucose control, and have high blood pressure. The most common type is peripheral neuropathy, which affects the arms and legs. This type of nerve damage causes numbness in the feet. This increases the chance of foot injuries, which, if left untreated, can lead to amputation.
2. Damage to large blood vessels (called Macrovascular disease)
High blood glucose causes hardening of the arteries (atherosclerosis), which can lead to a heart attack, stroke or poor circulation in the feet.
Heart disease is the leading cause of diabetes-related death. Adults with diabetes have heart disease death rates about 2 to 4 times higher than adults without diabetes. The risk of stroke is also 2 to 4 times greater for people with diabetes.
3. Damage to small blood vessels such as capillaries (called Microvascular disease)
High blood glucose also thickens capillary walls, makes blood stickier and can cause small blood vessels to 'leak'. Together, these effects reduce blood circulation to the skin, arms, legs, and feet. They can also change the circulation to the eyes and kidneys. Reduced capillary blood flow may cause some brown patches on the legs.
With good blood glucose control, many of these complications can be lessened. Your first priority should be to achieve HbA1c levels of 7% or less. Research has shown that for every 1% that you reduce your HbA1c level, the risk of heart attack drops by 14%, the risk of microvascular disease falls by 37% and the risk of peripheral vascular disease drops by 43%. Each additional 1% drop in your HbA1c score reduces the risk of complications even more.
If you already have a diabetes complication, take heart. Treatments are available for many diabetes-related problems. Ask your doctor if there are treatments that might be right for you.
Diabetes Requires Total Body Care
Doctors now believe that diabetes is not just a blood glucose problem. It is a complicated metabolic disorder that is closely associated with heart disease. Studies show that most people with diabetes also have high blood pressure and/or high cholesterol.
Research is underway to help us better understand causes and effects. For now, we know that if you have high cholesterol and high blood pressure, they will need to be treated as seriously as your high blood glucose. That means your doctor may ask you to take some other medications along with your diabetes pills.
That's why the American Diabetes Association's 2007 Standards for Diabetes Care look at the whole body. The chart below highlights the ADA's recommendations to healthcare professionals who treat people with diabetes.
Factor
Goals for adults with diabetes mellitus
Comments
 
Blood glucose control
Goals for non-pregnant patients:

Pre-meal plasma glucose: 90-130 mg/dL

Peak post-meal plasma glucose: less than 180 mg/dL

A1c Level less than 7%
People with type 1 diabetes and pregnant women taking insulin should test their blood glucose three times or more per day.




Test A1c twice a year in patients who are meeting treatment goals, and every 3 months in patients whose therapy has changed or who are not meeting their blood glucose goals.
 
Blood pressure
Systolic blood pressure less than 130

Diastolic blood pressure less than 80
Check blood pressure at every routine visit.

Orthostatic measurement of blood pressure should be performed to check for the presence of autonomic neuropathy.
 
Lipids
LDL cholesterol less than 100 mg/dL

Triglycerides: less than 150 mg/dL

HDL cholesterol more than 40 mg/dL for men, and more than 50 mg/dL for women
Adults: test for lipid disorders at least once a year, more often if necessary to meet goals.

Children less than 2 years old: Perform a lipid profile after diagnosis. Check every 5 years.
 
Coronary heart disease (CHD)
Goal: reduce hardening of the arteries that can lead to heart attack or stroke.
Assess the person's cardiovascular risk factors and perform an exercise test at least annually.

Refer people with symptoms to a cardiologist.
 
Aspirin therapy
75-162 mg/day
Use aspirin therapy in all adult patients with diabetes and cardiovascular disease.

Consider aspirin therapy for patients over 40 years who have diabetes and one or more cardiovascular risk factors.
No aspirin therapy to people who:
  • Are younger than 21 years due to Reye's syndrome.
  • Are allergic to aspirin
  • Have bleeding tendency or recent gastrointestinal bleeding
  • Receive anticoagulant therapy
  • Have clinically active hepatic disease
 
Kidney care
Albumin secretion: Less than 30 µg/mg, spot collection
Perform annual test for presence of microalbumininuria in all people with type 1 diabetes more than 5 years, and in all type 2 diabetes patients starting at diagnosis.
 
Foot care
Goal: prevent ulcers and other injuries that can lead to amputation.
Perform an annual comprehensive foot exam.

Perform a visual inspection at every routine visit.
 
Eye care
Goal: prevent or minimize diabetic retinopathy, which can lead to blindness.
Type 1: schedule an initial dilated and comprehensive eye exam by an ophthalmologist or optometrist 3-5 years after diagnosis, then once a year.

Type 2: schedule comprehensive eye exam right after diagnosis, then once a year.
 
Neuropathy
Goal is to prevent or minimize nerve damage that can lead to loss of feeling in the feet, digestive disorders, bladder dysfunction or heart function.

Aim for stable blood glucose control and avoid extreme blood glucose fluctuations.
All patients should be screened for distal symmetric polyneuropathy (DPN) at diagnosis and at least annually thereafter, using simple clinical tests.
Screen for autonomic neuropathy at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes.
Lifestyle
Goal is to reduce other risk factors such as diet, weight, smoking and alcohol use.
These can worsen the complications of diabetes.
People with diabetes should receive nutrition education, a regular exercise program, annual flu shots, and at least one lifetime pneumonia vaccine.
People who smoke are advised to quit.
 
Vision Complications
Early detection of eye problems will allow for more effective treatment and could halt the progression of further damage to your vision. Diabetes can lead to serious eye problems including blurred vision, diabetic retinopathy, cataracts, and glaucoma. Keeping your blood sugar within your target range is one of the best ways to prevent eye complications. And it's a good idea to be proactive in preserving your eyesight by visiting your eye doctor yearly for a full exam.
Retinopathy
Retinopathy is a serious eye disease associated with diabetes. Treatments are available, and the most successful are usually applied during the early phases of the condition. You should see your ophthalmologist every year to be checked for the two types of retinopathy: non-proliferative and proliferative.
Non-proliferative retinopathy is a mild form of retinopathy which may slightly decrease vision. Abnormalities are limited to the retina and usually will only seriously interfere with vision if they involve the macula (the area of the retina that gives us the sharpest vision). The earlier this type of retinopathy is discovered, the more successful the treatment. If left untreated, it can progress to proliferative retinopathy.
Proliferative retinopathy is a more serious condition in which new blood vessels branch out in and around the retina. These new blood vessels are very thin and fragile; they easily break and cause bleeding in the fluid-filled center of the eye. Serious diabetic eye disease may also lead to swelling of the retina. Either one may lead to blindness.
Early Cataracts
People with diabetes are at risk for developing cataracts at an earlier age than people without diabetes. A cataract is a cloud over your eye's lens, usually caused by a thickening of the tissue in the lens. As a result, light cannot be focused properly on your retina and vision becomes cloudy. This condition may be corrected by a surgery in which the lens is removed and a plastic lens is inserted in its place.
Glaucoma
People with diabetes are at risk for developing glaucoma at an earlier age than people without diabetes. Glaucoma is a condition caused by the buildup of pressure in the eye that can, over time, damage the optic nerve. The first symptom of glaucoma may be loss of vision from the sides of the eyes. Glaucoma can be treated by an eye doctor with special daily eye drops that lower the pressure in the eyes. Laser surgery is another alternative to reducing eye pressure. It is essential that you have your eye pressure measured by an ophthalmologist or other doctor every year.
Be sure to schedule yearly eye exams, which should be performed by an opthamologist who has been trained to look at the back of the eye. During your exam, ask the doctor to check for signs of diabetic retinopathy, cataracts, and glaucoma.
Smart Tips: Proper Eye Care
In between your annual visits, you should call your doctor if you experience any of the following signs of eye disease: 
  • Blurry vision 
  • Double vision 
  • Difficulty reading 
  • Pain or pressure in one or both eyes 
  • Rings, flashing light, or blank spots 
  • Spots or "floaters" appearing in your field of vision 
  • Decreased peripheral vision 
  • Bleeding in your eye 

If you have diabetes and you become pregnant, consult with your eye doctor within the first three months to check for retinopathy. Tight diabetes control during pregnancy can affect existing retinopathy.

And finally, if you smoke, here is another reason to quit. Smoking narrows the small blood vessels in your eyes and will affect circulation.
Eye Disease Simulations
 
Normal Vision
Scene as it might be viewed by a person with normal vision
National Eye Institute,
National Institutes of Health
 
 
Severe Diabetic Retinopathy
Scene as it might be viewed by a person with severe diabetic retinopathy
National Eye Institute,
National Institutes of Health
 
 
Cataracts
Scene as it might be viewed by a person with cataracts
National Eye Institute,
National Institutes of Health
 
 
Glaucoma
Scene as it might be viewed by a person with glaucoma
National Eye Institute,
National Institutes of Health
 
Heart Disease and Stroke
Heart disease and stroke are the leading causes of early death in people with diabetes. At least 65% of people with diabetes die from one of these two conditions. Heart attacks and stroke result from the same blood circulation problems. You can lower your risk by controlling your blood glucose, lowering your blood pressure and cholesterol, and not smoking.
How Diabetes Affects Blood Circulation
High blood glucose leads to poor circulation, blood clots and high blood pressure, which are at the root of heart disease and stroke.
1. Reduced blood flow; high blood pressure
People with diabetes tend to have high levels of LDL (bad) cholesterol, low levels of HDL (good) cholesterol, and high triglyceride levels. These can lead to atherosclerosis, sometimes called "hardening of the arteries". This condition happens when fatty deposits, cholesterol and other substances build up on artery walls.
This buildup, called plaque, reduces the flow of blood to the heart, brain and kidneys, and increases blood pressure. High blood glucose causes artery walls to stiffen, which also increases blood pressure.
2. Blood Clots More Easily
High blood glucose makes the blood "sticky" so it coagulates more easily. It can also cause small blood vessels to 'leak'. Together, these factors can cause blood clots to occur.
Sometimes plaque in an artery breaks off and causes blood clots to form. These clots can block the blood flow right where they are. When this happens in a blood vessel that feeds the heart, the result is a heart attack. When a clot blocks a blood vessel that feeds the brain, the result is a stroke.
Traveling clots called emboli can also cause blockages in other parts of the body, such as the legs.
SMART TIPS: MAINTAINING GOOD CIRCULATION
People with diabetes have such a high risk of heart disease and stroke that the American Diabetes Association and the American College of Cardiology have joined forces. They are running a campaign called the ABC's of Diabetes. The ABC's reflect the fact that blood pressure and cholesterol are as important as blood glucose in keeping your circulation system healthy:
A stands for A1c test, a measure of blood glucose levels
B stands for blood pressure
C stands for cholesterol, especially the bad LDL cholesterol
To prevent the cardiovascular complications of diabetes,  
  • Keep your blood glucose at the target set by your doctor. The American Diabetes Association recommends an A1c level less than 7% for most people. The American Association of Clinical Endocrinologists and the European Association for the Study of Diabetes prefer to set the A1c goal at 6.5%. Ask your doctor what A1c target is right for you.
  • Keep your blood pressure at 130/80 or less. Some people can achieve this through diet and exercise alone. Other people may require medication. Your doctor will advise you what steps you should take.
  • Keep your LDL (bad) cholesterol at 100 mg/dL or less. A value above 130 usually needs to be treated with medication.
  • If you smoke, quit.
 
Kidney Complications
The kidneys filter waste products from the blood. The filtering is done by small structures (called "glomeruli") that are similar to blood vessels. In healthy kidneys, the glomeruli filter waste products from the blood but keep protein inside the body, where it can be used to keep you healthy. Filtered blood leaves the kidney and goes back into the bloodstream.
High blood glucose and high blood pressure can damage the glomeruli. If damaged, they are not able to do their filtering job as well, so protein leaks out of the kidneys into the urine. If left untreated, large amounts of protein are lost in the urine. Eventually the kidneys are so damaged that they stop working altogether.
Kidney failure from diabetes happens so slowly that you may not feel sick for many years. About 30% of people with Type 1 diabetes, and 10-40% of those with Type 2 diabetes will develop this kidney disease, which is called diabetic nephropathy.
Symptoms of Kidney Disease
The earliest clinical sign of kidney disease is when the kidneys leak small amounts of a protein called albumin into the urine. Some people experience weight gain and swollen ankles, and more frequent urination at night.
As the kidney damage gets worse, more protein is leaked into the urine. This is called proteinuria. More and more wastes build up in the blood, too. The person may feel nauseous, weak and tired from anemia. They may lose their appetite or suffer leg cramps.

Prevention and Treatment
You can avoid kidney disease or slow down its progress by keeping your blood glucose at normal levels and treating high blood pressure. Your doctor may check for early signs of kidney disease with a test for excess protein in the urine, called microalbuminurea.

If you have high blood pressure, your doctor or a kidney specialist called a nephrologist may prescribe ACE inhibitors or similar medications to control your blood pressure and prevent future kidney damage. If you have a small amount of protein in the urine you may also be put on a low-protein diet.

If your kidneys fail, the nephrologist will choose from three possible treatments:
  • Hemodialysis. In this process, your blood flows through a tube from your arm to a machine that filters out the waste products and extra fluid. The clean blood flows back into your arm. Hemodialysis is usually done in an outpatient center. It can sometimes be done at home.
  • Peritoneal dialysis. In this approach, your abdomen is filled with a special fluid. The fluid collects waste products and extra water from your blood. Then the fluid is drained and discarded. This type of dialysis can be done at home.
  • Kidney transplant. In this major surgery, one of your failed kidneys is replaced with a healthy kidney from a close family member, friend, or someone you do not know. The new kidney must be a good match for your body.
  
SMART TIPS FOR KIDNEY CARE 
  • Keep your blood glucose in the target zone.
  • Keep your blood pressure under control.
  • Follow a healthy eating plan.
  • Ask your doctor to do a microalbuminurea test to check kidney function at least once a year.
  • If you have kidney damage, discuss all over-the-counter and prescription medications with your doctor before taking them. Check the labels of all medications (especially pain relievers) and ask your doctor if the label indicates that they might cause kidney damage.
  • See your doctor right away if you think you may have a bladder or kidney infection. Urinary tract infections are more common in people with diabetes. Symptoms include: 

    • Pain or burning when urinating
    • Cloudy or reddish urine 
    • A need to urinate often
    • Fever or shakiness
    • Back pain or pain on your side below your ribs
Foot Complications
There are two effects of diabetes that can be damaging to your feet.
  • Blood flow to the legs and feet is reduced.
  • The neuropathy (nerve damage) that results from high blood glucose levels may reduce the sense of feeling in the legs and feet.
Do you have high risk feet?
Your healthcare team will determine if your feet are at low risk or high risk of developing serious problems in the future.

A high risk foot has one or more of the following conditions:
  • Loss of protective sensation so you cannot feel a foot injury
  • Poor blood circulation (doctors call it absent pedal pulses)
  • Foot deformity
  • History of foot ulcer
  • Prior amputation
You can help to prevent ulcers and other foot problems by controlling other risk factors, such as smoking, drinking alcohol, high cholesterol, and high blood glucose.

Be sure to take special care of your feet and examine them often. Check visually for cuts and sores every day, because you may not feel them. Good foot care will help you to avoid serious infections, as well as reduce the risk of diabetes-related amputation by 50 percent.
Signs that might help you to recognize potential problems include:
  • Hammer toes, especially with redness at the top
  • High arch
  • Calluses

Smart Tips: Keeping Feet in Top Condition
  • Check your feet and toes daily. Look for any cuts, corns, blisters, bruises, bumps, or infections. You can use a mirror or ask someone else to examine them for you.
  • If you have an injury or sore and notice that it is not healing well, contact your doctor immediately.
  • Wear shoes that fit you well. New shoes should be worn for only one hour at a time to break them in and avoid sores and blisters.
  • Do not cross your legs while sitting - it reduces circulation.
  • Wash your feet daily and dry them thoroughly, especially between the toes. Use warm water (not hot) and mild soap. Do not soak your feet.
  • Never go barefoot, especially on the beach, hot sand, or rocks.
  • Moisturize your feet (except for the skin in between your toes).
  • See a specialist who can provide you with corrective shoes or inserts.
  • Cut your toenails straight across and smooth them. If you have difficulty cutting your toenails, you should see a podiatrist who can do it for you.
  • Use a pumice stone to slough away dead skin.
  • Avoid harsh chemicals such as wart or corn removers.
Visual Foot Inspection
Careful inspection of the diabetic foot on a regular basis is one of the easiest and most effective ways to prevent foot complications.

All people with diabetes should have an annual foot inspection performed by a doctor, nurse, or other trained healthcare professional.

The purpose of the inspection is to identify early warnings signs of nerve damage or minor injuries that could lead to ulcers down the road. If any problems are found, the patient is referred to a podiatrist who will perform a detailed foot exam.
Elements of the Foot Inspection
  1. Inspect the foot between the toes, and from toe to heel. Examine the skin for injury, calluses, blisters, cracks, ulcers or other unusual conditions. These are possible entry points for infection. 
  2. Look for thin, fragile, shiny and hairless skin. These are signs of reduced blood flow to the foot.
  3. Feel the temperature of the feet. Are they too hot? Too dry? Decreased sweating and dryness could be signs of nerve damage in the skin. 
  4. Remove any nail polish. Inspect the nails for length, thickening, ingrown corners, and fungal infection. 
  5. Inspect the socks or hose for blood or other discharge that indicates an open wound in the foot. 
  6. Examine the shoes for torn linings, abnormal wear, breathable material and proper fit. Check for foreign objects in the shoes. 
  7. If any new foot abnormality is found, schedule the patient for a detailed foot exam by a specialist.
Visual Foot Inspection
Careful inspection of the diabetic foot on a regular basis is one of the easiest and most effective ways to prevent foot complications.

All people with diabetes should have an annual foot inspection performed by a doctor, nurse, or other trained healthcare professional.
The purpose of the inspection is to identify early warnings signs of nerve damage or minor injuries that could lead to ulcers down the road. If any problems are found, the patient is referred to a podiatrist who will perform a detailed foot exam.
Elements of the Foot Inspection
  1. Inspect the foot between the toes, and from toe to heel. Examine the skin for injury, calluses, blisters, cracks, ulcers or other unusual conditions. These are possible entry points for infection. 
  2. Look for thin, fragile, shiny and hairless skin. These are signs of reduced blood flow to the foot.
  3. Feel the temperature of the feet. Are they too hot? Too dry? Decreased sweating and dryness could be signs of nerve damage in the skin. 
  4. Remove any nail polish. Inspect the nails for length, thickening, ingrown corners, and fungal infection. 
  5. Inspect the socks or hose for blood or other discharge that indicates an open wound in the foot. 
  6. Examine the shoes for torn linings, abnormal wear, breathable material and proper fit. Check for foreign objects in the shoes. 
  7. If any new foot abnormality is found, schedule the patient for a detailed foot exam by a specialist.
Detailed Foot Exam
The detailed foot exam is typically performed in a podiatrist office. It doesn't take long, and it doesn't hurt.
Elements of the Foot Exam
The podiatrist will look at your medical history to see if you have diabetes complications such as nerve damage, eye disease, heart disease, kidney disease, blood circulation problems, and previous foot problems or amputations. You'll be asked whether you smoke, and what your most recent A1c test result was.
You will be asked questions about your feet, such as
  • Do you currently have a foot ulcer or have you ever had one?
  • When you walk, do you feel pain in your calf muscles that goes away after you rest?
  • Any change in your foot since the last exam?
  • Any shoe problems?
  • Any blood or discharge in your socks or hose?
Next, the podiatrist will perform the detailed foot exam:
  • Check skin, hair and nail condition. The podiatrist uses a foot diagram like the one on this page, marking the location of any problems such as a callous, ulcer, cracks, etc.
  • Note foot deformities, such as misshapen toes, bunions, Charcot foot, foot drop, or prominent metatarsal heads.
  • Check the pedal pulse (blood pressure) in both feet.
  • Push a thin nylon wire (monofilament) into the bottom of the toes and the soles of the feet to see how well you can feel the sensation. These spots are shown in the diagram on the right.
  • Check your shoes to see if they are appropriate, or if you need inserts or corrective footwear.
 
Based on tests, the podiatrist will categorize your feet as low risk or high risk. A lack of protective sensation combined with foot deformities can lead to stresses on the feet that result in ulcers, infection, and ultimately, amputation. This would be a high risk foot.
The doctor will show you how to care for your feet. If necessary the podiatrist will prescribe special shoes.
If follow-up by other specialists is indicated, the podiatrist will refer you to them. Lastly, the podiatrist will schedule a date for a follow-up visit.
Foot Facts
Did you know...
  1. The 52 bones in your two feet make up about one fourth of all the bones in your body.
  2. The average person takes 8,000 to 10,000 steps a day. Those cover several miles, and they all add up to about 115,000 miles in a lifetime --- more than four times the circumference of the Earth. 
  3. Women have about four times as many foot problems as men. Lifelong wearing of high heels is often a factor. 
  4. Each year about 5% of the US population has foot infections such as athlete's foot, other fungal infections, and warts. 
  5. There are approximately 250,000 sweat glands in a pair of feet, and they excrete as much as half a pint of moisture each day. 
  6. Medicare covers therapeutic footware such as depth-inlay shoes, custom-molded shoes, and shoe inserts for people with diabetes who qualify under Medicare Part B. 
  7. During their lifetime, 15% of people with diabetes will experience a foot ulcer. Between 14% and 24% of the people with a foot ulcer will require amputation. 
  8. Each year, more than 86,000 amputations are performed on people with diabetes. 
  9. Around half of these lower extremity amputations might be prevented by easy foot care steps. These are:
  • Early identification of the high-risk foot
  • Early diagnosis of foot problems
  • Early specialist care to prevent foot problems from getting worse
  • Proper care of your feet and shoes
Pregnancy Complications
If you have diabetes, with some advance planning you can generally have a successful pregnancy and a healthy baby. The most important step you can take is to keep your blood glucose tightly controlled and your A1c on target for several months before the baby is even conceived. 

Risks to the Fetus
Low blood glucose generally does not cause health problems for your baby. However, even an occasional episode of high blood glucose can affect your baby. The first trimester is a critical time for your developing baby's health.
  • During the first three months of pregnancy, there is a higher risk of miscarriage. If the mother has high blood glucose, the fetus may develop breathing problems at birth or deformities of the spine, skeleton, kidneys, heart and circulatory system.
  • In months four through nine, the major risks are an overly large baby (called Macrosomia) or a stillbirth. About one third of babies born to mothers with diabetes have Macrosomia. Aside from their large size, these babies are otherwise generally healthy.
Risks to the Mother

During pregnancy, you may face three diabetes-related health risks:
  • Vision and kidney complications.  Vision problems due to retinopathy can sometimes worsen during pregnancy. In addition, some women experience high blood pressure by the third trimester of pregnancy. High blood pressure can lead to kidney damage. Keeping your blood glucose under tight control before and during pregnancy can help prevent these complications. 
  • Childbirth problems. If your baby is larger than normal, your doctor may ask you to give birth a little earlier or to have a cesarean delivery. This is because a very large baby can be bigger than the actual birth canal, so a standard childbirth approach might cause injury to you and your baby.
  • Hypoglycemia. If you are trying to keep your blood glucose in tight control, you may sometimes have hypoglycemia. Although low blood glucose does not harm your developing baby, repeated hypoglycemia episodes might create health problems for you.
Smart Tips for Pregnancy
  1. Plan for the pregnancy. Keep your blood glucose close to normal before and during the pregnancy to protect your health and the baby's well being. Your blood glucose and A1c should be within target for a number of months before you try to conceive.

    The American Diabetes Association recommends that women achieve the following stable blood glucose levels:

    • Plasma glucose 80-110 mg/dL before meals
    • Plasma glucose less than 155 mg/dL 2 hours after meals
    • During the preconception period and the first trimester, obtain the lowest A1c test level possible without undue risk of hypoglycemia in the mother.
  2. During pregnancy, your doctor may want to check your A1c level more often. Your A1c goal may also be set to less than 6%. Women with type 1 diabetes may need to test and inject three or more times a day in order to achieve this goal. The good news: today's thin lancets, syringes and insulin pen needles make it easier to test and inject with less pain.
  3. You will need to visit the doctor and have ultrasound tests more often than nondiabetic women do. These check-ups will help to ensure a healthy pregnancy.
Skin Conditions
Some people with diabetes may experience minor skin conditions. These conditions may be annoying, but most of them are not harmful to your health. By testing and injecting often to keep your blood glucose within target, you can also help to prevent skin problems.
 
Diabetes-related skin conditions include:

Dry skin. High blood glucose increases fluid loss, which dries out the skin. Dry skin can crack, allowing bacteria and germs to enter and cause infections.

Thickening of the skin, especially of the hands, due to changes in skin collagen. There is no clinical importance to this, other than its association with diabetes.

Yellowing of the nails, palms of the hands and soles of the feet. This is believed to occur because sugar molecules in the bloodstream attach to proteins. This yellowing is not a health concern.

Facial blush, redness around the nails and brown spots on legs. These are caused by thickened capillary walls and increased 'viscosity' (coagulation) of the blood.

Yeast infections. These tend to occur in moist areas where skin touches skin, such as the space between the fingers or the genital area.

Fungal infections under the nails
. The nails become yellow and thicker. They may also crack. This type of infection needs to be treated with medication prescribed by your doctor.
 Smart Tips for Avoiding Skin Problems
  • Keep your blood sugar in your target zone
  • Wash with mild soaps and shampoos, and rinse and dry your entire body thoroughly
  • Use talcum powder in armpit and groin areas
  • Do not take very hot baths or showers
  • Moisturize your skin daily
  • Drink plenty of fluids to keep your skin hydrated
  • Treat cuts right away. Wash minor cuts with soap and water; use antibiotic ointment only if your doctor recommends it. See your doctor immediately for any major cuts or burns.
  • Do not use feminine hygiene sprays
  • Check your feet daily
Dental Complications
People with diabetes may experience tooth and gum problems because of high blood sugar in the saliva, which promotes the growth of bacteria in the mouth and could lead to gum disease. Have your teeth and gums checked twice a year and inform your dentist of your diabetes.

Recognizing Symptoms of Dental Problems

See your dentist if you experience one or more of the following symptoms:
  • Red, sore, or swollen gums
  • Bleeding gums
  • Gums pulling away from the teeth making them appear "longer"
  • Loose or sensitive teeth
  • Bad breath
  • A bite that feels different
  • Dentures that do not fit well
Communicating with Your Dentist

Here are a few topics to discuss with your dentist:
  • Tell your dentist that you have diabetes.
  • If your dentist tells you about a problem, take care of it right away.
  • If you are having specific dental work done, ask your dentist if any special procedures should be followed in regards to your medication or meals.
SMART TIPS: GOOD DENTAL HEALTH
  • Keep your blood sugar within your target zone.
  • Brush your teeth after each meal or snack with a soft toothbrush.
  • Floss your teeth after each meal or snack by using a sawing motion between the teeth and scraping from the base upwards.
  • If you wear false teeth, keep them clean.
  • Talk to your dental hygienist about proper tooth and gum care.
  • Let your dentist know you have diabetes prior to any dental work.
Depression
It is not uncommon to experience depression if you have diabetes. Take comfort that you are not alone and that the condition can be successfully treated. Some research suggests that depression can be a trigger for the onset of Type 2 diabetes because both involve imbalances in the same hormones. Fortunately, there are therapies and medications available to help.
The common symptoms of depression include:
  • Feeling sad or empty for two weeks or more  
  • Less interest or pleasure from activities you previously enjoyed
  • Significant weight loss or weight gain  
  • Irregular sleep patterns nearly every day
  • Feeling "slowed down" or having no energy  
  • Feelings of worthlessness or inappropriate guilt
  • Difficulty concentrating nearly every day  
  • Recurrent thoughts of death or suicide
You can combat the symptoms of depression through stress management techniques and relaxation methods. A local diabetes support group is a great way to share your thoughts. Family and friends can also offer help and understanding in dealing with your mood disorder.

If you and your doctor feel that your depression has lasted longer than usual and is more than you can handle with family and community support, you should discuss other options such as counseling or medication.

Do not let depression keep you from following you daily diabetes regimen, diet and exercise. Controlling your blood sugar levels is your best bet for keeping in top physical and mental health. Stick with your winning plan!

 

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