What is diabetes?

Diabetes Mellitus is a condition in which the amount of glucose in the blood is too high because the body cannot use it properly. Glucose comes from the digestion of stracgy foods such as bread, rice, potatoes, chapatis, yams and plantain, from sugar and other sett foods, and from the liver which makes glucose.

Insulin is vital for life. It is a hormone produced by the pancreas, that helps the glucose to enter the cells where it is used by fuel by the body.

There are currently over 2.3 million people with diabetes in the UK and there are up to another 750,000 people with diabetes who have the condition and don’t know it.


There are two types of diabetes :

- Type 1 diabetes
- Type 2 diabetes

Type 1 diabetes

This type of diabetes occurs when the body is unable to produce any insulin. It usually appears before the age of 40 and is the least common of the two main types and accounts for between 5 – 15% of all people with diabetes.

Type 2 diabetes

Type 2 diabetes occurs when the body can still make some insulin, but not enough, or when the insulin that is produced does not work properly (known as insulin resistance). Often this type of diabetes occurs in people who are overweight and over the age of 40. But, has also been seen in children as young as seven. It is also seen in ages 25+ of people of South Asian and African-Carribean descent. Type 2 diabetes is the most common of the two main types and accounts for between 85 - 95% of all people with diabetes.


What are the symptoms of diabetes?

- Frequency of passing urine
- An increase in tiredness
- Weight loss
- Increased thirst
- Blurred vision
- Slow healing of wounds
- Genital itching or regular thrush

In people with Type 2 diabetes the symptoms do not show as readily or may even not show at all. Early detection is important and if in doubt or any symptoms display themselves request an appointment with your doctor.

With Type 1 diabetes the symptoms generally display themselves quickly (within a few weeks) and are quite apparant.


Causes of diabetes

Type 1 diabetes

This type of diabetes happens as a result of destroyed insulin-producing cells in the pancreas. Even though it is not fully understood how this damage happens, it is thought to be an abnormal reaction of the body to thesecells often through an infection or virus.

Type 2 diabetes

Type 2 diabetes is caused by a complicated interplay of genes, environment, insulin abnormalities, increased glucose production in the liver, increased fat breakdown, and possibly defective hormonal secretions in the intestine. The recent dramatic increase indicates that lifestyle factors (obesity and sedentary lifestyle) may be particularly important in triggering the genetic elements that cause this type of diabetes.


Risk factors of diabetes

Type 1 diabetes

Type 1 diabetes is equally common among men and women, but it occurs more often in whites than in nonwhites. The main risk factors include the following:

Family History - If someone has a parent, brother, or sister with type 1 diabetes, they (or their child) are at greater risk of having it, too. Scientists continue to believe that genetic factors play a role in the development of type 1 diabetes.

Autoimmune Conditions - Type 1 diabetes is most commonly an autoimmune disease, caused by the body's immune system attacking the insulin-producing cells of the pancreas. A person may be at a greater than average risk of developing type 1 diabetes if they have another autoimmune condition.

Environmental Factors - Stress: physical or emotional may increase the chance of a person developing type 1 diabetes as well as a diet that is high in nitrosamines or dairy products and toxins.

Race - White people have a greater risk for developing type 1 diabetes than black, Asian, or Hispanic people.


Type 2 diabetes

Below are the major risk factors for type 2 diabetes

Age - Older than 45 years (though type 2 diabetes mellitus is occurring with increasing frequency in young individuals)

Obesity - Weight greater than 120% of desirable body weight (true for approximately 90% of patients with type 2 diabetes mellitus)

Apple-shaped figure -Individuals who carry most of their weight in the trunk of their bodies (i.e., above the hips) tend to have a higher risk of diabetes than those of similar weight with a pear-shaped body (excess fat carried mainly in the hips and thighs). A waist measurement of more than 100 cm (39.5 inches) in men and 95 cm (37.5 inches) in women suggests an increased risk

Family history of type 2 diabetes in a first-degree relative (eg, parent or sibling)

Race - Hispanic, Native American, African American, Asian American, or Pacific Islander descent

History of previous impaired glucose tolerance (IGT) or impaired fasting glucose (IFG)

High blood pressure, high cholesterol or raised triglycerides (a type of bllod fat)

History of gestational diabetes mellitis or of delivering a baby with a birth weight of >9 lb

Polycystic ovarian syndrome (which results in insulin resistance)


Complications of diabetes

Short term complications

Hypoglycaemia

Hypoglycaemia or low blood glucose is a condition in which the level of glucose (sugar) in the blood, drops below a certain point (about 2.5mmol/l). The condition manifests itself by a number of symptoms that usually disappear 10 to 15 minutes after eating sugar.

A hypo may occur if you have taken too much diabetes medication, delayed or missed a meal or snack, not eaten enough carbohydrate, taken part in unplanned or more strenuous exercise than usual, and have been drinking alcohol without food. Sometimes there is no obvious cause

Symptoms of a hypoglycaemic attack include paleness, trembling, perspiration, a feeling of weakness, rapid heartbeat, hunger, agitation, difficulty concentrating, irritability, fatigue, blurred vision.

Treatment is usually very simple and requires taking some fast acting carbohydrate, such as a sugary drink or some glucose tablets, and following this up with some longer acting carbohydrate, such as a cereal bar, a sandwich, piece of fruit, biscuits and milk or the next meal if it is due.

If left untreated a person may lose consciousness and require treating with an injectable form of glucose (glucagon)

Hypos are not normally dangerous in themselves. In the vast majority of cases the body will release its own stores of glucose and raise the blood glucose level to normal, though this may take several hours.

If left completely untreated a hypoglycaemic attack may result in serious consequences sometimes proving to be fatal. Therefore it is of utmost importance than when symptoms present themselves that they are dealt with quickly and not ignored.


Ketoacidosis

In the short term, consistent high blood glucose levels can lead to a condition called diabetic ketoacidosis (DKA). This happens because of a lack of glucose entering the cells where it can be used as energy. The body begins to use stores of fat as an alternative source of energy, and this in turn produces an acidic by-product known as ketones.

Ketones are very harmful and the body will immediately try to get rid of them by excreting them in urine. Consequently, when ketones are present and blood glucose levels are rising, people often become increasingly thirsty as the body tries to flush them out. If the level of ketones in the body continues to rise, ketoacidosis develops (ketoacidosis means acidity of the blood, due to an excess of ketones in the body). Their harmful effect becomes more apparent, and nausea or vomiting may start. In addition, the skin may become dry, eyesight blurred and breathing deep and rapid.

Unfortunately, because of vomiting, the body becomes even more dehydrated and less efficient at flushing out the ketones, allowing levels to rise even faster. As the level of ketones rise, it may be possible to smell them on the breath - often described as smelling like pear drops or nail varnish. Eventually, if untreated, the level of ketones will continue to rise and, combined with high blood glucose levels, a coma will develop which can be fatal. However, at any of these intermediate stages, ketoacidosis can be treated and damage usually limited. Obviously, the sooner, the better.

Anyone who relies on insulin injections could develop ketoacidosis. This includes everyone with Type 1 diabetes and people with Type 2 who control their diabetes with insulin injections. In exceptionally rare cases, people controlling their diabetes with diet or tablets have been known to develop ketoacidosis when severely ill.

The high-risk time for developing ketoacidosis is when a person is unwell, as part of the body's response to illness and infection is to release more glucose into the bloodstream, and to stop insulin from working properly. You should do more frequent blood glucose testing when you are unwell.

Ketones are easily detected by a simple urine test, using strips available on prescription. If a person has high blood sugar levels (over 15 mmol/l), their urine should be tested for the presence of ketones. If a test proves positive or if a person has a high blood sugar level or is displaying any signs of ketoacidosis, it is essential that they contact their doctor immediately.


Hyperosmolar non-ketotic acidosis

Hyperosmolar non-ketotic acidosis, is a serious condition most frequently seen in older persons. It can happen to people with either type 1 or type 2 diabetes, but it occurs more often in people with type 2. It is usually brought on by something else, such as an illness or infection.

In hyperosmolar non-ketotic acidosis, blood sugar levels rise, and your body tries to get rid of the excess sugar by passing it into your urine. You make lots of urine at first, and you have to go to the bathroom more often. Later you may not have to go to the bathroom as often, and your urine becomes very dark. Also, you may be very thirsty. Even if you are not thirsty, you need to drink liquids. If you don't drink enough liquids at this point, you can get dehydrated.

If it continues, the severe dehydration will lead to seizures, coma and eventually death. Hyperosmolar non-ketotic acidosis may take days or even weeks to develop. Therefore it is important to know the warning signs.


Long term complications

Eye complications
Glaucoma

People with diabetes are 40% more likely to suffer from glaucoma than people without diabetes. The longer someone has had diabetes, the more common glaucoma is. Risk also increases with age.

Glaucoma occurs when pressure builds up in the eye. In most cases, the pressure causes drainage of the aqueous humor to slow down so that it builds up in the anterior chamber. The pressure pinches the blood vessels that carry blood to the retina and optic nerve. Vision is gradually lost because the retina and nerve are damaged.

There are several treatments for glaucoma. Some use drugs to reduce pressure in the eye, while others involve surgery.


Cataracts

Many people without diabetes get cataracts, but people with diabetes are 60% more likely to develop this eye condition. People with diabetes also tend to get cataracts at a younger age and have them progress faster. With cataracts, the eye's clear lens clouds, blocking light.

To help deal with mild cataracts, you may need to wear sunglasses more often and use glare-control lenses in your glasses. For cataracts that interfere greatly with vision, doctors usually remove the lens of the eye. Sometimes the patient gets a new transplanted lens. In people with diabetes, retinopathy can get worse after removal of the lens, and glaucoma may start to develop.


Retinopathy

Retinopathy affects the blood vessels supplying the retina – the seeing part of the eye. Blood vessels in the retina of the eye can become blocked, leaky or grow haphazardly. This damage gets in the way of the light passing through to the retina and if left untreated can damage vision.

Keeping blood glucose and blood pressure and blood fat levels under control will help to reduce the risk of developing retinopathy. But, your best protection against retinopathy is having your eyes specially screened by an optition.

Retinopathy can be treated by laser which is very successful if the condition is caught early and is generally pain free. In 80 percent of cases it can prevent any further loss of sight.


Kidneys (nephropathy)

Diabetes can damage the kidneys and cause them to fail. Failing kidneys lose their ability to filter out waste products, resulting in kidney disease.

It is now known that keeping blood glucose levels as near normal as possible (between 4 and 6 mmol/l before meals, and less than 10 mmol/l two hours after food) can greatly reduce the risk of kidney disease developing as well as other diabetes complications. It is also very important to keep blood pressure controlled (130/80mmHg or less).

When these methods fail, certain medicines may be able to lower blood pressure. There are several kinds of blood pressure drugs. Not all are equally good for people with diabetes. Some raise blood sugar levels or mask some of the symptoms of low blood sugar. Doctors usually prefer people with diabetes to take blood pressure drugs called ACE inhibitors.

ACE inhibitors are recommended for most people with diabetes, high blood pressure, and kidney disease. Recent studies suggest that ACE inhibitors, which include captopril and enalapril, slow kidney disease in addition to lowering blood pressure. In fact, these drugs are helpful even in people who do not have high blood pressure.

Another treatment some doctors use is a low-protein diet. Protein seems to increase how hard the kidneys must work. A low-protein diet can decrease protein loss in the urine and increase protein levels in the blood. Never start a low-protein diet without talking to your health care team.

Once kidneys fail, dialysis is necessary. The person must choose whether to continue with dialysis or to get a kidney transplant. This choice should be made as a team effort. The team should include the doctor and diabetes educator, a nephrologist (kidney doctor), a kidney transplant surgeon, a social worker, and a psychologist.


Nerves (neuropathy)

About half of all people with diabetes have some form of nerve damage. It is more common in those who have had the disease for a number of years. Neuropathy causes damage to the nerves that transmit impulses to and from the brain and spinal cord, to the muscles, skin, blood vessels and other organs. This includes erectile disfunction.

There's a lot you can do to prevent or delay nerve damage. And, if you already have diabetic neuropathy (nerve damage), these steps can prevent or delay further damage and may lessen your symptoms.

Keep your blood glucose levels in your target range, meal planning, physical activity and medications, if needed, all can help you reach this target range.


Skin complications

Diabetes can affect every part of the body, including the skin. As many as one third of people with diabetes will have a skin disorder caused or affected by diabetes at some time in their lives. In fact, such problems are sometimes the first sign that a person has diabetes. Luckily, most skin conditions can be prevented or easily treated if caught early.

Some of these problems are skin conditions anyone can have, but people with diabetes get more easily. These include bacterial infections, fungal infections, and itching. Other skin problems happen mostly or only to people with diabetes. These include diabetic dermopathy, necrobiosis lipoidica diabeticorum, diabetic blisters and eruptive xanthomatosis.


Cardiovascular disease

The term cardiovascular disease includes heart disease, stroke and all other diseases of the heart and circulation, such as hardening and narrowing of the arteries supplying blood to the legs, which is known as peripheral vascular disease. However, heart disease and stroke are the two most common forms of cardiovascular disease.

Most people with diabetes have health problems -- or risk factors -- such as high blood pressure and cholesterol that increase one's risk for heart disease and stroke. When combined with diabetes, these risk factors increase up to fivefold compared to those without. By managing diabetes, high blood pressure and cholesterol, people with diabetes can reduce their risk by

-Being more physically active.
-Losing weight if overweight.
-Stopping smoking.
-Eating a healthy balanced diet.
-Taking medication as prescribed.
-Keeping blood glucose levels well controlled – between 4 – 6mmol/l before meals and less than 10mmol/ll 2 hours after.
-Keeping blood pressure well controlled – it should be treated if it is above 130/80 mmHg.
-Controlling cholesterol.
-Having regular medical checkups at least once a year.


Foot Complications

People with diabetes can develop many different foot problems. Even ordinary problems can get worse and lead to serious complications.

Foot problems most often happen when there is nerve damage, also called neuropathy, which results in loss of feeling in your feet. Poor blood flow or changes in the shape of your feet or toes may also cause problems. Although it can hurt, diabetic nerve damage can also lessen your ability to feel pain, heat, and cold. Loss of feeling often means you may not feel a foot injury. You could have a tack or stone in your shoe and walk on it all day without knowing. You could get a blister and not feel it. You might not notice a foot injury until the skin breaks down and becomes infected.

Diabetes can cause changes in the skin of your foot. At times your foot may become very dry. The skin may peel and crack. The problem is that the nerves that control the oil and moisture in your foot no longer work.

Wash your feet every day with ordinary soap and warm water. Dry them carefully – especially between the toes.

Do not put oils or creams between your toes. The extra moisture can lead to infection. Also, don't soak your feet - that can dry your skin.

Calluses occur more often and build up faster on the feet of people with diabetes. This is because there are high-pressure areas under the foot. Too much callus may mean that you will need therapeutic shoes and inserts.

Calluses, if not trimmed, get very thick, break down, and turn into ulcers (open sores). Never try to cut calluses or corns yourself - this can lead to ulcers and infection. Let your health care provider cut your calluses.

Using a pumice stone every day will help keep calluses under control.

Ulcers occur most often on the ball of the foot or on the bottom of the big toe. Ulcers on the sides of the foot are usually due to poorly fitting shoes. Remember, even though some ulcers do not hurt, every ulcer should be seen by your health care provider right away. Neglecting ulcers can result in infections sometimes serious.

Keeping off your feet if you have an ulcer is very important. Walking on an ulcer can make it get larger and force the infection deeper into your foot.

If your ulcer is not healing and your circulation is poor, your health care provider may need to refer you to a vascular surgeon. Good diabetes control is important. High blood glucose levels make it hard to fight infecton.

Poor circulation (blood flow) can make your foot less able to fight infection and to heal. Diabetes causes blood vessels of the foot and leg to narrow and harden. You can control some of the things that cause poor blood flow. Don't smoke - smoking makes arteries harden faster. Also, ensure you keep your blood pressure and cholesterol under control.

Exercise is good for poor circulation. It stimulates blood flow in the legs and feet. Walk in sturdy, good-fitting, comfortable shoes. Don't walk when you have open sores.

Don’t expose your feet to extremes of heat or cold.

Most importantly check your feet daily.


Musculoskeletal Conditions

Musculoskeletal conditions (conditions affecting the muscles or skeleton) can affect anyone, but people with diabetes can be at an increased risk of developing them. The reasons for this are not fully understood, but it is thought that raised blood glucose levels may, overtime, cause changes to the naturally occurring protein collagen. As a result the whole structure of the skin, or a tendon or ligament, can become thicker and less flexible, and this may lead to, or aggravate, a range of musculoskeletal conditions.

If musculoskeletal conditions do develop then treatment options include resting the affected joint, physiotherapy, anti-inflammatory painkillers, steroid injections (to help reduce any inflammation, although these can raise blood sugars initially and therefore sugar levels should be monitored more frequently for 24hrs) and, in extreme cases, surgery. Ultrasound may also sometimes be beneficial - the reasons for this are not fully understood, but it is thought to help reduce inflammation.

Musculoskeletal conditions include limited joint mobility, Dupuytren's Contracture, carpal tunnel syndrome, tenosynovitis, frozen shoulder and Charcot joint.

Good blood glucose control can help reduce the risk of developing these types of disorder.


Treatment of Diabetes

Although diabetes cannot be cured, it can be treated very successfully.

Type 1 diabetes

This type of diabetes is treated by insulin injections and diet. Insulin cannot be taken by mouth because it is destroyed by the digestive juices in the stomach. People with this type of diabetes commonly take either two or four injections of insulin each day. Regular exercise is also recommended.

Type 2 diabetes

Type 2 diabetes is treated with lifestyle changes such as a healthier diet, weight loss and increased physical activity. Tablets and/or insulin may also be required to achieve normal blood glucose levels. There are several kinds of tablets for people with Type 2 diabetes. Some kinds help your pancreas to produce more insulin. Others help your body to make better use of the insulin that your pancreas does produce. Another type of tablet slows down the speed at which the body absorbs glucose from the intestine. Type 2 diabetes is progressive. If your diabetes cannot be controlled through lifestyle changes and tablets your doctor may recommend that you take insulin injections.

The main aim of treatment of both types of diabetes is to achieve blood glucose, blood pressure and cholesterol levels as near to normal as possible. This, together with a healthy lifestyle, will help to improve wellbeing and protect against long-term damage to the eyes, kidneys, nerves, heart and major arteries.


For further information and help on diabetes please visit Diabetes org.uk on our Further Information and Support Groups page.