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(2) Diabetes

All about diabetes

There are two main types of people with diabetes:

Type 1 – this type of diabetes usually appears in younger people under the age of 40. It is treated by insulin injections and diet;

Type 2 – this type of diabetes usually appears in people over the age of 40. They may have had undetected diabetes for many years and may not feel particularly unwell.

Diabetes in older people is often discovered by chance and commonly responds well to diet or tablets, although in due course insulin and diet may be needed.

There are other rare types of diabetes, which we also mention later on. Someone with diabetes might feel before the condition is diagnosed and treated. Once treatment has been started, people with diabetes should feel perfectly well. We also make the point that older people may have diabetes and yet feel quite well in themselves. In such cases the condition will be discovered following a routine blood or urine test for glucose, and diabetes may therefore exist for many years without being discovered.

Unfortunately undetected diabetes over a period of years may lead to complications affecting eyes, nerves and blood vessels.

What is diabetes?

 The pancreas is a gland situated in the upper part of your abdomen and connected by a fine tube to your intestine. One of its functions is to release digestive juices, which are mixed with food soon after it leaves your stomach. These are needed for digestion and absorption of food into your body. This part of the pancreas has nothing to do with diabetes. Your pancreas also produces a number of hormones, which are released directly into your bloodstream, unlike the digestive juices which pass into the intestine. The most important of these hormones is insulin, the shortage of which causes diabetes. The other important hormone produced by the pancreas is glucagon, which has the opposite action to insulin and may be used in correcting serious hypos. Both hormones come from a part of your pancreas known as the islets of Langerhans.

 Why does my body need insulin?

 Without insulin the body cannot make full use of food that is eaten. Normally, food is eaten, taken into the body and broken down into simple chemicals, such as glucose, which provide fuel for all the activities of the body. These simple chemicals also provide building blocks for growth or replacing worn-out parts, and any extra is stored for later use. In diabetes, food is broken down as normal but, because of the shortage of insulin or because insulin does not work properly, excess glucose is not stored and builds up in the bloodstream, spilling over into the urine. Insulin ensures that a perfect balance is kept between the production of glucose by the liver and its use. The breakdown of food takes place in the liver, which can be regarded as a food processing factory. Glucose is one of the simple chemicals made in the liver from all carbohydrate foods. In the absence of insulin, glucose pours out of the liver into the bloodstream. Insulin switches off this outpouring of glucose from the liver and causes glucose to be stored in the liver as

starch or glycogen. Insulin also helps glucose to get into cells where it is used as a fuel. Insulin has a similar regulatory effect on amino acids and fatty acids, which are the breakdown products of protein and fat respectively.

Question: What happens to the insulin production in diabetes?

Answer: In people without diabetes, insulin is stored in the pancreas and released into the blood as soon as the blood glucose level starts to rise after eating. Insulin is released straight into the liver where it has the important role of regulating glucose production and promoting the storage of glucose as glycogen. The level of glucose in the blood then falls and, as it does so, insulin production is switched off . Thus people who do not have diabetes have a very sensitive system for keeping the amount of glucose in the blood at a steady level. In diabetes this system is faulty. People with Type 2 diabetes can still produce some insulin but not in adequate amounts to keep the blood glucose level normal. This is because their insulin does not work properly (a condition called ‘insulin resistance’). People with Type 1 diabetes have little or no insulin of their own and need injections of insulin to try to keep the blood glucose level normal. Even if given four or five times a day, an injection of insulin is not as efficient at regulating blood glucose as the pancreas, which responds to small changes in blood glucose by switching the insulin supply on or off at a moment’s notice.

There are three main factors affecting your blood glucose:

food (which puts it up)

insulin

exercise (which both bring it down).

Any form of stress, in particular an illness like ’flu, puts up your blood glucose. Learning how to balance your blood glucose level is a matter of trial and error. This involves taking a lot of measurements and discovering how various foods and forms of exercise affect your blood glucose.

In the past, people with Type 1 diabetes were brought into hospital to be ‘stabilized’ on a certain dose of insulin. Experience has shown that the insulin needed in the artificial surroundings of a hospital ward bears little relation to the amount needed in someone leading an active life in the outside world. Nowadays, you can ‘stabilize’ your own diabetes at home yourself.

Types of diabetes

I hadn’t realised that there were different types of diabetes until was diagnosed with what my GP called Type 2. What is the difference between my diabetes and Type 1 diabetes? Diabetes does exist in many different forms. Two main groups are recognized:

Type 1 diabetes is found in younger people under 40 years old. This condition develops in a dramatic way and insulin injections are nearly always needed. About 1 in 10 of all people with diabetes fall into this category, which used to be called insulin dependent diabetes.

• At the other end of the scale Type 2 diabetes occurs in older people, who often are overweight, and have less obvious symptoms. Obesity is linked to insulin resistance, which is a root cause of Type 2 diabetes. Insulin resistance occurs many years before diabetes itself begins. At the onset of Type 2 diabetes, treatment is with diet with or without tablets. After a few years, people with Type 2 diabetes may need to use insulin.

There are plenty of exceptions to this rule. Occasionally young people can be well controlled with diet or tablets and a large number of people who develop diabetes late in life are much better off on insulin injections.

Question: I have been told that I have diabetes insipidus? Is this the same as the diabetes that my friend’s elderly father has?

Answer: The only connection between diabetes insipidus and the more common form of diabetes (where the full name is diabetes mellitus) is that people with both conditions pass large amounts of urine. Diabetes insipidus is a rare condition caused by an abnormality in the pituitary gland and not the pancreas. One disorder does not lead to the other, and diabetes insipidus does not carry the risk of long-term complications found in diabetes mellitus.

Question: My wife has just given birth to a baby boy who weighed 4.3 kg (9 lb) at birth. Apparently she may have had diabetes while she was pregnant. Is this likely to happen again with her next baby?

Answer: Women who give birth to heavy babies (over 4 kg or 9 lb) may have had a raised blood glucose level during pregnancy. This extra glucose crosses into the unborn baby, who responds by producing extra insulin of its own. The combination of excess glucose and excess insulin makes the unborn baby grow fat and bloated. After birth the baby is cut off from the high glucose input and then runs the risk of a low glucose concentration (hypoglycaemia). Overweight babies of mothers with diabetes are at risk of hypoglycaemia. Women who develop diabetes during pregnancy and return to normal after delivery have a condition called gestational diabetes. Once the problem has been identified, it is very likely to recur during subsequent pregnancies. Provided that glucose levels are kept within normal limits (insulin may be needed for this), the baby will be a normal weight and will not be at risk. Women who have diabetes during pregnancy are more likely to develop diabetes later in life. 17.01.2012

Causes of diabetes

Despite a vast amount of research throughout the world the cause of diabetes is not known. Some families carry an extra risk of diabetes and the disease may follow an infection such as a cold.

 Question: Why have I got diabetes?

The short answer is that your pancreas is no longer making enough insulin for your body’s needs. The long answer as to why this has happened to you is not so well understood but there are a few clues. Diabetes often runs in families. It is not a rare condition and in the European Union, about 3 people in 100 are known to have diabetes, with an equal number of people who have diabetes but are unaware of it. If a whole population is carefully screened for diabetes, many new people with diabetes are discovered, usually 1 new one for every known one. About 3 children per 1000 have diabetes and the risk is increasing, particularly in young children below the age of 5 years.

 Question: Could diabetes be triggered by a virus?

Answer: Some scientists used to suspect that a certain virus could be the cause of diabetes in young people but proof is lacking and this theory now seems very unlikely. There is certainly no ‘diabetes virus’ and you cannot catch diabetes like chickenpox. There is no suggestion that diabetes in older people could be caused by a virus infection.

 Question: I was very overweight when I was diagnosed with diabetes. Can this have caused my diabetes?

Answer: If the tendency or genetic makeup towards diabetes is present, then being obese (or even just overweight) may bring on the disease. This is because being overweight, particularly carrying all about diabetes excess fat around the abdomen (central obesity), stops insulin from lowering blood sugar properly (called insulin resistance). This is the common cause of diabetes in middle-aged or older people and is generally rare in young people. However, in parts of the western world where young people are often very obese, Type 2 diabetes is becoming common in children. In most cases this type of diabetes can be controlled at first by dieting and weight loss. Many people with diabetes who are overweight find it hard to lose weight; others find that strict dieting alone is insufficient to lower the blood glucose and have to take tablets or have insulin injections. This is second best, as the sensible and safe treatment for an overweight older person is weight loss.

 Question: Is diabetes a disease of modern times?

Answer: The earliest detailed description of diabetes was made 2000 years ago but it is much more common now than in the past. This is particularly true of Type 2 diabetes, which is becoming very common in some countries such as India. Diabetes in younger people is also becoming more common, and this has been related to increasing affluence and obesity.

 Question: My mother died very suddenly last year and not long afterwards I was diagnosed with diabetes. Can a bad shock bring on diabetes?

Answer: Sometimes diabetes develops soon after a major disturbance in life, such as bereavement, a heart attack or a bad accident, and the diabetes is blamed on the upset. This is not really the case, as insulin failure in the pancreas takes a long time to develop. However, a bad shock could stress your system and bring on diabetes a bit earlier if your insulin supply is already running low.

Question: I was very ill last year and developed diabetes, which has since got better. Can a severe illness cause diabetes?

Answer: Any serious medical condition (such as a heart attack or injuries from a traffic accident) can lead to diabetes. This is because the hormones produced in response to stress tend to oppose the effect to insulin and cause the glucose level in the blood to rise. Most people simply produce more insulin to keep the blood glucose stable. However, in some cases, if the reserves of insulin are inadequate, the blood glucose level will climb. You had temporary diabetes, and the glucose level returned to normal once your stress was over. However, you will carry an increased risk of developing permanent diabetes later in life.

 Question: My latest baby was very big at birth. Would she have caused me to have developed diabetes?

Answer: No, the opposite is true. In any woman who has given birth to a baby weighing more than 4 kg (9 lb), the possibility of diabetes should be considered by her doctors or midwives. If you had diabetes during pregnancy but recovered soon after your baby was

born, you will carry an increased risk of diabetes for the rest of your life. The baby itself does not carry this risk.

Question: Was there anything I should have done to prevent my diabetes?

Answer: No. At the present time, if you are going to get diabetes, you get diabetes. It is possible, under certain circumstances, to identify some people who do not have diabetes but who have a very high risk of developing it in the future. Various drugs have been tried to prevent diabetes in these high-risk people, but so far with no lasting success. In the case of Type 2 diabetes, a strict programme of exercise and weight loss has been shown to delay the onset of diabetes.

 Question: My doctor said that the drugs I am taking for asthma might have caused my diabetes. Is this true?

Answer: Yes, several drugs in common use can either precipitate diabetes as an unwanted side effect or make existing diabetes worse. The most important group of such medicines are hormones. Hormones are substances produced by special glands in the body and insulin from the pancreas is an example of a hormone. Some hormones have an anti-insulin effect and one of these, a steroid hormone, is often used to treat such medical conditions as severe asthma or rheumatoid arthritis. The most commonly used steroid is prednisolone, which opposes insulin and therefore puts up the level of glucose in the blood. Steroids in large doses will often precipitate diabetes, which usually gets better when the steroids are stopped. The contraceptive pill is another type of steroid hormone with a mild anti-insulin effect. Sometimes people on insulin find that they have to give themselves more insulin while taking the pill. Glucagon is a hormone from the pancreas with a strong ant insulin effect. It is used to correct a severe insulin reaction.

Apart from other hormones, certain medicines, such as water tablets (diuretics) may have an anti-insulin effect and precipitate diabetes.

 Question: I have recently been given steroid treatment (prednisolone) for severe arthritis. My joints are better but my doctor has now found sugar in my urine and tells me I have diabetes. Is this likely to be permanent?

Answer: Steroids are effective treatment for a number of conditions but they may cause  side effects, as you have just discovered. One of these is to cause diabetes, which can sometimes be controlled with tablets (e.g. gliclazide). However if large doses of steroids

are being used, people often need insulin to control the blood glucose. When you stop steroid therapy, there is a good chance that the diabetes will go away completely. However, you may have had diabetes without knowing it before you started on steroids, in which case you will continue to have diabetes after stopping steroids and will need to continue some form of treatment indefinitely.

 Question: I am told that other hormones that the body produces, apart from insulin, may cause diabetes. Is this true?

 Answer: It is a deficiency of enough insulin to meet demand that leads to diabetes. Sometimes excessive amounts of other hormones will tend to push the blood sugar levels up. If the body cannot respond with enough extra insulin, diabetes may result. Thus someone who produces too much thyroid hormone (‘thyrotoxicosis’ or ‘hyperthyroidism’) may develop diabetes, which clears up when their thyroid is restored to normal. Thyrotoxicosis and diabetes tend to run together in families, and people with one of these conditions are more likely to develop the other. Sometimes a person will produce excessive quantities of steroid hormones (Cushing’s disease or Cushing’s syndrome), and this may lead to diabetes. Acromegaly is a condition where excess quantities of growth hormone are produced and this too may lead to diabetes.

 Question: I have had to go to hospital for repeated attacks of pancreatitis and now have diabetes. I am told that these two conditions are related – is this true?

 Answer: Pancreatitis means that your pancreas has become inflamed and this can be a very painful and unpleasant illness. The pancreas is the gland that produces insulin as well as other hormones and digestive juices. If it is severely inflamed or damaged, it may not be able to produce enough insulin. Sometimes diabetes develops during or after an attack of pancreatitis and tablets or insulin are needed to keep control of the blood glucose. This form of diabetes is usually, but not always, permanent.

 What other diseases would increase the chances of getting diabetes?

There are four groups of such diseases:

Glandular disorders, in particular thyrotoxicosis (overactive thyroid), acromegaly (excess growth hormone) and Cushing’s disease (excess steroid hormone) (see an

earlier question).

Diseases of the pancreas, including pancreatitis, cancer of the pancreas, iron overload (haemochromatosis) and cystic fibrosis (a serious inherited childhood disorder); surgical removal of the pancreas (for either pancreatitis or cancer) also causes diabetes.

Virus diseases, such as rubella (German measles), mumps and Coxsackie virus can be very rare causes of diabetes.

Medical problems, such as heart attacks, pneumonia and major surgical operations put stress on the body; the diabetes usually clears up when the stress is removed but these individuals may be more at risk of diabetes. 

 Symptoms

 Question: Why does someone of my son’s age (he is 11) feel thirsty when diabetes is first discovered?

Answer: The first signs of diabetes in a young person are thirst and loss of weight. These two symptoms are related and one leads to the other (we deal in more detail with weight loss in the answer to the next question). The first thing to go wrong is the increased amount of urine. Normally we pass about 11⁄2 litres (approximately 2 pints) of urine per day but people with uncontrolled diabetes may produce five times that amount. The continual loss of fluid dries out the body and the sensation of thirst is a warning that, unless they drink enough to replace the extra urine, they will soon be in trouble.

Of course people who do not have diabetes may also pass large amounts of urine. Every beer drinker knows the effects of 5 pints of best bitter! In this case the beer causes the extra urine, whereas in diabetes the extra urine causes the thirst. In the early

stages, the resulting thirst is usually mild and most people fail to realize its significance unless they have had some personal experience of diabetes. Someone with undiagnosed diabetes may take jugs of water up to bed, wake in the night to quench their thirst and pass urine, and still not realize that something is wrong. It would be helpful if more people knew that unexplained thirst may be due to diabetes.

 Question: I had lost quite a lot of weight before I was finally diagnosed with diabetes. Why was this?

Answer: The main fuel for the body is glucose, which is obtained from the digestion of sugary or starchy food. People with untreated diabetes have too much glucose in their bloodstream and this glucose overflows into the urine and also cannot properly use the sugar to provide energy and build tissues. Body tissues are broken down to form glucose and ketones, and this causes weight loss. Someone who has uncontrolled diabetes may lose as much as 1000 g (just over 2 lb) of glucose (sugar) in their urine in 24 hours. Anyone trying to lose weight knows that sugar = calories. These calories contained in the urine are lost to the body and are a drain on its resources. The 1000 g of glucose lost are equivalent to 20 currant buns (4000 calories per day).

 Question: My vagina has been really itchy and sore. My family doctor says it’s to do with my diabetes. Can this be right?

Answer: A woman whose diabetes is out of control may be troubled by itching around her vagina. The technical name for this distressing symptom is pruritus vulvae. The equivalent complaint may be All about diabetes seen in men when the end of the penis becomes sore (balanitis). If the foreskin is also affected, it may become thickened (phimosis), which prevents the foreskin from being pulled back and makes it difficult to keep the penis clean.

These problems are the result of infection from certain yeasts, which thrive on the high concentration of glucose in this region. If you keep your urine free from glucose by good control of your diabetes, the itching and soreness will normally clear up. Anti-yeast cream from your doctor may speed up the improvement but this is only a holding measure while glucose is cleared from your urine.

 Question: I have had blurred vision for weeks now. Can my eyesight be affected early on in diabetes?

Answer: The lens of the eye is responsible for focusing the image on the retina. Blurred vision is usually a temporary change, which can be corrected by wearing glasses. The lens of the eye becomes swollen when diabetes is out of control and this leads to short-sightedness. As the diabetes comes under control, so the lens of the eye returns to normal. A pair of glasses fitted for a swollen lens at a time of uncontrolled diabetes will no longer be suitable when the diabetes is brought under control. If you have been newly diagnosed with diabetes and find that you have blurred vision, you should wait for a few months after things have settled down before visiting an optician for new spectacles. The blurred vision may improve on its own and new glasses may not be needed.

Most of the serious eye problems caused by diabetes are due to damage to the retina (retinopathy). The retina is the ‘photographic plate’ at the back of the eye. Even minor changes in the retina take several years to develop but older people may have diabetes for years without being aware of it. In such cases the retina may already be damaged by the time diabetes is diagnosed.

In very rare cases the lens of the eye may be permanently damaged (cataract) when diabetes is badly out of control.

 Question: Can diabetes be discovered by chance?

Answer: Yes, but this usually happens only in Type 2 diabetes. In Type 1 diabetes the diagnosis is usually made because someone feels unwell and goes to the doctor. In older people with no obvious medical problems, diabetes is often discovered as a result of a routine urine test – say in the course of an insurance examination. Once the diagnosis is made, the person may admit to feeling slightly thirsty or tired, but these symptoms may not be very dramatic, and are often put down to ‘old age’. So, in older people, diabetes may appear to be a minor problem, but must be taken very seriously as so-called ‘mild’ diabetes can lead to serious problems. In any case, people often feel better with more energy once diabetes is controlled, often by diet or by diet and tablets, although in the long run insulin injections may be needed.

 Question: I have been told that I have ‘fatty liver’. Did my diabetes cause this and is there anything one can do to help reverse the situation?

Answer: Your liver may become enlarged in cases of poorly controlled diabetes, owing to an accumulation of fat within the substance of the liver. Insulin plays an important part in the metabolism of fat and, when the insulin supply is deficient, the levels in the blood of both glucose and fat may become very high. It is also thought that, when insulin does not work properly (insulin resistance), this fat is much more likely to be laid down in the liver.

‘Fatty liver’ is more common in children and young people with poorly controlled diabetes and sometimes the liver may become greatly enlarged. The only treatment is to improve control of the diabetes, following which the liver will steadily shrink back to its normal size.

Inheritance

 Question: My father had diabetes. Am I likely to get it too?

 Answer: Diabetes is a common disorder in European Union member states and United States and is diagnosed in about 3 in 100 people – in fact it probably affects about 5 in 100 people, because it hasn’t been diagnosed yet. So in any large family more than one person may be affected, simply by chance alone. However, certain families do seem to carry a very strong tendency for diabetes. The best example of this is a whole tribe of Native Indians (the Pima): over half of its members develop diabetes by the time they reach middle age.  Genes are the parts of a human cell that decide which characteristics you inherit from your parents. The particular genes that you get from each parent are a matter of chance – in other words, hither you grow up with your father’s big feet or your mother’s blue eyes. Similarly it is a matter of chance whether you pass on the genes carrying the tendency for diabetes to one of your children. It is only the tendency to diabetes that you may pass on – the full-blown condition will not develop unless something else causes the insulin cells in the pancreas to fail.

Question: If diabetes is known to be in my family, should I or my children take any preventive action?

Answer: The inheritance of diabetes is a complicated subject – indeed different sorts of diabetes appear to be inherited in different ways. For instance, a tendency for one sort of diabetes (Type 1) can be inherited, but only a small proportion of the people who inherit this tendency will go on to develop diabetes. It is now possible to tell if these people at risk have inherited the family of relevant genes, and to a certain extent their chances of developing diabetes can be predicted. In practice these tests are only carried out when people are taking part in a research project.

The more common Type 2 diabetes, often treated by diet or by diet and tablets, is only rarely associated with known single gene abnormality but it is thought to be strongly inherited in many cases. Although there is a great deal more to learn about it, there may be several different subtypes which cannot be distinguished from one another – all inherited in different ways. We know that many of these people are overweight and that obesity not only makes diabetes worse but it may even lead to its appearance in susceptible people.

There is now evidence that family members who are at risk may put off developing diabetes by taking regular exercise and dieting to lose weight. They should have a blood glucose test as soon as they develop any relevant symptoms, so that the diabetes can be detected and treated early.

Question: I am 16 and have had diabetes for 5 years. Why has my identical twin brother not got diabetes?

Answer: A large study has been carried out in which examples of identical twins with diabetes have been collected for over 20 years. These results show a difference between Type 1 and Type 2 diabetes. If you have an identical twin with Type 1 diabetes, you have only a 50% chance of developing diabetes yourself. On the other hand, if you had Type 2 diabetes (extremely unusual at the age of 11) your twin would be almost 100% certain to get the same sort of diabetes. In your case if your twin brother has not developed diabetes within the last 5 years, he has a very low risk of developing the condition.

In younger people there is usually no choice and they need to start insulin injections fairly soon, but in older people found to have diabetes, the eventual form of treatment that they will need may not be obvious at the outset. Provided that they are not feeling terribly ill, they are usually given advice to change the type and quantity of food that they eat. This alone may have a dramatic effect on their condition, especially in overweight people who manage to get their weight down. If changing the diet fails to control diabetes, tablets are usually tried next by adding them to the diet. These may be very effective but tablets do not always work and in such cases insulin is the only alternative

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