What causes Diabetes ?
Type 1 Diabetes
Interspersed evenly throughout the pancreas, is a very specialized tissue, containing cells which make and secrete hormones. This tissue, called the "Islets of Langerhans" is named after the German pathologist Paul Langerhans, who discovered them in 1869. Through a microscope, Langerhans observed these cells cluster in groups, which he likened to little islands in the pancreas.
One such group of cells, the beta cells, produce insulin in response to blood glucose. These beta cells are tiny insulin factories that sense the level of glucose in the blood stream, and produce insulin in precise proportion to that level. Therefore, following a meal, blood sugar levels will rise significantly, and the beta cells will release a large amount of insulin. This insulin will cause body cells to take up the sugar, causing blood sugar to quickly return to its normal range. Once blood sugar is in the normal range, the beta cells will reduce the output of insulin to an idling state. In this way, the beta cells adjust their production of insulin on a minute-by-minute basis, always producing just enough insulin to deal with the amount of blood sugar presently in the blood stream.
In type 1 diabetes, the islets are destroyed by the person's own immune system, which mistakenly identifies these essential cells as foreign invaders. This self-destructive mechanism is the basis of many so-called autoimmune diseases. Once the islets are killed, the ability to produce insulin is lost, and the overt symptoms and consequences of diabetes begin.
Type 1 diabetes is a completely different disease than Type 2. Type 1 is an autoimmune disease of the insulin-producing beta cells of the pancreas. Scientists believe that it may be a virus that triggers the immune system to attack the cells and permanently destroy them. The pancreas can no longer make the insulin necessary to transport sugar from the blood into the other cells of the body for energy. Sugar builds up in the blood and over time can damage internal organs and blood vessels.
Insulin and Blood Sugar:
What does this mean to the person who is diagnosed? Someone who has Type 1 diabetes must take insulin everyday to survive. It becomes a delicate balance of finding the right amount of insulin necessary to keep the blood sugar level as close to normal as possible. The person with diabetes has to check their blood sugar levels often and then inject themselves with the correct amount of insulin to counteract the amount of sugar. This mimics the action of the pancreas.
Warning Signs for Type 1:
This can be an overwhelming process for the newly diagnosed person, especially since Type 1 diabetes typically strikes children and young adults, although adults age 40 and older, can get Type 1. The onset of the disease happens quickly. As the insulin stops being produced and the blood sugar rises, this causes hyperglycemia. Several warning signs appear. Increased thirst, increased urination, fatigue, weight loss and blurred vision are a few of the most noticeable signs of Type 1 diabetes.
Testing Blood Sugar:
Frequently testing blood sugar levels helps to let you know how much insulin you will need to keep your levels as near to normal as possible. The usual times to test are: before meals, before bedtime and maybe one to two hours after meals or a big snack. Also test before you exercise because exercise will lower blood sugar also, and you don't want your blood sugar to drop too low either. This is called hypoglycemia.
When and What to Eat:
For diabetes, when you eat is as important as what you eat. Eating meals that are approximately the same size and combination of carbohydrates and fats at the same time everyday helps to keep blood sugar regular and predictable. The best diet is one that is low in fat, low in salt and low in added sugars. Complex carbohydrates such as whole grains, fruits and vegetables are preferable over simple carbohydrates like sugary soft drinks and and candy.
Living a Healthy Life:
Until the 1920's, when insulin was first discovered, people usually died from Type 1 diabetes. Today with all the advances of medicine that are available, a person diagnosed with Type 1 diabetes can live a very normal, long life. There are many adjustments that need to made and skills that need to be learned, but these can be incorporated into a daily routine, and can become just as automatic as brushing your teeth. Working with your doctors and a nutritionist will give you the tools you need.
Type 2 Diabetes
Type 2 diabetes also called type 2 diabetes mellitus, adult-onset diabetes, non-insulin-dependent diabetes, or just diabetes is a common disorder that affects the way the body processes and uses carbohydrates, fats and proteins. Each of these nutrients is a source of glucose (sugar), which is the most basic fuel for the body. The clearest sign of diabetes is a high level of sugar in the blood.
Glucose enters your body's cells with the help of insulin, a hormone produced by the pancrease that acts like a gatekeeper. Without insulin, glucose cannot pass through the cell wall, and the cell must rely on less efficient fuels for energy. Type 2 diabetes occurs when your body's cells do not react efficiently to the insulin produced by the pancreas, a condition called insulin resistance. In people with insulin resistance, the pancreas first makes extra insulin to maintain a normal blood sugar. Eventually, as the body's insulin resistance progresses, the pancreas is unable to keep up with the demand for more and more insulin, and blood glucose levels rise.
About 95% of people with diabetes have type 2 diabetes. It runs in families and most often affects people who are older than 40. With the rise in obesity in the United States in the last decade, type 2 diabetes is now seen in greater numbers in younger people, particularly African-Americans, Hispanics, and American Indians. Obesity, especially in the abdomen and at the waistline, greatly increases the risk of diabetes.
Diabetes with insulin resistance (type 2 diabetes) is one of several conditions known as metabolic syndrome when they occur together. Metabolic syndrome, originally called syndrome X, is a set of problems that increase the risk of heart disease and stroke. The conditions that combine to create metabolic syndrome include obesity, insulin resistance with elevated blood sugar, increased blood levels of insulin (hyperinsulinemia), high blood pressure, elevated levels of triglycerides, and low levels of high-density lipoprotein (HDL) cholesterol (the "good" cholesterol). These problems commonly occur together and are related to each other by a genetic or metabolic link. Both the metabolic syndrome and type 2 diabetes increase the risk of heart disease, stroke and peripheral artery disease.
The symptoms of diabetes are related to high blood glucose levels. They include:
- Excessive urination, thirst and hunger
- Weight loss
- Increased susceptibility to infections, especially yeast or fungal infections of the skin and vagina
Extremely high blood sugar levels can lead to a dangerous complication called hyperosmolar syndrome, also known as hyperosmolar hyperglycemic nonketotic syndrome (HHNS), hyperosmolar hyperglycemic state (HHS), or hyperosmolar coma. Hyperosmolar syndrome is a life-threatening form of dehydration that can result from untreated high blood sugar levels. Hyperosmolar syndrome can complicate a severe acute illness, such as a stroke; it can also happen when poor fluid intake triggers dehydration. In some cases, hyperosmolar coma is the first sign that a person has type 2 diabetes. This dangerous condition causes confused thinking, weakness, nausea or more extreme symptoms such as seizure and coma.
When people with type 2 diabetes take medications to reduce blood sugar, sugar levels may drop below the normal range and cause low blood sugar (hypoglycemia). Symptoms of hypoglycemia include sweating, trembling, dizziness, hunger and confusion. Hypoglycemia that you do not recognize and correct can lead to seizures and loss of consciousness. You can correct hypoglycemia by eating or drinking something with carbohydrates, which raises your blood sugar level.
Type 2 diabetes affects all parts of the body and can cause serious, potentially life-threatening complications, including:
- Atherosclerosis Metabolic syndrome and type 2 diabetes are associated with fat buildup in the artery walls. This can impair blood flow to the all the organs. The heart, brain and legs are most often affected.
- Retinopathy Tiny blood vessels at the back of the eye become damaged by high blood sugar. Caught early, retinopathy damage can be minimized by keeping tight control of blood sugar and by using laser therapy. Untreated retinopathy can lead to blindness.
- Neuropathy This is nerve damage. The most common type is peripheral neuropathy. The longest nerves in the body, the ones to the legs, are damaged first, causing pain and numbness in the feet. This can advance to cause symptoms in the legs and hands. Autonomic neuropathy is damage to the nerves that control vital autonomic functions, such as digestion, sexual function and urination.
- Foot problems Sores and blisters occur for two reasonsA: 1) If peripheral neuropathy causes numbness, the person will not feel an irritation or pressure point in the foot. The skin can break down and form an ulcer. 2) Blood circulation can be poor, leading to slow healing. Left untreated, a simple sore can become infected and very large.
- Nephropathy Damage to the kidneys is more likely if blood sugars remain elevated and high blood pressure is not treated aggressively.
Diabetes is diagnosed by testing the blood for sugar levels. Blood is taken in the morning after you have fasted overnight. Typically, the body keeps blood sugar levels between 70 and 100 milligrams per deciliter (mg/dL), even after fasting. If a blood sugar level after fasting is greater than 125 mg/dL, diabetes is diagnosed.
Your doctor will examine you to look for signs that you have complications or risk factors that increase the risk of complications. These include:
- Obesity, especially abdominal obesity (waist circumferences greater than 40 inches in men or 35 inches in women)
- High blood pressure
- Deposits or areas that have leaked blood on your retina, seen through an instrument called an ophthalmoscope during an eye examination
- Decreased sensation in the legs
- Weak pulses in the feet or abnormal pulses in the abdomen
- Blisters, ulcers or infections of the feet
Laboratory tests used routinely to evaluate diabetes include:
- Fasting glucose, a test of your blood sugar level after you have not eaten for several hours
- Hemoglobin A1C, which indicates how close to average your blood glucose has been during the previous two months
- Blood creatinine and urine microalbumin for evidence of kidney disease
- Lipid profile (cholesterol, triglycerides, high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol) to evaluate the risk of atherosclerosis
Diabetes is a lifelong illness. Aging and episodic illness can cause the body's insulin resistance to increase, so additional treatment typically is required over time.
You can help to prevent type 2 diabetes by maintaining your ideal body weight, especially if you have a family history of diabetes. Diet and exercise have been shown to delay the onset of diabetes in people who are in the early stages of insulin resistance, identified by borderline blood sugar levels. The medication metformin (Glucophage) offers some additional protection for people with blood glucose levels that are between 100 and 125 mg/dL, near the diabetes range. People with blood sugar levels in this range sometimes are said to have pre-diabetes.
If you already have type 2 diabetes, you can delay or prevent complications by keeping tight control of your blood sugar. You can lower your risk of heart-related complications by taking an aspirin daily, and by aggressively managing other risk factors for atherosclerosis, such as high blood pressure, high blood levels of cholesterol and triglycerides, cigarette smoking and obesity. Yearly visits with an eye doctor and a foot specialist (podiatrist) are recommended to reduce eye and foot complications.
In most people with type 2 diabetes, treatment begins with weight reduction through diet and exercise. A healthy diet for a person with diabetes is low in cholesterol, low in total calories, and nutritionally balanced with abundant amounts of whole-grain foods, monounsaturated oils, fruits and vegetables. A daily multivitamin is recommended for most people with diabetes.
Type 2 diabetes can be controlled with medications taken by mouth (oral medications) or injected medicine (usually insulin, although insulin is not the only injected medicine that can be used for diabetes). Medicines for type 2 diabetes include:
- Metformin (Glucophage), which improves insulin resistance in the muscle tissues and liver
- Sulfonylureas, including glyburide (DiaBeta, Glynase, Micronase), glipizide (Glucotrol), and others, which increase the amount of insulin made and released by the pancreas
- Repaglinide (Prandin) and nateglinide (Starlix), which cause a burst of insulin release with each meal
- Thiazolidinediones, including rosiglitazone (Avandia) and pioglitazone (Actos), which decrease the conversion of fat to glucose, and which improve insulin resistance
- Acarbose (Precose) and miglitol (Glyset), which delay the absorption of sugars from the intestine
- Exanatide (Byetta) and pramlintide (Symlin), which slow your digestion and reduce your appetite for large meals, making blood sugar more manageable Exanatide also causes a burst of insulin to be released from your pancreas with each meal. These medicines are both available by injection only.
- Insulin, which adds to your own insulin supply When you have enough insulin, you can adequately process glucose despite having insulin resistance.
About one out of three people with type 2 diabetes use injectable insulin regularly. Insulin often is used in small doses before bed to help to prevent the liver from producing and releasing glucose during sleep. In advanced type 2 diabetes, or for people who want to tightly control glucose levels, insulin may be needed more than once per day and in higher doses. Treatment plans that include very long-acting glargine insulin (Lantus) and very short-acting lispro insulin (Humalog) or aspart insulin (Novolog), are frequently the most successful ways for people with type 2 diabetes to control their blood sugar. To accommodate eating patterns that vary, doses of very short-acting insulin can be adjusted depending on the amount of carbohydrates taken in with each meal.
Medications used to treat type 2 diabetes can have side effects. The major side effects of sulfonylureas, repaglinide, nateglinide and insulin are low blood sugar levels (hypoglycemia) and weight gain. The most common side effects of metformin are nausea and diarrhea, but these are less likely to happen if the drug is taken with meals. Metformin should not be used in people with kidney failure because of the risk of a life-threatening buildup of lactic acid in the blood. Rosiglitazone and pioglitazone frequently cause weight gain and can cause leg swelling or worsen heart failure. They also may cause inflammation of the liver, so liver tests should be monitored. Acarbose, which is taken before each meal, can cause excessive gas and bloating, as can other medicines that slow digestion.
Medicines are also available to reduce the risk of complications, or the rate at which complications develop. People with diabetes who have early signs of kidney damage benefit from medicines called ACE inhibitors, including lisinopril (Prinivil, Zestril), enalapril (Vasotec), benazepril (Lotensin) and others, or medicines called angiotensin receptor blockers, including losartan (Cozaar), valsartan (Diovan) and others). These medicines slow the worsening of kidney disease.
All diabetics should consider taking medication to lower their cholesterol, particularly those who have low-density lipoprotein (LDL) cholesterol levels above 100 mg/dL. Cholesterol medicines include statin drugs such as atorvastin (Lipitor), simvastin (Zocor), lovastatin (Mevacor) or pravastatin (Pravachol) and other cholesterol treatments such as gemfibrozil (Lopid) or fenofibrate (TriCor).
Diabetics with blood pressure greater than 130/80 mm/Hg should use medication to control blood pressure if blood pressure can't be improved by exercise and a low-salt diet.
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