Health Topics - Diabetes

Big thank you to Lenore Hernandez member and diabetes nurse who submitted the following info on all types of diabetes. Below is a very informative article on each common type of diabetes, symptons and coping mechanims. Thank you Lenore !

Gestational Diabetes
Gestational diabetes is a common problem and complicates 2-5% of all pregnancies in the United States. You are more likely to develop gestational diabetes if you have a family history of Type 2 Diabetes, are of advanced maternal age (35 years old and greater), obese, expecting multiples and of non-white ethnicity.

Glucose testing is recommended for women in all high-risk groups and should be done as early as feasible. A fasting blood glucose of 105 and greater is associated with fetal death during the last 4-8 weeks of gestation. Gestational diabetes is also associated with an increase in hypertension disorders.

Classifications of Diabetes in Pregnancy
Class A Gestational Diabetes
Class B Onset at > or equal to 20 years of age and <10>20 years’ duration
Class F Diabetic Nephropathy (kidney disease related to diabetes)
Class R Proliferative Retinopathy (eye disease related to diabetes)
Class FR Nephropathy and proliferative retinopathy
Class H Coronary Artery Disease
Class T Renal Transplant


Monitoring a Pregnancy Complicated by Diabetes
Class A:
Daily self-monitoring of blood sugars (fasting and 1-2 hours after meals).
Serial ultrasound examinations in the third trimester
Nonstress test at 34-36 weeks then weekly
HgbA1C every 4-6 weeks (lab test for 3 month average on blood sugars)
Daily fetal movement counts

Class B and C:
Daily self-monitoring of blood sugars (5-7 times/day)
Ultrasound and fetal electrocardiogram at 20 weeks then follow-up every 4-6 weeks
HgbA1C every 4-6 weeks
Nonstress test at 32 weeks then weekly
Ophthamologic evaluation
24 hour urine collection initially and in each trimester
Daily fetal movement counts beginning at 28 weeks’ gestation

Classes D to FR
All of the above plus initial electrocardiogram
Check blood tests: uric acid, liver function, fibrinogen (assesses the ability of the body to fort clots), fibrin split products (may repeat in each trimester)


The main goal for management of pregnancies complicated by diabetes is to maintain healthy levels of blood sugars throughout the gestational period. The treatment involves medical nutrition therapy, exercise, insulin and frequent blood sugar checks. The goals of nutrition therapy are to provide adequate maternal and fetal nutrition, achieve appropriate gestational weight gain and control blood sugars. In Gestational Diabetes, it is generally accepted that carbohydrate intake should not exceed 40-45% of total calories.

Regular aerobic exercise has been shown to lower both before and after meal blood sugars. Several studies have indicated that upper extremity exercise for 20 minutes 3 times a week can significantly lower blood sugars. This has not shown to increase the risk of pregnancy complications.

Insulin is the only current medication used to treat diabetes during pregnancy. The goal of insulin therapy is to achieve blood glucose levels that are nearly identical to those observed in healthy pregnant women. Diabetes control is mainly monitored through checking blood sugars.
Recommended blood sugar levels for pregnancy are:
60-90 before breakfast, lunch, dinner and bedtime snack. Less then 120 1 hour after meals and 60-90 overnight (2 am – 6 am)

After delivery, blood sugars decrease due to the decrease in placental hormones. Women with type 1 diabetes may need very little insulin for up to 48 hours after the delivery. Women with type gestational diabetes may no longer require insulin after delivery. If blood sugars continue elevated after delivery, the mother will require medication/insulin to control her blood sugars. Women who breast feed are more likely to need less insulin than mothers who do not breast feed. Education on preventing low blood sugars should be provided. Additional blood sugar checking and snacks may be required before, during and after breast feeding.

For women with gestational diabetes, the goal is prevent type 2 diabetes. Because of the high risk of developing type 2 diabetes after gestational diabetes, women should have their glycemic status retested at least 6 weeks after delivery. The risk of gestational diabetes occurring in subsequent pregnancies has been reported to be 60-90%.

Type 2 Diabetes
Type 2 diabetes affects 90-95% of all people with diabetes. Because elevated blood sugars develop slowly over time, many people do not have symptoms and may have had diabetes for up to 10 years before diagnosis. Type 2 diabetes is most common in obese people who are older than 45 years of age. However, due to the increasing rate of obesity in the United States, we are seeing Type 2 diabetes in children as young as 10 years old.

If glucose is to be used or stored efficiently in the body, the pancreas must secrete sufficient insulin and that insulin needs to be used properly by the body. Type 2 diabetes often has three components, insufficient production of insulin by the pancreas, insulin resistance (the body not utilizing the insulin well) in the muscle, adipose cells and liver and an overproduction of glucose from the liver.
Modest weight loss (5-10% of weight) in overweight adults reduces the risk of developing diabetes. Weight loss and regular physical activity are primary treatment strategies with Type 2 Diabetes. Weight loss leads to a decreased need for medications and improvement in blood sugar control. Awareness of carbohydrate types and amounts are integral part of blood sugar control. Carbohydrates are important for a well balanced diet but excessive amounts, coupled with diabetes, leads to issues with blood sugar control.
Carbohydrates are:
Milk
Yogurt
Fruit
Bread
Rice
Noodles
Cereal
Tortillas
Beans
Peas
Corn
Winter squash
Concentrated sweets
Blood sugar goals for Type 2 Diabetes are 90-130 before meals/fasting and 160 or less 2 hours after meals/bedtime

There are many oral medications on the market that work in different ways to lower the blood sugar. It is not unusual for a person with type 2 diabetes to have several types of diabetes medications prescribed to them. It is also not unusual to have insulin prescribed in addition to oral medications. Type 2 diabetes is chronic and progressive – by the time a person is diagnosed with diabetes, their beta cell function (the cells in the pancreas that make insulin) is usually decreased by 50% - 6 years after diagnosis the Beta Cell function is decreased by 75%.

Complications Related to Uncontrolled Diabetes

Heart Disease: Blood Pressure should be controlled to 130/80 or less and low density lipoproteins less than 100 for heart attack and stroke prevention. Daily aspirin of 81 mg suggested as well.

Retinopathy: Retinopathy is the leading cause of new blindness in Americans aged 20-74 – up to 90% of diabetes related blindness is preventable. It is recommended that all Type 2 Diabetics have a yearly Retinal Screening to detect retinopathy.

Nephropathy: Approximately 20 million Americans have kidney disease. In 2000, there were nearly 400,000 people who had kidney failure that required dialysis or a kidney transplant. This figure is expected to double by this year (2010). Diabetes accounts for as much as 40% of all new cases of kidney failure.

Neuropathy: Peripheral neuropathy starts with numbness and tingling/pain in either/or hands and feet. Nerves can also be effected that control the movement of food through the intestines, urinary tract, sweat glands, cardiovascular system, eyes, and adrenal medulla.

Infections and amputations:
Diabetics are at much greater risk for infections, in particular infections in the lower extremities. Because of neuropathy, pain from a food injury may not be evident. Therefore, an infection may not be evident to the diabetic person until it has advanced. It is crucial for diabetics to inspect both the top and bottom of their feet every day and NEVER to go barefoot. Infections of the soft tissue can lead to infections in the bone and even possible amputations.
Peripheral vascular disease is also more prevalent within the diabetic population. This includes peripheral arterial disease (inadequate circulation to the lower extremities via the arteries), vasculitis (inflammation of the blood vessels), venous thrombosis (clots), and disorders of the lymphatic system. Peripheral vascular disease limits the amount of oxygenation and circulation to the lower extremities which also contributes towards the risk for infection and/or amputations.

Type 1 Diabetes
Type 1 diabetes is a complex multihormonal disease. Insulin is the primary treatment for type 1 diabetes. There are many insulin options and strategies allowing for more physiological (closer to natural) insulin replacement. Insulin delivery methods include syringes, pens, injectors and insulin pumps. To successfully manage type 1 diabetes individuals must integrate several diabetes treatment components into their lifestyle – including insulin action times (when the insulin starts to work and how long it works), food intake and physical activity. Type 1 diabetes is not preventable and can occur at any age – but primarily occurs in populations less than the age of 20. Type 1 diabetes is autoimmune (when the body attacks itself) and involves genetic predispositions and related to poorly defined environmental factors. People with type 1 diabetes are prone to other autoimmune disorders such as Graves disease (hyperthyroidism), Hashimoto’s thyroiditis (hypothyroidism), vitiligo (body attacks melanin producing cells resulting in hypopigmentation), pernicious anemia (body not absorbing B12 from the food – B12 is needed for the formation of red blood cells), multiple sclerosis and celiac disease (body not absorbing gluten).

Symptoms of Type 1 Diabetes:
Polyuria (increased urination)
Polyphagia (increased appetite)
Polydypsia (increased thirst)
Unexplained weight loss
In children, bedwetting
Yeast infections
Flushed skin
Fruity breath
Severe abdominal pain
Nausea and/or vomiting
Lethargy

Complications related to type 1 diabetes that is not well controlled are the same as type 2 diabetes with the addition of diabetic ketoacidosis. Diabetic ketoacidosis is a medical emergency and occurs when the blood sugars are elevated due to insufficient insulin. Insulin allows the glucose to enter the cells of the body and provide energy. If insulin is insufficient, the body uses fat for energy. Fat is acidic and changes the PH of the body. The body works hard to regulate the PH back to normal – this puts a strain on the lungs, kidneys and heart. Individuals with type 1 are also at risk for low blood sugars. Hypoglycemia is defined as a blood sugar less than 50-60. It is estimated that most people with type 1 diabetes have at least 2 symptomatic episodes of hypoglycemia each week . Common symptoms are elevated heart rate, pallor, elevated blood pressure, cold sweat, and tremors. Low blood sugars are treated with a fast acting glucose source – glucose tablets (3), ½ can regular sweetened soda, 3-4 ounces of juice (apple, grape or orange), small box of raisins, 8 ounces of milk or 5 regular sweetened lifesavers.