Diabetes And Its Complications

Complications

Diabetes increases your risk for many serious health problems. The good news? With the correct treatment and recommended lifestyle changes, many people with diabetes are able to prevent or delay the onset of complications 

Skin Complications

Diabetes can affect every part of the body, including the skin. 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. 

General Skin Conditions

Bacterial Infections

Several kinds of bacterial infections occur in people with diabetes:

Styes (infections of the glands of the eyelid)
Boils
Folliculitis (infections of the hair follicles)
Carbuncles (deep infections of the skin and the tissue underneath)
Infections around the nails

Inflamed tissues are usually hot, swollen, red, and painful. Several different organisms can cause infections, the most common being Staphylococcus bacteria, also called staph.

Once, bacterial infections were life threatening, especially for people with diabetes. Today, death is rare, thanks to antibiotics and better methods of blood sugar control.

But even today, people with diabetes have more bacterial infections than other people do. Doctors believe people with diabetes can reduce their chances of these infections by practicing good skin care.

Fungal Infections

The culprit in fungal infections of people with diabetes is often Candida albicans. This yeast-like fungus can create itchy rashes of moist, red areas surrounded by tiny blisters and scales. These infections often occur in warm, moist folds of the skin. Problem areas are under the breasts, around the nails, between fingers and toes, in the corners of the mouth, under the foreskin (in uncircumcised men), and in the armpits and groin.

Common fungal infections include jock itch, athlete's foot, ringworm (a ring-shaped itchy patch), and vaginal infection that causes itching.

Itching

Localized itching is often caused by diabetes. It can be caused by a yeast infection, dry skin, or poor circulation. When poor circulation is the cause of itching, the itchiest areas may be the lower parts of the legs.

You may be able to treat itching yourself. Limit how often you bathe, particularly when the humidity is low. Use mild soap with moisturizer and apply skin cream after bathing.

Diabetes-Related Skin Conditions

Acanthosis Nigricans

Acanthosis nigricans is a condition in which tan or brown raised areas appear on the sides of the neck, armpits and groin. Sometimes they also occur on the hands, elbows and knees.

Acanthosis nigricans usually strikes people who are very overweight. The best treatment is to lose weight. Some creams can help the spots look better.

Diabetic Dermopathy

Diabetes can cause changes in the small blood vessels. These changes can cause skin problems called diabetic dermopathy.

Dermopathy often looks like light brown, scaly patches. These patches may be oval or circular. Some people mistake them for age spots. This disorder most often occurs on the front of both legs. But the legs may not be affected to the same degree. The patches do not hurt, open up, or itch.

Dermopathy is harmless and doesn't need to be treated.

Necrobiosis Lipoidica Diabeticorum

Another disease that may be caused by changes in the blood vessels is necrobiosis lipoidica diabeticorum (NLD). NLD causes spots similar to diabetic dermopathy, but they are fewer, larger, and deeper.

NLD often starts as a dull, red, raised area. After a while, it looks like a shiny scar with a violet border. The blood vessels under the skin may become easier to see. Sometimes NLD is itchy and painful. Sometimes the spots crack open.

NLD is a rare condition. Adult women are the most likely to get it. As long as the sores do not break open, you do not need to have it treated. But if you get open sores, see your doctor for treatment.

Allergic Reactions

Allergic skin reactions can occur in response to medicines, such as insulin or diabetes pills. You should see your doctor if you think you are having a reaction to a medicine. Be on the lookout for rashes, depressions, or bumps at the sites where you inject insulin.

Diabetic Blisters (Bullosis Diabeticorum)

Rarely, people with diabetes erupt in blisters. Diabetic blisters can occur on the backs of fingers, hands, toes, feet and sometimes on legs or forearms. These sores look like burn blisters and often occur in people who have diabetic neuropathy. They are sometimes large, but they are painless and have no redness around them. They heal by themselves, usually without scars, in about three weeks. The only treatment is to bring blood sugar levels under control.

Eruptive Xanthomatosis

Eruptive xanthomatosis is another condition caused by diabetes that's out of control. It consists of firm, yellow, pea-like enlargements in the skin. Each bump has a red halo and may itch. This condition occurs most often on the backs of hands, feet, arms, legs and buttocks.

The disorder usually occurs in young men with type 1 diabetes. The person often has high levels of cholesterol and fat in the blood. Like diabetic blisters, these bumps disappear when diabetes control is restored.

Digital Sclerosis

Sometimes, people with diabetes develop tight, thick, waxy skin on the backs of their hands. Sometimes skin on the toes and forehead also becomes thick. The finger joints become stiff and can no longer move the way they should. Rarely, knees, ankles, or elbows also get stiff.

This condition happens to about one third of people who have type 1 diabetes. The only treatment is to bring blood sugar levels under control.

Disseminated Granuloma Annulare

In disseminated granuloma annulare, the person has sharply defined ring- or arc-shaped raised areas on the skin. These rashes occur most often on parts of the body far from the trunk (for example, the fingers or ears). But sometimes the raised areas occur on the trunk. They can be red, red-brown, or skin-colored.

See your doctor if you get rashes like this. There are drugs that can help clear up this condition.

Eye Complications

You may have heard that diabetes causes eye problems and may lead to blindness. People with diabetes do have a higher risk of blindness than people without diabetes. But most people who have diabetes have nothing more than minor eye disorders.

With regular checkups, you can keep minor problems minor (see our Eye Care page). And if you do develop a major problem, there are treatments that often work well if you begin them right away.

Eye Insight

To understand what happens in eye disorders, it helps to understand how the eye works. The eye is a ball covered with a tough outer membrane. The covering in front is clear and curved. This curved area is the cornea, which focuses light while protecting the eye.

After light passes through the cornea, it travels through a space called the anterior chamber (which is filled with a protective fluid called the aqueous humor), through the pupil (which is a hole in the iris, the colored part of the eye), and then through a lens that performs more focusing. Finally, light passes through another fluid-filled chamber in the center of the eye (the vitreous) and strikes the back of the eye, the retina.

The retina records the images focused on it and converts those images into electrical signals, which the brain receives and decodes.

One part of the retina is specialized for seeing fine detail. This tiny area of extra-sharp vision is called the macula. Blood vessels in and behind the retina nourish the macula.

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

Diabetic retinopathy is a general term for all disorders of the retina caused by diabetes. There are two major types of retinopathy: nonproliferative and proliferative.

Nonproliferative retinopathy

In nonproliferative retinopathy, the most common form of retinopathy, capillaries in the back of the eye balloon and form pouches. Nonproliferative retinopathy can move through three stages (mild, moderate, and severe), as more and more blood vessels become blocked.

Macular edema

Although retinopathy does not usually cause vision loss at this stage, the capillary walls may lose their ability to control the passage of substances between the blood and the retina. Fluid can leak into the part of the eye where focusing occurs, the macula. When the macula swells with fluid, a condition called macula edema, vision blurs and can be lost entirely. Although nonproliferative retinopathy usually does not require treatment, macular edema must be treated, but fortunately treatment is usually effective at stopping and sometimes reversing vision loss.

Proliferative retinopathy

In some people, retinopathy progresses after several years to a more serious form called proliferative retinopathy. In this form, the blood vessels are so damaged they close off. In response, new blood vessels start growing in the retina. These new vessels are weak and can leak blood, blocking vision, which is a condition called vitreous hemorrhage. The new blood vessels can also cause scar tissue to grow. After the scar tissue shrinks, it can distort the retina or pull it out of place, a condition called retinal detachment.

How is it Treated?

Huge strides have been made in the treatment of diabetic retinopathy. Treatments such as scatter photocoagulation, focal photocoagulation, and vitrectomy prevent blindness in most people. The sooner retinopathy is diagnosed, the more likely these treatments will be successful. The best results occur when sight is still normal.

In photocoagulation, the eye care professional makes tiny burns on the retina with a special laser. These burns seal the blood vessels and stop them from growing and leaking.

In scatter photocoagulation (also called panretinal photocoagulation), the eye care professional makes hundreds of burns in a polka-dot pattern on two or more occasions. Scatter photocoagulation reduces the risk of blindness from vitreous hemorrhage or detachment of the retina, but it only works before bleeding or detachment has progressed very far. This treatment is also used for some kinds of glaucoma.

Side effects of scatter photocoagulation are usually minor. They include several days of blurred vision after each treatment and possible loss of side (peripheral) vision.

In focal photocoagulation, the eye care professional aims the laser precisely at leaking blood vessels in the macula. This procedure does not cure blurry vision caused by macular edema. But it does keep it from getting worse.

When the retina has already detached or a lot of blood has leaked into the eye, photocoagulation is no longer useful. The next option is vitrectomy, which is surgery to remove scar tissue and cloudy fluid from inside the eye. The earlier the operation occurs, the more likely it is to be successful. When the goal of the operation is to remove blood from the eye, it usually works. Reattaching a retina to the eye is much harder and works in only about half the cases.

There are two types of treatment for macular edema: focal laser therapy that slows the leakage of fluid, and medications that can be injected into the eye that slow the growth of new blood vessels and reduce the leakage of fluid into the macula.

Am I at Risk for Retinopathy?

Several factors influence whether you get retinopathy:

blood sugar control
blood pressure levels
how long you have had diabetes
genes

The longer you've had diabetes, the more likely you are to have retinopathy. Almost everyone with type 1 diabetes will eventually have nonproliferative retinopathy. And most people with type 2 diabetes will also get it. But the retinopathy that destroys vision, proliferative retinopathy, is far less common.

People who keep their blood sugar levels closer to normal are less likely to have retinopathy or to have milder forms.

Your retina can be badly damaged before you notice any change in vision. Most people with nonproliferative retinopathy have no symptoms. Even with proliferative retinopathy, the more dangerous form, people sometimes have no symptoms until it is too late to treat them. For this reason, you should have your eyes examined regularly by an eye care professional.



Neuropathy (Nerve Damage)

Nerve damage from diabetes is called diabetic neuropathy (new-ROP-uh-thee). 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 and can lead to many kinds of problems.

If you keep your blood glucose levels on target, you may help prevent or delay nerve damage. If you already have nerve damage, this will help prevent or delay further damage. There are also other treatments that can help 

Peripheral Neuropathy

LOOK AT THE LIST BELOW, MAKE A NOTE ABOUT ANY SYMPTOMS YOU HAVE AND SHARE IT WITH YOUR DOCTOR DURING YOUR NEXT OFFICE VISIT.

Tingling

• My feet tingle.
• I feel "pins and needles" in my feet.

Pain or Increased Sensitivity

• I have burning, stabbing or shooting pains in my feet.
• My feet are very sensitive to touch. For example, sometimes it hurts to have the bed covers touch my feet.
• Sometimes I feel like I have socks or gloves on when I don't.
• My feet hurt at night.
• My feet and hands get very cold or very hot.

Numbness or Weakness

• My feet are numb and feel dead.
• I don't feel pain in my feet, even when I have blisters or injuries.
• I can't feel my feet when I'm walking.
• The muscles in my feet and legs are weak.
• I'm unsteady when I stand or walk.
• I have trouble feeling heat or cold in my feet or hands.

Other

• It seems like the muscles and bones in my feet have changed shape.
• I have open sores (also called ulcers) on my feet and legs. These sores heal very slowly.

Autonomic Neuropathy

Autonomic neuropathy affects the autonomic nerves, which control the bladder, intestinal tract, and genitals, among other organs.

Paralysis of the bladder is a common symptom of this type of neuropathy. When this happens, the nerves of the bladder no longer respond normally to pressure as the bladder fills with urine. As a result, urine stays in the bladder, leading to urinary tract infections.

Autonomic neuropathy can also cause erectile dysfunction (ED) when it affects the nerves that control erection with sexual arousal. However, sexual desire does not usually decrease.

Diarrhea can occur when the nerves that control the small intestine are damaged. The diarrhea occurs most often at night. Constipation is another common result of damage to nerves in the intestines.

Sometimes, the stomach is affected. It loses the ability to move food through the digestive system, causing vomiting and bloating. This condition, called gastroparesis, can change how fast the body absorbs food. It can make it hard to match insulin doses to food portions.

Scientists do not know the precise cause of autonomic neuropathy and are looking for better treatments for his type of neuropathy.

SYMPTOMS

This type of nerve damage affects the nerves in your body that control your body systems. It affects your digestive system, urinary tract, sex organs, heart and blood vessels, sweat glands, and eyes. Look at the list below and make a note about any symptoms you have. Bring this list to your next office visit.

About my digestive system

• I get indigestion or heartburn.
• I get nauseous and I vomit undigested food.
• It seems like food sits in my stomach instead of being digested.
• I feel bloated after I eat.
• My stomach feels full, even after I eat only a small amount.
• I have diarrhea.
• I have lost control of my bowels.
• I get constipated.
• My blood glucose levels are hard to predict. I never know if I'll have high or low blood glucose after eating.

About my urinary tract

• I have had bladder control problems, such as urinating very often or not often enough, feeling like I need to urinate when I don't, or leaking urine.
• I don't feel the need to urinate, even when my bladder is full.
• I have lost control of my bladder.
• I have frequent bladder infections.

About my sex organs

• (For men) When I have sex, I have trouble getting or keeping an erection.
• (For women) When I have sex, I have problems with orgasms, feeling aroused, or I have vaginal dryness.

About my heart and blood vessels

• I get dizzy if I stand up too quickly.
• I have fainted after getting up or changing my position.
• I have fainted suddenly for no reason.
• At rest, my heart beats too fast.
• I had a heart attack but I didn't have the typical warning signs such as chest pain.

About my body's warning system for low blood glucose levels (hypoglycemia)

• I used to get nervous and shaky when my blood glucose was getting too low, but I no longer have those warning signals.

About my sweat glands

• I sweat a lot, especially at night or while I'm eating.
• I no longer sweat, even when I'm too hot.
• The skin on my feet is very dry.

About my eyes

• It's hard for my eyes to adjust when I go from a dark place into a bright place or when driving at night.

DIAGNOSIS

To diagnose this kind of nerve damage, you will need a physical exam and special tests as well. For example, an ultrasound test uses sound waves to check on your bladder. Stomach problems can be found using x-rays and other tests. Reporting your symptoms plays a big part in making a diagnosis.

TREATMENT

There are a number of treatments for damage to nerves that control body systems. For example, a dietitian can help you plan meals if you have nausea or feel full after eating a small amount. Some medications can speed digestion and reduce diarrhea. Problems with erections can be treated with medications or devices.

Additional Types of Neuropathy

CHARCOT'S JOINT

Charcot's Joint, also called neuropathic arthropathy, occurs when a joint breaks down because of a problem with the nerves. This type of neuropathy most often occurs in the foot.

In a typical case of Charcot's Joint, the foot has lost most sensation. The person no longer can feel pain in the foot and loses the ability to sense the position of the joint. Also, the muscles lose their ability to support the joint properly. The foot then becomes unstable, and walking just makes it worse.

An injury, such as a twisted ankle, may make things even worse. Joints grind on bone. The result is inflammation, which leads to further instability and then dislocation. Finally, the bone structure of the foot collapses. Eventually, the foot heals on its own, but because of the breakdown of the bone, it heals into a deformed foot.

People at risk for Charcot's Joint are those who already have neuropathy. They should be aware of symptoms such as:

• swelling
• redness
• heat
• strong pulse
• insensitivity of the foot.

Early treatment can stop bone destruction and aid healing.

CRANIAL NEUROPATHY

Cranial neuropathy affects the 12 pairs of nerves that are connected with the brain and control sight, eye movement, hearing, and taste.

Most often, cranial neuropathy affects the nerves that control the eye muscles. The neuropathy begins with pain on one side of the face near the affected eye. Later, the eye muscle becomes paralyzed. Double vision results. Symptoms of this type of neuropathy usually get better or go away within 2 or 3 months.

COMPRESSION MONONEUROPATHY

Compression mononeuropathy occurs when a single nerve is damaged. It is a fairly common type of neuropathy. There seem to be two kinds of damage. In the first, nerves are squashed at places where they must pass through a tight tunnel or over a lump of bone. Nerves of people with diabetes are more prone to compression injury. The second kind of damage arises when blood vessel disease caused by diabetes restricts blood flow to a part of the nerve.

Carpal tunnel syndrome is probably the most common compression mononeuropathy. It occurs when the median nerve of the forearm is compressed at the wrist. Symptoms of this type of neuropathy include numbness, swelling, or prickling in the fingers with or without pain when driving a car, knitting, or resting at night. Simply hanging your arm by your side usually stops the pain within a few minutes. If the symptoms are severe, an operation can give complete relief from pain.

FEMORAL NEUROPATHY

Femoral neuropathy occurs most often in people with type 2 diabetes. A pain may develop in the front of one thigh. Muscle weakness follows, and the affected muscles waste away. A different kind of neuropathy that also affects the legs is called diabetic amyotrophy. In this case, weakness occurs on both sides of the body, but there is no pain. Doctors do not understand why it occurs, but blood vessel disease may be the cause.

FOCAL NEUROPATHY

Focal Neuropathy affects a nerve or group of nerves causing sudden weakness or pain. It can lead to double vision, a paralysis on one side of the face called Bell's palsy, or a pain in the front of the thigh or other parts of the body.

THORACIC/LUMBAR RADICULOPATHY

Thoracic or lumbar radiculopath is another common mononeuropathy. It is like femoral neuropathy, except that it occurs in the torso. It affects a band of the chest or abdominal wall on one or both sides. It seems to occur more often in people with type 2 diabetes. Again, people with this neuropathy get better with time.

UNILATERAL FOOT DROP

Unilateral foot drop is when the foot can't be picked up. It occurs from damage to the peroneal nerve of the leg by compression or vessel disease. Foot drop can improve.

- See more at: http://www.diabetes.org/living-with-diabetes/complications/neuropathy/additional-types-of-neuropathy.html#sthash.JEx18ZJZ.dpuf

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. This can cause tingling, pain (burning or stinging), or weakness in the foot. It can also cause loss of feeling in the foot, so you can injure it and not know it. Poor blood flow or changes in the shape of your feet or toes may also cause problems.

Neuropathy

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.

Nerve damage can also lead to changes in the shape of your feet and toes. Ask your health care provider about special therapeutic shoes, rather than forcing deformed feet and toes into regular shoes.

Skin Changes

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.

After bathing, dry your feet and seal in the remaining moisture with a thin coat of plain petroleum jelly, an unscented hand cream, or other such products.

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

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. Also, do not try to remove calluses and corns with chemical agents. These products can burn your skin.

Using a pumice stone every day will help keep calluses under control. It is best to use the pumice stone on wet skin. Put on lotion right after you use the pumice stone.

Foot Ulcers

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, which in turn can lead to loss of a limb.

What your health care provider will do varies with your ulcer. Your health care provider may take x-rays of your foot to make sure the bone is not infected. The health care provider may clean out any dead and infected tissue. You may need to go into the hospital for this. Also, the health care provider may culture the wound to find out what type of infection you have, and which antibiotic will work best.

Keeping off your feet is very important. Walking on an ulcer can make it get larger and force the infection deeper into your foot. Your health care provider may put a special shoe, brace, or cast on your foot to protect it.

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 infection.

After the foot ulcer heals, treat your foot carefully. Scar tissue under the healed wound will break down easily. You may need to wear special shoes after the ulcer is healed to protect this area and to prevent the ulcer from returning.

Poor Circulation

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, follow your health care provider's advice for keeping your blood pressure and cholesterol under control.

If your feet are cold, you may be tempted to warm them. Unfortunately, if your feet cannot feel heat, it is easy for you to burn them with hot water, hot water bottles, or heating pads. The best way to help cold feet is to wear warm socks.

Some people feel pain in their calves when walking fast, up a hill, or on a hard surface. This condition is called intermittent claudication. Stopping to rest for a few moments should end the pain. If you have these symptoms, you must stop smoking. Work with your health care provider to get started on a walking program. Some people can be helped with medication to improve circulation.

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

Amputation

People with diabetes are far more likely to have a foot or leg amputated than other people. The problem? Many people with diabetes have peripheral arterial disease (PAD), which reduces blood flow to the feet. Also, many people with diabetes have nerve disease, which reduces sensation. Together, these problems make it easy to get ulcers and infections that may lead to amputation. Most amputations are preventable with regular care and proper footwear.

For these reasons, take good care of your feet and see your health care provider right away about foot problems. Ask about prescription shoes that are covered by Medicare and other insurance. Always follow your health care provider's advice when caring for ulcers or other foot problems.

One of the biggest threats to your feet is smoking. Smoking affects small blood vessels. It can cause decreased blood flow to the feet and make wounds heal slowly. A lot of people with diabetes who need amputations are smokers.


DKA (Ketoacidosis) & Ketones

Diabetic ketoacidosis (DKA) is a serious condition that can lead to diabetic coma (passing out for a long time) or even death.

When your cells don't get the glucose they need for energy, your body begins to burn fat for energy, which produces ketones. Ketones are acids that build up in the blood and appear in the urine when your body doesn't have enough insulin. They are a warning sign that your diabetes is out of control or that you are getting sick.

High levels of ketones can poison the body. When levels get too high, you can develop DKA. DKA may happen to anyone with diabetes, though it is rare in people with type 2. 

Treatment for DKA usually takes place in the hospital. But you can help prevent it by learning the warning signs and checking your urine and blood regularly.

What are the Warning Signs of DKA?

DKA usually develops slowly. But when vomiting occurs, this life-threatening condition can develop in a few hours. Early symptoms include the following:

Thirst or a very dry mouth
Frequent urination
High blood glucose (blood sugar) levels
High levels of ketones in the urine

Then, other symptoms appear:

Constantly feeling tired
Dry or flushed skin
Nausea, vomiting, or abdominal pain
(Vomiting can be caused by many illnesses, not just ketoacidosis. If vomiting continues for more than 2 hours, contact your health care provider.)
Difficulty breathing
Fruity odor on breath
A hard time paying attention, or confusion

Warning!Ketoacidosis (DKA) is dangerous and serious. If you have any of the above symptoms, contact your health care provider IMMEDIATELY, or go to the nearest emergency room of your local hospital.


How Do I Check for Ketones?

You can detect ketones with a simple urine test using a test strip, similar to a blood testing strip. Ask your health care provider when and how you should test for ketones. Many experts advise to check your urine for ketones when your blood glucose is more than 240 mg/dl.

When you are ill (when you have a cold or the flu, for example), check for ketones every 4 to 6 hours. And check every 4 to 6 hours when your blood glucose is more than 240 mg/dl.

Also, check for ketones when you have any symptoms of DKA.

What If I Find Higher-than-normal Levels of Ketones?

If your health care provider has not told you what levels of ketones are dangerous, then call when you find moderate amounts after more than one test. Often, your health care provider can tell you what to do over the phone.

Call your health care provider at once if you experience the following conditions:

Your urine tests show high levels of ketones.
Your urine tests show high levels of ketones and your blood glucose level is high.
Your urine tests show high levels of ketones and you have vomited more than twice in four hours.

Do NOT exercise when your urine tests show ketones and your blood glucose is high. High levels of ketones and high blood glucose levels can mean your diabetes is out of control. Check with your health care provider about how to handle this situation.

What Causes DKA?

Here are three basic reasons for moderate or large amounts of ketones:

Not enough insulin

Maybe you did not inject enough insulin. Or your body could need more insulin than usual because of illness.

Not enough food

When you're sick, you often don't feel like eating, sometimes resulting in high ketone levels. High levels may also occur when you miss a meal.

Insulin reaction (low blood glucose)

If testing shows high ketone levels in the morning, you may have had an insulin reaction while asleep.

Kidney Disease (Nephropathy)

Kidneys are remarkable organs. Inside them are millions of tiny blood vessels that act as filters. Their job is to remove waste products from the blood.

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

How Does Diabetes Cause Kidney Disease?

When our bodies digest the protein we eat, the process creates waste products. In the kidneys, millions of tiny blood vessels (capillaries) with even tinier holes in them act as filters. As blood flows through the blood vessels, small molecules such as waste products squeeze through the holes. These waste products become part of the urine. Useful substances, such as protein and red blood cells, are too big to pass through the holes in the filter and stay in the blood.

Diabetes can damage this system. High levels of blood sugar make the kidneys filter too much blood. All this extra work is hard on the filters. After many years, they start to leak and useful protein is lost in the urine. Having small amounts of protein in the urine is called microalbuminuria.

When kidney disease is diagnosed early, during microalbuminuria, several treatments may keep kidney disease from getting worse. Having larger amounts of protein in the urine is called macroalbuminuria. When kidney disease is caught later during macroalbuminuria, end-stage renal disease, or ESRD, usually follows.

In time, the stress of overwork causes the kidneys to lose their filtering ability. Waste products then start to build up in the blood. Finally, the kidneys fail. This failure, ESRD, is very serious. A person with ESRD needs to have a kidney transplant or to have the blood filtered by machine (dialysis).

Who Gets Kidney Disease?

Not everyone with diabetes develops kidney disease. Factors that can influence kidney disease development include genetics, blood sugar control, and blood pressure.

The better a person keeps diabetes and blood pressure under control, the lower the chance of getting kidney disease.

What are the Symptoms?

The kidneys work hard to make up for the failing capillaries so kidney disease produces no symptoms until almost all function is gone. Also, the symptoms of kidney disease are not specific. The first symptom of kidney disease is often fluid buildup. Other symptoms of kidney disease include loss of sleep, poor appetite, upset stomach, weakness, and difficulty concentrating.

It is vital to see a doctor regularly. The doctor can check blood pressure, urine (for protein), blood (for waste products), and organs for other complications of diabetes.

How Can I Prevent It?

Diabetic kidney disease can be prevented by keeping blood sugar in your target range. Research has shown that tight blood sugar control reduces the risk of microalbuminuria by one third. In people who already had microalbuminuria, the risk of progressing to macroalbuminuria was cut in half. Other studies have suggested that tight control can reverse microalbuminuria.

Treatments for Kidney Disease

Self-care

Important treatments for kidney disease are tight control of blood glucose and blood pressure. Blood pressure has a dramatic effect on the rate at which the disease progresses. Even a mild rise in blood pressure can quickly make kidney disease worsen. Four ways to lower your blood pressure are losing weight, eating less salt, avoiding alcohol and tobacco, and getting regular exercise.

Drugs

When these methods fail, certain medicines may be able to lower blood pressure. There are several kinds of blood pressure drugs, however, 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.

Diet

Another treatment some doctors use with macroalbuminuria 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.

Kidney Failure

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.


High Blood Pressure (Hypertension)

Nearly 1 in 3 American adults has high blood pressure and 2 in 3 people with diabetes report having high blood pressure or take prescription medications to lower their blood pressure. Your heart has to work harder when blood pressure is high, and your risk for heart disease, stroke and other problems goes up.

High blood pressure won’t go away without treatment. That could include lifestyle changes and, if your doctor prescribes it, medicine.

What Is Blood Pressure?

Blood pressure is the force of blood flow inside your blood vessels. Your doctor records your blood pressure as two numbers, such as 120/80, which you may hear them say as "120 over 80." Both numbers are important.

The first number is the pressure as your heart beats and pushes blood through the blood vessels. Health care providers call this the "systolic" pressure. The second number is the pressure when the vessels relax between heartbeats. It's called the "diastolic" pressure.

Here's what the numbers mean:

Healthy blood pressure: below 120/80
Early high blood pressure: between 120/80 and 140/90
High blood pressure: 140/90 or higher
The lower your blood pressure, the better your chances of delaying or preventing a heart attack or a stroke.

When your blood moves through your vessels with too much force, you have high blood pressure or hypertension. Your heart has to work harder when blood pressure is high, and your risk for heart disease and diabetes goes up. High blood pressure raises your risk for heart attack, stroke, eye problems and kidney disease. High blood pressure is a problem that won't go away without treatment and changes to your diet and lifestyle.

You should always have an idea of what your blood pressure is, just as you know your height and weight.

How Will I Know if I Have High Blood Pressure?

High blood pressure is a silent problem — you won't know you have it unless your health care provider checks your blood pressure. Have your blood pressure checked at each regular health care visit, or at least once every two years (people without diabetes or other risk factors for heart disease).

What Can I Do About High Blood Pressure?

Here are some easy tips to help reduce your blood pressure:

Work with your health care provider to find a treatment plan that's right for you.
Eat whole-grain breads and cereals.
Try herbs and spices instead of salt to flavor foods.
Check food labels and choose foods with less than 400 mg of sodium per serving.
Lose weight or take steps to prevent weight gain.
Limit alcohol consumption and consult your health care provider about whether it is safe to drink alcohol at all.
If you smoke, get help to quit.
Ask your health care provider about medications to help reduce high blood pressure. Samples of these types of medications include ACE inhibitors, ARBs, beta blockers, calcium channel blockers and diuretics.

Stroke

What is a stroke?

A stroke happens when the blood supply to part of your brain is suddenly interrupted. Then brain tissue is damaged. Most strokes happen because a blood clot blocks a blood vessel in the brain or neck. A stroke can cause movement problems, pain, numbness and problems with thinking, remembering or speaking. Some people also have emotional problems, such as depression, after a stroke.

What does diabetes have to do with strokes?

If you have diabetes, your chances of having a stroke are 1.5 times higher than in people who don't have diabetes. But you can lower your risk by taking care of your health.

How do I know whether I'm at high risk for a stroke?

Having diabetes raises your risk for stroke. But your risk is even greater if:

you’re over age 55
your family background is African American
you’ve already had a stroke or a transient ischemic (ih-SKEE-mik) attack (also called a TIA or a mini-stroke)
you have a family history of stroke or TIAs
you have heart disease
you have high blood pressure
you’re overweight
you have high LDL (bad) cholesterol and low HDL (good) cholesterol levels
you are not physically active
you smoke

You can't change some of these risk factors. But you can lower your chances of having a stroke by taking care of your diabetes and tackling some of the other risk factors, such as losing weight if you're overweight. It's up to you.

How can I lower my risk of having a stroke?

Lower your risk by keeping your blood glucose (blood sugar), blood pressure and cholesterol on target with healthy eating, physical activity, and, if needed, medicine. And if you smoke, quit. Every step you take will help. The closer your numbers are to your targets, the better your chances of preventing a stroke.

What are the warning signs of a stroke?

Typical warning signs of a stroke develop suddenly and can include:

weakness or numbness on one side of the body
sudden confusion or trouble understanding
trouble talking
dizziness, loss of balance, or trouble walking
trouble seeing out of one or both eyes
double vision
severe headache

If you have warning signs of a stroke, call 9-1-1 right away. Getting treatment as soon as possible after a stroke can help prevent permanent damage to your brain.

Review the symptoms of a stroke with your family and friends. Make sure they know about the importance of calling 9-1-1.

If the blood flow to your brain is blocked for a short time, you might have one or more of the warning signs temporarily, meaning you've had a TIA (mini-stroke). TIAs put you at risk for a stroke in the future.

How is a stroke diagnosed?

A number of tests may be done if a stroke is suspected:

Your health care provider will check for changes in how your body is working. For example, your provider will check your ability to move your arms and legs. Your health care provider also can check brain functions such as your ability to read or to describe a picture.
CT and MRI tests use special scans to provide images of the brain.
An ECG (electrocardiogram) provides information on heart rate and rhythm.
An ultrasound examination can show problems in the carotid (kuh-ROT-ihd) arteries, which carry blood from the heart to the brain.
In a cerebral (seh-REEB-rahl) arteriogram (ar-TEER-ee-oh-gram), a small tube is inserted into an artery and positioned in the neck. The health care provider injects dye into the artery. Then the provider takes X-rays to look for narrowed or blocked arteries.

What are the treatments for stroke?

Treatment you need right away

"Clot-busting" drugs must be given within hours after a stroke to minimize damage. That's why it's important to call 9-1-1 if you're having symptoms.

Surgical treatments you may need

Several options for surgical treatment of blocked blood vessels are available. These include:

Carotid artery surgery, also called carotid endarterectomy (en-dar-tuh-REK-tuh-mee) removes buildups of fat inside the artery and restores blood flow to the brain.

Carotid stenting can remove a blockage in a blood vessel to the brain. A small tube with a balloon attached is threaded into the narrowed or blocked blood vessel. Then the balloon is inflated, opening the narrowed artery. A wire tube, or stent, may be left in place to help keep the artery open.

Other treatments

The way you are cared for following a stroke includes treatments and exercises to restore function or help people relearn skills. Physical, occupational and speech therapy may be included, as well as psychological counseling. Steps to prevent future problems should include quitting smoking, healthy eating, physical activity, to manage blood glucose, blood pressure and cholesterol levels.

Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)

Hyperosmolar Hyperglycemic Nonketotic Syndrome, or HHNS, is a serious condition most frequently seen in older persons. HHNS can happen to people with either type 1 or type 2 diabetes that is not being controlled properly, but it occurs more often in people with type 2. HHNS is usually brought on by something else, such as an illness or infection.

In HHNS, 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 HHNS continues, the severe dehydration will lead to seizures, coma and eventually death. HHNS may take days or even weeks to develop. Know the warning signs of HHNS.

What are the Warning Signs?

Blood sugar level over 600 mg/dl
Dry, parched mouth
Extreme thirst (although this may gradually disappear)
Warm, dry skin that does not sweat
High fever (over 101 degrees Fahrenheit, for example)
Sleepiness or confusion
Loss of vision
Hallucinations (seeing or hearing things that are not there)
Weakness on one side of the body

If you have any of these symptoms, call someone on your health care team.

How Can I Avoid It?

HHNS only occurs when diabetes is uncontrolled. The best way to avoid HHNS is to check your blood sugar regularly. Many people check their blood sugar several times a day, such as before or after meals. Talk with your health care team about when to check and what the numbers mean. You should also talk with your health care team about your target blood sugar range and when to call if your blood sugars are too high, or too low and not in your target range. When you are sick, you will check your blood sugar more often, and drink a glass of liquid (alcohol-free and caffeine-free) every hour. Work with your team to develop your own sick day plan.

Gastroparesis

Gastroparesis is a disorder affecting people with both type 1 and type 2 diabetes in which the stomach takes too long to empty its contents (delayed gastric emptying). The vagus nerve controls the movement of food through the digestive tract. If the vagus nerve is damaged or stops working, the muscles of the stomach and intestines do not work normally, and the movement of food is slowed or stopped.

Just as with other types of neuropathy, diabetes can damage the vagus nerve if blood glucose levels remain high over a long period of time. High blood glucose causes chemical changes in nerves and damages the blood vessels that carry oxygen and nutrients to the nerves.

What are the Symptoms?

Signs and symptoms of gastroparesis include the following:

Heartburn
Nausea
Vomiting of undigested food
Early feeling of fullness when eating
Weight loss
Abdominal bloating
Erratic blood glucose (sugar) levels
Lack of appetite
Gastroesophageal reflux
Spasms of the stomach wall

These symptoms may be mild or severe, depending on the person.

What are the Complications?

Gastroparesis can make diabetes worse by making it more difficult to manage blood glucose. When food that has been delayed in the stomach finally enters the small intestine and is absorbed, blood glucose levels rise.

If food stays too long in the stomach, it can cause problems like bacterial overgrowth because the food has fermented. Also, the food can harden into solid masses called bezoars that may cause nausea, vomiting, and obstruction in the stomach. Bezoars can be dangerous if they block the passage of food into the small intestine.

How is it Diagnosed?

The diagnosis of gastroparesis is confirmed through one or more of the following tests:

Barium X-ray

After fasting for 12 hours, you will drink a thick liquid containing barium, which covers the inside of the stomach, making it show up on the X-ray. Normally, the stomach will be empty of all food after 12 hours of fasting. If the X-ray shows food in the stomach, gastroparesis is likely. If the X-ray shows an empty stomach, but the doctor still suspects that you have delayed emptying, you may need to repeat the test another day. On any one day, a person with gastroparesis may digest a meal normally, giving a falsely normal test result. If you have diabetes, your doctor may have special instructions about fasting.

Barium Beefsteak Meal

You will eat a meal that contains barium, which allows the doctor to watch your stomach as it digests the meal. The amount of time it takes for the barium meal to be digested and leave the stomach gives the doctor an idea of how well the stomach is working. This test can help find emptying problems that do not show up on the liquid barium X-ray. In fact, people who have diabetes-related gastroparesis often digest fluid normally, so the barium beefsteak meal can be more useful.

Radioisotope Gastric-Emptying Scan

You will eat food that contains a radioisotope, a slightly radioactive substance that will show up on the scan. The dose of radiation from the radioisotope is small and not dangerous. After eating, you will lie under a machine that detects the radioisotope and shows an image of the food in the stomach and how quickly it leaves the stomach. Gastroparesis is diagnosed if more than half of the food remains in the stomach after two hours.

Gastric Manometry

This test measures electrical and muscular activity in the stomach. The doctor passes a thin tube down the throat into the stomach. The tube contains a wire that takes measurements of the stomach's electrical and muscular activity as it digests liquids and solid food. The measurements show how the stomach is working and whether there is any delay in digestion.

Blood tests

The doctor may also order laboratory tests to check blood counts and to measure chemical and electrolyte levels.
To rule out causes of gastroparesis other than diabetes, the doctor may do an upper endoscopy or an ultrasound.

Upper Endoscopy

After giving you a sedative, the doctor passes a long, thin tube called an endoscope through the mouth and gently guides it down the esophagus into the stomach. Through the endoscope, the doctor can look at the lining of the stomach to check for any abnormalities.

Ultrasound

To rule out gallbladder disease or pancreatitis as a source of the problem, you may have an ultrasound test, which uses harmless sound waves to outline and define the shape of the gallbladder and pancreas.

How is it Treated?

The most important treatment goal for diabetes-related gastroparesis is to manage your blood glucose levels as well as possible. Treatments include insulin, oral medications, changes in what and when you eat, and, in severe cases, feeding tubes and intravenous feeding.

Insulin for Blood Glucose Control

If you have gastroparesis, your food is being absorbed more slowly and at unpredictable times. To better manage blood glucose, you may need to try the following:

Take insulin more often
Take your insulin after you eat instead of before
Check your blood glucose levels frequently after you eat and administer insulin whenever necessary

Your doctor will give you specific instructions based on your particular needs.

Medication

Several drugs are used to treat gastroparesis. Your doctor may try different drugs or combinations of drugs to find the most effective treatment.

Meal and Food Changes

Changing your eating habits can help control gastroparesis. Your doctor or dietitian may give you specific instructions to improve your symptoms.  It can be helpful to eat less food at one time.  For example, eating six small meals a day instead of three larger meals. Other helpful tips are to eat slowly, sit upright after eating, and take a walk after meals.

The doctor may also recommend that you avoid high-fat and high-fiber foods. Fat naturally slows digestion which can further slow down digestion.  Fiber can be difficult to digest and it may be possible that the undigested fiber can form bezoars.  Depending on the severity, your doctor may want you to try liquid meals or may prescribe medications to help speed up your digestion.  

Feeding Tube

If other approaches do not work, you may need surgery to insert a feeding tube. The tube, called a jejunostomy tube, is inserted through the skin on your abdomen into the small intestine. The feeding tube allows you to put nutrients directly into the small intestine, bypassing the stomach altogether. You will receive special liquid food to use with the tube. A jejunostomy is particularly useful when gastroparesis prevents the nutrients and medication necessary to regulate blood glucose levels from reaching the bloodstream.

By avoiding the source of the problem (the stomach) and putting nutrients and medication directly into the small intestine, you ensure that these products are digested and delivered to your bloodstream quickly. A jejunostomy tube can be temporary and is used only if necessary when gastroparesis is severe.

It is important to note that in most cases treatment does not cure gastroparesis — it is usually a chronic condition. Treatment helps you manage gastroparesis, so that you can be as healthy and comfortable as possible.


Heart Disease

People with diabetes have a higher-than-average risk of having a heart attack or stroke. These strike people with diabetes more than twice as often as people without diabetes.

There’s a big link between diabetes, heart disease, and stroke. In fact, two out of three people with diabetes die from heart disease or stroke, also called cardiovascular disease. Clogged blood vessels can lead to heart attack, stroke, and other problems. But there are treatments for heart disease, stroke, and blood vessel disease.

Healthy ABCs

Taking care of your diabetes and the conditions that come with it can help you lower your chances of heart and blood vessel disease.

Even if you have heart disease or have already had a heart attack or a stroke, every step you take to keep your ABCs (A1C, blood pressure, and cholesterol) in your target range will help lower your risk of future heart disease or a stroke.

A is for A1C. Your A1C check, which also may be reported as estimated average glucose (eAG) tells you your average blood glucose for the past 2 to 3 months. .

B is for blood pressure. High blood pressure makes your heart work harder than it should. 

C is for cholesterol. Your cholesterol numbers tell you about the amount of fat in your blood. Some kinds, like HDL cholesterol, help protect your heart. Others, like LDL cholesterol, can clog your arteries. High triglycerides raise your risk for a heart attack or a stroke. 

Types of Heart Disease

Coronary artery disease, sometimes called hardening of the arteries, is caused by narrowing or blocking of the blood vessels that go to your heart.

Your blood carries oxygen and other needed materials to your heart. If the blood vessels to your heart become partially or totally blocked by fatty deposits, then the blood supply is reduced or cut off. Then a heart attack, sometimes called a myocardial infarction or MI, can occur.

WHAT ARE THE WARNING SIGNS OF A HEART ATTACK?

Become familiar with these signs:

• chest pain or discomfort
• pain or discomfort in your arms, back, jaw, neck or stomach
• shortness of breath
• sweating
• indigestion or nausea
• light-headedness
• tiredness or fatigue

You may not experience all of these symptoms, and they may come and go. Chest pain that doesn't go away after resting may signal a heart attack. Diabetes can cause nerve damage that can make heart attacks painless or "silent."

 FaiHeartlure

In heart failure, the heart is less able to pump blood. Heart failure may be caused by a number of problems, such as heart attack, coronary artery disease and high blood pressure. In congestive heart failure, another heart condition, fluid builds up inside body tissues such as the lungs. Then breathing becomes difficult.

What are the warning signs of heart failure?

Warning signs can differ among people but they include:

• shortness of breath
• weakness
• nausea
• fatigue
• swelling of the feet and ankles (from fluid retention)
• 
  

• Peripheral Arterial Disease (PAD)

• Peripheral arterial disease, also called PAD, occurs when blood vessels in the legs are narrowed or blocked by fatty deposits and blood flow to your feet and legs decreases.

If you have PAD, you have an increased risk for heart attack and stroke. An estimated 1 out of every 3 people with diabetes over the age of 50 have this condition. However, many of those with warning signs don't realize that they have PAD and therefore don't get treatment.

WHAT DOES DIABETES HAVE TO DO WITH PAD?

If you have diabetes, you're much more likely to have PAD, a heart attack, or a stroke. But you can cut your chances of having those problems by taking special care of your blood vessels.

HOW DO I KNOW WHETHER I'M AT HIGH RISK FOR PAD?

Just having diabetes puts you at risk, but your risk is even greater under the following conditions:

• Smoking
• High blood pressure
• Abnormal blood cholesterol levels
• Overweight
• Not physically active
• Over age 50
• History of heart disease, or you've have had a heart attack or a stroke
• Family history of heart disease, heart attacks, or strokes

You can't change your age or your family history, but taking care of your diabetes and the conditions that come with it can lower your chances of having PAD.

WHAT ARE THE WARNING SIGNS OF PAD?

Many people with diabetes and PAD do not have any symptoms. Some people may experience mild leg pain or trouble walking and believe that it's just a sign of getting older. Others may have the following symptoms:

• Leg pain, particularly when walking or exercising, which disappears after a few minutes of rest
• Numbness, tingling, or coldness in the lower legs or feet
• Sores or infections on your feet or legs that heal slowly

HOW IS PAD DIAGNOSED?

The ankle brachial index (ABI) is one test used to diagnose PAD. This test compares the blood pressure in your ankle to the blood pressure in your arm. If the blood pressure in the lower part of your leg is lower than the pressure in your arm, you may have PAD. An expert panel brought together by the American Diabetes Association recommends that people with diabetes over the age of 50 have an ABI to test for PAD. People with diabetes younger than 50 may benefit from testing if they have other PAD risk factors.

These other tests can also be used to diagnosis PAD:

• Angiogram (AN-gee-oh-gram): a test in which dye is injected into the blood vessels using a catheter and X rays are taken to show whether arteries are narrowed or blocked.
• Ultrasound: a test using sound waves to produce images of the blood vessels on a viewing screen.
• MRI (magnetic resonance imaging): a test using special scanning techniques to detect blockages within blood vessels.

HOW IS PAD TREATED?

People with PAD are at very high risk for heart attacks and stroke, so it is very important to manage cardiovascular risk factors. Here are some steps you can take:

• Quit smoking. Your health care provider can help you.
• Aim for an A1C below 7%. The A1C test measures your average blood glucose (sugar) over the past 2 to 3 months.
• Lower your blood pressure to less than 140/80 mmHg.
• Get your LDL cholesterol below 100 mg/dl.
• Talk to your health care provider about taking aspirin or other antiplatelet medicines. These medicines have been shown to reduce heart attacks and strokes in people with PAD.

Studies have found that exercise, such as walking, can be used both to treat PAD and to prevent it. Medications may help relieve symptoms.

In some cases, surgical procedures are used to treat PAD:

• Angioplasty, also called balloon angioplasty: a procedure in which a small tube with a balloon attached is inserted and threaded into an artery; then the balloon is inflated, opening the narrowed artery. A wire tube, called a stent, may be left in place to help keep the artery open.
• Artery bypass graft: a procedure in which a blood vessel is taken from another part of the body and is attached to bypass a blocked artery

Mental Health

Deal with natural emotions like stress, sadness, anger and denial before they lead to depression.

Anger

Diabetes is the perfect breeding ground for anger. Anger can start at diagnosis with the question, "Why me?" You may dwell on how unfair diabetes is: "I'm so angry at this disease! I don't want to treat it. I don't want to control it. I hate it!"

One reason diabetes and anger so often go hand in hand is that diabetes can make you feel threatened. Life with diabetes can seem full of dangers - insulin reactions or complications. When you fear these threats, anger often surges to your defense.

While it's true that out-of-control anger can cause more harm than good, that's only part of the story. Anger can also help you assert and protect yourself. You can learn to use your anger. You can even put it to work for better diabetes care.

ANGER AND SELF-CARE

Anger worked against Mary H., a woman in her mid-fifties who was diagnosed with diabetes six months ago. She was furious. She saw diabetes as not just a threat to her health, but also to her whole way of life. A very proud woman, active in community and social affairs, she found it impossible to be open about her "weakness." She didn't want her friends to prepare special foods for her. She even felt her husband now saw her as an "invalid" and that she was "less of a woman" to him. Denial fueled Mary's anger at diabetes.

THE ANGER CIRCLE

Mary was stuck in an anger circle. She was angry at diabetes for changing her life. She refused to face her health care needs because she refused to change her life. Her diabetes went uncared for and her blood sugar levels stayed high. As the disease went on poorly controlled, Mary felt worse. Her anger at diabetes grew.

If you find yourself in an anger circle, like Mary, you don't have to stay stuck. One way to break the circle comes from Dr. Weisinger's Anger Work Out Book by Hendrie Weisinger, PhD. He suggests you do three things:

1. Figure out what's making you angry. How is that anger affecting your life? Keep track of when you feel angry. Each evening, think back over the day. When were you angry? What time was it? Who were you angry at? What did you do about it?
   
   After several weeks, read over your notes. See any patterns? When Mary read her anger diary, she learned that social situations made her angry. She did not like talking about her diabetes in public. She felt angry if friends asked her what she could eat or made special food. When she and her husband tried to go out with friends, she felt her diabetes was the center of attention.
2. Change the thoughts, physical responses, and actions that fuel your anger. Look for warning signs that your anger is building. Do you feel tense? Are you talking louder and faster? When you feel anger taking over, calm yourself by:
   1. talking slowly
   2. slowing your breathing
   3. getting a drink of water
   4. sitting down
   5. leaning back
   6. quieting yourself. Silence is golden in these situations.
      These steps don't mean you stop feeling angry. Instead, they mean you are taking charge of your anger.
3. Find ways to make your anger work for you. Your anger diary can help. Read your notes again. Look at each situation. Ask yourself - How was my anger helping me cope? Mary decided her anger was helping her avoid talking about her diabetes with others. She decided to try answering questions in a matter-of-fact way. But she found that talking about diabetes in public still made her furious.

Mary's anger told her something very important. She still hadn't accepted having diabetes. To get more support, she joined her local American Diabetes Association. Meeting other people with diabetes helped her feel less alone. She also realized that having diabetes did not make her less of a person.

Slowly, she was able to enjoy her friends again. She was able to talk openly about her disease and also tell her friends that she didn't want special treatment.

LET ANGER BE YOUR ALLY

The goal is not to get anger out of your life. You may go on feeling angry about the same things. When you feel threatened, afraid, or frustrated, anger is a normal response. But you can put your anger to work for you. Your anger may be a signal that you need to take action. A few sessions with a skilled counselor might help.

Anger can be a force for action, change, and growth. The better you understand your anger, the better you will be able to use it for good self-care.

Denial

Denial is that voice inside repeating: "Not me." Most people go through denial when they are first diagnosed with diabetes. "I don't believe it. There must be some mistake," they say.

That first reaction is not the real problem. In fact, it's so common that some doctors think it's part of the process of accepting the diagnosis.

The trouble comes when you keep on denying your diabetes. Long-term denial stops you from learning what you need to know to keep yourself healthy.

WHY DENY?

Sometimes denial serves a purpose. It is a way of coping with bad news. It can keep you from getting overwhelmed and depressed. It lets you accept news little by little, when you are ready.

But denial can return later on because it seems easier. Denying that your diabetes is serious lets you avoid self-care. It shields you from the fact that diabetes is a lifelong, chronic illness, which, if left untreated, can result in complications. Denial also lets your family and friends pretend that "nothing is wrong."

Doctors who do not specialize in diabetes care may fuel your denial. They may talk about a "mild" case of diabetes or say there is "just a touch of sugar" in your blood. Though well-meaning, these terms send the wrong message. What you hear is "Don't worry. Your diabetes is not serious enough to hurt you."

SPOTTING DENIAL

Denial has a few catch phrases. If you hear yourself thinking or saying them, you are avoiding some part of your diabetes care.

• One bite won't hurt.
• This sore will heal by itself.
• I'll go to the doctor later.
• I don't have time to do it.
• My diabetes isn't serious. I only have to take a pill, not shots.

HIDDEN DANGER

Because denial can creep into any aspect of diabetes self-care, it can be dangerous. Any denial sabotages your health care.

Not Testing

It can be a bother to check your blood glucose regularly. You may decide you "know" what your blood glucose is by how you feel. But a meter is a much better measure of blood glucose than feelings are.

Ignoring Your Meal Plan

Changing eating habits and food choices is tough. When your doctor told you to see a dietitian, follow a meal plan, and change your eating habits, maybe you thought to yourself:

• It's too expensive to see a registered dietitian.
• I can't ask my family to change what they eat. I don't want to eat alone or fix two meals.
• There's no place to buy healthy food where I work.
• It's too hard to bring my lunch.

Eating right may not be as difficult as you think. A dietitian can help you put together a plan that meets your personal needs.

Forgetting Your Feet

You know you should check your feet each day, but it takes too much time. Or you forget. Or you have limited mobility and it's too hard. Washing and checking your feet for signs of trouble every day is essential to avoid serious injury. This is true no matter what type of diabetes you have.

Smoking

You might tell yourself, "I only take a few puffs." You may say smoking keeps you from eating too much. "If I quit, I'll gain weight." Smoking and diabetes are a deadly duo. Smoking increases your risk for complications. Quitting is one of the best things you can do for your health.

CONFRONTING DENIAL

Denial is human. It's bound to crop up from time to time. When it does, you can recognize what's going on and fight back.

• Make a plan — Write down your diabetes care plan and your health care goals. Understand why each item in your plan is important. Accept that it will take time to reach your goals.
• Ask for help — If you find you are denying some parts of your diabetes care, ask your diabetes educator for help. If you have trouble with your food plan, talk to a registered dietitian. Together you can come up with solutions.
• Enlist friends and family — Tell your friends and family how they can help. Let them know that encouraging you to go off your plan is not a kindness. Inform them about how you take care of your diabetes — they might want to adopt some of your healthy habits.

Depression

Feeling down once in a while is normal. But some people feel a sadness that just won't go away. Life seems hopeless. Feeling this way most of the day for two weeks or more is a sign of serious depression.

DOES DIABETES CAUSE DEPRESSION?

At any given time, most people with diabetes do not have depression. But studies show that people with diabetes have a greater risk of depression than people without diabetes. There are no easy answers about why this is true.

The stress of daily diabetes management can build. You may feel alone or set apart from your friends and family because of all this extra work.

If you face diabetes complications such as nerve damage, or if you are having trouble keeping your blood sugar levels where you'd like, you may feel like you're losing control of your diabetes. Even tension between you and your doctor may make you feel frustrated and sad.

Just like denial, depression can get you into a vicious cycle. It can block good diabetes self-care. If you are depressed and have no energy, chances are you will find such tasks as regular blood sugar testing too much. If you feel so anxious that you can't think straight, it will be hard to keep up with a good diet. You may not feel like eating at all. Of course, this will affect your blood sugar levels.

SPOTTING DEPRESSION

Spotting depression is the first step. Getting help is the second.

If you have been feeling really sad, blue, or down in the dumps, check for these symptoms:

• Loss of pleasure — You no longer take interest in doing things you used to enjoy.
• Change in sleep patterns — You have trouble falling asleep, you wake often during the night, or you want to sleep more than usual, including during the day.
• Early to rise — You wake up earlier than usual and cannot to get back to sleep.
• Change in appetite — You eat more or less than you used to, resulting in a quick weight gain or weight loss.
• Trouble concentrating — You can't watch a TV program or read an article because other thoughts or feelings get in the way.
• Loss of energy — You feel tired all the time.
• Nervousness — You always feel so anxious you can't sit still.
• Guilt — You feel you "never do anything right" and worry that you are a burden to others.
• Morning sadness — You feel worse in the morning than you do the rest of the day.
• Suicidal thoughts — You feel you want to die or are thinking about ways to hurt yourself.

If you have three or more of these symptoms, or if you have just one or two but have been feeling bad for two weeks or more, it's time to get help.

GETTING HELP

If you are feeling symptoms of depression, don't keep them to yourself. First, talk them over with your doctor. There may a physical cause for your depression.

Poor control of diabetes can cause symptoms that look like depression. During the day, high or low blood sugar may make you feel tired or anxious. Low blood sugar levels can also lead to hunger and eating too much. If you have low blood sugar at night, it could disturb your sleep. If you have high blood sugar at night, you may get up often to urinate and then feel tired during the day.

Other physical causes of depression can include the following:

• Alcohol or drug abuse
• Thyroid problems
• Side effects from some medications

Do not stop taking a medication without telling your doctor. Your doctor will be able to help you discover if a physical problem is at the root of your sad feelings.

MENTAL HEALTH TREATMENT

If you and your doctor rule out physical causes, your doctor will most likely refer you to a specialist. You might talk with a psychiatrist, psychologist, psychiatric nurse, licensed clinical social worker, or professional counselor. In fact, your doctor may already work with mental health professionals on a diabetes treatment team.

All of these mental health professionals can guide you through the rough waters of depression. In general, there are two types of treatment:

• Psychotherapy, or counseling
• Antidepressant medication

Psychotherapy

Psychotherapy with a well-trained therapist can help you look at the problems that bring on depression. It can also help you find ways to relieve the problem. Therapy can be short term or long term. You should be sure you feel at ease with the therapist you choose.

Medication

If medication is advised, you will need to consult with a psychiatrist (a medical doctor with special training in diagnosing and treating mental or emotional disorders). Psychiatrists are the only mental health professionals who can prescribe medication and treat physical causes of depression.

If you opt for trying an antidepressant drug, talk to the psychiatrist and your primary care provider about side effects, including how it might affect your blood sugar levels. Make sure that the doctors will consult about your care when needed. Many people do well with a combination of medication and psychotherapy.

If you have symptoms of depression, don't wait too long to get help. If your health care provider cannot refer you to a mental health professional, contact your local psychiatric society or psychiatry department of a medical school, or the local branch of organizations for psychiatric social workers, psychologists, or mental health counselors. Your local American Diabetes Association may also be a good resource for counselors who have worked with people with diabetes.

Pregnancy

Health care providers now know that the key to a healthy pregnancy for a woman with diabetes is keeping blood glucose (sugar) in the target range—both before she is pregnant and during her pregnancy.

[This section is for women who have been diagnosed with type 1 or 2 diabetes before getting pregnant. We have a separate section for women who develop gestational diabetes.]

Before Pregnancy

Despite advances, babies born to women with diabetes, especially women with poor diabetes control, are still at greater risk for birth defects.

High blood glucose levels and ketones (substances that in large amounts are poisonous to the body) pass through the placenta to the baby. These increase the chance of birth defects.

High blood glucose levels during the first trimester — the time when the baby's organs are forming — increase the risk of birth defects and also miscarriage. Since the baby's organs are completely formed by 7 weeks after your last period, when you may have just realized you are pregnant, it's important to get blood glucose levels under control before getting pregnant.

Because these early weeks are so important to your baby, you need to plan your pregnancy. If your blood glucose levels are not in your target range, work to bring your diabetes under control before getting pregnant. It is a good idea to be in good blood glucose control three to six months before you plan to get pregnant. You'll want to keep excellent blood glucose control during pregnancy, and after as well.

Some of the possible risks to the mother and baby if blood glucose levels are too high during pregnancy are:

• Risks for the baby
• Premature delivery
• Miscarriage
• Birth defects (not usually a risk for women with gestational diabetes)
• Macrosomia (having a large baby)
• Low blood glucose at birth (hypoglycemia)
• Prolonged jaundice (yellowing of the skin)
• Respiratory distress syndrome (difficulty breathing)

Risks for the mother

• Worsening of diabetic eye problems
• Worsening of diabetic kidney problems
• Infections of the urinary bladder and vaginal area
• Preeclampsia (high blood pressure usually with protein in the urine)
• Difficult delivery or cesarean section

Target blood glucose goals before getting pregnant

• Premeal (before eating): 60-119 mg/dl
• 1 hour after meals: 100-149 mg/dl

Your health care provider may have you use goals such as these, but check with your own team about your specific goals.

Along with getting your blood glucose levels in your target range, it's also important to establish a set of healthy lifestyle habits that will reduce the risk for complications and improve the health of your baby. For women with diabetes, this means an A1C as normal as possible (less than 7%), achieving or maintaining a healthy body weight, improving diet and exercise, and having a pre-pregnancy exam.

A pre-pregnancy exam by your doctor typically includes: measuring your A1C level to make sure blood glucose levels are under control. It also will include an assessment of any complications, such as high blood pressure, heart disease, and kidney, nerve, and eye damage. If you have type 1 diabetes, your doctor will likely check the function of your thyroid.

You should also review all you medications and supplements with your doctor to make sure they are safe to continue using with pregnancy. Drugs commonly used to treat diabetes and its complications may not be recommended in pregnancy, especially statins, ACE inhibitors, ARBs, and most noninsulin therapies.

While you are getting your blood glucose levels under control and your healthy lifestyle habits where you want them to be, its important to have a family planning method in place. Women with diabetes have the same birth control options as women without diabetes. The pill, the intrauterine device (IUD), implants, barrier methods such as a diaphragm or condoms, and spermicides are all ways to reduce the risk of unplanned pregnancy. Which method you choose will depend on your own health history and you and your partner's preferences.

Prenatal Care

Pregnancy is often a time of great highs and lows. It can be awesome and thrilling—when you hear the baby's heartbeat or feel the first tiny kick. It can also be frustrating and even scary.

Because we know more about diabetes than ever before, there has never been a better time for you to plan a pregnancy. For the best prenatal care, assemble a team that includes the following:

• A doctor, trained to care for people with diabetes, who has cared for pregnant women with diabetes
• An obstetrician who handles high-risk pregnancies and has cared for other pregnant women with diabetes
• A pediatrician (children's doctor) or neonatologist (doctor for newborn babies) who knows and can treat special problems that can happen in babies of women with diabetes
• A registered dietitian who can change your meal plan as your needs change during and after pregnancy
• A diabetes educator who can help you manage your diabetes during pregnancy

It’s important to remember that YOU are the leader of your health care team. Keep track of any questions 

CHECKING YOUR BLOOD GLUCOSE

Your body is changing as the baby grows. Because you have diabetes, these changes will affect your blood glucose level. Pregnancy can also make symptoms of low blood glucose hard to detect.

During pregnancy, your diabetes control will require more work. The blood glucose checks you do at home are a key part of taking good care of yourself and your baby before, during and after pregnancy.

Blood glucose targets are designed to help you minimize the risk of birth defects, miscarriage and help prevent your baby from getting too large. If you have trouble staying in your target range or have frequent low blood glucose levels, talk to your health care team about revising your treatment plan. Target blood glucose values may differ slightly in different care systems and with different diabetic teams. Work with your health care team on determining your specific goals before and during pregnancy.

The American Diabetes Association suggests the following targets for women with preexisting diabetes who become pregnant. More or less stringent glycemic goals may be appropriate for each individual.

• Before a meal (preprandial) and Bedtime/Overnight: 60-99 mg/dl
• After a meal (postprandial): 100-129 mg/dl
• A1C: less than 6%

*Postprandial glucose measurements should be made 1-2 hours after the beginning of the meal, which is generally when levels peak in people with diabetes.

Check your blood glucose levels at the times your diabetes team advises; this may be up to eight tests daily and will probably include after-meal checks.

• Write down your results
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• Keep notes on your meal plan and exercise.
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• Make changes in your meal plan and insulin only with the advice of your diabetes team.

INSULIN AND DIABETES PILLS

Insulin is the traditional first-choice drug for blood glucose control during pregnancy, because it is the most effective for fine-tuning blood glucose and it doesn’t cross the placenta. Therefore, it is safe for the baby. Insulin can be injected with a syringe, an insulin pen, or through an insulin pump. All three methods are safe for pregnant women.

If you have type 1 diabetes, pregnancy will affect your insulin treatment plan. During the months of pregnancy, your body's need for insulin will go up. This is especially true during the last three months of pregnancy. The need for more insulin is caused by hormones the placenta makes. The placenta makes hormones that help the baby grow. At the same time, these hormones block the action of the mother's insulin. As a result, your insulin needs will increase.

If you have type 2 diabetes, you too need to plan ahead. If you are taking diabetes pills to control your blood glucose, you may not be able to take them when you are pregnant. Because the safety of using diabetes pills during pregnancy has not been established, your doctor will probably have you switch to insulin right away. Also, the insulin resistance that occurs during pregnancy often decreases the effectiveness of oral diabetes medication at keeping your blood glucose levels in their target range.

For women with gestational diabetes, meal planning and exercise often work to keep blood glucose levels in control; however, if blood glucose levels are still high, your doctor will probably start you on insulin.

Only a small number of studies have been published analyzing the safety and effectiveness of oral medications during pregnancy. Unlike insulin, oral medications cross the placenta to the unborn baby in varying degrees. For these reasons, the American Diabetes Association does not recommend their use in pregnancy. However, oral medications are now used more frequently than in the past by some health care providers to manage blood glucose levels that are not controlled by diet and exercise alone during pregnancy.

FOOD

During pregnancy you and your dietitian or doctor may need to change your meal plan to avoid problems with low and high blood glucose levels. This is the most important reason for keeping track of your blood glucose results. For most women, the focus of a good meal plan during pregnancy is improving the quality of foods you eat rather than merely increasing the amount of food eaten. A good meal plan is designed to help you avoid high and low blood glucose levels while providing the nutrients your baby need to grow.

Including a variety of different foods and watching portion sizes is key to a healthy diet. Healthy eating is important before, during, and after pregnancy, as well as throughout your life. Healthy eating includes eating a wide variety of foods, including:

• vegetables
• whole grains
• nonfat dairy products
• fruits
• beans
• lean meats
• poultry
• fish

Many people think eating for two means eating a lot more than you did before. This isn’t true. You only need to increase your calorie intake by about 300 more calories each day. If you start pregnancy weighing too much, you should not try to lose weight. Instead work with your dietitian or doctor to curb how much weight you gain during pregnancy.

Your dietitian will keep track of your weight gain. If you start pregnancy at a normal weight, expect to add between 25 to 35 pounds. Women who start pregnancy too thin need to gain more. If you are obese at the start of your pregnancy, work with your dietitian to limit your weight gain to about 15–25 pounds. You can determine your healthy weight by finding your BMI level by using our BMI calculator.

Pregnancy Weight Goals
If your prepregnancy weight is…	Then gain…
Underweight	28-40 pounds
Normal	25-35 pounds
Overweight	15-25 pounds
Obese	11-20 pounds
These are averages to give you an idea of how much weight you should gain. Talk to your health care provider about your specific weight goals during pregnancy.

EXERCISE

Exercise is a key part of diabetes treatment. Just as you need to get your blood glucose under control before getting pregnant, it's best to get fit before you get pregnant. Can you keep your current exercise program during pregnancy? Is it safe to start exercise after you are pregnant?

Discuss your exercise plans with your diabetes team. Ask for guidelines. Pregnant women frequently question whether it is safe to exercise during pregnancy. Regular physical activity is not only safe for pregnant women, it benefits health by offsetting some of the problems of pregnancy, such as varicose veins, leg cramps, fatigue and constipation. For women with diabetes, exercise, especially after meals may help the muscles use the glucose in the bloodstream, and help keep your blood glucose levels in your target range. But if you have any of the following conditions (see the list below), then you will need to talk to your diabetes team about the risks of exercise during pregnancy.

• High blood pressure
• Eye, kidney, or heart problems
• Damage of the small or large blood vessels
• Nerve damage

In general, it's not a good idea to start a new strenuous exercise program during pregnancy. Good exercise choices for pregnant women include walking, low-impact aerobics, swimming, or water aerobics. Activities to avoid during pregnancy are:

• Activities that put you in danger of falling or receiving abdominal injury, such as contact sports
• Activities that put pressure on your abdomen (exercises done while lying on your stomach)
• Scuba diving
• Vigorous, intense exercise, such as running too fast to carry on a conversation
• Activities with bouncing or jolting movements (horseback riding or high-impact aerobics)

Delivery

As your due date nears, your doctors will study your health and that of your growing baby. Then, you and the team will discuss the best time and method for delivery.

To determine the safest time and method to deliver your baby, your health care team will examine a variety of factors:

• blood glucose control
• blood pressure
• kidney function

• any diabetes complications you may have.

The team will also study your baby’s size and movements, his or her heart-rate pattern and the amount of amniotic fluid in the uterus.

LABOR

Your labor may start on its own, or you may decide to have labor induced or have a planned cesarean section (C-section). During a cesarean birth, an incision is made through the abdomen and uterus, through which the baby is removed. Because of the surgery, your recovery time may be longer than if you delivered your baby vaginally.

No matter how you deliver your baby, your doctors will be working during labor and delivery to keep your blood glucose level under control. At the start of active labor, your insulin needs will drop. You will most likely not need any insulin during labor and for 24 to 72 hours after delivery. Your blood glucose will be checked frequently (probably every few hours) and your insulin and glucose regimen will be tailored to your needs during that time.

To help you prepare for labor, many hospitals and other organizations offer classes (such as lamaze) to help you have a smooth delivery. They teach you what to expect during delivery, techniques to improve delivery and to relieve pain during labor, and how to care for your baby after birth. Because of the care needed for both mom and baby during and after delivery, home births are not advised for women with diabetes.

It’s important to have a partner or coach helping you throughout the labor and delivery process. This can be a spouse, parents, relative, or friend. Having a support system with you before and during the birth can help you be more relaxed during your time at the hospital.