Exercise Precautions and Recommendations for Patients With Autonomic Neuropathy

In BriefNearly everyone with diabetes can derive some benefit from an exercise program, although not all benefits will be realized by each person with diabetes. Autonomic neuropathy may affect several systems that are necessary for the body’s adjustment to exercise, and careful screening is extremely important. The risks and benefits of exercise must be carefully considered in those with chronic complications of diabetes, as should the deleterious effects of not participating in any physical activity.

 Physical activity has the potential to yield several health benefits for people with diabetes. These benefits can include improvements in glucose control,^1-3 insulin sensitivity,^4-6 lipid profile,^7,8 blood pressure,^9,10 coagulation properties,¹¹ body composition,^12,13 and psychological well-being.^14,15

Nearly everyone with diabetes can derive some benefit from an exercise program, although not all benefits will be realized by each person with diabetes. Both health care professionals and patients with diabetes need to remember this when determining the components of an exercise program. When chronic complications of diabetes develop, the benefits and risks of exercise must be carefully considered to maximize the benefits and assure safety.¹⁶ This is especially true when evaluating the use of exercise in diabetes complicated by autonomic neuropathy.

In considering the benefits and risks of exercise for those with chronic complications of diabetes, attention must also be given to the effects of not participating in some level of physical activity. Known as disuse syndrome, the deleterious effects of an imbalance between rest and physical activity include decreased physical work capacity, muscle atrophy, negative nitrogen and protein balance, cardiovascular deconditioning, pulmonary restrictions, and depression.¹⁷ The consequences of disuse combined with the complications of diabetes are likely to lead to more disability than the diabetes complications alone. Since physical activity can prevent or reverse disuse syndrome, serious consideration must be given to the use of exercise in all people with diabetes, including those with autonomic neuropathy.

Table 1. Effects of Diabetic Autonomic Neuropathy on Exercise Risk

Silent myocardial ischemia Resting tachycardia and decreased maximal responsiveness Decreased heart-rate variability Orthostasis/hypotension with exercise Exaggerated blood pressure responses with supine position and exercise. Loss of diuranal blood pressure variation Cardiovascular and cardiorespiratory instability Abnormal systolic ejection fractions at rest/exercise Poor exercise tolerance Failure of pupil adaptation to darkness Gastroparesis and diabetic diarrhea Hypoglycemia Decreased hypoglycemia awareness Hypoglycemia unresponsiveness Heat intolerance due to defective sympathetic thermoregualtion and sweating (prone to dehydration) Susceptibility to foot ulcers and limb loss due to disordered regulation of cutaneous blood flow Incontinence Reprinted with permission from the American Diabetes Association, Health Professional's Guide to Diabetes and Exercise, p. 190

Diabetic autonomic neuropathy can strike any system of the body (e.g., cardiovascular, respiratory, neuroendocrine, gastrointestinal, genitourinary, sudomotor, or ocular), since the autonomic nervous system regulates all involuntary functions in the body. Many of these systems are integral to the ability to perform exercise. The possible risks from autonomic neuropathy on the body’s response to exercise and resulting safety considerations are discussed below. Table 1 provides a summary of the effects of autonomic neuropathy on exercise risk.¹⁸
EFFECTS OF AUTONOMIC  NEUROPATHY ON EXERCISE RESPONSE Cardiovascular Autonomic NeuropathyHeart rate. The impact of autonomic neuropathy on the cardiovascular system is of utmost importance to exercise capacity and safety, since cardiovascular autonomic neuropathy (CAN) is manifested by abnormal heart rate, blood pressure, and redistribution of blood flow. The cardiovascular anomalies of autonomic neuropathy involve both the sympathetic and parasympathetic nervous systems.¹⁹ Resting heart-rate is primarily controlled by the parasympathetic system, whereas maximal heart-rate and blood pressure responses to standing, sustained hand grip, and other types of exercise are mainly functions of sympathetic activity (which controls blood vessel tone).
It is generally considered that parasympathetic dysfunction precedes sympathetic loss. However, more sensitive tests have revealed that there may be pervasive but uneven areas of sympathetic denervation of the heart, which otherwise appears normal, and these findings indicate significant risk for premature death.^20,21
Patients with CAN have higher resting heart rates and lower maximal heart rates during exercise than diabetic patients without autonomic neuropathy.²² The lower maximal heart rate achieved during exercise makes the use of heart rate to gauge exercise intensity inappropriate for many of these patients.
Unexplained sudden death not associated with myocardial infarction, in which the heart becomes unresponsive to nerve impulses (cardiac denervation syndrome), has been reported in diabetic patients with CAN.^23,24 A variety of potential mechanisms have been proposed to explain sudden death, but an exact understanding of this occurrence remains speculative.
Prolonged QT intervals corrected for heart rate (QTc) have been found in diabetic patients with autonomic neuropathy.^24,25 A prolonged QTc is an indicator of increased risk for sudden death. Lengthening of QT/QTc intervals over time is associated with deterioration of autonomic function.
Some investigators have suggested that the electrocardiographic evaluation of QT/QTc interval should be conducted to evaluate autonomic neuropathy in that this evaluation may provide some information about the risk of sudden death.¹⁸ It should be noted, however, that inter-observer variability with regard to the measurement of QT interval and QT dispersion is high.²⁶ Thus, although this noninvasive method for identifying patients who may be at an increased risk of life-threatening ventricular arrhythmias is promising, one should be aware of difficulties with regard to QT measurements.
Ventricular function. Abnormal left ventricular responses to exercise have been observed in patients with CAN.^27,28 Zola and associates found depressed left ventricular systolic function in the absence of ischemic heart disease in approximately one-third of patients with autonomic neuropathy.^22,29 Reduced mean ejection fractions at rest and with maximal exercise have also been reported.³⁰Abnormal diastolic function has been found in patients with more severe CAN.³¹This finding was correlated with a reduction in catecholamine levels and postural hypotension, indicating sympathetic involvement with cardiac diastolic dysfunction.³¹ These potential ventricular function abnormalities indicate the importance of prescribing exercise at low to moderate intensities in this patient population.
Blood pressure. Blood pressure response with posture change and during exercise is abnormal in those with CAN. Postural hypotension, often defined as a drop in systolic blood pressure of >20–30 mmHg or a drop in diastolic blood pressure of >10 mmHg upon standing, may be seen.
Postural hypotension is caused by the failure of reflex vasoconstriction in the splanchnic area and the subcutaneous tissues, and its extent is related to the severity of baroreflex dysfunction.³² As a result of this vasoconstrictive dysfunction, the blood pressure response to exercise does not increase to expected levels in these patients. A lower mean systolic blood pressure response at comparable relative exercise workloads in patients with autonomic neuropathy compared to diabetic subjects without this complication has been reported.^19,22 Zola and Vinik, however, also found that subjects occasionally have severely exaggerated increases in blood pressure.³
The symptoms of postural hypotension may occur with eating or within a few minutes of taking insulin. The effect of insulin may be the result of direct action on the peripheral blood vessels, causing vasodilation.³⁴ The insulin-induced hypotension is often worse in the morning and improves later in the day.¹⁸ This must be taken into consideration when determining the timing of exercise in relation to meals and insulin injections. Exercise may need to be deferred to later in the day, and insulin should not be injected just before exercise, regardless of the location of the injection.
Postural hypotension symptoms are similar to those of hypoglycemia and may be mistaken for a drop in blood glucose, even though they are due to a drop in blood pressure. Patients should be alerted to the potential confusion in these symptoms and instructed to check blood glucose before treating for hypoglycemia.
Ventilatory ReflexesPatients with autonomic neuropathy may have impaired ventilatory reflexes. However, it is not clear if this is the direct result of autonomic dysfunction.
Sobotka and associates reported that five of eight patients with diabetic autonomic neuropathy lost their ventilatory drive and ventilatory response to hypoxemic conditions at rest.³⁵ They concluded that the respiratory dysfunction in these patients resulted from the failure of initiation of respiratory drive under conditions of hypoxia and that the defect was either in the carotid body or in the parasympathetic afferents. No significant difference in the ventilatory response to transient hypoxia with exercise between diabetic subjects with and without autonomic neuropathy was found by Calverly and associates.³⁶
During exercise, additional input from other sources, such as catecholamines or local chemical changes in muscles, may compensate.³⁷ Tantucci and associates found that diabetic subjects with autonomic neuropathy had an excessively increased respiratory rate and alveolar ventilation with stressful exercise (>90% maximum predicted heart rate or symptom-limited).³⁸ A progressively higher inspiratory activity was proposed to be involved with the greater ventilatory response to exercise. The suggested mechanism was reduced neural inhibitory modulation from sympathetic afferents and/or increased CO2 chemosensitivity. This finding emphasizes the need to be cautious about exercise intensity.
Abnormal Neuroendocrine ResponseIn the normal response to exercise, catecholamines rise due to activation of the sympathetic nervous system. The increase in catecholamines is directly related to the intensity of the exercise. This catecholamine response causes blood glucose levels to increase through hepatic glycogenolysis and gluconeogenesis, as well as through lipolysis. In addition, glucagon, cortisol, and growth hormone are increased by adrenergic stimulation, adding to the increase in blood glucose.
A blunted response of catecholamines and other glucoregulatory hormones to exercise has been reported in those with autonomic neuropathy, but with no effect on blood glucose values.³⁹ The specific importance of this abnormal neuroendocrine response on exercise or post-exercise metabolism is unclear, but it may be a contributing factor to exercise intolerance.
GastroparesisGastroparesis may be present in some patients with autonomic neuropathy. The effect of gastroparesis on exercise capacity is related to timing of the arrival of nutrients to the bloodstream. It is important that patients be aware of their specific presentation of gastroparesis and timing of nutrient delivery. Use of medications and techniques to assist with normalizing gastric emptying should be attempted if not contraindicated.⁴⁰
Liquids are preferred over solids to prevent or treat hypoglycemia in patients with gastroparesis, since the rate of liquid emptying remains within the normal range for most of these patients.⁴⁰ Individuals using diabetes medications that can cause hypoglycemia should keep liquids containing carbohydrate available during and after exercise.
Hypoglycemia UnawarenessThe loss of early warning signs of hypoglycemia (hypoglycemia unawareness) can occur in diabetic patients with autonomic neuropathy. Normally, as blood glucose begins to fall, there is an asymptomatic slowing of the heart rate and mild hypotension produced by a parasympathetic response. This is followed by sympathetic release of norepinephrine that does produce symptoms of hypoglycemia, which are usually easily recognized.³¹ With diabetic autonomic neuropathy, the ability to recognize these symptoms may be reduced or absent.
It is vital for patients with hypoglycemia unawareness to frequently check their blood glucose to prevent episodes of unconsciousness. Frequent monitoring of blood glucose is especially important when participating in physical activity, since reductions in blood glucose can occur up to several hours after the conclusion of exercise.
Sweating and Cutaneous Blood Flow DisturbancesReduced or absent sweating in the lower body and hyperhydrosis of the upper half of the body may be present in autonomic neuropathy. The loss of sweating in the lower body can cause dry, brittle skin on the feet, which can contribute to ulcer formation. In addition, microvascular skin blood flow may be impaired in patients with autonomic neuropathy. This causes a poor response to vasoconstrictors (such as cold) and vasodilators (such as heat).⁴¹ Vinik identifies dryness of the skin with cracking fissures and cold toes with bounding pulses as sufficient indication of reduced small-vessel reactivity.¹⁸
Both sweating disturbances and compromised cutaneous blood flow in the lower limbs underscore the need to provide appropriate foot care information to these patients before they begin an exercise program. Patients must use properly fitting shoes and routinely examine their feet before and after exercise. It is also extremely important that patients stay adequately hydrated and do not exercise in extreme temperatures.
NECESSARY TESTING
Autonomic FunctionThe clinical features of autonomic neuropathy are often easily missed since they can be mild and nonspecific.⁴² Subclinical abnormalities may be present at diagnosis, even in teenagers.^43-46 This emphasizes the importance of careful screening and appropriate testing for the presence of autonomic neuropathy before embarking on an exercise program.
Tests that evaluate the cardiovascular reflexes are most often used because of their noninvasive nature and the importance of identifying the potentially serious cardiovascular problems resulting from autonomic neuropathy. The reader is referred to pages 224 and 227 for discussions of autonomic testing.
Exercise Capacity and Evaluation for the Presence of Coronary Artery DiseaseIn addition to evaluating the patient for the presence and severity of autonomic neuropathy, testing should be conducted to determine exercise capacity and whether coronary artery disease (CAD) is present. Exercise testing protocols for populations at risk for CAD are recommended for those who meet any of the following criteria: type 1 diabetes and >35 years of age, type 2 diabetes and >35 years of age, type 1 diabetes for >15 years, presence of any microvascular or neurological diabetes complications, presence of one or more additional coronary risk factors, or presence of suspected or known CAD.^47,48
The exercise test should begin at an intensity significantly below the expected peak or symptom-limited capacity. The test should gradually increase in 2- or 3-minute stages with a suggested duration of 10 ± 2 minutes.⁴⁹ Indications for terminating the test should be carefully observed. Test results should be the basis for determining duration and intensity of the exercise program.
CAD is a major concern in patients with diabetes, and it is important that those with autonomic neuropathy also be screened carefully for this. Symptoms of angina are not reliable indicators of CAD in those with autonomic neuropathy, since these patients have a higher frequency of silent myocardial ischemia and infarction. Exercise thallium scintigraphy is the preferred screening for CAD in those with diabetic autonomic neuropathy.^29,50
The need to carefully assess patients should not serve as a deterrent for recommending safe exercise for those with autonomic neuropathy, particularly if a patient expresses an interest in physical activity.
EXERCISE PRESCRIPTIONTo maximize the benefits of physical activity, it is imperative that exercise prescriptions be tailored to each person’s individual set of circumstances (e.g., extent of complication involvement, medications, interest level, and desired outcomes of the exercise program). Exercise prescriptions must be developed jointly by the health care team and the person with diabetes.¹⁶ The desired outcomes of an exercise program must be carefully considered, remembering that not all benefits of exercise (especially the cardiovascular-related ones) will be realized by each patient. The increased sense of well-being and positive outlook that can result from regular physical activity are extremely important benefits for this population.
Exercise recommendations for those with complications of diabetes are based primarily on test results from acute bouts of exercise and on clinical judgement, with primary attention given to safety—not on the results of specific training studies in these diabetic populations. Therefore, exercise guidelines are considered approximate, and modifications must be made for each patient. A conservative approach to exercise is recommended for those with autonomic neuropathy.
The exercise prescription must address recommendations on intensity, type, duration, frequency, and rate of progression of physical activity based on the findings of careful evaluation. In addition, patients must be given information on safety precautions and symptoms to be aware of if discernible ones do develop. It may be most appropriate for those with CAN to participate in exercise programs supervised by people trained in cardiac care who have an adequate understanding of diabetes.¹⁸

Table 2. Rating of Perceived Exertion

RPE Scale 0 Nothing at all 0.5 Very, very weak 1 Very weak 2 Weak 3 Moderate 4 Somewhat strong 5 6 Strong 7 8 9 Very strong 10 Very, very strong Maximal

IntensityIt is frequently recommended that heart rate be used to determine the intensity of exercise. In patients with CAN, heart rate is not an appropriate indicator of intensity, since maximal heart rate is depressed.
Instead, careful attention should be given to a patient’s subjective feelings of intensity using the Rating of Perceived Exertion (RPE) scale (Table 2). The exercise intensity is prescribed according to the numerical values associated with corresponding adjectives subjectively describing intensity. Vinik recommends that patients strive to reach a moderate-range RPE (~3) gradually over 2–4 weeks.18 It is important that health care professionals clearly explain the RPE scale and emphasize its reliance on patients’ subjective feelings. Exercise should be terminated if a patient is unable to continue talking or, if pedaling, to maintain a consistent pedaling frequency.⁵¹
TypeA patient’s interest level should be what primarily drives the type of activity selected. It is important, however, that the person with diabetes and the health care professional give careful consideration to the Ease of Access and Ease of Performance Indices when selecting the most appropriate types of activities (see below).
Activities that should be encouraged in this population are stationary cycling, semi-recumbent cycling, and water exercises.⁵¹ Water activities and semi-recumbent cycling are especially beneficial for those with orthostatic hypotension, since the pressure of water surrounding the body and the semi-recumbent posture, respectively, help maintain blood pressure. Sitting in a chair doing light resistance exercises (e.g., lifting light weights or using an elastic exercise band) may help maintain or increase muscle strength.
Activities that should be avoided are those that cause rapid changes in body position (e.g., certain calisthenics) or that cause rapid and significant changes in heart rate and blood pressure (e.g., high-intensity running or lifting heavy weights).
DurationPatients with clinically significant autonomic neuropathy have reduced exercise tolerance resulting, in large part, from reduced cardiac output and faulty redistribution of blood flow to the working muscles. Consequently, the duration of exercise in these patients must be determined by patient tolerance. The starting duration should be based on the results of the exercise screening that was conducted before initiation of the exercise program and may be just a few minutes. The intensity of the exercise should not be increased to compensate for shortened exercise sessions.¹⁸
FrequencyThe U.S. Surgeon General now recommends for all people that physical activity be performed on most, if not all, days of the week to obtain health-related benefits.⁵²For those with diabetes complications, this recommendation has added significance.
The intensity and duration of physical activity may be modest in many of these patients. If even a small amount of physical activity can be done each day, it will allow patients to derive some of the benefits of physical activity more safely. It is more likely the activity will become a habit if participation occurs on a daily basis. In addition, daily activity will lessen the difficulty of balancing insulin dosages and food intake with physical activity in those taking insulin. Daily physical activity should be attempted, but it is important to remind patients that when days are missed, they should begin again as soon as possible and not feel defeated.
Rate of ProgressionProgression of exercise in those with autonomic neuropathy must be done cautiously. Emphasis should be placed on increasing the frequency (if exercise is not yet being done daily) and duration of activity before increasing the intensity. The duration of physical activity should be gradually increased to accommodate the patient’s functional capacity and clinical status. Any increase in intensity should be small and approached cautiously to minimize the risk of any dangerous cardiovascular events, musculoskeletal injuries, and/or relapse. Since those with CAN have a higher incidence of abnormal ventricular response to exercise, it is especially important to advance the exercise program slowly and with more careful monitoring.¹⁸
PREVENTION OF HYPERGLYCEMIA AND HYPOGLYCEMIAThe importance of self-monitoring of blood glucose (SMBG) cannot be overemphasized for those with autonomic neuropathy, since the metabolic response to exercise is highly variable in these patients. In patients with type 1 diabetes, when the blood glucose is greater than ~240 mg/dL (13.3 mmol/L) and adequate insulin will not soon be available, there is decreased muscle uptake of glucose and ongoing hepatic glycogenolysis and gluconeogenesis. Under these circumstances, blood glucose may become severely elevated, and it is best to postpone exercise until metabolic control is regained.
A mismatch between insulin levels and blood glucose may be especially common in patients with gastroparesis. Exercise should be planned around gastric delivery of nutrients in order to try to maximize the acute glucose-lowering effects of exercise.
Because of the risk of hypoglycemia unawareness in patients with autonomic neuropathy, patients must receive careful instruction about the frequency and timing of SMBG, insulin action (peak and duration), and the importance of trying to avoid exercise at the peak of insulin action or before the stomach has delivered its contents (if gastroparesis is also present). Patients should be instructed on how to treat hypoglycemia, and significant others should be trained in the use of glucagon. A set time for participating in physical activity may be helpful in reducing the adjustments that need to be made to avoid hypo- and hyperglycemia.
MAINTENANCE OF THE EXERCISE PROGRAM In addition to developing a safe exercise prescription and considering exercise precautions for those with autonomic neuropathy, attention must be given to factors that will assist patients in maintaining a regular physical activity program. Marrero and Sizemore have developed the Ease of Access Index and Ease of Performance Index to help patients determine how realistic their activity selections are.⁵³
The Ease of Access Index asks the question, "How easily can I engage in my activity of choice where I live?" Many times, people select activities that they initially feel they can accomplish, but when examined in more depth, they find that they may have ignored, rationalized, or just not been aware of factors that may serve as barriers to long-term adherence to an exercise plan. To determine the ease of access for a given activity, patients should be asked to consider the following questions:

1. Does it require special facilities, and are these facilities available?
2. Does it require special equipment, and is this equipment available and affordable?
3. Does it require special training or instruction, and is this instruction readily available, scheduled at convenient times, easy to get to, and affordable?
4. Does it require others to do it, and will these people be available at the appropriate times?
5. Is it seasonal, and what will be done at other times of the year?

If the selected exercise activity is reasonably accessible, then an assessment of the ease of performance should be conducted. The Ease of Performance Index assesses of how suitable the activity is in terms of personal physical attributes and lifestyle. Patients should be asked to consider the following questions:

1. Does the activity suit your physical attributes?
2. Can you realistically integrate the chosen activity into your current lifestyle?
3. Can you afford any costs associated with it?
4. Do you have a good support network if you need one for the activity?

The use of these two indices will hopefully help patients and health care professionals to consider in advance issues that often undermine long-term participation in physical activity.
Other factors that may assist patients in maintaining a physical activity program include the following:⁵⁴

1. Taking measures to avoid injury. A warm-up and cool-down consisting of low-intensity activity and static stretches should be done to reduce the likelihood of injury.
2. Setting well-defined exercise goals. The goals should be precisely defined by exercise behavior (e.g., walk for 10 minutes daily at a 2 RPE rating) rather than by a hoped-for outcome (e.g., reduction in HbA_1c by 1%).
3. Setting an exercise schedule in advance. Having a schedule can help both in terms of forming a habit of physical activity and in making adjustments to the diabetes management plan easier.
4. Involving an exercise partner. An exercise partner can help with motivation and encouragement, as well as provide safety for a patient with chronic complications. As mentioned above, a monitored exercise program may be best for patients with CAN.
5. Identifying alternative activities. To reduce boredom, it may be helpful to assist patients in considering more than one type of activity. All possible activities should be evaluated for safety, as well as ease of access and ease of performance, as described above.

SUMMARYPhysical activity should be carefully considered for all patients with diabetes. When the chronic complications of diabetes develop, it is especially important to weigh the risks and benefits of an exercise program in formulating the exercise prescription. The deleterious effects of not participating in any physical activity must also be factored in when making decisions about the use of exercise in those with chronic complications.

Autonomic neuropathy may affect several systems that are necessary for the body’s adjustment to exercise, particularly the cardiovascular system. Careful testing to evaluate autonomic function and to determine exercise capacity and the presence of CAD are extremely important. The need for careful evaluation before starting an exercise program should not prevent participation in physical activity. Working with patients to develop an appropriate exercise plan will yield a program with the greatest capability of maximizing the benefits.

Best Precautions for Diabetic Patients

As the ‘World Diabetes Day’ is being observed today, we bring to you simple ways and techniques that can keep a diabetic person healthy for a longer period of time.

1. Avoid Sugar and Spicy Food

Refined sugar must be avoided at all times as it increases the blood glucose level. Oily or spicy food should be avoided as it is more difficult for a diabetic person to digest such kind of foods as compared to a non-diabetic person. Oily or spicy food can cause massive stomach irritation in a diabetic patient, according to WebMD.





A diabetic person should avoid the two extremes; fasting and feasting. Missing meals or overeating disturbs the balance of the body and the blood glucose levels start fluctuating abnormally, according to WebMD.





As the ‘World Diabetes Day’ is being observed today, we bring to you simple ways and techniques that can keep a diabetic person healthy for a longer period of time.


Alcohol is like poison for a diabetic patient as it can cause severe hypoglycemia and can permanently damage the nerves. Even regular alcohol consumption can fluctuate the blood glucose levels in a diabetic person, according to WebMD.




Exercising helps a diabetic person immensely as it improves the body’s use of insulin and burns the excess fat from the body. Exercising also allows a diabetic to lower the blood pressure and gain extra energy. Although, it should be noted that intense exercising is not advisable for a diabetic person as it may increase the blood glucose levels in the body, according to WebMD.





The amount and the time of food intake are very important factors when it comes to diabetes. Both of them need control, specially the intake of carbohydrates. Variation in the intake of carbohydrates will also change the blood glucose level in a diabetic patient. Hence, regular meals and proper time with the right amount of carbohydrates are the most important precautions a diabetic person requires, according to WebMD.

Diabetes Types Its Causes,Symtoms,Treatments

1- Type 1 Diabetes

Type 1 Diabetes affects the body such that it can no longer produce insulin Type 1 diabetes affects the body such that it can no longer produce insulin
Often referred to as juvenile diabetes, type 1 diabetes is a form of diabetes mellitus that is most common in children but can be diagnosed at any age.

Type 1 diabetes is an autoimmune disease that permanently destroys beta cells in the pancreas, meaning that the body can no longer produce insulin.

People with type 1 diabetes therefore require regular insulin delivery to manage their diabetes.

Type 1 causes

The causes of type 1 diabetes are different than those for type 2 diabetes, though the exact mechanisms for development of both diseases are unknown.
Type 1 diabetes, also known as insulin-dependent diabetes, is commonly thought to be caused by a combination of genetic predisposition and an environmental trigger, which causes the immune system to target and kill off its own insulin producing cells.

What triggers the immune system to behave this way is not yet well understood.

Theories include the possibility that a virus may stimulate the auto-immune response.

As more insulin producing cells in the pancreas are killed off, the body can no longer control its blood glucose levels and the symptoms of diabetes begin to appear.

Type 1 diabetes symptoms


Type 1 diabetes symptoms should be acted upon immediately, as without treatment this type of diabetes can be deadly.


Symptoms include:

Above average thirst
Feeling tired
Needing to pee regularly
Losing weight
Skin infections
Genital itchiness

Sometimes, type 1 diabetics may be mis-diagnosed as being type 2, particularly if the condition develops later in life.

Please see Diabetes Symptoms and Diabetes Signs for more information.
Treatment for type 1 diabetes

Lack of insulin production by the pancreas makes type 1 diabetes particularly difficult to control.

Treatment requires a strict regimen that typically includes a carefully calculated diet, planned physical activity, home blood glucose testing several times a day, and multiple daily insulin injections.


Staying physically active and exercising regularly, maintaining a constant weight and eating a healthy diet are all invaluable in type 1 diabetes treatment.

Although diet and exercise have a role to play in type 1 diabetes management, they cannot reverse the disease or eliminate the need for insulin.

Type 1 diabetes and complications

Type 1 diabetes is a serious condition which can lead to complications including:

Heart disease
Stroke
Retinopathy
Kidney disease
Neuropathy

Whilst the list of complications is a scary prospect, the chances of developing these can be significantly reduced by maintaining good control of your blood glucose levels and ensuring you attend all your diabetic complication screening appointments.

Type 1 diabetes facts

The risk of developing type 1 diabetes can be affected by your genetics; i.e. if your parents or siblings have type 1 diabetes.

In terms of inheritance of type 1 diabetes - there is a 2% risk if the mother has type 1 diabetes, 8% risk if the father has type 1 diabetes; and a 30% risk of the child developing type 1 diabetes if both parents are type 1 [5]
Within 20 years of diagnosis of type 1 diabetes, nearly all of those diagnosed have some degree of retinopathy [1]
There is also a sub-type of type 1 diabetes known as brittle diabetes.


2- Type 2 Diabetes

Diabetes Mellitus Type 2 is commonly known as Type 2 Diabetes
Type 2 diabetes mellitus is a metabolic disorder that results in hyperglycemia (high blood glucose levels) due to the body:

Being ineffective at using the insulin it has produced; also known as insulin resistance and/or
Being unable to produce enough insulin
Type 2 diabetes was formerly known as non-insulin-dependent or adult-onset diabetes due to its occurrence mainly in people over 40.

However, type 2 diabetes is now becoming more common in young adults, teens and children and accounts for roughly 90% of all diabetes cases worldwide.

Type 2 diabetes statistics

According to the International Diabetes Federation (IDF), more than 371 million people across the globe have diabetes and this figure is predicted to rise to over 550 million by 2030.


Of the total global diabetes rate, 90% are living with type 2 diabetes but it is estimated that up to half of these people are unaware of their condition (undiagnosed diabetes).

In the UK, more than 2.7 million people are diagnosed with type 2 diabetes whilst a further 750,000 people are believed to have the symptoms but are yet to be diagnosed with the disease.

How serious is type 2 diabetes?

Type 2 diabetes is a serious medical condition that often requires the use of anti-diabetic medication, or insulin to keep blood sugar levels under control. However the development of type 2 diabetes and its side effects (complications) can be prevented if detected and treated at an early stage.

Following pre-diabetes or metabolic disorder, type 2 diabetes can potentially be avoided through diet and exercise.

What causes type 2 diabetes?

Type 2 diabetes occurs when the hormone insulin is not used effectively by the cells in your body. Insulin is needed for cells to take in glucose (sugar) from the bloodstream and convert it into energy.

Ineffective use of insulin results in the body becoming resistant to normal levels of insulin - also known as insulin resistance, which in turn causes blood sugar levels to rise (hyperglycemia).

In advanced stages, type 2 diabetes may cause damage to insulin producing cells in the pancreas, leading to insufficient insulin production for your body's needs.

Type 2 diabetes risk factors

A number of factors can increase the risk of developing type 2 diabetes.

These include:

Being overweight or obese
Having a waist size of 31.5 inches or more (women) or more than 37 inches (men)
Eating an unhealthy diet
Physical inactivity
Having a first-degree relative with type 2 diabetes
Having high blood pressure or raised cholesterol levels
Being of South Asian and African-Caribbean descent
Smoking

The likelihood of developing type 2 diabetes is also influenced by genetics and environmental factors. For example, research shows that:

If either parent has type 2 diabetes, the risk of inheritance of type 2 diabetes is 15%
If both parents have type 2 diabetes, the risk of inheritance is 75%

3- Gestational Diabetes

Gestational diabetes is a type of diabetes that can develop in pregnancy

Finding out you have gestational diabetes can be very frightening.

Not only do you have to deal with all the emotions (the ups and the downs) and the questions that come with being pregnant, but also the uncertainty of this new-found condition.

Fortunately, as with all types of diabetes, there are many well-informed health professionals to help answer your questions and to guide you through this very important time in your life.

The more you know, the easier it is to accept and make the necessary changes for a successful and happy pregnancy.

HOW DID I GET GESTATIONAL DIABETES?

Somewhere between 24 and 28 weeks into your pregnancy your doctor most likely sent you to be screened for the presence of gestational diabetes.

If you were at greater risk for getting gestational diabetes, your doctor may have sent you for a screening test before you reached 16 weeks.

You may think this is too late in your pregnancy to be finding out about such a problem, but in most cases, screening before this time would be of little value.

HORMONAL CHANGES AND INSULIN

It is the hormonal changes (hormones made by the placenta that resist insulin) in the second and third trimesters of pregnancy, along with the growth demands of the foetus, that increase a pregnant woman's insulin needs by two to three times that of normal.

Insulin is needed to take the sugar from your blood and move it into your cells for energy.

If your body cannot make this amount of insulin, sugar from the foods you eat will stay in your blood stream and cause high blood sugars.

This is gestational diabetes.

HOW COMMON IS GESTATIONAL DIABETES?

Gestational diabetes means diabetes mellitus (high blood sugar) first found during pregnancy.

It occurs in 3-5% of all pregnancies (in other words, 1 in 20 pregnant women will develop gestational diabetes); so, you can take comfort in the fact that you are not alone.

In most cases, gestational diabetes is managed by diet and exercise and goes away after the baby is born.

Very few women with gestational diabetes require insulin to control this type of diabetes.

If you do need insulin, it will ensure blood glucose stays in the acceptable range, thereby reducing the risks to you and your baby.

Gestational diabetes should not be taken lightly. Immediate risks to the mother and fetus are very real; however, these risks can be minimized with good care and follow up.

Ante-natal care

Ante-natal care should be hospital-based, from a multi-disciplinary team.

Individualise insulin regimens and recommend 4-times daily glucose monitoring.

Aim to maintain glucose 4-7 mmol/L and HbA1c within the normal non-diabetic range.

Remember insulin requirements increase progressively from the 2nd trimester until the last month of gestation, when a slight fall-off may be noted

Hypoglycemia and loss of awareness is common in early pregnancy. Hypoglycemia does not appear to have long-term adverse effects on fetal development

Ketoacidosis can cause fetal death at any stage. All women should test urine for ketones if blood glucose is high, if vomiting occurs or if they are unwell.

4- Diabetes LADA

LADA stands for Latent Autoimmune Diabetes of Adulthood

Diabetes occurs in many types beyond type 1 diabetes and type 2 diabetes. One of these is Latent Autoimmune Diabetes of Adulthood (LADA).

Some patients receive the diagnosis of type 2 diabetic, despite not exhibiting all the classic symptoms associated with this condition.

In some instances, a more accurate diagnosis would be LADA.

How does LADA differ from type 2 diabetes?

Patients with LADA may lack some of the type 2 diabetes symptoms. These could include age, obesity, and the difficulty in achieving glycaemic control using standard oral hypoglycaemic agents.

If these are lacking from diagnosis, it is quite possible that the patient has LADA. LADA is more typical of the immune markers common to type 1 diabetes, yet in its early stages does not require insulin.

Patients in the early stages of LADA may also lack ketoacidosis symptoms.

However, there may be a more rapid progression to requiring insulin amongst LADA patients when compared to normal type 2 diabetics. LADA patients share features common to both type 1 and type 2 diabetics.

5-  Diabetes MODY

MODY is an acronym for Maturity Onset Diabetes of the Young

Diabetes comes in many forms, one of which is Maturity Onset Diabetes of the Young, or MODY. This type of diabetes is more likely to be inherited than other types of diabetes, due to a stronger genetic risk factor.

MODY is sometimes compared to type 2 diabetes, and shares some type 2 diabetes symptoms.

However, MODY is not linked to obesity, and typical MODY patients are young and not necessarily overweight.

What is MODY diabetes?

Maturity Onset Diabetes of the Young affects approximately one or two per cent of people who have diabetes, and may often go unrecognised in its early stages.

It is a form of diabetes that develops before the patient reaches 25.

It also runs in families, and can pass from one generation to the next. MODY does not always require insulin treatment.

Why is MODY inherited so easily?

MODY is directly caused by the change in a single gene, and all children of an affected parent have a 50 per cent chance of inheriting this gene, and consequently developing MODY themselves.


Why does MODY differ from other strains of diabetes, why does it matter?

Knowing and understanding MODY and even the different forms of MODY (six types have been identified), means that the affected person can be treated in the most appropriate way possible.

Advice can also be provided about how the disease will progress, and what complications can be expected. Furthermore, other family members can be advised about the risks of inheriting the disease.

What are the different types of MODY?

The most common MODY type is HNF1 alpha. This is responsible for 70% of MODY.

The amount of insulin produced by the pancreas becomes less as the person gets older, and MODY develops during adolescence or the early twenties.

Glucokinase is the second type of MODY, and occurs when this gene (that aids the body in recognising blood glucose levels) malfunctions.

This type of MODY can be hard to identify, and symptoms can be particularly slow in manifesting themselves.

It is usually picked up during routine testing. When a person is pregnant, it is important to screen for it.

HNF4 - alpha is a less common form of MODY that is often diagnosed at a later stage. HNF1 - beta is a type of MODY associated with renal cysts.

PDX1 and IPF1 are the same type of MODY, and are incredibly rare, affecting only one UK family to date.

NeuroD1 is another rare type of MODY, affecting only two families in the UK. Little information is available about the rarer forms of MODY.

What complications are caused by MODY?

It has recently been found that MODY can initiate complications. Managing the disease strictly is just as important for MODY patients as other types of diabetic.

6- Double Diabetes

Double diabetes is when someone with type 1 diabetes develops insulin resistance, the key feature of type 2 diabetes.

Someone with double diabetes will always have type 1 diabetes present but the effects of insulin resistance can be reduced somewhat.

The most common reason for developing insulin resistance is obesity and whilst type 1 diabetes is not itself brought on by obesity.

People with type 1 diabetes are able to become obese and suffer from insulin resistance as much as anyone else.

What is the difference between type 1 and type 2 diabetes?

Type 1 diabetes is an autoimmune disease whereby the body’s immune system attacks and kills off its own insulin producing cells.

The autoimmune effect is not prompted by being overweight. Over a period of time, the vast majority, if not all, of insulin producing cells are destroyed.

Without being able to produce insulin, blood sugar levels rise and the symptoms of diabetes appear.

Type 2 diabetes is closely related to obesity, 85% of cases of type 2 diabetes occur in people who are obese.  Although the process is not yet fully understood, it is largely believed that obesity causes the body’s cells to become resistant to insulin.

As a result, people with either type 2 diabetes or pre-diabetes start to produce more insulin than those without the condition and one of the consequences of this is further weight gain which helps to reinforce the condition.

Progression of double diabetes

Similar to type 2 diabetes, double diabetes, if not treated appropriately can become more severe over time.

If double diabetes is allowed to progress more insulin will need to be injected which promotes further weight gain and increases the body’s resistance to the insulin further requiring even greater insulin.

Treating double diabetes

Someone with double diabetes will need to keep taking their insulin every day as their type 1 diabetes will always be present. In addition, they will need to try to combat the insulin resistance by adapting their lifestyle to help regain their sensitivity to insulin and slowly and safely reducing the amount of insulin they take.

Eating foods with fewer carbohydrates and a higher fibre content can be effective. Including more exercise into one’s daily routine can also help to increase insulin sensitivity.

Medication usually prescribed for type 2 diabetes may also be prescribed to help improve insulin sensitivity as well as to aid weight loss.

Prognosis of double diabetes

Double diabetes can be problematic in that it is taking a condition, type 1 diabetes, with a relatively high risk of complications, such as heart disease, stroke and kidney disease, and then increasing the risks by adding the associated problems of weight gain and obesity. If overall blood glucose control is also not good, the risks are further increased.

If blood sugar levels are well controlled and body weight is reduced, the risks of diabetic complications can be reduced.

7- Type 3 Diabetes

Type 3 diabetes is a term for insulin resistance in the brain

Type 3 diabetes is a title that has been proposed for Alzheimer's disease which results from resistance to insulin in the brain.

Studies carried out by the US Brown Medical School research team identified the possibility of a new form of diabetes after finding that insulin is produced by the brain as well as the pancreas.

Lead researcher, Dr Suzanne de la Monte, carried out a further study in 2012 for Rhode Island Hospital to further investigate the link.

The researchers pinpoint resistance to insulin and insulin-like growth factor as being a key part of the progression of Alzheimer’s disease.

Whereas type 1 and type 2 diabetes are characterised by hyperglycemia (increased blood sugar), a separate study, carried out by the University of Pennsylvania and published in 2012, excluded people with a history of diabetes, indicating that Alzheimer’s can develop without the presence of significant hyperglycemia in the brain. 

Increased risk of Alzheimer's

People that have insulin resistance, in particular those with type 2 diabetes have an increased risk of suffering from Alzheimer's disease estimated to be between 50% and 65% higher.

Researchers at the medical school discovered that many type 2 diabetics have deposits of a protein called amyloid beta in their pancreas which is similar to the protein deposits found in the brain tissue of Alzheimer's sufferers.

8- Steroid Induced Diabetes

Steroids are used to reduce inflammation

Corticosteroids are used to reduce harmful inflammation but can lead to diabetes - often referred to as steroid diabetes.

People on steroids who are already at a higher risk of type 2 diabetes or those who need to take steroids for longer periods of time are the most susceptible to developing steroid induced diabetes.

What is the role of steroids?

Steroids are taken to reduce inflammation, brought on by the body’s immune system, and can be taken as treatment for a number of illnesses including:

Asthma
Lupus
Rheumatoid arthritis
Crohn’s disease
Ulcerative colitis

To achieve their purpose, corticosteroids mimic the action of cortisol, a hormone produced by the kidneys and responsible for brining on our body’s classic stress response of higher blood pressure and increased blood glucose levels.

Corticosteroids increase insulin resistance thus allowing blood glucose levels to rise and remain higher.
Read more on steroids and their side effects.

What are the symptoms of steroid induced diabetes?

Steroids and diabetes

Role of steroid receptors in insulin resistance investigated
Inhaled steroids can increase diabetes risk
People taking steroids may notice the following symptoms of diabetes:

Dry mouth
Blurred vision
Increased thirst 
Increased need to urinate
Tiredness and lethargy

However, symptoms may not be present unless blood sugar levels are significantly higher than normal.

Is steroid induced diabetes permanent?

High blood glucose levels whilst taking steroids may subside after you stop taking steroids, however, some people may develop type 2 diabetes which will need to be managed for life.

Type 2 diabetes is more likely to develop following longer term usage of steroids, such as usage of oral corticosteroids for longer than 3 months.

Am I at risk of developing steroid induced type 2 diabetes?


People at a higher risk of developing type 2 diabetes include:

Those that are overweight
If you have one or more close family members with type 2 diabetes
If you have had gestational diabetes
If you have polycystic ovary syndrome
If you are over 40 and of caucasian origin
If you are over 25 and are of South Asian, African-Caribbean or Middle Eastern origin

Did steroids bring on my type 2 diabetes?

There has been debate as to whether corticosteroids are a cause for diabetes or whether steroids advance the development of existing type 2 diabetes.

A study published in 2012, carried out by the University of Sydney, looked to investigate answers to the question.

The study, titled Steroid-Induced Diabetes: Is It Just Unmasking of Type 2 Diabetes?, found that those which developed new onset steroid induced diabetes had lower risk profiles than is typical of people with type 2 diabetes.

How is steroid induced diabetes treated?

The treatment for diabetes you are put on may depend on the extent of insulin resistance and how high your blood glucose levels are. It may be possible to treat your diabetes with diet and physical activity but you may need oral anti-diabetic medication or insulin.

If you have been diagnosed with diabetes, you will need to attend health screenings at least once annually so your health can be monitored and treated appropriately.

9- Brittle Diabetes (Labile Diabetes)

Brittle diabetes is a sub-type of type 1 diabetes

Brittle diabetes mellitus (or labile diabetes) is a term used to describe particularly hard to control type 1 diabetes.

Those people who have brittle diabetes will experience frequent, extreme swings in blood glucose levels, causing hyperglycemia or hypoglycemia.

How does brittle diabetes develop and what is it associated with?

Brittle diabetes has a number of potential causes.

It can be caused by absorption problems in the intestines. This includes delayed stomach emptying, drug interactions, insulin absorption issues and malfunctioning hormones.

Severely low blood sugar levels may also create thyroid and adrenal gland problems.

Gastroperesis, delayed stomach emptying, can affect the rate at which food, glucose and insulin is absorbed into the bloodstream.

Brittle diabetes is often associated with psychological issues such as stress and depression.

Is brittle diabetes different from stable diabetes?

All people with diabetes will a certain level of blood glucose level fluctuation. However, when these shifts are not extreme or over-frequent they do not impair the ability to lead a normal life.

With brittle diabetes, however, the fluctuations are more serious and tend to result in frequent hospital visits, interruption to employment and can often contribute to psychological issues such as stress.

Life expectancy with brittle diabetes

The life expectancy for someone with brittle diabetes is no different to someone who has type 1 or type 2 diabetes.

In fact, brittle diabetes can also be described poorly controlled type 2 diabetes.

Is brittle diabetes common?

Brittle diabetes is rare but serious. Around 3 in 1,000 people with type 1 diabetes mellitus will develop brittle diabetes.


Will I get brittle diabetes?

Those people suffering from psychological problems, including stress and depression, face a greater risk of developing brittle diabetes. This can be as simple as psychological problems causing neglect of diabetes care (such as stopping eating healthily, taking medication or exercising regularly).

Blood sugar control quickly becomes less regular, and imbalances in the metabolism can exacerbate this.
Furthermore, psychological problems can then become worse, causing a symbiotic cycle which reinforces brittle diabetes.

Brittle diabetes is most likely to affect women who are overweight, between the ages of 15 and 30. 

How is brittle diabetes treated?

The most effective treatment for brittle diabetes is to identify and correct underlying physical or psychological problems. Glucose instability is often able to be tracked using blood tests.

Often treatment seeks to address behavioural, psychological or environmental causes. This can be a lengthy and difficult process of treatment.

Treatment may involve trying to lessen stress, and psychotherapy has also proven to be effective in the treatment of brittle diabetes.

Caring for brittle diabetes

Sometimes, a completely fresh start in diabetes care is needed to break the brittle diabetes cycle.

Brittle diabetes treatment may sometimes require a long stay in hospital with monitoring of food, blood glucose levels and insulin.


Furthermore, physical brittle diabetes diagnosis may require insulin pump therapy to control blood glucose levels.

Islet and pancreas transplants

There may even be a case for islet transplants or even pancreas transplant. However, this therapy is at an early stage, and includes its own risks.

Healthcare professionals play a crucial role in treating brittle diabetes.

Patients require close supervision, with the diabetes care team making sure that the patient gets all of the relevant information and education.

Support for the patient themselves and their family and friends are an essential part of brittle diabetes management.



10- Secondary Diabetes

Secondary diabetes can result from a variety of other health conditions

Secondary diabetes is diabetes that results as a consequence of another medical condition.

Because the cause of diabetes ranges between different conditions, the way in which blood glucose levels are controlled can also vary.

Secondary diabetes will often be permanent but for some forms, it may be possible to reverse or eradicate the effects of hyperglycemia.

Which conditions can lead to secondary diabetes?

Health conditions which can cause diabetes include:

Cystic fibrosis
Hemochromatosis
Chronic pancreatitis
Polycystic ovary syndrome (PCOS)
Cushing's syndrome
Pancreatic cancer
Glucagonoma
Pancreatectomy

Drug induced diabetes includes diabetes that results from taking certain medications. Medications which may bring on diabetes include corticosteroids, beta-blockers and thiazide diuretics.

Managing secondary diabetes

How secondary diabetes is managed can vary quite significantly depending on which condition has caused it.

Insulin resistance

Some medical conditions listed will result in insulin resistance, which is where the body is not able to adequately respond to insulin.

This forces the body to release more insulin in an attempt to keep blood glucose levels under control. Insulin resistance is a characteristic of type 2 diabetes.

Insulin resistance is a feature of diabetes caused by Cushing’s syndrome and PCOS. Lifestyle changes are an important part of treatment.

If medication is required to control blood glucose levels, metformin is commonly prescribed with stronger medication, including insulin, available if blood glucose levels remain elevated.

LOSS OF PANCREATIC FUNCTION

Some forms of secondary diabetes, such as diabetes as a result of pancreatitis, cystic fibrosis or hemochromatosis, may result in a loss of pancreatitic function; that is the pancreas may not be able to produce enough insulin to keep blood glucose levels stable.

In these forms of secondary diabetes, injections of insulin may need to be taken to keep blood sugar levels under control.

However, in some cases, taking diabetes medication in tablet form may be sufficient.

People that have had a pancreatectomy will not be able to produce any of their own insulin and will therefore need to take regular insulin injections in a similar way to people with type 1 diabetes.

Excess glucagon production

In glucagonoma, tumours in the pancreas lead to too much glucagon being released. Glucagon works in the opposite way to insulin, and instructs the release of glucose into the blood, which can result in blood sugar levels going too high.

Treatment for glucagonoma is to directly target the tumour with anti-tumour therapy such as chemotherapy or through surgery to remove the tumour.

Is secondary diabetes permanent?

In some cases diabetes will be permanent. The cases when diabetes needn’t be permanent are if the cause of diabetes can be corrected. For instance, it can sometimes be possible to reverse the effects of diabetes in hemochromatosis if the condition is adequately treated in time.

Diabetes as a result of glucagonoma may also be temporary if treated successfully soon enough.


11- Diabetes Insipidus

Diabetes Insipidus is a rare form of diabetes

Diabetes insipidus, often shortened to DI, is a rare form of diabetes that is not related to blood sugar-related diabetes mellitus, but does share some of its signs and symptoms.

Diabetes insipidus is simply excessive urination (polyuria) and complications thereof, caused by an antidiuretice hormone called a vasopressin.

Read on to find out more about what diabetes insipidus is, how it affects the body, the different forms of the disease, and how it is diagnosed and treated.

What are the symptoms of diabetes insipidus?

Diabetes Insipidus leads to frequent urination, and this is the most common and clear symptom. In extreme cases, urination can be in excess of 20 litres per day.

A secondary symptom is increased thirst, as a result of passing so much water.

If this is not met, then dehydration can occur which, in turn, can lead to:

Cracked skin
Fatigue
Confusion
Dizziness and even
Unconsciousness

Children suffering from the condition may become irritable or listless, with fever and vomiting also possible.

How does diabetes insipidus compare with diabetes mellitus?

Diabetes insipidus and diabetes mellitus should not be confused. The two conditions are unrelated, with diabetes insipidus a completely different type of illness. Diabetes mellitus is also far more common.

Diabetes mellitus occurs due to insulin resistance or insulin deficiency and subsequent high blood glucose levels.

Diabetes Insipidus on the other hand develops as a result of the stilted production of a hormone in the brain, which is released to stop the kidneys producing so much urine in order to retain water. Without this hormone, water is not retained and the kidneys constantly work to their maximum capacity.

The word "Mellitus" tagged onto the main form of diabetes comes from an old word roughly meaning "to sweeten with honey" and is a reference to the high levels of sugar in the blood.

By contrast, "Insipidus" means "un-tasty" and so is used to describe a form of diabetes that does not result in high sugar levels.

The different types of diabetes insipidus

There are 4 types of diabetes insipidus, including:

1-Neurogenic diabetes insipidus

Neurogenic diabetes Insipidus, or central and cranial diabetes insipidus as it is sometimes referred to, is a form of DI that is caused by a problem in the hypothalamus section of the brain. It can stop producing the antidiuretic hormone (ADH), also known as vasopressin.

This hormone tells the kidneys to stop producing urine, and is released when there is a relatively low amount of water in the body. If ADH isn't produced, the kidneys will go on producing urine, resulting in frequent trips to the toilet and a higher risk of dehydration.

Head injury, brain tumours or brain surgery can all result in damage to the hypothalamus or pituitary gland, which can prevent it from producing and storing the ADH.

A lack of oxygen reaching the brain, caused by a stroke or a breathing trauma, such as choking or drowning, can cause sufficient damage to prevent production, as can some infections such as meningitis.

2-Nephrogenic diabetes insipidus

There are 2 forms of nephrogenic diabetes:

Congenital nephrogenic diabetes insipidus

Congenital diabetes Insipidus is present from birth and is caused by several genes that cause the kidneys of the foetus to form improperly. Kidneys contain cells called nephrons which regulate what water is passed by urine and what water is reabsorbed back into the body. These nephrons react to the ADH released by the hypothalamus, and if they are damaged, they can end up 'ignoring' the ADH, leading to constant production of urine.

Deformations can occur in the body by the presence of several rogue genes. This mutation can only be passed from unaffected mothers to their sons. However, this very rarely happens, apparently affecting just 1 in 250,000 births.

There is an even rarer gene mutation that can cause nephrogenic diabetes insipidus in both males and females.

3-Acquired nephrogenic diabetes insipidus

Acquired diabetes insipidus occurs after birth as a result of an outside factor damaging the kidneys and leading to the excessive urination.

Lithium is used in some medications, particularly for bi-polar disorder, and long term intake of lithium can cause damage to the nephrons in the kidneys. Being taken off lithium however, can restore normal kidney function if it is diagnosed early, so having kidney function tests every three months is advised by the NHS if you are on lithium containing medication. Your doctor will talk to you about this.

Infections, blockages (such as kidney stones) or other forms of damage to the kidney could lead to diabetes insipidus, so if you have undergone any of these and are experiencing excessive urination, you should contact your doctor.

4-Gestational diabetes insipidus

During pregnancy, the uterus produces vasopressinase which can break down ADH. The nephrones in the kidneys do not receive the 'stop making urine' message and continue to produce it.

Usually Gestational diabetes insipidus will disappear after the pregnancy. Just like gestational diabetes mellitus, one case of gestational diabetes insipidus means that another case during subsequent pregnancies is likely.

5-Dipsogenic diabetes insipidus

Some cases of diabetes insipidus occur because of an issue with the thirst function. Similar damage to the hypothalamus that causes neurogenic diabetes insipidus can also result in a malfunction to the thirst mechanism, resulting in thirst that won't go away. This will lead to a constant need to drink, which in turn can lead to excessive urination.

How is diabetes insipidus diagnosed?

Diagnosing DI can be complicated as it shares many symptoms of diabetes mellitus. There are however, a series of tests that can determine exactly what the patient is suffering from. These include urinalysis, fluid deprivation, and even MRI scans.

If a GP thinks a patient may have DM, they will carry out a urine glucose test, which should result negatively if the patient has DI.

Treating diabetes insipidus

If you have a mild form of DI, usually only passing around 3-4 litres of urine a day, you may not be given any treatment and told that the disorder is manageable by drinking plenty of water.


If your condition is more severe, you may be given one of the following:

Desmopressin for treating neurogenic diabetes insipidus

Desmopressin is a manufactured version of ADH given as a medication for diabetes insipidus. It acts in place of the natural hormone your body can't produce.

In more extreme cases of DI, desmopressin may be prescribed in either a tablet or a nasal spray form. The nasal spray is more effective, and gets into the bloodstream more efficiently and quicker, but can be blocked by colds or flu.

There are fairly low rates of side effects in patients on desmopressin, but they can include

Headache
Nausea and vomiting
Dizziness

The main concern with desmopressin is overdosing, as this can cause your body to retain too much water.

Stick to the dosage your doctor has prescribed and don't increase the dose if it is 'not working'. Consult your doctor if the symptoms persist, even whilst on treatment.

Thiazide diuretic treatment for neurogenic diabetes insipidus

Thiazide diuretics are a type of medication that increases urination rate but can strangely help prevent urination in sufferers of diabetes insipidus. This is because thiazides increase the concentration of the waste product in the urine, which can have a consequential effect of reducing the amount of urine produced in DI sufferers.

Nephrogenic diabetes insipidus treatment

Nephrogenic DI is much harder to treat. This is because there is a problem with the kidneys themselves, not just the message that tells them what to do.

If you are on a medication containing lithium, coming off that prescription may help. However, you should not alter your medication without consulting your doctor, and they will tell you what to take or try to find and alternative treatment.

Dietary changes may also help to alleviate your symptoms, but again, consult your GP before making any drastic change to your diet.

12- Juvenile Diabetes

Diabetes is the most common metabolic disease in young people

Juvenile diabetes refers to diabetes in the young. Type 1 diabetes effects 90% of people younger than 25 who have diabetes.

Diabetes is the most common metabolic disease in the young.

There is no agreed definition of what is meant by a young person in this context, however most people would refer to a young person as being under 16 or 18 years of age.

Various age ranges have been used in the literature.

Diagnosis and epidemiology

The Scottish Study Group for the Care of the Diabetes in the Young showed that currently there are nearly 2000 people with diabetes aged under 16 years in Scotland, with an annual incidence of 25 per 100,000 population and a near tripling of new cases in the last 30 years.

Type 1 diabetes, resulting from beta-cell destruction and absolute insulin deficiency, accounts for over 90% of diabetes in young people younger than 25, and is autoimmune in origin.

Non-type 1 diabetes is recognised with increasing frequency, particularly emerging molecular forms of diabetes, diabetes secondary to pancreatic disease and a rise in type 2 diabetes and other insulin resistance syndromes in the young.

Type 1 diabetes

12-15% of young people under the age of 15 with diabetes mellitus have an affected first degree relative (a positive family history).

Children are thrice as likely to develop diabetes if their father has diabetes rather than their mother.

While there are known antibody markers of prediction in high-risk subjects, there is no evidence for effective methods of prevention of diabetes.

Screening is currently considered unethical except in the context of a trial.

There are several randomised trials in progress (e.g. ENDIT, DPT-1, DIPP) investigating different therapies for the prevention of type 1 diabetes. It is anticipated that results will be available in the next five years.

Diabetes and cystic fibrosis

20% of patients with cystic fibrosis develop secondary diabetes by the age of 20, with an incidence which increases thereafter to 80% by the of age 35.

Limited data suggest that clinical symptoms deteriorate when diabetes develops in cystic fibrosis, although no evidence exists that the presence of diabetes or its treatment affects long-term survival.

Initiating therapy at diagnosis

Home-based instruction of the newly diagnosed child or young person appears to be at least as effective as inpatient instruction in terms of glycaemic control and family acceptability over a two-year period. Management in the community using a home-based education programme for patients with newly diagnosed diabetes has been shown also to be cost-effective.

The evidence on the role of the intensification of therapy in the attempt to achieve as rapid as possible normoglycaemia is inconsistent. In particular, there is no evidence of a sustained effect of any specific insulin therapy on glycaemic control during the first few months after diagnosis.

Therefore, no recommendation can be given for the most appropriate insulin therapy at diagnosis.

Continuing management

There is at present no evidence for the effectiveness of any medication other than insulin in the management of type 1 diabetes in the young.

Insulin regimen

Conventional therapy for type 1 diabetes (twice daily insulin with support from a multidisciplinary healthcare team and regular diabetes and health monitoring) is associated with variable results.

Limited data support an improvement in glycaemic control using three rather than two injections per day.

Evidence regarding the impact of an intensive insulin regimen upon long term control is derived principally from the Diabetes Control and Complication Trial (DCCT) which also involved a comprehensive patient support element (diet and exercise plans, monthly visits to the health care team etc).

Intensive insulin therapy (four injections or more per day or pump insulin) significantly improves glycaemic control over a sustained period compared with conventional insulin therapy (two injections per day). DCCT did not include children aged less than 13, due to the study design, it is impossible to separate the benefits of intensive insulin therapy from intensive support.

While there is no evidence on the most effective form of support package, in general this refers to increased contact between patients and their families with a local multidisciplinary team of health professionals delivering specific health care strategies

.The risk of hypoglycemia increases with intensive therapy but rapid acting insulin analogues, as part of a three or four injection regimen can reduce hypoglycaemia.

Diet control

A discipline that includes diet control improves glycaemic control. Limited evidence was identified concerning the optimal type of dietary therapy.

There is a lack of evidence to recommend either a qualitative or quantitative approach as the most effective mode of dietary therapy.

Psychological factors

Specifics that contribute to an increased risk of young people with diabetes developing psychological problems include:

a reluctance to cope with the situation
too great an onus placed on the child
family difficulties
lack of communication, both within families and with the diabetes team
low socio-economic status
non-traditional family structure
poor maternal health, especially depression.

Eating disorders are more prevalent in adolescents with diabetes compared with non-diabetic peers, and adversely affect glycaemic control.

Specific psychological problems (e.g. maladaptive coping strategies) linked to future glycaemic control, can be identified at diagnosis and 1-2 years later, using validated tools performed by a trained practitioner.

Psychological or educational interventions have positive effects on psychological outcomes, knowledge about diabetes and glycaemic control. Maintaining parental involvement improves glycaemic control. Interventions which promote diabetes-specific coping skills are effective and add to the effectiveness of intensive management.