Diabetes

Diabetes

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Diabetes mellitus refers to a group of diseases that affect how your body uses blood sugar (glucose). Glucose is vital to your health because it's an important source of energy for the cells that make up your muscles and tissues. It's also your brain's main source of fuel.

The underlying cause of diabetes varies by type. But, no matter what type of diabetes you have, it can lead to excess sugar in your blood. Too much sugar in your blood can lead to serious health problems.

Chronic diabetes conditions include type 1 diabetes and type 2 diabetes. Potentially reversible diabetes conditions include prediabetes — when your blood sugar levels are higher than normal, but not high enough to be classified as diabetes — and gestational diabetes, which occurs during pregnancy but may resolve after the baby is delivered.

Symptoms

Diabetes symptoms vary depending on how much your blood sugar is elevated. Some people, especially those with prediabetes or type 2 diabetes, may not experience symptoms initially. In type 1 diabetes, symptoms tend to come on quickly and be more severe.

Some of the signs and symptoms of type 1 and type 2 diabetes are:

  • Increased thirst
  • Frequent urination
  • Extreme hunger
  • Unexplained weight loss
  • Presence of ketones in the urine (ketones are a byproduct of the breakdown of muscle and fat that happens when there's not enough available insulin)
  • Fatigue
  • Irritability
  • Blurred vision
  • Slow-healing sores
  • Frequent infections, such as gums or skin infections and vaginal infections

Type 1 diabetes can develop at any age, though it often appears during childhood or adolescence. Type 2 diabetes, the more common type, can develop at any age, though it's more common in people older than 40.

Causes

To understand diabetes, first you must understand how glucose is normally processed in the body.

How insulin works

Insulin is a hormone that comes from a gland situated behind and below the stomach (pancreas).

  • The pancreas secretes insulin into the bloodstream.
  • The insulin circulates, enabling sugar to enter your cells.
  • Insulin lowers the amount of sugar in your bloodstream.
  • As your blood sugar level drops, so does the secretion of insulin from your pancreas.

The role of glucose

Glucose — a sugar — is a source of energy for the cells that make up muscles and other tissues.

  • Glucose comes from two major sources: food and your liver.
  • Sugar is absorbed into the bloodstream, where it enters cells with the help of insulin.
  • Your liver stores and makes glucose.
  • When your glucose levels are low, such as when you haven't eaten in a while, the liver breaks down stored glycogen into glucose to keep your glucose level within a normal range.

Causes of type 1 diabetes

The exact cause of type 1 diabetes is unknown. What is known is that your immune system — which normally fights harmful bacteria or viruses — attacks and destroys your insulin-producing cells in the pancreas. This leaves you with little or no insulin. Instead of being transported into your cells, sugar builds up in your bloodstream.

Type 1 is thought to be caused by a combination of genetic susceptibility and environmental factors, though exactly what those factors are is still unclear. Weight is not believed to be a factor in type 1 diabetes.

Causes of prediabetes and type 2 diabetes

In prediabetes — which can lead to type 2 diabetes — and in type 2 diabetes, your cells become resistant to the action of insulin, and your pancreas is unable to make enough insulin to overcome this resistance. Instead of moving into your cells where it's needed for energy, sugar builds up in your bloodstream.

Exactly why this happens is uncertain, although it's believed that genetic and environmental factors play a role in the development of type 2 diabetes too. Being overweight is strongly linked to the development of type 2 diabetes, but not everyone with type 2 is overweight.

Causes of gestational diabetes

During pregnancy, the placenta produces hormones to sustain your pregnancy. These hormones make your cells more resistant to insulin.

Normally, your pancreas responds by producing enough extra insulin to overcome this resistance. But sometimes your pancreas can't keep up. When this happens, too little glucose gets into your cells and too much stays in your blood, resulting in gestational diabetes.

Diagnosis

Symptoms of type 1 diabetes often appear suddenly and are often the reason for checking blood sugar levels. Because symptoms of other types of diabetes and prediabetes come on more gradually or may not be evident, the American Diabetes Association (ADA) has recommended screening guidelines. The ADA recommends that the following people be screened for diabetes:

  • Anyone with a body mass index higher than 25 (23 for Asian-Americans), regardless of age, who has additional risk factors, such as high blood pressure, abnormal cholesterol levels, a sedentary lifestyle, a history of polycystic ovary syndrome or heart disease, and having a close relative with diabetes.
  • Anyone older than age 45 is advised to receive an initial blood sugar screening, and then, if the results are normal, to be screened every three years thereafter.
  • Any woman who has had gestational diabetes, is advised to be screened for diabetes every three years.
  • Anyone who has been diagnosed with prediabetes is advised to be tested every year.

Tests for type 1 and type 2 diabetes and prediabetes

  • Glycated hemoglobin (A1C) test. This blood test, which doesn't require fasting, indicates your average blood sugar level for the past two to three months. It measures the percentage of blood sugar attached to hemoglobin, the oxygen-carrying protein in red blood cells.

    The higher your blood sugar levels, the more hemoglobin you'll have with sugar attached. An A1C level of 6.5 percent or higher on two separate tests indicates that you have diabetes. An A1C between 5.7 and 6.4 percent indicates prediabetes. Below 5.7 is considered normal.

If the A1C test results aren't consistent, the test isn't available, or you have certain conditions that can make the A1C test inaccurate — such as if you're pregnant or have an uncommon form of hemoglobin (known as a hemoglobin variant) — your doctor may use the following tests to diagnose diabetes:

  • Random blood sugar test. A blood sample will be taken at a random time. Regardless of when you last ate, a random blood sugar level of 200 milligrams per deciliter (mg/dL) — 11.1 millimoles per liter (mmol/L) — or higher suggests diabetes.
  • Fasting blood sugar test. A blood sample will be taken after an overnight fast. A fasting blood sugar level less than 100 mg/dL (5.6 mmol/L) is normal. A fasting blood sugar level from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) is considered prediabetes. If it's 126 mg/dL (7 mmol/L) or higher on two separate tests, you have diabetes.
  • Oral glucose tolerance test. For this test, you fast overnight, and the fasting blood sugar level is measured. Then you drink a sugary liquid, and blood sugar levels are tested periodically for the next two hours.

    A blood sugar level less than 140 mg/dL (7.8 mmol/L) is normal. A reading of more than 200 mg/dL (11.1 mmol/L) after two hours indicates diabetes. A reading between 140 and 199 mg/dL (7.8 mmol/L and 11.0 mmol/L) indicates prediabetes.

If type 1 diabetes is suspected, your urine will be tested to look for the presence of a byproduct produced when muscle and fat tissue are used for energy because the body doesn't have enough insulin to use the available glucose (ketones). Your doctor will also likely run a test to see if you have the destructive immune system cells associated with type 1 diabetes called autoantibodies.

Tests for gestational diabetes

Your doctor will likely evaluate your risk factors for gestational diabetes early in your pregnancy:

  • If you're at high risk of gestational diabetes — for example, if you were obese at the start of your pregnancy; you had gestational diabetes during a previous pregnancy; or you have a mother, father, sibling or child with diabetes — your doctor may test for diabetes at your first prenatal visit.
  • If you're at average risk of gestational diabetes, you'll likely have a screening test for gestational diabetes sometime during your second trimester — typically between 24 and 28 weeks of pregnancy.

Your doctor may use the following screening tests:

  • Initial glucose challenge test. You'll begin the glucose challenge test by drinking a syrupy glucose solution. One hour later, you'll have a blood test to measure your blood sugar level. A blood sugar level below 140 mg/dL (7.8 mmol/L) is usually considered normal on a glucose challenge test, although this may vary at specific clinics or labs.

    If your blood sugar level is higher than normal, it only means you have a higher risk of gestational diabetes. Your doctor will order a follow-up test to determine if you have gestational diabetes.

  • Follow-up glucose tolerance testing. For the follow-up test, you'll be asked to fast overnight and then have your fasting blood sugar level measured. Then you'll drink another sweet solution — this one containing a higher concentration of glucose — and your blood sugar level will be checked every hour for a period of three hours.

    If at least two of the blood sugar readings are higher than the normal values established for each of the three hours of the test, you'll be diagnosed with gestational diabetes.

Treatment

Depending on what type of diabetes you have, blood sugar monitoring, insulin and oral medications may play a role in your treatment. Eating a healthy diet, maintaining a healthy weight and participating in regular activity also are important factors in managing diabetes.

Treatments for all types of diabetes

An important part of managing diabetes — as well as your overall health — is maintaining a healthy weight through a healthy diet and exercise plan:

  • Healthy eating. Contrary to popular perception, there's no specific diabetes diet. You'll need to center your diet on more fruits, vegetables, lean proteins and whole grains — foods that are high in nutrition and fiber and low in fat and calories — and cut down on saturated fats, refined carbohydrates and sweets. In fact, it's the best eating plan for the entire family. Sugary foods are OK once in a while, as long as they're counted as part of your meal plan.

    Yet understanding what and how much to eat can be a challenge. A registered dietitian can help you create a meal plan that fits your health goals, food preferences and lifestyle. This will likely include carbohydrate counting, especially if you have type 1 diabetes.

  • Physical activity. Everyone needs regular aerobic exercise, and people who have diabetes are no exception. Exercise lowers your blood sugar level by moving sugar into your cells, where it's used for energy. Exercise also increases your sensitivity to insulin, which means your body needs less insulin to transport sugar to your cells.

    Get your doctor's OK to exercise. Then choose activities you enjoy, such as walking, swimming or biking. What's most important is making physical activity part of your daily routine.

    Aim for at least 30 minutes or more of aerobic exercise most days of the week. Bouts of activity can be as brief as 10 minutes, three times a day. If you haven't been active for a while, start slowly and build up gradually.

Treatments for type 1 and type 2 diabetes

Treatment for type 1 diabetes involves insulin injections or the use of an insulin pump, frequent blood sugar checks, and carbohydrate counting. Treatment of type 2 diabetes primarily involves lifestyle changes, monitoring of your blood sugar, along with diabetes medications, insulin or both.

  • Monitoring your blood sugar. Depending on your treatment plan, you may check and record your blood sugar as many as four times a day or more often if you're taking insulin. Careful monitoring is the only way to make sure that your blood sugar level remains within your target range. People with type 2 diabetes who aren't taking insulin generally check their blood sugar much less frequently.

    People who receive insulin therapy also may choose to monitor their blood sugar levels with a continuous glucose monitor. Although this technology hasn't yet completely replaced the glucose meter, it can significantly reduce the number of fingersticks necessary to check blood sugar and provide important information about trends in blood sugar levels.

    Even with careful management, blood sugar levels can sometimes change unpredictably. With help from your diabetes treatment team, you'll learn how your blood sugar level changes in response to food, physical activity, medications, illness, alcohol, stress — and for women, fluctuations in hormone levels.

    In addition to daily blood sugar monitoring, your doctor will likely recommend regular A1C testing to measure your average blood sugar level for the past two to three months.

    Compared with repeated daily blood sugar tests, A1C testing better indicates how well your diabetes treatment plan is working overall. An elevated A1C level may signal the need for a change in your oral medication, insulin regimen or meal plan.

    Your target A1C goal may vary depending on your age and various other factors, such as other medical conditions you may have. However, for most people with diabetes, the American Diabetes Association recommends an A1C of below 7 percent. Ask your doctor what your A1C target is.

  • Insulin. People with type 1 diabetes need insulin therapy to survive. Many people with type 2 diabetes or gestational diabetes also need insulin therapy.

    Many types of insulin are available, including rapid-acting insulin, long-acting insulin and intermediate options. Depending on your needs, your doctor may prescribe a mixture of insulin types to use throughout the day and night.

    Insulin can't be taken orally to lower blood sugar because stomach enzymes interfere with insulin's action. Often insulin is injected using a fine needle and syringe or an insulin pen — a device that looks like a large ink pen.

    An insulin pump also may be an option. The pump is a device about the size of a cellphone worn on the outside of your body. A tube connects the reservoir of insulin to a catheter that's inserted under the skin of your abdomen.

    A tubeless pump that works wirelessly also is now available. You program an insulin pump to dispense specific amounts of insulin. It can be adjusted to deliver more or less insulin depending on meals, activity level and blood sugar level.

    An emerging treatment approach, not yet available, is closed loop insulin delivery, also known as the artificial pancreas. It links a continuous glucose monitor to an insulin pump, and automatically delivers the correct amount of insulin when needed.

    There are a number of versions of the artificial pancreas, and clinical trials have had encouraging results. More research needs to be done before a fully functional artificial pancreas receives regulatory approval.

    However, progress has been made toward an artificial pancreas. In 2016, an insulin pump combined with a continuous glucose monitor and a computer algorithm was approved by the Food and Drug Administration. However, the user still needs to tell the machine how many carbohydrates will be eaten.

  • Oral or other medications. Sometimes other oral or injected medications are prescribed as well. Some diabetes medications stimulate your pancreas to produce and release more insulin. Others inhibit the production and release of glucose from your liver, which means you need less insulin to transport sugar into your cells.

    Still others block the action of stomach or intestinal enzymes that break down carbohydrates or make your tissues more sensitive to insulin. Metformin (Glucophage, Glumetza, others) is generally the first medication prescribed for type 2 diabetes.

  • Transplantation. In some people who have type 1 diabetes, a pancreas transplant may be an option. Islet transplants are being studied as well. With a successful pancreas transplant, you would no longer need insulin therapy.

    But transplants aren't always successful — and these procedures pose serious risks. You need a lifetime of immune-suppressing drugs to prevent organ rejection. These drugs can have serious side effects, which is why transplants are usually reserved for people whose diabetes can't be controlled or those who also need a kidney transplant.

  • Bariatric surgery. Although it is not specifically considered a treatment for type 2 diabetes, people with type 2 diabetes who are obese and have a body mass index higher than 35 may benefit from this type of surgery. People who've undergone gastric bypass have seen significant improvements in their blood sugar levels. However, this procedure's long-term risks and benefits for type 2 diabetes aren't yet known.

Treatment for gestational diabetes

Controlling your blood sugar level is essential to keeping your baby healthy and avoiding complications during delivery. In addition to maintaining a healthy diet and exercising, your treatment plan may include monitoring your blood sugar and, in some cases, using insulin or oral medications.

Your doctor also will monitor your blood sugar level during labor. If your blood sugar rises, your baby may release high levels of insulin — which can lead to low blood sugar right after birth.

Treatment for prediabetes

If you have prediabetes, healthy lifestyle choices can help you bring your blood sugar level back to normal or at least keep it from rising toward the levels seen in type 2 diabetes. Maintaining a healthy weight through exercise and healthy eating can help. Exercising at least 150 minutes a week and losing about 7 percent of your body weight may prevent or delay type 2 diabetes.

Sometimes medications — such as metformin (Glucophage, Glumetza, others) — also are an option if you're at high risk of diabetes, including when your prediabetes is worsening or if you have cardiovascular disease, fatty liver disease or polycystic ovary syndrome.

In other cases, medications to control cholesterol — statins, in particular — and high blood pressure medications are needed. Your doctor might prescribe low-dose aspirin therapy to help prevent cardiovascular disease if you're at high risk. However, healthy lifestyle choices remain key.