Diabetes is a chronic condition in which the body produces too little insulin or can’t use available insulin efficiently. Insulin is a hormone vital to helping the body use digested food for growth and energy.
An estimated 25.8 million people in the United States, or approximately 8.3% of the population, have diabetes. In 2010, about 1.9 million people age 20 or older were diagnosed, according to the American Diabetes Association (ADA).
You are at higher risk for developing type 2 diabetes if you are overweight, don’t exercise, are over 45, or have close relatives with diabetes, especially type 2 diabetes. Higher-risk ethnic groups include African American, Latino/Hispanic, Native American, Alaska Native, Asians and Pacific Islanders. Native Americans and Alaska Natives are at more than twice the risk of Caucasians for developing type 2 diabetes.
Although diabetes is a potentially life-threatening condition, people with well-managed diabetes can expect to live healthy lives.
How Diabetes Develops
Much of the food we eat is broken down by digestive juices into a simple sugar called glucose, which is the body’s main source of energy. Glucose passes into the bloodstream and, from there, into cells, which use it for energy.
However, most cells require the hormone insulin to “unlock” them so glucose can enter. Insulin is normally produced by beta cells in the pancreas (a large gland behind the stomach). In healthy people, the process of eating signals the pancreas to produce the right amount of insulin to enable the glucose from the food to get into cells. If this process fails or doesn’t work properly, diabetes develops.
In people with diabetes, the pancreas produces little or no insulin, or the body’s cells do not respond to the insulin that is produced. As a result, glucose builds up in the blood, overflows into the urine and passes out of the body. Thus, the body loses its main source of fuel even though the blood contains large amounts of glucose.
Types of Diabetes
There are several types of diabetes:
Type 1 diabetes is classified as an autoimmune disease—a condition that results when the immune system turns against a specific part or system of the body. In diabetes, the immune system attacks and destroys the insulin-producing beta cells in the pancreas. Scientists do not know exactly what causes the body’s immune system to attack the beta cells, but they believe that both genetic and environmental factors are involved.
Type 2 diabetes is on the rise in the United States, and rates are expected to continue increasing for several reasons. The increasing prevalence of obesity among Americans is a major contributor to the rise in type 2 diabetes. According to the Centers for Disease Control and Prevention (CDC), 34 percent of adults are obese and 34 percent are overweight (and not obese), for a total of 68 percent of adults who are over their ideal weight. And adults aren’t the only ones struggling with their weight. The CDC reports that 17 percent of children age 12 to 19, 20 percent of children age 6 to 11 and 10 percent of children age 2 to 5 are obese. Another reason is related to the relatively low levels of physical activity among American adults. (At least 50 percent of American adults don’t get enough physical activity.)
Other factors contributing to the rise of type 2 diabetes include:
During normal pregnancy, hormones produced by the placenta increase the mother’s resistance to insulin. Gestational diabetes results when the insulin resistance exceeds the body’s capacity to make additional insulin to overcome it. This resistance usually disappears when the pregnancy ends, but women who have had gestational diabetes have a 35 to 60 percent chance of developing diabetes during the 10 to 20 years after their pregnancy, according to the CDC. All pregnant women are routinely screened for gestational diabetes between their 24th and 28th weeks.
Those with prediabetes have impaired fasting glucose (between 100 and 126 mg/dL after an overnight fast), or they have impaired glucose tolerance as indicated by one or more simple tests used to measure glucose levels. The ADA reports that in one study, about 11 percent of people with prediabetes developed type 2 diabetes each year during the average three years of follow-up. Other research shows that most people with this condition go on to develop type 2 diabetes within 10 years unless they make modest changes in their diet and level of physical activity.
Some long-term damaging effects to the body, particularly the heart and circulatory system, may start during the prediabetes phase of the disease.
Women and Diabetes: Special Concerns
In the United States, 11.5 million women age 20 and older (10.2 percent) have diabetes. Women with diabetes develop heart disease more often than other women, and their heart disease is more severe. In fact, approximately two-thirds of women with diabetes die from cardiovascular disease, and they die younger than women without diabetes. Women under age 50 with diabetes are more vulnerable to heart attacks and strokes than those without diabetes because the disease seems to cancel the protective effects of estrogen on a woman’s heart before menopause. Women with diabetes are also at even greater risk for developing heart disease after menopause.
Women with diabetes have lower levels of high-density lipoproteins (HDL) cholesterol (the good cholesterol) and higher levels of triglycerides, or fats, in the blood. Elevated low-density lipoproteins (LDL) cholesterol is a major cause of coronary heart disease and should be treated aggressively. Although LDL cholesterol (the type of cholesterol that contributes to plaque buildup in your arteries) levels are not higher in women with diabetes, studies find that reducing LDL levels to less than 100 mg/dL can help prevent heart attacks and strokes in women with diabetes.
High cholesterol is typically treated with specially designed diets low in saturated fat, weight loss, exercise and, if necessary, medication.
For more information on the link between diabetes and heart disease, check out the National Heart, Lung and Blood Institute’s web site at www.nhlbi.nih.gov.
Other health issues of concern to women with diabetes include:
Developing a chronic disease is not your fault, although many women who develop type 2 diabetes may feel this way, especially when obesity is an issue. If you are diagnosed with diabetes, it is essential that you receive comprehensive information—whether from a primary health care professional, certified diabetes educator or endocrinologist—on how to manage your condition and avoid complications.
Many people with diabetes don’t have access to the help they need to adequately manage their condition. In addition, learning diabetes management skills takes time. People with diabetes need to regularly review and revise their strategies for managing their disease, under the guidance of their health care professionals.
Women with diabetes should be seen regularly by a health care professional who monitors their diabetes and checks for complications. Health care professionals who specialize in diabetes are called endocrinologists or diabetologists. In addition, people with diabetes often see ophthalmologists for eye examinations, podiatrists for routine foot care, registered dietitians for help in planning meals and diabetes educators for instruction in day-to-day care.
The goal of diabetes management is to keep blood glucose levels as close to normal as possible (without causing adverse consequences, such as hypoglycemia) to prevent complications associated with the condition. One government study proved that keeping blood glucose levels close to normal reduces the risk of developing major complications of diabetes. The National Diabetes Education Program urges people with diabetes to control not only their blood glucose, but also their blood pressure and cholesterol. This comprehensive management of diabetes is crucial to helping prevent heart attack and stroke.
Living with diabetes can be overwhelming at times. Like all chronic diseases, it affects every aspect of your daily routine. Diabetes management is not as simple as just taking a pill. It requires timing of meals, checking blood glucose and being vigilant about exercise, all in accordance with a personalized management plan developed in consultation with health care professionals.
Managing What You Eat
Your blood glucose can stabilize or skyrocket, depending on what you eat. Food is a mixture of fats, proteins and carbohydrates. All three are necessary parts of a healthy eating plan, but people with diabetes need to be most concerned about carbohydrates.
Carbohydrates in food end up as glucose (sugar) when they are absorbed into the bloodstream. The more carbohydrates you eat, the higher your blood glucose level. Although all carbohydrates raise blood glucose, different foods have different effects, depending on the type of food, which foods your carbohydrates are eaten with and how the food is prepared.
Raw foods, for example, are digested more slowly than cooked foods. Foods that are broken down more slowly release glucose into the blood more slowly. Foods that contain fat also take longer to digest than foods without fat. That’s why an ice cream cone or a chocolate bar may not cause blood glucose levels to rise as quickly as you might expect. Checking your blood glucose two hours after eating carbohydrates is the best way to learn the effects of different foods.
Moderation is key. At one time, people with diabetes were told not to eat sweets at all. Today, sweets and snacks are allowed, but portions need to be small and balanced during the day.
Unlike carbohydrates, fats do not raise blood glucose levels but fatty foods do add pounds. Plus, a diet high in saturated fats increases insulin resistance and your risk for heart disease.
Cutting back on dietary fat, which contributes to high cholesterol levels, is important for people with diabetes because they are already at higher risk for heart disease. Women on low-fat diets should be aware that some low-fat and nonfat foods contain considerably more carbohydrates than the full-fat versions.
For women with type 1 diabetes, who must take insulin daily, balancing food intake with insulin and exercise is essential to prevent high blood glucose (called hyperglycemia) or low blood glucose (called hypoglycemia) in which blood glucose levels dip below 70 mg/dL.
Hypoglycemia can occur suddenly. Early indicators of low blood levels include: shakiness and sweating, dizziness, pounding heart, weakness, hunger and confusion. Both hyperglycemia and hypoglycemia can be life threatening. If you suffer from hypoglycemic unawareness, you should keep with you a supply of glucagon, a medication that replicates the glucagon produced by the pancreas. It is usually injected beneath the skin and quickly raises very low blood glucose levels. Glucagon is sold in powder and liquid form and must be mixed just before it is used.
To determine how much insulin is needed to prevent blood glucose problems, it is important to know how meals and snacks influence blood glucose levels. Generally, the more carbohydrates you eat, the more insulin you need; the fewer carbohydrates you eat, the less insulin you need. Still, only by checking blood glucose two to three hours after eating can you know the effect of different kinds and amounts of food.
The American Diabetes Association recommends limiting saturated fat intake to less than 7 percent of total daily calories and minimizing intake of trans fat. In addition, the ADA recommends monitoring carbohydrates through carbohydrate counting, exchanges or estimation based on experience. It suggests that the glycemic index and glycemic load, which rank foods based on how they affect blood glucose, may also help people with diabetes control blood glucose levels.
The American Diabetes Association offers the following tips:
For more information on nutrition and diabetes, check out http://www.diabetes.org/food-and-fitness/food.
Weight Management and Exercise
More than 85 percent of people newly diagnosed with prediabetes or type 2 diabetes are overweight, making weight management very important.
Although we still don’t know why, being overweight makes you less responsive to insulin, while losing weight has the opposite effect. You don’t have to lose a lot of weight to see an improvement. Even losing 7 to 10 percent of your body weight helps. The focus for women with diabetes, however, should be on improving blood glucose levels—not on the scale.
Exercise is another cornerstone of any diabetes treatment plan. Besides burning calories and promoting weight loss, exercise reduces blood glucose levels and makes cells more sensitive to insulin, allowing some people with diabetes to use less medication.
Exercise has psychological benefits too. People who exercise are generally more aware of their bodies and the factors that affect their blood glucose. They often have a more positive outlook and are better able to manage their condition. Improved self-focus, self-esteem and positive outlook may be especially important for women.
Regular exercise is an essential part of managing type 1 diabetes, too, but management of blood glucose during exercise can be complicated. Those with type 1 diabetes have to adjust their food or insulin to keep their blood glucose from getting too high or too low. A vigorous workout, for example, can increase the amount of glucose the liver releases into the bloodstream, causing blood glucose levels to rise, especially right after exercising. Strenuous exercise can push high blood glucose levels even higher if there isn’t enough circulating insulin available, leading to a life-threatening condition called diabetic ketoacidosis. Or, if blood glucose levels are low when exercise starts or if exercise is prolonged, low blood glucose or hypoglycemia can result.
Women with type 2 diabetes may also have low blood glucose after exercise, especially those using oral medications or insulin. Low blood glucose can last for hours as the muscles use glucose from the blood to replenish that used during a workout.
Thus, it’s important to know and heed the signs of low blood glucose and be prepared to adjust meals or medication to keep glucose levels from plummeting. You need to check blood glucose levels before, during and after exercise to see what affect your workout has. No two people with diabetes will have the same response to exercise.
Before starting an exercise program, check with your health care professional. Exercise is a two-sided coin. It is the most important thing you can do to improve blood glucose and prevent diabetes complications, but the wrong type of exercise can make diabetes-related problems worse. Bouncing can aggravate diabetic eye disease, for example. Exercises that strain the upper body or require heavy lifting can raise blood pressure. Activities such as running and high-impact aerobics may be too hard on the feet and legs if you have any nerve damage.
To avoid injury, start slowly and don’t overdo the intensity. Be sure to include a warm-up and cool-down phase. And understand that the effect of exercise on insulin resistance is short-lived. You have to stay with it to see improvement.
Exercise doesn’t have to be sports-oriented or vigorous, however. It can be recreational, such as gardening, hiking, swimming or dancing. Brisk walking is one of the best things to do. Aim for at least 30 minutes of exercise a day, most days of the week. If you’re trying to lose weight, you may need to exercise 60 to 90 minutes a day.
These guidelines can help keep exercise safe and healthy:
Along with lifestyle modifications, medical treatment is essential to the management of type 1 diabetes. While not a cure, insulin is the most powerful glucose-lowering agent available. Insulin therapies administered two times or more per day through injections or pump therapy can stabilize and manage the disease, helping delay or avoid complications.
Most insulin is still primarily administered as an injection, using a small short needle. At this point, insulin can’t be delivered in a pill, because it is a protein; that means your body would break it down and digest it before it could get into your bloodstream. However, investigators are exploring ways of making insulin easier to take, including insulin pills with a special coating or altered structure to get it through the stomach (not much research has been done on insulin pills at this point, though), skin patches, insulin that is delivered as a spray into the back of the mouth and inhaler devices.
Insulin devices have become more convenient in recent years. Insulin pens, for example, can be helpful if you want to carry insulin with you. A fine, short needle, similar to the needle on an insulin syringe, is on the tip of the pen. You turn a dial to select the desired dose of insulin and press a plunger on the end to deliver the insulin just under the skin.
The FDA has also approved insulin jet injectors, which look like large pens and send a fine spray of insulin through the skin by a high-pressure air mechanism. These are not widely used, partly because of cost. If you plan to purchase one, try out several models before you buy.
There are several types of insulin with varying speeds of action. They range from rapid-acting, which begins working within 15 minutes after injection, to very long-acting, which works evenly for up to 24 hours. Many people with insulin-dependent diabetes take two types of insulin. How quickly or slowly insulin works in your body depends on your own response, where on your body you inject insulin, the type and amount of exercise you do and the length of time between your shot and exercise.
If you have type 2 diabetes, you may be able to manage your blood glucose with lifestyle or oral medications as long as your pancreas continues to make insulin. However, because diabetes is a progressive disease, most people eventually need medication to help their body better use insulin, and some eventually require insulin.
Medications used to manage type 2 diabetes can be divided into two groups: those that augment your own supply of insulin and those that make your own insulin more effective. Talk with your health care provider about the advantages and possible side effects of medications; some have potentially serious side effects.
Insulin Sensitizing Agents
If one type of medication alone fails to control your blood glucose, your health care professional may prescribe two or three of these medications, or one or more of them with insulin.
Of course, taking certain glucose-lowering medication can push blood glucose too low (which is hypoglycemia), as can skipping a meal or eating too little, exercising more than usual or drinking alcohol. You will know your blood glucose is low (70 mg/dL or less) when you feel one or more of the following: dizzy or light-headedness, hungry, nervous and shaky, sleepy or confused or sweaty. Check your glucose to make sure it’s low, and if it is at or below 70 mg/dL, consume 15 grams of carbohydrate—for example, drinking a half cup of juice or three-fourths of a cup of regular (not diet!) soda or taking three to four glucose tabs. Recheck your blood glucose in 15 minutes. If it is not above 80mg/dL, repeat the treatment. The lower your blood glucose, the greater the amount of carbohydrate you will need to bring it up and the longer it may take to reach an acceptable level.
On the other hand, a person can become very ill if blood glucose levels rise too high, a condition known as hyperglycemia. Severe hypoglycemia and hyperglycemia, which can occur in people with type 1 diabetes or type 2 diabetes, are both potentially life-threatening emergencies.
Ask your health care professional or diabetes teacher about the best testing tools for you and how often to test. Many glucose monitors are available, ranging widely in price and features. In addition to meter prices, compare costs of supplies—test strips and lancets—because in the long run, these add up to more than the monitor cost. All monitors require needle sticks, but most meters allow testing on alternate sites such as the palm or forearm.
Verify your monitor’s accuracy and your skill at using it by taking it with you to an appointment with a health care professional and running the test at the same time as a venous test. Your monitor’s number should come within 20 percent of the laboratory test.
You should track your readings with a log or diary (often available from your health care professional). Increasingly, patients and their health care professionals can use computerized systems to upload meter results and automatically generate comprehensive charts. Also, the simple statistics and graphs built into the meter itself can be helpful.
In addition, your doctor should measure your A1C level a minimum of two times a year. (If you change diabetes treatment, or if you are not meeting your blood glucose goals, you and your doctor will want to check your A1C level more often, about every three months). This test measures how much glucose has become attached to a protein called hemoglobin in your red blood cells. Because the glucose sticks to the hemoglobin for several months, it provides a long-term picture of your blood glucose control. Ideally, your results should be below 7 percent.
Other Considerations with Diabetes
If you are using hormone therapy, talk with your health care professional first before stopping your medication.
Some risk factors for diabetes can’t be changed, such as family history of the disease, advancing age or ethnic heritage. However, evidence suggests that people who are at risk for developing diabetes may reduce their risks by controlling their weight and exercising. (Always consult with your health care professional about diet and exercise programs.)
The Diabetes Prevention Program (DPP), a major clinical trial sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), compared diet and exercise to treatment with the oral anti-diabetic drug metformin (Glucophage) in 3,234 people with impaired glucose tolerance (IGT), a condition that often precedes diabetes. The study found that diet and exercise could delay diabetes in a diverse American population of overweight people by about 58 percent. This group got at least 150 minutes of physical activity per week, usually walking or other moderate-intensity exercise, and lost 5 to 7 percent of their body weight. Participants randomized to treatment with metformin reduced their risk of type 2 diabetes by 31 percent.
Screening for Diabetes
If you’re overweight and age 45 or older, you should be screened for diabetes via regular office visits with your primary care physician using either the fasting blood glucose test, which identifies impaired fasting glucose, or the oral glucose tolerance test, which identifies impaired glucose tolerance.
You should also be screened if you’re younger than 45 and are significantly overweight and have one or more of the following risk factors:
Treating diabetes comprehensively—that is, managing not only blood glucose, but also blood pressure and cholesterol—is crucial to helping prevent heart attack and stroke. The good news is that women with diabetes who maintain lower blood glucose, blood pressure and cholesterol levels can lower their risk of cardiovascular disease.
If you have type 1 diabetes, comprehensive diabetes treatment usually includes at least the following:
For those with type 2 diabetes, good management includes at least the following components:
If these measures don’t work, you might have to take diabetes medication or insulin shots.
While you may not be able to prevent diabetes, there are many steps you can take to delay or lessen the severity of possible diabetes-related complications. If you have diabetes, you should have your eyes examined for diabetic retinopathy at least once a year by an eye specialist, or ophthalmologist. Progressive damage to the eye’s retina caused by long-term uncontrolled diabetes can result in loss of vision. People with both type 1 and type 2 diabetes are at risk for developing diabetic retinopathy.
Diabetic retinopathy is a disease of the small blood vessels of the retina of the eye. When retinopathy starts, the tiny blood vessels in the retina become swollen, leaking fluid into the center of the retina. Your vision may become blurred, a condition called background retinopathy.
About 80 percent of people with nonproliferative (background) retinopathy never have serious vision problems, and the disease never goes beyond this first stage. However, if retinopathy progresses, the damage to your sight can be more serious. Abnormal blood vessels grow over the surface of the retina. These vessels may break and bleed into the clear gel that fills the center of the eye, blocking vision. Scar tissue may form near the retina, pulling it away from the back of the eye.
The incidence and severity of retinopathy increases with the duration of diabetes and appears to be worse if diabetes control is poor in the first years of onset. Typically, the disease can progress silently for many years. Symptoms of advanced disease can include decreased visual acuity and floaters (spots in front of your eyes) and loss of vision. Early detection by a dilated eye exam and treatment can prevent or significantly delay progression. The earlier treatment is begun, the better the chances for recovery.
Almost everyone who has diabetes for more than 30 years shows signs of retinal damage, and African Americans and women with diabetes are at higher risk of developing retinopathy. If you control your diabetes (and high blood pressure, if present) it may slow the progression of this condition.
Diabetic nephropathy, or kidney damage, is a leading cause of kidney failure and dialysis. Patients with diabetes should be screened with blood tests and urine tests for signs of early kidney damage, such as protein spilling into the urine. Certain medications, such as ACE inhibitors and angiotensin receptor blockers, may slow the progression of kidney failure. Aggressive control of high blood pressure, as well as smoking cessation, is also important to protect your kidneys.
Diabetic neuropathy, or nerve damage, is another major complication that can be minimized by intensive glucose management.