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DIABETES - A CHRONIC DISEASE III

Diagnosis

If diabetes is suspected it is important to see a doctor promptly so that an accurate diagnosis can be made and appropriate treatment given. Early diagnosis and treatment will help to prevent diabetes-related complications. To assist with diagnosis, blood tests are used to measure the glucose levels in the blood. These include:

Fasting blood glucose test:

A sample of blood is taken to measure the blood glucose levels in the blood after the person has not eaten for several hours. This is usually performed in the morning, before breakfast. It is the most common blood test used to assist with diagnosis.

Random blood glucose test: A sample of blood is taken to measure the glucose levels in the blood – regardless of when the person last ate. The acceptable range for glucose in the blood is 4.0 – 8.0mmol/L (mmol of glucose per litre of blood) before a meal. A diagnosis of diabetes can usually be made if there are classical symptoms of the condition and blood glucose levels of greater than 11mmol/L for a random blood glucose test, or greater than 7mmol for a fasting blood glucose test.

HbA1c test

A blood test called the haemoglobin A1c (HbA1c) assay is often used to indicate a person’s average blood glucose levels over a period of time. As well as being a diagnostic tool, this test is useful in monitoring the progress of the condition and the effectiveness of treatment. To further confirm the diagnosis of diabetes, a glucose tolerance test (GTT) may be recommended. This is a very sensitive test in which the person drinks a measured quantity of glucose after having a sample of blood taken. Further blood samples are taken at fixed intervals in the two hours following the glucose drink. The results will indicate how the body responds to increased glucose levels in the blood. In a person who does not have diabetes, the blood glucose levels will rise after the drink, then slowly fall as insulin is produced to metabolise it. In a person with diabetes, the levels of glucose in the blood will remain high for a long time, or they may be very slow to fall.

Urine tests may also be done and will demonstrate high levels of glucose. They are not used in isolation in the diagnosis of diabetes, as the results can be misleading.

If diabetes is suspected the doctor may also check the eyes, kidneys and heart to make sure there has been no damage due to diabetes.

Treatment While diabetes cannot be cured, it can be controlled. The aim of treatment is to maintain healthy blood glucose levels (ie: between 4.0 mmol/L and 8.0 mmol/L) and to prevent diabetic complications.

This will normally involve balancing lifestyle factors (eg: diet and exercise) and medications.

In order for a person to effectively control the diabetes, it is important that they are treated and monitored by a doctor. Usually this is the person’s GP, however other healthcare professionals will be included in a wider “diabetes management” team to assist with ongoing education, monitoring and treatment. This team may include a diabetes specialist (endocrinologist), diabetes nurse educator,

dietitian, foot care specialist (podiatrist) and an eye specialist (ophthalmologist).

Health promotion, early detection, knowledge of the condition and effective monitoring of blood glucose levels are also considered to be important. Therefore, as part of the nation-wide management of diabetes all people in New Zealand with the condition are entitled to a free diabetes check with their GP or practice nurse once a year.

LIFESTYLE FACTORS:

Diet

Generally it is recommended that foods containing refined sugars be avoided. This includes foods such as chocolate, jam, soft drinks, sweet biscuits, cakes, pastries and some fruit juices. Natural carbohydrates, which can be converted to energy, are recommended. This includes foods such as fruit, vegetables, wholemeal bread and cereals. The diet should also be low in fat and high in dietary fibre. Alcohol contains a lot of sugar so intake should be minimised. Having a regular eating pattern is also important as this helps to keep blood glucose levels balanced. In some cases, having snacks between meals may be recommended. Again this helps to balance blood glucose levels. It is recommended that people with diabetes seek dietary advice from a dietitian and that they follow an individualised food plan.

Exercise

Regular exercise is important in maintaining balanced blood glucose levels. Exercise also helps to maintain a healthy body weight and control high blood pressure and high blood cholesterol levels. This in turn helps to reduce the risk of related health conditions such as cardio-vascular disease (heart attacks and strokes). It should be remembered however that excessive and/or prolonged exercise can cause the blood glucose levels to drop too low. It is therefore recommended that any exercise undertaken is regular and moderate.

Other Lifestyle Factors

When the body is stressed, the blood glucose levels are more difficult to control. It is therefore important that stress is adequately managed. It is recommended that people with diabetes do not smoke. Smoking plays a part in increasing the risk of developing many diabetic complications. Illness can also make blood glucose levels more difficult to control. If blood glucose levels become unstable due to illness, it is important to consult a doctor – particularly if vomiting occurs.

MEDICATIONS:

Tablets People with Type 2 diabetes may not be able to adequately control their blood glucose levels through diet, exercise and lifestyle changes alone. Therefore, in many cases diabetic tablets are required. There are a variety of tablets available, which work in different ways. These include:

Tablets to increase insulin output from the pancreas eg: Glipizide, Glibenclamide

Tablets to reduce insulin resistance eg: Metformin

Tablets that stop the absorption of carbohydrates from the bowel eg: Acarbose.

Insulin

In people with Type 1 diabetes and in some people with Type 2 diabetes, insulin injections are required. There are a number of different types of insulin available that vary in the duration of time they are effective. Some are short-acting; meaning they are absorbed quickly by the body and are effective for a short period of time. Others are long-acting; meaning they are absorbed more slowly by the body and are effective for a longer period of time. Often a combination of different types of insulin is rrequired. Insulin is injected under the skin of the abdomen or thigh and can be administered by using a disposable syringe and needle, or a preloaded insulin “pen”. Insulin can also be administered by a pre-programmed insulin pump. An insulin pump is a small battery powered device into which insulin can be a loaded. The insulin is pumped into the abdomen via a thin plastic tube connected to a very thin plastic needle that is secured under the skin. It is important that the person is trained in how to correctly administer the insulin. This training is usually given by a diabetes nurse educator. The amount of insulin required, and how often it is to be administered will vary according to the needs of the individual and the glucose levels in the blood.

BLOOD GLUCOSE TESTING (“BLOOD SUGARS”)

To enable blood glucose levels to be tested, a droplet of blood is obtained from a small finger prick test and is measured on a special testing strip. The results will help to determine how much medication is required, how much exercise can be undertaken and what foods should be eaten. This simple home test needs to be performed regularly, in some cases up to several times per day. It is important to follow the guidelines given by the treating doctor as to how often they should be done. Complications

Diabetes can cause both acute (sudden onset) and chronic (long-term) complications. Complications will be worsened by diabetes that is poorly managed.

ACUTE COMPLICATIONS

Hypoglycaemia

This is a situation where there are abnormally low levels of glucose in the blood. It can occur when excessive amounts of diabetic medications have been given, when not enough food has been eaten, or when too much exercise has been undertaken. Because cells rely on glucose for fuel in order to function, hypoglycaemia can affect the proper functioning of the cells – particularly the cells in the nervous system. This can lead to initial symptoms such as nervousness, dizziness, weakness,

confusion, blurred vision and tremors. The first signs of hypoglycaemia must be treated quickly in order to prevent symptoms becoming severe. This involves eating or drinking something sugary eg: orange juice, glucose tablets. If left untreated, hypoglycaemia can cause seizures and coma. This situation requires urgent treatment in hospital.

Ketoacidosis Some people with Type 1 diabetes can develop a complication called diabetic ketoacidosis. Ketoacidosis develops when the body doesn’t have enough insulin to break down glucose and use it as fuel, so it breaks down fat to use for fuel instead. When fat is broken down acids called ketones are produced. If too much fat is broken down at any one time, excessive amounts of ketones may be released, causing the blood to become acidic. This can lead to symptoms such as vomiting, headache, drowsiness, a rapid pulse and abdominal pain. There may also be an acetone smell on the person’s breath. If left untreated, and in severe cases, diabetic ketoacidosis can lead to coma and death. If ketoacidosis is suspected, urgent medical treatment should be sought.

CHRONIC COMPLICATIONS:

Chronic complications essentially occur as a result of damage to blood vessels. Diabetes can cause the small blood vessels to weaken and break, and the large blood vessels to harden, narrow and become blocked with fatty deposits (a process known as atheroscerlosis). The resultant poor circulation, compounded by the fact that people with diabetes are more prone to infections, can lead to various complications. Chronic diabetic complications occur when diabetes has remained uncontrolled over a period of many years. However, most of the following complications can be minimised or prevented by good control of the diabetes.

Circulatory problems

Atherosclerosis and damage to the large blood vessels can impede the circulation of blood around the body – particularly affecting to the heart, brain and lower limbs. This is compounded by the fact that people with diabetes are more prone to high blood pressure and high blood cholesterol levels. When circulation to the heart is affected (cardiovascular disease) there is an increased risk of angina and heart attack. When circulation to the brain is affected (cerebrovascular disease) there is an increased risk of stroke. When circulation to the lower legs is affected it is known as peripheral vascular disease (PVD). This can cause pain in the lower legs, known medically as claudication. PVD can also slow the healing of small injuries of the lower legs. This can lead to the development of infections, ulcers and in some cases, gangrene. In severe cases, surgery to repair blood vessels or to amputate diseased tissue is required.

Nerves

Diabetes can damage the nerves – particularly the nerves of the lower legs and sometimes the hands. The nerve damage can cause symptoms such as decreased sensation, numbness, burning, tingling and pain in the affected area. When damage to the nerves is caused by diabetes it is referred to as diabetic neuropathy. Medications to help relieve the pain caused by diabetic neuropathy may be given.

Medications commonly used in the treatment of epilepsy and depression are sometimes used for this purpose. Decreased sensation in the lower legs can make it difficult for the person to know when an injury occurs.


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