Diabetes

An estimated 15.7 million Americans (5.2% of the general population) suffer from diabetes and one in three (5.4 million) are unaware they have this condition. Diabetics typically have the disease for seven years before it is diagnosed. Diabetes is a chronic disease that has no cure; it is the seventh leading cause of death in the United States. Among those age 65 and older, diabetes is the No. 6 leading cause of death and reduces life expectancy, on average, by10 to 15 years.

Diabetes costs an estimated $98 billion annually in direct (medical) and indirect (work loss, disability, premature mortality) expenditures. Older adults with diabetes are hospitalized 2 to 3 times more often then the general population and use primary care services 2 to 3 times more often than non-diabetics.

The prevalence of diabetes increases with age as is seen in the table below. About 18.4% of people (6.3 million) between 65 and 74 years of age have diabetes.

Diabetes is more common among certain ethnic groups. African Americans (10.8%) and Hispanics (10.6%) are almost twice as likely to have type 2 diabetes. Native Americans (12.2) are more than twice as likely to have type 2 diabetes as the general population (5.2%) and in some tribes (e.g., Pima) more up to 50% of the population has diabetes

Diabetes is often called the silent killer because many people do not know they have diabetes until they develop one of its life-threatening complications. The major complications of diabetes include:

• Blindness. Diabetes is the single leading cause of blindness in adults between the ages of 20-74 years.. Each year, from 12,000 to 24,000 people lose their sight because of diabetes. High serum glucose levels can cause damage to the blood vessels of the eyes.
• Kidney Disease. Diabetes is the leading cause of end-stage renal disease (kidney failure), accounting for 40 percent of all new cases. Up to 21 percent of all people with diabetes go on to develop kidney disease that requires dialysis or a kidney transplant in order to live.
• Nerve Damage/Amputations. Diabetes is the most frequent cause of non-traumatic lower-limb amputations, diabetics have a 15 to 40 times greater risk of leg amputation. About 60 to 70 percent of diabetics have nerve damage that can contribute to risk for amputations. More than 56,000 diabetics have amputations each year.
• Heart Disease and Stroke. Diabetics are 2 to 4 times more likely to have heart disease or suffer a stroke.
• Impotence. About 50-60 percent of the men with diabetes who are ages 50 and older develop impotence.
  

Screening Test

Diabetes is usually identified with a blood test.

Warning Signs of Diabetes

• Extreme Fatigue
• Excessive thirst and hunger
• Frequent urination
• Blurry vision
• Weight loss
• Frequent headaches
• Frequent skin infections such as foot fungus
• Tingling or numbness in hands and feet
• Slow healing of wounds
  

Diagnosis

All individuals should be routinely screened for diabetes at age 45 and every 3 years thereafter. You should be tested more frequently if you have any of the risk factors for diabetes. The American Diabetes Association recommends a fasting plasma glucose test (no food for 8 hours before) because it is a simple, cheap (about $10) and reliable measure of blood levels of glucose.

Diabetes is present if you have:

• a fasting blood sugar of 126 mg/dl or more on two occasions
• a random plasma glucose of 200 or more if symptoms of diabetes are present, or
• a 2-hour plasma glucose of at least 200 mg/dl during an oral glucose tolerance test.

If your result is between 110 and 125 mg/dl you have "impaired fasting glucose" which is a borderline area. A normal fasting blood sugar ranges from 70-100 mg/dl. Further tests such as a 2 hour plasma glucose level may be needed to determine if Type II diabetes is present.

Obesity is the leading risk factor; it increases the chances of diabetes tenfold. If you are overweight you are more likely to develop insulin resistance. There also seems to be a genetic predisposition to diabetes; a family history of diabetes in parents increases risk twofold. In addition, age and lack of exercise are important factors.

Risk Factors for Diabetes

• Obese
• Parent or sibling has diabetes
• Black, Hispanic, Native American or belong to another high-risk ethnic group
• Gave birth to a baby weighing more than 9 pounds, or developed gestational diabetes during pregnancy
• Hypertensive
• HDL cholesterol is less than 35 and/or triglyceride level is 250 or higher.

Prevention

One of the most important things you can do to lower your risk for type II diabetes is to maintain a healthy weight. Even small amounts of weight loss can significantly improve the ability of the body to use its own insulin more efficiently. A low-fat, high-fiber, semi-vegetarian diet can help in weight control and also lower risk for heart disease and cancer.

Treatment

Among younger diabetics the goal is to maintain blood glucose levels as close to normal as possible to prevent or delay the long-term complications of diabetes. However the degree to which older adults must have their blood sugars controlled is more controversial.

Routine self-monitoring of blood glucose is an important part of self-management of diabetes because it provides a measurement of the immediate blood glucose level. The frequency and methods of self-monitoring can vary. People with diabetes need access to the tools necessary for self-management, usually including blood glucose meters and strips.

In addition, diabetic should includes monitoring the hemoglobin A1c (also called glycohemoglobin). Hemoglobin A1c assesses long-term blood glucose control by indicating the average blood glucose over the previous 8-12 weeks. Many of the long-term complications of diabetes are related to elevated hemoglobin A1c levels so this test should be a regular part of assessing diabetes management. People with diabetes need to know their own hemoglobin A1c, and whether they are controlling their blood sugar adequately.

Usually people with Type 2 diabetes are encouraged to lose weight, exercise regularly and follow a diabetic diet to regulate their blood sugars. Initially, most Type 2 diabetes can be controlled with oral medications which include the following:

• Sulfonurias (e.g., diabinese, glucatrol, repaglinide) increase insulin release from the pancreas. The major side effects include weight gain and hypoglycemia.
• Glucosidase inhibitors (e.g., acarbose) delay absorption of sugars from the intestine. The most common side effect of glucosidate inhibitors is excessive gas and bloating.
• Biguanide (e.g., metformin) decreases liver glucose release and increase glucose uptake by muscles. Metformin cannot be used by patients with kidney failure because of the risk of lactic acidosis.
• Thiazolidinediones (e.g., rezulin, avandia) increase insulin sensitivity and can improve lipid levels. Importantly, these medications do not cause hypoglycemia. However, rezulin can cause serious and even fatal liver disease so liver function must be monitored closely with blood levels. So far, Avandia has not shown any signs of causing liver damage. Avandia also can cause side effects, including mild to moderate swelling, an increase in blood cholesterol and anemia, but the problems are usually not severe. Symptoms of liver damage include unexplained nausea, vomiting, abdominal pain, fatigue, anorexia and dark urine or jaundice. If jaundice occurs, the thiazolidinedione should be stopped.
• Insulin is given by injection and requires close monitoring of blood sugars. Diabetics who have been on oral medications for a long time may eventually need to switch to insulin.

Diabetics are at risk for two dangerous conditions- hypoglycemia and hyperglycemia. Hypoglycemia is a low blood sugar (less than 70 mg/dl) which must be treated quickly because brain damage can result if it is prolonged. Older adults may not recognize hypoglycemia or may fail to communicate their symptoms to others. Some elderly are unable to treat their hypoglycemia themselves because of disability. Hypoglycemia is treated by raising their blood sugar with some form of sugar, such as juice or hard candy.

Hyperglycemia is a high blood sugar and can lead to a diabetic coma due to ketoacidosis. Ketoacidosis develops when your body doesn't have enough insulin and is unable to use glucose for fuel. Instead, your body begins to breaks down fat to use for energy. This process produces a waste product called ketones which begin to accumulate in the blood and can lead to coma.