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Diabetes is a chronic (long term) condition marked by abnormally high levels of sugar (glucose) in the blood. People with diabetes either do not produce enough insulin -- a hormone that is needed to convert sugar, starches and other food into energy needed for daily life -- or cannot use the insulin that their bodies produce. As a result, glucose builds up in the bloodstream. If left untreated, diabetes can lead to blindness, kidney disease, nerve disease, heart disease, and stroke.
According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), 20.8 million Americans have diabetes.
While an estimated 14.6 million have been diagnosed with diabetes (both type 1 and type 2), unfortunately, 6.2 million people (or nearly one third) are unaware that they have type 2 diabetes.
Diabetes is widely recognized as one of the leading causes of death and disability in the United States. The Centers for Disease Control and Prevention (CDC) recognize diabetes as the 6th leading cause of death in the U.S.
There are two major types of diabetes:
- Type 1 -- Also known as juvenile or insulin dependent diabetes, type 1 diabetes occurs when the pancreas produces too little insulin to regulate blood sugar levels appropriately. It is usually diagnosed in childhood.
- Type 2 -- This form of the disease is far more common than type 1 and makes up 90% or more of all cases of diabetes. It usually occurs in adulthood. It occurs when the pancreas does not make enough insulin to keep blood glucose levels normal. Many people with type 2 diabetes do not know they have it, although it is a serious condition. Type 2 diabetes is becoming more common due to the growing number of older Americans, increasing obesity, and failure to exercise.
Pre-diabetes occurs in those individuals with blood glucose levels that are higher than normal but not high enough for a diagnosis of diabetes. This condition raises the risk of developing type 2 diabetes, heart disease, and stroke. Pre-diabetes is also called impaired fasting glucose (IFG) or impaired glucose tolerance (IGT), depending on the test used to diagnose it. Some individuals have both IFG and IGT. In IFG, glucose levels are a little high when it has been several hours after eating. In IGT, glucose levels are a little higher than normal right after eating. Pre-diabetes is becoming more common in the U.S., according to estimates provided by the U.S. Department of Health and Human Services (DHHS). Many individuals with pre-diabetes go on to develop type 2 diabetes within 10 years.
Gestational diabetes is high blood glucose that develops at any time during pregnancy in a person who does not have diabetes. Four percent of all pregnant women develop gestational diabetes. Although it usually disappears after delivery, the mother is at increased risk of developing type 2 diabetes later in life.
Diabetes may also be associated with genetic syndromes, surgery, drugs, malnutrition, infections, and other illnesses.
Signs and Symptoms
Type 1: Type 1 diabetes can occur at any age, but it usually starts in people younger than 30. Symptoms are usually severe and occur rapidly. They include:
- Increased thirst
- Increased urination
- Weight loss despite increased appetite
- Abdominal pain
- Absence of menstruation
Type 2: People with type 2 diabetes often have no symptoms, and their condition is detected only when a routine exam reveals high levels of glucose in their blood. Occasionally, however, a person with type 2 diabetes may experience symptoms listed below, which tend to appear slowly over time:
- Numbness or burning sensation of the feet, ankles, and legs
- Blurred or poor vision
- Poor wound healing
In some cases, symptoms may mimic type 1 diabetes and appear more abruptly:
- Excessive urination and thirst
- Yeast infections
- Whole body itching
- Coma -- in severe cases, high blood glucose may affect water distribution in brain cells, causing a state of deep unconsciousness, or coma.
Both type 1 and type 2 diabetes are caused by the absence, insufficient production, or lack of response by cells in the body to the hormone insulin. Insulin is a key regulator of the body's metabolism. After meals, food is digested in the stomach and intestines. Sugar (glucose) molecules are absorbed directly into the bloodstream, and blood glucose levels rise. Under normal circumstances, the rise in blood glucose levels signals specific cells in the pancreas -- called beta cells -- to secrete insulin into the bloodstream. Insulin, in turn, enables glucose to enter cells in the body that may be burned for energy or stored for future use.
In type 1 diabetes, the beta cells of the pancreas produce little or no insulin, the hormone that allows glucose to enter body cells. Once glucose enters a cell, it is used as fuel. Without adequate insulin, glucose builds up in the bloodstream instead of going into the cells. The body is unable to use this glucose for energy despite high levels in the bloodstream, leading to increased hunger.
In addition, the high levels of glucose in the blood cause the patient to urinate more, which leads to excessive thirst. Within 5 - 10 years after diagnosis, the insulin producing beta cells of the pancreas are completely destroyed, and no more insulin is produced.
The exact cause of type 1 diabetes is not known. Type 1 diabetes accounts for 3% of all new cases of diabetes each year. There is 1 new case per every 7,000 children per year. New cases are less common among adults older than 20.
Type 2 diabetes usually develops in older, overweight individuals who become resistant to the effects of insulin over time. When type 2 diabetes is diagnosed, the pancreas is usually producing enough insulin but, for unknown reasons, the body cannot use the insulin effectively. This is called insulin resistance. This means that the insulin produced by your pancreas cannot connect with fat and muscle cells to let glucose inside and produce energy. This causes hyperglycemia (high blood glucose). To compensate, the pancreas produces more insulin. The cells sense this flood of insulin and become even more resistant, resulting in a vicious cycle of high glucose levels and often high insulin levels.
Inflammation is also common among those with type 2 diabetes. Inflammatory markers (chemicals in the body that lead to inflammation), such as interleukin-6 (Il-6) and C-reactive protein, have been found to be increased in those with type 2 diabetes.
Type 2 diabetes usually occurs gradually. Most people with type 2 diabetes are overweight at the time of diagnosis. However, the disease can also develop in lean people, especially the elderly.
Type 1 diabetes
- Family history of type 1 diabetes
- Mother who had pre-eclampsia (a condition characterized by a sharp increase in blood pressure during the third trimester of pregnancy)
- Family history of autoimmune diseases, including Hashimoto's thyroiditis, Graves disease, myasthenia gravis, Addison's disease, or pernicious anemia
- Viral infections during infancy, including mumps, rubella, and coxsackie
- Child of an older mother
- Northern European or Mediterranean descent
- Lack of breast-feeding and consumption of cow's milk during infancy (still controversial)
Type 2 diabetes
- Family history of type 2 diabetes (one quarter to one third of all individuals with type 2 diabetes have a family history of the condition)
- Age older than 45 years
- Excess body fat, particularly around the waist
- Sedentary lifestyle and high fat, high calorie diet
- Abnormal levels of cholesterol or triglycerides in the blood
- High blood pressure
- History of gestational diabetes or polycystic ovary syndrome (a hormonal disorder that causes women to have irregular or no menstruation)
- African-American, Hispanic American or Native American (particularly Pima tribe in Arizona) descent
- Low birth weight or a mother's malnutrition in pregnancy (this may cause metabolic disturbances in a fetus that lead to diabetes later in the child's life)
- Depression is associated with a 60% increased risk of type 2 diabetes
According to the American Diabetes Association, all pregnant women should be screened for gestational diabetes during their third trimester, People who are 45 years or older should have their blood glucose levels checked every 3 years. Those who have a high risk of developing diabetes (such as people with a family history of the disease) should be tested more often.
Different types of tests are used to diagnose diabetes: Random plasma glucose level, fasting plasma glucose level, and oral glucose tolerance test.
If the fasting glucose level is 100 - 125 mg/dL, the individual has a form of pre-diabetes called impaired fasting glucose (IFG), meaning that the individual is more likely to develop type 2 diabetes but does not have the condition yet. A level of 126 mg/dL or above, confirmed by repeating the test on another day, means that the individual has diabetes.
Other diagnostic tests for diabetes includes fructosamine testing and hemoglobin A1c. The American Diabetes Association (ADA) recommends A1c as the best test to find out if an individual's blood sugar is under control over time. The test should be performed every 3 months for insulin treated patients, during treatment changes, or when blood glucose is elevated. For stable patients on oral agents, health care professionals recommended testing A1c at least twice per year. The ADA currently recommends an A1c goal of less than 7%. Studies have reported that there is a 10% decrease in relative risk of microvascular complications, such as diabetic nephropathy or diabetic neuropathy, for every 1% reduction in hemoglobin A1c. Many nutritionally oriented physicians look for much lower A1c's as goals for their patients.
People with diabetes must closely monitor their blood sugar and see their doctor regularly. Self monitoring of blood glucose is done by checking the glucose content of a drop of blood. Regular testing tells you how well diet, medication, and exercise are working together to control your diabetes. Dieticians can also be an integral part of care.
Type 1 diabetes
There is currently no proven way to prevent type 1 diabetes. However, research conducted in Finland suggests that adequate amounts of vitamin D, particularly in the first year of life, may decrease one's chances of developing type 1 diabetes within the first 30 years of life. In northern Finland (where the annual exposure to sunlight is very limited) researchers followed 10,000 infants for up to 30 years. Those given at least 2,000 IU of vitamin D per day (generally from cod liver oil) for the first year of life were significantly less likely to develop type 1 diabetes over a 30 years than infants who were given less than that. Other studies have confirmed that doses of 2,000 IU or higher of vitamin D may have a strong protective effect against type 1 diabetes. For this reason, caretakers of infants and children at increased risk for type 1 diabetes might wish to consider supplementation. Experts suggest supplementing these individuals at the high end of current U.S. recommendations for vitamin D, which is 200 - 1,000 IU.
Type 2 diabetes
Considerable evidence from population based studies suggests that type 2 diabetes is highly preventable -- particularly through exercise and weight management. Individuals who are physically inactive or overweight are much more likely to develop type 2 diabetes. Similarly, people who move from a non-Westernized country to a Westernized country (such as the United States where more people are overweight and live sedentary lives), increase their risk for type 2 diabetes. Studies suggest that you do not need vigorous physical activity to lower your risk of diabetes; moderate, regular exercise such as walking for 30 minutes most days of the week, is enough. In general, lifestyle changes recommended to treat diabetes may help prevent the condition as well.
The goal of diabetes treatment is to achieve and maintain a healthy blood glucose levels. A major study called the Diabetes Control and Complications Trial (DCCT) found that people with diabetes who kept their blood glucose levels close to normal reduced their risk of developing major complications from the condition.
People with diabetes can use the following therapies to help manage their blood glucose levels and to prevent complications:
- Lifestyle changes, such as a well balanced diet and regular exercise
- Medications, particularly insulin for individuals with type 1 diabetes and some people with type 2 diabetes
- Supplements, including fiber and chromium
- Relaxation techniques
- Acupuncture for pain from nerve damage
People with diabetes can improve significantly from lifestyle changes -- particularly diet and exercise. People with type 2 diabetes may even eliminate the need for medications when they make appropriate lifestyle changes.
The American Diabetes Association (ADA) recommends that people with diabetes consume a healthy, low fat diet, rich in grains, fruits, and vegetables. A healthy diet typically includes 10 - 20% of daily calories from protein such as poultry, fish, dairy, and vegetable sources. People with diabetes who also have kidney disease should work with their health care providers to limit protein intake to 10% of daily calories. A low-fat diet typically includes 30% or less of daily calories from fat -- less than 10% from saturated fats and up to 10% from polyunsaturated fats (such as fats from fish).
Carbohydrates tend to have the greatest effect on blood glucose. The balance between the amount of carbohydrate eaten and the available insulin determines how much the blood glucose level goes up after meals or snacks. To help control blood glucose, people should watch how many carbohydrate servings they eat each day. Foods that contain a high amount of carbohydrates include grains, pasta, and rice; breads, crackers, and cereals; starchy vegetables, including potatoes, corn, peas, and winter squash; legumes such as beans, peas, and lentils; fruits and fruit juices; milk and yogurt; and sweets and desserts. Non-starchy vegetables, such as spinach, kale, broccoli, salad greens, and green beans, are very low in carbohydrates. Carbohydrate counting can ensure that the right amount of carbohydrate is eaten at each meal and snack. A dietician can help each person work out a dietary plan that is right for them.
In addition, weight loss should be part of the plan for those with type 2 diabetes. Moderate weight loss (achieved by reducing calories by 250 - 500 per day and exercising regularly) not only controls blood sugars, but also blood pressure and cholesterol. People with diabetes who eat healthy, well balanced diets will not need to take extra vitamins or minerals to treat their condition.
Exercise plays an important role in both the prevention and management of diabetes because it lowers blood sugar and helps insulin work more efficiently in the body. Exercise also enhances cardiovascular fitness by improving blood flow and increasing the heart's pumping power, promoting weight loss, and lowering blood pressure. However, exercise has the most value when it’s done regularly -- at least 3 - 4 sessions per week for 30 - 60 minutes per session. As little as 20 minutes of walking, 3 times a week, has a proven beneficial effect. People with type 2 diabetes who exercise regularly have been shown to lose weight and gain better control over their blood pressure, thereby reducing their risk for cardiovascular disease (a major complication of diabetes). Studies have also shown that people with type 1 diabetes who regularly exercise reduce their need for insulin injections.
Despite the benefits of exercise, many people have difficulty sticking with an exercise program for a long period of time. Health care providers can help develop suitable routines as well as strategies that may improve adherence to such routines. Anyone with long standing diabetes should have a thorough screening before starting an exercise program and receive careful monitoring from a physician.
Medications for diabetes must always be used in combination with lifestyle changes, particularly diet and exercise, to improve the symptoms of diabetes. Medications include insulin, oral sulfonylureas (like glimepiride, glyburide, and tolazamide), biguanides (Metformin), alpha-glucosidase inhibitors (such as acarbose), thiazolidinediones (such as rosiglitazone) and meglitinides (including repaglinide and nateglinide). A new agent in the fight against diabetes, exenatide (Byetta), is an injectable drug that reduces the level of sugar (glucose) in the blood. In clinical studies, exenatide treated patients achieved lower blood glucose levels and experienced weight loss. Exenatide was approved by the U.S. Food and Drug Administration in May 2005.
Nutrition and Dietary Supplements
Considerable research has been conducted on the relationship between diabetes and specific nutrients and dietary supplements. Dietary supplements may increase the effects of blood sugar lowering medications, including insulin. When considering the use of supplements or making dietary changes, be sure to discuss these changes with your health care provider to ensure safety and appropriateness.
Supplements with Blood Sugar Lowering Effects
Chromium -- Found in a variety of foods and supplements, including liver, brewer's yeast, cheese, meats, fish, fruits, vegetables, and whole grains, chromium appears to enhance the body's sensitivity to insulin. Researchers believe that chromium helps insulin pull glucose from the bloodstream into the cells for energy. The benefit of chromium supplements for diabetes has been studied and debated for a number of years. While some studies show no beneficial effects of chromium use for people with diabetes, other studies have shown that chromium supplements may reduce blood glucose levels in individuals with type 2 diabetes and reduce the need for insulin in those with type 1 diabetes. Most Americans get at least 50 mcg of chromium in their diets each day. The National Research Council estimates that intakes of 50 - 200 mcg per day are safe and effective. Clinical studies showing improved blood sugar control for those with diabetes have used doses of chromium picolinate ranging from 200 - 1,000 mcg per day. However, until human studies of long term safety are conducted with higher doses, it is best to use 200 mcg or less per day.
Magnesium -- Several clinical studies have demonstrated a strong association between low levels of magnesium in the blood and type 2 diabetes. However, researchers are still unclear about the cause and effect in that association. They are investigating whether low magnesium levels worsen blood sugar control in people with type 2 diabetes or whether diabetes causes magnesium deficiencies. Some experts believe that low magnesium levels worsen blood sugar control and that foods rich in magnesium (such as whole grains, green leafy vegetables, bananas, legumes, nuts, and seeds) or magnesium supplements may promote healthy blood glucose levels. At least one small study suggests that taking magnesium supplements may improve the action of insulin and decrease blood sugar levels, particularly in the elderly. People with severe heart disease or kidney disease should not take magnesium supplements. People with diabetes should discuss whether it’s safe and appropriate to take magnesium supplements with a health care provider.
Fiber -- Studies suggest that a high fiber diet may help:
- Prevent development of type 2 diabetes
- Lower average glucose and insulin levels in people who already have type 2 diabetes
- Improve cholesterol and triglyceride levels in those with diabetes
In a large scale study of nurses in the United States, women who consumed the most whole grain foods in their diets were nearly 40% less likely to develop diabetes than women who consumed the least.
Studies have also shown that cholesterol levels improved in people with type 2 diabetes after they took supplements of a soluble fiber known as psyllium (Plantago psyllium).
Beta-glucan is a soluble fiber derived from the cell walls of algae, bacteria, fungi, yeast, and plants. It is commonly used for its cholesterol lowering effects. There are several human trials supporting the use of beta-glucan for glycemic (blood sugar) control.
Vanadium -- Vanadium is an essential trace mineral present in the soil and in many foods. It appears to mimic the action of insulin and, in a number of human studies, vanadyl sulfate (a form of vanadium) has increased insulin sensitivity in those with type 2 diabetes. Animal studies and some small human studies also suggest that vanadium may lower blood glucose to normal levels (reducing the need for insulin) in people with diabetes. One preliminary clinical study found that people with diabetes using insulin who were given vanadium were able to lower their dose of insulin.
Antioxidants such as beta-carotene and vitamin C are scavengers of free radicals -- unstable and potentially damaging molecules generated by normal chemical reactions in the body. Free radicals are unstable because they lack one electron. In an attempt to replace this missing electron, the free radical molecules react with neighboring molecules in a process called oxidation. Some clinical studies suggest that people with diabetes have elevated levels of free radicals and lower levels of antioxidants. Preliminary clinical studies show that the following antioxidants may improve symptoms of diabetes (by returning blood glucose levels to the normal range) and reduce the risk of associated complications:
- Vitamin E
Two additional substances that show preliminary evidence to possibly help control blood sugar include:
- Biotin (a B-complex vitamin) -- helpful for type 2 diabetes; brewer's yeast is a good source of biotin
- Vitamin B6 -- helpful for both type 1 and type 2 diabetes
Supplements with Cardiovascular Effects
Because insulin resistance is often associated with cardiovascular disease, people with diabetes may benefit from nutrients that help manage elevated blood lipid levels, high blood pressure, or heart failure. Although the following supplements have been shown to improve cardiovascular health, there is some concern that they may raise blood glucose levels. People with diabetes interested in trying the following supplements should first consult with their health care providers:
- Coenzyme Q10 (CoQ10)
- Omega-3 Fatty acids
Although clinical studies have not shown that either CoQ10 or omega-3 fatty acid supplements raise blood sugar levels, people with diabetes should discuss the safety and appropriateness of using these, or any supplements, with their doctor or pharmacist.
In addition, the following antioxidants have been shown to improve cholesterol levels in people with type 2 diabetes:
- Vitamin C (1000 mg per day)
- Vitamin E (800 IU per day)
Several clinical studies have also found that elevated manganese levels may help protect against LDL oxidation (a process that contributes to the development of plaque in the arteries).
Supplements that May Reduce Complications of Diabetes
More than one third of all people with diabetes develop a painful condition known as diabetic neuropathy (nerve damage). Some researchers speculate that elevated levels of free radicals, which can cause damage to nerves and blood vessels, may cause this condition. Clinical studies suggest that the following antioxidant supplements may improve nerve communication in damaged areas and reduce the symptoms of diabetic neuropathy:
- Alpha-lipoic acid
- Gamma-linolenic acid [evening primrose oil (Oenothera biennis) is a rich source]
People have long used plant based medicines in the treatment of diabetes. For instance, the plant extract guanidine, which lowers blood glucose, prompted the development and use of biguanides, a commonly used oral medication for diabetes. Other herbs may have a role in the management or prevention of diabetes. These include:
- Bitter melon (Momordica charantia). Bitter melon has traditionally been used as a remedy for lowering blood glucose in patients with diabetes mellitus. Preliminary clinical studies have indicated that bitter melon may decrease serum glucose levels.
- Fenugreek seeds (Trigonella foenum graecum). Fenugreek seeds, a spice found in many curry preparations, are high in fiber and have been shown to regulate glucose and improve lipid levels in both animals and humans. In two small studies of people with either type 1 or type 2 diabetes, fenugreek seed powder lowered blood glucose and improved levels of blood cholesterol and trigylcerides, among other beneficial effects.
- Gymnema (Gymnema sylvestre). Preliminary human research reports that gymnema may be beneficial in patients with type 1 or type 2 diabetes when it is added to diabetes drugs being taken by mouth or to insulin. Gymnema may alter the ability to detect sweet tastes.
- Cinnamon (Cinnamomum zeylanicum). In a clinical study of 60 people with type 2 diabetes, intake of 1, 3, or 6 grams of cinnamon per day reduced glucose, triglyceride, LDL cholesterol, and total cholesterol. Other clinical studies have found similar results. As a result, experts claim that cinnamon may play an important role in regulating blood sugar in people with diabetes.
- American ginseng (Panax quinquefolium). Although both Asian (Panax ginseng) and American (Panax quinquefolium) appear to lower blood glucose levels, only American ginseng has been studied scientifically. Several clinical studies report a blood sugar lowering effect of American ginseng (Panax quinquefolium) in individuals with type 2 diabetes, both on fasting blood glucose and on postprandial glucose levels. One clinical study found that people with type 2 diabetes who take American ginseng before or together with a glucose meal experience a reduction in glucose levels after they consume the meal.
Some researchers speculate that acupuncture may trigger the release of natural painkillers and reduce the debilitating symptoms of a complication of diabetes known as neuropathy (nerve damage). In one clinical study of people with diabetes suffering from chronic, painful neuropathy, acupuncture reduced pain and improved sleep in 77% of the participants and eliminated the need for pain medications in 32% of the participants. Given these findings, acupuncture may be a reasonable option for people with diabetes who have neuropathy and either find no symptom relief or develop side effects from conventional drug treatment.
Stressful life events can worsen diabetes in several ways. For example, stress stimulates the nervous and endocrine systems in ways that increase blood glucose levels and disrupts healthful behaviors (increasing the chances that an individual may consume a high level of calories and limit his or her physical activity -- a pattern that leads to elevated blood glucose).
It makes sense, then, to consider stress management as part of the treatment and prevention of diabetes. Clinical studies have reported that people with diabetes who participate in biofeedback sessions (a technique that increases awareness and control of the body's response to stress) are more likely to reach target blood glucose levels than those who do not receive biofeedback. Although other studies have produced results that contradict this, researchers and clinicians agree that long term stress is likely to worsen diabetes and that biofeedback, tai chi, yoga, and other forms of relaxation may help motivate people with diabetes to change their habits in order to manage their condition.
Women of child bearing age who have diabetes should consult an endocrine specialist about the benefits of managing glucose levels before trying to conceive.
About 4% of all pregnant women in the United States are diagnosed with gestational diabetes. Risk factors for developing diabetes while pregnant include:
- Modest weight gain prior to pregnancy (11 - 22 pounds or more)
- Family history of diabetes
- Tobacco use
- African-American, Hispanic American, or Asian ancestry
- Age older than 50 at conception
Normalizing glucose levels in women with gestational diabetes reduces their risk of complications, such as having an overweight baby, birth trauma, or the need for cesarean section. If the mother's glucose levels are uncontrolled, an infant can be stillborn or suffer from any number of complications, including defects of the brain or central nervous system, an abnormally large body or organs, heart or kidney abnormalities, asphyxia, respiratory distress, and congestive heart failure.
If dietary restrictions fail to improve glucose levels, a woman with gestational diabetes may need insulin. Women should not take oral diabetes medications during pregnancy. Women who develop gestational diabetes may experience the condition again in subsequent pregnancies. Gestational diabetes also increases the risk for developing type 2 diabetes.
Prognosis and Complications
People who maintain tight control over their blood glucose levels can prevent or delay the development of long term complications from diabetes. Type 1 diabetes generally has more complications than type 2 diabetes.
Long term complications of diabetes may include:
- Heart disease and stroke
- Vision loss and blindness
- Kidney disease
- Neuropathy (nerve damage)
- Foot ulcers and infections
- Skin problems, including bruising, dryness, itching, hair loss, warts, gangrene (tissue death), and skin ulcers
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