Price: Rs.1500/- (US $35 approx)

Introduction

The two major forms of diabetes are type 1 (previously called insulin-dependent diabetes mellitus, IDDM, or juvenile-onset diabetes) and type 2 (previously called noninsulin-dependent diabetes mellitus, NIDDM, or maturity-onset diabetes).
Insulin

Both diabetes type 1 and type 2 share one central feature: elevated blood sugar ( glucose) levels due to insufficiencies of insulin, a hormone produced by the pancreas. Insulin is a key regulator of the body's metabolism. It normally works in the following way:

• During and immediately after a meal the process of digestion breaks down carbohydrates into sugar molecules (including glucose) and proteins into amino acids.
• Right after the meal, glucose and amino acids are absorbed directly into the bloodstream, and blood glucose levels rise sharply.
• The rise in blood glucose levels signals important cells in the pancreas, called beta cells, to secrete insulin, which pours into the bloodstream. Within ten minutes after a meal, insulin rises to its peak level.
• Insulin then enables glucose and amino acids to enter cells in the body, particularly muscle and liver cells. Here, insulin and other hormones direct whether these nutrients will be burned for energy or stored for future use. (Note that the brain and nervous system are not dependent on insulin; they regulate their glucose needs through other mechanisms.)
• When insulin levels are high, the liver stops producing glucose and stores it in other forms until the body needs it again.
• As blood glucose levels reach their peak, the pancreas reduces the production of insulin.
• About two to four hours after a meal, both blood glucose and insulin are at low levels, with insulin being slightly higher. The blood glucose levels are then referred to as fasting blood glucose concentrations .


Diabetes: Type 1

What is type 1 diabetes?

Your body changes most of the food you eat into a form of sugar (also called glucose). Insulin is a hormone that allows this sugar to enter all the cells of your body and be used as energy. A person who has type 1 diabetes can't make insulin. Without insulin, sugar builds up in the blood and can damage internal organs, the nervous system and blood vessels.

Type 1 diabetes is also called insulin-dependent diabetes. It is sometimes called juvenile diabetes because it is usually discovered in children and teenagers, but adults may also have it.

What problems can type 1 diabetes cause?

People with type 1 diabetes are more likely to have heart disease, stroke, kidney failure, high blood pressure, blindness, nerve damage and gum disease. These things happen 2 to 4 times more often in people with diabetes than in people without diabetes. When you have type 1 diabetes, blood may not move as well through your legs and feet. If left untreated, this condition can become very serious and lead to amputation (removal) of your feet. Untreated type 1 diabetes can cause a person to go into a coma. It can even kill you. The good news is that treatment can help prevent these problems.

How can these problems be prevented?

To help prevent these problems, follow your doctor's advice about diet and exercise. Also, carefully follow your doctor's instruction for taking your insulin. You shouldn't smoke, and you should keep your blood pressure and cholesterol at healthy levels. If you do all of these things, your risk of problems from diabetes can be cut by more than 75 percent.

What should I eat?

The best diet for people with type 1 diabetes is low in fat, low in salt and low in added sugars. It has lots of complex carbohydrates (like whole-grain breads, cereals and pasta), fruits and vegetables. This diet will help you control your blood sugar level, as well as your blood pressure and cholesterol levels. It's also important to watch your portion size so you can maintain a healthy weight.

How do I control my blood sugar level?

People with type 1 diabetes take insulin to keep their blood sugar level as close to normal as possible. Your doctor will explain how and when you should take insulin.

Many people with type 1 diabetes take short-acting insulin before each meal. You can adjust the amount of insulin you take for each meal based on how many calories you eat and how physically active you plan to be in the next 3 to 4 hours. Most people with type 1 diabetes need to take about 8 to 10 units of insulin for every 500 calories they eat. (An average daily diet has about 2,000 to 2,500 calories.) You may need slightly less or slightly more insulin, depending on how your body reacts to insulin.

To keep their blood sugar levels from rising during the night, most people with type 1 diabetes need to take an intermediate-acting insulin before they go to sleep. Your doctor will work with you to determine the right amount of insulin for you to take with meals and at bedtime.

How will I know if my blood sugar level is too high?
The best way to monitor your blood sugar level is to test it at least 3 times each day, including at bedtime.

What should I do if my blood sugar level is too high?

If your blood sugar level goes higher than it should, you may need to take an extra dose of short-acting insulin to return your blood sugar to the normal range. Your doctor can tell you how much insulin you need to take to lower your blood sugar level.

What are the signs of low blood sugar?

People who take insulin may have times when their blood sugar level is too low. This low blood sugar is called hypoglycemia. Signs of hypoglycemia include the following:
• Feeling tired for no reason
• Yawning a lot
• Being unable to speak or think clearly
• Losing muscle coordination
• Sweating
• Twitching
• Having seizures
• Suddenly feeling like you're going to pass out
• Becoming very pale

If you have any of the problems listed above, eat or drink something sweet, such as fruit juice, regular (not diet) soda or candy, right away.

Be sure you teach your friends, work colleagues and family members how to treat hypoglycemia, because sometimes you may need their help. Also, keep a supply of glucagon at home. Glucagon is another medicine you inject in a shot. It will raise your blood sugar level. If you are unconscious or can't eat or drink, another person can give you a shot of glucagon. This will bring your blood sugar level back to normal.

How else can I prevent complications?

The tips below can help you stay healthy if you have type 1 diabetes:
• Keep your blood pressure below 130/85 mm Hg.
• Keep your cholesterol level under 200 mg.
• Take care of your feet and check them every day for signs of infection.
• Have an eye exam every year to check your vision.
• See your dentist twice a year to check your teeth and gums.

Can I live a normal life with diabetes?

Yes, you can live a normal life. Remember, many successful athletes and people in all professions have type 1 diabetes. You can stay healthy if you do what it takes to control diabetes.

Type 2 Diabetes

Type 2 diabetes is the most common form of diabetes, accounting for 90% of cases. An estimated 16 million Americans have type 2 diabetes and half are unaware they have it. The disease mechanisms in type 2 diabetes are not wholly known, but some experts suggest that it may involve the following three stages in most patients:

• The first stage in type 2 diabetes is the condition called insulin resistance. Although insulin can attach normally to receptors on liver and muscle cells, certain mechanisms prevent insulin from moving glucose (blood sugar) into these cells where it can be used. Most type 2 diabetics produce variable, even normal or high, amounts of insulin. In the beginning, this amount is usually sufficient to overcome such resistance.
• Over time, the pancreas becomes unable to produce enough insulin to overcome resistance. In type 2 diabetes, the initial effect of this stage is usually an abnormal rise in blood sugar right after a meal (called postprandial hyperglycemia). This effect is now believed to be particularly damaging to the body.
• Eventually, the cycle of elevated glucose further impairs and possibly destroys beta cells, thereby stopping insulin production completely and causing full-blown diabetes. This is made evident by fasting hyperglycemia , in which elevated glucose levels are present most of the time.

Causes

Type 2 diabetes is caused by a complicated interplay of genes, environment, insulin abnormalities, increased glucose production in the liver, increased fat breakdown, and possibly defective hormonal secretions in the intestine. The recent dramatic increase indicates that lifestyle factors (obesity and sedentary lifestyle) may be particularly important in triggering the genetic elements that cause this type of diabetes.

Insulin Abnormalities
The characteristic features of most patients with type 2 diabetes are the following:
• Insulin resistance in muscle cells.
• Normal or even excessive levels of insulin (to compensate for this resistance), eventually followed by a drop in insulin production.
In addition, researchers are trying to determine the factors that might promote insulin resistance:
• Both obesity and insulin resistance at different phases are marked by elevated levels of free fatty acids and the hormones resistin and leptin. It is not known yet if elevated levels are simply a product of obesity or play some causal role in diabetes.
• Insulin resistance is associated with a chronic low inflammatory response, which involves a number of immune factors, such as TGH-beta 1 and C-reactive protein. Such factors can cause damage over time and may be responsible for the association between insulin resistance and heart disease.

Genetic Factors
Genetic factors play an important role in type 2 diabetes, but the pattern is complicated, since both impairment of beta cell function and an abnormal response to insulin are involved. Researchers have identified a number of genetic factors that may be responsible for selected or more general cases of diabetes:
• Researchers have identified genes responsible for maturity-onset diabetes in youth (MODY), a rare genetic form of type 2 diabetes that develops only in Caucasian teenagers. (This is not the diabetes associated with obesity that is now being seen increasingly in young people.)
• A defective fatty-acid binding protein 2 (FABP2) gene may result in higher levels of unhealthy fat molecules (particularly triglycerides), which may be critical in the link between obesity and insulin resistance in some people with type 2 diabetes.
• Alterations in five genes that beta cell and pancreas function have been identified that may plan an important role in inherited cases of type 2 diabetes.
• Variations in a gene that regulates a protein called calpain-10 is proving to affect insulin secretion and action and may play a role in type 2 diabetes in certain populations. There is some disagreement, however, about its significance. Calpains are enzymes that play a wide role in many essential cellular functions. Evidence is now strongly suggesting that genetic activation of these enzymes may be important in many aging-related diseases.
• Defective genes that regulate a molecule called peroxisome proliferator-activated receptor (PPAR) gamma may contribute to both type 2 diabetes and high blood pressure in some patients.
• A defective gene has been detected that reduces activity of a protective substance called beta 3-adrenergic receptor, which is found in visceral fat cells (those occurring around the abdominal region). The result is a slow-down in metabolism and an increase in obesity.

The Thrifty Gene. One theory suggests that some cases of type 2 diabetes and obesity are derived from normal genetic actions that were once important for survival. Some experts postulate the existence of a so-called "thrifty" gene, which regulates hormonal fluctuations to accommodate seasonal changes. In certain nomadic populations, hormones are released during seasons when food supplies have traditionally been low, which results in resistance to insulin and efficient fat storage. The process is reversed in seasons when food is readily available. Because modern industrialization has made high-carbohydrate and fatty foods available all year long, the gene no longer serves a useful function and is now harmful because fat, originally stored for famine situations, is not used up. Such a theory could help explain the high incidence of type 2 diabetes and obesity found in Pima tribes and other Native American tribes with nomadic histories and Western dietary habits.

Risk Factors

At this time, about 15.6 million Americans have diabetes; up to 95% of these cases are type 2. The prevalence of type 2 diabetes increased from 4.9% in 1990 to nearly 7% in 1999. Historically, type 2 diabetes usually developed after the age of 40, but it is now also increasing in children. Given the current epidemic of obesity, experts are now estimating that over a third of all people born in 2002 will eventually develop diabetes. Furthermore, the dramatic increase in diabetes is occurring worldwide as American lifestyles become global. Evidence strongly suggests that healthy lifestyles can prevent most cases of type 2 diabetes.

Obesity and Metabolic Syndrome

Obesity is the number one risk factor for type 2 diabetes. It is estimated that 80% to 95% of the current dramatic increases in type 2 diabetes are due to obesity. Excess body fat appears to play a strong role in insulin resistance, but the way the fat is distributed is also significant. Weight concentrated around the abdomen and in the upper part of the body (apple-shaped) is associated with insulin resistance and diabetes, heart disease, high blood pressure, stroke, and unhealthy cholesterol levels. Waist circumferences greater than 35 inches in women and 40 inches in men have been specifically associated with a greater risk for heart disease and diabetes. (People with a "pear-shape"--fat that settles around the hips and flank--appear to have a lower risk for with these conditions.) Of note: obesity does not explain all cases of type 2 diabetes. It is also common among people in countries where weights tend to be low, such as Asia or India.

Metabolic Syndrome. A set of conditions referred to as metabolic syndrome (also called syndrome X) is a pre-diabetic condition that is significantly associated with heart disease and higher mortality rates from all causes. The syndrome consists of obesity marked by abdominal fat, unhealthy cholesterol levels, high blood pressure, and insulin resistance. A 2002 study estimated that nearly a quarter of the U.S. population now has this condition. Even worse, according to a 2003 study, nearly a million American teenagers have this syndrome.

Family History
Between 25% and 33% of all type 2 patients have family members with diabetes. Having a first-degree relative with the disease poses a 40% risk of developing diabetes . One study reported that people with positive family histories have a higher risk for developing the disease at an earlier stage with more severe features. Because families share many lifestyle features (eating and exercise habits) it is difficult to determine when genetics or environment play the major role. When clusters of diabetes type 1 and 2 appear within families, genetic factors should be strongly suspected.

Ethnicity
The risk for type 2 diabetes varies among population groups. Diabetes also seems to pose higher or lower risks for specific complications among ethnic groups. Genetic, socioeconomic factors, or both seem to be involved in some ethnic differences, but in most cases the observed increase in ethnic groups in Americans is due to changes in traditional lifestyles.

• African Americans. African American men have one and a half times the risk of developing type 2 diabetes and African American women have twice the risk as their Caucasian peers. African Americans with diabetes are also at higher risk for amputations than diabetic Caucasians. This is most likely due to a higher incidence of high blood pressure and smoking as well as poorer health care in African Americans. Genetic factors also play a role. For example, there is some evidence that African Americans process insulin in the liver differently from Caucasians, which may make them more susceptible to diabetes when other risk factors are present.
• Native Americans. The Pima tribe in Arizona has an incidence of type 2 diabetes that is 19 times higher than that of the white population. The risk for diabetic complications among young Pima adults is also very high. Other Native American tribes in North America are also at high risk for type 2 diabetes. The association between diet and diabetes among this population remains critical, however, in assessing the reason for their higher risk. For example, in one study, Pimas who lived in Mexico exercised more and ate less fat (but consumed more calories) than Pima tribes in Arizona. Mexican Pimas have a prevalence of diabetes of only 6%, while half of their Arizona Pima neighbors had diabetes.
• Hispanic Americans. The rate of type 2 diabetes is also very high among Mexican Americans, approximately double that for Caucasians. This group may also be at higher risk for heart problems than other ethnic groups with diabetes.

Low Birth Weight

Low birth weight is now a recognized risk factor for type 2 diabetes and heart disease in adulthood. The reasons are unclear, although recent studies are suggesting it may represent a genetic factor. Studies in 2002 and 2003 observed that babies of fathers with type 2 diabetes and of women who later developed type 2 diabetes tended to weigh less than babies of parents without diabetes. Such studies suggest that such parents may have some specific gene that affects insulin factors, putting both themselves and their children at risk for future diabetes. Theoretically, such a gene might also affect insulin factors in the developing fetus, causing low birth weight. (Of note, mothers of very high-weight babies are also at risk for diabetes -- although in these cases it is most often associated with gestational diabetes.)

Diabetes in Children and Adolescents
Obesity-Related Type 2 Diabetes in Children. Until recent years, diabetes in children was almost always type 1 (an autoimmune disease). Between 1982 and 1994, however, the incidence of type 2 diabetes in children multiplied by ten, until in 1996, a study reported that a third of all new diabetes cases in children were type 2. This increase parallels the rising epidemic in childhood obesity that has occurred both in the US and worldwide, notably Europe and Japan. In some areas of Japan, type 2 diabetes has now become the dominant form of diabetes in children and adolescents. Obesity in children is also related to abnormalities in cholesterol, blood pressure, and insulin levels in adults. Administering glucose tolerance tests in overweight children may be helpful in identifying those at high risk for diabetes.

Maturity-Onset Diabetes in Caucasian Youth. Maturity-onset diabetes in youth (MODY) is a rare genetic form of type 2 diabetes that develops only in Caucasian teenagers. It accounts for 2% to 5% of type 2 cases. (This form of type 2 diabetes is not associated with obesity.)
Diabetes in the Pregnant Woman (Gestational Diabetes)
An estimated 5% of pregnant women develop a form of type 2 diabetes, usually temporary, in their third trimester called gestational diabetes.

Gestational Diabetes

Gestational diabetes is a diabetic condition (nearly always temporary) that develops during the third trimester. After delivery, blood glucose levels generally return to normal, although between one-third and one-half of these women develop type 2 diabetes within 10 years.

Who Gets Gestational Diabetes?
Estimates for the prevalence of gestational diabetes are generally about 4%. Some studies, however, have suggested significantly higher rates. In one German study, 13% of pregnant women were diagnosed with this form of diabetes, including many who did not have any risk factors.

Risk factors include the following:
• Weight gain (11 to 22 pounds) during early adulthood.
• Family history of diabetes.
• Smoking.
• Belonging to African American, Hispanic, or Asian ethnic groups.
• Gaining weight before getting pregnant.
• Being an older mother.

It should be noted that some studies suggest that women who develop gestational diabetes during pregnancy and take progestin-only contraceptives while breast-feeding are at high risk for developing full-blown type 2 diabetes.

Who Should Be Tested for Gestational Diabetes?

A number of expert groups now recommend that nearly all pregnant women be tested for gestational diabetes between their 24th and 28th week. Pregnant women at high risk for diabetes should be tested earlier. The only women who do not need to be tested are those at very low risk. Generally they have the following characteristics:
• Under 25 years old.
• Normal weight.
• No first-degree relatives with diabetes.
• Not belonging to the following ethnic groups: Native American, Hispanic, Asian or African-American.

How Serious Is Diabetes During Pregnancy?

Effect of Diabetes on the Fetus. Because glucose crosses the placenta, a woman with diabetes can pass high levels of blood glucose to the fetus. In response, the fetus secretes high level of insulin. Studies indicate that such conditions may effect the developing fetus as soon as it is conceived, placing the unborn child at risk for the following:

• Birth defects. (It should be noted that the risk is significant only in women who had diabetes before they became pregnant. A 2002 study reported no excess risk for infant malformations in women with gestational diabetes.)
• Excessive growth of the fetus.
• Delayed lung development.
• Possibly a higher risk for future diabetes and obesity in the child.

Effect of Diabetes on the Pregnant Woman.

In addition to endangering the fetus, diabetes also presents risks to the pregnant woman.

In one German study, 25% of women with gestational diabetes required a cesarean section. (The non-diabetic rate in the study was also high however, 19.6%.)

The most serious potential complications from diabetes are high blood pressure and preeclampsia, a potentially dangerous condition. In one study, blood pressure was abnormally high in 6.5% of women with gestational diabetes compared to 1.7% of pregnant women without diabetes. (Note that one study suggested mortality rates in pregnant women with gestational diabetes vary widely, and normal rates have been reported in some countries, suggesting that good prenatal care can be fully protective.)

How Is Gestational Diabetes Managed?

Some suggestions for preventing complications include the following:
• In most cases, increases in glucose levels can be managed with diet and exercise. Aerobic exercise before and during pregnancy may lower glucose levels and may be protective for women at risk or who have gestational diabetes. (Any pregnant woman should check with her physician before embarking on a vigorous exercise regimen.)
• If a woman with gestational diabetes cannot keep her glucose under control with lifestyle measures, then she usually is given insulin.
• Oral agents commonly used for type 2 diabetes have not been routinely prescribed because of a higher risk for birth defects and severe hypoglycemia in the newborn. Studies suggest that newer agents, such as glyburide, however, may be effective and safe alternatives to insulin.
Other Medical Conditions
Polycystic Ovary Syndrome. Polycystic ovary syndrome (PCO) is a condition that affects about 6% of women and results in the ovarian production of high amounts of androgens (male hormones), particularly testosterone. It appears to be an important cause of many menstrual disorders. Women with PCO are at higher risk for insulin resistance, and about half of PCO patients also have diabetes.

Hepatitis C. Patients with hepatitis C have a higher incidence of type 2 diabetes. The reasons for this are unclear.
Symptoms

Type 2 diabetes usually begins gradually and progresses slowly. Symptoms in adults include the following:
• Excessive thirst.
• Increased urination.
• Fatigue.
• Blurred vision.
• Weight loss.
• In women, vaginal yeast infections or fungal infections under the breasts or in the groin.
• Severe gum problems.
• Itching.
• Impotence in men.
• Unusual sensations, such as tingling or burning, in the extremities.
Symptoms in children are often different:
• Most children are obese or overweight.
• Increased urination is mild or even absent.
• Many develop a skin problem called acanthosis, which is characterized by velvety, dark colored patches of skin.

Emergency Complications
Hypoglycemia
People with diabetes who need to intensively control glucose levels are at risk for hypoglycemia (also called insulin shock). The condition develops if blood glucose levels fall below normal and may also be caused by insufficient intake of food, excess exercise, or alcohol intake. Usually the condition is manageable, but occasionally, it can be severe or even life threatening, particularly if the patient fails to recognize the symptoms. Mild hypoglycemia is common among people with type 2 diabetes, but severe episodes are rare, even among those who are taking insulin. Still, all patients who are intensively controlling glucose levels should be aware of warning symptoms.
Risk Factors for Severe Hypoglycemia. People at highest risk for severe hypoglycemia are those who intensively control blood glucose and also have one or more of the following conditions:
• Long-term diabetes.
• Less education on their condition.
• A previous history of severe hypoglycemia.
• Hypoglycemia unawareness. This is a condition in which people become insensitive to hypoglycemic symptoms. It affects about 25% of those who use insulin, nearly always type 1 diabetics. In such cases, hypoglycemia appears suddenly, without warning, and can escalate to a severe level. Even a single recent episode of hypoglycemia may make it more difficult to detect the next episode. With vigilant monitoring and by rigorously avoiding low blood glucose levels, such patients can often regain the ability to sense the symptoms. Note that even very careful testing may fail to detect a problem, particularly one that occurs during sleep.
Symptoms. Mild symptoms usually occur at moderately low and easily correctable levels of blood glucose. They include the following:
• Sweating.
• Trembling.
• Hunger.
• Rapid heartbeat.
Severely low blood glucose levels can precipitate neurologic symptoms:
• Confusion.
• Weakness.
• Disorientation.
• Combativeness.
• In rare and worst cases, coma, seizure, and death.
Preventive Measures. The following tips may help avoid hypoglycemia or prepare for attacks.
• Patients are at highest risk for hypoglycemia at night. Bedtime snacks may be helpful.
• Patients who intensively control their blood sugar should monitor blood levels as often as possible, four times or more per day. This is particularly important for patients with hypoglycemia unawareness.
• In adults, it is also particularly critical to monitor blood glucose levels before driving, when hypoglycemia can be very hazardous.
• Diabetic patients on therapies that put them at risk for hypoglycemia should always carry hard candy, juice, sugar packets, or commercially available glucose substitutes designed for diabetic individuals.
Family and friends should be aware of the symptoms and be prepared:
• If the patient is helpless (but not unconscious), family or friends should administer three to five pieces of hard candy, two to three packets of sugar, half a cup (four ounces) of fruit juice, or a commercially available glucose solution for diabetics.
• If there is inadequate response within 15 minutes, additional oral sugar should be provided or the patient should receive emergency medical treatment, including the intravenous administration of glucose.
• Family members and friends can learn to inject glucagon, a hormone, which, in contrast to insulin, raises blood glucose.

Diabetic Ketoacidosis (DKA)
Diabetic ketoacidosis (DKA) is a life-threatening complication caused by insulin depletion. Until recently, it has been a complication almost exclusively of type 1 diabetes. In such cases, it is nearly always due to noncompliance with insulin treatments. However, DKA is being reported increasingly in type 2 diabetes, especially among Hispanic and African Americans. It is not clear, however, what causes total insulin depletion in these patients. Research is needed to find which individuals are at particular risk.

Diabetic ketoacidosis often develop as follows:
• The process is usually triggered in insulin-deficient patients by a stressful event, most often pneumonia or urinary tract infections. Other triggers include alcohol abuse, physical injury, pulmonary embolism, heart attacks, or other illnesses.
• Severely low insulin levels cause excessive amounts of glucose in the bloodstream (hyperglycemia).
• Fat breakdown then accelerates and increases the production of fatty acids.
• These fatty acids are converted into chemicals called ketone bodies, which are toxic at high levels.
Symptoms and complications include the following:
• Nausea and vomiting.
• Breathing may be abnormally deep and rapid with frequent sighing.
• The heartbeat may be rapid.
• If the condition persists, coma and, eventually, death, may occur, although over the past 20 years, death from DKA has decreased to about 2% of all cases.
• Other serious complications from DKA include aspiration pneumonia and adult respiratory distress syndrome.

Life-saving treatment employs rapid rehydration using a saline solution followed by low-dose insulin and potassium replacement.

Testing for Diabetes

Fasting Plasma Glucose. The fasting plasma glucose (FPG) test is the standard test for diabetes. It is a simple blood test taken after eight hours of fasting. In general, results indicate the following:
• FPG levels are considered normal up to 110 mg/dl (or 6.1 mmol/L).
• Levels between 110 and 125 (6.1 to 6.9 mmol/L) are referred to as impaired fasting glucose. They are only slightly above normal but are considered to be risk factors for type 2 diabetes and its complications.
• Diabetes is diagnosed when FPG levels are 126 mg/dl (7.0 mmol/L) or higher on two different days.

The FPG test is not always reliable, so a repeat test is recommended if the initial test suggests the presence of diabetes, or if the test is normal in people who have symptoms or risk factors for diabetes . For example, people who take the test in the afternoon and show normal results may actually have abnormal levels that would be revealed if they are tested in the morning.
Glucose Tolerance Test. The glucose tolerance test is more complex than the FPG and may over-diagnose diabetes in people who do not have it. It is, then, not used as often anymore. Some experts recommend it follow-up after FPG, if the latter test results are normal but the patient has symptoms or risk factors of diabetes. The glucose tolerance test may be more accurate than the FPG in certain groups (e.g., women with a history of gestational diabetes or certain Asian populations).

The test uses the following procedures:
• It first employs an FPG test.
• A blood test is then taken two hours later after drinking a special glucose solution.
The following results suggest different conditions:
• In people without diabetes, blood sugar increases modestly after drinking the glucose beverage and decreases after two hours.
• In diabetes, the initial increase is significant and the level remains high, 200 mg/dL (11.1 mmol/L) or more.
• Measurements that fall between 7.8 and below 11.1 mmol/l put a person at risk for diabetes and are referred to as impaired glucose tolerance. This condition is now strongly associated with a high risk for future diabetes and a higher than average risk for heart disease and poorer survival rates. (Studies suggest it is a much stronger predictor of diabetes than impaired fasting glucose.)

Screening Tests for Complications
Screening for Heart Disease. All patients with diabetes should be tested for hypertension and unhealthy cholesterol and lipid levels and given an electrocardiogram. Other tests may be warranted in patients with signs of heart disease.

Screening for Kidney Damage. The earliest manifestation of kidney damage is microalbuminuria, in which tiny amounts (30 to 299 mg per day) of protein called albumin are found in the urine. About 20% of type 2 patients show evidence of microalbuminuria upon diagnosis of diabetes. It should be noted, however, that only a small percentage of type 2 diabetics eventually develop kidney disease. Microalbuminuria typically shows up in type 2 diabetics who have high blood pressure.

Screening for Thyroid Abnormalities. Thyroid function tests should be administered.
Treatment
The major treatment goals for people with type 2 diabetes are twofold:
• To treat all conditions that place the patients at risk for heart disease and stroke, which are the major killers of people with type 2 diabetes.
• To control blood glucose levels. The goal is to achieve fasting blood glucose levels of less than 110 mg/dl and glycolated hemoglobin (HbA1c) levels of less than 7%. The objective is to reduce complications in small blood vessels and the nerve damage associated with diabetes.
An intensive multi-pronged approach is critical for reducing complications and improving survival rates in diabetics. In one major study, patients with diabetes and early signs of kidney involvement embarked on an intensive preventive program. At the end of about seven years, their risk for heart, stroke, death, and other complications was 24% compared to 44% of patients who had conventional therapy. Intensive therapy involved the following:
• Healthy lifestyle changes: Exercise for 30 minutes three to five times a week; low-fat diet; smoking cessation; vitamins and mineral supplements (vitamin E and C, folic acid, and chrome picolinate).
• Controlling blood sugar levels. The use of an oral anti-hyperglycemic agent, such as a sulfonylurea or metformin (Glucophage), for patients whose HbA1c levels were over 6.5%. Of note, studies suggest that metformin significantly reduces mortality rates compared to other agents, including insulin. It should be considered as the first option in managing blood sugar for most patients with type 2 diabetes. Other oral anti-hyperglycemic agents (OHAs) are also available. Insulin may eventually be needed.
• Taking heart protective agents. Among anti-hypertensive agents angiotensin converting enzyme (ACE) inhibitors are first choice for diabetics, particularly those with evidence of kidney problems--even without high blood pressure. Controlling high blood pressure, in fact, is one of the few factors proven to reduce mortality rates. Among cholesterol-lowering agents, statins are the first choice alone or in combinations. They protect people with diabetes, even if cholesterol levels are not abnormal. Aspirin is important to prevent blood clots and heart attack.
Of note, most people with diabetes would find such intensive treatment difficult to comply with. Still, they should make every effort, especially to control blood pressure, cholesterol levels, and blood glucose levels.

Treating Special Populations
Different goals may be required for specific individuals, including pregnant women, very old and very young people, and those with accompanying serious medical conditions. Treating children with type 2 diabetes depends on the severity of the condition at diagnosis. Metformin is now approved for children. Until recently, only insulin was approved for treating children with any diabetes .

Lifestyle Changes
A simple heart-healthy diet with weight control may be sufficient for people with type 2 diabetes. In fact, a 2002 study reported that successful lifestyle changes were more effective than metformin -- a major drug used in type 2 diabetes -- in preventing type 2 diabetes in high-risk individuals. On the other hand, the so-called Western diet (higher consumption of red meat, processed meat, French fries, high-fat dairy products, refined grains, and sweets and desserts) poses a high risk for type 2 diabetes. Lifestyle changes are difficult to initiate and sustain, however. Patients should be certain to surround themselves with a solid network of doctors, dietitians, family, and friends who understand both their condition and their needs.

Heart-Healthy Diet
Currently, there is much controversy over the best balance of carbohydrates, fats, and protein. A number of dietary approaches for improving the heart are available:

• Therapeutic Lifestyle Changes (TLC) from the National Cholesterol Education Program.
• The Mediterranean Diet.
• Very low-fat diets, particularly the Ornish Program.
• The Dietary Approaches to Stop Hypertension (DASH) diet. This diet has been designed specifically to help people reduce blood pressure.
• Restricted calorie diets.
Although all the major dietary approaches differ in important aspects, they have some recommendations in common:
• Choose fiber-rich food (whole grains, legumes).
• Choose fresh fruits and vegetables.
• Choose unsaturated fats (found in vegetable and fish oils) over saturated fats (found mostly in animal products) and trans-fatty acids (found in hydrogenated fats and many commercial products and fast-foods).
• In selecting proteins, choose soy protein, poultry, and fish over meat.
• Weight control and exercise are essential companions of any diet program.
• After embarking on any heart-healthy diet, it generally takes an average of three to six months before any noticeable reduction in cholesterol occurs, although some people have reported better levels in as few as four weeks.

Weight Loss
The Diabetic Diet. The current state of the diabetic diet is in flux, and at this time, there is no single diet that meets all the needs of everyone with diabetes. Patients should meet with a professional dietitian to plan an individualized diet that takes into consideration all health needs. There are some constants, however:
• Limit fats (particularly saturated fats and trans-fatty acids).
• Limit dietary cholesterol.
• Consume plenty of fiber-rich foods in the form of whole grains and fresh fruits and vegetables.
• Limit protein.
• Reduce salt.

Weight Loss with Diet and Medications. Being overweight is the number one risk factor for type 2 diabetes. Even modest weight loss can help prevent type 2 diabetes from developing. It can also help control or even stop progression of type 2 diabetes in people with the condition. Unfortunately, not only is weight loss difficult to sustain, but many of the oral medications used in type 2 diabetes cause weight gain as a side effect. For obese patients who cannot control weight using dietary measures alone, weight-loss drugs, such as orlistat (Xenical) or sibutramine (Meridia), may be beneficial. Orlistat may have specific benefits for people with diabetes. It may not only achieve weight but also improved glucose, cholesterol, and lipid levels. Surgical procedures are proving to be extremely beneficial in selected cases.

Exercise
Sedentary habits, especially watching television, are associated with significantly higher risks for obesity and type 2- diabetes. Regular exercise, even of moderate intensity (such as brisk walking), improves insulin sensitivity and may play a significant role in preventing type 2 diabetes--regardless of weight loss. An important study reported a 58% lower risk for type 2 diabetes in adults who performed moderate exercise for as little as 2.5 hours a week.

In 2002, a well-conducted study on overweight adults confirmed previous research that reported beneficial changes in cholesterol and lipid levels, including lower LDL levels (the so-called bad cholesterol), even when people performed low amounts of moderate or high intensity exercise ( e.g., walking or jogging 12 miles a week). However, more intense exercise is required to significantly change cholesterol levels, notably increasing HDL (the so-called good cholesterol). An example of such a program would be jogging about 20 miles a week. Such benefits in the study occurred even with very modest weight loss, suggesting that overweight people who have trouble losing pounds can still achieve considerable heart benefits by exercising.

Aerobic Exercises. Aerobic exercise is proving to have significant and particular benefits for people with both type 1 and type 2 diabetes. Regular aerobic exercise, even of moderate intensity, improves insulin sensitivity. People with diabetes are at particular risk for heart disease, so the heart protective effects of aerobic exercise are very important for this patient population. Moderate exercise, in fact, protects the heart in people with type 2 diabetes, even if they have no risk factors for heart disease other than diabetes itself. (In general, when exercising people with diabetes , should aim for a heart rate target of 55% to 75% of their maximum heart rate.)
Strength Training. Strength training, which increases muscle and reduces fat, may be particularly helpful for people with diabetes, but evidence is needed to confirm this.

Yoga. One study reported that yoga helped patients with type 2 diabetes reduce their need for oral medications.Studies have indicated that yoga and Tai Chi (an ancient Chinese exercise involving slow relaxing movements) may lower blood pressure almost as well as moderate-intensity aerobic exercises.

Some Precautions for People with Diabetes Who Exercise. The following are precautions for all people with diabetes, whether type 1 or 2:

• Because people with diabetes are at higher than average risk for heart disease, they should always check with their physicians before undertaking vigorous exercise. For the best and fastest results, frequent high-intensity (not high-impact) exercises are best for people who are cleared by their physicians. For people who have been sedentary or have other medical problems, lower-intensity exercises are recommended using regimens designed with physicians.
• Strenuous strength training or high-impact exercise is not recommended for people with uncontrolled diabetes. Such exercises can strain weakened blood vessels in the eyes of patients with retinopathy. High-impact exercise may also injure blood vessels in the feet.
Patients who are taking medications that lower blood glucose, particularly insulin, should take special precautions before embarking on a workout program.
• Glucose levels swing dramatically during exercise; people with diabetes should monitor their levels carefully before, during, and after workouts.
• Patients should probably avoid exercise if glucose levels are above 300 mg/dl or under 100 mg/dl.
• To avoid hypoglycemia, diabetics should inject insulin in sites away from the muscles they use the most during exercise.
• They should also drink plenty of fluids. Before exercising, they should also avoid alcohol, which increases the risk of hypoglycemia.
• Insulin-dependent athletes may need to decrease insulin doses or take in more carbohydrates prior to exercise but may need to take an extra dose of insulin after exercise. Stress hormones released during exercise may increase blood glucose levels; in non-diabetics insulin is released to control this. The diabetic therefore needs to test their blood sugar and take an extra dose as instructed by their diabetes healthcare provider.
• Anyone with existing hypertension should discuss an exercise program with their physician. Before starting to exercise, people with moderate to severe hypertension should lower their pressure and be able to control it with medications. They should avoid caffeinated beverages, which increase heart rate, the workload of the heart, and blood pressure during physical activity. Everyone, and especially people with high blood pressure, should breath as normally as possible through each exercise. Holding the breath increases blood pressure.
• Good, protective footwear is essential to help avoid injuries and wounds in the feet.