When he was 21, Ken developed a puzzling thirst. He also had to urinate frequently, eventually every 20 Minutes. He was chronically tired, and his vision became blurry.

AUSTRALIAN International Diabetes Association: Diabetes presents one of the most challenging problems of the 21st century

INDIA: "At least 30 Million people have diabetes. We hardly had any patients under the age of 40 about 15 years ago," says a doctor, "today, every other person diagnosed is within this age group"

SINGAPORE: Nearly a third of the people between the age of 30 and 69 have diabetes. Many children, some as young as 10 have been diagnosed

United States: Approximately 16 Million people are affected, each year, some 800,000 new cases are diagnosed. Millions have the disease but do not know it.

Treatment for diabetes is made more difficult because a person can have diabetes a long time before it is diagnosed. "Because the early symptoms are relatively mild" notes Asiaweek Magazine, "diabetes often goes unrecognized". Hence, diabetes has been dubbed the Silent Killer.

What is diabetes?
Diabetes is a situation where the glucose "sugar" level in the blood is too high.

What causes diabetes?
Diabetes mellitus occurs when the pancreas doesn't make enough or any of the hormone insulin, or when the insulin produced doesn't work effectively. In diabetes, this causes the level of glucose in the blood to be too high.

In Type 1 diabetes the cells in the pancreas that make insulin are destroyed, causing a severe lack of insulin. This is thought to be the result of the body attacking and destroying its own cells in the pancreas - known as an autoimmune reaction.

It's not clear why this happens, but a number of explanations and possible triggers of this reaction have been proposed. These include:

• infection with a specific virus or bacteria;

• exposure to food-borne chemical toxins; and

• exposure as a very young infant to cow's milk, where an as yet unidentified component of this triggers the autoimmune reaction in the body.

Heredity is a major cause of diabetes. If both parents have Type 2 diabetes, there is a chance that nearly all of their children will have diabetes. If both parents have Type 1 diabetes, fewer than 20 percent of their children will develop Type 1 diabetes. In identical twins, if one twin develops Type 2 diabetes, the chance is nearly 100 percent that the other twin will also develop it. In Type 1 diabetes, however, only 40 to 50 percent of the second twins will develop the disease, indicating that while inheritance is important, environmental factors (for example, too much food, too much stress, viral infection, and so forth) are also involved in the development of Type 1 diabetes.

Early Forms of Diabetes
Once called chemical diabetes or prediabetes, early forms of carbohydrate intolerance include impaired glucose tolerance (IGT) and impaired fasting glucose (IFG). Impaired glucose tolerance is the diagnosis of a person with a normal fasting sugar (glucose) level who, after drinking a certain amount of a liquid that contains sugar (glucose), has a value at 2 hours above 200 mg/dl or 11 mmol. The measurement "mmol" is metric. To convert mg/dl to mmol for blood sugar, divide by 18. For example: 200 mg/dl / 18 = 11 mmol.

For whatever reason, this genetic factor, perhaps interacting with some environmental factors such as obesity, excess caloric intake, deficient caloric expenditure, and aging, may result then in a resistance to insulin. That is, the peripheral cell, a muscle or fat or other cell, does not respond appropriately to the insulin present. The body then begins to produce more insulin in order to try to overcome the insulin resistance. The next part of the sequence may involve two factors. One is that the increasing insulin secretion may ultimately exhaust the beta cells, thus resulting in insulin deficiency. Another factor has been identified recently and this is called glucotoxicity. It turns out that sugar in high amounts can be toxic or poisonous to the cells of the body. In the person with insulin resistance who is running high blood sugars that have been undetected and untreated, or even in the person who know he or she has the disease but does not treat it appropriately, the continuing high levels of sugar have a toxic effect on the insulin-producing cells of the pancreas, thus damaging those cells and reducing insulin secretion. So we then end up with a combination of peripheral resistance to the action of insulin and at the same time insulin deficiency, and those two can then precipitate a severe case of Type 2 diabetes that may in fact require insulin for treatment.

In summary, Type 2 diabetes is believed to develop when:

• the receptors on cells in the body that normally respond  to the action of insulin fail to be stimulated by it - insulin resistance. In response to this more insulin may be produced, and this over-production exhausts the insulin-manufacturing cells in the pancreas;

• there is simply insufficient insulin available; and

• the insulin that is available may be abnormal and therefore doesn't work properly.

The following risk factors increase the chances of someone developing Type 2 diabetes:

• Increasing age;

• obesity; and

• physical inactivity.

Rarer causes of diabetes include:

• Certain medicines;

• pregnancy (gestational diabetes); and

• any illness or disease that damages the pancreas and affects its ability to produce insulin e.g. pancreatitis.

Other Causes of Diabetes
Drugs such as steroids, Dilantin, and others may elevate the blood sugar through a variety of mechanisms. Certain other drugs, such as alloxan, streptozocin, and thiazide diuretics, are toxic to the beta cells of the pancreas and can cause diabetes. Certain syndromes (for example, Prader-Willi, Down's, Progeria, and Turner's) may result in a hyperglycemic state; if this state is prolonged, the result can be permanent diabetes.

What doesn't cause diabetes
It's important to also be aware of the different myths that over the years have arisen about the causes of diabetes.

Stress does not cause diabetes, although it may be a trigger for the body turning on itself as in the case of Type 1 diabetes. It does, however, make the symptoms worse for those who already have diabetes.

Diabetes is not contagious. Someone with diabetes cannot pass it on to anyone else.

How to cope with the disorder?
How do you feel about having diabetes? Do you see it as a daily challenge, one that requires your own strength, energy, and attention as well as the support of your fiends and family? If so, you're probably coping well with your diabetes. You understand that diabetes is a serious condition, but you are optimistic about your treatment plan. You're committed to taking responsibility for your self-care, to following your regimen, and to learning as much as you can about your diabetes. You trust your health-care team, and you feel free to participate in decisions about your diabetes care plan. Your attitude is positive.

Your health-care professionals should provide:

• A treatment plan and self-care targets

• Regular checks of blood sugar (glucose) levels and of your physical condition

• Treatment for special problems and emergencies

• Continuing education for you and your family

• Information on available social and economic support

Your role is to build this advice into your daily life and to be in control of your diabetes on a day-to-day basis.

TREATMENT PLAN
You should receive the following:

• Personalized advice on proper eating -- types of food, amounts, and timing of meals

• Advice on physical activity

• Your dose and timing of tablets or insulin and how to take them; advice on how to change doses based on your self-monitoring

• Your target values for blood glucose, blood fats, blood pressure, and weight

At each visit, your health-care professional should:

• Review your self-monitoring results and current treatment

• Talk about your targets and change where necessary

• Talk about any problems and questions you may have

• Continue diabetes education

The health-care team should check:

• Your blood glucose control by taking special tests.
  (These tests, done two to four times per year if diabetes is well controlled, include measures of "glycohemoglobin" (sometimes abbreviated as HbA1c or GHb) or "fructosamine." Fasting blood glucose tests are advised for individuals treated without insulin.

• Your weight

• Your blood pressure and blood fats, if necessary

The following should be checked at least once per year:

• Your eyes and vision

• Your kidney function (blood and urine tests)

• Your feet

• Your risk factors for heart disease, such as blood pressure,

• blood fats, and smoking habits

• Your self-monitoring and injection techniques

• Your eating habits

The following are important items you should learn about:

• Why to control blood glucose levels

• How to control your blood glucose levels through proper eating, physical activity, tablets, and/or insulin

• How to monitor your control with blood or urine tests (self-monitoring) and how to act on the results

• The signs of low and high blood glucose levels and ketosis, how to treat them, and how to prevent them

• What to do when you are ill

• Prevention and treatment of long-term complications, including possible damage to eyes, nerves, kidneys, feet, and hardening of the arteries

• How to deal with life-style variations, such as exercise, traveling, and social activities (including alcohol consumption)

• How to handle possible problems with employment, insurance, and driving licenses

Special Situations

Advice and care should be available in special circumstances, especially if you are a child, adolescent, an elderly person, or planning to become or are pregnant.

The first months after your diabetes has been discovered are often difficult. Remember, you cannot learn everything during this period; learning will continue for the rest of your life.

If you have problems with your eyes, kidneys, feet, blood vessels, or heart, then you should be able to see specialists quickly. In addition, you should receive clear information on what to do in emergencies.

You have a role here. You must learn to take control of your diabetes on a day-to-day basis. This will be easier the more you learn about your diabetes.

Learn about and practice self-care. This includes self-monitoring of blood glucose and learning how to change your treatment regimen according to the results.

Follow these guidelines:

• Examine your feet on a regular basis.

• Follow good life-style practices. These include choosing the right food, maintaining a health weight, getting regular exercise, and avoiding smoking.

• Know when to contact your health-care team.

• Keep in regular contact with your health-care team about any questions or concerns you may have. Have your questions prepared beforehand and repeat them if the answer is unclear to you.

• Speak to your health-care team, others, with diabetes, and your local or national diabetes association.

• Read pamphlets and books about diabetes provided by your health-care team or diabetes association.

• Make sure that your family and friends know about your needs as someone with diabetes.

YOUR GUIDE TO BETTER DIABETES CARE: RIGHTS & ROLES
An individual with diabetes can, in general, lead a normal, healthy, and long life. Looking after yourself and learning about your diabetes provide the best chance to do this. Your doctor and the other members of the health-care team (made up of doctors, nurses, dietitians, and chiropodists) are there to advise you and to provide the information, support, and technology for you to look after yourself and live your life in the way you choose. It is important for you to know what your health-care providers should provide to help you reach these goals and what you should do.

References
The Diabetes Sourcebook
Copyright © Diana W. Guthrie, R.N., Ph.D., and Richard A. Guthrie, M.D.
Copyright © Ruth E. Lundstrom, R.N. and Aldo A. Rossini, M.D.
Copyright © BBC Health
 

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