Diabetes mellitus, a life-long disease for which there is not yet a cure, is caused by a problem in the way the body makes or uses insulin. Insulin is necessary for glucose to move from the blood to the inside of the cells.

Unless glucose gets into cells, the body cannot use it for energy. Excess glucose remains in the blood, and is then removed by the kidneys. Symptoms of excessive thirst, frequent urination, hunger, fatigue, and weight loss develop.

There are several types of diabetes: type I diabetes, which requires total insulin replacement in order to live; type II diabetes, which is related to insulin resistance, obesity, high cholesterol, and high blood pressure; and gestational diabetes mellitus, which occurs during pregnancy. Diabetes affects up to 6% of the population in the U.S. and type II diabetes accounts for 90% of all cases.

A main component of type II diabetes is insulin resistance at the level of the fat and muscle cells. This means the insulin produced by the pancreas cannot connect with 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 more resistant, resulting in high glucose levels and often times high insulin levels.

A person with type II diabetes often does not require insulin injections. The primary treatment is exercise and diet. Type II diabetes usually occurs gradually. Some 75% to 80% of people with type II diabetes are obese at the time of diagnosis. However, the disease can also develop in lean people, especially the elderly.

Genetics play a large role in type II diabetes and family history is a risk factor. However, environmental factors (such as a low activity level and poor diet) can increase a person's risk for type II diabetes.

Other risk factors are as follows: race/ethnicity (African-Americans, Hispanic-Americans, Native Americans, Asian-Americans, Pacific Islanders); age greater than 45 years; previously identified impaired glucose tolerance; hypertension (high blood pressure); HDL cholesterol of less than 35 and/or triglyceride level of greater than 250; history of gestational diabetes mellitus or babies over nine pounds.

Symptoms of type II diabetes include:

• increased thirst
• increased urination
• increased appetite
• fatigue
• blurred vision
• frequent and/or slow-healing infections (including bladder, vaginal, skin)
• weight loss despite increased appetite
• erectile dysfunction in men

Note: There may be no symptoms or symptoms may develop slowly.

Type II diabetes is diagnosed when:

• a fasting glucose level is above 126 milligrams per deciliter (mg/dl) on two occasions.
• a random glucose level is above 200 milligrams per deciliter with the classic symptoms of increased thirst, urination, and fatigue.
• a glucose level greater than 200, 2 hours after getting a standardized carbohydrate beverage (Glucose Tolerance Test).

At diagnosis, the goals of treatment are to eliminate symptoms of hyperglycemia, stabilize blood glucose, and restore normal body weight. The ongoing goals of treatment are to prolong life, relieve symptoms, and prevent long-term complications.

These goals are achieved through diabetes education, self-monitoring of blood glucose (SMBG), careful dietary management, weight control, regular physical activity, medication, proper foot care, and continuing care.

EDUCATION
Diabetes education is an important part of a treatment plan. Diabetes educators and health care providers can teach essential skills needed after initial diagnosis of the disease. Appropriate education teaches a person with diabetes how to incorporate diabetes management principles into daily life and reduce need for medical treatment.

Basic principles include:

• How to test and record blood glucose (see blood glucose monitoring).
• What to eat and when.
• How to take medications, if indicated.
• How to recognize and treat low and high blood sugar.
• How to handle sick days.
• Where to buy diabetes supplies and how to store them.

Learning the basic principles of diabetes self-care and establishing a routine may take several months. Once the condition has been stabilized, in-depth diabetes education programs can help the diabetic learn more about the disease process, learn how to control and live with diabetes, and learn more about intermediate and long-term complications of the disease and how to minimize them. Annual review of diabetic education is recommended to help the diabetic stay current on new research and treatment.

SELF-TESTING
Blood sugar testing, or self-monitoring of blood glucose, is done by checking the glucose content of a small drop of blood. Regular testing tells the person with diabetes how well diet, medication, and exercise are working together to control diabetes.

The results of the test can be used to adjust meals, activity, or medications to keep blood sugar levels in an appropriate range. Testing provides valuable information for the health care provider and identifies high and low blood sugar levels before serious problems develop.

There is one method of testing blood glucose measurements at home. A glucometer is a small machine that provides an exact reading of blood glucose. A test strip is used to collect a small drop of blood, obtained by pricking the finger with a small, specially-designed needle.

The strip is then placed in the meter. Results are available in 30 to 45 seconds. A health care provider or diabetes educator will help set up an appropriate testing schedule.

Tests are usually done before meals and at bedtime. More frequent testing may be indicated during illness or stress. Accurate record keeping of test results will make the testing more useful for planning the care of the person with diabetes.

DIETARY MANAGEMENT AND WEIGHT CONTROL
Meal planning includes choosing healthy foods, eating the right amount of food, and eating meals at the right time. The American Diabetes Association (ADA) currently recommends that 50% to 60% of a person's diet should come from carbohydrates, 10% to 20% from lean sources of protein, and less than 30% from fats.

The exact breakdown of these percentages is different for each individual. The ADA no longer recommends a diet of 1,800 to 2,000 calories a day for all patients. A registered dietitian can be helpful in determining an individual's specific dietary needs.

In type II, weight management and a well-balanced diet are important. Some people with type II diabetes can discontinue medications after intentional weight loss, although the diabetes is still present. Consultation with a registered dietitian is an invaluable planning tool.

REGULAR PHYSICAL ACTIVITY
Regular exercise is important for everyone, but especially for people with diabetes. Regular exercise helps control the amount of glucose in the blood. It also helps burn excess calories and fat to achieve optimal weight.

Exercise improves overall health by improving blood flow and blood pressure. It naturally decreases insulin resistance even without weight loss. Exercise also increases the body's energy level, lowers tension, and improves a person's ability to handle stress. Everyone should obtain medical approval before starting an exercise program, but this is especially important if you have diabetes.

The following should be considered:

• Choose an enjoyable physical activity that is appropriate for the current fitness level.
• Exercise every day, and at the same time of day, if possible.
• Monitor blood glucose levels by home testing before and after exercise.
• Carry food that contains a fast-acting carbohydrate in case blood glucose levels get too low during or after exercise.
• Carry diabetes identification card and change for a phone call in case of emergency.
• Drink extra fluids that do not contain sugar before, during and after exercise.
• Changes in exercise intensity or duration may necessitate diet or medication modification to keep blood glucose levels in an appropriate range.

MEDICATION
When the person with type II diabetes cannot achieve normal or near-normal blood glucose levels with diet and exercise, medication is added to the treatment plan. A person with diabetes may require oral agents.

These medications are taken by mouth, to lower blood glucose levels. They do not contain insulin themselves, so they are not helpful for Type I diabetes. Some people may find they no longer need medication if they lose weight and increase activity, because when their ideal weight is reached their own insulin can control their blood sugar. Medications are usually not given in pregnancy. They include:

• Oral sulfonylureas: These medications work by triggering the pancreas to make more insulin.
• Biguanides (Metformin): This medication works by telling the liver to decrease its production of glucose, which increases glucose levels in the blood stream.
• Alpha-glucosidase inhibitors: These pills work by decreasing the absorption of carbohydrates from the digestive tract, thereby lowering the after-meal glucose levels.
• Thiazolidinediones: This group of medications work by helping the insulin work better at the cell site. In essence, they increase the cell's sensitivity to insulin.
• Meglitinides: These medications trigger the pancreas to make more insulin in response to how much glucose is in the blood.

Insulin is also used in people with type II diabetes who have poor blood glucose control with oral hypoglycemic agents or bad reactions to oral hypoglycemic agents. Insulin must be injected under the skin using a syringe and cannot be taken orally.

Insulin preparations differ in how fast they start to work and how long they work. The health-care professional measures blood glucose to determine the appropriate type of insulin to use.

More than one type may be mixed together in an injection to achieve the best control of blood glucose. The injections are needed, in general, from one to four times a day. People requiring insulin injections are taught how to give themselves injections by their health care provider or a diabetes educator referred by their provider.

FOOT CARE
People with diabetes are prone to foot problems because of complications caused by damage to blood vessels and nerves and decreased ability to fight infection. Blood flow to the feet may become compromised and damage to the nerves may cause an injury to the foot to go unnoticed until infection develops. Death of skin and other tissue can occur. If left untreated, amputation of the affected foot may be necessary.

To prevent injury to the feet, diabetics should adopt a daily routine of checking and caring for the feet as follows:

• Check your feet every day, and report sores or changes and signs of infection.
• Wash feet every day with lukewarm water and mild soap, and dry them thoroughly.
• Soften dry skin with lotion or petroleum jelly.
• Protect feet with comfortable, well-fitting shoes.
• Exercise daily to promote good circulation.
• See a podiatrist for foot problems, or to have corns or calluses removed.
• Remove shoes and socks during a visit to the health care provider to remind them to examine your feet.
• Discontinue smoking because it worsens blood flow to the feet.

CONTINUING CARE:
A person with type II diabetes should have a visit with a diabetes care provider every three months. A thorough three-month evaluation includes:

• Glycosylated hemoglobin (HbA1c) is a weighted three-month average of what your blood glucose has been. This test measures how much glucose has been sticking to the red blood cells. It also indicates how much glucose has been sticking to other cells. A high HbA1c is an indicator of risk for long-term complications. Currently, the ADA recommends an HbA1c of less than 7% to protect oneself from complications. This test should be done every three months.
• Blood pressure check.
• Foot and skin examination.
• Ophthalmoscopy examination.
• Neurological examination.

The following evaluations should be done annually, unless otherwise indicated:

• Random microalbumin (urine test for protein).
• BUN and serum creatinine.
• Serum cholesterol, HDL, and triglycerides.
• ECG.
• Dilated retinal exam.

The stress of illness can often be helped by joining a support group where members share common experiences and problems. See diabetes - support group.

For many years, physicians thought that the long-term complications of diabetes were inevitable. We now know this does not have to be true for most people.

The United Kingdom Prospective Diabetes Study (UKPDS) was completed in 1997. It followed close to 4,000 people with type II diabetes for 10 years. The study monitored how tight control of blood glucose (meaning a HbA1c of 7%) and tight control of blood pressure (meaning a blood pressure of less than 144 over less than 82) could protect a person from the long-term complications of diabetes.

At the end of the 10 years, the study showed that those people with the best control of blood glucose and blood pressure had a 32% decreased risk of all diabetes-related deaths, a 44% decreased risk of stroke, a 56% decreased risk of heart failure, and a 37% decreased risk for micro-vascular (small blood vessel) complications.

The study also found that for every one percentage-point decrease in HbA1c, a person could decrease his risk for all complications by 25%. The UKPDS dramatically demonstrated that with good self-care skills, blood glucose control, and blood pressure control, many complications can be prevented.

Emergency complications include nonketotic hyperosmolar coma (see diabetic hyperglycemic hyperosmolar coma).

Long-term complications include:

• diabetic retinopathy
• diabetic nephropathy
• diabetic neuropathy
• peripheral vascular disease
• hyperlipidemia, hypertension, atherosclerosis, and coronary artery disease

• trembling
• weakness
• drowsiness
• headache
• confusion
• dizziness
• double vision
• lack of coordination

This can rapidly progress to emergency conditions (such as convulsions, unconsciousness, or hypoglycemic coma).

Maintaining ideal body weight (weight management) and an active lifestyle may prevent the onset of type II diabetes in people at risk for the disease.