pink panther - diabetes management - chapter 22

TOPICS:Prevent, Detectand Treat ChronicComplicationsThrough RiskReductionMonitoring(Complicationsand AssociatedDiseases)TEACHING OBJECTIVES:1. Discuss the relationship between

glucose control and diabeticcomplications (eye, kidney,nerve).

2. Summarize the tests, whichmonitor eye and kidneycomplications.

3. Present associated autoimmunediseases (e.g., thyroid and celiac).

LEARNING OBJECTIVES:Learner (parents, child, relative orself) will be able to:1. Describe the relationship

between glucose control andcomplications.

2. Identify routine tests used tomonitor the eyes and kidneys.

3. List one symptom associatedwith each disease (thyroid andceliac).

Chapter 22

Long-TermComplicationsof Diabetes

INTRODUCTIONIn addition to the acute complications of diabetes, insulin

reactions and acidosis, there are also problems known as long-term complications. Generally, the long-term complicationsoccur in people who have had diabetes and high blood sugarlevels for many years.

About this chapter:

Many families may prefer to read this chapter when they areready to deal with the subject.

Teenagers may be able to understand the material betterthan pre-teens.

Many new and difficult words are used in this chapter.They are introduced and defined in the back. If yourdiabetes care provider uses them you will have a place tofind their meaning.

The four most common parts of the body to be affected by highsugar levels are:

1. Eyes (retinopathy)2. Kidneys (nephropathy)3. Nerves (neuropathy)4. Heart and blood vessels

Three other areas that can be affected by high sugar levels are:

5. Joints (finger curvatures)6. Children born to mothers with poorly controlled

diabetes (birth defects)7. Foot problems

235

236 Chapter 22 Long-Term Complications of Diabetes

THE DCCTThe Diabetes Control and Complications

Trial (DCCT) has been mentioned previously inthis book (Chapter 14). The results of this studybecame available in 1993 and proved withoutquestion that eye, kidney and nerve problemsof type 1 diabetes were decreased in peopleages 13-39 years whose blood sugars werekept closer to normal. In June, 2005 it wasreported that the good control group alsohad a 57 percent reduction in nonfatal heartattacks, strokes and coronary vascular disease.

For people with type 2 diabetes, studies inthe U.K. and Japan showed the risks for eye,kidney and nerve complication were alsoreduced as a result of better sugar control.

Some important factors which affect thecomplications:

4 good blood sugar control: Although thisis one important factor in relation to thesecomplications, IT IS NOT THE ONLYFACTOR

4 blood pressure is important in relation toeye, kidney and heart complications

4 tobacco use adds to the risk for kidney, eyeand heart damage

4 increased blood clotting is also a possiblerisk factor

4 other unknown factors

Some facts about the occurrence of complications:

4 Most of the long-term complications do notoccur in young children.

4 The years of greatest risk for complicationsseem to start after puberty. Research hasshown that in people with diabetes, thesmall blood vessels show no changes beforepuberty, whether good sugar control waspresent or not.

4 After puberty, the blood vessels usuallyremain normal in people with good sugarcontrol, but changes may appear in peoplewith poor sugar control.

4 Around the time of puberty, levels ofgrowth hormone, sex hormones and otherhormones increase greatly. These hormonescause increased blood sugar levels.

4 The risk of complications after puberty mayincrease because of the changes in hormonelevels, because of poor sugar control causedby the changes in hormone levels orpossibly due to both.

We do not know how the high blood sugarlevels cause the complications.

Sugar does attach:

4 to the protein (hemoglobin) in the redblood cells to form hemoglobin A1c orHbA1c (see Chapter 14)

4 to the skin proteins in people who havecurvatures of several fingers (see FingerCurvatures in this chapter)

4 to other proteins in the blood vessels andother parts of the body when the bloodsugar levels are very high

Once the sugar attaches to any bodyprotein, the protein may not work as well aswhen sugar is not attached.

Even though the actual complications arenot usually seen until puberty, it is important towork for good sugar control in the pre-pubertalyears. There are some side effects of poor sugarcontrol that can occur at any time (see Chapter14 on Diabetes and Blood Sugar Control).Also, the habits for the future are formed whenthe person is young.

Chapter 22 Long-Term Complications of Diabetes 237

COMPLICATIONS INPEOPLE WITH DIABETES

We have divided complications into twogroups: Complications related at least in partto blood sugar control and complications notrelated to blood sugar control.

Complications related, at least in part, to bloodsugar control:

1. EYE PROBLEMS

Cataracts

Cataracts are small thickenings in the lens(which is located at the front of the eye; seepicture in this chapter).

l The damage to the lens is believed to becaused by sorbitol, a compound made in thelens from glucose.

l Sorbitol damage occurs when blood glucose(sugar) levels have been very high in thebody for a long time.

l Sorbitol in foods is changed by thebody (liver) and does not cause thisdamage.

l Damage to the lens can happen at any age.

l Cataracts can be present at the onset ofdiabetes if sugar levels have been high fora long time before insulin is started.

l They may show some improvement withgood sugar control.

l These lens changes are not the same as themore severe retinal complications in theback of the eye that are discussed next.

l The eye doctor (ophthalmologist) will do a detailed exam for cataracts in theyearly eye exam.

l If cataracts interfere with vision they canbe removed surgically by the eye doctor.

Retinal Changes or Retinopathy

The word retinopathy refers to changes ofthe retina, which is the layer of tissue at theback of the eye. This part of the eye has manysmall blood vessels similar to those found in thekidney.

A. Retinopathy facts:

Retinopathy is a change in the small bloodvessels found in the back of the eye (retina),which occurs mainly after puberty.

These changes depend on various factors:

t the duration of diabetes after puberty

t the degree of blood sugar control


The DCCT showed that in people withouteye changes from diabetes, lower blood sugarsdelayed development of retinopathy by 76percent. The DCCT also showed that, in peoplewith known early eye changes from diabetes,intensive therapy slowed the progression ofretinopathy by 54 percent and reduced theincidence of severe retinopathy by 47 percent.

t increased blood pressure also results in agreater risk for retinal changes

t tobacco use makes these changes progressmore rapidly

We do not understand all of the causes ofthe eye changes of diabetes. There is a smallgroup of people for whom the presence orabsence of eye changes seems to not show arelation to sugar control.

B. Early detection:

4 is very important and is one clear argumentfor having diabetes check-ups every threemonths.

4 the diabetes care provider doing the physicalexam should be able to detect eye changesand make appropriate referrals to an eyedoctor (ophthalmologist) who specializes indiabetic changes (retinal specialist).

4 The ADA does not suggest seeing an eyedoctor for diabetic reasons before age 10years. We usually wait until the personwith type 1 diabetes has had diabetesthree years and is 10 years old. Howlong someone has had type 2 diabetesbefore diagnosis is often not known. Forthis reason, people with type 2 diabetesshould see the eye doctor soon afterdiagnosis (if 10 years old).

4 Thereafter, if there are no diabetic eyechanges, or if the changes are minor, yearlyvisits to the diabetes eye specialist areadequate.

4 Minor eye changes include a ballooning ofthe small retinal blood vessels; these changesare reversible and are calledmicroaneurysms. Some people can havethese minor changes for many years and notdevelop more severe eye disease. Carefulblood sugar control is particularly importantwhen any changes are detected. If moresevere eye changes occur, then more frequentvisits to the diabetes eye specialist are needed.

C. More severe eye disease:

4 pre-proliferative and proliferativeretinopathy:

l Usually involves formation of new(proliferative) and fragile retinal bloodvessels, which are at a greater risk forbreaking (hemorrhaging).

l The more severe changes are referred forlaser treatment. This involves the use of avery bright light. It was begun in the 1970sas a way to save vision in people withdiabetes who have severe eye changes.

l Laser treatment destroys the fragile(proliferative) new blood vessels and hasbeen very effective in preventing loss ofvision.

l The most important factor is to have closefollow-up once the more severe changesappear. Laser treatment can then be done atthe proper time to prevent loss of vision.

Retina (back of eye)

Lens


l The biggest danger is a hemorrhage. Itcould damage the retina or send blood intothe vitreous fluid between the lens andretina (vitreous hemorrhage) or cause theretina to separate from the other layers inthe back of the eye (retinal detachment).

2. KIDNEY DISEASE OR DIABETICNEPHROPATHY

A. The job of the kidneys in the body:

4 They normally filter wastes and water fromour blood and make urine (Chapter 2).

4 When blood sugar levels are high, sugar ispassed into the urine. When this happens,the pressures are higher in the kidneyfiltering system (the glomerulus) andchanges in the small blood vessels of thekidney can occur. This increased pressurecauses damage to the filtering system so thatsome proteins start leaking through thefilter and appear in the urine.

B. Kidney disease is one of the most feared of thecomplications of diabetes and is spoken of asnephropathy. Nephropathy is more likely tooccur in people:

4 after puberty

4 who have had diabetes for a long time

4 with poor sugar control

4 with elevated blood pressure

4 who smoke or chew tobacco

It occurs in about one in three people withtype 1 (insulin-dependent) diabetes, and inabout one in four people with type 2 (adultonset) diabetes.

C. Signs of kidney disease may include:

t increased blood pressure

t ankle swelling, also known as edema (due tofluid collection)

t excessive urine protein spillage

t elevation of the waste materials in the blood(increased blood creatinine and ureanitrogen or BUN)

D. The Microalbumin Test:

l detects diabetic kidney damage at an earlystage when it might still be reversible

l is usually done on a timed overnight or on a24-hour urine sample

l is essential for people who have had type 1diabetes for three or more years and are atleast 10 years of age

l should be done soon after diagnosis forpeople with type 2 diabetes

l should then be done once yearly so that theinterval is not missed when the earlydamage is still reversible

l is best done by collecting the overnighturine sample (see directions at the end ofthis chapter)

If there is an increased level of microalbumin inthe urine:

t WITH A LEVEL ABOVE 20MICROGRAMS (g) PER MINUTE, ITIS NOW ACCEPTED THAT THERE IS A95 PERCENT RISK FOR DEVELOPINGNEPHROPATHY AND KIDNEYFAILURE IF NOTHING IS DONE.

t A borderline microalbumin level fortimed overnight urine collections is a valuebetween 7.6 g/minute and 20 g/minute.This borderline range represents a timeperiod when good sugar and/or bloodpressure control may help to lower the valueor keep it from going higher.

t Medications are not usually given for aborderline level, as it may still be possibleto return the value to normal by loweringthe HbA1c.

t If the urine microalbumin value is between20 and 200 g/minute, it is calledmicroalbuminuria and may still bereversible with good sugar and bloodpressure control and medications (ACE-inhibitor, see part E).

t Smoking cigarettes and chewing tobacco


lead to a greater risk for kidney damage andmust be avoided by people with diabetes.

t A decrease in protein intake is recommended(to lessen the load on the kidneys) for anyonewho has microalbumin levels above 20g/minute, but particularly for those whohave levels above 300 g/minute(nephropathy or macroalbuminuria).

t The DCCT showed that improved glucosecontrol reduced the occurrence ofmicroalbuminuria by 39 percent. Grosskidney damage (nephropathy oralbuminuria) was reduced by 54 percent. Itmust once again be remembered thatglucose control is NOT the only cause ofdiabetic kidney damage.

E. The 1980s and the 1990s have broughtsignificant advances in the prevention, detectionand treatment of diabetic kidney damage.

4 It is up to the family and the physician tomake sure that the urine tests to detectkidney changes are done at therecommended times.

4 If the family is unable to collect anovernight urine as described in the back ofthis chapter, bringing in a portion of thefirst morning void is second best. Thisprovides a urine sample from when theperson slept and it can be analyzed per mgof creatinine. It avoids the 10-15 percentfalse positives (due to orthostaticproteinuria) that occur with the lastresort, collecting a random sample in theclinic.

4 If the tests are not done, the windowduring which changes may be reversiblecould be missed.

4 If the microalbumin levels are high on theovernight or 24-hour urine test, medicinesmay be effective in reversing or slowing thekidney damage.

l The usual medicine that is tried first is anACE-inhibitor (ACE = Angiotensin-Converting Enzyme). This medication

prevents formation of angiotensin II, whichis a very potent constrictor of blood vessels.The result is less pressure buildup in thekidneys. There are several varieties of ACE-inhibitors, all of which are probably effectiveif given in adequate dosage.

l Early kidney damage is detectable andmethods to reverse or slow down kidneydamage are available. This has now resultedin a decline in the incidence of renal kidneyfailure from diabetes.

3. NEUROPATHY (NERVE DAMAGE)

Diabetic neuropathy, or damage to thenerves, is a condition seen after puberty,usually in people who have had very high sugarlevels for a long time.

About neuropathy:

4 It is a complex condition that we still do notcompletely understand.

4 The DCCT found that the incidence ofneuropathy was 60 percent less in the groupwith the lower blood sugar levels.

4 As with cataracts, neuropathy is believed tobe related, at least in part, to increasedsorbitol levels deposited in the nerves. Thesorbitol is made from sugar.

4 There is also a decrease in anothercompound (myoinositol) which is importantfor the nerves.

4 Some people with type 2 diabetes haveneuropathy when they are diagnosed withdiabetes.

The neuropathy usually makes itself known with:

t numbness, tingling, sharp pains in the lowerlegs or feet

t changes in other parts of the body: e.g., therate at which food moves through theintestines may change (gastroparesis)

Much research is being done to find newand better medications for the treatment ofneuropathy.


4. CORONARY (HEART) AND OTHERBLOOD VESSELS

The larger blood vessels are in contrast tothe very small (sometimes microscopic) onesfound in our eyes and kidneys. The larger onesinclude the heart blood vessels that provideblood (and thus nutrition and oxygen) to ourheart. When a heart blood vessel is blocked, aheart attack can result. Approximately 65percent of deaths for people with diabetes aredue to heart attacks. Heart attacks have manycauses, but high risk factors include:

4 poor glycemic (sugar) control4 increased blood pressure4 family history of relatives who had heart

attacks before age 504 smoking4 elevated LDL (low-density lipoprotein)

cholesterol, reduced HDL (high-densitylipoprotein), which is the goodcholesterol

4 elevated total blood cholesterol levels

Some causes of high cholesterol levels:

t Until a few years ago, diets that contained40 percent of calories from fat wereroutinely recommended. Most dietitiansnow recommend that no more than 30percent of calories be from fat sources (seeChapters 11 and 12).

t Heredity and poor sugar control also can becauses of high cholesterol levels.

Recommendations:

l Blood cholesterol levels should be checkedeach year. Desired levels are given in Table2 of Chapter 11.

l Medications (the statins) that block ourbodys cholesterol synthesis are available forpeople who have very high cholesterol orLDL levels. The statins have been shown todecrease the risk for heart attacks.

l The blood pressure should be checked atregular clinic visits. Increases in bloodpressure should be treated early.

l People with diabetes should not use tobacco!

5. JOINT CONTRACTURES

Some facts:

4 Some people cannot touch the knuckles ofthe second joint in their fifth fingers (littlefingers) when their hands are in a prayingposition.

4 The joints of the other fingers or otherjoints in the body can also be involved.

4 When other joints or fingers other than justthe fifth finger are involved, there hasusually been a period of very high sugarlevels and sugar has attached to the proteinsin the skin over the joints.

4 No pain or other problems are usuallyrelated to these changes.

4 Some doctors believe the curvatures of thefifth fingers may be partly inherited.

4 Parents and siblings of people with diabetesoften have curvatures of the fifth fingerseven though they dont have diabetes.

4 It is not yet known if the more severecurvatures will disappear as blood sugarcontrol improves.

6. BIRTH DEFECTS (discussed in moredetail in Chapter 27)

This complication is primarily important toa woman who might get pregnant.

Some facts:

4 IT IS VERY IMPORTANT TO TALK TOYOUR DIABETES PHYSICIAN BEFOREGETTING PREGNANT.

4 Insulin pumps and intensive diabetesmanagement must be considered PRIORTO THE PREGNANCY.

4 If diabetes is not well controlled (e.g., highHbA1c), a pregnant woman with diabetes ismore likely to have a baby with one or morebirth problems or defects.

4 The first few months of pregnancy are themost important in preventing defects.


4 A woman should not stop using birthcontrol or decide to get pregnant until herdiabetes is well controlled.

4 If the HbA1c, blood pressure and kidney testsare normal or low prior to the pregnancy, thelikelihood of kidney deterioration duringpregnancy is minimized.

4 Diabetic eye changes do sometimes worsenduring pregnancy and it is wise to befollowed more closely by ones retinalspecialist during this time.

7. FOOT PROBLEMS

Some facts:

4 Foot problems due to poor or decreasedblood flow and neuropathy do not occur inchildren. Some families who are educatedby diabetes care providers who care mainlyfor adults with diabetes will be told thatchildren must wash their feet daily ornever go barefoot. Although it is nice tohave clean feet for clinic visits, theseprecautions are NOT necessary for children.

4 Foot problems usually occur in older adultsand may be related to poor circulation or toneuropathy.

4 There is research suggesting that regularexercise may help to maintain normal footcirculation later in life (see Chapter 13).

4 It is important for diabetes care providers todo careful examinations of feet in post-pubertal patients.

4 It is also important for a person to know tocall the doctor if a foot sore does not healwell or if there is any sign of an infection(redness, warmth or pus) or ulcer.

4 Ingrown toenails (an infection) occurwith similar frequency in childrenwith or without diabetes.

4 The ingrowntoenails are usuallycaused by toenailsthat are cut too short at the corners.

4 The toenails should be cut straight acrosswith a straight nail clipper and the lengthshould be even with the end of the toe.Good prevention is much easier thantreatment.

4 Ingrown toenails are more of a problem inpeople with diabetes as infections cause highsugar levels. The high sugar levels, in turn,support the infection.

4 Warts are not more common in people withdiabetes. The best way to remove them iswith the use of liquid nitrogen.


COMPLICATIONS NOTPRIMARILY RELATED TOSUGAR CONTROLOther Autoimmune (self-allergy) DiseasesAssociated with Type 1 Diabetes

Thyroid Disorders

Some facts:

4 Some thyroid enlargement occurs in abouthalf of people with type 1 diabetes,although only about one in 20 ever needstreatment. The reason for this is believed tobe a similar self-allergy (autoimmune)type of reaction that causes both diabetesand the related thyroid enlargement.

4 People who get diabetes often have anantibody (allergic reaction) in their bloodagainst their pancreas (specifically, the isletcells in the pancreas as discussed in Chapter3). Likewise, people with diabetes who getthyroid problems usually have an antibody(allergic reaction) in their blood against thethyroid gland.

4 Thyroid antibody tests can be done, but areusually not done as they are expensive andare often not paid for by insurance.

4 It is important for the diabetes care providerto always check the size of the thyroid glandat the time of clinic visits.

4 If the thyroid is not functioning normally,body growth may be slowed.

4 The person may feel tired all the time.

4 If the gland is enlarged, specialized bloodtests should be done (particularly a TSHtest, as this is almost always the first test tobecome abnormal). If thyroid problems aresuspected, a TSH ( free T4) test should bedone.

4 If the thyroid tests are abnormal, a thyroidtablet can then be taken once daily. Thyroidproblems are not serious unlessunrecognized or untreated. The treatmentis excellent, easy, inexpensive and involvestaking pills (not shots).

4 Sometimes the tablets can be discontinued(under a doctors supervision) when theperson is finished growing.

4 Thyroid problems are common even inpeople who do not have diabetes (aboutone in 50 adults).

Adrenal Disorders (autoimmune adrenalinsufficiency, Addisons Disease)

Some facts:

4 Autoimmunity against the adrenal gland canalso occur.

4 It is quite rare (about one in 500 peoplewith type 1 diabetes), but it is important todiagnose and treat, as it can result in deathif untreated. President Kennedy is anexample of a famous person who hadautoimmune adrenal insufficiency.

Some early signs for someone with diabetes maybe:

l an increased frequency of severe low bloodsugars

l episodes of feeling weak or faint (withnormal blood sugars - but sometimes lowblood pressure)

l two electrolytes in the blood, sodium (Na+)and potassium (K+), may be low and high,respectively

l later, darker skin coloring over the back ofthe hands (or knuckles or elbows) mayoccur

4 Initial screening may be for an antibodyagainst the adrenal gland.

4 Eventually, a morning ACTH andcortisol (cortisone) blood levels ( anACTH stimulation test) should beobtained.

4 The treatment (as with thyroid disease)is with tablets. Treatment includestraining the person (or family) toincrease the tablets during periods ofstress (as with an infection or withsurgery).


Celiac Disease

Some facts:

4 Celiac disease (Sprue, Gluten-enteropathy)is carried on one of the genes (DR types,DR3) that is also related to being at highrisk for type 1 diabetes (see Chapter 3).

4 Approximately one in 20 people withdiabetes also has celiac disease.

4 As other family members who do not havediabetes may also have the DR3 genetictype, they are also more likely to have celiacdisease (even though they do not havediabetes).

4 Celiac disease is an allergy to the protein,gluten.

4 It can be diagnosed using a blood antibodytest (transglutaminase and/or anti-endomysial antibodies). At present, anintestinal biopsy is usually also done toconfirm the diagnosis.

4 Some people with celiac disease havesymptoms, whereas others may not have anysymptoms at all.

Symptoms may include:

l stomach pain

l gas

l diarrhea

l in children, decreased height or weight gain

t The symptoms, the abnormal bloodtests and the intestinal biopsy changesmay return to normal within a fewmonths after treatment is begun.

t The treatment involves:

l removing all wheat, rye and barley productsfrom the diet (rice, corn, oat products, andall foods except those containing gluten canstill be eaten)

l working with a dietitian to learn whichfoods contain the protein, gluten

4 Adults who have no symptoms may notwish to restrict all gluten from their diet.The main argument for doing so is thatin a few case reports of adults dying witha cancer (lymphoma) of the intestine,celiac disease has been found present(and a possible causative factor).

Table 1Ingredient Content Guideline for Celiac Disease

Acceptable Use with Caution Not Acceptable

Corn Oats White flourRice Flax Wheat, whole wheatSoy and other beans RyeTapioca BarleyPotato DurumHominy SemolinaAmaranth SpeltBuckwheat KamutMillet TriticaleQuinoa GrahamTeff Bulgar

BranWheat germ


There is a series of cookbooks called TheGluten Free Gourmet, which can be orderedfrom any of the on-line bookstores such asAmazon.com and there are also several goodbread mixes now. It is easier if the entire familyeats as gluten free as possible. In the U.S.,products are available in most health foodstores. The following are some other placesyou can shop/links:

www.glutenfree.com

www.glutenfreemall.com

www.causeyourespecial.com/index_nn4.html(please note the underscore)

www.celiac.com

www.celiacdisease.com

There is much that we still do not knowabout this disease. Some people may have asecondary deficiency of vitamin B12. Thisdeficiency can cause symptoms similar to thoseof neuropathy or multiple sclerosis (MS).

Skin Problems

Some facts:

4 Yellow fatty deposits (necrobiosis) cancollect in the skin over the front of thelower legs. No one knows what causesthese fat deposits.

4 A rare condition called dermatitisherpetiformis is also related to a sensitivityto the protein, gluten (see celiac disease). Itis characterized by blisters on the elbows,buttocks and knees. Like celiac disease, itresponds to a gluten-free diet.

Sexual Function

4 Some males with diabetes have problemswith penile erections. The cause of thisproblem is unknown. The medicine Viagra

may be helpful to some men with diabeteswho have this problem.

4 There is no evidence that women withdiabetes have problems with sexualityrelated to diabetes.

SUMMARYIn summary, much is now known about the

long-term complications of diabetes. Recentresearch suggests that good sugar control,normal blood pressure and not using tobaccocan help prevent many of the complications.

DEFINITIONSAdrenal gland: A hormone-producing glandlocated above each kidney, which has thefunction of making cortisone, salt-retaininghormones and other hormones.

Autoimmunity (self-allergy): As defined inChapter 3, this involves forming an allergicreaction against ones own tissues. This happensin type 1 diabetes and can happen in thyroiddisorders and, more rarely, with the adrenalgland.

Blood pressure: The blood pressure consistsof a higher (systolic) pressure that reflects thepumping or working pressure of the heart and alower (diastolic) pressure which reflects theresting pressure of the heart between beats. Itis important to have the blood pressure checkedregularly.

Blood Urea Nitrogen (BUN): A material inthe blood normally cleared by the kidneys. It iselevated in advanced kidney disease as well aswith dehydration.

Cataract: A density (clouding) in the lens thatmay cause spots, blurred or reduced vision.

Celiac disease (Sprue, Gluten-enteropathy):An allergy to the protein, gluten.

Creatinine: A material in the blood normallycleared by the kidneys. The test to measure itsclearance from the blood is called a creatinineclearance test.

DCCT: Diabetes Control and ComplicationsTrial. A very large trial of people ages 13-39years old, which showed that lower HbA1cvalues resulted in a lower risk for diabetic eye,kidney, nerve and heart problems. The trialended in June, 1993.


Edema: Collection of fluid (swelling) underthe skin.

Filter: To separate out or remove. Thekidneys filter wastes from our blood.

Gastroparesis: Neuropathy involving thestomach and/or intestine.

Glomerulus: Small groups of blood vessels inthe kidneys that filter the blood to removewastes and water to make urine.

Gluten: The protein found in wheat thatpeople are allergic to if they have celiac disease.

Hemorrhage: The breaking of a blood vessel.In the eye, this can occur in the retinal layer or,in more advanced cases, in the fluid (vitreous)in front of the retina (vitreous hemorrhage).

Laser treatment: Using a very bright beam oflight to destroy the new (proliferative) bloodvessels in the retina, which are at high risk forhemorrhaging and causing a loss of vision.

Lens (see picture of eye in this chapter): The oval structure in the front of the eye thatchanges shape to allow the eye to focus on nearor distant objects.

Microalbumin: A test that can measure smallamounts of a protein (albumin) in the urine todetect kidney damage from diabetes at a stagein which it might still be reversible.

Microaneurysm: A small dilatation (ballooning)of a blood vessel, which is a minor change thatcan be reversible. It is caused by diabetes.

Myoinositol: A compound, which is reducedin nerves when sorbitol levels are elevated (inneuropathy).

Necrobiosis: The name for yellow fattydeposits that can occur over the lower legs inpeople with diabetes.

Nephropathy: A generic name for kidneydisease. It is usually used to indicate a moreadvanced stage of kidney involvement.

Neuropathy: A disease of the nerves. This isbelieved to happen in people with diabetes dueto accumulation of sorbitol (formed from bloodglucose), or possibly due to deficiency ofanother metabolite, myoinositol.

Ophthalmologist: The name for a doctor(MD) who specializes in eye diseases. Theophthalmologist may further specialize in theretinal layer in the back of the eye, which isaffected by diabetes. The doctor is then called aretinal specialist.

Optometrist: A person who is primarilytrained to check for the need for glasses. Anoptometrist is not an MD (although they arestill important care providers).

Podiatrist: A person who is specially trained inthe care of the feet. They are not MDs(although they are still important careproviders).

Pre-proliferative or proliferative retinopathy:Terms for more advanced stages of eyeinvolvement from diabetes (when a diabetes eyespecialist needs to be seen more frequently).

Puberty: The time in a teens life when adultsexual changes start to occur.

Retina (see picture of eye in this chapter): The layers of small blood vessels and nerves in theback of the eye that are very important for vision.

Retinal detachment: Separation of the retinallayer in the back of the eye from other layers inthe eye.

Retinopathy: Changes in the retinal (smallblood vessel) layer in the back of the eye fromdiabetes. These are more likely to occur afterpuberty in people who have had diabetes for along time and who have been in poor sugarcontrol.

Sorbitol: A compound derived from glucose,which collects in the lens and nerves whenblood sugars are high and is believed to causecataracts and neuropathy.

Thyroid: A hormone-producing gland in thelower front of the neck on each side of thewindpipe (trachea). The hormone is calledthyroid hormone.

Vitreous fluid: The fluid between the lens andthe retina. When retinal blood vessels break,they can bleed into the vitreous fluid (vitreoushemorrhage).


QUESTIONS AND ANSWERSFROM NEWSNOTES

What is the best way to screen forearly microvascular (small vessel)disease of the kidneys and the eyes

in people with diabetes and when should itbe done?

The microalbumin urine test is thebest way to currently diagnose earlykidney involvement in people with

diabetes. The test is best done by measuringthe microalbumin in a timed overnight urinecollections. It is very important to repeat thetwo overnight urine collections every year. If aperson has begun pubertal changes (usuallyages 11-13 years) and has had diabetes for atleast three years, we recommend doing the twoovernight urine collections for microalbuminand having an eye exam by an ophthalmologistonce yearly. Directions for the urine collectionsare in the back of this chapter.

Why is it necessary to reduce myprotein intake as I lose protein inmy urine? Shouldnt I eat more

protein?

The protein (albumin, microalbumin)loss in the urine is most likely due tokidney damage from diabetes. This is

a result of HbA1c levels being too high, theblood pressure being too high (hypertension)or as a result of using tobacco. There areprobably other causes as well that we do not yetunderstand. When someone gets kidneydamage from any cause (diabetes, hypertension,nephritis, lupus, etc.), it generally helps to slowdown the process by eating less protein. Theprotein seems to be an extra load for the kidneyto handle, and reducing the protein will makeless work for the damaged kidneys. It is wise tomeet with the dietitian at this stage to discusswhat the correct amount of protein should be.

What level of glucose control isnecessary to prevent the eye andkidney complications of diabetes?

A study reported in the Journal of theAmerican Medical Association in 1989correlated longitudinal HbA1c values

with complications and showed that blood sugarcontrol (HbA1c levels) were definitely related tothe eye and kidney complications. No person whohad kept their HbA1c levels below 6.8 percent forthe DCA 2000 method (normal to 6.2 percent)had evidence of eye changes. Likewise, no personwho had kept their HbA1c below 7.4 percent hadkidney changes, and only two of 230 had seriouseye changes. This is in contrast to people who hada mean HbA1c above 9.3 percent, where 41percent of the people had more severe eye changesand 28 percent had evidence of kidney damage.

The extra effort to stay in good blood sugarcontrol may indeed save much work later in lifein dealing with diabetes complications, such aseye and kidney.

Is cigarette smoking bad forsomeone with diabetes?

Yes. It is linked to lung cancer, highblood pressure and heart attacks inALL people and is thus a poor choice

for everyone. In addition, data from ourCenter has shown that smoking results in abouta three-fold greater likelihood of diabetickidney complications. Smoking also causesdiabetic eye disease to progress more rapidly.The mechanism by which smoking does this isunknown, but as people who chew tobaccoseem to have the same consequences, it may befrom the absorption of nicotine into the body.HbA1c levels are often high in smokers withdiabetes. Therefore, these effects had to beremoved before a conclusion about smokingcould be reached. Smoking results in higherHbA1c levels by increasing levels of otherhormones, such as adrenaline, which raise theblood sugar. The heart rate and blood pressurealso increase and this may be related to theincreased eye and kidney problems.

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Our son has been chewing tobacco.Is this really bad? Should we bebothered by it or just be glad he is

not smoking cigarettes?

The use of smokeless tobacco isincreasing in teenagers and should beactively discouraged. One study of

Denver high school students (mean age = 16years) showed that more than 10 percent usedsmokeless tobacco.

The tobacco contains dangerouscomponents that could be cancer-causing. Inaddition to the increased risk for cancer of themouth, the nicotine is absorbed from thetobacco and can cause any of the following:stimulation, increased muscle tone, aggression,increase in heart rate and blood pressure,dizziness, nausea and shakiness of theextremities. The latter three symptoms maybe confused with the symptoms of lowblood sugar. Reduced taste is common andincreased use of salt (and sugar) often occurs.Dentists note that users typically havediscolored teeth, receding gums, periodontaldestruction and excessive wear of the teeth dueto abrasives in the tobacco. Withdrawalsymptoms of irritability and decreased cognitivefunctions are frequently found between doses.

Fortunately, the Comprehensive SmokelessTobacco Health Education Act, which bans radioand TV advertisements, was signed into lawduring the Reagan Administration. As a result,famous sports and movie stars are no longer seenpromoting chewing tobacco on TV. Needless tosay, it is well worthwhile for responsible people(including parents) to take a strong stand againstchewing (or smoking) tobacco!

Are thyroid problems morecommon in children with diabetes,and if so, why?

Yes, thyroid problems are morecommon in children with diabetes.They are caused by an autoimmune

or allergic-type reaction that is very similar to

the allergic-type reaction that is believed to beimportant in causing diabetes. Thus, mostpeople with new-onset diabetes have islet cellantibodies (an allergic reaction against the isletcells that make the insulin) at the time ofdiagnosis of type 1 (but not type 2) diabetes.Likewise, the people with diabetes who developthyroid problems have an antibody in theirblood against the thyroid gland. Both thepancreas and the thyroid are endocrine glandsthat make the hormones insulin and thyroidhormone, respectively. Thus, the two glandshave much in common. Some physiciansrecommend thyroid blood tests yearly inchildren with diabetes. The practice in ourClinic is to do the tests if the thyroid gland islarge or if there is a special indication, such as afall-off in height. Fortunately, when lowthyroid function is detected, it can be treatedwith a tablet. Also, the pills can sometimes bediscontinued after growth is complete.

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How common is kidney disease inassociation with diabetes, and can itbe prevented?

Kidney problems occur in up to 30percent of people with type 1 diabetes,usually when the person reaches their

30s or 40s. There are things that we can donow to help reduce the likelihood of kidneyproblems. These include: good sugar control,keeping the blood pressure normal, prompttreatment of bladder and kidney infections andnot smoking. It is very important to get theurine microalbumins checked yearly for peoplewho have had type 1 diabetes for three or moreyears who have reached puberty.

Are contact lenses OK for a personwith diabetes to use?

Yes, people with diabetes can wearcontact lenses, but there are someextra precautions. The contact lensfits over the superficial layer of the eye

called the cornea. The cornea needs a constantsupply of oxygen and tears to keep it healthy.Thus, the contact lens must fit properly so thatthe cornea is not injured and the tears are ableto continue to flow. A qualified (experienced)eye doctor should fit the lenses - probably in acontact lens clinic.

It is even more important for people withdiabetes to follow the instructions for care andcleaning of the contact lenses than it is for otherpeople. The corneas of people with diabetes aresometimes less sensitive to pain or irritation, sopeople may be less likely to feel discomfortwhen their contacts are causing problems.Infections may also not clear as quickly if theydo occur. Thus, use the solutions anddisinfectants exactly as your eye doctorrecommends. Dont get lazy in cleaning or tryto cut corners. Dont leave the contacts in anylonger than recommended. Dont mix cleaningsolutions. Finally, it is probably better not toget the extended wear lenses.

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MICROALBUMINSDoctor: ____________________________________ Your Name: _____________________________________

A. INSTRUCTIONS FOR DOING THE OVERNIGHT URINE COLLECTIONS

COLLECTION #1 DATE: _______________________________

1. Empty your bladder at bedtime and discard this sample. TIME: _______________________________

2. Save EVERY DROP of urine during the night.

3. Save EVERY DROP of the first morning sample. TIME: _______________________________ALL urine from collection #1 should be placed in the same container.

4. Measure the volume of the urine sample. TOTAL VOLUME: ___________________

COLLECTION #2 DATE: _______________________________

1. Empty your bladder at bedtime and discard this sample. TIME: _______________________________

2. Save EVERY DROP of urine during the night.

3. Save EVERY DROP of the first morning sample. TIME: _______________________________ALL urine from collection #2 should be placed in the same container.

4. Measure the volume of the urine sample. TOTAL VOLUME: ___________________

B. IMPORTANT INFORMATION ABOUT YOURCOLLECTIONS

1. Label each container with your name and #1 or #2.

2. You may use any CLEAN container you have at homethat will not leak to collect the sample. We do notprovide containers.

3. Store urine aliquots in refrigerator until your visit(samples are good for one week if kept cold).

4. DO NOT mix collections #1 and #2 together in the samecontainer.

5. DO NOT drink caffeinated or alcoholic beverages or usetobacco after 10 p.m. the evening of the collections.

6. DO NOT exercise strenuously for the four hours prior tobedtime.

7. DO NOT collect specimens during a menstrual period.

8. Failure to follow directions exactly may cause incorrectresults.

9. If you have any questions, please call your healthcareprovider.

C. DIRECTIONS FOR MEASURINGTHE VOLUME

1. Have a measuring cup or (better) acylinder - preferably marked in cc (ml).One cup is 240cc. Urine is sterile andit is ok to use cooking measuring cups(just wash prior to next use forcooking).

2. Measure the total cc of each overnightsample and put the amounts in theblanks for step 4 for collections #1 and#2.

3. Put a sample of each urine collectionin a clean tube. The rest may bediscarded. Any clean red top tubefrom a doctors office, clinic orhospital lab will work. Label whichsample (#1 or #2) it is, put your nameon the tube, and put the tube in a cupin the refrigerator until you get toyour clinic. Bring this sheet with thetimes and total volumes with you.

pink panther - diabetes management - chapter 22

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