ALL ABOUT DIABETES

By M H Ahssan

What is diabetes? What causes diabetes?

Diabetes (diabetes mellitus) is classed as a metabolism disorder. Metabolism refers to the way our bodies use digested food for energy and growth. Most of what we eat is broken down into glucose. Glucose is a form of sugar in the blood - it is the principal source of fuel for our bodies.


When our food is digested the glucose makes its way into our bloodstream. Our cells use the glucose for energy and growth. However, glucose cannot enter our cells without insulin being present - insulin makes it possible for our cells to take in the glucose.


Insulin is a hormone that is produced by the pancreas. After eating, the pancreas automatically releases an adequate quantity of insulin to move the glucose present in our blood into the cells, and lowers the blood sugar level.


A person with diabetes has a condition in which the quantity of glucose in the blood is too elevated (hyperglycemia). This is because the body either does not produce enough insulin, produces no insulin, or has cells that do not respond properly to the insulin the pancreas produces. This results in too much glucose building up in the blood. This excess blood glucose eventually passes out of the body in urine. So, even though the blood has plenty of glucose, the cells are not getting it for their essential energy and growth requirements.

Why is it called Diabetes Mellitus?

Diabetes comes from Greek, and it means a siphon. Aretus the Cappadocian, a Greek physician during the second century A.D., named the condition diabainein. He described patients who were passing too much water (polyuria) - like a siphon. The word became "diabetes" from the English adoption of the Medieval Latin diabetes.


In 1675 Thomas Willis added mellitus to the term, although it is commonly referred to simply as diabetes. Mel in Latin means honey; the urine and blood of people with diabetes has excess glucose, and glucose is sweet like honey. Diabetes mellitus could literally mean "siphoning off sweet water".


In ancient China people observed that ants would be attracted to some people's urine, because it was sweet. The term "Sweet Urine Disease" was coined.

There are three main types of diabetes:

Diabetes Type 1 - You produce no insulin at all.
Diabetes Type 2 - You don't produce enough insulin, or your insulin is not working properly.
Gestational Diabetes - You develop diabetes just during your pregnancy.

Diabetes Types 1 & 2 are chronic medical conditions - this means that they are persistent and perpetual. Gestational Diabetes usually resolves itself after the birth of the child.

Treatment is effective and important

All types of diabetes are treatable, but Type 1 and Type 2 diabetes last a lifetime; there is no known cure. The patient receives regular insulin, which became medically available in 1921. The treatment for a patient with Type 1 is mainly injected insulin, plus some dietary and exercise adherence.

Patients with Type 2 are usually treated with tablets, exercise and a special diet, but sometimes insulin injections are also required.

If diabetes is not adequately controlled the patient has a significantly higher risk of developing complications, such as hypoglycemia, ketoacidosis, and nonketotic hypersosmolar coma. Longer term complications could be cardiovascular disease, retinal damage, chronic kidney failure, nerve damage, poor healing of wounds, gangrene on the feet which may lead to amputation, and erectile dysfunction.

Symptoms of Diabetes

People can often have diabetes and be completely unaware. The main reason for this is that the symptoms, when seen on their own, seem harmless. However, the earlier diabetes is diagnosed the greater the chances are that serious complications, which can result from having diabetes, can be avoided.

Here is a list of the most common diabetes symptoms:

• Frequent urination
  Have you been going to the bathroom to urinate more often recently? Do you notice that you spend most of the day going to the toilet? When there is too much glucose (sugar) in your blood you will urinate more often. If your insulin is ineffective, or not there at all, your kidneys cannot filter the glucose back into the blood. The kidneys will take water from your blood in order to dilute the glucose - which in turn fills up your bladder.
• Disproportionate thirst
  If you are urinating more than usual, you will need to replace that lost liquid. You will be drinking more than usual. Have you been drinking more than usual lately?
• Intense hunger
  As the insulin in your blood is not working properly, or is not there at all, and your cells are not getting their energy, your body may react by trying to find more energy - food. You will become hungry.
• Weight gain
  This might be the result of the above symptom (intense hunger).
• Unusual weight loss
  This is more common among people with Diabetes Type 1. As your body is not making insulin it will seek out another energy source (the cells aren't getting glucose). Muscle tissue and fat will be broken down for energy. As Type 1 is of a more sudden onset and Type 2 is much more gradual, weight loss is more noticeable with Type 1.
• Increased fatigue
  If your insulin is not working properly, or is not there at all, glucose will not be entering your cells and providing them with energy. This will make you feel tired and listless.
• Irritability
  Irritability can be due to your lack of energy.
• Blurred vision
  This can be caused by tissue being pulled from your eye lenses. This affects your eyes' ability to focus. With proper treatment this can be treated. There are severe cases where blindness or prolonged vision problems can occur.
• Cuts and bruises don't heal properly or quickly
  Do you find cuts and bruises take a much longer time than usual to heal? When there is more sugar (glucose) in your body, its ability to heal can be undermined.
• More skin and/or yeast infections
  When there is more sugar in your body, its ability to recover from infections is affected. Women with diabetes find it especially difficult to recover from bladder and vaginal infections.
• Itchy skin
  A feeling of itchiness on your skin is sometimes a symptom of diabetes.
• Gums are red and/or swollen - Gums pull away from teeth
  If your gums are tender, red and/or swollen this could be a sign of diabetes. Your teeth could become loose as the gums pull away from them.
• Frequent gum disease/infection
  As well as the previous gum symptoms, you may experience more frequent gum disease and/or gum infections.
• Sexual dysfunction among men
  If you are over 50 and experience frequent or constant sexual dysfunction (erectile dysfunction), it could be a symptom of diabetes.
• Numbness or tingling, especially in your feet and hands
  If there is too much sugar in your body your nerves could become damaged, as could the tiny blood vessels that feed those nerves. You may experience tingling and/or numbness in your hands and feet.

Diagnosis of diabetes

Diabetes can often be detected by carrying out a urine test, which finds out whether excess glucose is present. This is normally backed up by a blood test, which measures blood glucose levels and can confirm if the cause of your symptoms is diabetes.

If you are worried that you may have some of the above symptoms, you are recommended to talk to your Doctor or a qualified health professional.

What is insulin?

Insulin is a hormone. It makes our body's cells absorb glucose from the blood. The glucose is stored in the liver and muscle as glycogen and stops the body from using fat as a source of energy.

When there is very little insulin in the blood, or none at all, glucose is not taken up by most body cells. When this happens our body uses fat as a source of energy. Insulin is also a control signal to other body systems, such as amino acid uptake by body cells. Insulin is not identical in all animals - their levels of strength vary.

Porcine insulin, insulin from a pig, is the most similar to human insulin. Humans can receive animal insulin. However, genetic engineering has allowed us to synthetically produce 'human' insulin.

The Pancreas

The pancreas is part of the digestive system. It is located high up in your abdomen and lies across your body where the ribs meet at the bottom. It is shaped like a leaf and is about six inches long. The wide end is called the head while the narrower end is called the tail, the mid-part is called the body.

The pancreas has two principal functions:

1. It produces pancreatic digestive juices.
2. It produces insulin and other digestive hormones.

The endocrine pancreas is the part of the pancreas that produces insulin and other hormones.

The exocrine pancreas is the part of the pancreas that produces digestive juices.

Insulin is produced in the pancreas. When protein is ingested insulin is released.

Insulin is also released when glucose is present in the blood. After eating carbohydrates, blood glucose levels rise.

Insulin makes it possible for glucose to enter our body's cells - without glucose in our cells they would not be able to function. Without insulin the glucose cannot enter our cells.

Within the pancreas, the Islets of Langerhans contain Beta cells, which synthesize (make) the insulin. Approximately 1 to 3 million Islets of Langerhans make up the endocrine part of the pancreas (mainly the exocrine gland), representing just one fiftieth of the pancreas' total mass.

Etymology (history) of the word pancreas

It is said that the pancreas was described first by Herophilus of Chalcedon in about 300B.C. and the organ was named by Rufus of Ephesus in about 100A.D

However, it is an established fact that the word pancreas had been used by Aristotle (384-322B.C.) before Herophilus.

In Aristotle's Historia Animalium, there is a line saying "another to the so-called pancreas". It is considered that the words "so-called pancreas" imply that the word pancreas had been popular at the time of Aristotle, but it had not been authorized yet as an anatomical term.

However, the word pancreas presumably has been accepted as an anatomical term since Herophilus.

The word pancreas comes from the Greek pankreas, meaning sweetbread.

Type 1 diabetes

Type 1 diabetes is an autoimmune disease - the person's body has destroyed his/her own insulin-producing beta cells in the pancreas.

People with Diabetes Type 1 are unable to produce insulin. Most patients with Diabetes Type 1 developed the condition before the age of 40. Approximately 15% of all people with diabetes have Type 1.

Type 1 diabetes is fatal unless the patient regularly takes exogenous insulin. Some patients have had their beta cells replaced through a pancreas transplant and have managed to produce their own insulin again.

Type 1 diabetes is also known as juvenile diabetes or childhood diabetes. Although a large number of diabetes Type 1 patients become so during childhood, it can also develop after the age of 18. Developing Type 1 after the age of 40 is extremely rare.

Type 1, unlike Type 2, is not preventable. The majority of people who develop Type 1 are of normal weight and are otherwise healthy during onset. Exercise and diet cannot reverse Type 1. Quite simply, the person has lost his/her insulin-producing beta cells. Several clinical trials have attempted to find ways of preventing or slowing down the progress of Type 1, but so far with no proven success.

A C-peptide assay is a lab test that can tell whether somebody has Type 1 or Type 2. As external insulin has no C-peptide a lack of it would indicate Type 1. The test is only effective when ALL the endogenous insulin has left the body - this can take several months.

Diet for a person with type 1

A person with Type one will have to watch what he/she eats. Foods that are low in fat, salt and have no or very little added sugar are ideal. He/she should consume foods that have complex carbohydrates, rather than fast carbohydrates, as well as fruits and vegetables. A diet that controls the person's blood sugar level as well as his/her blood pressure and cholesterol levels will help achieve the best possible health. Portion size is also important in order to maintain a healthy bodyweight.

Meal planning needs to be consistent so that the food and insulin can work together to control blood glucose levels. According to the Mayo Clinic there is no 'diabetes diet'.

The Clinic says you do not need to restrict yourself to boring bland foods. Rather you should, as mentioned above, consume plenty of fruits, vegetables and whole grains - foods that are highly nutritious, low in fat, and low in calories. Even sugary foods are acceptable now and again if you include them in your food plan.

If you have Type 1 you should seek the help of a registered dietitian. A dietitian can help you create a food plan that suits you. Most dietitians agree that you should aim to consume the same quantity of food, with equal portions of carbs, proteins and fats at the same time each day.

Complications - the bad news and the good news

A person with Type 1 has a two to four times higher risk of developing heart disease, stroke, high blood pressure, blindness, kidney failure, gum disease and nerve damage, compared to a person who does not have any type of diabetes.

A person with Type 1 is more likely to have poor blood circulation through his/her legs and feet. If left untreated the problem may become such that a foot has to be amputated. A person with Type 1 will likely go into a coma if untreated.

The good news is that treatment is available and it is effective and can help prevent these complications from happening.

How to help prevent complications

Keep your blood pressure under 130/85 mm Hg.
Keep your cholesterol level below 200 mg.
Check your feet every day for signs of infection.
Get your eyes checked once a year.
Get your dentist to check your teeth and gums twice a year.

Physical activity helps regulate blood sugar levels

Before starting exercise make sure your doctor tells you it is OK. Try to make physical activity part of your daily life. You should try to do at least 30 minutes of exercise or physical activity each day. Physical activity or exercise means aerobic exercise.

If you have not done any exercise for a while, start gently and build up gradually. Physical activity helps lower your blood sugar. Remember that exercise is good for everybody, not just people with Type 1.

The benefits are enormous for your physical and mental health. You will become stronger, fitter, your sleep will improve as will your skin tone - and after some time you will look great!
Exercise will help your circulation - helping to make sure your lower legs and feet are healthy.

Remember to check your blood sugar level more frequently during your first few weeks of exercise so that you may adapt your meal plans and/or insulin doses accordingly. Remember that a person with Type 1 has to manually adjust his/her insulin doses - the body will not respond automatically.

Type 2 diabetes

A person with diabetes type 2 either:

1. Does not produce enough insulin. Or
2. Suffers from 'insulin resistance'. This means that the insulin is not working properly.

The majority of people with Type 2 have developed the condition because they are overweight. Type 2 generally appears later on in life, compared to Type 1. Type 2 is the most common form of diabetes.

In the case of insulin resistance, the body is producing the insulin, but insulin sensitivity is reduced and it does not do the job as well as it should do. The glucose is not entering the body's cells properly, causing two problems:

1. A build-up of glucose in the blood.
2. The cells are not getting the glucose they need for energy and growth.

In the early stages of Type 2 insulin sensitivity is the main abnormality - also there are elevated levels of insulin in the blood. There are medications which can improve insulin sensitivity and reduce glucose production by the liver.

As the disease progresses the production of insulin is undermined, and the patient will often need to be given replacement insulin.

"Excess abdominal fat is much more likely to bring on Type 2 Diabetes than excess fat under your skin"

Many experts say that central obesity - fat concentrated around the waist in relation to abdominal organs - may make individuals more predisposed to develop Type 2 diabetes.

Central obesity does not include subcutaneous fat - fat under the skin. The fat around your waist - abdominal fat - secretes a group of hormones called adipokines. It is thought that adipokines may impair glucose tolerance.

The majority of people who develop diabetes Type 2 were overweight during the onset, while 55% of all Type 2 patients were obese during onset.

"Sometimes all the patient needs is to do more exercise,
lose weight and eat fewer carbs"

It is not uncommon for people to achieve long-term satisfactory glucose control by doing more exercise, bringing down their bodyweight and cutting down on their dietary intake of carbohydrates.

However, despite these measures, the tendency towards insulin resistance will continue, so the patient must persist with his/her increased physical activity, monitored diet and bodyweight.

If the diabetes mellitus continues the patient will usually be prescribed orally administered anti-diabetic drugs. As a person with Type 2 does produce his/her own insulin, a combination of oral medicines will usually improve insulin production, regulate the release of glucose by the liver, and treat insulin resistance to some extent.

If the beta cells become further impaired the patient will eventually need insulin therapy in order to regulate glucose levels.

The risk factors for type 2

Age and ethnicity. The older you are the higher your risk is, especially if you are over 40 (for white people), and over 25 (for black, South Asian and some minority groups). It has been found in the UK that black people and people of South Asian origin have five times the risk of developing Type 2 compared to white people.

Diabetes in the family. If you have a relative who has/had diabetes your risk might be greater. The risk increases if the relative is a close one - if your father or mother has/had diabetes your risk might be greater than if your uncle has/had it.

Bodyweight (and inactivity combined with bodyweight). Four-fifths of people who have Type 2 became so because they were overweight. The more overweight a person is the higher his/her risk will be. The highest risk is for a person who is overweight and physically inactive. In other words, if you are very overweight and do not do any exercise your risk is greatest.

Cardiovascular problems and stroke. A person who has had a stroke runs a higher risk of developing Type 2. This is also the case for people who suffer from hypertension (high blood pressure), or have had a heart attack. Any diagnosis of a problem with circulation indicates a higher risk of developing Type 2.

Gestational Diabetes. A woman who became temporarily diabetic during pregnancy - gestational diabetes - runs a higher risk of developing Type 2 later on. Women who give birth to a large baby may run a higher risk, too.

Impaired fasting glycaemia (IFG) - Impaired glucose tolerance (IGT). A person who has been diagnosed as having impaired fasting glycaemia or impaired glucose tolerance and does not have diabetes runs a significantly higher risk of eventually developing Type 2. People with IFG or IGT have higher than normal levels of glucose in their blood. In order to prevent diabetes it is crucial that you eat healthily, keep an eye on your weight and do exercise.

Severe mental health problems. It has been found that people with severe mental health problems are more likely to develop Type 2.

Treatment for diabetes - how is diabetes managed?

A long time ago

Before insulin was discovered in 1921 Diabetes Type 1 was a fatal disease - most patients would die within a few years of onset. Things have changed a great deal since then.

You can lead a normal life

If you have Type 1 and follow a healthy eating plan, do adequate exercise, and take insulin, you can lead a normal life.

Balance insulin intake with food and lifestyle

The quantity of insulin intake must be closely linked to how much food you consume, as well as when you eat. Your daily activities will also have a bearing on when and how much insulin you take.

Checking your blood glucose levels

A person with diabetes has to have his/her blood glucose levels checked periodically. There is a blood test called the A1C which tells you what your average blood glucose levels were over a two-to-three month period.

Type 2 patients need to eat healthily, be physically active, and test their blood glucose. They may also need to take oral medication, and/or insulin to control blood glucose levels.

Prevent developing cardiovascular disease

As the risk of cardiovascular disease is much higher for a diabetic, it is crucial that blood pressure and cholesterol levels are monitored regularly.

Healthy eating, doing exercise, keeping your weight down will all contribute towards good cardiovascular health - some patients will need oral medication for this.

Stop smoking!

As smoking might have a serious effect on the cardiovascular health the patient should stop smoking.

A health care provider

A health care professional (HCP) will help the patient learn how to manage his/her diabetes. The HCP will also monitor the diabetes control. It is important that you know what to do and that a professional is helping and monitoring the management of your diabetes.

In most countries the GP (general practitioner, primary care physician, family doctor) provides this regular care. There are also diabetitians, endocrinologists, cardiologists, nurses, internists, pediatricians, dietitians, podiatrists, ophthalmologists, optometrists, sports specialists and many others.

If a diabetes patient is pregnant she should see an obstetrician who specializes in diabetes (gestational diabetes). There are pediatricians who specialize in caring for the infants of diabetic mothers.

The aim of diabetes management

The main aim of diabetes management is to keep the following under control:

• Blood glucose levels
• Blood pressure
• Cholesterol levels

High and low blood glucose

The patient will need to make sure his/her blood glucose levels do not fluctuate too much.

Hypoglycemia - low blood glucose - can have a bad effect on the patient. Hypoglycemia can cause:

• Shakiness
• Anxiety
• Palpitations, Tachycardia
• Feeling hot, sweating
• Clamminess
• Feeling cold
• Hunger
• Nausea
• Abdominal discomfort
• Headache
• Numbness, pins and needles
• Depression, moodiness
• Apathy, Tiredness, Fatigue, Daydreaming
• Confusion
• Dizziness
• Bad coordination, slurred speech
• Seizures
• Coma

Hyperglycemia - when blood glucose is too high - can also have a bad effect on the patient. Hyperglycemia can cause:

• Polyphagia - frequently hungry
• Polydipsia - frequently very thirsty
• Polyuria - frequent urination
• Blurred vision
• Extreme tiredness
• Weight loss
• Cuts and scrapes will heal slowly and badly
• Dry mouth
• Dry or itchy skin
• Erectile dysfunction (impotence)
• Recurrent infections
• Kussmaul hyperventilation: deep and rapid breathing
• Cardiac arrhythmia
• Stupor
• Coma

How is diabetes managed? - Self-monitoring of blood glucose

Monitoring your own glucose is done with a Glucose Meter. Self-monitoring is often called SMBG (self-monitoring of blood glucose). Glucose meters today are small, battery-operated devices.

A sample of blood

When you want to test for glucose with a glucose meter you need to place a small sample of your blood on a test strip. Your skin is pricked with a lancet - like a very fast pin-prick.

These test strips are disposable. You then place the strip in the monitor. The strips are coated with glucose dehydrogenase or hexokinase that combines with glucose in blood.

The blood is usually taken from a finger, but some meters allow the use of other parts of the body to supply the blood sample.

How the meter works

The meter tells you how much glucose is present in your blood. How meters do this may vary. With some meters a measurement of the amount of electricity that passes through your blood sample is measured, while others measure the degree of reflection of light. The glucose level is displayed as a number. In the case of this picture (below right) the person's glucose level is low. Many of the new meters can store a series of test results, while others can be connected to your personal computer to store results, which you can also print out.

How to choose a glucose meter

According to the FDA there are 25 different meters on the market. They are not all the same. You should bear the following in mind when choosing one:

• Testing speed
• Size
• Memory (ability to store results)
• Price

The newer models have automatic timing, error codes and signals, barcode readers to help with calibration. Some have spoken instructions for people who are visually impaired.

Using your meter

Frequency of meter usage varies significantly from patient-to-patient. It is important that you adhere to the instructions given to you from your health care provider. Every person with diabetes should be self-monitoring his/her blood glucose - this is especially so for people who are taking insulin.

According to the American Diabetes Association (ADA), patients with Type 1 should self-monitor blood glucose at least three times per day.

The ADA says that women with gestational diabetes (diabetes during pregnancy) should self-test twice a day.

There is no general recommendation from the ADA regarding frequency of self-testing for Type 2 patients.

Most patients who do have to self-test will generally have to do so before meals, a couple of hours after meals, at bedtime, 3.a.m., and whenever signs or symptoms are felt.

When a patient changes medication testing should be carried out more frequently.

If you have an unusual illness or sudden stress, you should test more frequently.

Knowing how to use your meter

As meters work in different ways you should get training from a diabetes educator.

Using a glucose meter - instructions

• Wash your hands with warm water and soap. Dry completely. You could also dab or wipe the area with alcohol and then dry completely.
• Use the lancet to prick your fingertip.
• Hold your hand down. Hold your finger at the same time until you see a small droplet of blood appear.
• Place the blood on the test strip.
• Follow the instructions for placing the test strip and using your meter.
• Keep a record of your result.

Many regulatory authorities, such as the FDA, require that meters and test strips come with instructions. It is important that you become familiar with these instructions, which should be included in the User Manual. Some meters give out an error code if something is wrong. Checking the User Manual will tell you what the error code means.

In many countries the User Manual will have a toll free number. If you call and cannot get through call your health care provider or your local emergency room. Check out the website of the manufacturer. The FDA advises patients to visit the manufacturer's website regularly for any updates or issues.

How is diabetes managed? Planning your food consumption

Three things will have a major impact on your blood glucose and blood lipids (cholesterol, triglycerides) levels

• What you eat
• How much you eat
• When you eat

By selecting the right types of foods, as well as appropriate quantities you can significantly improve your ability to control your blood glucose and blood lipids.

What does healthy eating mean?

Healthy eating most certainly does not mean you will go hungry and have to spend much of your life desperately trying to resist temptation. You can still consume the food you like. All it means is that you will have to be much more aware of how much carbohydrate, fat and protein you consume each time you eat. You just have to get the balance right.

Carbohydrates

Carbohydrates are most abundantly found in fruit, vegetables, yoghurt, sweets, pasta and bread.

Our body needs carbohydrates; we cannot live without them. When consumed, our bodies turn the carbohydrate into blood glucose - glucose is needed by our cells for energy and growth.

If you consume the same amount of carbohydrates each time you eat - especially if those times are at the same time each day - you will be well on your way towards controlling your blood glucose.

It is important that you do not skip meals, no matter what your blood glucose readings indicate. All you will achieve by skipping meals is a more aggressive fluctuation in your blood glucose levels - something you want to try to avoid.

If your consumption of glucose can follow a regular pattern, it will be easier for you to balance food with your medicine(s) and physical activity with optimum blood glucose control.

Variety and moderation

A varied and moderated diet is ideal if you want to enjoy good health. Your carbohydrate intake should consist of a variety of grains, fruits and vegetables. They have plenty of fiber - fiber helps control blood glucose.

Remember that brown rice has more fiber than white rice; whole-grain breads have the most fiber. If you are cooking or baking, opt for whole-wheat or whole grain flours. Include pulses, such as beans; they are a great source of fiber. Dark green leafy vegetables and dark yellow ones have a slower release of carbohydrates than most other vegetables.

Carb, protein and fat mix

According to the Mayo Clinic, your daily intake of calories should consist of:

• Carbohydrates 45% to 65%
• Proteins 15% to 20%
• Fats 20% to 35%

If you adhere to your meal plan for portion sizes and eating times you should eat the same mix of carbohydrates, proteins and fats each day. Your blood sugar control will be ideal, as will your weight. The more you vary from your food plan, the Mayo Clinic informs, the more your blood glucose will fluctuate.

The rewards will be worth it

The ideal eating pattern for a person with diabetes is not really any different from what a non-diabetic person would do if he/she aimed for optimum health and fitness. However, the diabetes patient has the added incentive of trying to prevent complications from developing, such as cardiovascular disease, kidney problems, vision problems and leg and feet sores.

Foods on offer for a diabetes patient are extensive and varied. You will be able to plan a wide range of tasty and interesting meals.

The food pyramid

When you talk to your health care professional, diabetes educator or dietician, they will probably mention the Food Pyramid.

At the base there are foods rich in carbohydrates, such as grains, then there are fruit and vegetables.

Above are meat, fish, milk and cheese; which are rich in protein. At the top are the fatty foods.

Almost all diabetes and medical associations say that you should eat more from the groups at the bottom of the pyramid, and less from those at the top.

It is vital that you talk to an expert about your eating plan. It needs to be tailored according to your weight, age, which medications you are taking and how physically active you are (and, if so, when during the day you are likely to be the most active).

Glycemic index

Not all carbohydrates are the same. The Glycemic Index (GI) describes what effect certain foods can have on our blood glucose levels. A high GI tends to cause more blood glucose fluctuations than a low one. Ask your dietician.

How is diabetes managed? - physical activity, exercise

Physical activity Is crucial for a person with diabetes

• it helps control your blood glucose
• it helps keep your weight down
• it helps keep your blood pressure down
• it helps raise your HDL (High-density lipoprotein), good cholesterol levels
• it helps lower your LDL (Low-density lipoprotein), bad cholesterol levels

These five benefits have a DIRECT bearing on how successfully you manage your diabetes. Exercise also has other general health benefits - you sleep better, your mental state improves, etc.

How much exercise should you do?

Most experts say you should do exercise on at least five days of each week. Each session should be of moderate-intensity and should not last less than thirty minutes. The following activities could be classed as of moderate-intensity:

• fast walking
• swimming
• cycling 5-9mph (level terrain, perhaps some slight hills)
• dancing
• rowing
• mowing the lawn

What is moderate-intensity physical activity?

• You should experience some increase in your breathing rate
• There should be an increase in your heart rate
• A Borg Scale perceived exertion of 11 to 14
• You should burn 3.5 to 7 calories per minute
• You should reach a METs of 3 to 6

What is MET?

MET stands for Metabolic Equivalent. An MET of 1 is when you are sitting down doing nothing. If you walk slowly your MET may rise to 2 or 2.5. If you walk normally it will go up to 3, while a brisk walk may bring it to 5. If a wild gorilla suddenly appeared in the street and started chasing you your desperate sprint would shoot your MET right up to about 8 or even perhaps 9.

Beginners be careful!

If you have not done exercise for a long time you will need to start with a little light exercise and build up slowly over time. Each week add a little more time to each session and/or increase the intensity.



Remember regular exercise is what matters. 5 days of 30 minutes each is great. One day per week at 150 minutes is not.

You must talk to your health care provider about an exercise plan. He/she may want to check you over before you start. Certain exercises are not ideal for patients who suffer from high blood pressure, eye and/or foot problems.

Strength training is also good

The Centers for Disease Control and Prevention (CDC) says that strength training exercises are good because they help you build muscle. Strength training usually involves using weights.

Join a gym

There are many gyms today whose staff are experienced and qualified to receive and train people for various illnesses and conditions. In North America, Western Europe, Japan and Australasia gyms receive doctors' referrals - doctors send them to specific gyms as part of their therapy.

Having somebody there to help you along, occasionally to push you along, can be a great motivator - especially for beginners who may view the whole experience with apprehension.

Gyms are all-weather; they have equipment which gives you immediate feedback on how well you are doing - your speed, heart rate, calories burnt per minute/hour, your progress, etc.

Numerous people prefer gyms because it gives them a feeling of doing something with others. Do not be afraid of joining one. They are generally welcoming and members will not be concerned about what you look like or how unfit you may be - they are there for their health, just like you.

Diabetes treatment - hypoglycemia

Hypoglycemia is sometimes called insulin reaction. It is when your blood glucose is too low. Even though you may do all you can to manage your diabetes, hypoglycemia can happen, and it can and must be treated before it gets worse.

If you remember to check your blood glucose when your doctor tells you to, your chances of experiencing hypoglycemia are much lower. Also, a low blood glucose result will tell you that you need to treat it.

If you feel the symptoms of hypoglycemia you should check your blood glucose. If the reading tells you that your blood glucose is low, you should treat it immediately.

The American Diabetes Association (ADA) says that if you feel a hypoglycemic reaction but cannot check your blood glucose it is better to treat the reaction than to wait till you can check.

How do I treat hypoglycemia?

You need to raise your blood glucose. The fastest way to do this is to eat some form of sugar. The ADA advises:

• Take 3 glucose tablets (easily bought)
• 1/2 a cup of fruit juice
• 5 to 6 pieces of hard candy (UK 'sweets')

You should ask your dietitian or health care professional for more advice on what you could eat to treat hypoglycemia.

Make sure you always carry at least one type of sugar with you so that you are prepared.

Check blood glucose, treat It and wait 20 minutes

After you have checked your blood glucose and treated the hypoglycemia wait between 15 to 20 minutes and check your blood glucose again. If your blood glucose is still low repeat the whole process - eat some glucose, wait about 15-20 minutes and check your blood glucose again.

Remember to stick to your eating times - your regular meals and snacks are vital for keeping your blood glucose levels as stable as possible. Hypoglycemia can affect all the organs in your body, especially your brain.

Take hypoglycemia seriously

Hypoglycemia, if not treated quickly gets worse rapidly and the patient will soon pass out.

A patient who passes out because of hypoglycemia will need immediate treatment - probably a glucagon injection, or an emergency visit to a hospital.

What does glucagon do?

Glucagon is injected, just like insulin is. However, glucagon raises blood glucose.

You should ask your doctor to make sure you have some.

Hypoglycemia unawareness

It is possible, and not very unusual, for a person to pass out and never have noticed they had been suffering from hypoglycemia. This is known as hypoglycemia unawareness. The patient's blood glucose drops and he/she is not aware of it.

Hypoglycemia unawareness is more common among patients who have lived with diabetes for a long time, those with nerve damage (neuropathy), patients on medication for hypertension (high blood pressure) and those on tight glucose control.

Hypoglycemia symptoms

• Tingling sensation around the mouth
• Lightheadedness, dizziness
• Sweats
• Trembling, shakiness
• Headache
• Pallid skin (you go pale)
• Irritability, moodiness, you might become tearful
• Seizure (you have a fit, spasm)
• Absent mindedness
• Confusion
• Clumsiness
• Strong desire to eat

Diabetes treatment - hyperglycemia

Hyperglycemia is when your blood glucose is too high; it is the opposite of hypoglycemia. Hyperglycemia needs to be treated immediately as it is a major cause of complications among people with diabetes.

Hyperglycemia happens when there is no insulin in the blood, not enough insulin in the blood, or the insulin in the blood is not working properly.

The main reason for hyperglycemia for a patient who is being treated for diabetes type 1 is that he/she has not given himself enough insulin. For a type 2 diabetic it could be the same reason, but also his/her insulin is less effective than it should be.

For a patient with diabetes, overeating can bring on hyperglycemia, as can too little exercise on a given day. Mental stress can also bring it on. Remember that your body's supply of insulin is determined by how much you give yourself, and when. For a person who does not have diabetes his/her body will respond automatically with appropriate quantities of insulin.

Symptoms of hyperglycemia

• High blood glucose
• High levels of sugar in the urine
• Very hungry, hungry often (polyphagia)
• Excessive thirst, frequent thirst (polydipsia)
• Excessive and frequent urination (polyuria)
• Blurred vision - Weight loss
• Wounds and cuts heal poorly
• Dry mouth
• Cardiac arrhythmia
• Deep and rapid breathing (kussmaul hyperventilation)
• Impotence (erectile dysfunction)
• Itchy and/or dry skin
• Tiredness
• Stupor
• Coma

Good diabetes management is crucial

Your doctor will tell you what your glucose levels should be and how often you should check it. If you stick to good diabetes management practices your chances of experiencing hyperglycemia are significantly reduced.

Ketoacidosis

As soon as you detect hyperglycemia, treat it immediately. People who experience hyperglycemia and do not treat it run a significantly high risk of going into diabetic coma (ketoacidosis).

Ketoacidosis happens when there is not enough insulin in your blood. Remember that without the insulin your cells cannot get the vital fuel (energy) they need. Your body starts breaking down fats to get its energy. This process of breaking down fats produces ketones - waste products. Large amounts of ketones are bad for you. Excess ketones in your blood will result in frequent urination as your body tries to eliminate it. However, it eventually becomes a losing battle, with the build up of ketones happening faster than their elimination through urination.

Symptoms of ketoacidosis are:

• your breath smells fruity
• nausea and sometimes vomiting
• your mouth is extremely dry
• you are short of breath

Treating hyperglycemia

The American Diabetes Association says exercising can help lower blood glucose levels. If your blood glucose is above 240mg/dl. Check your urine for ketones and do not exercise if there are ketones present as this will raise your blood glucose levels even more!

Reducing your food intake will also help lower your blood glucose. It is important that you stick to your meal plan, which should be worked out with a dietitian or health care professional.

Ask your doctor for the best way to lower blood glucose levels.

If none of the measures mentioned above manages to lower your blood glucose it is possible that your medication may have to be re-scheduled. Your insulin and medication doses may need to be altered, as might their timing (when you have them).

Remember that good diabetes management helps reduce the incidence of hyperglycemia. Learn to detect hyperglycemia quickly so that you can treat it early on.

Diabetes treatment - taking insulin

You cannot take insulin as a pill. If you did, the moment it got to your stomach it would be digested and would never get into your bloodstream.

You have to inject insulin into the fat just under your skin - from there it will get to your bloodstream.

There are many types of insulin. According to the American Diabetes Association (ADA) there are over 20 types of insulin in the American market. They work in different ways, they are made differently, and they vary in price.

Insulin is most commonly made in laboratories today. It can also come from animals, mainly pigs.

Rapid-acting insulin

This type of human insulin starts to work within five minutes of being injected and peaks after about one hour. It continues to be active for 2 to 4 hours. Examples of rapid-acting insulin are lispro marketed by Eli Lilly, insulin aspart marketed by Novo Nordisk, or insulin glulisine marketed by sanofi-aventis.

Short-acting insulin

Also known as Regular (acting) insulin. This type of human insulin reaches your bloodstream approximately 30 minutes after you inject it, and peaks from 2 to 3 hours after injection. It is effective for 3 to 6 hours.

Intermediate-acting insulin

This human insulin takes from 2 to 4 hours to reach the bloodstream after injection. It peaks at 4 to 12 hours. It is effective for approximately 12 to 18 hours.

Long-acting insulin

This insulin gets into your bloodstream about 6 to 10 hours after you inject it. It is effective for 20 to 24 hours. This type of insulin is also known as ultralente.

Pre-mixed insulin

Some patients have to mix two different types of insulin. If they find that difficult they can have the insulin pre-mixed. This is especially useful for people who are visually impaired.

Allergic reaction to insulin additives

The insulin a diabetic takes has additives to keep it free of bacteria and to tweak its time of action. Some patients may have an allergic reaction to some additives found in intermediate and long-acting insulins - however, this is very rare.