Complications

Introduction

With good diabetes self-care and the support of your health care team, complications of diabetes can be prevented or reduced.

How do complications develop? Long standing high blood glucose levels, along with poorly controlled blood lipid levels and blood pressure, all contribute to damage to the body over time. Blood vessel damage increase heart disease. High glucose levels can also cause oxidative stress, which produces free radicals. Free radicals cause damage to the small blood vessels. High blood glucose levels also create the accumulation of advanced glycation end products, or AGEs, which damage the body.

The problems that follow diabetes are of two kinds: macrovascular and microvascular disease. Whatever the problem, the earlier you detect it and treat it, the less impact on your health.

Macrovascular complications - the most common complication of diabetes - are with the larger blood vessels of your heart and circulatory system. Problems such as coronary artery disease, heart attack, heart failure and stroke result from poor diabetes care. Blood vessels in the legs could develop poor circulation and foot healing problems. This is called peripheral vascular disease.

Microvascular complications are of the small blood vessels, which are weakened over time. Problems occur with the eyes, kidney, feet, teeth and nerves. Nerve damage, or neuropathy, is more common the longer you have diabetes. It might first affect the feet, with a tingling or burning sensation, numbness or reduced balance. The nervous system damage could affect other body systems that control the digestive system, the heart, circulatory system, sexual organs, body temperature, eyes, and blood sugar changes.

Cardiovascular Issues

Atherosclerosis

Arteriosclerosis denotes a general term that describes a group of diseases where the wall of an artery becomes thicker and less elastic. Also known as "hardening of the arteries," arteriosclerosis causes coronary artery disease.

Several types of arteriosclerosis exist, but atherosclerosis is the most common type. Atherosclerosis refers to hardening of atheroma, the fatty deposits called plaque within arteries. This disease can affect the medium-sized and larger arteries of major organs including the brain, heart, and kidneys. It also can affect the legs.

As a progressive disease, atherosclerosis worsens over time.

What Causes Atherosclerosis? 
Over time, cholesterol, fats, blood platelets, calcium, and cellular debris can get stuck on the artery walls. This build-up, called plaque, narrows the diameter of the artery, making it impossible for as much blood to flow through. The result is less oxygen reaching areas of the body that lay beyond the plaque.

Several risk factors exist for hardening of the arteries. However, you can avoid many of them through lifestyle changes.

Risk Factors You Can Change:

  • Type 2 Diabetes
  • High LDL (bad) cholesterol level
  • Low HDL (good) cholesterol level (High HDL decreases the risk)
  • Smoking
  • High blood pressure
  • Lack of exercise
  • Obesity
  • High homocystein levels in the blood 

Risk Factors You Can't Change:

  • Type 1 Diabetes
  • Insulin resistance (a condition where the body does not use insulin efficiently, thus raising blood sugar levels)
  • Gender (males face an increased risk)
  • Family history of early onset atherosclerosis
  • Familial hypercholesterolemia (genetic high cholesterol)
  • Age (older people face an increased risk) 

How Do You Know If You Have Atherosclerosis? 
Symptoms often do not occur until plaque blocks more than 70 percent of the artery, at which point you might suffer a heart attack or stroke. Prior to this, you might notice the first, subtle symptom of atherosclerosis - pain or cramps during exercise. A lack of oxygen in the blood flow to the chest or legs could cause pain or cramps.

If your doctor thinks you are high risk, he or she may suggest that you get an angiography or an ultrasound test. An angiography uses dye injected into the bloodstream to help measure how much blood flows through the artery. (Cardiac catheterization is a type of angiography.) An ultrasound uses sound waves, a microphone, and a monitor to record the size and shape of your arteries, pinpointing narrow arteries that might need treatment.

How Can You Prevent Atherosclerosis? 
Keeping blood sugar levels, blood pressure, and cholesterol all within normal ranges can go a long way toward reducing the severity of complications.

Many complications of diabetes result from lifestyle choices, so making some positive changes can reduce your risk:

  • Eat a heart-healthy diet
  • Exercise
  • Lose weight
  • Quit smoking

How Can You Treat Atherosclerosis? 
Because you rarely feel symptoms of atherosclerosis before leg pain, stroke, or a heart attack, treatment often consists of managing the resulting complication of the disease.

Prior to that treatment, your healthcare team might suggest lifestyle changes to avoid the complications that atherosclerosis can cause.

Cardiovascular Disease

Cardiovascular disease refers to a group of conditions that affect the heart or vascular (blood vessel) system. The most common conditions are heart disease and stroke.

Heart diseases include:

  • Coronary artery disease 
  • Heart failure
  • Heart valve disease

Vascular diseases include:

  • Arteriosclerosis (hardening of the arteries) 
  • Atherosclerosis (clogging of the arteries) 
  • Hypertension (high blood pressure) 
  • Peripheral vascular disease
  • Stroke

What Causes Cardiovascular Disease?

Lifestyle choices such as smoking, eating fatty food, and being sedentary can all contribute to the development of cardiovascular disease.

In addition, when you have diabetes, the disease itself can harm your arteries, especially if your blood sugar levels consistently run high. This in turn can increase the risk of developing cardiovascular disease.

How Do You Know If You Have Cardiovascular Disease?

Symptoms of cardiovascular disease depend greatly on where, and to what organ, the normal flow of blood has been interrupted. With a severe interruption, you might experience some - or even all - of the symptoms below. Keep in mind that heart attack symptoms in women often differ from those in men.

Heart Attack Symptoms (men):

- An oppressive, squeezing pain in the central chest that lasts for a few minutes - the pain can spread to the neck, shoulders, or arms
- A feeling of light-headedness, sweating, faintness, nausea or having difficulty breathing

Heart Attack Symptoms (women):

  • Shortness of breath, often without any chest pain
  • A flu-like feeling including nausea, clamminess or cold sweats
  • Extreme tiredness, feeling of dizziness or weakness
  • Discomfort and feeling of anxiety stroke symptoms

A stroke occurs when a blocked or bleeding blood vessel suddenly disrupts blood flow to the brain. Some of the more common symptoms include:

  • Sudden, sharp headache
  • Weakness in one or both legs
  • Loss of feeling in the face or body
  • Sudden loss or decrease in vision, especially in one eye
  • Difficulty forming words
  • Inability to walk steadily
  • Dizziness

How Can You Treat Cardiovascular Disease?

The first step to treat cardiovascular diseases starts with lifestyle changes, including eating a balanced, healthful, low-fat diet, quitting smoking, and exercising.

Other treatments include drug therapy and/or surgery, depending on your specific condition or disease.

How Can You Prevent Cardiovascular Disease?

Keep your blood sugar levels under control. Remember, for each one percent reduction in your A1C level (the measure of your average blood sugar level for several weeks), you significantly reduce your risk of heart or vascular disease.

Keep your blood pressure under control. Even a 10 mmHg reduction in your systolic blood pressure (the top number in a blood pressure reading) makes a significant difference.

Keep your blood cholesterol levels within the normal range. This can reduce your risk for cardiovascular disease by as much as 50 percent.

Coronary Disease

Coronary artery disease (CAD) occurs when the blood vessels that bring blood to the heart - the coronary arteries - thicken and narrow. When this occurs, the oxygen-rich blood supplied to the heart slows down or completely stops. This can cause chest pains (known as angina) as well as a heart attack.

Coronary artery disease is the leading cause of death in the United States and people with diabetes face an even greater risk of CAD. Over time, it can weaken the heart muscle and lead to heart failure or irregular heart rhythms (called arrhythmias) which can sometimes be quite serious.

Angina is when your heart does not get the blood it needs, you feel chest pain called angina. The pain, which can be sharp and fleeting, often occurs under the breastbone and may feel like pressure or a squeezing-type pain. For some people, it feels like heartburn. For others, it feels like pain in the back, arm, or even the abdomen. Rest or nitroglycerin can often relieve the symptoms, which usually last only a minute or two.

The most common type of angina, called stable angina, can stem from emotional situations or exercise. With stable angina, you will probably learn to predict when it might occur, even after just a few episodes.

In some people with diabetes, episodes of low or high blood sugar may bring on angina. 

Heart Attack - Sometimes enough plaque builds up in a coronary artery that a blood clot develops. The clot can quickly cut off all, or most, of the blood supply to the heart, resulting in a heart attack.

Warning signs of a heart attack may include:

  • Severe chest pain that lasts several minutes (as opposed to the one- to two-minute angina pain) however, this pain might stop and start and might feel like fullness, squeezing, or pressure, even heartburn.
  • Shortness of breath - this may accompany chest discomfort, or it may occur before the pain begins
  • Feeling of discomfort in the upper body, including arms, back, stomach, neck, and/or jaw
  • Nausea and vomiting
  • Dizziness or light-headedness
  • Breaking out in a cold sweat

If you suspect you are having a heart attack, call emergency help immediately - early treatment can minimize the damage to your heart and prolong your life.

What Causes Coronary Artery Disease? 

Most often, coronary artery disease results from the build-up of fatty material and plaque, also called atherosclerosis. Risk factors that you can somewhat control includes:

  • Type 2 Diabetes
  • High LDL (bad) cholesterol level
  • Low HDL (good) cholesterol level (high HDL decreases the risk)
  • Smoking
  • High blood pressure
  • Lack of exercise
  • Obesity
  • High homocysteine levels in the blood

Risk factors that you cannot control include:

  • Family history of CAD (especially before age 50)
  • Ethnicity (African American or Asian Indian)
  • Gender (male)
  • Type 1 Diabetes
  • Age (65+ years old)
  • Post-menopause or experiencing menopause
  • Inflammation in the artery caused by infection

How Do You Know If You Have Coronary Artery Disease? 

Many people do not know they have coronary artery disease until chest pain hits. In fact, for people with diabetes, ischemia (or cramping of the heart) and heart attacks can occur without any warning signs.

Because coronary artery disease often lacks warning signs, prevention plays a critical role.

How Can You Prevent Coronary Artery Disease? 

You can help minimize the amount of plaque that builds up in your arteries by making a few lifestyle changes.

  • Keep your blood sugar, blood pressure, and cholesterol levels as close to normal as possible.
  • Do not smoke.
  • Lose weight.
  • Develop - and follow - and exercise plan. (Talk with your doctor first!)
  • Eat a heart-healthy diet low in salt and saturated fat.

Also, if your doctor has prescribed medication, make sure you take it as directed.

How Can You Treat Coronary Artery Disease? 

A number of therapies exist to treat coronary artery disease, including drug therapy, percutaneous intervention, and surgery. 

Drug Therapy 

To manage your coronary artery disease, your doctor might prescribe a variety of drugs designed to make your heart work better and keep your cholesterol and blood pressure down.

These medications may include:

  • ACE inhibitors that can help reduce how much blood flows from the heart, thus reducing blood pressure, such as Accupril®, Capoten®, Monopril®, Zestril®, and others.
  • Beta-blockers to decrease your heart rate and reduce how much oxygen your heart uses, such as Coreg®, Lopressor®, Toprol-XL®, and many others.
  • Blood thinning drugs (antithrombin drugs) or antiplatet drugs like aspirin to reduce the risk of blood clots.
  • Calcium-channel blockers that can increase blood flow to the heart and control high blood pressure, such as verapamil, diltiazem, and nifedipine.
  • Statins, which can help lower cholesterol, such as Lipitor®, Crestor®, Ranexa®, and others.
  • Nitrates such as nitroglycerin to improve blood supply to the heart.

A note about cholesterol lowering drugs: Some statins have recently made headlines because of serious adverse effects, even death. However, the American College of Cardiology and the American Heart Association maintain that, for most people, the drugs remain safe and effective. If you have concerns, talk with your prescriber. Current studies are looking into drugs that might even reverse the damage caused by coronary artery disease.

Percutaneous Coronary Interventions (PCIs) 

PCIs refer to a group of minimally invasive surgical techniques where doctors can reach the heart via a major blood vessel rather than cutting open the chest.

PCIs include:

  • Ablative laser-assisted angioplasty: a laser dissolves and removes the plaque that blocks the artery.
  • Angioplasty: a balloon-tipped hollow tube threads through a blood vessel to the heart; doctors then inflate the balloon, causing the artery to expand.
  • Stents: tube-shaped devices get placed into an artery to help keep it open (may or may not be used with angioplasty).
  • Atherectomy: a rotating cutting blade threads through the artery and then cuts away the plaque.
  • Brachytherapy: implants a particular type of radioactive material into the artery to dissolve the plaque (primarily used if a stent-related problem develops).
  • Thrombectomy: inserts a thrombolytic device into a blood vessel via a catheter to break up a clot.

Surgery 

You might need surgery to treat a heart attack or other results of coronary artery disease. The procedures include coronary artery bypass surgery and minimally invasive heart surgery.

In coronary artery bypass surgery, also known as CABG (pronounced "cabbage"); doctors make a six to eight-inch incision in the chest. Doctors then use a blood vessel from one part of the body (usually from the leg or chest) to bypass a blockage in a coronary artery. This is called a graft. The vessel chosen to graft depends on the location of the blockage and how many blockages need repair.
If a doctor creates two bypasses, it's called double bypass surgery; three bypasses would be a triple bypass surgery, and so on.

The doctor creates a bypass by attaching the graft to the affected artery above and below the blocked area. This allows blood to flow around the blockage and get to the heart. This can improve heart function, relieve angina, and may prevent a heart attack.

During the procedure, doctors might place you on a heart-lung machine that takes over the heart function, allows the beating of your heart to be stopped, and lets the surgeon work on an area that is still.

Instead of traditional CABG, you might need minimally invasive heart surgery. In this case, doctors make a two- to four-inch incision, often between the ribs. The type of surgery implemented depends on the location of the blockage.

Heart Failure

What Is Heart Failure? 

Heart failure, even though a serious condition, is a misnomer. It does not mean your heart failed or that death is imminent. Instead, it means that your heart can no longer pump enough blood through your body. Because of the decreased ability of the heart to pump, you might experience:

  • Tiredness and/or shortness of breath
  • A back-up of fluid and blood in the lungs
  • Swelling of the feet, ankles, and/or legs

If the left side of your heart weakens (the side that pumps blood to the rest of the body), you might hear the term ejection factor (EF). This refers to how much blood your heart pushes out with each beat. Usually, the heart pushes out about half of the blood in it, but if your heart weakens on this side, it might only expel 30 percent or less.

Although the left side of the heart weakens more commonly than the right side, the right side that pumps blood to the lungs might also function at decreased capacity. This can occur if the pressure in your lungs rises higher than normal - a condition that might occur due to a weakened left side, emphysema, or pulmonary hypertension. People with high blood pressure and/or diabetes might face greater risk for right heart failure.

What Causes Heart Failure? 

Heart failure results from other diseases or conditions that damage the heart. The leading causes of heart failure include coronary artery disease and high blood pressure. Diabetes is also a major cause of heart failure. Blocked blood vessels and high blood glucose levels can damage the heart muscle.

Modifiable risks:

  • Type 2 diabetes

Non-modifiable risks:

  • Age (65+ years old)
  • Race (African American)

How Do You Know If You Have Heart Failure? 

Your doctor might perform several blood and cardiac tests to see if you have heart failure.

The most common signs and symptoms of the condition include:

  • Shortness of breath caused by fluid buildup in the lungs, sometimes accompanied by a cough
  • Feeling tired
  • Edema, or swelling in the ankles, feet, legs, and perhaps the abdomen. A buildup of fluid in the body causes edema, which might also be accompanied by frequent urination and/or weight gain.
  • Decreased alertness
  • Trouble staying asleep

How Can You Prevent Heart Failure? 

Keeping your blood sugar levels and your blood pressure within normal ranges can greatly reduce your risk of heart failure.

In addition, lifestyle changes can also help. These include:

  • Eating a heart-healthy diet that is low in salt, cholesterol, saturated fat, and trans fats
  • Quitting smoking
  • Losing weight, if you're overweight

Living with Heart Failure 

Medications can help treat heart failure, but no cure exists for the condition. After time, even with medicine, your symptoms might get worse and interfere with your normal activities.

To stay as comfortable as possible, make sure you:

  • Follow the advice of your doctor about your diet, and reduce the amount of salt you eat.
  • Take all prescribed medication.
  • Keep all doctor appointments.
  • Speak with your doctor before taking any new medications, even over-the-counter drugs and herbal supplements.
  • Limit the amount of fluids you drink.
  • Limit your alcohol intake since alcohol might make your symptoms worse.

How Can You Treat Heart Failure? 

Treatment for heart failure is designed to make you more comfortable, keep heart failure from worsening, and prolong your life. But you must still treat the disease or condition that caused your heart failure.

To help improve heart function and to relieve some of your symptoms, your doctor will prescribe some medications. Common ones include:

  • Angiotensin converting enzyme(ACE) inhibitors - such as captopril and enalapril to prevent the narrowing of blood vessels and lessen the strain on your heart function
  • Angiotensin II receptor blockers (ARBs) - such as losartan and candesartan to help widen blood vessels
  • Beta blockers - to help slow your heart rate and decrease the stress on your heart
  • Diuretics - including thiazide, loop diuretics, and potassium-sparing diuretics to eliminate excess water and salt from your body
  • Digoxin - to increase heart function and help it pump more blood

People with severe heart failure might need to use extra oxygen. Others might need a heart transplant or mechanical heart pump that doctors place inside the body to help the heart pump blood.

Some people might also need:

  • Implanted defibrillators to prevent sudden cardiac death. Placed under the skin, these devices track the electrical activity in the heart. If the defibrillator notes a problem, it sends out a small electrical shock, which restores the normal heartbeat.
  • Biventricular pacemakers that stimulate both sides of the heart and keep them working together.

Peripheral Artery Disease

What Is Peripheral Arterial Disease (PAD)? 

Peripheral arterial disease, commonly referred to as PAD, is a kind of atherosclerosis, or hardening of the arteries. PAD affects your cardiovascular health and can hamper your ability to walk well. It can also increase your chances of suffering a stroke or heart attack. In people with diabetes, PAD most often affects arteries in the thigh or lower leg, although other arterial areas can include the brain, kidney, and intestines.

What Causes Peripheral Arterial Disease? 

Atherosclerosis can lead to PAD. Smoking, high cholesterol, and high blood pressure all contribute to the fat deposits (plaque) that build up in the arteries. As plaque increases, the arteries narrow and harden, making it difficult for oxygen to move freely. Other risk factors include diabetes, inadequate exercise, and a high-fat diet low in vitamins C and E.

How Do You Know If You Have Peripheral Arterial Disease? 

Many people experience no symptoms with PAD. Others develop an ache, cramping, tiredness, or pain in their calf after walking, called claudication.

If you have very poor circulation in your leg, you might also experience pain in your feet and toes - even when you're not doing anything. The pain can worsen when you raise your legs.

How Can You Treat Peripheral Arterial Disease? 
Your first course of treatment should focus on reducing the risk of heart attack or stroke. Lifestyle changes such as smoking cessation, exercising, and eating a healthful diet - along with good control of diabetes, blood pressure, and cholesterol - can greatly reduce the progression of the disease and reduce the risk of stroke or heart attack.

If pain from the disease interferes with daily life, you may need angioplasty (either alone or with a stent) and/or bypass surgery.

Angioplasty widens the blocked artery by inserting a balloon-tipped, hollow tube into the area, then blowing up the balloon, causing the artery to stretch and widen a bit. Stents (tube-shaped devices) help keep an artery open.

Bypass surgery uses a vein from another part of your body to bypass the blockage in the affected artery. In cases of progressive deterioration, you may need arterial grafts, which remove the blockage and repair the artery using a piece of artery from elsewhere in the body.

Another treatment option involves drug therapy. Antiplatelet drugs, such as aspirin or clopidogrel, help prevent the formation of clots. Statins help lower "bad" cholesterol as well as total cholesterol. Blood pressure medication, particularly ACE drugs such as ramipril, are also often prescribed.

The treatment methods above help reduce the risk of heart attack and stroke, but do not reduce the pain associated with PAD. To treat the pain, your doctor may prescribe cilostazol or pentoxifylline, each of which increases blood flow to the limbs by preventing blood clots and widening the blood vessels. They may help increase the distance you can walk without pain.

What Are the Complications of PAD? 

PAD dramatically increases your risk for stroke or heart attack. In addition, it increases the risk of amputation of the foot or leg. Also, because PAD results from inadequate blood supply to part of the body, wounds in the affected area may not heal as well as they should. This can lead to ulcers, which can be painful unless neuropathy (nerve damage) also exists.

How Can You Prevent Peripheral Arterial Disease? While you can't always prevent PAD, the following lifestyle habits can help reduce your risk of PAD:

  • Stop smoking
  • Exercise
  • Keep blood sugar levels and blood pressure in the normal range
  • Eat a diet that helps keep blood fats close to normal. Avoid saturated fat and tropical oils, such as palm or coconut oil
  • Get enough vitamin B-6, B-12, and folic acid in your diet to help control homocysteine levels (high levels can cause damage to your arteries)
  • Talk with your healthcare provider about taking an aspirin every day
  • Manage your stress with biofeedback, meditation or whatever works for you to avoid stress-related high blood pressure

Skin Problems

Acanthosis Nigricans

What Is Acanthosis Nigricans? 
Acanthosis nigrican (AN), a skin condition, exists in two variations: a benign form and a malignant form. People with type 2 diabetes often develop the benign (non-cancerous) form of AN. 

What Causes Acanthosis Nigricans? 
The cause for Acanthosis Nigricans is still not clearly defined, but it appears to be related to insulin resistance. Frequently found in people with diabetes, Acanthosis Nigricans can occur as a result of obesity. Obesity associated Acanthosis is the most common type. Often, when the patient loses weight, the Acanthosis Nigricans disappears.

Another cause points to hyperinsulenemia, a consequence of insulin resistance, which can come from eating too many carbohydrates. Hyperinsulenemia causes an elevated fasting blood insulin level, which leads to turning on insulin receptors in the epidermis, or skin, and causes the skin cells to grow more quickly and a bit abnormally.

Some causes of Acanthosis Nigricans are not associated with diabetes include Cushing syndrome; a pituitary gland hormonal disorder called acromegaly; and gastric cancer. In some people, particular drugs or even family genetics can cause Acanthosis Nigricans.

What Are the Symptoms of Acanthosis Nigricans? 

When Acanthosis Nigricans begins, you might notice a piece of skin that looks like a tan or brown warts with a very soft, velvety feel to them. Often, it can appear on the neck, under the breast, in the groin area, in an armpit, or even on top of the knuckles. 

How Can You Treat Acanthosis Nigricans? 

The primary goal in treating Acanthosis Nigricans is to treat the underlying disease which led to the skin lesions (obesity, insulin resistance, etc.) Although no cure exists for Acanthosis Nigricans, you might find that the condition disappears when you lose weight.

If the cosmetic aspects of the condition bother you, dermabrasion (sort of a surgical sanding of the skin to smooth it out) or laser therapy might help.

In some instances, your doctor might also recommend medication, called keratolytic agents, to put on the Acanthosis Nigricans spots to help shed some of the skin. You should not use this medication without a doctor recommendation.

How Can You Prevent Acanthosis Nigricans? 

Maintaining a healthy weight might prevent Acanthosis Nigricans.

Dermopathy

What Is Diabetic Dermopathy?

Diabetic dermopathy, a harmless condition, is likely the most common skin problem in people who have had diabetes for a while, or whose blood sugar levels have remained high.

What Causes Diabetic Dermopathy?

One factor that influences the onset of diabetic dermopathy stems from the length of time you have had diabetes. Elevated blood sugar levels, and in some cases, trauma or injury might set off the condition.

What Are the Symptoms of Diabetic Dermopathy?

The first signs of diabetic dermopathy appear as a small, brownish-red, scaly area of skin with a round or oval shape and flat top level with the rest of the skin. Later, the area becomes depressed, causing the dermopathic patch to appear as a small dent. Most commonly, it appears on the shins, although it can also appear on the forearms, sides of the feet, and thighs.

How Can You Treat Diabetic Dermopathy?

Diabetic dermopathy heals itself eventually, although the redness might remain.

How Can You Prevent Diabetic Dermopathy?

Because some researchers see a link between prolonged elevated blood sugars and diabetic dermopathy, you can help protect yourself by keeping your blood sugar levels within the range your doctor recommends.

Diabetic Blisters

What Are Diabetic Blisters?

Diabetic blisters are also called bullosis diabeticorum or diabetic bullae. They can sometimes develop in people with diabetes, although the condition is relatively rare. Only about one-half of one percent of those with diabetes is ever diagnosed with diabetic blisters.

The blisters often appear on the legs and arms and seem to appear for no reason. In most cases, when they disappear, they do not leave scars.

What Causes Diabetic Blisters?

There is no single known cause for diabetic blisters. Many of those who have diabetic blisters may also have neuropathy and nephropathy. Some researchers think that a decreased ability to sustain an injury may play a role. And in people with heart failure, the swelling that can result from that condition may be enough to cause the blisters.

Many people who develop the diabetic blisters have had diabetes for many years or have several complications from the disease.

What Are the Symptoms of Diabetic Blisters?

Most commonly, the blisters appear on the legs and feet. Rarely, you may also notice them on your fingers or the backs of your hands. You might go to bed one night with no blisters, wake up, and notice them.

The blisters tend to be large and irregularly shaped. Sometimes, they look like a burn. They are commonly clear and contain sterile liquid.

You might feel a burning sensation or a twinge of discomfort, but many people do not feel anything - other than a bit of surprise at seeing the blisters where there were none before.

How Are Diabetic Blisters Treated?

In many cases, the blisters heal by themselves, within two to four weeks, and no treatment is needed other than keeping them clean.

On occasion though, the blisters may burst. If this happens, your doctor may prescribe an antibiotic ointment or something to help dry the blister.

If the blister becomes infected or develops an ulcer, it will be treated more like a wound. Antibiotics may be used. In very severe cases, skin may need to be debrided (removed) to help the healing process.

How Can Diabetic Blisters Be Prevented?

Keeping your blood sugar levels within the range recommended by your doctor may help prevent many complications of diabetes, including diabetic blisters.

If you do get blisters, however, they may re-occur.

Dry Skin

What Is Dry Skin?

Dry skin is just as the name implies: skin that feels drier than normal. Many people have dry skin on occasion and it can be particularly severe in colder climates.

What Causes Dry Skin?

Living in a winter climate where the air is dry can cause dry skin. So too, can over-bathing. Basically, anything that draws moisture out of your body can cause dry skin.

People with diabetes are especially prone to dry skin because of changes in blood sugar levels. High blood sugar makes your body lose fluid and this can dehydrate your skin.

Perspiring can help keep your skin moist, but if you have neuropathy, you may sweat less and your skin can become dry.

What Are the Symptoms of Dry Skin?

If you have dry skin, you will be able to see it and feel it.

Particular symptoms often include:

  • Itchiness
  • Flaking of skin
  • Fine lines or cracks in the skin

How Is Dry Skin Treated?

Dry skin is most often treated with creams to keep the skin moist. Some researchers suggest that oil-based creams are better at trapping moisture than those that are water-based.

In the event of very dry skin, your doctor may prescribe a special cream.

How Can Dry Skin Be Prevented?

There are several steps you can take to keep your skin from becoming too dry.

  • Use a moisturizer regularly. Some research suggests that moisturizers containing a combination of urea and lactic acid (alpha hydroxy acid) can be beneficial.
  • Keep your blood sugar levels within the range recommended by your doctor.
  • Drink plenty of water each day.
  • Use warm - not hot - water when you shower or bathe, and do not stay in too long.
  • Dry yourself thoroughly after bathing
  • Avoid deodorant or antibacterial soap that may dry your skin.
  • Avoid smoking since this can dry your skin.
  • Put a humidifier in your house during winter if you have radiators or forced air heat.

Eruptive Xanthomatosis

What Is Eruptive Xanthomatosis?

A harmless skin reaction that looks like small bumps, eruptive xanthomatosis might indicate that you have high cholesterol. You must treat high cholesterol, since it puts you at risk for atherosclerosis.

What Causes Eruptive Xanthomatosis?

Eruptive xanthomatosis results from poorly controlled blood sugar levels. It can also occur when your level of triglycerides (a form of fat) are elevated. Triglycerides exist normally in your body, but also come from food high in sugar, such as candy, honey and alcohol. Often, people with high triglycerides have high LDL, the "bad" cholesterol.

If you are insulin resistant, your body struggles to clear fat from your blood stream, and this can raise your triglycerides.

What Are the Symptoms of Eruptive Xanthomatosis?

Eruptive xanthomatosis usually appears on the shoulders, the buttocks or along the surfaces above the muscles that help you move your joints. On rare occasions, it can occur in your mouth.

Often the itchy, tender, pea-size bumps appear reddish-yellow.

How Can You Treat Eruptive Xanthomatosis?

Eruptive xanthomatosis often disappears by itself within a few weeks. However, you should still seek treatment because of the condition's strong association with high levels of triglycerides.

Treatment involves getting your triglyceride, cholesterol and blood glucose levels under control. Doing so might require the use of lipid-lowering drugs (such as statins like Lipitor® or Zocor®) or fibrates (such as TriCor® or Lopid®).

How Can You Prevent Eruptive Xanthomatosis?

Keep your blood sugar levels in the range recommended by your doctor. Limit your intake of sugar and alcohol - both of which can raise your triglycerides level.

Necrobiosis Lipoidica Diabeticorum

What Is Necrobiosis Lipoidica Diabeticorum? 

A skin condition called Necrobiosis Lipoidica Diabeticorum (NLD) occurs when collagen breaks down, deposits of fat build up and the blood vessel walls thicken.

As a chronic condition, NLD might progress slowly and might sometimes scar the skin. The condition might not bother you for a while, and other times it might flare up.

What Causes Necrobiosis Lipoidica Diabeticorum? 

Researchers do not know the exact cause of Necrobiosis Lipoidica diabeticorum. However, some studies indicate a possible connection between NLD and damage to small blood vessels that might result from diabetes.

Other theories point to possible causes such as inflamed blood vessels, antibodies or metabolic changes.

What Are the Symptoms of Necrobiosis Lipoidica Diabeticorum? 

NLD appears as a rash most often on the lower legs, but some people might notice it on their face, torso, scalp or arms.

In the beginning, the rash might appear reddish-brown with fairly well-defined borders. Over time, the lesions might grow larger and turn shiny and red, sometimes developing a yellow center. Eventually, the lesion develops into a purplish depression in the skin.

Sometimes, NLD itches and hurts; but many people report no symptoms other than the rash.

How Can You Treat Necrobiosis Lipoidica Diabeticorum? 

As long as the lesions of the rash do not break open, NLD does not usually require treatment. Your doctor might ask you to rest your legs occasionally and protect them with elastic support stockings. He or she might also recommend that you take a baby aspirin each day.

Treating NLD can be tricky. During a flare up, some people find relief using a topical cream that contains cortisone and covering the area with a sterile dressing. Others find that cortisone injections can help.

Some researchers have found that treating the area with ultraviolet light can control NLD during flare-ups. In some cases, doctors might prescribe steroids such as prednisone.

Trauma to the affected area might cause ulcers to form, and these do need treatment. If this occurs, see your doctor.

How Can You Prevent Necrobiosis Lipoidica Diabeticorum? 

Since people with diabetes face a greater chance of developing NLD than those without diabetes, it makes sense to control your disease. To do this, keep your blood sugar levels within the range recommended by your doctor.

Skin Care

People with diabetes need to pay special attention to their skin. Higher blood glucose causes reduced fluids in the body, and so your skin can become dry and even cracked. This can lead to itchiness, sores and infections. You are more susceptible to infections because of circulation problems. You may also notice a reduction in sweat caused by neuropathy. Sweat normally keeps your skin moist and soft.

Here are some tips for the care of your skin:

  1. Wash with a mild soap and lukewarm water, and pat your skin dry with a soft cloth. Be sure to dry between skin folds. Avoid rubbing, and scratching or bruising your skin.
  2. Use a moisturizing lotion after bathing to reduce dry skin.
  3. Pay special attention to your legs, feet, and elbows where they skin may be drier and likely to crack. Examine your skin for any marks or sores particularly that are not healing.
  4. Wash all sores and cuts with soap and water and cover with a bandage. Call your doctor if a cut is not healing, feels hot or looks red or swollen, or produces drainage.
  5. Wear cotton underwear and socks.
  6. Wear gloves when you are working, dress appropriately for warm and very cold weather.
  7. Use a sunscreen of SPF of 15 or higher to protect your skin in the sun.
  8. Drink adequate amounts of fluid, and continue to strive to keep your blood glucose as controlled as possible.

Thick Skin

What Is Thick Skin?

If you develop skin that has thickened over time, you might have either scleroderma diabeticorum or digital sclerosis.

In each condition, the skin might feel thicker and, in some instances, look rough or pebbled.

What Causes Thick Skin?

Some research suggests that people with diabetes might generally have thicker skin in some areas than people without diabetes. However, this does not mean they have either scleroderma diabeticorum or digital sclerosis.

Elevated blood sugar levels seem to be the major cause of skin that thickens over time.

About Scleroderma Diabeticorum

Scleroderma literally means hard skin. If you develop this condition, the skin on your upper back and the back of your neck gets thicker. This relatively rare condition can involve inflammation, blood vessel damage, and changes in your immune system.

Another condition, called sclerederma, includes tightness that might also extend to your upper arms.

About Digital Sclerosis

Digital sclerosis makes the skin on your digits (fingers and toes) and your hands and feet become thicker. 
The skin might also feel tight and rather wax-like. You might also experience stiffness in your finger joints.

How Can You Treat Thick Skin?

For either condition, moisturizing lotion might help the skin feel softer and less tight. Staying well hydrated by drinking plenty of water might also help.

If you feel stiffness from digital sclerosis, finger-stretching exercises might help limber things up.

How Can You Prevent Thick Skin?

To give yourself the best protection against either of these conditions, keep your blood sugar levels within the range that your doctor recommends.

Vision Problems

Eye Disease

What Is Diabetic Retinopathy?

Diabetes damages the small blood vessels in the retina (the lining at the back of the eye that senses light). Diabetic retinopathy can lead to poor vision and even blindness.

Two types of retinopathy exist, each varying progressively in severity:

  1. Non-proliferative diabetic retinopathy, or background retinopathy, can be mild, moderate or severe. In the earliest stage, a microaneurysm, or small swelling in a blood vessel occurs. Usually no symptoms occur. At the moderate stage, some blood vessels can become blocked. Then, at the severe stage, more vessels get blocked and begin to deprive the retina of the blood it needs.

  2. Proliferative diabetic retinopathy, a more advanced and severe form of the disease, occurs when badly damaged blood vessels close off. In response, abnormal and fragile blood vessels begin to grow in the retina and even within the vitreous. These new blood vessels can burst and bleed, which causes blurred vision.

Some people with retinopathy will also experience macular edema, a condition in which fluid leaks into the macula, the part of the eye responsible for sharp vision. In these instances the macula swells with fluid, creating blurred vision.

What Causes Diabetic Retinopathy? 

Retinopathy is caused when damage is done to the tiny blood vessels of the retina. The damage can cause blood vessels to weaken and swell, or get clogged. Over time, if left untreated, retinopathy may cause blood to seep into the vitreous, making it more difficult for light to reach the retina.

You face a greater chance of retinopathy occurring earlier and being more severe if you do not keep your blood sugar levels and blood pressure under control.

How Do You Know If You Have Diabetic Retinopathy? 

Only an eye exam by an eye care professional can discover whether you have diabetic retinopathy.

Not everyone with retinal damage experiences symptoms. Often, though, one of the first symptoms of diabetic retinopathy is poor night vision.

Other symptoms may include:

  • Seeing "floaters" or spots in front of your eyes
  • Blurred vision
  • Double vision
  • Seeing rings or flashing lights in the front of your eyes
  • Pain or pressure in one or both eyes
  • Difficulty seeing out of the corners of your eyes
  • Blindness

If you experience any of these symptoms, let your doctor know right away.

How Do You Treat Diabetic Retinopathy? 

Only a small percentage of people with diabetic retinopathy will experience serious vision problems. Getting an annual eye exam offers the best protection against vision loss by detecting problems early, thus making treatment more effective.

Treatment during the non-proliferative stages of retinopathy involves controlling your blood sugar levels and blood pressure. Of course, you'll still need an eye exam each year, and perhaps more often.

Although nothing cures proliferative retinopathy, treatment can help. And when the treatment is timely, there is less than a five percent chance of becoming blind (in five years).

Treatment involves a type of laser surgery called scatter laser treatment that shrinks the newly grown, abnormal blood vessels. The treatment might cause some loss of peripheral vision, but it can save the rest of your sight. Treatment works best before the abnormal vessels have begun to bleed - a good reason to ensure you get an annual eye exam.

If the bleeding has started, laser treatment might still be an option. With severe bleeding, however, treatment might consist of a vitrectomy. This surgery removes blood from the center of your eye, thus minimizing damage caused by the disease.

How Do You Treat Macular Edema? 

Like proliferative retinopathy, macular edema also uses laser surgery for treatment. The surgery slows down the fluid leak and reduces the amount of fluid in the retina. You might need more than one surgery. 

What Complications Develop With Diabetic Retinopathy? 

In addition to the risk of blindness from untreated retinopathy, other complications exist as well.

Although anyone can get glaucoma (a build-up of pressure within the eye), complications from retinopathy can increase the risk. If abnormal vessels begin to grow in the colored part of the eye (the iris), glaucoma may result. Daily eye drops can help reduce pressure in the eye.

Another complication can happen if the new blood vessels in the retina cause scar tissue to grow. This can detach the retina from the back of the eye. If this happens, you might see flashing lights or floating spots, or feel as if you are only seeing part of what you're looking at. Should this happen, see a doctor immediately.

How Can You Prevent Diabetic Retinopathy? 

If you have just been diagnosed with diabetes, get your eyes examined as soon as possible. The doctor can check for any early damage and get a baseline reading of your visual health.

Because you can treat retinopathy when detected in a timely manner, and because it seldom has symptoms, it is imperative that you get a yearly eye exam and more frequently if your doctor suggests it.

To minimize your chances of retinopathy, control your blood sugar, blood pressure, and cholesterol by keeping these levels as close to normal as possible and, don’t smoke.

What Is Diabetic Retinopathy?

Diabetes damages the small blood vessels in the retina (the lining at the back of the eye that senses light). Diabetic retinopathy can lead to poor vision and even blindness.

Two types of diabetic retinopathy exist, each varying progressively in severity:

  1. Non-proliferative diabetic retinopathy, or background retinopathy, can be mild, moderate or severe. In the earliest stage, a diabetic retinopathy microaneurysm, or small swelling in a blood vessel occurs. Usually no symptoms occur. At the moderate stage, some blood vessels can become blocked. Then, at the severe stage, more vessels get blocked and begin to deprive the retina of the blood it needs.
     
  2. Proliferative diabetic retinopathy, a more advanced and severe form of the disease, occurs when badly damaged blood vessels close off. In response, abnormal and fragile blood vessels begin to grow in the retina and even within the vitreous. These new blood vessels can burst and bleed, which causes blurred vision.

Some people with retinopathy will also experience macular edema, a condition in which fluid leaks into the macula, the part of the eye responsible for sharp vision. In these instances the macula swells with fluid, creating blurred vision.

What Causes Diabetic Retinopathy?

Damage to the tiny blood vessels of the retina cause retinopathy. The damage can cause blood vessels to weaken and swell, or get clogged. Over time, if left untreated, retinopathy may cause blood to seep into the vitreous, making it more difficult for light to reach the retina.

You face a greater chance of retinopathy occurring earlier and being more severe if you do not keep your blood sugar levels and blood pressure under control.

Infections

Dental Care

It is very important to see your dentist regularly. People with diabetes are more susceptible to periodontal disease because increased blood glucose enhances the level of bacterial in the mouth. Other factors can add to this problem such as poor diet, smoking, and even medications. Periodontal disease can be chronic or acute, and so your dentist is checking for problems with the gums and bone that support your teeth. 

What are symptoms of periodontal disease? Your gums may bleed when your brush or floss, are red, swollen and tender. The gum may be pulled back from your teeth, and even your teeth are loose. You may have bad breath that doesn’t go away.

Caring for your teeth and gums:

  1. Keep your blood glucose in the target range!
  2. Brush your teeth twice a day, and even after you eat.
  3. Use dental floss daily.
  4. See your dentist every six months and remind him/her you have diabetes.
  5. If you wear dentures, keep them clean, and rinse your mouth with mouthwash.
  6. Call your dentist if you notice any of the above symptoms.

Infections

What Are Infections?

Infections happen to everyone, but people with diabetes may be more susceptible to complications from infections than others.

Infections occur when pathogens like bacteria or fungi invade a part of the body and begin multiplying. This process can - but does not always - lead to tissue injury or an eventual disease.

Infections can occur on your skin, on your feet, in your kidneys, and on or in your gums.

A host of other possible infections exist, such as:

  • Urinary tract infections, which commonly occur in women with diabetes. Treatment with antibiotics usually clears up the infection.
  • Kidney infections, such as pyelonephritis, often accompanied by severe pain in the side.
  • Pneumonia, which may occur more severely in people with diabetes.
  • Mucormycosis, a serious, rare, fungal infection that can cause pain in the eyes or face and spread quickly through the nervous system and into the brain.

What Causes an Infection?

Diabetes might slow down the ability of your body to fight infections.

When your blood sugar measures high, the level of sugar in body tissues increases. This helps bacteria grow quickly, which in turn, can lead to infections. Because the blood sugar of many people with diabetes often fluctuates, they face an increased chance of developing infections.

Also, diabetes sometimes damages small blood vessels, increasing the likelihood of developing infections of the organs and soft tissues. Researchers are investigating other relationships between infection and diabetes.

What Are the Symptoms of an Infection?

The signs of an infection often depend on the location of the infection. Some of the more common symptoms include:

  • Warm, red, swollen patches of skin
  • Skin rash
  • A wound, cut, or sore that doesn't heal
  • Fever over 101° F
  • Sweating or chills
  • White patches in the mouth or on the tongue
  • Nausea, vomiting, or diarrhea
  • Flu-like symptoms or just feeling "lousy"
  • Vaginal itching
  • Pain or burning with urination

How Can You Treat Infections?

Because so many different infections could develop, a wide variety of treatments exist. Your doctor will identify your best treatment options depending on your particular infection.

How Can You Prevent Infections?

  • Keep your blood sugar levels in the range your doctor recommends so as to limit the amount of sugar that builds up in your tissues.
  • Wash your hands regularly to avoid spreading germs.
  • Keep your kitchen and bathroom - where lots of germs gather - clean and disinfected.
  • Take any prescription drugs as prescribed.
  • Avoid over-using antibiotics to give them a better chance to work when you really need them.
  • Avoid injury and trauma as best you can.
  • Check you feet each day. Look for any sores, blisters, or cuts, and let your doctor know if you find any.
  • After bathing, check your body for any signs of an infection, such as swollen areas, redness, or discharge where it does not belong.

Hyperglycemia & Hypoglycemia

Hyperglycemia

What Is Hyperglycemia? 
Hyperglycemia means high blood sugar or high blood glucose. It can develop when your body creates too little insulin, or when it does not properly use the insulin that it does make.

High blood sugar causes many of the complications that can accompany diabetes. To minimize your risk of complications, it is very important to keep your blood sugar levels as normal as possible.

What Causes Hyperglycemia? 

Hyperglycemia can occur for a number of reasons, including:

  • Eating too much food or consuming too many calories for the amount of insulin you take
  • Forgetting to take your diabetes medication
  • Illness or infection
  • Not exercising enough - or even exercising too much if your blood sugar is already high (usually more than 300 mg/dL)
  • High levels of stress

How Do You Know If You Have Hyperglycemia? 

Because high blood sugar levels do not always cause symptoms, test your blood sugar level often to know for sure.

Sometimes though, symptoms do occur, including:

  • Increased thirst
  • More frequent urination
  • Weight loss
  • Headaches
  • Difficulty concentrating
  • Blurred vision
  • General tiredness

If your blood sugar stays high, and if you urinate often, you can become dehydrated. If this happens, you might need medical care to provide your body with extra fluids.

How Can You Treat Hyperglycemia? 

The best way to treat hyperglycemia is to prevent it by checking your blood sugar levels before it happens.

However, if your blood sugar levels do run high, you can treat this condition in a variety of ways.

  • Drink more water.
  • Exercise — but check your blood sugar level first. If it measures more than 300 mg/dL do not exercise, since doing so might increase your blood sugar level.
  • You might also need to make other changes, such as changing the amount of food you eat, changing your medications, or even changing when you take those medications. Talk with your doctor to find what will work best for you.

How Can You Prevent Hyperglycemia? 

Test your blood sugar often to make sure it stays in your normal range.

Follow your meal plan to the best of your ability, and eat at regular and consistent meal times.

If you are taking diabetes medicine, remember to take it as prescribed. It is also important to let your doctor know what other medicines you take.

Also, speak with your doctor about whether you need to adjust your exercise routine.

Finally, if your blood sugar levels often run high, talk with your doctor. He or she may need to adjust your medication.

Hypoglycemia

What Is Hypoglycemia? 

Low blood sugar or low blood glucose is the condition when your blood glucose levels are below 70mg/dl. Early signs are hunger, shakiness, sweating, and may progress to slurred speech and confusion. A sign of emergency is seizure and coma. Medical intervention is necessary. People with type 1 diabetes are more likely to have these experiences, and may have a glucagon emergency kit because they are dependent on insulin. 
People with type 2 diabetes may also have hypoglycemic episodes if taking certain medications and skipping meals, or exercising more than usual. If these episodes happen often, talk with your healthcare provider to adjust your medications.

What Causes Hypoglycemia? 

Hypoglycemia means your body does not have enough sugar. This can happen if you skip meals, delay them or eat too little. It can also happen if you take too much insulin or certain diabetes medications. It can happen if you take some other drugs while taking your diabetes medicine and it can even happen if you exercise more than normal. 

Diabetes Medications 

Sometimes the medicine you take for diabetes can help cause low blood glucose. Some of the medicines include:

  • Insulin (too much of it)
  • Sulfonylureas (like Glucotrol, Micronase, Glynase, or Amaryl)
  • Meglitinides (like Prandin or Starlix)
  • Diabinese (chlorpropamide)
  • Orinase (tolbutamide)
  • Tolinase (tolazamide)
  • Alpha-glucosidase inhibitors (like Glyset and Precose), thiazolidinediones (like Actos or Avandia), or biguanides (like Metformin or Glucophage) should not cause low blood sugar by themselves. But, if you take them with other diabetes medicines, they might.

Other drugs that can cause low blood sugar while taking diabetes drugs can include:

  • Alcohol
  • Aspirin
  • Benemid or Probalan (probenecid)
  • Coumadin (warfarin)
  • Zyloprim (allopurinol)

Diet and Exercise 

Exercise usually lowers blood sugar levels. Test your blood sugar before exercising, and then a few minutes after. If below 100 mg/dL, take a snack. You should not drive unless your blood sugar is 100 mg/dl or higher. Some people do best with a light snack before exercise, which can prevent post-exercise lows. If the exercise is prolonged, stop and check your blood during exercise and you may need a drink with carbohydrate.

Medical conditions 

Sometimes other medical conditions along with your diabetes can cause low blood glucose. For instance, if you experience certain kidney problems, your insulin might last longer than usual and cause a low blood sugar reaction.

Some medical conditions (such as thyroid problems, hormone deficiencies, certain tumors, or stomach surgery) can also lead to low blood glucose levels even if you do not have diabetes.

How Do You Know If You Have Hypoglycemia? 

If your blood glucose level dips below 70 mg/dL you might or might not feel symptoms. The symptoms can vary from one person to another, and each person's symptoms can differ. In general, though, you might feel:

  • Confused
  • Dizzy or light-headed
  • Hungry
  • Nervous, shaky, or trembling
  • Anxious or weak
  • Irritable
  • Sleepy

You might also experience:

  • A headache
  • Sweaty skin
  • Pale skin
  • Pounding heart or fast pulse
  • Trouble speaking
  • Poor coordination

Low blood sugar can occur whether you are awake or asleep. If you are sleeping and your blood sugar gets too low, you could:

  • Have nightmares, or cry out in your sleep
  • Feel cranky, tired, or confused when you wake up
  • Notice that your sheets or nightclothes are damp from sweat

How Can You Treat Hypoglycemia? 

If you think you have low blood glucose, check your level with a blood glucose meter. If your blood level measures 70 mg/dL or less, use a "fix-it-now" food to raise the level. Check your blood sugar level again in 15 minutes. If it is still low, eat another serving of a fix-it-now food.

Fix-It-Now Foods (15 grams of carbohydrate - fast acting)

  • 2 or 3 glucose tablets (found at most drug stores)
  • 1 tube of glucose gel (found at most drug stores)
  • 4 - 6 pieces of hard candy (NOT sugar-free)
  • 1/2 cup (4 ounces) fruit juice
  • 1 cup (8 ounces) skim milk
  • 1/2 cup soft drink (NOT sugar-free or diet)
  • 1 or 2 teaspoons of sugar, honey, or corn syrup

Rule of 15

It is common when feeling so shaky and lightheaded, to overreact and take too much carbohydrate. Then your blood sugar will run high for a day or so. The Rule of 15 is: test blood glucose. If below 80 mg/dl, take 15 grams of carbohydrates and wait 15 minutes. Test again and if still low, take another 15 grams of carbohydrates. Continue taking 15 grams and checking after 15 minutes until blood glucose gets to 100 mg/dl. Then, get a hearty snack with carb and protein, like a peanut butter sandwich, or cheese and crackers. When treating the low blood sugar, it is important to consume simple sugars that can quickly get to your blood stream. The glucose tablets and gels are designed for this purpose. If not available, 15 grams of sugar such as 4 oz. regular soda or juice is a good choice. Protein and fat at this point will only slow the recovery. After recovery - get a hearty meal or snack!

How Can You Prevent Hypoglycemia? 

Follow your meal plan the best you can and eat at regular times. Talk with your doctor about whether you need to adjust your exercise routine. Also, let your doctor know what other medicines you take.

If you often have low blood sugar, talk with your doctor. He or she may need to adjust your medication. Your doctor might also suggest eating more balanced meals full of whole grains or perhaps eating smaller meals more often during the day.

Periodontal Disease

Periodontal Disease

What Is Periodontal Disease?

Periodontal disease, also called gum disease, occurs when plaque builds up between the teeth and gums, creating a bacterial infection. If you do not treat the infection, the plaque can destroy the bones and gums around the teeth. Sometimes, if you have had diabetes for a while and your blood sugar has been high, you face a greater risk for periodontal disease.

Recent studies indicate that having gum disease might increase your risk of atherosclerosis, heart disease, and kidney disease in people with type 2 diabetes.

Many people experience gingivitis, an inflammation of the gums. Treating it early can help prevent the gum disease from progressing to periodontitis, a more severe form of periodontal disease that requires more care.

What Causes Periodontal Disease?

Plaque, a colorless and very sticky substance, constantly forms on our teeth and tries to attack the enamel of the teeth. Plaque results from the breakdown of carbohydrates (sugars and starches). If plaque builds up too much, it hardens (i.e., calcifies), resulting in periodontal disease.

People with diabetes are more susceptible to periodontal disease because of increased and varying blood sugar levels that affect the level of bacteria in the mouth. But, other risk factors of the disease also exist, including:

  • A diet that lacks healthy nutrients, especially vitamin C
  • Genetics
  • Tobacco use
  • Autoimmune or systemic diseases, such as some herpes viruses or HIV
  • Constant clenching of the teeth
  • Hormonal change
  • Some medications, such as phenytoin or cyclosporine

What Are the Symptoms of Periodontal Disease?

Symptoms of periodontal disease might include gums that:

  • Bleed when you brush or floss
  • Are swollen, red, or tender
  • Seem to have pulled back from your teeth
  • Your teeth loosen or separate
  • Your dentures, if you wear them, do not fit quite right
  • You have bad breath that does not go away
  • Pus forms between your gums and teeth
  • The way you bite might have changed, indicating a realignment of your jaw

How Can You Treat Periodontal Disease?

Your dental professional will perform a procedure called scaling and root planing to remove the plaque. Think of it as a type of very deep cleaning of your teeth and gums.

Scaling scrapes the plaque off your teeth both above and below the gum line. Root planing smooths any rough spots on your teeth where bacteria might get stuck.

Some people might need to take antibiotics. You might also need to use an antimicrobial mouthwash to help keep your mouth clean and minimize the bacteria.

Often, your dentist will recommend that you get your teeth cleaned every three months if you have periodontal disease. This decreases the chance that plaque will cause more infections.

Some people do not respond to the root planing and scaling, and thus the periodontal disease persists. In these cases, the dentist might recommend a type of gum surgery.

How Can You Prevent Periodontal Disease?

You can help minimize your risk for periodontal disease by following these steps:

  • Test your blood sugar often to make sure it is in your normal range
  • Brush and floss your teeth at least twice each day
  • Use toothpaste that contains fluoride
  • Eat a healthy, balanced diet that is low in sugar
  • Avoid using tobacco
  • Visit your dentist regularly to get your teeth cleaned

Ketoacidosis

Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a serious complication of diabetes that can lead to diabetic coma or even death. DKA occurs when dangerously high levels of ketones (acids) accumulate in the blood. But, if caught early, it is very treatable.

Not too long ago, it was believed that DKA only happened to people with type 1 diabetes. Since then, it has been discovered that it can also occur in people with type 2 diabetes as well, particularly in African American and Hispanic populations.

But researchers have also discovered that DKA very rarely strikes without warning, but it can develop quickly, within 24 hours. Almost always, something else occurs first to set it off.

What Causes Diabetic Ketoacidosis?

DKA in type 2 diabetes seems to occur when there is less insulin available in the body and more glucagon (a hormone that helps maintain blood sugar levels) and other hormones. This combination results from reaction in the body to stress from a major infection such as a urinary tract infection; a severe illness such as pneumonia; or an interruption in the blood supply such as that which causes a heart attack.

When too little insulin is available, the amount of glucose in the bloodstream increases and speeds up the breakdown of fat. As the fat breaks down, the body increases the amount of glucagon and fatty acids, which then turn into ketones. Too many ketones can poison the body and lead to diabetic ketoacidosis.

What Are the Symptoms of Diabetic Ketoacidosis?

If you have been ill or have had an infection, DKA can develop, so watch for these signs:

  • Dehydration and increased urination
  • Nausea and vomiting for no apparent cause
  • Fruity-smelling breath
  • Deep, rapid breathing, punctuated by frequent sighs
  • Rapid heart beat
  • Confusion
  • Blood sugar of 300 mg/dl
  • Ketones in the urine

If you do not treat DKA quickly, it can lead to a coma and even death.

How Can You Treat Diabetic Ketoacidosis?

Ask your doctor if you can do anything to treat DKA at home.

To treat DKA quickly, doctors use a saline solution to promote hydration, a small dose of insulin to raise insulin levels, and intravenous potassium to restore potassium levels.

If you have type 2 diabetes and have experienced diabetic ketoacidosis, your doctor might place you on insulin therapy to ensure your body maintains adequate levels. Then, once your blood sugar levels fall within the recommended range, your doctor might try to replace the insulin with a diabetes pill.

How Can You Prevent Diabetic Ketoacidosis?

Find out if you have diabetes, and if you do, monitor your blood sugar levels and keep them in the range recommended by your doctor. If you are ill, stressed, had surgery or injured, check your blood glucose more frequently. Check ketones in your urine.

Nerve Damage

What Is Diabetic Neuropathy?

Diabetic neuropathy, a complication of diabetes, damages the nerves in your body. It occurs most commonly in people living with diabetes for many years and people with frequent and/or extended high blood sugar levels.

Four types of neuropathy exist: peripheral, autonomic, proximal and focal.

  • Peripheral neuropathy, the most common type, can cause either pain or numbness in the toes, feet, legs, hands and/or arms.
  • Autonomic neuropathy affects nerves that control involuntary vital functions such as the heart muscle, smooth muscles like your stomach, blood vessels, glands and sexual organs. Autonomic neuropathy can also affect your blood pressure levels, your digestion, bladder and bowels, and even your sexual response.
  • Proximal neuropathy can affect your hips, thighs or buttocks - usually on one side. It can also lead to weakness in your legs.
  • Focal neuropathy can appear suddenly and often weakens one nerve or a group of nerves. It appears most often in the head, leg or torso.

Most neuropathies develop in stages. In the beginning, pain or tingling might come and go. Later, the pain can be more pronounced and occur more often. Eventually, the pain might go away because the nerve cells have died. If this occurs, you face a greater risk of injury simply because you cannot feel pain in the damaged area.

What Causes Diabetic Neuropathy?

Decreased blood flow to the nerves can cause damage. And, although a major cause of diabetic neuropathy points to prolonged bouts of high glucose levels, researchers think the cause might actually involve a combination of factors which include:

  • Metabolism, such as duration of diabetes, abnormal blood fat levels, and high blood sugar levels
  • Factors affecting the blood vessels and capillaries that transport needed nutrients and oxygen to the nerves
  • Inflammation of the nerves caused by autoimmune factors
  • Mechanical injury to nerves, carpal tunnel syndrome
  • Genetic susceptibility to nerve disease
  • Use of alcohol and/or tobacco

How Do You Know If You Have Diabetic Neuropathy?

Symptoms of neuropathy often develop gradually, and they can differ depending on the type of the condition. 

Some of the more common symptoms include:

Peripheral

  • Numbness or tingling in the arms or legs, often worse at night
  • Decreased (or loss of) sensation to a body part, such as arm, leg, hand, or foot
  • Burning sensation
  • Pain
  • Changes in your normal walk
  • Slower reflexes

Autonomic

  • Diarrhea
  • Constipation
  • Loss of bladder control
  • Increased urination at night
  • Impotence
  • Decreased vaginal lubrication
  • Bloating or feeling full after eating
  • Heartburn
  • Nausea
  • Vomiting
  • Fainting or dizziness
  • Low blood pressure
  • Difficulty swallowing

Focal

  • Drooping of the face, eyelid, or mouth
  • Vision changes
  • Abdominal or chest pain

Proximal

  • Leg weakness
  • Pain in the thigh, hips, legs, or buttock area
  • Difficulty moving from a seated to standing position

If your health care provider suspects you have diabetic neuropathy, he or she will likely conduct blood and imaging tests like an MRI to rule out other possibilities.

How Can You Treat Diabetic Neuropathy?

Nerve damage can progress if left untreated. To prevent the progression, you must keep your blood glucose levels under control. Doing so can help alleviate symptoms and lessen neuropathy progression. Sometimes, losing weight and exercising can reduce the symptoms.

Specific treatment methods often focus on reducing the discomfort caused by neuropathy.

Some people find some relief by using aspirin, acetaminophen or ibuprofen, especially when used regularly throughout the day. Topical treatments like lidocaine, capsaicin or Ben Gay might also provide temporary relief. Pain management techniques such as acupuncture, hypnosis or biofeedback might also help.

On occasion, prescription drugs might help some people as well. Some respond to certain antidepressants like Elavil, which can take a few weeks to begin working. Others find gabapentin (Neurontin), which blocks nerve signals, helpful.

If your muscles grow weak, you might need splints for additional support.

Researchers are also studying the effects of other drugs and treatments to help relieve the symptoms. Clinical trials that look at early diagnosis and better management are going on and might provide new information for improved treatments.

What Are the Complications of Diabetic Neuropathy?

Nerves do not grow back. If the pain of neuropathy turns into numbness, the nerve cells have died. If this happens, the numbness will not go away. This lack of sensation can increase your risk of injury and infections in the affected areas.

In addition, autonomic neuropathy can make you unaware if your blood sugar measures low. This highlights the importance of testing your blood glucose levels regularly.

How Can You Prevent Diabetic Neuropathy?

Keeping your blood sugar levels within the range set by your healthcare provider might forestall neuropathy.

In addition, take good care of your feet and legs if you have peripheral neuropathy. Doing so can minimize your risk of complications.

  • Clean your feet each day, and dry them thoroughly — even between the toes. Apply moisturizing lotion if your skin looks or feels dry.
  • After the cleaning, examine your feet and legs. Look for swelling, calluses, cuts, blisters or redness, and tell your doctor if you find any.
  • Cut and trim your toenails regularly. Go to a foot doctor or podiatrist if you need help.
  • Wear shoes or slippers that let your toes move. Use this footwear at all times in order to prevent injury. 

What is Gastroparesis?

Gastroparesis is a condition related to the nerves of the digestive system. Diabetes can damage the nerves so that the stomach empties irregularly, perhaps too fast or more commonly, too slow. The vagus nerve controls the movement of food through the digestive tract, and high blood sugars over time can affect its ability to function normally.

Symptoms may be mild, or severe. They include: heartburn, nausea, vomiting undigested food, lack of appetite, gastroesophageal reflux, early feeling of fullness, weight loss. This alteration of stomach emptying can make blood glucose levels erratic.

There are specific medical tests that are conducted to diagnose gastroparesis. Treatment may include a special diet of foods that are more easily digested so the stomach empties properly. Medications can be effective. In severe cases, a new device called a Gastric Neurostimulator, or a pacemaker, can be implanted in the abdominal wall to normalize digestive function.

Kidney Disease

Nephropathy

What Is Nephropathy? 

Nephropathy, or kidney disease, can result as a complication of diabetes. Diabetes is the most common cause of kidney failure. It occurs when the kidneys do not function properly and cannot rid the body of waste.

Kidneys work on many levels. They clean our blood by removing waste and protein, along with excess fluids and minerals. They also make hormones that target bones and blood cells, keeping each strong and healthy. When the kidneys do not work properly, blood pressure can rise, causing poor waste management in our body and diminishing our ability to create red blood cells.

What Causes Nephropathy? 

High blood pressure can significantly contribute to the development of kidney disease. And, kidney disease itself can create high blood pressure, thus creating a cyclical effect. Factors that lead to diabetic nephropathy include heredity, diet and other medical conditions such as high blood pressure.

High blood sugar levels, another cause of nephropathy, can cause the kidneys to filter too much blood. Over time, this overworks the kidneys and might cause protein and waste to leak into the urine.

A small amount of protein in the urine (called microalbuminuria) signals the beginning of kidney disease. At this stage, early diagnosis can lead to treatment that can help prevent the disease from worsening.

If the disease goes unnoticed until large amounts of protein leak into the urine (called macroalbuminuria), end stage renal disease (ESRD) often follows. Treatment of ESRD requires a kidney transplant or kidney dialysis.

How Do You Know If You Have Nephropathy? 

Kidney disease usually produces no symptoms until damage has already occurred. However, a check of protein levels in your urine or of waste products in your blood can alert your doctor if kidney problems exist.

The first symptom of kidney disease is often fluid build-up.

Other symptoms of kidney disease might include:

  • Difficulty sleeping
  • Poor appetite or upset stomach
  • Nausea and vomiting
  • Difficulty concentrating
  • Swelling, most often around the eyes when you wake up, but later, the legs or entire body may swell
  • Weight gain from fluid build-up
  • Extra frothy urine
  • Tiredness
  • Headache
  • Itchiness
  • Frequent hiccups

How Do You Treat Nephropathy? 

The goals of treatment are to slow the progression of kidney damage and control related complications. Even a slight rise in blood pressure can make kidney disease worsen, so it is important to keep your blood pressure under control. To help do this, exercise regularly, lose weight, eat less salt, and eliminate the use of alcohol and/or tobacco. If your doctor prescribed blood pressure medication, take it regularly as directed.

Several major studies indicate that ACE inhibitors, such as enalapril or captopril, help slow down kidney disease while lowering blood pressure. Other important studies suggest that diuretics can help. A low-protein diet might also help, but talk with your doctor before you begin.

If nephropathy damaged your kidneys so badly that they no longer function, you will require kidney dialysis or a kidney transplant.

If you choose hemodialysis, you will first need surgery to create a place (often in your forearm) from which an artificial kidney (called a dialyzer) can take blood from the body. During hemodialysis, blood goes to the dialyzer to clean out waste, after which the machine returns healthy blood back into the body. You will need hemodialysis two or three times per week (usually performed at a clinic), with each session lasting three to five hours.

Another type of dialysis, called peritoneal dialysis, enables you to do the procedure yourself at home after you have been trained. This allows some greater flexibility, but also requires the ability to see well and follow procedures accurately.

Unless kidney transplantation is an option, once you begin dialysis, you might need it for lifelong therapy.

No matter what course of treatment you and your doctor choose, it is still important to follow your meal plan and diabetes treatment. Also, remember to keep your blood sugar levels as close to normal as possible.

How Can You Prevent Nephropathy? 

Keep your blood pressure under control, and take care of your diabetes.

Keeping your blood sugar levels under control can reduce your risk of developing microalbuminuria. If your urine already contains some protein, keeping your blood sugar under control can reduce your risk of developing macroalbuminuria.

Stroke

Stroke

What Is a Stroke?

A stroke occurs when an area of the brain does not get enough oxygen and nutrients. Strokes can cause a variety of problems, including weakness or paralysis, difficulty speaking or thinking, and emotional difficulties.

The American Diabetes Association says that two out of three people with diabetes die from stroke or heart disease. Taking care of your diabetes can help reduce that risk.

What Causes Stroke?

The most common type of stroke occurs when blood vessels become blocked or damaged, which in turn may cause a clump of blood cells, or a clot, to form. The clot narrows the vessels, making it more difficult for oxygen-rich blood to get through and nourish the brain. This type of stroke accounts for up to 85 percent of all strokes in the United States.

If the blockage in the vessel lasts for just a few moments, this temporary condition is called a transient ischemic attack (TIA) or mini-stroke.

Although less common, an aneurysm can also cause a stroke. This occurs when a balloon-like bulge (aneurysm) exists in an artery. If the vessel bursts and bleeds into the brain, a stroke occurs.

A top risk factor for stroke includes diabetes because of the circulation problems associated with the disease. In fact, in people newly diagnosed with type 2 diabetes, the risk of stroke is double that of the general population. People under age 55 face an even greatest risk.

Certain conditions increase your risk of stroke, including:

  • Smoking (this doubles your risk)
  • Being overweight, especially around the middle (i.e., men with a waist measurement of more than 40 inches and women more than 35 inches).
  • High blood pressure
  • Abnormal blood cholesterol levels, especially high LDL or "bad" cholesterol and low HDL or "good" cholesterol.
  • A personal or family history of stroke or TIA.

How Do You Know If You Are Having a Stroke?

Typically, a stroke or TIA comes on suddenly. When it occurs, you might be unable to call emergency help. Make sure the people you live with also know the warning signs so they can call for you.

Symptoms of a stroke can vary among individuals, but common warning signs can include:

  • Sudden weakness or numbness of the face, arms or legs, on one side of your body
  • Sudden change in mental awareness; being confused or having difficulty understanding others
  • Trouble talking
  • Loss of balance, dizziness, or difficulty walking
  • Double vision
  • Problems seeing normally out of one or both eyes
  • Severe headache

If you are having a stroke, it is imperative to get treatment right away to avoid permanent damage. Call 911 if you experience the warning signs.

If the symptoms disappear within a few minutes, it might be a TIA. If you suspect you have had a TIA, talk with your healthcare provider.

How Can You Prevent a Stroke?

You can take charge and reduce your risk of stroke by keeping your blood sugar levels within a normal range and making a few lifestyle changes. Every change will make a difference.

  • Do not smoke
  • Eat a heart-healthy diet - one high in fiber and low in saturated fat, Trans fat and cholesterol
  • Exercise often
  • Control your blood pressure, and get it checked often
  • Eat a low sodium diet - 2,300 mg sodium or less
  • Get your cholesterol levels checked, and aim for an LDL of less than 100 mg/dL (or even less than 70 mg/dL if you face greater risk)
  • Ask your doctor about taking an aspirin each day as preventive therapy

How Can You Treat a Stroke?

Prompt treatment of a stroke might minimize damage and boost chances for a strong recovery.

A drug called tPA can dissolve clots that cause strokes. But, in order for it to be effective, you must take it within the first three hours following the initial stroke symptoms.

Researchers are looking into other drugs, some of which show promise at stopping, or even reversing, the damage caused by stroke. These newer drugs also appear to work best when administered immediately after a stroke.

People with other medical conditions, such as recent heart surgery, cannot take tPA. In these cases, the Merci Retrieval System might be used. This surgical procedure uses a corkscrew-like device to pull the clot out of the brain to restore the blood flow. This procedure can work effectively up to eight hours after initial symptoms.

Some patients who experience a stroke might also need surgery to treat the blocked blood vessels.

Carotid endaterectomy removes the plaque inside the carotid artery to help improve the blood flow.

Carotid stenting uses a balloon-like tube to open the artery. A wire or mesh tube called a stent is then inserted to help keep the artery open.

Angioplasty (the widening of arteries) can also be performed on the cerebral arteries.

Doctors might recommend bypass surgery for people who have had several TIAs. This would re-route a good artery to the area of the brain that does not receive enough oxygen.

After a stroke

You will probably need some rehabilitation therapy after a stroke to help relearn skills and restore function. Physical, occupational, and/or speech therapy might help, as well as psychological counseling. You might also need to make some lifestyle changes to prevent additional strokes.

Foot Problems

Foot Care

People with diabetes need to take special care with their feet. Infections of the feet can be hard to heal, and could ultimately lead to amputation. Why are you more susceptible to foot problems? High blood glucose provides bacteria the fuel to grow on. Feet are difficult to keep clean, and easy to injure. Bacteria can get into a sore from your shoe rubbing or a nick with the toe clipper or a cut on your sole and multiply fast. Your ability to fight infection is also decreased by high blood glucose, as well as reduced circulation. You may also have peripheral neuropathy, which affects the nerves of your feet with tingling or numbness, so that you may not be aware of a cut or blister on your foot. If a foot sore goes untreated, it can quickly become a problem. It is estimated that more than half of the amputations are caused by preventable infection complications.

Tips for Keeping Your Feet Healthy:

  • Check your feet every day. Use a mirror to see the bottom of your feet, and look between your toes. If this is difficult, ask a family member or friend to check for you. 
  • Treat any skin break by washing with soap and water and an antibacterial cream and a small bandage.
  • Clean your feet daily with warm water and soap, not hot water. Do not soak your feet. Because of decreased sensations, you are susceptible to burning your skin.
  • Use a moisturizer to avoid dry skin and calluses, but don’t let it accumulate between your toes. Be sure to dry between your toes.
  • Be careful with the care of toenails and corns and calluses. You can irritate or break the skin easily, and risk infection. Use an emery file for toenails, not scissors. Never cut corns or calluses, see your foot doctor instead.
  • Avoid walking barefoot, even at home. 
  • Buy cotton socks, and shoes that are comfortable and don’t rub the skin. Break new shoes in slowly.
  • Increase blood flow to your feet by walking more.
  • Take your shoes and socks off when you go to a doctor appointment and have the nurse or doctor check your feet.

Diabetes and Foot Care

  • Take the pressure off your feet by losing weight if you are obese
  • Inspect your feet at least once per day; if you can't see well, ask someone to do it for you
  • Wash feet with mild soap and lukewarm water daily
  • Wear white cotton socks rather than synthetic ones with dyes
  • Don't go barefoot or wear ill-fitting shoes
  • See a podiatrist regularly for toenail trims and other routine maintenance
  • Avoid plastic and waterproof footwear, as they encourage perspiration and fungal growth
  • Avoid tight or unventilated footwear
  • Do not wear boots all day
  • Choose cotton or leather footwear
  • Wear sandals as much as possible in the warm weather
  • Do not wear the same footwear two days in a row
  • Air footwear in the sun to help prevent fungal growth

Believe it or not, socks are a critical defense against keeping blisters away from your feet. Throw out any cotton socks you have, as they retain sweat and can help form blisters. Purchase socks made of today's "miracle fabrics," which absorb sweat and prevent blisters from forming on your feet.

Check your feet for cuts, blisters, and swelling that can result from diabetes-related nerve damage. Call your healthcare provider right away if you have sores that won't heal.

Don’t wear high heels, sandals, or shoes with pointed toes. These types of footwear can put undue pressure on parts of the foot and contribute to bone and joint disorders, as well as diabetic ulcers. In addition, open toed shoes and sandals with straps between the first two toes should also be avoided.

Never try to remove calluses, corns or warts yourself. Commercial, over-the-counter preparations that remove warts or corns should be avoided because they can burn the skin and cause irreplaceable damage to the foot of a person with diabetes. Never try to cut calluses with a razor blade or any other instrument because the risk of cutting yourself is too high, and such wounds can often lead to more serious ulcers and lacerations. See your podiatric physician for assistance in these cases.

Erectile Dysfunction

Erectile Dysfunction with Diabetes - 9 Healthy Habits to Help Prevent and Control Erectile Dysfunction

One of the most neglected areas in diabetes education is the topic of men’s sexual health. As a diabetes educator, before each consult I like to ask what topics my patients would like to discuss. Over time I have come to the conclusion that erectile dysfunction (ED) needs discussion but only very few men are ready to discuss it. In the last few minutes of a consult if it is brought to my attention, bam! This is where the questions start! I have made it my policy to bring it up myself because left to the end of a consult there is hardly any time for understanding. As a very important subject we need to discuss erectile dysfunction so every man can have a starting place to approach the topic with his healthcare team.

What is Erectile Dysfunction?

The National Institutes of Health defines erectile dysfunction (ED) as: “the persistent inability to achieve or maintain penile erection sufficient for satisfactory sexual performance. A period of persistence over three months has been suggested as a reasonable clinical guideline.”(1) When men with diabetes grow older, the problem of ED usually develops earlier than in those without diabetes. After age 50 estimates are as much as 50-60 percent of men with diabetes have this problem increasing to as much as 95 percent of men that are over 70 years of age. (2)

9 Prevention and Possible First Steps
Unfortunately, by the time men think about the topic, the window for prevention of ED may be gone. The following are recommended steps to take to prevent ED, but may also be first steps in helping to control ED. Make sure you discuss ED with your healthcare professional and discuss an individualized plan to help with prevention.

1. Stop smoking! If you never did then don’t start. Smoking can lead to narrowing of the arteries which can be a precursor of ED. (3,4,5,6) A meta-analysis study was conducted in 2013 evaluating the risk of ED between smokers vs. non-smokers. The total numbers of participants included in the studies was 28,586. Conclusions included the ED risk was increased by 51 percent for current smokers and 20 percent for ex-smokers compared with men that never smoked. The analysis also showed that when a smoker quits, the risk of ED may decrease. (7)

2. Don’t drink more than two alcoholic drinks per day. More than this can lead to reduction in blood flow and may affect testosterone levels. Proper testosterone levels help sex drive and erections. (4,5,6)

Many men are under the impression that a drink can be any size. Standards for the size of a drink are as follows:

  • 12 ounces of a beer or wine cooler
  • 8 ounces of malt liquor
  • 5 ounces of table wine
  • 1.5 ounces of 80 proof distilled spirits such as gin, vodka, whiskey, etc. (8)
     

3. According to a primary report published in the Journal of Sexual Medicine (2009), ED is commonly seen in heroin, amphetamine and Ecstasy users. (9)

4. Have a frank discussion with your physician and pharmacist about all medications you take (prescription and non-prescription). Ask if any have ED side effects and if so, can they be changed. Make sure you take all medications as prescribed. (3)(4) A list of medications that may cause problems can be found at nlm.nih.gov, Medline Plus publication.

Important: Do not stop or change any medications without consulting your physician! 

5. Maintain a healthy weight. (3,4,5) Losing as little as five percent of body weight when obese can help improve problems with ED. A study involving 31 type 2 obese men with diabetes published in 2011 found that an eight-week low-calorie prescribed diet resulted in rapid reversal of ED in some experiencing a weight loss of five percent. (10)

6. Have a regular exercise routine approved by your healthcare team and stick to it! (3,4) Ask your physician if you can have a prescription to see a physical therapist to learn proper procedures for pelvic floor exercises. In one study, participants with ED over the age of 20 underwent such therapy for three months. In the group that exercised, over 75 percent of participants showed improvement or regained normal erectile function. 

7. Preventing and controlling high blood pressure and limiting sodium intake, will decrease ED (5,6). People with diabetes are encouraged to follow the recommendations of The American Heart Association and the dietary guidelines for Americans of no more than 1,500mg of sodium per day (12,13). These recommendations were put in place to help control the increase of blood pressure that happens with aging and to help control increases that have already occurred.

8. Take steps to avoid high cholesterol as it can harden or block arteries all over the body including those needed for sexual function. (6) It is thought that successful treatment of high cholesterol can help to reduce ED. It is also important to note that ED is a risk factor for heart attack and stroke. Men with ED should make sure they ask their physicians to be screened for heart disease. (13)

9. Those with diabetes need to stay under good control. (3,4) According to Diabetes New Zealand: “Men with type 1 diabetes are more likely to experience impotence at an earlier age (this is because they have usually had diabetes for a longer period of time). Men who have type 2 diabetes (which usually develops in adulthood) may not experience the problem until later in life. If your diabetes is out of control, this can lead to temporary impotence.” (14) Treatment for those with diabetes includes improving blood sugar levels.

As you can see, ways to avoid ED include many healthy habits. Please do not be afraid to talk to your physician about this important issue.

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Erectile Dysfunction with Diabetes - Causes, Therapies and 5 Questions to Help You Have a Meaningful Discussion with Your Physician

There are many factors that contribute to Erectile Dysfunction (ED). Men with diabetes suffer with ED more frequently and at a younger age than those without diabetes. There are two kinds of medical specialists that should be included on your medical team if you suffer from ED. One is your endocrinologist (to discuss if there is a hormonal problem). The other specialist is an urologist (a doctor that specializes in the urinary tract of men and women and the reproductive system of men). (1) Know that ED is a very common problem in men who have diabetes. To get the proper diagnosis and treatment, ED must be discussed. This article contains possible causes and therapies for ED. Discussion will include hormones, medications, devices and surgery. Questions to ask your physician will be included to help you become comfortable in talking about ED with your medical team.

According to the National Kidney and Urologic Diseases Information Clearinghouse, ED is often caused by a physical disease or injury. (2) As mentioned in the previous section, potential reasons can also include side effects from medication. In men with diabetes the cause of ED can be complicated. Side effects from diabetes can include problems with nerves, blood vessels and muscle function which can contribute to ED. (3) Hormonal imbalances also need to be addressed.

The steps involved in treatment for ED may include filling out a screening form to gather information about your history and problems. The doctor most likely will want to perform a physical examination. Blood may be drawn to test for abnormal hormone levels as well as systemic diseases. Your doctor may also want to know if you have erections that occur during sleep and discuss any psychological reasons that may be contributing to Erectile Dysfunction. (2)

5 Questions for Your Doctor about ED:

Question 1: Could my ED be a hormonal problem? Do I have low testosterone, high prolactin, a problem with my thyroid or any other hormonal imbalances involved?

Altered levels of many hormones may contribute to ED. Testosterone, prolactin and thyroid hormone are among the hormones that may be involved.

Testosterone

It is thought that low levels of testosterone without other risk factors affects less than five percent of men but it can contribute to ED in men with other risk factors. (4) Testosterone levels in many individuals decline with age.

The Endocrine Society’s Clinical Guidelines (2010) recommends offering testosterone therapy to men who have low levels and ED after evaluating for causes of ED and consideration of established therapies. There are some men in which testosterone therapy is not recommended even if testosterone is low. These include men with high hematocrit values, heart failure, untreated sleep apnea and those with high risk of prostate cancer as well as other conditions. (5)

According to the American Diabetes Association, men with type 2 diabetes are twice as likely to have a deficiency of testosterone as men without diabetes. (6) The Urology Care Foundation estimates that 50 percent of men with diabetes will develop low testosterone levels. (7) When testosterone therapy is needed and prescribed in men with type 2 diabetes, it may help with ED and studies also show insulin sensitivity is increased and resistance is lowered by as much as 25 percent. (8) Not all men with ED and diabetes that take testosterone will become functional. (9) Please consult with your physician to see if testosterone is a possibility for you. Do not forget to discuss benefits as well as potential side effects of taking this hormone.

Prolactin
Prolactin is a hormone that is made in the pituitary gland of both males and females. It is thought to have more than 300 functions in the human body. (10) High levels of prolactin are sometimes found in men with low testosterone levels. In men, the most common symptom of prolactinoma (high prolactin levels) is erectile dysfunction. (11) Ask if there is a problem with your body making too much prolactin.

Thyroid Hormones
Studies have shown that ED is very common with both hyperthyroidism and hypothyroidism, which can be a problem with too much thyroid hormone or too little thyroid hormone. It is suggested that if there is a thyroid dysfunction, this should be treated before undergoing any specific treatment for ED. Normalizing thyroid hormones, if abnormal, may be appropriate treatment needed for ED. (12)

Question 2: Would a medication advertised for ED such as Cialis, Viagra, Levitra, Staxyn, or Stendra help me with sexual function or would there be a potential problem if I was prescribed one of these medications?

Oral medication may be part of an ED treatment plan for men with diabetes that is under control. The drugs that are currently available include; Cialis, Viagra, Levitra, Staxyn, and Stendra. Using one of these drugs as prescribed by ones physician may help approximately 50-60 percent of men with diabetes. (13) Not everyone with diabetes should use these medications. Please be careful and use a reputable pharmacy to obtain your order. If you get your medications from a pharmacy online, make sure that it is certified by the National Association of Boards of Pharmacy. Go to the Verified Internet Pharmacy Practice Sites (VIPPS) program to check on your pharmacy provider. This is to make sure you are getting the correct medication and it is not counterfeit. If you are in a country where one or more of these medications do not need a prescription, make sure you have permission to use the medication from your physician, review what would be a safe dose and when you can safely use it. Discuss how the medication may react with other medications and food. Please discuss with your doctor and pharmacist any contraindications you may have to these medications.

Question 3: Are there injection treatments for ED?

When oral medications do not work, sometimes Alprostadil, which is approved by the Food and Drug Administration (FDA), can be used. This medication is injected with a small needle. A man will need to be able to do this or the man’s partner will need to be trained. An auto-injector is also available to make injection easier. Instruction needs to take place under your physician’s guidance. This medication may also be prescribed using a devise that inserts the medication into the urethral opening instead of using a needle.

Question 4: Are there any devices, pumps or vibrators that are recommended?

Devices that use vacuum pressure to aid with erection are an option for some men. There are some devices that are FDA approved which limit the amounts of pressure allowed to help prevent possible injury. It is not recommended to acquire a device without discussing the options and being counseled by your physician. Be wary of companies that sell devices that are not FDA approved as these could potentially cause bodily harm. Pumps come in both manually and battery operated versions. FDA approved devices have a safety feature to limit pressures inside of the chamber used.

The FDA has also approved the use of a battery-operated device called the “Viberect.” This device, which is available only through prescription from your doctor, uses vibration to help develop an erection.

Question 5: Am I a candidate for surgery to help resolve my ED? If so can you review my options and tell me the benefits and risks?

There are different types of surgery for ED that may be possibilities for some men:

Penile Prostheses

Penile prostheses devises are implanted in the body by a surgeon usually in the hospital. There are two kinds to discuss with your doctor: 

  • The first kind consists usually of flexible cylinders that are inflated with fluid to get an erection. Fluid can be removed and stored in an abdominal reservoir.
  • The second is a malleable prosthesis. This type of prostheses is always rigid. It can be placed in the proper position for body functions such as intercourse and urination. Infections are noted in approximately one-third of surgical procedures for ED.

Vascular Reconstructive Surgery

When an artery is blocked for proper erectile function to happen, this type of surgery may be suggested. The surgeon takes an artery from the abdomen to bypass the blockage that inhibits blood flow. This surgery has a success rate in younger men with a single blockage of 50-75 percent, but unfortunately in older men results have only been successful five percent of the time.

Vein Ligation Surgery

This procedure is considered when veins leak and erections are not maintained. Veins are blocked surgically to aid in function. This procedure is not considered successful long-term and is not widely available in the United States.
 
There are many herbs and supplements that promise to help with ED. Remember not to take any supplements or herbs without first discussing possible adverse effects with your physician. Some substances may have dangerous side-effects and may also interfere with prescribed medications. An article from the University of Maryland discusses problems with some of the supplements including Yohimbe, Viramax, Gamma-Butyrolactone, L-arginine, DHEA and Spanish Fly.

The American Urological Society (AUS) also has statements and recommendations about herbs and supplements for ED. They do not recommend the use of herbal supplements. According to AUS, the only supplement identified so far that may potentially be of benefit for ED is Korean Red Ginseng. While promising, the efficacy of this supplement still needs to be validated by large clinical trials. Due to the lack of these trials and insufficient data available, not even this supplement is recommended. (14)

As you can see there are many kinds of therapies available to help with erectile dysfunction. Please do not be afraid to talk about this very important issue with your physician. We at DiabetesCare.net hope the information provided in our ED series will benefit you in discussions with your doctor and healthcare team.
 
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