World Diabetes Day

World Diabetes Day (WDD) is celebrated every year on 14th November to mark the birthday of Frederick Banting who, along with Charles Best, was instrumental in the discovery of insulin in 1921, a life-saving treatment for diabetes patients. The World Diabetes Day campaign is led by the International Diabetes Federation (IDF) and its member associations, which engages millions of people worldwide in diabetes advocacy and awareness. The theme for World Diabetes Day for 2009-2013 is ‘Diabetes Education and Prevention’ and this long-term theme will allow all diabetes stakeholders to take part in the campaign to make World Diabetes Day a global success. The World Health Organization projects that the number of diabetics will exceed 350 million by 2030. At least 50% of all people with diabetes are unaware of their condition and in some countries this figure may reach 80%. Up to 11% of India’s urban population and 3% of rural population above the age of 15 have diabetes. But the good news is that up to 80% of type-2 diabetes is preventable by adopting a healthy diet and increasing physical activity.

About World Diabetes Day. World Diabetes Day (WDD) is celebrated every year on November 14. The World Diabetes Day campaign is led by the International Diabetes Federation (IDF) and its member associations. It engages millions of people worldwide in diabetes advocacy and awareness. World Diabetes Day was created in 1991 by the International Diabetes Federation and the World Health Organization in response to growing concerns about the escalating health threat that diabetes now poses. World Diabetes Day became an official United Nations Day in 2007 with the passage of United Nation Resolution 61/225. The campaign draws attention to issues of paramount importance to the diabetes world and keeps diabetes firmly in the public spotlight. This year sees the first of a five-year campaign that will address the growing need for diabetes education and prevention programmes. World Diabetes Day is a campaign that features a new theme chosen by the International Diabetes Federation each year to address issues facing the global diabetes community. While the themed campaigns last the whole year, the day itself is celebrated on November 14, to mark the birthday of Frederick Banting who, along with Charles Best, first conceived the idea which led to the discovery of insulin in 1922. Diabetes Education and Prevention is the World Diabetes Day theme for the period 20092013. The campaign slogan for 2009 is "Understand Diabetes and Take Control". Diabetes is difficult. The disease imposes life-long demands on the 285 million people now living with diabetes and their families. People with diabetes must deliver 95% of their own care, so it is of paramount importance that they receive ongoing, high-quality diabetes education that is tailored to their needs and delivered by skilled health professionals. In addition, IDF estimates that over 344 million people worldwide are at risk for type 2 diabetes. Type 2 diabetes can be prevented in the many cases by helping and encouraging those at risk to maintain a healthy weight and take regular exercise. The key messages for everyone are: • •

Know the diabetes risks and know the warning signs Know how to respond to diabetes and who to turn to

•

Know how to manage diabetes and take control

Where is it celebrated? World Diabetes Day is celebrated worldwide by the 212 member associations of the International Diabetes Federation in more than 160 countries and territories, all Member States of the United Nations, as well as by other associations and organizations, companies, healthcare professionals and people living with diabetes and their families.

How is it marked? The global diabetes community including International Diabetes Federation member associations, diabetes organizations, NGOs, health departments, civil society, individuals and companies develop an extensive range of activities, tailored to a variety of groups. Activities organized each year include: • • • • • • • • • • • • • • •

Radio and television programmes Sports events Free screenings for diabetes and its complications Public information meetings Poster and leaflet campaigns Diabetes workshops and exhibitions Press conferences Newspaper and magazine articles Events for children and adolescents Monument lightings Human blue circles Walks Runs Cycle Race Political Events

Is there a theme? Each year World Diabetes Day is centred on a theme related to diabetes. Topics covered in the past have included diabetes and human rights, diabetes and lifestyle, and the costs of diabetes. Recent themes include: 2005: Diabetes and Foot Care 2006: Diabetes in the Disadvantaged and the Vulnerable 2007-2008: Diabetes in Children and Adolescents 2009-2013: Diabetes Education and Prevention

The World Diabetes Day logo

The World Diabetes Day logo is the blue circle - the global symbol for diabetes which was developed as part of the Unite for Diabetes awareness campaign. The logo was adopted in 2007 to mark the passage of the United Nations World Diabetes Day Resolution. The significance of the blue circle symbol is overwhelmingly positive. Across cultures, the circle symbolizes life and health. The colour blue reflects the sky that unites all nations and is the colour of the United Nations flag. The blue circle signifies the unity of the global diabetes community in response to the diabetes pandemic. DIABETES Overview of Diabetes Diabetes is a life-long disease marked by high levels of sugar in the blood. It can be caused by too little insulin (a hormone produced by the pancreas to regulate blood sugar), resistance to insulin, or both. Glucose, a form of sugar in the blood, acts as the main source of fuel for our body. It is created when our body breaks down food that we eat into energy with the help of insulin. Insulin acts like a key to unlock the body's cells, so glucose can enter and serve as fuel for the cells. This process helps to regulate the amount of sugar in the bloodstream. In people with diabetes, however, the pancreas either produces little or no insulin or the cells do not respond appropriately to the insulin that is produced causing blood sugar level to rise. High blood sugar sets off processes that can lead to complications like heart, kidney, and eye disease or other serious problems.

Symptoms of Diabetes

The symptoms are due to persistent high levels of sugar in the circulating blood:        

Maternal age of over 25 years. Family history of diabetes. Overweight women. A previous child with birth defects or history of unexplained still birth. Recurrent bladder or urinary tract infections. A prior baby weighing more than 3.75 kg/9 pounds. Race factor - African American, American Indian, Asian American, Hispanic/ Latino and Pacific Islander. Smoking.

Symptoms  Frequent urination (Polyuria).  Extreme thirst (Polydipsia).  Increased hunger (Polyphagia).  Blurry vision.  Weight loss.  Fatigue.  Nausea/Vomiting.  Frequent fungal or bacterial infections like skin infection or UTI (Urinary Tract Infection).  Poor wound healing - High blood sugar resists the flourishing of the white blood cell. Secondly, long standing diabetes leads to thickening of blood vessels which may affect proper circulation of blood in different body parts.  Loss of libido or erectile dysfunction.  Pruritus vulvae (itching of vulva) in females or balanitis (inflammation of the glans penis) in males.

Types of Diabetes

Type 1 Diabetes - This type of diabetes is an autoimmune disease. Your immune system turns on itself and destroys the insulin-producing cells in your pancreas. Although type 1 diabetes usually develops in childhood or teen years, it can appear later. It is also known as Insulin Dependent Diabetes Mellitus (IDDM) as dependence on exogenous insulin is a must to sustain life.

Type 2 Diabetes - Typically, with type 2 diabetes, the body still makes insulin but its cells can't use it. This is called insulin resistance. Over time, high levels of sugar build up in the bloodstream. Being overweight and inactive increase the chances of developing type 2 diabetes. This is also called known as Non Insulin Dependent Diabetes Mellitus (NIDDM) as this can be managed by medications or Insulin doses as prescribed for the individual cases. A compulsory dependency on exogenous insulin is not a must here.

Gestational Diabetes - This type of diabetes occurs in some pregnant women. In gestational diabetes, your body doesn't effectively use the insulin you produce. The cause may be metabolic changes that occur due to the effects of hormones in pregnancy. Gestational diabetes usually disappears after pregnancy but more than half of women who experience it eventually develop permanent type 2 diabetes.

Risk Factors of Diabetes

Some of the factors that increase the risk of Diabetes:        

Family history. Age (especially after age 45). Poor diet . Obesity and fat distribution. Sedentary lifestyle. Stress. Hypertension. Abnormal cholesterol levels.

Complications:  Diabetic ketoacidosis (a life-threatening complication characterized by characterized by high blood sugar, acidosis and high levels of ketone bodies).  Retinopathy (impaired vision).  Cataract (clouding that develops in the crystalline lens of the eye).  Nephropathy (renal failure).  Peripheral neuropathy (sensory loss and motor weakness).  Autonomic neuropathy (postural hypotension, gastro-intestinal problems).  Foot diseases like ulcerations and arthropathies (joint complains).  Coronary complains like myocardial ischaemia or infarction (heart attack).  Neurological complaints like stroke or coma.  Peripheral complaints issues like claudication (cramping pains in the legs) and ischaemia (reduced blood supply to the muscles).

Investigations

Several different types of blood glucose tests are used. They are:

    

Fasting blood sugar (FBS). 2-hour postprandial blood sugar (2-hour PC). Random blood sugar (RBS). Oral Glucose Tolerance Test (OGTT). Glycated Haemoglobin (%HbA1c).

People with diabetes should aim for an HbA1c value below 7%. The goal for average preprandial glucose should be 90 -130 mg/dl and for average bedtime glucose levels should be 110 - 150 mg/dl.

Some other tests used for diabetes patients:  Blood lipid levels - to learn the total cholesterol, HDL (high density lipid), LDL (low density lipid) and triglyceride as this is another important index of the overall metabolic control in the diabetic patients.  Urine test to detect the presence of glucose, proteins and ketones in urine.  Dilated Eye Exam: With diabetes, high blood sugar damages tiny blood vessels in the retina.  Foot Exam: Diabetes can cause numbness due to nerve damage and patient may not notice if they injure a foot as pain sensation is altered due to the nerve damage.

Management:  Diet Planning: Diet management is essential in a diabetic for restoration of normal glucose and optimal lipid levels. A diet plan that includes right foods in moderate portions and at regular times is very essential for a diabetic. Maintenance of blood glucose level close to physiologic levels is important to prevent onset or progression of complications. Incase of juvenile diabetes, maintenance of normal growth rate in children and adolescents as well as for the attainment and maintenance of reasonable body weight a planning of diet is vital. In gestational diabetes, diet management is very crucial for provision of adequate nutrition for the health of pregnant women and the developing baby.  Exercise: Regular exercises will help in the maintenance of desirable body weight as well as to loose extra weight, if any. This will also improve the sense of well being and enhance social interactions. It will also enhance insulin sensitivity, improve glucose control, decrease triglycerides and increase HDL cholesterol levels which are good for health. This will over all improve cardiac performance.  Medications: Besides, a planned diet and regular exercise regime, it is very essential to take the prescribed medications. The medications for diabetes management are oral hypoglycemic agents and /or Insulin injections prescribed depending on the individual blood glucose levels.  Glucose Levels: Regular monitoring of blood glucose levels is very important in the over all health management of a diabetic.  Follow-ups: It is also very essential to follow up regularly with your doctor and do the needed investigations for prevention or early detection and treatment of any diabetes complications.  Habits: If a diabetic person is a smoker or an alcoholic then quitting is the only solution to save from the development of complications.

Diabetes – Myths & Facts Diabetes – Myths & Facts

Diabetes is a contagious disease…Eating too much of sugar causes Diabetes…If you have Diabetes then you can never eat sugar…If you don't have a family history of Diabetes then you will never get Diabetes…Insulin cures Diabetes…and the list goes on.

Can you differentiate between the myths and facts related to diabetes? If no, then you are the one amongst those diabetics who is lost in the huge list of these myths. So, get yourself acquainted with the diabetes facts so that the next time you can decide what is right for your health.

Some Common Myths & Facts…

Myth: Eating too much sugar causes diabetes.

Fact: Diabetes is not caused by eating too much sugar. Type 1 diabetes is caused by a destruction of the insulin-producing cells of the pancreas, which is not related to sugar consumption. Type 2 diabetes results from the body's inability to respond to insulin normally. The tendency to get type 2 diabetes is genetically inherited in most cases. With a guided exercise regime and following a planned diet, the average person can eat sweets in limited quantities.

Myth: Diabetes is a contagious disease.

Fact: Diabetes is not contagious. Diabetes is an endocrine disease and is caused due to problem with the amounts of insulin produced by the beta cells in the pancreas. Diabetes tends to have an inherited trait that runs in families.

Myth: If you are a diabetic then you can never eat sugar again.

Fact: The management of carbohydrate intake (not just sugar) is a critical part of diabetes management as diabetes affects the entire body. Diabetics can eat sweets, but sugary treats must be part of a careful meal plan along with a balanced medication and exercise regime. This will help you keep your blood sugar levels near normal, feel healthy and prevent long term complications.

Myth: Children with diabetes can never eat sweets.

Fact: Children having diabetes can eat a certain amount of sugary food as part of a balanced diet, but they need to control the total amount of carbohydrates intake, which includes sugary treats. As sweets provide no real nutritional value other than calories, they should be limited but not necessarily eliminated.

Myth: If you are good in maintaining your blood glucose levels and if you feel fine then you don't have to go for check ups.

Fact: High or low blood sugar doesn't always produce symptoms. Regular monitoring is the only way to know your blood sugar levels. Diabetes is always serious. You need to take proper medications along with appropriately planned diet and exercise. You may be good in maintaining it but that is no reason to escape regular health checkups.

Myth: If you are good in maintaining your blood glucose levels and if you feel fine then you don't have to go for check ups.

Fact: High or low blood sugar doesn't always produce symptoms. Regular monitoring is the only way to know your blood sugar levels. Diabetes is always serious. You need to take proper medications along with appropriately planned diet and exercise. You may be good in maintaining it but that is no reason to escape regular health checkups.

Myth: Diabetics can feel whether their blood sugar levels are high or low.

Fact: There is no way for sure that will tell you your blood glucose levels except for testing them. A person with diabetes may feel physical symptoms (such as extreme thirst, weakness, or fatigue) if blood sugar levels are high or low. But some people may not show symptoms when their blood glucose is too high or low. And also as some of the symptoms of high and low blood glucose are similar, it may be difficult to know what these symptoms mean. The only way to be sure is to check your blood glucose levels.

Myth: High blood sugar levels are normal for some people and they aren't really a sign of diabetes.

Fact: High blood sugar levels are never normal. Certain conditions and certain medications may temporarily raise the blood sugar levels in people without diabetes. But people who have higher than normal blood sugar levels or sugar in their urine should be checked for diabetes by a doctor.

Myth: It's possible to have just ‘slight' diabetes.

Fact: There is nothing like ‘slight' diabetes. Either you will have diabetes or you won't. Any diabetic condition (type-1 or type-2) demands medical attention and careful lifestyle choices.

Myth: If you don't have a family history of diabetes then you won't get it.

Fact: Diabetes tends to be an inherited trait that runs in families. It increases the chances of some people of developing diabetes than the others. But plenty of people diagnosed with the disease don't have a family history of diabetes. Weight and lifestyle are factors playing a major role in someone acquiring diabetes.

Myth: Diabetes is not easy to control.

Fact: Diabetes is metabolic disorder which is not curable. But it can be controlled when patients properly manage their meals, exercise, and take the right medications. With the proper guidance and education, patients can prevent and/or minimize many of the more serious complications that diabetes causes.

Myth: Insulin cures diabetes.

Fact: Diabetes is a metabolic disorder and diabetes is not a curable disease. Taking insulin helps in managing diabetes, but does not cure it. Insulin helps in utilizing the glucose in the body to be used for producing energy. This helps in keeping the blood sugar levels under control, but taking insulin doesn't correct the underlying cause.

Myth: All people with diabetes need to take insulin always.

Fact: All people with type 1 diabetes have to take insulin injections as their pancreases don't produce insulin. Some, but not all, people with type 2 diabetes have to take insulin with or without pills to manage their blood sugar levels as advised by their physician.

Myth: Tablets or pills for diabetes are a form of insulin.

Fact: Diabetes medicines taken orally are not a form of insulin. Insulin is a protein that would be broken down or destroyed by the acids and digestive enzymes in the stomach and intestines if taken orally. Insulin is delivered via injections, inhalers or patches but not orally.

Myth: Taking more insulin means your diabetes is getting worse.

Fact: Many factors affect blood sugar levels like diet, exercise, and also, the time of the day. Therefore, insulin doses are required to be continuously adjusted to help a person keep his or her blood sugar levels in a healthy range. Your doctor will guide you with the right insulin dosages.

Myth: Children can outgrow diabetes.

Fact: Children never outgrow diabetes. In cases of type 1 diabetes, the cells of the pancreas that produce insulin are destroyed. Once they are destroyed, they will never produce insulin again. Kids with type 1 diabetes will always need to take insulin (until a cure is found). Although in kids with type 2 diabetes, an improvement in their blood sugar levels may be seen after puberty or with lifestyle adjustments, they will probably always have a tendency toward having high blood sugar levels, especially if they are physically inactive or gain too much weight.

Taking Control of Diabetes Taking Control of Diabetes Diabetes can bring about many changes, but the most important thing to remember is that you are in control! Making small changes in the way you manage diabetes and how you eat and live can bring about a healthier future.

Having a sick day? Illness, such as a cold or flu, can cause serious problems with your diabetes control. Because everyone reacts differently to illness, talk to your doctor or diabetes educator about the best ways to manage your diabetes when you are sick. Here are some general guidelines:

 Always take your diabetes medication, even if you are not eating. Check the dosage with your doctor.  Check your temperature four times a day.  Drink plenty of calorie-free liquids (8 to 12 ounces per hour).  Check your blood glucose every four to six hours and record results.  If you can't eat your meals, drink regular liquids (with sugar) and try eating crackers, toast, soup, hot cereal, juices, milk, eggs, etc.

How to care for your feet? Your feet need special attention because diabetes can reduce the body's ability to sense problems. By checking your feet daily, you can detect blisters, calluses or cuts and act to prevent bugger problems. Follow these guidelines for healthy feet:             

Wash your feet every day. Dry them, even between toes. Get your feet checked at every doctor's visit. See a foot doctor for nail and foot care. Inspect feet daily - especially between toes. File nails - do not cut them. Treat infections or sores right away. Protect feet from injury - do not go barefoot. Wear proper fitting shoes. Exercise feet, ankles and legs. If you can't see the bottoms of your feet, use a mirror or have someone check them for you. Do not wear shoes without socks. Wear cotton socks. Do not use inserts or pads. Avoid pointed or open-toe shoes.

Daily Monitoring

You are the person making decisions about your health on a daily basis. Monitoring is the key to staying in control. Checking glucose levels allows you to:    

Detect problems before they get out of hand. Determine where changes in your diabetes plan are needed. Determine if how you feel is because of high or low blood glucose levels. See the effect of food or activity on glucose levels.

Check your blood sugar more often when:    

You are sick. There are changes in your treatment program, activity or food intake. Glucose values are outside of the desired range. There are many high or low blood glucose levels.

Exercise

There is no big secret to getting in shape. But there are some things you should know that can make it easier. There are several benefits of regular exercising including that it     

Relieves tension and stress. Reduces body fat. Controls your appetite. Improves muscle tone and strength. Helps lower glucose levels. Lowers blood pressure.

REMEMBER TO CHECK WITH YOUR DOCTOR BEFORE STARTING ANY EXERCISE PROGRAM!

Know Your Target Values

The HbA1c is a blood test done in the lab that averages all the glucose levels in your body over the past two to three months. Together with a record of your daily glucose levels, you and your doctor will be able to see how well your overall treatment plan is working and where changes are needed.

Use the Blood Glucose Tracker to keep a track of your daily glucose levels.

It is important to know what you are working so hard to achieve. Discuss what your glycohemoglobin and glucose levels should be most of the time with your diabetes doctor.

Making Sense of Those Blood Glucose Readings

To be in charge of your diabetes, you need to know how to respond to your glucose results. Try these steps:      

Know your target glucose levels. Monitor glucose levels for three to four days in a row. Look for a pattern of glucose levels. If they are higher or lower than target, determine which factors are responsible for the patterns. If patterns are outside your desired range and you do not know what to do, call someone. DO NOT ignore your results!

Prevention

Make sure you're doing all you can to prevent health problems later! During each visit, discuss the following points with your Diabetes Team or Doctor:       

Glucose goals. Meal plans. Activity program. Glucose testing schedule. Treatment of high and low blood glucose levels. Changes in medication. Birth control (if applicable)

Your Annual Review At least once a year, be sure to have these tests:  Kidney function: Protein may signal that your kidneys are not working properly.  Blood fats:Cholesterol and triglycerides tell you about your risk for developing or worsening heart disease.  Eye exam by an eye doctor specializing in diabetics: Early detection and the proper treatment does make a difference.

 Blood pressure: Uncontrolled high blood pressure increases the chances for all the diabetes health problems.  Blood flow and nerve check of the feet: Your feet are the only ones that you have! Protect and treat them with tender loving care.

Coping Strategies

Research shows the coping strategies can help people stay healthy. See if you can work some of these ideas into your own routine:     

Take time each day to relax. Focus on your positive qualities. Maintain a good support system - including friends, family and pets. Use humour and laughter to ease stressful times. Give yourself a positive "self" message every day.

Dos, Don'ts and Diabetes "Oh! Those painful insulin injections! I would rather control my diabetes than take those insulin doses"…Did you not ever think this way? Yes, controlling diabetes is a very good idea. Besides proper medications, diet and lifestyles changes play a crucial role on the health of a diabetic. The diabetic diet may be used alone or else in combination with oral hypoglycemic drugs or with insulin doses. The main objective of diabetic diet is to maintain ideal body weight by providing adequate nutrition along with normal blood sugar levels. The diet plan for a diabetic patient is based on the height, weight, age, sex, physical activity and the nature of diabetes. Diabetes Mellitus is a chronic metabolic disorder in which the body fails to convert sugars, starches and other foods into energy. Many of the foods you eat are normally converted into a type of sugar called glucose, during the process of digestion. The bloodstream then carries glucose through the body. This glucose is either converted to quick energy by the hormone insulin or is stored in the body for further use. In diabetes, the body either does not make enough insulin or it cannot use the insulin correctly, and this causes the glucose levels to rise in the bloodstream. Therefore, it is important that you need to select foods that are high in nutrition and low in calories. Dos and Don'ts for Diabetics Dos… • Eat food at fixed hours. Make sure that you have three proper meals & light snacks in between • Eat about the same amounts of food each day • Eat slowly and chew your food well before you swallow • Drink sufficient amounts of water that will help flush the toxins off your system • Include fresh vegetable salad in every meal • Take your medicines at the same time every day and exercise at about the same time every day • Fat free milk, yogurt, and cheese to be taken • Eggs whites can be included • White meat - chicken and fish are good • Have beverages – Tea or coffee with out sugar or with sugar free in it • Increase fibre intake in the form of raw fruits, vegetables and whole cereals • Include sprouts in your diet

• Intake of bitter gourd, fenugreek, Indian blackberry (jamun), flaxseed, cinnamon, garlic, and onion are known to considerably reduce blood glucose level • Check your feet for cuts, blisters, and swelling which are likely to result from diabetes-related nerve damage • Have good sleep daily • Check your blood sugar level regularly and also check the other tests such as kidney function, liver function, heart function, ketone levels as required • Check your weight from time to time, and always maintain an ideal body weight Don'ts • Do not skip meals and medicine times • Do not eat directly after a workout • Do not overeat • Do not fry foods. Instead bake, boil, poach or saut? in a nonstick pan. Use less oil in cooking • Eat less high-fat red meat and avoid organ meats • Limit the use of condiments such as ketchup, Soya sauce, mustard and salad dressings as they're high in salt and can be high in sugar, too • Limit your salt intake • Avoid white flour, white rice, potatoes, carrots, breads and bananas as they increase the blood-sugar levels • Avoid milk cream, egg yolk or food items cooked in coconut milk • Avoid processed, ready-to-eat food preparations, sweets and sugary drinks (canned beverages) that provide empty calories • Choose fresh foods over canned • Quit smoking • Stop alcohol consumption

Exercises and Diabetes Understanding Diabetes Diabetes is a condition where individual have a higher level of blood glucose in the body. Glucose is the energy source for the body but too much content can hurt the body's mechanism. Diabetes often brings number of other diseases in the body such as heart attacks and stroke. The risks associated with the diabetes can only be reduced by  Being physically active.  Maintaining a healthy diet.  Medications prescribed by the doctor.

Regular exercise not only helps the individual to prevent the risks of diabetes but also offer protection from other harmful diseases. Regular exercise plays a vital role in preventing type 2 diabetes. The risks associated with diabetes can be eliminated or minimized by    

Staying extra active Adopting aerobic exercise Opting for strength training and Inculcating stretching.

Ways to normalize irregular periods

It is always better to opt for a natural approach that can encourage your body to re-establish regular ovulation. Our body has a remarkable ability to balance itself by the use of natural approaches. There are two common ways to re-establish the menstruation cycle naturally, through supplements and herbs. Some of the supplements that are usually recommended to overcome irregular periods are:    

Staying extra active Adopting aerobic exercise Opting for strength training and Inculcating stretching.

How to stay extra active?

Being extra active helps the individual to prevent number of complications by increasing the number of calories burn. Staying extra active needs little extra effort while performing some common daily activities. Some common activities like playing with kids, taking the dog for walk, cleaning the house and washing the car can help to stay active. Some of the other simple objectives that can be accomplished to stay active throughout the day are as follows:  Try to avoid laziness such as using remote control while watching TV. Instead you can always go near the TV and swap the channels.  Try parking your car or vehicle away from the shop or mall. When inside the mall, always to choose stairs instead of elevators.  During the lunch break, take a short walk around the office building or to the nearby park.  Whenever you receive a call on the mobile, try to walk around while talking.

Aerobic Exercises

Aerobic exercise uses the large muscles and makes your heart beat faster. A regular aerobic exercise for 30 minutes on a daily basis can prove much beneficial to many. Aerobic exercise must be carried out with the consultation from a doctor. The conversation with the doctor will provide you the essential information about how to warm up and how to cool down after exercise. Aerobic exercise shall be started slowly with 5 to 10 minutes a day and gradually aiming till 150 to 200 minutes per week. Some of the aerobic exercises that can be adopted to gain the benefits are:     

Hiking, dancing and walking briskly. Swimming or taking a water-aerobic class. Playing sports such as basketball, volleyball etc. Cross-country skiing, in-line skating or ice skating. Taking an aerobic class.

Strength Training

Strength training is specially advised to build muscles. This target is achieved by doing exercises with hand weights, elastic bands, or weight machines for two to three times a week. Presence of more muscles in the body helps it to burn more calories. Strength training also helps the individual to improve the balance and coordination along with healthy bones. However, strength training must be started by consulting with the health care team. Thereafter, an individual continue the strength training at home, fitness center or class.

Eye & Foot Care Tips For Diabetics Are you a diabetic? Have you heard of the complications that diabetes cause? Have you taken the necessary steps to save yourself from these complications? If no, then it is high time you start taking care of yourself.

In Diabetes, the level of sugar in the blood is higher than normal. This high blood sugar level can damage your blood vessels and the nerves that run throughout your body. The damage to blood vessels and nerves can lead to a number of problems like blindness and feet problems. Your Eyes… Uncontrolled or poorly controlled diabetes can damage the small blood vessels of the retina leading to retinopathy. If retinopathy is found early, laser treatment can help keep you from losing your vision. But if it's not treated, retinopathy can cause blindness. Therefore, is important to have your eyes checked regularly. At least once a year an eye check should be done as the changes in your eyes can only be seen through special equipment and you may not notice the early signs. Some alert signs are… • • • •

Blurred vision for more than two days Sudden loss of vision in one or both the eyes Redness, pain or pressure felt in your eye Black spots, cobwebs or flashing lights in your vision that really does not exist

Tips for preventing eye problems … • • • • • • •

Control your blood glucose levels Control on blood pressure Control on blood cholesterol levels Regularly visit your family doctor To have a balanced planned diet Avoid foods that are high in fat and sugar To give up addictions like tobacco and alcohol

Your Feet… In diabetes, nerves are damaged (called as diabetic neuropathy). Neuropathy most often affects the feet and legs. Also, the damaged blood vessels may affect the blood supply to your feet. The damaged nerve and blood supply may give rise to foot injuries like blisters, calluses, in growing toenails, fungal infections, ulcers, etc. So, it is important that every diabetic should check his/her feet everyday for any unusual sign or sensation. Use a mirror to check your feet as it is difficult to have a complete look of your foot. Call your doctor if you notice anything unusual, including foot pain, coldness, a shiny appearance to your skin, loss of hair on the foot or toes, or thickened nails. Be sure to have your feet checked by your doctor at least once a year. The tips listed in the box below can help you prevent problems

Tips for foot care are… • Wash you feet daily in warm and soapy water • Gently dry your feet • Check for injuries everyday on your feet • Change your socks everyday • Avoid going barefoot • Wear shoes that properly fit your feet and provide plenty of room for our feet • A worn out pair of shoes will lose their ability to support you and will cause feet, leg and back fatigue. Therefore, you should replace your shoes within six months of use • It is always advisable to check your shoes regularly to make sure that they are free of stones, sharp and lumpy objects • Trim your toe nails after soaking your foot in warm water for 10 minutes as it softens the toe nails • Never cut the nails very close to your skin • Foot massages are also helpful • Always check with your doctor first before treating corns and calluses Diabetes also affects other organs of the body like kidneys and heart. Diabetes can also damage the blood vessels of the kidneys so much that they can't filter out waste from your body. This damage is called diabetic nephropathy. Some people who have nephropathy may need dialysis or kidney transplant. Presence of protein in urine is an important sign of nephropathy. Hence, this should be checked yearly as an early detection will protect your kidneys from damage. People with diabetes are at greater risk for cardiac diseases and stroke. The risk is even greater for people who have hypertension, who smoke, who a family history of heart disease and those who are overweight. It is very important to see your doctor on a regular basis as your doctor can test for early signs of any heart disease or stroke. The risk for nephropathy, heart diseases and stroke is highly increased if you have both diabetes and high blood pressure. The most imperative thing for a diabetic is to control his/her blood sugar level. Equally important is to control the blood cholesterol levels and blood pressure. It is also crucial to maintain a healthy weight. Besides these, eating healthy foods which are low in fat and sugar, quitting smoking and being physically active on a regular basis are few steps that every diabetic must take to save himself/herself from the complications of the disease. Remember ‘A stitch in time saves nine.' Therefore, it is advisable to go for regular check-ups with your doctor even if you are feeling fine as an early detection of any complication can save you from lot of problems. It is the time to deal with your health problems. So, do not wait…Act Now!

8 Ways to Avoid Diabetes Complications Diabetes is one of the life threatening diseases in the recent days. Once you are titled with Diabetes, you will have to take initiatives to avoid any future complications. People with diabetes can still live a happy life by taking some precautions. Here are 8 efficient ways to prevent the complications that may arise in diabetic patients. Do an annual physical-check up

It is strongly advised to undergo a physical examination every year besides the regular check up. As the doctor is aware that you have diabetes, he will look for emerging problems caused by the disease such as eyes, heart or kidney disease.

Updating the Vaccinations

Keep a track on vital vaccinations that will help you avoid serious diabetes complications. Some of the vaccinations that you must stay up-to-date with are:  An annual flu shot is very essential for diabetic patient of every age. As you have diabetes, you are more prone to develop serious complications from flu such as diabetic ketoacidosis (DKA) and hyperosmolar syndrome.  Pneumonia vaccine is usually recommended by doctors to the diabetic patients. Usually, people above 65 years of age or who have complications from diabetes such as kidney or heart disease are recommended for a five-year booster shot.  Other vaccinations such as tetanus shot and its 10-year boosters and Hepatitis B vaccinations must be taken. Keep an up-to-date record of all such vaccinations to prevent future complications. Dentist Visit

Diabetes affects the immune system making the person unable to fight against the bacteria and other viruses that causes several infections. Our mouth is occupied with bacteria and the gums provide a common site of infection. Hence, it is highly advised to visit a dentist twice a year. An Ophthalmologist Visit

Diabetes is one of the causes for vision problems. These vision problems can be easily treated, if the symptoms are identified in early stages. Hence, a visit to an ophthalmologist becomes very essential for a diabetic patient. Caring your feet

Diabetes is found to create a lot of problems to your feet. Diabetes can reduce the sensation of pain by damaging the network of nerves in your feet. It can also reduce the flow of blood to your feet by blocking off the arteries. Therefore, care must be taken for the feet to avoid any complications. Avoid Smoking

People with diabetes who smoke are more likely to die of heart disease and stroke. Smoking affects in three ways:  It reduces the blood flow by narrowing the arteries. Narrowed arteries results in heart attacks and stroke.  It also increases the risk of nerve damage and kidney problems.  It lowers the immune power making the person more susceptible to colds and other respiratory infections.Monitoring Blood Pressure

Diabetes is often associated with high blood pressure. Once they join together, life-threatening conditions such as heart attack, stroke can occur. The best way to monitor your blood pressure is to cultivate habits of a balanced diet and regular exercise. Reducing the salt-content in the diet and controlling the alcohol consumption can minimize the risk to a greater extent. Monitoring Blood sugar

Monitoring the blood sugar is the foremost task for any diabetic patient. By keeping the blood sugar levels within the range, you can always stay away from risks that are associated with eyes, kidney, blood vessel and nerve damage.

"Expecting Diabetes "Expecting" Diabetes

"I'm expecting…But I have got diabetes….I am worried."

Your worry is right if you are pregnant and are diagnosed of gestational diabetes. It means that increased care is needed for your health and your baby's health.

Gestational diabetes is diabetes that is found for the first time when a woman is pregnant. Statistics show that it affects about three out of 100 of pregnant women. Gestational diabetes affects about 4% of all the pregnant women, i.e. about 135,000 cases of gestational diabetes in the United States each year.

The body uses glucose to produce energy. But too much glucose in the blood can be damaging. During pregnancy too much glucose is not good for your baby. Gestational diabetes begins when your body is not able to produce and use the insulin it needs during pregnancy. Without enough insulin, glucose cannot leave the blood and neither can be changed to energy. Therefore, glucose builds up in the blood to high levels. This is called hyperglycaemia. The high blood sugar in the mother can damage the health of the foetus. Some of the complications the baby may face include premature delivery, respiratory problems, congestive heart failure and decreased ability to tolerate labour.

Risk factors that may predispose a woman to develop gestational diabetes…        

Maternal age of over 25 years. Family history of diabetes. Overweight women. A previous child with birth defects or history of unexplained still birth. Recurrent bladder or urinary tract infections. A prior baby weighing more than 3.75 kg/9 pounds. Race factor - African American, American Indian, Asian American, Hispanic/ Latino and Pacific Islander. Smoking.

Symptoms…     

Excessive thirst. Increased urination. Unexplained excessive weight gain or weight loss. Constant fatigue and tiredness which may be accompanied by nausea and vomiting. Blurred vision.

Effects Of Gestational Diabetes On Mother…    

High risk of high blood pressure during pregnancy. Large baby and the need for caesarean section at delivery. More likely to develop type 2 diabetes as they get older. If a woman had it during one pregnancy she is more likely to have it in her next pregnancy.

Effects Of Gestational Diabetes On The Baby…  Macrosomia (baby may grow too large).  Hypoglycaemia (low blood sugar).

 Jaundice (the yellow colour seen in the skin of newborns, which happens when a chemical called bilirubin builds up in the baby's blood).  Increased risk of childhood and adult obesity.  Increased risk of type 2 diabetes in later life.  Low calcium and magnesium.  Respiratory Distress Syndrome (RDS - a condition that makes breathing difficult).

Diagnosis…

The main method of diagnosis of gestational diabetes is the  Detection of traces or high levels of glucose in urine.  Detection of high levels of glucose in the blood.

Treatment…

Gestational diabetes if not taken care of then can hurt you and your baby. The treatment for diabetes during pregnancy requires expert supervision and also constant medical care to avoid any complications during pregnancy. Therefore, you need to start treatment early. The treatment for gestational diabetes aims to keep the blood glucose levels equal to those of pregnant women who do not have gestational diabetes. The treatment for gestational diabetes always includes special meal plans and scheduled physical activity. Daily blood glucose testing and insulin injections may also be a line of treatment. You will need help from your doctor and other members of your health care team so that your treatment for gestational diabetes can be changed as required. Women who have had gestational diabetes should continue to be tested for diabetes in every 1 to 2 years as she may develop type 2 diabetes later and an early diagnosis can help prevent complications such as heart disease later in life.

Artificial Sweeteners A Product that can be of a great aid to a diabetic is presented with few facts Artificial sweeteners (provides very little calories) are basically made for people who cannot eat sugar. For example, diabetics who already have high sugar levels or overweight people who want to cut down on calories from sugary food to lose weight. Artificial sweeteners that are generally seen in market include Saccharin, Aspartame, Sucralose, Neotame, D-tagatose, and Aclame.

Types of Artificial Sweeteners:

Noncaloric sweeteners & Sugar alcohols are two types of artificial sweeteners that are used instead of sugars in foods. Noncaloric sweeteners do not add calories to foods. They are used in many kinds of foods such as snack foods and drinks. These sweeteners do not cause as much tooth decay as sugar. Non-calorie sweeteners include saccharin, aspartame, and acesulfame-K and Sucralose.  Saccharine - (sold as Sweet n Low TM and Sweet Twin TM and as a brown sugar substitute), saccharine when used in large quantities gives peculiar after- taste.  Aspartame, (i.e. sold as NutraSweet TM and Equal TM) has very little aftertaste, but it loses its sweet taste when heated  Acesulfame-K (i.e. sold as Sweet One TM or Swiss Sweet TM) has less after taste than saccharin, and is more heat stable than aspartame.

 Sucralose (i.e. sold as Splenda TM) is more like our normal table sugar.

Sugar alcohols contain about the same number of calories as sugar (do not help people who are trying to lose weight) however they are absorbed more slowly by the body. They are used in chewing gums and hard candies. In some they may cause gastrointestinal upset. These sugar alcohols include: sorbitol and mannitol.

Though artificial sweeteners are low calorie substitute for sugar it is always better to limit the intake of these. They should be used knowledgeably and sparingly. It is also known that the use of these artificial sweeteners can have some side effects.

Problems of Artificial Sweeteners  Artificial sweeteners are sweeter than sugar hence they have the tendency to increase our sweet tooth and increase our liking for sweet foods.  Regular users of artificial sweeteners may throw off their natural ability to monitor calories and increase the likelihood of overeating.  It is also believed that use of artificial sweeteners may slow down digestion and increase appetite, thus leading to weight gain instead of weight loss.  Artificial Sweeteners may be linked with different types of cancer.

Watch out for some Tips for using artificial sweeteners:

Check up the use of particular sweetener for specific recipe.

Most artificial sweeteners are 100 times plus sweeter than sugar. They need to be used in small amounts at first and increased only gradually to avoid an overly sweet taste or unpleasant aftertaste.

Its possible to use less and get more! When two different classes of artificial sweeteners are combined (i.e. saccharin + aspartame), the result is much sweeter taste than it is when one kind is used alone. This can result in money savings.

Although as discussed above, the use of an artificial sweetener is allowed in permissible amounts. But it is more appropriate for a diabetic to rather enjoy the natural sweetness of foods like dates, figs and raisons as well as natural bitterness of tea and coffee.

Blood Glucose Description Blood glucose test is a test where the amount of a type of blood sugar level is measured. This blood sugar type is known as glucose. Glucose is derived from the carbohydrate foods. Body uses glucose as a main energy source. To use and control the glucose amount in your blood, a hormone named insulin is used. Production of insulin occurs in the pancreas and it is released into the blood when there is rise in the glucose amount of the blood. After eating, glucose level of your blood rises slightly. As a result, pancreas secret insulin and controls glucose level in blood. If

there is high level of glucose in your body, then it may damage your eyes, kidneys, nerves and blood vessels.

Need The necessity of blood glucose test:    

Checking diabetes Monitoring diabetes treatment Checking diabetes that occurs during pregnancy (gestational diabetes) Detecting presence of hypoglycemia (low blood sugar level)

Procedure The blood sample is collected like in any other test.  Fasting blood sugar (FBS): You should not eat or drink anything other than water for at least 8 hours before the blood sample is taken. Do not take any medicine for diabetes or insulin before blood test.  2- Hour postprandial test (2 hour PC): For this test, eat a meal exactly before 2 hours of the blood sample is taken. Home blood sugar test can be used for 2 hour postprandial testing.  Random blood sugar: This test does not require any special preparation.

Result The results are available in 1-2 hours.  Fasting blood glucose: 70-99milligrams per deciliters or 5.5mmol/L  2 hours after eating (postprandial): 70-145mg/dL (less than 7.9mmol/L)  Random (causal): 70-125mg/dL (less than 7.0 mmol/L)

There may be difference in the normal results from lab to lab. In many conditions, blood glucose level can change. According to your symptoms and medical history, doctor will discuss any significant normal result with you. The diabetes diagnosed, if fasting blood glucose level is 126 mg/dL or higher and 2 hour oral glucose tolerance test is 200 mg/dL or higher.

If you have fasting blood glucose level between 100mg/dL and 126 mg/dL then there are greater chances of getting diabetes

In conditions such as stress, stroke, heart attack, Cushing's syndrome, excess production of the growth hormone, the level of blood in glucose may increase. If a level of fasting glucose is below 40mg/dL, in women or below 50 mg/dL in men, then it is considered as hypoglycemia.

There are some other reasons for the low levels of glucose in blood. Addison's disease, Decrease in thyroid levels, kidney failure, cirrhosis, a tumor in pituitary gland may be responsible for the low level of glucose in your blood.

Consideration Normally, there are no risks associated with any blood test. If you eat or drink anything less than 8 hours before the test, or less than 2 hours before the postprandial test, then the result of the test may come incorrect. If you drink alcohol, or smoke then the result may get affected. Emotional stress and caffeine also interferes in the results of the test.

Definition Type 2 diabetes in children is a chronic condition that affects the way your child's body metabolizes sugar (glucose). Type 2 diabetes is a disease more commonly associated with adults. But type 2 diabetes in children is on the rise, fueled largely by the obesity epidemic. There's plenty you can do to help manage or prevent type 2 diabetes in children. Encourage your child to eat healthy foods, get plenty of physical activity and maintain a healthy weight. If diet and exercise aren't enough, your child may need oral medication or insulin treatment to manage his or her blood sugar.

Symptoms By Mayo Clinic staff Type 2 diabetes in children may develop gradually. Some children who have type 2 diabetes have no signs or symptoms. Others experience:

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Increased thirst and frequent urination. As excess sugar builds up in your child's bloodstream, fluid is pulled from the tissues. This may leave your child thirsty. As a result, your child may drink — and urinate — more than usual.

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Increased hunger. Without enough insulin to move sugar into your child's cells, your child's muscles and organs become depleted for energy. This triggers intense hunger.

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Weight loss. Despite eating more than usual to relieve hunger, your child may lose weight. Without the energy sugar supplies, muscle tissues and fat stores simply shrink.

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Fatigue. If your child's cells are deprived of sugar, he or she may become tired and irritable.

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Blurred vision. If your child's blood sugar is too high, fluid may be pulled from the lenses of your child's eyes. This may affect your child's ability to focus clearly.

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Slow-healing sores or frequent infections. Type 2 diabetes affects your child's ability to heal and resist infections.

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Areas of darkened skin. Some children who have type 2 diabetes have patches of dark, velvety skin in the folds and creases of their bodies — usually in the armpits and neck. This condition, called acanthosis nigricans, may be a sign of insulin resistance.

When to see a doctor To diagnose type 2 diabetes before it does serious damage, diabetes screening is

recommended for all children and adolescents at high risk of type 2 diabetes, even if they have no signs or symptoms of the condition. Those considered at high risk include children:

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With a body mass index (BMI) over the 85th percentile

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With a sibling, parent, grandparent, aunt, uncle or cousin with type 2 diabetes

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Who are black, Hispanic, Native American or Asian-American, as these racial groups have a higher incidence of type 2 diabetes

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With signs of insulin resistance, such as darkened skin on the neck

Talk to your child's doctor if you're concerned about diabetes or if you notice any of the signs or symptoms of type 2 diabetes — increased thirst and frequent urination, extreme hunger, weight loss, blurred vision, fatigue, slow-healing sores or frequent infections.

Causes By Mayo Clinic staff Type 2 diabetes develops when the body becomes resistant to insulin or when the pancreas stops producing enough insulin. Exactly why this happens is unknown, although excess weight and inactivity seem to be important factors. Insulin: The key for sugar Insulin is a hormone that comes from the pancreas, a gland located just behind the stomach. When your child eats, the pancreas secretes insulin into the bloodstream. As insulin circulates, it acts like a key by unlocking microscopic doors that allow sugar to enter your child's cells. Insulin lowers the amount of sugar in your child's bloodstream. As your child's blood sugar level drops, so does the secretion of insulin from the pancreas. Glucose: The energy source Glucose — sugar — is a main source of energy for the cells that make up muscles and other tissues. Glucose comes from two major sources: the food your child eats and your child's liver. During digestion, sugar is absorbed into the bloodstream. Normally, sugar then enters cells with the help of insulin. Liver: Production and storage The liver acts as a glucose storage and manufacturing center. When your child's insulin levels are low — when your child hasn't eaten in a while, for example — the liver releases the stored glucose to keep your child's glucose level within a normal range. In type 2 diabetes, this process works improperly. Instead of moving into your child's cells, sugar builds up in his or her bloodstream. This occurs when your child's pancreas doesn't make enough insulin or your child's cells become resistant to the action of insulin.

Risk factors By Mayo Clinic staff

Researchers don't fully understand why some children develop type 2 diabetes and others don't, even if they have similar risk factors. It's clear that certain factors increase the risk, however, including:

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Weight. Being overweight is a primary risk factor for type 2 diabetes in children. The more fatty tissue a child has, the more resistant his or her cells become to insulin. The good news is that many children who have type 2 diabetes can improve their blood sugar levels simply by losing excess weight.

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Inactivity. The less active your child is, the greater his or her risk of type 2 diabetes. Physical activity helps your child control his or her weight, uses glucose as energy, and makes your child's cells more responsive to insulin.

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Family history. The risk of type 2 diabetes increases if a parent or sibling has type 2 diabetes — but it's difficult to tell if this is related to lifestyle, genetics or both.

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Race. Although it's unclear why, children of certain races — especially blacks, Hispanics, American Indians and Asian-Americans — are more likely to develop type 2 diabetes.

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Gender. Type 2 diabetes is more common in girls than in boys during childhood.

Complications Type 2 diabetes can be easy to ignore, especially in the early stages when your child is feeling fine. But type 2 diabetes must be taken seriously. The condition can affect nearly every major organ in your child's body, including the heart, blood vessels, nerves, eyes and kidneys. Keeping your child's blood sugar level close to normal most of the time can dramatically reduce the risk of these complications. The long-term complications of type 2 diabetes develop gradually. But eventually, diabetes complications may be disabling or even life-threatening.

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Heart and blood vessel disease. Diabetes dramatically increases your child's risk of various cardiovascular problems, including coronary artery disease with chest pain (angina), heart attack, stroke, narrowing of the arteries (atherosclerosis) and high blood pressure.

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Nerve damage (neuropathy). Excess sugar can injure the walls of the tiny blood vessels (capillaries) that nourish your child's nerves, especially in the legs. This can cause tingling, numbness, burning or pain that may begin at the tips of the toes or fingers and gradually spread upward. Left untreated, your child could lose all sense of feeling in the affected limbs.

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Nonalcoholic fatty liver disease. Children with type 2 are more likely to develop nonalcoholic fatty liver disease, which can eventually lead to scarring of the liver and cirrhosis. Weight loss, along with good blood sugar control, may help this condition.

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Kidney damage (nephropathy). The kidneys contain millions of tiny blood vessel clusters that filter waste from your child's blood. Diabetes can damage this delicate filtering system. The earlier diabetes develops, the greater the concern. Severe damage can lead to kidney failure or irreversible end-stage kidney disease, requiring dialysis or a kidney transplant.

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Eye damage. Diabetes can damage the blood vessels of the retina (diabetic retinopathy). Diabetes can also lead to cataracts and a greater risk of glaucoma.

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Foot damage. Nerve damage in the feet or poor blood flow to the feet increases the risk of various foot complications. Left untreated, cuts and blisters can become serious infections.

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Skin conditions. Diabetes may leave your child more susceptible to skin problems, including bacterial infections, fungal infections and itching.

Preparing for your appointment By Mayo Clinic staff Your child's family doctor or pediatrician will probably make the initial diagnosis of diabetes. However, you'll likely then be referred to a doctor who specializes in metabolic disorders in children (pediatric endocrinologist). Your child's health care team will also generally include a nutritionist, a certified diabetes educator, and a doctor who specializes in eye care (ophthalmologist). If your child's blood sugar levels are very high, your doctor may send your child to the hospital for treatment. Because appointments can be brief, and there's often a lot of ground to cover, it's a good idea to be well prepared for any appointments you have with your child's health care team. Here's some information to help you get ready for your appointment, and what you can expect from your doctor. What you can do

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Be aware of any pre-appointment restrictions. If your doctor is going to test your child's blood sugar, he or she will ask you to have your child refrain from eating or drinking anything but water for eight hours for a fasting glucose test or four hours for a pre-meal test. When you're making an appointment, ask if any type of fasting is necessary.

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Write down any symptoms your child is experiencing, including any that may seem unrelated.

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Ask a family member or friend to join you, if possible. Managing diabetes well requires you to retain a lot of information, and it can sometimes be difficult to soak up all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.

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Bring a notebook and a pen or pencil, to write down important information.

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Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions can help you make the most of your time together. List your questions from most important to least important in case time runs out. For type 2 diabetes in children, some basic questions to ask your doctor include: Glucose monitoring

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How often do I need to monitor my child's blood sugar? At what times should I check?

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What is the goal range?

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What should my child's blood sugar levels be before bed?

Lifestyle changes

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What types of changes do we need to make to our family's diet?

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How can I learn about counting carbohydrates in foods?

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Should I see a dietitian to help with meal planning at home?

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How much exercise should my child get each day?

Medications

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Will my child need to take medicine? If so, what kind and how much?

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Does the medicine need to be taken at any particular time of the day?

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Does my child need to take insulin?

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What types of insulin delivery options are available? Which do you recommend for my child and why? How should insulin be stored?

Complications

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What are the signs and symptoms of low blood sugar?

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How do I treat low blood sugar? How long should I wait before I retest?

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What about high blood sugar — what are the signs and symptoms?

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When should we test for ketones, and how do we do it?

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What do we do if ketones are present?

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My child has this other health condition. How can we best manage them together?

Medical management

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How often does my child need to be monitored for diabetes complications? What specialists do we need to see?

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What does my child's school need to know about managing diabetes? What about summer camp?

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What precautions do you suggest I take if my child goes to a friend's house for a sleepover?

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Are there any resources available if I'm having trouble paying for diabetes supplies?

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Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something. What to expect from your doctor Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

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Do you feel confident about your child's treatment plan?

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Any questions or concerns about his or her current situation?

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How do you feel your child is coping with the diabetes and its treatment?

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Has your child experienced any low blood sugars?

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What's a typical day's diet like?

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Is your child exercising? If so, how often?

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On average, how much insulin are you using daily?

What you can do in the meantime If your child's blood sugar isn't well controlled, or if you're not sure about what to do in a certain situation, don't hesitate to contact your child's doctor or diabetes educator in between appointments for advice and guidance.

Tests and diagnosis If your child's doctor suspects diabetes, he or she will recommend a screening test. The primary test used to diagnose diabetes in children is the:

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Random blood sugar test. A blood sample will be taken at a random time. Regardless of when your child last ate, a random blood sugar level of 200 milligrams per deciliter (mg/dL) or higher suggests diabetes.

If your child's random blood sugar test results don't suggest diabetes, but your doctor still suspects it, your doctor may do a:

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Glycated hemoglobin (A1C) test. This blood test indicates an average blood sugar level for the past two to three months. It works by measuring the percentage of blood sugar attached to hemoglobin, the oxygen-carrying protein in red blood cells. The higher the blood sugar levels, the more hemoglobin that has sugar attached. An A1C level of 6.5 percent or higher on two separate tests indicates diabetes. A result between 6 and 6.5 percent is considered prediabetes, which indicates a high risk of developing diabetes.

Another test your doctor might use is a fasting blood sugar test. A blood sample will be taken after an overnight fast. A fasting blood sugar level less than 100 mg/dL is normal. A fasting blood sugar level from 100 to 125 mg/dL is considered prediabetes. If it's 126 mg/dL or higher on two separate tests, your child will be diagnosed with diabetes. Your doctor may also perform an oral glucose tolerance test. For this test, your child fasts overnight, and the fasting blood sugar level is measured. Then, your child drinks a sugary liquid, and blood sugar levels are tested periodically for the next several hours. A reading of more than 200 mg/dL after two hours indicates diabetes. A reading between 140 and 199 mg/dL indicates prediabetes. If your child is diagnosed with diabetes, the doctor may do other tests to distinguish between type 1 and type 2 diabetes — which often require different treatment strategies because in type 1 diabetes, the pancreas no longer makes insulin. After the diagnosis At first, your child may need frequent — once a month or more — visits. Once your child's blood sugar is stabilized, he or she will regularly visit his or her doctor to ensure good diabetes management. Your child's doctor will also check your child's A1C levels periodically. Your child's target A1C goal may vary depending on his or her age and various other factors. Ask your doctor what your child's A1C target is. The American Diabetes Association has introduced a formula that translates the A1C into what's known as an estimated average glucose (eAG). The eAG more closely correlates with daily blood sugar readings. An A1C of 7 percent translates to an eAG of 154 mg/dL. That would mean that your child's average blood sugar levels are around 150 mg/dL. Compared with repeated daily blood sugar tests, A1C testing better indicates how well your child's diabetes treatment plan is working. An elevated A1C level may signal the need for a change in your child's insulin regimen or meal plan. Other periodic tests In addition to the A1C test, the doctor will also take blood and urine samples periodically to check your child's cholesterol levels, thyroid function, liver function and kidney function. The doctor will also examine your child to assess his or her blood pressure and make sure he or she is growing properly. Regular eye exams also are important.

Treatments and drugs By Mayo Clinic staff Treatment for type 2 diabetes is a lifelong commitment of blood sugar monitoring, healthy eating, regular exercise and, sometimes, insulin or other medications — even for kids. And as your child grows and changes, so will his or her diabetes treatment plan. If managing your child's diabetes seems overwhelming, take it one day at a time. And remember that you're not in it alone. You'll work closely with your child's diabetes treatment team — doctor, diabetes educator and registered dietitian — to keep your child's blood sugar level as close to normal as possible. Blood sugar monitoring Depending on what type of insulin therapy your child needs, you may need to check and record your child's blood sugar at least three times a day, but probably more. This usually requires frequent finger sticks, though some blood glucose meters allow for testing at other sites. Frequent testing is the only way to make sure that your child's blood sugar level remains within his or her target range — which may change as your child grows and changes. Your child's doctor will let you know what your child's blood sugar target range is. The doctor may ask you to keep a log of your child's blood glucose readings, or he or she may download that information from your blood glucose meter. Even if your child eats on a rigid schedule, the amount of sugar in his or her blood can change unpredictably. With help from your child's diabetes treatment team, you'll learn how your child's blood sugar level changes in response to:

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Food. What and how much your child eats will affect your child's blood sugar level.

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Physical activity. Physical activity moves sugar from your child's blood into his or her cells. The more active your child is, the lower his or her blood sugar level.

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Medication. Any medications your child takes may affect his or her blood sugar level, sometimes requiring changes in your child's diabetes treatment plan.

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Illness. During a cold or other illness, your child's body will produce hormones that raise his or her blood sugar level.

Healthy eating Contrary to popular perception, there's no diabetes diet. Your child won't be restricted to a lifetime of boring, bland foods. Instead, your child will need plenty of fruits, vegetables and whole grains — foods that are high in nutrition and low in fat and calories — and fewer animal products and sweets. In fact, it's the best eating plan for the entire family. Even sugary foods are OK once in a while, as long as they're included in your child's meal plan. Yet understanding what and how much to feed your child can be a challenge. A registered dietitian can help you create a meal plan that fits your child's health goals, food preferences and lifestyle. If your child is overweight or obese, gradual weight reduction will be a goal.

Physical activity Everyone needs regular aerobic exercise, and children who have type 2 diabetes are no exception. Encourage your child to get regular physical activity. Sign up for a sports team or dance lessons. Better yet, get in the act together. Play catch in the backyard. Take a walk or run through your neighborhood. Visit an indoor climbing wall or local pool. Make physical activity part of your child's daily routine. Remember that physical activity lowers blood sugar. If your child needs insulin treatment, check your child's blood sugar level before any activity. He or she might need a snack before exercising to help prevent low blood sugar. Medication and insulin Some children who have type 2 diabetes can control their blood sugar with diet and exercise alone, but many also need oral medication or insulin treatment. Metformin is the only oral medication that's approved for children (age 10 and older) who have type 2 diabetes. Metformin reduces the amount of sugar a child's liver releases into the bloodstream between meals. Side effects may include nausea, upset stomach, diarrhea and, rarely, a harmful buildup of lactic acid (lactic acidosis). Metformin isn't safe for anyone who has liver failure, kidney failure or heart failure. Because stomach enzymes interfere with insulin taken by mouth, oral insulin isn't an option for lowering blood sugar. Therefore, insulin has to be delivered under the skin. Insulin delivery options include:

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Injections. Usually, insulin delivery means injections using a fine needle and syringe or an insulin pen — a device that looks like an ink pen, except the cartridge is filled with insulin.

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Insulin pump. An insulin pump also may be an option for some children. The pump is a device about the size of a cell phone worn on the outside of the body. A tube connects the reservoir of insulin to a catheter that's inserted under the skin of the abdomen. A wireless pump that uses small pods filled with insulin is another option that's now available. The pump is programmed to dispense specific amounts of insulin automatically. It can be adjusted to deliver more or less insulin depending on meals, activity level and blood sugar level.

Many types of insulin are available, including rapid-acting insulin, long-acting insulin and intermediate options. Examples include regular insulin (Humulin R, Novolin R, others), NPH insulin (Humulin N, Novolin N), insulin lispro (Humalog), insulin aspart (NovoLog) and insulin glargine (Lantus). Depending on your child's needs, the doctor may prescribe a mixture of insulin types to use throughout the day and night. The decision about which treatment is best depends on the child, his or her blood sugar level, and the presence of any other health problems. Initially, children whose blood sugar is above 200 or who have an A1C above 8.5 percent will likely be started on insulin therapy to stabilize the blood sugar. Once blood sugar levels are normalized, your child may be weaned off insulin and placed on metformin alone. However, if blood sugar isn't well-controlled on metformin and lifestyle changes, insulin will have to be given again. A long-acting insulin, such as insulin glargine, is often used for type 2 diabetes in children.

Signs of trouble Short-term complications of type 2 diabetes require immediate care, including:

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Low blood sugar (hypoglycemia). If your child's blood sugar level drops below his or her target range, it's known as low blood sugar. Your child's blood sugar level can drop for many reasons, including skipping a meal, getting more physical activity than normal or injecting too much insulin. Watch for early signs and symptoms of low blood sugar, including sweating, shakiness, drowsiness, hunger, dizziness and nausea. Later signs and symptoms include behavior changes, confusion, and passing out.

If your child has signs or symptoms of low blood sugar, give him or her fruit juice, glucose tablets, hard candy, regular (not diet) soda or another source of sugar, and then recheck the blood sugar levels in 15 minutes. If the blood sugar reading is still low, give your child another fast-acting source of sugar, and retest again in 15 minutes. Once the blood sugar reaches a normal level, give your child a mixed food snack, such as peanut butter and crackers, to stabilize the blood sugar levels. If your child loses consciousness, he or she may need an emergency injection of glucagon — a hormone that stimulates the release of sugar into the blood. This is a medical emergency.

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High blood sugar (hyperglycemia). Likewise, your child's blood sugar can rise for many reasons, including eating too much, not taking enough insulin or illness. Watch for frequent urination, increased thirst, dry mouth, blurred vision, fatigue and nausea. If you suspect hyperglycemia, check your child's blood sugar. You might need to adjust your child's meal plan or medications. If your child's blood sugar is dangerously high, call your child's doctor right away or seek emergency care.

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Increased ketones in your child's urine (diabetic ketoacidosis). If your child's cells are starved for energy, your child's body may begin to break down fat — producing toxic acids known as ketones. Although this condition is more common in children with type 1 diabetes, it can occur in children with type 2. Watch for loss of appetite, nausea, vomiting, fever, stomach pain and a sweet, fruity smell on your child's breath. If you suspect ketoacidosis, check your child's urine for excess ketones with an over-the-counter ketones test kit. If your child has excess ketones in his or her urine, call your child's doctor right away or seek emergency care.

Coping and support By Mayo Clinic staff Type 2 diabetes is a serious disease. Helping your child follow his or her diabetes treatment plan takes round-the-clock commitment. But your efforts are worthwhile. Careful management of type 2 diabetes can reduce your child's risk of serious — even life-threatening — complications. Counseling and support Talking to a counselor or therapist may help your child or you to cope with the lifestyle changes that come with a type 2 diabetes diagnosis. Your child may find encouragement and understanding in a type 2 diabetes support group for children. Support groups for parents also

are available. Although support groups aren't for everyone, they can be good sources of information. Group members often know about the latest treatments and tend to share their own experiences, or helpful information, such as where to find carbohydrate counts for your child's favorite takeout restaurant. If you're interested, your doctor may be able to recommend a group in your area. Or, you can visit the American Diabetes Association to check out local activities for people with type 2 diabetes. The American Diabetes Association also offers diabetes camp programs, online information, and an online forum for children and teens with diabetes. Getting your child actively involved As your child gets older, encourage him or her to take an increasingly active role in diabetes management. Teach your child how to test his or her blood sugar and, if needed, inject insulin. Stress the importance of lifelong diabetes care, which is particularly important for teens to understand as they may rebel against their diabetes care regimen. Foster a relationship between your child and his or her diabetes treatment team. Make sure your child wears a medical ID tag.

Prevention By Mayo Clinic staff Healthy lifestyle choices can help prevent type 2 diabetes in children and its complications. Encourage your child to:

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Eat healthy foods. Offer your child foods low in fat and calories. Focus on fruits, vegetables and whole grains. Strive for variety to prevent boredom.

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Get more physical activity. Encourage your child to get active. Sign up for a sports team or dance lessons, or look for active things to do together.

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Lose excess pounds. Help your child make permanent changes in his or her eating and exercise habits.

Better yet, make it a family affair. The same lifestyle choices that can help prevent type 2 diabetes in children can do the same for adults.

New Drugs for Type 2 Diabetes Eli Ipp, M.D. Until recently, there were few medications (only sulfonylureas or insulin) available for the treatment of type 2 diabetes (also known as non-insulin dependent or adult-onset diabetes). But today, doctors have a wide variety of new types of drugs to help you regulate your blood glucose (sugar). In this article, we will look at all these medications and describe how they work. Although we have little understanding of the underlying causes of type 2 diabetes, we now know that there are many different reasons why those who suffer from type 2 diabetes cannot control their blood sugar. Some do not produce enough insulin, the hormone that regulates blood sugar. Others produce enough insulin but are somehow

resistant to its action. It is also known that the livers of patients with type 2 diabetes produce excess glucose and that this, too, can contribute to high blood glucose levels.

Type 2 Diabetes Is Not Only a Disease of Carbohydrate Metabolism Patients with type 2 diabetes often have many associated disorders, including hypertension (high blood pressure), obesity, hyperlipidemia (excess fat in the blood) and accelerated atherosclerosis (damaged arteries caused by fatty deposits). Diabetes may worsen these disorders. For this reason, it is important to treat both the diabetes and the associated disorders together. Treatment goals for hypertension and hyperlipidemia are now included in all ADA (American Diabetes Association) recommendations for diabetes management. The presence of these associated disorders needs to be considered when choosing antidiabetic medications. A prime example is associated hyperlipidemia. Some antihyperglycemic agents, i.e., drugs that bring down blood glucose levels, also have beneficial effects on lipid (fat) disorders and may, therefore, be the best choice for patients who suffer from both conditions.

Not by Drugs Alone It must be remembered, even though the emphasis of this article is on drug treatments, that medications should never be used without non-drug therapies, such as diet, a regimen of physical activity and patient education. Newly diagnosed diabetic patients without severe symptoms should always try diet and exercise first. And even when drug treatment has begun, life-style changes and education remain an important part of managing diabetes.

Goals of Therapy Careful control of blood sugar reduces the long-term effects of type 2 diabetes on the body's circulatory system. We have learned a great deal about this from two recent studies (the Diabetes Control and Complications Trial [DCCT] study and the U.K. Prospective Diabetes Study [UKPDS]). As a result of these important large-scale research studies, the ADA has set new therapeutic goals. These include a target level of 7% for HbA1c (glycated hemoglobin - a measure of blood glucose control that provides information about average glucose levels over months rather than minutes or hours, which is all the information that blood glucose levels can provide); 80 - 120 mg/dl (4.46.6 mmol/l) for fasting plasma glucose (FPG); and 100-180 mg/dl (5.5-10 mmol/l) for postprandial (after eating a meal) glucose. When you start on an oral drug treatment, it is important that you see your doctor at least every 2-4 weeks, so you can quickly be placed on the best dose of the medicine. Frequent visits, at the start of treatment, may, if necessary, also help the doctor determine whether another medication should be added without delay. Table 1. Classes of Agents Available for Treatment of Type 2 Diabetes Mechanism of Action

Class of Agent

Indication for Use

Stimulates insulin secretion

Sulphonylureas Benzoic Acid Derivative

Primary or secondary Rx

Suppresses HGP*

Biguanides

Primary or

secondary Rx Insulin sensitizer

Thiazolidinediones

Secondary Rx

Reduces postprandial plasma glucose excursion

Alpha-glucosidase Inhibitors

Secondary treatment

Insulin replacement

Insulin/insulin analogues

Failure of oral agents

HGP, hepatic glucose production

*

Drugs that Promote the Body's Production of Insulin (Insulin Secretagogues) Sulfonylureas This class of agents was the mainstay of the treatment of type 2 diabetes for many years. They stimulate the body to produce, or secrete, more insulin. Other beneficial effects of the sulfonylurea class of drugs include suppression of glucose production in the liver and enhancement of the body's ability to dispose of excess glucose into fat and muscle tissue. Sulfonylureas remain the most popular group of medications today. In part, this may be a function of physicians' habits but an important factor is their low cost. Many types of sulfonylureas are now generic and are among the cheapest medications available for the treatment of diabetes. A drawback of sulfonylureas is that, on average, they lose effectiveness for 44% of patients within six years of beginning their use. Individual patients may have a more prolonged course of successful sulfonylurea treatment and others may need supplements even earlier than six years. Failure occurs more rapidly in younger, more hyperglycemic individuals and in those with lower insulin secretion at the start of treatment. While this may sound like a high rate of failure, it is important to remember that some of the newer drugs have not been in use for very long and we don't yet know how effective they are long-term. No matter how long you benefit from a particular oral agent without side effects, it is worth the time gained because it delays dealing with the inconvenience of using insulin. Furthermore, when used together with other drugs (see below), even though the sulfonylurea seems to have lost its effectiveness, the other drugs will work better in combination than on their own. Hypoglycemia and weight gain are the two most frequent side effects of these drugs. An early study, the UGDP (University Group Diabetes Program), published in the 1970s, also raised the possibility that sulfonylureas might make heart disease worse. However, the UKPDS study, mentioned earlier, found that sulfonylureas are no more likely to increase coronary artery disease than any of the other agents tested (insulin and metformin), so the jury is out with respect to heart disease. We do know, however, that sulfonylureas have little or no effect on blood lipid concentrations. Benzoic Acid Derivatives (Repaglinide) Repaglinide stimulates insulin secretion in a different way from the sulfonylureas. It is rapidly absorbed and quickly metabolized in your body; this means that you will need three doses each day. For some patients, this presents an inconvenience but for others, with erratic lifestyles that lead them, occasionally, to miss meals, skipping repaglinide at the same time appears to be very effective.

Repaglinide seems to have little effect on lipids and can, like the sulfonylureas, cause weight gain and hypoglycemia. Table 2. List of Oral Agents Class of Agent

Generic Name

Trade Name(s)

Sulphonylureas: 1st generation*

tolbutamide chlorpropamide tolazamide

Orinase® Diabinese®

Sulphonylureas: 2nd generation

glyburide glipizide glimepiride

Diabeta®, Micronase®, Glynase®, Glucotrol®, Glucotrol XL®, Amaryl®

Benzoic Acid Derivatives

repaglinide

Prandin®

Biguanides

metformin

Glucophage®

Thiazolidinediones

troglitazone roziglitazone pioglitazone

Rezulin® Avandia® Actos®

Alpha-glucosidase inhibitors

acarbose miglitol

Precose® Glyset®

* This is not a complete list of 1st generation sulphonylureas. Their only current indication is cost. When costs of generic second generation sulphonylureas become low enough, there will not be an indication for first generation agents any longer in the treatment of diabetes.

Drugs that Reduce Glucose Production by the Liver Metformin Metformin is not a new medication, although it was only approved by the FDA for use in the United States in 1995. Its primary effect is to inhibit the liver's production of glucose and, possibly, to stimulate the process of transporting glucose into muscle, a process which requires insulin. Thus it only works when there is insulin around, for example in type 2 diabetes, but not type 1 diabetes, which is characterized by insulin deficiency. Exactly how metformin works is not well understood. Metformin can be used as a first line of therapy. It is useful for patients who are obese because it does not cause the weight gain seen with sulfonylureas; it may even bring about some degree of weight loss. Metformin is also as capable as the sulfonylureas in reducing HbA1c. An additional benefit of metformin is its positive effect upon lipid metabolism -- it reduces blood triglyceride and LDL (the "bad") cholesterol levels by about 10% and also lowers fatty acids. Side effects can be a problem with metformin. Up to 30% of patients develop gastrointestinal complaints, though these may be mild and temporary, especially if dosages are brought up slowly. The largest concern with metformin is the potential to produce a build up of lactic acid. However, this is a very rare side effect of the drug, particularly if care is taken not to prescribe metformin when it is contraindicated. Contraindications for this drug include evidence of kidney disease, significant liver disease, chronic alcoholism or congestive heart failure. Hypoglycemia and, as mentioned

above, weight gain, are not on the list of metformin's side effects.

Drugs that Help the Body Respond to Insulin (Insulin Sensitizers) Thiazolidinediones The thiazolidinediones (TZDs) enhance insulin action in muscle, fat and other tissues and are known as insulin sensitizers. They require the presence of insulin in order to work, so TZDs are not indicated for type 1 ("insulin dependent diabetes") and certain other varieties of diabetes. TZDs are effective in reducing HbA1c. They are also effective in combination with either sulfonylureas or metformin. Compared to other drugs, it takes a patient a long time to see the benefits of the TZDs. For this reason, doses should not be increased until after 4-6 weeks, the time it normally takes for maximal biological effect to occur. About 25% of patients do not respond to TZDs. Some TZDs also have beneficial effects on blood lipids. Troglitazone has a lipid lowering effect and increases HDL, or high-density lipoprotein ("the good cholesterol"). Pioglitazone also decreases triglycerides. The major side effect, seen with troglitazone, the first TZD to be approved by the FDA, is liver damage. The effects observed range from an elevation in liver enzymes, which is reversible, to liver failure, which has caused death in a small number of patients. Because of this dangerous side-effect, the FDA, in March 2000, removed troglitazone (Rezulin®) from the market. Two other members of the TZD class that have recently been approved by the FDA, rosiglitazone and pioglitazone, do not appear to cause liver damage. However, the FDA requires regular monitoring of liver enzyme levels with these drugs as well. Other side effects of TZD are mild elevations of LDL (the "bad") cholesterol and fluid retention -- if you have heart trouble, TZDs may not be a good choice. TZDs do not cause hypoglycemia when used alone.

Drugs that Reduce Postprandial Glucose Concentrations Glucosidase Inhibitors After you eat, the food is digested, then passes into the bloodstream and, thus, the level of sugar in the blood rises. Glucosidase inhibitors act in the intestine to block the action of enzymes that are responsible for breaking down complex carbohydrates into simple sugars. This delayed breakdown of carbohydrates helps slow down their absorption into the bloodstream and, thus, slow down the increase in blood glucose levels after a meal. These medicines are not usually used for primary therapy unless a patient appears to have large increases in blood glucose after meals ("postprandial"). Glucosidase inhibitors are most useful in combination with other drugs. Gastrointestinal side effects are common, affecting up to 30% of patients. Bloating, flatulence, diarrhea and abdominal discomfort and pain are the major complaints. However, these side effects can be reduced by eating less carbohydrates in the diet. Hypoglycemia is not often seen but, if the patient develops low blood glucose levels, he/she must be treated with glucose, not complex carbohydrates. This is because the action of these drugs, which prevent breakdown of complex carbohydrates in the intestine, will be unable to rapidly correct blood glucose concentrations. Weight gain does not occur with these drugs.

Combination Therapy

As mentioned above, primary therapy can begin with a sulfonylurea or metformin and the goal of therapy is to achieve ADA guidelines for glucose control. If treatment with one drug fails to achieve this goal, doctors may reevaluate your diet, exercise and knowledge about diabetes, and they may add another medication. If treatment with two drugs fails, your doctor will have to determine whether or not to add another medication. The major decision is whether to start insulin at this point or, instead, try a different oral medication. This decision should be guided by the following considerations: i. ii. iii. iv. v.

How poor is the glucose control? The patient's age and the presence of long-term complications of diabetes. Patient preference (insulin, which needs to be injected, versus a second or third oral agent). Other diseases (e.g., kidney disease will affect the decision to use metformin, liver disease for TZDs). Cost. This will play an important role since there is a wide range of costs for the medications reviewed here. In general, the most recent drugs are the most costly and insulin, depending on dosage, is cheaper than the newer drugs.

Future Antidiabetic Medications Many pharmaceutical companies are working to produce new drugs for type 2 diabetes. These include novel classes of drugs as well as new insulin sensitizers and new stimulators of insulin secretion. One example, which is expected to be available shortly, is nateglinide (Starlix®), a rapid-onset, short-duration drug that is similar to repaglinide in effect, though quite different chemically. This drug is an effective stimulator of insulin secretion, is used prior to meals and may be prove to be useful as primary therapy.

Islet cell transplantation in diabetes mellitus--from bench to bedside. Replacement of the patient's islets of Langerhans either by pancreas transplantation or by isolated islet transplantation is the only treatment of type I diabetes mellitus to achieve an insulin-independent, constant normoglycemic state. The expense for this benefit is the need for immunosuppressive treatment of the recipient with all its potential risks. Thus, indications for pancreas or islet transplantations at present exist almost exclusively in patients with end-stage renal disease who are waiting on dialysis for a kidney graft or in diabetics with an established kidney graft obliged to be immunosuppressed. Islet transplants possess significantly potential advantages over whole-gland transplants: it is a simple procedure with only small risk, if any; it offers the potential advantages of pre-transplant reduction of immunogenicity thus possibly obviating the need for continuous life-long recipient immunosuppression and it offers the future feasibility of transplanting heterologous (pig) islets. The effectiveness of this concept was demonstrated in animal experiments and may be successfully transferred into the clinical situation. In this case, the indications for

islet transplantation may be extended to non-uremic type I diabetics including diabetic children. This group of patients is the ultimate target group for this most direct and appealing concept of treating type I diabetes. As of 1994, more than 200 adult islet allografts were reported to the International Islet Transplant Registry (ITR) at the Justus-Liebig-University, Giessen, Germany. A detailed analysis of 75 well-documented cases grafted between 1990 and 1993 revealed a one-year survival rate of the patients and islets of 95% and 28% (in terms of significant basal C-peptide secretion), respectively, and insulin independence was achieved in 11% of the cases after simultaneous islet-kidney (SIK) or islet-after-kidney (IAK) transplants. At present, there is no clinical data available and the follow-up studies of the posttransplant period are too short to draw any conclusions concerning the effects of islet transplants on diabetic secondary complications. Moreover, islet transplantation is still a clinical investigational procedure. Obviously, a number of fundamental steps will have to be taken before the appealing concept of transplanting adult pancreatic islets can attain clinical importance in the treatment of type I diabetic subjects. Islet cell transplantation has come the long way from animal experiments to successful clinical application, but, more research at the bench has to be performed before islet cell transplants will be successfully performed in non-uremic, non-kidney transplanted type I diabetic patients.

Diabetes mellitus type 1 (Type 1 diabetes, T1D, T1DM, IDDM, juvenile diabetes) is a form of diabetes mellitus. Type 1 diabetes is an autoimmune disease[1] that results in destruction of insulin-producing beta cells of the pancreas. Lack of insulin causes an increase of fasting blood glucose (around 70-120 mg/dL in nondiabetic people) that begins to appear in the urine above the renal threshold (about 190-200 mg/dl in most people), thus connecting to the symptom by which the disease was identified in antiquity, sweet urine. Glycosuria or glucose in the urine causes the patients to urinate more frequently, and drink more than normal (polydipsia). Classically, these were the characteristic symptoms which prompted discovery of the disease. Type 1 diabetes is fatal unless treated with exogenous insulin. Injection is the traditional and still most common method for administering insulin; jet injection, indwelling catheters, and inhaled insulin has also been available at various times, and there are several experimental methods as well. All replace the missing hormone formerly produced by the now non-functional beta cells in the pancreas. In recent years, pancreas transplants have also been used to treat type 1 diabetes. Islet cell transplant is also being investigated and has been achieved in mice and rats, and in experimental trials in humans as well.[2] Use of stem cells to produce a new population of functioning beta cells seems to be a future possibility, but has yet to be demonstrated even in laboratories as of 2008. Type 1 diabetes (formerly known as "childhood", "juvenile" or "insulin-dependent" diabetes) is not exclusively a childhood problem; the adult incidence of type 1 is

noteworthy—in fact, many adults who contract type 1 diabetes are misdiagnosed with type 2 due to confusion at this point. There is currently no clinically useful preventive measure against developing type 1 diabetes, though a vaccine has been proposed and anti-antibody approaches are also being tested. Most people who develop type 1 were otherwise healthy and of a healthy weight on onset, though some can be slightly overweight upon diagnosis of type 1. Unfortunately, however, they can lose weight quickly and dangerously, if not promptly diagnosed. Although the cause of type 1 diabetes is still not fully understood, the immune system damage is characteristic of type 1. The most definite laboratory test to distinguish type 1 from type 2 diabetes is the Cpeptide assay, which is a measure of endogenous insulin production since external insulin has not (to date) included C-peptide. The presence of anti-islet antibodies (to Glutamic Acid Decarboxylase, Insulinoma Associated Peptide-2 or insulin), or lack of insulin resistance, determined by a glucose tolerance test, would also be suggestive of type 1. Many type 2 diabetics continue to produce insulin internally, and all have some degree of insulin resistance. Testing for GAD 65 antibodies has been proposed as an improved test for differentiating between type 1 and type 2 diabetes as it appears that the immune system malfunction is connected with their presence. Further, injections with GAD65 has in clinical trials delayed the destruction of beta cells for at least 30 months, without serious adverse effects. Patients treated with the substance showed higher levels of regulatory cytokines, thought to protect the beta cells. Phase III trials are under way in the USA and in Europe, with most sites actively pursuing participants. Type 1 treatment must be continued indefinitely in essentially all cases. Treatment need not significantly impair normal activities, if sufficient patient training, awareness, appropriate care, discipline in testing and dosing of insulin is taken. However, treatment is burdensome for patients; insulin is replaced in a non-physiological manner, and this approach is therefore far from ideal. The average glucose level for the type 1 patient should be as close to normal (80–120 mg/dl, 4–6 mmol/L) as is safely possible. Some physicians suggest up to 140–150 mg/dl (7-7.5 mmol/L) for those having trouble with lower values, such as frequent hypoglycemic events. Values above 400 mg/dl (20 mmol/L) are sometimes accompanied by discomfort and frequent urination leading to dehydration. Values above 600 mg/dl (30 mmol/L) usually require medical treatment and may lead to ketoacidosis, although they are not immediately life-threatening. However, low levels of blood glucose, called hypoglycemia, may lead to seizures or episodes of unconsciousness and absolutely must be treated immediately, via emergency highglucose gel placed in the patient's mouth, intravenous administration of dextrose, or an injection of glucagon.

[edit] Pathophysiology

The cause of type 1 diabetes is still not fully understood. Some theorize that type 1 diabetes is generally a virally triggered autoimmune response in which the immune system's attack on virus infected cells is also directed against the beta cells in the pancreas. The autoimmune attack may be triggered by reaction to an infection, for example by one of the viruses of the Coxsackie virus family or German measles, although the evidence is inconclusive. In type 1, pancreatic beta cells in the Islets of Langerhans are destroyed or damaged sufficiently to effectively abolish endogenous insulin production. This etiology distinguishes type 1's origin from type 2. It should also be noted that the use of insulin in treating a patient does not mean that patient has type 1 diabetes; the type of diabetes a patient has is determined only by the cause— fundamentally by whether the patient is insulin resistant (type 2) or insulin deficient without insulin resistance (type 1). This vulnerability is not shared by everyone, for not everyone infected by the suspected organisms develops type 1 diabetes. This has suggested presence of a genetic vulnerability[3] and there is indeed an observed inherited tendency to develop type 1. It has been traced to particular HLA genotypes, though the connection between them and the triggering of an auto-immune reaction is still poorly understood. Some researchers believe that the autoimmune response is influenced by antibodies against cow's milk proteins.[4] A large retrospective controlled study published in 2006 strongly suggests that infants who were never breastfed had a risk for developing type 1 diabetes twice that of infants who were breastfed for at least three months.[citation needed] The mechanism is not fully understood. No connection has been established between autoantibodies, antibodies to cow's milk proteins, and type 1 diabetes. A subtype of type 1 (identifiable by the presence of antibodies against beta cells) typically develops slowly and so is often confused with type 2. In addition, a small proportion of type 2 cases manifest a genetic form of the disease called maturity onset diabetes of the young (MODY). Vitamin D in doses of 2000 IU per day given during the first year of a child's life has been connected in one study in Northern Finland (where intrinsic production of Vitamin D is low due to low natural light levels) with an 80% reduction in the risk of getting type 1 diabetes later in life. The causal connection, if any, is obscure. Type 1 diabetes was previously known as juvenile diabetes because it is one of the most frequent chronic diseases in children; however, the majority of new-onset type 1 diabetes is seen in adults. Scientific studies that use antibody testing (glutamic acid decarboxylase antibodies (GADA), islet cell antibodies (ICA), and insulinoma-associated (IA-2) autoantibodies) to distinguish between type 1 and type 2 diabetes demonstrate that most new-onset type 1 diabetes is seen in adults. A 2008 book, “Type 1 Diabetes in Adults: Principles and Practice” (Informa Healthcare, 2008) says that adult-onset type 1 autoimmune diabetes is two to three times more common than classic childhood-onset autoimmune diabetes (p. 27). In type 1 diabetes, the body does not produce insulin. Insulin is a hormone that is needed to convert sugar (glucose), starches and other food into energy needed for daily life.

Some suggest that deficiency of Vitamin D3 (one of several related chemicals with Vitamin D activity) may be an important pathogenic factor in type 1 diabetes independent of geographical latitude, and so of available sun intensity.[citation needed] Some chemicals and drugs preferentially destroy pancreatic cells. Pyrinuron (Vacor, N-3pyridylmethyl-N'-p-nitrophenyl urea), a rodenticide introduced in the United States in 1976, selectively destroys pancreatic beta cells, resulting in type 1 diabetes after accidental or intentional ingestion. Vacor was withdrawn from the U.S. market in 1979, but is still used in some countries. Zanosar is the trade name for streptozotocin, an antibiotic and antineoplastic agent used in chemotherapy for pancreatic cancer; it also kills beta cells, resulting in loss of insulin production. Other pancreatic problems, including trauma, pancreatitis or tumors (either malignant or benign), can also lead to loss of insulin production. The exact cause(s) of type 1 diabetes are not yet fully understood, and research on those mentioned, and others, continues. In December 2006, researchers from Toronto Hospital for Sick Children published research that shows a link between type 1 diabetes and the immune and nervous system. Using mice, the researchers discovered that a control circuit exists between insulinproducing cells and their associated sensory (pain-related) nerves.[5] It's being suggested that faulty nerves in the pancreas could be a cause of type 1 diabetes.[citation needed]

[edit] Inheritance Type 1 diabetes is a polygenic disease, meaning many different genes contribute to its expression. Depending on locus or combination of loci, it can be dominant, recessive, or somewhere in between. The strongest gene, IDDM1, is located in the MHC Class II region on chromosome 6, at staining region 6p21. This is believed to be responsible for the histocompatibility disorder characteristic of type 1: Insulin-producing pancreas cells (beta cells) display improper antigens to T cells. This eventually leads to the production of antibodies that attack these beta cells. Weaker genes are also located on chromosomes 11 and 18. Environmental factors can strongly influence expression of type 1. A study showed that for identical twins, when one twin had type 1 diabetes, the other twin only had type 1 30%–50% of the time. Despite having the exact same genome, one twin had the disease, where the other did not; this shows that environmental factors, in addition to genetic factors, can influence disease prevalence.[6]

[edit] Treatment Main article: Diabetes management

Type 1 is treated with insulin replacement therapy—usually by insulin injection or insulin pump, along with attention to dietary management, typically including carbohydrate tracking, and careful monitoring of blood glucose levels using glucose meters. Today the most common insulins are biosynthetic products produced using genetic recombination techniques; formerly, cattle or pig insulins were used, and even sometimes insulin from fish. Major global suppliers include Eli Lilly and Company, Novo Nordisk, and SanofiAventis. A more recent trend, from several suppliers, is insulin analogs which are slightly modified insulins which have different onset of action times or duration of action times. Untreated type 1 diabetes commonly leads to coma, often from diabetic ketoacidosis, which is fatal if untreated. Continuous glucose monitors have been developed and marketed which can alert patients to the presence of dangerously high or low blood sugar levels, but technical limitations have limited the impact these devices have had on clinical practice so far. In more extreme cases, a pancreas transplant can restore proper glucose regulation. However, the surgery and accompanying immunosuppression required is considered by many physicians to be more dangerous than continued insulin replacement therapy, and is therefore often used only as a last resort (such as when a kidney must also be transplanted, or in cases where the patient's blood glucose levels are extremely volatile). Experimental replacement of beta cells (by transplant or from stem cells) is being investigated in several research programs. Thus far, beta cell replacement has only been performed on patients over age 18, and with tantalizing successes amidst nearly universal failure.

[edit] Pancreas transplantation Main article: Pancreas transplantation Pancreas transplants are generally performed together with or some time after a kidney transplant. One reason for this is that introducing a new kidney requires taking immunosuppressive drugs such as ciclosporin. Nevertheless this allows the introduction of a new, functioning pancreas to a patient with diabetes without any additional immunosuppressive therapy. However, pancreas transplants alone can be wise in patients with extremely labile type 1 diabetes mellitus.[7] Scientists have found another alternative mode of pancreas transplantation through the use of xenografts especially from animals such as pigs. This alternative mode of transplantation from animals provides an alternative therapy for the treatment of Type 1 diabetes.[citation needed]

[edit] Islet cell transplantation Main article: Islet cell transplantation Islet cell transplantation is expected to be less invasive than a pancreas transplant which is currently the most commonly used approach in humans.

In one variant of this procedure, islet cells are injected into the patient's liver, where they take up residence and begin to produce insulin. The liver is expected to be the most reasonable choice because it is more accessible than the pancreas, and islet cells seem to produce insulin well in that environment. The patient's body, however, will treat the new cells just as it would any other introduction of foreign tissue, unless a method is developed to produce them from the patient's own stem cells or there is an identical twin available who can donate stem cells. The immune system will attack the cells as it would a bacterial infection or a skin graft. Thus, patients now also need to undergo treatment involving immunosuppressants, which reduce immune system activity. Recent studies have shown that islet cell transplants have progressed to the point that 58% of the patients in one study were insulin independent one year after islet cell transplant.[8] Ideally, it would be best to use islet cells which will not provoke this immune reaction, but scientists in New Zealand are also looking into placing them within a protective housing derived of seaweed which enables insulin to flow out and nutrients to flow in while protecting the islets from immune system attack via white blood cells.

[edit] Epidemiology It is estimated that about 5%–10% of North American diabetes patients have type 1. The fraction of type 1 in other parts of the world differs; this is likely due to both differences in the rate of type 1 and differences in the rate of other types, most prominently type 2. Most of this difference is not currently understood. Variable criteria for categorizing diabetes types may play a part. The longest surviving Type I diabetes patient is Gladys Dull, who has lived with the condition for over 83 years.

[edit] Research foundations The Juvenile Diabetes Research Foundation (JDRF) is the major charitable organization in the USA, Canada and Australia devoted to type 1 diabetes research. JDRF's mission is to cure type 1 diabetes and its complications through the support of research. Since its founding in 1970, JDRF has contributed more than $1.3 billion to diabetes research, including more than $156 million in FY 2008. In FY 2008, the Foundation funded 1,000 centers, grants and fellowships in 22 countries. In November 2008 JDRF launched a new online social network for people with type 1 diabetes--*Juvenation. The International Diabetes Federation is a worldwide alliance of over 160 countries to address diabetes research and treatment. The American Diabetes Association funds some work on type 1 but devotes much of its resources to type 2 diabetes due to the increasing prevalence of the type 2 version. Diabetes Australia is involved in promoting research and education in Australia on both type 1 and type 2 diabetes. The Canadian Diabetes Association is also involved in educating, researching, and sustaining sufferers of type 1 Diabetics in Canada. Pacific Northwest Diabetes Research Institute conducts clinical and basic research on type 1 and type 2 diabetes.

[edit] Cure As of 2009, there is no known cure for diabetes mellitus type 1. Diabetes type 1 is caused by the destruction of enough beta cells to produce symptoms; these cells, which are found in the Islets of Langerhans in the pancreas, produce and secrete insulin, the single hormone responsible for allowing glucose to enter from the blood into cells (in addition to the hormone amylin, another hormone required for glucose homeostasis). Hence, the phrase "curing diabetes type 1" means "causing a maintenance or restoration of the endogenous ability of the body to produce insulin in response to the level of blood glucose" and cooperative operation with counterregulatory hormones. This section deals only with approaches for curing the underlying condition of diabetes type 1, by enabling the body to endogenously, in vivo, produce insulin in response to the level of blood glucose. It does not cover other approaches, such as, for instance, closedloop integrated glucometer/insulin pump products, which could potentially increase the quality-of-life for some who have diabetes type 1, and may by some be termed "artificial pancreas".

[edit] Reversion

[edit] Encapsulation approach The Bio-artificial pancreas: a cross section of bio-engineered tissue with encapsulated islet cells delivering endocrine hormones in response to glucose A biological approach to the artificial pancreas is to implant bioengineered tissue containing islet cells, which would secrete the amounts of insulin, amylin and glucagon needed in response to sensed glucose. When islet cells have been transplanted via the Edmonton protocol, insulin production (and glycemic control) was restored, but at the expense of continued immunosuppression drugs. Encapsulation of the islet cells in a protective coating has been developed to block the immune response to transplanted cells, which relieves the burden of immunosuppression and benefits the longevity of the transplant.[9] One concept of the bio-artificial pancreas uses encapsulated islet cells to build an islet sheet which can be surgically implanted to function as an artificial pancreas.[10] This islet sheet design consists of: • •

An inner mesh of fibers to provide strength for the islet sheet; Islet cells, encapsulated to avoid triggering a proliferating immune response, adhered to the mesh fibers;

• •

A semi-permeable protective layer around the sheet, to allow the diffusion of nutrients and secreted hormones; A protective coating, to prevent a foreign body response resulting in a fibrotic reaction which walls off the sheet and causes failure of the islet cells.

Islet sheet with encapsulation research is pressing forward with large animal studies at the present, with plans for human clinical trials within a few years. Clinical studies underway in New Zealand by Living Cell Technologies have encapsulated pig islet cells in a seaweed derived capsule. This approach has had very positive clinical studies and is currently underway in human trials as of 2008. So far, treatment using this method of cell encapsulation has been proven safe and effective and is the first to achieve insulin independence in human trials without immunosuppressant drugs.[11]

[edit] Islet cell regeneration approach Research undertaken at the Massachusetts General Hospital between 2001 and 2003 demonstrated a protocol to reverse type 1 diabetes in non-obese diabetic mice (a frequently used animal model for type 1 diabetes mellitus).[12] Three other institutions have had similar results, as published in the March 24, 2006 issue of Science. A fourth study by the National Institutes of Health achieved similar results, and also sheds light on the biological mechanisms involved.[13] Other researchers, most notably Dr. Aaron I. Vinik of the Strelitz Diabetes Research Institute of Eastern Virginia Medical School and a former colleague, Dr. Lawrence Rosenberg (now at McGill University) discovered in a protein they refer to as INGAP, which stands for Islet Neogenesis Associated Protein back in 1997. INGAP seems to be the product of a gene responsible for regenerating the islets that make insulin and other important hormones in the pancreas. INGAP has had commercialization difficulties. Although it has appeared promising, commercial rights have changed hands repeatedly, having once been owned by Procter & Gamble Pharmaceuticals, which eventually dropped it. Rights were then acquired by GMP Companies. More recently, Kinexum Metabolics, Inc. has since sublicensed INGAP from GMP for further clinical trials. Kinexum has continued development under Dr. G. Alexander Fleming, an experienced metabolic drug developer, who headed diabetes drug review at the FDA for over a decade. As of 2008, the protein had undergone Phase 2 Human Clinical Trials, and developers were analyzing the results. At the American Diabetes Association's 68th Annual Scientific Sessions in San Francisco, Kinexum announced a Phase 2 human clinical trial with a combination therapy, consisting of DiaKine's Lisofylline (LSF) and Kinexum's INGAP peptide, which is expected to begin in late 2008.[14] The trial will be unique in that patients who are beyond the 'newly diagnosed' period will be included in the study. Most current trials seeking to treat people with type 1 diabetes do not include those with established disease.

[edit] Stem cells approach Research is being done at several locations in which islet cells are developed from stem cells. [edit] South Korea

In January 2006, a team of South Korean scientists has grown pancreatic beta cells, which can help treat diabetes, from stem cells taken from the umbilical cord blood of newborn babies. [edit] Brazil

Stem cell research has also been suggested as a potential avenue for a cure since it may permit regrowth of Islet cells which are genetically part of the treated individual, thus perhaps eliminating the need for immuno-suppressants.[48] This new method autologous nonmyeloablative hematopoietic stem cell transplantation was developed by a research team composed by Brazilian and American scientists (Dr. Julio Voltarelli, Dr. Carlos Eduardo Couri, Dr Richard Burt, and colleagues) and it was the first study to use stem cell therapy in human diabetes mellitus This was initially tested in mice and in 2007 there was the first publication of stem cell therapy to treat this form of diabetes[15]. Until 2009, there was 23 patients included and followed for a mean period of 29.8 months (ranging from 7 to 58 months). In the trial, severe immunosuppression with high doses of cyclophosphamide and anti-thymocyte globulin is used with the aim of "turning off" the immunologic system", and then autologous hematopoietic stem cells are reinfused to regenerate a new one. In summary it is a kind of "immunologic reset" that blocks the autoimmune attack against residual pancreatic insulin-producing cells. Until December 2009, 12 patients remained continuously insulin-free for periods raging from 14 to 52 months and 8 patients became transiently insulin-free for periods ranging from 6 to 47 months. Of these last 8 patients, 2 became insulin-free again after the use of sitagliptin, a DPP-4 inhibitor approved only to treat type 2 diabetic patients and this is also the first study to document the use and complete insulin-independendce in humans with type 1 diabetes with this medication. In parallel with insulin suspension, indirect measures of endogenous insulin secretion revealed thate it significantly increased in the whole group of patients, regardless the need of daily exogenous insulin use[16]. However, there were no control subjects, which means that all of the processes could have been completely or partially natural. Secondly, no theory for the mechanism of cure has been promoted. It is too early to say whether the results will be positive or negative in the long run. [edit] University of North Carolina

In September 2008, scientists from the University of North Carolina at Chapel Hill School of Medicine have announced their success in transforming cells from human skin into cells that produce insulin.[17]

The skin cells were first transformed into stem cells and then had been differentiated into insulin-secreting cells.[18] However, other scientists have doubts, as the research papers fail to detail the new cells' glucose responsiveness and the amount of insulin they are capable of producing.

[edit] Gene therapy approach Gene therapy: Designing a viral vector to deliberately infect cells with DNA to carry on the viral production of insulin in response to the blood sugar level. Technology for gene therapy is advancing rapidly such that there are multiple pathways possible to support endocrine function, with potential to practically cure diabetes.[19] •

•

•

Gene therapy can be used to manufacture insulin directly: an oral medication, consisting of viral vectors containing the insulin sequence, is digested and delivers its genes to the upper intestines. Those intestinal cells will then behave like any viral infected cell, and will reproduce the insulin protein. The virus can be controlled to infect only the cells which respond to the presence of glucose, such that insulin is produced only in the presence of high glucose levels. Due to the limited numbers of vectors delivered, very few intestinal cells would actually be impacted and would die off naturally in a few days. Therefore by varying the amount of oral medication used, the amount of insulin created by gene therapy can be increased or decreased as needed. As the insulin producing intestinal cells die off, they are boosted by additional oral medications.[20] Gene therapy might eventually be used to cure the cause of beta cell destruction, thereby curing the new diabetes patient before the beta cell destruction is complete and irreversible.[21] Gene therapy can be used to turn duodenum cells and duodenum adult stem cells into beta cells which produce insulin and amylin naturally. By delivering beta cell DNA to the intestine cells in the duodenum, a few intestine cells will turn into beta cells, and subsequently adult stem cells will develop into beta cells. This makes the supply of beta cells in the duodenum self replenishing, and the beta cells will produce insulin in proportional response to carbohydrates consumed.[22]

[edit] Yonsei University

Scientists in the South Korean university of Yonsei have, in 2000, succeeded in reversing diabetes in mice and rats. Using a viral vector, a DNA encoding the production of an insulin analog was injected to the animals, which remained non-diabetic for at least the eight months duration of the study.[23]

[edit] Prevention

[edit] "Immunization" approach If a biochemical mechanism can be found that prevents the immune system from attacking beta cells, it may be administered to prevent commencement of diabetes type 1. Several groups are trying to achieve this by causing the activation state of the immune system to change from Th1 state (“attack” by killer T Cells) to Th2 state (development of new antibodies). This Th1-Th2 shift occurs via a change in the type of cytokine signaling molecules being released by regulatory T-cells. Instead of pro-inflammatory cytokines, the regulatory T-cells begin to release cytokines that inhibit inflammation.[24] This phenomenon is commonly known as "acquired immune tolerance".

[edit] DiaPep277 A substance designed to cause lymphocyte cells to cease attacking beta cells, DiaPep277 is a peptide fragment of a larger protein called HSP60. Given as a subcutaneous injection, its mechanism of action involves a Th1-Th2 shift. Clinical success has been demonstrated in prolonging the "honeymoon" period for people who already have type 1 diabetes.[25] The product is currently being tested in people with latent autoimmune diabetes of adults (LADA). Ownership of the drug has changed hands several times over the last decade. In 2007, Clal Biotechnology Industries (CBI) Ltd., an Israeli investment group in the field of life sciences, announced that Andromeda Biotech Ltd., a wholly owned subsidiary of CBI, signed a Term Sheet with Teva Pharmaceutical Industries Ltd. to develop and commercialize DiaPep277.[26]

[edit] Intra-nasal insulin There is pre-clinical evidence that a Th1-Th2 shift can be induced by administration of insulin directly onto the immune tissue in the nasal cavity. This observation has led to a clinical trial, called INIT II, which began in late 2006, based in Australia and New Zealand.

[edit] BCG research Tumor necrosis factor-alpha, or TNF-α, is part of the immune system. It helps the immune system distinguish self from non-self tissue. People with type 1 diabetes are deficient in this substance. Dr. Denise Faustman theorizes that giving Bacillus CalmetteGuérin (BCG), an inexpensive generic drug, would have the same impact as injecting diabetic mice with Freund's Adjuvant, which stimulates TNF-α production. TNF-α kills the white blood cells responsible for destroying beta cells, and thus prevents, or reverses diabetes.[27] She has reversed diabetes in laboratory mice with this technique, but was only able to receive funding for subsequent research from The Iaccoca Foundation, founded by Lee Iacocca in honor of his late wife, who died from diabetes complications. Human trials are set to begin in 2008.

[edit] Diamyd Diamyd is the name of a vaccine being developed by Diamyd Medical. Injections with GAD65, an autoantigen involved in type 1 diabetes, has in clinical trials delayed the destruction of beta cells for at least 30 months, without serious adverse effects. Patients treated with the substance showed higher levels of regulatory cytokines, thought to protect the beta cells. Phase III trials are under way in the USA and in Europe, with most sites actively pursuing participants. Two prevention studies, where the vaccine is given to persons who have not yet developed diabetes, will start in 2009.

[edit] Research This section is an incomplete list of mainly commercial companies but also other entities, namely governmental institutions and individual persons, actively involved in research towards finding a cure to diabetes type 1. It does not list research funds, hospitals in which research is undertaken, etc., but only the industrious, actual developers of such products. Entities are listed alphabetically along with their status of research in that field, so that also entities which ceased research into finding a cure to diabetes type 1 may be listed. • • • • • •

•

Amylin Pharmaceuticals – is working toward finding a cure, and has a drug on the market called Symlin (pramlintide acetate) that helps in treating type 1 diabetes Cerco Medical – Present status: Unknown. Denise Faustman– Present status: Working on immune modification DeveloGen– Present status: Developing DiaPep 277 Diamyd Medical – Present status: Developing GAD65-based vaccine (phase III trial started) Tolerx, Inc. [www.defendagainstdiabetes.com] - Present status: Now (4/2009) in Phase 3 clinical study of otelixizumab, an Fc-disabled, anti-CD3 monoclonal antibody in patients with new onset (diagnosis within last 10 weeks) type 1 diabetes. National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases.