Diabetic retinopathy is damage to the retina, the light sensitive area at the back of the eye. The damage is caused by changes in the blood vessels that supply the cells of the retina with oxygen and nutrition. In the first stage of retinopathy, called background or nonproliferative retinopathy, the blood vessels develop small balloon-like swellings called microaneurysms and leak fluid and blood, or become clogged. When these changes happen to enough of the blood vessels, the cells of the retina are deprived of their blood supply. In response to the lack of blood, new blood vessels grow. These new blood vessels are abnormal, fragile and leak blood. The result is loss of vision or blindness. This phase is called proliferative retinopathy. Usually, diabetic retinopathy progresses from nonproliferative to proliferative over a period of years. Most often, there are no symptoms of diabetic retinopathy. In some cases mild-to-severe blurring, seeing “strings,” “cobwebs” or specks floating in your visual field, or vision loss may be symptoms. Retinopathy can be treated with photocoagulation, laser treatment that stops blood leakage and shrinks blood vessels.
Your retina can be badly damaged before you notice any change in vision, and most people with nonproliferative retinopathy have no symptoms, the ADA says. Even with proliferative retinopathy, people sometimes have no symptoms until it’s too late to treat the condition. That’s why it’s crucial for people with diabetes to see an eye care professional every year for eye examinations.
If you have diabetic retinopathy, you may need an eye exam more often. People with proliferative retinopathy can reduce their risk of blindness by 95 percent with timely treatment and appropriate follow-up care.
The Diabetes Control and Complications Trial (DCCT) showed that better control of blood sugar levels slows the onset and progression of retinopathy. The people with diabetes who kept their blood sugar levels as close to normal as possible also had much less kidney and nerve disease. Better control also reduces the need for sight-saving laser surgery.
This level of blood sugar control may not be best for everyone, including some elderly patients, children under age 13, or people with heart disease. Be sure to ask your doctor if such a control program is right for you.
Other studies have shown that controlling elevated blood pressure and cholesterol can reduce the risk of vision loss. Controlling these will help your overall health as well as help protect your vision.
Foot Care Complications With Diabetes
Diabetes can decrease the blood supply to the feet and damage the nerves that carry sensation. These changes put the feet at risk for developing potentially serious complications such as ulcers. Foot complications are very common among people with diabetes, and may go unnoticed until the condition is severe. People with diabetes should examine their feet every day. It is important to examine all parts of the feet, especially the area between the toes. Look for broken skin, ulcers, blisters, areas of increased warmth or redness, or changes in callus formation; a healthcare provider should be notified if any of these changes are found.
Kidney Complications in Diabetes
Diabetes can alter the normal function of the kidneys. A urine test that measures the amount of protein (albumin) in the urine can determine if diabetes is affecting the kidney’s filtering action. Microscopic amounts of albumin in the urine (microalbuminuria) can be an early indicator of diabetes-related kidney complications (called nephropathy). The amount of albumin in the urine can also help the provider determine if nephropathy is worsening.
Urine screening tests should begin in people with type 1 diabetes about five years after diagnosis, and in people with type 2 diabetes at the time of diagnosis. If the test shows that there is protein in the urine, tight blood sugar and lipid (cholesterol and triglyceride) control are recommended.
A blood pressure medication (an ACE inhibitor or angiotensin receptor blocker [ARB]) is generally recommended if albuminuria does not improve, even if the blood pressure is normal. People with elevated blood pressure and albuminuria are also treated with an ACE inhibitor or ARB. These medications decrease the amount of protein in the urine and can prevent or slow the progression of diabetes-related kidney disease.
HYPERTENSION AND RELATED COMPLICATIONS IN DIABETES
Many people with diabetes have hypertension (high blood pressure). Although high blood pressure causes few symptoms, it has two negative effects: it stresses the cardiovascular system and speeds the development of diabetic complications of the kidney and eye. A healthcare provider can diagnose high blood pressure by measuring blood pressure on a regular basis. A blood pressure reading below 140/90 and perhaps below 130/80 is recommended for most people with diabetes who do not have kidney complications; a lower blood pressure goal (less than 130/80) is recommended for people with diabetes who have kidney disease.
CARDIOVASCULAR COMPLICATIONS IN DIABETES
In addition to lowering blood glucose levels, a number of other measures are important to reduce the risk of cardiovascular (heart and blood vessel) disease.
- Quit smoking.
- Manage high blood pressure with lifestyle modifications and/or medication(s).
- Have a blood test to measure cholesterol and triglyceride levels, and modify the diets if needed. Some people will also need a medication to lower their LDL (“bad cholesterol”) or triglycerides.If medication is needed, a statin drug should be included whenever possible. The statin drugs have been shown to decrease the future risk of heart attacks, strokes, and death in people with diabetes who are over age 40, even when cholesterol levels are normal.The American Diabetes Association recommends that people with diabetes have a low density lipoprotein (LDL) cholesterol level less than 100 mg/dL (2.59 mmol/L). Some studies suggest lowering LDL even further, to 70 to 80 mg/dL (1.81 to 2.07 mmol/L).
- Aspirin (81 to 100 mg per day) is recommended for anyone with diabetes who already has or is at increased risk of cardiovascular disease.
PREGNANCY AND DIABETES
Control of diabetes and its potential complications is especially important for women who are planning to become pregnant, as well as in those who already are pregnant. Controlling blood sugar levels before and during pregnancy decreases the risk of many complications in both the mother and the baby.
Glucose in the mother’s blood crosses the placenta to provide energy for the baby; thus, high blood glucose levels in the mother lead to high blood glucose levels in the developing baby as well.
High blood glucose levels can cause several problems:
- Early in pregnancy, high glucose levels increase the risk of miscarriage and birth defects. These risks are highest when hemoglobin A1C is >8 percent or the average blood glucose is >180 mg/dL (10 mmol/L).
- In the last half of pregnancy and near delivery, high blood glucose levels can cause the baby’s size and weight to be larger than normal and increase the risk of complications during and after delivery . In particular, women with large babies are more likely to have difficulty having a vaginal birth and have a higher chance of needing a cesarean delivery.
Over time, this can damage the covering on your nerves or the blood vessels that bring oxygen to your nerves. Damaged nerves may stop sending messages, or may send messages slowly or at the wrong times.
This damage is called diabetic neuropathy. Over half of people with diabetes get it. Symptoms may include
- Numbness in your hands, legs, or feet
- Shooting pains, burning, or tingling
- Nausea, vomiting, constipation, or diarrhea
- Problems with sexual function
- Urinary problems
- Dizziness when you change positions quickly
Your doctor will diagnose diabetic neuropathy with a physical exam and nerve tests.
Metabolism is the process your body uses to get or make energy from the food you eat. Food is made up of proteins, carbohydrates, and fats. Chemicals in your digestive system break the food parts down into sugars and acids, your body’s fuel. Your body can use this fuel right away, or it can store the energy in your body tissues, such as your liver, muscles, and body fat.
A metabolic disorder occurs when abnormal chemical reactions in your body disrupt this process. When this happens, you might have too much of some substances or too little of other ones that you need to stay healthy.
You can develop a metabolic disorder when some organs, such as your liver or pancreas, become diseased or do not function normally. Diabetes is one example.
The Pump Corner
More and more patients are considering intense insulin therapy using high-tech devices, as insulin pumps. There are a lot of enthusiasts for treatments with pumps. The question is whether an insulin pump is the right choice for each patient who considers it. The PUMP CORNER is our information section on insulin pumps.
About Insulin Pumps
An insulin pump is a device, a little bigger than a pack of playing cards, which contains an insulin syringe set in a cradle with a piston. The piston pushes the syringe in a variable rates, which allow for accurate delivery of different doses of insulin. The insulin is infused subcutaneously via a tubing from the pump to a small needle, which is placed under the skin. The needle can stay in that location for as long as two to three days without being changed. This eliminates the need for multiple injections of insulin on a daily basis and allows for intense control of blood sugars.
Advantages of Insulin Pumps
Studies show that, with proper use and medical treatment, patients on insulin pumps may achieve meticulous regulation of their blood sugars. In the landmark DCCT study (Diabetes Control and Complications Trial), patients on insulin pumps had as good or better control of blood sugars than patients on any other treatment. Pumps are also a more flexible way to control diabetes. Patients on pumps have much more freedom in their ability to choose their eating schedule and variations of activity.
Disadvantages of Pumps
Despite these definite advantages, pumps are not for everyone. They are the most expensive form of insulin therapy. Average first year costs exceed $ 7000. Blood sugars can vary much faster in patients on pumps than patients on other forms of therapy. Therefore, patients on pumps should measure their blood sugars more often than patients on traditional insulin treatment. Some people dislike the constant presence of the little box on their side. Finally, if something goes wrong with the pump or the infusion sets that connect the pump to the skin, severe hyperglycemia will occur much faster than with traditional therapy.
Deciding on Pump Treatment
Because of the many questions in regard to insulin pumps, we believe that patients should have a chance to assess pump therapy before they become committed to it. We have developed a protocol which allows people the time to judge whether this form of treatment is right for them. We prefer to place pumps on people we know well, so that we may help our patient make an informed decision about the pump. Secondly, we have a program to allow patients to wear a “loaner” pump for a week or two, which infuses saline instead of insulin. This gives them a “feel” for the experience of wearing a pump. While this is going on, our staff works with the patient and their health insurance company to make sure the purchase of the pump and supplies is feasible for the patient. Call or email us for further information about insulin pumps.
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