Diabetes is principally a disease of the middle-aged and elderly; more than one in ten people over 65 suffer from diabetes. Often the elderly do not have access to information about diabetes and this affects their ability and willingness to follow advice about diet, exercise and medicines. Doctors often do not have time to counsel them fully. The following information about diabetes is presented in the question-answer format. If your parents suffer from diabetes, you can ensure they have the knowledge and understanding to deal with diabetes with confidence and success.

What is diabetes?
Diabetes is a condition in which there is increased sugar (glucose) in the bloodstream. This happens because the pancreas does not produce enough insulin or because the body tissues are resistant to the action of insulin.

Insulin is responsible for moving glucose from the blood into the body cells especially after meals. It acts like a key opening a door into the cell for the glucose to enter. So, when there is no insulin or when the body is resistant to its action, glucose cannot enter the cells and accumulates in the blood. Increased blood glucose, over time, leads to progressive damage to blood vessels and nerves.

What are the symptoms of diabetes and how are they caused?
Many people with diabetes may not have any symptoms.

Fatigue is often the first symptom. Since glucose is unable to enter the cells, the muscles tire easily because they do not have the basic fuel they need for power.

Meanwhile, the glucose that cannot get into the cells of the body builds up in the blood. The kidneys are able to reabsorb all the glucose in the blood until blood glucose level is more than 180 mg/dl. Once the glucose in the blood exceeds 180 mg/dl, it passes through the kidneys into the urine and carries water along with it. So, extra water is lost in the urine resulting in thirst and increased intake of water. So, fatigue, increased urination and increased thirst are all symptoms of glucose not being able to get into your cells.

Also, you may lose weight even though you are eating plenty of food because nutrients are unable to enter your cells.

How is diabetes diagnosed?
Normal blood glucose is less than 100 mg/dl after an 8-hour fast and less than 140 mg/dl after a two-hour glucose tolerance test.)

Diagnosis of diabetes is confirmed if:

• blood glucose is 126 mg/dl (7.0 mmol/l) or higher after an 8-hour fast.
• blood glucose is 200 mg/dl (mg/dl) or higher, two hours after a meal.
• blood glucose is 200 mg/dl two hours after drinking 75 grams of glucose (glucose tolerance test).

Prediabetes (impaired tolerance of glucose) indicating increased risk of developing diabetes in future is diagnosed if:

• blood glucose is between 100 and 126 mg/dl after an 8-hour fast.
• blood glucose is between 140 to 200 mg/dl two hours after drinking 75 grams of glucose.

What are the different types of diabetes?

• Type 1 diabetes is caused by a lack of insulin and is usually seen in children.
• Type 2 diabetes is mainly because of resistance of body tissues to insulin and develops in middle-age. Ninety percent of all diabetics worldwide have type 2 diabetes.
• Gestational diabetes occurs during pregnancy. Though it disappears after childbirth, it is a sign of insulin resistance and such women are at greater risk of becoming diabetic in future.

What are the complications of diabetes?
If not controlled, the raised blood sugar level can progressively damage the delicate capillaries as well as the larger blood vessels and nerves in all tissues.

The most common complications of diabetes are:

• Heart disease
• Kidney failure
• Stroke
• Blindness
• Foot ulcers and eventual amputation
• Decrease in general immunity leading to increased risk of infection

What are the principles of treatment of diabetes?
Diabetes usually cannot be cured or reversed.

The principles of treatment are:

• Keep blood glucose within normal limits
• Prevent long-term complications of diabetes with the help of counseling, healthy diet, adequate exercise, and appropriate medication
• Control associated risk factors such as smoking, obesity, increased blood pressure, high blood cholesterol, and lack of exercise.
• Avoid prolonged physical inactivity because it is an independent risk factor for heart disease.

How should diabetes be monitored?

• Blood glucose should be checked as frequently as recommended by the doctor. Blood glucose may have to be checked more frequently if diet, medications, exercise routine or health status change.
• Hemoglobin A1c indicates how well your blood glucose has been controlled in the preceding three months. It is a better indicator of control of diabetes than individual blood glucose levels. Hemoglobin Ac1 values below 6.5 percent cut the risk of complications.

How should the complications of diabetes be monitored?

• Examine feet daily for ulcers
• Visit your doctor regularly and follow his or her advice
• Monitor the following:
  1. Body weight and waistline
  2. Blood pressure
  3. Blood cholesterol
  4. Kidney function (urine protein and serum creatinine)
  5. Heart function (EKG, stress test, echocardiography, coronary angiography)
  6. Vision (examination of eyes every 3-4 months)

What is the treatment of diabetes?

• Diet is the mainstay of treatment of diabetes. In many diabetics, control of diet and reduction of body weight is the only treatment required. Doctors usually advise a gradual loss of body weight of about one pound every week. To achieve this, doctors recommend a diet rich in nutrients and fiber and low in fats and refined carbohydrates. Diabetics are encouraged to eat more vegetables, fruits, whole grains, and legumes.
• Exercise improves control of diabetes by reducing blood glucose and improving insulin sensitivity. More importantly, exercise is a natural antidepressant and improves mental wellbeing and sleep.
• Medication: If diabetes is not controlled by diet and exercise, your doctor may have to prescribe anti-diabetic tablets or insulin.

What is hypoglycemia?
Hypoglycemia means low glucose level in the blood (below 70 mg/dl) and is usually seen in diabetics treated with insulin or anti-diabetic tablets such as Glimepiride (Amaryl), Nateglinide (Starlix), Glipizide (Glucotrol), Repaglinide (Prandin), and Glyburide (Glynase). It is either caused by exercise, delay in meal or increased dose of anti-diabetic medications. Early signs include shaking, sweating, hunger, anxiety, weakness, dizziness, rapid heartbeat, lightheadedness, sleepiness, confusion and difficulty in speaking. The immediate solution is to take about 2-3 spoonfuls of sugar or 4-6 glucose biscuits. Repeat after 15 minutes if the blood sugar is still low. Inform your doctor who may reduce your anti-diabetic medication.

Hypoglycemia is more common in the elderly and more dangerous so they must take extra precautions to deal with it.

• Avoid long gaps between meals, especially after exercise or insulin
• Always carry sugar or glucose biscuits and ingest at the first signs of hypoglycemia
• Wear an identification bracelet stating you are a diabetic and should be given sugar if you are unconscious or confused and taken to the nearest doctor.

What precautions about medications should be taken?
The elderly usually have more than one illness and have to take many medications several times a day. It is important to help them by labeling all medications clearly. If they are likely to miss or repeat doses, their medicines must be kept in individual boxes and labeled with the date and time when they are supposed to take them.

Elderly people with diabetes may be handicapped by insufficient knowledge of how to deal with their illness. The best way you can help your diabetic parent is to provide him or her with adequate information about diabetes. This will enable them to gain a better understanding of how to control diabetes and prevent its complications. It will also help them to be more responsible for their own health.

References:
1. Haslett Christopher et al, eds. Davidson’s Principles and Practice of Medicine. 19th ed. Oxford: Churchill Livingstone, 2002
2. Barnard Neal, Dr. Neal Barnard’s Program for Reversing Diabetes. New York: Rodale; 2007

Contributed by: Dr. Rohi Shetty