Type 1 Diabetes Complications

Heart Disease
People with diabetes have extra reason to be mindful of heart and blood vessel disease. Diabetes carries an increased risk for heart attack, stroke, and complications related to poor circulation.
 

Did you know that 2 out of 3 people with diabetes die from heart disease and stroke? Make the Link! Diabetes, Heart Disease and Stroke is an initiative of the American Diabetes Association and the American College of Cardiology, aimed at increasing awareness of the link between diabetes and heart disease.

Make the Link! stresses that diabetes management is more than control of blood glucose. People with diabetes must also manage blood pressure and cholesterol and talk to their health provider to learn about other ways to reduce their chance for heart attacks and stroke.

Kidney Disease (Nephropathy)/Kidney Transplantation
Diabetes can damage the kidneys, which not only can cause them to fail, but can also make them lose their ability to filter out waste products. This is called nephropathy.
 

Kidney Disease (nephropathy)
Kidneys are remarkable organs. Inside them are millions of tiny blood vessels that act as filters. Their job is to remove waste products from the blood.

Sometimes this filtering system breaks down. Diabetes can damage the kidneys and cause them to fail. Failing kidneys lose their ability to filter out waste products, resulting in kidney disease.

Why diabetes can cause kidney disease (nephropathy)
When our bodies digest the protein we eat, the process creates waste products. In the kidneys, millions of tiny blood vessels (capillaries) with even tinier holes in them act as filters. As blood flows through the blood vessels, small molecules such as waste products squeeze through the holes. These waste products become part of the urine. Useful substances, such as protein and red blood cells, are too big to pass through the holes in the filter and stay in the blood.

Diabetes can damage this system. High levels of blood sugar make the kidneys filter too much blood. All this extra work is hard on the filters. After many years, they start to leak. Useful protein is lost in the urine. Having small amounts of protein in the urine is called microalbuminuria. When kidney disease is diagnosed early, (during microalbuminuria), several treatments may keep kidney disease from getting worse. Having larger amounts is called macroalbuminuria. When kidney disease is caught later (during macroalbuminuria), end-stage renal disease, or ESRD, usually follows.

In time, the stress of overwork causes the kidneys to lose their filtering ability. Waste products then start to build up in the blood.

Finally, the kidneys fail. This failure, ESRD, is very serious. A person with ESRD needs to have a kidney transplant or to have the blood filtered by machine (dialysis).

Who gets kidney disease?

Not everyone with diabetes develops kidney disease. Factors that can influence kidney disease development include genetics, blood sugar control, and blood pressure.

The better a person keeps diabetes and blood pressure under control, the lower the chance of getting kidney disease.

Symptoms and diagnosis of kidney disease

The kidneys work hard to make up for the failing capillaries so kidney disease produces no symptoms until almost all function is gone. Also, the symptoms of kidney disease are not specific. The first symptom of kidney disease is often fluid buildup. Other symptoms of kidney disease include loss of sleep, poor appetite, upset stomach, weakness, and difficulty concentrating.

It is vital to see a doctor regularly. The doctor can check blood pressure, urine (for protein), blood (for waste products), and organs for other complications of diabetes.

Kidney Disease Prevention

Diabetic kidney disease can be prevented by keeping blood sugar in your target range. Research has shown that tight blood sugar control reduces the risk of microalbuminuria by one third. In people who already had microalbuminuria, the risk of progressing to macroalbuminuria was cut in half. Other studies have suggested that tight control can reverse microalbuminuria.

Treatments for kidney disease

Important treatments for kidney disease are tight control of blood glucose and blood pressure. Blood pressure has a dramatic effect on the rate at which the disease progresses. Even a mild rise in blood pressure can quickly make kidney disease worsen. Four ways to lower your blood pressure are losing weight, eating less salt, avoiding alcohol and tobacco, and getting regular exercise.

When these methods fail, certain medicines may be able to lower blood pressure. There are several kinds of blood pressure drugs. Not all are equally good for people with diabetes. Some raise blood sugar levels or mask some of the symptoms of low blood sugar. Doctors usually prefer people with diabetes to take blood pressure drugs called ACE inhibitors.

ACE inhibitors are recommended for most people with diabetes, high blood pressure, and kidney disease. Recent studies suggest that ACE inhibitors, which include captopril and enalapril, slow kidney disease in addition to lowering blood pressure. In fact, these drugs are helpful even in people who do not have high blood pressure.

Another treatment some doctors use with macroalbuminuria is a low-protein diet. Protein seems to increase how hard the kidneys must work. A low-protein diet can decrease protein loss in the urine and increase protein levels in the blood. Never start a low-protein diet without talking to your health care team.

Once kidneys fail, dialysis is necessary. The person must choose whether to continue with dialysis or to get a kidney transplant. This choice should be made as a team effort. The team should include the doctor and diabetes educator, a nephrologist (kidney doctor), a kidney transplant surgeon, a social worker, and a psychologist.

Kidney Transplantation

Diabetes sometimes damages kidneys so badly that they no longer work. When kidneys fail, the person needs a way to replace their function, which is to clean the blood. One option is kidney transplantation.

Dialysis

Dialysis is a way of cleaning the blood with an artificial kidney. Dialysis is the more common form of kidney-replacement therapy. There are two types of dialysis: hemodialysis and peritoneal dialysis.

No matter which type is chosen, the person undergoing dialysis needs to work closely with the health care team to keep diabetes under control.

Hemodialysis
In hemodialysis, an artificial kidney removes waste from the blood. A surgeon must first create an "access," a place where blood can easily be taken from the body and sent to the artificial kidney for cleaning. The access, usually in the forearm, can be made from the patient's own blood vessels or from a piece of implanted tubing. The access is inside the body and cannot be seen from the outside. Usually, this surgery is done 2 to 3 months before dialysis starts so the body has time to heal.

Hemodialysis must be done 2 to 3 days per week, and lasts 3 to 5 hours each time. Blood travels through the artificial kidney, where waste products are filtered out, and the clean blood returns to the body. Only about 1/2 cup of blood is out of your body at any one time.

Usually, hemodialysis is done in a clinic, with many people receiving dialysis at the same time. Hemodialysis can also be done at home, but it requires a partner, such as a relative or friend, and special training.

Hemodialysis is not perfect for everyone. During treatments, people can have high or low blood pressure, an upset stomach or muscle cramps. A special diet is needed to stay healthy. Other problems can develop over time, such as nerve problems, anemia, bone disease, poor nutrition, problems with infection, problems with the access, and difficulty regulating insulin doses.  Sometimes, these complications are the result of diabetes, not of hemodialysis.

Peritoneal dialysis
Another form of dialysis is called peritoneal dialysis. The lining inside your abdomen (the peritoneum) becomes the filter. A soft plastic tube is put into the abdomen by a surgeon. When the body heals, cleansing fluid (dialysate) is put into the abdomen through this tube. Waste products in the bloodstream pass through the peritoneum into the dialysate. Then the dialysate, along with the waste products is drained off.

The two main types of peritoneal dialysis are continuous ambulatory peritoneal dialysis (CAPD) and continuous cycling peritoneal dialysis (CCPD). People perform CAPD themselves by attaching a plastic bag filled with cleansing fluid to the tube in the abdomen and raising it to shoulder level. This causes the fluid to run into the abdomen. The bag is then unhooked or rolled up around the waist. In several hours, the fluid is drained out and thrown away. A fresh bag of fluid is then put into the abdomen to begin cleansing again. This is called an "exchange" and takes about 30-45 minutes. It is done 4 or 5 times a day. Between exchanges, the person can move around and perform daily activities.

In CCPD, a machine puts the cleansing fluid into the abdomen and drains it automatically. This is usually done at night during sleep.

CAPD and CCPD may be better treatments than hemodialysis for some people. With daily dialysis, the body does not build up too much fluid. This reduces the stress on the heart and blood vessels. A person is able to eat a more normal diet and have more time for work and travel.

Peritoneal dialysis is not for everyone, however. A person must be able to see well and do each step correctly to prevent infection in the abdomen. Anemia, bone disease, and poor nutrition can occur, just like in hemodialysis.

Your doctor will help you decide whether hemodialysis or peritoneal dialysis is right for you. Diabetes control remains important no matter which type of dialysis is chosen.

Eye Complications

Diabetes can cause eye problems and may lead to blindness. People with diabetes do have a higher risk of blindness than people without diabetes. Early detection and treatment of eye problems can save your sight.

You may have heard that diabetes causes eye problems and may lead to blindness. People with diabetes do have a higher risk of blindness than people without diabetes.

But most people who have diabetes have nothing more than minor eye disorders. You can keep minor problems minor. And if you do develop a major problem, there are treatments that often work well if you begin them right away.

Eyesight Insight

To understand what happens in eye disorders, it helps to understand how the eye works. The eye is a ball covered with a tough outer membrane. The covering in front is clear and curved. This curved area is the cornea, which focuses light while protecting the eye.

After light passes through the cornea, it travels through a space called the anterior chamber (which is filled with a protective fluid called the aqueous humor), through the pupil (which is a hole in the iris, the colored part of the eye), and then through a lens that performs more focusing. Finally, light passes through another fluid-filled chamber in the center of the eye (the vitreous) and strikes the back of the eye, the retina.

Like the film in a camera, the retina records the images focused on it. But unlike film, the retina also converts those images into electrical signals, which the brain receives and decodes.

One part of the retina is specialized for seeing fine detail. This tiny area of extra-sharp vision is called the macula.

Blood vessels in and behind the retina nourish the macula. The smallest of these blood vessels are the capillaries.

Glaucoma

People with diabetes are 40% more likely to suffer from glaucoma than people without diabetes. The longer someone has had diabetes, the more common glaucoma is. Risk also increases with age.

Glaucoma occurs when pressure builds up in the eye. In most cases, the pressure causes drainage of the aqueous humor to slow down so that it builds up in the anterior chamber. The pressure pinches the blood vessels that carry blood to the retina and optic nerve. Vision is gradually lost because the retina and nerve are damaged.

There are several treatments for glaucoma. Some use drugs to reduce pressure in the eye, while others involve surgery.

Cataracts

Many people without diabetes get cataracts, but people with diabetes are 60% more likely to develop this eye condition. People with diabetes also tend to get cataracts at a younger age and have them progress faster. With cataracts, the eye's clear lens clouds, blocking light.

To help deal with mild cataracts, you may need to wear sunglasses more often and use glare-control lenses in your glasses. For cataracts that interfere greatly with vision, doctors usually remove the lens of the eye. Sometimes the patient gets a new transplanted lens. In people with diabetes, retinopathy can get worse after removal of the lens, and glaucoma may start to develop.

Retinopathy

Diabetic retinopathy is a general term for all disorders of the retina caused by diabetes. There are two major types of retinopathy: nonproliferative and proliferative.

Nonproliferative retinopathy is the most common form of retinopathy. In nonproliferative retinopathy, capillaries in the back of the eye balloon and form pouches. Nonproliferative retinopathy can move through three stages (mild, moderate, and severe), as more and more blood vessels become blocked. Although retinopathy does not usually cause vision loss at this stage, the capillary walls may lose their ability to control the passage of substances between the blood and the retina. Fluid can leak into the part of the eye where focusing occurs, the macula. When the macula swells with fluid, a condition called macula edema, vision blurs and can be lost entirely. Although nonproliferative retinopathy usually does not require treatment, macular edema must be treated, but fortunately treatment is usually effective at stopping and sometimes reversing vision loss.

In some people, retinopathy progresses after several years to a more serious form called proliferative retinopathy. In this form, the blood vessels are so damaged they close off. In response, new blood vessels start growing in the retina. These new vessels are weak and can leak blood, blocking vision, which is a condition called vitreous hemorrhage. The new blood vessels can also cause scar tissue to grow. After the scar tissue shrinks, it can distort the retina or pull it out of place -- this is called retinal detachment.

Your retina can be badly damaged before you notice any change in vision. Most people with nonproliferative retinopathy have no symptoms. Even with proliferative retinopathy, the more dangerous form, people sometimes have no symptoms until it is too late to treat them. For this reason, you should have your eyes examined regularly by an eye care professional.

Several factors influence whether you get retinopathy. These include your blood sugar control, your blood pressure levels, how long you have had diabetes, and your genes.

The longer you've had diabetes, the more likely you are to have retinopathy. Almost everyone with type 1 diabetes will eventually have nonproliferative retinopathy. And most people with type 2 diabetes will also get it. But the retinopathy that destroys vision, proliferative retinopathy, is far less common.

People who keep their blood sugar levels closer to normal are less likely to have retinopathy or to have milder forms. Treating Retinopathy

Huge strides have been made in the treatment of diabetic retinopathy. Treatments such as scatter photocoagulation, focal photocoagulation, and vitrectomy prevent blindness in most people. The sooner retinopathy is diagnosed, the more likely these treatments will be successful. The best results occur when sight is still normal.

In photocoagulation, the eye care professional makes tiny burns on the retina with a special laser. These burns seal the blood vessels and stop them from growing and leaking.

In scatter photocoagulation (also called panretinal photocoagulation), the eye care professional makes hundreds of burns in a polka-dot pattern on two or more occasions. Scatter photocoagulation reduces the risk of blindness from vitreous hemorrhage or detachment of the retina -- but it only works before bleeding or detachment has progressed very far. This treatment is also used for some kinds of glaucoma.

Side effects of scatter photocoagulation are usually minor. They include several days of blurred vision after each treatment and possible loss of side (peripheral) vision.

In focal photocoagulation, the eye care professional aims the laser precisely at leaking blood vessels in the macula. This procedure does not cure blurry vision caused by macular edema. But it does keep it from getting worse.

When the retina has already detached or a lot of blood has leaked into the eye, photocoagulation is no longer useful. The next option is vitrectomy, which is surgery to remove scar tissue and cloudy fluid from inside the eye. The earlier the operation occurs, the more likely it is to be successful. When the goal of the operation is to remove blood from the eye, it usually works. Reattaching a retina to the eye is much harder and works in only about half the cases.

Diabetic Neuropathy (Nerve Damage) and Diabetes
One of the most common complications of diabetes is diabetic neuropathy. Neuropathy means damage to the nerves that run throughout the body, connecting the spinal cord to muscles, skin, blood vessels, and other organs.

Nerves send messages to and from your brain about pain, temperature and touch. They tell your muscles when and how to move. They also control body systems that digest food and pass urine. About half of all people with diabetes have some form of nerve damage. It is more common in those who have had the disease for a number of years. Nerve damage from diabetes is called diabetic neuropathy (new-ROP-uh-thee). It can lead to many kinds of problems.

But if you keep your blood glucose levels on target, you may help prevent or delay nerve damage. There are treatments that can help as well.

What types of nerve damage can occur?

There are two common types of nerve damage. The first is sensorimotor (sen-so-re-MO-tor) neuropathy, also known as peripheral (puh-RIF-uh-rul) neuropathy. This can cause tingling, pain, numbness, or weakness in your feet and hands.

The second is called autonomic (aw-toh-NOM-ik) neuropathy. This type can lead to:

• digestive problems such as feeling full, nausea,
• vomiting, diarrhea, or constipation
• problems with how well your bladder works
• problems having sex
• dizziness or faintness
• loss of the typical warning signs of a heart attack
• loss of the warning signs of low blood glucose
• increased or decreased sweating
• changes in how your eyes react to light and dark

People with diabetes can also have what is called focal (FOH-kal) neuropathy. In this kind of nerve damage, a nerve or a group of nerves is affected, causing sudden weakness or pain. It can lead to double vision, a paralysis on one side of the face called Bell's palsy, or pain in the front of the thigh or other parts of the body.

People with diabetes also are at risk for compressed nerves. Something in the body presses against a nerve preventing it from sending a signal. Carpal tunnel syndrome is a common cause of numbness and tingling in the fingers and can lead to muscle pain and weakness as well. Nerve damage can be hard to diagnose because its symptoms can be caused by other conditions. Symptoms can be very mild. Knowing the symptoms to look for and reporting them to your health care team can help. Make a list of your symptoms or use the checklists in this brochure. Your doctor will give you an exam and a number of tests to check for nerve damage.

What You Can Do If You Have Diabetic Neuropathy (Nerve Damage)

There's a lot you can do to prevent or delay nerve damage. And, if you already have diabetic neuropathy (nerve damage), these steps can prevent or delay further damage and may lessen your symptoms.

Keep your blood glucose levels in your target range.

Meal planning, physical activity and medications, if needed, all can help you reach your target range. There are two ways to keep track of your blood glucose levels:

• Use a blood glucose meter to help you make decisions about day-to-day care
• Get an A1C test (a lab test) at least twice a year to find out your average blood glucose for the past 2 to 3 months

Checking your blood glucose levels will tell you whether your diabetes care plan is working or whether changes are needed.

• Report all possible signs of diabetic neuropathy.
• If you have problems, get treatment right away. Early treatment can help prevent more problems later on. For example, if you take care of a foot infection early, it can help prevent amputation.
• Take good care of your feet. Check your feet every day. If you no longer can feel pain in your feet, you might not notice a foot injury. Instead, use your eyes to look for problems. Use a mirror to see the bottoms of your feet. Use your hands to feel for hot or cold spots, bumps or dry skin. Look for sores, cuts or breaks in the skin. Also check for corns, calluses, blisters, red areas, swelling, ingrown toenails and toenail infections. If it's hard for you to see or reach your feet, get help from a family member or foot doctor.
• Protect your feet. If your feet are dry, use a lotion on your skin but not between your toes. Wear shoes and socks that fit well and wear them all the time. Use warm water to wash your feet, and dry them carefully afterward.
• Get special shoes if needed. If you have foot problems, Medicare may pay for shoes. Ask your health care team about it.
• Be careful with exercising. Some physical activities are not safe for people with neuropathy. Talk with a diabetes clinical exercise expert who can guide you

People with diabetes can develop many different foot problems. Foot problems most often happen when there is nerve damage in the feet or when blood flow is poor. Learn how to protect your feet by following some basic guidelines.
People with diabetes can develop many different foot problems. Even ordinary problems can get worse and lead to serious complications.

Foot problems most often happen when there is nerve damage, also called neuropathy, which results in loss of feeling in your feet. Poor blood flow or changes in the shape of your feet or toes may also cause problems.

Neuropathy

Although it can hurt, diabetic nerve damage can also lessen your ability to feel pain, heat, and cold. Loss of feeling often means you may not feel a foot injury. You could have a tack or stone in your shoe and walk on it all day without knowing. You could get a blister and not feel it. You might not notice a foot injury until the skin breaks down and becomes infected.

Nerve damage can also lead to changes in the shape of your feet and toes. Ask your health care provider about special therapeutic shoes, rather than forcing deformed feet and toes into regular shoes.

Skin Changes

Diabetes can cause changes in the skin of your foot. At times your foot may become very dry. The skin may peel and crack. The problem is that the nerves that control the oil and moisture in your foot no longer work.

After bathing, dry your feet and seal in the remaining moisture with a thin coat of plain petroleum jelly, an unscented hand cream, or other such products.

Do not put oils or creams between your toes. The extra moisture can lead to infection. Also, don't soak your feet - that can dry your skin.

Calluses

Calluses occur more often and build up faster on the feet of people with diabetes. This is because there are high-pressure areas under the foot. Too much callus may mean that you will need therapeutic shoes and inserts.

Calluses, if not trimmed, get very thick, break down, and turn into ulcers (open sores). Never try to cut calluses or corns yourself - this can lead to ulcers and infection. Let your health care provider cut your calluses. Also, do not try to remove calluses and corns with chemical agents. These products can burn your skin.

Using a pumice stone every day will help keep calluses under control. It is best to use the pumice stone on wet skin. Put on lotion right after you use the pumice stone.

Foot Ulcers

Ulcers occur most often on the ball of the foot or on the bottom of the big toe. Ulcers on the sides of the foot are usually due to poorly fitting shoes. Remember, even though some ulcers do not hurt, every ulcer should be seen by your health care provider right away. Neglecting ulcers can result in infections, which in turn can lead to loss of a limb.

What your health care provider will do varies with your ulcer. Your health care provider may take x-rays of your foot to make sure the bone is not infected. The health care provider may clean out any dead and infected tissue. You may need to go into the hospital for this. Also, the health care provider may culture the wound to find out what type of infection you have, and which antibiotic will work best.

Keeping off your feet is very important. Walking on an ulcer can make it get larger and force the infection deeper into your foot. Your health care provider may put a special shoe, brace, or cast on your foot to protect it.

If your ulcer is not healing and your circulation is poor, your health care provider may need to refer you to a vascular surgeon. Good diabetes control is important. High blood glucose levels make it hard to fight infecton.

After the foot ulcer heals, treat your foot carefully. Scar tissue under the healed wound will break down easily. You may need to wear special shoes after the ulcer is healed to protect this area and to prevent the ulcer from returning.

Poor Circulation

Poor circulation (blood flow) can make your foot less able to fight infection and to heal. Diabetes causes blood vessels of the foot and leg to narrow and harden. You can control some of the things that cause poor blood flow. Don't smoke - smoking makes arteries harden faster. Also, follow your health care provider's advice for keeping your blood pressure and cholesterol under control.

If your feet are cold, you may be tempted to warm them. Unfortunately, if your feet cannot feel heat, it is easy for you to burn them with hot water, hot water bottles, or heating pads. The best way to help cold feet is to wear warm socks.

Some people feel pain in their calves when walking fast, up a hill, or on a hard surface. This condition is called intermittent claudication. Stopping to rest for a few moments should end the pain. If you have these symptoms, you must stop smoking. Work with your health care provider to get started on a walking program. Some people can be helped with medication to improve circulation.

Exercise is good for poor circulation. It stimulates blood flow in the legs and feet. Walk in sturdy, good-fitting, comfortable shoes. Don't walk when you have open sores.

Amputation

People with diabetes are far more likely to have a foot or leg amputated than other people. The problem? Many people with diabetes have artery disease, which reduces blood flow to the feet. Also, many people with diabetes have nerve disease, which reduces sensation. Together, these problems make it easy to get ulcers and infections that may lead to amputation. Most amputations are preventable with regular care and proper footware.

For these reasons, take good care of your feet and see your health care provider right away about foot problems. Ask about prescription shoes that are covered by Medicare and other insurance. Always follow your health care provider's advice when caring for ulcers or other foot problems. 

One of the biggest threats to your feet is smoking. Smoking affects small blood vessels. It can cause decreased blood flow to the feet and make wounds heal slowly. A lot of people with diabetes who need amputations are smokers.

Skin Complications

As many as one-third of people with diabetes will have a skin disorder caused or affected by diabetes at some time in their lives. In fact, such problems are sometimes the first sign that a person has diabetes. Luckily, most skin conditions can be prevented or easily treated if caught early.

Diabetes can affect every part of the body, including the skin. As many as one third of people with diabetes will have a skin disorder caused or affected by diabetes at some time in their lives. In fact, such problems are sometimes the first sign that a person has diabetes. Luckily, most skin conditions can be prevented or easily treated if caught early.

Some of these problems are skin conditions anyone can have, but people with diabetes get more easily. These include bacterial infections, fungal infections, and itching. Other skin problems happen mostly or only to people with diabetes. These include diabetic dermopathy, necrobiosis lipoidica diabeticorum, diabetic blisters, and eruptive xanthomatosis.

Bacterial Infections

Several kinds of bacterial infections occur in people with diabetes. One common one are styes. These are infections of the glands of the eyelid. Another kind of infection are boils, or infections of the hair follicles. Carbuncles are deep infections of the skin and the tissue underneath. Infections can also occur around the nails.

Inflamed tissues are usually hot, swollen, red, and painful. Several different organisms can cause infections. The most common ones are the Staphylococcus bacteria, also called staph.

Once, bacterial infections were life threatening, especially for people with diabetes. Today, death is rare, thanks to antibiotics and better methods of blood sugar control.

But even today, people with diabetes have more bacterial infections than other people do. Doctors believe people with diabetes can reduce their chances of these infections in several ways (read Good Skin Care farther down the page).

If you think you have a bacterial infection, see your doctor.

Fungal Infections

The culprit in fungal infections of people with diabetes is often Candida albicans. This yeast-like fungus can create itchy rashes of moist, red areas surrounded by tiny blisters and scales. These infections often occur in warm, moist folds of the skin. Problem areas are under the breasts, around the nails, between fingers and toes, in the corners of the mouth, under the foreskin (in uncircumcised men), and in the armpits and groin.

Common fungal infections include jock itch, athlete's foot, ringworm (a ring-shaped itchy patch), and vaginal infection that causes itching.

If you think you have a yeast or fungal infection, call your doctor. You will need a prescription medicine to cure it.

Itching

Localized itching is often caused by diabetes. It can be caused by a yeast infection, dry skin, or poor circulation. When poor circulation is the cause of itching, the itchiest areas may be the lower parts of the legs.

You may be able to treat itching yourself. Limit how often you bathe, particularly when the humidity is low. Use mild soap with moisturizer and apply skin cream after bathing.

Diabetic Dermopathy

Diabetes can cause changes in the small blood vessels. These changes can cause skin problems called diabetic dermopathy.

Dermopathy often looks like light brown, scaly patches. These patches may be oval or circular. Some people mistake them for age spots. This disorder most often occurs on the front of both legs. But the legs may not be affected to the same degree. The patches do not hurt, open up, or itch.

Dermopathy is harmless. You do not need to be treated.

Necrobiosis Lipoidica Diabeticorum

Another disease that may be caused by changes in the blood vessels is necrobiosis lipoidica diabeticorum (NLD). NLD is similar to diabetic dermopathy. The difference is that the spots are fewer, but larger and deeper.

NLD often starts as a dull red raised area. After a while, it looks like a shiny scar with a violet border. The blood vessels under the skin may become easier to see. Sometimes NLD is itchy and painful. Sometimes the spots crack open.

NLD is a rare condition. Adult women are the most likely to get it. As long as the sores do not break open, you do not need to have it treated. But if you get open sores, see your doctor for treatment.

Atherosclerosis

Thickening of the arteries - atherosclerosis - can affect the skin on the legs. People with diabetes tend to get atherosclerosis at younger ages than other people do.

As atherosclerosis narrows the blood vessels, the skin changes. It becomes hairless, thin, cool, and shiny. The toes become cold. Toenails thicken and discolor. And exercise causes pain in the calf muscles because the muscles are not getting enough oxygen.

Because blood carries the infection-fighting white cells, affected legs heal slowly when the skin in injured. Even minor scrapes can result in open sores that heal slowly.

People with neuropathy are more likely to suffer foot injuries. These occur because the person does not feel pain, heat, cold, or pressure as well. The person can have an injured foot and not know about it. The wound goes uncared for, and so infections develop easily. Atherosclerosis can make things worse. The reduced blood flow can cause the infection to become severe.

Allergic Reactions

Allergic skin reactions can occur in response to medicines, such as insulin or diabetes pills. You should see your doctor if you think you are having a reaction to a medicine. Be on the lookout for rashes, depressions, or bumps at the sites where you inject insulin.

Diabetic Blisters (Bullosis Diabeticorum)

Rarely, people with diabetes erupt in blisters. Diabetic blisters can occur on the backs of fingers, hands, toes, feet, and sometimes, on legs or forearms.

These sores look like burn blisters. They sometimes are large. But they are painless and have no redness around them. They heal by themselves, usually without scars, in about three weeks. They often occur in people who have diabetic neuropathy. The only treatment is to bring blood sugar levels under control.

Eruptive Xanthomatosis

Eruptive xanthomatosis is another condition caused by diabetes that's out of control. It consists of firm, yellow, pea-like enlargements in the skin. Each bump has a red halo and may itch. This condition occurs most often on the backs of hands, feet, arms, legs, and buttocks.

The disorder usually occurs in young men with type 1 diabetes. The person often has high levels of cholesterol and fat in the blood. Like diabetic blisters, these bumps disappear when diabetes control is restored.

Digital Sclerosis

Sometimes, people with diabetes develop tight, thick, waxy skin on the backs of their hands. Sometimes skin on the toes and forehead also becomes thick. The finger joints become stiff and can no longer move the way they should. Rarely, knees, ankles, or elbows also get stiff.

This condition happens to about one third of people who have type 1 diabetes. The only treatment is to bring blood sugar levels under control.

Disseminated Granuloma Annulare

In disseminated granuloma annulare, the person has sharply defined ring-shaped or arc-shaped raised areas on the skin. These rashes occur most often on parts of the body far from the trunk (for example, the fingers or ears). But sometimes the raised areas occur on the trunk. They can be red, red-brown, or skin-colored.

See your doctor if you get rashes like this. There are drugs that can help clear up this condition.

Acanthosis Nigricans

Acanthosis nigricans is a condition in which tan or brown raised areas appear on the sides of the neck, armpits, and groin. Sometimes they also occur on the hands, elbows, and knees.

Acanthosis nigricans usually strikes people who are very overweight. The best treatment is to lose weight. Some creams can help the spots look better.

Gastroparesis and Diabetes

Gastroparesis is a disorder affecting people with both type 1 and type 2 diabetes, where the stomach takes too long to empty its contents. It happens when nerves to the stomach are damaged or stop working. The vagus nerve controls the movement of food through the digestive tract. If the vagus nerve is damaged, the muscles of the stomach and intestines do not work normally, and the movement of food is slowed or stopped.

Just as with other types of neuropathy, diabetes can damage the vagus nerve if blood glucose levels remain high over a long period of time.  High blood glucose causes chemical changes in nerves and damages the blood vessels that carry oxygen and nutrients to the nerves.

Signs and Symptoms

Signs and symptoms of gastroparesis (delayed gastric emptying) are:

• heartburn
• nausea
• vomiting of undigested food
• an early feeling of fullness when eating
• weight loss
• abdominal bloating
• erratic blood glucose (sugar) levels
• lack of appetite
• gastroesophageal reflux
• spasms of the stomach wall

These symptoms may be mild or severe, depending on the person.

Complications of Gastroparesis

Gastroparesis can make diabetes worse by making it more difficult to manage blood glucose.  When food that has been delayed in the stomach finally enters the small intestine and is absorbed, blood glucose levels rise.

If food stays too long in the stomach, it can cause problems like bacterial overgrowth because the food has fermented. Also, the food can harden into solid masses called bezoars that may cause nausea, vomiting, and obstruction in the stomach.  Bezoars can be dangerous if they block the passage of food into the small intestine.

Diagnosis

The diagnosis of gastroparesis is confirmed through one or more of the following tests.

Barium X-ray

After fasting for 12 hours, you will drink a thick liquid containing barium, which covers the inside of the stomach, making it show up on the X-ray. Normally, the stomach will be empty of all food after 12 hours of fasting. If the X-ray shows food in the stomach, gastroparesis is likely. If the X-ray shows an empty stomach, but the doctor still suspects that you have delayed emptying, you may need to repeat the test another day. On any one day, a person with gastroparesis may digest a meal normally, giving a falsely normal test result. If you have diabetes, your doctor may have special instructions about fasting.

Barium Beefsteak Meal

You will eat a meal that contains barium, which allows the doctor to watch your stomach as it digests the meal. The amount of time it takes for the barium meal to be digested and leave the stomach gives the doctor an idea of how well the stomach is working. This test can help find emptying problems that do not show up on the liquid barium X-ray. In fact, people who have diabetes-related gastroparesis often digest fluid normally, so the barium beefsteak meal can be more useful.

Radioisotope Gastric-Emptying Scan

You will eat food that contains a radioisotope, a slightly radioactive substance that will show up on the scan. The dose of radiation from the radioisotope is small and not dangerous. After eating, you will lie under a machine that detects the radioisotope and shows an image of the food in the stomach and how quickly it leaves the stomach. Gastroparesis is diagnosed if more than half of the food remains in the stomach after two hours.

Gastric Manometry

This test measures electrical and muscular activity in the stomach. The doctor passes a thin tube down the throat into the stomach. The tube contains a wire that takes measurements of the stomach's electrical and muscular activity as it digests liquids and solid food. The measurements show how the stomach is working and whether there is any delay in digestion.

Blood tests
The doctor may also order laboratory tests to check blood counts and to measure chemical and electrolyte levels.

To rule out causes of gastroparesis other than diabetes, the doctor may do an upper endoscopy or an ultrasound.

Upper Endoscopy

After giving you a sedative, the doctor passes a long, thin tube called an endoscope through the mouth and gently guides it down the esophagus into the stomach. Through the endoscope, the doctor can look at the lining of the stomach to check for any abnormalities.

Ultrasound

To rule out gallbladder disease or pancreatitis as a source of the problem, you may have an ultrasound test, which uses harmless sound waves to outline and define the shape of the gallbladder and pancreas.

Treatment

The most important treatment goal for diabetes-related gastroparesis is to manage your blood glucose levels as well as possible. Treatments include insulin, oral medications, changes in what and when you eat, and, in severe cases, feeding tubes and intravenous feeding.

Insulin for blood glucose control

If you have gastroparesis, your food is being absorbed more slowly and at unpredictable times. To better manage blood glucose, you may need to

• take insulin more often
• take your insulin after you eat instead of before
• check your blood glucose levels frequently after you eat and administer insulin whenever necessary

Your doctor will give you specific instructions based on your particular needs.

Medication

Several drugs are used to treat gastroparesis. Your doctor may try different drugs or combinations of drugs to find the most effective treatment.

Meal and Food Changes

Changing your eating habits can help control gastroparesis. Your doctor or dietitian will give you specific instructions, but you may be asked to eat six small meals a day instead of three large ones. If less food enters the stomach each time you eat, it may not become overly full. Or the doctor or dietitian may suggest that you try several liquid meals a day until your blood glucose levels are stable and the gastroparesis has improved. Liquid meals provide all the nutrients found in solid foods, but can pass through the stomach more easily and quickly.

The doctor may also recommend that you avoid high-fat and high-fiber foods. Fat naturally slows digestion -- a problem you do not need if you have gastroparesis -- and fiber is difficult to digest. Some high-fiber foods like oranges and broccoli contain material that cannot be digested. Avoid these foods because the indigestible part will remain in the stomach too long and possibly form bezoars.

Feeding Tube

If other approaches do not work, you may need surgery to insert a feeding tube. The tube, called a jejunostomy tube, is inserted through the skin on your abdomen into the small intestine. The feeding tube allows you to put nutrients directly into the small intestine, bypassing the stomach altogether. You will receive special liquid food to use with the tube. A jejunostomy is particularly useful when gastroparesis prevents the nutrients and medication necessary to regulate blood glucose levels from reaching the bloodstream. By avoiding the source of the problem (the stomach) and putting nutrients and medication directly into the small intestine, you ensure that these products are digested and delivered to your bloodstream quickly. A jejunostomy tube can be temporary and is used only if necessary when gastroparesis is severe.

It is important to note that in most cases treatment does not cure gastroparesis -- it is usually a chronic condition. Treatment helps you manage gastroparesis, so that you can be as healthy and comfortable as possible.

Depression
Feeling down once in a while is normal. But some people feel a sadness that just won't go away. Life seems hopeless. Feeling this way most of the day for two weeks or more is a sign of serious depression.

At any given time, most people with diabetes do not have depression. But studies show that people with diabetes have a greater risk of depression than people without diabetes. There are no easy answers about why this is true.

The stress of daily diabetes management can build. You may feel alone or set apart from your friends and family because of all this extra work.

If you face diabetes complications such as nerve damage, or if you are having trouble keeping your blood sugar levels where you'd like, you may feel like you're losing control of your diabetes. Even tension between you and your doctor may make you feel frustrated and sad.

Just like denial, depression can get you into a vicious cycle. It can block good diabetes self-care. If you are depressed and have no energy, chances are you will find such tasks as regular blood sugar testing too much. If you feel so anxious that you can't think straight, it will be hard to keep up with a good diet. You may not feel like eating at all. Of course, this will affect your blood sugar levels.

What to do?
Spotting depression is the first step. Getting help is the second. If you have been feeling really sad, blue, or down in the dumps, check for these symptoms:

• Loss of pleasure You no longer take interest in doing things you used to enjoy.
• Change in sleep patterns You have trouble falling asleep, you wake often during the night, or you want to sleep more than usual, including during the day.
• Early to rise You wake up earlier than usual and cannot to get back to sleep.
• Change in appetite You eat more or less than you used to, resulting in a quick weight gain or weight loss.
• Trouble concentrating You can't watch a TV program or read an article because other thoughts or feelings get in the way.
• Loss of energy You feel tired all the time.
• Nervousness You always feel so anxious you can't sit still.
• Guilt You feel you "never do anything right" and worry that you are a burden to others.
• Morning sadness You feel worse in the morning than you do the rest of the day.
• Suicidal thoughts You feel you want to die or are thinking about ways to hurt yourself.

If you have three or more of these symptoms, or if you have just one or two but have been feeling bad for two weeks or more, it's time to get help.

Getting Help

If you are feeling symptoms of depression, don't keep them to yourself. First, talk them over with your doctor. There may a physical cause for your depression.

Diabetes that is in poor control can cause symptoms that look like depression. During the day, high or low blood sugar may make you feel tired or anxious. Low blood sugar levels can also lead to hunger and eating too much. If you have low blood sugar at night, it could disturb your sleep. If you have high blood sugar at night, you may get up often to urinate and then feel tired during the day.

Other physical causes of depression can include

• alcohol or drug abuse
• thyroid problems
• side effects from some medications

Do not stop taking a medication without telling your doctor. Your doctor will be able to help you discover if a physical problem is at the root of your sad feelings.

If you and your doctor rule out physical causes, your doctor will most likely refer you to a specialist. You might talk with a psychiatrist, psychologist, psychiatric nurse, licensed clinical social worker, or professional counselor. In fact, your doctor may already work with mental health professionals on a diabetes treatment team.

All of these mental health professionals can guide you through the rough waters of depression. In general, there are two types of treatment. One is psychotherapy, or counseling. The other is antidepressant medication.

Psychotherapy with a well-trained therapist can help you look at the problems that bring on depression. It can also help you find ways to relieve the problem. Therapy can be short term or long term. You should be sure you feel at ease with the therapist you choose.

If medication is advised, you will need to consult with a psychiatrist (a medical doctor with special training in diagnosing and treating mental or emotional disorders). Psychiatrists are the only mental health professionals who can prescribe medication and treat physical causes of depression.

If you opt for trying an antidepressant drug, talk to the psychiatrist and your primary care provider about side effects, including how it might affect your blood sugar levels. Make sure that the doctors will consult about your care when needed. Many people do well with a combination of medication and psychotherapy.

If you have symptoms of depression, don't wait too long to get help. If your health care provider cannot refer you to a mental health professional, contact your local psychiatric society or psychiatry department of a medical school, or the local branch of organizations for psychiatric social workers, psychologists, or mental health counselors. Your local American Diabetes Association may also be a good resource for counselors who have worked with people with diabetes.