CLEAR DIRECTION FOR GROWTH

Diabetes Damage Linked To Vitamin B1 Shortage

2008-08-09T16:36:00.001-07:00

Source: Telegraph Media Group, August 8, 2007

Diabetics have three-quarters less vitamin B1 in their blood than healthy people, research has shown.

A study by the University of Warwick has linked this shortfall, which occurs in sufferers with both type one and two of the disease, to damage to the kidneys, retina and nerves in the arms and legs that are all common symptoms of the disease.

Prof Paul Thornalley, from the university, said that vitamin supplements could be taken by all diabetics and could work alongside conventional glucose controls.

The study is published in Diabetologia, the diabetics journal. A LACK of vitamin B1 has been linked to vascular disease in diabetics sufferers.

Researchers at the University of Warwick found that diabetics-both type one and type two sufferers-had three quarters less thiamine (vitamin B1) in their blood than healthy people.

In what could be a major finding for treatment of diabetes-related vascular conditions, the experts found the shortage was linked to damage to the kidneys, retina and nerves in the arms and legs-common in diabetics. Prof Paul Thornalley, lead researcher, said a vitamin B1 supplement could be taken by all diabetics and would work alongside conventional glucose controls.

He said: "This is a particularly important study because thiamine has been found to prevent vascular problems in previous research." The study-published in diabetes journal Diabetologia-compared 26 type 1 and 48 type 2 with 20 healthy patients.

It found thiamine concentration in blood plasma was decreased 76 percent in type 1 sufferers and 75 percent in type 2 patients

Diabetic Complications

2008-08-09T16:05:00.000-07:00

The Factors Behind Complications of Diabetes

Authors: Janet Worsley Norwood and Charles B. Inlander
Excerpt from: Understanding Diabetes

Generally, you can't tell diabetic complications are developing, at least not without undergoing tests or medical procedures in a doctor's office. Diabetes proceeds unnoticed, silently ravaging the body. You might be without symptoms until some damage is already done.

There is, however, one surefire indication that problems are developing: persistently high blood-sugar levels. Diabetes experts believe that over the long haul levels above 240 mg/dl are unacceptable and dangerous. However, the ideal level for you is the target set by you and your physician. It will probably be in the 80 to 120 mg/dl range.

The length of time a person has diabetes also comes into play when looking at complications. Because people with type 1 diabetes usually get the disease earlier in life than those with type 2, they have the dubious distinction of running a greater risk of developing complications than those with type 2. For the most part, complications appear in people who have had diabetes for fifteen years or more, although certain short-term complications can appear (and disappear) at any time. Evidence of diabetes-related eye problems, for example, is present after five years in 1 percent of type 1 cases; by fourteen years, the percentage is close to 100.

The type of complications that develop also depends on diabetes type. Individuals with type 1 tend to develop different problems than those with type 2. For instance, type 1 diabetes tends to produce vision problems sooner than does type 2 diabetes, while type 2 diabetes appears to be linked to more heart attacks and strokes. The rates at which complications proceed also vary wildly.

Scientists don't really know why these differences exist. Nor do they know why complications sometimes develop in people who have blood-sugar levels firmly in hand while other people never develop complications, regardless of how well or how poorly they control their blood sugar. It may boil down to genetic differences or even to factors yet unknown.

The thing to remember is that everyone has different responses to high and low blood sugar, so you may want to know what their symptoms tend to be. Self-monitoring of blood glucose can track sugar patterns and guard against these short-term, but potentially deadly, complications.

Long-Term Complications

Long-term, chronic complications differ from short-term complications in that they take more time in developing, and once they arrive are less likely to disappear. Many long-term complications are tied to those structures that distribute blood throughout the body; the small and large blood vessels. Although scientists are not certain how it happens, they think that years of carrying blood with high sugar levels eventually damages or impairs blood vessels. The faulty metabolism of someone with diabetes may also create some chemical change that makes blood vessels more vulnerable to damage. Either way, many diabetic complications are vascular complications--complications pertaining to blood vessels, in other words.

Let's look now at some of the major long-term complications faced by people with diabetes.

EYE PROBLEMS

Eye problems that diabetes might cause include minor problems in focusing, premature development of cataracts, and various degrees of retinal damage (otherwise known as diabetic retinopathy).

If you have diabetes, it's very likely that you will experience at least one of these problems in the course of your lifetime. Most people who have had diabetes for five to ten years show some signs of eye damage, although it may be slight.

Cataracts

A cataract, a clouding of the lens in the eye, is a very common problem in older people, including folks who don't have diabetes. However, the evidence suggests that diabetes accelerates cataract development. The hastened development is thought to be a result of the intricate and still incompletely understood relationship between high blood-sugar levels and aging. One popular theory posits that when people have diabetes for an extended period of time, sugar by-products begin to build up in the lens of the eye, eventually leading to cataracts.

Mild cataracts are often left as they are--but an individual with diabetes is encouraged to work at keeping blood-sugar levels within the normal range, which seems to slow the accumulation of sugar by-products and, thus, slow the progression of complications. Once severe cataracts develop, however, many ophthalmologists believe that the best course of action is to remove the cataract and replace it with an artificial lens, also known as an intraocular lens. This surgical procedure can be done right in a doctor's office. Although cataracts certainly impede good vision, they are less troublesome than another long-term complication, diabetic retinopathy.

Diabetic Retinopathy

Diabetic retinopathy means damage to or disease of the retina, the delicate membrane that lines the inside wall of the eye. The retina responds to light and receives the image formed by the lens. When it becomes seriously damaged, blindness may result. In fact, retinopathy is the most frequent cause of vision loss in Americans 20 to 74 years old.

Diabetic retinopathy is caused by changes or abnormalities in the small blood vessels of the retina--changes that take years to occur. Experts estimate that 6,000 people a year develop retinopathy. Fortunately, early diagnosis and prompt treatment often can prevent blindness.

Almost everyone with diabetes develops this complication, but the first to feel its impact are people with type I diabetes, who frequently develop a mild form of this condition within five years of diagnosis of diabetes. In fact, there's a strong correlation between the amount of time someone has diabetes and the development of retinopathy. Quite simply, the longer you have diabetes, the greater your chance of developing retinopathy. Within ten years of diabetes diagnosis, half of all people with type 1 diabetes and a quarter with type 2 have some damage to their retinas. By twenty years after diagnosis of diabetes, nearly everyone with type 1 diabetes and over 60 percent with type 2 have some degree of retinopathy.

Retinopathy is not something to ignore. Among those with type 1 diabetes, retinopathy is responsible for four-fifths of all cases of blindness: among those with type 2, the number is one-third. Of course, not all cases of retinopathy result in blindness. The condition ranges in severity from mild to advanced.

The medical profession describes two forms of diabetic retinopathy: background retinopathy and proliferative retinopathy. Background retinopathy is a mild, early form of retinopathy that is characterized by gradual narrowing or weakening of the small blood vessels in the eye. Small bulges (called microaneurysms) develop on the vessels. Eventually a vessel may tear or break and then bleed (known in medical parlance as a hemorrhage).

Most folks with diabetes develop background retinopathy, but in the lion's share of the cases, the condition remains at a mild level. Vision is not affected unless blood vessels break and leak fluid into the macula, an area of the retina responsible for sharp, fine vision---the kind of vision needed to read this book. When fluid leaks into the macula, it swells and puts pressure on other areas of the eye. This situation is called a macular edema and it leads to blurred vision. The swelling is sometimes treated in people who appear to be at high risk for blindness with a high-tech procedure known as photocoagulation. In this, a precise laser beam is used to sear shut the leaking blood vessels. Photocoagulation doesn't cure retinopathy, but it can delay the loss of vision by a number of years or, in some cases, stop progression.

For the most part, however, because background retinopathy is mild, surgical treatment isn't necessary.

Proliferative retinopathy, as its name suggests, is a severe form of retinopathy that develops when a network of new, fragile blood vessels proliferates in the retina at the site of previous breakages or hemorrhages. The new vessels are an attempt by the eye to repair the damaged, worn-out vessels caused by diabetes. Over time the new, fragile vessels may tear and leak blood into the vitreous humor, the clear, gelatinous material that fills the center of the eye. A small amount of blood won't dim vision, but the major hemorrhages associated with proliferative retinopathy may be large enough to affect sight, in which case they are known as vitreous hemorrhages.

As the eye tries to repair the damage caused by hemorrhages, scar tissue forms. The buildup of scar tissue may eventually damage the retina, resulting in partial loss of sight, or it may displace or cause the retina to become detached, resulting in total loss of vision.

It may be difficult to tell if either form of retinopathy is developing. For the most part, people can have severe eye damage without knowing it, because the damage may not affect vision and may cause no pain. Of course, there are some obvious indications to the person with diabetes that something has happened to the eye. Partial loss of vision--even if very small--is an indication of a problem. "Floaters," "cobwebs," and "cotton wool balls" are terms that people have used to describe vision problems caused by tiny hemorrhages in the eye. A sudden, painful loss of vision may indicate a major hemorrhage.

Naturally, it's best to detect retinopathy before it reaches this stage. Eye examinations with a tool called a monocular direct ophthalmoscope are used to detect damage to the retina. A family physician can perform this test, although several studies indicate that physicians who are not ophthalmologists detect proliferative retinopathy in only 50 percent of the people who have the condition. That's not a particularly encouraging track record--"No better than random chance," in the words of one eye expert.

There are some treatment options for those people with advanced stages of either form of retinopathy: Photocoagulation--the use of laser beams---can seal leaking retinal blood vessels or reattach a detached retina. In some people, this is enough to stop the progression of diabetic retinopathy.

Vitrectomy is another, more intricate surgical procedure used in people with proliferative retinopathy. In this procedure, a physician removes the vitreous to clear out the light-blocking hemorrhage, uses microsurgery to repair the retina, if necessary, and then replaces the vitreous with a saline solution.

An article in the journal Annals of International Medicine explains that photocoagulation and vitrectomy prevent deterioration of vision in around 60 percent of patients. Laser therapy reportedly reduces the rate of vision loss by 50 percent in people with proliferative retinopathy and macular edema, conditions that often exhibit no symptoms. Vicrectomy reportedly improves visual acuity to 10/20 or better in 36 percent of treated eyes. That's the good news.

However, no surgery is free of potential complications. With vitrectomy, for example, the overall complication rate is about 25 percent, according to the Annals of International Medicine article. Potential complications include infection, cataract development, bleeding, elevated pressure in the eye (which can lead to a condition called glaucoma), loss of vision, and retinal detachment or scarring.

Medical research is also looking at ways of slowing or even preventing the progression of retinopathy. One small Norwegian study found that people with type 1 diabetes who maintained near-normal levels of blood sugar over a long period of time--at least seven years--were significantly less likely to develop severe retinopathy. The patients in this study followed a tight-control regimen, using either continuous subcutaneous infusion pumps or multiple insulin injections.

The results of the Diabetes Control and Complications Trial show that tight blood-sugar control can prevent new cases of retinopathy. Tight control also helps retinopathy from growing worse, According to the study, the earlier tight control is instituted, the more beneficial it is at fending off complications.

Scientists are also hoping to discover why high levels of blood glucose damage the body's blood vessels. One theory is that an enzyme called aldose reductase, which converts glucose into a sugar alcohol called sorbitol, may play a role in triggering diabetic complications. For that reason researchers are looking into a class of drugs called aldose reductase inhibitors that block the actions of the enzyme. They hope these drugs can reduce the chance of developing retinopathy and other long-term complications. Studies are underway.

In November 1997, the Journal of the American Medical Association reported on a number of other agents that may potentially prevent retinopathy. These include aminoguanidine, a drug that inhibits the formation of certain proteins and lipids that are thought to contribute to blood vessel damage. Other possibilities include drugs that interfere with the growth of blood vessels in the retina; antioxidants such as vitamin E, thought to prevent damage to the endothelium (the innermost layer of the cornea, the clear covering of the eye); and agents that would interfere with the molecular and cellular reactions within the eye that cause cell death.

Although these new treatments sound promising, the key action in the here and now is getting prompt medical care for retinopathy, particularly if you have macular edema or proliferative retinopathy. Studies have found that there is a 16 percent risk for severe visual loss if proliferative retinopathy is left untreated for two years. That may sound like a small risk, but is it really one that's worth taking? You and your doctor must decide.

There are other ways diabetes can exacerbate retinopathy. Poor blood-sugar control, high blood pressure, and a history of smoking increase the risk of retinopathy and increase the chances that the condition will worsen. And as we mentioned before, people with type 1 diabetes are more likely to develop severe retinopathy.

A woman with type 1, type 2, or gestational diabetes who has no retinopathy before pregnancy is unlikely to develop retinopathy during pregnancy. However, the story is different for women with diabetes who already have some retinal damage when they become pregnant. About 5 to 12 percent of women with diabetes with mild retinopathy will see their retinopathy worsen. Women who already have moderate to severe diabetic retinopathy are at greater risk during pregnancy. In recent studies, about 47 percent of pregnant women with diabetes had an increase in severity in retinal damage, and 5 percent developed proliferative retinopathy.

These rapid changes may be due to the increased levels of hormones that accompany pregnancy. Pregnancy-induced or chronic high blood pressure is thought to play a role, too. In one study, 55 percent of pregnant women with diabetes who had high blood pressure in addition to retinopathy saw their retinopathy worsen, compared with 25 percent of the women who had normal blood pressure and retinopathy.

Experts say that pregnant women with signs of retinal damage can slow the progression of retinopathy by lowering blood-pressure levels. Doctors have also found that treating a woman's retinopathy with photocoagulation can help reduce the risk of progression if the laser treatment is done before she becomes pregnant.

Like anyone with diabetic retinopathy, pregnant women should get regular eye examinations to monitor the course and development of this complication.

NEPHROPATHY

Officially known as diabetic nephropathy, nephropathy is a type of kidney disease that leads to kidney failure. Nephropathy tends to develop in people who have had diabetes for 20 years or more. It used to be that a third of all people with type 1 diabetes developed nephropathy, but today's treatment methods and the emphasis on better blood-sugar control are shrinking that percentage. People with type 2 diabetes develop nephropathy infrequently.

How It Happens

To see why nephropathy would be a problem, let's look first at what the kidneys do. The kidneys are organs located near the waist. Inside the kidneys are small blood vessels, called glomeruli, that act as filters, removing wastes from the blood and discharging them through the urine. Useful products, such as protein and glucose, are not eliminated but are sent back into the bloodstream.

Nephropathy is the condition in which small arteries in the kidneys become hardened and the glomeruli become damaged, in much the same way that the small vessels of the eye become damaged during retinopathy. The kidneys ultimately fail in their job of filtering out wastes. People with kidney failure must go on dialysis (the use of a machine to filter blood) or have a kidney transplant; otherwise, lethal levels of wastes and toxins build up in their bodies.

Nephropathy is caused by high blood-sugar levels. Also, high blood pressure, arteriosclerosis, smoking, and high cholesterol increase the likelihood of kidney complications. Frequent urinary tract infections add to the problem because an infection can easily spread to the kidneys and damage them.

Recognizing the Signs

Early warning signs of nephropathy include problems emptying the bladder, blood in the urine, and urinary tract infections. The disease can be confirmed through simple urine and blood tests. Just as the kidneys lose their ability to discharge wastes, they also lose their ability to keep protein and glucose in circulation. Sugar and protein begin to show up in the urine tests in larger and larger amounts. Blood tests also detect high levels of urea nitrogen and creatinine, another indication of kidney damage.

Handling the Problem

To halt kidney damage before kidney failure occurs, the wisest step is to take urinary tract infections seriously. Remember: Infections can back up further into the urinary system and spread to the kidneys, impairing their function.

If signs of developing kidney problems are detected, doctors often recommend a regimen of tight blood-sugar control and a low-protein diet to ease stress on the kidneys. Recent clinical studies suggest that use of the blood-pressure drug enalapril (Vasotec) may preserve kidney function, but more research is needed to confirm this.

CARDIOVASCULAR DISEASE

The word cardiovascular means "of the heart and blood vessels." Cardiovascular complications include problems such as angina, heart attack, stroke, and others related to poor circulation. Cardiovascular disease is the most common complication of type 2 diabetes. In fact, people with diabetes have a risk of cardiovascular disease that is two to five times that of people without the condition.

How It Happens

Just as diabetes changes the shape of the small blood vessels (known as microvascular changes), it also appears to thicken and obstruct the walls of the large blood vessels, thus restricting blood flow. These are called macrovascular changes. Macrovascular changes (such as arteriosclerosis, or hardening of the arteries) have been called the "underlying event" behind most cardiovascular disease. There's no doubt about it: Cardiovascular complications are very debilitating side effects of diabetes. However, the risk for such complications can be decreased by tight blood-sugar control.

Recognizing Risk Factors

Many factors can put a person with diabetes at risk of having a stroke or heart attack. Just having diabetes increases a person's risk of experiencing a stroke, according to the American Journal of Epidemiology, regardless of whether or nor the person has another risk factor--for example, if he follows a sedentary lifestyle, eats a high-fat diet, has high blood pressure, or smokes cigarettes. High blood pressure alone is a major cause of strokes.

Heart attacks and strokes are more common in people with type 2 diabetes than in those with type 1 diabetes, yet medical science is not sure exactly why this is. Experts believe it could be because people with type 2 diabetes tend to be overweight. (Obesity is a known risk factor for heart attack and stroke.)

Cardiovascular complications are, in the general population, more common in men than in women: Women experience strokes and heart attacks less frequently than men. Among people with diabetes, however, the men and women (especially those with type 2 diabetes) have an equal chance of suffering poor outcomes after heart attacks; they have a much higher cardiovascular death rate than their nondiabetic peers.

Overall, women seem to have a biological advantage when it comes to cardiovascular disease--most likely because of the effects of estrogen in women's systems. However, diabetes appears to be the great equalizer of the sexes, at least where heart attacks are concerned. Compared with men without diabetes, men with diabetes have about two times the average risk of developing cardiovascular disease; women with diabetes have three to five times the average risk of developing cardiovascular disease compared with women without the disease.

Handling the Problem

Because the rates of cardiovascular disease are so high in those with diabetes, the American Diabetes Association recommends and screening tests and intervention for heart disease for everyone with diabetes over age thirty.

Traditional screening tests include having your blood pressure taken with a blood pressure cuff and having your cholesterol evaluated with a blood test. An electrocardiogram (EKG) is also recommended. In this test, electrical leads are placed on the body to measure the electrical currents of the heart. The currents are then transcribed into a pattern along a continuous strip of graph paper, which is then read for any abnormalities.

To prevent heart disease in the first place, you can look to the obvious tactics of losing weight and lowering blood sugar in addition to some other methods. For example, if you've paid any attention to medical news in the past decade, then you should know that lowering levels of cholesterol and triglycerides is good for your heart. Cholesterol, a fatlike substance that comes from meat and diary products and is also produced by the body, is found in all the body's cells and in. the bloodstream. High levels of cholesterol in the blood, or hypercholesterolemia, have been implicated in the development of heart disease in general and arteriosclerosis (hardening of the arteries) in particular. What you may not know is that people with diabetes tend to have higher blood-cholesterol levels than other people. They also tend to have higher levels of low-density lipoprotein (LDL), what some call the "bad cholesterol" because it aids in the deposit of fats on artery and cell walls. As if that weren't bad enough, people with diabetes tend to have lower levels of the "good cholesterol," or high-density lipoprotein (HDL), the substance that escorts excess cholesterol from the body. All of this is unpleasant news for the cardiovascular system.

Triglycerides (sometimes known is VLDL, or very-low-density lipoprotein) are another form of fat in the body. High levels of triglycerides in the blood (hypertriglyceridemia) may not directly cause arteriosclerosis but may accompany other abnormalities that speed its development. People with diabetes tend to have high levels of triglycerides, too. Combine high triglyceride levels of 200 to 500 mg/dl with cholesterol levels between 200 and 300 mg/dl, and you have what the American Heart Journal calls combined hyperlipidemia, meaning too much fat. Triglycerides more than 500 mg/dl and/or cholesterol levels over 300 mg/dl are called massive hyperlipidemia. Combined and massive hyperlipidemia are found in over 30 percent of all people with diabetes--approximately two to three times more often than in people without diabetes.

We talk more about cholesterol and triglycerides in the next chapter when we examine diet. For now, it's enough to say that any person with diabetes who improves his cholesterol picture can help protect against developing cardiovascular problems. Evidence suggests that for every 1 percent reduction in blood-cholesterol level, there is a 2 percent reduction in coronary-artery disease for all people, regardless of whether they have diabetes.

Another thing that people with diabetes can do to reduce their risk of cardiovascular disease is to pop a simple pill, an aspirin. The remedy was discovered because a curious thing happened during the course of a clinical study known as the Early Treatment Diabetic Retinopathy Study.

Designed to gauge the effects of aspirin on diabetic retinopathy, the study included 3,700 people with type 1 and type 2 diabetes. Half took two aspirins a day (totaling 650 milligrams); the other half took a placebo. It turned out the aspirin had no effect, positive or negative, on retinopathy. But something positive did take place: People taking aspirin were 17 percent less likely to have had a heart attack during the five years of the study.

Aspirin can't solve all the cardiovascular woes of someone with diabetes, nor is aspirin useful for everyone. But it would be worth a trip to the doctor to discuss what aspirin can do for you.

Your doctor may also suggest treatment with drugs such as beta blockers or ACE (angiotensin-converting enzyme) inhibitors--which help reduce the risk of heart attack in people who already have cardiovascular disease-or simvastatin, a drug that helps lower cholesterol levels and reduces the risk of death from heart attack.

NEUROPATHY

Neuropathy is nerve damage. The word "damage" suggests something irrevocable and permanent, but actually, this is one long-term complication of diabetes with symptoms that can appear and disappear in a short period of time. It also varies in intensity, ranging from mild discomfort to severe, disabling pain.

How It Happens

As is true about many diabetic complications, neuropathy has stumped medical science when it comes to its causes. It's thought that something interferes with the body's nerve pathways so that nerve impulses are no longer transmitted properly. The culprit may be uncontrolled blood-sugar levels (although many people with good control develop this complication), or it may be that the nerves are somehow damaged during the metabolic changes associated with diabetes.

Neuropathy is relatively common. It's estimated that some form of nerve damage affects 60 to 70 percent of people with diabetes at some point in their lives. Some physicians claim that it's often the first noticeable sign of diabetes, particularly type 2. Unfortunately, neuropathy mimics many other medical conditions (as you'll see in a moment), so it's often initially diagnosed as something else.

Recognizing the Signs

In general, there are two main forms of neuropathy: peripheral and autonomic. The most common form of nerve damage, peripheral neuropathy, is sometimes called sensory neuropathy because it affects nerves that control sensations in the body. It also affects muscles controlled by sensory nerves. Sensory neuropathy can weaken muscles in the thighs, eyes, chest, and abdomen, sometimes causing painful muscle wasting, double vision and chest pain, More commonly, sensory neuropathy creates odd sensations (or, in some cases, loss of sensation) in the legs, feet, and hands. The sensations include numbness, tingling, muscle weakness and sporadic shooting pains. These sensations can be mild or they can be annoying. Some people experience double vision for short periods of time; others have great difficulty walking because of pain or because they lose some control of leg movements. Neuropathy has been known to interfere with sleep or rest.

In general, peripheral neuropathy is a temporary condition--one that disappears as mysteriously as it appears. However, it can lead to injury in cases where the person with diabetes feels no sensations of pain. This often happens on the bottoms of the feet, resulting in some of the foot problems that we discuss shortly.

Autonomic neuropathy is a less common complication, perhaps experienced by 20 percent of people with diabetes. Autonomic neuropathy is damage to the nerves that control various bodily functions, such as the digestive system, urinary tract, and cardiovascular system.

Autonomic neuropathy leads to many inconvenient problems: When it affects the nerves around the stomach, bladder, and bowels, it can cause vomiting, constipation, and feelings of bloatedness. When it affects the nerves that control the contraction of blood vessels, a condition called orthostatic hypotension may develop. This is a sudden drop in blood pressure when a person gets up after reclining, which may result in dizziness or fainting, Impotence, the loss of the ability to have an erection, is also related to (although not entirely caused by) neuropathic damage.

Handling the Problem

The symptoms of neuropathy of both types can be treated. Doctors often prescribe drugs to treat the symptoms of these different problems----for example, to relax muscles if the problem is constipation. Exercise helps some people; others benefit from bed rest. Because neuropathy varies tremendously from person to person, treating it is often a matter of trial and error.

But though symptoms can be treated, neuropathy itself cannot be reversed. Medications to treat or prevent nerve damage do not yet exist, although researchers are conducting studies using aldose reductase inhibitors-experimental drugs we discussed earlier in relation to retinopathy.

FOOT PROBLEMS

Cardiovascular complications damage blood vessels and diminish blood flow to the legs and feet. Add damage to the nerves of the legs and feet through neuropathy, and you've just laid the groundwork for serious foot ailments.

How They Happen

Foot ailments show up in about half of people who have had diabetes for 20 years or more. The scenario then proceeds like this: When people with diabetes lose sensation in their lower legs and feet, they are less likely to notice damage to the skin and tissues. Such seemingly minor injuries as cuts, bruises, blisters, bunions, corns, calluses, ingrown toenails, or even athlete's foot can develop into areas of infected tissue known as neuropathic ulcers.

It may seem impossible that a blister turns into an ulcer, yet the process is fairly simple. Let's say you have a new pair of shoes that has chafed and rubbed one foot raw. The area is red and inflamed. Once an inflammation or infection begins, its swelling compresses the blood vessels, which are already damaged or narrowed by diabetes itself. These factors diminish the flow of blood to the irritated area, meaning fresh oxygen and infection-fighting blood cells have a more difficult time getting to the problem site. All of this sets the stage for a serious infection. Once infection sets in, it's difficult to treat. Antibiotics, which are carried in the blood, can't reach the infected area efficiently. About 80 percent of foot ulcers occur on the bottom of insensate feet, or feet without feeling.

The real danger with the combination of infection and reduced blood flow is gangrene. If blood flow were to be completely blocked, the cells served by the obstructed blood vessels would die. Once gangrene sets in, the only way to stop its spread is by amputation of the dead tissue.

According to an article in Archives of Internal Medicine, "It has been estimated that the lifetime risk of a lower-extremity amputation is 5 to 15 percent among diabetic individuals, a risk fifteen times that of the nondiabetic population."

More than half of all lower-limb amputations in the United States are performed on people with diabetes. Each year, reports the American Podiatric Medical Association, the number of lower-limb amputations due to diabetic complications in the United States exceeds the number of limbs lost worldwide to land mines. Almost half of these 67,000 amputations could have been prevented through early detection and treatment.

Recognizing Risk Factors

As is true with all diabetic complications, certain factors increase risk of foot problems. The greatest of these is smoking. According to the American Diabetes Association, of the people with diabetes who need amputations, almost all are smokers. Other high-risk factors include being male and being African-American or Native American. Risk increases with age, too.

A 1998 study published in the Archives of Internal Medicine listed a number of criteria doctors can use to determine a patient's risk of foot ulcers. These include a history of amputation, diabetes for more than ten years, existing foot deformities, neuropathy, and difficulty feeling vibrations with the feet. The study authors encouraged practitioners to survey for these criteria in order to prevent such complications.

Handling the Problem

The trick to treating and preventing foot problems lies in finding out ifs a blood vessel is about to become blocked. It used to be that doctors could locate blockages in large vessels, such as those of the legs, only by ordering an x-ray called an angiogram. Then they might perform bypass surgery to detour blood around the blockage. In this surgery, a piece of healthy vein is "harvested" from an area of the body (possibly the thigh) and is attached at either end of the obstruction. The new vein directs blood to cells that had been receiving an inadequate supply. It's one method of preventing gangrene-albeit an invasive and expensive one.

Like many other diabetic complications we have discussed, amputation doesn't have to happen. With proper foot care, many, if not most, amputations may well be avoided.

Blood Sugar Levels - Guidelines for Diabetes

2008-08-02T20:06:00.000-07:00

Blood Glucose Goals - Desirable Blood Sugar Levels

Source: The American Diabetes Association's Complete Guide to Diabetes

Time of Test Person without diabetes Person with diabetes

Before meals Less than 115 mg/dl 80 to 120 mg/dl
__________________________________________________________

Before bedtime Less than 120 mg/dl 100 to 140 mg/dl

Your Blood Glucose Goals

Choosing blood glucose goals can be easy. You can simply follow guidelines supported by the American Diabetes Association (see table). However, these goals may not be easy for you to reach. Or they may not be appropriate for you because of a health problem. Your goals may be consistently higher. Why not see what your blood glucose levels are before and after meals and before bed and compare them to the goals in the table. Perhaps you can make small changes, a few at a time, to slowly lower your blood glucose levels.

Changes may include:
* how much food you eat
* the kinds of food you eat
* how much exercise you get
* how much insulin or medication you take.

Whether you have type 1 or type II diabetes or gestational diabetes, the goals of achieving control of blood glucose levels are similar: to keep blood glucose as close as possible to that of a person without diabetes. For many people with diabetes, getting normal blood glucose levels (like a person without diabetes) just isn't realistic or even desirable. For instance, if you are elderly and live alone, you may be more concerned with preventing severe low blood glucose than avoiding long-term complications. You and your health care team should decide together what goals are best for you.

Tips: Blood glucose goals for children are looser. For example, the target range may be 100 or 200 mg/dl. Most children under the age of 6 or 7 are not yet able to be aware of and respond to oncoming low blood glucose, and it's very important to limit episodes of low blood glucose. Tailor goals to the age and abilities of the child and be flexible with goals as the child grows.

The Diabetic Exchange List (Exchange Diet)

2008-08-02T20:01:00.000-07:00

*The Exchange Lists are the basis of a meal planning system designed by a committee of the American Diabetes Association and the American Dietetic Association. While designed primarily for people with diabetes and others who must follow special diets, the Exchange Lists are based on principles of good nutrition that apply to everyone.

The Exchange Lists

The reason for dividing food into six different groups is that foods vary in their carbohydrate, protein, fat, and calorie content. Each exchange list contains foods that are alike; each food choice on a list contains about the same amount of carbohydrate, protein, fat, and calories as the other choices on that list.

The following chart shows the amounts of nutrients in one serving from each exchange list. As you read the exchange lists, you will notice that one choice is often a larger amount of food than another choice from the same list. Because foods are so different, each food is measured or weighed so that the amounts of carbohydrate, protein, fat, and calories are the same in each choice.

	Carbohydrate (grams)	Protein (grams)	Fat (grams)	Calories
I. Starch/Bread	15	3	trace	80
II. Meat
Very Lean	.	7	0-1	35
Lean	.	7	3	55
Medium-Fat	.	7	5	75
High-Fat	.	7	8	100
III. Vegetable	5	2	.	25
IV. Fruit	15	.	.	60
V. Milk
Skim	12	8	0-3	90
Low-fat	12	8	5	120
Whole	12	8	8	150
VI. Fat	.	.	5	45

You will notice symbols on some foods in the exchange groups. Foods that are high in fiber (three grams or more per normal serving) have the symbol *. High-fiber foods are good for you, and it is important to eat more of these foods.
Foods that are high in sodium (400 milligrams or more of sodium per normal serving) have the symbol #. As noted, it's a good idea to limit your intake of high-salt foods, especially if you have high blood pressure.
If you have a favorite food that is not included in any of these groups, ask your dietitian about it. That food can probably be worked into your meal plan, at least now and then.

I. Starch/Bread List

Each item in this list contains approximately fifteen grams of carbohydrate, three grams of protein, a trace of fat, and eighty calories. Whole-grain products average about two grams of fiber per serving. Some foods are higher in fiber. Those foods that contain three or more grams of fiber per serving are identified with the symbol *.
You can choose your starch exchanges from any of the items on this list. If you want to eat a starch food that is not on the list, the general rule is this:

1/2 cup of cereal, grain, or pasta = one serving
1 ounce of a bread product = one serving

Your dietitian can help you to be more exact.

CEREALS/GRAINS/PASTA
*Bran cereals, concentrated (such as Bran Buds, All Bran)	1/3 cup
*Bran cereals, flaked	1/2 cup
Bulgur (cooked)	1/2 cup
Cooked cereals	1/2 cup
Cornmeal (dry)	2 1/2 tbsp
Grape Nuts	3 tbsp
Grits (cooked)	1/2 cup
Other ready-to-eat, unsweetened (plain) cereals	3/4 cup
Pasta (cooked)	1/2 cup
Puffed cereal	1 1/2 cups
Rice, white or brown (cooked)	1/3 cup
Shredded wheat	1/2 cup
*Wheat germ	3 tbsp
DRIED BEANS/PEAS/LENTILS
*Beans and peas (cooked) (such as kidney, white, split, blackeye)	1/3 cup
*Lentils (cooked)	1/3 cup
*Baked beans	1/4 cup
STARCHY VEGETABLES
*Corn	1/2 cup
*Corn on the cob, 6 in.	1 long
*Lima beans	1/2 cup
*Peas, green (canned or frozen)	1/2 cup
*Plaintain	1/2 cup
Potato, baked 1 small	(3 oz)
Potato, mashed	1/2 cup
Squash, winter (acorn, butternut)	3/4 cup
Yam, sweet potato	1/3 cup
BREAD
Bagel 1/2	(1 oz)
Bread sticks, crisp, 4 in. long x 1/2 in.	2 (2/3 oz)
Croutons low fat	1 cup
English muffin	1/2
Frankfurter or hamburger bun	1/2 (1 oz)
Pita, 6 in. across	1/2
Plain roll, small	1 (1 oz)
Raisin, unfrosted	1 slice
*Rye, pumpernickel	1 slice (1 oz)
White (including French, Italian)	1 slice (1 oz)
Whole wheat	1 slice
CRACKERS/SNACKS
Animal crackers	8
Graham crackers, 2 1/2 in. square	3
Matzoh	3/4 oz
Melba toast	5 slices
Oyster crackers	24
Popcorn (popped, no fat added)	3 cups
Pretzels	3/4 oz
Rye crisp (2 in. x 3 1/2 in.)	4
Saltine-type crackers	6
Whole-wheat crackers, no fat added (crisp breads such as Finn, Kavli, Wasa)	2-4 slices (3/4 oz)
STARCHY FOODS PREPARED WITH FAT (count as 1 starch/bread serving, plus 1 fat serving)
Biscuit, 2 1/2 in. across	1
Chow mein noodles	1/2 cup
Corn bread, 2-in. cube	1 (2 oz)
Cracker, round butter type	6
French-fried potatoes (2 in. to 3 1/2 in. long)	10 (1 1/2 oz)
Muffin, plain, small	1
Pancake, 4 in. across	2
Stuffing, bread (prepared)	1/4 cup
Taco shell, 6 in. across	2
Waffle, 4 1/2 in. square	1
Whole-wheat crackers, fat added (such as Triscuits)	4-6 (1 oz)

II. Meat List

Each serving of meat and substitutes on this list contains about seven grams of protein. The amount of fat and number of calories vary, depending on what kind of meat or substitute is chosen. The list is divided into four parts, based on the amount of fat and calories: very lean meat, lean meat, medium-fat meat, and high-fat meat. One ounce (one meat exchange) of each of these includes the following nutrient amounts:

	Carbohydrate (grams)	Protein (grams)	Fat (grams)	Calories
Very Lean	.	7	0-1	35
Lean	.	7	3	55
Medium-Fat	.	7	5	75
High-Fat	.	7	8	100

You are encouraged to use more lean and medium-fat meat, poultry, and fish in your meal plan. This will help you to decrease your fat intake, which may help decrease your risk for heart disease. The items from the high-fat group are high in saturated fat, cholesterol, and calories. You should limit your choices from the high-fat group to three times per week. Meat and substitutes do not contribute any fiber to your meal plan. Meats and meat substitutes that have 400 milligrams or more of sodium per exchange are indicated with the symbol #.

Tips
1. Bake, roast, broil, grill, or boil these foods rather than frying them with added fat.
2. Use a nonstick pan spray or a nonstick pan to brown or fry these foods.
3. Trim off visible fat before and after cooking.
4. Do not add flour, bread crumbs, coating mixes, or fat to these foods when preparing them.
5. Weigh meat after removing bones and fat and again after cooking. Three ounces of cooked meat are equal to about four ounces of raw meat. Some examples of meat portions are: 2 ounces meat (2 meat exchanges) = 1 small chicken leg or thigh, 1/2 cup cottage cheese or tuna; 3 ounces meat (3 meat exchanges) = 1 medium pork chop, 1 small hamburger, 1/2 of a whole chicken breast, 1 unbreaded fish fillet, cooked meat, about the size of a deck of cards.
6. Restaurants usually serve prime cuts of meat, which are high in fat and calories.

Lean Meat and Substitutes One exchange is equal to any one of the following items:
Beef	USDA Good or Choice grades of lean beef, such as round, sirloin, and flank steak; tenderloin; and chipped beef#	1 oz
Pork	Lean pork, such as fresh ham; canned, cured, or boiled ham#, Canadian bacon#, tenderloin	1 oz
Veal	All cuts are lean except for veal cutlets (ground or cubed)	1 oz
Poultry	Chicken, turkey, Cornish hen (without skin)	1 oz
Fish	All fresh and frozen fish	1 oz
	Crab, lobster, scallops, shrimp, clams (fresh or canned in water#)	2 oz
	Oysters	6 med
	Tuna# (canned in water)	1/4 cup
	Herring (uncreamed or smoked)	1 oz
	Sardines (canned)	2 med
Wild Game	Venison, rabbit, squirrel	1 oz
	Pheasant, duck, goose (without skin)	1 oz
Cheese	Any cottage cheese	1/4 cup
	Grated parmesan	2 tbsp
	Diet cheese# (with fewer than 55 calories per ounce)	1 oz
Other	95% fat-free luncheon meat	1 oz
	Egg whites	3
	Egg substitutes (with fewer than 55 calories per 1/4 cup)	1/4 cup
Medium-Fat and Meat Substitutes One exchange is equal to any one of the following items:
Beef	Most beef products fall into this category. Examples are: all ground beef, roast (rib, chuck, rump), steak (cubed, Porterhouse, T-bone), and meat loaf.	1 oz
Pork	Most pork products fall into this category. (Examples: chops, loin roast, Boston butt, cutlets)	1 oz
Lamb	Most lamb products fall into this category (examples: chops, leg, roast)	1 oz
Veal	Cutlet (ground or cubed, unbreaded)	1 oz
Poultry	Chicken (with skin), domestic duck or goose (well drained of fat), ground turkey	1 oz
Fish	Tuna# (canned in oil and drained)	1/4 cup
	Salmon# (canned)	1/4 cup
Cheese	Skim or part-skim milk cheeses, such as:
	Ricotta	1/4 cup
	Mozzarella	1 oz
	Diet cheeses# (with 56-80 calories per ounce)	1 oz
Other	86% fat-free luncheon meat#	1 oz
	Egg (high in cholesterol, so limit to 3 per week)	1
	Egg substitutes (with 56-80 calories per 1/4 cup)	1/4 cup
	Tofu (2 1/2 in. x 2 3/4 in. x 1 in.)	4 oz
	Liver, heart, kidney, sweetbreads (high in cholesterol)	1 oz
High-Fat Meat and Substitutes Remember, these items are high in saturated fat, cholesterol, and calories, and should be eaten only three times per week. One exchange is equal to any one of the following items:
Beef	Most USDA Prime cuts of beef, such as ribs, corned beef#	1 oz
Pork	Spareribs, ground pork, pork sausage! (patty or link)	1 oz
Lamb	Patties (ground lamb)	1 oz
Fish	Any fried fish product	1 oz
Cheese	All regular cheese#, such as American, Blue, Cheddar, Monterey, Swiss	1 oz
Other	Luncheon meat#, such as bologna, salami, pimiento loaf	1 oz
	Sausage#, such as Polish, Italian	1 oz
	Knockwurst, smoked	1 oz
	Bratwurst#!	1 oz
	Frankfurter# (turkey or chicken) (10/lb)	1 frank
	Peanut butter (contains unsaturated fat)	1 tbsp.
Count as one high-fat meat plus one fat exchange:
Frankfurter#	(beef, pork, or combination) (400 mg or more of sodium per exchange) (10/lb)	1 frank

III. Vegetable List

Each vegetable serving on this list contains about five grams of carbohydrate, two grams of protein, and twenty-five calories. Vegetables contain two to three grams of dietary fiber. Vegetables that contain 400 mg of sodium per serving are identified with a # symbol.
Vegetables are a good source of vitamins and minerals. Fresh and frozen vegetables have more vitamins and less added salt. Rinsing canned vegetables will remove much of the salt. Unless otherwise noted, the serving size for vegetables (one vegetable exchange) is:

1/2 cup of cooked vegetables or vegetable juice
1 cup of raw vegetables

Artichoke (1/2 medium)	Eggplant
Asparagus	Greens (collard, mustard, turnip)
Beans (green, wax, Italian)	Kohlrabi
Bean sprouts	Leeks
Beets	Mushrooms, cooked
Broccoli	Okra
Brussels sprouts	Onions
Cabbage, cooked	Pea pods
Carrots	Peppers (green)
Cauliflower	Tomato (one large)
Rutabaga	Tomato/vegetable juice
Sauerkraut	Turnips
Spinach, cooked	Water chestnuts
Summer squash (crookneck)	Zucchini, cooked

Starchy vegetables such as corn, peas, and potatoes are found on the Starch/Bread List.
For "free" vegetables (i.e., fewer than ten calories per serving), see the Free Food List.
# = 400 mg or more of sodium per serving.

IV. Fruit List

Each item on this list contains about fifteen grams of carbohydrate and sixty calories. Fresh, frozen, and dry fruits have about two grams of fiber per serving. Fruits that have three or more grams of fiber per serving have a * symbol. Fruit juices contain very little dietary fiber.
The carbohydrate and calorie contents for a fruit serving are based on the usual serving of the most commonly eaten fruits. Use fresh fruits or frozen or canned fruits with no sugar added. Whole fruit is more filling than fruit juice and may be a better choice for those who are trying to lose weight. Unless otherwise noted, the serving size for one fruit serving is:

1/2 cup of fresh fruit or fruit juice
1/4 cup dried fruit

Fresh, Frozen, and Unsweetened Canned Fruit
Apples (raw, 2 in. across)	1
Applesauce (unsweetened)	1/2 cup
Apricots (canned) (4 halves)	1/2 cup
Banana (9 in. long)	1/2
Blackberries (raw)	3/4 cup
*Blueberries (raw)	3/4 cup
Cantaloupe (5 in. across)	1/3
Cantaloupe (cubes)	1 cup
Cherries (large, raw)	12 whole
Cherries (canned)	1/2 cup
Figs (raw, 2 in. across)	2
Fruit cocktail (canned)	1/2 cup
Grapefruit (medium)	1/2
Grapefruit (segments)	3/4 cup
Grapes (small)	15
Honeydew melon (medium)	1/8
Honeydew melon (cubes)	1 cup
Kiwi (large)	1
Mandarin oranges	3/4 cup
Mango (small)	1/2
Nectarines (2 1/2 in. across)	1
Orange (2 1/2 in. across)	1
Papaya	1 cup
Peach (2 3/4 in. across)	1
Peaches (canned) (2 halves)	1 cup
Pear (1/2 large)	1 small
Pears (canned) (2 halves	1/2 cup
Persimmon (medium, native)	2
Pineapple (raw)	3/4 cup
Pineapple (canned)	1/3 cup
Plum (raw, 2 in. across)	2
*Pomegranate	1/2
*Raspberries (raw)	1 cup
*Strawberries (raw, whole)	1 1/4 cup
Tangerine (2 1/2 in. across)	2
Watermelon (cubes)	1 1/4 cup
*Dried Fruit
*Apples	4 rings
*Apricots	7 halves
Dates (medium)	2 1/2
*Figs	1 1/2
*Prunes (medium)	3
Raisins	2 tbsp
Fruit Juice
Apple juice/cider	1/2 cup
Cranberry juice cocktail	1/3 cup
Grapefruit juice	1/2 cup
Grape juice	1/3 cup
Orange juice	1/2 cup
Pineapple juice	1/2 cup
Prune juice	1/3 cup
* = 3 grams or more of fiber per serving

V. Milk List

Each serving of milk or milk products on this list contains about twelve grams of carbohydrate and eight grams of protein. The amount of fat in milk is measured in percent of butterfat. The calories vary depending on the kind of milk chosen. The list is divided into three parts, based on the amount of fat and calories: skim/very low-fat milk, low-fat milk, and whole milk. One serving (one milk exchange) of each of these includes:

Milk	Carbohydrate (grams)	Protein (grams)	Fat (grams)	Calories
Skim	12	8	trace	90
Low-fat	12	8	5	120
Whole	12	8	8	150

Milk is the body's main source of calcium, the mineral needed for growth and repair of bones. Yogurt is also a good source of calcium. Yogurt and many dry or powdered milk products have different amounts of fat. If you have questions about a particular item, read the label to find out the fat and calorie content.
Milk can be drunk or added to cereal or other foods. Many tasty dishes, such as sugar-free pudding, are made with milk (see the Combination Foods list). Add life to plain yogurt by adding one of your fruit servings to it.

Skim and Very Low-Fat Milk
Skim milk	1 cup
1/2% milk	1 cup
1% milk	1 cup
Low-fat buttermilk	1 cup
Evaporated skim milk	1/2 cup
Dry nonfat milk	1/3 cup
Plain nonfat yogurt	8 oz
Low-Fat Milk
2% milk	1 cup
Plain low-fat yogurt (with added nonfat milk solids)	8 oz
Whole Milk The whole-milk group has much more fat per serving than the skim and low-fat groups. Whole milk has more than 3 1/4% butterfat. Try to limit your choices from the whole-milk group as much as possible.
Whole milk	1 cup
Evaporated whole milk	1/2 cup
Whole milk plain yogurt	8 oz

VI. Fat List

Each serving on the fat list contains about five grams of fat and forty-five calories.
The foods on the fat list contain mostly fat, although some items may also contain a small amount of protein. All fats are high in calories and should be carefully measured. Everyone should modify fat intake by eating unsaturated fats instead of saturated fats. The sodium content of these foods varies widely. Check the label for sodium information.

Unsaturated Fats
Avocado	1/8 medium
Margarine	1 tsp
#Margarine, diet	1 tbsp
Mayonnaise	1 tsp
#Mayonnaise (reduced-calorie)	1 tbsp
Nuts and Seeds:
Almonds, dry roasted	6
Cashews, dry roasted	1 tbsp
Pecans	2
Peanuts (small)	20
Peanuts (large)	10
Walnuts	2 whole
Other nuts	1 tbsp
Seeds (except pumpkin), pine nuts, sunflower (without shells)	1 tbsp
Pumpkin seeds	2 tsp
Oil (corn, cottonseed, safflower, soybean, sunflower, olive, peanut)	1 tsp
#Olives (small)	10
#Olives (large)	5
Salad dressing, mayonnaise-type, regular	2 tsp
Salad dressing, mayonnaise-type reduced-calorie	1 tbsp
Salad dressing, all varieties, regular	1 tbsp
#Salad dressing, reduced-calorie (2 tbsp of low-calorie dressing is a free food)	2 tbsp
Saturated Fats
Butter	1 tsp
#Bacon	1 slice
Chitterlings	1/2 oz
Coconut, shredded	2 tbsp
Coffee whitener, liquid	2 tbsp
Coffee whitener, powder	4 tsp
Cream (light, coffee, table)	2 tbsp
Cream, sour	2 tbsp
Cream (heavy, whipping)	1 tbsp
Cream cheese	1 tbsp
#Salt pork	1/4 oz
# = 400 mg or more of sodium if more than one or two servings are eaten.

Free Foods

A free food is any food or drink that contains fewer than twenty calories per serving. You can eat as much as you want of items that have no serving size specified. You may eat two or three servings per day of those items that have a specific serving size. Be sure to spread them out through the day.

Drinks
#Bouillon or broth without fat
Bouillon, low-sodium
Carbonated drinks, sugar-free
Carbonated water
Club soda
Cocoa powder, unsweetened	(1 tbsp)
Coffee/tea
Drink mixes, sugar-free
Tonic water, sugar-free
Fruit
Cranberries, unsweetened	(1/2 cup)
Rhubarb, unsweetened	(1/2 cup)
Vegetables (raw, 1 cup)
Cabbage
Celery
#Chinese cabbage
Cucumber
Green onion
Hot peppers
Mushrooms
Radishes
#Zucchini
Salad Greens
Endive
Escarole
Lettuce
Romaine
Spinach
Sweets
Candy, hard, sugar-free
Gelatin, sugar-free
Gum, sugar-free
Jam/jelly, sugar-free	(2 tsp)
Pancake syrup, sugar-free	(1-2 tbsp)
Sugar substitutes (saccharin, aspartame)
Whipped topping	(2 tbsp)
Condiments
Catsup	(1 tbsp)
Horseradish
Mustard
#Pickles, dill, unsweetened
Salad dressing, low-calorie	(2 tbsp)
Taco sauce	(1 tbsp)
Vinegar
Nonstick pan spray

Seasonings Seasonings can be very helpful in making foods taste better. Be careful of how much sodium you use. Read labels to help you choose seasonings that do not contain sodium or salt.
Basil (fresh)	Lemon pepper
Celery Seeds	Lime
Cinnamon	Lime Juice
Chili powder	Mint
Chives	Onion powder
Curry	Oregano
Dill	Paprika
Flavoring extracts (vanilla, almond, walnut, butter, peppermint, lemon, etc.)	Pepper
Garlic	Pimento
Garlic powder	Spices
Herbs	#Soy sauce
Hot pepper sauce	Soy sauce, low sodium ("lite")
Lemon	Wine, used in cooking (1/4 cup)
Lemon juice	Worcestershire sauce

Combination Foods

Much of the food we eat is mixed together in various combinations. These combination foods do not fit into only one exchange list. It can be quite hard to tell what is in a certain casserole dish or baked food item. Following is a list of average values for some typical combination foods to help you fit these foods into your meal plan. Ask your dietitian for information about any other foods you'd like to eat. The American Diabetes Association/American Dietetic Association Family Cookbooks and the American Diabetes Association Holiday Cookbook have many recipes and further information about many foods, including combination foods. Check your library or local bookstore.

Food	Amount	Exchanges
Casserole, homemade	1 cup (8 oz)	2 medium-fat meat, 2 starches, 1 fat
#Cheese pizza, thin crust	1/4 of a 15-oz size pizza or a 10" pizza	1 medium-fat meat, 2 starches, 1 fat
*#Chili with beans (commercial)	1 cup (8 oz)	2 medium-fat meat, 2 starches, 2 fats
*#Chow mein (without noodles or rice)	2 cups (16 oz)	2 lean meat, 1 starch, 2 vegetable
#Macaroni and cheese	1 cup (8 oz)	1 medium-fat meat, 2 starches, 2 fats
Soup
*#Bean	1 cup (8 oz)	1 lean meat, 1 starch, 1 vegetable
#Chunky, all varieties	10 3/4-oz can	1 medium-fat meat, 1 starch, 1 vegetable
#Cream (made with water)	1 cup (8 oz)	1 starch, 1 fat
#Vegetable or broth	1 cup (8 oz)	1 starch
#Spaghetti and meatballs (canned)	1 cup (8 oz)	1 medium-fat meat, 1 fat, 2 starches
Sugar-free pudding (made with skim milk)	1/2 cup	1 starch
If beans are used as a meat substitute:
Dried beans, peas, *lentils	1 cup (cooked)	1 lean meat, 2 starches

Foods for Occasional Use

Moderate amounts of some foods can be used in your meal plan, in spite of their sugar or fat content, as long as you can maintain blood-glucose control. The following list includes average exchange values for some of these foods. Because they are concentrated sources of carbohydrate, you will notice that the portion sizes are very small. Check with your dietitian for advice on how often and when you can eat them.

Food	Amount	Exchanges
Angel-food cake	1/12 cake	2 starches
Cake, no icing	1/12 cake (3-in. square)	2 starches, 2 fats
Cookies	2 small (1 3/4 in. across)	2 starches, 1 fat
Frozen fruit yogurt	1/3 cup	1 starch
Gingersnaps	3	1 starch
Granola	1/4 cup	1 starch, 1 fat
Granola bars	1 small	1 starch, 1 fat
Ice cream, any flavor	1/2 cup	1 starch, 2 fats
Ice milk, any flavor	1/2 cup	1 starch, 1 fat
Sherbet, any flavor	1/4 cup	1 starch
#Snack chips, all varieties	1 oz	1 starch, 2 fats
Vanilla wafers	6 small	1 starch, 2 fats
# = If more than one serving is eaten, these foods have 400mg or more of sodium.

Management Tips

Here are some tips that can help you to change the way you eat.

Make Changes Gradually
Don't try to do everything all at once. it may take longer to accomplish your goals, but the changes you make will be permanent.

Set Short-term, Realistic Goals
If weight loss is your goal, try to lose two pounds in two weeks, not twenty pounds in one week. Walk two blocks at firest, not two miles. Success will come more easily, and you'll feel good about yourself.

Reward Yourself
When you achieve your short-term goal, do something special for yourselfgo to a movie, buy a new shirt, read a book, visit a friend.

Measure Foods
It is important to eat the right serving sizes of food. You will need to learn how to estimate the amount of food you are served. You can do this by measuring all the food you eat for a week or so. Measure liquids with a measuring cup. Some solid foods (such as tuna, cottage cheese, and canned fruits) can also be measured with a measuring cup. Measuring spoons are used for measuring smaller amounts of other foods (such as oil, salad dressing, and peanut butter). A scale can be very useful for measuring almost anything, especially meat, poultry, and fish. All food should be measured or weighed after cooking. Some food you buy uncooked will weigh less after you cook it. This is true of most meats. Starches often swell in cooking, so a small amount of uncooked starch will become a much larger amount of cooked food. The following table shows some of the changes:

Starch Group	Uncooked	Cooked
Oatmeal	3 level tbsp	1/2 cup
Cream of wheat	2 level tbsp	1/2 cup
Grits	3 level tbsp	1/2 cup
Rice	2 level tbsp	1/2 cup
Spaghetti	1/4 cup	1/2 cup
Noodles	1/3 cup	1/2 cup
Macaroni	1/4 cup	1/2 cup
Dried beans	3 tbsp	1/3 cup
Dried peas	3 tbsp	1/3 cup
Lentils	2 tbsp	1/3 cup
Meat Group
Hamburger	4 oz	3 oz
Chicken	1 small drumstick	1 oz
	1/2 of a whole chicken breast	3 oz

Read Food Labels
Remember, dietetic does not mean diabetic! When you see the word "dietetic" on a food label, it means that something has been changed or replaced. It may have less salt, less fat, or less sugar. It does not mean that the food is sugar-free or calorie-free. Some dietetic foods may be useful. Those that contain twenty calories or less per serving may be eaten up to three times a day as free foods.

Know Your Sweeteners
Two types of sweeteners are on the market: those with calories and those without calories. Sweeteners with calories (such as fructose, sorbitol, and mannitol) may cause cramping and diarrhea when used in large amounts. Remember, these sweeteners do have calories, which can add up. Sweeteners without calories include saccharin and aspartame (Equal, Nutrasweet) and may be used in moderation

Plan for Exercise

You may need to make some changes in your meal plan or insulin dose when you begin an exercise program. Check with your dietitian or doctor about this. Be sure to carry some form of carbohydrate with you to treat low blood glucose (for example, dried fruit or glucose tablets). Additional information on these topics is available from your dietitian or doctor.

TENTANG DIABETES Lagi

2008-06-15T19:02:00.000-07:00

PENYEBAB DIABETES

Pembentukan diabetes yang penting adalah dikarenakan kurangnya produksi insulin (diabetes mellitus tipe 1, yang pertama dikenal), atau kurang sensitifnya jaringan tubuh terhadap insulin (diabetes mellitus tipe 2, bentuk yang lebih umum). Selain itu, terdapat jenis diabetes mellitus yang juga disebabkan oleh resistansi insulin yang terjadi pada wanita hamil. Tipe 1 membutuhkan penyuntikan insulin, sedangkan tipe 2 diatasi dengan pengobatan oral dan hanya membutuhkan insulin bila obatnya tidak efektif. Diabetes mellitus pada kehamilan umumnya sembuh dengan sendirinya setelah persalinan.

Pemahaman dan partisipasi pasien sangat penting karena tingkat glukosa darah berubah terus, karena kesuksesan menjaga gula darah dalam batasan normal dapat mencegah terjadinya komplikasi diabetes. Faktor lainnya yang dapat mengurangi komplikasi adalah: berhenti merokok, mengoptimalkan kadar kolesterol, menjaga berat tubuh yang stabil, mengontrol tekanan darah tinggi, dan melakukan olah raga teratur.

Gejala

Tiga serangkai yang klasik tentang gejala kencing manis adalah polyuria ( urination yang sering), polydipsia ( dahaga ditingkatkan dan masukan cairan sebagai akibat yang ditingkatkan) dan polyphagia ( selera yang ditingkatkan). Gejala ini boleh kembang;kan sungguh puasa diset dicetak 1, terutama sekali di anak-anak ( bulan atau minggu) tetapi mungkin sulit dipisahkan atau dengan sepenuhnya absen & & mdash; seperti halnya mengembang;kan jauh lebih pelan-pelan & mdash; diset dicetak 2. Diset dicetak 1 [di/ke] sana boleh juga jadilah kerugian berat/beban ( di samping normal atau yang ditingkatkan makan) dan kelelahan yang tidak dapat diperkecil lagi. Gejala ini boleh juga menjelma diset dicetak 2 kencing manis di pasien kencing manis siapa adalah dengan kurang baik dikendalikan. Gejala awalnya berhubungan dengan efek langsung dari kadar gula darah yang tinggi. Jika kadar gula darah sampai diatas 160-180 mg/dL, maka glukosa akan sampai ke air kemih. Jika kadarnya lebih tinggi lagi, ginjal akan membuang air tambahan untuk mengencerkan sejumlah besar glukosa yang hilang. Karena ginjal menghasilkan air kemih dalam jumlah yang berlebihan, maka penderita sering berkemih dalam jumlah yang banyak (poliuri).

Akibat poliuri maka penderita merasakan haus yang berlebihan sehingga banyak minum (polidipsi).

Sejumlah besar kalori hilang ke dalam air kemih, penderita mengalami penurunan berat badan. Untuk mengkompensasikan hal ini penderita seringkali merasakan lapar yang luar biasa sehingga banyak makan (polifagi).

Gejala lainnya adalah pandangan kabur, pusing, mual dan berkurangnya ketahanan selama melakukan olah raga. Penderita diabetes yang kurang terkontrol lebih peka terhadap infeksi.

Karena kekurangan insulin yang berat, maka sebelum menjalani pengobatan penderita diabetes tipe I hampir selalu mengalami penurunan berat badan. Sebagian besar penderita diabetes tipe II tidak mengalami penurunan berat badan.

Pada penderita diabetes tipe I, gejalanya timbul secara tiba-tiba dan bisa berkembang dengan cepat ke dalam suatu keadaan yang disebut dengan ketoasidosis diabetikum. Kadar gula di dalam darah adalah tinggi tetapi karena sebagian besar sel tidak dapat menggunakan gula tanpa insulin, maka sel-sel ini mengambil energi dari sumber yang lain. Sel lemak dipecah dan menghasilkan keton, yang merupakan senyawa kimia beracun yang bisa menyebabkan darah menjadi asam (ketoasidosis). Gejala awal dari ketoasidosis diabetikum adalah rasa haus dan berkemih yang berlebihan, mual, muntah, lelah dan nyeri perut (terutama pada anak-anak). Pernafasan menjadi dalam dan cepat karena tubuh berusaha untuk memperbaiki keasaman darah. Bau nafas penderita tercium seperti bau aseton. Tanpa pengobatan, ketoasidosis diabetikum bisa berkembang menjadi koma, kadang dalam waktu hanya beberapa jam.

Bahkan setelah mulai menjalani terapi insulin, penderita diabetes tipe I bisa mengalami ketoasidosis jika mereka melewatkan satu kali penyuntikan insulin atau mengalami stres akibat infeksi, kecelakann atau penyakit yang serius.

Penderita diabetes tipe II bisa tidak menunjukkan gejala-gejala semala beberapa tahun. Jika kekurangan insulin semakin parah, maka timbullah gejala yang berupa sering berkemih dan sering merasa haus. Jarang terjadi ketoasidosis. Jika kadar gula darah sangat tinggi (sampai lebih dari 1.000 mg/dL, biasanya terjadi akibat stres-misalnya infeksi atau obat-obatan), maka penderita akan mengalami dehidrasi berat, yang bisa menyebabkan kebingungan mental, pusing, kejang dan suatu keadaan yang disebut koma hiperglikemik-hiperosmolar non-ketotik.

Gejala awalnya berhubungan dengan efek langsung dari kadar gula darah yang tinggi. Jika kadar gula darah sampai diatas 160-180 mg/dL, maka glukosa akan sampai ke air kemih. Jika kadarnya lebih tinggi lagi, ginjal akan membuang air tambahan untuk mengencerkan sejumlah besar glukosa yang hilang. Karena ginjal menghasilkan air kemih dalam jumlah yang berlebihan, maka penderita sering berkemih dalam jumlah yang banyak (poliuri).

Akibat poliuri maka penderita merasakan haus yang berlebihan sehingga banyak minum (polidipsi).

Gejala lainnya adalah pandangan kabur, pusing, mual dan berkurangnya ketahanan selama melakukan olah raga. Penderita diabetes yang kurang terkontrol lebih peka terhadap infeksi.

MITOS – MITOS TENTANG DIABETES

2008-06-14T00:19:00.000-07:00

Ketularan Diabetes Dari orang lain
Ngga bener. Walaupun kita tidak tahu bagaimana seseorang bisa mengidap diabetes, tetapi yang pasti tidak menular. Beberapa pendapat mengatakan penyakit ini diturunkan secara genetic misalnya orang tuanya atau keluarganya ada yang mengidap diabetes dipastikan orang tersebut mempunyai bakat mengidap diabetes terutama type. Faktor gaya hidup juga berpengaruh misalnya jarang olah raga, suka makan yang enak-enak, kurang suka makan buah dan sayur.
Diabetesi (orang yang mengidap diabetes) tidak boleh makan yang manis-manis dan coklat.
Selama masih dimakan dalam batas wajar atau digabungkan dengan olahraga makanan ini tidak perlu dihindari. Jadi Diabetesi bisa makan yang manis-manis seperti orang yang sehat.
Makan banyak gula atau yang manis-manis menyebabkan Diabetes
Tidak betul. Diabetes disebabkan oleh gabungan dari gaya hidup yang tidak sehat dan genetic. Walaupun begitu kelebihan berat badan meningkatkan resiko seseorang untuk mengidap diabetes tipe 2. Jika ada riwayat diabetes dikeluarga disarankan untuk memulai gaya hidup sehat dan berolahraga secara teratur untuk mengatur berat badan.
Diabetesi harus makan makanan khusus diabetes.
Makanan sehat yang dimakan oleh para penderita diabetes adalah sama dengan makanan sehat yang dimakan orang sehat lainnya yaitu rendah lemak terutama lemak jenuh dan trans fat, tidak terlalu banyak mengandung garam dan gula, memperbanyak makan makanan yang berbasis biji-bijian(whole grain food), buah-buahan dan sayur. Makanan yang mengandung gula khusus atau gula khusus diabetes tidak memberikan keuntungan berarti. Tetap menaikkan kadar gula darah dan biasanya lebih mahal. (www.diabetes.org)

Diabetes type 2

Diabetes type 2 ini adalah type yang sering diidap kebanyakan orang yang tidak mengatur gaya hidupnya dengan baik seperti malas berolah raga, malas makan sayur, suka begadang, minum alkohol dan ngokar.

Type 2 ini biasanya terdeteksi setelah umur 40 tahun tapi bukan berarti umur dibawah 40 tahun aman karena diabetes adalah penyakit akumulasi alias tidak tiba-tiba muncul karena salah makan satu atau dua hari. (IMHO) Kenapa umumnya baru terdiagnosa setelah umur 40 tahun? Karena umur dibawah 40 tahun masih aktif bergerak dan olah raga ketika umur diatas 40 tahun orang biasanya sudah malas gerak badan.

Oke langsung ke penjelasan :

Type 2 ini adalah keadaan dimana badan tidak dapat memproduksi cukup insulin atau sel2 dalam tubuh tidak merespons insulin., sedangkan insulin dibutuhkan untuk menggunakan glukosa menjadi energy.

Ketika kita menyantap makanan tubuh mengubah gula dan zat tepung menjadi glukosa yang akan menjadi bahan bakar untuk sel-sel didalam tubuh. Insulin membawa gula dalam darah kedalam sel tubuh. Jika glukosa menumpuk didalam darah ketimbang dipakai untuk sel dapat mengakibatkan dua hal berikut :

1. Sel-sel akan kelaparan akan energy.

2. Dalam jangka panjang, gula darah yang tinggi akan merusak mata, ginjal, syaraf atau jantung.

Kalau divonis dokter mengidap type 2 ini jangan kuatir karena walaupun serius penderita diabetes tetap dapat hidup normal, bahagia dan umur panjang seperti orang-orang lain.

Pengobatan.

Banyak yang mengira diabetes tidak dapat sembuh, well beberapa tahun lalu memang benar tapi dengan teknologi kedokteran sekarang hal ini dapat dilakukan.

Langsung saja, pengobatan Diabetes saya bagi menjadi tiga (3) yaitu cara herbal, medical dan extrem alias operasi. Semuanya ini harus dilakukan dengan rutin dan of course tetap rutin periksa gula darah ke dokter.

Cara herbal :

1. Meminum air rebusan daun salam, caranya ambil daun salam 10 lembar lalu direbus di panci sampai airnya berubah warna. Air ini yang diminum secara teratur sampai air dipanci habis. Butuh kesabaran untuk meminumnya karena tidak langsung sembuh.

2. Daun sambiloto juga bisa direbus untuk mengendalikan gula darah, caranya (kalau saya) daun sambiloto segar ditaruh di gelas dan diseduh air panas. Lalu setelah dingin diminum.

3. Kacang-kacangan, penderita diabetes disarankan untuk mengkonsumsi kacang karena kacang memiliki chromium picolinat yang bisa mengatur kadar gula darah.

4. Jamu-jamuan. Orang tua saya biasanya beli jamu kencing manis di pasa mayestik, efeknya lumayan. Gula darahnya bisa terkontrol.:army:

Cara Medical:

Biasanya diberikan obat-obatan yang merangsang produksi insulin a.l Diamicron MR, obat2 penghambat gula darah seperti metformin dan keluarganya. Untuk kasus yang sudah parah biasanya diberi suntikan insulin.

Perhatikan Ciri-Ciri ini

2008-06-12T18:50:00.000-07:00

Tanda seseorang mengidap diabetes.

Tanda-tanda seseorang mengidap diabetes seringkali tidak diperhatikan oleh yang bersangkutan karena dianggap wajar padahal kalau diketahui lebih dini maka dapat mengurangi komplikasi yang akan timbul dikemudian hari.

Tanda-tanda tersebut adalah :

Sering buang air kecil
Sering Haus
Sering merasa Lapar
Berat badan turun ngga jelas
Cepat cape
Irritability
Mata ngga focus alias berkabut.

Nah kalo diantara kalian ada yang merasa overweight dan sering mengalami tanda-tanda diatas cepat-cepatlah konsultasi ke dokter.