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When To Call a Professional

What Is It?

Gestational diabetes is the appearance of higher-than-expected blood sugars during pregnancy. Once it occurs, it lasts throughout the remainder of the pregnancy. It affects up to 14% of all pregnant women in the United States. It is more common in African-American, Latino, Native American and Asian women than in Caucasians. Like the other types of diabetes, gestational diabetes results when sugar (glucose) in the bloodstream can't be moved efficiently into body cells, such as muscle cells, that normally use sugar as a body fuel. The hormone insulin helps to move sugar from the bloodstream into the cells. In gestational diabetes, the body does not respond well to insulin, unless insulin can be produced or provided in larger amounts. In most women, the disorder goes away when the pregnancy ends, but women who have had gestational diabetes are at increased risk of developing type 2 diabetes later.

Diabetes occurs during pregnancy because hormones produced in a pregnancy make the body resistant to insulin's effects. These hormones include growth hormone and human placental lactogen. Both of these hormones are essential to a healthy pregnancy and fetus, but they partially block the action of insulin. In most women, the pancreas reacts to this situation by producing enough additional insulin to overcome the insulin resistance. In women with gestational diabetes, not enough extra insulin is produced, so sugar accumulates in the bloodstream.

As the fetus grows larger, larger quantities of the hormones are produced. Because it is the time when these hormone levels are highest, gestational diabetes usually starts in the last trimester of pregnancy. After delivery, the body's hormones quickly return to nonpregnant levels. Typically, the amount of insulin that is made by the pancreas is adequate for your needs once again, and blood glucose levels return to normal.

Symptoms

Some pregnant women with gestational diabetes have the symptoms of diabetes that are associated with high blood glucose (hyperglycemia). These include:

Increased thirst
More frequent urination
Weight loss despite increased appetite
Fatigue
Nausea or vomiting
Yeast infections
Blurred vision

However, some women have no recognizable symptoms. This is why screening tests for this disease are recommended for almost all pregnant women.

Diagnosis

Gestational diabetes usually is diagnosed during the routine testing that occurs as a part of complete prenatal care. In a normal pregnancy, blood sugars are about 20% lower than is seen in women who aren't pregnant because the developing fetus absorbs some glucose from the mother's blood. Diabetes is evident if blood sugar levels are higher than expected for pregnancy. To find gestational diabetes in its earliest form, doctors usually give the pregnant woman a heavily sugared drink prior to testing the blood so that the body's sugar-processing capability is maximally challenged. This is known as an oral glucose tolerance test.

It is appropriate for a woman who is overweight, has a family history of diabetes or has symptoms suggesting diabetes to undergo testing at the first prenatal visit. Most other women should be tested 24 to 28 weeks into their pregnancy.

Expected Duration

Diabetes that appears during a pregnancy usually goes away after the pregnancy is over. However, the fact that your pancreas can't keep up with insulin demands during pregnancy shows that it is operating without much reserve even when you are not pregnant. Women who have gestational diabetes are at increased risk of developing type 2 diabetes later in life. Twenty percent of women with gestational diabetes have elevated blood sugar levels that continue for a few weeks after they give birth. These women are the most likely to develop type 2 diabetes later in life.

Prevention

Gestational diabetes usually cannot be prevented. However, careful control of your weight before pregnancy may reduce your risk. Very low-calorie diets are not recommended during pregnancy because adequate nutrition is important.

Complications of gestational diabetes can be prevented by carefully controlling your blood sugar and by being monitored by an obstetrician throughout your pregnancy.

After your pregnancy, you can reduce your risk of developing type 2 diabetes. Regular exercise and a reduced-calorie diet have been shown to lower the risk of diabetes in people who are at high risk of diabetes. The medicine metformin (Glucophage) can help to prevent diabetes in people who have mildly elevated blood glucose levels outside of pregnancy, but who do not have levels high enough for a diagnosis of diabetes.

Treatment

Some pregnant women are able to keep blood glucose at healthy levels by managing their diet. This requires consultation with a dietitian to set up a diet plan, and regular monitoring of blood glucose.

If diet does not control blood glucose adequately, your doctor will prescribe insulin. Oral medicines to lower blood sugar are not approved by the U.S. Food and Drug Administration (FDA) for use in pregnant women because of possible adverse effects on the fetus, although one oral medicine (metformin or Glucophage) is used in some other nations. Insulin has been used during pregnancy to treat many women with type 1 and gestational diabetes and is safe for the fetus when blood sugar is monitored closely.

Gestational diabetes creates dangers for the developing fetus. Unlike type 1 diabetes,gestational diabetes rarely causes serious birth defects. However, in gestational diabetes the baby can have complications during delivery because it may be larger than normal (a large body size for a baby is called macrosomia). Large baby body size comes from the extra sugar exposure. If the diabetes is not treated carefully, high blood sugar levels can increase the chance of fetal death prior to delivery (stillbirth). Delivery itself may be more difficult, and the need for Caesarean delivery is more frequent. If natural labor and delivery has not occurred by 38 weeks of pregnancy, your doctor probably may recommend inducing labor or delivering by surgery to avoid macrosomia.

Complications also can affect the baby right after birth. Prior to delivery, the fetus's pancreas gets used to making a large amount of insulin each day, to help manage the fetus's exposure to high blood sugar levels. After delivery, it takes time for the baby's pancreas to adjust. If the baby makes too much insulin during its first hours after birth, low blood sugar may occur temporarily. If you have gestational diabetes, your baby's blood sugar should be measured after birth. If necessary, intravenous glucose will be given to the baby. Other chemical imbalances also may occur temporarily, so the baby's calcium and blood count also should be monitored.

All pregnant women should receive prenatal care and have regular visits with a qualified physician or midwife. Most women should receive an oral glucose challenge test during weeks 24 to 28 of their pregnancies, and women at high risk of diabetes should get tested earlier.

Prognosis

Most of the time, gestational diabetes is a short-term condition. In more than three-quarters of women who develop gestational diabetes, blood glucose levels go back to normal once the pregnancy ends. However, the pancreas has shown that it is operating without much reserve. Women who have had gestational diabetes are at increased risk of developing it again in subsequent pregnancies. They are also at increased risk of developing type 2 diabetes later in life and should have their blood glucose checked regularly even after the pregnancy is over.

Hypoglycemia

What Is It?

Hypoglycemia is an abnormally low level of blood sugar (blood glucose). Because the brain depends on blood sugar as its primary source of energy, hypoglycemia interferes with the brain's ability to function properly. This can cause dizziness, headache, blurred vision, difficulty concentrating and other neurological symptoms. Hypoglycemia also triggers the release of body hormones, such as epinephrine and norepinephrine. Your brain relies on these hormones to raise blood sugar levels. The release of these hormones causes additional symptoms of tremor, sweating, rapid heartbeat, anxiety and hunger.

Hypoglycemia is most common in people with diabetes. For a person with diabetes, hypoglycemia occurs because of too high a dose of diabetic medication, especially insulin, or a change in diet or exercise. Insulin and exercise both lower blood sugar and food raises it. Hypoglycemia is common in people who are taking insulin or oral medications that lower blood glucose, especially drugs in the sulfonylurea group (Glyburide and others).

True hypoglycemia with laboratory reports of low blood sugar rarely occurs in people who do not have diabetes. When it does occur outside of diabetes, hypoglycemia can be caused by many different medical problems. A partial list includes:

Gastrointestinal surgery, usually involving removal of some part of the stomach. Surgery that removes part of the stomach can alter the normal relationships between digestion and insulin release.
The antibiotics gatifloxacin (Tequin, which was recently removed from the market in the U.S.), levofloxacin (Levoquin), and related drugs
A pancreatic tumor, called an insulinoma, that secretes insulin
A deficiency of growth hormone from the pituitary gland or of cortisol from the adrenal glands. Both of these hormones help to keep blood sugars normal
Alcohol
Overdose of aspirin
Severe liver disease
Use of insulin by someone who does not have diabetes
Cancers, such as cancer of the liver
Rarely, an enzyme defect. Examples of enzymes that help keep blood sugar normal are glucose-6-phosphatase, liver phosphorylase, and pyruvate carboxylase

Symptoms

Hypoglycemia can cause:

Symptoms related to the brain "starving" for sugar -- Headache, dizziness, blurred vision, difficulty concentrating, poor coordination, confusion, weakness or fainting, tingling sensations in the lips or hands, confused speech, abnormal behavior, convulsions, loss of consciousness, coma
Symptoms related to the release of epinephrine and norepinephrine -- Sweating, tremors (feeling shaky), rapid heartbeat, anxiety, hunger

Diagnosis

If a person with diabetes has severe hypoglycemia, he or she may not be able to answer the doctor's questions because of confusion or unconsciousness. In this case, a family member or close friend will need to describe the patient's medical history and insulin regimen. To help ensure effective emergency treatment, all people with diabetes should consider wearing a medical alert bracelet or necklace. This potentially lifesaving jewelry will identify the patient as having diabetes, even if the patient is far from home and traveling alone. Family members or friends of a person with diabetes should learn how to bring a patient out of severe hypoglycemia by giving the person orange juice or another carbohydrate, or by giving an injection of the drug glucagon, which can raise blood sugar.

If a person with diabetes can answer questions appropriately, the doctor will ask about his or her current insulin dosage, as well as recent food intake, exercise schedule and other medications. If the patient has been self-monitoring blood sugar with a glucometer (a hand-held device to measure glucose levels in blood from a finger prick), the doctor will review the most recent glucometer readings to confirm low blood sugar and to check for a pattern of hypoglycemia related to diet or exercise.

In people who do not have diabetes, the doctor will review current medications and ask about any history of gastrointestinal surgery (especially involving the stomach), liver disease and an enzyme deficit. Patients should describe their symptoms and when the symptoms occur -- whether they occur before or after meals, during sleeping or after exercise.

In a person with diabetes, the diagnosis of hypoglycemia is based on symptoms and blood sugar readings. In most cases, no further testing is necessary.

In a person who is not diabetic, the ideal time for diagnostic testing is during an episode of symptoms. At that time, blood can be drawn to measure levels of glucose, and the patient's reactions to glucose intake can be tested. If these measures confirm the diagnosis of hypoglycemia, blood can be sent to a laboratory to measure insulin levels. If the patient has no symptoms at the time of evaluation, the doctor may ask him or her to measure his or her blood glucose when hypoglycemic symptoms occur. In non-diabetics, a blood sample can be tested to measure liver function and cortisol levels. If an insulinoma is suspected, the doctor may order a supervised 48-hour fast. During that period, blood levels of glucose and insulin will be measured whenever symptoms occur or once every 6 hours, whichever comes first. A blood glucose level of less than 40 milligrams per deciliter with a high level of insulin strongly suggests the person has an insulinoma or has given himself or herself an insulin injection.

If a person develops symptoms of hypoglycemia only after eating, the doctor may ask him or her to self-monitor blood sugar with a glucometer at the time the symptoms occur.

Expected Duration

An episode of hypoglycemia caused by exercise or by too much short-acting insulin usually can be stopped within minutes by eating or drinking a food or beverage that contains sugar (sugar tablets, candy, orange juice, nondiet soda). Hypoglycemia caused by sulfonylurea or long-acting insulin can take one to two days to go away.

People with diabetes remain at risk for episodes of hypoglycemia throughout life because they need medications that lower blood sugar. Hypoglycemic episodes at night are particularly dangerous because the person often sleeps through part of the time that their blood sugar is low, treating the sugar level less quickly. Over time, repeated episodes can lead to impaired brain function.

About 85% of patients with an insulinoma will be cured of hypoglycemia once the insulin-secreting tumor is removed.

Many people without diabetes who have symptoms, the symptoms that seem like signs of low blood sugar do not truly have low sugar levels. Instead the symptoms are caused by something other than low blood glucose.

Prevention

In people taking insulin, drinking alcohol can lead to an episode of hypoglycemia. Patients with diabetes should discuss with their doctors how much alcohol, if any, they can drink safely. Alcohol can cause serious episodes of hypoglycemia even when insulin was taken hours before. People with diabetes should be very aware of this possible problem if they drink.

People with diabetes should always have ready access to emergency supplies for treating unexpected episodes of hypoglycemia. These supplies may include candy, sugar tablets, sugar paste in a tube and/or a glucagon injection kit. A glucagon injection may be given by a knowledgeable family member or friend if a hypoglycemic patient is unconscious and cannot take sugar by mouth. For diabetic children, emergency supplies can be kept in the school nurse's office.

Any person at risk of hypoglycemic episodes can help to avoid delays in treating attacks by learning about his or her condition and sharing this knowledge with friends and family members. The risk of hypoglycemia is lower if you eat at regular times during the day, never skip meals and maintain a consistent exercise level. Like people with diabetes, nondiabetic people with hypoglycemia should always have ready access to a source of sugar. In rare circumstances, a doctor may prescribe a glucagon emergency kit for nondiabetic people who have a history of becoming disoriented or losing consciousness from hypoglycemia.

Treatment

If a conscious person is having symptoms of hypoglycemia, the symptoms usually go away if the person eats or drinks something sweet (sugar tablets, candy, juice, nondiet soda). An unconscious patient can be treated with an immediate injection of glucagon or with intravenous glucose infusions in a hospital.

People with diabetes who have hypoglycemic episodes may need to adjust their insulin dose or change their diet or exercise habits.

Even if you recognize that your symptoms are caused by hypoglycemia, you should treat yourself or seek treatment, and not try to just "tough it out." People with long-standing diabetes may stop experiencing the usual early warning symptoms of hypoglycemia. This is called hypoglycemic unawareness, and it can be very serious because the person may not know to seek treatment. If you and your doctor identify that you are unaware when you have low blood sugars, your dose of insulin probably will need to be reduced. You probably will need to check your blood sugar more often. You may need your insulin dose adjusted frequently to maintain reasonable blood sugars (but not "perfect" sugars) with less risk of hypoglycemia.

An insulinoma is treated with surgery to remove the tumor. Hypoglycemia caused by problems with the adrenal or pituitary glands is treated by replacing the missing hormones with medication. Nondiabetic people with hypoglycemic symptoms following meals are treated by modifying their diet. They usually need to eat frequent, small meals and avoid fasting.

When To Call a Professional

Call for emergency medical assistance whenever anyone is unconscious or obviously disoriented. Severe insulin reactions can be fatal, so it is important to seek treatment immediately.

People with diabetes should contact their doctors promptly if they experience frequent episodes of hypoglycemia. They may need to adjust their daily doses of insulin, oral hypoglycemic medication or their meal plans.

If you have diabetes and you develop one or more low blood sugars during a time when you are being treated with the antibiotic ciprofloxacin (Cipro), levofloxacin (Levaquin) or gatifloxacin (Tequin), do not take any additional doses of the medication until you are able to discuss the problem with your doctor.

Nondiabetic people who experience symptoms of hypoglycemia should contact their doctor for evaluation of the problem.

Prognosis

In people with diabetes, the outlook is excellent if they follow their prescribed insulin dosage, recommended diet and exercise guidelines.

Most patients with insulinomas can have them removed successfully by surgery. However, in about 15% of these patients, the insulinoma is cancerous and has spread, so it cannot be removed completely. These patients may still suffer from hypoglycemia after surgery.

Most patients with other forms of hypoglycemia can be treated successfully with changes in diet.

Diabetic Ketoacidosis

What Is It?

Diabetic ketoacidosis is a potentially fatal complication of diabetes that occurs when you have much less insulin than your body needs. This problem causes the blood to become acidic and the body to become dangerously dehydrated. Diabetic ketoacidosis can occur when diabetes is not treated adequately, or it can occur during times of serious sickness.

To understand this illness, you need to understand the way your body powers itself with sugar and other fuels. Foods we eat are broken down by the body, and much of what we eat becomes glucose (a type of sugar), which enters the bloodstream. Insulin helps glucose to pass from the bloodstream into body cells, where it is used for energy. Insulin normally is made by the pancreas, but people with type 1 diabetes (insulin-dependent diabetes) don't produce enough insulin and must inject it daily.

Your body needs a constant source of energy. When you have plenty of insulin, your body cells can get all the energy they need from glucose. If you don't have enough insulin in your blood, your liver is programmed to manufacture emergency fuels. These fuels, made from fat, are called ketones (or ketoacids). In a pinch, ketones can give you energy. However, if your body stays dependent on ketones for energy for too long, you soon will become ill. Ketones are acidic chemicals that are toxic at high concentrations.

In diabetic ketoacidosis, ketones build up in the blood, seriously altering the normal chemistry of the blood and interfering with the function of multiple organs. They make the blood acidic, which causes vomiting and abdominal pain. If the acid level of the blood becomes extreme, ketoacidosis can cause falling blood pressure, coma and death.

Ketoacidosis is always accompanied by dehydration, which is caused by high levels of glucose in the blood. Glucose builds up in the blood if there is not enough insulin to move glucose into your cells. During an episode of ketoacidosis, it is common for blood sugar to rise to a level over 400 milligrams per deciliter. When blood sugar levels are so high, some sugar "overflows" into the urine. As sugar is carried away in the urine, water, salt and potassium are drawn into the urine with each sugar molecule, and your body loses large quantities of your fluid and electrolytes, which are minerals that play a crucial role in cell function. As this happens, you produce much more urine than normal. Eventually it may become impossible for you to drink enough fluids to keep up with amounts that you urinate. Vomiting caused by the blood's acidity also contributes to fluid losses and dehydration.

People with type 1 diabetes are at risk of diabetic ketoacidosis. If you have type 1 diabetes, ketoacidosis can occur because you have stopped taking your insulin injections or because your insulin dose is too low. It can be triggered by an infection or severe physical stress, such as an injury or surgery, because your body can need more insulin than usual during these stresses. Ketoacidosis rarely occurs in people with type 2 diabetes. In most people who have type 2 diabetes, blood insulin levels usually do not get low enough to signal the liver to make ketones.

In about 25% of children with diabetes, symptoms from ketoacidosis are the first sign that they have diabetes.

Symptoms

Symptoms of diabetic ketoacidosis include:

Frequent urination
Extreme thirst
Dry mouth
Cool skin
Nausea and vomiting with or without abdominal pain

As blood ketone levels increase, the person's breathing pattern may become slow and deep, and his or her breath can have a fruity odor. A person with ketoacidosis may seem to be tired or confused or may have trouble paying attention. Without prompt treatment in the first day of symptoms, the illness may cause low blood pressure, a loss of consciousness, coma or death.

If you have type 1 diabetes, it is important to measure your blood glucose levels at home using a machine called a glucometer. You also should have paper test strips that can detect ketones in the urine. If your blood glucose reading is above 300 milligrams per deciliter, you should test your urine for ketones. If the urine test strip reads "moderate" or "large," it's possible you have ketoacidosis.

Diagnosis

People with diabetic ketoacidosis are always treated in a hospital. Your doctor will test your blood for levels of glucose, ketones, and electrolytes such as sodium and potassium. If you have been taking your insulin without missed doses, your doctor will want to determine if you have an infection.

Expected Duration

Symptoms of diabetic ketoacidosis can develop over a period of a few hours, and treatment results in rapid recovery. Commonly, people who develop ketoacidosis will remain in the hospital for one to three days.

Prevention

If you have type 1 diabetes, you usually can prevent diabetic ketoacidosis by following the insulin regimen and diet prescribed by your doctor and by testing your blood glucose regularly. If your body is stressed by an infection, ketoacidosis can develop within hours, and you may not be able to prevent it. It is important for you to check your blood sugar more frequently during an infection, so you can adjust your treatment. It is also important for you to recognize that vomiting and abdominal pain may be signs of ketoacidosis, so that you can get medical help quickly.

To help make sure that you receive proper emergency treatment for diabetic ketoacidosis if you are away from home, wear a medical identification necklace or bracelet that identifies you as a diabetic. This will help emergency personnel to recognize your problem quickly if you are among strangers and you are too sick to speak for yourself.

Treatment

When you are in the hospital, your diabetic ketoacidosis will be treated with insulin to lower your blood glucose level. You will also receive a large volume of fluids intravenously (through a vein). Your blood glucose and acid levels will be monitored frequently, and you will be given potassium supplements to restore your body's supply of this essential mineral. Until your blood chemistry returns to normal, your vital signs (temperature, pulse, respirations, blood pressure) and urine output will be monitored. If an infection has triggered your episode of ketoacidosis, antibiotics or other medications will be used to treat the infection.

When To Call a Professional

If you have type 1 diabetes and have a glucometer reading over 300 milligrams per deciliter, you should test your urine for ketones. Call your doctor if moderate or high levels of ketones are present, or if you have not previously discussed how to adjust your insulin dose when your sugar is this high. Your doctor will give you more specific guidelines about when and how often to test your blood glucose and urine and what readings to look for. Also call your doctor whenever you have unexplained nausea and vomiting, with or without abdominal pain.

Prognosis

With proper treatment, more than 95% of patients recover from diabetic ketoacidosis.

Diabetic Nephropathy

What Is It?

Diabetic nephropathy is kidney disease that is a complication of diabetes. It can occur in people with type 2 diabetes, the diabetes type that is most common and is caused by resistance to insulin, or in people with type 1 diabetes, the type that more often begins at an early age and results from decreased insulin production. Diabetic nephropathy is caused by damage to the tiniest blood vessels. When small blood vessels begin to develop damage, both kidneys begin to leak proteins into the urine. As damage to the blood vessels continues, the kidneys gradually lose their ability to remove waste products from the blood.

Up to 40% of people with type 1 diabetes eventually develop significant kidney disease, which sometimes requires dialysis or a kidney transplant. Only 4% to 6% of all type 2 diabetes patients end up requiring dialysis, although about 20% to 30% of people with type 2 diabetes will develop at least some kidney damage. About 40% of all people who need to start dialysis have kidney failure from type 1 or type 2 diabetes.

Symptoms

There are usually no symptoms in the early stages of diabetic nephropathy. When symptoms do begin to appear, they may include ankle swelling and mild fatigue. Later symptoms include extreme fatigue, nausea, vomiting and urinating less than usual.

Diagnosis

The first sign of kidney damage is protein in the urine, which a doctor can measure in microscopic amounts, called microalbuminuria. Small amounts of albumin show up in the urine 5 to 10 years before major kidney damage happens.

If you have diabetes, your doctor will suggest regular monitoring of urine and blood tests to check the health of your kidneys.

Occasionally, a doctor may be concerned that kidney injury in a diabetic person is related to a separate problem. In that case, other tests such as ultrasound or a kidney biopsy may be recommended. In a biopsy, a small piece of kidney tissue is removed through a needle and examined in a laboratory.

Expected Duration

Kidney disease can't be reversed once damage is done. Kidney disease from diabetes is progressive, meaning it continues to get worse. However, good control of blood sugar and blood pressure and treatment with medicine from either of two drug groups (see prevention below) can slow the progression of the disease.

Prevention

The best way to prevent diabetic nephropathy is to control your blood sugar. In addition, your blood pressure should be monitored frequently, and blood pressure should be kept below a peak level (systolic pressure, the "top" blood pressure number) of 130 millimeters of mercury (mmHg), and kept below a bottom number (diastolic pressure) of 80 mmHg. These goal numbers for blood pressure are lower than the numbers that are used for people who do not have diabetes.

Two types of blood pressure medicines protect against kidney damage in ways that go beyond lowering your blood pressure. Any person who has diabetes and who also has high blood pressure should regularly take one of these medications. These medicines come from a group of drugs called angiotensin-converting enzyme inhibitors (ACE inhibitors), including lisinopril (Zestril, Prinivil), enalapril (Vasotec), moexipril (Univasc), benazepril (Lotensin) and others, or from a group of drugs called angiotensin receptor blockers (ARBs), including losartan (Cozaar), valsartan (Diovan) and others.

Avoiding medications that can sometimes have harmful side effects upon the kidneys also can help to prevent kidney disease. If you have severe kidney disease, your doctor may advise you to avoid pain medications in the nonsteroidal anti-inflammatory drug group (NSAID group) such as ibuprofen. A low-protein diet (10% to 12% or less of total calories) also may slow or halt the progression of kidney disease. If you smoke cigarettes, you should quit.

Treatment

If you have diabetes with high blood pressure, microalbuminuria or blood test evidence of kidney disease, it is important for you to take a medication from the ACE inhibitor or ARB group. These medications slow the progression of kidney disease in people with diabetes, although kidney disease continues to develop gradually. These two medicine groups are closely related, so the drugs usually are not combined with each other.

Reducing the amount of protein in your diet also may be helpful to slow progressing kidney disease.

Once nephropathy reaches advanced stages, you may need dialysis to remove waste products from the blood. An alternative way to treat advanced kidney disease is with akidney transplant. There are two types of dialysis, hemodialysis and peritoneal dialysis. Hemodialysis filters waste substances and excess fluid out of the blood. Hemodialysis usually is done at a dialysis center in three- to four-hour sessions three times a week. Peritoneal dialysis does not directly filter the blood. Instead, for this form of dialysis, sterile fluid is allowed to flow into the abdominal cavity through a catheter that is permanently placed through the skin. The fluid is then removed after it has absorbed waste substances. After practice, peritoneal dialysis can be done at home. It is a good alternative for some people, although it requires significant time and self-care.

Kidney transplants have allowed many people with severe kidney disease to avoid or discontinue dialysis. However, the donor and the recipient have to match genetically, or the body will reject the new kidney. The waiting period for a matching donated kidney is between two and six years. Anti-rejection drugs that suppress the immune system help the body to accept the donated organ. An organ recipient can expect to take such medications as long as the transplanted kidney continues to function. A transplanted kidney is likely to function for at least 10 years if its genetics are closely matched. If a transplanted kidney stops functioning, dialysis or a new transplant is necessary.

In a person with type 1 diabetes and kidney failure, a kidney-pancreas transplant is another possible treatment. This option is available only for a small number of people because of the scarcity of organ donors, the risks of the surgery and the need for lifelong immunosuppressive drugs. When it is successful, the transplanted pancreas begins producing insulin and may reverse diabetes.

When To Call a Professional

If you have diabetes, your blood pressure should be checked every six months to a year, or more often if it is higher than goals. If you have not been diagnosed with diabetic nephropathy, your urine should be tested for microalbumin at least once a year to check for this problem and diagnose it as early as possible. People with kidney disease need to have regular tests of kidney function -- once a year or more often. If you have symptoms that suggest advanced kidney disease, you should discuss them with your physician.

Prognosis

Although kidney failure cannot always be prevented, worsening can be slowed with medications and control of risk factors. When full kidney failure occurs, dialysis and a kidney transplant are options that allow people to continue to lead active lives.

Diabetic Neuropathies

What Is It?

Diabetic neuropathies include several nerve disorders that affect people with diabetes.

Peripheral neuropathy. This is the most common type of diabetic neuropathy, affecting the longest nerves in your body. These nerves are part of your peripheral nervous system, the network of nerves that carry signals from your brain and spinal cord to the rest of your body and back. The most common symptoms of peripheral neuropathy are numbness or pain in the feet and lower legs.

Autonomic neuropathy. This neuropathy damages important collections of nerves that control your unconscious body functions. It especially may affect your digestion, your circulation and your sexual function.

Localized nerve failures (focal neuropathy). A nerve that controls a single muscle can lose its function. Examples of problems that this may cause are eye movement problems with double vision and drooping of the cheek on one side of the head (commonly known as Bell's palsy). One or more individual nerve failures sometimes is called mononeuritis multiplex.

Diabetic neuropathies occur in both type 1 and type 2 diabetes, and they are most common in people whose blood glucose (blood sugar) levels have not been well controlled. Although the various forms of diabetic neuropathy can occur in people who have had diabetes for a short time, they are most likely to affect those who have had the disease for more than a decade, and they are more common in people older than 40. Diabetics who smoke are especially at risk.

There are several changes in the nerves that combine to cause a diabetic neuropathy. When your nerve cells are surrounded by a high concentration of blood glucose, they must adjust their internal sugar content to be in balance with their surroundings, or else they would lose water through their cell membranes. To adjust to high blood glucose, nerve cells manufacture and store the sugar sorbitol. Sorbitol can gradually damage nerve cells. Damage to blood vessels also contributes to diabetic neuropathy, because the nerves may not get enough oxygen and nourishment.

Symptoms

More than half of all people with diabetes have developed some form of neuropathy by the time they have had diabetes for 25 years. Symptoms depend on the specific type of neuropathy.

Peripheral neuropathy. This form of neuropathy causes symptoms in the limbs, especially the lower legs and feet. Symptoms can include numbness, tingling, sharp or burning pain, cramps, hypersensitivity to touch, and problems in balance or coordination. If your feet are numb, you may not be aware when shoes don't fit properly, and this can lead to the formation of a callus. Calluses are serious problems for people with diabetes, because these thickened skin areas can break down over time and change into an open sore (ulcer) that may become infected.

Autonomic neuropathy. The symptoms of autonomic neuropathy are varied, depending on which of your automatic body functions have lost their normal nerve control. Any of the following problems can occur:

Incomplete bladder emptying. This can cause you to urinate more often, including at night. Urinary infections can be a problem, and so can loss of bladder control.

Sexual function problems. Problems with erection, ejaculation and libido (sexual drive) are common.

Stomach and bowel problems. Slow emptying of the stomach, called gastroparesis, can cause nausea, vomiting or bloating. The normal rhythmic squeezing of the small and large intestines that is known as peristalsis can be slow or irregular, causing constipation or diarrhea. Swallowing may become difficult, and loss of control over bowel movements is possible.

Dizziness when standing. Normally, your heart gears up to pump a little faster and harder when you are standing up, because it is pumping against gravity to move blood from your toes to your torso. Arteries help to keep your blood pressure steady by adjusting the squeeze of their muscular walls. Both your heart and arteries rely on nerve signals to know when to make these adjustments. These signals can fail in diabetes, leaving you with low blood pressure when you are standing. Low blood pressure that occurs when standing is also called orthostatic hypotension and is a common cause of lightheadedness or fainting in people with diabetes.

Changes in the amount that you sweat. An inability to sweat can lead to dry and cracking feet, which can allow fungal infections to develop more often. Excessive sweating or bursts of sweating also can occur.

Focal neuropathy. Common symptoms are double vision, drooping of the cheek on one side of the head (commonly known as Bell's palsy), problems with speech and double vision. Focal neuropathy also can cause a sudden weakness in the ankle, called foot drop. Damage to a nerve that originates in the spinal cord is called radiculopathy, which can cause pain in the chest, stomach, back or pelvis or in the front of the thigh.

Diagnosis

Your doctor usually can diagnose diabetic neuropathy based on your medical history, symptoms and the results of a physical examination. When necessary, more specialized testing may be done, such as:

Nerve conduction studies to check whether nerve impulses in the arms and legs are normal, and a test called electromyography to see how well arm and leg muscles move in response to nerve signals. These two tests usually are done together. They involve a series of momentary minor electric shocks through small needles or pads on the skin.

Ultrasound scan of the urinary bladder or drainage of the bladder through a catheter to evaluate how efficiently your bladder empties.

Gastric (stomach) emptying study to test how quickly food moves through your stomach. In this test, you eat a portion of specially prepared food that has been marked with radioactivity. A series of pictures is taken by a machine that detects the radioactive signal.

Nerve biopsy, which involves taking a small sample of a nerve to be examined under a microscope.

Expected Duration

Peripheral and autonomic neuropathies are usually long-term problems, but most cases of focal neuropathy last only a few weeks or months.

Prevention

Because diabetic neuropathy is caused by abnormally high levels of blood glucose, diabetics can help to prevent this problem by regulating their blood sugar levels intensely. In a 10-year study conducted by the National Institute of Diabetes and Digestive and Kidney Disease (NIDDK), diabetics who kept their blood glucose levels close to normal reduced their risk of peripheral neuropathy by 60%. Avoiding smoking can help to prevent or delay neuropathies, one of several important reasons that people with diabetes should not smoke.

Treatment

Treatment of diabetic neuropathy focuses on:

Tighter control of blood glucose
Pain relief
A regular exercise program to burn glucose and build muscle strength
Avoiding smoking
Medications to treat autonomic problems and prevent bladder infections
Physical therapy
Meticulous care of the feet

To relieve the pain of peripheral neuropathy, your doctor may prescribe a medicine. A growing number of medicines are available to reduce nerve pain, including low doses of tricyclic medications, such as amitriptyline (Elavil), nortriptyline (Aventyl, Pamelor) and desipramine (Norpramin and other brand names). Other medicines that may help include gabapentin (Neurontin), pregabalin (Lyrica), duloxetine (Cymbalta) and carbamazepine (Tegretol). For persisting pain, your doctor may suggest that you take aspirin, acetaminophen (Tylenol) or ibuprofen (Advil, Motrin and other brand names) by mouth or that you rub on a pain-relieving cream containing capsaicin. In more severe cases, doctors may prescribe narcotic medicines.

To treat mild digestive problems caused by slow stomach emptying, your doctor may suggest that you eat small, frequent meals that are low in fat and fiber. For more severe symptoms, your doctor may prescribe the medication metoclopramide (Reglan and other brand names) to help digestion. A device called a "gastric pacemaker" has helped a few people to have improved symptoms, but the utility and safety of this strategy has not been tested in patients for very long and it is not yet in wide use.

There are many available treatments for constipation and diarrhea. Constipation can be treated effectively by drinking more nonalcoholic beverages and exercising regularly. You also can take fiber and stool bulking and softening agents such as psyllium (Metamucil, Konsyl and other brand names) or methylcellulose (Citrucel), stool lubricants such as docusate sodium (Colace), enemas, or laxative agents. For diarrhea, your doctor may prescribe fiber, bulking agents (which help to change liquid stool into a soft solid stool), diphenoxylate with atropine (Lomotil) or loperamide (Imodium).

Antibiotics also are used to treat infections associated with poor emptying of the urinary bladder, and your medication list can be adjusted to minimize medicines that could contribute to the problem of incomplete bladder emptying. Catheters can be used to empty the bladder when neuropathy is severe.

For impotence, your doctor may prescribe the medication sildenafil (Viagra), vardenafil (Levitra) or tadalafil (Cialis). Other treatments that commonly are used to treat impotence include a vacuum cylinder with a hand pump, injections into the penis of a drug that promotes erections, or surgery to implant a small inflatable balloon inside the penis, which can be filled or deflated as needed.

Dizziness when standing can be treated by drinking more fluids and by using medicines that increase your body salt and water.

If peripheral neuropathy affects your feet, you should wash your feet every day and check them for any cuts, sores or swellings. You should wear soft, clean socks and well-fitting shoes and never go barefoot. Cut your toenails straight across to avoid ingrown toenails. Never try to remove calluses or warts yourself. Always show them to your doctor. All diabetics should visit a podiatrist once each year.

When To Call a Professional

If you have diabetes, call your doctor whenever you have a cut or sore that becomes infected or doesn't heal, especially on your feet. It is extremely important to react promptly to injuries and infections, however minor. Also, see your doctor for help if you develop new or worsening symptoms of neuropathy.

Prognosis

In most cases of focal neuropathy, muscle weakness or pain subsides within a few weeks or months with no long-term damage. Peripheral and autonomic neuropathies are persistent problems. Some people who have peripheral neuropathy find that symptoms are easier to tolerate after the pain turns to numbness, as occurs for many people after months or years.

Pre-Diabetes

What Is It?

In pre-diabetes, blood sugar levels are slightly higher than normal, but still not as high as in diabetes. If diabetes is "runaway blood sugar" think of pre-diabetes as blood sugar that is "halfway out the door."

People almost always develop pre-diabetes before they get type 2 diabetes. The rise in blood sugar levels that is seen in pre-diabetes starts when the body begins to develop a problem called "insulin resistance." Insulin is an important hormone that helps you to process glucose (blood sugar). If usual amounts of insulin can't trigger the body to move glucose out of the bloodstream and into your cells, then you have insulin resistance.

Once insulin resistance begins, it can worsen over time. When you have pre-diabetes, you make extra insulin to keep your sugar levels near to normal. Insulin resistance can worsen as you age, and it worsens with weight gain. If your insulin resistance progresses, eventually you can't compensate well enough by making extra insulin. When this occurs, your sugar levels will increase, and you will have diabetes.

Depending on what a blood sugar test finds, pre-diabetes can be more specifically called "impaired glucose (sugar) tolerance" or "impaired fasting glucose." Impaired fasting glucose means that blood sugar increase after you haven't eaten for awhile – for example, in the morning, before breakfast. Impaired glucose tolerance means that blood sugar levels reach a surprisingly high level after you eat sugar. To diagnose impaired glucose tolerance, doctors usually use what is called a "glucose tolerance test." For this test you drink a sugary solution, and then you have blood drawn after a short time.

Having pre-diabetes does not automatically mean you will get diabetes, but it does put you at an increased risk. Pre-diabetes is also a risk factor for heart disease. Like people with type 2 diabetes, those with pre-diabetes tend to be overweight, have high blood pressure and have unhealthy cholesterol levels.

Symptoms

Pre-diabetes is often called a "silent" condition because it usually has no symptoms. You can have pre-diabetes for several years without knowing it. However, if your doctor notices that you have certain risk factors for pre-diabetes and diabetes, he or she may order a blood test. These risk factors include:

Being overweight
Being 45 years or older
A family history of diabetes
Low levels of high-density lipoprotein (HDL) cholesterol (the "good" cholesterol)
High triglycerides
High blood pressure
A history of gestational diabetes
Being African-American, American Indian, Asian-American, Pacific Islander or Hispanic American/Latino

Abnormal results on a blood sugar test are likely to be the first sign that you have pre-diabetes.

Diagnosis

The same blood sugar tests that are used for diabetes are used to diagnose pre-diabetes. For diagnosing pre-diabetes, your doctor can use either of two common tests:

Fasting glucose test
Oral glucose tolerance test

In a fasting glucose test, blood sugar levels are measured after at least eight hours of not eating. Most people prefer to have the test done the morning after fasting overnight.

In the oral glucose tolerance test, blood sugar levels are first measured after an overnight fast. You then drink a sugary solution, and two hours later another blood sample is drawn. This second test is known as a "glucose challenge." In healthy people, the glucose challenge will cause blood sugar levels to rise slightly and fall quickly. In someone with pre-diabetes or diabetes, these levels rise very high or fall slowly, so they will be abnormally high during the two-hour blood test.

Here is how to interpret the results of these tests (mg/dL = milligrams per deciliter):

Fasting glucose test

Normal – Between 70 and 100 mg/dL
Pre-diabetes – Between 100 and 126 mg/dL
Diabetes – Above 126 mg/dL

Oral glucose tolerance test

Normal – Below 140 mg/dL
Pre-diabetes – Between 140 mg/dL and 200 mg/dL
Diabetes – Above 200 mg/dL

Expected Duration

Pre-diabetes sugar levels can remain slightly above normal, can return to normal, or can increase to a range that leads to a diagnosis of diabetes. As many as 1 in 10 people with impaired glucose tolerance will develop diabetes within one year. What happens to your pre-diabetes depends on whether you are able to prevent insulin resistance from progressing. If insulin resistance is kept in check, pre-diabetes may never become diabetes. If you do not adjust your lifestyle to increase exercise and improve diet, blood sugar levels will probably eventually rise to diabetic levels. Once this happens, medication is required to bring your blood sugar back to near-normal levels.

Prevention

It surprises many people to learn that they may be able to prevent pre-diabetes and diabetes. To reduce your risk of both pre-diabetes and diabetes:

Maintain an ideal body weight. Aim for a body mass index (BMI) between 18.5 and 25.
Exercise regularly. Both aerobic and strengthening exercises can reduce blood sugar. Try for 30 minutes of aerobic exercise, such as brisk walking, 5 to 7 days a week.
Eat a balanced diet, following the recommendations of the U.S. Department of Agriculture's Food Pyramid.

If you are overweight, aim to lose weight. Even modest weight loss of 10 or 15 pounds in a person who is 200 pounds can dramatically reduce the risk of diabetes.

Treatment

The purpose for treating pre-diabetes is to prevent diabetes from setting in. The same measures recommended for preventing pre-diabetes (see above) work for treating it, too.

The most effective treatment for pre-diabetes is to lose weight and exercise at least 30 minutes a day. Weight loss and exercise can improve insulin resistance and can lower elevated blood sugar levels so that you don't progress to develop diabetes.

Additionally, the drug metformin (Glucophage) can lower the risk of getting diabetes, and it can add to the benefits of weight loss and exercise. Check with your doctor about whether taking metformin to prevent diabetes is a good idea for you. If your doctor feels that you have an especially high risk for progressing to diabetes, you may want to consider preventive treatment with this medication.

When To Call a Professional

It's best to have annual glucose tests to monitor pre-diabetes. Also, look for symptoms that can suggest the development of new diabetes, such as:

Excessive urination, thirst and hunger
Unexplained weight loss
Increased susceptibility to infections, especially yeast or fungal infections of the skin and vagina
Confused thinking, weakness or nausea

Prognosis

If you have pre-diabetes, you have about a 10% chance of developing type 2 diabetes within one year. Your chance of developing type 2 diabetes during your lifetime is roughly 70%.

Fortunately, improvements in diet and exercise habits can help to delay or prevent type 2 diabetes. Research has shown that people with pre-diabetes who lose 5% to 7% of their body weight and exercise about 30 minutes a day can reduce their risk for diabetes during the next 3 years by almost 60%.

People with pre-diabetes have a higher risk of heart disease than average, even before diabetes develops. With the onset of diabetes, your risks for heart disease and stroke increase sharply. Diabetes also leads to complications such as blindness, kidney failure, foot ulcers, pain with walking due to poor circulation, and nerve damage. That's why it's important to take action to improve your health when you are diagnosed with pre-diabetes.

Some studies even suggest that people with pre-diabetes may be more likely to get dementia. One study showed that people who had borderline diabetes were 70% more likely than those with normal blood sugar to develop Alzheimer's disease.

Pre-Diabetes

What Is It?

Symptoms

Being overweight
Being 45 years or older
A family history of diabetes
Low levels of high-density lipoprotein (HDL) cholesterol (the "good" cholesterol)
High triglycerides
High blood pressure
A history of gestational diabetes
Being African-American, American Indian, Asian-American, Pacific Islander or Hispanic American/Latino

Abnormal results on a blood sugar test are likely to be the first sign that you have pre-diabetes.

Diagnosis

The same blood sugar tests that are used for diabetes are used to diagnose pre-diabetes. For diagnosing pre-diabetes, your doctor can use either of two common tests:

Fasting glucose test
Oral glucose tolerance test

In a fasting glucose test, blood sugar levels are measured after at least eight hours of not eating. Most people prefer to have the test done the morning after fasting overnight.

Here is how to interpret the results of these tests (mg/dL = milligrams per deciliter):

Fasting glucose test

Normal – Between 70 and 100 mg/dL
Pre-diabetes – Between 100 and 126 mg/dL
Diabetes – Above 126 mg/dL

Oral glucose tolerance test

Normal – Below 140 mg/dL
Pre-diabetes – Between 140 mg/dL and 200 mg/dL
Diabetes – Above 200 mg/dL

Expected Duration

Prevention

It surprises many people to learn that they may be able to prevent pre-diabetes and diabetes. To reduce your risk of both pre-diabetes and diabetes:

Maintain an ideal body weight. Aim for a body mass index (BMI) between 18.5 and 25.
Exercise regularly. Both aerobic and strengthening exercises can reduce blood sugar. Try for 30 minutes of aerobic exercise, such as brisk walking, 5 to 7 days a week.
Eat a balanced diet, following the recommendations of the U.S. Department of Agriculture's Food Pyramid.

If you are overweight, aim to lose weight. Even modest weight loss of 10 or 15 pounds in a person who is 200 pounds can dramatically reduce the risk of diabetes.

Treatment

The purpose for treating pre-diabetes is to prevent diabetes from setting in. The same measures recommended for preventing pre-diabetes (see above) work for treating it, too.

When To Call a Professional

It's best to have annual glucose tests to monitor pre-diabetes. Also, look for symptoms that can suggest the development of new diabetes, such as:

Excessive urination, thirst and hunger
Unexplained weight loss
Increased susceptibility to infections, especially yeast or fungal infections of the skin and vagina
Confused thinking, weakness or nausea

Prognosis

If you have pre-diabetes, you have about a 10% chance of developing type 2 diabetes within one year. Your chance of developing type 2 diabetes during your lifetime is roughly 70%.

Retinopathy

What Is It?

Retinopathy refers to diseases that affect the retina, the collection of light-sensitive cells lining the back half of each eye. The retina contains nerve cells that translate what you see into electrical impulses. These impulses are transmitted to the brain, where they are interpreted.

The retina contains many blood vessels. Abnormalities in these vessels cause several forms of retinopathy. Retinopathy can cause partial loss of vision or complete blindness. It can develop slowly or occur suddenly. Retinopathy can get better on its own at any time or it can cause permanent damage, depending on what's causing it and how far it has progressed.

Some types of retinopathy (for example, central serous retinopathy) do not have an obvious cause. Most forms of retinopathy, though, are caused by a known medical illness. Types of retinopathy caused by illnesses include:

Retinopathy of prematurity occurs in some infants who are born prematurely or at a low birth weight. Retinal blood vessels develop at the back of the eye and grow outward to cover the area of the retina. When a child is born too early, this process doesn't have time to finish. An eye doctor (ophthalmologist) should closely monitor infants who are at risk by carefully examining the eyes. A baby is at risk if the baby is born before the end of the 29th week of pregnancy, or if the baby weighs less than 1,200 grams at birth. Babies who are born before the 35th week of pregnancy or who have a birth weight less than 1,500 grams also may need an eye examination if they have had other complications from their premature birth. Early stages of this illness involve only subtle changes without obvious symptoms. In more advanced stages, the retina can become detached, causing blindness.

Diabetic retinopathy develops in people with diabetes. Two kinds of diabetic retinopathy have the potential to diminish vision: nonproliferative and proliferative retinopathy.

In nonproliferative retinopathy, existing blood vessels in the retina deteriorate. Deteriorating blood vessels can become blocked or can develop balloonlike deformities called aneurysms. Fluids, fats and proteins leak out of the abnormal blood vessels. Fluid can collect in the area of the retina that is responsible for sharp vision (the macula). Macular swelling (edema) impairs the fine vision necessary for reading and detail work.

In proliferative retinopathy, new, structurally unstable blood vessels grow on the surface of the retina. These unstable blood vessels cause frequent small hemorrhages (bleeding), causing local irritation with scar formation. In areas that have scarred, the clear mass of gel between the lens and the retina, called the vitreous, can adhere to the retina. These abnormal attachments between the retina and vitreous eventually distort the shape of the vitreous and cause the vitreous to pull against its tethers. This force can pull apart the layers of the retina, so that the retina can't function. This separation of layers is known as retinal detachment and is one of the most serious consequences of proliferative retinopathy. Sudden bleeding into the vitreous also can obscure vision, often quite suddenly.

Diabetic retinopathy takes years to develop. It is present in close to 80% of people with type 1 diabetes who have had diabetes for 20 years or longer. Diabetic retinopathy is less predictable in people with type 2 diabetes. It can occur relatively soon after the diagnosis of type 2 diabetes is made because some people have no or minimal symptoms for many years before type 2 diabetes is diagnosed. Other people have very mild sugar abnormalities and may never develop retinopathy.

People with diabetic retinopathy usually also have kidney damage caused by diabetes.

Diabetic retinopathy is the leading cause of blindness in the United States for people between the ages of 20 and 64.

Hypertensive retinopathy occurs in people who have high blood pressure (hypertension). It results from the thickening of the small arteries. Despite the potentially serious nature of high blood pressure, people with this disease frequently have no symptoms. Hypertensive retinopathy sometimes is discovered during a routine eye exam. High blood pressure causes blood vessel abnormalities, including blockages of retinal blood vessels and bleeding from them. These changes may not affect vision in early stages. Sudden, severe high blood pressure may cause swelling of the optic nerve (papilledema).

Central serous retinopathy, begins for reasons that are not well understood. In this condition, fluid accumulates in the membrane behind your retina, called the choroid. This fluid seeps in between tissue layers in the retina and causes them to separate, resulting in blurred vision or poor night vision. This condition usually affects males between the ages of 20 and 50, but women also can get this condition. A person who develops this retinopathy is more likely than average to have been exposed to certain treatments or to have had certain medical problems, so these treatments and conditions are suspected to be possible triggers. Suspected triggers includ steroid medicines, pregnancy, antihistamines, antibiotics, alcohol abuse, nasal allergies, asthma, autoimmune problems and untreated high blood pressure. It is not clear whether emotional stress also may trigger this form of retinopathy, although some experts suspect a link.

Symptoms

Retinopathy of prematurity. There are no outward physical signs. Only an experienced ophthalmologist examining the eye through a dilated pupil can find signs of this illness.

Diabetic retinopathy. Symptoms may not be noticed until the late stages of the illness and can include:

Blurred vision
Sudden loss of vision in one or both eyes
Black spots
Flashing lights
Difficulty reading or seeing detailed work

Hypertensive retinopathy. There are often no symptoms, though some people complain of blurred vision.

Central serous retinopathy. Symptoms include:

Blurred or dim vision, sometimes coming on suddenly
Blind spots
Distorted shapes
Reduced visual sharpness

Diagnosis

Retinopathy of prematurity. An ophthalmologist examines the inside of the eye, including the retina and its blood vessels, as well as the optic disc, macula and retinal blood vessels for abnormalities.

Diabetic retinopathy. An ophthalmologist examines the retina and inside of the eye with an instrument called an ophthalmoscope. A dye may be injected into a vein in the arm. The dye then travels to the retina, where it can reveal leaky blood vessels.

Hypertensive retinopathy. A physician examines the eye with an ophthalmoscope and looks for tiny areas of the retina that look pale or white compared to the rest because these areas are not getting enough blood. The doctor also may see areas of bleeding from ruptured blood vessels. Occasionally, the retina may show areas of swelling, particularly at the area that controls fine vision (macula), or swelling of the optic nerve.

Central serous retinopathy. A doctor or ophthalmologist uses an ophthalmoscope to detect clear fluid that has seeped between one layer of the retina and another. Fluid between these layers can resemble bubbles on the retina, visible with an ophthalmoscope.

Expected Duration

Retinopathy of prematurity. In most affected babies, this condition gets better on its own without treatment, and abnormal vessels disappear. More serious cases (about 6% of babies with this condition) will continue to get worse without treatment. Babies who need treatment are treated in the first few months of life. Within several months after treatment, it is usually possible to know whether there is any significant long-term damage to vision.

Diabetic retinopathy. Controlling blood sugar and blood pressure can slow or halt the progress of the disease, and treatments, usually with LASER, can repair existing damage.

Hypertensive retinopathy. Lowering blood pressure often can stop ongoing damage to the retina, although some damage that is established can persist.

Central serous retinopathy. Most cases go away without any treatment within three to four months. In cases that persist, laser is often used. Full vision can return within six months.

Prevention

Retinopathy of prematurity. The first line of defense is regular prenatal care to prevent premature birth and complications during childbirth. Premature and low-birth-weight infants should be screened for retinopathy of prematurity if they are born at less than 36 weeks of gestation or weigh less than 4 pounds 6 ounces (2,000 grams) at birth. Because retinopathy of prematurity can be caused by or get worse from not having enough oxygen after birth or having too much, oxygen levels are monitored closely and adjusted accordingly.

Diabetic retinopathy. Controlling blood sugar and blood pressure are essential to prevent diabetic retinopathy. Doctors monitor blood sugar control by measuring a type of hemoglobin protein in the blood, hemoglobin A1C. If you are able to reduce your blood sugar average by the equivalent of one A1C point, you will reduce your risk of retinopathy by 35% over the next 10 years. Annual eye exams are crucial for people with diabetes. If proliferative and nonproliferative retinopathies are discovered during an annual exam, your doctor probably will recommend more frequent eye exams. Treatment can start before sight is affected and can delay vision impairment. The most commonly used treatment is laser.

Hypertensive retinopathy. Avoid high blood pressure by getting regular exercise, maintaining proper body weight, eating a healthy diet and seeing your doctor for regular checkups. Many Americans do not control their blood pressure well enough. It is important to take blood pressure medications as directed by your doctor if your blood pressure remains high even after you have made lifestyle changes.

Central serous retinopathy. Because the possible causes of this disease are still not understood, prevention is difficult. Many cases of central serous retinopathy have been associated with prescription corticosteroid treatment, so it's important to limit the amount of corticosteroids you take.

Treatment

Retinopathy of prematurity. No treatment is recommended during the early stages, but close monitoring is essential. An ophthalmologist should examine high-risk infants before they are discharged from the newborn nursery and again at 8 weeks of age. If the disease is active, the infant should be examined every 1 to 2 weeks until he or she is 14 weeks old, and every 1 to 2 months after that. More advanced disease may require treatment to get rid of abnormal blood vessels. Treatment includes a procedure called cryotherapy, in which cold is used to destroy abnormal cells, and laser treatments. A detached retina can be reattached.

Diabetic retinopathy. To keep diabetic retinopathy from getting worse, blood sugar and blood pressure must be controlled to avoid complications. Specific treatment for diabetic retinopathy depends on the nature of the problem:

Proliferative disease and macular edema (swelling or leaking of the main part of the retina) can be treated with laser therapy (photocoagulation).
The formation of new blood vessels (neovascularization) is treated with laser surgery to create scars that slow the growth of new blood vessels. Laser surgery also is used to secure the retina to the back of the eye.
Hemorrhaging that clouds vision can be treated by removing all or part of the vitreous material. Laser surgery may be used during the procedure.
Retinal detachment requires surgery to reattach the retina to the back of the eye. All or part of the vitreous material may be removed at this time.

Hypertensive retinopathy. Medications can lower blood pressure and improve changes in the retina. People with very high blood pressure and swelling of the optic nerve require emergency treatment in a hospital.

Central serous retinopathy. This condition usually goes away on its own, but an ophthalmologist should monitor you closely for three to six months to make sure the condition improves. If it does not, laser treatment may be used to speed healing.

When To Call a Professional

Call a doctor if you notice changes in your vision, particularly if they are sudden, including blurring, spots, flashes, blind spots, distortion, or difficulty reading or doing detail work.

Prognosis

Retinopathy of prematurity. In up to 85% of affected babies, this condition gets better on its own without treatment, and the abnormal vessels disappear. However, more advanced cases can lead to a number of eye problems, including blindness. Children with retinopathy of prematurity have an increased risk of retinal detachment, cataract, glaucoma, crossed eyes, lazy eye and nearsightedness.

Diabetic retinopathy. The outlook depends on how well blood pressure and blood sugar are controlled, how far the disease has progressed, and how closely it is monitored. Treatments can repair damage and slow the progress of the disease. Advanced stages of diabetic retinopathy lead to blindness.

Hypertensive retinopathy. Most changes in the retina caused by hypertensive retinopathy disappear after blood pressure has been lowered, although some signs of damage can remain.

Central serous retinopathy. Most cases go away on their own within three to four months. Full visual acuity usually returns within six months. Lasting symptoms can include distortion, decreased contrast sensitivity and difficulty with night vision. It's common for this condition to return.

Type 1 Diabetes Mellitus

What Is It?

Type 1 diabetes is a disease in which the body does not make enough insulin to control blood sugar levels. Type 1 diabetes was previously called insulin-dependent diabetes or juvenile diabetes.

Insulin is a hormone produced by the pancreas. It helps to regulate the body's blood sugar levels.

During digestion, food is broken down into basic components. The liver processes these nutrients into one type of sugar -- glucose. Insulin helps move this sugar into the body's cells and tissues. The body later uses this stored sugar for energy.

Type 1 diabetes occurs when some or all of the pancreas's insulin-producing cells are destroyed. This leaves the patient with little or no insulin. Without insulin, sugar accumulates in the bloodstream rather than entering the cells. As a result, the body cannot use this glucose for energy.

When cells can't use glucose for energy, they have to use something else. As an alternative fuel, the liver produces acidic substances called ketones. These ketones build up in the blood. They make the blood abnormally acidic. This creates a severe, potentially life-threatening condition called ketoacidosis. Ketoacidosis can cause heart problems and affect the nervous system. Within hours, it may put a person at risk of coma or death.

Type 1 diabetes is an autoimmune disease. This means it begins when the body's immune system attacks cells in the body. In type 1 diabetes, the immune system destroys insulin-producing cells (beta cells) in the pancreas.

Why the immune system attacks the beta cells remains a mystery. Experts suspect that some people are genetically predisposed to the disease. And an environmental factor may act as a trigger. Viral infections and diet are two possible triggers.

Type 1 diabetes is not caused by the amount of sugar in a person's diet before the disease develops.

Type 1 diabetes is a chronic disease. It is diagnosed most commonly between ages 10 and 16. Type 1 diabetes equally affects males and females.

Symptoms

Symptoms usually come on suddenly and strongly. They include extreme thirst, frequent urination and vomiting.

Children may start to wet the bed again. Weight loss, with no loss of appetite, can be one of the first signs in children.

If the disease is untreated, sugar and ketone buildup in the blood can cause weakness, confusion, coma and even death.

Type 1 diabetes affects all body systems. It can cause serious, potentially life-threatening complications. These include:

Eye damage (retinopathy). Tiny blood vessels at the back of the eye are damaged by high blood sugar. Caught early, retinopathy can be stopped by tightly controlling blood sugar and laser therapy. If blood sugar remains high, retinopathy eventually causes blindness.

Nerve damage (neuropathy). High blood sugar can damage nerves, leading to pain or numbness of the affected body part. Damage to nerves in the feet, legs and hands (peripheral neuropathy) is most common. Nerves that control body functions, such as digestion and urination, also can be damaged.

Foot problems. Sores and blisters commonly occur on the feet of people with diabetes. If peripheral neuropathy causes numbness, a sore may not be noticed. It can become infected. Blood circulation can be poor, leading to slow healing. Left untreated, a simple sore can lead to gangrene. Amputation may be necessary.

Kidney disease (nephropathy). High blood sugar can damage the kidneys. If blood sugar remains high, it can lead to kidney failure.

Heart and artery disease. People with type 1 diabetes are more likely to have heart disease, strokes and problems related to poor circulation.

Diabetic ketoacidosis. This occurs when ketones are made by the body as a substitute for glucose. Symptoms include:

Nausea and vomiting
Abdominal pain
Fatigue
Lethargy
Coma and death (if ketoacidosis is left untreated)

Hypoglycemia. Low blood sugar (hypoglycemia) can result from insulin treatment (see Treatment section, below). Hypoglycemia may occur if too much insulin is taken. Or it may occur if not enough carbohydrates are taken in to balance the insulin. Symptoms include:

Weakness
Dizziness
Trembling
Sudden sweating
Headache
Confusion
Irritability
Blurry or double vision

Hypoglycemia can lead to coma if it is not corrected by eating or drinking carbohydrates. Glucagon is a substance that makes the liver release glucose into the bloodstream. An injection of glucagon can also correct hypoglycemia.

Diagnosis

Type 1 diabetes is diagnosed by a combination of symptoms, a person's age and blood tests. The blood tests include tests for sugar levels and for other substances.

Fasting plasma glucose (FPG) test. Blood is taken in the morning after fasting overnight. Normally, blood sugar levels remain between 70 and 100 milligrams per deciliter (mg/dL). Diabetes is diagnosed if a fasting blood sugar level is 126 mg/dL or higher.

Oral glucose tolerance test (OGTT). Blood sugar is measured 2 hours after drinking 75 grams of glucose. Diabetes is diagnosed if the 2-hour blood sugar level is 200 mg/dL or higher.

Random blood glucose test. A blood sugar of 200 mg/dL or greater at any time of day combined with symptoms of diabetes is sufficient to make the diagnosis.

Hemoglobin A1C (glycohemoglobin). This test measures the average glucose level over the prior 2 to 3 months. Diabetes is diagnosed if the hemoglobin A1C level is 6.5% or higher.

Expected Duration

Type 1 diabetes is a lifelong disease.

People with type 1 diabetes need regular checkups. They must carefully monitor their blood sugar levels every day. They must receive insulin treatment throughout life.

A small number of people can become exceptions to this rule. Some people with diabetes eventually require kidney transplants. A pancreas transplant occasionally can be done at the same time. Since the new pancreas can make insulin, this can cure the diabetes. Pancreas transplantation is not recommended by itself. It is only considered for people who must have another organ transplanted.

Prevention

There is no proven way to prevent type 1 diabetes. Vitamin D deficiency, which is very common, may increase the risk of diabetes. However, correcting the deficiency has not been yet shown to prevent diabetes. Likewise, avoiding cow's milk during infancy may possibly prevent type 1 diabetes in genetically susceptible infants. But there is no definite proof that this prevents the disease.

Treatment

Treatment of type 1 diabetes requires daily insulin injections. The injected insulin makes up for the insulin that is not produced by the body. Most people with type 1 diabetes need two to four injections per day.

Some people use a syringe for injections. Other patients use semiautomatic injector pens that help to measure precise amounts of insulin. An increasing number of patients use insulin pumps. Insulin pumps deliver a regulated dose of insulin through a needle implanted under the skin. The insulin pump is worn in a pack on the body.

People with type 1 diabetes must properly regulate insulin intake. Enough insulin must be taken to keep blood sugar levels from getting or staying too high. But low blood sugar can also be dangerous. Low blood sugar may occur if too much insulin is taken or if not enough carbohydrates are ingested in to balance the insulin.

To properly regulate their insulin intake, people with type 1 diabetes need to monitor their blood sugar levels several times per day. They do this by testing a sample of blood. They must prick their finger and place a small drop of blood on a test strip. The test strip is inserted into a device called a glucose monitor. An accurate reading of blood sugar levels is returned within seconds.

Newer glucose monitors have test strips that take the blood directly from the spot that was pricked. This process requires less blood. Other monitors allow blood to be taken from the forearm, thigh or the fleshy part of the hand. This can be less painful.

People with diabetes need to watch their diets. A healthy diet for someone with type 1 diabetes keeps the amount of glucose in the blood relatively constant. This makes blood glucose levels easier to control with insulin. A person with type 1 diabetes typically is advised to eat, exercise and take insulin at about the same times every day. Regular habits help to keep glucose levels within the normal range.

Fast-acting insulin may be taken as needed, depending on the amount of carbohydrates ingested. Your doctor or dietitian will help you determine the best insulin and diet schedule for you or your child.

People with type 1 diabetes should get regular exercise. Exercise helps to keep the heart and blood vessels healthy. It also helps to control blood sugar by causing muscles to use glucose and by keeping body weight down. Ask your doctor how much and when to exercise to best control your diabetes.

When To Call a Professional

Call your health care professional if you experience a sudden increase in thirst and urination. Unexplained weight loss always should be reported to a physician.

If you or your child has type 1 diabetes, see your doctor regularly to make sure that you are keeping good control of your blood sugar. You should also be checked regularly for early signs of complications such as heart disease, eye problems and skin infections.

Your doctor most likely will suggest that you also visit other specialists regularly. These may include a podiatrist to check your feet and an ophthalmologist to check your eyes for signs of diabetes complications.

Prognosis

People with type 1 diabetes generally adjust quickly to the time and attention that is needed to monitor blood sugar, treat the disease and maintain a normal lifestyle.

As time goes on, the risk of complications is substantial. But it can be reduced greatly if you strictly monitor and control your blood glucose levels.

Type 2 Diabetes Mellitus