Diabetes: Common causes and Treatment

What is diabetes?

Diabetes affects 2.3 million people in the UK.

Diabetes is a condition where the blood sugar level is higher than normal.

There are two main types of diabetes.

• Type 1 diabetes or insulin-dependent diabetes. It is usually seen in young people.
• Type 2 diabetes - usually non insulin-dependent diabetes. It tends to affect adults over 40 and overweight people.

There are also other types of diabetes.

• Pregnancy diabetes. This is known as gestational diabetes. It's associated with pregnancy and symptoms usually disappear after the birth. If you get gestational diabetes, you have an increased risk of developing one of the main types of diabetes later in life.
• Secondary diabetes. This is when diabetes is caused as the result of another condition, eg inflammation of the pancreas, or by the use of certain medication such as diuretics or steroids (the most common cause).

How common is diabetes?

There are currently 2.3 milion people with diabetes in the UK. However, it's estimated that more than half a million people have the condition but are unaware of it.

The last 30 years has seen a threefold increase in the number of cases of childhood diabetes. This is especially worrying in respect of the rising numbers of children and teenagers with type 2 diabetes, usually only seen in older people, and which reflects obesity levels in young people.

Obesity levels have also risen and this has led to Type 2 diabetes, which is linked to diet, being seen for the first time in young people in Europe and America.

But obesity doesn't explain the increase in the numbers of Type 1 diabetes in children, who make up the majority of new cases.

What causes diabetes?

Insulin is a hormone produced by the pancreas gland in the abdomen. It controls the use of glucose within the body.

The blood sugar level will rise if:

• the pancreas produces little or no insulin(Type 1 diabetes)
• the pancreas produces insulin, but it's inadequate for the body’s needs and its effectiveness is reduced (Type 2 diabetes).

It's thought Type 2 diabetes is related to factors associated with a Western lifestyle, since it's most common in people who are overweight and who don't get enough exercise.

Gestational diabetes is brought about by the many hormone changes and demands placed upon the body during pregnancy.

Secondary diabetes is much like Type 2 diabetes. It's quite variable, depending on the underlying cause. It can be caused by damage to the pancreas (eg by alcohol), and drugs such as steroids and diuretics can impair insulin secretion from the pancreas.

Common symptoms of diabetes

Glucose is one of the body’s main fuels. If there isn't enough, blood sugar levels rise and glucose is secreted into urine. This causes:

• increased thirst
• frequent urination
• tiredness
• weight loss, although appetite often increases (especially in Type 1 diabetes)
• itchiness, especially around the genitals
• recurrent infections on the skin, eg boils.

People with Type 1 diabetes usually develop these symptoms within days or weeks.

In Type 2 diabetes, these symptoms often don't show for years. Many are diagnosed by chance through routine medical check-ups.

Heredity plays a part in diabetes, but only 10 per cent of people with Type 1 have a family history of diabetes. For Type 2, this rises to 30 per cent.

How is a diagnosis made?

Glucose levels are measured in blood samples. This is done using the following tests:

• random glucose test: glucose levels are taken at a random time on two occasions. Any figure above 11.1mmol/l is a diagnosis of diabetes
• fasting glucose test: the glucose level is measured after an overnight fast and on two different days. Above 7.0mmol/l is a diagnosis of diabetes.

You may only need to give one blood sample if you have other symptoms of diabetes.

Glucose tolerance test

If the diagnosis is still unclear from these tests, a glucose tolerance test can be carried out.

A glucose drink is given containing a standard amount of glucose (75g). Blood samples are taken before the drink is given and two hours later. The test is done after an overnight fast.

• A two-hour blood glucose level above 11.1mmol/l is a diagnosis of diabetes.
• A level below 7.8mmol/l is normal.

If the level falls between these values, it suggests a decreased tolerance for glucose.

This is known as impaired glucose tolerance (IGT).

Impaired glucose tolerance is more than just a pre-diabetic state.

People who have IGT are at increased risk of developing some of the conditions associated with diabetes, such as heart disease.

Pregnant women with IGT have an increased risk of miscarriage and stillbirth.

How is diabetes treated?

Diabetes is treated in two ways:

• a combination of healthy diet and exercise
• medication with tablets and/or insulin.

Insulin injections increase the amount of insulin in your body and bring down the blood sugar level. Insulin injections are used in Type 1 diabetes and in some cases of Type 2.

These can be given once a day as a long-acting insulin, or as shorter-acting injections given more frequently through the day, and can be used in combination with tablet treatment if necessary.

There are different types of oral medication for treating Type 2 diabetes:

• some increase the amount of insulin secreted by the pancreas
• some increase the action of insulin in the body
• some delay the absorption of glucose from the digestive system
• some suppress a hormone called glucagon, which is secreted by the pancreas and stops insulin from working.

Treatment for diabetes depends on the individual.

It starts the first time you give yourself an insulin injection or take a diabetes tablet, and continues through eating a well-balanced diet and starting an exercise programme.

To help you get the most out of treatment, consult your GP or hospital healthcare team, which should include a diabetes nurse specialist.

Blood sugar levels

Monitoring blood sugar levels is an important aspect of treatment, especially in Type 1 diabetes where levels can change markedly.

This can be done easily at home with a small blood glucose meter.

Depending on the reading, you may need to adjust your diet, the amount you exercise or your insulin intake.

Managing diabetes

In the long term, diabetes is monitored through routine check-ups by your doctor and/or annual check-ups at the hospital on an outpatient basis.

Their purpose is to determine if treatment is satisfactory and to look out for any evidence of longer-term complications such as eye or kidney disease.

Tests for these complications are usually done at the annual check-up, while routine check-ups may be carried out every three to six months.

Routine check-ups

• Blood sample to check the level of HbA1c (a measure of long-term glucose) in the blood.
• Evaluation of home glucose readings.
• Discussion of diet.
• Blood pressure.
• Weight check.
• Other tests and examinations as determined by your doctor.

Annual check-ups

• Blood sample to check the amount of HbA1c in the blood.
• Blood sample to determine the amount of fats in the blood.
• Blood sample to check kidney function and various salts in the blood (mainly sodium and potassium).
• Blood pressure.
• Urine sample to determine the presence of protein (albuminuria). The appearance of protein can indicate that the small blood vessels (capillaries) in the kidneys are beginning to be affected by the diabetes.
• Foot examination, including a check of various pulse points on the foot to assess circulation, and a check for vibration sensation to determine if there's any neuropathy (nerve damage) to the foot.
• Weight check.
• Measuring the waistline.
• Discussion of exercise habits.
• Discussion of smoking habits.

Long-term prospects

Both types of diabetes have the risk of complications.

Acute complications

• Low glucose level, caused by treatment with insulin or oral hypoglycaemic drugs that increase insulin secretion from the pancreas.
• Diabetic acidosis, a life-threatening condition caused by the lack of insulin.

Late-stage diabetic complications

• Retinopathy (eye disease) that can cause blindness.
• Diabetic kidney disease that can lead to kidney failure.
• Diabetic neuropathy (nerve disease) that can cause foot ulcers and foot infections.
• Atherosclerosis (hardening of the arteries), particularly in smokers and those with high blood pressure and abnormal fat levels in the blood.

Late-stage complications do not usually develop for 10 to 15 years with Type 1 diabetes.

In Type 2 diabetes, however, symptoms can appear close to the time of actual diagnosis because the disease may go undetected for longer.

Many studies now show that good glucose control can significantly reduce or even stop complications. This means keeping the blood sugar level as close to normal as possible.

Recent studies have also confirmed the need for people with diabetes to reduce their risk of atherosclerosis (fatty deposits in your arteries).

This is because if you have Type 2 diabetes, you have a four to five times greater risk of developing serious problems with your circulation that can lead to a heart attack or a stroke.

The main factors that increase your risk are:

• smoking
• high blood pressure
• raised levels of fats such as cholesterol in the blood.

By taking measures to address these issues, you will reduce your chance of developing complications such as heart disease.

Cholesterol causes cardiovascular illness and diabetes

Cholesterol facts

Diet is just one of the things that can reduce cholesterol.

A high level of cholesterol is one of the factors that can increase your risk of cardiovascular disease, eg angina, heart disease and stroke.

This is because high levels of cholesterol lead to fatty deposits that cause the arteries to narrow (atherosclerosis) and restrict blood flow to the heart. This is what causes cardiovascular disease.

What is cholesterol?

Cholesterol is an important substance that's used by the body in many ways.

It's the starting point of manufacture for many of the body’s natural steroid hormones and for vitamin D, which controls calcium in the body.

It is also an essential component of the membrane that forms the walls of individual cells in all tissues.

Eighty per cent of the cholesterol we have is produced within our own body – mostly by the liver. It's then transported from the liver via the blood stream to other tissues.

Cholesterol travels through the blood in minute packages mixed with large molecules called lipoproteins. Lipoproteins are themselves combinations of fats and proteins.

Fats such as cholesterol don't dissolve well in the blood stream, but become soluble when coated with lipoproteins.

What are lipoproteins?

Four main groups of lipoproteins exist, based mainly on their different sizes and density:

Each group has a different function in the body.

high-density lipoproteins (HDL)

low-density lipoproteins (LDL)

very low-density lipoproteins (VLDL)

chylomicrons.

How do they affect cardiovascular health?

High-density lipoproteins (HDL) mop up excess cholesterol in the body and return it to the liver for re-processing. HDL is often called good cholesterol and raised levels give protection against heart disease.
Low-density lipoproteins (LDL) transport cholesterol from the liver to be deposited elsewhere in the body. LDL is known as bad cholesterol because it deposits cholesterol in the lining of your arteries. The more LDL you have, the more likely you are to develop heart disease.

What affects levels of lipoproteins?

Men generally have higher levels of LDL compared to women.

This is probably because of the protective effect of oestrogen, one of the female hormones. Following the menopause, this difference disappears.

Exercise raises HDL levels, as does modest alcohol intake.

Why test cholesterol?

Every adult should have it measured at least once before they are far past middle age.

Cholesterol is easily measured in a blood sample. If high cholesterol runs in your family, it's better to measure cholesterol at a much younger age - some time in your 20s.

Cholesterol levels don't tend to fluctuate, so if you have a normal level it doesn't need to be repeated for many years.

If it's high, it may need quite frequent re-testing to gauge the effect of treatment.

What do the figures mean?

Total cholesterol

This is the single figure for your cholesterol level, which is all the subtypes combined.

The desirable upper limit of total cholesterol (TC) for people who have diabetes is 4mmol/l.

As with the other risk factors for cardiovascular disease, raised cholesterol is of more concern if there are other factors present:

someone who has a TC of 6mmol/l, but is fit, is not overweight, has no family history of heart disease and doesn't have diabetes or smoke will have little or no benefit from lowering their cholesterol.
someone with the same cholesterol level but who smokes, is overweight and has high blood pressure will reduce his cardiovascular risk quite a lot by getting his cholesterol down.

LDL cholesterol

People with diabetes who have an LDL cholesterol level of more than 2mmol/l should generally receive cholesterol-lowering drug treatment.

HDL cholesterol

The usual range of HDL levels is 0.5 to 1.6mmol/l.

Higher levels are good. Cholesterol experts often divide the total cholesterol (TC) by the HDL level to give a better judge of your risk level than the TC alone.

When the HDL is greater than 1, this has the effect of lowering the TC/HDL ratio, lowering your risk.
When the HDL is low, the TC/HDL ratio goes up and so does your risk.

How can I lower my cholesterol levels?

Most cholesterol in the body is produced in the liver. This means dieting only has a small effect on levels.

Even so, this amount is still helpful, especially as part of a healthier diet in general. Some cholesterol-lowering margarines may also be helpful.

A large proportion of the UK population will not achieve target cholesterol levels without extra help in the form of cholesterol-lowering drug treatment.

Cholesterol treatment and diabetes

The most common drug that is prescribed is a statin. Statins should be prescribed as primary prevention in all diabetic patients over 40 years old with a TC of more than 4mmol/l or and LDL-cholesterol of more than 2mmol/l.

Statins may be prescribed to younger diabetic patients if there are additional risk factors for cardiovascular disease or there is evidence of diabetic eye disease (retinopathy) or diabetic kidney disease (nephropathy).

All diabetic patients with a history of heart attack, stroke or cardivascular disease should be prescribed a statin to preven further attacks (secondary prevention).

Some people find they are intolerant of statins and experience side-effects, such as muscle pains, fatigue and nausea. If that occurs, there are a number of prescribable alternatives - such as ezetimibe or fibrate drugs, which may not cause these problems.

Influenza (flu): common cause and treatment

What is influenza?

Influenza is characterised by a runny nose, sore throat, headache, fever and aching muscles and joints.

Influenza is a viral disease that usually strikes between October and May.

It lasts from three to five days and can be followed by fatigue for two or three weeks. It usually causes aching muscles and joints, headaches, cough and fever with a temperature of between 38^o and 40^oC.

Although it can become a much more severe illness, leading to pneumonia, nerve and brain damage and even death – such complications are rare.

Because it is a viral infection, it cannot be treated with antibiotics. Antiviral agents can reduce the severity and duration of infection, but these are generally prescribed only if there are concerns regarding complications of the infection or transmission of more severe strains of the virus. The best remedy is rest while drinking plenty of fluids.

It's possible to get vaccinated against influenza, which is especially advisable for the elderly and people with heart and lung diseases.

In 2009, a pandemic (global outbreak) of swine flu (H1N1 influenza A) was associated with high complication rates in pregnant women.

H1N1 has been included in the 2010 to 2011 vaccination programme. Vaccination is recommended therefore for pregnant women and is also advised for children under 5 years

In the UK vaccination is offered to:

• anyone with chronic cardiac or respiratory conditions, such as asthma
• anyone with chronic kidney diseases
• anyone with chronic neurological diseases
• anyone with immunodeficiency
• pregnant women
• children under 5 years of age
• anyone who may otherwise be at increased risk.

What are the symptoms?

• Headache.
• Fever (38^o to 40^oC).
• Aching muscles and joints.
• Chest pains.
• Lack of appetite.
• Fatigue and weakness.
• A runny nose and sore throat.
• Dry cough.
• Restless sleep.
• Chills and shivering.
• Indigestion.
• Vomiting or diarrhoea.

What can I do?

• Step up your fluid intake – you lose a lot of liquids during a fever.
• Rest, preferably by staying in bed.
• Try to get plenty of sleep.
• If you have a cough, an over-the-counter cough remedy may ease your symptoms. The pharmacist is the best person to advise on this.
• Avoid smoking and drinking alcohol.
• Paracetamol (eg Panadol, Calpol) or aspirin (eg Aspro clear) will reduce fever and muscle aches. (Note that aspirin should not be given to children under 16 years of age, unless on the advice of a doctor.) Ibuprofen (eg Nurofen) will also relieve these symptoms. These painkillers are also found combined with medicines such as nasal decongestants in various over-the-counter cold and flu remedies. Ask your pharmacist for advice about which are most suitable for relieving your symptoms.
• Consult a doctor if the symptoms do not disappear after a week, or sooner if you feel worse.

How is influenza spread?

Influenza is a viral disease, which is passed from one person to another through the air. The disease infects the nose, throat or lungs. Droplets can contaminate the skin and frequent hand washing is advised.

It often breaks out as an epidemic, which quickly spreads from town to town and country to country. Typically, an area can have epidemic conditions for a period of four to six weeks before it eases off.

Are there different types of influenza?

Yes, there are three types of influenza.

Type A

The most serious type with the most acute symptoms. It is also the most common form, usually breaking out every two or three years. The 2009/2010 pandemic was caused by influenza A H1N1.

Type B

Similar symptoms to type A, but not as serious. The outbreaks happen every four to five years.

Type C

The mildest type, with symptoms similar to a cold.

How long will the influenza last?

Usually, influenza lasts three to five days. If it goes on for more than a week or if the symptoms are very severe, you are advised to consult your doctor.

A bad case of influenza has the potential to develop into a more serious condition like pneumonia or sinus trouble, and in rare cases it can be life-threatening.

Who is at risk?

Influenza can be dangerous to the elderly, especially those who live in residential homes where there is more risk of contracting the virus through contact with others.

People with lung and heart diseases are also more likely to develop complications due to an attack of flu. Those at risk are advised to get a yearly vaccination. Consult your doctor if you have any problems or questions.

Other important facts

• Both colds and flu are caused by a virus but the symptoms of influenza are usually more severe.
• Antibiotics have no effect against influenza.
• Damp or cold cannot cause influenza. However, sudden changes in temperature may cause the symptoms to appear more quickly.
• People are seldom infected by the same type of influenza twice because resistance develops within two or four weeks. However, the influenza virus constantly mutates into slightly different versions of itself, which is one reason why vaccination is sometimes ineffective. The vaccination also needs to be done yearly to keep up the person's level of immunity. The type of vaccination given each year changes slightly, as this is the ‘best guess’ vaccination to cover the likely type of influenza virus that will be most common that year.
• It's possible to pass on the infection the day before you develop the symptoms yourself. You can also pass on the infection until the day after your fever has disappeared.

Current evidence does not support a preventative effect of homeopathy in influenza and influenza-like syndromes. Vaccination should still be the preventive measure for patients at risk, ie those over 65 years and with heart or lung diseases.

Antiviral agents such as oseltamivir (Tamiflu) and zanamivir (Relenza) can shorten the duration of infection.

There are concerns that widespread use of such agents can encourage the emergence of resistant strains of virus. These agents are generally used therefore when there are particular risks of complications or to limit transmission of the more severe strains of the virus.

Despite the bewildering number of over-the-counter remedies for 'flu', all are symptom relievers only, and the number of active ingredients is quite small.

People taking other medicines should check with the pharmacist before taking a flu remedy in case of interaction between medicines.

Lower abdominal pain in women

What causes lower abdominal or 

pelvic pain?

All women feel discomfort or pain in the lower abdomen below the navel from time to time, for instance, before or during menstruation.

Taking note of certain symptoms will help you and your doctor accurately diagnose the problem, although this can be difficult.

In many cases it can be difficult to identify the cause of the pain, but noting certain features will help you and your doctor come to a likely diagnosis.

The most common causes are a urinary disorder such as a bladder or kidney problem, a bowel problem or a condition involving the reproductive system – the uterus, Fallopian tubes and ovaries.

Type of pain arising from the 

urinary system

Pain from the urinary system can indicate such conditions as cystitis (inflammation of the bladder), inflammation of the collecting system of one or both kidneys (pyelonephritis), kidney stones or uncommonly tumours.

Typical symptoms of infections are a burning sensation when passing urine and a need to empty the bladder more frequently. In addition, pain travelling from the back and around to the front might suggest a kidney infection or kidney stone.

The pain associated with kidney stones may be particularly severe. The presence of blood in the urine raises the possibilities of infection, kidney or bladder stones or even a bladder or kidney tumour. Both benign and malignant tumours can first make themselves noticed in this way. The presence of blood in the urine always requires further investigation and should be reported to your doctor.

The duration of the pain will further help you and your doctor to make the correct diagnosis.

Type of pain arising from conditions of the 

intestines

The bowel can give rise to a wide variety of symptoms including pain.

Constipation and diarrhoea can be painful in themselves, and the change in bowel habit usually identifies the pain as coming from the bowel. Pain from the bowel is often described as colicky in nature. This means that the pain or discomfort comes in waves with little or no discomfort in between the pain.

Bloating or swelling of the lower abdomen may be present in many intestinal (bowel) conditions including irritable bowel syndrome.

The passing of fresh blood or altered blood (black motions) from the back passage should be reported to your doctor as investigation is usually necessary.

Type of pain arising from conditions of the 

reproductive organs

Pain might originate from the uterus (womb), Fallopian tubes or ovaries. It is usually felt in the middle of the lower abdomen, above the line of pubic hair as far up as the navel. Occasionally, the pain is more to one side, which is more typical of a pain coming from an ovary.

There might be discomfort or even pain during intercourse (called dyspareunia) felt deep within the pelvis.

Pain originating from the uterus is usually worse at the time of a woman's period (dysmenorrhoea).

Examples of conditions of the reproductive organs giving rise to pain includeendometriosis, pelvic inflammatory disease, ovarian cysts, fibroids and problems related to the early stages of pregnancy such as miscarriage and ectopic pregnancy.

In any case of sudden, severe, unexplained abdominal pain your doctor should be contacted.

What will the doctor do?

Acute and sudden pains are always worrying but chronic pain can also have serious implications and a doctor should be consulted.

The doctor will ask about periods, passing of urine and bowel movements. They might also ask if there have been episodes of nausea, vomiting, or fever. If appropriate, they may ask questions concerning the person's emotional life - family, friends, work - and their sex life.

The doctor will want to examine you. This will involve feeling your abdomen and, in addition, an internal examination (vaginal,rectal or sometimes both) may be necessary.

Further investigations or treatment will be based upon the description of the pain and the findings of the doctor's examination.

Typically, a urine sample will be requested and tested for any signs of infection.

If a kidney problem is suspected than an ultrasound scan of the kidneys and bladder will be arranged.

If a problem with the womb or ovaries is suspected, swabs from the vagina looking for any infection might be performed and an ultrasound scan of the womb and ovaries is commonly performed.

If a bowel problem is suspected, a sample of the motion is often investigated for signs of infection and you may be recommended to have a telescopic examination of the bowel called an endoscopy.