American Diabetes Association Complete Guide to Diabetes: The Ultimate Home Reference from the Diabetes Experts

CHAPTER 14

Diabetes Complications and Prevention

• Warning Signs

• Cardiovascular Disease, Stroke, and Peripheral Arterial Disease

• Eye Problems

• Kidney Disease

• Nerve Disorders

• Infections and Skin Problems

• Depression and Other Mental Health Disorders

Perhaps the most difficult thing about diabetes is thinking about the complications that can arise in the future. It’s true that people with diabetes have a higher risk of heart, eye, kidney, and nerve disease than other people.

However, you can take active, positive steps to reduce the risk of these problems. The best way to prevent diabetes complications is to keep your blood glucose levels as close to normal as possible. Focusing on the daily goal of controlling your blood glucose will help you stay positive about your long-term future with diabetes.

Warning Signs

A good rule is to call or visit your provider any time you “just don’t feel right” and cannot explain it. Your health care providers can help you troubleshoot problems as they arise. Your problem may be something as simple as changing your exercise routine or something more serious like a complication.

Warning Signs of Diabetes Complications

• Vision problems, such as blurry or spotty vision or flashes

• Unexplained, overwhelming tiredness

• Discomfort in your legs when walking

• Numbness or tingling in your hands or feet

• Chest pain that comes on when you start to exert yourself

• Cuts or sores that stay infected or take a long time to heal

Some people have the unpleasant experience of finding out about diabetes complications soon after diagnosis. Sometimes, they may find that they already have complications when they are diagnosed. This is more likely if you’re diagnosed with type 2 diabetes.

The signs of type 2 diabetes may be so subtle that you may have had high blood glucose levels for some time without ever realizing it. The damage was occurring even before your diagnosis, and perhaps the signs of the complications brought you to the doctor in the first place. In this case, you probably got a crash course in diabetes complications.

This chapter will provide background on the connection between blood glucose and complications. It will also detail some common diabetes complications, including ways to detect, prevent, and treat them.

Five Common Complications

• Cardiovascular disease and stroke

• Retinopathy (eye disease)

• Nephropathy (kidney disease)

• Neuropathy (nerve disease)

• Infections, including dental disease

Research behind Glucose Control

Luckily, we know a lot about what causes diabetes complications and how to prevent them. Two landmark studies showed that keeping blood glucose levels as close to normal as possible can help prevent or slow the progression of many complications.

The Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS) showed that tight control lessens the chance for eye, kidney, and nerve disease.

The DCCT showed that people with type 1 diabetes could delay or even prevent many of the complications of diabetes by tightly managing blood glucose levels. The volunteers in the DCCT’s intensive management group monitored their blood more often—4–7 times each day—and injected insulin more often. They stayed in close touch with their health care team, and their hard work paid off.

They reduced their risk for developing complications by more than 50%. For example, those who kept their A1C levels closer to normal had 76% less eye disease, 60% less nerve damage, and 35–56% less kidney damage than the study group participants who used standard therapy.

The UKPDS showed that tight blood glucose control and blood pressure management could help people with type 2 diabetes delay or prevent diabetes complications. In the UKPDS, people who tightly controlled their glucose reduced their risk of complications such as eye and nerve disease by 25%. People who lowered their blood pressure reduced their risk of stroke by 44% and their risk of heart failure by 56%. Improved blood glucose control also reduced the risk of heart attacks and diabetes-related deaths.

For more information about the DCCT, the UKPDS, and intensive management, see chapter 9.

Take Action

The bottom line is that any improvement you can make in lowering your blood glucose level will benefit you. The less time you spend with high blood glucose levels, the lower your risk for developing complications.

Even if you already have some complications, it’s not too late to slow the progression. Lowering your blood glucose levels can help improve most complications—even if they’ve already developed.

Cardiovascular Disease, Stroke, and Peripheral Arterial Disease

People with diabetes are two to four times as likely to have a heart attack or stroke as people without diabetes. It is the number one killer of people with diabetes. Therefore, it’s important to understand and mitigate the risk of cardiovascular disease and stroke.

Most people associate vascular disease with heart attacks and strokes. Yet, vascular disease can affect all the blood vessels in your body. For example, blocked arteries around your heart can interrupt blood flow to the legs and cause peripheral arterial disease (PAD). This can cause painful cramping, aches, or burning sensation in your legs and feet.


Blood Flow and Cardiovascular Disease

There are several kinds of cardiovascular disease, and they are all due to problems in how the heart pumps blood or how blood circulates throughout the body.


Risk of Cardiovascular Disease, Stroke, and PAD

• People with diabetes are at least twice as likely to have heart disease or a stroke.

• People with diabetes tend to develop heart disease or have strokes at an earlier age than other people.

• Heart attacks in people with diabetes are more serious and more likely to cause death.

• One of every three people with diabetes over 50 is thought to have PAD.

Causes of Cardiovascular Disease, Stroke, and PAD

Blood flows through the blood vessels in your body to deliver all the oxygen, glucose, nutrients, and other substances needed to run your body and keep your cells alive. When blood can’t get to cells and tissues, they can become damaged or die.

Atherosclerosis

Most of the cardiovascular complications related to diabetes have to do with a blockage or slowdown in blood flowing throughout the body. Diabetes can change the chemical makeup of some of the substances found in blood, which can cause blood vessels to narrow or to clog up completely. This is called atherosclerosis, or hardening of the arteries, and diabetes seems to speed it up.

If you have diabetes or insulin resistance, you have a higher risk for atherosclerosis. Paying attention to conventional risk factors, such as smoking, high fats in the blood, or high blood pressure, is important for people for diabetes.

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High Cholesterol

High cholesterol and triglycerides can contribute to hardening of the arteries. These blood fats, also called lipids, stay in the blood and collect in the walls of the blood vessels. Keep in mind that there are several kinds of lipids. LDL, or bad, cholesterol can narrow or block your blood vessels, which can lead to a heart attack or a stroke.

HDL cholesterol is sometimes called helpful or “good” cholesterol. This lipid helps remove deposits from the insides of your blood vessels and keeps them from getting blocked. You can raise your HDL cholesterol level by getting more exercise, avoiding saturated fats, choosing more omega-3 and omega-6 fats, and lowering your triglyceride levels.

Target Lipid Levels

• LDL cholesterol below 100 mg/dl.

• Triglyceride level below 150 mg/dl.

• HDL cholesterol above 40 mg/dl for men and above 50 mg/dl for women.

Lipid abnormalities are quite common in people with diabetes, especially type 2 diabetes. That has led researchers to ask whether there is a link between lipid abnormalities and obesity and type 2 diabetes. If you and other family members have severely high levels of cholesterol, you may have a lipid disorder that is not related to diabetes.

High Blood Pressure

High blood pressure, or hypertension, can also contribute to cardiovascular disease. When you have high blood pressure, blood flows more forcibly through blood vessels and makes the heart work harder than usual. This extra stress can damage the lining of your arteries, causing a type of fatty tissue called atheroma to form. Atheroma can cause your arteries to narrow or become completely blocked.

High blood pressure not only increases your risk for heart disease but also increases your risk for other diabetes complications. It can damage small blood vessels and capillaries, especially in the eyes and kidneys. People with diabetes need to be especially careful to control their blood pressure because of the potential damage to blood vessels and tissues.

Hypertension itself usually has no symptoms. If you have it, you probably won’t even realize it unless you have your blood pressure checked.

Hypertension is especially common among people with type 2 diabetes. Over 70% of people with diabetes also have high blood pressure or use medicines to treat hypertension.


ADA Blood Pressure Goals

The recommended blood pressure for most people with diabetes is <130/80 mmHg.


Complications of Cardiovascular Disease, Stroke, and PAD

Blood supply to the heart, brain, and other tissues and organs can be restricted when blood vessels narrow or clog because of cardiovascular disease. If blood flow is restricted for a long time, chest pain known as angina can occur. Angina is not itself a disease, but it can be a warning sign that something is slowing the flow of blood to the heart.

A complete blockage of blood to the heart is a heart attack. A complete blockage of blood to the brain is a stroke. Another serious problem for people with diabetes is PAD. Blockage of blood flow to the feet puts your feet at risk for amputation.

One of the symptoms of PAD is intermittent claudication. The leg arteries become blocked and painful, especially when walking. The pain sometimes comes and goes.

Prevention of Cardiovascular Disease, Stroke, and PAD

There are six things you can do to prevent cardiovascular disease. All of these actions will help keep your large blood vessels open for blood to flow to all your vital organs, and you will dramatically lower your risk of developing cardiovascular disease.

Five Steps to Prevent Onset or Recurrence of Cardiovascular Disease and Stroke

• Quit smoking

• Lower your cholesterol levels

• Lower high blood pressure

• Increase your physical activity

• Ask your provider if taking aspirin will benefit you

Quit Smoking

The role of smoking in causing lung disease is well known. But smoking is even more risky for people with diabetes. Over time, smoking damages your heart and circulatory system by hardening your blood vessels.

Narrow blood vessels can restrict the flow of blood to cells in your body. These cells can die, and the damage can lead to heart disease, impotence, and amputation. If you smoke now, talk to the members of your health care team about strategies that can help you quit.

Lower Your Cholesterol

Healthy eating can help you keep your blood glucose on target, as well as lower your cholesterol and triglycerides. Healthy eating habits are contagious, too. Your family will benefit from your healthy eating plan. A visit with a dietitian can help you make healthy food choices.

Healthy Food, Healthy Cholesterol

• Develop a meal plan low in trans and saturated fat, as well as cholesterol.

• Include whole grains, fruits, vegetables, and a moderate amount of protein in your meals each day.

• Watch the total number of calories you eat to lose or maintain your weight.

High levels of LDL cholesterol are usually treated with medications called statins.

Tips for Starting Statins and Other Medications

• Watch carefully for changes in your blood glucose levels; even if you have type 2 diabetes, you may want to monitor your blood glucose level several times each day.

• Start new drugs one at a time, if possible; some medications can interfere with the breakdown, absorption, and removal of other medicines.

• Know that many kinds of medications are used to treat high lipid levels and that side effects may occur; report anything unusual to your provider.

Triglyceride levels are closely linked to blood glucose levels. Triglycerides can usually be lowered by lowering your blood glucose levels; losing weight; increasing physical activity; eating a healthy, low-fat, high-fiber diet; or taking medications called fibrates. Consuming more omega-3 fats will help lower triglycerides too.

Lower Your Blood Pressure

High blood pressure, or hypertension, puts a strain on your body, especially your heart, blood vessels, and kidneys. In addition, high blood pressure accelerates the progression of eye and kidney complications.

You can lower your blood pressure by losing weight and working out. For some people, limiting sodium intake helps lower blood pressure. You may also take medications to keep your blood pressure at or below the recommended level.

The most commonly prescribed medications are angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). They lower blood pressure and help protect your kidneys. Diuretics, beta-blockers, and calcium channel blockers may also be prescribed.

It will take time to figure out the best medicine plan for you. Be sure to keep in close contact with your health care team during this time and let them know if you are experiencing any side effects from these medications.

Get Moving

Physical activity helps people with diabetes in several ways. It can delay or help stop cardiovascular disease. It can help clear glucose from your blood, so that cells can use it for energy. This lowers blood glucose levels and in some individuals may lower the amount of insulin needed.

Working out also gives you a positive way to cope with stress. For people who are overweight, exercise helps with weight loss, and losing weight lowers your insulin resistance. Exercise helps your body work better. See chapter 11 on working with your health care team to design an exercise program that is safe for you.

Treatment of Cardiovascular Disease, Stroke, and PAD

Taking preventive steps can slow or stop the progression of cardiovascular disease. But sometimes, prevention alone isn’t enough, especially if you have had cardiovascular disease for a while. You may need medication to reduce blood clotting, to lower cholesterol levels, or to reduce high blood pressure.

You may need surgery if your blood vessels are already blocked or significantly narrowed. Both preventive and surgical steps can also treat angina. The goal is to increase the amount of oxygen going to the heart.

Treatments for Heart Problems

Several different surgical procedures are now commonly used to remove the blockages of blood vessels. All of these procedures are performed by a cardiologist—a doctor specialized in treating people with heart problems.

Balloon angioplasty, while not performed as often as it used to be in people with diabetes, is a procedure that uses a balloon at the tip of a long tube. A cardiologist inserts the tube into the blocked artery and then inflates the balloon. This opens up the blocked vessel. A metal stent, or ring, may be left in place to help the blood vessel stay open.

Atherectomy is another kind of minor surgery used to open blood vessels. With this technique, the cardiologist bores a hole through a blocked blood vessel. Laser surgery can also be used to melt away blockages with an intense beam of light. All of these surgeries can remove smaller blockages and require little recovery time.

A more severe blockage calls for more serious surgery. Surgeons can create a detour around the blocked artery through arterial bypass surgery. Now, instead of running up against a wall, blood can flow around the blockage and through the new blood vessel.


Bypass Surgery

Maybe you already know someone who has had a single, double, triple, or even quadruple bypass surgery of the heart. Surgeons can construct one, two, three, four, or even more detours, if there are multiple blockages.


Treatments for Stroke

Strokes are usually treated by a combination approach: treatments to lower blood glucose, lipid levels, and blood pressure; therapy to help the person recover mental and physical abilities; and medications that reduce blood clotting. Sometimes surgery is needed.

Treatments for PAD

The best treatment for PAD is regular physical activity. If you have intermittent claudication and exercise is painful, your doctor can help design an activity program. Other treatments include quitting smoking, medications, and procedures or surgery similar to that for blocked heart arteries.

People with cardiovascular disease are advised to be physically active and to eat foods that protect the heart and blood vessels. Because of diabetes, you’ll also need to manage your blood glucose levels and perhaps lose weight as part of your recovery.

Eye Problems

The most common eye disease in people with diabetes is retinopathy, a disease of the retina. The retina is the light-sensing region of the inner eye. It acts like a miniature “movie screen” in the back of your eye, on which the images you see are projected.

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Risks for Retinopathy

• Diabetic retinopathy is estimated to be the most frequent cause of new blindness among adults aged 20–74 years.

• Nearly all people with type 1 diabetes show signs of retinopathy after 20 years of diabetes.

• More than half of all people with type 2 diabetes develop some signs of retinopathy after 20 years of diabetes.

Causes of Retinopathy

Retinopathy is caused by damage to the blood vessels that supply blood to the retina. High blood pressure, high blood glucose, and smoking can all damage blood vessels. Retinopathy is more common among people with type 1 diabetes, but people with type 2 diabetes can also develop it.

Complications of Retinopathy

There are two major forms of retinopathy: nonproliferative and proliferative.

Nonproliferative Retinopathy

• Also called background retinopathy.

• Blood vessels can close off or weaken.

• The blood vessels leak blood, fluid, and fat into the eye.

• It can cause blurry vision, but not usually blindness.

Proliferative Retinopathy

• A more serious, although less common, form of eye disease.

• New blood vessels sprout, or proliferate, in the retina. This may seem like a good thing, but the new vessels don’t grow in the way they should. Instead, they grow out of control.

• The blood vessels are fragile and rupture easily during exercise or even while sleeping, especially if you have high blood pressure. Blood can leak into the fluid-filled portion of the eye in front of the retina, which can block light coming into the eye and impair vision.

• In addition, scar tissue can form on the retina. The scar tissue often shrinks, and when that happens, it can tear the layers of the retina apart. This damages your eyesight and can cause blindness.

Glaucoma, or high pressure within the eye, and cataracts occur more often in people with diabetes. If found early, glaucoma can be treated.

Macular edema can also occur in people with diabetes. Retinopathy causes swelling of the macula of the eye. Because the macula is that central portion of the retina that allows you to see fine detail, when it swells, vision can be impaired and blindness can result.

Prevention of Retinopathy

You probably won’t even notice any changes in your vision when diabetic retinopathy first begins. The starting point for detection of early changes in blood vessels is a dilated eye exam performed by an ophthalmologist or optometristspecially trained in diabetic eye disease. You can read more about eye exams and your eye doctor in chapter 17.

Early detection is the key to keeping this disease from interfering with your vision. You can have retinopathy severe enough to threaten your vision without knowing it. Treatment can protect your vision. This is the reason for having regular examinations, even when you do not have symptoms.

Tips for Eye Care

• Get a yearly eye exam from an ophthalmologist or optometrist. Your eyes should be dilated for the exam. The early detection of any eye problems is critical to keeping your vision.

• Adults with type 1 diabetes need a dilated eye exam within five years after the onset of diabetes. Adults with type 2 diabetes need an eye exam shortly after diagnosis.

• Call your diabetes care provider if you notice changes in your vision, but don’t panic. Highs and lows in your blood glucose level may cause temporary blurring in your vision.

• Keep your blood glucose levels close to normal. You will help prevent damage to the small blood vessels that run through your retina.

• Check your blood pressure regularly, and work to keep your blood pressure on target.

• Quit smoking.

• Discuss your physical activity with your eye doctor. Some activities can raise the pressure inside your eyes and lead to bleeding in the retina.

• If you have retinopathy, avoid taking birth control pills because they may affect the clotting of your blood or increase your blood pressure.

• Get early treatment for eye problems! Early intervention, such as laser treatment for retinopathy, cuts the risk of blindness by 90%.

The DCCT found the most striking results for the power of controlling blood glucose to prevent retinopathy. The UKPDS showed that people with type 2 diabetes who lowered their blood glucose and blood pressure also lowered their risk of retinopathy.

The bottom line, whether you have type 1 or type 2 diabetes, is that you can significantly reduce your chances of developing retinopathy or of having your retinopathy worsen.

Vision Warning Signs

• Unexplained visual problems, such as spots, “floaters,” or cobwebs in your field of vision; blurring or distortion; blind spots; eye pain; or persistent redness.

• Trouble reading books or traffic signs or difficulty distinguishing familiar objects.

• Increased pressure within the eye, which could be a warning sign of glaucoma. Some physicians and most optometrists routinely test for this.

• Any retinal abnormalities. Most endocrinologists, internists, primary care practitioners, and optometrists will test for this but should refer problems with the retina to an ophthalmologist specializing in diabetic eye disease.

• Leaking of blood vessels that supply the retina, which leads to retinopathy, the main cause of blindness in people with diabetes.

Treatment of Retinopathy

The best way to treat proliferative retinopathy is with a laser procedure called photocoagulation. An ophthalmologist aims a laser beam at the retina. This creates hundreds of tiny burns in the retina. These burns will destroy abnormal blood vessels, patch leaky ones, and slow the formation of new fragile blood vessels. If you have the more serious form of retinopathy (proliferative retinopathy) or macular edema, photocoagulation can usually prevent blindness.

Photocoagulation may not be for everyone, however. It may not work if the retina has bled a lot or has detached. In these cases, a surgery called a vitrectomy can remove the excess blood and scar tissue, stop the bleeding, replace some of the vitreous humor—the clear jelly-like substance that fills the eye—with salt solution, and repair the detached retina.

If you need either of these procedures, choose an ophthalmologist who specializes in retinal disease and who has a lot of experience in treating patients with diabetes. Don’t put off visiting your eye specialist. The earlier you get treated, the greater your chances of preventing blindness or further eye damage.

Kidney Disease

Nephropathy or kidney disease can occur in people with type 1 or type 2 diabetes. However, severe kidney damage is more common in people with type 1 diabetes than in those with type 2.

Your kidneys are your body’s filter units. They work 24 hours a day to rid your body of the toxins that your body makes or takes in. Toxins from the blood enter the kidneys by crossing the walls of tiny blood vessels along its border.

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Risk of Nephropathy

• Approximately 43% of new cases of end-stage renal disease (kidney failure) are caused by diabetes.

• Of all people with diabetes, around 30% have nephropathy.

• Native Americans, Hispanics, and African Americans are at a greater risk for developing nephropathy than whites with type 2 diabetes.

Causes of Nephropathy

Sometimes in people with diabetes, the blood vessels on the kidneys become damaged and can no longer filter out the impurities in your blood. They begin to leak, and some of the waste products that should be removed are allowed to stay in your blood. When this happens, some of the proteins and nutrients that should remain in your blood are lost in the urine. This is called nephropathy.

The exact cause of nephropathy is unknown. However, scientists know that high blood glucose in combination with high blood pressure contributes to kidney damage. Years of high blood pressure can damage the delicate filters in the kidneys, leading to less efficient removal of waste products from the blood. The good news is that there are steps you can take to reduce your risk of nephropathy.


Urine Tests for Nephropathy

Your urine needs to be checked once a year starting 5 years after the diagnosis of type 1 diabetes or starting at the diagnosis of type 2 diabetes. Make sure your urine is tested for microalbuminuria, not just proteinuria.


Complications of Nephropathy

The kidneys are so effective that noticeable problems will not appear until 80% of the kidneys are damaged. Symptoms of kidney disease may be subtle: fluid buildup, sleeplessness and tiredness, vomiting, or weakness. The complications of nephropathy are serious and include chronic kidney failure, in which your kidneys slowly stop working over time, and end-stage kidney disease, in which the kidneys completely fail and can no longer filter toxins from the body.

Prevention of Nephropathy

The most important thing you can do to prevent kidney damage is to keep your blood glucose levels close to normal. The DCCT showed that people who tightly controlled their blood glucose reduced their risk of kidney disease by 35–56%.

Another important step you can take is to keep your blood pressure on target. If your blood pressure is high, the delicate capillaries in your kidneys can become damaged. Two things that you can do to lower high blood pressure are to maintain a healthy body weight and to eat less sodium. If kidney damage is advanced or if you cannot reduce your blood pressure with these methods, you may need medications to lower blood pressure. ACE inhibitors and ARBs are blood pressure medications that also preserve kidney function.


Extra Proteins at Diabetes Diagnosis

Nephropathy should not be confused with excess protein in your urine that can occur when you are first diagnosed with diabetes. This is usually a temporary condition, caused by unchecked high blood glucose and high blood pressure. Protein in the urine may be seen temporarily during fever, after exercise, or under other temporary conditions.


Treatment of Nephropathy

The earliest sign of kidney disease is small amounts of protein in the urine, a condition called microalbuminuria. Microalbuminuria is detected using a urine test.

If you have microalbuminuria, then you may be advised to take certain steps. The first step is to bring your blood glucose levels into the target range. In the DCCT, people with microalbuminuria who tightly controlled their blood glucose cut their risk of progressing to more serious kidney disease by more than 50%. To achieve this benefit, the study participants maintained an A1C of 8.1% or lower.

Another step is to achieve optimal blood pressure control. You may be advised to begin a diet that is low in sodium. You may also take blood pressure medications, either ACE inhibitors or ARBs. These can be prescribed even if your blood pressure is in the recommended range. ACE inhibitors and ARBs slow the progression of kidney disease.

You’ll need to take more aggressive steps if your kidney disease advances. You cannot live without functioning kidneys. There are two treatment options during end-stage renal disease, when the kidneys fail. Both remedies attempt to replace the kidneys’ function: dialysis and kidney transplantation.

Dialysis

Dialysis uses a machine to artificially do the job that the kidneys are no longer able to do. There are two different types of dialysis: hemodialysis and peritoneal dialysis. They both remove toxins from the blood. The illustration on p. 247 shows the differences between the two methods.

Hemodialysis

• Your blood is removed from an artery (usually in the arm), filtered through a machine, and returned to a vein.

• Most patients go to a dialysis treatment center three times a week for 2–4 hours.

• Some patients have a trained caregiver come to their home to perform hemodialysis.

Peritoneal dialysis

• A patient’s abdominal cavity serves as the filtering site, instead of using a machine to filter the blood.

• A solution called a dialysate is poured through a small tube into the abdomen, where it is allowed to sit and collect waste products.

• After a few hours, the dialysate, which now contains the wastes, is drained out of the abdomen. This process can be performed manually by letting gravity carry the dialysate into the cavity and drain it out again. Or, a machine can carry out the exchange, usually overnight.

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Kidney Transplantation

Transplantation is usually more effective than dialysis. A new kidney functions as well as your old ones did before disease.

However, kidneys are in high demand and transplantation requires taking drugs that suppress the immune system to prevent rejection of the new kidney. Having a genetically near-identical donor is desirable, but not essential. A relative may be willing to donate a healthy kidney, or a kidney may become available from someone who has just died. People often go on dialysis while waiting for a transplant.

Some people choose to have a pancreas transplant at the same time. Pancreas transplants are always from organ donors who have died.

Transplantation has its risks as well. It is major, expensive surgery and requires good cardiovascular health. The drugs you must take to prevent immune rejection of the new kidney may put you at a greater risk of developing infections, and the new kidney will face the same pressures as the old ones did.

Nerve Disorders

The nerves in your body are like electrical circuits. They are the wires that send and receive signals from your brain and tell other cells what to do. Your body’s nervous system controls virtually everything you do and every move you make. They control your breathing, sense of feeling, blinking, and thinking, as well as move your muscles and empty your stomach.

Diabetes usually doesn’t impair the brain and spinal cord, but it can damage the nerves in other parts of the body. The nerves may be unable to send messages, may send them at the wrong times, or may send them too slowly. This is called diabetic neuropathy.

Your nerves send signals to so many places in your body that damaged nerves can have a range of effects, including pain in your feet or hands, trouble with stomach bloating or bladder or bowel control, sexual dysfunction, loss of sensation or feeling, or weakness in your muscles.

Risk of Neuropathy

• Neuropathy is more likely to affect people who have had diabetes for a long time or who have had high glucose levels for some time.

• About 60–70% of people with diabetes have mild to severe forms of neuropathy.

Causes of Neuropathy

High blood glucose seems to cause nerve damage, but no one really knows why. It may be that proteins coated with glucose cause direct damage. Or high levels of glucose may upset the chemical balance inside nerves. Or the blood supply to nerves may be cut off or constricted, and nerves may not receive the oxygen they need. The tissues surrounding them might squeeze single nerves. However, neuropathy can have causes other than diabetes.

Complications of Neuropathy

There are many types of nerve damage. Our nervous systems are so complex that it is often hard to determine exactly what type of neuropathy is present. In addition, high blood glucose levels can damage nerves in two ways: directly and by slowing down or stopping blood flow. Sometimes it’s hard to know whether a problem is caused by nerve damage or by circulation problems.

Peripheral Neuropathy

Peripheral neuropathy can affect the nerves in many parts of your body, but it is most common in the legs, feet, and hands. Sensation can be either increased or decreased in peripheral neuropathy.

Some people have muscle weakness, painful cramps, and twitching. Others complain that their feet feel numb, or they lose the ability to sense temperature or the position of their feet. Some people lose all sensation in their feet, which means they need to take extra care with their feet and protect them from injury. You may also experience changed sensations in your fingers.


Foot Dangers

With neuropathy, you can step on something and not feel it or burn your feet 

with your bath water. If you don’t realize it and treat the injury, you can get an infection. If you remain unaware of the infection and don’t treat that, serious problems can arise.


Autonomic Neuropathy

Some of your nerves control operations in your body that you don’t ever think about, like keeping your heart beating and digesting your food. These are called autonomic nerves. Autonomic neuropathy occurs when these nerves are damaged. It is complex and can have wide-ranging effects on the body.

Autonomic Neuropathy Takes Different Forms

• Gastroparesis. Your stomach and intestines slow down or become less efficient at emptying, leading to feeling full after a few bites of food, erratic glucose levels, nausea and vomiting, constipation, or diarrhea.

• Bladder Problems. Nerves to the bladder can become damaged, causing diminished sensation of bladder fullness and an inability to completely empty the bladder. Because urine can then stay in the bladder for long periods, you are at high risk for developing urinary tract infections.

• Erectile Dysfunction. Men may find that they cannot have an erection even though they may still have sexual desire. Read more about erectile dysfunction in chapter 16.

• Vaginal Problems. Women may experience vaginal dryness and decreased sexual response. Read more about vaginal problems in chapter 15.

• Blood Pressure Problems. You may find yourself feeling lightheaded or dizzy when you stand because of a drop in blood pressure. This is called orthostatic hypotension. When you exercise, your blood pressure may go way up.

• Skin Problems. Nerves to the skin may cause too much or too little sweating or very dry, itchy skin.

• Heart Problems. Nerves to the heart may fail to speed up or slow down your heart rate in response to exercise. That is one of the reasons why it is important to get a checkup before starting any exercise program. If your heart rate doesn’t respond as it should to exertion, you won’t be able to use a standard method, such as counting your pulse, to find your target heart rate during and after a workout.

Focal Neuropathy

Damage to a single nerve or group of nerves is called focal neuropathy. It may develop when the blood supply to a nerve is shut off because of a blockage in the blood vessel that supplies the nerve. It could also result from a pinched nerve. Focal neuropathy can injure nerves that sense touch and pain as well as nerves that move muscles. Fortunately, it is not usually a permanent condition. It usually goes away within 2 weeks to 18 months.

Carpal Tunnel Syndrome

Carpal tunnel syndrome is a type of focal neuropathy. It occurs about three times more often in people with diabetes than in the general population and more often in women than in men. It occurs when the median nerve of the forearm is squeezed in its passageway, or tunnel, by the carpal bones of the wrists. It can cause tingling, burning, and numbness and can make you drop things you are holding without even realizing it. You might have carpal tunnel syndrome if you have tingling in your hands or fingers that goes away when your arms are relaxed down at your sides. Carpal tunnel syndrome is often treated with splints, medication, or surgery to remove the pressure on the nerve.


Charcot’s Foot

Sometimes neuropathy can trigger a cascade of diabetes-related complications. Many people who have had diabetes for a long time develop a condition known as Charcot’s foot.

• Affects weight-bearing joints, such as the ankles.

• It may start with a loss of feeling and thinning of bones in the feet. This can lead to a painless fracture.

• Because the injury doesn’t cause pain, it can go unnoticed and untreated. You may continue walking on the fracture, making matters worse.

• Muscle shrinking (atrophy) and joint damage can occur and add to the damage, which can become severe enough to deform the foot.

• The key to treating Charcot’s foot is keeping weight off the joint and wearing special footwear early on.

• If you notice any swelling in a joint, especially in your ankle or foot, see your provider right away.


Prevention of Neuropathy

The best thing you can do to prevent neuropathy is to keep your blood glucose close to normal. The DCCT showed that people with type 1 diabetes who intensively managed their diabetes reduced their risk of neuropathy by 60%. Nerves need a constant blood supply to function properly. Keeping blood vessels healthy will protect the nerves they supply.

It’s also important to stop smoking and exercise regularly to help keep the nervous system in prime working condition. Alcohol is also a direct toxin to nerves and can be another cause of neuropathy.

Treatment of Neuropathy

Each type of neuropathy calls for a different treatment. For example, treating gastroparesis is different from treating a burning sensation in your feet. Your health care provider will help you find the best treatment for your symptoms.

Treatment of Peripheral Neuropathy

The symptoms of your neuropathy will dictate your treatment. However, managing the pain caused by neuropathy is one of the most common treatments. Many people find that their pain gets better when their glucose levels are lower. Some even notice that their pain worsens when their blood glucose levels go up temporarily. Walking may help decrease calf pain. Medications may help.

Medications for Neuropathy Pain

• Nonsteroidal anti-inflammatory drugs (NSAIDs) are generally the first medications that are prescribed.

• Low doses of antidepressants and anti-seizure medications.

• Drugs designed specifically for neuropathy pain, such as duloxetine HCl.

• Medicines that contain narcotics are generally not used unless the pain is very severe.

• Lidocaine patches can be used to numb the affected area, and a high-potency, hot pepper cream (capsaicin) can be rubbed on the area.

If these therapies aren’t effective, ask for a referral to a pain clinic. There are also less conventional methods to treat the pain. Biofeedback training, hypnosis, relaxation exercises, acupressure, acupuncture, and use of a TENS (transcutaneous electrical nerve stimulation) unit have all been effective for some people.

Treatment of Autonomic Neuropathy

Different types of autonomic neuropathy call for different treatments.

Gastroparesis. If you feel full or bloated, it may help to eat small frequent meals instead of three large ones. Medications, such as metoclopramide, can help food move through your stomach. There are other medications and dietary adjustments that you can use to treat constipation or diarrhea.

Bladder Problems. Incontinence, or urine leakage, can be treated with training in bladder control and timed urination using a planned bladder-emptying program. Rather than waiting until your bladder feels full, you can try urinating every 2 hours.

Men sometimes find it easier to urinate sitting down. Applying pressure over the bladder may also be helpful. If these steps don’t work, oral medication may be needed. Or you may need to use a catheter or have surgery. Fecal incontinence (passing stool involuntarily) is treated in a similar way, with medicine for diarrhea and biofeedback training.

Erectile Dysfunction. There are several medications and products that men can use before sex to improve and prolong an erection. The oral medications are called phosphodiesterase-5 inhibitors. Other options include vacuum pumps, constriction rings, injections, and suppositories. Read more about erectile dysfunction in chapter 16.

Vaginal Problems. There are many causes for vaginal problems such as dryness. You may need to use a water-based cream or lubricant made especially for the vaginal area. Read more about vaginal problems in chapter 15.

Blood Pressure Problems. If you are experiencing a sudden drop in blood pressure when you stand up, there are several treatment options. If you drink alcohol or take medications, such as diuretics, ask your provider about stopping them. Other options include medications for low blood pressure, raising the sodium content of your food, or raising the head of your bed.

However, low blood pressure in itself is not unhealthy. It only becomes a problem if it makes you dizzy or disoriented. Try to stand up more slowly and avoid staying still for long periods to prevent fainting. When you get up in the morning, sit on the edge of the bed before you stand up.

Infections and Skin Problems

People with diabetes have a higher risk than other people for infection and skin problems. Skin problems and infections include everything from a scrape on the toe that gets out of hand to gum disease.

Risk of Infections

• About one-third of people with diabetes will have a skin disorder caused or affected by diabetes at some time in their lives.

• Almost one-third of people with diabetes have severe gum disease.

• People with diabetes are twice as likely to need to be hospitalized to treat a kidney infection.

Causes of Infections

During infections, your white blood cells attack the invading bacteria, viruses, and fungi. Excess glucose in your blood makes the white cells less effective. This can keep them from reaching and killing the invading germs. Extra glucose in blood can also provide food for invading pathogens and make infection even more likely.

In addition, diabetes complications can make infections worse. For example, your bladder is more likely to become infected if you have neuropathy. Neuropathy can make you unaware that you need to urinate, which increases the risk for bladder infection. Having neuropathy in your arms, legs, or feet makes you less likely to notice a cut or burn because you will not feel pain. If such a wound is left untreated, even minor skin abrasions can lead to infection.


More Infections after Surgery

People with diabetes tend to have more infections after surgery: in the mouth, ears, gums, lungs, skin, feet, and genital areas and in the incision areas.


Legs and Feet Are Vulnerable to Infection

• Neuropathy numbs legs and feet, making you unaware of injury and infection.

• Injury opens the door to infection.

• Blocked blood vessels slow blood flow to the legs and feet, impairing the healing process.

• High blood glucose disables the body’s immune cells—white blood cells.

Complications of Infections

It doesn’t matter where in the body an infection happens to start—the gums, vagina, skin, or feet. Infections need to be treated. They can quickly get worse and cause serious problems.

Bacterial Infections and Gum Disease

There are several different types of bacterial infections that can occur in people with diabetes. Your nails, scalp, and eyelids can become infected. Probably the most common bacterial infection among people with diabetes is gum disease.

People with diabetes are at high risk for gum disease and periodontitis. Bacteria love to feast on the areas between your gums and teeth. If bacteria set in, they can destroy the bone in your tooth socket. This can cause sores on your gums.

If gums are inflamed or infected, they will pull away from the teeth and jawbone, and the situation can get even worse. Bacteria will multiply in the newly created gap. The teeth may even become loose and fall out.

Fungal Infections

The most common cause of fungal infections is the yeast Candida albicans, which flourishes in a moist environment nourished by high levels of glucose. It causes an itchy rash that can sometimes have scales. Fungal infections include vaginal infections and jock itch.

Many women with diabetes find that they are susceptible to vaginal yeast infections. Candida or other vaginal infections can happen to women regardless of their age, sexual activity, or hygiene. Infections occur more often after menopause because estrogen levels are lower. Estrogen helps protect the vaginal lining. Infections are also more likely to occur just before your period, during pregnancy, or after you take antibiotics for another infection.

Foot Infections

Your feet deserve special attention. No matter how much you weigh, pound for pound, your feet carry a heavy load. You never realize how important your feet are until they are injured and you suddenly find that you can’t rely on them. Because the feet are vulnerable to injury, you need to check them every day for signs of injury and infection. This is doubly important if you have neuropathy, because you may not feel pain due to an injury or abnormality.

Foot ulcers can occur in people with diabetes. The word “ulcer” probably brings stomach problems to mind, but foot ulcers are more common in people with diabetes than stomach ulcers. An injured or infected area of the bottom of the foot can develop an ulcer. When you have an ulcer, layers of skin are destroyed by infection, which causes an open wound or sore to form, which allows the infection to spread further. Foot ulcers are very serious business. If you discover that you have a foot ulcer, you need to see your provider that day or go to the emergency room.

If untreated, the ulcers may go as deep as the bone and infect the bone, too. This can happen surprisingly fast. So don’t underestimate the importance of daily foot care, especially if you have any loss of feeling in your feet.

Infectious Diseases

Common infectious diseases, such as influenza (the flu) and pneumonia, are often more serious for people with diabetes and are more likely to result in hospitalization.

Other Skin Problems

Besides infections of your skin, you may experience other diabetes-related skin problems. Atherosclerosis thickens arteries and creates skin problems in the feet and legs. Diabetic dermopathy causes scaly patches on the skin. Some rare skin problems occur when diabetes and blood glucose are way out of control. This can cause waxy skin, blisters, and other bumps.

Prevention of Infections

Keep your blood glucose in your target range to prevent many of the infections mentioned in this chapter. There are also specific tasks that you can do to prevent things such as gum disease and foot infections.

Prevention of Gum Disease

People with diabetes need to be extra vigilant about brushing their teeth and flossing daily. Have your teeth cleaned at least every 6 months.

Mouth Care Tips

• High blood glucose levels can cause severe gum disease and abscesses.

• Have your teeth cleaned and checked by the dentist at least every 6 months.

• Brush at least twice a day to fight plaque. Use a soft nylon brush with rounded ends on the bristles. Tilt the bristles at about a 45-degree angle against the gum line and brush gently in a scrubbing motion. Brush front and back and also brush the chewing surfaces.

• Brush the rough upper surface of your tongue.

• Use dental floss once a day to remove bacteria from between your teeth. Special floss holders and various types of floss are available to make flossing easier.

Prevention of Fungal Infections

Keeping your blood glucose close to your target range can help to prevent infections in the future. Avoiding irritating products, such as bubble bath and douches, may help prevent vaginal infections for some women. Keeping your groin area clean and dry may help reduce the risk of jock itch.

Prevention of Foot Infections

Your diabetes care provider needs to examine your feet at each visit. Taking your shoes and socks off when you go into the exam room will be a good reminder for him or her to check your feet.

Once each year, your feet should be examined more thoroughly. Sensation will be tested with a monofilament and a tuning fork, and your provider will check your reflexes and pulses.

Keeping the blood flowing to your feet is an important aspect of foot care. To do this, take steps to lower high blood pressure and cholesterol levels. If you smoke, ask your health care team for help in quitting.

Foot Care Tips

• Keep your feet clean and dry. Wash them every day with a mild soap. Dry them off carefully, especially between the toes. If the skin on your feet is too dry, apply a thin layer of lotion everywhere but between the toes.

• Inspect your feet and between your toes daily. Look for swollen, red areas and cuts or breaks in the skin. Feel for very cold areas (this could mean poor blood circulation) and very warm areas (this could mean infection).

• Never go barefoot. Although this is a good rule for everyone, it is really important for people who have lost sensation in their feet. Wear swimmers’ shoes whenever you go swimming.

• Make a habit of cutting your toenails to follow the curve of your toe. This helps you avoid ingrown toenails.

• Wear only comfortable, well-fitting shoes. Don’t expect to break in new shoes—they should feel comfortable right away. Shoes made of leather help your feet get the air circulation they need to stay healthy.

• Check the inside of your shoes every time you put them on. Make sure that the lining is smooth and that there are no objects inside.

• If you have a loss of sensation in your feet or have neuropathy, you may not be able to trust how a shoe feels to decide whether the fit is good for you. Find a shoe specialist who is trained to fit shoes for people with diabetes.

• Never try amateur surgery on your feet. Have your provider or podiatrist treat calluses, corns, plantar warts, and the like.

Prevention of Infectious Diseases

Flu vaccines are recommended every year for adults and children (over the age of 6 months) with diabetes. All adults need a one-time pneumococcal vaccine.

Prevention of Other Skin Problems

The number one thing that you can do to prevent skin problems is to keep your blood glucose under control. Many of the rare skin disorders are caused by extremely high blood glucose

Skin Care Tips

• Keep your skin clean. If you have dry skin, use a super-fatted soap such as Dove or Keri.

• Dry off well after washing. Be sure to prevent moisture in the folds of the skin—at the groin area, between the toes, under the breasts, and in armpits—where fungal infections are more likely. Try using talcum powder in these moist areas.

• Avoid very hot baths and showers if you have loss of sensation, because you can easily burn yourself without knowing it.

• Prevent dry skin. When you scratch dry, itchy skin, you can break the skin and open the door to bacteria. After you dry off from a shower, you may need an oil-in-water skin cream such as Lubriderm or Alpha-Keri. On cold and windy days, you may need to moisturize often to prevent chapping.

• Drink lots of water, unless your provider advises otherwise.

• Treat cuts quickly. For minor cuts, clean the area with soap, water, and hydrogen peroxide. Do not use antiseptics such as Mercurochrome, alcohol, or iodine because they irritate the skin. Only use antibiotic creams and ointments for a few days without consulting your provider.

Skin Problem Warning Signs

• Redness, swelling, pus, or pain that might indicate a bacterial infection.

• Jock itch, athlete’s foot, ringworm, vaginal itching, or other signs of a fungal infection.

• Blisters or bumps anywhere, especially on the backs of your fingers, hands, toes, arms, legs, or buttocks—these are signs of high glucose levels; rashes, bumps, or pits near insulin injection site.

• Call your health care provider immediately if you notice any of these problems.

Treatment of Infections

Treating an infection depends on the area of the body that is infected as well as the level of infection. It also depends whether the infection is bacterial or fungal in nature.

Treatment of Bacterial Infections and Gum Disease

Luckily, many bacterial infections can be treated with antibiotics, either creams or pills.

Treatments for gum disease depend on the level of gum infection. In some cases, your dentist may need to scrape the plaque from your teeth and remove tissue from around the root of the tooth. In other cases, you may need to use medications (prescription mouthwash or antibiotics) or have surgery on your gums.

Treatment of Fungal Infections

You can buy antifungal products to treat infections like vaginal infections or jock itch. They usually come as creams that are placed on the problem area. They work by destroying the yeast that causes the infection. Your pharmacist can help you choose one that will work for you.

Jock itch will usually go away if you dry the affected area and apply an antifungal cream. However, talk to you doctor if the rash persists or worsens.

With vaginal creams or suppositories, it is important that you follow the product directions carefully. Be sure to use it for the entire time, even if your infection seems better. Even though it may seem to be gone sooner, the infection is more likely to return if the treatment is not completed.

If your infection is not better after using the product for the recommended period, or if it comes back right away, make an appointment to see your primary care provider or gynecologist. They can prescribe stronger medications.

Treatment of Foot Infections

If a foot or leg infection is not treated, a part of the foot or leg may need to be removed to keep the infection from spreading dangerously or to save a person’s life.

Amputation is traumatic and is always the last resort. The surgeon will remove as little of the limb as possible to make walking possible. After the limb heals, you will most likely be fitted with a prosthesis. Today, prosthetic limbs are lighter and more comfortable than the clunkier models of the past.

Depression and Other Mental Health Disorders

Everyone gets the blues now and then. It’s easy to feel blue when there is too much stress in your life, when sad things happen to you or your family, or when the everyday strain of living with diabetes gets you down.

However, people with diabetes are twice as likely to experience clinical depression as people without diabetes. They can also have anxiety disorders such as generalized anxiety disorder or even diabetes-specific phobias.

Risks of Depression and Other Mental Health Disorders

• Clinical depression is at least twice as likely among people with diabetes compared with people without diabetes.

• Depression also reoccurs more frequently and lasts longer.

• One study found that 14% of people with diabetes have generalized anxiety disorder.

Causes of Depression

The causes of depression and other mental health disorders are not entirely clear. However, having consistently high blood glucose can contribute to the symptoms of depression, such as fatigue. In addition, some studies have shown that depression might actually be a risk factor for type 2 diabetes. In other words, if you have depression, you are more likely to develop type 2 diabetes.

Managing your diabetes might also contribute to depression or other mental health disorders. The frustration, fear, and stress that go along with managing a chronic disease can be mentally exhausting.

Complications of Depression and Other Mental Health Disorders

It’s normal to feel sad or frustrated with your diabetes sometimes. However, serious feelings of depression or anxiety disorders are nothing to ignore.

Usually, people feel relieved when they find out that depression is more common in people with diabetes. It can be comforting to know that you aren’t the only out there dealing with these problems.

Depression

Depression can occur any time—when you are first diagnosed or after you have been dealing with diabetes for years. Depression can coexist with other feelings, such as denial, anxiety, or even anger. When you are depressed, it is often harder to pay attention to your diabetes.

People respond to depression in different ways. Some find that they aren’t hungry at all, whereas others eat in order to feel better. Some people sleep all of the time; others can’t sleep at all. People with depression often withdraw from family and friends and stop doing things that they enjoy.

Symptoms of Depression

• You no longer find pleasure in activities you once enjoyed.

• You have trouble falling asleep at night or wake up once you have fallen asleep.

• You feel tired during the day.

• You no longer enjoy eating the foods you once liked.

• You find yourself eating more or less than you used to.

• You either gain or lose weight.

• You have a hard time concentrating.

• You have a difficult time sitting still.

• You cannot seem to make even the most trivial decision.

• You experience feelings of guilt or a lack of self-worth.

• You feel that everyone else would be better off without you.

• You entertain thoughts of suicide or think of ways to hurt yourself.

It is important to recognize the symptoms of serious depression and to seek help right away. Unfortunately, when you feel depressed, you probably feel even less able to seek help. But it is the best thing you can do to get your life and health back on track.

Anxiety Disorders

Feeling anxiety is normal. After all, anxiety is a survival mechanism that gets you through a difficult situation. If you are face to face with a man-eating bear or have to give a lecture in front of 1,000 people, feeling a little anxious can help you get through the ordeal. However, for some people, their worries are more intense, frequent, or last longer than for others in a similar situation. Feelings of anxiety can coexist with feelings of depression.

There are several anxiety disorders, and together these disorders affect more Americans than any other mental illness. General anxiety disorder refers to feelings of anxiety and worry about everyday life. There are also diabetes-specific phobias that can be problematic. For example, some people have excessive fear of high or low blood glucose or fear of injecting insulin or some other medication. Other people are obsessive about tracking their blood glucose or recording their results.

Signs of an Anxiety Disorder

• You feel restless, feel irritable, and have difficulty concentrating much of the time.

• You tend to feel very worried or concerned about almost everything.

• You feel tired or easily fatigued.

• You have problems sleeping.

• You avoid people or places.

• You feel panicked or scared for no reason.

• You are not able to stop thinking about something.

• You feel like you have to do something over and over again, such as washing your hands or checking door locks.

• Your muscles feel tense or you experience frequent headaches.

If your worries or concerns are beginning to interfere with daily living or prevent you from enjoying the things you once enjoyed, it is time to seek help. First, try talking with your provider. Your anxiety may have a physical cause.

If there is no physical cause, you may be referred to a mental health counselor. Through medication, counseling, or a combination of both, your mental health counselor may help you find a way to handle or decrease your feelings of anxiety.

Dementia and Alzheimer’s Disease

• People with diabetes may be at increased risk of dementia and Alzheimer’s disease.

• Dementia is the term for a group of brain problems including memory loss, personality changes, and loss of daily functioning.

• One recent study showed that older people with type 2 diabetes who had a history of hypoglycemic episodes had an increased risk of dementia.

Prevention of Depression and Other Mental Health Disorders

Keeping your blood glucose levels on target will help you feel better physically and mentally. For example, people with type 2 diabetes who have blood glucose close to normal report that they feel more zest for living and experience an improved quality of life.

There may also be a physical reason for your feelings of depression. For example, you may be taking a medication that contributes to your symptoms of depression; you may need to stop or switch medications.

However, more serious physical and mental issues may require treatment. Only your health care provider can diagnose and treat a mental health disorder, so talk to him or her if you’re struggling with depression or anxiety.

Treatment of Depression and Other Mental Health Disorders

Roughly two-thirds of people being treated for depression are cared for by their primary care physician. Your primary care physician is probably the first person you will talk to if you are having concerns about depression or anxiety.

It can be difficult to find the time to talk about depression in your regular checkup. After all, you probably have a number of diabetes issues to discuss with your health care provider. However, it is important for you, the patient, to take the time to bring up any symptoms of depression or anxiety.

Your primary care physician may feel comfortable diagnosing you—and then treating you—for a mental health disorder such as depression. Your health care provider can prescribe antidepressants or other medications to treat depression. However, your health care provider may also refer you (or you can ask to be referred) to a mental health professional.

You may see a psychiatrist, psychologist, psychiatric nurse, licensed social worker, family therapist, or other mental health counselor. Your counselor may recommend psychotherapy, medications, or both. Seeing a mental health professional does not mean that there is something wrong with you as a person. It simply means that you may have a medical problem that affects your emotions.

Psychotherapy

Psychotherapy, or talk therapy, can help treat your depression or anxiety disorder. There are several types of therapy that address mental health issues, such as modifying your thoughts and changing your behaviors.

Antidepressants

Many emotional problems are caused by chemical imbalances in the brain, and antidepressants can help you get back on track. Lots of people find successful relief from depression from a combination of talk therapy and medication.

Main Types of Antidepressants

• Selective serotonin reuptake inhibitors (SSRIs)

• Serotonin and norepinephrine reuptake inhibitors (SNRIs)

• Norepinephrine and dopamine reuptake inhibitors (NDRIs)

• Tricyclic antidepressants

• Monoamine oxidase inhibitors (MAO inhibitors)

Only you and your health care provider can help you find the right medication. Discuss any symptoms or improvements with new medications. Keep in mind that it can take up to 6 weeks for patients to notice significant differences.

You may need to try several different pills before you get the right one. Some experts say that the first antidepressant works well, but only half the time.

Keep in mind that your blood glucose or weight could be affected by antidepressants. You’ll want to ask about any side effects of these medications as well as extra steps you should be taking to monitor or treat your blood glucose.

Dealing with Complications

Despite your best efforts, you may someday develop diabetes complications. Factors you can’t control—your age, race, and genetic makeup—can affect your risk of developing complications.

If you have been taking steps to prevent complications, you may feel cheated if you develop a diabetes-related health problem. You may have many of the same feelings you had when you were first diagnosed with diabetes—anger, fear, guilt, or denial. You may feel overwhelmed that on top of dealing with diabetes and the ordinary stresses of everyday life, you now have new health problems with which to contend. You may feel tired of having worked so hard to prevent complications, only to have them develop anyway.

But there are treatments for diabetes complications, and they are getting better all the time. The earlier the signs of complications are found, the more effective these treatments can be. So be sure you are getting up-to-date information on treatments and prevention (see chapter 17 for a complete diabetes care schedule). Read all you can, and ask your diabetes care provider and other members of your health care team for updates on new treatments and research. Don’t rely on hearsay from friends and relatives, who may not be up on the latest research.



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