The long-term goals of treatment are to prolong life, improve the quality of life and prevent diabetes-related complications such as blindness, kidney failure and amputation of limbs.

These goals are accomplished through education, insulin, meal planning and weight control, exercise, self-testing of blood glucose, foot care and careful monitoring of blood glucose levels.

INSULIN:
Insulin lowers blood sugar by allowing it to leave the blood stream and enter body cells. Everyone needs insulin. People with Type I diabetes can't make their own insulin, and they must take insulin injections every day to survive. Insulin is injected under the skin using a syringe, or in some cases, an infusion pump that delivers the insulin continuously. It is not available in an oral form.

Insulin preparations differ in how fast they start to work and how long they work. The health care professional measures blood glucose to determine the appropriate type of insulin to use. More than one type of insulin may be mixed together in an injection to achieve the best control of blood glucose.

The injections are needed, in general, from 1 to 4 times a day. People are taught how to give insulin injections by their health care provider or a diabetes nurse educator. Initially, a child's injection may be given by a parent or other adult. By age 14, most children can be expected, but not required, to give their own injections.

GLUCAGON EMERGENCY KIT:
Glucagon is a medication that is injected and raises blood sugar. Every person who takes insulin should have glucagon on hand. It is indicated when the blood sugar gets so low that the person is unable to swallow or loses consciousness.

People in close contact with the diabetic should be instructed on how to give glucagon in an emergency, since the person needing it may be unable to do so.

CURRENT RESEARCH:
Pancreas transplants have been attempted to treat diabetes with varied success due to the need for long-term use of drugs to suppress the immune system. Studies are now underway to evaluate a new beta-cell transplantation procedure.

Additional research efforts are aimed at developing an insulin pump that can sense glucose levels and release appropriate insulin amounts, similar to the function of the pancreas.

EDUCATION:
You are the most important person in managing your diabetes. Diabetes education is therefore a crucial part of the treatment plan. Diabetes education basically involves learning how to live with your diabetes.

Knowledge of disease management is imperative to avoid developing short term complications (hypoglycemia, hyperglycemia) and to delay or slow the onset of long term complications of the disease (diabetic retinopathy - eye disease, nephropathy - kidney disease). See also diabetes- diabetic education.

You should be knowledgeable about the basic principles (survival skills) of diabetes management. Basic "survival skills" include:

• how to recognize and treat low blood sugar (hypoglycemia)
• how to recognize and treat high blood sugar (hyperglycemia)
• meal planning (refer to DIABETIC DIET)
• how to administer insulin
• how to test and record blood glucose (see blood glucose monitoring) and urine ketones (see urine ketone monitoring)
• how to adjust insulin and/or food intake during exercise (see EXERCISE AND WEIGHT CONTROL FOR DIABETICS)
• how to handle sick days (see DIABETIC SICK DAYS)
• where to buy diabetic supplies and how to store them

DIABETIC DIET:
Diabetic diet management for insulin-dependent diabetes (Type I) requires dietary consistency to allow food and insulin to work together to regulate blood glucose levels. If meals and insulin are out of balance, extreme variations in blood glucose can occur.

The American Diabetes Association and the American Dietetic Association developed 6 food exchange lists for planning healthy, balanced meals. Consultation with a registered dietitian or nutrition counselor is an invaluable tool for meal planning and dietary control for diabetics. See diabetes- diabetic diet.

PHYSICAL ACTIVITY:
Regular exercise is especially important for the person with diabetes. It helps control the amount of sugar in the blood and helps burn excess calories and fat to achieve optimal weight.

Before people with diabetes begin any exercise program, they should obtain medical approval. Diabetic's, especially Type I diabetics, must take special precautions before, during and after participation in intense physical activity or exercise. See diabetes- exercise and weight control.

SELF-TESTING:
Blood-sugar testing or self monitoring of blood glucose is done by checking the glucose content of a small drop of blood. The testing is done on a regular basis and will inform the person with diabetes how well diet, medication, and exercise are working together to control diabetes.

The results can be used to adjust meals, activity, or medications to keep blood-sugar levels within an appropriate range. It will provide valuable information for the health care provider to suggest changes to improve care and treatment. Testing will identify high and low blood-sugar levels before serious problems develop. See diabetes- blood glucose monitoring.

FOOT CARE:
People with diabetes are prone to foot problems because of complications of the diabetes. Diabetes cause damage to the blood vessels and nerves. These changes can result in a decreased ability to sense trauma or pressure on the foot. A foot injury could go unnoticed until severe infection develops.

Additionally, diabetes alters the bodies immune system, thus decreasing the bodies ability to fight infection. Small infections can rapidly progress to death of the skin and other tissues (necrosis), necessitating amputation.

To prevent injury to the feet, diabetics should adopt a daily routine of checking and caring for the feet. See diabetes - diabetic foot care.

MONITORING:

• Visit your physician and/or diabetes educator at least 4 times a year.
• Have your glycohemoglobin (HbA1c) measured 4 times a year to evaluate your level of glucose control.
• Have your cholesterol and triglyceride level, and kidney function evaluated yearly.
• Visit your ophthalmologist (preferably one that specializes in diabetic retinopathy) at least once a year, more frequently if signs of diabetic retinopathy.
• Every 6 months have a thorough dental cleaning and examination. Inform your dentist and hygienist that your are a diabetic.
• Daily, monitor your feet for early signs of injury or infection. Make sure that your health care provider inspects your feed at each visit.
• Get a flu shot every year in the fall.

Prognosis

The outcome for diabetes mellitus varies. Recent studies show that tight control of blood glucose can prevent or delay the progression of eye disease, kidney disease and nervous system disease that is caused by diabetes. However, complications may occur even when good diabetes control is achieved with insulin and diet.

Complications

EMERGENCY COMPLICATIONS:

• DIABETIC KETOACIDOSIS

  In a person with diabetes, if insulin is not present for the body to use glucose as a fuel source, body fat is used as fuel. The by-products of fat metabolism are ketones.

  Ketones build up in the blood and "spill" over into the urine. A condition called ketoacidosis develops when the blood is made acidic by ketones.

• HYPOGLYCEMIA

  Hypoglycemia (low blood glucose) occurs when the balance between insulin, food intake and exercise is disturbed. Symptoms of mild hypoglycemia include hunger, nervousness and fast heart rate. More serious hypoglycemia can lead to confusion and even loss of consciousness. Loss of consciousness due to low blood sugar is called hypoglycemic coma.

LONG-TERM COMPLICATIONS:

People who have had diabetes for several years are likely to develop long-term complications.

A recent study called the Diabetes Control and Complications Trial (DCCT), sponsored by the National Institutes of Health, showed that a program of tight glucose control, with frequent self glucose monitoring, can actually delay or slow the progression of complications caused by insulin dependent diabetes (Type I). These serious complications include:

• VASCULAR DISEASE

  By age 55, about 35% of men and women with Type I diabetes have died from a heart attack compared to 8% of non-diabetic men and 4% of non-diabetic women.

  Type I diabetics are also at higher risk to develop blockages in the major arteries of the legs than non-diabetics. Type I diabetics can lower their risk of vascular disease by tight control of blood glucose, aggressive treatment of cholesterol and blood pressure, regular exercise, and avoiding or quitting tobacco products.

• MICROVASCULAR DISEASE

  Microvascular (small vessel) changes occur in capillaries of every organ of the body. There is a thickening of the wall of the small blood vessels. These changes are responsible for many of the diabetes complications.

• EYE COMPLICATIONS

  Changes in the small blood vessels of the retina (also known as diabetic retinopathy) predispose the diabetic to several eye disorders. After 15 years of diabetes, 80% of diabetics will have some diabetic retinopathy.

  If bleeding and scarring has developed, a retinal detachment may occur, causing blindness. Vascular changes in the iris may cause obstruction of the flow of ocular fluid and cause glaucoma. Diabetics are also more likely than non-diabetics to develop cataracts.

• DIABETIC NEPHROPATHY (kidney disease/degeneration)

  Kidney abnormalities may be noted early in the disease. Also, poorly controlled diabetes may accelerate the development of kidney failure. Urinary tract infections in diabetics tend to be more severe and may result in kidney damage.

  Diabetics are more vulnerable to kidney damage from high blood pressure than non-diabetics.

• DIABETIC NEUROPATHY(nerve damage)

  People with diabetes may develop temporary or permanent damage to nerve tissue. Neuropathy is more likely to develop if blood glucose is poorly controlled. Some diabetics will not develop neuropathy, while others may develop this condition relatively early.

  On average, symptoms such as numbness and tingling occur 10 to 20 years after diabetes has been diagnosed.

• DIABETIC FOOT PROBLEMS

  The feet of diabetics are very susceptible to infection and injury. Studies have shown that 20% of all diabetes-related hospital admissions are for foot problems, and half of all non-accident related leg amputations are performed on diabetics.

  Several foot problems are common in people with diabetes, including skin changes (loss of hair, loss of ability to sweat, and dry, cracked skin), arterial insufficiency (impaired blood supply to feet), neuropathy (decreased ability to feel pressure or injury), and specific foot deformities (hallux valgus, bunion, hammertoe, calluses).

• SKIN AND MUCUS MEMBRANE PROBLEMS

  People with diabetes are more likely than non-diabetics to develop infections. Hyperglycemia (high blood sugar) predisposes diabetics to fungal infections of the skin, nails and female genital tract and urinary tract infection.

Call Your Health Care Provider If:

Medical follow-up for a person newly diagnosed with Type I diabetes mellitus will probably occur weekly until good control of blood glucose is achieved. The health care provider will want to review results of home glucose monitoring, urine testing, and a diary of meals, snacks, and insulin injections. As the disease becomes more stable, follow-up visits will be less frequent. Periodic evaluation is very important for the evaluation of long-term complications associated with diabetes.

Call your health care provider or go to the emergency room if symptoms of ketoacidosis are present:

• increased thirst and urination
• nausea
• deep and rapid breathing
• abdominal pain
• sweet smelling breath
• loss of consciousness (This may occur in insulin dependent diabetics when a dose of insulin is missed, or if illness or infection is present.)

Go to the emergency room or call the local emergency number (such as 911) if symptoms of severe hypoglycemia or insulin reaction are present:

• trembling
• weakness
• drowsiness
• headache
• confusion
• dizziness
• double vision
• lack of coordination
• convulsions or unconsciousness

Early signs of hypoglycemia may be treated at home by ingesting a sugar source or injecting glucagon. If the signs of hypoglycemia are not relieved by the above action or if blood glucose levels remain below 60 mg/dl go to the emergency room.

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