Most of us know something about diabetes. As described by the National Institutes of Health, it is a disorder of metabolism—the way our bodies use digested food for growth and energy. Most of the food we eat is broken down into glucose, the form of sugar in the blood. Glucose is the main source of fuel for the body. After digestion of food, glucose passes into the bloodstream where it is used by cells for growth and energy. For glucose to get into cells, insulin must be present. Insulin is a hormone produced by the pancreas, a large gland behind the stomach. When we eat, the pancreas automatically produces the right amount of insulin to move glucose from the blood into our cells. In people with diabetes, however, the pancreas either produces little or no insulin, or the cells do not respond appropriately to the insulin that is produced. Glucose builds up in the blood, overflows into the urine, and passes out of the body in the urine. Thus, the body loses its main source of fuel even though the blood contains large amounts of glucose.

Because it is so common, most of us likely know someone, perhaps even ourselves, who has diabetes. It is estimated that 20.8 million people in the United States—7.0 percent of the population—have diabetes. Of these, 14.6 million have been diagnosed, and 6.2 million have yet to be diagnosed. In 2005, about 1.5 million people aged 20 or older were diagnosed with diabetes. The most common form of diabetes is type 2 diabetes, as 90 to 95 percent of people with diabetes have this type of the disease. This form of diabetes is most often associated with older age, obesity, family history of diabetes, previous history of gestational diabetes, physical inactivity, and certain ethnicities. It is thought that about 80 percent of people with type 2 diabetes are overweight. Symptoms of type 2 diabetes develop gradually, unlike the quicker onset of type 1 diabetes. Symptoms may include fatigue, frequent urination, increased thirst and hunger, weight loss, blurred vision, and slow healing of wounds or sores. There are some people who have no symptoms; this group likely contributes to the high degree of undiagnosed diabetics.

A recent report, State of Diabetes Complications in America, examined the prevalence and cost of complications that result from type 2 diabetes. It is estimated that three out of five people with type 2 diabetes have at least one of the serious health problems commonly linked to the disease. These health problems take a heavy financial toll on the United States. In 2006, the nation spent an estimated $22.9 billion on direct medical costs related to diabetes complications. The report showed that estimated annual healthcare costs for a person with type 2 diabetes complications are about three times higher than that of the average American without diagnosed diabetes. These complications include heart disease, stroke, eye damage, chronic kidney disease and foot problems that can lead to amputations. They cost a person with type 2 diabetes almost $10,000 each year. People with diabetes complications pay nearly $1,600 out of their own pockets for costs not reimbursed by insurance, such as co-payments and deductibles. This amount is significant considering an estimated 40 percent of adults with diabetes reported a family income of less than $35,000 per year in 2005.

The paper on complications from diabetes pointed out that many people with type 2 diabetes develop more than one health complication associated with the disease. It is estimated that one out of three people with the disease has one other serious health problem; one out of ten people has two other serious health problems; one out of 15 people has three other serious health problems; and one out of 13 people has four or more other serious health problems. The report estimated that in people with diabetes, there are specific health problems that are more prevalent than in people with normal blood sugar levels. The prevalence of problems related to the heart and large blood vessels in people with diabetes vs. people with normal blood sugar levels were listed as:

• Congestive heart failure occurs in 7.9 percent of people with diagnosed diabetes vs. 1.1 percent of people without diabetes

• Heart attack occurs in 9.8 percent of people with diabetes vs. 1.8 percent without diabetes

• Coronary heart disease occurs in 9.1 percent of people with diabetes vs. 2.1 percentwithout diabetes

• Stroke occurs in 6.6 percent of people with diabetes vs. 1.8 percent without diabetes

In terms of problems related to small blood vessels, the prevalence is as follows:

• Chronic kidney disease occurs in 27.8 percent of people with diabetes vs. 6.1 percent without diabetes

• Foot problems such as foot/toe amputation, foot lesions and numbness in the feet occur in 22.8 percent of people with diabetes vs. 10 percent without diabetes

• Eye damage occurs in 18.9 percent of people with diabetes.

While type 2 diabetes is closely tied to the development of these complications, it is possible that some people may have developed these health problems independent of their diabetes, due to family history or other underlying medical conditions.

Comments: The report, State of Diabetes Complications in America, has a sobering effect in showing that there is a high risk of developing health complications associated with type 2 diabetes. It suggests that patients must be ever vigilant to managing their disorder. Perhaps the only bright is that there are approaches that can be taken to prevent diabetes or to control the condition once it develops. Key to both prevention and control is daily self-management by patients of their health and behavior.

Prevention. The Diabetes Prevention Program was a major clinical trial conducted with support from the National Institutes of Health. They analyzed whether behavioral changes, such as diet and exercise, would have the same effect as medication in preventing or delaying the onset of type 2 diabetes in people with impaired glucose tolerance (IGT). The results showed that lifestyle behavioral sharply reduced the chances that a patient with IGT would develop diabetes. Medications also reduced risk, but less dramatically. The approach that should be taken with an individual patient, however, would depend upon their IGT. Whereas lifestyle changes may be enough for one person, these behavioral changes coupled with medications might be needed by a second patient with diabetes. The success of any approach taken by someone with the disorder, however, could depend upon how effective and confident he or she is at performing self-management skills on a regular basis.

Controlling diabetes

Taking care of diabetes is a team effort between a patient and his or her health care team—doctor, diabetes nurse educator, diabetes dietitian educator, pharmacist, and others. The patient, however, is the most important member of the team, as he or she must perform the daily behaviors needed to control diabetes. People with type 2 diabetes need to work with their healthcare provider to develop a personal diabetes management plan. A good plan includes healthy eating and regular physical activity although, as noted, these lifestyle changes alone may not be enough to lower blood sugar adequately. Many people with type 2 diabetes also may need one or more medications. Some drugs work together in different ways to control blood sugar levels. People should track how their diabetes plan is working by monitoring their blood sugar regularly and checking with their doctor to see if more lifestyle or medicine changes need to be made.

If you have type 2 diabetes, other common behaviors you should perform on a daily basis include:

• Follow the healthy eating plan that you and your doctor or dietitian have worked out. If you stick to the plan, you are likely to keep your diabetes under control. No one is perfect and you cannot be expected to always eat in accordance with your plan. However, don’t get upset over any setbacks; make them but brief glitches in your attempt to eat properly by gaining the confidence you can manage personal setbacks. That can only come through the self-efficacy you acquire through successful performance.

• Be active a total of 30 minutes most days. Ask your doctor what activities are best for you, although many of you have exercises you like to perform. Do something you agree to do and, hopefully, enjoy. That makes the 30 minutes period of exercise something you look forward to each day.

• Take your medicines as directed. The behavior of taking drugs should be one you establish as part of your daily life. Work out with your doctor the best schedule for you in taking medications, set up reminders of when they should be taken, and always take them as directed. Again, no one is perfect and you will likely miss taking a dose of a prescribed drug from time to time. Know the instructions of all of the drugs you take on how to manage a missed dose. Rather than being discouraged at a missed dose, have plans to remedy the matter and bounce back to your regular schedule.

• Check your blood glucose every day if asked to do so. Each time you check your blood glucose, write the number in your record book. Self-monitoring your behavior is the backbone of self-management; the better you can observe and record what occurs, the better a picture you and your health care provider have of your diabetes. Your blood glucose results will help you and your health care provider prepare a plan for keeping your blood glucose under control. Always bring your record book to your doctor visits so you can talk about reaching your glucose goals.

• Check your feet every day for cuts, blisters, sores, swelling, redness, or sore toenails. If you notice changes, you may want to talk to your doctor during your next visit.

• Brush and floss your teeth every day. This suggestion is good for anyone, including those of us who don’t have diabetes.

• Control your blood pressure and cholesterol. This is yet another bromide for all of us.

• Don’t smoke.

In large measure, how well your diabetes is controlled depends on you. This is why self-management is rapidly becoming such a big part of the treatment of the disorder. Your doctor or health care provider can assist you in finding a self-management program that will work for you and your needs. With proper performance of the skills you learn, the likelihood is that you will never need to worry about complications, such as those described, from diabetes.

There are a number of websites that include information on diabetes, particularly type 2 diabetes. Perhaps the most comprehensive site is a discussion of a number of topics that are online at www.nih.gov/ Complications from type 2, as described in this essay, can be found at www.stateofdiabetes.com/ The report is well worth reading if you are concerned about any complications in having type 2 diabetes.