Noninsulin-dependent diabetes mellitus (NIDDM)

Causes and Risks:
Diabetes is a life-long disease for which there is not yet a cure. There are several forms of diabetes mellitus : insulin-dependent diabetes mellitus ( IDDM or Type I); noninsulin-dependent diabetes mellitus (NIDDM or Type II), gestational diabetes mellitus , and a several other genetic syndromes.

In noninsulin-dependent diabetes mellitus (NIDDM or Type II), insulin levels may be normal, high, or low. Insulin resistance is present and decreased sensitivity to insulin of liver, muscle , and fat-tissue is also present. The metabolism of carbohydrates , fats , and protein in diet is altered.

Noninsulin-dependent diabetes mellitus usually does not require insulin, but is treated primarily with diet and exercise . Sulfonureas (oral "antidiabetic" medications) or occasionally insulin may be required in some individuals. The onset of the disease usually occurs gradually. At the time of diagnosis, 75% of people are obese , but the disease can develop in lean people, especially in the elderly. The cause of this disease is unknown, but genetic and environmental factors may play a role. Risk factors for type II are obesity , physiological or emotional stress , pregnancy , certain medications, being over 40 years old, and family history. Diabetes mellitus affects up to 5% of the population in the U.S., almost 14 million people. Noninsulin-dependent diabetes mellitus accounts for 90% of all cases of diabetes mellitus. The incidence is increased among Native Americans, African-Americans, and Hispanics.

In children, there tends to be a strong genetic predisposition in those who develop NIDDM.

Prevention:
Controlling body weight ( weight management ) in individuals at risk may prevent the onset of Type II diabetes in certain people.

Symptoms:

Note: There may be no symptoms or symptoms develop slowly.

Signs and Tests:

Evaluation for complications may include:



Treatment:
At diagnosis, the goals of treatment are to stabilize the metabolism , restore normal body weight, and eliminate the symptoms of high blood glucose . The ongoing goals of treatment are to prolong life, relieve symptoms, and prevent long-term complications. These goals are achieved through diabetes education, careful dietary management and weight control , regular physical activity , medication, self-testing, and proper foot care.

EDUCATION
Diabetes education is an important part of a treatment plan. Diabetes educators and health care providers can teach essential skills needed after initial diagnosis of the disease. Appropriate education teaches a person with diabetes how to incorporate the management principles into daily life and become less dependent upon the health care provider.

Basic principles, called survival skills, include:

  • how to take oral hypoglycemic agents, if indicated
  • what to eat and when
  • how to test and record blood glucose (see blood glucose monitoring ) and urine ketones
  • how to recognize and treat low and high blood sugar
  • how to handle sick days
  • where to buy diabetes supplies and how to store them

Learning the basic principles of diabetes self-care and establishing a routine may take several months. Then in-depth diabetes education programs can help the diabetic learn more about the disease process, learn how to control and live with diabetes, and learn intermediate and long-term complications of the disease. Annual review of diabetic education is recommended to help the diabetic stay current on new research and treatment.

DIETARY MANAGEMENT AND WEIGHT CONTROL
Meal planning includes choosing healthy foods, eating the right amount of food, and eating meals at the right time. The American Diabetes Association and the American Dietetic Association developed 6 food exchange lists for the purpose of planning diabetic meals. The 6 lists are: starch/bread, meat and substitutes, vegetables, fruits, milk or dairy, and fat . Every food on each list has approximately the same amount of carbohydrate , fat, protein , and calories for the amount given. Any food on the list can be exchanged for any other food on the same list. The food exchange lists also show the number of food choices that can be eaten at each meal and snack. Using the foods on the exchange list along with a personally designed meal plan will control the distribution of calories and the balance of insulin throughout the day.

In noninsulin-dependent diabetes, weight management and a well balanced diet are important. Some noninsulin-dependent diabetics can discontinue medications after intentional weight loss , although the diabetes is still present. Consultation with a registered dietitian or nutrition counselor is an invaluable planning tool.

REGULAR PHYSICAL ACTIVITY
Regular exercise is important for everyone, but especially for diabetics. Regular exercise helps control the amount of sugar in the blood. It also helps burn excess calories and fat to achieve optimal weight. Exercise improves overall health by improving blood flow and blood pressure . Exercise also increases the body's energy level, lowers tension , and improves a person's ability to handle stress . Everybody should obtain medical approval before starting an exercise program, but this is especially important if you have diabetes.

The following should be considered:

  • Choose an enjoyable physical activity that is appropriate for the current fitness level.
  • Exercise every day, and at the same time of day if possible.
  • Monitor blood glucose levels by home testing before and after exercise.
  • Carry food that contains sugar in case blood glucose levels get too low during or after exercise.
  • Carry diabetes identification card and change for a phone call in case of emergency.
  • Drink extra fluids that do not contain sugar during and after exercise.
  • Changes in exercise intensity or duration may mean diet or medication modification to keep blood glucose levels in an appropriate range.

MEDICATION
When the person with noninsulin-dependent diabetes cannot achieve normal or near-normal blood glucose levels with diet and exercise, medication is added to the treatment plan. Medication is not a substitute for diet and exercise, however.

The diabetic may require oral hypoglycemic agents. Taken by mouth, to lower blood glucose levels. These medications are not the same as insulin and are not effective for a person with Type I diabetes who does not make insulin. The medications help people with Type II diabetes to lower blood sugar levels , triggering the body to release more insulin into the bloodstream and helping move glucose from the bloodstream into the cells. The medication is usually taken once or twice a day. Some people may find they no longer need medication if they lose weight. This happens because, in some people, their own insulin works better for them if their ideal weight is reached. The medication is usually not given in pregnancy .

For some insulin-dependent diabetics, insulin may be added to the treatment plan during infection, injury, surgery, or pregnancy. Insulin may also be advised for noninsulin-dependent diabetics who have poor blood glucose control with oral hypoglycemic agents, or reaction to oral hypoglycemic agents. Insulin must be injected under the skin using a syringe, or, in some cases, an infusion pump. 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 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 requiring insulin injections are taught how to give themselves injections by their health care provider or a diabetes educator referred by their provider.

SELF-TESTING
Blood sugar testing or self-monitoring of blood glucose is done by checking the sugar (glucose) content of a small drop of blood. Regular testing tells the diabetic how well diet, medication, and exercise are working together to control diabetes. The results of the test can be used to adjust meals, activity, or medications to keep blood sugar levels in an appropriate range. Testing provides valuable information for the health care provider and identifies high and low blood sugar levels before serious problems develop.

There are two methods of testing blood glucose measurements at home. One is a visual comparison with small plastic strips. A small drop of blood is placed on the pad of a strip, and the color change is matched with the colors on the test strip bottle. The results are accurate if small changes in shades of color can be determined. The results are given in a range rather than a specific number. The second type is a meter test that provides a more exact reading of blood glucose. A test strip is used, and placed in a meter to read the result. Testing is easy to do. A health care provider or diabetes educator will help set-up an appropriate testing schedule. Tests are usually done before meals and at bedtime. More frequent testing may be indicated during illness or stress. Accurate record keeping of the test results will make the testing more useful for planning the care of the person with diabetes.

Ketone testing is a 2nd test that is used more frequently in Type I diabetes, but is also used in Type II diabetes during stress, illness, or complications. The test is done on a sample of urine. Ketones build up in the blood and spill over into the urine when sugar is not available as a fuel for the body, and fat is burned as an alterative fuel source. High levels of blood ketones may result in a serious condition called ketoacidosis .

Ketone testing is usually done in the following circumstances:

  • when the blood sugar is over 240 mg/dl (milligrams per deciliter)
  • illness
  • nausea or vomiting
  • ketoacidosis
  • extreme stress
  • pregnancy

FOOT CARE
People with diabetes are prone to foot problems because of complications that are caused by damage to large and small blood vessels, damage to nerves, and decreased ability to fight infection. Blood flow to the feet may become compromised, and damage to the nerves may cause an injury to the foot to go unnoticed until infection develops. Death of skin and other tissue can occur necessitating its removal.

To prevent injury to the feet, a daily routine of checking and caring for the feet should be adopted. Check the feet every day and report sores or changes and signs of infection. Wash the feet every day with lukewarm water and mild soap, and dry thoroughly. Soften dry skin with lotion or petroleum jelly. Protect the feet with comfortable, well-fitting shoes. Exercise daily to promote good circulation. See a podiatrist for foot problems, or to have corns or calluses removed. Remove shoes and socks during a visit to the health care provider to remind them to examine the feet.

Smoking worsens blood flow to the feet and should be discontinued.

SUPPORT GROUPS
The stress of illness can often be helped by joining a support group where members share common experiences and problems. See diabetes - support group .

Prognosis:
The outcome for diabetes mellitus varies. Even with good control by diet and medication of both types of diabetes , complications may result.

Complications:
Emergency complications:

Other complications:



Call Your Healthcare Provider:
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 when blood sugar control is inadequate, or if infection is present.

Call the health care provider if symptoms of insulin reaction are present: trembling , weakness , drowsiness , headache , confusion , dizziness , double vision , lack of coordination . This can rapidly progress to emergency conditions such as convulsions , unconsciousness , or hypoglycemic coma .


Mal perforans on the heel of the foot: This condition results from changes in the vasculature that supplies the extremities. This individual has diabetes, which is responsible for his vascular disease and ultimately responsible for this condition.