Diabetes is rapidly becoming a national epidemic. An estimated eighteen million Americans have diabetes and the number is growing, especially among children. The Centers for Disease Control and Prevention (CDC) reports that between 1990 and 1998, the incidence of diabetes rose by 70% in the population aged 30-39, by 40% among those 40-49, and by 31% in the 50-59 age group. Even more frightening is the fact that it is estimated that as many as 33% of the population with Type I diabetes and up to 55% with Type II go undiagnosed.
Many patients have been hyperglycemic for at least six years before diagnosis. Many chronic complications have been implicated with the diagnosis of diabetes. Keeping these conditions in check is vital. Retinopathy is damage to the small blood vessels in the retina. It is important to note that there are no early warning signs for retinopathy. Annual eye exams with an ophthalmologist is imperative to catch this condition early.
Retinopathy is the most frequent cause of new blindness and is related to the duration of the diabetes and also to the level of glucose control. In the nonproliferative stage there may no evidence of disease in the retinal vessels or there may be signs of beginning damage, such as yellow deposits. Microaneursyms, or intraretinal hemorrhages may be seen on exam. In this stage the treatment is blood pressure control, blood glucose control, and annual dilated eye exam.
In the proliferative stage there is abnormal, fragile retinal vessel growth, vitreous hemorrhage, and vision loss. Common complaints are blurred vision, or spots and cobwebs in the visual field. Treatment for this stage is photocoagulation, which involves 1200-1600 scatter burns throughout the periphery of the eye, surgery for retinal detachment, and vitrectomy for persistent vitreous hemorrhage. The third phase of retinopathy is maculopathy, or macular edema.
This involves a loss of central vision and the treatment is photocoagulation with argon laser. Retinopathy (treated or untreated) may worsen with exercise that increases intraabdominal pressure. This would include stretches, isometrics, rapid head movements, weight lifting, excessive jarring movements, and repetitive low head position movements. Another complication associated with diabetes is nephropathy. The kidneys filtering ability lessens and allows waste to remain in the blood. There are no early warning signs.
Interestingly, 95% of patients with nephropathy also have retinopathy. Diabetes is the most common cause of ESRD (End Stage Renal Disease) and accounts for 30% of all cases. Native Americans, and Hispanic Americans are at higher risk that their white counterparts. Renal failure occurs in 5-15% of patients with Type II, and 30-40% with Type I diabetes. Renal disease is classified in stages from I-V. Stage I begins at diagnosis and there are no symptoms, although there may be renal hypertrophy and hyperfunction.
Microalbumin levels are normal. Stage II usually begins after about two years. In this stage there are no symptoms, although there may be structural changes such as glomerulosclerosis. Stage III usually occurs after approximately 7-15 years and is accompanied by hypertension and a positive microalbumin level. Stage IV starts at 10-30 years after diagnosis and includes proteinuria.
Stage V is ESRD and usually occurs 20-40 years after diagnosis. Dialysis is the temporary treatment until a transplant is possible for end-stage renal disease. Onset of nephropathy may be prevented or delayed by blood sugar control, tight blood pressure control, ACE inhibitors, and microalbumin screening. This screening should begin at diagnosis and then be done annually with Type II, and for Type I screening should begin around five years after diagnosis and then done annually.
Other renal threats to watch for in diabetic patients are urinary tract infections, and neurogenic bladder. It is important that a urinalysis be performed at every visit with the doctor, especially for older individuals. Positive cultures should be treated with antibiotics. Neurogenic bladder symptoms include frequent voiding, nocturia, incontinence and frequent urinary tract infections. If pharmacologic therapy does not prove to be successful, intermittent straight catheterization 2-3 times a day will be necessary. Peripheral neuropathy is the most common long-term complication of diabetes.
Distal nerves of the hands and feet are the first to be affected. There are varying degrees of severity and the diagnosis usually comes late in the process after damage has already started. The process is irreversible and there is no specific treatment, except to treat the symptoms. Symptoms begin with parathesia, then progresses to burning pain and aching (usually more intense at night), to numbness and tingling, and finally to loss of sensation. Loss of protective sensation (LOPS) is the #1 cause of foot injuries, ulcers, and amputations.
An annual foot exam with monofiliment testing is essential for diabetics. There are over 50,000 lower extremity amputations from diabetic complications every year. Some of the risk factors for diabetic foot include LOPS, vascular insufficiency, limited joint mobility, obesity, impaired vision, poor glucose control which leads to impaired wound healing, and poor footwear which causes tissue breakdown. Vascular signs and symptoms of diabetic foot include cold feet, intermittent claudication of calf or foot, pain at rest (especially at night), absent pedal, popliteal, or femoral pulses, prolonged capillary filling time (>3-4 seconds), and decreased skin temperature. Neurologic signs and symptoms include burning, tingling, or crawling sensations, pain and hypersensitivity. There may also be diminished to absent sweating, and diminished to absent deep-tendon reflexes.
Musculoskeletal signs and symptoms include a gradual change in foot shape, foot drop, rocker-bottom foot, or cavus feet with claw toes. Dermatologic signs and symptoms include slow-healing or non-healing wounds, necrosis, cyanosis, redness, chronic scaling, dryness, and itching of the feet. There may also be recurrent infections such as athletes foot. Diligent foot care should be taken to avoid amputation.
High-risk patients need to be identified. This would include those people with peripheral vascular disease, LOPS, neuropathy, foot deformities, and either a current foot ulcer or a history of one. Referral for foot care and special shoes or inserts if necessary should be considered. Diabetic patients must be taught the importance of reducing modifiable risk factors such as smoking, hypertension, hyperglycemia, hyperlipidemia, and obesity.
Foot ulcers must be managed aggressively with non-weight bearing treatment. A daily foot inspection along with checking the inside of shoes daily is important. Pain is not always a reliable indicator of problems. Regular foot evaluations by a physician with monofiliment testing are essential to maintain healthy feet. Another complication of diabetes is macrovasular disease, which involves multiple assaults on the vascular system. The three most common are coronary artery disease, cerebral vascular disease, and peripheral vascular disease.
Coronary artery disease accounts for 50-60% of all deaths in diabetic patients. The mortality rate from cerebral vascular disease is 3-5 times greater in the diabetic population, and 50% of all nontraumatic lower extremity amputations are related to peripheral vascular disease in diabetic patients. Risk factors are hypertension, hyperglycemia, hyperlipidemia, smoking, inactivity, obesity, and age. Interventional treatments would include aggressive treatment of hypertension, cessation of smoking, optimal blood sugar control, exercise, treatment for hyperlipidemia, and proper nutrition.
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