Complications of Diabetes
Heart Disease and Stroke
Diabetes carries an increased risk for heart attack, stroke, and complications related to poor circulation. Too much glucose in the blood for prolonged periods of time can lead to damage in many parts of the body, such as the heart, blood vessels, eyes, and kidneys. In the heart and blood vessels, diabetes can lead to heart attacks and strokes, the leading causes of death for people with diabetes. According to the American Diabetes Association, adults with diabetes have heart disease death rates about 2 to 4 times higher than adults without diabetes, and the risk for stroke is 2 to 4 times higher, with the risk of death from stroke 2.8 times higher among people with diabetes. In women with diabetes, deaths from heart disease have increased 23 percent over the past 30 years compared to a 27 percent decrease in women without diabetes. Deaths from heart disease in men with diabetes have decreased by only 13 percent compared to a 36 percent decrease in men without diabetes.
Heart Disease
Heart disease in patients with diabetes is generally associated with coronary atherosclerosis, or the deposition of fatty materials inside vessel walls causing clogging and hardening of the arteries. Narrowed and clogged blood vessels place diabetics at a 3 to 5 times greater risk of myocardial infarction, which is the leading cause of death in patients with type 2 diabetes. Cardiovascular disease risk is increased in patients with type 1 diabetes as well; although, the absolute risk is lower than in patients with type 2 diabetes. The increased risk in patients with type 2 diabetes reflects the combination of hyperglycemia, or high blood glucose levels, hyperlipidemia, high lipid or cholesterol levels, hypertension and blood coagulation abnormalities. Blockage of the blood vessels and high blood glucose levels cause damage to the heart muscle that also causes irregular heartbeats or arrhythmias. People with damage to the heart muscle, a condition called cardiomyopathy, may have no symptoms in the early stages, but later they may experience weakness, shortness of breath, a severe cough, fatigue, and swelling of the legs and feet. This may lead to angina, heart failure and or myocardial infarction. Diabetes can also interfere with pain signals normally carried by the nerves, and the typical warning signs of a heart attack may not be experienced by a diabetic. Heart failure, a chronic condition in which the heart cannot pump blood adequately to support the body, develops over a period of years and symptoms can get worse over time. People with diabetes have at least twice the risk of heart failure as other people. One type of heart failure is congestive heart failure, in which fluid builds up inside body tissues. If the buildup is in the lungs, breathing becomes difficult. Another condition related to heart disease and common in people with diabetes is peripheral arterial disease (PAD). With this condition, the blood vessels in the legs are narrowed or blocked by fatty deposits, decreasing blood flow to the legs and feet. PAD increases the chances of a heart attack or stroke occurring. Poor circulation in the legs and feet also raises the risk of amputation.
Stroke
A stroke results when the blood supply to the brain is suddenly cut off, which can occur when a blood vessel in the brain or neck is blocked or bursts. Brain cells are then deprived of oxygen and die. A stroke can result in problems with speech or vision or can cause weakness or paralysis that may be permanent.
Kidney Disease and Failure (Nephropathy)
Diabetes is the most common cause of kidney failure, accounting for as many as 4,000 new cases per year. Especially when blood glucose levels are not carefully controlled, diabetes can lead to kidney disease, also known as nephropathy. In severe cases, this condition can progress to kidney failure, the final stage of kidney disease in which the kidneys are unable to filter waste from the body.
Diabetic kidney disease can take several years to develop. The earliest signs may include an increase in kidney function or hyperfiltration. In later stages, small amounts of albumin, a blood protein, leak into the urine. This condition is known as microalbuminuria and usually occurs with normal kidney function. Gradual progression of kidney disease leads to a stage called overt diabetic nephropathy or macroalbuminuria, during which greater amounts of albumin pass into the urine, and kidney filtration becomes impaired. As the kidney function declines, harmful levels of waste produces such as urea and creatinine accumulate. Complete loss of kidney function requires a procedure called dialysis in order to remove waste from the blood.
The onset of diabetic nephropathy and the progression of kidney disease into kidney failure can be reduced by early treatment of diabetes, controlling blood glucose, and correcting elevated blood pressure, notably, with the use of ACE inhibitors which reduce stress on the kidneys. Signs of kidney complications, including frothy urine or unexplained foot and leg swelling, should be reported to a physician as soon as possible.
Nerve Damage and Diabetes (Neuropathy)
About half of all people with diabetes have some form of nerve damage. It is more common in those who have had the disease for a number of years. This can cause tingling, pain, numbness, or weakness in the feet and hands. Nerve damage may also cause problems with the digestive system, bladder control, and sexual impotence and can even mask the typical warning signs of a heart attack. Symptoms can be as mild as numbness or tingling in the fingers, nausea, vomiting or diarrhea and constipation or more severe such as double vision, fainting and paralysis. Keeping blood glucose levels on target may help to prevent or delay the kind of nerve damage that could lead to loss of sensation or paralysis. Treatments are also available that can help to limit the progression of neuropathies.
Foot Complications
Diabetics are very prone to problems with their feet mainly due to reduced sensation due to neuropathy or nerve damage. Diabetics will not readily feel injuries to their feet such as blisters and ulcers and therefore won’t treat the injuries properly. These untreated wounds can become infected and eventually lead to partial or complete amputations of the feet. Another related cause of foot complications for diabetics is poor peripheral circulation which inhibits the bodies healing process. With proper daily foot care, a diabetic can prevent many of these foot complications.
Skin Problems
As many as one-third of people with diabetes will have a skin disorder caused or affected by diabetes at some time in their lives. In fact, such problems are sometimes the first sign that a person has diabetes. Luckily, most skin conditions can be prevented or easily treated if caught early. Complications for patients with diabetes include bacterial infections, fungal infections, foot ulcers, diabetic dermopathy, diabetic blisters, and itching. It is believed that patients with diabetes are more prone to these skin conditions because of varying factors that include vascular disease, neuropathies, and the presence of high blood glucose levels. The most common culprit in bacterial infections is Staphylococcus, which can be easily treated with antibiotics. The most common fungal infection is Candida albicans; fungal infections include athlete’s foot, ringworm, and jock itch. Foot problems are common among people with diabetes and may become severe enough to cause ulceration, infection, and eventually, a need for amputation. It is very important that people with diabetes inspect their feet daily and wear proper fitting shoes. Localized itching is common among diabetics because of poor blood circulation. Using lotions and mild soap usually helps this problem. Diabetic blisters, although rare, are blisters that erupt around the back of hands, fingers and feet. They are usually caused by poor sugar level management. Because of the neuropathy and cardiovascular complications, these skin conditions sometimes are worsened and need to be treated properly.
Gastroparesis
Gastroparesis: gastro = stomach and paresis = weakness or paralysis or slow emptying of the stomach (delayed gastric emptying) results from nerve damage to the nerves needed for coordinating and driving the muscular action of grinding, pumping and moving food through the gut. Gastroparesis can cause people with diabetes to endure stomach viruses that seemingly never go away, endless bouts of nausea or vomiting of undigested food, abdominal pain and bloating with stomach acid and food refluxing back up into the mouth. Undigested food may sit for hours in the upper gut. Gastroparesis can also make diabetes worse by making it more difficult to manage blood glucose. When food that has been delayed in the stomach finally enters the small intestine and is absorbed, blood glucose levels rise. Food remaining in the stomach too long can also cause problems like bacterial overgrowth because the food has begun to ferment. The food can harden into solid masses called bezoars that may cause nausea, vomiting, and obstruction in the stomach. Bezoars can be dangerous if they block the passage of food into the small intestine.
Depression
Depression for those with diabetes is an important co-morbidity that requires careful management because of its severe impact on quality of life. In recent years, many studies have shown that patients with diabetes are twice as likely to have depression than people without diabetes. However, it's not clear whether people who have a history of depression are more likely to get diabetes.
People with newly diagnosed diabetes were 30% more likely to have had a history of depression than people without diabetes. Being newly diagnosed with a severe chronic illness is considered a major life stress and precipitates the stages of grief/loss that have been well documented.
Denial is a stage that can be particularly dangerous since inadequate monitoring of a diabetic’s glucose and diet can have very severe consequences. Bargaining may also work against the diabetic’s acceptance and proper care, and the patient may seek out alternatives to therapy that at best do not work and at worst cause the diabetic to suffer major complications. Anger can make successful glucose monitoring and control very difficult by the way additional glucose is allowed to build-up in the blood stream as a response to more stress hormones being released. And finally, depression may become prolonged and the final stage of acceptance may not be reached or maintained. Depression may lead to inadequate diet and glucose monitoring causing the diabetic to suffer severe consequences of poorly managed disease.
Depression associated with the diabetic should be recognized as early as possible through standard established depression screening methods. If needed, the depression may be treated with specific anti-depressive medications. A combination of cognitive behavior therapy and supportive diabetic education may also be an effective non-pharmacological treatment for major depression in patients with diabetes and be associated with improved glycemic control and a healthier approach to managing their diabetes and increasing the quality of their life.