Research shows that you prevent, delay and manage diabetes through lifestyle changes, weight loss, and increased physical activity, along with diabetes medication, metformin.

Diabetes Prevention Program Research Results

The Diabetes Prevention Program (DPP) research results indicate that millions of high-risk people can delay or avoid developing type 2 diabetes by losing weight through regular physical activity and a diet low in fat and calories. Weight loss and physical activity lower the risk of diabetes by improving the body's ability to use insulin and process glucose. The DPP also suggests that metformin can help delay the onset of diabetes.

Participants in the lifestyle intervention group—those receiving intensive individual counseling and motivational support on effective diet, exercise, and behavior modification—reduced their risk of developing diabetes by 58 percent. This finding was true across all participating ethnic groups and for both men and women. Lifestyle changes worked particularly well for participants aged 60 and older, reducing their risk by 71 percent. About 5 percent of the lifestyle intervention group developed diabetes each year during the study period, compared with 11 percent of those in the placebo group.

Participants taking metformin reduced their risk of developing diabetes by 31 percent. Metformin was effective for both men and women, but it was least effective in people aged 45 and older. Metformin was most effective in people 25 to 44 years old and in those with a body mass index of 35 or higher, meaning they were at least 60 pounds overweight. About 7.8 percent of the metformin group developed diabetes each year during the study, compared with 11 percent of the group receiving the placebo.

Lifestyle Changes to Prevent, Delay and Manage Diabetes

In the years since the DPP was completed, further analyses of DPP data continue to yield important insights into the value of lifestyle changes in helping people prevent type 2 diabetes and associated conditions. For example, one analysis confirmed that DPP participants carrying two copies of a gene variant, or mutation, that significantly increased their risk of developing diabetes benefited from lifestyle changes as much as or more than those without the gene variant. Another analysis found that weight loss was the main predictor of reduced risk for developing diabetes in DPP lifestyle intervention group participants. The authors concluded that diabetes risk reduction efforts should focus on weight loss, which is helped by increased exercise.

Analyses of DPP data have added to the evidence that changes in diet and physical activity leading to weight loss are especially effective in helping reduce risk factors associated with both diabetes and cardiovascular disease, including high blood pressure and metabolic syndrome. A person with metabolic syndrome has several of a specific group of risk factors for developing diabetes and heart disease, such as having excess fat deposited around the waist, high triglyceride levels, and high fasting blood glucose levels. One analysis found that DPP participants in the lifestyle intervention group who did not have metabolic syndrome at the beginning of the study—about half of the participants—were less likely to develop it than those in the other groups. Another analysis of DPP data found that the presence of high blood pressure in DPP participants decreased in the lifestyle intervention group but increased in the metformin and placebo groups over time. Measures of triglyceride and HDL cholesterol levels also improved in the lifestyle intervention group. A third analysis found that levels of C-reactive protein and fibrinogen—risk factors for heart disease—were lower in the metformin and lifestyle intervention groups, with a larger reduction in the lifestyle group.

In addition, one study focused on urinary incontinence in women who participated in the DPP. Women in the lifestyle intervention group who lost 5 to 7 percent of their body weight through dietary changes and exercise had fewer problems with urinary incontinence than women in the other study groups.

Points to Remember

• The DPP showed that people at risk for developing diabetes can prevent or delay the onset of diabetes by losing a modest amount of weight through diet and exercise. DPP participants in the lifestyle intervention group reduced their risk of developing diabetes by 58 percent during the study.
• DPP participants who took the oral diabetes medication metformin also reduced their risk of developing diabetes, but not as much as those in the lifestyle intervention group.
• The DPP's impact continues as new research builds on the study's results to find the best ways to delay, prevent, and treat diabetes.

Hope through Research

The DPP contributed to a better understanding of how diabetes develops in people at risk and how they can prevent or delay the development of diabetes by making behavioral changes leading to weight loss. These findings are reflected in recommendations from the American Diabetes Association for the prevention or delay of type 2 diabetes, which stress the importance of lifestyle changes and weight loss. The DPP's impact continues as new research, building on the study's results, seeks the most effective ways to prevent, delay, or even reverse diabetes.

DPP researchers continue to examine the roles of lifestyle and metformin and other diabetes medications in preventing type 2 diabetes. They also continue to monitor participants to learn more about the study's long-term effects through the Diabetes Prevention Program Outcomes Study (DPPOS), a follow-up to the DPP. DPPOS is examining the impact of long-term risk reduction on diabetes-related health problems, such as nerve damage and heart, kidney, and eye disease.

Participants in clinical trials can play a more active role in their own health care, gain access to new research treatments before they are widely available, and help others by contributing to medical research. For information about current studies, visit www.ClinicalTrials.gov.

Sources:

• National Diabetes Information Clearinghouse, NIH Publication No. 09-5099, October 2008
• NDIC

Overview of types of glucose monitoring devices and explanation of continuous glucose monitoring. 

• What is glucose monitoring?
• What is continuous glucose monitoring?
• What are the prospects for an artificial pancreas?
• Points to remember

What is Glucose Monitoring?

Glucose monitoring helps people with diabetes manage the disease and avoid its associated problems. A person can use the results of glucose monitoring to make decisions about food, physical activity, and medications. The most common way to check glucose levels involves pricking a fingertip with an automatic lancing device to obtain a blood sample and then using a glucose meter to measure the blood sample's glucose level.

People with diabetes typically use a lancing device to obtain a blood sample and a glucose meter to measure the glucose level in the sample.

Many types of glucose meters are available, and all are accurate and reliable if used properly. Some meters use a blood sample from a less sensitive area than the fingertip, such as the upper arm, forearm, or thigh.

What is Continuous Glucose Monitoring?

Continuous glucose monitoring (CGM) systems use a tiny sensor inserted under the skin to check glucose levels in tissue fluid. The sensor stays in place for several days to a week and then must be replaced. A transmitter sends information about glucose levels via radio waves from the sensor to a pager-like wireless monitor. The user must check blood samples with a glucose meter to program the devices. Because currently approved continuous glucose monitoring devices are not as accurate and reliable as standard blood glucose meters, users should confirm glucose levels with a meter before making a change in treatment.

CGM systems provide glucose measurements as often as once per minute. The measurements are transmitted to a wireless monitor.

CGM systems are more expensive than conventional glucose monitoring, but they may enable better glucose control. CGM devices produced by Abbott, DexCom, and Medtronic have been approved by the U.S. Food and Drug Administration (FDA) and are available by prescription. These devices provide real-time measurements of glucose levels, with glucose levels displayed at 5-minute or 1-minute intervals. Users can set alarms to alert them when glucose levels are too low or too high. Special software is available to download data from the devices to a computer for tracking and analysis of patterns and trends, and the systems can display trend graphs on the monitor screen.

Additional CGM devices are being developed and tested. To learn more about such monitors and new products after approval, call the FDA at 1-888-INFO-FDA (463-6332) or check the FDA's website section titled "Glucose Meters & Diabetes Management".

---

What are the prospects for an artificial pancreas?

To overcome the limitations of current insulin therapy, researchers have long sought to link glucose monitoring and insulin delivery by developing an artificial pancreas. An artificial pancreas is a system that will mimic, as closely as possible, the way a healthy pancreas detects changes in blood glucose levels and responds automatically to secrete appropriate amounts of insulin. Although not a cure, an artificial pancreas has the potential to significantly improve diabetes care and management and to reduce the burden of monitoring and managing blood glucose.

An artificial pancreas based on mechanical devices requires at least three components:

• a CGM system
• an insulin delivery system
• a computer program that "closes the loop" by adjusting insulin delivery based on changes in glucose levels

With recent technological advances, the first steps have been taken toward closing the loop. The first pairing of a CGM system with an insulin pump—the MiniMed Paradigm REAL-Time System—is not an artificial pancreas, but it does represent the first step in joining glucose monitoring and insulin delivery systems using the most advanced technology available.

Points to Remember

• Glucose monitoring helps people with diabetes manage the disease and avoid its associated problems.
• The most common way to check glucose levels involves pricking a fingertip to obtain a blood sample and using a glucose meter to measure the glucose level in the sample.
• Continuous glucose monitoring (CGM) systems use a tiny sensor inserted under the skin to check glucose levels in tissue fluid. A transmitter sends glucose measurements to a wireless monitor.
• An artificial pancreas based on mechanical devices will consist of a CGM system, an insulin delivery system, and a computer program to adjust insulin delivery based on changes in glucose levels.

Source: NIH Publication No. 09-4551, October 2008

Gastroparesis is a digestive problem, a diabetes complication. Causes, symptoms, treatment of diabetes-related gastroparesis.

What is gastroparesis?

Gastroparesis, also called delayed gastric emptying, is a disorder in which the stomach takes too long to empty its contents. Normally, the stomach contracts to move food down into the small intestine for digestion. The vagus nerve controls the movement of food from the stomach through the digestive tract. Gastroparesis occurs when the vagus nerve is damaged and the muscles of the stomach and intestines do not work normally. Food then moves slowly or stops moving through the digestive tract.

The digestive system

What causes gastroparesis?

The most common cause of gastroparesis is diabetes. People with diabetes have high blood glucose, also called blood sugar, which in turn causes chemical changes in nerves and damages the blood vessels that carry oxygen and nutrients to the nerves. Over time, high blood glucose can damage the vagus nerve.

Some other causes of gastroparesis are

• surgery on the stomach or vagus nerve
• viral infections
• anorexia nervosa or bulimia
• medications—anticholinergics and narcotics—that slow contractions in the intestine
• gastroesophageal reflux disease
• smooth muscle disorders, such as amyloidosis and scleroderma
• nervous system diseases, including abdominal migraine and Parkinson's disease
• metabolic disorders, including hypothyroidism

Many people have what is called idiopathic gastroparesis, meaning the cause is unknown and cannot be found even after medical tests.

What are the symptoms of gastroparesis?

Signs and symptoms of gastroparesis are

• heartburn
• pain in the upper abdomen
• nausea
• vomiting of undigested food—sometimes several hours after a meal
• early feeling of fullness after only a few bites of food
• weight loss due to poor absorption of nutrients or low-calorie intake
• abdominal bloating
• high and low blood glucose levels
• lack of appetite
• gastroesophageal reflux
• spasms in the stomach area

---

Eating solid foods, high-fiber foods such as raw fruits and vegetables, fatty foods, or drinks high in fat or carbonation may contribute to these symptoms.

The symptoms of gastroparesis may be mild or severe, depending on the person. Symptoms can happen frequently in some people and less often in others. Many people with gastroparesis experience a wide range of symptoms, and sometimes the disorder is difficult for the physician to diagnose.

What are the complications of gastroparesis?

If food lingers too long in the stomach, it can cause bacterial overgrowth from the fermentation of food. Also, 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.

Gastroparesis can make diabetes worse by making blood glucose control more difficult. When food that has been delayed in the stomach finally enters the small intestine and is absorbed, blood glucose levels rise. Since gastroparesis makes stomach emptying unpredictable, a person's blood glucose levels can be erratic and difficult to control.

How is gastroparesis diagnosed?

After performing a full physical exam and taking your medical history, your doctor may order several blood tests to check blood counts and chemical and electrolyte levels. To rule out an obstruction or other conditions, the doctor may perform the following tests:

• Upper endoscopy. After giving you a sedative to help you become drowsy, the doctor passes a long, thin tube called an endoscope through your mouth and gently guides it down the throat, also called the esophagus, into the stomach. Through the endoscope, the doctor can look at the lining of the stomach to check for any abnormalities.

• Ultrasound. To rule out gallbladder disease and pancreatitis as sources of the problem, you may have an ultrasound test, which uses harmless sound waves to outline and define the shape of the gallbladder and pancreas.
• Barium x ray. After fasting for 12 hours, you will drink a thick liquid called barium, which coats the stomach, making it show up on the x ray. If you have diabetes, your doctor may have special instructions about fasting. Normally, the stomach will be empty of all food after 12 hours of fasting. Gastroparesis is likely if the x ray shows food in the stomach. Because a person with gastroparesis can sometimes have normal emptying, the doctor may repeat the test another day if gastroparesis is suspected.

Once other causes have been ruled out, the doctor will perform one of the following gastric emptying tests to confirm a diagnosis of gastroparesis.

• Gastric emptying scintigraphy. This test involves eating a bland meal, such as eggs or egg substitute, that contains a small amount of a radioactive substance, called radioisotope, that shows up on scans. The dose of radiation from the radioisotope is not dangerous. The scan measures the rate of gastric emptying at 1, 2, 3, and 4 hours. When more than 10 percent of the meal is still in the stomach at 4 hours, the diagnosis of gastroparesis is confirmed.
• Breath test. After ingestion of a meal containing a small amount of isotope, breath samples are taken to measure the presence of the isotope in carbon dioxide, which is expelled when a person exhales. The results reveal how fast the stomach is emptying.
• SmartPill. Approved by the U.S. Food and Drug Administration (FDA) in 2006, the SmartPill is a small device in capsule form that can be swallowed. The device then moves through the digestive tract and collects information about its progress that is sent to a cell phone-sized receiver worn around your waist or neck. When the capsule is passed from the body with the stool in a couple of days, you take the receiver back to the doctor, who enters the information into a computer.

How is gastroparesis treated?

Treatment of gastroparesis depends on the severity of the symptoms. In most cases, treatment does not cure gastroparesis—it is usually a chronic condition. Treatment helps you manage the condition so you can be as healthy and comfortable as possible.

Medication

Several medications are used to treat gastroparesis. Your doctor may try different medications or combinations to find the most effective treatment. Discussing the risk of side effects of any medication with your doctor is important.

• Metoclopramide (Reglan). This drug stimulates stomach muscle contractions to help emptying. Metoclopramide also helps reduce nausea and vomiting. Metoclopramide is taken 20 to 30 minutes before meals and at bedtime. Side effects of this drug include fatigue, sleepiness, depression, anxiety, and problems with physical movement.
• Erythromycin. This antibiotic also improves stomach emptying. It works by increasing the contractions that move food through the stomach. Side effects include nausea, vomiting, and abdominal cramps.
• Domperidone. This drug works like metoclopramide to improve stomach emptying and decrease nausea and vomiting. The FDA is reviewing domperidone, which has been used elsewhere in the world to treat gastroparesis. Use of the drug is restricted in the United States.
• Other medications. Other medications may be used to treat symptoms and problems related to gastroparesis. For example, an antiemetic can help with nausea and vomiting. Antibiotics will clear up a bacterial infection. If you have a bezoar in the stomach, the doctor may use an endoscope to inject medication into it to dissolve it.

 

---

Dietary Changes

Changing your eating habits can help control gastroparesis. Your doctor or dietitian may prescribe six small meals a day instead of three large ones. If less food enters the stomach each time you eat, it may not become overly full. In more severe cases, a liquid or pureed diet may be prescribed.

The doctor may recommend that you avoid high-fat and high-fiber foods. Fat naturally slows digestion—a problem you do not need if you have gastroparesis—and fiber is difficult to digest. Some high-fiber foods like oranges and broccoli contain material that cannot be digested. Avoid these foods because the indigestible part will remain in the stomach too long and possibly form bezoars.

Feeding Tube

If a liquid or pureed diet does not work, you may need surgery to insert a feeding tube. The tube, called a jejunostomy, is inserted through the skin on your abdomen into the small intestine. The feeding tube bypasses the stomach and places nutrients and medication directly into the small intestine. These products are then digested and delivered to your bloodstream quickly. You will receive special liquid food to use with the tube. The jejunostomy is used only when gastroparesis is severe or the tube is necessary to stabilize blood glucose levels in people with diabetes.

Parenteral Nutrition

Parenteral nutrition refers to delivering nutrients directly into the bloodstream, bypassing the digestive system. The doctor places a thin tube called a catheter in a chest vein, leaving an opening to it outside the skin. For feeding, you attach a bag containing liquid nutrients or medication to the catheter. The fluid enters your bloodstream through the vein. Your doctor will tell you what type of liquid nutrition to use.

This approach is an alternative to the jejunostomy tube and is usually a temporary method to get you through a difficult period with gastroparesis. Parenteral nutrition is used only when gastroparesis is severe and is not helped by other methods.

Gastric Electrical Stimulation

A gastric neurostimulator is a surgically implanted battery-operated device that releases mild electrical pulses to help control nausea and vomiting associated with gastroparesis. This option is available to people whose nausea and vomiting do not improve with medications. Further studies will help determine who will benefit most from this procedure, which is available in a few centers across the United States.

Botulinum Toxin

The use of botulinum toxin has been associated with improvement in symptoms of gastroparesis in some patients; however, further research on this form of therapy is needed.

What if I have diabetes and gastroparesis?

The primary treatment goals for gastroparesis related to diabetes are to improve stomach emptying and regain control of blood glucose levels. Treatment includes dietary changes, insulin, oral medications, and, in severe cases, a feeding tube and parenteral nutrition.

Dietary Changes

The doctor will suggest dietary changes such as six smaller meals to help restore your blood glucose to more normal levels before testing you for gastroparesis. In some cases, the doctor or dietitian may suggest you try eating several liquid or pureed meals a day until your blood glucose levels are stable and the symptoms improve. Liquid meals provide all the nutrients found in solid foods, but can pass through the stomach more easily and quickly.

Insulin for Blood Glucose Control

If you have gastroparesis, food is being absorbed more slowly and at unpredictable times. To control blood glucose, you may need to

• take insulin more often or change the type of insulin you take
• take your insulin after you eat instead of before
• check your blood glucose levels frequently after you eat and administer insulin whenever necessary

Your doctor will give you specific instructions for taking insulin based on your particular needs.

---

 

Hope through Research

The National Institute of Diabetes and Digestive and Kidney Diseases' Division of Digestive Diseases and Nutrition supports basic and clinical research into gastrointestinal motility disorders, including gastroparesis. Among other areas, researchers are studying whether experimental medications can relieve or reduce symptoms of gastroparesis, such as bloating, abdominal pain, nausea, and vomiting, or shorten the time the stomach needs to empty its contents following a meal.

Points to Remember

• Gastroparesis is the result of damage to the vagus nerve, which controls the movement of food through the digestive system. Instead of moving through the digestive tract normally, the food is retained in the stomach.
• Gastroparesis may occur in people with type 1 diabetes or type 2 diabetes. The vagus nerve becomes damaged after years of high blood glucose, resulting in gastroparesis. In turn, gastroparesis contributes to poor blood glucose control.
• Symptoms of gastroparesis include early fullness, abdominal pain, stomach spasms, heartburn, nausea, vomiting, bloating, gastroesophageal reflux, lack of appetite, and weight loss.
• Gastroparesis is diagnosed with tests such as x rays, manometry, and gastric emptying scans.
• Treatment includes dietary changes, oral medications, adjustments in insulin injections for people with diabetes, a jejunostomy tube, parenteral nutrition, gastric neurostimulators, or botulinum toxin.

For More Information

American College of Gastroenterology
www.acg.gi.org

American Diabetes Association
www.diabetes.org

International Foundation for Functional Gastrointestinal Disorders
www.iffgd.org

The National Digestive Diseases Information Clearinghouse (NDDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health of the U.S. Department of Health and Human Services.

Source: NIH Publication No. 07-4348, July 2007.

Diabetes can cause sexual and urological problems in both men and women. Discover the causes and treatments for these diabetes complications.

Contents:

• Diabetes and Sexual Problems
• What sexual problems can occur in men with diabetes?
• What sexual problems can occur in women with diabetes?
• Diabetes and Urologic Problems
• Who is at risk for developing sexual and urologic problems of diabetes?
• Can diabetes-related sexual and urologic problems be prevented?
• Points to Remember

Troublesome bladder symptoms and changes in sexual function are common health problems as people age. Having diabetes can mean early onset and increased severity of these problems. Sexual and urologic complications of diabetes occur because of the damage diabetes can cause to blood vessels and nerves. Men may have difficulty with erections or ejaculation. Women may have problems with sexual response and vaginal lubrication. Urinary tract infections and bladder problems occur more often in people with diabetes. People who keep their diabetes under control can lower their risk of the early onset of these sexual and urologic problems.

+++

Diabetes and Sexual Problems

Both men and women with diabetes can develop sexual problems because of damage to nerves and small blood vessels. When a person wants to lift an arm or take a step, the brain sends nerve signals to the appropriate muscles. Nerve signals also control internal organs like the heart and bladder, but people do not have the same kind of conscious control over them as they do over their arms and legs. The nerves that control internal organs are called autonomic nerves, which signal the body to digest food and circulate blood without a person having to think about it. The body's response to sexual stimuli is also involuntary, governed by autonomic nerve signals that increase blood flow to the genitals and cause smooth muscle tissue to relax. Damage to these autonomic nerves can hinder normal function. Reduced blood flow resulting from damage to blood vessels can also contribute to sexual dysfunction.

What sexual problems can occur in men with diabetes?

Erectile Dysfunction

Erectile dysfunction is a consistent inability to have an erection firm enough for sexual intercourse. The condition includes the total inability to have an erection and the inability to sustain an erection.

Estimates of the prevalence of erectile dysfunction in men with diabetes vary widely, ranging from 20 to 75 percent. Men who have diabetes are two to three times more likely to have erectile dysfunction than men who do not have diabetes. Among men with erectile dysfunction, those with diabetes may experience the problem as much as 10 to 15 years earlier than men without diabetes. Research suggests that erectile dysfunction may be an early marker of diabetes, particularly in men ages 45 and younger.

In addition to diabetes, other major causes of erectile dysfunction include high blood pressure, kidney disease, alcohol abuse, and blood vessel disease. Erectile dysfunction may also occur because of the side effects of medications, psychological factors, smoking, and hormonal deficiencies.

Men who experience erectile dysfunction should consider talking with a health care provider. The health care provider may ask about the patient's medical history, the type and frequency of sexual problems, medications, smoking and drinking habits, and other health conditions. A physical exam and laboratory tests may help pinpoint causes of sexual problems. The health care provider will check blood glucose control and hormone levels and may ask the patient to do a test at home that checks for erections that occur during sleep. The health care provider may also ask whether the patient is depressed or has recently experienced upsetting changes in his life.

Treatments for erectile dysfunction caused by nerve damage, also called neuropathy, vary widely and range from oral pills, a vacuum pump, pellets placed in the urethra, and shots directly into the penis, to surgery. All of these methods have advantages and disadvantages. Psychological counseling to reduce anxiety or address other issues may be necessary. Surgery to implant a device to aid in erection or to repair arteries is usually used as a treatment after all others fail.

Retrograde Ejaculation

Retrograde ejaculation is a condition in which part or all of a man's semen goes into the bladder instead of out the tip of the penis during ejaculation. Retrograde ejaculation occurs when internal muscles, called sphincters, do not function normally. A sphincter automatically opens or closes a passage in the body. With retrograde ejaculation, semen enters the bladder, mixes with urine, and leaves the body during urination without harming the bladder. A man experiencing retrograde ejaculation may notice that little semen is discharged during ejaculation or may become aware of the condition if fertility problems arise. Analysis of a urine sample after ejaculation will reveal the presence of semen.

---

Poor blood glucose control and the resulting nerve damage can cause retrograde ejaculation. Other causes include prostate surgery and some medications.

For additional information about erectile dysfunction, see the fact sheet Erectile Dysfunction, available from the National Kidney and Urologic Diseases Information Clearinghouse at 1-800-891-5390.

Retrograde ejaculation caused by diabetes or surgery may be helped with a medication that strengthens the muscle tone of the sphincter in the bladder. A urologist experienced in infertility treatments may assist with techniques to promote fertility, such as collecting sperm from the urine and then using the sperm for artificial insemination.

What sexual problems can occur in women with diabetes?

Many women with diabetes experience sexual problems. Although research about sexual problems in women with diabetes is limited, one study found 27 percent of women with type 1 diabetes experienced sexual dysfunction. Another study found 18 percent of women with type 1 diabetes and 42 percent of women with type 2 diabetes experienced sexual dysfunction.

Sexual problems may include

• decreased vaginal lubrication, resulting in vaginal dryness
• uncomfortable or painful sexual intercourse
• decreased or no desire for sexual activity
• decreased or absent sexual response

Decreased or absent sexual response can include the inability to become or remain aroused, reduced or no sensation in the genital area, and the constant or occasional inability to reach orgasm.

Causes of sexual problems in women with diabetes include nerve damage, reduced blood flow to genital and vaginal tissues, and hormonal changes. Other possible causes include some medications, alcohol abuse, smoking, psychological problems such as anxiety or depression, gynecologic infections, other diseases, and conditions relating to pregnancy or menopause.

Women who experience sexual problems or notice a change in sexual response should consider talking with a health care provider. The health care provider will ask about the patient's medical history, any gynecologic conditions or infections, the type and frequency of sexual problems, medications, smoking and drinking habits, and other health conditions. The health care provider may ask whether the patient might be pregnant or has reached menopause and whether she is depressed or has recently experienced upsetting changes in her life. A physical exam and laboratory tests may also help pinpoint causes of sexual problems. The health care provider will also talk with the patient about blood glucose control.

Prescription or over-the-counter vaginal lubricants may be useful for women experiencing vaginal dryness. Techniques to treat decreased sexual response include changes in position and stimulation during sexual relations. Psychological counseling may be helpful. Kegel exercises that help strengthen the pelvic muscles may improve sexual response. Studies of drug treatments are under way.

Diabetes and Urologic Problems

Urologic problems that affect men and women with diabetes include bladder problems and urinary tract infections.

The urinary tract.

---

Bladder Problems

Many events or conditions can damage nerves that control bladder function, including diabetes and other diseases, injuries, and infections. More than half of men and women with diabetes have bladder dysfunction because of damage to nerves that control bladder function. Bladder dysfunction can have a profound effect on a person's quality of life. Common bladder problems in men and women with diabetes include the following:

• Overactive bladder. Damaged nerves may send signals to the bladder at the wrong time, causing its muscles to squeeze without warning. The symptoms of overactive bladder include
  • urinary frequency—urination eight or more times a day or two or more times a night
  • urinary urgency—the sudden, strong need to urinate immediately
  • urge incontinence—leakage of urine that follows a sudden, strong urge to urinate
• Poor control of sphincter muscles. Sphincter muscles surround the urethra—the tube that carries urine from the bladder to the outside of the body—and keep it closed to hold urine in the bladder. If the nerves to the sphincter muscles are damaged, the muscles may become loose and allow leakage or stay tight when a person is trying to release urine.
• Urine retention. For some people, nerve damage keeps their bladder muscles from getting the message that it is time to urinate or makes the muscles too weak to completely empty the bladder. If the bladder becomes too full, urine may back up and the increasing pressure may damage the kidneys. If urine remains in the body too long, an infection can develop in the kidneys or bladder. Urine retention may also lead to overflow incontinence—leakage of urine when the bladder is full and does not empty properly.

Diagnosis of bladder problems may involve checking both bladder function and the appearance of the bladder's interior. Tests may include x rays, urodynamic testing to evaluate bladder function, and cystoscopy, a test that uses a device called a cystoscope to view the inside of the bladder.

Treatment of bladder problems due to nerve damage depends on the specific problem. If the main problem is urine retention, treatment may involve medication to promote better bladder emptying and a practice called timed voiding—urinating on a schedule—to promote more efficient urination. Sometimes people need to periodically insert a thin tube called a catheter through the urethra into the bladder to drain the urine. Learning how to tell when the bladder is full and how to massage the lower abdomen to fully empty the bladder can help as well. If urinary leakage is the main problem, medications, strengthening muscles with Kegel exercises, or surgery can help. Treatment for the urinary urgency and frequency of overactive bladder may involve medications, timed voiding, Kegel exercises, and surgery in some cases.

Urinary Tract Infections

Infections can occur when bacteria, usually from the digestive system, reach the urinary tract. If bacteria are growing in the urethra, the infection is called urethritis. The bacteria may travel up the urinary tract and cause a bladder infection, called cystitis. An untreated infection may go farther into the body and cause pyelonephritis, a kidney infection. Some people have chronic or recurrent urinary tract infections. Symptoms of urinary tract infections can include

• a frequent urge to urinate
• pain or burning in the bladder or urethra during urination
• cloudy or reddish urine
• in women, pressure above the pubic bone
• in men, a feeling of fullness in the rectum

If the infection is in the kidneys, a person may have nausea, feel pain in the back or side, and have a fever. Frequent urination can be a sign of high blood glucose, so results from recent blood glucose monitoring should be evaluated.

The health care provider will ask for a urine sample, which will be analyzed for bacteria and pus. Additional tests may be done if the patient has frequent urinary tract infections. An ultrasound exam provides images from the echo patterns of sound waves bounced back from internal organs. An intravenous pyelogram uses a special dye to enhance x-ray images of the urinary tract. Cystoscopy might be performed.

Early diagnosis and treatment are important to prevent more serious infections. To clear up a urinary tract infection, the health care provider will probably prescribe antibiotic treatment based on the type of bacteria in the urine. Kidney infections are more serious and may require several weeks of antibiotic treatment. Drinking plenty of fluids will help prevent another infection.

The National Kidney and Urologic Diseases Information Clearinghouse, at www.kidney.niddk.nih.gov or 1-800-891-5390, offers additional information about urologic problems.

---

Who is at risk of developing sexual and urologic problems of diabetes?

Risk factors are conditions that increase the chances of getting a particular disease. The more risk factors people have, the greater their chances of developing that disease or condition. Diabetic neuropathy and related sexual and urologic problems appear to be more common in people who

• have poor blood glucose control
• have high levels of blood cholesterol
• have high blood pressure
• are overweight
• are older than 40
• smoke
• are physically inactive

Can diabetes-related sexual and urologic problems be prevented?

People with diabetes can lower their risk of sexual and urologic problems by keeping their blood glucose, blood pressure, and cholesterol levels close to the target numbers their health care provider recommends. Being physically active and maintaining a healthy weight can also help prevent the long-term complications of diabetes. For those who smoke, quitting will lower the risk of developing sexual and urologic problems due to nerve damage and also lower the risk for other health problems related to diabetes, including heart attack, stroke, and kidney disease.

Points to Remember

The nerve damage of diabetes may cause sexual or urologic problems.

• Sexual problems in men with diabetes include
  • erectile dysfunction
  • retrograde ejaculation
• Sexual problems in women with diabetes include
  • decreased vaginal lubrication and uncomfortable or painful intercourse
  • decreased or no sexual desire
  • decreased or absent sexual response
• Urologic problems in men and women with diabetes include
  • bladder problems related to nerve damage, such as overactive bladder, poor control of sphincter muscles, and urine retention
  • urinary tract infections
• Controlling diabetes through diet, physical activity, and medications as needed can help prevent sexual and urologic problems.
• Treatment is available for sexual and urologic problems.

Source: NIH Publication No. 09-5135, December 2008

Diabetes is the leading cause of kidney failure. Info on diabetes kidney disease complications - diagnosis, causes, treatments and diabetes and kidney failure.

Contents:

• The Burden of Kidney Failure
• The Course of Kidney Disease
• Diagnosis of CKD
• Effects of High Blood Pressure
• Preventing and Slowing Kidney Disease
• Dialysis and Transplantation
• Good Care Makes a Difference
• Points to Remember
• Hope through Research

 

The Burden of Kidney Failure

Each year in the United States, more than 100,000 people are diagnosed with kidney failure, a serious condition in which the kidneys fail to rid the body of wastes. Kidney failure is the final stage of chronic kidney disease (CKD).

Diabetes is the most common cause of kidney failure, accounting for nearly 44 percent of new cases. Even when diabetes is controlled, the disease can lead to CKD and kidney failure. Most people with diabetes do not develop CKD that is severe enough to progress to kidney failure. Nearly 24 million people in the United States have diabetes, and nearly 180,000 people are living with kidney failure as a result of diabetes.

People with kidney failure undergo either dialysis, an artificial blood-cleaning process, or transplantation to receive a healthy kidney from a donor. Most U.S. citizens who develop kidney failure are eligible for federally funded care. In 2005, care for patients with kidney failure cost the United States nearly $32 billion.

Source: United States Renal Data System. USRDS 2007 Annual Data Report.

African Americans, American Indians, and Hispanics/Latinos develop diabetes, CKD, and kidney failure at rates higher than Caucasians. Scientists have not been able to explain these higher rates. Nor can they explain fully the interplay of factors leading to kidney disease of diabetes—factors including heredity, diet, and other medical conditions, such as high blood pressure. They have found that high blood pressure and high levels of blood glucose increase the risk that a person with diabetes will progress to kidney failure.

¹United States Renal Data System. USRDS 2007 Annual Data Report. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, U.S. Department of Health and Human Services; 2007.

²National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics, 2007. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services, 2008.

---

The Course of Kidney Disease

Diabetic kidney disease takes many years to develop. In some people, the filtering function of the kidneys is actually higher than normal in the first few years of their diabetes.

Over several years, people who are developing kidney disease will have small amounts of the blood protein albumin begin to leak into their urine. This first stage of CKD is called microalbuminuria. The kidney's filtration function usually remains normal during this period.

As the disease progresses, more albumin leaks into the urine. This stage may be called macroalbuminuria or proteinuria. As the amount of albumin in the urine increases, the kidneys' filtering function usually begins to drop. The body retains various wastes as filtration falls. As kidney damage develops, blood pressure often rises as well.

Overall, kidney damage rarely occurs in the first 10 years of diabetes, and usually, 15 to 25 years will pass before kidney failure occurs. For people who live with diabetes for more than 25 years without any signs of kidney failure, the risk of ever developing it decreases.

Diagnosis of CKD

People with diabetes should be screened regularly for kidney disease. The two key markers for kidney disease are eGFR and urine albumin.

• eGFR. eGFR stands for estimated glomerular filtration rate. Each kidney contains about 1 million tiny filters made up of blood vessels. These filters are called glomeruli. Kidney function can be checked by estimating how much blood the glomeruli filter in a minute. The calculation of eGFR is based on the amount of creatinine, a waste product, found in a blood sample. As the level of creatinine goes up, the eGFR goes down.

  Kidney disease is present when eGFR is less than 60 milliliters per minute.

  The American Diabetes Association (ADA) and the National Institutes of Health (NIH) recommend that eGFR be calculated from serum creatinine at least once a year in all people with diabetes.

• Urine albumin. Urine albumin is measured by comparing the amount of albumin to the amount of creatinine in a single urine sample. When the kidneys are healthy, the urine will contain large amounts of creatinine but almost no albumin. Even a small increase in the ratio of albumin to creatinine is a sign of kidney damage.

  Kidney disease is present when urine contains more than 30 milligrams of albumin per gram of creatinine, with or without decreased eGFR.

  The ADA and the NIH recommend annual assessment of urine albumin excretion to assess kidney damage in all people with type 2 diabetes and people who have had type 1 diabetes for 5 years or more.

If kidney disease is detected, it should be addressed as part of a comprehensive approach to the treatment of diabetes.

Effects of High Blood Pressure

High blood pressure, or hypertension, is a major factor in the development of kidney problems in people with diabetes. Both a family history of hypertension and the presence of hypertension appear to increase the chances of developing kidney disease. Hypertension also accelerates the progress of kidney disease when it already exists.

Blood pressure is recorded using two numbers. The first number is called the systolic pressure, and it represents the pressure in the arteries as the heart beats. The second number is called the diastolic pressure, and it represents the pressure between heartbeats. In the past, hypertension was defined as blood pressure higher than 140/90, said as "140 over 90."

The ADA and the National Heart, Lung, and Blood Institute recommend that people with diabetes keep their blood pressure below 130/80.

Hypertension can be seen not only as a cause of kidney disease but also as a result of damage created by the disease. As kidney disease progresses, physical changes in the kidneys lead to increased blood pressure. Therefore, a dangerous spiral, involving rising blood pressure and factors that raise blood pressure, occurs. Early detection and treatment of even mild hypertension are essential for people with diabetes.

---

Preventing and Slowing Kidney Disease

Blood Pressure Medicines

Scientists have made great progress in developing methods that slow the onset and progression of kidney disease in people with diabetes. Drugs used to lower blood pressure can slow the progression of kidney disease significantly. Two types of drugs, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), have proven effective in slowing the progression of kidney disease. Many people require two or more drugs to control their blood pressure. In addition to an ACE inhibitor or an ARB, a diuretic can also be useful. Beta blockers, calcium channel blockers, and other blood pressure drugs may also be needed.

An example of an effective ACE inhibitor is lisinopril (Prinivil, Zestril), which doctors commonly prescribe for treating kidney disease of diabetes. The benefits of lisinopril extend beyond its ability to lower blood pressure: it may directly protect the kidneys' glomeruli. ACE inhibitors have lowered proteinuria and slowed deterioration even in people with diabetes who did not have high blood pressure.

An example of an effective ARB is losartan (Cozaar), which has also been shown to protect kidney function and lower the risk of cardiovascular events.

Any medicine that helps patients achieve a blood pressure target of 130/80 or lower provides benefits. Patients with even mild hypertension or persistent microalbuminuria should consult a health care provider about the use of antihypertensive medicines.

Moderate-protein Diets

In people with diabetes, excessive consumption of protein may be harmful. Experts recommend that people with kidney disease of diabetes consume the recommended dietary allowance for protein, but avoid high-protein diets. For people with greatly reduced kidney function, a diet containing reduced amounts of protein may help delay the onset of kidney failure. Anyone following a reduced-protein diet should work with a dietitian to ensure adequate nutrition.

Intensive Management of Blood Glucose

Antihypertensive drugs and low-protein diets can slow CKD. A third treatment, known as intensive management of blood glucose or glycemic control, has shown great promise for people with diabetes, especially for those in the early stages of CKD.

The human body normally converts food to glucose, the simple sugar that is the main source of energy for the body's cells. To enter cells, glucose needs the help of insulin, a hormone produced by the pancreas. When a person does not make enough insulin, or the body does not respond to the insulin that is present, the body cannot process glucose, and it builds up in the bloodstream. High levels of glucose in the blood lead to a diagnosis of diabetes.

Intensive management of blood glucose is a treatment regimen that aims to keep blood glucose levels close to normal. The regimen includes testing blood glucose frequently, administering insulin throughout the day on the basis of food intake and physical activity, following a diet and activity plan, and consulting a health care team regularly. Some people use an insulin pump to supply insulin throughout the day.

A number of studies have pointed to the beneficial effects of intensive management of blood glucose. In the Diabetes Control and Complications Trial supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), researchers found a 50 percent decrease in both development and progression of early diabetic kidney disease in participants who followed an intensive regimen for controlling blood glucose levels. The intensively managed patients had average blood glucose levels of 150 milligrams per deciliter—about 80 milligrams per deciliter lower than the levels observed in the conventionally managed patients. The United Kingdom Prospective Diabetes Study, conducted from 1976 to 1997, showed conclusively that, in people with improved blood glucose control, the risk of early kidney disease was reduced by a third. Additional studies conducted over the past decades have clearly established that any program resulting in sustained lowering of blood glucose levels will be beneficial to patients in the early stages of CKD.

Dialysis and Transplantation

When people with diabetes experience kidney failure, they must undergo either dialysis or a kidney transplant. As recently as the 1970s, medical experts commonly excluded people with diabetes from dialysis and transplantation, in part because the experts felt damage caused by diabetes would offset benefits of the treatments. Today, because of better control of diabetes and improved rates of survival following treatment, doctors do not hesitate to offer dialysis and kidney transplantation to people with diabetes.

Currently, the survival of kidneys transplanted into people with diabetes is about the same as the survival of transplants in people without diabetes. Dialysis for people with diabetes also works well in the short run. Even so, people with diabetes who receive transplants or dialysis experience higher morbidity and mortality because of coexisting complications of diabetes—such as damage to the heart, eyes, and nerves.

---

Good Care Makes a Difference

People with diabetes should

• have their health care provider measure their A1C level at least twice a year. The test provides a weighted average of their blood glucose level for the previous 3 months. They should aim to keep it at less than 7 percent.
• work with their health care provider regarding insulin injections, medicines, meal planning, physical activity, and blood glucose monitoring.
• have their blood pressure checked several times a year. If blood pressure is high, they should follow their health care provider's plan for keeping it near normal levels. They should aim to keep it at less than 130/80.
• ask their health care provider whether they might benefit from taking an ACE inhibitor or ARB.
• ask their health care provider to measure their eGFR at least once a year to learn how well their kidneys are working.
• ask their health care provider to measure the amount of protein in their urine at least once a year to check for kidney damage.
• ask their health care provider whether they should reduce the amount of protein in their diet and ask for a referral to see a registered dietitian to help with meal planning.

Points to Remember

• Diabetes is the leading cause of chronic kidney disease (CKD) and kidney failure in the United States.
• People with diabetes should be screened regularly for kidney disease. The two key markers for kidney disease are estimated glomerular filtration rate (eGFR) and urine albumin.
• Drugs used to lower blood pressure can slow the progression of kidney disease significantly. Two types of drugs, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), have proven effective in slowing the progression of kidney disease.
• In people with diabetes, excessive consumption of protein may be harmful.
• Intensive management of blood glucose has shown great promise for people with diabetes, especially for those in the early stages of CKD.

Hope through Research

The number of people with diabetes is growing. As a result, the number of people with kidney failure caused by diabetes is also growing. Some experts predict that diabetes soon might account for half the cases of kidney failure. In light of the increasing illness and death related to diabetes and kidney failure, patients, researchers, and health care professionals will continue to benefit by addressing the relationship between the two diseases. The NIDDK is a leader in supporting research in this area.

Several areas of research supported by the NIDDK hold great potential. Discovery of ways to predict who will develop kidney disease may lead to greater prevention, as people with diabetes who learn they are at risk institute strategies such as intensive management of blood glucose and blood pressure control.

Source: NIH Publication No. 08-3925, September 2008

A common diabetes complication is hypoglycemia (low blood sugar). Causes, symptoms, and treatment of diabetic hypoglycemia.

Contents:

• What is hypoglycemia?
• What are the symptoms of hypoglycemia?
• What causes hypoglycemia in people with diabetes?
• How can hypoglycemia be prevented?
• How is hypoglycemia treated?
• Hypoglycemia in People Who Do Not Have Diabetes
• Points to Remember
• Hope through Research

What is hypoglycemia?

Hypoglycemia, also called low blood glucose or low blood sugar, occurs when blood glucose drops below normal levels. Glucose, an important source of energy for the body, comes from food. Carbohydrates are the main dietary source of glucose. Rice, potatoes, bread, tortillas, cereal, milk, fruit, and sweets are all carbohydrate-rich foods.

After a meal, glucose is absorbed into the bloodstream and carried to the body's cells. Insulin, a hormone made by the pancreas, helps the cells use glucose for energy. If a person takes in more glucose than the body needs at the time, the body stores the extra glucose in the liver and muscles in a form called glycogen. The body can use glycogen for energy between meals. Extra glucose can also be changed to fat and stored in fat cells. Fat can also be used for energy.

When blood glucose begins to fall, glucagon—another hormone made by the pancreas—signals the liver to break down glycogen and release glucose into the bloodstream. Blood glucose will then rise toward a normal level. In some people with diabetes, this glucagon response to hypoglycemia is impaired and other hormones such as epinephrine, also called adrenaline, may raise the blood glucose level. But with diabetes treated with insulin or pills that increase insulin production, glucose levels can't easily return to the normal range.

Hypoglycemia can happen suddenly. It is usually mild and can be treated quickly and easily by eating or drinking a small amount of glucose-rich food. If left untreated, hypoglycemia can get worse and cause confusion, clumsiness, or fainting. Severe hypoglycemia can lead to seizures, coma, and even death.

In adults and children older than 10 years, hypoglycemia is uncommon except as a side effect of diabetes treatment. Hypoglycemia can also result, however, from other medications or diseases, hormone or enzyme deficiencies, or tumors.

What are the symptoms of hypoglycemia?

Hypoglycemia causes symptoms such as

• hunger
• shakiness
• nervousness
• sweating
• dizziness or light-headedness
• sleepiness
• confusion
• difficulty speaking
• anxiety
• weakness

Hypoglycemia can also happen during sleep. Some signs of hypoglycemia during sleep include

• crying out or having nightmares
• finding pajamas or sheets damp from perspiration
• feeling tired, irritable, or confused after waking up

---

What causes hypoglycemia in people with diabetes?

Diabetes Medications

Hypoglycemia can occur as a side effect of some diabetes medications, including insulin and oral diabetes medications—pills—that increase insulin production, such as

• chlorpropamide (Diabinese)
• glimepiride (Amaryl)
• glipizide (Glucotrol, Glucotrol XL)
• glyburide (DiaBeta, Glynase, Micronase)
• nateglinide (Starlix)
• repaglinide (Prandin)
• sitagliptin (Januvia)
• tolazamide
• tolbutamide

Certain combination pills can also cause hypoglycemia, including

• glipizide + metformin (Metaglip)
• glyburide + metformin (Glucovance)
• pioglitazone + glimepiride (Duetact)
• rosiglitazone + glimepiride (Avandaryl)
• sitagliptin + metformin (Janumet)

Other types of diabetes pills, when taken alone, do not cause hypoglycemia. Examples of these medications are

• acarbose (Precose)
• metformin (Glucophage)
• miglitol (Glyset)
• pioglitazone (Actos)
• rosiglitazone (Avandia)

However, taking these pills along with other diabetes medications—insulin, pills that increase insulin production, or both—increases the risk of hypoglycemia.

In addition, use of the following injectable medications can cause hypoglycemia:

• Pramlintide (Symlin), which is used along with insulin
• Exenatide (Byetta), which can cause hypoglycemia when used in combination with chlorpropamide, glimepiride, glipizide, glyburide, tolazamide, and tolbutamide

For more information about diabetes medications, see the National Diabetes Information Clearinghouse's booklet What I need to know about diabetes medicines, or by calling 1-800-860-8747.

Other Causes of Hypoglycemia

In people on insulin or pills that increase insulin production, low blood glucose can be due to

• meals or snacks that are too small, delayed, or skipped
• increased physical activity
• alcoholic beverages

How can hypoglycemia be prevented?

Diabetes treatment plans are designed to match the dose and timing of medication to a person's usual schedule of meals and activities. Mismatches could result in hypoglycemia. For example, taking a dose of insulin—or other medication that increases insulin levels—but then skipping a meal could result in hypoglycemia.

To help prevent hypoglycemia, people with diabetes should always consider the following:

• Their diabetes medications. A health care provider can explain which diabetes medications can cause hypoglycemia and explain how and when to take medications. For good diabetes management, people with diabetes should take diabetes medications in the recommended doses at the recommended times. In some cases, health care providers may suggest that patients learn how to adjust medications to match changes in their schedule or routine.
• Their meal plan. A registered dietitian can help design a meal plan that fits one's personal preferences and lifestyle. Following one's meal plan is important for managing diabetes. People with diabetes should eat regular meals, have enough food at each meal, and try not to skip meals or snacks. Snacks are particularly important for some people before going to sleep or exercising. Some snacks may be more effective than others in preventing hypoglycemia overnight. The dietitian can make recommendations for snacks.
• Their daily activity. To help prevent hypoglycemia caused by physical activity, health care providers may advise
  • checking blood glucose before sports, exercise, or other physical activity and having a snack if the level is below 100 milligrams per deciliter (mg/dL)
  • adjusting medication before physical activity
  • checking blood glucose at regular intervals during extended periods of physical activity and having snacks as needed
  • checking blood glucose periodically after physical activity
• Their use of alcoholic beverages. Drinking alcoholic beverages, especially on an empty stomach, can cause hypoglycemia, even a day or two later. Heavy drinking can be particularly dangerous for people taking insulin or medications that increase insulin production. Alcoholic beverages should always be consumed with a snack or meal at the same time. A health care provider can suggest how to safely include alcohol in a meal plan.
• Their diabetes management plan. Intensive diabetes management—keeping blood glucose as close to the normal range as possible to prevent long-term complications—can increase the risk of hypoglycemia. Those whose goal is tight control should talk with a health care provider about ways to prevent hypoglycemia and how best to treat it if it occurs.

---

What to Ask the Doctor about Diabetes Medications

People who take diabetes medications should ask their doctor or health care provider

• whether their diabetes medications could cause hypoglycemia
• when they should take their diabetes medications
• how much medication they should take
• whether they should keep taking their diabetes medications when they are sick
• whether they should adjust their medications before physical activity
• whether they should adjust their medications if they skip a meal

How is hypoglycemia treated?

Signs and symptoms of hypoglycemia vary from person to person. People with diabetes should get to know their signs and symptoms and describe them to their friends and family so they can help if needed. School staff should be told how to recognize a child's signs and symptoms of hypoglycemia and how to treat it.

People who experience hypoglycemia several times a week should call their health care provider. They may need a change in their treatment plan: less medication or a different medication, a new schedule for insulin or medication, a different meal plan, or a new physical activity plan.

Prompt Treatment for Hypoglycemia

When people think their blood glucose is too low, they should check the blood glucose level of a blood sample using a meter. If the level is below 80 mg/dL, one of these quick-fix foods should be consumed right away to raise blood glucose:

• 3 or 4 glucose tablets
• 1 serving of glucose gel—the amount equal to 15 grams of carbohydrate
• 1/2 cup, or 4 ounces, of any fruit juice
• 1/2 cup, or 4 ounces, of a regular—not diet—soft drink
• 1 cup, or 8 ounces, of milk
• 5 or 6 pieces of hard candy
• 1 tablespoon of sugar or honey

Recommended amounts may be less for small children. The child's doctor can advise about the right amount to give a child.

The next step is to recheck blood glucose in 15 minutes to make sure it is 80 mg/dL or above. If it's still too low, another serving of a quick-fix food should be eaten. These steps should be repeated until the blood glucose level is 80 mg/dL or above. If the next meal is an hour or more away, a snack should be eaten once the quick-fix foods have raised the blood glucose level to 80 mg/dL or above.

For People Who Take Acarbose (Precose) or Miglitol (Glyset)

People who take either of these diabetes medications (Acarbose or Miglitol) should know that only pure glucose, also called dextrose—available in tablet or gel form—will raise their blood glucose level during a low blood glucose episode. Other quick-fix foods and drinks won't raise the level quickly enough because acarbose and miglitol slow the digestion of other forms of carbohydrate

Help from Others for Severe Hypoglycemia

Severe hypoglycemia—very low blood glucose—can cause a person to pass out and can even be life-threatening. Severe hypoglycemia is more likely to occur in people with type 1 diabetes. People should ask a health care provider what to do about severe hypoglycemia. Another person can help someone who has passed out by giving an injection of glucagon. Glucagon will rapidly bring the blood glucose level back to normal and help the person regain consciousness. A health care provider can prescribe a glucagon emergency kit. Family, friends, or coworkers—the people who will be around the person at risk of hypoglycemia—can learn how to give a glucagon injection and when to call 911 or get medical help.

Physical Activity and Blood Glucose Levels

Physical activity has many benefits for people with diabetes, including lowering blood glucose levels. However, physical activity can make levels too low and can cause hypoglycemia up to 24 hours afterward. A health care provider can advise about checking the blood glucose level before exercise. For those who take insulin or one of the oral medications that increase insulin production, the health care provider may suggest having a snack if the glucose level is below 100 mg/dL or adjusting medication doses before physical activity to help avoid hypoglycemia. A snack can prevent hypoglycemia. The health care provider may suggest extra blood glucose checks, especially after strenuous exercise.

---

Hypoglycemia When Driving

Hypoglycemia is particularly dangerous if it happens to someone who is driving. People with hypoglycemia may have trouble concentrating or seeing clearly behind the wheel and may not be able to react quickly to road hazards or to the actions of other drivers. To prevent problems, people at risk for hypoglycemia should check their blood glucose level before driving. During longer trips, they should check their blood glucose level frequently and eat snacks as needed to keep the level at 80 mg/dL or above. If necessary, they should stop for treatment and then make sure their blood glucose level is 80 mg/dL or above before starting to drive again.

Hypoglycemia Unawareness

Some people with diabetes do not have early warning signs of low blood glucose, a condition called hypoglycemia unawareness. This condition occurs most often in people with type 1 diabetes, but it can also occur in people with type 2 diabetes. People with hypoglycemia unawareness may need to check their blood glucose level more often so they know when hypoglycemia is about to occur. They also may need a change in their medications, meal plan, or physical activity routine.

Hypoglycemia unawareness develops when frequent episodes of hypoglycemia lead to changes in how the body reacts to low blood glucose levels. The body stops releasing the hormone epinephrine and other stress hormones when blood glucose drops too low. The loss of the body's ability to release stress hormones after repeated episodes of hypoglycemia is called hypoglycemia-associated autonomic failure, or HAAF.

Epinephrine causes early warning symptoms of hypoglycemia such as shakiness, sweating, anxiety, and hunger. Without the release of epinephrine and the symptoms it causes, a person may not realize that hypoglycemia is occurring and may not take action to treat it. A vicious cycle can occur in which frequent hypoglycemia leads to hypoglycemia unawareness and HAAF, which in turn leads to even more severe and dangerous hypoglycemia. Studies have shown that preventing hypoglycemia for a period as short as several weeks can sometimes break this cycle and restore awareness of symptoms. Health care providers may therefore advise people who have had severe hypoglycemia to aim for higher-than-usual blood glucose targets for short-term periods.

Being Prepared for Hypoglycemia

People who use insulin or take an oral diabetes medication that can cause low blood glucose should always be prepared to prevent and treat low blood glucose by

• learning what can trigger low blood glucose levels
• having their blood glucose meter available to test glucose levels; frequent testing may be critical for those with hypoglycemia unawareness, particularly before driving a car or engaging in any hazardous activity
• always having several servings of quick-fix foods or drinks handy
• wearing a medical identification bracelet or necklace
• planning what to do if they develop severe hypoglycemia
• telling their family, friends, and coworkers about the symptoms of hypoglycemia and how they can help if needed

Normal and Target Blood Glucose Ranges
Normal Blood Glucose Levels in People Who Do Not Have Diabetes
Upon waking—fasting	70 to 99 mg/dL
After meals	70 to 140 mg/dL
Target Blood Glucose Levels in People Who Have Diabetes
Before meals	80 to 130 mg/dL
1 to 2 hours after the start of a meal	below 180 mg/dL

Source: American Diabetes Association. Standards of Medical Care in Diabetes—2008. Diabetes Care. 2008;31:S12-S54.

For people with diabetes, a blood glucose level below 80 mg/dL is considered hypoglycemia.

---

Hypoglycemia in People Who Do Not Have Diabetes

Two types of hypoglycemia can occur in people who do not have diabetes:

• Reactive hypoglycemia, also called postprandial hypoglycemia, occurs within 4 hours after meals.
• Fasting hypoglycemia, also called postabsorptive hypoglycemia, is often related to an underlying disease.

Symptoms of both reactive and fasting hypoglycemia are similar to diabetes-related hypoglycemia. Symptoms may include hunger, sweating, shakiness, dizziness, light-headedness, sleepiness, confusion, difficulty speaking, anxiety, and weakness.

To find the cause of a patient's hypoglycemia, the doctor will use laboratory tests to measure blood glucose, insulin, and other chemicals that play a part in the body's use of energy.

Reactive Hypoglycemia

Diagnosis
To diagnose reactive hypoglycemia, the doctor may

• ask about signs and symptoms
• test blood glucose while the patient is having symptoms by taking a blood sample from the arm and sending it to a laboratory for analysis
• check to see whether the symptoms ease after the patient's blood glucose returns to 80 mg/dL or above after eating or drinking

A blood glucose level below 80 mg/dL at the time of symptoms and relief after eating will confirm the diagnosis. The oral glucose tolerance test is no longer used to diagnose reactive hypoglycemia because experts now know the test can actually trigger hypoglycemic symptoms.

Causes and Treatment
The causes of most cases of reactive hypoglycemia are still open to debate. Some researchers suggest that certain people may be more sensitive to the body's normal release of the hormone epinephrine, which causes many of the symptoms of hypoglycemia. Others believe deficiencies in glucagon secretion might lead to reactive hypoglycemia.

A few causes of reactive hypoglycemia are certain, but they are uncommon. Gastric—or stomach—surgery can cause reactive hypoglycemia because of the rapid passage of food into the small intestine. Rare enzyme deficiencies diagnosed early in life, such as hereditary fructose intolerance, also may cause reactive hypoglycemia.

To relieve reactive hypoglycemia, some health professionals recommend

• eating small meals and snacks about every 3 hours
• being physically active
• eating a variety of foods, including meat, poultry, fish, or nonmeat sources of protein; starchy foods such as whole-grain bread, rice, and potatoes; fruits; vegetables; and dairy products
• eating foods high in fiber
• avoiding or limiting foods high in sugar, especially on an empty stomach

The doctor can refer patients to a registered dietitian for personalized meal planning advice. Although some health professionals recommend a diet high in protein and low in carbohydrates, studies have not proven the effectiveness of this kind of diet to treat reactive hypoglycemia.

Fasting Hypoglycemia

Diagnosis
Fasting hypoglycemia is diagnosed from a blood sample that shows a blood glucose level below 50 mg/dL after an overnight fast, between meals, or after physical activity.

Causes and Treatment
Causes of fasting hypoglycemia include certain medications, alcoholic beverages, critical illnesses, hormonal deficiencies, some kinds of tumors, and certain conditions occurring in infancy and childhood.

Medications. Medications, including some used to treat diabetes, are the most common cause of hypoglycemia. Other medications that can cause hypoglycemia include

• salicylates, including aspirin, when taken in large doses
• sulfa medications, which are used to treat bacterial infections
• pentamidine, which treats a serious kind of pneumonia
• quinine, which is used to treat malaria

If using any of these medications causes a person's blood glucose level to fall, the doctor may advise stopping the medication or changing the dose.

---

Alcoholic beverages. Drinking alcoholic beverages, especially binge drinking, can cause hypoglycemia. The body's breakdown of alcohol interferes with the liver's efforts to raise blood glucose. Hypoglycemia caused by excessive drinking can be serious and even fatal.

 Critical illnesses. Some illnesses that affect the liver, heart, or kidneys can cause hypoglycemia. Sepsis, which is an overwhelming infection, and starvation are other causes of hypoglycemia. In these cases, treating the illness or other underlying cause will correct the hypoglycemia.

Hormonal deficiencies. Hormonal deficiencies may cause hypoglycemia in very young children, but rarely in adults. Shortages of cortisol, growth hormone, glucagon, or epinephrine can lead to fasting hypoglycemia. Laboratory tests for hormone levels will determine a diagnosis and treatment. Hormone replacement therapy may be advised.

Tumors. Insulinomas are insulin-producing tumors in the pancreas. Insulinomas can cause hypoglycemia by raising insulin levels too high in relation to the blood glucose level. These tumors are rare and do not normally spread to other parts of the body. Laboratory tests can pinpoint the exact cause. Treatment involves both short-term steps to correct the hypoglycemia and medical or surgical measures to remove the tumor.

Conditions occurring in infancy and childhood. Children rarely develop hypoglycemia. If they do, causes may include the following:

• Brief intolerance to fasting, often during an illness that disturbs regular eating patterns. Children usually outgrow this tendency by age 10.
• Hyperinsulinism, which is the overproduction of insulin. This condition can result in temporary hypoglycemia in newborns, which is common in infants of mothers with diabetes. Persistent hyperinsulinism in infants or children is a complex disorder that requires prompt evaluation and treatment by a specialist.
• Enzyme deficiencies that affect carbohydrate metabolism. These deficiencies can interfere with the body's ability to process natural sugars, such as fructose and galactose, glycogen, or other metabolites.
• Hormonal deficiencies such as lack of pituitary or adrenal hormones.

*A personal blood glucose monitor cannot be used to diagnose reactive hypoglycemia.

Points to Remember

Diabetes-related Hypoglycemia

• When people with diabetes think their blood glucose level is low, they should check it and treat the problem right away.
• To treat hypoglycemia, people should have a serving of a quick-fix food, wait 15 minutes, and check their blood glucose again. They should repeat the treatment until their blood glucose is 80 mg/dL or above.
• People at risk for hypoglycemia should keep quick-fix foods in the car, at work—anywhere they spend time.
• People at risk for hypoglycemia should be careful when driving. They should check their blood glucose frequently and snack as needed to keep their level 80 mg/dL or above.

Hypoglycemia Unrelated to Diabetes

• In reactive hypoglycemia, symptoms occur within 4 hours of eating. People with reactive hypoglycemia are usually advised to follow a healthy eating plan recommended by a registered dietitian.
• Fasting hypoglycemia can be caused by certain medications, critical illnesses, hereditary enzyme or hormonal deficiencies, and some kinds of tumors. Treatment targets the underlying problem.

Hope through Research

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) was established by Congress in 1950 as one of the National Institutes of Health of the U.S. Department of Health and Human Services. The NIDDK conducts and supports research in diabetes, glucose metabolism, and related conditions. Researchers supported by the NIDDK are investigating topics such as the causes of hypoglycemia and whether use of continuous glucose monitoring devices can help prevent hypoglycemia.

Participants in clinical trials can play a more active role in their own health care, gain access to new research treatments before they are widely available, and help others by contributing to medical research. For information about current studies, visit www.ClinicalTrials.gov.

The U.S. Government does not endorse or favor any specific commercial product or company. Trade, proprietary, or company names appearing in this document are used only because they are considered necessary in the context of the information provided. If a product is not mentioned, the omission does not mean or imply that the product is unsatisfactory.

---

For More Information

National Diabetes Education Program
1 Diabetes Way
Bethesda, MD 20814-9692
Internet: www.ndep.nih.gov

American Diabetes Association
1701 North Beauregard Street
Alexandria, VA 22311
Internet: www.diabetes.org

Juvenile Diabetes Research Foundation International
120 Wall Street
New York, NY 10005
Internet: www.jdrf.org

The National Diabetes Information Clearinghouse collects resource information about diabetes diseases for the NIDDK Reference Collection. This database provides titles, abstracts, and availability information for health information and health education resources.

This publication may contain information about medications. When prepared, this publication included the most current information available. For updates or for questions about any medications, contact the U.S. Food and Drug Administration toll-free at 1-888-INFO-FDA (463-6332) or visit www.fda.gov. Consult your doctor for more information.

National Diabetes Information Clearinghouse

1 Information Way
Bethesda, MD 20892-3560
Internet: www.diabetes.niddk.nih.gov

The National Diabetes Information Clearinghouse (NDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health of the U.S. Department of Health and Human Services. Established in 1978, the Clearinghouse provides information about diabetes to people with diabetes and to their families, health care professionals, and the public. The NDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about diabetes.

Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scientists and outside experts. This fact sheet was reviewed by Vivian A. Fonseca, M.D., F.R.C.P., Tulane University Health Sciences Center, New Orleans, LA; Catherine L. Martin, M.S., A.P.R.N., B.C.-A.D.M., C.D.E., University of Michigan Health System, Ann Arbor, MI; and Neil H. White, M.D., C.D.E., Department of Pediatrics, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, MO.

This publication is not copyrighted. The Clearinghouse encourages users of this publication to duplicate and distribute as many copies as desired.

---

NIH Publication No. 09-3926
October 2008

There's a direct link between diabetes and erectile dysfunction (ED). Find out about the causes and treatments of diabetes erectile dysfunction.

Between 35 and 50 percent of men with diabetes will experience erectile dysfunction. It can be a complication of diabetes. There are, however, men that have diabetes and don't experience any sexual dysfunction.

Compared to men without diabetes, diabetic men tend to develop erectile dysfunction 10 to 15 years earlier. As these diabetic men get older, erectile dysfunction becomes even more common. At age 50+, 50-60% of these men with diabetes are likely to experience erection problems. Above age 70, there is about a 95% likelihood of having some difficulty with erectile function.

Causes of Erectile Dysfunction in Men with Diabetes

For men with diabetes, the causes of erectile dysfunction involve impairments in nerve, blood vessel and muscle function.

To get an erection, men need healthy blood vessels, nerves, male hormones, and a desire to be sexually stimulated. Diabetes can damage the blood vessels and nerves that control erection. Therefore, even if you have normal amounts of male hormones and you have the desire to have sex, you still may not be able to achieve a firm erection.

Contents:

• How does an erection occur?
• What causes erectile dysfunction (ED)?
• How is ED diagnosed?
• How is ED treated?
• Hope through Research
• Points to Remember
• For More Information

Erectile dysfunction, sometimes called "impotence," is the repeated inability to get or keep an erection firm enough for sexual intercourse. The word "impotence" may also be used to describe other problems that interfere with sexual intercourse and reproduction, such as lack of sexual desire and problems with ejaculation or orgasm. Using the term erectile dysfunction makes it clear that those other problems are not involved.

Erectile dysfunction, or ED, can be a total inability to achieve erection, an inconsistent ability to do so, or a tendency to sustain only brief erections. These variations make defining ED and estimating its incidence difficult. Estimates range from 15 million to 30 million, depending on the definition used. According to the National Ambulatory Medical Care Survey (NAMCS), for every 1,000 men in the United States, 7.7 physician office visits were made for ED in 1985. By 1999, that rate had nearly tripled to 22.3. The increase happened gradually, presumably as treatments such as vacuum devices and injectable drugs became more widely available and discussing erectile function became accepted. Perhaps the most publicized advance was the introduction of the oral drug sildenafil citrate (Viagra) in March 1998. NAMCS data on new drugs show an estimated 2.6 million mentions of Viagra at physician office visits in 1999, and one-third of those mentions occurred during visits for a diagnosis other than ED.

In older men, ED usually has a physical cause, such as disease, injury, or side effects of drugs. Any disorder, like diabetes, that causes injury to the nerves or impairs blood flow in the penis has the potential to cause ED. Incidence increases with age: About 5 percent of 40-year-old men and between 15 and 25 percent of 65-year-old men experience ED. But it is not an inevitable part of aging.

ED is treatable at any age, and awareness of this fact has been growing. More men have been seeking help and returning to normal sexual activity because of improved, successful treatments for ED. Urologists, who specialize in problems of the urinary tract, have traditionally treated ED; however, urologists accounted for only 25 percent of Viagra mentions in 1999.

How does an erection occur?

The penis contains two chambers called the corpora cavernosa, which run the length of the organ (see figure 1). A spongy tissue fills the chambers. The corpora cavernosa are surrounded by a membrane, called the tunica albuginea. The spongy tissue contains smooth muscles, fibrous tissues, spaces, veins, and arteries. The urethra, which is the channel for urine and ejaculate, runs along the underside of the corpora cavernosa and is surrounded by the corpus spongiosum.

Erection begins with sensory or mental stimulation, or both. Impulses from the brain and local nerves cause the muscles of the corpora cavernosa to relax, allowing blood to flow in and fill the spaces. The blood creates pressure in the corpora cavernosa, making the penis expand. The tunica albuginea helps trap the blood in the corpora cavernosa, thereby sustaining erection. When muscles in the penis contract to stop the inflow of blood and open outflow channels, erection is reversed.

Figure 1. Arteries (top) and veins (bottom) penetrate the long, filled cavities running the length of the penis—the corpora cavernosa and the corpus spongiosum. Erection occurs when relaxed muscles allow the corpora cavernosa to fill with excess blood fed by the arteries, while drainage of blood through the veins is blocked.

 

---

What causes erectile dysfunction (ED)?

Since an erection requires a precise sequence of events, ED can occur when any of the events is disrupted. The sequence includes nerve impulses in the brain, spinal column, and area around the penis, and response in muscles, fibrous tissues, veins, and arteries in and near the corpora cavernosa.

Damage to nerves, arteries, smooth muscles, and fibrous tissues, often as a result of disease, is the most common cause of ED. Diseases—such as diabetes, kidney disease, chronic alcoholism, multiple sclerosis, atherosclerosis, vascular disease, and neurologic disease—account for about 70 percent of ED cases. Between 35 and 50 percent of men with diabetes experience ED.

Lifestyle choices that contribute to heart disease and vascular problems also raise the risk of erectile dysfunction. Smoking, being overweight, and avoiding exercise are possible causes of ED.

Also, surgery (especially radical prostate and bladder surgery for cancer) can injure nerves and arteries near the penis, causing ED. Injury to the penis, spinal cord, prostate, bladder, and pelvis can lead to ED by harming nerves, smooth muscles, arteries, and fibrous tissues of the corpora cavernosa.

In addition, many common medicines—blood pressure drugs, antihistamines, antidepressants, tranquilizers, appetite suppressants, and cimetidine (an ulcer drug)—can produce ED as a side effect.

Experts believe that psychological factors such as stress, anxiety, guilt, depression, low self-esteem, and fear of sexual failure cause 10 to 20 percent of ED cases. Men with a physical cause for ED frequently experience the same sort of psychological reactions (stress, anxiety, guilt, depression). Other possible causes are smoking, which affects blood flow in veins and arteries, and hormonal abnormalities, such as not enough testosterone.

How is ED diagnosed?

Patient History

Medical and sexual histories help define the degree and nature of ED. A medical history can disclose diseases that lead to ED, while a simple recounting of sexual activity might distinguish among problems with sexual desire, erection, ejaculation, or orgasm.

Using certain prescription or illegal drugs can suggest a chemical cause, since drug effects account for 25 percent of ED cases. Cutting back on or substituting certain medications can often alleviate the problem.

Physical Examination

A physical examination can give clues to systemic problems. For example, if the penis is not sensitive to touching, a problem in the nervous system may be the cause. Abnormal secondary sex characteristics, such as hair pattern or breast enlargement, can point to hormonal problems, which would mean that the endocrine system is involved. The examiner might discover a circulatory problem by observing decreased pulses in the wrist or ankles. And unusual characteristics of the penis itself could suggest the source of the problem—for example, a penis that bends or curves when erect could be the result of Peyronie's disease.

Laboratory Tests

Several laboratory tests can help diagnose ED. Tests for systemic diseases include blood counts, urinalysis, lipid profile, and measurements of creatinine and liver enzymes. Measuring the amount of free testosterone in the blood can yield information about problems with the endocrine system and is indicated especially in patients with decreased sexual desire.

Other Tests

Monitoring erections that occur during sleep (nocturnal penile tumescence) can help rule out certain psychological causes of ED. Healthy men have involuntary erections during sleep. If nocturnal erections do not occur, then ED is likely to have a physical rather than psychological cause. Tests of nocturnal erections are not completely reliable, however. Scientists have not standardized such tests and have not determined when they should be applied for best results.

Psychosocial Examination

A psychosocial examination, using an interview and a questionnaire, reveals psychological factors. A man's sexual partner may also be interviewed to determine expectations and perceptions during sexual intercourse.

How is erectile dysfunction treated?

Most physicians suggest that treatments proceed from least to most invasive. For some men, making a few healthy lifestyle changes may solve the problem. Quitting smoking, losing excess weight, and increasing physical activity may help some men regain sexual function.

Cutting back on any drugs with harmful side effects is considered next. For example, drugs for high blood pressure work in different ways. If you think a particular drug is causing problems with erection, tell your doctor and ask whether you can try a different class of blood pressure medicine.

Psychotherapy and behavior modifications in selected patients are considered next if indicated, followed by oral or locally injected drugs, vacuum devices, and surgically implanted devices. In rare cases, surgery involving veins or arteries may be considered.

---

Psychotherapy

Experts often treat psychologically based ED using techniques that decrease the anxiety associated with intercourse. The patient's partner can help with the techniques, which include gradual development of intimacy and stimulation. Such techniques also can help relieve anxiety when ED from physical causes is being treated.

Drug Therapy

Drugs for treating ED can be taken orally, injected directly into the penis, or inserted into the urethra at the tip of the penis. In March 1998, the Food and Drug Administration (FDA) approved Viagra, the first pill to treat ED. Since that time, and tadalafil (Cialis) have also been approved. Additional oral medicines are being tested for safety and effectiveness.

Viagra, Levitra, and Cialis all belong to a class of drugs called phosphodiesterase (PDE) inhibitors. Taken an hour before sexual activity, these drugs work by enhancing the effects of nitric oxide, a chemical that relaxes smooth muscles in the penis during sexual stimulation and allows increased blood flow.

While oral medicines improve the response to sexual stimulation, they do not trigger an automatic erection as injections do. The recommended dose for Viagra is 50 mg, and the physician may adjust this dose to 100 mg or 25 mg, depending on the patient. The recommended dose for either Levitra or Cialis is 10 mg, and the physician may adjust this dose to 20 mg if 10 mg is insufficient. A lower dose of 5 mg is available for patients who take other medicines or have conditions that may decrease the body's ability to use the drug. Levitra is also available in a 2.5 mg dose.

None of these PDE inhibitors should be used more than once a day. Men who take nitrate-based drugs such as nitroglycerin for heart problems should not use either drug because the combination can cause a sudden drop in blood pressure. Also, tell your doctor if you take any drugs called alpha-blockers, which are used to treat prostate enlargement or high blood pressure. Your doctor may need to adjust your ED prescription. Taking a PDE inhibitor and an alpha-blocker at the same time (within 4 hours) can cause a sudden drop in blood pressure.

Oral testosterone can reduce ED in some men with low levels of natural testosterone, but it is often ineffective and may cause liver damage. Patients also have claimed that other oral drugs—including yohimbine hydrochloride, dopamine and serotonin agonists, and trazodone—are effective, but the results of scientific studies to substantiate these claims have been inconsistent. Improvements observed following use of these drugs may be examples of the placebo effect, that is, a change that results simply from the patient's believing that an improvement will occur.

Many men achieve stronger erections by injecting drugs into the penis, causing it to become engorged with blood. Drugs such as papaverine hydrochloride, phentolamine, and alprostadil (marketed as Caverject) widen blood vessels. These drugs may create unwanted side effects, however, including persistent erection (known as priapism) and scarring. Nitroglycerin, a muscle relaxant, can sometimes enhance erection when rubbed on the penis.

A system for inserting a pellet of alprostadil into the urethra is marketed as Muse. The system uses a prefilled applicator to deliver the pellet about an inch deep into the urethra. An erection will begin within 8 to 10 minutes and may last 30 to 60 minutes. The most common side effects are aching in the penis, testicles, and area between the penis and rectum; warmth or burning sensation in the urethra; redness from increased blood flow to the penis; and minor urethral bleeding or spotting.

Research on drugs for treating ED is expanding rapidly. Patients should ask their doctor about the latest advances.

Vacuum Devices

Mechanical vacuum devices cause erection by creating a partial vacuum, which draws blood into the penis, engorging and expanding it. The devices have three components: a plastic cylinder, into which the penis is placed; a pump, which draws air out of the cylinder; and an elastic band, which is placed around the base of the penis to maintain the erection after the cylinder is removed and during intercourse by preventing blood from flowing back into the body (see figure 2).

Figure 2. A vacuum-constrictor device causes an erection by creating a partial vacuum around the penis, which draws blood into the corpora cavernosa. Pictured here are the necessary components: (a) a plastic cylinder, which covers the penis; (b) a pump, which draws air out of the cylinder; and (c) an elastic ring, which, when fitted over the base of the penis, traps the blood and sustains the erection after the cylinder is removed.

One variation of the vacuum device involves a semirigid rubber sheath that is placed on the penis and remains there after erection is attained and during intercourse.

---

Surgery

Surgery usually has one of three goals:

• to implant a device that can cause the penis to become erect 
• to reconstruct arteries to increase the flow of blood to the penis
• to block off veins that allow blood to leak from the penile tissues

Implanted devices, known as prostheses, can restore erection in many men with ED. Possible problems with implants include mechanical breakdown and infection, although mechanical problems have diminished in recent years because of technological advances.

Malleable implants usually consist of paired rods, which are inserted surgically into the corpora cavernosa. The user manually adjusts the position of the penis and, therefore, the rods. Adjustment does not affect the width or length of the penis.

Inflatable implants consist of paired cylinders, which are surgically inserted inside the penis and can be expanded using pressurized fluid (see figure 3). Tubes connect the cylinders to a fluid reservoir and a pump, which are also surgically implanted. The patient inflates the cylinders by pressing on the small pump, located under the skin in the scrotum. Inflatable implants can expand the length and width of the penis somewhat. They also leave the penis in a more natural state when not inflated.

Figure 3. With an inflatable implant, erection is produced by squeezing a small pump (a) implanted in a scrotum. The pump causes fluid to flow from a reservoir (b) residing in the lower pelvis to two cylinders (c) residing in the penis. The cylinders expand to create the erection.

Surgery to repair arteries can reduce ED caused by obstructions that block the flow of blood. The best candidates for such surgery are young men with discrete blockage of an artery because of an injury to the crotch or fracture of the pelvis. The procedure is almost never successful in older men with widespread blockage.

Surgery to veins that allow blood to leave the penis usually involves an opposite procedure—intentional blockage. Blocking off veins (ligation) can reduce the leakage of blood that diminishes the rigidity of the penis during erection. However, experts have raised questions about the long-term effectiveness of this procedure, and it is rarely done.

Hope through Research

Advances in suppositories, injectable medications, implants, and vacuum devices have expanded the options for men seeking treatment for ED. These advances have also helped increase the number of men seeking treatment. Gene therapy for ED is now being tested in several centers and may offer a long-lasting therapeutic approach for ED.

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) sponsors programs aimed at understanding the causes of erectile dysfunction and finding treatments to reverse its effects. NIDDK's Division of Kidney, Urologic, and Hematologic Diseases supported the researchers who developed Viagra and continue to support basic research into the mechanisms of erection and the diseases that impair normal function at the cellular and molecular levels, including diabetes and high blood pressure.

Points to Remember

• Erectile dysfunction (ED) is the repeated inability to get or keep an erection firm enough for sexual intercourse.
• ED affects 15 to 30 million American men.
• ED usually has a physical cause.
• ED is treatable at all ages.
• Treatments include psychotherapy, drug therapy, vacuum devices, and surgery.

For More Information

American Urological Association (AUA)
1000 Corporate Boulevard
Linthicum, MD 21090
Internet: www.auanet.org and www.urologyhealth.org

AUA can refer you to a urologist in your area.

Source: NIH Publication No. 06-3923, December 2005

Diabetes is the leading cause of blindness. If you have diabetic eye problems, here's what you need to know.

High blood sugar increases the risk of diabetes eye problems. The three major eye problems that people with diabetes may develop are cataracts, glaucoma, and retinopathy ("Vision Loss from Diabetes and Dealing with Related Anxiety").

Contents:

• What are diabetes problems?
• What should I do each day to stay healthy with diabetes?
• What can I do to prevent diabetic eye problems?
• How can diabetes hurt my eyes?
• What happens as diabetes retina problems get worse?
• What can I do about diabetes retina problems?
• How do I know if I have retina damage from diabetes?
• What other eye problems can happen to people with diabetes?
• Pronunciation Guide
• For More Information

What are diabetes problems?

Too much glucose in the blood for a long time can cause diabetes problems. This high blood glucose, also called blood sugar, can damage many parts of the body, such as the heart, blood vessels, eyes, and kidneys. Heart and blood vessel disease can lead to heart attacks and strokes. You can do a lot to prevent or slow down diabetes problems.

This booklet is about eye problems caused by diabetes. You will learn the things you can do each day and during each year to stay healthy and prevent diabetes problems.

High blood glucose can cause eye problems.

What should I do each day to stay healthy with diabetes?

 

Follow the healthy eating plan that you and your doctor or dietitian have worked out.

Be active a total of 30 minutes most days. Ask your doctor what activities are best for you.

Take your medicines as directed.

Check your blood glucose every day. Each time you check your blood glucose, write the number in your record book.

Check your feet every day for cuts, blisters, sores, swelling, redness, or sore toenails.

Brush and floss your teeth every day.

Control your blood pressure and cholesterol.

Don't smoke.

---

What can I do to prevent diabetes eye problems?

You can do a lot to prevent diabetes eye problems.

• Keep your blood glucose and blood pressure as close to normal as you can.
• Have an eye care professional examine your eyes once a year. Have this exam even if your vision is OK. The eye care professional will use drops to make the black part of your eyes—pupils—bigger. This process is called dilating your pupil, which allows the eye care professional to see the back of your eye. Finding eye problems early and getting treatment right away will help prevent more serious problems later on.

Dilated eye. 

Undilated eye. 

• Ask your eye care professional to check for signs of cataracts and glaucoma. See What other eye problems can happen to people with diabetes? to learn more about cataracts and glaucoma.
• If you are planning to get pregnant soon, ask your doctor if you should have an eye exam.
• If you are pregnant and have diabetes, see an eye care professional during your first 3 months of pregnancy.
• Don't smoke.

How can diabetes hurt my eyes?

High blood glucose and high blood pressure from diabetes can hurt four parts of your eye:

• Retina. The retina is the lining at the back of the eye. The retina's job is to sense light coming into the eye.
• Vitreous. The vitreous is a jelly-like fluid that fills the back of the eye.
• Lens. The lens is at the front of the eye. The lens focuses light on the retina.
• Optic nerve. The optic nerve is the eye's main nerve to the brain.

A side view of the eye.

How can diabetes hurt the retinas of my eyes?

Retina damage happens slowly. Your retinas have tiny blood vessels that are easy to damage. Having high blood glucose and high blood pressure for a long time can damage these tiny blood vessels.

First, these tiny blood vessels swell and weaken. Some blood vessels then become clogged and do not let enough blood through. At first, you might not have any loss of sight from these changes. Have a dilated eye exam once a year even if your sight seems fine.

One of your eyes may be damaged more than the other. Or both eyes may have the same amount of damage.

Diabetic retinopathy is the medical term for the most common diabetes eye problem.

What happens as diabetes retina problems get worse?

As diabetes retina problems get worse, new blood vessels grow. These new blood vessels are weak. They break easily and leak blood into the vitreous of your eye. The leaking blood keeps light from reaching the retina.

You may see floating spots or almost total darkness. Sometimes the blood will clear out by itself. But you might need surgery to remove it.

Over the years, the swollen and weak blood vessels can form scar tissue and pull the retina away from the back of the eye. If the retina becomes detached, you may see floating spots or flashing lights.

You may feel as if a curtain has been pulled over part of what you are looking at. A detached retina can cause loss of sight or blindness if you don't take care of it right away.

---

Call your eye care professional right away if you are having any vision problems or if you have had a sudden change in your vision.

Drawing of a cross section of an eye showing no diabetes damage with the retina, blood vessels on the retina, the optic nerve, the vitreous, and the lens labeled. Drawing of a cross section of an eye showing some diabetes damage with the retina, blood vessels on the retina, the optic nerve, the vitreous, and the lens labeled. Drawing of a cross section of an eye showing a lot of diabetes damage with the retina, blood vessels on the retina, the optic nerve, new blood vessels, the vitreous, and the lens labeled.

What can I do about diabetes retina problems?

Keep your blood glucose and blood pressure as close to normal as you can.

Your eye care professional may suggest laser treatment, which is when a light beam is aimed into the retina of the damaged eye. The beam closes off leaking blood vessels. It may stop blood and fluid from leaking into the vitreous. Laser treatment may slow the loss of sight.

If a lot of blood has leaked into your vitreous and your sight is poor, your eye care professional might suggest you have surgery called a vitrectomy. A vitrectomy removes blood and fluid from the vitreous of your eye. Then clean fluid is put back into the eye. The surgery can make your eyesight better.

How do I know if I have retina damage from diabetes?

You may not have any signs of diabetes retina damage, or you may have one or more signs:

• blurry or double vision
• rings, flashing lights, or blank spots
• dark or floating spots
• pain or pressure in one or both of your eyes
• trouble seeing things out of the corners of your eyes

Normal vision

Blurry vision

If you have retina damage from diabetes, you may have blurry or double vision.

---

What other eye problems can happen to people with diabetes?

You can get two other eye problems—cataracts and glaucoma. People without diabetes can get these eye problems, too. But people with diabetes get these problems more often and at a younger age.

• A cataract is a cloud over the lens of your eye, which is usually clear. The lens focuses light onto the retina. A cataract makes everything you look at seem cloudy. You need surgery to remove the cataract. During surgery your lens is taken out and a plastic lens, like a contact lens, is put in. The plastic lens stays in your eye all the time. Cataract surgery helps you see clearly again.
• Glaucoma starts from pressure building up in the eye. Over time, this pressure damages your eye's main nerve—the optic nerve. The damage first causes you to lose sight from the sides of your eyes. Treating glaucoma is usually simple. Your eye care professional will give you special drops to use every day to lower the pressure in your eyes. Or your eye care professional may want you to have laser surgery.

Pronunciation Guide

cataracts (KAT-uh-rakts)

dilating (DY-layt-eeng)

glaucoma (glaw-KOH-muh)

lens (lenz)

optic nerve (AHP-tik) (nerv)

retina (RET-ih-nuh)

retinopathy (RET-ih-NOP-uh-thee)

vitrectomy (vih-TREK-tuh-mee)

vitreous (VIT-ree-uhss)

For More Information

Eye Care Professionals (ophthalmologists, optometrists)

To find an eye care professional near you, ask your doctor for a recommendation, contact a nearby hospital or medical school, or call a state or county association of ophthalmologists or optometrists.

See the American Academy of Ophthalmology website at www.aao.org and use the "Find an Eye M.D." service.

See the American Optometric Association website at www.aoa.org and click on "Find an Optometrist" or call 1-800-365-2219.

Diabetes Teachers (nurses, dietitians, pharmacists, and other health professionals)

To find a diabetes teacher near you, call the American Association of Diabetes Educators toll-free at 1-800-TEAMUP4 (832-6874), or look on the Internet at www.diabeteseducator.org and click on "Find a Diabetes Educator."

Dietitians

To find a dietitian near you, contact the American Dietetic Association at www.eatright.org and click on "Find a Nutrition Professional."

Government

The National Eye Institute (NEI) is part of the National Institutes of Health. To learn more about eye problems, write or call the NEI, 2020 Vision Place, Bethesda, MD 20892-3655, 301-496-5248; or see www.nei.nih.gov on the Internet.

Source: NIH Publication No. 09-4279, November 2008

High blood sugar from diabetes can lead to nerve damage. Learn about diabetic neuropathy. Symptoms, types and diabetic neuropathy treatment.

Contents:

• What are diabetic neuropathies?
• What causes diabetic neuropathy?
• What are the symptoms of diabetic neuropathies?
• What are the types of diabetic neuropathy?
• Neuropathy Affects Nerves Throughout the Body
• What is peripheral neuropathy?
• What is autonomic neuropathy?
• What is proximal neuropathy?
• What is focal neuropathy?
• How can I prevent diabetic neuropathy?
• How are diabetic neuropathies diagnosed?
• How are diabetic neuropathies treated?
• Points to Remember

What are diabetic neuropathies?

Diabetic neuropathies are a family of nerve disorders caused by diabetes. People with diabetes can, over time, develop nerve damage throughout the body. Some people with diabetes nerve damage have no symptoms. Others may have symptoms such as pain, tingling, or numbness—loss of feeling—in the hands, arms, feet, and legs. Nerve problems can occur in every organ system, including the digestive tract, heart, and sex organs.

About 60 to 70 percent of people with diabetes have some form of neuropathy. People with diabetes can develop nerve problems at any time, but risk rises with age and longer duration of diabetes. The highest rates of neuropathy are among people who have had diabetes for at least 25 years. Diabetic neuropathies also appear to be more common in people who have problems controlling their blood glucose, also called blood sugar, as well as those with high levels of blood fat and blood pressure and those who are overweight.

What causes diabetic neuropathies?

The causes are probably different for different types of diabetic neuropathy. Researchers are studying how prolonged exposure to high blood glucose causes nerve damage. Nerve damage is likely due to a combination of factors:

• metabolic factors, such as high blood glucose, long duration of diabetes, abnormal blood fat levels, and possibly low levels of insulin
• neurovascular factors, leading to damage to the blood vessels that carry oxygen and nutrients to nerves
• autoimmune factors that cause inflammation in nerves
• mechanical injury to nerves, such as carpal tunnel syndrome
• inherited traits that increase susceptibility to nerve disease
• lifestyle factors, such as smoking or alcohol use

What are the symptoms of diabetic neuropathies?

Symptoms depend on the type of neuropathy and which nerves are affected. Some people with nerve damage have no symptoms at all. For others, the first symptom is often numbness, tingling, or pain in the feet. Symptoms are often minor at first, and because most nerve damage occurs over several years, mild cases may go unnoticed for a long time. Symptoms can involve the sensory, motor, and autonomic—or involuntary—nervous systems. In some people, mainly those with focal neuropathy, the onset of pain may be sudden and severe.

Symptoms of nerve damage may include

• numbness, tingling, or pain in the toes, feet, legs, hands, arms, and fingers
• wasting of the muscles of the feet or hands
• indigestion, nausea, or vomiting
• diarrhea or constipation
• dizziness or faintness due to a drop in blood pressure after standing or sitting up
• problems with urination
• erectile dysfunction in men or vaginal dryness in women
• weakness

Symptoms that are not due to neuropathy, but often accompany it, include weight loss and depression ("Anxiety and Diabetic Neuropathy: What Helps?").

---

What are the types of diabetic neuropathy?

Diabetic neuropathy can be classified as peripheral, autonomic, proximal, or focal. Each affects different parts of the body in various ways.

• Peripheral neuropathy, the most common type of diabetic neuropathy, causes pain or loss of feeling in the toes, feet, legs, hands, and arms ("Diabetic Necrosis: Definition, Symptoms, and Anxiety It Causes").
• Autonomic neuropathy causes changes in digestion, bowel and bladder function, sexual response, and perspiration. It can also affect the nerves that serve the heart and control blood pressure, as well as nerves in the lungs and eyes. Autonomic neuropathy can also cause hypoglycemia unawareness, a condition in which people no longer experience the warning symptoms of low blood glucose levels.
• Proximal neuropathy causes pain in the thighs, hips, or buttocks and leads to weakness in the legs.
• Focal neuropathy results in the sudden weakness of one nerve or a group of nerves, causing muscle weakness or pain. Any nerve in the body can be affected.

Neuropathy Affects Nerves Throughout the Body

Peripheral neuropathy affects

• toes
• feet
• legs
• hands
• arms

Autonomic neuropathy affects

• heart and blood vessels
• digestive system
• urinary tract
• sex organs
• sweat glands
• eyes
• lungs

Proximal neuropathy affects

• thighs
• hips
• buttocks
• legs

Focal neuropathy affects

• eyes
• facial muscles
• ears
• pelvis and lower back
• chest
• abdomen
• thighs
• legs
• feet

---

What is peripheral neuropathy?

Peripheral neuropathy, also called distal symmetric neuropathy or sensorimotor neuropathy, is nerve damage in the arms and legs. Your feet and legs are likely to be affected before your hands and arms. Many people with diabetes have signs of neuropathy that a doctor could note but feel no symptoms themselves. Symptoms of peripheral neuropathy may include

• numbness or insensitivity to pain or temperature
• a tingling, burning, or prickling sensation
• sharp pains or cramps
• extreme sensitivity to touch, even light touch
• loss of balance and coordination

These symptoms are often worse at night.

Peripheral neuropathy may also cause muscle weakness and loss of reflexes, especially at the ankle, leading to changes in the way a person walks. Foot deformities, such as hammertoes and the collapse of the midfoot, may occur. Blisters and sores may appear on numb areas of the foot because pressure or injury goes unnoticed. If foot injuries are not treated promptly, the infection may spread to the bone, and the foot may then have to be amputated. Some experts estimate that half of all such amputations are preventable if minor problems are caught and treated in time.

What is autonomic neuropathy?

Autonomic neuropathy affects the nerves that control the heart, regulate blood pressure, and control blood glucose levels. Autonomic neuropathy also affects other internal organs, causing problems with digestion, respiratory function, urination, sexual response, and vision. In addition, the system that restores blood glucose levels to normal after a hypoglycemic episode may be affected, resulting in loss of the warning symptoms of hypoglycemia.

Hypoglycemia Unawareness

Normally, symptoms such as shakiness, sweating, and palpitations occur when blood glucose levels drop below 70 mg/dL. In people with autonomic neuropathy, symptoms may not occur, making hypoglycemia difficult to recognize. Problems other than neuropathy can also cause hypoglycemia unawareness. For more information about hypoglycemia, see the fact sheet Hypoglycemia.

Heart and Blood Vessels

The heart and blood vessels are part of the cardiovascular system, which controls blood circulation. Damage to nerves in the cardiovascular system interferes with the body's ability to adjust blood pressure and heart rate. As a result, blood pressure may drop sharply after sitting or standing, causing a person to feel light-headed or even to faint. Damage to the nerves that control heart rate can mean that your heart rate stays high, instead of rising and falling in response to normal body functions and physical activity.

Digestive System

Nerve damage to the digestive system most commonly causes constipation. Damage can also cause the stomach to empty too slowly, a condition called gastroparesis. Severe gastroparesis can lead to persistent nausea and vomiting, bloating, and loss of appetite. Gastroparesis can also make blood glucose levels fluctuate widely, due to abnormal food digestion. For more information, see the fact sheet Gastroparesis.

Nerve damage to the esophagus may make swallowing difficult, while nerve damage to the bowels can cause constipation alternating with frequent, uncontrolled diarrhea, especially at night. Problems with the digestive system can lead to weight loss.

---

Urinary Tract and Sex Organs

Autonomic neuropathy often affects the organs that control urination and sexual function. Nerve damage can prevent the bladder from emptying completely, allowing bacteria to grow in the bladder and kidneys and causing urinary tract infections. When the nerves of the bladder are damaged, urinary incontinence may result because a person may not be able to sense when the bladder is full or control the muscles that release urine.

Autonomic neuropathy can also gradually decrease sexual response in men and women, although the sex drive may be unchanged. A man may be unable to have erections or may reach sexual climax without ejaculating normally. A woman may have difficulty with arousal, lubrication, or orgasm.

For more information, see the fact sheets Nerve Disease and Bladder Control and Sexual and Urologic Problems of Diabetes at www.kidney.niddk.nih.gov.

Sweat Glands

Autonomic neuropathy can affect the nerves that control sweating. When nerve damage prevents the sweat glands from working properly, the body cannot regulate its temperature as it should. Nerve damage can also cause profuse sweating at night or while eating.

Eyes

Finally, autonomic neuropathy can affect the pupils of the eyes, making them less responsive to changes in light. As a result, a person may not be able to see well when a light is turned on in a dark room or may have trouble driving at night.

What is proximal neuropathy?

Proximal neuropathy, sometimes called lumbosacral plexus neuropathy, femoral neuropathy, or diabetic amyotrophy, starts with pain in the thighs, hips, buttocks, or legs, usually on one side of the body. This type of neuropathy is more common in those with type 2 diabetes and in older adults with diabetes. Proximal neuropathy causes weakness in the legs and the inability to go from a sitting to a standing position without help. Treatment for weakness or pain is usually needed. The length of the recovery period varies, depending on the type of nerve damage.

What is focal neuropathy?

Focal neuropathy appears suddenly and affects specific nerves, most often in the head, torso, or leg. Focal neuropathy may cause

• inability to focus the eye
• double vision
• aching behind one eye
• paralysis on one side of the face, called Bell's palsy
• severe pain in the lower back or pelvis
• pain in the front of a thigh
• pain in the chest, stomach, or side
• pain on the outside of the shin or inside of the foot
• chest or abdominal pain that is sometimes mistaken for heart disease, a heart attack, or appendicitis

Focal neuropathy is painful and unpredictable and occurs most often in older adults with diabetes. However, it tends to improve by itself over weeks or months and does not cause long-term damage.

People with diabetes also tend to develop nerve compressions, also called entrapment syndromes. One of the most common is carpal tunnel syndrome, which causes numbness and tingling of the hand and sometimes muscle weakness or pain. Other nerves susceptible to entrapment may cause pain on the outside of the shin or the inside of the foot.

How can I prevent diabetic neuropathies?

The best way to prevent neuropathy is to keep your blood glucose levels as close to the normal range as possible. Maintaining safe blood glucose levels protects nerves throughout your body.

---

How are diabetic neuropathies diagnosed?

Doctors diagnose neuropathy on the basis of symptoms and a physical exam. During the exam, your doctor may check blood pressure, heart rate, muscle strength, reflexes, and sensitivity to position changes, vibration, temperature, or light touch.

Foot Exams

Experts recommend that people with diabetes have a comprehensive foot exam each year to check for peripheral neuropathy. People diagnosed with peripheral neuropathy need more frequent foot exams. A comprehensive foot exam assesses the skin, muscles, bones, circulation, and sensation of the feet. Your doctor may assess protective sensation or feeling in your feet by touching your foot with a nylon monofilament—similar to a bristle on a hairbrush—attached to a wand or by pricking your foot with a pin. People who cannot sense pressure from a pinprick or monofilament have lost protective sensation and are at risk for developing foot sores that may not heal properly. The doctor may also check temperature perception or use a tuning fork, which is more sensitive than touch pressure, to assess vibration perception.

Other Tests

The doctor may perform other tests as part of your diagnosis.

• Nerve conduction studies or electromyography are sometimes used to help determine the type and extent of nerve damage. Nerve conduction studies check the transmission of electrical current through a nerve. Electromyography shows how well muscles respond to electrical signals transmitted by nearby nerves. These tests are rarely needed to diagnose neuropathy.
• A check of heart rate variability shows how the heart responds to deep breathing and to changes in blood pressure and posture.
• Ultrasound uses sound waves to produce an image of internal organs. An ultrasound of the bladder and other parts of the urinary tract, for example, can show how these organs preserve a normal structure and whether the bladder empties completely after urination.

How are diabetic neuropathies treated?

The first treatment step is to bring blood glucose levels within the normal range to help prevent further nerve damage. Blood glucose monitoring, meal planning, physical activity, and diabetes medicines or insulin will help control blood glucose levels. Symptoms may get worse when blood glucose is first brought under control, but over time, maintaining lower blood glucose levels helps lessen symptoms. Good blood glucose control may also help prevent or delay the onset of further problems. As scientists learn more about the underlying causes of neuropathy, new treatments may become available to help slow, prevent, or even reverse nerve damage.

As described in the following sections, additional treatment depends on the type of nerve problem and symptom. If you have problems with your feet, your doctor may refer you to a foot care specialist.

Pain Relief

Doctors usually treat painful diabetic neuropathy with oral medications, although other types of treatments may help some people. People with severe nerve pain may benefit from a combination of medications or treatments. Talk with your health care provider about options for treating your neuropathy.

Medications used to help relieve diabetic nerve pain include

• tricyclic antidepressants, such as amitriptyline, imipramine, and desipramine (Norpramin, Pertofrane)
• other types of antidepressants, such as duloxetine (Cymbalta), venlafaxine, bupropion (Wellbutrin), paroxetine (Paxil), and citalopram (Celexa)
• anticonvulsants, such as pregabalin (Lyrica), gabapentin (Gabarone, Neurontin), carbamazepine, and lamotrigine (Lamictal)
• opioids and opioid-like drugs, such as controlled-release oxycodone, an opioid; and tramadol (Ultram), an opioid that also acts as an antidepressant

Duloxetine and pregabalin are approved by the U.S. Food and Drug Administration specifically for treating painful diabetic peripheral neuropathy.

You do not have to be depressed for an antidepressant to help relieve your nerve pain. All medications have side effects, and some are not recommended for use in older adults or those with heart disease. Because over-the-counter pain medicines such as acetaminophen and ibuprofen may not work well for treating most nerve pain and can have serious side effects, some experts recommend avoiding these medications.

Treatments that are applied to the skin—typically to the feet—include capsaicin cream and lidocaine patches (Lidoderm, Lidopain). Studies suggest that nitrate sprays or patches for the feet may relieve pain. Studies of alpha-lipoic acid, an antioxidant, and evening primrose oil have shown that they can help relieve symptoms and may improve nerve function.

A device called a bed cradle can keep sheets and blankets from touching sensitive feet and legs. Acupuncture, biofeedback, or physical therapy may help relieve pain in some people. Treatments that involve electrical nerve stimulation, magnetic therapy, and laser or light therapy may be helpful but need further study. Researchers are also studying several new therapies in clinical trials.

---

Gastrointestinal Problems

To relieve mild symptoms of gastroparesis—indigestion, belching, nausea, or vomiting—doctors suggest eating small, frequent meals; avoiding fats; and eating less fiber. When symptoms are severe, doctors may prescribe erythromycin to speed digestion, metoclopramide to speed digestion and help relieve nausea, or other medications to help regulate digestion or reduce stomach acid secretion.

To relieve diarrhea or other bowel problems, doctors may prescribe an antibiotic such as tetracycline, or other medications as appropriate.

Dizziness and Weakness

Sitting or standing slowly may help prevent the light-headedness, dizziness, or fainting associated with blood pressure and circulation problems. Raising the head of the bed or wearing elastic stockings may also help. Some people benefit from increased salt in the diet and treatment with salt-retaining hormones. Others benefit from high blood pressure medications. Physical therapy can help when muscle weakness or loss of coordination is a problem.

Urinary and Sexual Problems

To clear up a urinary tract infection, the doctor will probably prescribe an antibiotic. Drinking plenty of fluids will help prevent another infection. People who have incontinence should try to urinate at regular intervals—every 3 hours, for example—since they may not be able to tell when the bladder is full.

To treat erectile dysfunction in men, the doctor will first do tests to rule out a hormonal cause. Several methods are available to treat erectile dysfunction caused by neuropathy. Medicines are available to help men have and maintain erections by increasing blood flow to the penis. Some are oral medications and others are injected into the penis or inserted into the urethra at the tip of the penis. Mechanical vacuum devices can also increase blood flow to the penis. Another option is to surgically implant an inflatable or semirigid device in the penis.

Vaginal lubricants may be useful for women when neuropathy causes vaginal dryness. To treat problems with arousal and orgasm, the doctor may refer women to a gynecologist.

Foot Care

People with neuropathy need to take special care of their feet. The nerves to the feet are the longest in the body and are the ones most often affected by neuropathy. Loss of sensation in the feet means that sores or injuries may not be noticed and may become ulcerated or infected. Circulation problems also increase the risk of foot ulcers.

More than half of all lower-limb amputations in the United States occur in people with diabetes—86,000 amputations per year. Doctors estimate that nearly half of the amputations caused by neuropathy and poor circulation could have been prevented by careful foot care.

Follow these steps to take care of your feet:

• Clean your feet daily, using warm—not hot—water and a mild soap. Avoid soaking your feet. Dry them with a soft towel and dry carefully between your toes.
• Inspect your feet and toes every day for cuts, blisters, redness, swelling, calluses, or other problems. Use a mirror—laying a mirror on the floor works well—or get help from someone else if you cannot see the bottoms of your feet. Notify your health care provider of any problems.
• Moisturize your feet with lotion, but avoid getting the lotion between your toes.
• After a bath or shower, file corns and calluses gently with a pumice stone.
• Each week or when needed, cut your toenails to the shape of your toes and file the edges with an emery board.
• Always wear shoes or slippers to protect your feet from injuries. Prevent skin irritation by wearing thick, soft, seamless socks.
• Wear shoes that fit well and allow your toes to move. Break in new shoes gradually by first wearing them for only an hour at a time.
• Before putting your shoes on, look them over carefully and feel the insides with your hand to make sure they have no tears, sharp edges, or objects in them that might injure your feet.
• If you need help taking care of your feet, make an appointment to see a foot doctor, also called a podiatrist.

For additional information about foot care, contact the National Diabetes Information Clearinghouse at 1-800-860-8747. Materials are also available from the National Diabetes Education Program.

Points to Remember

• Diabetic neuropathies are nerve disorders caused by many of the abnormalities common to diabetes, such as high blood glucose.
• Neuropathy can affect nerves throughout the body, causing numbness and sometimes pain in the hands, arms, feet, or legs, and problems with the digestive tract, heart, sex organs, and other body systems.
• Treatment first involves bringing blood glucose levels within the normal range. Good blood glucose control may help prevent or delay the onset of further problems.
• Foot care is an important part of treatment. People with neuropathy need to inspect their feet daily for any injuries. Untreated injuries increase the risk of infected foot sores and amputation.
• Treatment also includes pain relief and other medications as needed, depending on the type of nerve damage.
• Smoking significantly increases the risk of foot problems and amputation. If you smoke, ask your health care provider for help with quitting.

NIH Publication No. 08-3185
February 2009

For people with type 2 diabetes, heart disease and stroke are the number 1 causes of death and disability. Here's what you can do about this diabetes complication.

At least 65 percent of people with diabetes die of some form of heart disease or stroke, according to the American Heart Association. By controlling your risk factors, you can avoid or delay cardiovascular disease (heart and blood vessel disease).

Contents:

• What is the connection between diabetes, heart disease, and stroke?
• What are the risk factors for heart disease and stroke in people with diabetes?
• What is metabolic syndrome and how is it linked to heart disease?
• What can I do to prevent or delay heart disease and stroke?
• How will I know whether my diabetes treatment is working?
• What types of heart and blood vessel disease occur in people with diabetes?
• How will I know whether I have heart disease?
• What are the treatment options for heart disease?
• How will I know whether I have had a stroke?
• What are the treatment options for stroke?
• Points to Remember

Having diabetes or prediabetes puts you at increased risk for heart disease and stroke. You can lower your risk by keeping your blood glucose (also called blood sugar), blood pressure, and blood cholesterol close to the recommended target numbers—the levels suggested by diabetes experts for good health. (For more information about target numbers for people with diabetes, see "Diabetes Complications: Heart Disease and Stroke"). Reaching your targets also can help prevent narrowing or blockage of the blood vessels in your legs, a condition called peripheral arterial disease. You can reach your targets by

• choosing foods wisely
• being physically active
• taking medications if needed

If you have already had a heart attack or a stroke, taking care of yourself can help prevent future health problems. 

Connection Between Diabetes, Heart Disease, and Stroke

If you have diabetes, you are at least twice as likely as someone who does not have diabetes to have heart disease or a stroke. People with diabetes also tend to develop heart disease or have strokes at an earlier age than other people. If you are middle-aged and have type 2 diabetes, some studies suggest that your chance of having a heart attack is as high as someone without diabetes who has already had one heart attack. Women who have not gone through menopause usually have less risk of heart disease than men of the same age. But women of all ages with diabetes have an increased risk of heart disease because diabetes cancels out the protective effects of being a woman in her child-bearing years.

People with diabetes who have already had one heart attack run an even greater risk of having a second one. In addition, heart attacks in people with diabetes are more serious and more likely to result in death. High blood glucose levels over time can lead to increased deposits of fatty materials on the insides of the blood vessel walls. These deposits may affect blood flow, increasing the chance of clogging and hardening of blood vessels (atherosclerosis).

---

Risk Factors for Heart Disease and Stroke in People with Diabetes

Diabetes itself is a risk factor for heart disease and stroke. Also, many people with diabetes have other conditions that increase their chance of developing heart disease and stroke. These conditions are called risk factors. One risk factor for heart disease and stroke is having a family history of heart disease. If one or more members of your family had a heart attack at an early age (before age 55 for men or 65 for women), you may be at increased risk.

You can't change whether heart disease runs in your family, but you can take steps to control the other risk factors for heart disease listed here:

• Having central obesity. Central obesity means carrying extra weight around the waist, as opposed to the hips. A waist measurement of more than 40 inches for men and more than 35 inches for women means you have central obesity. Your risk of heart disease is higher because abdominal fat can increase the production of LDL (bad) cholesterol, the type of blood fat that can be deposited on the inside of blood vessel walls.
• Having abnormal blood fat (cholesterol) levels.
  • LDL cholesterol can build up inside your blood vessels, leading to narrowing and hardening of your arteries—the blood vessels that carry blood from the heart to the rest of the body. Arteries can then become blocked. Therefore, high levels of LDL cholesterol raise your risk of getting heart disease.
  • Triglycerides are another type of blood fat that can raise your risk of heart disease when the levels are high.
  • HDL (good) cholesterol removes deposits from inside your blood vessels and takes them to the liver for removal. Low levels of HDL cholesterol increase your risk for heart disease.
• Having high blood pressure. If you have high blood pressure, also called hypertension, your heart must work harder to pump blood. High blood pressure can strain the heart, damage blood vessels, and increase your risk of heart attack, stroke, eye problems, and kidney problems.
• Smoking. Smoking doubles your risk of getting heart disease. Stopping smoking is especially important for people with diabetes because both smoking and diabetes narrow blood vessels. Smoking also increases the risk of other long-term complications, such as eye problems. In addition, smoking can damage the blood vessels in your legs and increase the risk of amputation.

Metabolic Syndrome and Its Link to Heart Disease

Metabolic syndrome is a grouping of traits and medical conditions that puts people at risk for both heart disease and type 2 diabetes. It is defined by the National Cholesterol Education Program as having any three of the following five traits and medical conditions:

Traits and Medical Conditions	Definition
Elevated waist circumference	Waist measurement of 40 inches or more in men 35 inches or more in women
Elevated levels of triglycerides	150 mg/dL or higher or Taking medication for elevated triglyceride levels
Low levels of HDL (good) cholesterol	Below 40 mg/dL in men Below 50 mg/dL in women or Taking medication for low HDL cholesterol levels
Elevated blood pressure levels	130 mm Hg or higher for systolic blood pressure or 85 mm Hg or higher for diastolic blood pressure or Taking medication for elevated blood pressure levels
Elevated fasting blood glucose levels	100 mg/dL or higher or Taking medication for elevated blood glucose levels

Source: Grundy SM, et al. Diagnosis and Management of the Metabolic Syndrome: An American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation. 2005;112:2735-2752.
Note: Other definitions of similar conditions have been developed by the American Association of Clinical Endocrinologists, the International Diabetes Federation, and the World Health Organization.

---

Preventing or Delaying Heart Disease and Stroke

Even if you are at high risk for heart disease and stroke, you can help keep your heart and blood vessels healthy. You can do so by taking the following steps:

• Make sure that your diet is "heart-healthy." Meet with a registered dietitian to plan a diet that meets these goals:
  • Keep the amount of trans fat in your diet to a minimum. It's a type of fat in foods that raises blood cholesterol. Limit your intake of crackers, cookies, snack foods, commercially prepared baked goods, cake mixes, microwave popcorn, fried foods, salad dressings, and other foods made with partially hydrogenated oil. In addition, some kinds of vegetable shortening and margarines have trans fat. Check for trans fat in the Nutrition Facts section on the food package.
  • Keep the cholesterol in your diet to less than 300 milligrams a day. Cholesterol is found in meat, dairy products, and eggs.
  • Cut down on saturated fat. It raises your blood cholesterol level. Saturated fat is found in meats, poultry skin, butter, dairy products with fat, shortening, lard, and tropical oils such as palm and coconut oil. Your dietitian can figure out how many grams of saturated fat should be your daily maximum amount.
  • Include at least 14 grams of fiber daily for every 1,000 calories consumed. Foods high in fiber may help lower blood cholesterol. Oat bran, oatmeal, whole-grain breads and cereals, dried beans and peas (such as kidney beans, pinto beans, and black-eyed peas), fruits, and vegetables are all good sources of fiber. Increase the amount of fiber in your diet gradually to avoid digestive problems.
• Make physical activity part of your routine. Aim for at least 30 minutes of exercise most days of the week. Think of ways to increase physical activity, such as taking the stairs instead of the elevator. If you haven't been physically active recently, see your doctor for a checkup before you start an exercise program.
• Reach and maintain a healthy body weight. If you are overweight, try to be physically active for at least 30 minutes a day, most days of the week. Consult a registered dietitian for help in planning meals and lowering the fat and calorie content of your diet to reach and maintain a healthy weight. Aim for a loss of no more than 1 to 2 pounds a week.
• If you smoke, quit. Your doctor can help you find ways to quit smoking.
• Ask your doctor whether you should take aspirin. Studies have shown that taking a low dose of aspirin every day can help reduce the risk of heart disease and stroke. However, aspirin is not safe for everyone. Your doctor can tell you whether taking aspirin is right for you and exactly how much to take.
• Get prompt treatment for transient ischemic attacks (TIAs). Early treatment for TIAs, sometimes called mini-strokes, may help prevent or delay a future stroke. Signs of a TIA are sudden weakness, loss of balance, numbness, confusion, blindness in one or both eyes, double vision, difficulty speaking, or a severe headache.

Confirming Your Diabetes Treatment is Working

You can keep track of the ABCs of diabetes to make sure your treatment is working. Talk with your health care provider about the best targets for you.

A stands for A1C (a test that measures blood glucose control). Have an A1C test at least twice a year. It shows your average blood glucose level over the past 3 months. Talk with your doctor about whether you should check your blood glucose at home and how to do it.

A1C target
Below 7 percent

 

Blood glucose targets
Before meals	80 to 130 mg/dL
1 to 2 hours after the start of a meal	Less than 180 mg/dL

B is for blood pressure. Have it checked at every office visit.

Blood pressure target
Below 130/80 mm Hg

C is for cholesterol. Have it checked at least once a year.

Blood fat (cholesterol) targets
LDL (bad) cholesterol	Under 100 mg/dL
Triglycerides	Under 150 mg/dL
HDL (good) cholesterol	For men: above 40 mg/dL For women: above 50 mg/dL

Control of the ABCs of diabetes can reduce your risk for heart disease and stroke. If your blood glucose, blood pressure, and cholesterol levels aren't on target, ask your doctor what changes in diet, activity, and medications can help you reach these goals.

---

Diabetes and the Types of Heart and Blood Vessel Disease That Occurs

Two major types of heart and blood vessel disease, also called cardiovascular disease, are common in people with diabetes: coronary artery disease (CAD) and cerebral vascular disease. People with diabetes are also at risk for heart failure. Narrowing or blockage of the blood vessels in the legs, a condition called peripheral arterial disease, can also occur in people with diabetes.

Coronary Artery Disease

Coronary artery disease, also called ischemic heart disease, is caused by a hardening or thickening of the walls of the blood vessels that go to your heart. Your blood supplies oxygen and other materials your heart needs for normal functioning. If the blood vessels to your heart become narrowed or blocked by fatty deposits, the blood supply is reduced or cut off, resulting in a heart attack.

Cerebral Vascular Disease

Cerebral vascular disease affects blood flow to the brain, leading to strokes and TIAs. It is caused by narrowing, blocking, or hardening of the blood vessels that go to the brain or by high blood pressure.

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. Most strokes are caused by fatty deposits or blood clots—jelly-like clumps of blood cells—that narrow or block one of the blood vessels in the brain or neck. A blood clot may stay where it formed or can travel within the body. People with diabetes are at increased risk for strokes caused by blood clots.

A stroke may also be caused by a bleeding blood vessel in the brain. Called an aneurysm, a break in a blood vessel can occur as a result of high blood pressure or a weak spot in a blood vessel wall.

TIAs

TIAs are caused by a temporary blockage of a blood vessel to the brain. This blockage leads to a brief, sudden change in brain function, such as temporary numbness or weakness on one side of the body. Sudden changes in brain function also can lead to loss of balance, confusion, blindness in one or both eyes, double vision, difficulty speaking, or a severe headache. However, most symptoms disappear quickly and permanent damage is unlikely. If symptoms do not resolve in a few minutes, rather than a TIA, the event could be a stroke. The occurrence of a TIA means that a person is at risk for a stroke sometime in the future. See page 3 for more information on risk factors for stroke.

Heart Failure

Heart failure is a chronic condition in which the heart cannot pump blood properly—it does not mean that the heart suddenly stops working. Heart failure 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.

Blockage of the blood vessels and high blood glucose levels also can damage heart muscle and cause irregular heart beats. People with damage to 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. Diabetes can also interfere with pain signals normally carried by the nerves, explaining why a person with diabetes may not experience the typical warning signs of a heart attack.

Peripheral Arterial Disease

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. Sometimes people with PAD develop pain in the calf or other parts of the leg when walking, which is relieved by resting for a few minutes.

How will I know whether I have heart disease?

One sign of heart disease is angina, the pain that occurs when a blood vessel to the heart is narrowed and the blood supply is reduced. You may feel pain or discomfort in your chest, shoulders, arms, jaw, or back, especially when you exercise. The pain may go away when you rest or take angina medicine. Angina does not cause permanent damage to the heart muscle, but if you have angina, your chance of having a heart attack increases.

A heart attack occurs when a blood vessel to the heart becomes blocked. With blockage, not enough blood can reach that part of the heart muscle and permanent damage results. During a heart attack, you may have

• chest pain or discomfort
• pain or discomfort in your arms, back, jaw, neck, or stomach
• shortness of breath
• sweating
• nausea
• light-headedness

---

Symptoms may come and go. However, in some people, particularly those with diabetes, symptoms may be mild or absent due to a condition in which the heart rate stays at the same level during exercise, inactivity, stress, or sleep. Also, nerve damage caused by diabetes may result in lack of pain during a heart attack.

Women may not have chest pain but may be more likely to have shortness of breath, nausea, or back and jaw pain. If you have symptoms of a heart attack, call 911 right away. Treatment is most effective if given within an hour of a heart attack. Early treatment can prevent permanent damage to the heart.

Your doctor should check your risk for heart disease and stroke at least once a year by checking your cholesterol and blood pressure levels and asking whether you smoke or have a family history of premature heart disease. The doctor can also check your urine for protein, another risk factor for heart disease. If you are at high risk or have symptoms of heart disease, you may need to undergo further testing.

What are the treatment options for heart disease?

Treatment for heart disease includes meal planning to ensure a heart-healthy diet and physical activity. In addition, you may need medications to treat heart damage or to lower your blood glucose, blood pressure, and cholesterol. If you are not already taking a low dose of aspirin every day, your doctor may suggest it. You also may need surgery or some other medical procedure.

For additional information about heart and blood vessel disease, high blood pressure, and high cholesterol, call the National Heart, Lung, and Blood Institute Health Information Center at 301-592-8573 or see www.nhlbi.nih.gov on the Internet.

How will I know whether I have had a stroke?

The following signs may mean that you have had a stroke:

• sudden weakness or numbness of your face, arm, or leg on one side of your body
• sudden confusion, trouble talking, or trouble understanding
• sudden dizziness, loss of balance, or trouble walking
• sudden trouble seeing out of one or both eyes or sudden double vision
• sudden severe headache

If you have any of these symptoms, call 911 right away. You can help prevent permanent damage by getting to a hospital within an hour of a stroke. If your doctor thinks you have had a stroke, you may have tests such as a neurological examination to check your nervous system, special scans, blood tests, ultrasound examinations, or x rays. You also may be given medication that dissolves blood clots.

What are the treatment options for stroke?

At the first sign of a stroke, you should get medical care right away. If blood vessels to your brain are blocked by blood clots, the doctor can give you a "clot-busting" drug. The drug must be given soon after a stroke to be effective. Subsequent treatment for stroke includes medications and physical therapy, as well as surgery to repair the damage. Meal planning and physical activity may be part of your ongoing care. In addition, you may need medications to lower your blood glucose, blood pressure, and cholesterol and to prevent blood clots.

For additional information about strokes, call the National Institute of Neurological Disorders and Stroke at 1-800-352-9424 or see www.ninds.nih.gov on the Internet.

Points to Remember

• If you have diabetes, you are at least twice as likely as other people to have heart disease or a stroke.
• Controlling the ABCs of diabetes—A1C (blood glucose), blood pressure, and cholesterol—can cut your risk of heart disease and stroke.
• Choosing foods wisely, being physically active, losing weight, quitting smoking, and taking medications (if needed) can all help lower your risk of heart disease and stroke.
• If you have any warning signs of a heart attack or a stroke, get medical care immediately—don't delay. Early treatment of heart attack and stroke in a hospital emergency room can reduce damage to the heart and the brain.

Source: NIH Publication No. 06-5094
December 2005