Diabetes

Many factors encourage the development of Type 2 diabetes. On the one hand, genetic issues seem to play a part because it seems to run in families. On the other hand, lifestyle also contributes to the disease, as obesity and a sedentary lifestyle, in particular, can commonly be found in the medical history of people with Type 2 diabetes. Fatty tissue produces messenger substances that can promote insulin resistance. Additional risk factors include high blood pressure, an unhealthy diet, alcohol consumption, smoking, stress and impaired fat metabolism.

The first symptoms of Type 2 diabetes are usually quite non-specific: tiredness and fatigue, an increased susceptibility to infection, dry skin or poorly healing wounds initially aren’t identified as a sign of a serious metabolic disorder. That’s why Type 2 diabetes often goes unnoticed in the beginning or is detected only by coincidence as part of a blood test. Typical symptoms that may be an indication of Type 2 diabetes type include increased thirst and a frequent urge to urinate, as the body is trying to get rid of the excess sugar via the urine. Those who notice these symptoms should therefore have their blood sugar level checked by a physician.

Technically, everyone can reduce his/her individual diabetes risk. In addition to congenital factors, lifestyle in particular plays an important role in the development of Type 2 diabetes. A balanced diet, abstaining from alcohol and nicotine, as well as regular physical activity contribute a lot to lowering the risk of this illness occurring. In the case of obesity, weight loss is recommended, and lipid metabolism disorders should be medically treated.

The condition is initially treated with movement therapy and weight loss, combined with drug therapy. In many cases, weight loss can contribute to significantly reduce blood sugar levels. Regular physical activity also helps the sugar metabolism level off, improving the cells’ sensitivity to insulin. In this way, insulin injections to control blood sugar can often be delayed by many years.

As the condition progresses, however, insulin will be used when the pancreas’ hormone production decreases because of age. It’s important to keep the blood sugar level in a healthy range to prevent secondary diseases such as diabetic foot syndrome.

In cases of diabetic angiopathy, the cells that line the arteries on the inside are often affected. In a healthy person, they form a smooth layer (endothelium) to which deposits cannot stick. If this endothelium is damaged by the elevated blood sugar, rough patches develop, on which deposits – or plaques – can form. In the early stages of the condition, they don’t cause any problems. Over time, however, more plaques deposit on these sites, and they gradually calcify. A bottleneck develops impeding blood flow, meaning an insufficient supply to the organs and tissue behind it. This, in turn, impairs their function and – depending on which organ is affected and where the stenosis forms – causes problems such as an increased risk of stroke or heart attack.

Typical angiopathy symptoms are difficult to specify because stenosis can occur practically anywhere in the body and can go unnoticed for a long time.

• Microangiopathy of the kidneys is often detected by coincidence during routine laboratory tests if a certain protein (albumin) is excreted in an unusually high concentration.
• If the eye is affected, there are also no symptoms for a long time. Only later on, vision problems occur such as blurry, cloudy vision as well as dark spots in the visual field. These are the first indications of a condition called retinopathy, which can lead to blindness in severe cases.
• If vessels in the brain are affected, indications may include problems concentrating or remembering, mood swings, or depression.
• In the early stages, angiopathy in larger vessels (macroangiopathy) can lead to a decreased heart rate as well as cold feet and hands, or pain during extended periods of walking.

It’s very difficult to detect angiopathy early. That’s why people suffering from diabetes should have regular medical check-ups in order to identify early symptoms in time.

Angiopathy treatment mainly aims at minimizing risk factors, such as a high blood sugar level, smoking, alcohol, obesity, and high blood pressure. Improving circulation is just as important. Initially, the main focus is getting the blood sugar level right.

Treatment of microangiopathy is not easy because the affected blood vessels are too small to perform surgery on. Instead, the objective is to improve the blood’s flow properties to increase blood supply to the affected area. Stenoses in larger blood vessels can be expanded using various surgical procedures, including:

• removal of plaques (calcium deposits)
• stretching of the narrowed vessel using a balloon catheter (balloon catheter dilation)
• bypass surgery
• implanting a stent that keeps narrowed vessels open, thus improving blood flow

The excessive sugar concentration in the blood damages nerve cells, causing impaired functioning and even dying of the nerves. Depending on which nerve paths are affected, diabetic neuropathy can have very different indicators. Nerves that control organs such as the liver, heart or kidneys, or relay sensory stimuli, can be affected and consequently cause impaired functioning.

Nerve cells run through all organs in our body. They control movements and organ functions, for example, transmit tactile and other sensory perceptions to the brain and spinal cord, and, as pain fibers, signal injuries and damage. The tasks these nerves carry out are very versatile. That means that the indicators of diabetic neuropathy can also be very varied:

• If nerve fibers that transmit environmental and tactile stimuli are damaged, there can be paresthesia, tingling, itching, burning, pins and needles or numbness, as well as reduced or abnormal temperature perception.
• If pain fibers are damaged, those affected suffer from pain without a detectable cause, or a lack of pain perception.
• If organ nerves are damaged (autonomic neuropathy), irregular heartbeat or digestive problems can develop that can manifest as blood pressure fluctuations, nausea, vomiting, bladder weakness, problems swallowing, or impotence.
• If motor nerves are damaged, muscle weakness, muscle wasting, paralysis, an unsteady gait, or tripping can be symptoms.
• If the nerve fibers of the eye are affected (diabetic retinopathy), indications include impaired vision; in severe cases, it can lead to blindness.

Die ärztliche Behandlung besteht überwiegend in der Patientenaufklärung und in einer strikten Kontrolle und Einstellung des Blutzuckers, um eine fortschreitende Schädigung des Nervensystems aufzuhalten. Dabei ist die Mitarbeit des Betroffenen entscheidend.

Eigenständige Kontrollen des Blutzuckerspiegels und des Blutdrucks sowie eine gesunde Lebensweise mit Verzicht auf Nikotin und Alkohol, die ihrerseits Nerven schädigen können, sind dazu unverzichtbar. Je nach Beschwerdebild können verschiedene Maßnahmen eingeleitet werden, um die Lebensqualität der Betroffenen zu verbessern:

• Gewichtsreduzierung bei Übergewicht
• Schmerztherapie
• medikamentöse Therapie
• Einlagen, orthopädische Schuhe oder Schienen
• Physiotherapie (Wärme- oder Kältetherapie, Elektrotherapie, Bewegungstherapie wie Gymnastik oder Gangschule, Massage)
• bei Funktionsstörungen innerer Organe gezielte Therapien, um die Funktionsstörung auszugleichen (zum Beispiel ACE-Hemmer oder Antiarrhythmika bei Herzrhythmusstörungen oder Implantation eines Magenschrittmachers bei schweren Störungen der Magenfunktion)
• begleitende Psychotherapie oder Selbsthilfegruppen

In the medical background of diabetic foot, the following factors often play a role:

• Disorders of the small and minute vessels (diabetic angiopathy)
• Nerve damage (diabetic polyneuropathy)
• Impaired circulation (peripheral arterial disease, PAD)

High blood pressure and smoking are additional risk factors for PAD. Nerve damage means that those affected are no longer able to feel pain – for example in the case of incorrect posture or strain on the feet, because of tight or rubbing footwear, or foreign substances in the shoe.

That’s how small wounds on the toes or balls of the feet initially go unnoticed. Their development is also encouraged by increasingly dry and cracked skin, which is a consequence of neuropathy. Owing to reduced circulation and impaired metabolism, wounds don’t heal well and become chronic. Diabetes patients are particularly vulnerable to developing diabetic foot syndrome if several risk factors (obesity, smoking, lack of movement, impaired metabolism or circulation, high blood pressure) are present at the same time.

The first symptoms can often be detected long before the development of diabetic foot:

• Paresthesia in the feet (itching, tingling, pins and needles)
• Poor sense of touch (“feet fall asleep”)
• Foot pulse hardly or not at all detectable
• Painful legs after walking long distances that force frequent stopping (also known as “window-shopper’s disease” or intermittent claudication)

These can be indicators of impaired circulation, early peripheral arterial disease (PAD) or damaged nerves. Poorly healing wounds are the main symptom of diabetic foot syndrome.

Appropriate footwear is particularly important to minimize one’s risk. It mustn’t pinch, rub, or constrict, especially when the sense of touch and sensitivity are reduced. Comfort shoes with soft, seamless inner lining and padding or foot orthoses with soft cushioning can decrease the risk of pressure points on and injuries to the feet. Individually tailored orthopedic footwear (custom-made shoes for people suffering from diabetes) also helps.

Furthermore, regular check-ups and care of the feet are vital. The following aspects must be taken into account:

• Check your feet daily for visible changes (increased callusing, cracks under or between the toes, reddening) or small wounds
• Use pH neutral, lipid-replenishing soap for foot care
• Keep foot baths short (about three minutes) to prevent the skin from going soft, use lukewarm water (check with a bath thermometer if needed)
• Dry your feet carefully with a soft towel, especially between the toes
• Have calluses or corns removed regularly by a diabetologically trained podiatrist – many health insurance providers will reimburse the costs of medical foot care
• Ensure careful foot hygiene with a daily change of socks
• File toenails instead of cutting them, round off the corners of the nails to prevent ingrowing
• Use non-scented skin cream rich in lipids on your feet every day to prevent dry skin and the formation of cracks (products suitable for people suffering from diabetes are often labeled accordingly)
• Do not walk bare-foot to reduce your risk of injury
• Do not self-treat or have foot baths if you have small injuries – skin injuries on the feet should be shown to the treating physician immediately

Additionally, all measures that promote circulation in the feet and legs help, such as frequent, short walks or leg and foot exercises. Sports for people with diabetes in suitable exercise groups can also help to promote circulation and maintain physical fitness.

People suffering from diabetes have a life-long risk of developing diabetic foot syndrome. That’s why proficient management of the condition is essential. Diabetes education training courses convey the required basic knowledge and should be taken by all who are affected.