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Updated April 30, 2008

Navigating Your Way to Optimal Health

by Laura Hieronymus, M.S.Ed., A.P.R.N., B.C.-A.D.M., C.D.E., and Gregory Hood, M.D.

The following are the current recommendations for adults with diabetes regarding eye examinations:

• Adults with Type 1 diabetes should have an initial dilated and comprehensive eye examination within three to five years of the onset of diabetes.
• Adults with Type 2 diabetes should have an initial dilated and comprehensive eye examination shortly after the diagnosis of diabetes because retinal changes may already have occurred by the time diabetes is diagnosed.
• All people with diabetes should have the eye examination repeated annually.
• Women with diabetes who are planning a pregnancy should be counseled on the risk of the development and/or progression of diabetic retinopathy. Pregnant women should have an eye examination during the first trimester of pregnancy and follow-up exams as recommended.

Nephropathy is the most common cause of kidney failure in the United States and the greatest threat to life in adults with Type 1 diabetes. One-third of people with Type 1 diabetes develop kidney disease within 15 years of diagnosis. Diabetes damages the small blood vessels in the kidneys, impairing their ability to remove impurities from the blood. People with severe kidney damage must have a kidney transplant or rely on dialysis to filter waste from their blood.

Intensive diabetes management with the goal of achieving near-normal blood glucose levels has been shown to reduce the risk and slow the progression of kidney disease in people with Type 1 and Type 2 diabetes. Optimal control of blood pressure is another recommendation to reduce risk for nephropathy. It is essential that people with diabetes undergo an annual test for the presence of microalbuminuria (the spilling of small amounts of the protein albumin into the urine, which indicates kidney damage). This should be done in everyone who has had Type 1 diabetes for five years or more and in everyone with Type 2 diabetes starting at diagnosis. Testing for microalbuminuria should also occur during pregnancy.

If microalbuminuria is detected, optimal blood glucose control, as well as controlling blood pressure using either angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) can slow the progression to kidney damage. In this situation, your dietitian will recommend restricting protein intake to about 10% of calories daily, or 0.8 grams per kilogram of body weight per day (the current adult recommended dietary allowance for protein), which may also slow the decline of kidney function. If a person has nephropathy, early detection and treatment can improve his quality of life and delay or prevent the need for dialysis and renal transplantation.

Neuropathy (diabetic nerve disease) is one of the most common and most challenging complications of diabetes. Elevated blood glucose levels can cause damage to the peripheral nervous system (peripheral neuropathy), which affects the sensory nerves that reach the arms, legs, hands, and feet. Neuropathy is a major contributing factor in foot and leg amputations among people with diabetes. Damage can also be done to the autonomic nerves (autonomic neuropathy), which control blood pressure, heart rate, digestion, and sexual function, as well as other internal organ processes. Studies have shown that intensive control of blood glucose can reduce the development and progression of nerve damage in Type 1 and Type 2 diabetes by as much as 60%.

Although most neuropathies are detected based on symptoms, your physician should screen you annually for peripheral neuropathy with tests such as those for sensation (feeling); pressure, temperature, and vibration perception; and reflexes. Your physician should also check your feet at each diabetes visit to assess any potential problems. While there have been several advances in therapies to treat neuropathy, there is no known direct treatment for the underlying causes of neuropathy at this time (though stabilizing blood glucose levels is an important first step). Treatment of peripheral neuropathy currently focuses on pain management. Your diabetes educator should give you guidelines for foot care to help prevent any injury and infection to your feet and legs due to loss of sensation from peripheral neuropathy. Treatment of autonomic neuropathy also focuses on relief of symptoms and is based on each individual’s condition.

Setting sail
With the ADA’s standards of care serving as a map to guide you, you can control your diabetes destiny. The sailing may not always be smooth, but if you stay on course with self-care, optimal blood glucose control, continuing diabetes education, and regular visits to and communication with your diabetes care providers, good health and prevention of diabetes-related complications can be your charted destination.

Also in this article:
Monitoring for Control and Complications
Symptoms of Diabetes

Laura Hieronymus is the program coordinator for an American Diabetes Association–recognized education service, and Gregory Hood is a practicing internist. They are diabetes care and education providers at Drs. Borders & Associates, PSC, in Lexington, Kentucky.

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