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Type 2 Diabetes
Type 2 diabetes occurs mainly in people aged over 30. The 'first-line' treatment is diet and
exercise. If the blood glucose level remains high despite a trial of diet and exercise, then
tablets to reduce the blood glucose level are usually advised. Insulin injections are
needed in some cases. Other treatments include reducing blood pressure if it is high, and
other measures to reduce the risk of complications.
What is diabetes?
Diabetes mellitus (just called diabetes from now on) occurs when the level of glucose (sugar) in the blood
becomes higher than normal. There are two main types of diabetes - Type 1 diabetes and Type 2
diabetes.
Understanding blood glucose and insulin
After you eat, various foods are broken down in your gut into sugars. The main sugar is called glucose
which passes through your gut wall into your bloodstream. However, to remain healthy, your blood
glucose level should not go too high or too low.
So, when your blood glucose level begins to rise (after you eat), the level of a hormone called insulin
should also rise. Insulin works on the cells of your body and makes them take in glucose from the
bloodstream. Some of the glucose is used by the cells for energy, and some is converted into glycogen or
fat (which are stores of energy). When the blood glucose level begins to fall (between meals), the level of
insulin falls. Some glycogen or fat is then converted back into glucose which is released from the cells
into the bloodstream.
Insulin is a hormone made by special 'islands' of cells in the pancreas. (Hormones are chemicals which
are released into the bloodstream and work on various parts of the body.)
Type 1 diabetes
In this type of diabetes the pancreas stops making insulin. The illness and symptoms develop quickly
(over days or weeks) because the level of insulin in the bloodstream becomes very low. Type 1 diabetes
used to be known as juvenile, early onset, or Insulin Dependent Diabetes. It usually first develops in
children or in young adults.
Type 1 diabetes is treated with insulin injections and diet.
Type 2 diabetes
With Type 2 diabetes, the illness and symptoms tend to develop gradually (over weeks or months). This is
because in Type 2 diabetes you still make insulin (unlike Type 1 diabetes). However, you develop
diabetes because:
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you do not make enough insulin for your body's needs, OR
the cells in your body do not use insulin properly. (This is called 'insulin resistance'. The cells in
your body become resistant to normal levels of insulin. So, you need more insulin than you
normally make to keep the blood glucose level down), OR
a combination of the above two reasons.
Type 2 diabetes used to be known as maturity onset, or Non-Insulin Dependent Diabetes. It develops
mainly in people older than 30 (but can occur in younger people). In the UK about 3 in 100 people aged
over 40, and about 10 in 100 people aged over 65, have Type 2 diabetes. It is more common in people
who are overweight or obese. It also tends to run in families. It is also more common in African, AfroCaribbean and Asian people.
The rest of this leaflet deals only with Type 2 diabetes.
What are the symptoms of Type 2 diabetes?
The four common symptoms are:
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being thirsty a lot of the time.
passing large amounts of urine. (The reason you make a lot of urine and become thirsty is
because glucose leaks into your urine which 'pulls out' extra water through the kidneys.)
tiredness.
weight loss.
The symptoms may develop so gradually that you can become used to your increased thirst and
tiredness. You may not recognise that you are ill for some time. Some people also develop blurred vision
and frequent infections such as recurring thrush. However, some people with Type 2 diabetes do not
have any symptoms if the blood glucose level is not too high. (But, even if you do not have symptoms,
you should still have treatment to reduce the risk of long term complications.)
How is diabetes diagnosed?
A simple 'dipstick' test can detect glucose in a sample of urine. If you have glucose in your urine, it is
likely that you have diabetes. (Urine does not normally contain glucose. If the blood glucose level goes
above a certain level, then some glucose 'spills' through the kidneys into the urine.)
But, some people have kidneys which are more 'leaky', and glucose may leak into urine with a normal
blood level. So, if your urine contains any glucose you should have a blood test to measure the blood
level of glucose to confirm, or rule out, diabetes.
What are the possible complications of diabetes?
Very high blood glucose level
This is not common with Type 2 diabetes. It is more common in untreated Type 1 diabetes when a very
high level of glucose can develop quickly and cause dehydration, drowsiness, and serious illness which
can be life-threatening. However, a very high glucose level develops in some people with Type 2
diabetes.
Long term complications
If your blood glucose level is higher than normal over a long period of time, it can gradually damage your
blood vessels. This may lead to some of the following complications (often years after you first develop
diabetes).
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Atheroma ('furring or hardening of the arteries'). This can cause problems such as angina, heart
attacks, stroke, and poor circulation.
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Eye problems which can affect vision (due to damage to the small arteries of the retina at the
back of the eye).
 Kidney damage which sometimes develops into kidney failure.
 Nerve damage.
 Foot problems (due to poor circulation and nerve damage).
 Impotence.
 Other rare problems.
The type and severity of long-term complications varies from case to case. You may not develop any at
all. In general, the nearer your blood glucose level is to normal, the less your risk of developing
complications. Your risk of complications is also reduced if you deal with any other 'risk factors' which you
may have such as high blood pressure.
Treatment complications
Too much insulin or medication can make the blood glucose level become too low (hypoglycaemia or
'hypo'). Symptoms of hypoglycaemia include: trembling, sweating, anxiety, blurred vision, tingling lips,
paleness, mood change, vagueness or confusion. To treat hypoglycaemia: take a sugary drink or some
sweets. Then eat a starchy snack, such as a sandwich. Some people carry a glucagon injection (a
hormone which has the opposite effect to insulin) for use in emergencies to reverse hypoglycaemia. Note:
hypoglycaemia cannot occur if you are treated with diet alone.
What are the aims of treatment?
If a high blood glucose level is brought down to a near normal level, your symptoms will ease and you are
likely to feel well again. But, you still have some risk of complications in the long-term if your blood
glucose level remains even mildly high - even if you have no symptoms in the short-term. So, the main
aims of treatment are:
1. To keep your blood glucose level as near normal as possible.
2. To reduce any other 'risk factors' which may increase your risk of developing complications. In
particular, to lower your blood pressure if it is high.
3. To detect any complications as early as possible. Treatment can prevent, or delay, some
complications from getting worse.
Treatment aim 1 - keeping your blood glucose level down
What is the level of blood glucose to aim for?
Some people with diabetes check their blood glucose level each day. If you do, ideally you should aim to
keep your blood glucose level between 4 and 7 mmol/l before meals, and less than 10 mmol/l two hours
after meals. This 'tight' control is not realistic for everybody, and a target level to aim for may be agreed
between you and your doctor or nurse.
Not everybody checks their blood so often. Another type of blood test is called HbA1c. This test may be
done every 2-6 months by your doctor or nurse. This test measures what your recent average blood
glucose level has been. (The test measures a part of the red blood cells. Glucose in the blood attaches to
part of the red blood cells. This part can be measured and gives a good indication of your average blood
glucose over the last 2-3 months.) Treatment aims to lower you HbA1c to below a target level which is
usually agreed between you and your doctor. The target level is usually somewhere between 6.5% and
7.5%. If your HbA1c is above your target level then you may be advised to 'step up' treatment to keep
your blood glucose level down (for example, by increasing the dose of medication, etc).
Diet and exercise
You can usually reduce the level of your blood glucose (and HbA1c) if you:
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Eat a healthy balanced diet. A practice nurse and/or dietician will give details on how to eat a
healthy diet. The diet is the same as recommended for everyone. (The idea that you need special
foods for diabetes is a myth.) Basically, you should aim to eat a diet low in fat, high in fibre, and
with plenty of starchy foods, fruit and vegetables.
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Lose weight if you are overweight. Getting to a 'perfect weight' is unrealistic for many people. But,
losing some weight will help to reduce your blood glucose level (and have other health benefits
too).
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Exercise regularly. If you are able, a minimum of 30 minutes brisk walking at least 5 times a week
is advised. Anything more is even better. You can spread the exercise over the day. (For
example, three 10 minute spells per day of brisk walking, cycling, dancing, etc.) Regular exercise
also reduces your risk of having a heart attack or stroke.
Many people with Type 2 diabetes can reduce their blood glucose (and HbA1c) to a target level by the
above measures. However, if the blood glucose (or HbA1c) level remains too high after a trial of these
measures for a few months, then medication is usually advised.
Medication
There are various tablets which can reduce the blood glucose level. Different ones suit different people.
Some tablets work by helping insulin to work better on the body's cells. Others work by boosting the
amount of insulin made by the pancreas. Another type works by slowing down the absorption of glucose
from the gut. Some people need a combination of tablets to control their blood glucose level. Tablets do
not work instead of a healthy diet - you need to eat a healthy diet as well. See a separate leaflet called
'Treatments for Type 2 Diabetes'.
Insulin injections
Insulin is needed in some cases if diet, exercise and tablets do not work well enough. You cannot take
insulin by mouth as it is destroyed by the digestive juices in the gut.
Treatment aim 2 - to reduce other risk factors
You are less likely to develop complications of diabetes if you reduce any other 'risk factors'. These are
briefly mentioned below, but are discussed more fully in another leaflet called Preventing Heart Disease
and Stroke. Everyone should aim to cut out preventable 'risk factors', but people with diabetes have even
more of a reason to do so.
Keep your blood pressure down
Have your blood pressure checked regularly. The combination of high blood pressure and diabetes is a
particularly high risk factor. Even mildly raised blood pressure should be treated if you have diabetes. The
aim is to keep your blood pressure below 140/80 (lower in some cases). Medication, sometimes with two
or even three different tablets, may be needed to keep your blood pressure down. See separate leaflet
called 'Diabetes and High Blood Pressure'.
If you smoke - now is the time to stop
Smoking is a high risk factor. See a practice nurse if you have difficulty stopping. If necessary, medication
or nicotine replacement therapy (nicotine gum, etc) may help you to stop.
Other medication
You may be advised to take tablets to lower your cholesterol level, and to take a daily aspirin. These help
to lower the risk of developing some complications such as heart disease and stroke.
Treatment aim 3 - to detect early, and treat any complications
Most GP's surgeries and hospitals have special diabetes clinics. Doctors, nurses, dieticians, chiropodists,
optometrists, and other health care workers all play a role in giving advice, and checking on progress.
Activities in diabetes clinics include:
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Checking levels of blood glucose, HbA1c, and blood pressure.
Ongoing advice on diet and lifestyle.
Checking for early signs of complications, for example:
o eye checks - to detect problems with the retina (a possible complication of diabetes)
which can often be prevented from getting worse. Glaucoma is also more common in
people with diabetes, and can usually be treated.
o urine tests - which include testing for protein in the urine which may indicate early kidney
problems.
o foot checks.
o other blood tests.
It is important to have regular checks as some complications, particularly if detected early, can be treated
or prevented from getting worse.
Immunisation
You should be immunised against 'flu (each autumn), and against the pneumococcus bacteria (just given
once). These infections can be particularly unpleasant if you have diabetes.
Diabetes UK
This leaflet gives only a brief account of diabetes. For further information contact Diabetes UK (formerly
the British Diabetic Association). There are numerous branches throughout the country. They produce
information leaflets on all topics related to diabetes, and their careline answers enquiries on all aspects of
diabetes.
Diabetes UK, 10 Parkway, London, NW1 7AA
Tel (careline): 020 7424 1030
Tel (office): 020 7424 1000
Web: http://www.mentor-update.com/gateway.cfm?site=http://www.diabetes.org.uk
Diabetes and High Blood Pressure
If you have diabetes it is important to keep your blood pressure in check to reduce
the risk of developing complications of diabetes such as heart disease, stroke, and
eye problems. In some cases blood pressure can be reduced by: losing weight,
regular exercise, a healthy diet, drinking less alcohol, and reducing salt. If needed,
medication can lower blood pressure.
What is high blood pressure?
High blood pressure (hypertension) means that the pressure of the blood in your arteries is too high.
Blood pressure is recorded as two figures. For example, 140/80 mmHg. This is said as '140 over 80'.
Blood pressure is measured in millimetres of mercury (mmHg).
What do the numbers mean?
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The top (first) number is the systolic pressure. This is the pressure in the arteries when the
heart contracts.
The bottom (second) number is the diastolic pressure. This is the pressure in the arteries
when the heart rests between each heartbeat.
The machine that measures blood pressure is called a sphygmomanometer. The cuff is placed around
your arm and pumped up. The pressure in the cuff around your arm is then gradually reduced. A doctor or
nurse listens with a stethoscope over an artery in the arm as the pressure in the cuff is lowered. They can
hear typical noises when the pressure in the cuff equals your systolic and diastolic pressures. Modern
electronic devices can also measure blood pressure.
What are normal and high blood pressure values?
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Normal blood pressure
o If you have diabetes a blood pressure below 140/80 mmHg is usually fine. However, if
you have a complication of diabetes called diabetic nephropathy (kidney damage) then
you should aim for a level below 135/75 mmHg.
o If you do not have diabetes a 'normal' blood pressure is below 140/90 mmHg.
 High blood pressure is anything above normal. But, the risk to health increases the higher the
blood pressure becomes. So, for example, a reading of 170/110 mmHg is much more serious
than a reading of 141/81 mmHg.
High blood pressure can be:
 just a high systolic pressure, for example, 170/70 mmHg.
 just a high diastolic pressure, for example, 130/104 mmHg.
 or both, for example, 170/110 mmHg.
How common is high blood pressure?
In the UK, about half of people over 65, and about 1 in 4 middle aged adults, have high blood pressure. It
is less common in younger adults. It is more common in people from African-Caribbean origin, and from
the Indian sub-continent.
High blood pressure is also more common in people with diabetes.
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About 3 in 10 people with type 1 diabetes eventually develop high blood pressure.
About 7 in 10 people with type 2 diabetes eventually develop high blood pressure.
What causes high blood pressure?
The cause is not known in most cases
It is then called 'essential hypertension'. The pressure in the blood vessels depends on how hard the
heart pumps, and how much resistance there is in the arteries. Slight narrowing of the arteries increases
the resistance to blood flow, which increases the blood pressure. The cause of the slight narrowing of the
arteries is not clear. A variety of factors probably contribute.
(It is a bit like water in a hosepipe. The water pressure is increased if you open the tap more, but also if
you make the hosepipe narrower by partially blocking the outflow with your thumb.)
Diabetes kidney disease causes some cases
A complication which develops in some people with diabetes is called diabetic nephropathy. In this
condition the kidneys are damaged which can cause high blood pressure. This is more common in people
with type 1 diabetes.
Rarely, high blood pressure is caused by other conditions
For example, certain hormone problems can cause high blood pressure.
How is high blood pressure diagnosed?
A one-off blood pressure reading which is high does not mean that you have 'high blood pressure'. Your
blood pressure varies throughout the day. It may be high for a short time if you are anxious, stressed, or
have just been exercising.
You are said to have 'high blood pressure' (hypertension) if you have several blood pressure readings
which are high, and which are taken on different occasions, and when you are relaxed.
Observation period
If one reading is found to be high, your doctor or nurse will usually advise a time of observation. This
means several blood pressure checks at intervals over time. It is also a good time to address any lifestyle
factors (see below). The length of the observation period varies depending on the initial reading, and if
you have other health risk factors. If the blood pressure readings remain high after an observation period
then treatment with medication is usually advised.
Why is high blood pressure a problem?
High blood pressure usually causes no symptoms. However, over the years high blood pressure may do
some damage to the arteries and put a strain on your heart. In general, the higher your blood pressure
above normal, the greater your health risk.
So, high blood pressure is a 'risk factor' for developing heart disease (angina, heart attacks, heart
failure), stroke, peripheral vascular disease, and kidney damage sometime in the future. In addition,
having diabetes also increases your risk of developing these conditions. If you have diabetes and high
blood pressure, your risk is even greater.
Other risk factors which also increase the risk of developing these conditions are:
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smoking.
lack of exercise.
an unhealthy diet.
excess alcohol.
obesity.
high cholesterol level.
a strong family history of heart disease or stroke.
being male.
ethnic group. (For example, south Asians in the UK have an increased risk.)
In addition, if you have diabetes, high blood pressure increases your risk of developing some
other complications of diabetes. For example, diabetic retinopathy (damage to the back of the
eye).
But, if you reduce a high blood pressure your risk to health goes down. A large research study
called the the UK Prospective Diabetes Study confirmed this. In this study a lot of people with
diabetes were monitored over a number of years. The study found that people whose blood
pressure was well controlled had nearly a third less risk of dying from complications related to
diabetes (such as heart attack, stroke, etc).
What can I do to lower blood pressure?
Lose weight if you are overweight
Losing some weight can make a big difference. On average, blood pressure falls by about 2.5/1.5 mmHg
for each excess kilogram which is lost. Losing weight has other health benefits apart from lowering blood
pressure.
Exercise regularly
You should aim to do some exercise on 5 or more days of the week, for at least 30 minutes. For example,
brisk walking, swimming, cycling, dancing, gardening, etc. Regular exercise can lower blood pressure in
addition to giving other health benefits.
Eat a healthy diet
If you have diabetes you will normally be given a lot of advice about a healthy diet. A healthy diet is an
important part of treatment. Briefly, it means:
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AT LEAST five portions of a variety of fruit and vegetables per day.
THE BULK OF MOST MEALS should be starch-based foods (such as cereals, wholegrain bread,
potatoes, rice, pasta), plus fruit and vegetables.
 NOT MUCH fatty food such as fatty meats, cheeses, full-cream milk, fried food, butter, etc. Use
low fat, mono-, or poly-unsaturated spreads.
 INCLUDE 2-3 portions of fish per week. At least one of which should be 'oily' (such as herring,
mackerel, sardines, kippers, pilchards, salmon, or fresh tuna).
 If you eat meat it is best to eat lean meat, or poultry such as chicken.
 If you do fry, choose a vegetable oil such as sunflower, rapeseed or olive oil.
 Try not to add salt to food, and avoid foods which are salty.
o Use herbs and spices to flavour food rather than salt.
o Choose foods labelled 'no added salt' and try not add salt to food at the table.
o Use fresh fish and meat rather than canned or processed.
A healthy diet provides health benefits in different ways. For example, it can lower cholesterol, help
control your weight, and has plenty of vitamins, fibre, and other nutrients which help to prevent certain
diseases. Some aspects of a healthy diet also directly affect blood pressure. For example, a diet which is
low-fat, low-salt, and high in fruit and vegetables can lower blood pressure.
Drink alcohol in moderation
A small amount of alcohol (1-2 units per day) may help to protect you from heart disease. One unit is
about half a pint of normal strength beer, or one small glass of wine, or one pub measure of spirits.
However, too much can be harmful. Men should drink no more than 21 units of alcohol per week (and no
more than 4 units in any one day). Women should drink no more than 14 units of alcohol per week (and
no more than 3 units in any one day).
Smoking and cholesterol
Smoking and a high cholesterol level do not directly affect the level of your blood pressure. But, they
greatly add to your health risk if you already have high blood pressure and/or diabetes.
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If you smoke, you should make every effort to stop.
If your cholesterol level is high, then it can be treated.
What is the treatment for high blood pressure?
There are several medicines that can lower blood pressure. The one chosen depends on such things as:
if you have other medical problems; if you take other medication; side-effects; your age; etc. Some
medicines work well in some people, and not so well in others. Occasionally, one or two medicines are
tried before one is found to suit.
The 'target' is to reduce blood pressure to below 140/80 mmHg. The target blood pressure is to less than
135/75 if you have kidney problems caused by diabetes.
One medicine can control high blood pressure in about half of cases. But, it is quite common to need two
or more different medicines to reduce high blood pressure to a target level. In about a third of cases,
three medicines or more are needed to get blood pressure to the target level.
Diabetes, Foot Care and Foot Ulcers
About 1 in 10 people with diabetes develop a foot ulcer at some stage. A foot
ulcer is prone to infection, which may become severe. This leaflet aims to explain
why foot ulcers sometimes develop, what you can do to help prevent them, and
typical treatments if one does occur.
What is a foot ulcer?
A skin ulcer is where an area of skin has broken down and you can see the underlying tissue. Most skin
ulcers occur on the lower legs or feet. The skin normally heals quite quickly if it is cut. But, in some people
with diabetes the skin on the feet does not heal so well and is prone to develop an ulcer, even after a mild
injury such as stepping on a small stone in your bare feet.
Why are people with diabetes prone to foot ulcers?
Because one or both of the following complications may develop in some people with diabetes.
Reduced sensation of the skin on the feet
Reduced sensation may develop because even a slightly high blood sugar level can, over time, damage
nerves. This is a complication of diabetes called 'peripheral neuropathy of diabetes'. The nerves that take
messages of sensation and pain from the feet are commonly affected. If you lose sensation in parts of
your feet, you may not know if you damage your feet. For example, if you tread on something sharp, or
develop a blister due to a tight shoe. So, you are more prone to problems such as minor cuts, bruises,
blisters. Also, if you cannot feel pain so well from the foot, you do not protect these small wounds by not
walking on them. So, they can quickly become worse and develop into ulcers.
Narrowing of arteries (blood vessels) going to the feet
If you have diabetes you have an increased risk of developing 'furring' of the arteries. This is caused by
fatty deposits called atheroma which build up on the inside lining of arteries. This can reduce the blood
flow to various parts of the body. The arteries in the legs are quite commonly affected. This can cause a
reduced blood supply ('poor circulation') to the feet. Skin with a poor blood supply does not heal as well
as normal and is more likely to be damaged. So, if you get a minor cut or injury, it may not take longer to
heal and is prone to become worse and develop into an ulcer. Particularly if you also have reduced
sensation and cannot feel the wound.
What increases the risk of developing foot ulcers?
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If you have reduced sensation to your feet (see above). The risk of this occurring increases:
o the longer you have diabetes, and the older you are.
o if your diabetes is poorly controlled. This is one of the reasons why one aim of treating
diabetes is to keep the blood sugar level as near normal as possible.
If you have narrowed arteries (see above). The risk of this occurring increases:
o the longer you have diabetes, the older you become, and if you are male.
o if you have any other 'risk factors' for developing 'furring of the arteries'. For example, if
you smoke, do not exercise regularly, have a high cholesterol level, high blood pressure,
or you are overweight.
If you have had a foot ulcer in the past.
If you have other complications of diabetes such as kidney or eye problems.
If your feet are more prone to minor cuts, grazes, corns or calluses which can occur
o if you have foot problems such as bunions which put pressure on points on the feet.
o if your shoes do not fit properly which can put pressure on your feet.
o if you have leg problems which affect the way that you walk, or prevent you bending to
care for your feet.
Are foot ulcers serious?
Foot ulcers can take a long time to heal if you have diabetes, particularly if your circulation is not so good.
Foot ulcers often respond well to treatment. However, because of the complications of diabetes, infection
can occur. Sometimes more serious problems can develop such as gangrene. In extreme cases,
amputation may have to take place - but by taking care of your feet you can help avoid this
So, if you have diabetes, even a small ulcer may get worse and develop into a serious problem.
What can I do to help prevent foot ulcers?
Have you feet regularly examined
Most people with diabetes are reviewed at least once a year by a doctor and other health professionals.
Part of the check is to examine the feet to look for problems such as reduced sensation or poor
circulation. If any problems are detected then more frequent feet examinations will be recommended.
Treatment of diabetes and other health risk factors
As a rule, the better the control of your diabetes, the less likely you are to develop complications such as
foot ulcers. Also, where appropriate, treatment of high blood pressure, high cholesterol level, and
reducing any other risk factors will reduce your risk of diabetes complications. In particular, you are
strongly advised to stop smoking if you smoke.
Foot care
Research has shown that people with diabetes who take good care of their feet, and protect their feet
from injury, are much less likely to develop foot ulcers. Good foot care includes:
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Looking carefully at your feet each day, including between the toes. If you cannot do this yourself,
you should get someone else to do it for you.
o Looking is particularly important if you have reduced sensation in your feet, as you may
not notice anything wrong at first until you look.
o If you see anything new (such as a cut, bruise, blister, redness, or bleeding) and don't
know what to do, see your doctor or podiatrist (chiropodist).
o Do not try to deal with corns, calluses, verrucas, or other foot problems by yourself. They
should be treated by a health professional such as a podiatrist. In particular, do not use
chemicals or special 'acid' plasters to remove corns, etc.
o Use a moisturising oil or cream for dry skin to prevent cracking. But, do not apply it
between the toes.
o Look out for athlete's foot (a common minor skin infection). It causes flaky skin and
cracks between the toes which can be sore and can become infected. So, if you get
athletes foot, treat it with antifungal cream. You can buy antifungal cream from
pharmacies, or get it on prescription.
Cut your nails 'straight across' rather than 'round'. If you cannot see properly do not try to cut your
nails as you may cut your skin. Get someone else to do it.
Wash your feet regularly, and dry carefully, especially between the toes.
Do not walk barefoot, even at home. You might tread on something and damage the skin.
Always wear socks with shoes or other footwear. But, don't wear socks which are too tight around
the ankle which may affect the circulation.
Shoes, trainers and other footwear should:
o fit well to take into account any awkward shapes or deformities (such as bunions).
o have broad fronts with plenty of room for the toes.
o have low heels to avoid pressure on the toes.
o have thick shock-absorbent soles.
o have good laces, buckles or Velcro fastening to prevent movement and rubbing of feet
within the shoes.
Always feel inside footwear before you put them on (to check for stones, rough edges, etc).
If your feet are an abnormal shape, or if you have bunions or other foot problems, you may need
specially fitted shoes to stop your feet rubbing.
What if I develop a foot ulcer?
Tell your doctor or podiatrist if you suspect an ulcer has formed. Treatment aims to dress and protect the
ulcer, to prevent or treat any infection, and to help the skin to heal.
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The ulcer is usually covered with a protective dressing.
A nurse or podiatrist will normally examine, clean and re-dress the ulcer regularly.
You may be advised to wear special shoes, special cushioned insoles, or special casts,
depending on the site and size of the ulcer. The aim is to take the pressure off the ulcer which will
allow better healing.
Antibiotics will be advised if the ulcer, or nearby tissue, becomes infected.
Sometimes a small operation is needed to drain pus and clear dead tissue if infection becomes
more severe.
In some cases the arteries in the legs are very narrow and greatly reduce the blood flow to the
feet. In these cases an operation to bypass, or widen, the arteries may be advised.
Many foot ulcers will heal with the above measures. However, they can take a long time to heal.
In some cases the ulcer becomes worse, badly infected, and does not heal. Sometimes infection spreads
to nearby bones or joints which can be difficult to clear, even with a long course of antibiotics. Sometimes
the tissue in parts of the foot cannot survive and the only solution then is to amputate the affected part.
Further help and information
Diabetes UK have numerous branches throughout the country. They produce information leaflets on all
topics related to diabetes and its careline answers enquiries on all aspects of diabetes.
Diabetes UK, 10 Parkway, London, NW1 7AA
Tel (careline): 020 7424 1030
Tel (office): 020 7424 1000
Web: http://www.mentor-update.com/gateway.cfm?site=http://www.diabetes.org.uk
Diabetic
Retinopathy
And Other Eye
Complications of
Diabetes
If you have diabetes, have your eyes checked regularly. Retinopathy (damage to the
retina) is a common complication of diabetes. If left untreated, it can get worse and cause
some loss of vision, or blindness in severe cases. Good control of blood glucose and
blood pressure slows down the progression of retinopathy. Treatment with a laser, before
the retinopathy gets severe, can often prevent loss of vision. Glaucoma and cataracts are
more common in people with diabetes.
What is diabetic retinopathy?
What is diabetes?
Diabetes mellitus (just called diabetes from now on) occurs when the level of glucose (sugar) in the blood
becomes higher than normal. There are two main types of diabetes - Type 1 and Type 2. See separate
leaflets called 'Type 1 Diabetes' and 'Type 2 Diabetes' for more general information about diabetes.
What is the retina?
The retina is made up from special cells called rods and cones which line the back of your eyes. Light
enters your eye and passes through the lens which focuses the light onto the retina. Messages about
what you see are then passed from the cells in the retina to the optic nerve, and on to the brain. There
are many tiny blood vessels next to the retina which take oxygen and nutrients to the cells of the retina.
What is retinopathy?
The term 'retinopathy' covers various disorders of the retina which can affect vision. Retinopathy is
usually due to damage to the tiny blood vessels next to the retina. Retinopathy is commonly caused by
diabetes, but is sometimes caused by other diseases such as very high blood pressure.
How does diabetic retinopathy occur?
Over several years, a high blood glucose (sugar) level can weaken and damage the tiny blood vessels
next to the retina. This can result in various problems which include:
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Small 'blow-out' swellings of blood vessels (microaneurysms).
Small leaks of fluid from damaged blood vessels (exudates).
Small bleeds from damaged blood vessels (haemorrhages).
Blood vessels may just block which can cut off the blood and oxygen supply to small sections of
the retina.
New abnormal blood vessels may grow from damaged blood vessels. This is called proliferative
retinopathy. These new vessels are delicate and can bleed easily.
The leaks or fluid, bleeds and blocked blood vessels may damage the cells of the retina . In some severe
cases, damaged blood vessels bleed into the vitreous humour (the jelly-like centre of the eye). This can
also affect vision by blocking light rays going to the retina.
Different types of diabetic retinopathy
Different parts of the retina can be affected
The macula is a small part of the retina which is roughly in the centre at the back of the eye. The macula
is where you focus your vision. So, when you read or look at an object, the light focuses on the macula.
The central and most important part of the macula is called the fovea. The outer part of the retina is used
for peripheral vision.
Retinopathy can affect the macula (when it is called maculopathy), the peripheral (outer part) of the
retina, or both. It is much more serious if the macula is affected.
The severity of the retinopathy can vary
Retinopathy usually develops gradually and tends to become worse over a number of years.
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Background retinopathy is not too serious. With this you have some tiny microaneurysms, and
tiny leaks of fluid and tiny bleeds in various parts of the retina. A doctor or optometrist can see
these as tiny 'dots' and 'blots' on the retina when they examine the back of the eye. Your vision is
not usually affected if you have background retinopathy.
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Pre-proliferative retinopathy is more extensive than background retinopathy, but not yet showing
new blood vessels growing (see below).
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Proliferative retinopathy means you have new blood vessels growing in some part(s) of the retina.
These are thought to develop because damaged blood vessels in the retina make a chemical
called vascular endothelial growth factor (VEGF). This can cause new tiny blood vessels to grow
(proliferate) from the damaged blood vessels. This may occur as the retinal blood vessels try to
fix or compensate for the damage by making new blood vessels. However, these new blood
vessels are not normal. They are delicate, and can easily bleed which can damage the cells of
the retina. In this type of retinopathy, without laser treatment, vision is likely to become badly
affected.
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Advanced retinopathy is when you have many abnormal new blood vessels growing, more
serious bleeding in the eye, and a lot of damage and scarring on the retina from bleeds and
leaks. Parts of the retina may 'detach' from the back of the eye.
The effects of retinopathy may be different in each eye. Also, if you have high blood pressure in addition
to diabetes, it can make retinopathy worse, or progress more quickly.
Who gets diabetic retinopathy?
Retinopathy is the most common complication of diabetes. The longer you have diabetes, the more likely
retinopathy will develop. Twenty years after the onset of diabetes, some degree of retinopathy will have
developed in almost all people with Type 1 diabetes, and in about 6 in 10 people with Type 2 diabetes.
Even when Type 2 diabetes is first diagnosed, some degree of background retinopathy is seen in about 1
in 4 cases.
Can diabetic retinopathy be prevented?
You are less likely to develop retinopathy, or if you have mild (background) retinopathy it is less likely to
progress to more serious retinopathy if:
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your blood glucose level is well controlled. Treatment to control blood glucose is discussed in
another leaflet. Briefly it involves: a healthy diet, losing weight if you are overweight, regular
exercise, and medication if required.
your blood pressure is well controlled.
Some studies also suggest that smoking can make retinopathy worse. So, you are also advised to stop
smoking if you smoke.
Eye checks for diabetic retinopathy
Treatment can prevent loss of vision and blindness in most cases. So, if you have diabetes it is vital that
you have regular eye checks to detect retinopathy before your vision becomes badly affected. You should
have at least an annual eye check. This includes:
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Testing your vision.
Looking at the back of the eye with a light to examine the retina.
Taking photographs of your retina (to compare with previous examinations).
If you are found to have mild (background) retinopathy, and your vision is not affected, then you are likely
just to be monitored and re-checked every few months. The retinopathy may not progress to more serious
forms, particularly if your diabetes and blood pressure are well controlled. If more severe changes are
detected you may be referred to an eye specialist for a detailed eye examination, and treatment if
necessary.
Note: if you notice any change in your vision before you are due a routine check, tell your doctor or
optometrist who should arrange an eye-check earlier.
What is the treatment for diabetic retinopathy?
Laser treatment
Laser treatment is used mainly if you have new vessels growing (proliferative retinopathy), or if any type
of retinopathy is affecting the macula. A laser is a very bright light that is very focused so it makes tiny
burns on whatever it is focussed on. A 'burn' can seal leaks from blood vessels, and stops new vessels
from growing further. The burns are so tiny and accurate that they can treat a tiny abnormal blood vessel.
Several hundred 'burns' may be needed to treat retinopathy.
Treatment usually works well to prevent retinopathy from getting worse, and so often prevents loss of
vision or blindness. But, laser treatment cannot restore vision which is already lost.
Other treatments
Various eye operations may be needed if you have a bleed into the vitreous humour, or develop a
detached retina (which are possible consequences of severe retinopathy).
Other eye complications of diabetes
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Glaucoma is more common in people with diabetes. This can cause a painless rise in pressure in
the eye, which if left untreated can damage the eye and cause loss of vision. Regular eye
pressure checks can detect glaucoma in the early stages.
Cataracts are more common in people with diabetes. A cataract affects the lens and blocks light
getting to the back of the eye. Cataracts can be removed. See separate leaflet.
Further help and information
Diabetes UK 10 Parkway, London, NW1 7AA
Tel (careline): 020 7424 1030 Web: http://www.mentorupdate.com/gateway.cfm?site=http://www.diabetes.org.uk
Type 2 Diabetes: Meal Planning
There is no “diabetic diet.” People with diabetes have the same nutritional needs as those
without diabetes. When you have diabetes, however, it is important to be aware of the
carbohydrate content of the food you eat. This is because carbohydrates are broken down
into sugar and released into the blood stream. Everyone will have different carbohydrate
needs that depend on personal eating habits, blood sugar, medications and activity. With a
regular and consistent intake of carbohydrates any food can fit in your meal plan in
moderation.
When you have diabetes you need to meet with a registered dietitian to develop your
individual meal plan. This will be based on your eating habits, your likes and dislikes and your
specific nutritional needs. You may want a set amount of carbohydrates at meals and snacks
or you may want the ability to vary your carbohydrates. The ability to do this depends to a
large amount upon the medication you are on. You should discuss these options with you
medical team.
Nutrients in food:
There are three main nutrients in foods. All three nutrients have important functions and need
to be included in your meal plan. Here is a brief overview of the three nutrients including food
sources, important functions, and the effect they have on blood sugars:
Carbohydrates – Carbohydrates are the body's main source of energy (fuel). They are also
important for proper fat metabolism.
Sources –
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Breads, grains, cereal, rice,
pasta
Fruit and fruit juices
Milk and milk products
Legumes (dried beans)
Sweets – candy, ice cream,
cookies
Starchy vegetables –corn,
potato, green peas
Starch snacks – chips, popcorn,
crackers, etc
Some "sugar free" foods
Blood sugar effect –100% of
carbohydrate eaten becomes sugar
in the blood Carbohydrates
usually peak in the blood stream
in 1 hour and are out of the blood
stream in about 2 hours.
To find out if the amount of
carbohydrate you eat is working for you,
check your blood sugars before you eat
and 2 hours after. The post meal value
should be about 30 points of the premeal value. If the post meal value is not
within 30 points of the pre meal value an
adjustment needs to be made in the
carbohydrate content of the meal or in
your medications.
Protein - Protein helps the body build tissues. Proteins are also important in immunity and
wound healing.
Sources 
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Beef
Poultry – chicken, turkey
Pork
Fish
Eggs
Cheese
Blood sugar effect – If you consume more protein than your body needs to build tissue (for
most people this is about 6 oz or less at a meal), some may be converted to sugar and could
cause an increase in your blood sugar. Protein has less of an effect on your blood sugars
then carbohydrates and takes a longer time to get into the blood, usually about 3 hours.
Fat - Fat works to slow digestion and makes you feel fuller. It improves the taste of food. Fat
is needed to absorb fat soluble vitamins (A,D,E and K).
Sources 
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Butter
Oils
Margarine
Creams and cream products
Salad dressings
Nuts
Avocado
Olives
Blood sugar effect –
Very little of the fat in food becomes sugar in the blood. Fat does, however, slow digestion so
that the carbohydrate in your food will sit in the stomach longer thus delaying an increase in
the blood sugars. This is most obvious with very high fat meals such as pizza or cream
sauces on pasta. In these cases instead of the blood sugars being elevated at 1 hour after
eating, the slowed digestion may lead to an elevation in blood sugars anywhere from 3-12
hours after the meal.
Guidelines for better blood sugar control:
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Eat breakfast to increase your metabolism
Have meals at consistent times everyday
Have about the same amount of carbohydrate at a particular meal each day.
Spread carbohydrates out throughout the day – for example instead of having 2 large
meals a day, have 3 or more smaller meals.
Choose higher fibre foods such as whole grains, fruits, vegetables, and beans. The
fibre slows down digestion allowing the body to respond better to the incoming sugar.
Eat meals and snacks balanced with carbohydrate, protein and fat. A good rule of
thumb is to divide you plate into thirds. 1/3 should be a carbohydrate food, 1/3 should
be protein and 1/3 should be vegetables.
Determining carbohydrates in a meal:
It is important for you talk with a dietitian to get a meal plan with the appropriate amount of
carbohydrates that works best for you.
Food Label:
Total Carbohydrates based on serving size is the most important number on the food label for
people with diabetes.
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Total carbohydrates includes all the sources that will effect your blood sugar (sugar,
starch, and sugar alcohols).
Fibre is included within the total carbohydrates but does not get absorbed and thus
will not increase your blood sugars. If there is more than 5g of fiber in the serving you
are eating you need to subtract it from the total carbohydrate. This will give you the
amount of carbohydrate that will effect your blood sugar.
Sugar alcohols commonly used in foods are sorbitol, manitol, isomalt, etc. These
sugar substitutes provide somewhat fewer calories than table sugar, mainly because
they are not absorbed as well and they may also cause diarrhoea.
Sugar Alcohols are often subtracted along with fibre from the total carbohydrate to
determine “net carbs” on low carbohydrate foods. While it is still being studied it
appears that sugar alcohols do affect blood sugars although not as fast or as much
as real sugar.
Food without a label: To determine the carbohydrate content of foods without a label ask
your dietitian for a carbohydrate content list or seek out good resources on the internet or at
your local bookstore. There are many books available that supply lists of foods and their
carbohydrate content. Here are a few typical foods and the serving size that would equal 15g
carbohydrate. Remember most people need at least 45g carbohydrate at a meal.
Food Serving Size
15 gm Carbohydrate
Pasta, rice, beans
1/3cup
Bread
1 slice (1oz)
Milk
1 cup
Cookies
2 small
Ice Cream (vanilla, chocolate or strawberry) ½ cup
Fresh Fruit
1 medium
Cut Fruit
1 cup