Disorders of the Pancreas

Located just behind the stomach, your pancreas releases hormones—such as insulin—that control how your body uses the sugar, fats, and protein consumed in your diet. The most common disorders of the pancreas are diabetes and pancreatitis (see page 277). Cancer also can affect the pancreas.

Diabetes

Diabetes is a serious, chronic condition that affects an estimated 16 million Americans. Up to 95 percent of people with diabetes have type 2 diabetes, also referred to as adult-onset or non-insulin-dependent diabetes. One-third of these people do not know they have the disease because type 2 diabetes seldom causes symptoms in the early stages.

When you have diabetes, the amount of glucose (a simple sugar that is the body's main source of fuel) in your blood is too high. Your blood always has some glucose in it, but excessive amounts are not good for your health.

Diabetes affects the way your body uses food for energy and growth. Most of the food you consume is broken down into glucose, which passes into the bloodstream and is transported throughout the body for use by the cells. To get inside the cells, a hormone called insulin must be present. Insulin is produced by the pancreas.

When you eat, the pancreas normally produces the proper amount of insulin to allow glucose to enter your cells. But in people with diabetes, either the pancreas produces insufficient insulin or the cells do not respond to the insulin produced. Glucose builds up in the blood and overflows into the urine. During urination, the body loses its vital source of energy.

Diabetes is widely recognized as one of the leading causes of death and disability in the United States. It can produce serious, long-term complications that affect every major part of the body. Some of these complications are heart disease, stroke, nerve damage, blindness, kidney failure, and amputations.

Type 1 Diabetes Type 1 diabetes, the less common form of the disorder, occurs when the body's immune system (see page 376) attacks the insulin-producing

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Concerns cells in the pancreas and destroys them. The pancreas then loses its ability to produce an adequate supply of insulin.

Type 1 diabetes is sometimes referred to as insulin-dependent diabetes because people who have it need daily injections of insulin to stay alive. If the person's insulin level is not sufficient, symptoms appear quickly, including increased thirst, feeling hungry, frequent urination, weight loss, blurred vision, irritability, and extreme fatigue. Without insulin these symptoms worsen, and the person can lapse into a life-threatening coma.

At present, the cause of type 1 diabetes is unknown, but both a person's genetic makeup and environmental factors such as viruses may have a role in the development of the disorder. Type 1 diabetes accounts for 5 to 10 percent of all cases of diagnosed diabetes in the United States. It most often develops in children and young adults, but it can appear at any age. This type of diabetes occurs equally among men and women. Type 1 diabetes most frequently occurs in whites.

To diagnose type 1 diabetes, your doctor will give you a thorough physical examination and will ask you questions about your symptoms, your family health history (see page 80), and your personal health history (see page 82). He or she will order blood tests to measure the level of glucose in your blood. Your blood also will be tested for changes in levels of electrolytes such as sodium and potassium. The doctor may also order a urine test that can detect the presence of substances known as ketones that accumulate in your urine if your body does not produce enough insulin.

To treat this type of diabetes, the doctor will teach you how to give yourself daily injections of insulin. He or she may recommend an insulin pump, which is implanted just under the skin on the abdomen and provides insulin continuously 24 hours a day according to a plan programmed just for you. The steady infusion of insulin keeps your blood glucose level in the healthy range between meals and overnight. When you eat, you program the pump to deliver an extra dose of insulin based on the amount of food you eat.

You will also learn how to test your blood glucose level at home using a home glucose meter that measures the amount of glucose present in a small drop of blood taken from your finger. (Newer monitors are available that allow you to measure the blood glucose level without sticking your finger.) Frequent monitoring of your blood glucose level can help you gauge how often to take your insulin injections or how well your insulin pump is working.

Diet is a key component of diabetes management. A dietitian will help you to plan meals that are tailored to your individual needs. The diet plan will tell you not only what types of food to eat—mostly complex carbohydrates and highfiber foods—but also when to eat, because it is important to balance your insulin injections with your food intake. This balance will ensure that you keep your blood glucose level as close to normal as possible.

Regular exercise actually helps to reduce the level of glucose in your blood by 367

improving your body's ability to convert the food you eat into energy. Exercise Endocrine also strengthens your heart and blood vessels, which can be adversely affected system by uncontrolled diabetes. Work with your doctor to plan an exercise program that fits your schedule and includes activities you like. Be sure to plan your exercise sessions around your mealtimes and insulin injections so you can keep your blood glucose level within the normal range.

Type 2 Diabetes The more common form of diabetes is type 2 diabetes. Ninety to 95 percent of people with diabetes have this form. In people with type 2 diabetes, the pancreas produces insulin, but the body's cells cannot effectively use it. The end result is the same as that in type 1 diabetes: an unhealthy buildup of the sugar glucose in the blood and the body's inability to make efficient use of its main source of fuel.

The symptoms of type 2 diabetes develop very gradually and are barely noticeable at first. Over time, however, people with type 2 diabetes may feel tired, urinate frequently (especially at night), be unusually thirsty, lose weight, and have blurred vision. Eventually, they may develop frequent infections—especially of the skin—and sores that are slow to heal.

Type 2 diabetes usually develops in adults over age 40 and is most common over age 55. About 80 percent of people with this form of diabetes are overweight, and obesity is an important risk factor for type 2 diabetes. It is more common in older women than in older men. In contrast with type 1, the incidence of type 2 diabetes is about 60 percent higher in African Americans and up to 120 percent higher in Hispanic Americans than it is in whites. Native Americans have the highest incidence of diabetes in the world. People who have family members with type 2 diabetes are at greater risk of developing the disease.

Doctors use a number of tests to diagnose type 2 diabetes. If you have a family history of type 2 diabetes or are otherwise at risk of developing it, you will be given a screening blood test to measure the level of glucose in your blood. A high or a low glucose level in a screening blood test will warrant a fasting blood glucose test, which measures the glucose level in your blood after you have fasted for 10 to 12 hours, usually overnight. Blood glucose levels of 125 mg/dL (milligrams of glucose per deciliter of blood) or more on two or more fasting blood glucose tests show that you have diabetes. If your blood glucose levels fall between 105 and 124 mg/dL, or if your fasting blood glucose levels are normal but you have symptoms of diabetes, the doctor may recommend an oral

Warning Signs of Type 1 Diabetes

Symptoms of type 1 diabetes appear suddenly and develop most often in children and young adults. See your doctor right away if you have any of the following symptoms:

  • increased thirst
  • frequent urination
  • constant hunger
  • abdominal pain
  • nausea
  • weight loss
  • blurred vision
  • fatigue glucose tolerance test. Before taking this test, the doctor will ask you to eat a carbohydrate-rich diet for a few days and then to fast overnight. You will then receive a glucose-containing liquid to drink, and your blood glucose level will be monitored for 2 hours through blood tests taken every 30 minutes. High levels (over 200 mg/dL) of glucose in the blood indicate that you have type 2 diabetes. Moderately high levels show that you have a condition called impaired glucose tolerance, which places you at an increased risk of developing type 2 diabetes and at an increased risk of developing heart disease.

A test called a glycosylated hemoglobin test measures the percentage in your blood of a particular type of hemoglobin (the substance in red blood cells that carries oxygen). If you have too much glucose in your blood, the extra glucose forms a link with (glycosylates) the hemoglobin. The blood test can determine the average level of glucose in your blood over the past 120 days. In a person who does not have diabetes, about 6 percent of all hemoglobin is glycosylated. In a person whose diabetes has been poorly controlled for a long time, the level of glycosylated hemoglobin can be as high as 25 percent. If you are diagnosed with diabetes, your doctor is likely to recommend that you have a glycosylated hemoglobin test twice a year to monitor the effectiveness of your treatment.

Obesity is the number one cause of type 2 diabetes, so weight reduction is the primary goal of treatment. A balanced weight-loss diet and regular exercise are often all that are needed to reach and maintain a normal blood glucose level. If not, your doctor will prescribe oral medication (including sulfonylureas such as glipizide or glyburide, or other medications such as metformin or acarbose) that reduces the level of glucose in your blood. Although most people with type 2 diabetes take oral medication, some people who have the disorder need to take daily injections of insulin. The doctor will probably recommend that you routinely check your blood glucose level at home using a simple test so that you can determine whether your program of diet, exercise, and medication is working.

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Warning Signs of Type 2 Diabetes

Type 2 diabetes is the more common form of the disease. The symptoms of type 2 diabetes develop gradually and are not as noticeable as those of type 1 diabetes. See your doctor right away if you experience any of the following symptoms:

  • frequent urination, especially at night
  • unusual thirst
  • weight loss
  • blurred vision
  • fatigue
  • frequent infections
  • slow healing of sores

Managing Diabetes Before the discovery of insulin in 1921, people with type 1 diabetes died within a few years after getting the disease. Insulin is not considered a cure for the disease, but daily injections of the hormone help the affected person live a normal life. The insulin injections have to be balanced with diet, proper timing of meals, and exercise. Frequent blood glucose testing helps to monitor the level of glucose in the blood. Diet, exercise, and blood glucose testing also are indispensable for the management of type 2 diabetes. Some people with this form of diabetes also take drugs or insulin to lower their blood 369

glucose level. Endocrine

People who have either type of diabetes must take responsibility for their own system day-to-day care to keep their blood glucose level from getting too low or too high. If the blood glucose level drops too low, usually because the person has taken too much insulin or oral medication or has not balanced the insulin or medication with the proper food intake, a condition known as hypoglycemia occurs. Hypoglycemia causes the person to tremble and become weak, confused, hungry, and dizzy. Pale skin, headache, irritability, sweating, rapid heartbeat, and a cold and clammy feeling are additional symptoms of hypoglycemia. In severe cases the person can lose consciousness and even lapse into a coma. The symptoms of low blood glucose can be mistaken for those of other conditions, such as anxiety or overindulgence in alcohol. The best way to correct a low blood glucose level is to eat or drink something—such as hard candy, soda pop, or orange juice—that contains sugar. Many people with diabetes carry glucose tablets for just such an emergency. A person who has diabetes should always wear a medical identification bracelet or necklace and carry a wallet card containing up-to-date personal medical information. This will identify the person's condition and help ensure appropriate medical treatment if he or she ever has a hypoglycemic reaction while in public.

A person also can become very ill if the blood glucose level rises too high, a condition known as hyperglycemia. This usually happens when the person has not taken enough insulin or oral medication or has not properly regulated his or her blood glucose level with diet. Symptoms are the same as those of type 1 diabetes. Hypoglycemia and hyperglycemia can occur in people with both types of diabetes, and both are potentially life-threatening emergencies.

Keeping the blood glucose level as close to normal as possible reduces the risk of developing serious complications. In a person who does not have diabetes, the normal level of glucose in the blood ranges from 60 to 110 mg/dL. The blood glucose level goes up after eating but returns to the normal range within 1 or 2 hours. Most people with diabetes should aim for a blood glucose range of about 90 to 120 mg/dL before a meal and less than 150 mg/dL about 2 hours after their latest meal.

The doctor will monitor how well you control your diabetes and check for any possible complications, such as nerve damage. Doctors who specialize in treating diabetes and other disorders of the endocrine system are called endo-crinologists. People with diabetes should also see an ophthalmologist (a doctor who specializes in treating diseases of the eyes) for eye examinations (see page 370) and a podiatrist (a doctor who specializes in care of the feet) for routine foot care (see page 371).

The biggest problem for people with diabetes is heart and blood vessel disease, which can lead to heart attacks, stroke, and high blood pressure. Diabetes

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Concerns also can cause poor circulation (blood flow) in the legs and feet. To check for heart and blood vessel disease, the doctor will order certain tests, including an electrocardiogram (which measures and records the flow of electricity through the heart) and a cholesterol test. The doctor will take your blood pressure at each visit and check the pulse in your feet and legs to make sure you have good circulation. He or she will recommend that you eat foods low in fat and salt, lose weight if you need to, and exercise regularly. Your doctor will also advise you not to smoke and to limit your intake of alcohol.

Having diabetes also is a risk factor for kidney disease. After several years, a high blood glucose level can cause your kidneys to stop functioning. This condition is called kidney (or renal) failure (see page 291). Diabetes is the primary preventable cause of kidney failure in the United States. The doctor will check your urine at least once a year for protein, a sign of kidney damage. A blood pressure medication called an angiotensin-converting enzyme (ACE)

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