People with diabetes can be more prone to get dandruff due to a compromised immune system caused by persistent high blood glucose levels.

What is dandruff?

Dandruff is a condition caused by the scalp shedding dead skin cells. Everyone sheds skin cells, but some people can shed them more regularly than others which results in dandruff.

Itchiness, redness, and flaking of the scalp are common symptoms of the illness.

What causes dandruff?

Researchers think that dandruff is caused by a number of causes including:

• Dry skin/scalp
• Oily scalp: the Malassezia globosa fungi feeds on oils on the scalp which some people’s body’s can be be irritated by causing a red, itchy and inflamed scalp and dandruff.
• Poor hygiene
• Stress
• Seborrheic dermatitis: a form of eczema that affects areas of the body that secrete oil.

Your age, hormones and immune system status can also affect your susceptibility to dandruff.

Conditions such as Alzheimer’s disease, epilepsy, Parkinson’s disease, and traumatic brain injury can elevate a person’s risk of Seborrheic dermatitis

People with uncontrolled diabetes, or chronically high blood glucose levels are more likely to get dandruff due to their immune systems being weaker. This makes the body more susceptible to fungal and bacterial infections. Spend as much time in range to minimise this risk.

• How to Bring Down High Blood Sugar Levels

Symptoms of dandruff

As obvious as it sounds, the flaking of the scalp is the most prevalent sign of dandruff.

You may notice flakes on clothes or in the hair can range in size from little and white to huge and yellowish.

If you have eczema or dry skin already, it can sometimes be hard to distinguis. Other dandruff symptoms include:

• Itchiness
• Dry scalp
• Redness
• Burning feeling on the scalp

Treatment for dandruff

To minimise dandruff, try washing your hair with a medicated shampoo or topical treatments which contain chemicals such as zinc pyrithione, ketoconazole, and selenium sulphide that help to inhibit yeast and fungal development on the scalp.

Corticosteroid topical creams can be used to relieve scalp irritation and itching.

Home treatments including tea tree oil, aloe vera, and apple cider vinegar can be used to soothe and moisturise the scalp.

Dandruff is a common scalp condition and usually not something to be overly concerned about. However, it is essential to understand the cause and seek treatment to avoid future consequences.

People who are more prone to dandruff should take extra care to maintain good hygiene and maintain good blood glucose control.

Although typically found in central and western Africa, there are now reports of multiple monkeypox outbreaks across the UK.

While monkeypox is not very contagious and is less dangerous than other viruses, it is always important to be able to identify the signs of a disease and the risks it may pose to you.

Transmission of monkeypox

Monkeypox is a viral zoonosis, which means it is a type of virus transmissible to humans from animals. The first instance of the virus was identified in laboratory monkeys in 1958, hence the name monkeypox.  However, it is thought that people catch the virus from infected wild animals, specifically rodents like rats and squirrels.

Between people, monkeypox is transmitted through bodily fluids, close contact with lesions (touching monkeypox blisters or scabs), respiratory droplets (if someone with the rash coughs or sneezes) and contaminated materials like clothing, bedding and towels.

Those living in the UK are unlikely to contract monkeypox, although certain people are more at risk.

If you have recently travelled to west or central Africa, where the disease is endemic, there is a higher chance you could get the virus.

Being in close contact, including sexual contact, with someone who has monkeypox or is symptomatic also puts you at a higher risk of getting monkeypox. Even touching another person’s skin or sharing their bedding counts as close contact.

While anyone can become infected with monkeypox, there have been a higher amount of cases in people who are gay or bisexual and in men who have sex with men.

Symptoms of monkeypox

Symptoms of monkeypox usually appear between 5 and 21 days after infection. These include:

• A high temperature
• A headache
• Muscle aches
• Backache
• Swollen glands
• Shivering
• Exhaustion

A rash will often develop between days 1 to 5. Beginning on the face, the rash can spread to other parts of the body, including the genitals.

Sometimes a monkeypox rash can look similar to chickenpox. The rash will typically look like raised spots to start with, which will turn into small blisters filled with fluid. Eventually, these blisters will form scabs and peel off.

What to do if you think you have monkeypox

The NHS recommends contacting a sexual health clinic if you have symptoms of monkeypox and have been in close contact with anyone who has or may have the virus in the past three weeks.

You should also contact a clinic if you have visited west or central Africa in the past three weeks and are exhibiting symptoms.

Find your nearest sexual health clinic here.

Ring ahead before visiting the clinic and explain your concerns. It is important that you stay at home and avoid close contact with others until you’ve been given further advice.

Treating monkeypox

In most cases, monkeypox is mild with most people usually recovering within a few weeks without the need for treatment.

As with other viral infections, those diagnosed with monkeypox should isolate themselves to help prevent the further spread of the disease.

A person with more severe symptoms, or a higher risk of developing serious secondary complications, may have to stay in a specialist hospital until they fully recover.

People may also be offered a vaccine to help fight off the virus. Previously, vaccination against smallpox has been found to be 85% effective in treating monkeypox.[1]

Who is at risk: monkeypox and diabetes

Although monkeypox is not usually fatal, with most people recovering within a few weeks of contracting the disease, it may be more severe in certain individuals, including children, pregnant women, or those considered immunosuppressed.

Having diabetes does mean you are considered immunosuppressed. However, those who do not have their condition under control can be more susceptible to infection as high blood sugar (also called hyperglycaemia) can negatively affect the body’s immune system. There are many ways you can take control of your blood sugar levels, such as eating a healthy diet and keeping fit

A ketogenic diet has been shown to be effective for improving blood glucose control and helping towards weight loss in people with diabetes. It has also been shown to significantly benefit a number of other conditions.

Whilst the benefits are clear in some conditions, such as epilepsy, in which the ketogenic diet has been extensively studied.

In other conditions, the ketogenic diet shows promise but there is a lack of robust clinical trials to give strong evidence.

Epilepsy and seizure disorders

The ketogenic diet is one of the medically accepted treatment for chronic seizures in epilepsy and other epileptic disorders, including Lennox-Gastaut syndrome and Dravet syndrome.


^[220]

Research has shown that it helps reduce the frequency of seizures in children.

About half the children whose seizures don’t respond to any medications almost immediately stop seizure activity once they are in ketosis.


^[221]

The reason for the effectiveness of ketogenic diets in treating children is not entirely clear. Researchers are investigating this approach in adults.

Scientists don’t know whether the seizure activity is improved by the presence of the ketone B-OHB (beta-hydroxyburyrate) or the stark reduction in

blood glucose
or insulin in the body. It could that this results from a combination of these factors or something altogether different.

Cancer

By producing a state of ketosis, the ketogenic diet may have a role in helping to treat aggressive metastatic cancers and brain tumours that are not treated effectively with standard care alone.

Sugar is a fuel source which can feed cancer and insulin is essentially a growth hormone. The ketogenic diet can dramatically reduce carbohydrate, which helps reduce blood sugar and the amount of insulin in the body.

The theory states that this cuts down on the amount of sugar and insulin that certain cancers rely on and that malignant tumours can’t adapt readily to using ketones instead of sugar like normal tissue can. This is part of the Warburg effect.


^[222]

Whilst this is the theory, no significant studies have been run that have shown whether or not this effect occurs in practice and there is some evidence to suggest that cancers may adapt to using ketones.


^[223]

As a result, the benefits of a ketogenic diet on cancer is still an unknown area.

Alzheimer’s disease

Alzheimer’s disease
(AD) often manifests itself as the inability of certain regions of the brain to use sugar as a fuel. Thus, researchers are investigating whether uncontrolled type 2 diabetes, where too much sugar remains in the blood, could damage the brain and contribute to the development of AD.


^[224]

There is evidence that changing the body’s energy fuel from mainly sugar towards ketones may have a significant role in brain health and perhaps even Alzheimer’s treatment.


^[225]

Ketones, which the brain can use for over half of its fuel requirements, once carbohydrate intake is lowered, essentially boost the energy levels of

brain
cells by increasing the number of energy powerhouses (mitochondria) in these cells.

A higher number of mitochondria in brain cells is thought to help improve learning and memory abilities, leading to a better quality of life for people with AD.


^[226]

Parkinson’s disease

There’s evidence that a ketogenic diet could potentially help in preventing or combatting Parkinson’s disease.

In a very small, uncontrolled study, Parkinson’s disease patients experienced a mean of 43% reduction in Parkinson’s disease symptoms after following a ketogenic diet for 28 days. However, because the study was only seven participants, the researchers could not rule out the fact that the improvement may have been a placebo effect.


^[227]

Other research studies have suggested that

ketones
produced on a ketogenic diet may have beneficial effects on how the brain responds to dopamine, which could reduce the symptoms of the condition.


^[228]

More research will be needed though before we can say with any certainty whether the diet can indeed help.

Traumatic brain injury

Research suggest that a severe head trauma is often followed by the person having very-high blood sugars. There is some evidence that elevated

blood sugar levels
may worsen the injury and impair recovery from the trauma.


^[229]

Several compelling studies, in animal models and small clinical trials, tend to support that a ketogenic diet could protect against further damage from the injury by

bringing blood sugar levels down

<sup>[230]



[231]</sup>

Researchers who have tried to attenuate the effects of brain injury with ketones supplements have found that the brain’s uptake of ketones increases significantly following an injury, suggesting that the brain preferentially changes its fuel source during recovery.


^[232]

The mechanisms of action of ketones after an injury are unclear, but it is thought that they may lower inflammation in the brain and prevent brain cell death. It has been suggested that high ketone levels could also increase blood flow.

ADHD

Recent research and controlled studies suggest that diet plays an important part in the management of attention-deficit/hyperactivity disorder (ADHD).

One of the diets that helps reduce symptoms associated with ADHD include the ketogenic diet.

The diet is especially thought to help with a symptom of ADHD overlapping with epilepsy called epileptiform discharges.


^[234]

In one study involving 37

children, treatment with the ketogenic diet resulted in a reduction of epileptiform discharges by 13.6 per cent in more than half of these children after only one month.

Further research needs to be done on the relationship between improvement of ADHD symptoms and eating ketogenic, but the diet can provide an alternative to stimulant medications, which can come with side effects.

Chronic Lyme disease symptoms

Lyme disease is a chronic autoimmune condition that can affect the joints,

memory
and heart in the long-term.


^[235]

Lyme disease damages the brain by producing profound inflammation. Ketones may help alleviate some of the post-Lyme symptoms thanks to their significant anti-inflammatory effects.

Ketones bring down inflammation by reducing levels of cytokines – a commonly elevated inflammatory marker found in the brain of people affected by Lyme.

Providing ketones as a fuel source for the brain of people who have had Lyme may help speed up their recovery by lifting brain fog as well as improving memory and concentration.

Exocrine pancreatic insufficiency (EPI) is a condition that occurs then the pancreas starts to lose its ability to aid digestion.

What is the pancreas?

The

pancreas

is well known amongst people with diabetes as the gland that produces and releases insulin. However, this is not its only function.

The pancreas releases hormones into the blood (endocrine), but also sends some through tube like ducts (exocrine) to certain organs,

mainly in the digestive system

The exocrine enzymes it releases – elastase, lipase, protease and amylase – are used in the intestines to help with digestion. It also releases bicarbonate to neutralise stomach acid.

What is exocrine pancreatic insufficiency?

Exocrine pancreatic insufficiency (EPI) is when the pancreatic functions start to falter and there are not enough exocrine enzymes released to digest food properly. As a result, the body struggles to absorb a lot of vital nutrients.

This usually happens due to tissue damage of the pancreas, or as a blockage of the ducts that transfer the enzymes into the intestines, and can lead to several symptoms and complications.

What causes EPI?

One of the most common causes of EPI is cystic fibrosis. About 90% of

cystic fibrosis patients

have EPI, and many will have it from birth.

However, EPI can also be caused by

chronic pancreatitis

(CP).

CP is an inflammation of the pancreas, caused, among other things, by

alcohol

or gallstones. It can stop the pancreas from producing and releasing the hormones or enzymes that it is supposed to. For this reason, it can also cause

secondary diabetes

Symptoms of EPI

Because of how it affects the digestive system, the symptoms of EPI have to do with not absorbing enough nutrients from food or digesting it properly. They can include:

• 
  Diarrhoea
  
• Loss of appetite
• 
  Weight loss
  
• Steatorrhea (foul smelling feces caused by undigested fat)
• Flatulence
• Stomach pain

Diabetes and EPI

It is unknown exactly what causes certain cases of EPI, but it does occur often in people with insulin dependent diabetes.

Among other theories such as it being caused by a virus, EPI has been hypothesised to be as a result of an autoimmune disease attacking the pancreas, just as

type 1 diabetes

is.

In 2003, a study of over 1,000 diabetic patients found that insulin dependent diabetics were more likely to produce abnormally low levels of exocrine pancreatic enzymes.

Between 25% and 50% of insulin dependent diabetics were found to have developed exocrine pancreatic insufficiency.

Furthermore, another study published in 2011 found that obese women produced less elastase, one of the exocrine enzymes. A person’s development of type 2 diabetes may be related to obesity, and so they could well suffer with a form of EPI.

Many people with diabetes will describe themselves as feeling tired, lethargic or fatigued at times.

It could be a result of stress, hard work or a lack of a decent night’s

sleep
but it could also be related to having too high or too low blood glucose levels.

Tiredness as a symptom of diabetes

Regular tiredness, particularly tiredness following meals, is a common symptom of diabetes.

• Read more on the
  
  symptoms of diabetes

What causes people with diabetes to be tired?

Two common reasons for tiredness or lethargy are having

too high
or too low blood sugar levels.

In both cases, the tiredness is the result of having an imbalance between one’s level of blood glucose and the amount or effectiveness of circulating insulin.

If you feel tired during the day, despite having slept well, it could be a result of either high or low sugar levels.

It is best to test your

blood glucose levels
to see whether the tiredness is indeed a result of having high or low sugar levels.

This is particularly important for people on insulin.

• Read about the recommended blood glucose levels ranges

Tiredness and high blood sugar levels

Blood glucose levels go high when there is either insufficient insulin (typically in the case of

type 1 diabetes
) or the insulin is not working effectively enough (typically in type 2 diabetes).

To provide us with energy,

insulin
is needed to transport glucose from blood into our cells to be used for energy.

When there is not enough insulin, or the insulin isn’t working effectively, it means the sugar in our blood cannot get into our cells and therefore our cells do not receive the energy they need. As a result, we feel tired.

Managing tiredness and high blood sugar after meals

If tiredness is accompanied by high blood glucose levels after meals, it can indicate one or more of the following:

• The
  
  carbohydrate
  you are eating is too quick acting for you medication to cope with
• You are eating too much carbohydrate for your medication/dosage
• Your medication/dosage is not strong enough

You should only change your medication dosage if your doctor has approved you to.

Putting on weight is a common indication that one’s insulin levels are too high. People who are overweight and experiencing tiredness as a result of high blood glucose levels may be able to combat tiredness by reducing their carbohydrate intake.

A doctor or dietitian should be able to help you with how to

reduce your blood glucose levels
whilst achieving a healthy weight.

Tiredness and hypoglycemia (low blood glucose levels)

When blood glucose levels are low the body is in a similar position as a car that has run out of fuel; unless you are able to add more fuel, the car will quickly come to a juddering halt.

Similarly, when blood glucose levels are low, you need to take in more carbohydrate to provide your body with the energy your body needs.

If you are regularly experiencing low blood sugar levels, your dosage of medication may be too high.

For people on insulin,

hypoglycemia
can also occur if insulin is injected (or bolused) too soon before eating.

Tiredness upon waking

If tiredness occurs upon waking after a full night’s sleep, it can also be a result of too high or to low blood sugar levels overnight.

Tiredness accompanied by a headache in the morning can often be a sign of an

overnight hypo
in people taking insulin.

Managing morning tiredness

If you are regularly feeling tired in the morning, despite having had a full night’s sleep, it’s worth testing your blood sugar upon waking to see if your tiredness is related to your

blood glucose

Some people may also wish to wake during the night to test their blood glucose levels to see if they’re experiencing high or low blood sugar overnight.

Blood sugar levels can fluctuate overnight and your doctor or

diabetes specialist
should be able to advise if your sugar levels are causing any problems.

Acanthosis nigricans is a relatively common skin condition that is one of the symptoms of diabetes.

Acanthosis nigricans is characterised by darkening of the skin at particular areas such as the neck and armpits.

It is not a dangerous condition in itself but is typically a sign of the presence of a problematic condition such as

type 2 diabetes

and sometimes cancer.

Symptoms

The signs of acanthosis nigricans are quite distinctive and result in a darkening of the skin around folds of skin, typically affecting the:

• Neck
• Armpits
• Groin
• Joints of the fingers or toes

As well being darker, the skin may take on a leathery or velvety feel and the skin may itch or smell.

Causes and risk factors

Appearance of acanthosis nigricans is often associated with the following conditions:

• Type 2 diabetes
• 
  Obesity
  
• Underactive thyroid function
• If taking corticosteroids or oral contraceptives
• A tumour affecting an internal organ

Acanthosis nigricans is more commonly observed in people of African-Caribbean or Hispanic origin.

Diagnosis

Acanthosis nigricans will usually be diagnosed by an examination of the affected area of skin.

Blood tests

, an endoscopy or x-rays may be required, however, to explore whether the cause is related to diabetes or

cancer

Treatment

Treatment for acanthosis nigricans involves treating the underlying cause.

In people with diabetes,

controlling blood glucose levels

and losing can help to reduce the symptoms of the condition.

Lipohypertrophy can be unpleasant for you from an aesthetic perspective and it can also affect the rate at which

insulin

is absorbed so can also lead to erratic blood glucose results.

What is lipohypertrophy?

Lipohypertrophy is when fatty lumps appear on the surface of the skin and is a fairly common side effect of

insulin injections

This will usually occur if

multiple injections

are administered to roughly the same part of the skin over a period of time.

When the skin becomes lumpy, it may mean that if insulin is injected into the lumpy area, it won’t be absorbed consistently, which can mean the insulin takes longer to be absorbed, leading to higher than normal blood glucose levels, or can get absorbed too quickly, leading to

hypoglycemia

Symptoms of lipohypertrophy

The signs of lipohypertrophy (lumpy skin) are a raised area of the skin

where you tend to inject

The raised area may cover quite a wide area, say over an inch in diameter.

The skin will usually feel firmer than the skin elsewhere on your body.

Occasionally you may hit a vein when you inject which will result in some bleeding, leaving a raised area and a bruise over the next day or so.

This in itself is not lipohypertrophy though.

Diagnosing lipohypertrophy

You may be able to recognise when you have lumpy skin but if you’re not sure, your health team can help to diagnose whether lipohypertrophy has formed and can help to advise you to help your skin recover and prevent it reoccurring.

Treating lipohypertrophy

Treatment for lipohypertrophy will usually involve making sure you don’t inject the affected area of skin until it has fully healed. The Plymouth Diabetes Service recommends avoiding into the affected area for at least 2 to 3 months.

Preventing lipohypertrophy

Lipohypertrophy is caused by injecting into the same area too many times so to avoid lumpy skin developing, make sure you pick a different area of skin to put each injection into.

This practice is known as

rotating your injection site

Ideally, you should aim to keep each new injection spot at least an inch away from your previous injection sites.

Necrobiosis lipoidica diabeticorum (NLD) is a rare skin condition in which lesions normally develop on the

lower part of the legs

Other body parts can be affected, though.

NLD occurs due to collagen degeneration and inflammation associated with the thickening of blood vessel walls and fat disposition.

A rash of several spots usually appears as raised patches that are shiny red-brown in colour. These spots may develop into open sores which can be slow to heal.

While the exact cause of NLD is unknown, it shares a complicated

relationship

with diabetes.

NLD and diabetes

As NLD occurs in patients without diabetes – the first case of this was in 1935 – it can be referred to as necrobiosis lipoidica. However, its full title stems back to 1929.

M. Oppenheim first diagnosed the condition as dermatitis atrophicans lipoidica diabetic, as it was only observed in conjunction with diabetes patients. It was renamed in 1932 as

necrobiosis lipoidica diabetica

by E. Urbach.

The prevalence of NLD in patients with diabetes has been reported at different figures by researchers, but is generally regarded as being below 2%.

However, MH Lowitt and JS Dover illustrated the differences between NLD and patients with diabetes in their 1991 study, which showed that:

• NLD preceded the onset of diabetes in 15% of patients
• 60% of patients had diabetes prior to the onset of NLD
• 25% of patients had NLD appear simultaneously with the onset of diabetes

The 40% of participants who did not have diabetes prior to developing NLD were observed to have abnormal glucose tolerance by the researchers.

NLD can be confused with granuloma annulare, a similar skin condition in which a high percentage of patients also have diabetes.

Symptoms of NLD

The legs are the most commonly affected site for NLD, but other body parts such as the face, abdomen, and scalp have been reported as affected areas. Initially, red-brown patches between 1-3mm develop over months or years, but these can increase in size and become progressively yellow and shiny.

Ulcerations can occur following trauma, which may be associated with some pain. The Koebner phenomenon – in which new psoriasis plaques form following a skin infection or injury – has been established in patients with NLD.

When legions are multiple and bilateral, they may either be painless due to cutaneous nerve damage, which is often the case, or they can be extremely painful.

Causes of NLD

The underlying cause of NLD is unknown, but the leading etiological theory tends to focus on microangiopathy – which occurs when blood vessels become damaged – a complication which can be caused by diabetes.

O Cohen et al reported that NLD is usually associated with poor glycemic control, and that improved management of blood glucose levels could improve or prevent the disorder.

Research has also been conducted investigating the effects of smoking in relation to NLD, with WF Kelly et al reporting that smoking was prevalent in diabetic patients with NLD. This was also the case for

retinopathy

and

nephropathy

Other possible theories for causes of NLD include trauma and inflammatory and metabolic changes.

Diagnosis of NLD

A skin biopsy is used to diagnose NLD, which can also be the first sign of diabetes in some patients. This is why a patient’s glucose tolerance may also be checked.

When legions appear on the face, scalp or upper arms, NLD is less likely to be correctly

diagnosed

Treatment of NLD

Treatment of NLD is challenging, as certain techniques can diminish the lesions, but they do not heal completely and have been known to spontaneously reoccur.

Baby aspiri, cortisone creams and corticosteroid therapy may help patients with NLD. However, people with diabetes should consult their doctor regarding treatment in the event their blood glucose levels could be affected.

Surgical and laser therapy may be recommended if lesions reoccur alongside underlying vascular damage.

People with

type 1 diabetes

tend to have a lower bone density and hence at an increased risk of osteoporosis, a condition resulting in weakened bones.

Osteoporosis is believed to affect around 3 million people in the UK. Our bones weaken as we get older but some factors can speed up the loss of bone density.

Symptoms of osteoporosis

Osteoporosis may not present noticeable symptoms and the first indication that you may have osteoporosis is usually if you suffer a bone fracture.

Osteoporosis may be noticeable in older as weak and fractured bones in the spine can cause the head to permanently lean forwards and a hunchback appearance developing.

Osteoporosis and common bone fractures

Common bone fractures resulting from osteoporosis include:

• Wrist fractures
• Hip fractures
• Spinal fractures
• Foot fractures

Diagnosing osteoporosis

Osteoporosis can be diagnosed using a DEXA scan, which measures your bone mineral density (BMD). DEXA stands for dual energy X-ray absorptiometry.

There are three different different grades of bone density, normal, osteopenia and osteoporosis.

Osteopenia is where you have lower than normal bone density but a higher bone density, and therefore lower risk of fractures, than osteoporosis.

Risks and causes

Our bones generally become weaker as we get older but a number of factors can speed up the weakening of bones and include:

• After the menopause in women
• A low
  
  body mass index
  
  (BMI)
• Being bed bound or otherwise getting very little
  
  physical activity
  
• Over consumption of
  
  alcohol
  
• Being a
  
  heavy smoker
  
• Prolonged use of
  
  corticosteroids
  
• 
  Cushing’s syndrome
  
• Crohn’s disease
• 
  Coeliac disease
  
• Overactive thyroid gland (hyperthyroidism)

Diabetes and osteoporosis

Higher rates of osteoporosis have been noted in people with type 1 diabetes. People with type 1 diabetes have been found to have, on average, lower bone mineral density.

Researchers are yet to fully understand the mechanism to explain why people with type 1 diabetes have a lower bone density but one hypothesis is that insulin may play a part as our bones are known to play a part in the regulation of blood sugar levels.

• Read more about the science behind
  
  diabetes and our bones
  

People with type 2 diabetes typically have a higher bone mineral density but studies have shown that people with type 2 diabetes are at an increased risk of suffering fractures.


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Treatment for osteoporosis

People with osteoporosis are recommended by the NHS to have a good intake of vitamin D and calcium, which can be obtained either through your diet or by taking appropriate

vitamin supplements

Drug treatments may be suitable for some people. Your health team can help to select a drug that is most suitable for you, which may include one of the following:

• Bisphosphonates – the most commonly prescribed drug treatment for osteoporosis
• Raloxifene
• Strontium ranelate
• Parathyroid hormone (PTH) treatment
• Denosumab
• Selective estrogen receptor modulators (SERMs)
• Calcitonin
• Hormone replacement therapy (HRT)
• 
  Testosterone
  
  treatment

Preventing osteoporosis and bones fractures

A

healthy diet and regular physical activity

are beneficial for preventing osteoporosis, as well as being good for our diabetes.

If you have osteoporosis, it may be advisable to take part in low impact physical activity such as:

• Walking
• Swimming
• Yoga

These activities are advisable over higher impact activity such as running or activities involving jumping.

Quit smoking

Quitting smoking and reducing alcohol intake are also recommended to help your bones stay healthy.

People with diabetes on medication which puts them at

risk of hypoglycemia

will have a higher risk of falling which can cause bone fractures.

Minimise the risk of falling

Elderly people also have a higher risk of falling and sustaining bone fractures.

Installing hand rails on stairs and ensuring walkways are free of hazards, such as loose rugs or stray wires on the floor, can help to reduce the likelihood of falls and fractures.

People with diabetes should check their feet each day and looks for examples of foot damage and discolouration of the skin.

Charcot’s foot

is a condition caused by foot fractures which can occur in people with diabetes.

Hip fractures

Hip fractures affect an estimated 76,000 people every year, according to the government website, a figure that is rising. It is most commonly caused by a combination of osteoporosis and a fall, and most commonly occurs to older women.

However, because diabetics can suffer from osteoporosis at an earlier age, they are more at risk of suffering a fracture from a fall.

Have I broken my hip?

If you have fractured a hip, you are unlikely to be able to:

• Move the leg
• Place weight on the leg
• And the leg could face outwards slightly.

Treating a broken gip

A broken hip is most likely going to require surgery, and you need to get to a hospital as soon as you can. This is most likely going to involve phoning for an ambulance.

While waiting, try to stay as warm as possible as this will help to prevent shock.

If you are waiting for an ambulance with someone who has fractured their hip, keep an eye on them, try to keep them warm, and if they feel nauseous or are sick, make sure they do not choke by gently turning their head to the side. Otherwise, try not to move them and wait with them for the paramedics.

Rheumatoid arthritis (RA) is an

autoimmune disease

that results in the immune system destroying cartilage, the tissue that provides the lining of bones that allows joints to move freely.

Whilst RA can happen to anyone, people with other autoimmune diseases, including

type 1 diabetes

, in the family have a higher chance of developing the condition.

Rheumatoid arthritis and diabetes

Research has shown that a number of specific genetic regions are associated with increased susceptibility for both type 1 diabetes (which includes

diabetes LADA

) and rheumatoid arthritis.

These research findings explain why people with type 1 diabetes are statistically more likely to develop rheumatoid arthritis.

Variants of the following genes have been linked with higher susceptibility to both type 1 diabetes and rheumatoid arthritis:

• PTPN22
• TNFAIP3
• CTLA4

People with other forms of diabetes may also develop rheumatoid arthritis, albeit there is no increased risk.

Symptoms of rheumatoid arthritis

As with other forms of arthritis,

the condition causes inflamed joints

, which can be stiff and painful. Stiffness in the morning that lasts for more than 30 minutes may indicate that rheumatoid arthritis is present rather than other forms of arthritis.

The joints of the fingers and

feet

are often the first parts of the body to be affected. It is common for rheumatoid arthritis to affect joints of the body in a symmetric fashion. That is, if one wrist is affected, it is common for the other wrist to be affected too.

In addition to directly affecting the joints, rheumatoid arthritis may also cause other symptoms including:

• Anaemia
• 
  Fatigue
  
• Fever (a temperature above 37.5C)
• Decreased appetite
• 
  Weight loss
  

Diagnosis

If you have the symptoms of rheumatoid arthritis, see your doctor to get a diagnosis. There are many different forms of arthritis and this can sometimes complicated the

process of diagnosing the correct form of arthritis

Autoimmune diseases frequently run in families so let your doctor know if you or others in your close family, such as siblings, parents or grandparents have or had rheumatoid arthritis or other autoimmune diseases such as type 1 diabetes and

coeliac disease

The following blood tests can be taken to help diagnose rheumatoid arthritis:

• Erythrocyte sedimentation rate (ESR)
• Rheumatoid factor
• Anti-cyclic citrullinated peptide (anti-CPP )
• C-reactive protein (CRP)
• Full blood count

X-rays, ultrasound scans and magnetic resonance imaging (MRI) scans can be used to view the joints for specific signs of inflammation and damage to the cartilage.

Causes of rheumatoid arthritis

It is not known what the underlying cause is that leads the

body’s immune system

to attack and break down cartilage but a number of risk factors have been associated with a greater risk of developing rheumatoid arthritis, which include:

• Genetic variants – causing rheumatoid arthritis to sometimes run in families
• Women are more likely to develop RA
• 
  Smokers also have an increased risk
  

Treatment

There are a number of different treatments for rheumatoid arthritis and it is common for people with RA to take a combination of treatments.

Medications commonly taken for rheumatoid arthritis include:

• Disease-modifying anti-rheumatic drugs (DMARDs)
• Biological therapies
• Non-steroidal anti-inflammatory drugs (NSAIDs) – such as ibuprofe, aspiri, diclofenac, naproxen
• Painkillers – such as paracetamol, codeine, tramadol
• 
  Corticosteroids
  

The table below lists names of the medications in the DMARDs and biological therapies medication classes.

The different types of medication treat the condition in different ways, with DMARDs and biological therapies taken to limit the development of the condition, painkillers to reduce the pain of flare ups and NSAIDs and steroids to treat inflammation.

If you have diabetes, alternatives to NSAIDs should be used where possible as these medications can cause a small increase in risk of heart problems, stroke and kidney function.

Note also that

corticosteroids may lead to increased blood glucose levels

and present additional challenges in controlling diabetes.

Complications of rheumatoid arthritis

Untreated rheumatoid arthritis can lead to erosion of the joint causing joint deformities.

Less well controlled rheumatoid arthritis may also raise the risk of a number of other conditions including:

• 
  Carpal tunnel syndrome
  
• Inflammation of the heart, lungs, eye and blood vessels (vasculitis)
• Cervical myelopathy

Adopting a healthy lifestyle of eating a balanced diet, exercising regularly, cutting down on alcohol and quitting smoking will help to reduce the risk of certain complications of the conditions.

Prevention

With the underlying cause of RA not yet well understood, there is little that can be done to prevent the condition developing. If you are a smoker, though,

quitting smoking may help to reduce your risk of developing RA

Deep vein thrombosis is the name for blood clots that develop in larger veins such as in the legs.

Thrombosis means blood clot and deep veins are those that lie within the muscle and not visible through the skin. Deep vein thrombosis affects about 1 in 1,000 people each year.

People with diabetes may have an increased risk of DVT, particularly those that have needed surgery or have other inflammatory conditions such as

rheumatoid arthritis

Symptoms of deep vein thrombosis

In some cases, deep vein thrombosis may present no symptoms.

If symptoms occur, these can include pain, swelling or aching in the affected leg, often in the calf. You may notice redness or warm skin at the affected part.

Diagnosing DVT

A diagnosis for DVT may include one or more of the following:

• A D-dimer test – a blood test which looks to detect the presence of loose pieces of a blood clot
• An ultrasound scan – which can be used to identify blood clots in deep veins

If the above methods cannot confirm DVT, a venogram may be used. A venogram involves a dye being injected into the foot and X-rays can detect whether the dye is blocked by a blood clot.

What causes deep vein thrombosis?

Deep vein thrombosis is a blood clot and is more likely to occur if we are not able to move around for long periods of time and the blood in the veins slow down. For this reason, deep vein thrombosis has been linked with long distance flights of 8 hours or more.

Being in hospital can increase the risk of DVT as movement may also be limited for long periods of time.

Deep vein thrombosis risk factors

The following factors reflect a higher risk of developing deep vein thrombosis:

• Prolonged inactivity
• 
  Being dehydrated
• Being over 60
• If you are overweight or obese
• 
  Smoking
• If you have existing damage to blood vessels
• 
  If undergoing cancer treatment
• Having inflammatory conditions such as rheumatoid arthritis

Pregnant women and women on the combined contraceptive pill or hormone replacement therapy also have an increased risk of DVT.

Treating deep vein thrombosis

Treatment for DVT will include being given an anticoagulant, such heparin or warfarin, to prevent the blood clot getting worse. Anticoagulants can also prevent the clot from breaking off which can be a life threatening complication of DVT.

Treatment also includes wearing a compression stocking. The stocking is to be worn all day, each day for at least two years to help prevent future clotting developing. You will also be advised to keep your leg raised when resting as this can help the blood to flow from your leg.

Complications of DVT

DVT may result in complications affecting other veins in the leg. This is known as post thrombotic syndrome and its symptoms include pain, swelling, a rash or ulcers on the calf. Speak to your doctor if these symptoms appear.

Pulmonary embolism

A serious complication that can occur following DVT is known as a venous thromboembolism (VTE).

A pulmonary embolism occurs if part of the blood clot breaks off, travels through the veins and gets stuck in the pulmonary artery, preventing blood reaching the lungs.

Symptoms of a pulmonary embolism include chest pain, a shortage of breath, coughing, feeling faint or passing out. Call the emergency services if these symptoms appear as a pulmonary embolism can be severe and can cause death. VTE is estimated to affect 1 in 10 people that have had DVT.

Arthritis is the term for conditions which cause inflammation of the joints.

There are more than 100 different forms of arthritis, with a broad range of causes. Some of these forms of arthritis have close associations with certain types of diabetes.

Arthritis can usually be treated to help reduce symptoms and slow progression of the condition.

How common is arthritis?

Arthritis is common, with an estimated 10 million people living with the condition in the UK alone. Osteoarthritis is the most common form of arthritis, affecting around 8 million in the UK.

Whilst arthritis is most commonly associated with the elderly, a number of forms or arthritis can affect people of any age, including children.

Types of arthritis

Whilst there are many dozen forms or causes of arthritis, the following are some of the more common forms:

• Osteoarthritis – caused by damage to the cartilage in the joints
• Rheumatoid arthritis – an autoimmune form of arthritis
• Gout – caused by a build up of uric acid
• Ankylosing spondylitis – a form which usually causes stiffness in the spine
• Reactive arthritis – can result from certain infections causing red swollen joints
• Secondary arthritis – may occur following joint injury
• Juvenile arthritis – forms of arthritis that affect children

Arthritis and diabetes

Certain forms of arthritis may be more common in people with certain types of diabetes.

People with type 2 diabetes have higher risks of developing osteoarthritis and gout, which is likely on account of the fact that obesity increases the risk of type 2 diabetes as well as these forms of arthritis.

People with type 1 diabetes have significantly higher risks of also having rheumatoid arthritis. Both conditions are autoimmune diseases and research suggests that certain genes may increase the risk of both conditions.

Symptoms

The common symptoms of arthritis are inflamed, swollen joints, which may be painful and may lead to limited movement of the affected joint.

Other symptoms may also occur and these will vary depending on the type of arthritis.

Causes and treatment

The causes vary considerably by type of arthritis. Similarly, treatment for arthritis can also vary considerably too depending on the type.

There are some treatments, however, that will be commonly applied to a number of forms of arthritis, such as painkillers and corticosteroids to reduce inflammation.

For some types of arthritis, specialist drugs can be taken to slow the development of the condition.

Surgery is a less common treatment but may be needed to treat particular problems that can’t otherwise be treated.

Osteoarthritis

Osteoarthritis is the most common form of arthritis. It is caused by damage to the joints which can be brought on by a number of factors including joint injury, other forms of arthritis and excess pressure on the joints caused by obesity

Whilst osteoarthritis is more common in the elderly, younger people can also develop the condition. This form of arthritis most commonly affects the knees, hips and the joints in the hands, making these joints stiff and painful.

Life with osteoarthritis can be made easier through taking exercise and, if overweight, reducing the strain on your joints. For this reason, water exercises (aquatic exercises) and swimming are particularly good for people that have osteoarthritis in their knees or hips.

Painkillers and corticosteroids may be prescribed to treat painful symptoms or inflammation.

Rheumatoid arthritis

Rheumatoid arthritis is an autoimmune disease that affects around 400,000 people in the UK.

The condition results in the body’s immune system mistakenly attacking and destroying the lining of joints. The condition causes joints, particularly the joints of the hands, wrists and feet, to be swollen, painful and difficult to move.

Other symptoms, such as fatigue, anaemia and flu-like symptoms can also result from the condition. The symptoms of rheumatoid arthritis may flare up and become worse for periods of time before settling again.

People with rheumatoid arthritis will usually take more than one type of medication, which include painkillers, anti-inflammatory drugs, steroids and disease-modifying anti-rheumatic drugs (DMARDs).

DMARDs are taken  specifically to prevent the immune system from damaging the joints.

Gout

Gout is caused by high levels of uric acid which can result in formation of crystals in and around the joint that can then lead to red, swollen and painful joints.

Symptoms of gout may come and go. Some people have regular episodes of gout whereas other people may experience episodes separated by years.

Lifestyle changes, such as those recommended for people with type 2 diabetes, can help to prevent future episodes of gout. Should an attack of gout occur, anti-inflammatory drugs are usually effective in relieving the symptoms.

Gout is a

form of arthritis

(inflammation of joints) caused by high levels of uric acid. Gout can be a painful condition but one that can be managed to reduce the frequency at which gout attacks occur.

Gout is known to affect around

1 in 100 people

in the UK and is around

four times more common in men

than in women.

Research shows that people with gout are significantly more likely to develop

type 2 diabetes

than people without gout.

Gout and diabetes

A number of research papers have shown associations between gout and type 2 diabetes including a study from Harvard Medical School, published in 2014, which showed

gout to be associated with a 70 increased risk of developing type 2 diabetes

A common medication for treating gout, allopurinol, has shown promise for

reducing thickening of heart muscle

and is currently undergoing testing as a possible medication for reducing risk of diabetic nephropathy (kidney disease).

Symptoms of gout

Gout is characterised by

swelling of joints

The base of the big toe is most commonly affected by gout. More than one joint may be affected by gout in some people.

Symptoms can come on quickly, with swelling occurring within a few hours. The swollen joint can be very painful and sensitive to touch. During swelling, skin covering the joint may typically turn red and shiny in appearance.

The swelling and symptoms may occur for several days if not treated. Once the inflammation has subsided, the skin on the joint may become itchy and flaky.

Causes of gout

Gout occurs if high levels of uric acid in the blood leads to crystals of sodium urate forming in and around the joints. If these crystals spill into the joint space, this can cause the joint to become inflamed.

Risk factors

High levels of uric acid are more likely to build if you have any of the following risk factors:

• Family history of gout
• 
  Obesity
  
• Medical conditions that lead to increased uric acid levels
• A diet high in purines – a compound that is broken down into uric acid

Medical conditions which may lead to high uric acid levels include hypoparathyroidism, leukaemia, nephrolithiasis and renal failure.

Foods that are very high in purines include:

• Liver
• Kidneys
• Sardines
• Anchovies
• Sweetbreads (pancreas or thymus) and
• Gravy

Other foods that are relatively high in purines include

red meat

, oily fish, spinach, asparagus, beans, lentils, oatmeal and wheat bran.

Diagnosing gout

There are other forms of arthritis which can display similar symptoms to gout so tests are needed to confirm whether gout is the cause of inflammation.

The best diagnosis method is to test for presence of uric acid crystals in the affected joint. A needle is pushed in and synovial fluid is collected from the joint and examined, under a microscope, for the presence of sodium urate.

Blood tests, x-rays and ultrasound scans may also be used for diagnosing gout.

Treatment

Treating gout involves measures to prevent gout attacks and treatment when an attack occurs.

A low purine diet is recommend to reduce uric acid from building up. Avoid having foods that are high in purines. Dairy, eggs and most fruit and vegetables are low or relatively low in purines.

Aim to avoid alcohol

and sweetened foods and drinks as these can increase the risk of gout. Aim to drink 1.5 litres of water a day.

Medications, called urate-lowering therapy (ULT), may commonly be prescribed to reduce levels of uric acid, particularly if gout attacks are frequent or if you have complications of gout such as joint damage or a history of kidney stones.

Common examples of ULT medications are allopurinol and febuxostat.

Treating gout attacks

If an attack of gout develops, treatment will aim to reduce inflammation and pain and may include self-care or

medication

Self-care treatment includes keeping the joint rested, to prevent further inflammation or irritation and keeping the joint cool.

You can use an ice pack to cool the joint but don’t put ice directly onto the skin and don’t use an ice pack for more than 20 minutes so as not to damage the skin.

Medications for treating inflammation include:

• NSAIDs (Non-steroidal anti-inflammatory drugs)
• Colchicine
• 
  Corticosteroids
  

NSAIDs treat pain as well as inflammation but may not be advised if you are at

higher risk of heart disease

or stroke. Colchicine may lower blood glucose levels so care needs to be taken if you are on hypo causing medication such as insulin, sulphonylureas or glinides.

Corticosteroids may be used to treat

severe attacks of gout but can lead to increased blood glucose levels

whilst they are being taken.

Diabetes and Fibromyalgia syndrome are linked conditions.

FMS (Fibromyalgia syndrome) literally means pain in the fibrous tissues, the most common symptoms being widespread musculoskeletal pain and fatigue.

Unfortunately, the

causes

of Fibromyalgia remain unknown, and the disorder has only gained increasing recognition in the past twenty years.

What are the symptoms of Fibromyalgia?

Symptoms of Fibromyalgia include a burning ache, a feeling like the muscles have been pulled or torn. Muscles may twitch or even burn.

A

major symptom

is a profound lack of energy and extreme fatigue.

Pain from FMS may be localised to one area. Due to the tiredness element of FMS, comparisons are often drawn with CFS (Chronic Fatigue Syndrome).

This level of tiredness can affect ability to focus and concentrate, and even influence the ability to move limbs. FMS has also been likened to the symptoms of those with Gulf War Syndrome. FMS is more common amongst women than men.

The widespread aching pain felt by FMS sufferers comes from the connective tissues, including tendons, ligaments and the muscles.

Pain may be most acute early in the morning or following

exercise

However, unlike arthritis, FMS is not a joint-related condition. FMS affects both

people with diabetes

and people without diabetes.

Common Fibromyalgia Symptoms

• Chest pain
• Chronic headache
• Memory impairment
• Dizziness
• Impaired coordination
• Dry mouth and eyes
• IBS
• Numbness and tingling
• Sleep disorders (alpha EEG-anomaly,
  
  sleep apnea
  
  , restless legs, etc)
• Temporomandibular joint dysfunction syndrome (TMJ or TMD)
• Stiffness in the morning
• Muscle twitching, pain, or burning
• Premenstrual syndrome including painful periods
• Feeling of swollen extremities
• Sensitivity to odours, loud noises, bright lights, and some
  
  medications
  
• 
  Skin
  
  sensitivity

How is diabetes associated with Fibromyalgia syndrome?

FMS is associated with a range of conditions, including diabetes. Other FMS related conditions include sleep disorders, IBS, TMJ and rheumatoid arthritis.

A study carried in Israel in 2003,

Fibromyalgia in diabetes mellitus,

noted that fibromyalgia is commonly found in people with diabetes, and more so in people with type 1 diabetes. The researchers found evidence to suggest that the development of fibromyalgia is more likely in people with less well controlled diabetes.

So FMS affects sleeping?

Sleeping Disorders Associated with FMS include Alpha-EEG anomaly, sleep apnea, upper-airway resistance syndrome and restless leg syndrome.

What triggers Fibromyalgia?

Often, Fibromyalgia sufferers report common triggers that prompt attacks of Fibromyalgia. Triggers include:

• allergies
• infections
• exposure to cold
• 
  depression
  
• injury
• hormones
• over-exerted muscles
• stress

• anxiety and
• even
  
  changes in the weather
  

How is FMS caused?

Fibromyalgia is caused by an underlying abnormality or predisposition, and there is no certainty surrounding the cause.

Abnormalities in the pain-related chemical makeup of the brain are the suspected cause.

The following incidents are often reported prior to FMS diagnosis:

• infection
• a related disorder including diabetes and
• bodily trauma such as an accident

How is Fibromyalgia treated?

Often treating sleep disorders is the first treatment for FMS sufferers. Quality of sleep strongly impacts pain levels and helps the body to naturally regulate itself and repair damaged tissues. Serotonin boosting medication may also be prescribed.

FMS sufferers may be prescribed neurotransmitters, pain medications, muscle relaxants, physical or occupational therapy and alternative treatments such as acupuncture,

biofeedback

, chiropractic care and

therapeutic massage

What is the prognosis for sufferers with Fibromyalgia Syndrome?

At this stage, there is no known cure for FMS. The profound pain and fatigue caused by FMS may also flare up at any time and in varying degrees.

Irritable bowel syndrome, commonly abbreviated to IBS, is a common condition and so having both diabetes and IBS is also relatively common.

Both IBS and diabetes can be managed through diet and medication.

Irritable bowel syndromen, commonly abbreviated to IBS, can cause uncomfortable and unpleasant symptoms.

The good news is that the symptoms are not a result of damage to the gut but it is a condition that needs managing either through dietary choices,

medication

or other therapies.

People following more restrictive diets for their diabetes may need to make some compromises between choosing a diet suitable for their IBS and one that’s appropriate for their diabetes.

Symptoms

Symptoms of irritable bowel syndrome include:

• Stomach pain or cramps, which tend to subside after passing stools or wind
• Bloating
• Flatulence
• Diarrhoea
• Constipation
• An urgent need to visit the toilet to open your bowels
• Feeling your bowels have not been fully emptied after having visited the toilet
• Mucus in your stools

Passing blood or experiencing unexplained weight loss or anaemia are not associated with IBS. Tell your doctor if you notice any of these symptoms.

Causes

People with IBS tend to find that particular foods will trigger their symptoms.

These food triggers typically vary from person to person but the following list are more common food triggers.

• Greasy foods such as chips
• Snacks such as biscuits and crisps
• 
  Alcohol
  
• Carbonated drinks such as cola and lemonade
• Foods containing the sweetener sorbitol
• 
  Whole grain foods
  
• Dairy foods
• 
  Chocolate
  
• Certain raw fruits and vegetables
• Drinks with caffeine including tea, coffee and caffeinated cola

IBS has been linked with stress, with patients reporting worse symptoms during periods of stress. Usage of antibiotics may also lead to a worsening of symptoms as the antibiotics may lead to some of the good bacteria in the gut being killed.

It is also possible that undiagnosed food intolerance may be causing the symptoms.

Lactose and gluten intolerance are common examples which can lead to similar symptoms as IBS.

Diagnosis

In order to diagnose irritable bowel syndromen, your doctor will likely ask you questions about the symptoms you have and your bowel movements.

A blood test may be carried out to investigate whether an infection or a different condition, such as

coeliac disease

is responsible for the symptoms.

Treatment – dietary changes

It may be necessary to make changes to your diet to help prevent or reduce the symptoms. If you know a particular type of food is causing flare ups, it may be advisable to avoid eating this food. It can help to keep a

food diary

, noting down which foods are eaten and which symptoms appear to spot any patterns.

If you suffer from

diarrhoea

as a result of your IBS, it may be advisable to reduce the amount of soluble fibre you eat. Soluble fibre is a type of fibre that our body can digest and it is found in foods such as oats, rye, apples, bananas, carrots and potatoes.

If you tend to get constipated as a result of IBS, it can help to increase your intake of insoluble fibre. This type of fibre does not get digested by the body and instead helps to move digested food through the gut.

Sources of insoluble fibre include whole grain foods, cereals, nuts and bran. Drinking more fluids may also help to reduce the effects of constipation.

Treatment – dedication

Treatment by medication may also be advised:

• If you have spasm-like pains, an antispasmodic medicine such as mebeverine (brand name Colofac) or peppermint oil may be prescribed to relax the muscles involved in digestion.
• If you have constipatio, you can take laxatives to help make your stools easier to pass.
• If you have diarrhoea resulting from IBS, loperamide can help to slow muscle contractions in the bowel which can help stools to solidify.
• If symptoms of pain and diarrhoea are not eased by the methods above, antidepressants such as TCAs (tricyclic antidepressants) and or SSRIs (selective serotonin reuptake inhibitors) may be prescribed.

Treatment – other therapies

As stress can be a contributing factor, other therapies such as cognitive behavioural therapy and

mindfulness

can be used to alleviate stress.

These therapies may be available on the NHS if other treatments have not been successful or can be accessed privately through qualified therapists.

Diabetes and irritable bowel syndrome

IBS often requires some degree of dietary change and in some cases, having diabetes may mean needing to make some compromises between the best diet for your diabetes and the best for minimising symptoms of IBS.

If you suffer from constipatio, the advice is to include more insoluble fibre from food such as whole grain foods, cereals and bran. Those on

low carb diets

may need to make a compromise whereby the symptoms can be eased without raising blood glucose levels too high.

If such a compromise is hard to reach, taking medication for IBS or taking alternative diabetes medication are further options.

Pancreatitis is a condition in which the pancreas becomes inflamed, which can be very painful in the short term and could lead to complications including

secondary diabetes

Alcohol

and gall stones are the main risk factors for pancreatitis but some medications, including certain

diabetes medications

, may increase the risk of pancreatitis.

Types of pancreatitis

Acute pancreatitis is when the

pancreas

becomes inflamed for up to a few days.

Chronic pancreatitis is if inflammation of the pancreas persists over a long period of time, say years.

Symptoms

The main symptom of acute pancreatitis is a strong pain in the upper abdomen, where the pancreas is located.

Other symptoms that may be present include:

• nausea
• vomiting or
  
  diarrhoea
  
• fever

If you have chronic pancreatitis you may experience regular pain within the upper part of the abdomen and possibly some of the following symptoms, caused by difficulty in digesting food properly:

• Stomach cramps
• Bloating and wind
• Foul smelling stools
• 
  Unexplained weight loss
  
• Jaundice

Seek medical help if you experience sudden severe pain in your abdomen.

Causes

The NHS notes that pancreatitis may be caused by a digestive enzyme becoming prematurely activated within the pancreas, causing the pancreas to become inflamed.

• Having two or more
  
  alcoholic drinks
  
  a day
• Gallstones
• An automimmune response
• Hypertriglyceridemia – high levels of triglyceride blood fats in the blood
• Genetic mutation of MCP-1 gene

The following medications may also raise the risk of pancreatitis:

• Oestrogens
• 
  Corticosteroids
  
• Thiazide diuretics
• Certain diabetes medications – see below for more info

Treatment

Treatment for pancreatitis will need to be carried out in hospital. You may need to be given oxygen and intravenous fluids, and may be given strong painkillers, such as morphine, if the pain is severe.

Severe acute pancreatitis will require treatment in a high dependency or intensive care unit.

It is important that underlying cause is addressed to prevent further inflammation. If gallstones are a cause, it may be recommended that you undergo surgery to have your gall bladder removed.

Complications and outlook of pancreatitis

In most cases people can expect to leave hospital within a week or two following acute pancreatitis but it can be more serious in some cases. Pancreatitis is responsible for around 25,000 hospitalisations and almost 1,000 fatalities each year in the UK.

Pancreatitis and diabetes

Diabetes is a relatively common complication of chronic pancreatitis. The NHS states that around 50 per cent of people with chronic pancreatitis will go on to develop diabetes. Forms of diabetes caused by other medical conditions are referred to as being

secondary diabetes

Pancreatitis causes diabetes by affecting the amount of insulin the body produces. As a result, diabetes as a consequences of pancreatitis may require

insulin injections

If you have chronic pancreatitis, it is useful therefore to be aware of the

symptoms of diabetes

Pancreatitis and diabetes medication

Certain diabetes medications have been linked with an increased risk of pancreatitis. The drugs

Januvia

and

Byetta

were found to be linked with a doubled risk of pancreatitis.

These drugs are in the DPP-4 inhibitors and

incretin mimetics

drug classes respectively. These drugs work by suppressing glucagon release and increasing insulin release from the pancreas.

Drugs in the same drug class tend to work in similar ways and so other DPP-4 inhibitor drugs (such as Galvus and Onglyza) and other incretin mimetics (such as Victoza and Bydureon) may also be found to raise the risk of pancreatitis.

• 
  Januvia and Byetta diabetes drugs could double risk of pancreatitis
  

People with type 1 diabetes are more likely to develop other autoimmune diseases, especially ones which can affect the thyroid gland.

Hashimoto’s disease is an autoimmune disease that causes the body’s immune system to turn on the thyroid gland, just as

type 1 diabetes

causes it to turn and attack the pancreas.

This attack on the thyroid gland causes hypothyroidism.

Graves’ disease on the other hand causes the thyroid to become overactive, again because of a

malfunction with the immune system

It is thought about 30% of female type 1 diabetes patients will develop Graves’ disease and suffer with their thyroid. In the non-diabetic population, women are about 10 times more likely to have the disease than men.

Graves’ and Hashimoto’s disease have no direct treatment, but hypothyroidism and hyperthyroidism do.

What does the thyroid do?

The thyroid is a gland in the neck, located just behind the muscle at the base of the neck and in front of the windpipe. It produces and releases several hormones that are related to body’s metabolism.

The main hormones it releases are triiodothyronine and thyroxine, which help to regulate the growth and the rate of function of many of the body’s systems.

Hyperthyroidism and Graves’ disease

As a result of Grave’s disease, the thyroid can become overactive and produce too many of the hormones.

It is unknown why it does, but Graves’ disease causes some of the cells of the immune system to bond to receptors on the thyroid, and act like thyroid stimulating hormones, tricking it into over working and producing more hormones than it should.

In turn, this can cause the body’s systems to speed up, resulting in a variety of symptoms and

complications

These can include:

• Weight loss
• Rapid heartbeat or heart palpitations
• Sweating
• Diarrhoea or excessive bowel movement
• Muscle weakness
• Feeling too hot
• Being able to tolerate cold temperatures
• Increased appetite
• Bulging eyeballs
• Irregular or absent menstruation
• Personality changes (anxiety, depression, agitation)
• Goitre (swollen thyroid and neck)

Treating hyperthyroidism

Hyperthyroidism is normally treated in one of two ways: with a dose of radioactive iodine to destroy cells in the thyroid, or with a thyroidectomy, surgery which removes some or all of the thyroid. Both cases reduce the ability of the thyroid to produce hormones, and so make the symptoms and complications go away.

In both cases however, follow up medication is likely to be needed.

Hypothyroidism and Hashimoto’s disease

A lot of the symptoms for hypothyroidism can be seen as the opposite of those of hyperthyroidism. This is because hypothyroidism is an underactive thyroid, often caused by Hashimoto’s disease.

This causes the immune system to attack the thyroid, reducing its ability to create hormones.

This slows down a lot of the metabolic processes in the body due to producing a low amount of thyroxine and triiodothyronine.

Symptoms of hypothyroidism include:

• Weight gain
• Tiredness
• Sensitivity to the cold
• Dry skin
• Muscle aches
• 
  Heart disease
  
• Personality changes (depression)
• Goitre (swollen thyroid and neck)

Treating hypothyroidism

Hypothyroidism can be treated by taking daily medications that supply the body with the hormones that they thyroid cannot. Unfortunately, sufferers will likely have to be on medication for the rest of their life, but in most cases these drugs do not prevent the patient from leading a normal life and can prevent major complications, such as heart disease and pregnancy issues.

Diabetes and thyroidism

As thyroidism affects the body’s metabolism, it can mean a big problem for diabetics. The hunger, muscle weakness and fatigue that can occur from either hypo- or hyperthyroidism can make sticking to a strict,

healthy diet

and

getting in enough exercise

difficult.

This is why it is important to be aware of the signs and symptoms and get checked for Graves’ and Hashimoto’s disease as soon as possible as it may

affect blood glucose control

Developing the disease

It is not known what causes the immune system to act oddly and affect the thyroid.

As with type 1 diabetes, some think it may be triggered by certain viruses and bacteria.

However, there are some factors that have been found to increase your chances of developing them.

It is known that having one autoimmune disease can leave you vulnerable to another autoimmune attack, so anyone with type 1 diabetes could be at greater risk of developing either Graves’ disease or Hashimoto’s disease, and vice versa.

Genetic susceptibility is also known to play a role, just like with type 1 diabetes, meaning Graves’ and Hashimoto’s diseases are more likely to develop if you have a close relative who has either the disease.

Women are also more susceptible to developing these diseases than men.

Reactive hypoglycemia is the general term for having a hypo after eating, which is when blood glucose levels become dangerously low following a meal.

Also known as postprandial hypoglycemia,

drops in blood sugar are usually recurrent
and occur within four hours after eating.

Reactive hypoglycemia can occur in both people with and without diabetes, and is thought to be more common in

overweight individuals or those who have had gastric bypass surgery

What are the causes of reactive hypoglycemia?

Scientists believe reactive hypoglycemia to be the

result of too much insulin
being produced and released by the pancreas following a large carbohydrate-based meal.

This excess insulin production and secretion continues after the glucose derived from the meal has been digested, causing the amount of glucose in the bloodstream to fall to a lower-than-normal level.

What causes this increase in pancreatic activity is unclear.

One possible explanation is that in rare cases, a benign (non-cancerous) tumour in

the pancreas may cause an overproduction of insulin, or too much glucose may be used up by the tumour itself.

Another is that reactive hypoglycemia is caused by

deficiencies in glucagon secretion

In the U.S. the National Institutes of Health (NIH) states that “the causes of most cases of reactive hypoglycemia are still open to debate”.

Signs and symptoms of reactive hypoglycemia

Symptoms of reactive hypoglycemia can include:

• Anxiety
• 
  Blurred vision
• Confusion
• 
  Dizzy spells
• 
  Fatigue
• Headaches
• Heart palpitations
• Increased hunger
• Irritability
• Light-headedness
• Sleeping problems
• Sweating
• Weakness

When talking about the signs of reactive hypoglycemia, it’s important to note that many of

these symptoms can be experienced without actually having low blood sugar

In fact, it is rare for such symptoms to be caused by falling blood sugar levels after eating, with the actual cause for many people often relating to what food was eaten or variations in the timing of the food moving through the stomach and intestinal tract.

If there is no hypoglycemia at the time of the symptoms, you may have what is known as “postprandial syndrome”.

Treatment

No medical treatment is usually required for cases of reactive hypoglycemia. Instead, patients are generally advised to:

• 
  Reduce carbohydrate intake and/or eat frequent small meals
  – the first step of treatment is to split your daily diet into several small meals and snacks, no more than 3 hours apart., which are less carb-heavy.
• 
  Eat a well-balanced diet, including meat, poultry, fish, nonmeat sources of protein, dairy products and fibre-rich foods such as whole grains, fruit and vegetables.
• 
  Avoid or limit sugary foods and drinks, especially soft drinks rich in glucose or sucrose.
• Exercise regularly – physical activity increases sugar uptake which, in turn, decreases excessive insulin release.
• 
  Eat food when drinking alcohol
  and avoid using sugary soft drinks as mixers.

Further evaluation by a doctor may be required for some people, such as those who have had intestinal surgery (e.g. gastric bypass).

Can hypo unawareness be dangerous?

Reduced hypo awareness can potentially be dangerous. If you suffer hypoglycemia you should be careful to test before putting either yourself or others in any potential danger.

Examples when hypoglycemia and unawareness of it could be particularly dangerous include driving, operating dangerous machinery

at work
and even day to day tasks such as cooking or even crossing the road.

Improving hypo awareness signs

If you are suffering from impaired hypo unawareness, you may be advised to increase your window of

blood glucose control
for a period of time to get your numbers higher and prevent hypos from occurring so often.

Studies have found this method to be successful.

If you have frequent hypos you may need to test your blood sugar more often, to help get better control as well as to catch hypos earlier. Try to record which events lead to hypos so you can spot trends and prevent them in future.

Cushing’s syndrome is a condition in which can occur if you have high levels of the stress hormone, cortisol, in your blood.

Cortisol increases our blood pressure and blood glucose levels and diabetes is one

complication

which can result from untreated Cushing’s syndrome.

Symptoms of Cushing’s syndrome

Physical signs of Cushing’s syndrome may include:

• Fatty tissue building up typically around the waist, upper back, between the shoulders and the face.
• Slim arms and legs contrasting significantly with fat deposits around your middle
• Swollen cheeks with red patches
• Striae – red or purple stretch marks, which may resemble tiger stripes, commonly found on the abdomen, near the armpits or around the breasts and thighs
• Acne
• Thin skin which easily bruises

Women may experience thicker than normal facial and body hair (hirsutism) and missed or irregular periods.

Men may experience a

loss of libido

, difficulty achieving erections and loss of fertility.

High blood pressure and high blood glucose levels (

hyperglycemia

) may commonly be experienced with Cushing’s syndrome.

Causes of Cushing’s syndrome

Usage of corticosteroids is the most common cause of Cushing’s syndrome.

Corticosteroids

are used to treat illnesses including:

• Atopic eczema
• Asthma
• Chrone’s disease

Doctors will prescribe the lowest effective dose to reduce the likelihood of complications, such as Cushing’s syndromen, developing.

When Cushing’s syndrome results from steroid usage, this is known as iatrogenic Cushing’s syndrome.

A less common reason for Cushing’s syndrome developing is known as endogenous Cushing’s syndromen, which is caused by the development of a tumour in the pituitary gland, one of your adrenal glands or one your lungs.

A tumour in the pituitary gland is the more common cause for endogenous Cushing’s syndromen, accounting for about 7 out of 10 cases, and is referred to as Cushing’s disease.

Diagnosis of Cushing’s syndrome

Cushing’s syndrome can be diagnosed by measuring levels of cortisol in the urine, the blood or saliva.

You may be asked to take dexamethasone before the test is carried out. If you don’t Cushing’s syndromen, the dexamethasone should decrease your cortisol levels.

The

NHS advise

that these tests are helpful but cannot guarantee accuracy.

Treatment for steroid induced Cushing’s syndrome

When Cushing’s syndrome results from taking corticosteroids, the dosage you are taking will need to be reduced or stopped. If you have been taking higher doses of steroids for a significant period of time, the dosage you take will usually be reduced before they can be stopped.

Your health team will advise you on how your steroid dosages should be reduced.

Treatment for endogenous Cushing’s syndrome

Treatment for endogenous Cushing’s syndrome includes surgery to remove the tumour. In some cases, particularly in the case whereby the tumour is on one of your adrenal glands, the gland may be removed.

If a tumour in the lungs is the cause of Cushing’s disease, and the tumour is situated deep inside the lungs, surgery may not be appropriate and you may need to take cortisol-inhibiting medication such as ketoconazole or metyrapone.

If surgery is not successful, radiotherapy may be used to shrink the tumour or, if Cushing’s syndrome is putting your health at risk, you may have both your adrenal glands removed.

Complications of Cushing’s syndrome

If not treated, Cushing’s syndrome may lead to one or more of the following complications developing:

• 
  Hypertension
  
• Diabetes
• Osteoporosis
• Kidney stones

Diarrhoea is commonly experienced as a result of gastroenteritis but may also be caused by specific medication including statins and metformin.

Diarrhoea is defined as passing loose, watery stools more than three times a day.

Diarrhoea may also result from conditions such as irritable bowel syndromen, coeliac disease and autonomic neuropathy.

Common causes of diarrhoea

The NHS lists gastroenteritis, bowel infection, as the most common cause of diarrhoea. Gastroenteritis can be caused by a bacterial or viral infection.

Other relatively common causes of diarrhoea include:

• Food intolerances – such as lactose or gluten intolerance
• 
  Irritable Bowel Syndrome
• Drinking too much
  
  coffee
  or
  
  alcohol

Read further below for causes more specifically related to diabetes.

Diagnosing diarrhoea

In most cases diarrhoea will clear within a week. If diarrhoea persists longer is accompanied by other symptoms such as:

• Fever
• Blood in your stools
• Vomiting
• Unexplained weight loss

If you have recently been treated in hospital or have recently been put onto antibiotics see your GP.

To diagnose the cause of persistent diarrhoea, your GP will review the medications you are on and will likely ask questions about your bowel movements and other questions which may help to isolate a possible cause.

Your GP may need to take a stool sample or a blood test or perform a rectal examination if further information is needed.

Treating diarrhoea

Depending on the cause of diarrhoea, treatment may vary. See further below for more about specific causes related to diabetes.

Whilst you have diarrhoea, it is important to take regular drinks of fluid, ideally water, as you will lose more water than usual through diarrhoea. High blood glucose, which can also commonly result from viral infections, can also increase the

risk of dehydration

Loperamide is a medication that can be taken to slow down the movement of the gut which allows more water to be absorbed by the body and therefore helps stools become firmer.

Autonomic neuropathy

Autonomic neuropathy is when damage occurs to the nerves which help control involuntary functions of the body, including the movements of the large intestine. If the large intestine is affected by nerve damage, you may experience alternating periods of constipation and diarrhoea.

Loperamide may also be prescribed to reduce the effects of diarrhoea. If you have spasm-like pains, an antispasmodic medication such as mebeverine or peppermint oil may help to reduce these symptoms.

If you have autonomic neuropathy, it is important to keep your blood glucose levels under control as best as you can to help prevent further nerve damage.

Metformin

Diarrhoea is a relatively common symptom of taking metformin.

The symptoms will usually be most pronounced after starting on metformin and normally subside after a few weeks.

Diarrhoea and other gastrointestinal symptoms, such as nausea, stomach pain and vomiting, can be reduced by taking metformin just after or towards the end of a meal.

If unpleasant symptoms such as diarrhoea persist, your GP may prescribe you with extended release

metformin
which can help to alleviate symptoms.

Alternative options include reducing your dosage of metformin, if your diabetes is well controlled, or taking an alternative diabetes medication.

Other medications associated with diarrhoea

Other relatively commonly taken medications which can result in diarrhoea include:

• 
  Statins
  – taken to reduce cholesterol levels
• SSRIs (selective serotonin reuptake inhibitors) – antidepressant medications
• Antibiotics

If these medications are thought to be the cause of diarrhoea, your GP will be able to advise how best to go ahead with treatment.

Coeliac disease

Coeliac disease is an autoimmune disease which affects the small intestine and is made worse by ingestion of foods containing gluten.

People with type 1 diabetes (also an autoimmune disease) have an increased risk of developing coeliac disease.

Symptoms of coeliac disease include changes in bowel movements including:

• Stomach cramps
• Diarrhoea
• Constipation

The symptoms of

coeliac disease
can be alleviated by eliminating sources of gluten from your diet.

Artificial sweeteners – sugar alcohols

Sorbitol is a form of sweetener known as sugar alcohols. Sorbitol and other sugar alcohols are commonly found in foods labelled as

diabetic foods
as well as other sugar free products such as sugar free gum.

Sugar alcohols have a lower sugar content and affect blood glucose levels less than table sugar (sucrose) but they can have a laxative effect and thus may cause stomach cramps and diarrhoea.

If you experience these symptoms after having food with sugar alcohols, it is best to avoid these foods or only consume small amounts. Some people will be more sensitive than others to the effects of sorbitol and other

sugar alcohols