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1 c eda rs Issue 67 November 2014 The E - Bulletin is a service provided from the in-house team of physicians (Specialists, GP s & the CEDARS Training Center) at the CEDARS Jebel Ali International Hospital in order to raise awareness about health issues. This November, we focus on the disease that has reached pandemic proportions and has affected many lives across the globe not just the patients but their families and friends alike. In 2013, there is an estimated 382 Million cases of and by 2035, it is estimated to be as 592 Million. At CEDARS Jebel Ali International Hospital, we have established a Clinic which will offer a comprehensive cure to our diabetic patients. At the clinic, we aim to educate people about the disease, its complications, prevention and cure. With CEDARS Diabetic Clinic, life is still sweet despite the. What is? is a lifelong (chronic) disease in which there are high levels of sugar in the blood. This is because the body does not make enough insulin or insulin does not work properly. Types of Type 1 - Juvenile Onset Type 2 - Mellitus Gestational during pregnancy only Insulin is a hormone produced by the pancreas to control blood sugar. can be caused by too little insulin, resistance to insulin, or both. What is Type 1? In people with type 1 diabetes, the pancreas cannot make insulin. This vital hormone helps the body's cells convert sugar into energy. Without it, sugar builds up in the blood and can reach dangerous levels. To avoid life-threatening complications, people with type 1 diabetes must take some form of insulin for their entire lives.

2 Page 2 Warning Signs: Unusual Thirst A person with Type 1 experiences feeling more thirsty than usual with Dry mouth, fruity breath and frequent urination. Weight Loss - As blood sugar levels remain high, type 1 diabetes often leads to unintentional weight loss, increase in appetite, lack of energy, and drowsiness. Skin Problems - Many people with type 1 diabetes experience uncomfortable skin conditions, including bacterial infections, fungal infections, itching, dry skin, poor circulation. Girls with type 1 diabetes are more likely to get genital yeast infections. Babies can develop candidiasis, a severe form of diaper rash caused by yeast that can easily spread from the diaper area to the thighs and stomach. More Dangerous Signs When blood sugars are not controlled, type 1 diabetes can cause more serious symptoms, such as: numbness or tingling in the feet blurred vision treatment induced low blood sugar/hypoglycemia loss of consciousness Some patients have no obvious warning signs before falling into a diabetic coma, which requires emergency treatment. More Dangerous Signs: Ketoacidosis Without treatment, type 1 deprives your cells of the sugar they need for energy. Your body starts burning fat for energy instead, which causes ketones to build up in the blood. These are acids that can poison the body. High levels of acid in your blood and the other abnormalities that result from the change in your blood's ph level may trigger a life-threatening coma known as diabetic ketoacidosis. This is an emergency that must be treated quickly and oftentimes in the hospital. Symptoms of diabetic ketoacidosis include: passing large amounts of urine feeling very thirsty vomiting abdominal pain Type 1 vs. Type 2 Type 1 The body's immune system mistakenly attacks and destroys the pancreatic cells that produce insulin Sudden onset Mostly in children Thin or normal body Common ketoacidosis Antibodies usually present Low or absent Insulin 10% prevalence vs The symptoms of the two forms are similar, but usually come on more rapidly in people with type 1. Type 2 The pancreas is not under attack and usually produces enough insulin. But for numerous reasons, the body doesn't use the insulin effectively. Gradual onset Mostly in adults Often obese Rare ketoacidosis Antibodies absent Normal< decreased or increased Insulin 90% prevalence What Causes Type 1? Doctors aren't sure what makes the immune system turn against the pancreas, but most suspect a combination of genetic susceptibility and environmental factors. Scientists have identified 50 genes or gene regions that raise the risk of developing type 1 diabetes. But genetics alone don't account for all the risk, so having these genes doesn't mean that you'll develop type 1 diabetes. Some researchers believe that environmental triggers, such as a virus, or dietary or pregnancy-related factors may play a role as well.

3 Page 3 Who Gets Type 1? Type 1 diabetes can develop at any age. However, it accounts for two-thirds of the new cases of diabetes diagnosed in those under the age of 19. There appear to be two peaks in the "age of onset": the first in early childhood and the second during puberty. The condition affects males and females equally, but is more common in whites than in other ethnic groups. According to the World Health Organization, type 1 diabetes is rare in most African, Native American, and Asian populations. How to diagnose Type 1? Simple blood tests can diagnose diabetes. A fasting blood sugar test or a random blood sugar test (plus the presence of symptoms) can be used. An A1c test, which reveals average blood sugar levels for the past 2-3 months, can also be used. Tests should be repeated on two separate days to diagnose diabetes. A less convenient glucose tolerance test will also help determine whether you have diabetes. If you're diagnosed with type 1 diabetes, your doctor may be able to determine the type by checking for certain antibodies in the blood. Long-Term Complications Prolonged high blood sugar can damage many of the body's systems over time: Heart disease, stroke, kidney failure, vision problems and blindness, gum disease and tooth loss, nerve damage in the hands, feet, and organs Prevention Monitor Your Blood Sugar - The first step toward preventing complications is to regularly monitor your blood sugar or glucose level. This involves pricking your finger, putting a drop of blood onto a test strip, and putting the strip into a glucose meter. The results will help you optimize your treatment plan. When your blood sugar stays near the normal range, you'll have more energy, fewer skin problems, and a reduced risk of heart disease and kidney damage. Management of Type 1 Insulin Shots - Everyone with type 1 diabetes must take insulin to help the body process blood sugar. Most patients take insulin as an injection and need multiple shots per day. Your healthcare provider will explain how to adjust your insulin shots based on the results of your blood sugar testing. The goal is to keep glucose levels in the normal range as often as possible. Insulin Reaction Warning Signs - Taking too much insulin can lower your blood sugar to dangerous levels (Hypoglycemia). These reactions can be mild, moderate, or severe, requiring the help of others. Warning signs include: Exhaustion or excessive yawning, unable to speak or think clearly, loss of muscle coordination, sweating, twitching, turning pale, seizures and loss of consciousness Neutralizing an Insulin Reaction People who take insulin should carry at least 15 grams of a quick-acting carb at all times. Fast carbs are a way to bring the blood sugar up quickly to combat an insulin reaction. Examples include: 1/2 cup of fruit juice or nondiet soda, 1 cup of milk, 2 tablespoons of raisins, 3 glucose tablets or 5 Lifesavers If your blood sugar is still too low after 15 minutes, have another 15 grams. For a severe reaction, a drug called glucagon should be injected under the skin by a family member. Insulin Pump - One way to reduce the odds of an insulin reaction is to use an insulin pump. This device provides insulin through a tiny tube inserted into the skin. It delivers insulin around the clock, eliminating the need for insulin shots. An insulin pump can help keep your blood sugar more stable and may allow more flexibility in planning your meals. Insulin pumps do have some disadvantages, so talk to your doctor to learn if this option is right for you. How well is your treatment working? To find out how well your treatment is working, your doctor will probably suggest you have an A1c blood test every three to six months. This test reveals how well your blood sugar has been controlled over the past two to three months. If the results show poor blood sugar control, you may need to adjust your insulin therapy, meal planning, or physical activity.

4 Page 4 Pancreatic Islet Cell Transplant If insulin therapy fails to control your blood sugar or you have frequent insulin reactions, you may be a candidate for pancreatic islet cell transplant. Still an experimental procedure, a surgeon transfers healthy insulin-producing cells from a donor into the pancreas of someone with type 1 diabetes. Unfortunately, the results may last only few years. Medications used to prevent rejection are necessary and can have very serious side effects. Type 1 and Exercise People with type 1 diabetes need to take precautions when exercising. To prevent a sudden drop in blood sugar, your health care team may recommend: Checking your blood sugar before exercising Adjusting your insulin dosage before exercising Eating a snack before or during exercise Your doctor may also suggest checking your urine for ketones, a sign that your blood sugar is too high. Avoid strong activity whenever ketones are present. Type 1 and Diet There are many myths about what people with diabetes can and cannot eat. The reality is there are no "off limits" foods. You can eat sweets as part of a well-balanced diet and treatment plan. The key is to work with your health care team to balance your insulin therapy, meals, and level of physical activity. Type 1 and Pregnancy Let your doctor know if you plan to become pregnant. When type 1 diabetes is poorly controlled, it can cause complications, including birth defects. Achieving good blood sugar control before conception lowers the risk of miscarriage and birth defects to a rate similar to that of the general population. It also reduces the risk of complications, such as dangerous increases in blood pressure and damage to the retina in the mother. Type 1 in Children When a child is diagnosed with diabetes, it affects the whole family in a very practical way. Parents must help children monitor blood sugar, plan meals, and adjust insulin dosages around the clock. Because diabetes requires 24-hour maintenance, arrangements must be made for treatment during school and extracurricular activities. Laws vary from state to state regarding which employees may administer insulin at school. What is Type 2? Type 2 diabetes or Mellitus strikes people of all ages, and early symptoms are subtle. In fact, about one out of three people with type 2 diabetes don't know they have it. This chronic condition thwarts the body's ability to use the carbohydrates in food for energy. The result is elevated blood sugar. Over time, this excess sugar raises the risk for heart disease, loss of vision, nerve and organ damage, and other serious conditions. 1 out of 3 people with Mellitus do not know they have it. Warning Signs: Thirst - People with type 2 diabetes frequently have no symptoms. When symptoms do appear, one of the first may be an increase in thirst. This is often accompanied by additional problems, including dry mouth, increased appetite, frequent urination -- sometimes as often as every hour -- and unusual weight loss or gain. Headaches - As blood sugar levels become more abnormal, additional symptoms may include headaches, blurred vision, and fatigue. Infections - In most cases, type 2 diabetes is not discovered until it takes a noticeable toll on health. One red flag is troubling infections, such as: Cuts or sores that are slow to heal. Frequent yeast infections or urinary tract infections Itchy skin, especially in the groin area Sexual Dysfunction - Sexual dysfunction is common among people with diabetes. can cause damage to blood vessels and nerve endings in the genitals, leading to a loss of feeling and making orgasm difficult. Other complications can include vaginal dryness and impotence in men. It's estimated between 35% and 70% of men with diabetes will have at least some degree of impotence in their lifetime. And about 1 in 3 women with diabetes will experience some form of sexual dysfunction.

5 Page 5 Risk Factors You Can Control Some health habits and medical conditions related to your lifestyle can increase the odds of developing type 2 diabetes, including: Being overweight, especially at the waist Sedentary lifestyle Smoking Diet high in red meat, processed meat, high-fat dairy products, and sweets Abnormal cholesterol and blood fats, such as HDL "good" cholesterol lower than 35 mg/dl or a triglyceride level over 150 mg/dl. Risk Factors You Can't Control Other risk factors are out of your control, including: Race or ethnicity: Hispanics, African Americans, Native Americans, and Asians have a higher than average risk. Family history of diabetes: Having a parent or sibling with diabetes boosts your risk. Age: Being 45 and older increases your risk of type 2 diabetes. T Risk factor for women having gestational diabetes when pregnant puts you at higher risk for developing type 2 diabetes later on. Women who give birth to a baby weighing over 9 pounds are also at risk. Having a history of polycystic ovary syndrome can also cause insulin resistance that can lead to diabetes. How Does Insulin Work? In a healthy person, insulin helps turn food into energy -- in an efficient manner. The stomach breaks down carbohydrates from food into sugars, including glucose. Glucose then enters the bloodstream, which stimulates the pancreas to release insulin in just the right amount. Insulin, a hormone, allows glucose to enter cells throughout the body, where it is used as fuel. Excess glucose is stored in the liver. Metabolism Mishaps In type 2 diabetes The cells cannot absorb glucose properly. That means glucose levels in the blood become elevated. If you've developed a condition called insulin resistance, the body makes excess insulin, but the muscle, liver, and fat cells do not use or respond properly to the insulin. With longstanding uncontrolled type 2 diabetes, the pancreas will reduce the amount of insulin it produces. Diagnosing Type 2 A simple blood test can diagnose diabetes. The A1C test gives a snapshot of your average blood glucose level over the past 2-3 months. An A1C level of 6.5% or higher may indicate diabetes. With a fasting plasma glucose test, a result above 120 is considered diabetes. Your doctor may order an oral glucose challenge test with a two-hour blood test. In people with classic symptoms of diabetes, a random blood glucose level of greater than 200 can help diagnosis diabetes. Management of Type 2 Diet - controlling blood sugar levels by changing diet can also cut your risk of complications. People with type 2 diabetes should carefully monitor carbohydrate consumption, as well as total fat and protein intake, and reduce calories. Ask your doctor for a referral to a registered dietitian to help you with healthy choices and an eating plan that will work for you. Exercise Routine - exercise, such as strength training or walking, improves the body's use of insulin and can lower blood sugar levels in people with type 2 diabetes. Being active also helps reduce body fat, lower blood pressure, and protect against heart disease. People with type 2 diabetes should try to get 30 minutes of moderate exercise on most days of the week. Stress Reduction - Stress can cause blood pressure to rise. It can also increase glucose levels in your blood as part of your "fight or flight" response. Or you may turn to food to cope with stress. All are bad when living with diabetes. Instead of letting stress take its toll, try practicing relaxation techniques such as deep breathing, meditation, or visualization. Sometimes talking to a friend, family member, counselor, or member of the clergy can help. If you're still battling stress, reach out to your doctor.

6 Page 6 Oral Medication - When people with type 2 diabetes are unable to control blood sugar sufficiently with diet and exercise, medication may be added. There are many types of diabetes pills available, and they are often used in combination. Some work by stimulating the pancreas to make more insulin, and others improve the effectiveness of insulin, or block the digestion of starches. Insulin - Your doctor may prescribe insulin early on in your treatment and in combination with pills. Insulin is also used in people with type 2 diabetes who develop "beta-cell failure." This means the cells in the pancreas no longer produce insulin in response to high blood sugar levels. In this case, insulin therapy -- injections or an insulin pump -- must become part of the daily routine. Non-Insulin Injectables - New drugs are available for people with type 2 diabetes. Pramlintide (Symlin), exenatide (Byetta), and liraglutide (Victoza) are non-insulin injectable drugs. Whereas insulin pulls glucose into the cells, these medications cause the body to release insulin to control blood sugar levels Monitoring your Glucose Testing - Testing your blood glucose level will let you know how controlled your blood sugars are and if you need to take actions to change your treatment plan. How often and when you test will be based on how controlled your diabetes is, the type of therapy used to control your diabetes, and whether you are experiencing symptoms of fluctuating sugars. Talk with your doctor to find out how often you should use a glucose meter to check your blood sugar. Some common testing times may be when waking up, before and after meals and exercise, and at bedtime. Continuous glucose monitor (CGM) may be useful to those with type 1 diabetes to help lower their blood glucose. Long Term Complications: Arteries - Overtime, untreated type 2 diabetes can damage many of the body's systems. About two out of three people with diabetes die of heart disease. Having diabetes also puts you at a two to four times higher risk for stroke. People with diabetes are likely to develop plaque in their arteries, reducing blood flow and increasing risk of clots. This hardening of the arteries (atherosclerosis) raises the risk of heart attack and stroke. Kidneys The longer you have diabetes, the greater the risk of developing chronic kidney disease. is the leading cause of kidney failure, accounting for 44% of new cases in Controlling risk factors such as uncontrolled diabetes, high blood pressure, and high cholesterol reduces your risk of developing this complication. Annual screening for kidney disease and medications, which slow the development and progression of kidney disease, are used to reduce your risk of kidney failure. Nerve Pain Over time, uncontrolled diabetes and elevated blood sugars create a very real risk for nerve damage. Symptoms can include tingling, numbness, pain, and a pins and needles sensation -- often in the fingers, hands, toes, or feet. The damage is not reversible, but treatments can help with the pain and numbness. And controlling your diabetes can help prevent further damage Eyes - High blood sugar can damage the tiny blood vessels that bring oxygen and nutrients to the retina, a critical part of the eye. This is known as diabetic retinopathy, and it can cause progressive, irreversible vision loss. It is the leading cause of new cases of blindness in people between the ages of 20 and 74. Pools of blood, or hemorrhages, on the retina of an eye are visible in this image. Feet Diabetic nerve damage can make it difficult to feel your feet and detect injury. At the same time, hardening of the arteries results in poor blood flow to the feet. Foot sores and gangrene can occur, even from small injury. In severe cases, infections can go unchecked and result in an amputation. Preventing Type 2 One of the most astonishing things about type 2 diabetes is that such a life-altering condition is often preventable. To lower your risk, follow the same guidelines for warding off heart disease: Eat a healthy diet. Exercise for 30 minutes, five days a week. Maintain a healthy weight. Talk to your doctor about being screened for prediabetes. In people with pre-diabetes, lifestyle changes and medication can help prevent the progression to type 2 diabetes.

7 Page 7 CEDARS Clinic At CEDARS Jebel Ali International Hospital, we established the Clinic committed to turning diabetes around through awareness, prevention, detection, management and the search for a cure Services offered Consultation with our doctors and dietician Comprehensive check up (glucose, urine, cholesterol, liver and kidney function tests Monitoring Patient support program For appointments Monday and Wednesday from 9am to 1pm or marketing@cedars-jaih.com/customerservice@cedars-jaih.com Medical Consultant for November 2014 Dr. Audette Abdalla GP - Diploma Head of Clinic Dr. Audette Abdalla has a Post Graduate Diploma in from Cardiff University, UK. She received her Medical Degree at Damascus University, Syria and has more than 20 years experience in practicing medicine in Syria & Dubai. Dr. Audette s main interests are in internal medicine particularly managing pre-, Mellitus with its complications; Hypertension and Cardiovascular diseases and have continually attended local and international courses in Internal Medicine for training. She finished Clinical Attachment scheme at the University Hospital Wales in She also has extensive experience in handling gynecological, orthopedic and trauma cases. About CEDARS - Jebel Ali International Hospital Established in 1999, CEDARS Jebel Ali International Hospital was the only full-fledged 24-hour medical center in the Jebel Ali area and it was upgraded into a hospital in August Today it is a full-fledged multi-specialty hospital offering services ranging from Pediatrics to Occupational Health, Laparoscopic Surgery to Internal Medicine. The Hospital is equipped with ICU for medical and surgical emergencies, with two major and one minor operation theatres as well as with fully equipped Laboratory and Radiology departments. The CEDARS Training Center is offering classes in basic life support and advanced cardiac life support through an alliance with the American Heart Association (AHA). Further attached to the hospital are the 24-hour-pharmacy and Dr. Adnan Kaddaha Clinic (Bur Dubai). Projects to expand the hospital structure and add more services that enable CEDARS Jebel Ali International Hospital to become a comprehensive healthcare provider are under way.