The Vascular Complications of Type 2 Diabetes

SEDENTARY STAN: The Vascular Complications of Type 2 Diabetes 11

Sedentary Stan: The Vascular Complications of Type 2 Diabetes So, you can look at Sedentary Stan and tell that some vital organs are colored what does it all mean? How will his quality of life be affected? This booklet will help you figure out what has happened to Stan based upon the health-related choices he made after he was diagnosed with Type 2 Diabetes. Follow instructions below and prepare to explain to Stan what has happened to his body and what he needs to do to protect the quality of life he has now. If Stan died as a result of his choices, explain what he should have done to prevent his untimely demise. The rest of the book corresponds to the Sedentary Stan Student Data Page. You will find graphics of each body part affected by arterial disease associated with diabetes. 1. First read the introduction about the dangers of high blood pressure followed by information about blood vessel disease. Many complications of type 2 diabetes result from damage to arteries in the body. Body organs that are supplied by damaged arteries do not receive adequate blood supply because these arteries are completely or partially blocked. 2. Now, look at the second section of this booklet. You will see pictures of each body organ with different parts shaded. For each body part, you will find the one that has the same amount of shading as the one on your completed Sedentary Stan Student Data Page. 3. For example, find the page with the graphic of a heart You will see that the first graphic has no part of the heart colored. If that matches the heart on your completed Sedentary Stan Student Data Page, read the text and determine how Stan s lifestyle choices have affected his heart. Write a brief summary in the lined boxes next to the heart on your Sedentary Stan Student Data Page. The next graphic of the heart has one part shaded, if that matches the heart on your Sedentary Stan Student Data Page, read the text and write a brief summary in the lined boxes next to the heart on your Sedentary Stan Student Data Page. If these examples do not match the heart on your Sedentary Stan Student Data Page, find the one that does and read the text. Write a brief summary in the lined boxes next to the heart on your Sedentary Stan Student Data Page. 4. Look at your completed Sedentary Stan Student Data Page and repeat step 3 for all other body parts to determine the state of Stan s health. Write a brief summary of what has happened to Stan in the lined boxes next to each body part on your Sedentary Stan Student Data Page. 12

HIGH BLOOD PRESSURE High blood pressure, or hypertension, occurs when the force of blood pushing on your blood vessels is too high. This high pressure causes your heart to work harder and damages your arteries. Two out of three diabetics, like Stan, have high blood pressure. Untreated hypertension causes major damage to the body and must be monitored and controlled by diet, exercise, and sometimes medication. The recommended blood pressure for diabetics is 125/75mmHg. ACE Inhibitors (angiotensin-converting enzyme inhibitors) are drugs commonly used in the treatment of hypertension. BRAIN - The most important risk factor for a stroke is high blood pressure. Because of high blood pressure, weakened blood vessels in the brain can break and bleed into brain tissue, causing a stroke. Blood clots can lodge in narrowed arteries to the brain, also causing a stroke. EYES - High blood pressure can cause blood vessels in the eye to break or bleed. Blurry vision or blindness may result. HEART - High blood pressure is a major risk factor for heart attack. Coronary arteries taking oxygen-rich blood to the heart muscle become blocked and when the heart cannot get enough oxygen, a heart attack results. KIDNEY DAMAGE - The kidneys filter blood to rid the body of wastes. Because of high blood pressure, arteries that carry blood to the kidneys become narrowed. With less blood reaching the kidneys, they filter less and wastes build up in the blood. The kidneys may fail altogether so dialysis or a kidney transplant may be needed. ARTERIES - High blood pressure causes arteries in the body to harden, especially those in the heart, brain, and kidneys, causing these organs to work harder and become damaged. Additionally, in diabetics, the eyes, legs, and feet are susceptible to damage from reduced blood supply. National Heart Lung and Blood Institute website: http://www.nhlbi.nih.gov/hbp/hbp/effect/effect.htm National Institutes of Health Medline Plus website: http://www.nlm.nih.gov/medlineplus/ency/imagepages/18166.htm 13

BLOOD VESSELS Blood vessels make up our vascular system and carry blood to all parts of our body. Blood carries food and oxygen needed to sustain life and removes wastes. There are three types of blood vessels; arteries, veins and capillaries. Arteries carry oxygen-rich blood away from the heart to all parts of the body (except the pulmonary artery, which carries oxygen-poor blood). Veins carry oxygen-poor blood from the body back to the heart (except the pulmonary vein which carries oxygen-rich blood). Capillaries are tiny blood vessels that connect veins and arteries; it is in the capillaries that materials are delivered to body cells. Vascular disease involves changes in larger arteries. The artery walls thicken and become hard and non-elastic (arteriosclerosis). Arteries can also become clogged with plaque (atherosclerosis). Eventually, the flow of blood may be blocked. Damage caused by this reduced blood flow depends upon which part of the body is supplied by the diseased arteries. Blocked blood flow to the legs and feet will cause damage to those body parts. Reduced blood flow to the heart causes damage to the heart; reduced blood flow to the kidney causes kidney damage and so on. Diabetics, like Stan, are at much higher risk for vascular disease and to avoid serious problems with circulation, must: keep blood sugar in control maintain normal blood pressure keep weight at a healthy level eat a healthy, low-fat diet exercise regularly avoid smoking take prescribed medications as directed work closely with their doctor NIDDK website: http://diabetes.niddk.nih.gov/dm/pubs/complications_heart/ 14

BRAIN Like all other organs in our body, the brain needs oxygen and nutrients. A network of blood vessels supplies the brain with oxygen-rich blood and removes waste products. When any of those blood vessels are damaged or blocked, blood flow to the brain is reduced. If any part of our brain is without oxygen for more than 3-4 minutes, that part dies. Strokes are caused by a ruptured or blocked artery to the brain. High blood sugar and high blood pressure in diabetes damage arteries, making them less elastic and more likely to be blocked by plaque. The risk of a stroke is 2 1/2 times higher in diabetics and their outcome is worse if they ultimately have a stroke. Many doctors advise high-risk diabetic patients to take low-dose baby aspirin* to reduce their risk of stroke. Stan has worked closely with his doctor and kept his blood sugar under control. His latest test results indicate that the carotid arteries leading to his brain are open and blood is flowing freely to his brain. Stan has not followed his medical routine as well as he should and his blood pressure and blood sugar have been high for a very long time. He is now experiencing headaches, dizziness, memory lapses, and occasional disorientation. His doctor admitted him to the hospital for further testing and test results show that Stan needs surgery to open his blocked carotid arteries in order to avoid having a stroke. *Take a daily dose of aspirin only when directed to do so by a doctor. 15

Stan has not kept his blood pressure and blood sugar under control for a long time and he is experiencing very worrisome symptoms. He was at work and felt a bad headache coming on, then he had a fleeting loss of vision, and finally lost consciousness. After being rushed to the hospital, Stan was told he had experienced a TIA (transient ischemic attack or mini-stroke). Blockage in the carotid arteries leading to the brain was found, so Stan will have surgery to clean out the blockage. He will also have to alter his diet and exercise routine and will be on medication to help prevent a stroke. Stan s blood pressure and blood sugar increased and he did not follow his doctor s advice to bring them down. Now, he is having numbness in his left leg and left arm, feeling nauseated, slurring his speech, and has a very painful headache. At the hospital, Stan is told that he has had a cardiovascular accident (stroke). Doctors cannot tell if he will be able to use his arm and leg or if his speech will be normal again. He will require a long hospital stay and daily physical therapy and weekly speech therapy. Stan has ignored his doctor s warning to keep his blood sugar and blood pressure under control and he has not taken his medicine regularly. He has experienced dizziness, nausea, brief periods of vision loss, but has ignored the symptoms. His doctor is very worried about Stan s high blood pressure. Stan is rushed to the hospital; he was unable to move his left arm and leg and experienced a very sharp, painful headache before he lost consciousness. Unfortunately, Stan dies from a fatal stroke without ever regaining consciousness. National Heart Lung and Blood Institute website: http://www.nhlbi.nih.gov/health/prof/heart/index.htm 16

EYES Vitreous gel Cornea Pupil Lens Iris Macula Optic nerve Retina Diabetics, like Sedentary Stan, are at high risk for diabetic eye disease that can cause vision loss or blindness. Diabetic eye disease can include one or all of the following: Diabetic retinopathy 40-45% of diabetics have some degree of diabetic retinopathy. High blood glucose and high blood pressure can damage tiny, fragile blood vessels in the retina. First, the blood vessels swell and weaken. Some blood vessels become clogged and do not let enough blood through. These changes lead to vision loss or blindness. Laser surgery can reduce the risk of blindness, but cannot restore lost vision. Cataract Cataracts are clouding of the eye s lens. They develop at an earlier age in diabetics and can usually be treated with surgery. Glaucoma Diabetics are twice as likely to get glaucoma. This condition involves an increase in fluid pressure inside the eye which leads to optic nerve damage and loss of vision. It affects side vision before central vision is affected. It can be treated with medications and/or surgery. 1 2 1 2 Stan has been following his medical plan carefully and as a result, his diabetes has not yet caused damage to his eyes. With continued care, he can reduce the risk of damage to his eyesight. By managing his diabetes carefully, Stan can keep his good vision! Stan has been fairly good at keeping his blood sugar under control, although he made a few poor choices along the way. As a result, he is beginning 17

to develop cataracts and has some cloudy vision. In the future, Stan may need to have eye surgery to remove the cataracts and to put in lens implants. He is very motivated to take better care of his health! 1 2 1 2 1 2 Stan is bothered by foggy vision and rings of color when he looks directly at lights. His eyes do not adjust well to darkened rooms. In addition to cataracts, Stan has glaucoma, which is twice as likely in diabetics. He will have to take medicine for glaucoma and will have eye surgery to treat this new complication of his type 2 diabetes. At some point in his future, he will require another surgery for his cataracts. Stan has diabetic eye disease. Eye problems are nothing new to Stan, since he does not manage his diabetes well. His eye problems, however, are getting worse. High blood sugar has damaged the small blood vessels in his retinas and he now has diabetic retinopathy. Although he has some permanent vision loss, the doctors are optimistic that they can reduce his risk of blindness with laser surgery. Stan s cataracts have worsened and he will need more surgery later to remove them. His glaucoma has not gotten worse since his last doctor s visit. Stan will have to manage his diabetes very carefully to keep from going blind. Unfortunately, Sedentary Stan has not kept his blood sugar under control, nor followed his doctor s advice. Over time, these poor choices have caused damage to the tiny blood vessels in the retina of Stan s eyes. The damage is severe and laser surgery is not an option for him; Stan is now blind. Blindness will have a major impact on Stan s quality of life since he cannot do some of the things he used to enjoy. 18

HEART When healthy, your heart is a muscle about the size of your fist. It pumps blood through blood vessels (arteries and veins) to all parts of the body, supplying food and oxygen and removing wastes. Like all other organs of the body, the heart muscle has arteries that supply oxygen-rich blood needed by the heart muscle. When these arteries, called coronary arteries, are blocked, blood flow to the heart is reduced causing a heart attack. High blood sugar commonly found in diabetics, can damage the coronary arteries, causing heart attacks. Therefore, diabetics have more heart attacks than people without diabetes. Diabetics must keep their blood sugar under control to avoid heart attacks. Stan s heart functions well and he has no symptoms of heart disease. He can lead an active, normal life as long as he continues to manage his type 2 diabetes. Stan begins to feel angina pains because his heart is not getting enough blood. The pain is sometimes a pressure in his chest and sometimes feels like indigestion. The pain can also occur in his shoulders, arms, neck, jaw or back. Stan must take medication to keep his heart working as well as possible. The angina pain causes Stan to worry all the time that he may have a heart attack. 19

Sedentary Stan has made many poor choices regarding his type 2 diabetes. He is having chest discomfort, pain in his arms and severe shortness of breath. Stan has had a heart attack. Because he received immediate emergency treatment and surgery to place stents in the blocked vessels to keep them open, Stan will live. However, he is at much higher risk of having a major heart attack that will affect his quality of life. Stan will have to be very careful to prevent more heart attacks and he will not be able to do all of the things he enjoyed in the past. Stan began feeling chest pain, shortness of breath, nausea and dizziness. Knowing that these signs could mean trouble, he called 911. He has had a major heart attack with permanent damage to his heart; Stan was rushed into surgery (a quadruple bypass) and experienced a very long recuperation. He will suffer many changes in his quality of life since he can no longer do many things he enjoys to do. The choices Stan has made in not controlling his type 2 diabetes over a long period of time have finally had dire consequences. Stan felt chest pain, shortness of breath, nausea and dizziness. He had a sharp chest pain and lost consciousness. Stan has had fatal heart attack. 20

KIDNEY Diabetic nephropathy Normal Kidney Kidney Disease healthy function proper size low urine protein granular surface decreased function smaller size Ureter high urine protein Diabetic nephropathy is disease of the kidney caused by diabetes. High blood sugar and high blood pressure cause damage to the small blood vessels that supply the kidneys with food and oxygen. Over time, the kidneys are damaged and may ultimately fail. Healthy kidneys filter waste products from the blood but as diabetic neuropathy progresses; kidneys lose the ability to filter wastes normally. Waste products that need to be eliminated in urine begin to build up, causing symptoms such as fatigue, headache, general itching, nausea and vomiting, and swelling of the face, hands, and feet. Both type 1 and type 2 diabetics can develop diabetic nephropathy, but the risk is highest among patients who do not follow their doctor s advice on controlling blood glucose level and blood pressure. Sedentary Stan is following his doctor s instructions to the letter and is protecting his kidneys. He has no evidence of kidney disease and can go about his normal routine. 21

Stan has the beginning stages of diabetic nephropathy; small amounts of protein are being released in his urine, but so far, Stan has no major symptoms. He is, however, at high risk of developing more serious diabetic neuropathy (kidney disease caused by diabetes). Stan is noticing his feet swell and he sees puffiness around face; he is often very tired, has a poor appetite and complains of headaches. Stan has diabetic neuropathy (kidney disease caused by diabetes). Sedentary Stan s symptoms are much more severe; his feet and face are swollen and puffy all the time, now; his urine is foamy and frothy; he experiences nausea and vomiting, constant fatigue, bad headaches, and general itching Stan is very sick and needs medical attention. Stan is at very high risk for developing kidney failure and his kidneys are permanently damaged. Stan s history of making poor choices and failing to follow his medical routine have had dire consequences. Stan is now in end-stage kidney failure ; he will require dialysis or a kidney transplant in order to survive. National Institutes of Health Medline Plus website: http://www.nlm.nih.gov/medlineplus/ency/imagepages/18166.htm American Diabetes Association website: http://care.diabetesjournals.org/cgi/content/full/26/suppl_1/s94 22

FOOT Diabetics are very susceptible to arterial damage from high blood pressure and high blood glucose (sugar). When an artery that supplies the foot becomes blocked, the foot will not receive enough blood. This impaired circulation increases the risk of foot ulcers, which increase the chance of infection. Impaired circulation also decreases the ability to fight infections and heal wounds normally. Kidney disease may also slow wound healing and eye disease can make it difficult for a diabetic to see damage to the feet. In addition, diabetics often develop a condition called neuropathy that keeps them from feeling cuts, sores and other damage to the feet. When a diabetic fails to check the feet often and take special care of them, untreated wounds can lead to infection or amputation. Sedentary Stan has carefully followed his medical advice and taken care of his type 2 diabetes. His blood sugar and blood pressure are within healthy ranges. He also checks his feet daily for cuts, blisters or other sores, washes his feet daily and dries them well, puts lotion of the top and bottom of his feet, and wears shoes and sock that fit properly. As a result, Stan has no foot problems caused by his diabetes! In general, Stan follows his doctor s advice and keeps his blood sugar and blood pressure under control, but he has mild numbness in his legs from diabetic neuropathy. The loss of sensation annoys him, but otherwise does not interfere with his activities. Stan knows he must take extra care because he may not feel cuts and sores on his feet. 23

Because he has a loss of sensation in his legs from diabetic neuropathy, Stan did not feel pain when he stepped on a piece of glass. He never knew he cut himself because he does not inspect his feet daily, as all diabetics must do. Because of the untreated cut, Stan developed a dangerous foot infection from a rare type of bacteria. He was very lucky that the doctors were able to stop the infection and save his foot from being amputated. Stan developed a deep foot ulcer that exposed the tendons and joints in his foot. Fortunately, Stan s doctors were able to surgically clean the wound and treat him with strong antibiotics. They explained to Stan that since he has developed this one ulcer, he is much more likely to develop other foot ulcers in the future and is at much higher risk for losing his foot to amputation. Stan must take very good care of his feet everyday to prevent amputation. Stan has not managed his diabetes and because of diabetic neuropathy and poor circulation to his feet, he developed a deep foot ulcer several years ago. His doctors were able to clean the wound surgically and treat him with strong antibiotics. Now, however, Stan developed a serious, grade IV ulcer on his foot. The ulcer became infected (abscessed) and because of the blocked arteries going to his foot, the tissue in Stan s foot is dieing (gangrene). Stan will lose his foot to amputation in order to save his life. Epodiatry website: http://www.epodiatry.com/diabetic-foot.htm NIDDK website: http://diabetes.niddk.nih.gov/dm/pubs/complications_heart/ E Medicine website: http://www.emedicine.com/orthoped/topic387.htm University of Maryland Medicine website: http://www.umm.edu/diabetes-info/foot.htm 24

LEGS Because high blood glucose and high blood pressure damage arteries, diabetics often have arterial blockages. The effects of these blockages and the impaired circulation that result vary, depending upon the location and severity of the blockage. Minor effects might include aches, numbness, or cramping in the legs when walking or exercising. These symptoms often go away with rest. When arteries in the calf or lower thigh become blocked, the foot or calf will be affected. Blocked arteries leading from the pelvis or aorta cause symptoms in the thigh or buttocks. Blockages that are more numerous or occur over longer lengths of major arteries cause more severe symptoms; gangrene (tissue death due to lack of blood), nonhealing wounds or continual pain can all result. Gangrene is cause for amputation of the affected limb. 7 8 Sedentary Stan takes his blood pressure medication, watches his diet and exercises regularly to keep his blood pressure and blood glucose under control. His last physical revealed that arterial circulation to his legs is excellent! 5 6 7 8 5 6 Stan has taken some measures to control his blood sugar and blood pressure, but he has not been exercising on a regular basis and his diet is not as healthy as it should be. As a result, he has arterial blockage that causes weakness, cramps and pain in his legs when he walks. Fortunately, the leg pain goes away when he rests. Stan s doctor has prescribed medicine to control his cholesterol, blood pressure and to prevent blood clots. He must also eat a low-fat diet and walk 30 minutes 3 times a week to improve circulation in his legs. 25

7 8 5 6 Stan started out following his doctor s advice after being diagnosed with type 2 diabetes, but his busy schedule got in the way and he slipped into his old routine of eating fast food and not exercising. As a result, his blood glucose and blood pressure have been too high for a long time. Stan has arterial blockage that has gotten worse; blood circulation to his legs is not adequate. Stan has difficulty walking because of weakness, pain and cramping in his legs; even when walking short distances. He also noticed the cut on his foot has not healed in the 10 days since it happened. Stan made an appointment with his doctor, who told him he was in danger of losing part of his leg because of poor circulation. He must take medication for his high blood pressure, high blood sugar, and to prevent blood clots in his legs. He must eat a low-fat diet and exercise regularly. 7 8 5 6 Sedentary Stan has not controlled his type 2 diabetes and circulation to his legs is much worse than last time he saw the doctor. He has severe numbness, pain and cramping when he walks and his leg is cold and pale-looking. He has dry, graycolored ulcers on his foot and he is unable to do many of the things he likes to do because it is so difficult to walk. His doctor is very concerned about him and told him he needs surgery to bypass the blocked artery or he may lose part of his leg to amputation. Lifestyle changes alone will not be enough to prevent the loss of his leg. 7 8 5 6 Unfortunately, Stan has not taken care of his diabetes and when he went to the doctor, his leg was cold and pale-looking with black sores on his feet and lower leg. The doctor advised him that one of the arteries to his leg is blocked. His doctor told him he the sores have become dead tissue due to lack of blood supply (gangrene). Stan will have to have part of his leg amputated or he may die. National Heart Lung and Blood Institute website: http://www.nhlbi.nih.gov/health/prof/heart/index.htm Vascular website: http://www.vascularweb.org/_contribution_pages/patient_ Information/NorthPoint/Leg_Artery_Disease.html 26

HEALTHY CHOICES FOR TYPE 2 DIABETICS Sedentary Stan is a type 2 diabetic and must make some lifestyle changes to protect his health; the way he chooses to care for his diabetes on a daily basis will determine his quality of life. What Stan Can do to Protect His Health Keep blood glucose levels in target range Keep weight in healthy range Healthy Diet Exercise Daily Avoid Alcohol Avoid or Stop Smoking Take Medications as Prescribed HIGH BLOOD PRESSURE BLOOD VESSELS HEART KIDNEYS EYES BRAIN NERVES FOOT/ LEG Check feet daily for cuts or sores McKinley Health Center/ University of Illinois website http://www.mckinley.uiuc.edu/handouts/diabetes/eat-healt-pre-diab.html NIDDK website http://diabetes.niddk.nih.gov/dm/pubs/complications_kidneys/index.htm 27

DIABETES AND EXERCISE BEFORE: Include 5 minute warm up Check blood sugar AFTER: Include 5 minute cool down Check blood sugar Type 2 diabetics, like Stan, can often keep their blood sugar (glucose) within normal limits by exercising and eating a healthy diet as defined by their doctor and dietician. Following such a routine can have tremendous benefit to overall health and will help protect the brain, heart, blood vessels, eyes, kidneys, legs and feet. National Institutes of Health Medline Plus website: http://www.nlm.nih.gov/medlineplus/ency/imagepages/19811.htm A1C Test An A1C (also known as glycated hemoglobin) test provides a good look at how well a person has controlled his or her blood sugar (glucose) over time. The results are a good indication of how well a diabetes management program is working and can provide early warning when changes need to be made. How does the test work? Hemoglobin, found in red blood cells, can bind with glucose. When diabetes is not controlled, glucose levels in the blood can be very high. The more glucose in the blood, the more hemoglobin will bind to it. The A1C test measures the percentage of glycated hemoglobin (hemoglobin bound to glucose) in a person s blood. The result is an indication of how well blood sugar has been controlled in the past 2 3 months. NIDDK website: http://diabetes.niddk.nih.gov/dm/pubs/complications_kidneys/index.htm 28

TEXAS DIABETES INSTITUTE Because diabetes affects so many body systems and processes, excellent health care is needed to manage the disease; it is daily disease management that will determine quality of life. Cutting-edge treatment is available at facilities such as the Texas Diabetes Institute (TDI) in San Antonio, Texas. Such facilities provide one-stop care, meaning that many health services are located in one place and all of them are specialized for diabetes management. The Texas Department of Health reports that 1.2 million Texans have been diagnosed with diabetes and 10% of them live in Bexar County. TDI website: http://www.texasdiabetesinstitute.com/default.htm 29