Healing through an active life

Whether you have type 1 or type 2 diabetes, you may someday face one or more diabetes complications. Complications are medical problems that occur more often in people with diabetes. Over time, diabetes can cause changes in blood vessels or nerves. These changes can lead to medical problems. You may have diabetes for decades before complications show up, if they ever do.

If they do occur, these complications can affect many different parts of the body. Large blood vessels may become narrow. When blood flow is slowed, you run a risk of heart disease, stroke, or amputation. Small blood vessels often get damaged, too. Damage to vessels in the eyes (retinopathy) can threaten your vision. The damage can lead to blindness if not treated early. The small blood vessels in the kidney may also be injured, leading to kidney disease (nephropathy).

Nerve damage (neuropathy) is another common complication of diabetes. Neuropathy can numb parts of the body, especially the feet and legs, or cause feelings of tingling or burning. It can also impair the function of internal organs such as the stomach, intestines, and bladder.

The combination of neuropathy and blood vessel disease can lead to amputation. If you lose feeling in your feet, you may not feel blisters, small sores, ulcers, or foreign bodies in your shoe. Diabetes raises the chances that these wounds will become infected. If they do, blood vessel damage can make infections hard to heal. An out-of-control infection could require amputation to save the rest of the limb.

Warning Signs

Some complications, such as kidney disease, do not cause symptoms early on. But they can be detected through special screening tests by your health care team, so regular checkups are important.

If you notice a change in your health, take action. Do not ignore small warning signs that point to a complication. You may be able to slow things down and avoid more serious trouble. If you have any of the following symptoms, tell your doctor:

• Blurry or spotty vision
• Fatigue
• Obesity (defined as 20 percent or more over your ideal body weight)
• Numbness or tingling in hands or feet
• Chest pain
• Infections that occur often or cuts that heal slowly
• Constant headaches (may signal high blood pressure)

Any other changes in your health that feel "wrong" should be brought to the attention of your doctor.

New treatments exist for many complications. Laser surgery can repair damage to the eyes and prevent blindness. Many surgical techniques have made it easier to treat blocked arteries. Kidney transplantation has grown more successful for people with kidney disease. New methods of treating blocked blood vessels and wounds may help prevent amputation. In many cases, the faster and earlier you spot the problem, the better the outcome.

Facing Trouble

Some people work hard to control their blood sugar and care for themselves. Yet they may still face the shock of learning they have a complication.

News of a complication is not a signal to stop caring for your diabetes. Yes, it is bad news. You may feel angry or hopeless. You may think, "I've done so much to take care of myself, and now this happens. What was the point?"

The point was this: the care you took may have delayed the complication for years. In fact, the problem may be milder because you took such good care of yourself. Keep it up, because a healthy body is better able to fight back.

Paying attention to your health will also help you cope mentally. You will know that you are doing everything you can to live well with the complication.

• Do not smoke
• Keep your blood sugar levels as close to normal as possible
• Eat a healthy, balanced meal plan
• Get regular exercise (with your doctor's okay)
• See your doctor (dentist and eye doctor, too) regularly, even if you feel great
• Check your feet each day for small cuts or blisters. Your doctor should check your feet at least once a year-more often if you have foot problems
• Keep your weight under control
• Keep your blood pressure and blood fat levels in the normal range

When you are diagnosed with a complication, you take on a new job: learning to cope with this change. An action plan can help. Here are some suggestions:

• Keep a positive attitude. Staying hopeful and upbeat can improve and possibly lengthen your life. A negative attitude makes living with the complication harder not only on you but also on your family and friends.
• Be an active member of your health care team. Speak up. If you don't think something will work for you, explain your feelings. Make suggestions. Ask about other treatments.
• Learn about your complication. Chances are, the better you understand your complication, the less out of control you will feel.

Groups that focus on your complication may be good resources. Your local American Diabetes Association can refer you to organizations such as the National Kidney Foundation or the Foundation for the Blind. Such organizations often know about the latest medical advances. They may supply names of leading doctors in the field and medical centers doing the latest research. They may even have information about insurance or government reimbursement.

• Think about seeing a specialist (a doctor with special training) who works with your complication. Don't worry about making your primary care doctor angry. Any doctor who wants the best for you will be glad you want to see a specialist. In fact, your doctor may refer you to a specialist when your complication is diagnosed.
• Try to get a second opinion. Any time you face a major change in your health or diabetes care, it is a good idea to get a second opinion. Before you go, check your health insurance. It may pay for the second opinion or even require it.
• Ask questions of any health care professional who examines you. What are the likely side effects of this treatment? How often will I need the treatment? Will I need new medications? How many patients with this problem have you treated? What were the results?
• Be a wise medical consumer. Don't be afraid to discuss money with your doctor. Some treatments cost more than others, but the most costly option may not be the best choice for you. What are the alternatives? Know what your insurance will pay for. If your insurance doesn't cover a treatment, you can try an appeal to the insurance company.
• Build a support system. You will probably feel better if you can open up, at least to one or two people.

Make your family and friends part of that system. Let them know what it's like to live with your complication. Tell them about problems and choices you might face. When you don't talk about your feelings and needs, it's hard for others to know how to help.

If you find it hard to talk with family or friends, you may want to get help from a social worker or psychologist. Short-term counseling can help you through a time of high stress and change. Social workers may be able to help you find other resources that would help.

Ask your doctor or American Diabetes Association office to put you in touch with others who have dealt with the same complication. Talking with someone who has "been there" is a good way to get moral support. It may also give you leads on treatment options or doctors.

Living Well With Complications

Coping with a complication may mean making some changes in your lifestyle. But with work, you can often continue doing the same activities that you have always enjoyed. To stay active, you will need the support of others. You will also need to rely strongly on yourself. There are many ways you can manage your own treatment and your own rehabilitation-retraining yourself to do tasks such as walking, preparing food, and exercising.

Vision loss. If eye disease has left you with serious vision loss or blindness, many resources can help you. First, you may want to contact local agencies that work with the blind (you can get names from the American Diabetes Association). Large-print books and books on cassette can give you access to written material. Low-vision aids, such as telescopes or magnifiers placed on glasses, can help you see objects far and near.

You can also regain certain skills through rehabilitation. You can learn to walk alone using a cane or a guide dog. You can learn to pour coffee and even to inject your own insulin with the help of devices that indicate when you have measured the right amount. Counselors can teach you to function in your job, housekeeping, and child care. You can sharpen your other senses-hearing, smell, touch-and the sense of your body's movement in space.

Amputation. An amputation is a scary prospect. But be confident that surgeons will always try to save as much of your leg or foot as possible. They just need to make sure that the part they leave will be able to heal. If you are having an amputation, you will want to work with a health care team that includes a physician, a physical therapist, a prosthetist (someone who makes artificial limbs), a social worker, and a psychologist.

Physical therapy will start a day or two after surgery. You will work on balance with your physical therapist by using parallel bars. Later, you will move up to a walker or crutches. The therapist can show you how to fall and get up safely.

About 4 to 8 weeks after surgery, the prosthetist will fit you with an artificial foot or leg. New designs permit easier walking and even running using prosthetic feet.

Losing a limb can often cause feelings of grief. It may help to talk to peer counselors who have also had amputations or to see a psychologist or social worker.

Dialysis. Dialysis is a common treatment for kidney disease. It replaces the function of the kidney by cleaning the blood. Depending on the type of dialysis, you will get treatment every day or three times a week. A team of people will help you decide how to carry out dialysis:

• Nephrologist (a kidney specialist)
• Nephrology nurse who may also be a trained dialysis nurse
• Kidney transplant surgeon and coordinator
• Social worker
• Psychologist
• Renal dietitian
• Physical therapist

The two types of dialysis are hemodialysis and peritoneal dialysis. Hemodialysis cleans the blood by filtering it through a machine outside the body. If you choose hemodialysis, you will probably get treated at a dialysis center three times a week. Each session will take about 3 to 5 hours. You may be able to get training with a partner so that the two of you can perform hemodialysis at home.

Unlike hemodialysis, peritoneal dialysis cleans the blood using a solution poured into the abdomen through a tube called a catheter. You can learn to perform this type of dialysis on your own at home. It is usually done daily.

Nerve damage. The best way to handle nerve damage is to prevent injuries and additional complications. For example, when you lose feeling in your feet and toes, as in distal neuropathy, it is easy to injure your foot without ever feeling it. For this reason, you should check your feet every day. Also check your shoes to make sure they contain no stones, staples, rough spots, or other foreign objects that could injure your feet. Also, never go barefoot.

Loss of feeling is why electric blankets and heating pads carry warning labels that say people with diabetes should not use them without talking to their doctor first. You can be seriously burned by an electric blanket or heating pad because you cannot feel how hot it really is.

Be on the alert for urinary infections. These tend to happen again and again when your bladder is affected by nerve damage, known as autonomic neuropathy. Tell your doctor if you have cloudy or bloody urine, painful urination, low back pain, or fever. One way to help prevent these infections is to urinate every 3 to 4 hours when you are awake, even if you feel you don't need to.

There are drugs that can treat faintness, stomach trouble, or diarrhea caused by autonomic neuropathy.

What Exercise Can Do

Staying active in your health care is a key aspect of coping well. Staying physically active is equally important for most people. When diabetes seems to be dealing you hard blows, exercise may be the last thing you want to think about. After all, isn't it out of the question for someone in your condition? No. In fact, regular exercise is a good idea for almost everyone. When you live with a diabetes complication, you may need exercise more than ever.

When a physical problem like vision loss or surgery keeps you from being active, your whole body suffers. That's because parts of your body are not getting used enough. Muscles need to be exercised regularly to stay strong. If they aren't, they become too weak to even do easy tasks like taking out the trash or making the bed.

You can make your muscles stronger and more effective with regular exercise. This doesn't mean you have to lift weights, go to the gym, or make drastic changes. Regular exercise can be modest. In fact, if you haven't done much for a long time or are adjusting to limited mobility, you must start slowly. Of course, you need to talk about exercise with your doctor. Never start an exercise program without your doctor's okay. Very high or low blood sugar levels may make exercise dangerous. Be sure to have a heart evaluation before starting an exercise program if you:

• Are over 35 years of age
• Have had type 2 diabetes more than 10 years
• Have had type 1 diabetes more than 15 years
• Have other heart disease risk factors
• Have eye, nerve, or kidney damage

The following are good exercise choices for some common complications. Discuss these with your doctor. Ask your doctor to help you find an exercise physiologist who has worked with people with your complication. You, your doctor, and the exercise specialist can plan a safe exercise program for you.

Nerve damage in the limbs. If you have nerve damage to the hands, legs, or feet, you may feel pain, tingling, or numbness in those areas. Exercise won't cure the problem, but it can help. Regular exercise can help you keep your strength, flexibility, and blood flow to those damaged areas. If you combine regular exercise with good blood sugar control, you may be able to relieve some of the pain. This may take time, however.

Good exercise choices for people with nerve damage in the legs or feet are activities that don't put pressure on the feet, such as bicycling or easy rowing on a rowing machine. If pushing with your feet doesn't feel good or isn't safe, you can try a special machine that you pedal with your arms.

Swimming and aqua aerobics are also good choices for almost anyone. Be sure to take care of your feet. Wear shoes such as water socks while you are in the water or walking around the pool and locker room area. If you have an open wound, do not use the pool until it heals.

Autonomic neuropathy. Avoid activities that require quick changes in body position. You may have problems with low blood pressure, which can make you faint. Aerobics or sports such as baseball, basketball, or tennis are not good choices for you. Do not exercise at high intensity.

Good exercise choices include recumbent stationary cycling (using a special kind of bike that allows you to stretch your legs out in front to pedal) and aqua aerobics.

Retinopathy and vision loss. If you have proliferative retinopathy (serious damage to the small blood vessels of the eye), exercise can hurt your vision. First, get treatment. After treatment, when your retinopathy is stable, you will probably be able to exercise. Make sure your eye doctor and your primary care doctor say your eyes are ready.

When you have retinopathy or vision loss from diabetes, you may be told not to do strenuous exercises such weight lifting or jogging. You may also be told not to play contact sports like basketball.

If your vision is mildly impaired, you can still enjoy aerobic exercise such as:

• Ride a stationary bike
• Take a brisk walk on a tread-mill
• Row at an easy pace on a rowing machine
• Dancing with a partner who can guide you
• Ride on the back of a bicycle built for two

Water exercises are great for people with low or partial vision. You can swim laps, guiding yourself by touching the pool's lane ropes. You can do aqua aerobics in the pool's shallow end.

Kidney disease and high blood pressure. You need to take care when you exercise. Get your doctor's okay on your exercise plans. Avoid activities that are high intensity. They will increase your blood pressure. If your workout feels too hard, it probably is. Do not do competitive weight lifting. You can use light weights to build muscle strength and mass.

If you do endurance aerobic sports-like running-it is important to drink fluids before, during, and after the workout and test your blood glucose.

Blood vessel damage. Has your doctor said that you have intermittent claudication? Do you get an aching pain in your legs when you walk? This happens because the blood vessels in your legs are not supplying enough blood to the muscle. Talk to your doctor about types of exercise that might help increase blood flow in the legs. Ask about interval walking. You alternate resting and walking short distances to avoid pain and fatigue. Ask your doctor if any of your medications will make it hard to exercise.

Heart disease and high blood pressure. If you have heart disease or high blood pressure, you can still benefit from regular exercise. But you must work out a program with your doctor and exercise specialist. Your doctor may refer you to a cardiac rehabilitation program. This is a medically supervised program that tests your fitness level and makes specific exercise suggestions for you. When you start to exercise in such a program, you can build your confidence and abilities in a safe environment.

After transplantation. Why is exercise a key part of your recovery from kidney, pancreas, or kidney-pancreas transplantation? First, organ transplantation usually leads to weight gain for people with diabetes. This happens because you can eat more foods than you could before transplantation, and you have to take the drug prednisone. Prednisone helps your body accept the new organ, but it also causes weight gain. Prednisone causes muscles to waste and weaken.

Regular aerobic exercise and strength training are the best ways to keep these side effects under control. You need to go slowly, however. Discuss your exercise program with your health care team and an exercise specialist.

Amputation and limited mobility. If you have limited mobility from diabetes or other health problems (such as arthritis), some good exercise choices might be water exercise or chair aerobics. Often, there are special classes available. Staying with regular exercise can help you keep the mobility you have.

You may have trouble with balance or standing on your feet, or you may have had a foot or leg amputation. If your feet can't hold your body weight, you can try riding a stationary bike, chair exercise, or some form of adapted water exercise. You will be surprised how much exercise can help improve your strength and flexibility. Discuss your options with your doctor and an exercise specialist.

A Final Word