About Diabetes Related Conditions
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Learn more about celiac disease, hemochromatosis and frozen shoulder, and how they relate to type 1 diabetes, in this section. Celiac Disease: Wheat Ails You? You've been to your family doctor so often you both have your litany of symptoms memorized. You've made the round of specialists. Still, you can't find what ails you. Maybe the cause of all your problems is lurking in your kitchen -- in your breadbox, in your pasta cabinet, and on your cookie shelf. Foods made from wheat and certain other grains contain a protein called gluten. If you have a condition called celiac disease, every time you eat something with gluten, a reaction damages the lining of your small intestine. Nutrients aren't absorbed properly, and this leads to a host of problems. Many people with celiac disease (also called celiac sprue, nontropical sprue, or gluten-sensitive enteropathy) go a long time without being diagnosed. There are many possible symptoms. They may start in childhood or adulthood. They may come and go. A classic symptom is diarrhea, but not everyone has this. Stools may be foul-smelling and bulky, and they may float. Other signs and symptoms
If you think you might have celiac disease, discuss the possibility with your doctor. Blood tests and a biopsy of your small intestine -- the gold standard for diagnosing celiac disease -- can reveal whether you have the disease. Celiac disease is not the only cause of chronic diarrhea. Other possibilities: Lactose intolerance
It's not going to be easy. Gluten is found in wheat, rye, barley, possibly oats, and some other grains. That means all the common flours found in mainstream breads, cookies, crackers, and pasta are now off-limits. You can't just reduce your gluten intake; your diet has to be 100 percent gluten-free. And you can't "cheat." The damage to your intestine from a meal with gluten takes time to heal. It's this damage that leads to symptoms, so symptoms continue long after that one meal containing gluten is out of your system. If you diligently follow a gluten-free diet for five days and then have one cookie at an office party, your intestine will suffer. Hidden gluten is a problem. If you unknowingly consume some gluten (many brands of soy sauce, for example, contain gluten) and don't see much improvement in your symptoms after two weeks of your diet, you might think, "Well, I guess it wasn't celiac." Then you might go additional months or years before getting diagnosed. Some medications contain gluten as part of their inactive ingredients. Glucotrol, for example, may contain gluten. Check with your pharmacist or call the manufacturer of each of the drugs you take to see if the drug may contain gluten. If it does contain gluten, do not stop taking the drug. Talk to your doctor about what to do. People with diabetes have additional challenges in going gluten-free. You'll be changing many of your usual sources of carbohydrate. This will very likely affect your blood sugar levels. So again, if you do have celiac disease, it would be much, much better to get a real diagnosis. You'll have more reason to be committed to the diet, and you can get professional guidance as you make the required diet changes. That said, if you're determined to try a gluten-free diet on your own, we have some suggestions. 19th Century
20th Century
Assume nothing! Read all ingredient lists. One would think that Rice Chex cereal would be safe. But when you read the ingredients, you find it contains barley malt extract -- not safe. Beware of hidden gluten. Flavorings, colorings, and other additives may contain gluten. When checking ingredients, follow the rule: "Don't know? Don't eat." Gluten that is part of the packaging isn't listed in the ingredients. For example, chewing gum wrappers may be dusted with flour. For long lists of foods you can and can't eat, get books about celiac disease, or check out the Web sites listed below (search the keywords "celiac," "gluten," or "gastrointestinal"). You'll be surprised and perhaps overwhelmed at the number of foods and additives that you can't eat (caramel color, communion wafers, curry powder). You might then decide to go back to the 19th century, or skip down to the ... 21st Century
If you eat a lot of pasta, you're in luck. Rice pasta tastes very much like wheat pasta. Potato-rice pasta is passable, though a bit mushy. Don't get quinoa-corn pasta; quinoa may not be entirely safe for someone with celiac disease. Bread lovers don't have it as easy. Gluten is an elastic protein that gives bread its structure. Gluten-free breads are dense and heavy. Our advice: Don't eat bread for the first week or so. Then the beans-on-a-camping-trip phenomenon will set in. By the second or third week, you'll be craving any bread, and gluten-free breads might not seem so bad. Actually, Ener-G Tapioca Loaf makes good French toast. If you're a nut for cookies and start to feel deprived, try Pamela's Chunky Chocolate Chip Cookies. They have so much chocolate you'll barely notice they're gluten- and dairy-free. Web Resources www.niddk.nih.gov/health/digest/pubs/celiac No Matter Which Century
Keep your lactose consumption low or nonexistent during this trial. If you want to keep consuming milk and milk products, you can buy lactose-reduced milk (in the dairy case next to all the other milk), lactase drops (add the drops to regular milk), or over-the-counter lactase caplets or chews (in your grocery store or pharmacy, near other digestive aids). Consider less variety. Consider eating the same thing frequently, for example, gluten-free pancakes every morning. (Arrowhead Mills makes a good gluten-free pancake mix.) One, you'll soon learn how your blood sugar levels are going to be affected by the new foods. (Check your blood sugars often during your gluten-free trial.) Two, if it turns out you are not sensitive to gluten, you won't have a bunch of partially-used gluten-free foods left over at the end of your experiment. Pay attention to carb counts. Read the Nutrition Facts labels to get carb counts. Don't assume a sandwich made with gluten-free bread has the same amount of carbohydrate as one made with your usual bread. Avoid alcohol. Alcohol made from grain (beer, for example) contains gluten. Consider avoiding alcohol during this trial. Alcohol can have unexpected effects on your blood sugar levels, and you'll have enough going on during this trial as it is. Feeling Better?
As soon as you start to feel better, see your doctor and get a referral to a gastroenterologist. Blood tests that show whether you react to gluten may now be negative, because you've been off gluten. If you wait too long and your small intestine starts to heal, a biopsy may not be as clear cut as if you had seen a doctor while you were still eating gluten, so don't delay seeing a doctor. Taken from the October 2001 issue of Diabetes Forecast. Written by Marie McCarren, a writer and editor in Arnold, Md. Jean Guest, MS, RD, a graduate research assistant at the University of Nebraska at Lincoln, provided invaluable assistance with this article.
Hemochromatosis What is it?
How common is it?
How is it treated?
Hemochromatosis: The Background
Hereditary hemochromatosis is the most common of several "iron overload" diseases, which are characterized by an excess accumulation of iron in the body. In the case of hemochromatosis, a single gene mutation causes extra iron to be absorbed from food in the intestine, and the body lacks an efficient means of excreting the excess iron it takes in. Over time, this iron accumulates in the tissues of the body, most notably the pancreas, the liver, and the heart. The extra iron builds up in the organs and damages them. Without treatment, the disease can cause these organs to fail, leading to diabetes, cirrhosis, and heart disease. In many patients, the buildup of iron eventually becomes so excessive that it visibly shows up in the skin, turning it a dark gray or bronze color. In fact, hemochromatosis is sometimes referred to as "bronze diabetes" because of the appearance of some patients when they are diagnosed. Symptoms and Diagnosis
Blood tests (a transferrin saturation test or a serum ferritin test) can determine whether the amount of iron stored in the body is too high. It is also possible to test directly for the defective gene. Despite its prevalence and the availability of simple tests for it, hemochromatosis is often undiagnosed and untreated. The initial symptoms can be diverse and vague and can mimic the symptoms of many other diseases. Also, doctors may focus on the conditions caused by hemochromatosis -- arthritis, liver disease, heart disease, or diabetes -- rather than on the underlying iron overload. Cause
The Founder Effect: An Interesting Genetic Story
Men versus Women
Treatment
If treatment begins before any organs are damaged, associated conditions -- such as liver disease, heart disease, arthritis, and diabetes -- can be prevented. The outlook for people who already have these conditions at diagnosis depends on the degree of organ damage. For example, treating hemochromatosis can stop the progression of liver disease in its early stages, which means a normal life expectancy. However, if cirrhosis has developed, the person's risk of developing liver cancer increases, even if iron stores are reduced to normal levels. People with diabetes resulting from pancreatic damage usually see an improvement if not a reversal of their diabetes, depending on how much damage has occurred. Where does the blood go?
FDA regulations do permit hemochromotosis patients to donate blood, but with some special restrictions on how the blood is marked and how the blood banks operate. As a consequence, few blood blanks in the US currently accept blood from people with hemochromatosis, and most of the blood given as a result of therapeutic phlebotomy is discarded (people with hemochromatosis who wish to donate blood should check to see if any blood banks in their area will accept their donations). This is not true in other countries, which have generally removed any restrictions on this blood. The American Medical Association and many other groups have advocated for removal of restrictions for the acceptance of blood donations from people with hemochromatosis.
Frozen Shoulder A body in motion tends to stay in motion, and a body at rest tends to stay at rest. Such is the case with your shoulder and a condition called adhesive capsulitis. Adhesive capsulitis is more commonly known as frozen shoulder, and with good reason: It can render your shoulder so stiff, it's almost impossible to button your shirt -- that is, if you aren't in too much pain to get dressed in the first place. Frozen shoulder usually begins innocently enough. Your shoulder is bothering you, so you don't use it. Sure, there's something to be said for resting an overused joint after a weekend softball tournament. But if you've injured your shoulder or are suffering from chronic shoulder pain and you don't use your shoulder for a long time, your joint will stiffen up. From there, it becomes a vicious cycle. If your joint begins to stiffen up, it's more difficult and more painful to use your shoulder. So you use your shoulder even less. Your shoulder gets more and more stiff, and eventually, the lining of the joint gets stiff. Once that happens, you won't be able to move your shoulder much, even if you want to. It simply won't budge past a certain point because of pain and stiffness. In general, frozen shoulder can come on after an injury to your shoulder or a bout with another musculo-skeletal condition such as tendonitis or bursitis. It can also develop after a stroke. Quite often its cause can't be pinpointed. Nonetheless, any condition that causes you to refrain from moving your arm and using your shoulder joint can put you at risk for developing frozen shoulder. Diabetes is also a risk factor for frozen shoulder, although precisely why that's so is a subject the medical community is still researching. One theory involves collagen, one of the building blocks of ligaments and tendons. Collagen is a major part of the ligaments that hold the bones together in a joint. Glucose (sugar) molecules attach to collagen. In people with diabetes, the theory goes, this can contribute to abnormal deposits of collagen in the cartilage and tendons of the shoulder. The buildup then causes the affected shoulder to stiffen up. Overall, frozen shoulder affects about 20 percent of people with diabetes, compared with 5 percent of people without diabetes. Other risk factors are gender and age. Women are more likely to develop frozen shoulder than men, and frozen shoulder occurs most frequently in people between the ages of 40 and 60. It usually affects only one shoulder at a time, and for reasons unknown, the non-dominant shoulder is affected most often. A Lengthy Condition
The next stage usually isn't as painful, but the shoulder does become more stiff. This is when the ligaments shorten and do not stretch, causing you to lose mobility in your shoulder. This "stiffening" stage can last from two to six months. Third is the recovery stage. Like the stiffening stage, this stage generally is not as painful as the first stage. The ligaments start to stretch and, gradually, your shoulder and arm regain some or most of their natural movement. However, recovery may come in fits and starts, with a bout of pain before each step along the way as the lining of the joint stretches out. The recovery stage can last from one to nine months. So, if left to run its course, frozen shoulder can last from eight months to 17 months or more. Some cases have lasted as long as two years. The Importance Of Early Treatment
"If we catch it early, it might be possible to work through it with physical therapy, even if there's some pain," she says. "But once you enter the middle stage, there's already been some stiffness and that makes it tougher to work through." She notes that in the middle stage, treatment can go beyond physical therapy and exercise and include shots of saline or cortisone to help you regain shoulder mobility and loosen up the stiff joint. Most experts agree that physical therapy should be the first treatment attempted for frozen shoulder. But such therapy, during which a therapist stretches and moves your shoulder, along with daily home exercise, may not appear to make much sense, especially if your shoulder hurts. After all, pain is an indication that something is wrong, and it could be a sign of inflammation. Why move your shoulder if there is pain and inflammation? Because lack of use and motion is what leads to stiffness. "Inflammation should be taken into consideration by your physical therapist, but unless the shoulder is severely inflamed, you would want physical therapy" says Michael Mueller, PT, PhD, associate professor at the Washington University School of Medicine in St. Louis, MO. Anti-inflammatory drugs like ibuprofen can help bring mild to moderate inflammation down to the point where you are able to start therapy. After that, it's a matter of how much you hurt. "The gauge is how much pain you are in," he says. "Your physical therapist should work with you to see what you can tolerate." But if you cannot do physical therapy because of pain, you should see your doctor for medication or shots. How Early Is Early Enough?
That depends on what your symptoms are, says Rachel Peterson Kim, MD, staff rheumatologist at the Scripps Clinic in La Jolla, CA. "If it's a mild nagging pain, you can try rest, ice, and anti-inflammatory drugs such as ibuprofen for a week or two," she says. "But if you suddenly can't move it at all, or there's a lot of pain, see a doctor." If you've lost any mobility in your shoulder, it's time to see a doctor as well, says Mueller. He suggests a simple test. Lie on the floor or on your bed. Bring your arm up and over like you are doing a backstroke. You should almost be able to touch the floor or bed with the back of your hand. Of course, if you can actually touch it, that's great, but as long as you can come within a few inches, that's fine. If not, you've lost some range of motion in your shoulder and you should talk to your doctor about it. When you go to your doctor, provide as much information as you can, and don't be afraid to ask questions or repeat yourself. The shoulder is vulnerable to many different conditions and injuries, and your doctor will need as much information as possible to give you a correct diagnosis. It's not unheard of for a doctor to mistake frozen shoulder for other conditions, particularly a torn rotator cuff. "There are lots of different reasons for shoulder pain, and some doctors will think of torn rotator cuffs because that is another important condition and part of so many other problems," says Mueller. So don't be afraid to ask your doctor why he or she has come to a diagnosis -- any diagnosis. If your doctor confirms frozen shoulder, take his or her advice about exercise seriously and act immediately, says Kim. "Patients should definitely be doing physical therapy or exercises at home, in addition to their physical therapy, and they should follow up with their doctors if there is no improvement," Kim says. She adds that this is especially important for people with diabetes because they are less likely than others to have a complete recovery, even with therapy. According to Kim, permanent loss of as much as 50 percent of shoulder mobility can occur among people with diabetes. (In the general population, any permanent decrease of range of motion is usually negligible.) That's why it's so important to stack the odds in our favor. "We don't know why people with diabetes have a greater risk of incomplete recovery," she says. "No one has really looked at it yet. Is it their blood sugars? Are they less active? I don't think there's a good answer for it yet." Siegel adds that it's important not to ignore any signs that the condition is getting worse. "It's easy to 'cheat' with the shoulder," she says. "A lot of people compensate for it by bending in other ways or relying on other muscles, but that can lead to other chronic pain syndromes. It's really a quality-of-life issue." And if there's no improvement? If it's not getting worse, but it's not getting better either, then it's time to consider more aggressive treatments, including surgery. Your doctor may give you general anesthesia and then, while you are completely out and unable to feel pain, manipulate your arm to loosen the joint. Surgery is the last resort and should be approached with great caution because the condition usually improves on its own over time. The bottom line is, if you've had a traumatic injury to one of your shoulders, like a fall or a blow, or you suddenly experience intense shoulder pain or a loss of mobility, even for no apparent reason, get to a doctor. Then learn everything you can about all of the treatment options available. Taken from the August 2002 issue of Diabetes Forecast
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