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Dehydration

What is dehydration?

Water is a critical element of the body, and adequate hydration is a must to allow the body to function. Up to 75% of the body's weight is made up of water. Most of the water is found within the cells of the body (intracellular space). The rest is found in what is referred to as the extracellular space, which consists of the blood vessels (intravascular space) and the spaces between cells (interstitial space).

Total body water = intracellular space + intravascular space + interstitial space

Dehydration occurs when the amount of water leaving the body is greater than the amount being taken in. The body is very dynamic and always changing. This is especially true with water in the body. We lose water routinely when we:

• breathe and humidified air leaves the body;
  
  
• sweat to cool the body; and
  
  
• urinate or have a bowel movement to rid the body of waste products.

In a normal day, a person has to drink a significant amount of water to replace this routine loss.

If intravascular (within the blood vessels) water is lost, the body can compensate somewhat by shifting water from within the cells into the blood vessels, but this is a very short-term solution. The body lives within a very narrow range of normal parameters, and signs and symptoms of dehydration will occur quickly if the water is not replenished.

The body is able to monitor the amount of fluid it needs to function. The thirst mechanism signals the body to drink water when the body is dry. As well, hormones like anti-diuretic hormone (ADH) work with the kidney to limit the amount of water lost in the urine when the body needs to conserve water.

What causes dehydration?

Dehydration occurs because there is too much water lost, not enough water taken in, or most often a combination of the two.

• Diarrhea: Diarrhea is the most common reason for a person to loose excess amounts of water. A significant amount of water can be lost with each bowel movement. Worldwide, more than four million children die each year because of dehydration from diarrhea.
  
  
• Vomiting: Vomiting can also be a cause of fluid loss and it is difficult for a person to replace water by drinking it if they are unable to tolerate liquids.
  
  
• Sweat: The body can lose significant amounts of water when it tries to cool itself by sweating. Whether the body is hot because of the environment (for example, working in a warm environment), intense exercising in a hot environment, or because a fever is present due to an infection; the body uses a significant amount of water in the form of sweat to cool itself. Depending upon weather conditions, a brisk walk may generate up to 16 ounces of sweat (a pound of water) to allow body cooling, and that water needs to be replaced.
  
  
• Diabetes: In people with diabetes, elevated blood sugar levels cause sugar to spill into the urine and water then follows, which may cause significant dehydration. For this reason, frequent urination and excessive thirst are among the early symptoms of diabetes.
  
  
• Burns: Burn victims become dehydrated because the damaged skin cannot prevent fluid from seeping out of the body. Other inflammatory diseases of the skin are also associated with fluid loss.
  
  
• Inability to drink fluids: The inability to drink adequately is the other potential cause of dehydration. Whether it is the lack of availability of water or the lack of strength to drink adequate amounts, this, coupled with routine or extraordinary water losses can compound the degree of dehydration.

Cholera

What is cholera?

Cholera is an acute infectious disease caused by a bacterium, Vibrio cholerae (V. cholerae), which results in a painless, watery diarrhea in humans. Some affected individuals have copious amounts of diarrhea and develop dehydration so severe it can lead to death. Most people who get the disease ingest the organisms through food or water sources contaminated with V. cholerae. Although symptoms may be mild, approximately 5%-10% of previously healthy people will develop a copious diarrhea within about one to five days after ingesting the bacteria. Severe disease requires prompt medical care. Hydration (usually by IV for the very ill) of the patient is the key to surviving the disease.

The term cholera has a long history (see history section below) and has been assigned to several other diseases. For example, fowl or chicken cholera is a disease that can rapidly kill chickens and other avian species rapidly with a major symptom of diarrhea. However, the disease-causing agent in fowl is Pasteurella multocida, a gram-negative bacterium. Similarly, pig cholera (also termed hog or swine cholera) can cause rapid death (in about 15 days) in pigs with symptoms of fever, skin lesions, and seizures. This disease is caused by a pestivirus termed CSFV (classical swine fever virus). Neither one of these animal diseases are related to human cholera, but the terminology can be confusing.

What are cholera symptoms and signs?

The symptoms and signs of cholera are a watery diarrhea that often contains flecks of whitish material (mucus and some epithelial cells) that are about the size of pieces of rice. The diarrhea is termed "rice-water stool" (See Figure 1) and smells "fishy." The volume of diarrhea can be enormous; high levels of diarrheal fluid such as 250 cc per kg or about 10 to 18 liters over 24 hours for a 70 kg adult can occur. People may go on to develop one or more of the following symptoms and signs:

• vomiting



• rapid heart rate



• loss of skin elasticity (washer woman hands sign; see figure 2)



• dry mucous membranes



• low blood pressure



• thirst



• muscle cramps



• restlessness or irritability (especially in children)

People require immediate hydration to prevent these symptoms from continuing because these signs and symptoms indicate that the person is becoming or is dehydrated and may go on to develop severe cholera. People with severe cholera (about 5%-10% of previously healthy people; higher if a population is compromised by poor nutrition or has a high percentage of very young or elderly people) can develop severe dehydration, leading to acute renal failure, severe electrolyte imbalances (especially potassium an sodium), and coma. If untreated, this severe dehydration can rapidly lead to shock and death. Severe dehydration can often occur four to eight hours after the first liquid stool with death in about 18 hours to a few days in undertreated or untreated people. In epidemic outbreaks in underdeveloped countries where little or no treatment is available, the mortality (death) rate can be as high as 50%-60%.

Figure 1: Rice-water stool from a patient with cholera; note the flecks of mucus precipitated at the bottom of the cup that resemble rice grains. SOURCE: CDC

Figure 2: Washer woman hands (loss of skin elasticity) are a sign of cholera. SOURCE: CDC

Nausea and Vomiting

Introduction to nausea and vomiting

Nausea and vomiting are symptoms of an underlying disease and not a specific illness. Nausea is the sensation that the stomach wants to empty itself, while vomiting (emesis) or throwing up, is the act of forcible emptying of the stomach.

Vomiting is a violent act in which the stomach has to overcome the pressures that are normally in place to keep food and secretions within the stomach. The stomach almost turns itself inside out - forcing itself into the lower portion of the esophagus (the tube that connects the mouth to the stomach) during a vomiting episode.

What causes nausea or vomiting?

There are numerous causes of nausea and vomiting. These symptoms may be due to the following:

• acute gastritis
• central causes (signals from the brain)
• association with other illnesses remote from the stomach
• medications and medical treatments
• mechanical obstruction of the bowel

Acute gastritis

Acute gastritis (gastro=stomach + it is= inflammation) is often caused by an offending agent which irritates the lining of the stomach. Examples of these include:

• Infections: Infections are often the cause, whether it is a common virus or an infection that is contracted from travel. There may be associated crampy upper abdominal pain, fever ,and chills may be present. Common viral infections include noroviruses and rotavirus. Parasitic infections often are associated with diarrhea but may also have a component of nausea and vomiting. Infection by bacteria in the Helicobacter family (like H. Pylori) can also be the infectious agent.
• Stomach flu: Stomach flu is a non-specific term used to describe vomiting and diarrhea associated with a viral infection. It should not be confused with influenza, whose symptoms include fever, chills, cough, and myalgias (muscle pain).
• Food poisoning: Food poisoning may cause significant vomiting and usually is caused by a bacterial toxin. Symptoms begin within a couple hours of eating contaminated or poorly prepared food and may last for 1-2 days. Sources of food poisoning include Salmonella, Campylobacter, Shigella, E. coli, Listeria, or Clostridium botulinum (botulism).
• Other stomach irritants: alcohol, smoking, and non steroidal anti-inflammatory medications such as aspirin and ibuprofen may irritate the stomach lining.
• Peptic ulcer disease: Peptic ulcer disease can range from mild irritation of the stomach lining to the formation of a defect in the protective lining of the stomach called an ulcer.

· Gastroesophageal reflux disease (GERD, reflux esophagitis): Nausea or vomiting is also associated with irritation of the lining of the esophagus

Vaccination FAQs

Why do we need vaccines? What is immunization? What is immunity?

Vaccines are medications that boost our ability to fight off certain diseases. Many of the vaccine-preventable diseases are highly contagious and even fatal in unimmunized individuals (Table 1). Prior to the development of vaccines, these diseases disabled or killed millions of children. Many people living in developed countries today do not appreciate the value of vaccines because the successful use of vaccines has almost eradicated many of these diseases. These diseases are still dangerous and can kill people who are not adequately immunized.

Table 1: Vaccine-preventable diseases (http://www.cdc.gov/vaccines/vpd-vac/default.htm)

Anthrax Cervical cancer Diphtheria Haemophilus influenza type B (Hib) Hepatitis A Hepatitis B Human papillomavirus (HPV) Influenza (flu) Japanese encephalitis (JE) Lyme disease Measles Meningococcal disease Monkeypox Mumps Pertussis (whooping cough) Pneumococcal disease Poliomyelitis (polio) Rabies Rotavirus (severe diarrhea) Rubella (German measles) Shingles Smallpox Tetanus (lockjaw) Varicella (chickenpox) Yellow fever

Immunization is the act of receiving a vaccine. Immunity is the ability of the body to recognize specific infecting organisms as foreign and thereby protect against them.

How can I become immune (protected)?

Immunity (protection) can occur one of two ways:

• The first way to become immune is by actually getting the natural disease. For many organisms, this confers immunity for life. When the person is exposed again to the organism, the immune system quickly reestablishes protection.



• The second way to become immune is through the use of a vaccine. The vaccine interacts with the immune system and creates the same protection as if the person had the natural infections. This is done without being exposed to the risks involved with getting the natural infection.

Typhoid Fever

Typhoid fever facts

• Typhoid fever usually is caused by Salmonellae typhi bacteria.

• Typhoid fever is contracted by the ingestion of contaminated food or water.

• Diagnosis of typhoid fever is made when the Salmonella bacteria is detected with a stool culture.

• Typhoid fever is treated with antibiotics.

• Typhoid fever symptoms are poor appetite, headaches, generalized aches and pains, fever, and lethargy.

• Approximately 3%-5% of patients become carriers of the bacteria after the acute illness.

What is typhoid fever? What is the history of typhoid fever?

Typhoid fever is an acute illness associated with fever that is most often caused by the Salmonella typhi bacteria. It can also be caused by Salmonella paratyphi, a related bacterium that usually leads to a less severe illness. The bacteria are deposited in water or food by a human carrier and are then spread to other people in the area. Typhoid fever is rare in industrial countries but continues to be a significant public-health issue in developing countries.

The incidence of typhoid fever in the United States has markedly decreased since the early 1900s. Today, approximately 400 cases are reported annually in the United States, mostly in people who recently have traveled to endemic areas. This is in comparison to the 1920s, when over 35,000 cases were reported in the U.S. This improvement is the result of improved environmental sanitation. Mexico and South America are the most common areas for U.S. citizens to contract typhoid fever. India, Pakistan, and Egypt are also known high-risk areas for developing this disease. Worldwide, typhoid fever affects more than 13 million people annually, with over 500,000 patients dying of the disease.

If traveling to endemic areas, you should consult with your health-care professional and discuss if you should receive vaccination for typhoid fever.

10 Tips To Help You Control Your High Blood Pressure

1. Make sure your blood pressure is under 140/90 mm Hg. If your systolic pressure (the top number) is over 140, ask your doctor what you can do to lower it.
2. Take your high blood pressure medicine, if prescribed, every day. If you have questions, talk to your doctor.
3. Aim for a healthy weight. If you are overweight or obese, carrying this extra weight increases your risk of high blood pressure. One way to determine if you need to lose weight is to find out your body mass index or BMI. If your BMI is above the healthy range (i.e., 25 or greater), or if your waist measurement is greater than 35 inches (women) or 40 inches (men) you probably have excess abdominal weight and you may benefit from weight loss especially if you have other risk factors. Talk to your doctor to see if you are at increased risk for high blood pressure and need to lose weight.
4. Increase your physical activity. Do at least 30 minutes of moderate activity, such as walking, most days of the week. You can do 30 minutes in three 10-minute segments.
5. Choose foods low in salt and sodium. Most Americans should consume no more than 2.4 grams (2,400 milligrams) of sodium a day. That equals 6 grams, about one teaspoon of table salt a day. For someone with high blood pressure, the doctor may advise less.
6. Read nutrition labels. Almost all packaged foods contain sodium. Every time you prepare or eat a packaged food, know how much sodium is in one serving.
7. Keep a sodium diary. You may be surprised at how much sodium you consume each day and the diary will help you decide which foods to decrease or eliminate.
8. Use spices and herbs instead of salt to season the food you prepare at home.
9. Eat more fruits, vegetables, grains, and low-fat dairy foods.
10. If you consume alcohol at all, consume moderate amounts. For men, this is less than two 12 oz servings of beer, or two 5 oz glasses of wine, or two 1 1/2 oz servings of "hard" alcohol a day. Women or lighter weight people should have not more than a single serving of any one of these beverages in a given day.

For more, please visit the MedicineNet.com

Source: National Heart, Lung, and Blood Institute (http://www.nhlbi.nih.gov/index.htm)

Home Remedies fοr High Blood Pressure

Home Remedies fοr High Blood Pressure

1. Watermelons аrе very effectual іn preventing high blood pressure.


2. Drink one glass οf water bу adding lemon juice οf half lemon іntο іt. Drinking thіѕ еνеrу two-hour wіll give уου relief frοm hypertension.


3. Mix аbουt one tablespoon οf Amla (Indian Gooseberry) juice аnd honey together. Taking thіѕ mixture еνеrу day early dawn wіll bе very effective over hypertension. Thіѕ іѕ one οf thе very effective home remedies fοr high blood pressure.


4. Take watermelon seeds аnd khas khas іn equal amounts аnd grind thеm together. Eating one teaspoon οf thіѕ mixture wіth water, еνеrу day early morning wіth аn empty stomach. Take thіѕ once again іn thе evening time.


5. Early іn thе morning аnd аlѕο іn thе twilight, οn аn empty stomach take one teaspoon οf fenugreek seeds. Thіѕ іѕ one οf thе very helpful home remedies fοr high blood pressure . Continue using thіѕ remedy fοr аbουt half οf a month fοr seeing results.


6. Garlic іѕ аlѕο very efficient іn controlling thе blood pressure. Hence mаkе sure thаt уου υѕе enough οf garlic whіlе prepare уουr food.

High Blood Pressure Tips

1. Read nutrition lаbеlѕ. Almοѕt аll package foods contain sodium. Eνеrу time уου prepare οr eat a packaged food, know hοw much sodium іѕ іn one serving.


2. Keep a sodium diary. Yου mау bе astonished аt hοw much sodium уου consume each day аnd thе diary wіll hеlр уου dесіdе whісh foods tο decrease οr eliminate.


3. Uѕе spices аnd herbs instead οf salt tο period thе food уου prepare аt home.


4. Eat more fruits, vegetables, grains, аnd low-fаt dairy foods.


5. Read nutrition lаbеlѕ. Almοѕt аll package foods contain sodium. Eνеrу time уου prepare οr eat a packaged food, know hοw much sodium іѕ іn one serving.


6. Keep a sodium diary. Yου mау bе surprised аt hοw much sodium уου consume each day аnd thе diary wіll hеlр уου mаkе a dесіѕіοn whісh foods tο decrease οr eliminate.

Recipes For Reducing High Blood Pressure

By Owen Jones

A lot of individuals in the West suffer from high blood pressure brought on by being overweight or/ |and the high degrees of stress that contemporary life provokes. Most sufferers are told to lose weight, take up yoga or walking or take tablets for life. This means that most people end up taking tablets for life, because lifestyle changes are so difficult to accomplish.

However, there is one enjoyable way of decreasing your blood pressure and that is eating tasty food that does not require additional salt, because it is flavoured by other spices. Here are three such recipes.

Recipe One: France

Leeks Vinaigrette (Poireaux En Salade)

Serves 4

12 leeks 1/4 cup olive oil 4 tspn vinegar of your preference black pepper, fresh ground 1 tbls fresh parsley, chopped mustard to taste

PREPARATION: Clean the leeks; cut off most of the green bits and wash thoroughly, split if necessary, under cold running water. If they are substantial, split them lengthwise; each piece should be around the size of a big stalk of asparagus.

Tie them into bundles in two places, put them in boiling salted water just enough to cover, and cook gently for 25 minutes, or until they are softish but not lifeless. Drain them well (but be certain to save the broth to add to a soup).

The leeks can be served in a serving dish or put on individual plates. Create your vinaigrette in a bowl, adding mustard to taste, and whip the dressing well until it is almost opaque, or emulsified; pour it on top of the leeks.

Recipe Two: Germany

Birnensuppe (Pear Soup)

Serves 2

2 tbspn raisins 1 tbspn dry sherry 2 small pears, cored, peeled and sliced 1 1/2 cup water 1 inch cinnamon stick 1 pinch crushed aniseed 2 tspns granulated sugar 1/2 teaspoons lemon juice

In small bowl combine raisins and sherry; put aside.

In 1-quart saucepan combine pears, water, cinnamon stick, and aniseed; bring to a boil and cook until pears are very soft, around 15 minutes. Remove cinnamon stick and let cool. Transfer to liquidizer and process until smooth; pour into bowl or container and mix in raisin mixture, sugar, and lemon juice. Cover and refrigerate until well chilled.

Recipe Three: Greece

Fried Swordfish With Mediterranean Spices

Serves 4

1/2 cups white wine vinegar 1/2 tspn paprika 1/2 tspn red pepper flakes, dried 1/2 tspn oregano 1/2 tspn cumin, ground 1/2 tspn thyme 3 cloves garlic, minced 1 bay leaf 1 1/2 lb swordfish, cut in 1" pieces olive oil for frying 1/2 cup white flour

PREPARATION: Mix first 8 ingredients in a medium non-reactive bowl. Add swordfish pieces; toss to coat. Cover and leave stand at room temperature at least 1 hour. (Can be marinated for up to 3 hours.)

TO COOK: Heat oven to 200F. Heat oil in a frying pan or an electric deep fryer to 365F. Transfer swordfish from marinade to a sieve. Drain swordfish; discard marinade. Pat swordfish pieces dry with paper towels, then toss in flour.

Working in batches to avoid overcrowding, fry swordfish until golden brown, 2 to 3 minutes. Drain swordfish pieces on paper towel; transfer to a heatproof platter but keep them warm in the oven until about to serve. (Can be kept warm in the oven up to 1/2 hour.)

About the Author:

Owen Jones, the writer of this piece writes on several of topics, but is currently involved with work on high blood pressure charts. If you want to know more or check out some great offers, please go to our website at High Blood Pressure Recipes.

Is there a Vaccine for Pneumonia ?

Is there a vaccine for pneumonia?

There isn’t a vaccine for all types of pneumonia, but 2 vaccines are available. The first is called the pneumococcal conjugate vaccine (PCV). It is recommended for all children younger than 5 years of age. The pneumococcal polysaccharide vaccine (PPSV) is recommended for children 2 years of age and older who are at increased risk for pneumonia (such as children who have weakened immune systems), and for adults who have risk factors for pneumonia. This vaccine is recommended if you:

• Are 65 years of age or older
• Smoke
• Abuse alcohol
• Have certain chronic conditions, such as asthma, diabetes, heart disease or lung disease
• Have cirrhosis
• Have a condition that weakens your immune system, such as the human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS), kidney failure or a damaged spleen
• Have had your spleen removed for any reason
• Have sickle cell disease
• Have cochlear implants (an electronic device that helps you hear)
• Are taking medicine for a recent organ transplant (these medicines suppress your immune system)
• Are receiving chemotherapy

The pneumococcal vaccines can’t prevent all cases of pneumonia. But they can make it less likely that people who are at risk will experience the severe, and possibly life-threatening, complications of pneumonia.

Source : familydoctor.org

Tips to Prevent Pneumonia

Pneumonia is an inflammation of the lungs and is caused by bacterial or viral infections. The disease is extremely dangerous and life threatening, especially if the affected are those who are young, elderly or those who are suffering from chronic diseases.

Here are some tips you can do to prevent pneumonia or pneumonia.

• Wash hands frequently especially after using the restroom, after changing diapers, before and after preparing food or eating and after sneezing or remove the snot.
• Do not smoke.
• Ask for pneumonia or flu vaccinations.
• Children also should get Hib vaccine.
• In children aged under 24 months, the doctor will give medicine for the prevention of pneumonia, especially in infants who are at risk.

Dengue Fever

What is dengue fever?

Dengue fever is a disease caused by a family of viruses that are transmitted by mosquitoes. It is an acute illness of sudden onset that usually follows a benign course with symptoms such as headache, fever, exhaustion, severe muscle and joint pain, swollen glands (lymphadenopathy), and ash. The presence (the "dengue triad") of fever, rash, and headache (and other pains) is particularly characteristic of dengue. Other signs of dengue fever include bleeding gums, severe pain behind the eyes, and red palms and soles. Dengue (pronounced DENG-gay) strikes people with low levels of immunity. Because it is caused by one of four serotypes of virus, it is possible to get dengue fever multiple times. However, an attack of dengue produces immunity for a lifetime to that particular serotype to which the patient was exposed.

Dengue goes by other names, including "breakbone" or "dandy fever." Victims of dengue often have contortions due to the intense joint and muscle pain, hence the name breakbone fever. Slaves in the West Indies who contracted dengue were said to have dandy fever because of their postures and gait.

Dengue hemorrhagic fever is a more severe form of the viral illness. Manifestations include headache, fever, rash, and evidence of hemorrhage in the body. Petechiae (small red or purple blisters under the skin), bleeding in the nose or gums, black stools, or easy bruising are all possible signs of hemorrhage. This form of dengue fever can be life-threatening and can progress to the most severe form of the illness, dengue shock syndrome.

What areas are at high risk for contracting dengue fever?

Dengue is prevalent throughout the tropics and subtropics. Outbreaks have occurred recently in the Caribbean, including Puerto Rico, the U.S. Virgin Islands, Cuba, and Central America. Cases have also been imported via tourists returning from areas with widespread dengue, including Tahiti, Singapore, the South Pacific, Southeast Asia, the West Indies, India, and the Middle East (similar in distribution to the areas of the world that harbor malaria and yellow fever). Dengue is now the leading cause of acute febrile illness in U.S. travelers returning from the Caribbean, South America, and Asia.

A 2009 outbreak of dengue fever in Key West, Fla., showed that three patients who did not travel outside of the U.S. contracted the virus. Subsequent testing of the population of Key West has shown that up to 55 of the people living in the area have antibodies to dengue. As of July 17, 2010, 17 individuals have been identified that acquired dengue in Key West in 2010.

Dengue fever is common, and statistics show it may be increasing in Southeast Asia. Thailand, Vietnam, Singapore, and Malaysia have all reported an increase in cases. According to the U.S. Centers for Disease Control and Prevention (CDC), there are an estimated 100 million cases of dengue fever with several hundred thousand cases of dengue hemorrhagic fever requiring hospitalization each year. Nearly 40% of the world's population lives in an area endemic with dengue.

How is dengue fever contracted?

The virus is contracted from the bite of a striped Aedes aegypti mosquito that has previously bitten an infected person. The mosquito flourishes during rainy seasons but can breed in water-filled flower pots, plastic bags, and cans year-round. One mosquito bite can inflict the disease.

The virus is not contagious and cannot be spread directly from person to person. There must be a person-to-mosquito-to-another-person pathway.

Source : medicinenet.com

What is Cancer? What Causes Cancer?

Cancer is a class of diseases characterized by out-of-control cell growth. There are over 100 different types of cancer, and each is classified by the type of cell that is initially affected.

Cancer harms the body when damaged cells divide uncontrollably to form lumps or masses of tissue called tumors (except in the case of leukemia where cancer prohibits normal blood function by abnormal cell division in the blood stream). Tumors can grow and interfere with the digestive, nervous, and circulatory systems, and they can release hormones that alter body function. Tumors that stay in one spot and demonstrate limited growth are generally considered to be benign.

More dangerous, or malignant, tumors form when two things occur:

1. a cancerous cell manages to move throughout the body using the blood or lymph systems, destroying healthy tissue in a process called invasion
2. that cell manages to divide and grow, making new blood vessels to feed itself in a process called angiogenesis.

When a tumor successfully spreads to other parts of the body and grows, invading and destroying other healthy tissues, it is said to have metastasized. This process itself is called metastasis, and the result is a serious condition that is very difficult to treat.

In 2007, cancer claimed the lives of about 7.6 million people in the world. Physicians and researchers who specialize in the study, diagnosis, treatment, and prevention of cancer are called oncologists.

What causes cancer?

Cancer is ultimately the result of cells that uncontrollably grow and do not die. Normal cells in the body follow an orderly path of growth, division, and death. Programmed cell death is called apoptosis, and when this process breaks down, cancer begins to form. Unlike regular cells, cancer cells do not experience programmatic death and instead continue to grow and divide. This leads to a mass of abnormal cells that grows out of control.

What is cancer? - Video

A short, 3D, animated introduction to cancer. This was originally created by BioDigital Systems and used in the Stand Up 2 Cancer telethon.

Genes - the DNA type

Cells can experience uncontrolled growth if there are damages or mutations to DNA, and therefore, damage to the genes involved in cell division. Four key types of gene are responsible for the cell division process: oncogenes tell cells when to divide, tumor suppressor genes tell cells when not to divide, suicide genes control apoptosis and tell the cell to kill itself if something goes wrong, and DNA-repair genes instruct a cell to repair damaged DNA.

Cancer occurs when a cell's gene mutations make the cell unable to correct DNA damage and unable to commit suicide. Similarly, cancer is a result of mutations that inhibit oncogene and tumor suppressor gene function, leading to uncontrollable cell growth.

Carcinogens

Carcinogens are a class of substances that are directly responsible for damaging DNA, promoting or aiding cancer. Tobacco, asbestos, arsenic, radiation such as gamma and x-rays, the sun, and compounds in car exhaust fumes are all examples of carcinogens. When our bodies are exposed to carcinogens, free radicals are formed that try to steal electrons from other molecules in the body. Theses free radicals damage cells and affect their ability to function normally.

Genes - the family type

Cancer can be the result of a genetic predisposition that is inherited from family members. It is possible to be born with certain genetic mutations or a fault in a gene that makes one statistically more likely to develop cancer later in life.

Other medical factors

As we age, there is an increase in the number of possible cancer-causing mutations in our DNA. This makes age an important risk factor for cancer. Several viruses have also been linked to cancer such as: human papillomavirus (a cause of cervical cancer), hepatitis B and C (causes of liver cancer), and Epstein-Barr virus (a cause of some childhood cancers). Human immunodeficiency virus (HIV) - and anything else that suppresses or weakens the immune system - inhibits the body's ability to fight infections and increases the chance of developing cancer.

What are the symptoms of cancer?

Cancer symptoms are quite varied and depend on where the cancer is located, where it has spread, and how big the tumor is. Some cancers can be felt or seen through the skin - a lump on the breast or testicle can be an indicator of cancer in those locations. Skin cancer (melanoma) is often noted by a change in a wart or mole on the skin. Some oral cancers present white patches inside the mouth or white spots on the tongue.

Other cancers have symptoms that are less physically apparent. Some brain tumors tend to present symptoms early in the disease as they affect important cognitive functions. Pancreas cancers are usually too small to cause symptoms until they cause pain by pushing against nearby nerves or interfere with liver function to cause a yellowing of the skin and eyes called jaundice. Symptoms also can be created as a tumor grows and pushes against organs and blood vessels. For example, colon cancers lead to symptoms such as constipation, diarrhea, and changes in stool size. Bladder or prostate cancers cause changes in bladder function such as more frequent or infrequent urination.

As cancer cells use the body's energy and interfere with normal hormone function, it is possible to present symptoms such as fever, fatigue, excessive sweating, anemia, and unexplained weight loss. However, these symptoms are common in several other maladies as well. For example, coughing and hoarseness can point to lung or throat cancer as well as several other conditions.

When cancer spreads, or metastasizes, additional symptoms can present themselves in the newly affected area. Swollen or enlarged lymph nodes are common and likely to be present early. If cancer spreads to the brain, patients may experience vertigo, headaches, or seizures. Spreading to the lungs may cause coughing and shortness of breath. In addition, the liver may become enlarged and cause jaundice and bones can become painful, brittle, and break easily. Symptoms of metastasis ultimately depend on the location to which the cancer has spread.

How is cancer classified?

There are five broad groups that are used to classify cancer.

1. Carcinomas are characterized by cells that cover internal and external parts of the body such as lung, breast, and colon cancer.
2. Sarcomas are characterized by cells that are located in bone, cartilage, fat, connective tissue, muscle, and other supportive tissues.
3. Lymphomas are cancers that begin in the lymph nodes and immune system tissues.
4. Leukemias are cancers that begin in the bone marrow and often accumulate in the bloodstream.
5. Adenomas are cancers that arise in the thyroid, the pituitary gland, the adrenal gland, and other glandular tissues.

Cancers are often referred to by terms that contain a prefix related to the cell type in which the cancer originated and a suffix such as -sarcoma, -carcinoma, or just -oma. Common prefixes include:

• Adeno- = gland
• Chondro- = cartilage
• Erythro- = red blood cell
• Hemangio- = blood vessels
• Hepato- = liver
• Lipo- = fat
• Lympho- = white blood cell
• Melano- = pigment cell
• Myelo- = bone marrow
• Myo- = muscle
• Osteo- = bone
• Uro- = bladder
• Retino- = eye
• Neuro- = brain

How is cancer diagnosed and staged?

Early detection of cancer can greatly improve the odds of successful treatment and survival. Physicians use information from symptoms and several other procedures to diagnose cancer. Imaging techniques such as X-rays, CT scans, MRI scans, PET scans, and ultrasound scans are used regularly in order to detect where a tumor is located and what organs may be affected by it. Doctors may also conduct an endoscopy, which is a procedure that uses a thin tube with a camera and light at one end, to look for abnormalities inside the body.

Extracting cancer cells and looking at them under a microscope is the only absolute way to diagnose cancer. This procedure is called a biopsy. Other types of molecular diagnostic tests are frequently employed as well. Physicians will analyze your body's sugars, fats, proteins, and DNA at the molecular level. For example, cancerous prostate cells release a higher level of a chemical called PSA (prostate-specific antigen) into the bloodstream that can be detected by a blood test. Molecular diagnostics, biopsies, and imaging techniques are all used together to diagnose cancer.

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After a diagnosis is made, doctors find out how far the cancer has spread and determine the stage of the cancer. The stage determines which choices will be available for treatment and informs prognoses. The most common cancer staging method is called the TNM system. T (1-4) indicates the size and direct extent of the primary tumor, N (0-3) indicates the degree to which the cancer has spread to nearby lymph nodes, and M (0-1) indicates whether the cancer has metastasized to other organs in the body. A small tumor that has not spread to lymph nodes or distant organs may be staged as (T1, N0, M0), for example.

TNM descriptions then lead to a simpler categorization of stages, from 0 to 4, where lower numbers indicate that the cancer has spread less. While most Stage 1 tumors are curable, most Stage 4 tumors are inoperable or untreatable.

How is cancer treated?

Cancer treatment depends on the type of cancer, the stage of the cancer (how much it has spread), age, health status, and additional personal characteristics. There is no single treatment for cancer, and patients often receive a combination of therapies and palliative care. Treatments usually fall into one of the following categories: surgery, radiation, chemotherapy, immunotherapy, hormone therapy, or gene therapy.

Surgery

Surgery is the oldest known treatment for cancer. If a cancer has not metastasized, it is possible to completely cure a patient by surgically removing the cancer from the body. This is often seen in the removal of the prostate or a breast or testicle. After the disease has spread, however, it is nearly impossible to remove all of the cancer cells. Surgery may also be instrumental in helping to control symptoms such as bowel obstruction or spinal cord compression.

Radiation

Radiation treatment, also known as radiotherapy, destroys cancer by focusing high-energy rays on the cancer cells. This causes damage to the molecules that make up the cancer cells and leads them to commit suicide. Radiotherapy utilizes high-energy gamma-rays that are emitted from metals such as radium or high-energy x-rays that are created in a special machine. Early radiation treatments caused severe side-effects because the energy beams would damage normal, healthy tissue, but technologies have improved so that beams can be more accurately targeted. Radiotherapy is used as a standalone treatment to shrink a tumor or destroy cancer cells (including those associated with leukemia and lymphoma), and it is also used in combination with other cancer treatments.

Chemotherapy

Chemotherapy utilizes chemicals that interfere with the cell division process - damaging proteins or DNA - so that cancer cells will commit suicide. These treatments target any rapidly dividing cells (not necessarily just cancer cells), but normal cells usually can recover from any chemical-induced damage while cancer cells cannot. Chemotherapy is generally used to treat cancer that has spread or metastasized because the medicines travel throughout the entire body. It is a necessary treatment for some forms of leukemia and lymphoma. Chemotherapy treatment occurs in cycles so the body has time to heal between doses. However, there are still common side effects such as hair loss, nausea, fatigue, and vomiting. Combination therapies often include multiple types of chemotherapy or chemotherapy combined with other treatment options.

Immunotherapy

Immunotherapy aims to get the body's immune system to fight the tumor. Local immunotherapy injects a treatment into an affected area, for example, to cause inflammation that causes a tumor to shrink. Systemic immunotherapy treats the whole body by administering an agent such as the protein interferon alpha that can shrink tumors. Immunotherapy can also be considered non-specific if it improves cancer-fighting abilities by stimulating the entire immune system, and it can be considered targeted if the treatment specifically tells the immune system to destroy cancer cells. These therapies are relatively young, but researchers have had success with treatments that introduce antibodies to the body that inhibit the growth of breast cancer cells. Bone marrow transplantation (hematopoetic stem cell transplantation) can also be considered immunotherapy because the donor's immune cells will often attack the tumor or cancer cells that are present in the host.

Hormone therapy

Several cancers have been linked to some types of hormones, most notably breast and prostate cancer. Hormone therapy is designed to alter hormone production in the body so that cancer cells stop growing or are killed completely. Breast cancer hormone therapies often focus on reducing estrogen levels (a common drug for this is tamoxifen) and prostate cancer hormone therapies often focus on reducing testosterone levels. In addition, some leukemia and lymphoma cases can be treated with the hormone cortisone.

Gene therapy

The goal of gene therapy is to replace damaged genes with ones that work to address a root cause of cancer: damage to DNA. For example, researchers are trying to replace the damaged gene that signals cells to stop dividing (the p53 gene) with a copy of a working gene. Other gene-based therapies focus on further damaging cancer cell DNA to the point where the cell commits suicide. Gene therapy is a very young field and has not yet resulted in any successful treatments.

How can cancer be prevented?

Cancers that are closely linked to certain behaviors are the easiest to prevent. For example, choosing not to smoke tobacco or drink alcohol significantly lower the risk of several types of cancer - most notably lung, throat, mouth, and liver cancer. Even if you are a current tobacco user, quitting can still greatly reduce your chances of getting cancer.

Skin cancer can be prevented by staying in the shade, protecting yourself with a hat and shirt when in the sun, and using sunscreen. Diet is also an important part of cancer prevention since what we eat has been linked to the disease. Physicians recommend diets that are low in fat and rich in fresh fruits and vegetables and whole grains.

Certain vaccinations have been associated with the prevention of some cancers. For example, many women receive a vaccination for the human papillomavirus because of the virus's relationship with cervical cancer. Hepatitis B vaccines prevent the hepatitis B virus, which can cause liver cancer.

Some cancer prevention is based on systematic screening in order to detect small irregularities or tumors as early as possible even if there are no clear symptoms present. Breast self-examination, mammograms, testicular self-examination, and Pap smears are common screening methods for various cancers.

How to eat to prevent cancer - Video

A guide to some everyday foods that contain nutrients that may help reduce your risk of getting cancer. Video by Howcast.

Cancer / Oncology news

Medical News Today is a leading resource for the latest headlines on Cancer and Oncology. So, check out our cancer news section. You can also sign up to daily medical news alerts or our weekly digest medical newsletters to ensure that you stay up-to-date with the latest news.

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This what is cancer? information section was written by Peter Crosta for Medical News Today, and may not be re-produced in any way without the permission of Medical News Today.

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Sources of information:

• American Cancer Society
• Cancer Research, UK
• Wikipedia

Further information

• Useful Cancer Website Links

Disclaimer: This guide is provided for general information purposes only. The materials contained within this guide do not constitute medical or pharmaceutical advice, which should be sought from qualified medical and pharmaceutical advisers. Full disclaimer.

© MediLexicon International Ltd

Heart Attack (Myocardial Infarction)

What is a heart attack?

A heart attack (also known as a myocardial infarction) is the death of heart muscle from the sudden blockage of a coronary artery by a blood clot. Coronary arteries are blood vessels that supply the heart muscle with blood and oxygen. Blockage of a coronary artery deprives the heart muscle of blood and oxygen,causing injury to the heart muscle. Injury to the heart muscle causes chest pain and chest pressure sensation. If blood flow is not restored to the heart muscle within 20 to 40 minutes, irreversible death of the heart muscle will begin to occur. Muscle continues to die for six to eight hours at which time the heart attack usually is "complete." The dead heart muscle is eventually replaced by scar tissue.

Approximately one million Americans suffer a heart attack each year. Four hundred thousand of them die as a result of their heart attack.

What causes a heart attack?

Atherosclerosis

Atherosclerosis is a gradual process by which plaques (collections) of cholesterol are deposited in the walls of arteries. Cholesterol plaques cause hardening of the arterial walls and narrowing of the inner channel (lumen) of the artery. Arteries that are narrowed by atherosclerosis cannot deliver enough blood to maintain normal function of the parts of the body they supply. For example, atherosclerosis of the arteries in the legs causes reduced blood flow to the legs. Reduced blood flow to the legs can lead to pain in the legs while walking or exercising, leg ulcers, or a delay in the healing of wounds to the legs. Atherosclerosis of the arteries that furnish blood to the brain can lead to vascular dementia (mental deterioration due to gradual death of brain tissue over many years) or stroke (sudden death of brain tissue).

In many people, atherosclerosis can remain silent (causing no symptoms or health problems) for years or decades. Atherosclerosis can begin as early as the teenage years, but symptoms or health problems usually do not arise until later in adulthood when the arterial narrowing becomes severe. Smoking cigarettes, high blood pressure, elevated cholesterol, and diabetes mellitus can accelerate atherosclerosis and lead to the earlier onset of symptoms and complications, particularly in those people who have a family history of early atherosclerosis.

Coronary atherosclerosis (or coronary artery disease) refers to the atherosclerosis that causes hardening and narrowing of the coronary arteries. Diseases caused by the reduced blood supply to the heart muscle from coronary atherosclerosis are called coronary heart diseases (CHD). Coronary heart diseases include heart attacks, sudden unexpected death, chest pain (angina), abnormal heart rhythms, and heart failure due to weakening of the heart muscle.

Atherosclerosis and angina pectoris

Angina pectoris (also referred to as angina) is chest pain or pressure that occurs when the blood and oxygen supply to the heart muscle cannot keep up with the needs of the muscle. When coronary arteries are narrowed by more than 50 to 70 percent, the arteries may not be able to increase the supply of blood to the heart muscle during exercise or other periods of high demand for oxygen. An insufficient supply of oxygen to the heart muscle causes angina. Angina that occurs with exercise or exertion is called exertional angina. In some patients, especially diabetics, the progressive decrease in blood flow to the heart may occur without any pain or with just shortness of breath or unusually early fatigue.

Exertional angina usually feels like a pressure, heaviness, squeezing, or aching across the chest. This pain may travel to the neck, jaw, arms, back, or even the teeth, and may be accompanied by shortness of breath, nausea, or a cold sweat. Exertional angina typically lasts from one to 15 minutes and is relieved by rest or by taking nitroglycerin by placing a tablet under the tongue. Both resting and nitroglycerin decrease the heart muscle's demand for oxygen, thus relieving angina. Exertional angina may be the first warning sign of advanced coronary artery disease. Chest pains that just last a few seconds rarely are due to coronary artery disease.

Angina also can occur at rest. Angina at rest more commonly indicates that a coronary artery has narrowed to such a critical degree that the heart is not receiving enough oxygen even at rest. Angina at rest infrequently may be due to spasm of a coronary artery (a condition called Prinzmetal's or variant angina). Unlike a heart attack, there is no permanent muscle damage with either exertional or rest angina.

Atherosclerosis and heart attack

Occasionally the surface of a cholesterol plaque in a coronary artery may rupture, and a blood clot forms on the surface of the plaque. The clot blocks the flow of blood through the artery and results in a heart attack (see picture below). The cause of rupture that leads to the formation of a clot is largely unknown, but contributing factors may include cigarette smoking or other nicotine exposure, elevated LDL cholesterol, elevated levels of blood catecholamines (adrenaline), high blood pressure, and other mechanical and biochemical forces.

Unlike exertional or rest angina, heart muscle dies during a heart attack and loss of the muscle is permanent, unless blood flow can be promptly restored, usually within one to six hours.

While heart attacks can occur at any time, more heart attacks occur between 4:00 A.M. and 10:00 A.M. because of the higher blood levels of adrenaline released from the adrenal glands during the morning hours. Increased adrenaline, as previously discussed, may contribute to rupture of cholesterol plaques.

Approximately 50% of patients who develop heart attacks have warning symptoms such as exertional angina or rest angina prior to their heart attacks, but these symptoms may be mild and discounted.

Diabetes Overview

Almost everyone knows someone who has diabetes. An estimated 23.6 million people in the United States—7.8 percent of the population—have diabetes, a serious, lifelong condition. Of those, 17.9 million have been diagnosed, and 5.7 million have not yet been diagnosed. In 2007, about 1.6 million people ages 20 or older were diagnosed with diabetes. For additional statistics, see the National Diabetes Statistics, 2007 fact sheet online at www.diabetes.niddk.nih.gov/dm/pubs/statistics or call the National Diabetes Information Clearinghouse (NDIC) at 1–800–860–8747 to request a copy.

Source: 2003–2006 National Health and Nutrition Examination Survey estimates of total prevalence—both diagnosed and undiagnosed—were projected to year 2007.
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What is diabetes?

Diabetes is a disorder of metabolism—the way the body uses digested food for growth and energy. Most of the food people eat is broken down into glucose, the form of sugar in the blood. Glucose is the main source of fuel for the body.

After digestion, glucose passes into the bloodstream, where it is used by cells for growth and energy. For glucose to get into cells, insulin must be present. Insulin is a hormone produced by the pancreas, a large gland behind the stomach.

When people eat, the pancreas automatically produces the right amount of insulin to move glucose from blood into the cells. In people with diabetes, however, the pancreas either produces little or no insulin, or the cells do not respond appropriately to the insulin that is produced. Glucose builds up in the blood, overflows into the urine, and passes out of the body in the urine. Thus, the body loses its main source of fuel even though the blood contains large amounts of glucose.

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What are the types of diabetes?

The three main types of diabetes are

• type 1 diabetes
• type 2 diabetes
• gestational diabetes

Type 1 Diabetes

Type 1 diabetes is an autoimmune disease. An autoimmune disease results when the body’s system for fighting infection—the immune system—turns against a part of the body. In diabetes, the immune system attacks and destroys the insulin-producing beta cells in the pancreas. The pancreas then produces little or no insulin. A person who has type 1 diabetes must take insulin daily to live.

At present, scientists do not know exactly what causes the body’s immune system to attack the beta cells, but they believe that autoimmune, genetic, and environmental factors, possibly viruses, are involved. Type 1 diabetes accounts for about 5 to 10 percent of diagnosed diabetes in the United States. It develops most often in children and young adults but can appear at any age.

Symptoms of type 1 diabetes usually develop over a short period, although beta cell destruction can begin years earlier. Symptoms may include increased thirst and urination, constant hunger, weight loss, blurred vision, and extreme fatigue. If not diagnosed and treated with insulin, a person with type 1 diabetes can lapse into a life-threatening diabetic coma, also known as diabetic ketoacidosis.

Type 2 Diabetes

The most common form of diabetes is type 2 diabetes. About 90 to 95 percent of people with diabetes have type 2. This form of diabetes is most often associated with older age, obesity, family history of diabetes, previous history of gestational diabetes, physical inactivity, and certain ethnicities. About 80 percent of people with type 2 diabetes are overweight.

Type 2 diabetes is increasingly being diagnosed in children and adolescents, especially among African American, Mexican American, and Pacific Islander youth.

When type 2 diabetes is diagnosed, the pancreas is usually producing enough insulin, but for unknown reasons the body cannot use the insulin effectively, a condition called insulin resistance. After several years, insulin production decreases. The result is the same as for type 1 diabetes—glucose builds up in the blood and the body cannot make efficient use of its main source of fuel.

The symptoms of type 2 diabetes develop gradually. Their onset is not as sudden as in type 1 diabetes. Symptoms may include fatigue, frequent urination, increased thirst and hunger, weight loss, blurred vision, and slow healing of wounds or sores. Some people have no symptoms.

Gestational Diabetes

Some women develop gestational diabetes late in pregnancy. Although this form of diabetes usually disappears after the birth of the baby, women who have had gestational diabetes have a 40 to 60 percent chance of developing type 2 diabetes within 5 to 10 years. Maintaining a reasonable body weight and being physically active may help prevent development of type 2 diabetes.

About 3 to 8 percent of pregnant women in the United States develop gestational diabetes. As with type 2 diabetes, gestational diabetes occurs more often in some ethnic groups and among women with a family history of diabetes. Gestational diabetes is caused by the hormones of pregnancy or a shortage of insulin. Women with gestational diabetes may not experience any symptoms.

Diabetes in Youth

The SEARCH for Diabetes in Youth multicenter study, funded by the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH), has determined that

• based on data from 2002 to 2003, a total of 15,000 youth in the United States were newly diagnosed with type 1 diabetes each year. In addition, about 3,700 youth were newly diagnosed with type 2 diabetes each year.
• non-Hispanic white youth had the highest rate of new cases of type 1 diabetes.
• type 2 diabetes was rarely diagnosed among youth younger than 10 years of age.

Additional information about specific rates of new cases of type 1 and type 2 diabetes among youth younger than age 20 can be found in the fact sheet National Diabetes Statistics, 2007, available online at www.diabetes.niddk.nih.gov/dm/pubs/statistics.

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Other Types of Diabetes

A number of other types of diabetes exist. A person may exhibit characteristics of more than one type. For example, in latent autoimmune diabetes in adults (LADA), also called type 1.5 diabetes or double diabetes, people show signs of both type 1 and type 2 diabetes.

Other types of diabetes include those caused by

• genetic defects of the beta cell—the part of the pancreas that makes insulin—such as maturity-onset diabetes of the young (MODY) or neonatal diabetes mellitus (NDM)
• genetic defects in insulin action, resulting in the body’s inability to control blood glucose levels, as seen in leprechaunism and the Rabson-Mendenhall syndrome
• diseases of the pancreas or conditions that damage the pancreas, such as pancreatitis and cystic fibrosis
• excess amounts of certain hormones resulting from some medical conditions—such as cortisol in Cushing’s syndrome—that work against the action of insulin
• medications that reduce insulin action, such as glucocorticoids, or chemicals that destroy beta cells
• infections, such as congenital rubella and cytomegalovirus
• rare immune-mediated disorders, such as stiff-man syndrome, an autoimmune disease of the central nervous system
• genetic syndromes associated with diabetes, such as Down syndrome and Prader-Willi syndrome

Latent Autoimmune Diabetes in Adults (LADA)

People who have LADA show signs of both type 1 and type 2 diabetes. Diagnosis usually occurs after age 30. Researchers estimate that as many as 10 percent of people diagnosed with type 2 diabetes have LADA. Some experts believe that LADA is a slowly developing kind of type 1 diabetes because patients have antibodies against the insulin-producing beta cells of the pancreas.

Most people with LADA still produce their own insulin when first diagnosed, like those with type 2 diabetes. In the early stages of the disease, people with LADA do not require insulin injections. Instead, they control their blood glucose levels with meal planning, physical activity, and oral diabetes medications. However, several years after diagnosis, people with LADA must take insulin to control blood glucose levels. As LADA progresses, the beta cells of the pancreas may no longer make insulin because the body’s immune system has attacked and destroyed them, as in type 1 diabetes.

Diabetes Caused by Genetic Defects of the Beta Cell

Genetic defects of the beta cell cause several forms of diabetes. For example, monogenic forms of diabetes result from mutations, or changes, in a single gene. In most cases of monogenic diabetes, the gene mutation is inherited. In the remaining cases, the gene mutation develops spontaneously. Most mutations in monogenic diabetes reduce the body’s ability to produce insulin. Genetic testing can diagnose most forms of monogenic diabetes.

NDM and MODY are the two main forms of monogenic diabetes. NDM is a form of diabetes that occurs in the first 6 months of life. Infants with NDM do not produce enough insulin, leading to an increase in blood glucose. NDM can be mistaken for the much more common type 1 diabetes, but type 1 diabetes usually occurs after the first 6 months of life. More information about the two types of NDM, permanent neonatal diabetes and transient neonatal diabetes mellitus, is provided in the fact sheet Monogenic Forms of Diabetes, available online from the NDIC at www.diabetes.niddk.nih.gov/dm/pubs/mody. For printed copies of the fact sheet, call the NDIC at 1–800–860–8747.

MODY usually first occurs during adolescence or early adulthood. However, MODY sometimes remains undiagnosed until later in life. A number of different gene mutations have been shown to cause MODY, all of which limit the pancreas’ ability to produce insulin. This process leads to the high blood glucose levels characteristic of diabetes. More information about specific types of MODY is provided in the fact sheet Monogenic Forms of Diabetes.

Diabetes Caused by Genetic Defects in Insulin Action

A number of types of diabetes result from genetic defects in insulin action. Changes to the insulin receptor may cause mild hyperglycemia—high blood glucose—or severe diabetes. Symptoms may include acanthosis nigricans, a skin condition characterized by darkened skin patches, and, in women, enlarged and cystic ovaries plus virilization and the development of masculine characteristics such as excess facial hair. Two syndromes in children, leprechaunism and the Rabson-Mendenhall syndrome, cause extreme insulin resistance.

Diabetes Caused by Diseases of the Pancreas

Injuries to the pancreas from trauma or disease can cause diabetes. This category includes pancreatitis, infection, and cancer of the pancreas. Cystic fibrosis and hemochromatosis can also damage the pancreas enough to cause diabetes.

Diabetes Caused by Endocrinopathies

Excess amounts of certain hormones that work against the action of insulin can cause diabetes. These hormones and their related conditions include growth hormone in acromegaly, cortisol in Cushing’s syndrome, glucagon in glucagonoma, and epinephrine in pheochromocytoma.

Diabetes Caused by Medications or Chemicals

A number of medications and chemicals can interfere with insulin secretion, leading to diabetes in people with insulin resistance. These medications and chemicals include pentamidine, nicotinic acid, glucocorticoids, thyroid hormone, phenytoin (Dilantin), and Vacor, a rat poison.

Diabetes Caused by Infections

Several infections are associated with the occurrence of diabetes, including congenital rubella, coxsackievirus B, cytomegalovirus, adenovirus, and mumps.

Rare Immune-mediated Types of Diabetes

Some immune-mediated disorders are associated with diabetes. About one-third of people with stiff-man syndrome develop diabetes. In other autoimmune diseases, such as systemic lupus erythematosus, patients may have anti-insulin receptor antibodies that cause diabetes by interfering with the binding of insulin to body tissues.

Other Genetic Syndromes Sometimes Associated with Diabetes

Many genetic syndromes are associated with diabetes. These conditions include Down syndrome, Klinefelter’s syndrome, Huntington’s chorea, porphyria, Prader-Willi syndrome, and diabetes insipidus.

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How is diabetes diagnosed?

The fasting blood glucose test is the preferred test for diagnosing diabetes in children and nonpregnant adults. The test is most reliable when done in the morning. However, a diagnosis of diabetes can be made based on any of the following test results, confirmed by retesting on a different day:

• A blood glucose level of 126 milli grams per deciliter (mg/dL) or higher after an 8-hour fast. This test is called the fasting blood glucose test.
• A blood glucose level of 200 mg/dL or higher 2 hours after drinking a beverage containing 75 grams of glucose dissolved in water. This test is called the oral glucose tolerance test (OGTT).
• A random—taken at any time of day—blood glucose level of 200 mg/dL or higher, along with the presence of diabetes symptoms.

Gestational diabetes is diagnosed based on blood glucose levels measured during the OGTT. Glucose levels are normally lower during pregnancy, so the cutoff levels for diagnosis of diabetes in pregnancy are lower. Blood glucose levels are measured before a woman drinks a beverage containing glucose. Then levels are checked 1, 2, and 3 hours afterward. If a woman has two blood glucose levels meeting or exceeding any of the following numbers, she has gestational diabetes: a fasting blood glucose level of 95 mg/dL, a 1-hour level of 180 mg/dL, a 2-hour level of 155 mg/dL, or a 3-hour level of 140 mg/dL.

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What is pre-diabetes?

People with pre-diabetes have blood glucose levels that are higher than normal but not high enough for a diagnosis of diabetes. This condition raises the risk of developing type 2 diabetes, heart disease, and stroke.

Pre-diabetes is also called impaired fasting glucose (IFG) or impaired glucose tolerance (IGT), depending on the test used to diagnose it. Some people have both IFG and IGT.

• IFG is a condition in which the blood glucose level is high—100 to 125 mg/dL—after an overnight fast, but is not high enough to be classified as diabetes. The former definition of IFG was 110 mg/dL to 125 mg/dL.
• IGT is a condition in which the blood glucose level is high—140 to 199 mg/dL—after a 2-hour OGTT, but is not high enough to be classified as diabetes.

Pre-diabetes is becoming more common in the United States. The U.S. Department of Health and Human Services estimates that at least 57 million U.S. adults ages 20 or older had pre-diabetes in 2007. Those with pre-diabetes are likely to develop type 2 diabetes within 10 years, unless they take steps to prevent or delay diabetes.

The good news is that people with pre-diabetes can do a lot to prevent or delay diabetes. Studies have clearly shown that people can lower their risk of developing diabetes by losing 5 to 7 percent of their body weight through diet and increased physical activity. A major study of more than 3,000 people with IGT found that diet and exercise resulting in a 5 to 7 percent weight loss—about 10 to 14 pounds in a person who weighs 200 pounds—lowered the incidence of type 2 diabetes by nearly 60 percent. Study participants lost weight by cutting fat and calories in their diet and by exercising—most chose walking—at least 30 minutes a day, 5 days a week.

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What are the scope and impact of diabetes?

Diabetes is widely recognized as one of the leading causes of death and disability in the United States. In 2006, it was the seventh leading cause of death. However, diabetes is likely to be underreported as the underlying cause of death on death certificates. In 2004, among people ages 65 years or older, heart disease was noted on 68 percent of diabetes-related death certificates; stroke was noted on 16 percent of diabetes-related death certificates for the same age group.

Diabetes is associated with long-term complications that affect almost every part of the body. The disease often leads to blindness, heart and blood vessel disease, stroke, kidney failure, amputations, and nerve damage. Uncontrolled diabetes can complicate pregnancy, and birth defects are more common in babies born to women with diabetes.

In 2007, diabetes cost the United States $174 billion. Indirect costs, including disability payments, time lost from work, and reduced productivity, totaled $58 billion. Direct medical costs for diabetes care, including hospitalizations, medical care, and treatment supplies, totaled $116 billion.

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Who gets diabetes?

Diabetes is not contagious. People cannot “catch” it from each other. However, certain factors can increase the risk of developing diabetes.

Type 1 diabetes occurs equally among males and females but is more common in whites than in nonwhites. Data from the World Health Organization’s Multinational Project for Childhood Diabetes indicate that type 1 diabetes is rare in most African, American Indian, and Asian populations. However, some northern European countries, including Finland and Sweden, have high rates of type 1 diabetes. The reasons for these differences are unknown. Type 1 diabetes develops most often in children but can occur at any age.

Type 2 diabetes is more common in older people, especially in people who are overweight, and occurs more often in African Americans, American Indians, some Asian Americans, Native Hawaiians and other Pacific Islander Americans, and Hispanics/Latinos. National survey data in 2007 indicate a range in the prevalence of diagnosed and undiagnosed diabetes in various populations ages 20 years or older:

• Age 20 years or older: 23.5 million, or 10.7 percent, of all people in this age group have diabetes.
• Age 60 years or older: 12.2 million, or 23.1 percent, of all people in this age group have diabetes.
• Men: 12.0 million, or 11.2 percent, of all men ages 20 years or older have diabetes.
• Women: 11.5 million, or 10.2 percent, of all women ages 20 years or older have diabetes.
• Non-Hispanic whites: 14.9 million, or 9.8 percent, of all non-Hispanic whites ages 20 years or older have diabetes.
• Non-Hispanic blacks: 3.7 million, or 14.7 percent, of all non-Hispanic blacks ages 20 years or older have diabetes.

Diabetes prevalence in the United States is likely to increase for several reasons. First, a large segment of the population is aging. Also, Hispanics/Latinos and other minority groups at increased risk make up the fastest-growing segment of the U.S. population. Finally, Americans are increasingly overweight and sedentary. According to recent estimates from the CDC, diabetes will affect one in three people born in 2000 in the United States. The CDC also projects that the prevalence of diagnosed diabetes in the United States will increase 165 percent by 2050.

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How is diabetes managed?

Before the discovery of insulin in 1921, everyone with type 1 diabetes died within a few years after diagnosis. Although insulin is not considered a cure, its discovery was the first major breakthrough in diabetes treatment.

Today, healthy eating, physical activity, and taking insulin are the basic therapies for type 1 diabetes. The amount of insulin must be balanced with food intake and daily activities. Doctors may also prescribe another type of injectable medicine. Blood glucose levels must be closely monitored through frequent blood glucose checking. People with diabetes also monitor blood glucose levels several times a year with a laboratory test called the A1C. Results of the A1C test reflect average blood glucose over a 2- to 3-month period.

Healthy eating, physical activity, and blood glucose testing are the basic management tools for type 2 diabetes. In addition, many people with type 2 diabetes require one or more diabetes medicines—pills, insulin, and other injectable medicine—to control their blood glucose levels.

Adults with diabetes are at high risk for cardiovascular disease (CVD). In fact, at least 65 percent of those with diabetes die from heart disease or stroke. Managing diabetes is more than keeping blood glucose levels under control—it is also important to manage blood pressure and cholesterol levels through healthy eating, physical activity, and the use of medications, if needed. By doing so, those with diabetes can lower their risk. Aspirin therapy, if recommended by a person’s health care team, and smoking cessation can also help lower risk.

People with diabetes must take responsibility for their day-to-day care. Much of the daily care involves keeping blood glucose levels from going too low or too high. When blood glucose levels drop too low—a condition known as hypoglycemia—a person can become nervous, shaky, and confused. Judgment can be impaired, and if blood glucose falls too low, fainting can occur.

A person can also become ill if blood glucose levels rise too high.

People with diabetes should see a health care provider who will help them learn to manage their diabetes and who will monitor their diabetes control. Most people with diabetes get care from primary care physicians—internists, family practice doctors, or pediatricians. Often, having a team of providers can improve diabetes care. A team can include

• a primary care provider such as an internist, a family practice doctor, or a pediatrician
• an endocrinologist—a specialist in diabetes care
• a dietitian, a nurse, and other health care providers who are certified diabetes educators—experts in providing information about managing diabetes
• a podiatrist—for foot care
• an ophthalmologist or an optometrist—for eye care

The team can also include other health care providers, such as cardiologists and other specialists. The team for a pregnant woman with type 1, type 2, or gestational diabetes should include an obstetrician who specializes in caring for women with diabetes. The team can also include a pediatrician or a neonatologist with experience taking care of babies born to women with diabetes.

The goal of diabetes management is to keep levels of blood glucose, blood pressure, and cholesterol as close to the normal range as safely possible. A major study, the Diabetes Control and Complications Trial (DCCT), sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), showed that keeping blood glucose levels close to normal reduces the risk of developing major complications of type 1 diabetes.

This 10-year study, completed in 1993, included 1,441 people with type 1 diabetes. The study compared the effect of two treatment approaches—intensive management and standard management—on the development and progression of eye, kidney, nerve, and cardiovascular complications of diabetes. Intensive treatment aimed to keep A1C levels as close to normal—6 percent—as possible. Researchers found that study participants who maintained lower levels of blood glucose through intensive management had significantly lower rates of these complications. More recently, a follow-up study of DCCT participants showed that the ability of intensive control to lower the complications of diabetes has persisted more than 10 years after the trial ended.

The United Kingdom Prospective Diabetes Study, a European study completed in 1998, showed that intensive control of blood glucose and blood pressure reduced the risk of blindness, kidney disease, stroke, and heart attack in people with type 2 diabetes.

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Hope through Research

The NIDDK conducts research in its own laboratories and supports a great deal of basic and clinical research in medical centers and hospitals throughout the United States. It also gathers and analyzes statistics about diabetes. Other Institutes at the NIH conduct and support research on diabetes-related eye diseases, heart and vascular complications, autoimmunity, pregnancy, and dental problems.

Other Government agencies that sponsor diabetes programs are the CDC, the Indian Health Service, the Health Resources and Services Administration, the Department of Veterans Affairs, and the Department of Defense.

Many organizations outside the Government support diabetes research and education activities. These organizations include the American Diabetes Association (ADA), the Juvenile Diabetes Research Foundation International (JDRF), and the American Association of Diabetes Educators.

In recent years, advances in diabetes research have led to better ways of managing diabetes and treating its complications. Major advances include

• development of quick-acting and long-acting insulins
• better ways to monitor blood glucose and for people with diabetes to check their blood glucose levels
• development of external insulin pumps that deliver insulin, replacing daily injections
• laser treatment for diabetic eye disease, reducing the risk of blindness
• successful kidney and pancreas transplantation in people whose kidneys fail because of diabetes
• better ways of managing diabetes in pregnant women, improving their chances of a successful outcome
• new drugs to treat type 1 and type 2 diabetes and better ways to manage these forms of diabetes through weight control
• evidence that intensive management of blood glucose reduces and may prevent development of diabetes complications
• demonstration that two types of antihypertensive drugs, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), are more effective than other antihypertensive drugs in reducing a decline in kidney function in people with diabetes
• advances in transplantation of islets—clusters of cells that produce insulin and other hormones—for type 1 diabetes
• evidence that people at high risk for type 2 diabetes can lower their chances of developing the disease through diet, weight loss, and physical activity

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What will the future bring?

Researchers continue to look for the cause or causes of diabetes and ways to manage, prevent, or cure the disorder. Scientists are searching for genes that may be involved in type 1 or type 2 diabetes. Some genetic markers for type 1 diabetes have been identified, and it is now possible to screen relatives of people with type 1 diabetes to determine whether they are at risk.

Type 1 Diabetes

A number of federally funded research studies and clinical trials are under way. Studies focus on the prevention and causes of type 1 diabetes as well as experimental treatments such as islet transplantation.

Diabetes Prevention Trial–Type 1 (DPT–1)
The NIDDK and other groups sponsored DPT–1, which showed that people at risk for developing type 1 diabetes can be identified. The DPT–1 researchers discovered ways to identify two populations at risk of developing type 1 diabetes within 5 years—those at high risk, with at least a 50 percent chance, and those at intermediate risk, with a 25 to 50 percent risk. Then researchers explored possible ways of preventing type 1 diabetes in both groups. Although the study found that neither low-dose insulin injections nor insulin capsules taken orally prevented or delayed type 1 diabetes in the study population, research that follows up on DPT–1 findings is under way. For more information about DPT–1, see www.niddk.nih.gov/patient/dpt_1/dpt_1.htm.

The Environmental Determinants of Diabetes in the Young (TEDDY) Consortium
The main mission of the TEDDY consortium, an international group of clinical centers, is to identify infectious agents, dietary factors, or other environmental factors—including psychosocial events—that trigger type 1 diabetes in those who are genetically susceptible. In addition, the consortium aims to

• create a central repository of data and biological samples for use by researchers
• develop novel approaches to finding the causes of type 1 diabetes
• find ways to understand how the disease starts and progresses
• discover new methods to prevent, delay, and reverse type 1 diabetes

TEDDY is funded by the NIDDK, the National Institute of Allergy and Infectious Diseases (NIAID), the National Institute of Child Health and Human Development (NICHD), the National Institute of Environmental Health Sciences, the CDC, the JDRF, and the ADA. For more information, see http://teddy.epi.usf.edu.

Type 1 Diabetes Genetics Consortium (T1DGC)
The T1DGC is a group of researchers from around the world who are studying the genetics of type 1 diabetes. They are studying families with siblings who have type 1 diabetes to look for genes that may show a person’s risk of getting type 1 diabetes or might keep someone from getting type 1 diabetes. For more information, see www.t1dgc.org.

Type 1 Diabetes TrialNet
Type 1 Diabetes TrialNet is a network of experts and facilities dedicated to developing new approaches to the understanding, prevention, and treatment of type 1 diabetes. Clinical centers are located in the United States, Canada, Europe, and Australia.

TrialNet studies are focusing on

• understanding the natural history of type 1 diabetes to determine its causes and progression
• preventing type 1 diabetes in those at risk
• developing ways to preserve the function of the insulin-producing cells in the pancreas in people recently diagnosed with type 1 diabetes

For more information, see www.DiabetesTrialNet.org or call 1–800–HALT–DM1 (425–8361).

TrialNet will identify people at risk who may be eligible for clinical trials. In addition, TrialNet will conduct trials to save beta cell function in those with new onset type 1 diabetes.

TrialNet is funded by the NIDDK, NICHD, and NIAID. The JDRF and ADA also support this effort.

The Immune Tolerance Network
TrialNet works closely with the Immune Tolerance Network, another international, collaborative consortium. Its goal is to find safe and effective ways to induce long-term immune tolerance—prevention of an unwanted immune response by the body. For example, type 1 diabetes might be prevented if scientists could learn how to prevent the immune system from mistakenly attacking the insulin-producing cells in the pancreas. Effective immune tolerance could possibly

• prevent the body’s rejection of organ or tissue transplants
• prevent or treat autoimmune diseases
• prevent or treat allergies and asthma

For more information, see www.immunetolerance.org or call 415–514–2530.

The Trial to Reduce IDDM in the Genetically at Risk (TRIGR)
The TRIGR study will help determine whether delayed exposure to cow’s milk can prevent type 1 diabetes in infants at risk of developing the disease. Instead of receiving cow’s milk, infants in the TRIGR study will primarily breastfeed. Babies whose mothers cannot breastfeed will be given a special formula made with milk proteins that may be easier for babies to tolerate. The TRIGR study will help clarify whether infant feeding practices are related to the development of diabetes. For more information, see www.trigrnorthamerica.org or call 1–888–STOP–T1D (786–7813).

Islet Transplantation
Researchers are working on a way for people with type 1 diabetes to live without daily insulin injections. In an experimental procedure called islet transplantation, islets are taken from a donor pancreas and transferred into a person with type 1 diabetes. Once implanted, the beta cells in these islets begin to make and release insulin.

Although scientists have made many advances in islet transplantation in recent years, transplanted islets tend to lose function over time, and few transplant recipients are able to stop using insulin for very long. But even partial islet function can help patients reduce their need for insulin, achieve better glucose stability, and reduce problems with hypoglycemia.

Problems with islet transplantation include the severe shortage of islets available for transplants and the need for patients to take drugs with significant side effects to stop the immune system from rejecting the transplanted islets. Researchers are seeking solutions to these problems.

For more information about islet transplantation, see the fact sheet Pancreatic Islet Transplantation at www.diabetes.niddk.nih.gov/dm/pubs/pancreaticislet.

Type 2 Diabetes

Diabetes Prevention Program
In 1996, the NIDDK launched its Diabetes Prevention Program (DPP). The goal of this research effort was to learn how to prevent or delay type 2 diabetes in people with impaired glucose tolerance, a strong risk factor for type 2 diabetes.

The findings of the DPP, released in August 2001, showed that people at high risk for type 2 diabetes could sharply lower their chances of developing the disorder through diet and exercise. In addition, treatment with the oral diabetes drug metformin also reduced diabetes risk, though less dramatically. Metformin lowers the amount of glucose released by the liver and also fights insulin resistance, a condition in which the body doesn’t use insulin properly.

Participants randomly assigned to intensive lifestyle intervention reduced their risk of getting type 2 diabetes by 58 percent. On average, this group maintained their physical activity at 30 minutes per day, usually with walking or other moderate intensity exercise, and lost 5 to 7 percent of their body weight. Participants randomized to treatment with metformin reduced their risk of getting type 2 diabetes by 31 percent.

Of the 3,234 participants enrolled in the DPP, 45 percent were from minority groups that suffer disproportionately from type 2 diabetes: African Americans, Hispanics/ Latinos, Asian Americans and Pacific Islanders, and American Indians. The DPP also recruited other groups known to be at higher risk for type 2 diabetes, including individuals ages 60 or older, women with a history of gestational diabetes, and people with a first-degree relative with type 2 diabetes.

Participants are still being followed to check for long-term effects of the interventions, including the effects on CVD. Recent analyses of data from the DPP have added to the evidence that lifestyle changes are especially effective in helping to reduce the risk of developing conditions associated with type 2 diabetes, including high blood pressure and the metabolic syndrome. Researchers also confirmed that study participants carrying two copies of a gene variant that significantly increased their risk of developing diabetes benefited from lifestyle changes as much as or more than those without the gene variant.

Type 2 Diabetes in Children and Teens
Two studies focusing on type 2 diabetes in children and teens are under way. The Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) study, a 13-site study sponsored by the NIDDK, will compare treatments for type 2 diabetes in children and teens. Participants will undergo one of three treatments:

• taking one diabetes medication—metformin
• taking two diabetes medications—metformin and rosiglitazone, another medication that fights insulin resistance
• taking metformin and participating in an intensive lifestyle change program designed to promote weight loss by cutting calories and increasing physical activity

The main goal of the study is to determine how well each type of treatment controls blood glucose levels. The study also will evaluate how long each type of treatment is effective.

Current NIDDK-sponsored research includes the HEALTHY study, which is part of a broad research initiative called STOPP T2D (Studies to Treat or Prevent Pediatric Type 2 Diabetes). The study explores whether improving nutrition, promoting physical activity, and making changes in behavior can lower risk factors for type 2 diabetes in children from 42 middle schools across the country. Participating schools are randomly assigned to a program group, which implements the changes, or to a comparison group, which continues to offer food choices and physical education programs typically found in middle schools across the country. Students in the program group will have healthier choices available in the cafeteria and vending machines; longer, more intense periods of physical activity; and activities and awareness campaigns that promote long-term healthy behaviors. Results from the HEALTHY study are expected in 2009.

Preventing and Treating CVD in People with Type 2 Diabetes
CVD is the main killer of people with type 2 diabetes. For this reason, the NIH is studying the best strategies to prevent and treat CVD in people with diabetes in three major studies. These studies are all joint efforts of the NIDDK and the National Heart, Lung, and Blood Institute (NHLBI).

The Look AHEAD (Action for Health in Diabetes) trial is the largest clinical trial to date to examine the long-term health effects of voluntary weight loss. This multicenter, randomized clinical trial is studying the effects of a lifestyle intervention designed to achieve and maintain weight loss over the long-term through decreased caloric intake and increased exercise. Look AHEAD will focus on the disorder most associated with being overweight or obese, type 2 diabetes, and on the outcome that causes the greatest morbidity and mortality in people with type 2 diabetes, CVD. Results after 1 year of the study show that people receiving the lifestyle intervention lost an average of 8.6 percent of their initial body weight. In addition, they showed improved control of diabetes as well as improvements in cardiovascular risk factors, such as high blood pressure and blood fat levels.

The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, a multicenter, randomized trial, is studying three approaches to preventing major cardiovascular events in individuals with type 2 diabetes. ACCORD was designed to compare current practice guidelines with more intensive glycemic control in 10,000 individuals with type 2 diabetes, including those at especially high risk for cardiovascular events because of age, evidence of subclinical atherosclerosis, or existing clinical CVD. More intensive control of blood pressure than is called for in current guidelines and a medication to reduce triglyceride levels and raise HDL, or “good,” cholesterol levels will also be studied in subgroups of these 10,000 volunteers. Each treatment strategy will be accompanied by standard advice regarding lifestyle choices, including diet, physical activity, and smoking cessation, appropriate for individuals with diabetes.

The primary outcome to be measured is the first occurrence of a major cardiovascular event, specifically heart attack, stroke, or cardiovascular death. In addition, the study will investigate the impact of the treatment strategies on other cardiovascular outcomes; total mortality; limb amputation; eye, kidney, or nerve disease; health-related quality of life; and cost-effectiveness.

In February 2008, the NHLBI decided to stop one part of the study—the intensive glycemic control treatment—before the end of the entire trial because of safety concerns. However, the trial will continue with the other treatments until the planned end in 2009.

The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial, a 5-year, multicenter clinical trial, is comparing medical versus early surgical management of patients with type 2 diabetes who also have coronary artery disease and stable angina or ischemia. At the same time, BARI 2D will study the effect of two different strategies to control blood glucose—providing insulin versus increasing the sensitivity of the body to insulin—on the risk of cardiovascular mortality and morbidity.

Participants in clinical trials can play a more active role in their own health care, gain access to new research treatments before they are widely available, and help others by contributing to medical research. For information about current studies, visit www.ClinicalTrials.gov.

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Points to Remember

What is diabetes?

• a disorder of metabolism—the way the body uses or converts food for energy and growth

What are the main types of diabetes?

• type 1 diabetes
• type 2 diabetes
• gestational diabetes

What is the impact of diabetes?

• It affects 23.6 million people—7.8 percent of the U.S. population.
• It is a leading cause of death and disability.
• It costs $174 billion per year.

Who gets diabetes?

• people of any age
• people with a family history of diabetes
• others at high risk for type 2 diabetes: older people, overweight and sedentary people, African Americans, Alaska Natives, American Indians, Asian Americans, Native Hawaiians, some Pacific Islander Americans, and Hispanics/Latinos