Feeling down once in a while is normal. But some people feel a sadness that just won’t go away. Life seems hopeless. Feeling this way most of the day for two weeks or more is a sign of serious depression.

At any given time, most people with diabetes do not have depression. But studies show that people with diabetes have a greater risk of depression than people without diabetes. There are no easy answers about why this is true.

The stress of daily diabetes management can build. You may feel alone or set apart from your friends and family because of all this extra work.

If you face diabetes complications such as nerve damage, or if you are having trouble keeping your blood sugar levels where you’d like, you may feel like you’re losing control of your diabetes. Even tension between you and your doctor may make you feel frustrated and sad.

Just like denial, depression can get you into a vicious cycle. It can block good diabetes self-care. If you are depressed and have no energy, chances are you will find such tasks as regular blood sugar testing too much. If you feel so anxious that you can’t think straight, it will be hard to keep up with a good diet. You may not feel like eating at all. Of course, this will affect your blood sugar levels.

What to do?

Spotting depression is the first step. Getting help is the second. If you have been feeling really sad, blue, or down in the dumps, check for these symptoms:

• Loss of pleasure You no longer take interest in doing things you used to enjoy.
• Change in sleep patterns You have trouble falling asleep, you wake often during the night, or you want to sleep more than usual, including during the day.
• Early to rise You wake up earlier than usual and cannot to get back to sleep.
• Change in appetite You eat more or less than you used to, resulting in a quick weight gain or weight loss.
• Trouble concentrating You can’t watch a TV program or read an article because other thoughts or feelings get in the way.
• Loss of energy You feel tired all the time.
• Nervousness You always feel so anxious you can’t sit still.
• Guilt You feel you “never do anything right” and worry that you are a burden to others.
• Morning sadness You feel worse in the morning than you do the rest of the day.
• Suicidal thoughts You feel you want to die or are thinking about ways to hurt yourself.

If you have three or more of these symptoms, or if you have just one or two but have been feeling bad for two weeks or more, it’s time to get help.

Getting Help

If you are feeling symptoms of depression, don’t keep them to yourself. First, talk them over with your doctor. There may a physical cause for your depression.

Diabetes that is in poor control can cause symptoms that look like depression. During the day, high or low blood sugar may make you feel tired or anxious. Low blood sugar levels can also lead to hunger and eating too much. If you have low blood sugar at night, it could disturb your sleep. If you have high blood sugar at night, you may get up often to urinate and then feel tired during the day.

Other physical causes of depression can include

• alcohol or drug abuse
• thyroid problems
• side effects from some medications

Do not stop taking a medication without telling your doctor. Your doctor will be able to help you discover if a physical problem is at the root of your sad feelings.

If you and your doctor rule out physical causes, your doctor will most likely refer you to a specialist. You might talk with a psychiatrist, psychologist, psychiatric nurse, licensed clinical social worker, or professional counselor. In fact, your doctor may already work with mental health professionals on a diabetes treatment team.

All of these mental health professionals can guide you through the rough waters of depression. In general, there are two types of treatment. One is psychotherapy, or counseling. The other is antidepressant medication.

Psychotherapy with a well-trained therapist can help you look at the problems that bring on depression. It can also help you find ways to relieve the problem. Therapy can be short term or long term. You should be sure you feel at ease with the therapist you choose.

If medication is advised, you will need to consult with a psychiatrist (a medical doctor with special training in diagnosing and treating mental or emotional disorders). Psychiatrists are the only mental health professionals who can prescribe medication and treat physical causes of depression.

If you opt for trying an antidepressant drug, talk to the psychiatrist and your primary care provider about side effects, including how it might affect your blood sugar levels. Make sure that the doctors will consult about your care when needed. Many people do well with a combination of medication and psychotherapy.

If you have symptoms of depression, don’t wait too long to get help. If your health care provider cannot refer you to a mental health professional, contact your local psychiatric society or psychiatry department of a medical school, or the local branch of organizations for psychiatric social workers, psychologists, or mental health counselors.

Just as with other types of neuropathy, diabetes can damage the vagus nerve if blood glucose levels remain high over a long period of time. High blood glucose causes chemical changes in nerves and damages the blood vessels that carry oxygen and nutrients to the nerves.

Signs and Symptoms

Signs and symptoms of gastroparesis (delayed gastric emptying) are:

• heartburn
• nausea
• vomiting of undigested food
• an early feeling of fullness when eating
• weight loss
• abdominal bloating
• erratic blood glucose (sugar) levels
• lack of appetite
• gastroesophageal reflux
• spasms of the stomach wall

These symptoms may be mild or severe, depending on the person.

Complications of Gastroparesis

Gastroparesis can make diabetes worse by making it more difficult to manage blood glucose. When food that has been delayed in the stomach finally enters the small intestine and is absorbed, blood glucose levels rise.

If food stays too long in the stomach, it can cause problems like bacterial overgrowth because the food has fermented. Also, the food can harden into solid masses called bezoars that may cause nausea, vomiting, and obstruction in the stomach. Bezoars can be dangerous if they block the passage of food into the small intestine.

Diagnosis

The diagnosis of gastroparesis is confirmed through one or more of the following tests.

Barium X-ray

After fasting for 12 hours, you will drink a thick liquid containing barium, which covers the inside of the stomach, making it show up on the X-ray. Normally, the stomach will be empty of all food after 12 hours of fasting. If the X-ray shows food in the stomach, gastroparesis is likely. If the X-ray shows an empty stomach, but the doctor still suspects that you have delayed emptying, you may need to repeat the test another day. On any one day, a person with gastroparesis may digest a meal normally, giving a falsely normal test result. If you have diabetes, your doctor may have special instructions about fasting.

Barium Beefsteak Meal

You will eat a meal that contains barium, which allows the doctor to watch your stomach as it digests the meal. The amount of time it takes for the barium meal to be digested and leave the stomach gives the doctor an idea of how well the stomach is working. This test can help find emptying problems that do not show up on the liquid barium X-ray. In fact, people who have diabetes-related gastroparesis often digest fluid normally, so the barium beefsteak meal can be more useful.

Radioisotope Gastric-Emptying Scan

You will eat food that contains a radioisotope, a slightly radioactive substance that will show up on the scan. The dose of radiation from the radioisotope is small and not dangerous. After eating, you will lie under a machine that detects the radioisotope and shows an image of the food in the stomach and how quickly it leaves the stomach. Gastroparesis is diagnosed if more than half of the food remains in the stomach after two hours.

Gastric Manometry

This test measures electrical and muscular activity in the stomach. The doctor passes a thin tube down the throat into the stomach. The tube contains a wire that takes measurements of the stomach’s electrical and muscular activity as it digests liquids and solid food. The measurements show how the stomach is working and whether there is any delay in digestion.

Blood tests

The doctor may also order laboratory tests to check blood counts and to measure chemical and electrolyte levels.

To rule out causes of gastroparesis other than diabetes, the doctor may do an upper endoscopy or an ultrasound.

Upper Endoscopy

After giving you a sedative, the doctor passes a long, thin tube called an endoscope through the mouth and gently guides it down the esophagus into the stomach. Through the endoscope, the doctor can look at the lining of the stomach to check for any abnormalities.

Ultrasound

To rule out gallbladder disease or pancreatitis as a source of the problem, you may have an ultrasound test, which uses harmless sound waves to outline and define the shape of the gallbladder and pancreas.

Treatment

The most important treatment goal for diabetes-related gastroparesis is to manage your blood glucose levels as well as possible. Treatments include insulin, oral medications, changes in what and when you eat, and, in severe cases, feeding tubes and intravenous feeding.

Insulin for blood glucose control

If you have gastroparesis, your food is being absorbed more slowly and at unpredictable times. To better manage blood glucose, you may need to

• take insulin more often
• take your insulin after you eat instead of before
• check your blood glucose levels frequently after you eat and administer insulin whenever necessary

Your doctor will give you specific instructions based on your particular needs.

Medication

Several drugs are used to treat gastroparesis. Your doctor may try different drugs or combinations of drugs to find the most effective treatment.

Meal and Food Changes

Changing your eating habits can help control gastroparesis. Your doctor or dietitian will give you specific instructions, but you may be asked to eat six small meals a day instead of three large ones. If less food enters the stomach each time you eat, it may not become overly full. Or the doctor or dietitian may suggest that you try several liquid meals a day until your blood glucose levels are stable and the gastroparesis has improved. Liquid meals provide all the nutrients found in solid foods, but can pass through the stomach more easily and quickly.

The doctor may also recommend that you avoid high-fat and high-fiber foods. Fat naturally slows digestion — a problem you do not need if you have gastroparesis — and fiber is difficult to digest. Some high-fiber foods like oranges and broccoli contain material that cannot be digested. Avoid these foods because the indigestible part will remain in the stomach too long and possibly form bezoars.

Feeding Tube

If other approaches do not work, you may need surgery to insert a feeding tube. The tube, called a jejunostomy tube, is inserted through the skin on your abdomen into the small intestine. The feeding tube allows you to put nutrients directly into the small intestine, bypassing the stomach altogether. You will receive special liquid food to use with the tube. A jejunostomy is particularly useful when gastroparesis prevents the nutrients and medication necessary to regulate blood glucose levels from reaching the bloodstream. By avoiding the source of the problem (the stomach) and putting nutrients and medication directly into the small intestine, you ensure that these products are digested and delivered to your bloodstream quickly. A jejunostomy tube can be temporary and is used only if necessary when gastroparesis is severe.

It is important to note that in most cases treatment does not cure gastroparesis — it is usually a chronic condition. Treatment helps you manage gastroparesis, so that you can be as healthy and comfortable as possible.

For this reason, good blood glucose control before you get pregnant is very important. Most women do not know they are pregnant until the baby has been growing for two to four weeks. During the first six weeks of pregnancy, the baby’s organs are forming. Your blood glucose levels during these early weeks affect the baby’s growing organs. High blood glucose levels can lead to birth defects.

Because these early weeks are so important to your baby, you need to plan your pregnancy. If your blood glucose levels are not in good control, work to bring your diabetes under control before getting pregnant. It is a good idea to be in good blood glucose control three to six months before you plan to get pregnant. You’ll want to keep excellent blood glucose control during pregnancy, and after as well.

How do high blood glucose levels cause problems? When extra sugar is in your blood, the baby is “fed” extra sugar, too. All this excess sugar can make the baby too big and fat. Delivery of big babies is harder on mom and baby.

Because your baby is getting extra sugar, your baby’s pancreas makes extra insulin. After birth, it’s hard for the baby to stop putting out extra insulin. The baby must be watched, and treated if the blood glucose level drops too low.

For some reason, jaundice happens more often in babies of women with diabetes. Jaundice is a build-up of old red blood cells that the body can’t process fast enough. This problem goes away rapidly with treatment.

A: Pre-diabetes is the state that occurs when a person’s blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes. About 11 percent of people with pre-diabetes in the Diabetes Prevention Program standard or control group developed type 2 diabetes each year during the average 3 years of follow-up. Other studies show that many people with pre-diabetes develop type 2 diabetes in 10 years.

Q: Is pre-diabetes the same as Impaired Glucose Tolerance or Impaired Fasting Glucose?

A: Yes. Doctors sometimes refer to this state of elevated blood glucose levels as Impaired Glucose Tolerance or Impaired Fasting Glucose (IGT/IFG), depending on which test was used to detect it.

Q: Why do we need to give it a new name? Has the condition changed?

A: The condition has not changed, but what we know about it has. We are giving IGT/IFG a new name for several reasons. Pre-diabetes is a clearer way of explaining what it means to have higher than normal blood glucose levels. It means you are likely to develop diabetes and may already be experiencing the adverse health effects of this serious condition. People with pre-diabetes are at higher risk of cardiovascular disease. People with pre-diabetes have a 1.5-fold risk of cardiovascular disease compared to people with normal blood glucose. People with diabetes have a 2- to 4-fold increased risk of cardiovascular disease. We now know that people with pre-diabetes can delay or prevent the onset of type 2 diabetes through lifestyle changes.

Q: How do I know if I have pre-diabetes?

A: Doctors can use either the fasting plasma glucose test (FPG) or the oral glucose tolerance test (OGTT) to detect pre-diabetes. Both require a person to fast overnight. In the FPG test, a person’s blood glucose is measured first thing in the morning before eating. In the OGTT, a person’s blood glucose is checked after fasting and again 2 hours after drinking a glucose-rich drink.

Q: How does the FPG test define diabetes and pre-diabetes?

A: Normal fasting blood glucose is below 100 mg/dl. A person with pre-diabetes has a fasting blood glucose level between 100 and 125 mg/dl. If the blood glucose level rises to 126 mg/dl or above, a person has diabetes.

Q: How does the OGTT define diabetes and pre-diabetes?

A: In the OGTT, a person’s blood glucose is measured after a fast and 2 hours after drinking a glucose-rich beverage. Normal blood glucose is below 140 mg/dl 2 hours after the drink. In pre-diabetes, the 2-hour blood glucose is 140 to 199 mg/dl. If the 2-hour blood glucose rises to 200 mg/dl or above, a person has diabetes.

Q: Which test is better?

A: According to the expert panel, either test is appropriate to identify pre-diabetes.

Q: Why do I need to know if I have pre-diabetes?

A: If you have pre-diabetes, you can and should do something about it. Studies have shown that people with pre-diabetes can prevent or delay the development of type 2 diabetes by up to 58 percent through changes to their lifestyle that include modest weight loss and regular exercise. The expert panel recommends that people with pre-diabetes reduce their weight by 5-10 percent and participate in some type of modest physical activity for 30 minutes daily. For some people with pre-diabetes, intervening early can actually turn back the clock and return elevated blood glucose levels to the normal range.

Q: Will my insurance cover testing and treatment?

A: Because all insurance plans are different, this is a difficult question to answer. However, Medicare and most insurance plans cover diabetes testing for people suspected of having diabetes. People at risk for diabetes are also at risk for pre-diabetes. Since the test is the same and the risk factors are the same for both conditions, a pre-diabetes test may be covered. It is best to consult your physician and health insurance representative with specific coverage questions.

Q: What is the treatment for pre-diabetes?

A: Treatment consists of losing a modest amount of weight (5-10 percent of total body weight) through diet and moderate exercise, such as walking, 30 minutes a day, 5 days a week. Don’t worry if you can’t get to your ideal body weight. A loss of just 10 to 15 pounds can make a huge difference. If you have pre-diabetes, you are at a 50 percent increased risk for heart disease or stroke, so your doctor may wish to treat or counsel you about cardiovascular risk factors, such as tobacco use, high blood pressure, and high cholesterol.

Q: Who should get tested for pre-diabetes?

A: If you are overweight and age 45 or older, you should be checked for pre-diabetes during your next routine medical office visit. If your weight is normal and you’re over age 45, you should ask your doctor during a routine office visit if testing is appropriate. For adults younger than 45 and overweight, your doctor may recommend testing if you have any other risk factors for diabetes or pre-diabetes. These include high blood pressure, low HDL cholesterol and high triglycerides, a family history of diabetes, a history of gestational diabetes or giving birth to a baby weighing more than 9 pounds, or belonging to an ethnic or minority group at high risk for diabetes.

Q: How often should I be tested?

A: If your blood glucose levels are in the normal range, it is reasonable to be checked every 3 years. If you have pre-diabetes, you should be checked for type 2 diabetes every 1-2 years after your diagnosis.

Q: Could I have pre-diabetes and not know it?

A: Absolutely. People with pre-diabetes don’t often have symptoms. In fact, millions of people have diabetes and don’t know it because symptoms develop so gradually, people often don’t recognize them. Some people have no symptoms at all. Symptoms of diabetes include unusual thirst, a frequent desire to urinate, blurred vision, or a feeling of being tired most of the time for no apparent reason.

Q: Should children be screened for pre-diabetes?

A: We are not recommending screening children for pre-diabetes because we don’t have enough evidence that type 2 diabetes can be prevented or delayed in children at high risk for the disease. However, a study published in the March 14, 2002, issue of the New England Journal of Medicine found 25 percent of very obese children and 21 percent of very obese adolescents had pre-diabetes. If future studies show that early intervention also works for children, a recommendation could be forthcoming.

· a doctor, trained to care for people with diabetes, who has cared for pregnant women with diabetes

· an obstetrician who handles high-risk pregnancies and has cared for other pregnant women with diabetes

· a pediatrician (children’s doctor) or neonatologist (doctor for newborn babies) who knows and can treat special problems that can happen in babies of women with diabetes

· a registered dietitian who can change your meal plan as your needs change during and after pregnancy

· a diabetes educator who can help you manage your diabetes during pregnancy

Pregnancy is often a time of great highs and lows. It can be awesome and thrilling — when you hear the baby’s heartbeat or feel the first tiny kick. It can be frustrating, even scary. It is always a time of change. Your body is changing as the baby grows. Because you have diabetes, these changes will affect your blood glucose level. Pregnancy can also make symptoms of low blood sglucose hard to detect. During pregnancy, your diabetes control will require more work. The blood glucose checks you do at home are a key part of taking good care of yourself and your baby before, during and after pregnancy.

Insulin and Diabetes Pills

If you have type 1 diabetes, pregnancy will affect your insulin treatment plan. During the months of pregnancy, your body’s need for insulin will go up. This is especially true during the last three months of pregnancy. The need for more insulin is caused by hormones the placenta makes. The placenta makes hormones that help the baby grow. At the same time, these hormones block the action of the mother’s insulin. As a result, your insulin needs will increase.

If you have type 2 diabetes, you too need to plan ahead. If you are taking diabetes pills to control your blood glucose, you may not be able to take them when you are pregnant. Because the safety of using diabetes pills during pregnancy has not been established, your doctor will probably have you switch to insulin right away.

Checking Your Blood Glucose

Blood checks will help you keep your blood glucose on target.

Check your blood glucose levels at the times your diabetes team advises; this may be up to eight tests daily and will probably include after-meal checks.

· Write down your results

· Keep notes on your meal plan and exercise

· Make changes in your meal plan and insulin only with the advice of your diabetes team

Pregnancy and Food

During pregnancy you and your dietitian or doctor may need to change your meal plan to avoid problems with low and high blood glucose levels. This is the most important reason for keeping track of your blood glucose results.

If you start pregnancy weighing too much, you should not try to lose weight. Instead work with your dietitian or doctor to curb how much weight you gain during pregnancy.

Your dietitian will keep track of your weight gain. If you start pregnancy at a normal weight, expect to add between 25 to 35 pounds. Women who start pregnancy too thin need to gain more. If you are obese at the start of your pregnancy, work with your dietitian to limit your weight gain to about 15-25 pounds.

Pregnancy and Exercise

Exercise, especially for people with type 2 diabetes, is a key part of diabetes treatment. Just as you need to get your blood glucose under control before getting pregnant, it’s best to get fit before you get pregnant. Can you keep your current exercise program during pregnancy? Is it safe to start exercise after you are pregnant?

Discuss your exercise plans with your diabetes team. Ask for guidelines. Exercise can help you stay healthy during pregnancy. But if you have any of the following conditions (see the list below), then you will need to talk to your diabetes team about the risks of exercise during pregnancy.

· high blood pressure

· eye, kidney, or heart problems

· damage of the small or large blood vessels

· nerve damage

In general, it’s not a good idea to start a new strenuous exercise program during pregnancy. Good exercise choices for pregnant women include walking, low-impact aerobics, swimming or water aerobics.