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In some people, an asthma episode is brought on by an allergy to something in the environment. Allergies occur when the body reacts to common harmless substances that normally don’t trigger a response in another person. These substances are called allergens.

In the person with allergic asthma, a flare-up of the airways can occur when the allergen is introduced to the body. At first, reactions may be very minor, barely noticeable. But repeated exposure gradually increases sensitivity.

In an allergic reaction, certain body cells release various chemicals. In an asthma attack brought on by an allergen, these chemicals irritate the already inflamed air passages and cause the reactions that make the airways narrow and breathing difficult.

Common things that can trigger allergic asthma include tiny particles in the air derived from:

•House dust mites

•Cockroaches

•Mold (spores)

•Plants (pollen)

•Animals dander
House Dust Mites
House dust mites are extremely small organisms that live in dust and feed on skin cells that have been shed by people. Products of dust mites are a common cause of allergies. They look like very tiny insects but are actually distant cousins of spiders. House dust mites thrive in warm, damp climates and are commonly found in mattresses, pillows, bedding, carpets, and upholstered furniture.

How-To Information

Ways to reduce exposure to dust mites:

Dust mites cannot be entirely avoided. But you should aim to lessen your exposure to them, particularly in the bedroom:

•Put plastic zippered covers on mattresses and pillows.

•In the bedroom, move out anything that collects dust (including the carpet if possible) and avoid upholstered furniture and clutter.

•Wash all bedding each week in hot water (at least 130º F).

•Linoleum, tile, and hardwood floors are best for minimizing both dust and dust mites.

•If possible, try to have someone who does not have allergic asthma do the vacuuming when you are not in the bedroom.

•Vacuuming will not get rid of mites, and in fact spreads them up into the air for several minutes before they settle again. Try to use a vacuum cleaner with a HEPA air filter (which stands for “high efficiency particle arresting”) or a double-layer collecting bag.

•Keep the humidity in the room low, around 35% if possible (never over 50%), because high humidity encourages dust mite growth.

•Curtains should be laundered often; it is better to avoid heavy curtains and use window coverings such as easy-to-clean blinds.
 

Cockroaches
The dried-up body parts of dead cockroaches are a very potent stimulator of asthma in those allergic to them. Regular cockroach control is essential to good control of asthma for people allergic and exposed to them. This can be a particular problem in big cities.

Mold
Mold is the greenish, gray, or black material that grows in damp places. Molds or fungi release microscopic particles called spores for their reproduction. These spores can float through open windows into the house, especially on cool nights in the spring and fall. Asthma attacks may also be triggered by the type of mold that grows in the house.

How-To Information

Ways to reduce exposure to molds include:

•The use of air conditioners and dehumidifiers to reduce humidity. (They must be cleaned often to prevent mold growth.)

•Regular ventilation of the kitchen, bathroom, basement, and other damp areas of the house. (Exhaust fans in the kitchen and bathrooms work well.)

•Cleaning out mold from damp places in the house such as shower stalls, and clearing out moldy objects from closets. Use a spray cleaner with a fungicide in it.

•Keeping bedroom windows closed to keep out mold spores and pollen.

•Keeping drainage from rain water away from the house, in order to decrease humidity in the basement.

Pollen
Pollen are microscopic particles released by plants for their reproduction. Pollen is more a cause of hay fever than asthma. But there are some people with allergic asthma who clearly have problems with ragweed and other typical plant pollens that can cause a flare-up in their asthma.

Make note of whether your episodes of asthma are worse when the pollen count is high.

How-To Information

To prevent allergic reactions due to pollens:

•Pay attention to the pollen count in your area. Whenever necessary, keep the windows shut.

•Air conditioning can be very helpful in minimizing pollen entry into the house and in keeping the humidity down. But check with your doctor before purchasing expensive equipment.

•On days of high mold and pollen counts, if you have been outside for a prolonged period, take a shower and wash your hair before bedtime (to get the pollen and mold out). Also, leave your outdoor clothes out of the bedroom.

•Change pillowcases every two to three days.

 Animal Hair And Dander
Many people are allergic to a substance in the saliva and on the skin of furry animals. This substance, called dander, is a powerful allergen. It gets on a dog’s or cat’s coat and is spread into the air and onto surfaces.

Dander can float through the air for hours. Cat allergen particles, for example, are only about one-tenth the size of dust mite allergen particles and can escape the filtration system on most vacuums. Cat dander can still be found in the dust of a house even months after a pet has left.

Hamsters, gerbils, mice, and rats can produce the same problem. In some individuals, fine particles on feathers may also set off an allergic reaction.

Nice To Know

Animal allergens are a potent stimulator of asthma. It is very likely that frequent asthma symptoms in someone living with a furry pet are caused by the pet.
 

How-To Information

To prevent allergic reactions due to exposure to animals:

•The best way to deal with pet allergy is to find the pet another home.

•If this is out of the question, the pet should be kept outdoors as much as possible and never allowed into the bedroom.

•Frequent washing (twice weekly at least) of the pet may also reduce the presence of animal dander in the home. Dog washing does not present any major problems when animal shampoo and lukewarm water are used. Cats present a greater challenge but can be slowly accustomed to the ritual by associating a positive experience such as feeding with the bath. Shampoo is not needed nor is it necessary to immerse the cat in water. A gentle wiping with a damp cloth will help remove some of the cat dander.

•Deciding what to do about a pet is not easy, but if its presence really worsens the asthma condition, making the hard decision is the right thing to do.

We don’t know what causes asthma. But we do know that:

•Asthma and allergies are likely to run in families and may be inherited.

•Children who have allergies at a young age may be at greater risk for developing asthma as adults.

•Some adults with asthma also had asthma as teenagers and as children. In some individuals, the condition may become less severe over time, but in others, the reappearance of symptoms in adulthood occurs. A respiratory infection sometimes sets it off, but often there is no apparent reason for the reoccurrence or increase in symptoms.For more information about asthma in children, go to Asthma In Children.

Certain conditions seem to make asthma worse. And for some it seems to be worse on certain days and at different times of the year. Asthma symptoms occur when sensitive lungs overreact to certain factors called triggers . These irritating factors are part of the environment in which we live and are different for different people.

•Allergies are a common asthma trigger.

•Other asthma triggers range from dust to air pollution, from exercise to weather changes.

Asthma is a condition that affects the air passages of the lungs. It is a two-step problem:

•When a person has asthma, the air passages are inflamed, which means that the airways are red and swollen.

•Inflammation of the air passages makes them over extra-sensitive to a number of different things that can “trigger,” or bring on, asthma symptoms.
During breathing, air is normally brought in through the nose where it is warmed, filtered, and humidified. It then passes through the throat and into the windpipe, called the trachea (TRAY-kee-a). The trachea divides into two large tubes called the right bronchus (BRONG-kus) and left bronchus. These then split up into much smaller tubes, which in turn branch into thousands of very small airways called bronchioles (BRONG-kee-olz). It is the large and small bronchi that are generally affected in asthma.

 When a person is exposed to one of these irritants, or triggers, the oversensitive air passages react by becoming narrower, swollen, and even more inflamed. This obstructs airflow to and from the lungs and makes it very difficult for the person to breathe.

Nice To Know

Is All Asthma The Same?

Asthma is a chronic condition. This means that while it often looks like it goes away for awhile, the inflammation of the air passages remains present all the time. However, in some instances, this inflammation may go unnoticed for long periods of time. As long as the air passages are inflamed, asthma can flare up at any time. This is one of the reasons that an awareness of the triggers that cause the flare-ups is so important in preventing asthma episodes.

•Allergic asthma – Allergic asthma is most common in children and adolescents. Usually, but not always, the allergies that cause the asthma appear before the age of 35. An asthma attack or episode occurs when a person comes into contact with something to which he or she has developed an allergy.

•Nonallergic asthma – This type of asthma is most common in middle-aged adults. Asthma attacks may occur in response to triggers such as exercise, cold air, or respiratory infections. The allergic mechanism is not responsible for the asthmatic reaction.
 

What Is An Asthma Episode (Asthma Attack)?
Asthma symptoms can vary from very mild to very severe. Some adults with asthma have only seasonal bouts of symptoms. Some have symptoms only after exercise or after exposure to something to which they are allergic, such as a dog or cat. Others have a chronic form of the disease and experience asthma symptoms almost daily.

In an “asthma episode,” also known as an “asthma attack,” the symptoms develop because the oversensitive airways of the lung react by becoming more inflamed and narrows, thus obstructing the normal flow of air through the air passages. The reduced size of the air passages occurs because:

•The muscles around the airways tighten

•The linings of the airways become swollen

•The normal secretion of the airways (called mucus) becomes “trapped,” thus clogging the airways
As the airways become narrower and more obstructed, it takes extra effort to breathe and force air through them. The air may make a whistling or wheezing sound as it goes past the narrowed parts of the air passages. A person having an asthma attack may also cough a lot and spit up a lot of very sticky mucus.

So one or more of the following symptoms may occur once the airways have narrowed in response to a trigger:

•Coughing. Coughing is often a sign of asthma, but is easily overlooked. As a general rule, healthy people don’t cough unless they have something in their throats or have a cold.

•Wheezing. Wheezing is a whistling noise heard during breathing, as if something is “caught” in one of the breathing passages.

•Tightness of the chest. Many adults with asthma describe a tightness of the chest, an uncomfortable feeling caused by over-inflation of the lungs due to difficulty in pushing air out through the narrowed airways.

•Shortness of breath. Shortness of breath is the feeling that a breath is barely finished before another is needed. It has been described as “air hunger” by some people.

•Mucus production. Many people with asthma produce excessive, thick mucus that obstructs the airways, which can lead to coughing.
For many people, asthma symptoms are worse at night and in the early morning or after exercise. Furthermore, an asthma episode often gives early warning signs, thus giving the person time to act.

Nice To Know

Q. What makes my breathing passages so sensitive to triggers?

A. The underlying cause of the sensitivity in the airways is inflammation. Inflamed airways are highly reactive to triggers. In other words, they are easily irritated and respond by contracting, swelling, and filling with thick mucus. Some of the breathing passages don’t have much supporting cartilage in their walls the way the windpipe does. As a result, they are not very “stiff” and are easily squeezed closed. Think of them as tiny tubes with thin muscle fibers wrapped around them like “rubber bands.” If the “rubber bands” (airway muscle) tighten, the thin-walled passages are more easily choked off, making you short of breath.
 

Are Asthma Episodes Dangerous?
Most of the time asthma episodes are mild, and the airways will open up in a few minutes to a few hours in response to medication. But some attacks can be severe, lasting for a long time and not responding to the regular medication. And they can be very dangerous. A very severe, prolonged attack can threaten a person’s life. Such an episode requires immediate emergency attention in a hospital.

Learning to recognize signals and take action to prevent asthma symptoms from becoming worse is an important step in the long-term control of asthma. So is managing an episode if it does occur.

Learning all about asthma will ultimately help a person have fewer and milder episodes and reduce the risk of a more serious attack. This includes understanding about:

•The way your lungs work

•The things that cause asthma episodes

•The ways you can avoid those things

•The medicines that help prevent and control symptoms
What Does “Good Asthma Control” Mean?
The long-term goal in asthma management is “good asthma control.” In fact, because of a better understanding of the disease and the development of newer drugs, drug treatments are so effective that many adults with asthma can go for long periods of time without symptoms.

Good asthma control includes the following goals:

•There is no wheezing, coughing, or shortness of breath.

•Nighttime sleep is not interrupted by asthma symptoms.

•Exercise and daily activities can be carried out normally.

•Reliever medication is used less than three times per week.
For asthma treatment to be successful you need to learn all you can about asthma and its treatment, work closely with your doctor, and cooperate fully with other members of your health care team.

Facts About Asthma

•The process of moving air into and out of the lungs is something most people take for granted. But for as many as 15 million Americans living with asthma, this simple activity requires significant effort.
•Asthma cannot be cured, but with proper treatment it can be effectively controlled. Good asthma control allows most adults to live full, active, trouble-free lives.
•Without satisfactory control of asthma, long-term damage can occur in the respiratory system. Poorly controlled asthma can lead to reduced physical activities, missed work, and extra visits to the emergency department.
•For most adults with asthma, a reduced quality of life doesn’t have to happen. Arming yourself with information is an important step in maintaining a healthy life.

Definition
Asthma is a chronic inflammatory disease of the airways in the lungs. This inflammation periodically causes the airways to narrow, producing wheezing and breath-lessness sometimes to the point where the patient gasps for air. This obstruction of the air flow either stops spontaneously or responds to a wide range of treatments. Continuing inflammation makes asthmatics hyper-responsive to such stimuli as cold air, exercise, dust, pollutants in the air, and even stress or anxiety.

Description
Between 16 and 17 million Americans have asthma and the number has been rising since 1980. As many as 9 million U.S. children under age 18 may have asthma. Blacks, Hispanics, American Indians, and Alaskan natives had higher rates of asthma-control problems than whites or Asians in the United States.

The changes that take place in the lungs of asthmatics make their airways (the bronchi and the smaller bronchioles) hyper-reactive to many different types of stimuli that do not affect healthy lungs. In an asthma attack, the muscle tissue in the walls of the bronchi go into spasm, and the cells that line the airways swell and secrete mucus into the air spaces. Both these actions cause the bronchi to narrow, a change that is called bronchoconstriction. As a result, an asthmatic person has to make a much greater effort to breathe.

Cells in the bronchial walls, called mast cells, release certain substances that cause the bronchial muscle to contract and stimulate mucus formation. These substances, which include histamine and a group of chemicals called leukotrienes, also bring white blood cells into the area. Many patients with asthma are prone to react to substances such as pollen, dust, or animal dander; these are called allergens. Many people with asthma do not realize that allergens are triggering their attacks. On the other hand, asthma also affects many patients who are not allergic in this way.

Asthma usually begins in childhood or adolescence, but it also may first appear in adult life. While the symptoms may be similar, certain important aspects of asthma are different in children and adults. When asthma begins in childhood, it often does so in a child who is likely, for genetic reasons, to become sensitized to common allergens in the environment. Such a child is known as an atopic person. In 2004, scientists in Helsinki, Finland, identified two new genes that cause atopic asthma. The discovery might lead to earlier prediction of asthma in children and adults. When these children are exposed to dust, animal proteins, fungi, or other potential allergens, they produce a type of antibody that is intended to engulf and destroy the foreign materials. This has the effect of making the airway cells sensitive to particular materials. Further exposure can lead rapidly to an asthmatic response. This condition of atopy is present in at least one third and as many as one half of the general population. When an infant or young child wheezes during viral infections, the presence of allergy (in the child or a close relative) is a clue that asthma may well continue throughout childhood.

Allergenic materials may also play a role when adults become asthmatic. Asthma can start at any age and in a wide variety of situations. Many adults who are not allergic have such conditions as sinusitis or nasal polyps, or they may be sensitive to aspirin and related drugs. Another major source of adult asthma is exposure at work to animal products, certain forms of plastic, wood dust, metals, and environmental pollution.

Causes & symptoms
In most cases, asthma is caused by inhaling an allergen that sets off the chain of biochemical and tissue changes leading to airway inflammation, bronchoconstriction, and wheezing. Because avoiding (or at least minimizing) exposure is the most effective way of treating asthma, it is vital to identify which allergen or irritant is causing symptoms in a particular patient. Once asthma is present, symptoms can be set off or made worse if the patient also has rhinitis (inflammation of the lining of the nose) or sinusitis. When, for some reason, stomach acid passes back up the esophagus in a reaction called acid reflux, this condition also can make asthma worse. In addition, a viral infection of the respiratory tract can inflame an asthmatic reaction. Aspirin and drugs called beta-blockers, often used to treat high blood pressure, also can worsen the symptoms of asthma. But the most important inhaled allergens giving rise to attacks of asthma are:

animal dander
dust mites
fungi (molds) that grow indoors
INHALED ALLERGENS MOST OFTEN TRIGGERING ASTHMA ATTACKS
Air pollutants
Animal dander
Cockroach allergens
Dust mites
Indoor fungi (molds)
Occupational allergens such as chemicals, fumes, particles of industrial materials
Pollen

cockroach allergens
pollen
occupational exposure to chemicals, fumes, or particles of industrial materials
tobacco smoke
air pollutants
In addition, there are three important factors that regularly produce attacks in certain asthmatic patients, and they may sometimes be the sole cause of symptoms. They are:

inhaling cold air (cold-induced asthma)
exercise-induced asthma (in certain children, asthma attacks are caused simply by exercising)
stress or a high level of anxiety
Wheezing often is obvious, but mild asthmatic attacks may be confirmed when the physician listens to the patient’s chest with a stethoscope. Besides wheezing and being short of breath, the patient may cough or report a feeling of tightness in the chest. Children may have itching on their back or neck at the start of an attack. Wheezing often is loudest when the patient exhales. Some asthmatics are free of symptoms most of the time but may occasionally be short of breath for a brief time. Others spend much of their days (and nights) coughing and wheezing until properly treated. Crying or even laughing may bring on an attack. Severe episodes often are seen when the patient gets a viral respiratory tract infection or is exposed to a heavy load of an allergen or irritant. Asthmatic attacks may last only a few minutes or can go on for hours or even days. Being short of breath may cause a patient to become very anxious, sit upright, lean forward, and use the muscles of the neck and chest wall to help breathe. The patient may be able to say only a few words at a time before stopping to take a breath. Confusion and a bluish tint to the skin are clues that the

OCCUPATIONS ASSOCIATED WITH ASTHMA
Animal Handling
Bakeries
Health Care
Jewelry Making
Laboratory Work
Manufacturing Detergents
Nickel Plating
Soldering
Snow Crab and Egg Processing
Tanneries

oxygen supply is much too low and that emergency treatment is needed. In a severe attack, some of the air sacs in the lung may rupture so that air collects within the chest, which makes it even harder to breathe. The good news is that almost always, even patients with the most severe attacks will recover completely.

Diagnosis
Apart from listening to the patient’s chest, the examiner should look for maximum chest expansion while taking in air. Hunched shoulders and contracting neck muscles are other signs of narrowed airways. Nasal polyps or increased amounts of nasal secretions are often noted in asthmatic patients. Skin changes, like dermatitis or eczema, are a clue that the patient has allergic problems. Inquiring about a family history of asthma or allergies can be a valuable indicator of asthma. A test called spirometry measures how rapidly air is exhaled and how much is retained in the lungs. Repeating the test after the patient inhales a drug that widens the air passages (a bronchodilator) will show whether the narrowing of the airway is reversible, which is a very typical finding in asthma. Often patients use a related instrument, called a peak flow meter, to keep track of asthma severity when at home.

Frequently, it is difficult to determine what is triggering asthma attacks. Allergy skin testing may be used, although an allergic skin response does not always mean that the allergen being tested is causing the asthma. Also, the body’s immune system produces an antibody to fight off the allergen, and the amount of antibody can be measured by a blood test. The blood test will show how sensitive the patient is to a particular allergen. If the diagnosis is still in doubt, the patient can inhale a suspect allergen while using a spirometer to detect airway narrowing. Spirometry also can be repeated after a bout of exercise if exercise-induced asthma is a possibility. A chest x-ray will help rule out other disorders.

Treatment
There are many alternative treatments available for asthma that have shown promising results. One strong argument for these treatments is that they try to avoid the drugs that allopathic treatment (combating disease with remedies to produce effects different from those produced by the disease) relies upon, which can be toxic and addictive. Mainstream journals have reported on the toxicity of asthma pharmaceuticals. A 1995 New Zealand study showed that before 1940, death from asthma was very low, but that the death rate promptly increased with the introduction of bronchodilators. The New England Journal of Medicine in 1992 reported that albuterol and other asthma drugs cause the lungs to deteriorate when used regularly. A 1989 study in the Annals of Internal Medicine showed that respiratory therapists, who are exposed to bronchodilator sprays, develop asthma five times more often than other healthcare professionals, which could imply that the drugs themselves may induce asthma. Theophylline, another popular drug, has been reported to cause personality changes in users. Steroids can also have negative effects on many systems in the body, particularly the hormonal system. Thus, natural and non-toxic methods for treating asthma are the preferred first choice of alternative practitioners, while drugs are used to manage extreme cases and emergencies.

Alternative medicine tends to view asthma as the body’s protective reaction to environmental agents and pollutants. As such, the treatment goal is often to restore balance to and strengthen the entire body and provide specific support to the lungs, immune and hormonal systems. Asthma sufferers can help by keeping a diary of asthma attacks in order to determine environmental and emotional factors that may be contributing to their condition.

Alternative treatments have minimal side effects, are generally inexpensive, and are convenient forms of selftreatment. They also can be used alongside allopathic treatments to improve their effectiveness and lessen their negative side effects.

Dietary and nutritional therapies
Some alternative practitioners recommend cutting down on or eliminating dairy products from the diet, as

these increase mucus secretion in the lungs and are sources of food allergies. Other recommendations include avoiding processed foods, refined starches and sugars, and foods with artificial additives and sulfites. Diets should be high in fresh fruits, vegetables, and whole grains, and low in salt. Asthma sufferers should experiment with their diets to determine if food allergies are playing a role in their asthma. Some studies have shown that a sustained vegan (zero animal foods) diet can be effective for asthma, as it does not contain the animal products that frequently cause food allergies and contain chemical additives. A vegan diet also eliminates a fatty acid called arachidonic acid, which is found in animal products and is believed to contribute to allergic reactions. A 1985 Swedish study showed that 92% of patients with asthma improved significantly after one year on a vegan diet. On the other hand, some people feel weaker on a vegan diet. In addition, many people are allergic to vegetables rather than to meat.

Plenty of water should also be drunk by asthma sufferers, as water helps to keep the passages of the lungs moist. Onions and garlic contain quercetin, a flavonoid (a chemical compound/biological response modifier) that inhibits the release of histamine, and should be a part of an asthmatic’s diet. Quercetin also is available as a supplement, and should be taken with the digestive enzyme bromelain to increase its absorption.

As nutritional therapy, vitamins A, C and E have been touted as important. Also, the B complex vitamins, particularly B6 and B12, may be helpful for asthma, as well as magnesium, selenium, and an omega-3 fatty acid supplement such as flaxseed oil. A good multivitamin supplement also is recommended. In 2004, a study of supplements at Cornell University showed that high levels of beta-carotene and vitamin C along with selenium lowered risk of asthma. However, the same study found that vitamin E had no effect.

Herbal remedies
Chinese medicine has traditionally used ma huang, or ephedra, for asthma attacks. It contains ephedrine, which is a bronchodilator used in many drugs. However, the U.S. Food and Drug Administration (FDA) issued a ban on the sale of ephedra that took effect in April 2004 because it was shown to raise blood pressure and stress the circulatory system, resulting in heart attacks and strokes for some users. Ginkgo has been shown to reduce the frequency of asthma attacks, and licorice is used in Chinese medicine as a natural decongestant and expectorant. There are many formulas used in traditional Chinese medicine to prevent or ease asthma attacks, depending on the specific Chinese diagnosis given by the practitioner. For example, ma huang is used to treat socalled “wind-cold” respiratory ailments.

Other herbs used for asthma include lobelia, also called Indian tobacco; nettle, which contains a natural antihistamine; thyme; elecampane mullein: feverfew; passionflower: saw palmetto: and Asian ginseng. Coffee and tea have been shown to reduce the severity of asthma attacks because caffeine works as a bronchodilator. Tea also contains minute amounts of theophylline, a major drug used for asthma. Ayurvedic (traditional East Indian) medicine recommends the herb Tylophora asthmatica.

Mind/body approaches
Mind/body medicine has demonstrated that psychological factors play a complex role in asthma. Emotional stress can trigger asthma attacks. Mind/body techniques strive to reduce stress and help asthma sufferers manage the psychological component of their condition. A 1992 study by Dr. Erik Peper at the Institute for Holistic Healing Studies in San Francisco used biofeedback, a treatment method that uses monitors to reveal physiological information to patients, to teach relaxation and deep breathing methods to 21 asthma patients. Eighty percent of them subsequently reported fewer attacks and emergency room visits. A 1993 study by Kaiser Permanente in Northern California worked with 323 adults with moderate to severe asthma. Half the patients got standard care while the other half participated in support groups. The support group patients had cut their asthma-related doctor visits in half after two years. Some other mind/body techniques used for asthma include relaxation methods, meditation, hypnotherapy,, mental imaging, psychotherapy, and visualization.

Yoga and breathing methods
Studies have shown that yoga significantly helps asthma sufferers, with exercises specifically designed to expand the lungs, promote deep breathing, and reduce stress. Pranayama is the yogic science of breathing, which includes hundreds of deep breathing techniques. These breathing exercises should be done daily as part of any treatment program for asthma, as they are a very effective and inexpensive measure.

Controlled exercise

Many people believe that those with asthma should not exercise. This is particularly true among parents of children with asthma. In a 2004 study, researchers reported that 20% of children with asthma do not get enough exercise. Many parents believe it is dangerous for their children with asthma to exercise, but physical activity benefits all children, including those with asthma. Parents should work with the child’s healthcare provider and any coach or organized sport leader to carefully monitor his or her activities.

Acupuncture
Acupuncture can be an effective treatment for asthma. It is used in traditional Chinese medicine along with dietary changes. Acupressure can also be used as a self-treatment for asthma attacks and prevention. The Lung 1 points, used to stimulate breathing, can be easily found on the chest. These are sensitive, often knotted spots on the muscles that run horizontally about an inch below the collarbone, and about two inches from the center of the chest. The points can be pressed in a circular manner with the thumbs, while the head is allowed to hang forward and the patient takes slow, deep breaths. Reflexology also uses particular acupressure points on the hands and feet that are believed to stimulate the lungs.

Other treatments
Aromatherapists recommend eucalyptus, lavender, rosemary, and chamomile as fragrances that promote free breathing. In Japan, a common treatment for asthma is administering cold baths. This form of hydrotherapy has been demonstrated to open constricted air passages. Massage therapies such as Rolfing can help asthma sufferers as well, as they strive to open and increase circulation in the chest area. Homeopathy uses the remedies Arsenicum album, Kali carbonicum, Natrum sulphuricum, and Aconite.

Allopathic treatment
Allopaths recommend that asthma patients should be periodically examined and have their lung functions measured by spirometry. The goals are to prevent troublesome symptoms, to maintain lung function as close to normal as possible, and to allow patients to pursue their normal activities, including those requiring exertion. The best drug therapy is that which controls asthmatic symptoms while causing few or no side effects.

Drugs
The chief methylxanthine drug is theophylline. It may exert some anti-inflammatory effect and is especially helpful in controlling nighttime symptoms of asthma. When, for some reason, a patient cannot use an inhaler to maintain long-term control, sustained-release theophylline is a good alternative. The blood levels of the drug must be measured periodically, as too high a dose can cause an abnormal heart rhythm or convulsions.

Beta-receptor agonists (drugs that trigger cell response) are bronchodilators. They are the drugs of choice for relieving sudden attacks of asthma and for preventing attacks from being triggered by exercise. Some agonists, such as albuterol, act mainly in lung cells and have little effect on the heart and other organs. These drugs generally start acting within minutes, but their effects last only four to six hours. They may be taken by mouth, inhaled, or injected. In 2004, a new lower concentration of albuterol was approved by the FDA for children ages two to 12.

Steroids are drugs that resemble natural body hormones. They block inflammation and are effective in relieving symptoms of asthma. When steroids are taken by inhalation for a long period, asthma attacks become less frequent as the airways become less sensitive to allergens. Steroids are the strongest medicine for asthma, and can control even severe cases over the long term and maintain good lung function. However, steroids can cause numerous side effects, including bleeding from the stomach, loss of calcium from bones, cataracts in the eye, and a diabetes-like state. Patients using steroids for lengthy periods may also have problems with wound healing, may gain weight, and may suffer mental problems. In children, growth may be slowed. Besides being inhaled, steroids may be taken by mouth or injected, to rapidly control severe asthma.

Leukotriene modifiers are among a newer type of drug that can be used in place of steroids, for older children or adults who have a mild degree of persistent asthma. They work by counteracting leukotrienes, which are substances released by white blood cells in the lung that cause the air passages to constrict and promote mucus secretion. Other drugs include cromolyn and nedocromil, which are anti-inflammatory drugs that often are used as initial treatments to prevent long-term asthmatic attacks in children. Montelukast sodium (Singulair) is a drug taken daily that is used to help prevent asthma attacks rather than to treat an acute attack. In 2004, the FDA approved an oral granule formula of Singulair for young children.

If a patient’s asthma is caused by an allergen that cannot be avoided and it has been difficult to control symptoms by drugs, immunotherapy may be worth trying. In a typical course of immunotherapy, increasing amounts of the allergen are injected over a period of three to five years, so that the body can build up an effective immune response. There is a risk that this treatment may itself cause the airways to become narrowed and bring on an asthmatic attack. Not all experts are enthusiastic about immunotherapy, although some studies have shown that it reduces asthmatic symptoms caused by exposure to dust mites, ragweed pollen, and cats.

Managing asthmatic attacks
A severe asthma attack should be treated as quickly as possible. It is most important for a patient suffering an acute attack to be given extra oxygen. Rarely, it may be necessary to use a mechanical ventilator to help the patient breathe. A beta-receptor agonist is inhaled repeatedly or continuously. If the patient does not respond promptly and completely, a steroid is given. A course of steroid therapy, given after the attack is over, will make a recurrence less likely.

Long-term allopathic treatment for asthma is based on inhaling a beta-receptor agonist using a special inhaler that meters the dose. Patients must be instructed in proper use of an inhaler to be sure that it will deliver the right amount of drug. Once asthma has been controlled for several weeks or months, it is worth trying to cut down on drug treatment, but this tapering must be done gradually. The last drug added should be the first to be reduced. Patients should be seen every one to six months, depending on the frequency of attacks. Starting treatment at home, rather than in a hospital, makes for minimal delay and helps the patient to gain a sense of control over the disease. All patients should be taught how to monitor their symptoms so that they will know when an attack is starting. Those with moderate or severe asthma should know how to use a flow meter. They also should have a written plan to follow if symptoms suddenly become worse, including how to adjust their medication and when to seek medical help. If more intense treatment is necessary, it should be continued for several days. When deciding whether a patient should be hospitalized, the physician must take into account the patient’s past history of acute attacks, severity of symptoms, current medication, and the availability of good support at home.

Expected results
Most patients with asthma respond well when the best treatment or combination of treatments is found and they are able to lead relatively normal lives. Patients who take responsibility for their condition and experiment with various treatments have good chances of keeping symptoms minimal. Having urgent measures to control asthma attacks and ongoing treatment to prevent attacks are important as well. More than one half of affected children stop having attacks by the time they reach 21 years of age. Many others have less frequent and less severe attacks as they grow older. A small minority of patients will have progressively more trouble breathing. Because they run a risk of going into respiratory failure, they must receive intensive treatment.

Prevention
Prevention is extremely important in the treatment of asthma, which includes eliminating all possible allergens from the environment and diet. Homes and work areas should be as dust and pollutant-free as possible. Areas can be tested for allergens and high-quality air filters can be installed to clean the air. If the patient is sensitive to a family pet, removing the animal or at least keeping it out of the bedroom (with the bedroom door closed) is advised. Keeping the pet away from carpets and upholstered furniture, and removing all feathers also helps. To reduce exposure to dust mites, it is recommended to remove wall-to-wall carpeting, keep the humidity low, and use special pillows and mattress covers. Cutting down on stuffed toys, and washing them each week in hot water, is advised for children with asthma. If cockroach allergen is causing asthma attacks, controlling the roaches (using traps or boric acid rather than chemicals) can help.

It is important to not to leave food or garbage exposed. Keeping indoor air clean by vacuuming carpets once or twice a week (with the asthmatic person absent), and avoiding use of humidifiers is advised. Those with asthma should avoid exposure to tobacco smoke and should not exercise outside when air pollution levels are high. When asthma is related to exposure at work, taking all precautions, including wearing a mask and, if necessary, arranging to work in a safer area, is recommended. For chronic sufferers who live in heavily polluted areas, moving to less polluted regions may even be a viable alternative.

Tuberculosis (TB) describes an infectious disease that has plagued humans since the Neolithic times. Two organisms cause tuberculosis — Mycobacterium tuberculosis and Mycobacterium bovis.

Physicians in ancient Greece called this illness “phthisis” to reflect its wasting character. During the 17th and 18th centuries, TB caused up to 25% of all deaths in Europe. In more recent times, tuberculosis has been called “consumption.”

•Robert Koch isolated the tubercle bacillus in 1882 and established TB as an infectious disease.

 ◦In the 19th century, patients were isolated in sanatoria and given treatments such as injecting air into the chest cavity. Attempts were made to decrease lung size by surgery called thoracoplasty.

 ◦During the first half of the 20th century, no effective treatment was available.

 ◦Streptomycin, the first antibiotic to fight TB, was introduced in 1946, and isoniazid (Laniazid, Nydrazid) became available in 1952.

•M. tuberculosis is a rod-shaped, slow-growing bacterium.

 ◦M. tuberculosis’ cell wall has high acid content, which makes it hydrophobic, resistant to oral fluids.

 ◦The cell wall absorbs a certain dye used in the preparation of slides for examination under the microscope and maintains this red color despite attempts at decolorization, hence the name acid-fast bacilli.

•M. tuberculosis continues to kill millions of people yearly worldwide. In 1995, 3 million people died from TB.

 ◦More than 90% of TB cases occur in developing nations that have poor resources and high numbers of people infected with HIV.
•In the United States, the incidence of TB began to decline around 1900, because of improved living conditions.

 ◦TB cases have increased since 1985, most likely due to the increase in HIV.
•Tuberculosis continues to be a major health problem worldwide. In 2008, the World Health Organization (WHO) estimated that one-third of the global population was infected with TB bacteria.

 ◦8.8 million new cases of TB developed.

 ◦1.6 million people died of this disease in 2005.

 ◦Each person with untreated active TB will infect on average 10-15 people each year.

 ◦A new infection occurs every second.

 •With the spread of AIDS, tuberculosis continues to lay waste to large populations. The emergence of drug-resistant organisms threatens to make this disease once again incurable.

The frequency of migraine headaches described as crushing, vicelike or eye-popping can be reduced by Botulinum shots used for cosmetics.

Migraine headaches affect approximately 28 million Americans, known to cause pain that is often debilitating. Researchers conducting clinical trials on botulinum toxin type A to treat facial

lines recognized a correlation between the shots and the alleviation of migraine symptoms.

Christine C. Kim, then of SkinCare Physicians, Chestnut Hill, Massachusetts, and now a private practitioner in Encino, California, and colleagues studied patients (average age 50.9 years) who

had already received or were planning to receive botulinum injections for cosmetic purposes but also reported having migraines.

Three months after treatment, more than two thirds of the patients had responded to the treatment with a reduction in migraine pain, including those who had imploding or ocular headaches and

those who had exploding headaches.

A JAMA release said that a third of the patients who did not respond had exploding headaches.

February issue of Archives of Dermatology has published these findings in the February issue of Archives of Dermatology. (With Input from Agencies)

Symptoms of migraine headaches differ from individual to individual and in the type of migraine the person suffers from. Here are 5 commonly recognized phases of migraine headaches.

1. Prodome
   A range of caveats could arise prior to onset of a migraine. These could comprise of an alteration in moods (for instance, a person would feel high, irate or feel depressed or low) or a faint variation of sensations (for instance, a weird taste or odor). Weariness and muscular tensions are additionally prevalent.
2. Aura
   This is prevalently an optical interruption or disturbance which develops prior to the headache stage. A number of people ailing from migraine would start developing blind spots known as scotomas; start seeing geometrical pattern types or blinking, multihued lights or eyesight loss on either left or right side – a condition known as hemianopsia.
3. Headache
   Though migraine-related pains generally appear on either left or right side of the head, thirty to forty percent of migraines develop on both the sides. Excruciating pains could develop. Over eighty percent of migraine sufferers experience feeling nauseous and several of them even sense vomiting. Nearly seventy percent of them show sensitiveness to light or photophobia and sounds – a condition is known as phonophobia. This stage could endure four to seventy-two hours.

Headache extinction

 
Even in case the headache is not treated, the pain would generally subside when a person gets some sleep.

1. Postdrome
   Other migraine signs and symptoms, for instance, unable to consume foods or liquids, issues with focusing or weariness could last subsequent to the pain having subsided.

Migraines headaches symptoms could arise in varied permutations and comprise of:

• Pains felt ranging from moderate to acute intensity (mostly illustrated as hammering, agonizing pains) which could afflict the entire head or could shift from the right to the left side of the head.
• Sensitiveness to illumination, noises or smells.
• Blurriness in vision.
• Feeling nauseous or puking, abdominal upset and pains.
• Lowered craving for foods.
• Feeling quite tepid or nippy.
• Pastiness.
• Exhaustion.
• Atypically fever develops.
• Vivid blinking dots/lights, undulating or serrated lines, blind spots – all indicators of aura.

Migraines could have a considerable damaging impact on the productivity of people suffering from them and is among the most prevalent complaints encountered by physicians.

Though drug therapies are effectual, individuals ailing from migraine could avail a wide-ranging array of complementary and alternative treatments which are intended to reduce stress like biofeedback technique. There are supplementary non-conventional headache treatments inclusive of acupuncture, massages, essential oils (ginger, peppermint, and lavender), herbs and dietetic modifications which vary in their degree of efficacy.

Several studies have shown potential benefits of taking supplements like melatonin and coenzyme Q10.

Migraine is a chronic condition with recurrent attacks. Most (but not all) migraine attacks are associated with headaches.

•Migraine headaches usually are described as an intense, throbbing or pounding pain that involves one temple. (Sometimes the pain is located in the forehead, around the eye, or at the back of the head).
•The pain usually is unilateral (on one side of the head), although about a third of the time the pain is bilateral (on both sides of the head).
•The unilateral headaches typically change sides from one attack to the next. (In fact, unilateral headaches that always occur on the same side should alert the doctor to consider a secondary headache, for example, one caused by a brain tumor).
•A migraine headache usually is aggravated by daily activities such as walking upstairs.
•Nausea, vomiting, diarrhea, facial pallor, cold hands, cold feet, and sensitivity to light and sound commonly accompany migraine headaches. As a result of this sensitivity to light and sound, migraine sufferers usually prefer to lie in a quiet, dark room during an attack. A typical attack lasts between 4 and 72 hours.
An estimated 40%-60% of migraine attacks are preceded by premonitory (warning) symptoms lasting hours to days. The symptoms may include:

•sleepiness,
•irritability,
•fatigue,
•depression or euphoria,
•yawning, and
•cravings for sweet or salty foods.
Patients and their family members usually know that when they observe these warning symptoms that a migraine attack is beginning.

Migraine aura
An estimated 20% of migraine headaches are associated with an aura. Usually, the aura precedes the headache, although occasionally it may occur simultaneously with the headache. The most common auras are:

1.flashing, brightly colored lights in a zigzag pattern (referred to as fortification spectra), usually starting in the middle of the visual field and progressing outward; and
2.a hole (scotoma) in the visual field, also known as a blind spot.
Some elderly migraine sufferers may experience only the visual aura without the headache. A less common aura consists of pins-and-needles sensations in the hand and the arm on one side of the body or pins-and-needles sensations around the mouth and the nose on the same side. Other auras include auditory (hearing) hallucinations and abnormal tastes and smells.

For approximately 24 hours after a migraine attack, the migraine sufferer may feel drained of energy and may experience a low-grade headache along with sensitivity to light and sound. Unfortunately, some sufferers may have recurrences of the headache during this period.

A migraine headache is a form of vascular headache. Migraine headache is caused by vasodilatation (enlargement of blood vessels) that causes the release of chemicals from nerve fibers that coil around the large arteries of the brain. Enlargement of these blood vessels stretches the nerves that coil around them and causes the nerves to release chemicals. The chemicals cause inflammation, pain, and further enlargement of the artery. The increasing enlargement of the arteries magnifies the pain.

Migraine attacks commonly activate the sympathetic nervous system in the body. The sympathetic nervous system is often thought of as the part of the nervous system that controls primitive responses to stress and pain, the so-called “fight or flight” response, and this activation causes many of the symptoms associated with migraine attacks; for example, the increased sympathetic nervous activity in the intestine causes nausea, vomiting, and diarrhea.

•Sympathetic activity also delays emptying of the stomach into the small intestine and thereby prevents oral medications from entering the intestine and being absorbed.
•The impaired absorption of oral medications is a common reason for the ineffectiveness of medications taken to treat migraine headaches.
•The increased sympathetic activity also decreases the circulation of blood, and this leads to pallor of the skin as well as cold hands and feet.
•The increased sympathetic activity also contributes to the sensitivity to light and sound sensitivity as well as blurred vision.
Migraine afflicts 28 million Americans, with females suffering more frequently (17%) than males (6%). Missed work and lost productivity from migraine create a significant public burden. Nevertheless, migraine still remains largely underdiagnosed and undertreated. Less than half of individuals with migraine are diagnosed by their doctors.

JENNIFER MAYFIELD, M.D., M.P.H.,
Bowen Research Center, Indiana University,
Indianapolis, Indiana   A patient information handout on diabetes mellitus, written by the author of this article, is provided on page 1369.
 

New recommendations for the classification and diagnosis of diabetes mellitus include the preferred use of the terms “type 1″ and “type 2″ instead of “IDDM” and “NIDDM” to designate the two major types of diabetes mellitus; simplification of the diagnostic criteria for diabetes mellitus to two abnormal fasting plasma determinations; and a lower cutoff for fasting plasma glucose (126 mg per dL [7 mmol per L] or higher) to confirm the diagnosis of diabetes mellitus. These changes provide an easier and more reliable means of diagnosing persons at risk of complications from hyperglycemia. Currently, only one half of the people who have diabetes mellitus have been diagnosed. Screening for diabetes mellitus should begin at 45 years of age and should be repeated every three years in persons without risk factors, and should begin earlier and be repeated more often in those with risk factors. Risk factors include obesity, first-degree relatives with diabetes mellitus, hypertension, hypertriglyceridemia or previous evidence of impaired glucose homeostasis. Earlier detection of diabetes mellitus may lead to tighter control of blood glucose levels and a reduction in the severity of complications associated with this disease.

Diabetes mellitus is a group of metabolic disorders with one common manifestation: hyperglycemia. Chronic hyperglycemia causes damage to the eyes, kidneys, nerves, heart and blood vessels. The etiology and pathophysiology leading to the hyperglycemia, however, are markedly different among patients with diabetes mellitus, dictating different prevention strategies, diagnostic screening methods and treatments. The adverse impact of hyperglycemia and the rationale for aggressive treatment have recently been reviewed.1

 
See editorial
on page 1290.
 

In June 1997, an international expert committee released a report with new recommendations for the classification and diagnosis of diabetes mellitus.2 These new recommendations were the result of more than two years of collaboration among experts from the American Diabetes Association and the World Health Organization (WHO). The use of classification systems and standardized diagnostic criteria facilitates a common language among patients, physicians, other health care professionals and scientists.

Previous Classification

 
Diabetes mellitus that is characterized by absolute insulin deficiency and acute onset, usually before 25 years of age, should now be referred to as type 1 (not type I, IDDM or juvenile) diabetes mellitus.
 
 

In 1979, the National Diabetes Data Group produced a consensus document standardizing the nomenclature and definitions for diabetes mellitus.3 This document was endorsed one year later by WHO.4,5 The two major types of diabetes mellitus were given names descriptive of their clinical presentation: “insulin-dependent diabetes mellitus” (IDDM) and “non­insulin-dependent diabetes mellitus” (NIDDM). However, as treatment recommendations evolved, correct classification of the type of diabetes mellitus became confusing. For example, it was difficult to correctly classify persons with NIDDM who were being treated with insulin. This confusion led to the incorrect classification of a large number of patients with diabetes mellitus, complicating epidemiologic evaluation and clinical management. The discovery of other types of diabetes with specific pathophysiology that did not fit into this classification system further complicated the situation. These difficulties, along with new insights into the mechanisms of diabetes mellitus, provided a major impetus for the development of a new classification system.

The National Diabetes Data Group also established the oral glucose tolerance test (using a glucose load of 75 g) as the preferred diagnostic test for diabetes mellitus.3 However, this test has poor reproducibility, lacks physiologic relevance and is a weaker indicator of long-term complications compared with other measures of hyperglycemia.6 Furthermore, many high-risk patients are unwilling to undergo this time-consuming test on a repeat basis. The new diagnostic criteria also address this issue.

Changes in the Classification System

The new classification system identifies four types of diabetes mellitus: type 1, type 2, “other specific types” and gestational diabetes. Arabic numerals are specifically used in the new system to minimize the occasional confusion of type “II” as the number “11.” Each of the types of diabetes mellitus identified extends across a clinical continuum of hyperglycemia and insulin requirements.

 
Any patient with two fasting plasma glucose levels of 126 mg per dL (7.0 mmol per L) or greater is considered to have diabetes mellitus.
 
 

Type 1 diabetes mellitus (formerly called type I, IDDM or juvenile diabetes) is characterized by beta cell destruction caused by an autoimmune process, usually leading to absolute insulin deficiency.2,7 The onset is usually acute, developing over a period of a few days to weeks. Over 95 percent of persons with type 1 diabetes mellitus develop the disease before the age of 25, with an equal incidence in both sexes and an increased prevalence in the white population. A family history of type 1 diabetes mellitus, gluten enteropathy (celiac disease) or other endocrine disease is often found. Most of these patients have the “immune-mediated form” of type 1 diabetes mellitus with islet cell antibodies and often have other autoimmune disorders such as Hashimoto’s thyroiditis, Addison’s disease, vitiligo or pernicious anemia. A few patients, usually those of African or Asian origin, have no antibodies but have a similar clinical presentation; consequently, they are included in this classification and their disease is called the “idiopathic form” of type 1 diabetes mellitus.2,7

Type 2 diabetes mellitus (formerly called NIDDM, type II or adult-onset) is characterized by insulin resistance in peripheral tissue and an insulin secretory defect of the beta cell.2,7 This is the most common form of diabetes mellitus and is highly associated with a family history of diabetes, older age, obesity and lack of exercise. It is more common in women, especially women with a history of gestational diabetes, and in blacks, Hispanics and Native Americans. Insulin resistance and hyperinsulinemia eventually lead to impaired glucose tolerance. Defective beta cells become exhausted, further fueling the cycle of glucose intolerance and hyperglycemia. The etiology of type 2 diabetes mellitus is multifactorial and probably genetically based, but it also has strong behavioral components.

Types of diabetes mellitus of various known etiologies are grouped together to form the classification called “other specific types.” This group includes persons with genetic defects of beta-cell function (this type of diabetes was formerly called MODY or maturity-onset diabetes in youth) or with defects of insulin action; persons with diseases of the exocrine pancreas, such as pancreatitis or cystic fibrosis; persons with dysfunction associated with other endocrinopathies (e.g., acromegaly); and persons with pancreatic dysfunction caused by drugs, chemicals or infections.2,7 The etiologic classifications of diabetes mellitus are listed in Table 1.2

TABLE 1
Etiologic Classifications of Diabetes Mellitus 
 
Type 1 diabetes mellitus*

Type 2 diabetes mellitus*

Other specific types:

Genetic defects of beta-cell function
Genetic defects in insulin action
Diseases of the exocrine pancreas
Pancreatitis
Trauma/pancreatectomy
Neoplasia
Cystic fibrosis
Hemochromatosis
Others
Endocrinopathies
Acromegaly
Cushing’s syndrome
Glucagonoma
Pheochromocytoma
Hyperthyroidism
Somatostatinoma
Aldosteronoma
Others
Drug- or chemical-induced
Vacor†
Pentamidine
Nicotinic acid
Glucocorticoids
Thyroid hormone
Diazoxide
Beta-adrenergic agonists
Thiazides
Phenytoin
Alfa-interferon
Others Infections
Congenital rubella
Cytomegalovirus
Others
Uncommon forms of immune- mediated diabetes
Other genetic syndromes sometimes associated with diabetes
Down syndrome
Klinefelter’s syndrome
Turner’s syndrome
Wolfram syndrome
Friedreich’s ataxia
Huntington’s chorea
Lawrence-Moon Beidel syndrome
Myotonic dystrophy
Porphyria
Prader-Willi syndrome
Others
Gestational diabetes mellitus
 

——————————————————————————–

*–Patients with any form of diabetes may require insulin treatment at some stage of the disease. Use of insulin does not, of itself, classify the patient.

†–Vacor is an acute rodenticide that was released in 1975 but withdrawn as a general-use pesticide in 1979 because of severe toxicity. Exposure produces destruction of the beta cells of the pancreas, causing diabetes mellitus in survivors.

Adapted with permission from Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1997;20:1183-97.
 
 

The definition and diagnosis of gestational diabetes mellitus was not altered in these new recommendations.2 Gestational diabetes mellitus is an operational classification (rather than a pathophysiologic condition) identifying women who develop diabetes mellitus during gestation.7 (Women with diabetes mellitus before pregnancy are said to have “pregestational diabetes” and are not included in this group.) Women who develop type 1 diabetes mellitus during pregnancy and women with undiagnosed asymptomatic type 2 diabetes mellitus that is discovered during pregnancy are classified with gestational diabetes mellitus. However, most women classified with gestational diabetes mellitus have normal glucose homeostasis during the first half of the pregnancy and develop a relative insulin deficiency during the last half of the pregnancy, leading to hyperglycemia. The hyperglycemia resolves in most women after delivery but places them at increased risk of developing type 2 diabetes mellitus later in life.

TABLE 2
Criteria for the Diagnosis of Diabetes Mellitus and Impaired Glucose Homeostasis 
 
Diabetes mellitus–positive findings from any two of the following tests on different days:
Symptoms of diabetes mellitus* plus casual† plasma glucose concentration >=200 mg per dL (11.1 mmol per L)
or
FPG >=126 mg per dL (7.0 mmol per L)
or
2hrPPG >=200 mg per dL (11.1 mmol per L) after a 75-g glucose load
Impaired glucose homeostasis
Impaired fasting glucose: FPG from 110 to <126 (6.1 to 7.0 mmol per L)
Impaired glucose tolerance: 2hrPPG from 140 to <200 (7.75 to <11.1 mmol per L)
Normal
FPG <110 mg per dL (6.1 mmol per L)
2hrPPG <140 mg per dL (7.75 mmol per L)

——————————————————————————–

Adapted with permission from Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1997; 20:1183-97.

†–Casual is defined as any time of day without regard to time since last meal.

*–Symptoms include polyuria, polydipsia or unexplained weight loss.

FPG=fasting plasma glucose; 2hrPPG=two-hour postprandial glucose.
 
 

New Diagnostic Criteria for Diabetes Mellitus

The new diagnostic criteria for diabetes mellitus have been greatly simplified (Table 2).2

The oral glucose tolerance test previously recommended by the National Diabetes Data Group has been replaced with the recommendation that the diagnosis of diabetes mellitus be based on two fasting plasma glucose levels of 126 mg per dL (7.0 mmol per L) or higher. Other options for diagnosis include two two-hour postprandial plasma glucose (2hrPPG) readings of 200 mg per dL (11.1 mmol per L) or higher after a glucose load of 75 g (essentially, the criterion recommended by WHO) or two casual glucose readings of 200 mg per dL (11.1 mmol per L) or higher. Measurement of the fasting plasma glucose level is the preferred diagnostic test, but any combination of two abnormal test results can be used. Fasting plasma glucose was selected as the primary diagnostic test because it predicts adverse outcomes (e.g., retinopathy) as well as the 2hrPPG test but is much more reproducible than the oral glucose tolerance test or the 2hrPPG test and easier to perform in a clinical setting.

The choice of the new cutoff point for fasting plasma glucose levels is based on strong evidence from a number of populations linking the risk of various complications to the glycemic status of the patient. Figure 1 shows the risk of diabetic retinopathy based on the glycemic status of 40- to 74-year-old participants in the National Health and Nutritional Epidemiologic Survey (NHANES III).2 The risk of retinopathy greatly increases when the patient’s fasting plasma glucose level is higher than 109 to 116 mg per dL (6.05 to 6.45 mmol per L) or when the result of a 2hrPPG test is higher than 150 to 180 mg per dL (8.3 to 10.0 mmol per L). However, the committee decided to maintain the cutoff point for the 2hrPPG test at 200 mg per dL (11.1 mmol per L) because so much literature has already been published using this criterion. They selected a cutoff point for fasting plasma glucose of 126 mg per dL (7.0 mmol per L) or higher. This point corresponded best with the 2hrPPG level of 200 mg per dL (11.1 mmol per L). The risk of other complications also increases dramatically at the same cutoff points.

A normal fasting plasma glucose level is less than 110 mg per dL (6.1 mmol per L) and normal 2hrPPG levels are less than 140 mg per dL (7.75 mmol per L). Blood glucose levels above the normal level but below the criterion established for diabetes mellitus indicate impaired glucose homeostasis. Persons with fasting plasma glucose levels ranging from 110 to 126 mg per dL (6.1 to 7.0 mmol per L) are said to have impaired fasting glucose, while those with a 2hrPPG level between 140 mg per dL (7.75 mmol per L) and 200 mg per dL (11.1 mmol per L) are said to have impaired glucose tolerance. Both impaired fasting glucose and impaired glucose tolerance are associated with an increased risk of developing type 2 diabetes mellitus. Lifestyle changes, such as weight loss and exercise, are warranted in these patients.

FIGURE 1
Prevalence of retinopathy by deciles of the distribution of FPG, 2hrPPG and HbAlc in 40- to 74-year-old participants in the National Health and Nutritional Epidemiologic Survey (NHANES III). The x-axis labels indicate the lower limit of each decile group. (FPG=fasting plasma glucose; 2hrPG=two-hour postprandial plasma glucose; HbA1c=glycosylated hemoglobin) 
 
 
 

The committee chose not to address the current controversies surrounding the diagnosis of gestational diabetes mellitus and did not alter the diagnostic criteria in this area. Screening for gestational diabetes mellitus is generally accomplished with administration of a 50-g glucose load one hour before determining a plasma glucose level. A positive screen (defined as a plasma glucose level of 140 mg per dL [7.75 mmol per L] or higher) should prompt a diagnostic test: fasting plasma glucose levels should be measured after a 100-g glucose load at baseline and at one, two and three hours after the glucose load. Two of the four values must be abnormal (105 mg per dL [5.8 mmol per L] or higher; 190 mg per dL [10.5 mmol per L] or higher; 165 mg per dL [9.15 mmol per L] or higher; and 145 mg per dL [8.05 mmol per L] or higher) for a patient to be diagnosed with gestational diabetes mellitus. The WHO criteria use a glucose load of 75 g with a test two hours after the glucose load, using the same criterion for the diagnosis of gestational diabetes mellitus.

Glycated Hemoglobin

 
Glycated hemoglobin (also known as glycohemoglobin, glycosylated hemoglobin or HbA1c) is used to monitor treatment in patients with diabetes mellitus; however, it is not recommended for routine diagnosis of this condition because of a lack of standardization of tests and results.
 
 

Measurements of glycated hemoglobin have commonly been used to monitor the glycemic control of persons already diagnosed with diabetes mellitus. Measurements of this hemoglobin, also called glycosylated hemoglobin, glycohemoglobin, hemoglobin A1c or hemoglobin A1, aid in the evaluation of the stable linkage of glucose to minor hemoglobin components. There is currently no agreement on standardization, so a variety of measurement methods and normal ranges are being used.

Some experts argue that a glycated hemoglobin test could be used for the diagnosis of diabetes mellitus.8,9 Glycated hemoglobin levels are as highly correlated to adverse clinical outcomes (e.g., retinopathy) as are fasting plasma glucose or postprandial plasma glucose levels and are as reproducible as fasting plasma glucose levels. The major advantage of measuring glycated hemoglobin is that the specimen can be collected without regard to when the patient last ate.

The expert committee, however, did not include glycated hemoglobin measurement in the recommendations for international standards for the diagnosis of diabetes mellitus.2 They noted the lack of standardization and normal ranges among the various tests, making it difficult to dictate a standard cutoff point. The test for measuring glycated hemoglobin is not widely available in developing countries; consequently, it was not favored for use as an international criterion. There is also some overlap in the levels of glycated hemoglobin in patients with diabetes mellitus and those without it.

Although it was not specifically recommended by the National Diabetes Data Group as a diagnostic test for diabetes mellitus, glycated hemoglobin may, in some cases, be used to diagnose diabetes mellitus. The diagnosis of diabetes mellitus is made in the following fashion.8,9 A glycated hemoglobin level of 1 percent above the reference laboratory’s upper range of normal is consistent with diabetes mellitus and has a specificity of 98 percent.8 People with normal glycated hemoglobin levels (i.e., within the laboratory’s published normal range) either do not have diabetes mellitus or have well-controlled diabetes mellitus (i.e., a false-negative test). However, incorrectly diagnosing these persons as normal would not alter their treatment because exercise and diet are adequately controlling their blood glucose levels. People who are not diagnosed with diabetes mellitus and who have near-normal glycated hemoglobin levels (less than 1 percent above the normal range) may be advised of the high probability that they have diabetes mellitus and may be offered the same treatment as a person with mild diabetes mellitus (i.e., dietary and exercise counseling), followed by repeat testing of glycated hemoglobin several months later. This method of screening and counseling high-risk persons is easier for many patients and clinicians because the blood specimen can be drawn at the time of the patient visit.

Impact of the New Diagnostic Criteria

Physicians may be concerned that the new diagnostic criteria for diabetes mellitus, including the lower cutoff for fasting plasma glucose levels, may greatly increase the number of people who are diagnosed with diabetes mellitus in their practices. Concerns about overdiagnosis include the harm created by anxiety, the risks and costs of unnecessary treatment, and possible insurance discrimination, especially if the condition that is being diagnosed is relatively benign or if no effective treatment is available. On the other hand, underdiagnosing a condition is harmful if early treatment can make a difference in patient outcome, especially if the treatment is relatively benign and inexpensive.

It is true that a rigorous screening program will increase the number of persons who are diagnosed with diabetes mellitus. However, currently one half of the people who have diabetes mellitus according to the old criteria have not been diagnosed and may remain undiagnosed for up to 10 years.10 People who are asymptomatic and undiagnosed continue to develop the complications of diabetes mellitus.1

TABLE 3
Recommendations for Diabetes Screening of Asymptomatic Persons 
 
Timing of first test and repeat tests

Test at age 45; repeat every three years:Patients 45 years of age or older

Test before age 45; repeat more frequently than every three years if patient has one or more of the following risk factors:

Obesity: >=120% of desirable body weight or BMI >=27 kg per m2
First-degree relative with diabetes mellitus
Member of high risk-ethnic group (black, Hispanic, Native American, Asian)
History of gestational diabetes mellitus or delivering a baby weighing more than 4,032 g (9 lb)
Hypertensive (>=140/90 mm Hg)
HDL cholesterol level ¾35 mg per dL (0.90 mmol per L) and/or triglyceride level >=250 mg per dL (2.83 mmol per L)
History of IGT or IFG on prior testing 

——————————————————————————–

BMI=body mass index; HDL=high density lipoprotein; IGT=impaired glucose tolerance; IFG=impaired fasting glucose.

Adapted with permission from Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1997;20:1183-97.
 
 

Screening Recommendations

The expert committee provided guidelines governing the selection of patients to be tested for diabetes and the frequency of that testing (Table 3).2 Testing should be considered for all persons who are 45 years or older and should be repeated at three-year intervals.

Testing should be considered at a younger age and be performed more frequently in persons who are obese (120 percent of desirable body weight or greater or a body mass index of 27 kg per m2 or greater); who have a first-degree relative with diabetes mellitus; who are black, Hispanic or Native American; who have delivered a baby weighing more than 4,032 g (9 lb), or who were diagnosed with gestational diabetes mellitus during pregnancy; are hypertensive; or have a high-density lipoprotein level of 35 mg per dL (0.90 mmol per L) or lower and/or a triglyceride level of 250 mg per dL (2.83 mmol per L) or higher. In addition, any patient with impaired glucohomeostasis should be reevaluated on a more frequent basis.

The expert committee recommended that screening for gestational diabetes mellitus be reserved for use in women who meet one or more of the following criteria: 25 years of age or older, obese (defined as more than 120 percent above their desirable body weight), a family history of a first-degree relative with diabetes mellitus, and belong to a high-risk ethnic population.

Final Comment

The changes recommended by the expert committee for the diagnosis of diabetes mellitus should prove beneficial to patients. Measurement of fasting plasma glucose levels should be more acceptable to patients than the oral glucose tolerance test and can be readily incorporated with fasting lipid determinations. Identifying asymptomatic persons earlier in the disease process will allow earlier institution of lifestyle changes and medical therapy that may decrease the complications of hyperglycemia. The National Diabetes Data Group emphasizes that these changes in diagnostic criteria have not changed the treatment goals in patients with diabetes mellitus. These goals include maintaining a fasting plasma glucose level of less than 120 mg per dL (6.65 mmol per L) and a glucose hemoglobin measurement of less than 7.0 percent.

Figure 1 adapted with permission from Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1997;20: 1183-97.
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The Author

JENNIFER MAYFIELD, M.D., M.P.H.,
is associate professor of family medicine at Bowen Research Center, Indiana University, Indianapolis. She received a medical degree from Loma Linda (Calif.) School of Medicine and completed a residency in family medicine at the University of Minnesota Medical School, Minneapolis. Dr. Mayfield has served as chair of the Council on Foot Care for the American Diabetes Association for the past two years and was previously the epidemiologist for the Indian Health Service Diabetes Program.

Address correspondence to Jennifer Mayfield, M.D., M.P.H., Bowen Research Center, Department of Family Practice, Indiana University, 1110 West Michigan St., Long Hospital Room 200, Indianapolis, IN 46202. Reprints are not available from the author.