Diabetes

DIABETES MELLITUS

WHAT IS DIABETES?

Most of the food consumed by an individual is converted in to glucose by the body through the normal metabolic process and transferred to all parts of the body by the blood. This glucose or sugar is used by the body as energy. The pancreas, an organ that lies near the stomach, makes a hormone called insulin to help glucose get into the cells of our bodies. When you have diabetes, your body either doesn’t make enough insulin or can’t use its own insulin as well as it should. This causes sugar to build up in your blood. Diabetes is a disease in which blood glucose levels are above normal.

Diabetes can cause serious health complications including heart disease, blindness, kidney failure, and lower-extremity amputations. Diabetes is the sixth leading cause of death in the world.

WHAT ARE THE TYPES OF DIABETES?

Diabetes is of following types:

1. TYPE 1 OR INSULIN-DEPENDENT DIABETES MELLITUS (IDDM) OR JUVENILE-ONSET DIABETES- in which the body fails to produce any insulin. It accounts for 5 to 10% of all diagnosed cases of diabetes.
2. TYPE 2 OR NON-INSULIN-DEPENDENT diabetes mellitus (NIDDM) OR ADULT-ONSET DIABETES- the insulin that the body produces is unable to adequately trigger the conversion of food into energy. 90 to 95% of all diagnosed cases fall in this category.
3. GESTATIONAL DIABETES- It is a type of diabetes that only pregnant women get. If not treated, it can cause problems for mothers and babies. Gestational diabetes develops in 2% to 5% of all pregnancies but usually disappears when a pregnancy is over. It is indicative of the woman likely to develop diabetes later in life.
4. OTHER SPECIFIC TYPES OF DIABETES- This could be resulting from various causes like specific genetic syndromes, surgery, drugs, malnutrition, infections, and other illnesses. About 1 to 2% of all diagnosed cases of diabetes are likely to be in this category.

Who is likely to suffer from diabetes?

As yet there has been no universally accepted theory as to the cause and cure of diabetes.  It is regarded as due to a disease of the pancreas, of the muscles, of the nervous system, of the kidneys.  Sometimes it has been considered as a metabolic and nutritional disturbance, and still again as a form of autotoxemia and acidosis.

The body in which diabetes develops generally is considered to have been supplied with an over-abundance of sugar and starch foods.  One reason for this belief, of course, is the appearance, in those affected by the disease, of an abnormal amount of sugar in the blood and the excretion of sugar in urine, where it does not belong.  It is true that the diabetic is unable to deal with sugars and other carbohydrate foods satisfactorily.  But when the body has been overfed on all classes of food, it can not be expected to assimilate properly any class.

It is the disturbance of metabolic processes by this over taxation that accounts for the body’s comparatively ready response to a program of diet and hygiene which allows recovery of a normal metabolic balance.  Many cases of this disease, some of which have been “given up” under orthodox treatment, have been greatly benefited or corrected entirely through the fast, the fruit diet, the milk diet, and suitable exercise. Action taken to control glucose levels in the food and as a result in the blood can prevent or delay the onset of symptoms.

Diabetes is likely to develop in people who:

• are 45 or over
• are overweight
• are habitually physically inactive
• have previously been identified as having IFG (impaired fasting glucose) or IGT (impaired glucose tolerance)
• have a family history of diabetes
• have had gestational diabetes or have given birth to a child weighing more than 9 pounds
• have elevated blood pressure
• have an HDL cholesterol level of 35 mg/dl or lower and/or a triglyceride level of 250 mg/dl or higher
• have polycystic ovary syndrome
• have a history of vascular disease

WHAT ARE THE SIGNS AND SYMPTOMS OF DIABETES?

It’s not unusual to have diabetes mellitus and yet have no symptoms. Type 2 diabetes, in particular, develops slowly. Many people have type 2 diabetes for as long as eight years before it is diagnosed. When symptoms do develop, they often vary. But two symptoms that occur in many people with the disease are increased thirst and frequent urination.

That’s because excess glucose circulating in your body draws water from your tissues, making you feel dehydrated. To quench your thirst, you drink a lot of water and other beverages, and that leads to more frequent urination.

Another condition, diabetes insipidus, also causes increased thirst and urination, but despite the similar name and symptoms, it’s not related to diabetes mellitus. Diabetes insipidus isn’t caused by a problem with blood sugar, but rather by a hormone disorder originating in the pituitary gland in your brain that makes your kidneys unable to conserve water.

This is a disease that often is well established before it is suspected.  Its onset is gradual as a rule, but may develop abruptly after some severe shock.  It may appear at any age, but the usual age is from thirty to sixty.  When it appears in early life the outlook is far from bright. Other warning signs of diabetes mellitus include:

1. Flu-like symptoms. Diabetes can sometimes give the feel of a viral illness. The patient suffers from fatigue, weakness and loss of appetite. Sugar is your body’s main fuel, and when it doesn’t reach your cells you may feel tired and weak.
2. Unexplained weight gain or loss. Because your body is trying to compensate for lost fluids and sugar, you may eat more than usual and gain weight. But the opposite also can occur. You may eat more than normal, but still lose weight because your muscle tissues don’t get enough glucose to generate growth and energy. This is especially true if you have type 1 diabetes, in which very little sugar gets into your cells. In fact, most people with type 1 diabetes are at or below their normal weight.
3. Blurred vision or blindness. High levels of blood sugar pull fluid out of the tissues in your body including the lenses of your eyes. This affects your ability to focus. Once your diabetes is treated and your blood sugar levels drop, your vision should improve. Over a period of years, however, diabetes can also cause new blood vessels to form in your retina the back part of your eye as well as damage old vessels. For most people this causes only mild vision problems. But for others, the effects may be much more serious. In some cases, diabetes can lead to blindness.

1. Slow-healing sores or frequent infections. Diabetes affects your body’s ability to heal and fight infection. Bladder and vaginal infections can be a particular problem for women.
2. Nerve damage (neuropathy). Excess sugar in your blood can damage the small blood vessels to your nerves, leading to a number of symptoms. The most common are tingling and loss of sensation in your hands and especially your feet. You may also experience burning pain in your legs, feet, arms and hands. In addition, more than half the men age 50 and older with diabetes may experience some degree of sexual dysfunction from damage to the nerves that help produce an erection.
3. Red, swollen, tender gums. Diabetes increases the risk of infection in your gums and in the bones that hold your teeth in place. As a result, your gums may pull away from your teeth, your teeth may become loose, or you may develop sores or pockets of pus in your gums. This is especially true if you have a gum infection before the onset of diabetes.
4. Irritability. Diabetes is also likely to result in temper tantrums because of the above mentioned symptoms. The patient feels permanently tired and in men impotence may cause serious psychological disorders.

Nausea, vomiting, or stomach pains may accompany some of these symptoms in the abrupt onset of insulin-dependent diabetes, called type 1 diabetes.

Often diabetes goes undiagnosed because many of its symptoms seem so harmless. The early detection of diabetes symptoms and treatment can decrease the chance of developing the complications of diabetes.

WHAT ARE THE COMPLICATIONS OF DIABETES?

1. People with diabetes are two to four more times more likely to develop heart disease or have a stroke than those who don’t have diabetes
2. Diabetes is the leading cause of new blindness among adults between 20 and 74 years old.
3. Diabetes is the leading cause of treated end-stage kidney disease in the U.S.
4. More than 60 percent of the limb amputations in the U.S. occur among people with diabetes
5. About 60-70 percent of the people with diabetes have mild to severe nerve damage

Sometimes a complication of diabetes may give a clue to the presence of the disease. The principal complications associated with diabetes are retinopathy, neuropathy, nephropathy and arteriosclerosis.

Keeping blood sugar levels as close to normal as possible through aggressive management slows the onset and progression of eye, kidney and nerve diseases caused by diabetes. In fact it demonstrated that any sustained lowering of blood sugar helps, even if the person has a history of poor control.

Lowering and maintaining more constant blood sugar levels reduced the risk of eye disease by 76%, kidney disease by 50%, nerve disease by 60% and cardiovascular disease by 35%.

Micro vascular and cardiovascular complications of diabetes (renal failure and myocardial infarction) are the major causes of morbidity in diabetics. These complications are responsible for a reduction in the life expectancy of a newly diagnosed insulin dependent diabetic by about one-third. The basis of managing diabetes is an improvement in the lifestyle of the diabetic and prevention of complications responsible for morbidity and mortality in diabetes.

Major complications of diabetes are:

• Neuropathy (diseases of the nerves)- 60% to 70% of diabetics have mild to severe forms of nervous system damage. The femoral nerve is commonly involved giving rise to symptoms in the legs and feet. Pain is the chief symptom and tends to worsen at night when the person is at rest. It is usually relieved by activity and aggravated by cold. Paraesthesias are a common accompaniment of the pain. Cramping, tenderness and muscle weakness also occur but atrophy is rare. Advanced femoral nerve disease is a major contributing cause of lower extremity amputations. Nerves in the arms, abdomen and back may also be affected. Symptoms may include impaired heart function, slowed digestion, reduced or absent perspiration, severe oedema, carpal tunnel syndrome, alternating bouts of diarrhoea and constipation, bladder atony, urinary and faecal incontinence and impotence.
• Sexual impotence- Diabetes is probably the single most common disease associated with erectile failure (termed neurogenic impotence in the diabetic). Since diabetes is a metabolic disease with vascular and nervous system complications and an erection involves all levels of the nervous system from the brain to the peripheral nerves, lesions anywhere along the path may be responsible for erectile failure. It has been estimated that close to 50% of diabetic males have some degree of erectile dysfunction. Neuropathies usually improve with the control of diabetes. Severe or chronic changes may require several weeks or months to show maximum improvement.

• Eye disease- Changes occurring in the eye which are distinctive of diabetes involve the narrowing, hardening, bulging, haemorrhaging or severing of the veins and capillaries of the retina. This is a serious complication known as retinopathy and may lead to loss of vision. Visual changes in the earlier stages may include diminished vision, contraction of the visual field, changes in the size of objects or photophobia. In the more advanced stage, termed ‘proliferative retinopathy’, haemorrhages, retinal detachment and other serious forms of deterioration are observed. When the disease progresses to this late stage total blindness may occur.It usually takes between 10-13 years for diabetic retinopathy to develop and it is present in some degree in most diabetics who have had the disease for 20 years. In only about half of the diabetics who develop it however, is vision markedly impaired and blindness occurs in only about 6%. Still, diabetes is the leading cause of blindness in adults 20 to 74 years old. Two other complications of diabetes, cataracts and glaucoma, can also lead to loss of vision.

• Arteriosclerosis (Disease of the blood vessels)- Atherosclerosis can be accurately described as the end stage of Type 1 and Type 2 diabetes, since the vast majority of diabetes patients will die from an atherosclerotic event. Most commonly these events are cardiovascular in nature (an estimated 60% to 65% of diabetics have high blood pressure) although 20-25% of atherosclerotic events may be cerebrovascular or microvascular. The cardiovascular-renal disease is the leading cause of death among diabetics.The incidence of coronary occlusion in persons with clinical diabetes has been estimated at from 8-17% with diabetic adults having heart disease death rates about 2 to 4 times as high as the general population. The risk of stroke is also found to be 2 to 4 times higher in people with diabetes. Arteriosclerosis obliterans in the lower extremities, a form of the peripheral vascular disease, may produce disturbances in sensation, decrease in muscular endurance, intermittent claudication on effort, absence of peripheral pulses in the lower legs and feet and gangrene, and ultimately lead to amputation of the extremity. Diabetic gangrene usually involves the toes, heels or other prominent parts of the feet and is precipitated by trauma, infection or extremes in temperature. Careful attention to proper foot care, avoidance of injury and consistent use of methods to improve peripheral circulation, including withdrawal from tobacco use in any form, are critical for the diabetic. The aetiology of large vessel disease is multi-factorial in the diabetic as well as the non-diabetic population with lipoprotein metabolism, hypertension, physical activity, obesity, cigarette smoking, stress, personality and genetic and racial factors all playing a part.

• Renal Failure /Disease-Nephropathy is a common and important accompaniment of diabetes and one that in young diabetics takes precedence over heart disease as a cause of illness and death. There is a wide variation in the type and degree of renal damage. Nephropathy is a development of long-standing diabetes. Diabetes is the leading cause of end-stage renal disease.Majority of diabetics have hypertension and two-thirds show significant albuminuria, but the fully developed nephrotic syndrome of hypertension, proteinuria, and edema occurs in less than 10% and renal function is impaired in only one half to three-quarters of those patients.Like other long-term complications, good blood glucose control goes a long way towards reducing the risk of diabetic nephropathy. In addition to monitoring the blood sugar levels, periodic monitoring of a diabetic patient’s kidney function (blood urea nitrogen, uric acid, creatinine, and creatinine clearance) is important.
• Low Blood sugar /Hypoglycaemia- if there is too much insulin in the body compared to the amount of blood sugar, and the blood sugar falls below normal levels, a condition known as hypoglycemia occurs. This problem of hypoglycemia due to insulin or oral hypoglycemic drugs is much more common in Type 1 than Type 2 diabetes since the Type 1 diabetic is directly injecting insulin. If too much insulin is administered, or the person misses a meal or over-exercises, hypoglycaemia may result. In this condition, commonly referred to as insulin shock, the brain is deprived of an essential energy source. The first sign is mild hunger, quickly followed by dizziness, sweating, palpitations, mental confusion and eventual loss of consciousness. Before the condition reaches emergency proportions, most diabetics learn to counteract the symptoms by eating a sweet or drinking a glass of orange juice. In some cases, the only effective measure is an intravenous injection of glucose.

• Digestive Disorders- Diabetics are more likely than the general population to report a number of digestive conditions, including ulcers, diverticulitis, symptoms of irritable bowel syndrome, abdominal pain, constipation, diarrhoea and gallstones.
• Oral Diseases- Diabetics are more prone to suffering from periodonatal disease, which can lead to tooth loss. The frequence and severity of the disease is also more in such cases. Periodontal disease has been reported to occur among 30% of people aged 19 years or older with Type1 diabetes.
• Multiple infections- Diabetics have a higher risk of some infections, including asymptomatic bacteriuria, lower extremity infections, re-activation tuberculosis, infections in surgical wounds and group B streptococcal infection. In a diabetis the healing of wounds is delayed and may lead to complications.
• Diabetic women and pregnancy- A diabetic woman is more likely to bear a child with major congenital malformations. The rate is low (0% to 5%) in women who receive preconception care and almost double (upto10% among) women who do not receive preconception care. The rate of death of the new born of a diabetic woman is also high (3% to 5%) as compared to women who do not have diabetes (1.5%).
• Metabolic disorders- IDDM patients may develop build up of chemical compounds called Ketoacids due to paucity of insulin in the body. Ketoacids are the natural bye product of fat metabolism. Ketoacidosis, the condition resulting there from, occurs because of excessive ketone bodies formed by the biochemical imbalance in uncontrolled or poorly managed diabetes. This could result in life threatening coma- a type of diabetic coma.

The symptoms of Ketoacidosis are:

1. The patient always appears to be extremely sick and in confused or comatose state.
2. Fruity smell in the breath.
3. Persistent condition of nausea and vomiting.
4. Extreme thirst.
5. Unexplained weight loss.
6. Feeling of being always hungry.

The presence and level of Ketoacids in the urine can be checked by using a urine dip stick at home.

WHAT ARE THE CAUSES OF DIABETES MELLITUS?

Diabetes is the direct result of reduced insulin levels in the blood when the pancreas does not produce enough insulin or the insulin available in the blood does not work effectively. As a result of this blood sugar levels go up.

The causes of type 1 diabetes appear to be much different than those for type 2 diabetes, though the exact mechanisms for developing both diseases are unknown. The appearance of type 1 diabetes is suspected to follow exposure to an “environmental trigger,” such as an unidentified virus, stimulating an immune attack against the beta cells of the pancreas in some genetically predisposed people.

Diabetes could be caused by multifarious causes:

• Excessive medication- Drugs such as steroids may elevate the blood sugar through a variety of mechanisms. Certain other drugs are toxic to the beta cells of the pancreas and can cause diabetes. Certain syndromes (for example, Prader-Willi, Down’s, Progeria, and Turner’s) may result in a hyperglycemic state; if this state is prolonged, the result can be permanent diabetes.
• Heredity- This is a major cause of diabetes. The chances of developing this disease in the next generation or twins are higher in case of Type 2 diabetes. If both parents have Type 2 diabetes, there is a high probability that nearly all of their children will have diabetes. If both parents have Type 1 diabetes, fewer than 20 percent of their children will develop Type 1 diabetes. In identical twins, if one twin develops Type 2 diabetes, the chance is nearly 100 percent that the other twin will also develop it.In Type 1 diabetes, however, only 40 to 50 percent of the second twins will develop the disease. Apparently while inheritance is important, environmental factors and life styles (for example, too much food, too much stress, viral infection, and so forth) also play a vital role in the development of Type 1 diabetes.

• Auto immune reaction- THIS IS LIKELY TO CAUSE TYPE I DIABETES. Diabetes is a syndrome or group of diseases resulting in the prolonged high blood sugar levels. If the immune system can not kill an infecting agent, this may kill the beta cells in the body. Also, if the immune system itself goes “erratic” attacking the body’s own tissue and destroying the beta cells. Type 1 diabetes results from this killing of the beta cells. The cells of the islets of Langerhans are inflamed, resulting from an infectious-disease process or, more commonly, from an autoimmune response. In this situation the auto immune system starts releasing antibodies which in turn start attacking the beta cells treating them as foreign bodies, thus aggravating the condition. This is known as the auto immune reaction.Until then the result is a lack of available insulin. While the onset is said to be sudden, changes resulting in decreased insulin availability may have occurred over a longer period of time. In short, insulin-dependent diabetes mellitus is an inherited defect of the body’s immune system, resulting in destruction of the insulin-producing beta cells of the pancreas. It’s not clear why this happens, but a number of explanations and possible triggers of this reaction have been proposed. These include:
  1. Infection with a specific virus or bacteria;
  2. Exposure to food-borne chemical toxins;
  3. Exposure as a very young infant to cow’s milk, where an as yet unidentified component of this triggers the autoimmune reaction in the body.

CAUSES OF TYPE 2 DIABETES

Type II (Adult Onset) diabetes is a sugar disease. You can control it, even prevent it. It appears when:

• The receptors on cells in the body that normally respond to the action of insulin fail to be stimulated by it – this is known as insulin resistance. In response to this more insulin may be produced, and this over-production exhausts the insulin-manufacturing cells in the pancreas;
• There is simply insufficient insulin available; and
• The insulin that is available may be abnormal and therefore doesn’t work properly.

WHAT ARE THE RISK FACTORS FOR DIABETES?

Risk factors are less well defined for type 1 diabetes. Some of these could be:

1. Autoimmune system disorder
2. Genetic factors
3. Environmental factors.

The following risk factors increase the chances of someone developing Type 2 diabetes:

• Increasing age;
• Obesity; and
• Physical inactivity.
• Family history of diabetes.
• Prior history of gestational diabetes.
• Impaired glucose tolerance.

Gestational diabetes risk factors include:

1. Obesity
2. Family history of diabetes.

Rarer causes of diabetes, may account for 1% to 2% of all diagnosed cases, include:

• Specific genetic syndromes.
• Surgery
• Certain Drugs / medicines;
• Pregnancy (gestational diabetes);
• Malnutrition.
• Infections
• Any illness or disease that damages the pancreas and affects its ability to produce insulin e.g. pancreatitis.

WHAT ARE THE MYTHS ABOUT CAUSES OF DIABETES

Various causes without any scientific basis are propagated about the onset of diabetes.
Eating sweets or the wrong kind of food does not cause diabetes. However, it may cause obesity and this is associated with people developing Type 2 diabetes.

Stress does not cause diabetes, although it may be a trigger for the body turning on itself as in the case of Type 1 diabetes. It does, however, make the symptoms worse for those who already have diabetes.

Diabetes is not contagious. Someone with diabetes cannot pass it on to anyone else.

CAN DIABETES BE PREVENTED?

After perusal of the causes of diabetes it is apparent that certain causes can definitely be controlled. This is more important for people with history of the disease in the family. Precautionary steps taken during early years of life can definitely prevent or delay the onset of diabetes in such cases. Non diabetic people should avoid a life style that puts them at greater risk for this disease.

Obesity and physical inactivity are the 2 major factors for diabetes and both can be controlled. Type II (Adult Onset) diabetes is a sugar disease. You can even prevent it by following simple steps:

• Managing your insulin (controlling sugar sources).
• Eating small and more number of meals a day instead of “filling up”.
• Keeping your body fat percentage down.

WHAT SHOULD BE THE DIETARY PATTERN FOR A DIABETIC?

Diet plays a significant role in the health of an individual. Most times improper foods are taken due to ignorance, family traditions / myths, economic conditions and non availability of better options. There can not be a specific diet for all and the same dietary pattern may not suit the same person for very long. One has to evolve a diet suitable to individual needs as per genetic and ethnic group food priorities.

Excluding the Eskimos and some other highly specialized ethnic groups, all diets must adhere to the same few macronutrient rules. For example:

• Reduce as much processed carbohydrates from your food as possible.
• Avoid carbohydrates at dinner or at least 2 hours before bedtime.
• Balance the ratio of your fat/carbohydrates/protein consumption to an approximate 30/40/30 ratio. Adapt this to suit your personal individual needs.
• Eat at least 5 or 6 small meals than 3 large meals a day.
• Your breakfast must have high protein content.

You need to avoid being obese. In any case there are hardly any lean and muscular diabetics. Consult your physician to plan your exercise pattern.

Walking is the best exercise. This will reduce your blood sugar and improve the metabolic rate. Good metabolism means burning calories even when sitting idle. You can walk to the office from the car park- park at a little distance. Use the stairs and adopt various other ways to burn calories rather than saving them.

WHAT TREATMENT IS AVAILABLE FOR DIABETES?

People can and do live healthy and happy lives with diabetes. People with diabetes must take responsibility for their day-to-day care, and keep blood glucose levels from going too low or too high. In response to the growing health burden of diabetes, the diabetes community has three choices: prevent diabetes; cure diabetes; and improve the quality of care of people with diabetes to prevent devastating complications.

Diabetes knowledge, treatment, and prevention strategies are essential.

• Treatment is aimed at keeping blood glucose near normal levels at all times.
• Training in self-management is integral to the treatment of diabetes.
• Treatment must be individualized and must address medical, psychosocial, and lifestyle issues.
• Preventive strategies result in avoiding deterioration of health.

Diabetes is a condition in which there can be no great amount of compromise; a rigid treatment must be followed.  It is necessary that food be utilized, that sugar taken in as such or formed from starch foods be oxidized, and exercise is the only way in which this can be assured in a physiological manner. Planned and a well balanced diet along with rigid exercise schedule helps. However, even greater benefit will result from general exercises involving every muscle group in the body.  There must be enough exercise to increase heart and lung activity so that muscle-sugar will be burned up and so that there will be no appreciable amount of sugar stored within the body.  Naturally there must be plenty of relaxation but the tendency to lie around and coddle the disease may lead to succumbing quickly from diabetes.

TREATMENT OF TYPE 1 DIABETES: Lack of insulin production by the pancreas makes type 1 diabetes particularly difficult to control. Treatment requires a strict regimen that typically includes a carefully calculated diet, planned physical activity, home blood glucose testing several times a day, and multiple daily insulin injections.

TREATMENT OF TYPE 2 DIABETES: Treatment typically includes diet control, exercise, home blood glucose testing, and in some cases, oral medication and/or insulin. Approximately 40% of people with type 2 diabetes require insulin injections.

People with diabetes should see a health care provider who will monitor their diabetes control and help them learn to manage their diabetes. In addition, people with diabetes may see endocrinologists, who may specialize in diabetes care; ophthalmologists for eye examinations; podiatrists for routine foot care; and dietitians and diabetes educators who teach the skills needed for daily diabetes management.

WHAT IS THE CURE FOR DIABETES?

Several approaches to “cure” diabetes are being pursued:

• Pancreas transplantation
• Islet cell transplantation (islet cells produce insulin)
• Artificial pancreas development
• Genetic manipulation (fat or muscle cells that don’t normally make insulin have a human insulin gene inserted — then these “pseudo” islet cells are transplanted into people with type 1 diabetes).

Transplant patients must take powerful drugs for the rest of their lives. These drugs suppress their immune system, to avoid rejection of the transplant. Having a suppressed immune system leaves the body with very little protection from other diseases, so pancreas transplants are not the answer.

If your child has type 2 diabetes, it may be possible for him to stop taking medicine one day. Some people with type 2 diabetes are able to manage diabetes by treating it with exercise and careful meal planning. But this is not a cure. Careful meal planning and exercise may help children with type 1 diabetes reduce the amount of insulin they take, stay within their target range, and feel better.

Each of these approaches still has a lot of challenges, such as preventing immune rejection; finding an adequate number of insulin cells; keeping cells alive; and others. But progress is being made in all areas.