DEAR DR. ROACH: My brother is 74 and has edema in his legs and feet. He doesn’t exercise; he basically just sleeps and plays games on his computer. His bedroom is upstairs, and he struggles going up and down the stairs. He takes a water pill (furosemide).

Is he doing more harm than good taking the pill? Is there anything he can do or take that is not a prescription? He has tried compression socks and a machine that massages his legs, but the edema keeps coming back. I have read that pineapple juice might help. — N.K.

ANSWER: There are both serious and less serious medical causes of swelling of the legs and feet. Among the most prominent of these are conditions of the heart, specifically heart failure, and conditions of the liver, caused by the inability to make the protein albumin.

This is a major reason why fluid stays in the vascular system. Without proteins, the fluid escapes the blood vessels and gathers where gravity pulls it. Many liver conditions impair the ability of the liver to make albumin, especially cirrhosis (of any cause).

Protein loss in the kidneys can also be impacted. (Nephrotic syndrome is the classic cause behind protein loss in the kidney.) A doctor’s visit involving an exam and a few blood and urine tests is usually enough to evaluate for these serious causes.

Most times, however, people in their 70s develop swelling in their feet due to failure of the valves in the leg’s veins. Valves help return blood to the heart, using the muscular action of the legs to send blood to the heart at a low pressure. When the valves fail, the veins develop a higher pressure and swell — visible varicose veins are one sign of this. The high pressure also forces out fluid into the tissues.

Treatment includes compression stockings and sometimes compression devices, but these won’t work well unless your brother exercises and keeps his feet above the level of his heart, ideally for at least 30 minutes three times a day. Keeping the feet down all day while playing games is practically guaranteed to cause leg swelling.

I do not recommend diuretics like furosemide. They aren’t effective as long-term treatment, and they can cause excess loss of potassium and magnesium. While furosemide is sometimes used in treating heart failure when there is swelling due to high pressures in the heart, it has no role in long-term treatment of edema due to leaky veins.

Pineapple juice contains bromelain, which has anti-inflammatory and anti-swelling properties, but it won’t keep fluid in the vein when pressures are high. Some people have such severe vein disease that lifestyle changes alone are inadequate. Referral to a specialist is appropriate after a thorough trial of conservative management. Vascular surgeons have a number of options for managing symptomatic leg swelling that hasn’t responded to conservative treatment.

An expert is also appropriate when the diagnosis is uncertain, since there are many more causes of leg swelling, such as thyroid disease, lymphedema and lipedema.

DEAR DR. ROACH: I was recently diagnosed with Type 1 diabetes at the age of 62. My mother was diagnosed with Type 1 diabetes at 57. My glutamic acid decarboxylase 65 (GAD65) antibody results came in at greater than 25,000 U/mL and was confirmed twice by the lab. My C-peptide level is below 1 ng/mL. My blood sugar level was 542 mg/dL, and I was immediately started on insulin.

I thought I was healthy prior to these tests, since I’m a marathon runner, high-mileage biker and hot yoga student; however, these numbers don’t seem good. I have not actually heard anything back from my new endocrinologist, so I’m assuming that they merely think the test results are wrong — or there’s nothing to be done. — Anon.

ANSWER: Most people think of adult-onset diabetes as Type 2, which sometimes requires insulin, and childhood-onset diabetes as Type 1, which always requires insulin. However, the situation is more complex, and there are several other causes of diabetes.

Type 1 diabetes is caused by the body attacking the insulin-making cells in the pancreas. You have a very high level of GAD65 antibodies, which are found in the islet cells of the pancreas, and this makes an autoimmune cause very likely. C-peptide is a smaller protein that is made on the same larger protein string as insulin. Since your C-peptide is very low, this confirms that your body is not making significant amounts of insulin, which makes the diagnosis of Type 1 diabetes essentially certain, in combination with the high level of autoantibodies.

Type 1 diabetes can appear in people of below normal, normal, or above normal weight and with any level of exercise, but late-onset Type 1 diabetes is uncommon compared to diagnoses made in childhood or adolescence. Type 1 diabetes typically presents itself more slowly in adults, so it’s likely you had the antibodies for a long time before you were diagnosed.

Treatment with insulin is effective at maintaining a near-normal blood sugar level for most people. This usually includes multiple shots per day, but an insulin pump may also be used to provide excellent control of blood sugar. A continuous glucose monitor can really help you and your doctor manage your diabetes. These are not required in people with well-controlled Type 2 diabetes, but I think they will become standard with Type 1 and in more-difficult-to-control cases of Type 2.

People with Type 1 diabetes absolutely need insulin. We have many great oral medicines for Type 2 diabetes and some non-insulin medicines that also help with Type 1 diabetes, but insulin is still a necessity. In my opinion, people with Type 1 diabetes should be managed by an endocrinologist whenever possible.

Finally, let me mention that autoimmune diseases often run together. People who get diagnosed with Type 1 diabetes at your age and have a high level of antibodies are at a high risk (30% or so) for developing other autoimmune diseases (especially of the thyroid, but also celiac disease). It may be worthwhile to get blood tests done to make an early diagnosis of celiac disease or autoimmune thyroid disease.

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