| The Basics about Diabetes |
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Around the world, diabetes is an increasingly significant public health issue. Whenever the topic of public health is addressed, it is important to recognize that it is individual people who comprise a population. Individuals are the ones who are shocked when told about a diagnosis. Individuals are saddened and confused when they or their loved ones experience negative outcomes of diabetes, such as heart disease, strokes, kidney disease, blindness, and amputations. Individuals are the ones who have to test blood sugar sometimes six or more times a day. Individuals have to think about keeping insulin protected from the heat inside a car during hot summer days. And individuals have to plan medication, meals and exercise times and quantities so that blood sugar doesn’t drop too low and cause weakness…or confusion…or seizures…or coma…or death. Diabetes is a life-long disease. While much can be done to keep it in good control and prevent complications, this doesn’t happen automatically and it doesn’t come easy. Education and motivation must be as on-going as diabetes itself. It is time to do something about diabetes. In the spirit of making an impact on its negative outcomes, this effort by the Las Cruces Sun-News and The Southern New Mexico Diabetes Outreach to educate and motivate for improvements in detection and management of diabetes is launched. In diabetes a lack of insulin or a problem with the use of insulin cause problems with using food for energy, growth, and healing. Absolute insulin deficiency at the time of diagnosis defines type 1 diabetes. Insulin resistance and problems with the release and use of insulin define type 2 diabetes. Both cause an excess in glucose levels in the bloodstream. While they have different origins, the outcomes and risks for complications are similar. Type 1 diabetes comprises about 5% of all diabetes cases. Type 2 is the overwhelming 95%. Both types should be treated very seriously. Glucose is the basic sugar molecule that cells use. Normal levels of sugar in the blood are essential for long-term good health. Imbalance of sugar and insulin levels in the blood can cause serious problems, both immediately and over time. Long-term complications are caused by damage to blood vessels and nerves, which may result in disability or early death. Complications may be delayed or prevented with good diabetes management. Common symptoms of diabetes include lack of energy, blurry vision, dry skin, headache, problems with healing, and excessive urination and thirst. Excess hunger is also a frequent symptom. Severe weight loss prior to the time of diagnosis is typical of type 1 diabetes. In type 2 diabetes weight loss may occur, but in its early stages, weight gain or maintenance of excessive weight is common. About 80% of those with type 2 diabetes have a history of being overweight. Obesity is a major contributor to insulin resistance, but even type 2 diabetics who have never been overweight also lack insulin sensitivity. Much research is currently taking place to unravel the mysteries of insulin resistance. Risks for type 2 diabetes include family history, lack of exercise, being overweight especially in the upper part of the body, the aging process, race (Hispanics, Native American Indians, and African Americans are at higher risk for type 2), and a history of blood sugar elevations during such times as pregnancy or injury or illness. Risks for type 1 diabetes are also related to family background, but include a response of the immune system to a virus or other foreign proteins. It is thought that some type 1 diabetics become immune to their own insulin-producing cells or even to their own insulin. Many of the words we use to describe diabetes come from the old Latin and Greek languages. It helps to study some of those word origins so that understanding and remembering them is easier. The full name of this disease is diabetes mellitus. (Mellitus is pronounced with a short “i” as in “it.”) In the Greek, diabetes is actually two words, dia and betes. Dia means through. Betes means flowing. Put together they mean “flowing through.” About two thousand years ago, when diabetes mellitus was first identified as a disease, it was realized that excess sugar was flowing out through the urine of certain people and not from others. The word mellitus comes from Latin. It means honey, or in this case, sugar. Put it all together and diabetes mellitus means sugar flowing through. As blood sugar becomes elevated beyond normal levels, the kidneys are the only organs capable of an attempt to rid the body of excess glucose. When blood sugar reaches a level of about 180 to 200 milligrams, the kidneys begin to excrete it. This explains the name diabetes mellitus. Sugar flows through the kidneys and into the urine. Another interesting word is pancreas. Its origin is from the Greek and also is two words in the original language: pan and creas. Pan means broad or widespread, as in panorama or Pan-American. Creas means flesh. The pancreas is the glandular organ which produces hormones responsible for the regulation of blood glucose. The hormone insulin lowers blood glucose by performing a key role in the transportation of sugar into cells. The pancreas also makes an opposite hormone called glucagon. Glucagon causes blood sugar to rise by influencing the liver to create and release glucose. Insulin is produced by beta cells within groups of cells called Islets of Langerhans. Alpha cells also reside within the islets and are the producers of glucagon. A third hormone produced from delta cells in the islets is called somatostatin. Its function is to regulate the alternating production of insulin and glucagon, depending on what the blood sugar is at any point in time. Other words useful for understanding diabetes are “hyper,” which means high, “hypo,” which means low, “emia” from the Greek word haima, which means blood, and “gluc” or “glyc” which means sugar. "Gluc" and “glyc” are the Greek equivalents of the Latin “mellitus.” Uria is Greek for urine. When these word origins are understood, it is easy to put a few terms together and make them much more understandable. For example, hyperglycemia is simply a combination of hyper and glyc and emia….or, in English, high blood sugar. Hypoglycemia is low blood sugar. Glucosuria is sugar in the urine. When a diagnosis of diabetes is made, hyperglycemia is always present. When treatment for diabetes includes insulin or an insulin-stimulating oral medication, hypoglycemia may occur as an undesirable side effect. If either hyperglycemia or hypoglycemia occur too frequently or severely, changes in the diabetes management plan must be made. If glucosuria is present, it means that blood glucose has risen to at least 180 mg, which is too high and, if left untreated, may result in the development of blood vessel or nerve complications. Modern management of diabetes no longer includes testing of urine for sugar, however, because blood glucose testing is far more accurate, timely, and efficient. Diabetes mellitus is a chronic illness in which a lack of insulin or ineffective insulin cause the body to be unable to use food properly. To understand diabetes well, it is necessary to understand food. All food, whether it is an apple or a hamburger or a seven- course feast, is composed of all or part of six basic substances. Two of the substances are called micronutrients and go by the more familiar names of vitamins and minerals. One is water. The other three components of food are called macronutrients and are the source of calories. These are carbohydrates, proteins, and fats. Although people often complain about calories because of the frequent problem of excess, calories are one of the necessary substances of life. They enable cells to produce heat, keeping our bodies at normal temperature and providing for energy, growth, and healing. All of these functions are going on continuously at every age for every person. When there is interruption in the ability of the body to use the macronutrients for proper metabolism, this can indicate the presence of diabetes. Insulin is the transport mechanism to put the final digestive products of the macronutrients into cells where they are used for energy, growth, and healing. Without insulin, as in type 1 diabetes, cells starve. When insulin is not being produced in a timely manner or when there is resistance to it in the fat and muscle tissues of the body, this is type 2 diabetes. Diabetes is all about the ability to use food effectively. Carbohydrates are starches and sugars and provide four calories of energy per gram. A gram is about one-fourth of a teaspoon. After digestion, the final point of carbohydrate breakdown is glucose and fiber. Protein foods also provide some glucose after digestion, and fats provide a small amount, too. Proteins provide four calories of energy potential per gram, and fats provide nine. The primary glucose source is from carbohydrates. It is the body and brain’s preferred fuel for energy. If glucose is unable to be used because of insulin deficiency or insulin resistance, for a short time fatty acids from food as well as those released from stored fat can be used. But this is an emergency measure, and eventually glucose and the ability to use it must be restored. In diabetes the glucose source is right there in the bloodstream, but if it can’t be moved into the tissues to be used, it is similar to having a pantry cupboard full of food….but locked. Glucose levels build up to high and dangerous levels in the bloodstream at the same time that the person is starving for food. When glucose reaches certain levels in the blood, the diagnosis of diabetes can be made. A normal fasting blood sugar is between 60 and 105 milligrams per deciliter. A milligram is one-thousandth of a gram, and a deciliter is one-tenth of a liter…or a little less than a cup of liquid. This much blood is never taken for testing, of course, but the numbers are calculated from a smaller sample. If the fasting blood sugar reaches 126 milligrams for two consecutive readings, this is diabetes. Or if blood sugar rises as high as 200 milligrams at any time of day, especially in the presence of symptoms, this is diabetes. The same numbers are used for diagnosis of both type 1 and type 2 diabetes and for both children and adults. Many people think that type 1 diabetes is a more serious condition than type 2. The diseases are not described by their seriousness, although it could be argued that in terms of risk for immediate metabolic complications, type 1 diabetes may be more severe. But in terms of blood vessel complications that can lead to heart attacks, strokes, amputations, and damage to other organs, type 2 diabetes takes the lead. Remember that the two main types of diabetes are defined by origins, not by outcomes. Type 1 diabetes can be described more simply than type 2 since it has one main onset characteristic. Insulin production by the pancreas has stopped to the degree that normal metabolism cannot be sustained. Without insulin replacement, severe metabolic decompensation would take place within a relatively short period of time. And without medical intervention, death from metabolic acidosis would occur. This could take days or weeks or even months, depending on if very small amounts of insulin are being produced by the pancreas. The onset of type 2 diabetes is far more complex. Type 2 diabetes represents a mixture of underlying causes and developmental signs and stages highly related to insulin resistance instead of insulin deficiency. That makes the pancreas have to work harder to produce more insulin, causing a serious condition called hyperinsulinemia…high levels of insulin in the blood. Excessive insulin in the blood is harmful to blood vessels, too, just as excess glucose is. In addition, in type 2 diabetes the pancreas may be slow to release what is called “first phase insulin.” When we eat a meal or have a caloric beverage, the pancreas must squeeze out some stored insulin into the bloodstream for a quick response. Remember that glucose is the digestive result of most of the foods we eat. Type 2 diabetes is thought to be a combination of both insulin resistance and diminished first phase insulin release. These abnormalities create problems of their own, such as overactivity of the liver, high blood pressure, abnormal cholesterol and triglyceride levels, weight gain, and a further increase in insulin resistance which compounds the situation, eventually resulting in high blood glucose levels. This complicated mixture of signs and stages of type 2 diabetes goes by several names. Insulin Resistance Syndrome, Reaven’s Syndrome, and Syndrome X have been used for some time, but now it is also being described as “Cardiovascular dysmetabolic syndrome,” a very long name to suggest that the variety of problems with metabolism related to type 2 diabetes, without good management, typically cause blood vessel disease in the heart (as well as other bodily locations). And sometimes, technically, diabetes still isn’t present…yet. In other words, perhaps blood glucose levels have not reached the diagnostic point for diabetes, but still damage has occurred. There are four main developmental stages for type 2 diabetes that comprise a classic onset. The first stage may have only the signs of excess weight, high blood pressure, and/or abnormal cholesterol and triglyceride levels. Stage two is Impaired Glucose Tolerance where blood sugar levels are inching up after meals and sugar is between 126 and 199 mg two hours after eating. The third stage is Impaired Fasting Glucose when morning glucose prior to eating is between 111 and 125 mg. And the fourth stage is type 2 diabetes when morning sugar is 126 or higher and two hours after meals when sugar is over 200. Either one of these elevations, fasting or after meals, would define the onset of true diabetes. Blood vessel complications of insulin resistance syndrome can occur at any of these four stages It is important to know risk factors for diabetes. Type 1 diabetes has only one known risk factor which is a certain kind of genetic makeup in combination with an immune attack on the pancreas. Other possible risk factors for type 1 diabetes are being researched extensively. And even though there is a risk for type 1 diabetes to occur in succeeding generations, it is far less than the genetic risk for type 2. Type 2 diabetes has many risk factors related to both lifestyle behaviors and to family history. While we can’t do much on our own to prevent type 1 diabetes, we can do a lot to prevent type 2. In Southern New Mexico as well as other parts of the United States with populations that have large numbers of people of retirement age as well as of Mexican and Native American Indian heritage, it is necessary to focus on risks for type 2 diabetes. While type 2 diabetes comprises about 95% of all diabetes around the country, the concentration of people highly prone to it in the Southwest makes it even a greater issue. African Americans are also at higher risk. Another group is the Asian American immigrant population who also have been found to be at high genetic risk for type 2 diabetes. When the genetic risk combines with the high risk United States lifestyle (sedentary activity and high caloric intake), type 2 diabetes is occurring at a very rapid rate in this group, too. What would cause certain groups of people to be at high risk for type 2 diabetes compared to others? It appears to be related to an inherited tendency for insulin resistance and to deposit a certain kind of fat. People who are genetically programmed to deposit fat in the middle and upper portions of the body instead of the hips and thighs are more likely to have insulin resistance resulting in diabetes. This is called visceral (organ) fat or abdominal fat or android fat. Visceral obesity is centrally located rather than at the outer areas of the body where the accumulation is called peripheral fat. Visceral fat accumulates around the belly and inside the abdominal cavity itself. Many people may deposit this kind of fat around the shoulders and the neck as well. Their arms and legs may be very thin, but they are still dangerously overweight. Recent research has shown that this kind of fat is highly resistant to insulin. Visceral fat is also metabolically active which means that it breaks down from its original form of stored triglycerides into free fatty acids, putting them into the bloodstream back and forth from storage to the liver and again to storage, on a more or less continuous basis. This is one of the reasons that people with insulin resistance syndrome are so prone to heart disease since high levels of triglycerides and free fatty acids are both risk factors for it. One simple measurement can predict risk for insulin resistance and diabetes related to abdominal fat. Men should always have a waistline below 40 inches. Women should keep their waistline below 35 inches. Other risk factors for type 2 diabetes include lack of physical exercise and excess stress. Inactive muscles have diminished blood flow, which increases the problem of insulin resistance. Stress hormones cause the liver to release extra sugar which can be the final push toward diabetes. The aging process is a risk factor as well, but it could be that this is more related to diminished physical activity than to aging itself. Keeping weight and stress levels in control by regular frequent physical activity and by eating healthy foods, rich in fiber, low in fat and without excess calories is the best way to help prevent type 2 diabetes. This applies to people of all ages. As in all discussions about diabetes, onset symptoms must be studied in terms of type 1 and type 2. While many symptoms overlap between the two types of diabetes, there are several significant differences. Generally, type 1 diabetes onset has far more profound and noticeable symptoms. Because of this, persons with type 1 are diagnosed promptly compared to those with type 2. Often type 2 diabetes has many years of slow and gradual development. Mild symptoms can be overlooked completely or sometimes dismissed as “merely the aging process.” Of course, with younger people now acquiring type 2 diabetes in increasing numbers, the “aging process” reasoning is even less rational. Type 1 diabetes is noted by what seems to be a sudden onset which usually includes extreme thirst and hunger, frequent urination in large quantities, and rapid and severe weight loss accompanied by the presence of ketones. When glucose is not able to be metabolized in a normal way with appropriate amounts of insulin from the pancreas, the body turns to stored fat for emergency energy. When fat is released in such quantities, as it is processed through the liver, ketones are formed as a by-product. Similar to nail polish remover, they make a person feel very sick. Nausea, vomiting, stomach pain, and a characteristic deep and labored type of breathing called Kussmaul respirations are signs of excess ketones in the blood. The breath may smell strongly of ketones, sometimes described as “fruity,” but more accurately smelling more like nail polish remover. These are signs of acute metabolic decompensation, a lengthy term that means the body is failing in its emergency measures to provide energy and medical intervention is needed urgently to reverse the process. When intravenous fluids and insulin are provided, the severe metabolic situation reverses, but if it is truly type 1 diabetes and until there is a cure, insulin must continue to be provided throughout life. Common to both types of diabetes are the extreme thirst, hunger, and urination. These go by the medical names of polydipsia, polyphagia, and polyuria. These three “poly’s” are classic diabetes symptoms. With the slower, more gradual onset of type 2 diabetes, the poly’s can be present, but usually not as severe as in type 1. Weight loss in type 2 is unpredictable. Early in the process, weight gain may actually be more of a problem while insulin levels in the blood remain to high due to insulin resistance. Sometimes weight is not affected. And yet sometimes, weight loss may occur. Fatigue, headaches, and blurry vision are also common symptoms, but along with the poly’s, in type 2 diabetes these symptoms are far too often dismissed as being unimportant or a part of normal aging. They are not unimportant or normal. During the years that such symptoms may be steadily progressing, blood vessel damage that leads to diabetes outcomes such as heart disease and strokes is also progressing. With the great numbers of younger people who are at risk for type 2 diabetes, one more symptom of insulin resistance and impending diabetes must be explained. Acanthosis nigricans is a darkening and thickening of skin in several body areas caused by over-production of insulin as the body struggles to keep blood sugar in control. It is most typically seen in overweight people around the neck, and may also be present in underarm skin, inner elbows, around the stomach and groin areas, and behind the knees….in any area where skin folds naturally occur. When it is seen in the neck, people may mistake it for dirt and even try to scrub it off. Acanthosis nigricans only disappears when improved lifestyle behaviors reverse the process or when diabetes eventually occurs and insulin production drops off. Acanthosis often begins to show at around age ten in youngsters at risk, but it has been seen in children as young as four or five. In either type 1 or type 2 diabetes, being able to judge the potential for the onset of complications is important. Risk factors should be continuously evaluated by the health care provider. (The term “health care provider” means doctor, physician assistant, or nurse practitioner. Many people are making the understandable mistake of thinking that health care provider means the insurer, or in other words, the one who is paying the bill. In this case it doesn’t mean who is providing the financing, but instead who is providing the care.) It is possible for people to live successfully for decades without complications if the risk factors for complications are kept under control. Duration of diabetes, along with the existence of several other indicators, are called “the multiple risk factors for complications.” They include high blood sugar, high blood pressure, abnormal blood fats (including triglycerides and the three measurements of cholesterol…total cholesterol, LDL, and HDL), and the use of any tobacco product which contains nicotine. In a future article all of these risk factors will be closely examined, but for the present, everyone interested in prevention of diabetes complications should be aware of the Hemoglobin A1c (HbgA1c or simply A1c) test. Focusing on the risk factor of high blood sugar or hyperglycemia, the HgbA1c is considered the “gold standard” for prediction of complications. It measures the amount of glucose that has attached to protein in red blood cells called hemoglobin. Everyone has a certain amount of glucose attached to protein, and in fact this process known as glycosylation is very much related to aging. If a person lives to be one hundred, many tissues in the body will have glucose permanently bonded to proteins in the blood vessels, the skin, the connective tissues, and anywhere in the body where blood flows. Glycosylation causes damage to those tissues which can be permanent, as in old age. No one expects a one hundred year old person’s blood vessels to again become youthful and flexible and more efficient at transporting oxygen and nutrients. The problem in diabetes is that this process often occurs at much younger ages. Measuring the glucose and protein bonding in the red blood cells is an easy way to estimate the amount of bonding in the remainder of tissues throughout the body, including the eyes, kidneys, and nerves, all frequent targets of glucose elevations. Although HgbA1c is not yet recognized as a useful tool for diagnosis of diabetes, it should be utilized as a standard part of management. Soon after diagnosis this test should be done. In type 1 diabetes or in type 2 diabetes where insulin is being used or where control of diabetes has not been well established, it should be performed every three months. It takes that long for an entirely new batch of red blood cells to be formed and released into the bloodstream. In type 2 patients who are being well managed with nutrition and exercise management and perhaps oral medications, the test may be performed every six months. The life of an RBC is about three months. Because of this the HgbA1c test is a good indicator of the average blood sugar over that period of time. Although the numbers may vary somewhat in different laboratories, usually a normal (non-diabetic) A1c is between 3.5 to 5%. This means that that percentage of RBCs have glucose attached. In very well controlled diabetes, the A1c should be at 7% or less. It is considered “acceptable” to have an A1c at 8% or less, but above that, additional interventions must be added to the diabetes management program. |
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