DIABETES...the facts - Part I

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By: Dr. S. Lawson MD and Dr. H. Boothe PharmD

diabetes_logo_slogan.jpgDiabetes mellitus is a chronic illness that requires continuing medical care and patient self-management education, to prevent acute complications and to reduce the risk of long-term complications. The disease is characterized by excess glucose in the blood that leads to excessive urination and results from inadequate production and or utilization of insulin.

• The different types of diabetes include Type 1, Type 2, Gestational (GDM), and Pre-diabetes.

• Diabetes not only complicates every other disease condition, it can precipitate other diseases.

• 171 million world-wide suffer from diabetes. One in 13 people in the USA have diabetes.

• In the year 2005 a total of 20.8 million have diabetes, of these 6.2 million are undiagnosed. 80% - 90% of the diagnosed are obese when diagnosed.

• It reduces life expectancy by 5 to 10 years.

• Diabetes is associated with obesity, sedentary lifestyle, and an increase in the elderly population.

• The Hispanic, African American and Aboriginal population (with high numbers of poor people with poor diets and inadequate medical attention) are at increased risk to develop diabetes than the rest of the population.

• It is the number 6 leading cause of death in the USA.

• Individuals with diabetes have a 2-4 times the risk of developing cardiovascular disease.

• It is the leading cause of kidney failure, blindness, and non-traumatic amputation.

• Prediabetes is characterized by insulin resistance and a compensatory increase in blood glucose (hyperinsulinemia).

Approximately 1.2 million are diagnosed with Type 1 diabetes mellitus.These numbers will double by the year 2030.

• Type 1 diabetes (results from beta-cell destruction, usually leading to absolute insulin deficiency, it is of autoimmune origin that occurs in the adolescence period of life, usually before the age of 30. Type 1 diabetes presents with sudden onset weight loss, fatigue, irritability and was previously called insulin dependent diabetes.

• Type 2 diabetes (results from a progressive insulin secretory defect on the background of insulin resistance, and is caused by inadequate insulin production by the beta cells in the pancreas, defective insulin, or resistance to insulin function at the insulin cell receptors. When insulin binds to its receptor on cell membrane, it allows glucose to enter the cell (i.e. muscle, liver, and fat cells); this is like the key that opens the lock to let glucose into the cell. When glucose is unable to leave the circulation, the blood glucose level rises above optimum level resulting in organ damage.

• Insulin, glucagons, adiponectin, amylin are hormones involved in glucose regulation. Glucagon accelerates the conversion of glycogen in the liver (and promotes the formation of glucose from lactic acid and certain amino acids).

• Insulin stimulates the release of glucose from the liver into the blood. And counteracts the action of glucagons by transporting glucose into cells. Insulin promotes the formation of fatty acids, increases the storage of glycogen, protein synthesis and DNA replication. Amylin is a hormone that acts like insulin.

• Human growth hormone, neurotransmitters, and regulatory peptides also play a role in glucose metabolism.

• In obese individuals, there is abnormal insulin activity (insulin resistance) at the muscles insulin receptors (sites on the muscle cells where insulin acts to pull glucose out of the blood into the cells).

• Cells use glucose as energy and when you have reduced production of insulin or the insulin is not working right glucose increases in the blood. If the cells don’t receive adequate supply of energy this sends message to the brain that results in increased hunger, at the same time, the blood becomes hyperosmolar( too thick) and absorbs water from tissue, this results in dehydration and increased thirst.

• Excess blood glucose destroys the kidney's filtering capability which results in excessive glucose and protein in the urine causing increased urination.

• In type1 diabetes there is a total destruction of the insulin producing cells by antibodies (an autoimmune dysfunction).

• Viral infection of the pancreas is implicated in this destructive mechanism.

• Type 1 diabetes mellitus (T1DM) requires insulin. Without insulin the body has to get its energy from fats. This results in Diabetic keto Acidosis (DKA) which leads to metabolic abnormalities. Treatment is Intravenous insulin and glucose. Type 1 diabetes is a result of the complete absence of insulin production in the pancreas, of viral etiology, genetic factors, presence of ketones in the blood (ketoacidosis), sudden onset and usually presents before age 30. These individuals with Type 1 diabetes usually have lean body composition. The diagnosis of Type 1 diabetes is made by detecting of antibodies and C-peptides in the blood.

These individuals usually do not have a family history of diabetes.
• Type2 diabetes mellitus (T2DM) frequently presents with poor wound healing, blurry vision, numbness and tingling in the hands and feet, recurring skin and gum infections, vaginal yeast infection, and urinary tract infection. Factors that predispose people to developing T2MD include obesity (waist to hip ratio) fetal malnutrition, gestational diabetes, children born prematurely, a positive family history of T2DM, cigarette smoking, hypothyroidism, trans fat, saturated fats, endothelial dysfunction, high levels of testosterones in women, decrease levels of sex hormones binding protein in men, HIV/AIDS.

• Medications which could increase blood glucose levels: (dose-dependent) thiazide diuretics , beta blockers (lopressor), oral contraceptives, tacrolimus, cyclosporine, Nicotinic acid (niacin), HIV protease inhibitors, antipsychotics (clozapine, olanzapine), Gonadotropin releasing hormones agonists, clonidine, Calcium channel blockers, Pentamidine, steroids, elevated level of plasminogen activating factors, and alcohol.

• The onset of T2DM is gradual and the diagnosis is usually delayed. As a result, circulatory complications are usually advanced at the time of diagnosis. Stroke, heart, cataract, macular degeneration, refractive errors (near or far sightedness), kidney disease, erection problems(ED), constipation, high blood pressure, and subtle infections not detectable by standard laboratory tests are complications of T2DM. The circulatory disturbance and a high Insulin level (insulin resistance) results in abnormal physiological processes. Excess insulin increases the storage of fat around the abdomen (visceral fat), stops the utilization of this stored fat as energy, down regulates the number of insulin receptors and increases the inflammatory substances in the tissues. Fat cells produce substances that are associated with insulin resistance. Inflammation leads to infections (Chlamydia pneumonia has been isolated from plaques that cause atherosclerosis). The pancreas of diabetics is often infected by Cytomegalovirus, Chlamydia trachomatis, and Mycobacterium tuberculosis (TB).

• Insulin increases the inflammatory substances that disturb the endothelium lining blood vessels leading to circulatory disturbances, including stroke. When blood glucose is high, it binds to protein on the endothelium resulting in micro vascular disturbances in the eyes (macula degeneration, glaucoma, cataracts) and disturbances in the filtering mechanism of the kidneys and results in protein leaking into the urine (microalbuminuria). This causes the liver to produce more cholesterol and triglycerides. Insulin resistance, high glucose level leads to dehydration and dehydration causes acidosis. Acidosis encourages cancers. Insulin stimulates DNA replication that predisposes to cancer.

Medication Treatment Options

The use of antihypertensives: Angiotensin converting enzyme(ACE) inhibitors (lotensin, vasotec, zestril) or Angiotensin receptor blockers(ARB’s) (Cozaar, Mircardis, Diovan) have been able to reduce morbidity and death associated with T2DM in people who have had heart attacks, heart failure and chronic kidney disease. These medications not only work on the kidney to reduce the damage caused by high blood pressure (hypertension) on the kidneys by stopping the enzymes that lead to narrowing of the blood vessels (angiotensin), but they work on the cells lining the blood vessels (endothelium) to reduce narrowing of blood vessels. They also reduce cholesterol levels.

• Actos and Avandia are drugs that improve the binding of insulin to its receptor site on cells so that glucose can leave the circulation and enter the cells. Avandia can cause Metabolic Syndrome. Actos can cause weight gain, anemia and edema.

• Alpha Lipoic acid is a potent antioxidant that reduces insulin resistance. It is approved as a drug, in Germany, to treat nerve damage due to diabetes and is beneficial to individual with high cholesterol, cataract, and circulatory problems. High doses can cause nausea, and excessive low blood sugar.

• Metformin(Glucophage) prevents the release of sugar from the liver, reduces insulin resistance, and reduces glucose uptake in the gut. It does not cause weight gain, so it is beneficial to obese individuals. It helps to reduce LDL and triglycerides. Lactic Acidosis is one of its side effects so it is not the first option in patients with heart or kidney disease.

• Glucotrol, Amaryl, and Diabeta (glyburide) stimulate the pancreas to secret insulin. Their main side effect is excessive low blood sugar. Glyburide should not be used by the elderly and individuals with kidney problems.

PREVENTION — Three factors have been evaluated in an attempt to prevent type 2 diabetes: exercise, weight loss, and drug therapy. Smoking cessation may also be important. Intensive lifestyle intervention provides the greatest benefit in prevention of diabetes.

LIFESTYLE MODIFICATION

Exercise — Although insulin resistance and impaired insulin secretion in type 2 diabetes have a substantial genetic component, they can also be influenced, both positively and negatively, by environmental and behavioral factors. The benefit of exercise in preventing diabetes has been demonstrated in several studies.

Proper diets Include supplementation not just restrictions

• When glucose is not available to make energy the cell uses a back up mechanism to make energy, this causes the body to become more acidic.

• Enzymes which keep our metabolism balanced don’t work in acidic environment.

• Efficient DNA replication requires enzymes which require coenzymes and cofactors obtained from the food we eat.

• Today’s soil is deficient of the nutrients required to make these substances and food is genetically modified to increase the yield.

• Heavy metals (aluminum, mercury) and asbestos from the environment, saturated fats, pesticides, and herbicides can contribute to the deterioration in insulin function and production, and at the same time make the pancreas more vulnerable to infections that cause it to malfunction.

• If the insulin function begins to deteriorate, that means other functions have started to deteriorate (i.e. the thyroid and the immune system).

• Available supplements include antioxidants, chelating agents (for heavy metals) and a number of herbals which have demonstrated beneficial effects for diabetics.

Part II will discuss the complications and alternative medicinal choices.

 

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