Diabetes - Type 1 & 2

 

What should I know about Diabetes? 

Diabetes mellitus, a term that means “the running through of sugar,” was first identified in the 1st century AD. The disease was described in old books as “the melting down of flesh into urine.” Diabetes mellitus is a chronic condition where there is less insulin than what the body needs. This can be low insulin, a problem with the release of insulin, insulin that cannot work in the cells that need it, or insulin that is inactivated before it is able to function. Diabetes mellitus is a disease in which the body does not produce or does not use insulin effectively. It is not simply hyperglycemia, or too much glucose (sugar) in the blood. 

Insulin is a hormone produced in the pancreas by the beta cells in the Islets of Langerhans. The release of insulin by these special cells is regulated by the amount of glucose in the blood. It is responsible for transporting glucose (from carbohydrates) into the cells for energy production. After a meal, when blood sugar increases, insulin release increases. 

Between meals, when blood sugar is low, insulin release is low. Insulin is released from the pancreas directly into the liver where some is used and some is broken down and eliminated from the body. The rest is released into the general blood circulation. By helping to move glucose into the cells, insulin decreases blood sugar. Insulin also decreases the breakdown of stored fat and builds triglycerides. Insulin is involved in the production of protein. The proper growth and development of children is dependent on insulin. 

Diabetes can affect people of any age. It increases the risk of chronic conditions like heart disease, retinopathy (a disease of the retina) and blindness, peripheral neuropathies (a disease of the nervous system), circulation problems that can lead to amputation, problems with the immune system, and skin ulcers and poor wound healing. 

Diabetes is diagnosed by lab tests, either a fasting plasma glucose (FPG) or a two-hour plasma glucose (OGTT – oral glucose tolerance test). There are two forms of diabetes mellitus: type 1 (also called IDDM, insulin dependent diabetes mellitus, or juvenile onset) and type 2 (NIDDM, non-insulin dependent diabetes, or adult onset). 

Type 1 Diabetes 

Type 1 diabetes is a condition where the beta cells in the pancreas do not release insulin. This is called an absolute insulin deficiency. This means that the individual has hyperglycemia and begins to break down their fats and protein in order to meet the energy demands of the body. This breakdown of fats and protein makes the insulin dependent diabetic build up waste products called ketone bodies, which causes a condition called ketoacidosis. Insulin dependent diabetics need a constant supply of insulin to prevent ketoacidosis and maintain a stable blood sugar.

Type 1 diabetes usually occurs in people younger than 30 years of age. It is thought that the disease is a caused by something in a person’s family history (genetic factor) that responds abnormally to the beta cells in the Islets of Langerhans. Islet cell antibodies have been found in 60-95 percent of persons with type 1 diabetes. Sometimes this unusual response by the body can be started by a virus, a vaccination, or a toxic fungus. 

Type 2 Diabetes 

Ninety percent of individuals with diabetes have type 2. Most of these individuals are over 40 years old. One in five patients is over the age of 65, and 80 percent are overweight. Many patients have increased blood sugar seven to ten years before symptoms occur. 

When something is wrong with a person’s blood sugar regulation even if insulin is being produced by their pancreas, the individual probably has type 2 diabetes. People with type 2 do not need to depend on insulin injections to survive. Type 2 diabetes is not fully understood. Three physical abnormalities usually occur in type 2: insulin resistance, increased glucose production in the liver, and poor beta cell function. These can occur individually or in combination. 

Insulin resistance appears to be the first stage of the disease. It means that insulin cannot help glucose go from the blood into the cells. While the beta cells are able to release normal or even higher than normal amounts of insulin, glucose movement into the cells is sluggish and blood glucose slowly begins to rise. Therefore, blood sugar remains increased even with insulin being produced by the pancreas. Then the pancreas releases even more insulin, and hyperinsulinemia (too much insulin in the blood) begins. 

This is likely due to a genetic defect that affects how insulin is used or the way it is transported to the cells. Insulin resistance is due to high insulin levels, not high glucose levels. Therefore, the individual is always hyperglycemic. Eventually, the beta cells “burn out” and insulin resistance may turn into diabetes. 

Many people with type 2 diabetes also produce a large amount of glucose in the liver. This increase in liver glucose production is likely related to fat breakdown. When the body is not efficiently using glucose as an energy source, stored fat becomes an important source of fuel. The breakdown of fat makes the liver produce glucose. Because patients with type 2 diabetes are insensitive to the effects of insulin, which normally stops the production of glucose in the liver, this condition continues. This situation also appears to be related to weight and physical activity. 

In type 2 diabetes, the ability of the beta cells to release the first amount of insulin needed after eating a meal (postprandial insulin release) deteriorates early on in the disease. Therefore, blood glucose remains increased for one to two hours after a large meal. As the disease gets worse, the insulin release that continues following a meal also worsens, resulting in something called pancreatic beta cell exhaustion. 

Type 2 diabetes appears to be caused by genetic defects that at first make a person not able to respond to the actions of insulin and, over time, the beta cells in the pancreas will stop releasing insulin. However, new evidence points to diet and lifestyle as important factors that may be responsible for the development of the disease. A person over the age of 45 and overweight is a likely candidate for developing type 2 diabetes. About 30-39 percent of Americans are obese, and many more are overweight. Research has shown a strong connection between upper body obesity (people with “apple shapes”) and the development of type 2 diabetes mellitus.

Complications of Diabetes 

The long-term complications associated with diabetes are serious, often life-threatening, and diagnosed in the late stages of the disease. These complications are due to continuous hyperglycemia from poor glucose control. Many of these chronic complications can be traced to changes in blood vessels that cause a decreased blood flow. These changes include coronary heart disease and peripheral vascular disease, retinopathy, nephropathy, and neuropathy. 

Heart disease is the leading cause of diabetes-related deaths, with adults having two to four times higher heart disease death rates than adults without the disease. The risk of stroke is two to four times higher in people with diabetes. Patient with diabetes develop more atherosclerosis (hardening of the arteries) than people without diabetes, and some 60-65 percent of patients with diabetes have high blood pressure. 

When high amounts of blood glucose are present in tissues such as the lens of the eye and nerve cells, the body finds other ways to handle the extra glucose in these cells. Enzymes (proteins that stimulate chemical reactions to occur in the body) work to breakdown the extra glucose, causing an increase in sorbitol and fructose (types of sugars). This excess sugar in these cells will then take on extra fluid, eventually damaging these cells. 

Retinopathy is the leading cause of new cases of blindness among adults 20 to 74 years of age. Because of increased glucose,  blood vessels weaken and microaneurysms (small swellings in the blood vessel) occur in the capillaries of the retina. The retinal cells can then burst and hemorrhage (bleed). This blurs vision and can lead to detachment of the retina.

Nephropathy (kidney disease) is the leading cause of kidney failure requiring dialysis. The first sign is microalbuminuria (a type of protein in the urine), which leads to proteinuria (protein in the urine), and eventually end stage kidney disease. 

Neuropathy (disease of the nervous system) causes numbness and tingling in the arms, legs, hands, and feet, eventually leading to injury and the development of diabetic ulcers (wounds) in these areas. Diabetes is the leading cause of amputations in the U.S. Other changes that occur with neuropathies include GI problems, such as gastroparesis (a paralysis in the gastrointestinal tract), chronic constipation, or diarrhea; loss of sexual function, bladder function, and heart problems. 

Signs and Symptoms

The following list does not insure the presence of this health condition. Please see the text and your healthcare professional for more information. 

General

• Frequent urination
• Thirst
• Weight loss despite increased appetite
• Fatigue
• Irritability
• Low blood sugar episodes (blood glucose <60mg/dl or 3.3 mmol/l ) can be marked by dizziness, lethargy, irritability, loss of coordination and perspiration
• High blood sugar episodes (blood glucose >250mg/dl or 13.9 mmol/l ) can be characterized by increased thirst, nausea, vomiting, and a “fruity” odor to the breath  

Initial symptoms of diabetes include frequent urination, thirst, weight loss despite an increased appetite, fatigue, and irritability. Dizziness, lethargy, irritability, loss of coordination, and perspiration are common during episodes of low blood sugar (blood glucose <60mg/dl). High blood sugar (blood glucose >250mg/dl) among insulin-dependent diabetics can lead to ketoacidosis which requires medical attention. Increased thirst, nausea, vomiting, and an acetone or “fruity” odor to the breath are common with ketoacidosis. 

Diabetic coma, or ketoacidotic coma, is a life threatening complication of type 1 diabetes. As the make up of the blood changes, a severe imbalance occurs between the amount of water in the blood plasma and the amount of electrolytes. Symptoms include abdominal pain, nausea, vomiting, and shortness of breath (Kussmaul breathing). Signs include flushing, decreased reflexes, and “fruity” breath. 

Treatment Options 

Conventional 

Treatment goals for diabetes include avoiding hyperglycemia, hypoglycemia (low blood sugar), and decreasing, slowing down, or avoiding the long-term complications of the disease. Therapy should be special for each person depending on his or her condition. It is important to realize that the disease will probably get worse throughout the patient’s lifetime, and that the treatment plan may need to be changed to control blood sugar and avoid other health problems. 

The treatment of diabetes involves making sure that insulin is controlling blood sugar properly. Along with a program of a healthy diet and exercise, insulin is the treatment of choice for the patient with type 1 diabetes. The patient or caregiver also needs to monitor blood glucose very carefully to decrease the risk of future complications. This is usually done at home with a blood glucose meter. A small amount of blood is taken with a fingerstick, and the amount of blood sugar is measured by the machine. Insulin doses can be changed based on this information. 

Insulin is a protein and a hormone. All insulin products on the market are from the pancreas of pigs or made synthetically. Animal-derived products are being phased out, although a few purified pork insulins are still available. Human insulin is a biosynthetic product that is made by using baker’s yeast, or a strain of the bacteria E. coli that does not cause disease. Insulin lispro or insulin aspart are also biosynthetic products on the market to treat diabetes. They are a little different from human insulin in order to get a specific effect.

Insulin is given by injection underneath the skin in a very specific dose to control blood glucose. Insulin must be injected because it is a protein and can be digested in the gastrointestinal (GI) tract. Insulin can be measured and injected with a traditional insulin syringe or with a pen-injection system. Insulin can also be given by using an infusion pump, which automatically injects a continuous dose of insulin. This is an alternative to giving daily injections at different times during the day. The following list summarizes the various insulin formulations currently on the market. 

Commercially Available Insulin Formulations 

Rapid-acting

• Human Insulin Lispro
• Human Insulin Aspart 

Short-acting

• Human Insulin (rDNA)
• Pork Purified Insulin

Intermediate-acting

• Isophane Human Insulin (rDNA)
• Pork Purified Isophane Insulin
• Human Insulin Zinc Suspension (rDNA)
• Pork Purified Insulin Zinc Suspension

Long-acting

• Human Insulin Zinc Suspension (rDNA), Extended
• Insulin Glargine 

Human Insulin (rDNA) Mixtures

• Isophane Insulin + Insulin 50/50
• Isophane Insulin + Insulin 70/30
• Insulin Lispro + Protamine 0.19mg (50/50 Mix)
• Insulin Lispro + Protamine 0.28mg (75/25 Mix) 

Treatment for patients with type 2 diabetes includes diet, exercise, and drug therapy. Diet is considered to be the first treatment to try. Maintaining ideal body weight can help the patient to control the disease. Exercise can help the insulin that is available to work better and help regulate glucose production in the liver. Even with diet and exercise, however, within the first five years after diagnosis, over 60 percent of patients will need oral antidiabetic drugs. It is also estimated that approximately 40 percent of patients will eventually need insulin injections to control their blood sugar. 

Oral Antidiabetic Drugs

Oral drug therapy for the management of type 2 diabetes now includes more choices in several drug classes, most of which work differently. Sulfonylureas cause release of insulin from the pancreas and help insulin to work better; biguanides work in the liver; thiazolidenedones work in muscles; glucosidase inhibitors work in the small intestine; and meglitinide causes release of insulin from the pancreas. 

Oral Drugs for Treating Diabetes 

 

First Generation

• Tolbutamide 250mg, 500mg
• Acetohexamide 125mg, 250mg
• Tolazamide 100mg, 250mg, 500mg
• Chlorpropamide 100mg, 250mg 

Second Generation

• Glipizide 5mg, 10mg
• Glipizide extended release 2.5mg, 5mg, 10mg
• Glyburide 1.25mg, 2.5mg, 5mg
• Glyburide Micronized 1.5mg, 3mg, 6mg
• Glimepiride 1mg, 2mg, 4mg 

Alpha-Glucosidase Inhibitors

• Acarbose 50mg, 100mg
• Miglitol 25mg, 50mg, 100mg 

Biguanides

• Metformin 500mg, 850mg, 1,000mg
• Metformin extended release 500mg 

Meglitinides

• Repaglinide 0.5mg, 1mg, 2mg 

Thiazolidinediones

• Rosiglitazone 2mg, 4mg, 8mg
• Pioglitazone 15mg, 30mg, 45mg 

Combination Products

• Glyburide and Metformin 1.25/250mg, 2.5/500mg, 5/500mg 

Sulfonylureas

Oral sulfonylureas are related to sulfa antibiotics but do not have antibacterial action. They stimulate insulin release, increase the amount of insulin circulating in the bloodstream, and make the beta cells more sensitive to the actions of glucose. They are used along with diet and exercise. They are only effective in patients that can produce insulin. They don’t prevent beta cell loss. Therefore, sulfonylureas can become less effective over time. The newer agents in this group of drugs have less drug interactions than the first drugs that were marketed in this group. About 50 percent of patients will successfully control their diabetes with the use of sulfonylureas. These agents can also be used in combination with injectable insulin. All of the sulfonylureas can be taken with food except for glipizide. Food slows down glipizide absorption, so it is recommended that this drug be taken 30 minutes before meals. 

Biguanides

Metformin is a member of the biguanide group of antidiabetic drugs and not related to the sulfonylureas. It makes the insulin that is available work better – it doesn’t increase the amount of insulin that is released. By not increasing insulin release, it does not cause hyperinsulinemia. It also decreases blood glucose without producing hypoglycemia. It can be used with diet or in combination with other drugs. It does not produce weight gain. Metformin is the only antidiabetic drug ever shown to extend the life of patients with type 2 diabetes. 

Thiazolidinediones

Troglitazone, a member of the thiazolidinedione drug class became available in January, 1997, and was reported to lower blood glucose by decreasing insulin resistance, not by increasing insulin release. It could be used alone, with insulin, or along with oral sulfonylureas. By December of that year, the FDA announced new guidelines to be followed to monitor patients for signs of liver injury. This was due to 35 reports of liver injury in U.S. and Japanese patients, including one liver transplant and one death. The manufacturer removed the drug from the market in March, 2000. 

In May, 1999, the FDA approved rosiglitazone, the second drug in this class of antidiabetic drugs. It does not seem to have the same liver problems that were seen with troglitazone. No significant drug-drug interactions have been reported. However, caution is still needed and watching patients on this drug is still recommended. 

The third drug in this group to receive FDA approval is pioglitazone. It has advantages over the other two drugs in this group. Most patients will have lower triglycerides, increased HDL cholesterol, and no changes in LDL cholesterol with this drug. This may be important for those patients with type 2 diabetes that are at high risk for heart disease. Watching patients on this drug is still recommended. 

Alpha-Glucosidase Inhibitors

Acarbose and miglitol are alpha-glucosidase inhibitors. They lower postprandial blood glucose by slowing down the digestion and absorption of carbohydrates. These agents do not affect the absorption of simple sugars, such as glucose and lactose. Unlike sulfonylureas, they do not cause hypoglycemia, hyperglycemia, or weight gain. They do not increase insulin release. They can be used with diet alone or combined with sulfonylurea or biguanide agents. They have been reported to decrease triglycerides and LDL cholesterol. These drugs are most useful for patients in the early stages of the disease who have high blood glucose after meals, but have normal fasting blood glucose lab results. 

Meglitinides

Repaglinide belongs to a drug class known as the meglitinides, not related to the sulfonylureas. It decreases blood glucose by increasing the release of insulin from the pancreas. It needs to have functioning beta cells to work effectively. Repaglinide can be used alone or in combination with metformin. When it is used along with metformin, the results are better than with using either drug alone. It must be taken multiple times daily, usually within 15 minutes of each meal. Patients who have not done well with a sulfonylurea will probably not do well with repaglinide. 

Use of Insulin in Type 2 Diabetes

In patients with type 2 diabetes, it is important to make sure that the drug therapy is special for each patient. When there is little or poor response to a drug from one class, a drug from another class can be substituted to see how that works in the patient. For those patients who need it, a second drug from another class can be added. However, control of blood glucose is likely to decrease over time, as type 2 diabetes is a progressive disease – that is, it does get worse with time. 

Even with the use of oral agents, postprandial hyperglycemia still is a problem for 60 percent of patients. The failure of oral agents to control blood sugar is common. More than 25 percent of type 2 patients will require insulin to adequately control their blood sugar. Blood sugar monitoring and taking all antidiabetic drugs properly are extremely important.

Natural Treatments

There are a great many vitamins, minerals, herbal supplements and other natural remedies that have been shown to effectively lower blood sugar safely and effectively. Which therapies are chosen will be based on the root cause of the elevations in blood sugar and not just the symptom. Your practitioner will carefully evaluate your situation and put together an effective protocol at safely lowering your blood sugar with natural remedies rather than just medications that merely treat the symptom. Please note it is dangerous to adjust the dosages or discontinue any medications without the advice of a qualified healthcare practitioner who will work with you and as your body increases insulin sensitivity and output your medications will be adjusted accordingly in conjunction with your primary healthcare provider.

Diet & Lifestyle 

Diet: 

Diabetes and obesity have increased over the past 50 years in the United States. People don’t eat enough fresh foods, and there are fewer micronutrients in the soil where food is grown. Fad diets of high protein, low or high fat, and low or no carbohydrates are not the answer. While this type of diet may help take weight off at first, it is not a long-term answer. Carbohydrates alone are not the cause because humans were eating carbohydrates long before these problems arose. It is true, however, that people are eating excessive amounts of carbohydrates, and it would be better to moderate that habit. 

There are several ways to support and improve insulin regulation by using natural agents, but the real key is to change the selection of foods in the diet. In general, the American diet is made up of a large amount of carbohydrates, especially refined carbohydrates. People limit their intake of fresh vegetables and fruits, and quality sources of protein and legumes, and they do not take in enough essential fats. As of 1985, the typical American diet was 46 percent carbohydrates, 43 percent fat (poor quality), and only 11 percent protein. With the average American eating approximately 150 pounds of sugar a year, there is a continuous demand for more insulin to be released.

The average person drinking two “big gulp” drinks a day is receiving about 54 teaspoons of sugar. Using diet drinks does not work either because they contain toxic sweeteners like aspartame as well as sodium. This is particularly a problem for diabetics with hypertension (high blood pressure). While current research shows that dietary fat and cholesterol are definite problems, this situation is only made worse by the continuous, increased amount of carbohydrates along with the fat. Dietary fat is then stored because of excess insulin that is released while eating a high amount of carbohydrates. 

Many experts over the years have praised the low-fat, high-carbohydrate diet. The problem with this diet has been that it does not cause weight loss. In fact, a diet with too many carbohydrates has been linked to increased LDL cholesterol and triglycerides. The other thing to be aware of is that many prepared foods may be labeled low fat, but are loaded with refined sugars, which increase insulin release, and therefore, fat storage. 

Exercise:

Along with diet, exercise is the most important step diabetics can take toward blood sugar control. Today, there is more stress and less physical activity than even a generation ago. Exercise can decrease the risk for heart problems in diabetic patients. Regular exercise can improve heart and lung health, make insulin work better, and increase HDL cholesterol while decreasing LDL cholesterol. Exercise also helps to regulate blood sugar. At a minimum, diabetics should get 30 minutes of some form of exercise at least four days a week, but more would be beneficial. Anyone who is over 40, or a brittle diabetic, and has not been exercising, should check with their health care professional before starting any exercise program.

Over­all, it’s more impor­tant to focus on the root cause and what are the under­ly­ing mech­a­nisms that are caus­ing disease rather than just treat­ing it symp­to­mati­cally.  Each per­son is encour­aged to seek out a qualified healthcare practitioner in order to assess exactly which nutri­ents, herbs, home­o­pathics and nat­ural reme­dies; in which com­bi­na­tion; in what pro­por­tion are right for the par­tic­u­lar indi­vid­ual and are intended at treat­ing the root cause rather than just a symptom.