Diabetes: Type 1 or Type 2
Diabetes: Type 1 or Type 2
Diabetes: Type 1 or Type 2
Diabetes is the disease someone in our family always gets until it happens to you. The fact of the matter is that diabetes is now essentially a worldwide epidemic and it is getting worse. The incidence of diabetes has a direct correlation with our standard of living. The more overweight the population is the more diabetes occurs. America's population is generally overweight; with over 3 in 5 adults are classified as overweight, and 1 in 5 as downright obese. Children and adolescents are not doing much better with a trend showing a continued rise in the amount of children who are overweight and a decrease in the age at which these problems begin.
Type I diabetes is usually seen early in life and has remained relatively stable. Type I diabetes is seen first in young people who have had their own immune system attack and destroy the insulin producing beta cells in the pancreas. Antibodies from the immune system are out of control and destroy these beta cells in the pancreas. Recently, researchers reported in Science Daily (March 6, 2009) a study that linked enteroviruses as possible causative agent in Type I diabetes with a study showing that 40% of damaged cells had an enterovirus infection that reduced their insulin function. Type I diabetics have very unique and complex insulin needs, and are generally best followed in consultation with endocrinology specialists.
The main target of our diagnostic and treatment abilities is directed toward Type II diabetes. Type II diabetes is linked to weight and develops insidiously over time. It is important to get your blood sugar checked every time your doctor advices it, especially if you have a family history. Times to do this would be at annual physical exams, at health fairs, or perhaps by a relative or friend who has a glucose meter. We want to see a fasting glucose of 70-100 fasting means no food, only water after 10 P.M. until about 7 to 9 A.M. when you should have your labs drawn. If it is between 100 and 126 (fasting), you are considered pre-diabetic, and chances are pretty good that you will develop this problem over your lifetime. If your fasting glucose is over 126 (fasting), then you are diabetic. All tests should be repeated at least once for confirmation. There are other glucose values for 2 hours after eating or specific random blood sugars, which help diagnose the condition.
The basic cause for the elevation in blood sugars of diabetics involves the pancreas and the beta cells. Beta cells in diabetics can produce too little insulin, and the same body cells that receive directions from insulin have developed a resistance to the insulin and do not recognize the insulin produced. Here's what happens to the rest of the body: The elevated glucose (sugar) starts causing damaging changes in both the tiny blood vessels, and in the larger ones, as well. The process of atherosclerosis called hardening of the arteries is started by the inflammation produced. As the disease progresses, the dreaded consequences of heart attack, strokes, blindness, kidney failure, and limb amputations may occur.
We can slow down the vascular disease by keeping blood sugar in the normal range. If every patient would walk 30-45 minutes per day and lose 5% to 7% of body weight, the insulin resistance would be markedly reduced. Doctors used to initially follow patients for long periods of time emphasizing exercise and diet. Of course, diet and exercise are very important, but we know now that the earlier we control the sugar the longer we can starve off the progression of the disease. Usually, by the time a patient is diagnosed, 50% of their beta cell function has already been lost. Medicines are started right away to lower insulin resistance and blood sugar. One other caveat is that you absolutely have to quit smoking, as smoking accelerates the vascular damage that is already taking place. Often times, a small dose of aspirin a day is given to lessen the chance of blood clots forming at the sites of arteriosclerotic plaque formation.
There are several medicines to treat Type II diabetes and can be broadly classified as Insulin sensitizers, secretealogues, and analogues. The sensitizers are usually started as initial treatment or can be added as second agents. The first one usually prescribed is metformin (Glucophage) which is in the biguanide class and works by lowering insulin resistance. There are several conditions of the liver, kidneys, and heart that must be considered when prescribing all of these medicines. Thiazolidinediones are other drugs in the sensitizer family and will not lower the sugar too low, but these have to be used with caution in people who have heart disease.
The next class of oral medicines which can be prescribed are the secretealogues. Sulfonylureas belong in this class which has been around the longest, and they are time-honored. One problem with them is that they can cause the blood sugar to go too low (hypoglycemia) and cannot be used in people allergic to sulfa since they contain a sulfonyl group. Other members of the secretalogues include meglitinides, GLP-1 analogues, and DDP-4 inhibitors. Members of the GLP-1 group such as Exenatide and Liraglutide is a class of medications that are interesting. They are based on the fact that the intestines release something called incretin which lowers blood sugar when it is taken by mouth by stimulating the release of insulin even before blood glucose is affected. One caveat with any of these oral medications is that many of them should not be used in pregnancy and some have been found to be teratogenic meaning tumor producing. Ideally you should have a consultation with your Obstetrician and plan a pregnancy with tight sugar control and use medications that have been proven to be the safest in pregnancy. Always consult with an Obstetrician when you are pregnant, suspect you are pregnant before continuing or before starting any diabetic regimen.
The most reliable of the medications to lower blood sugar has traditionally been the analogues. Analogues are injectible insulin and come in several different forms. The different varieties affect the length of time it is effective and can be anywhere from 2 hours to 18 hours. The downside to insulin is that it must be given by injection under the skin or in a vein. Just like the oral agents some have been linked to birth defects so it is important that a patient follows up with an Obstetrician as soon as possible. There are several other classes of medications used in diabetics such as alpha glucosidase inhibitors and SGLT-2 inhibitors but are beyond the scope of this article.
Turning from the outside of the body to the inside research has pointed to the fat adjacent to our intestines. This visceral fat has been described as the worst type for a diabetic patient to have, and is the main cause of "pot-bellied" obesity. Three pounds of visceral fat is as bad for you as twenty pounds on the hips when it comes to controlling your blood sugar. So try to keep your body weight (B.M.I) Body Mass Index in the normal to ideal ranges. Get plenty of exercise and don't smoke. Your doctor can tell you if you need to be on aspirin therapy to prevent atherosclerotic blood clots. Get your blood sugar checked whenever you can, or if you are already diabetic, get a glucose monitor and self-test regularly. A formal consult with a dietician is an excellent way to work out a proper diabetic diet and will teach you how to keep great glycemic control. Eat healthy, and avoid junk foods, high carbohydrates and trans-fats. Keep that fasting blood sugar below 100 and the Hemoglobin A1C below 7%. Walk 30-45 minutes a day and work to lose weight. Take your medicines faithfully the same way each day. Together, we can work to prevent and successfully treat diabetes for this generation and the ones to come.
John Drew Laurusonis
Doctors Medical Center
www.doctorsmedicalctr.com
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