(word processor parameters LM=8, RM=75, TM=2, BM=2) Taken from KeelyNet BBS (214) 324-3501 Sponsored by Vangard Sciences PO BOX 1031 Mesquite, TX 75150 Diabetes Details (c) HealthNet, Ltd. 1987 courtesy of Double Helix at 212-865-7043 Since blood sugar measurements are widely used in the diagnosis of diabetes, it is important to understand some basic concepts of hormone regulation to appreciate the mechanism of the various types of diabetes. The hormone in question is insulin, a complex chemical produced in small clusters of cells in the pancreas, which lies just behind the stomach. The insulin is absorbed into the blood stream where it is carried to the rest of the body. The actions of insulin are several: most importantly, it causes the glucose (blood sugar) to leave the blood and enter the cells of the various body organs. It is as if there were a gate between the blood and the organs, and insulin is the key to the gate. In addition to facilitating the passage of sugar from blood to cells, insulin also allows many other metabolic processes which all work toward the storage of energy into fat and other substances, and prevent the release of such stores into the blood. In the "fed" state, it is obviously advantageous to pack away for future use any energy or body fuel not immediately needed, and insulin does this. Even in very small quantities, insulin can prevent the breakdown of body stores into energy sources. It is possible to thus understand the effects of insufficient insulin. For one thing, the level of glucose in the blood will rise, especially after a meal which causes the digestion and absorption through the intestines of large amounts of sugar. Nothing stops the glucose from getting into the blood, but once there, it has no place to go, and levels rise. The kidney is able to block the passage of sugar into the urine up to a point, but once levels exceed around 180 milligrams per 10 cc of blood, there is some overflow into the urine as well. Without insulin, body organs which depend on glucose for energy are unable to extract it from the blood and begin to rely on alternate sources of energy. Among these are some forms of fat. The breakdown products of these fatty substances are highly acid in nature, and begin to accumulate in the blood. Called ketones, these byproducts are responsible for the condition called ketoacidosis which can occur in untreated diabetes. The disordered metabolism in diabetes can alter the way in which the body handles fats including cholesterol. Over the years, this leads to an accumulation of such fats in the small arteries of the body. Characteristically, the arteries so affected tend to be those of the eyes, the kidney, the heart, and the brain. Page 1 In addition, diabetes can cause blindness, kidney failure, heart attack, and stroke. Of course, the better the degree of control, the less likely the complications, according to most authorities. Types and Causes The causes of diabetes are not known, although some clues are available. Most cases fall into one of two types, which may be quite distinct in their causes. The first type, or Type I, is generally acquired in childhood, and usually is found to be a near total lack of internal insulin production. If untreated, patients often will develop the potentially urgent complication of ketoacidosis (discussed elsewhere). Such patients are usually thin, and always require insulin administration to sustain life. The other type, Type II, is generally acquired in adulthood, is most common in obese patients, and may be treated with dietary measures or occasionally oral medication, with only a small minority requiring insulin. Although severe short and long-term complications and symptoms may occur in the untreated case, ketoacidosis in unlikely. Type I diabetes is of unknown cause; it may be caused by a preceding virus which affects the pancreas, or an autoimmune process within the body. Although a genetic factor may play a role in some way the relationship is not clear or overwhelming. In genetically equivalent identical twins, only a third to a half of siblings with type I diabetes will also develop the disease. Perhaps a vulnerability is inherited, and only those exposed to some offending agent go on to develop the disease. Type II diabetes is highly genetic, with a nearly 100% occurrence in identical twins of affected patients. The actual cause is unknown, and it often occurs in patients with no family history of the disorder. Clearly obesity plays a critical role in bringing out the disease in susceptible patients. In general these patients retain the ability to produce some insulin, but in response to a meal, the response is long delayed, and often inadequate. In addition, many patients are resistant to the action of insulin even when it is present, especially if obesity is present; in these cases, the insulin level may actually be higher than normal, yet diabetes occurs due to insulin resistance. The incidence of Type II diabetes increases with age. Symptoms Symptoms of increased blood sugar include fatigue, increased appetite if enough blood sugar is wasted into the urine, and increased urination as the sugar causes the kidney to produce higher volumes to dissolve the excess load. When the latter occurs, thirst is increased as well to make up for the lost body fluid. As levels of blood sugar rise and ketosis occurs (see above), the body fluids become excessively acid. One of the defenses against acidity is to decrease the carbon dioxide in the blood, which is accomplished by increasing the rate and depth of respiration. Page 2 The full blown picture of ketoacidosis is a dehydrated, obtunded or even comatose patient, who is breathing heavily with a characteristic odor to the breath from the ketones in the blood. The lesser symptoms are as above. Diabetics are prone to symptoms from the complications due to arterial blockage discussed above. Vision loss, heart problems, and loss of kidney can occur. Nerves in the legs, arms, and face can become painful or numb for weeks, months, or permanently. Many of these complications require the presence of the disease for decades or more. Diagnosis Once the diagnosis is suspected, or an elevated sugar is detected on screening lab work, certain criteria have been established for doctors to follow. Typical numbers for adequate diagnosis in an appropriate setting might include a fasting sugar over 150 mg.%, or repeated after-meal levels over 200 mg%. The normals vary with age, and certain factors can interfere with the test. A controlled glucose "tolerance" test involves the administration of a measured amount of oral glucose, followed by checks of the blood every 30 to 60 minutes for 2 or more hours. Newer normal references consider many factors, and the ultimate diagnosis often requires repeated checks and judgment on the part of the treating physician. Treatment General measures common to all diabetics include reduction to normal body weight if obesity is present, moderate or even vigorous activity if this is considered safe from a general health standpoint (exercise has an insulin-like effect), and dietary discretion. Years ago, diabetic diets were strictly controlled formulae of rigid proportions of fat, carbohydrates, and protein organized into "exchanges" which made the diabetic's life highly structured around the diet. Today, diet remains crucial in a comprehensive management program, but it is recognized that much more flexibility is possible without harm. Total calories are determined, ranging usually from 1500 to 3000 per day. Sweets are largely avoided, but not entirely so, and carbohydrates are allowed liberally, as is dietary fiber. Vegetable fats are encouraged instead of animal or dairy fats, and should be moderate. Generally, one fifth of the days calories are taken at breakfast, with two fifths each at lunch and supper, or adjusted to allow for a small snack in between. This oversimplification is largely adjusted for individual variations, and a comprehensive dietary educational program of a personal nature is vital. Dietary professionals often provide such training as part of a larger diabetes program. When diet and exercise alone are inadequate to normalize blood sugars, one alternative for type II diabetics is the use of pills Page 3 which lower blood sugar either by acting like insulin, stimulating the pancreas to produce more insulin, or making body cells more sensitive to insulin. A long-running controversy exists over the report that these drugs can increase the risk of sudden death (presumably due to heart attacks), but the data is not clear at this time. Most authorities agree that the drugs have a genuine place in the management of the disease, especially in symptomatic elderly patients who can not or will not follow a dietary program, or who do not respond to such a program. Excellent control is rarely achieved, but the ease of use and lesser concern about overall life expectancy may outweigh the theoretical risks. This issue is always best decided by the physician and patient considering all the individual factors involved. Chlorpropamide, tolazimide, tolbutamide, and gliburide are examples of such drugs. Some physicians avoid these drugs altogether. Insulin is the main means of controlling diabetes which is not responding to diet, and is the necessary treatment for type I disease. Various types are available, varying in their peak onset of action, duration, etc. Often, two types are given in combination. Insulin is given by the patient as an injection under the skin using disposable very small needles and syringes, after appropriate training. Although the prospect seems drastic at first, diabetics quickly accept this as a routine part of their regimen. In the initial phase, many adjustments are necessary, sometimes in the hospital, until the right doses are determined. Side effects include allergic reactions and hypoglycemic (low blood sugar) episodes. Modern medicine stresses the importance of near-normal blood sugars in the prevention of complications of diabetes. The optimal patient checks her own blood tests through a finger stick one or more times daily, checks occasional urine samples for sugar, follows a consistent diet and activity program, and adjusts the insulin dose as needed within guidelines established by the physician. When problems arise, the physician is consulted as a resource, and regular medical follow-up is scheduled routinely. The effects of various stresses, both physical and emotional, are anticipated and allowed for. Occasional low sugar episodes are accepted as a price of good control, but are usually easily reversible with a light snack. Some diabetics use a portable insulin pump which injects insulin through an intravenous tube around the clock. It is felt that this is comparable to, but not necessarily superior to, a carefully applied program of standard injections of long- acting insulin with frequent blood sugar monitoring and appropriate adjustment. The pregnant woman with diabetes requires special control, since even modest blood sugar elevations are potentially harmful to the fetus. Stricter criteria apply, and closer management is in order. In some women, diabetes appears under the physiologic "stress" of pregnancy, only to improve after childbirth. Some such patients go on to develop long-standing diabetes in later years. Page 4 Only rarely are things as smooth as the above description, but most diabetics will do very well under the guidance of a concerned team of a physician, dietician, nurses, and other professionals. Many become highly sophisticated about their disease, and groups such as the American Diabetes Association and local resources offer invaluable support. Preventive measures such as immunizations, foot care (diabetes predisposes to infections of the feet), and travel precautions are also important. Prognosis It is very difficult to generalize about the prognosis of diabetes since it is such a variable disease. It seems fair to say that the disease decreases life expectancy, and diminishes quality of life through its complications and treatment requirements. Only recently has the concept of very rigid control been feasible through home blood glucose monitoring, and there is much evidence and great hope that tomorrow's diabetic can look forward to a near- normal life if such control is maintained. Horizons Research is proceeding in several directions which may provide breakthroughs in diabetes, though none is currently available for general application. One is an artificial pancreasœwhich takes regular readings of the blood sugar, and automatically injects through an intravenous tube the appropriate amount of insulin needed on almost an instantaneous basis. Another is the possibility of transplanting pancreatic tissue from a donor into the diabetic patient, although the troublesome rejection problems are seen here as in most transplant procedures. HealthNet will keep you alert to any meaningful advances in this area. -------------------------------------------------------------------- If you have comments or other information relating to such topics as this paper covers, please upload to KeelyNet or send to the Vangard Sciences address as listed on the first page. Thank you for your consideration, interest and support. Jerry W. 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