Diabetes Update

Diabetes is a hidden epidemic that is reaching epic proportions. About 17 million Americans have diabetes and about 6 million of those don't know it. What is diabetes and why are so many people unaware that they have it? Diabetes is a serious and complex metabolic disease, characterized by insulin dysfunction, that results in elevated blood glucose or sugar levels. Insulin is a hormone created in the beta cells of the pancreas. It takes the sugar from the blood into the cells. Sugar is the basic fuel for the cells in the body. Insulin and glucose are necessary for energy production. Elevated blood glucose/sugar levels over time cause damage to the body.

There are three main types of diabetes. Type 1, 2 and gestational diabetes. Type 1 diabetes is characterized by the absence of insulin. Its onset is usually rapid, and treatment is with insulin. In type 2 diabetes, the body either doesn't make enough insulin, or the insulin made is not effective. The majority, about 90 percent of people with diabetes, have type 2. Gestational diabetes occurs in pregnancy.

When blood glucose levels are higher than normal, but not yet high enough to be diagnosed as diabetes, it is called pre-diabetes. Doctors sometimes refer to this state of elevated blood glucose levels as impaired glucose tolerance or impaired fasting glucose (IGT/IFG), depending on which test was used to detect it. Research also has shown that action taken to control blood glucose in pre-diabetes patients can delay or prevent type 2 diabetes from ever developing.

The cornerstones for control are exercise, balanced nutrition and possibly medication..

The cause of diabetes is unknown. Ongoing research is under way in order to pinpoint exact causes. The signs and symptoms of type 2 diabetes can occur very subtly. Classic signs of diabetes are excessive thirst, frequency of urination, and sometimes extreme hunger. One overlooked sign of diabetes often is fatigue. This lack of energy is because insulin and glucose are needed for energy, and in type 2 diabetes insulin doesn't work like it should, therefore very little energy is produced. Many people ignore this symptom, blaming it on their hectic schedules, or the fact that they are getting older. This is one of the reasons people may not recognize diabetes. Early detection and treatment can prevent or delay the costly and burdensome complications of the disease.

Diabetes is diagnosed with two or more fasting readings of 126 or higher. A fasting blood sugar of 126mg/dL or higher is associated with an increased risk of diabetes complications. It is recommended that adults age 45 and older be tested for diabetes.

Who is at Risk? There are many risk factors, which include:

  • Having a parent or sibling with diabetes;
  • Being African American, Alaska Native, Hispanic American, Asian American or Pacific Islander;
  • Being more than 20 percent above ideal body weight;
  • A Body Mass Index greater than or equal to 27;
  • Giving birth to a baby that weighed more than 9 pounds at birth;
  • Having gestational diabetes during pregnancy;
  • Blood pressure at or above 140/90;
  • Abnormal blood lipids (blood fats), like triglycerides, greater than 25r0 mg/dL or HDL (high density lipoprotein) less than 35mg/dL;
  • Previous glucose abnormalities.
  • Diabetes is not curable, but it is controllable. The cornerstones for control are exercise, balanced nutrition and possibly medication. Elevated blood glucose levels damage the cells. Serious damage to the circulatory system, kidneys, eyes and nerves can occur over time. This is the reason control of glucose levels is so important. Type 2 diabetes is a progressive disease. It may be controlled through diet and exercise for a period of time. As the pancreas' beta cells function decreases, medication will probably be needed to control glucose levels.

    Exercise is often an overlooked part of diabetes control. Perhaps because when many people think of exercise, they think of calisthenics or physical education class. Exercise is activity, action or motion. When one increases activity, there is an increase in fitness. If you haven't been active, it is best to have a visit with your doctor before starting any activity plan.

    Walking is one of the least expensive ways to increase activity. However, housework, gardening and dancing are beneficial as well. Increase the number of steps you take, get a pedometer to see how many steps are taken and work on increasing the number on a daily basis. Plan on what you can do when it is raining, such as mall walking to get those steps in when the weather is not cooperative. If your sidewalks are uneven or your neighborhood unsafe to walk in, call the local school district and see which schools in your area have tracks where you can walk.

    Optimal exercise is considered 30 minutes daily at an aerobic level. It is known that 10 minutes three times a day is as beneficial. Choose something enjoyable. Start slowly and build up tolerance and time. Weights are a terrific way to increase strength. Athletic stores carry a variety of weights, but you don't have to go shopping to buy weights. Using 16-ounce cans from the pantry can work as well. Every time there is a commercial on television, do five bicep curls on each arm and leg lifts.

    Aqua aerobics at the YMCA, or natatorium, can be the answer for people with back or knee problems or arthritis. Chair exercises are also recommended. There are a variety of exercise videos available for homebound exercisers. Many local TV stations have programs where you can exercise along with the program's host, or tape them for later use.

    Exercise makes the body more sensitive to insulin, so glucose levels improve. It also improves oxygenation to the tissues, the elasticity of blood vessels and provides a sense of well-being. Optimal exercise is daily, but any activity is beneficial.

    Nutrition is a basic component of diabetes control. It is often referred to as a diet. The problem with the term diet is that it usually congers up a temporary state of starvation. People with diabetes have the same nutritional needs as everyone else, and there is no such thing as a diabetes diet. Diabetes nutrition is well balanced, and provides proper nutrients, minerals and vitamins. It offers a variety of foods in appropriate quantities. Eating well-balanced meals in appropriate amounts can control blood glucose levels, which is one of the goals of medical nutrition therapy. Other goals are control of lipid/blood fats, blood pressure and weight loss or weight maintenance.

    One major problem in our society is the tendency to over-do it. Obesity, which is associated with heart disease, hypertension and diabetes, is rampant. Why? We supersize, and as a result we are supersized. Often foods that are convenient are not the best choices, because they are high in fats and carbohydrates.

    Portions may be considered one of the more difficult aspects of the meal plan because we are accustomed to overly abundant servings. To identify appropriate portions for meat, servings should be the size of a deck of cards or the surface of your palm, and vegetable servings are 1 cup raw or half a cup cooked.

    An excellent way to have a better understanding of nutrition is consulting a registered/licensed dietitian. A nutritional consult is usually a covered insurance benefit with the diagnosis of diabetes. A visit with a dietitian can provide a plan to distribute fats, proteins and carbohydrates throughout the day. Carbohydrates, which are fruits, milk and starches, are the nutrients that impact glucose/sugar levels the most.

    Carbohydrates are the body's chief source of energy. A serving size of carbohydrates is 15 grams. Most nutrition plans have three to four servings of carbohydrates per meal or 45 to 60 grams of carbohydrates. Look at labels to see the amount of carbohydrates in a product. This is the nutrient that effects the sugar level the most. The amount of sugar on a label is not as important as the amount of carbohydrates.

    Fats are needed for certain body functions; however, they can provide unwanted calories, raise cholesterol levels and clog arteries. Dietary guidelines recommend no more than 30 percent of our daily intake come from fats. Reducing fats in the diet can reduce weight, calories and lower risk for heart disease. A little fat goes a long way. There are two types of fats. Saturated fats are from animal sources and solid at room temperature, the exceptions are palm and coconut oils. Unsaturated fats are generally from plant sources, and they are liquid at room temperature. The better choice is unsaturated fats in small amounts. Cholesterol is made by our bodies for cell membrane formation and is also ingested from animal sources. When the cholesterol level is too high in our bodies, it coats the blood vessels narrowing them; this impedes blood flow and increases blood pressure. This coating is called plaque and stiffens blood vessels. This is called atherosclerosis. If the vessel closes off completely, or a piece of the plaque breaks loose, it can clog the vessel completely causing heart attack or stroke.

    Proteins are the building blocks of the body. Proteins are categorized as complete or incomplete. Complete proteins supply the body with the nine amino acids in the right amount needed for protein synthesis. Complete sources include meat, poultry, fish, eggs and dairy products. Incomplete proteins lack one or two of the essential amino acids. These sources include seeds, beans, nuts, grains and vegetables. Protein should make up 15 percent or less of the day's food intake. Some patients with diabetes have kidney damage, and they should have even less protein.

    New recommendations encourage use of a daily multi-vitamin. Women should probably take supplemental calcium to help prevent osteoporosis. Use of daily aspirin is a recommendation for people with diabetes if they do not have a problem with ulcers or history of a bleeding disorder.

    In the past few years, the number of new medications to control glucose levels has dramatically risen. Until five years ago, the only medications were sulfonylureas, which stimulate the pancreas to release insulin. Now, there are many medications, including a biguanide, alpha glucose inhibitors, thiazolidinediones, meglitinides and insulin analogs. Combination therapy is now commonplace.

  • Sulfonylureas can be classified a first and second generation oral hypoglycemic agents. Their primary effect is to increase release of insulin from the pancreas, especially at the onset of therapy.
  • Biuganides reduces hepatic glucose production and enhances insulin-stimulated glucose transport to adipose (fat) tissue and skeletal muscles, thereby decreasing insulin resistance.
  • Alpha-Glucosidase Inhibitors affect enzymes of the small intestine and reduce the rate of digestion of starches and the absorption of glucose.
  • Thiazolidinediones are called insulin sensitizers. They enhance insulin action at the receptor and post receptor level in hepatic and peripheral tissues.
  • Meglintinides are not sulfonylureas, but are very similar to them in action. They increase release of insulin from the pancreas and are glucose dependent.
  • Insulin is a naturally occurring hormone made in the beta cells of the pancreas. Once upon a time, the only insulin available was from animals. However, through technology, human insulin is now available. Currently, insulin must be injected. All type 1 patients require insulin to sustain life. Many type 2 patients need insulin to control glucose levels as beta cell function diminishes. Women with gestational diabetes need insulin if they can not control blood sugar levels with diet and exercise. Currently, there has only been one study on the use of an oral agent to control gestational diabetes. Due to this limited research, oral agents have not been approved in gestational diabetes.

    Insulin analogues are insulins that have been created synthetically. In analogues, the amino acid chain sequence has been rearranged. In some instances, the molecular alteration yields an insulin with a faster absorption rate, in another, the insulin works like a basal rate and seems peakless. This area of research may yield many other options for glucose control.

    Insulin, as mentioned earlier, must be injected. Once upon a time, syringes and vials were the only option for injection insulin. There are now pen devices and other devices that eliminate drawing up insulin. Doses can be dialed and injected. There are insulin pumps that are inserted and inject minute amounts continuously; and when a meal is taken a bolus of insulin can be delivered much as a functioning pancreas would work. Research is in progress for insulin to be inhaled. There are many more options in today's world.

    Monitoring of blood glucose levels is an important part of the treatment plan for someone with diabetes. Years ago, the first glucose monitoring devices were large and the technique cumbersome. Now there are a variety of glucose monitors available on the market. The meters of today offer convenience in size, technique and timing. Newer meters read plasma glucose levels, which are closer to the laboratory values. Older meters read whole blood, which may yield a lower glucose value than plasma. Newer meters often have data management capabilities. The memory of the meter can be downloaded and results can be plotted on graphs or be summarized. Although technology is making strides toward noninvasive methods, current meters still need a drop of blood. However, the amount of blood needed for testing has been greatly reduced. New meters offer the option of alternate site testing. Traditionally, the sides of the fingertips are used to obtain the drop of blood, however, alternate sites such as the forearms and palmer aspect of the thumb can be used in people who have fairly stable glucose readings. For people who have wide swings of glucose levels, the fingertip is still the best site for testing.

    Self-glucose monitoring allows the patient to know what is going on in their body, and enables the patient to adjust meals, activity or medication to achieve and maintain specific glucose targets. Monitoring enables the patient to identify patterns, treat low blood glucose levels and make informed choices. A meter and strips are a covered benefit for Medicare and usually most insurance.

    There are other ways to monitor blood glucose levels. One way is an A1c. This used to be called a glycosolated hemoblogin, or HgbA1c. This test should be run a minimum or one to two times a year for someone with diabetes. An A1c provides a weighted mean over a long period of time. The normal value is in the range of 4-6 percent.

    Ketones are assessed usually in type 1 patients, as these patients are ketone prone, where as type 2 diabetes are generally ketosis resistant. Ketones result from the conversion of fat to energy as a waste byproduct. This occurs when there is not enough insulin to make energy. Urine is tested for ketones. Ketones are tested during illness for type 1 patients, during periods of elevated blood sugars and during pregnancy in all patients.

    Another very important test is a urine test for protein. The ability to detect low levels of albumin in the urine(microalbuminuria) represents an important advancement in the diagnosis and treatment of kidney. The presence of microalbuminuria shows early phase of nephropathy and allows early treatment. This test should be done annually.

    As mentioned in the beginning of this article, diabetes is a serious and complex metabolic disease. There have been a number of major studies that indicate good glucose control impacts quality of life. Individuals can impact their health by working with their medical team. By taking an active part in self-care, and working with a health team, people can reduce risks, optimize control and make wise choices.

    Cardiovascular disease is the major cause of mortality for persons with diabetes. Type 2 diabetes is an independent risk factor for macrovascular disease and conditions such as high blood pressure and high lipid levels. Control of elevated blood pressure and management of lipid levels, through lifestyle changes and medications, is necessary. There are a variety of means to assist with tobacco cessation, which is very important. Seeing a dentist on a regular basis helps to eliminate infections in teeth and gums and reduce caveties. Daily brushing and flossing reduces oral problems. Seeing an ophthalmologist on an annual basis identifies any early eye problems and can preserve vision. Annual testing for protein in the urine can identify problems early, when therapy with medications can begin to slow the progression of renal damage. Daily foot inspections and skin care can reduce chances of infection and ulcers. Well-fitting shoes reduce problems, and nails should be cut straight across. A professional should treat calluses and corns. If any problems are noted, the health care team should be notified. Feet should be tested by a health care professional with monofilament, tuning fork, palpation and visually at least on an annual basis. Visual inspections of feet should be done at each office visit. Keeping immunizations up to date is important. Influenza and pneumococcal pneumonia mortality rates are higher in people with diabetes. Vaccinations can reduce risk. Annual flu shots are recommended for those with diabetes, and the pneumococcal vaccine is recommended.

    Self-care and diabetes can affect you emotionally. Working daily at controlling your diabetes may make you feel blue or sad. Rates of depression are higher in people with chronic illness. Don't be afraid to discuss this with your health care provider and team. Successful treatment depends on working with your team.

    Since diabetes is controllable, knowing all that you can about the disease is very important. Team care is a gold standard for diabetes care and treatment. You are the center of the team. Be sure your teammates keep up to date on diabetes. Know your test results. Keep informed of new research findings, products and medications that are announced daily. These findings may be confusing. By relying on your team, you can stay up to date, knowledgeable and healthy.

    This article originally appeared in the March 2003 issue of HME Business.


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