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The Diabetes F.A.Q

By Dan Caruso MD

What is Diabetes?

Diabetes mellitus is an ancient term meaning, "flowing through sweetly". The observation was that the urine was sweet. It wasn't until the last 100 years or so scientists learned the reason urine had high sugar levels was because the blood had high sugar levels. High blood sugar levels spill into the urine through the kidneys, and water flows out with the sugar. That is the reason people with diabetes can have increased urination. The loss of water due to excess sugar leads to dehydration, which stimulates thirst. Glucose, a form of sugar, is the primary energy source for most body tissues. For many of the tissues glucose enters without difficulty. Other tissues, including muscle, liver and fat cells, require insulin for sugar to be processed. Insulin is a hormone made in the pancreas. Insulin levels normally rise when the pancreas detects glucose in the blood. If insulin is absent, blood glucose rises. If the liver, muscle and fat cells do not respond to insulin properly (insulin resistance), blood glucose rises. Lacking creativity, the scientists decided to call the absence of insulin 'type 1' diabetes and insulin resistance 'type 2' diabetes. The differences are very important, because they influence the pattern of possible complications as well as the method of treatment.

Type 1 Diabetes Mellistus - How it Develops

As mentioned previously, type 1 diabetes mellitus develops because the pancreas loses its ability to produce insulin. Specifically, the beta cells in the pancreas, which are the insulin producing cells, become targeted by the immune system. It is speculated that certain types of infections may trigger the immune system to go after the beta cells, but conclusive proof has not been found. Certain immunity components (antibodies) are frequently present in type 1 diabetes. The beta cells are destroyed over several months' time. Diabetes becomes evident when about 90% of the beta cells are lost. Many times the remaining 10% can temporarily fill in the gap, and the diabetes appears to get better. This is called the "honeymoon phase". Eventually the remaining beta cells are destroyed and the honeymoon is over. Blood glucose can skyrocket and insulin needs to be administered. Without insulin, type 1 diabetics will go into a coma and die.

Why do Type 1 Diabetics get so sick without Insulin?

The liver has no way to directly detect glucose. The liver does detect insulin.Diabetics can also use a blood glucose monitor to check glucose levels. Usually plenty of insulin means plenty of glucose and the liver stores it. In nondiabetics, absence of insulin usually means low blood glucose, and the liver will release glucose into the bloodstream. The liver doesn't know why the insulin is low, it is simply programmed to release the glucose. When the beta cells fail and insulin levels drop, glucose production increases. When the liver has released all its stored sugar, it starts making glucose from proteins and starts fat breakdown for energy. These two processes cause ketosis. Severe ketosis causes acid buildup in the system. When this happens, nausea, vomiting, weakness and weight loss occur. People can fall into a coma if this is severe enough. This, combined with the dehydration caused by glucose and water loss through the kidneys, can lead to death if not properly treated.

How is Diabetic Ketoacidosis treated?

Diabetic ketoacidosis is best treated in a hospital. Intravenous (IV) fluids, sometimes over 15 liters are given over many hours. IV insulin is necessary to lower the glucose and control the ketones. When the glucose is lowered, IV glucose is given along with the insulin to completely stop the ketones. This usually takes 24-96 hours. Blood glucose is tested every 2-4 hours, and the levels of potassium, sodium and phosphorus need to be checked every 4-8 hours.

How is Type 1 Diabetes treated day to day?

Insulin is critical in treating type 1 diabetes mellitus. Specifically the amount of insulin is critical. It needs to be matched to food, exercise, stress and natural hormonal variations to keep the blood sugars in a reasonable range. What is a reasonable range, you may ask? Nondiabetics range from 60-110 mg/dl before meals, and rarely go over 140 mg/dl one to two hours after meals. Reasonable sugar levels for a type 1 diabetic would be 80-150 mg/dl before meals and under 200 after meals. If a person too easily drops under 70 mg/dl (hypoglycemia), then a higher target range of 100-180 before meals may be chosen. If frequent or severe hypoglycemia occurs (such as passing out, having a seizure or needing to call 911) then a range of 120-200 may be appropriate. The appropriate range for you should be discussed with your doctor. In order to treat type 1 diabetes mellitus insulin injections are necessary. Experiments with insulin skin patches were disappointing and the Food and Drug Administration never approved this. Inhalable insulin is currently being studied but has not yet been released on the market.

Diabetes is a serious health problem and has become an epidemic throughout the world. Diabetes is now the THIRD leading cause of death in the USA. Eighty-percent of patients with diabetes die from heart disease or a stroke. The increase in body weight and a decrease in physical activity play a major role in why we have seen such a steep increase in the number of people with diabetes. People suffer from what I call the DEADLY DUET: HYPERACTIVE FORK and HYPOACTIVE FOOT! We love to eat and hate to exercise. This trend must be reversed or the situation will only get worse.

Empowerment is the key to successful management of Diabetes.

We must empower people with diabetes to TAKE CHARGE. They must become a member of the HERTZ #1 CLUB-We put you in the drivers seat. We can NO longer afford to practice the old tradition of the GREYHOUND BUS-Leave the driving to us.

In a perfect world, your health care provider would spend as much time with you as you need. He or she would recall every detail about you, and every diabetes care guideline would be followed. REAL LIFE-Life is not perfect, and neither are health care providers.Like anyone else, they forget things. Like anyone else, they get caught in traffic jams and are late or feel distracted. Patients with urgent problems can put them far behind schedule so that they have less time for you. THIS IS WHERE YOU COME IN. Know what your health care provider should be doing at each visit. REMIND your health care provider to DO IT!Even drugs approved by the FDA are no guarantee.In a recent report, the drug called Actos® (pioglitazone ) used for treatment of diabetes is suggested to increase the chances of getting bladder cancer.

Checklists for your visit

At your appointment REMIND your health care provider to:

1. Measure your blood pressure (each visit);

2. Measure your hemoglobin A1C (HbA1C) at least one a year

3. Test your cholesterol (at least once a year)

4. Measure your urine for protein (at least once a year)

5. Test each foot's ability to feel a monofilament (at least once a year)

6. Refer you to an eye doctor (at least once a year)

7. Counsel you to stop smoking, if you smoke (every visit)

8. Provide education, such as reviewing your goals and glucose records

9. Provide advise on nutrition (hypoactive FORK if you are overweight) and encourage a regular exercise program (hyperactive FOOT)

10. Emphasize proper dental care and immunizations (pneumovax and annual influenza vaccination.

Always wear your medical alert necklace or bracelet

Remember the key: Hertz #1 Club-Take Charge. Put yourself in the Driver Seat. Get the Care you need and Deserve.

Dr. Lardinois is a professor of Medicine and Director of the Endocrinology Division at the University of Nevada School of Medicine. He is also the Chief Operating Officer and Medical Director of the Nevada Diabetes Association for Children and Adults (NDACA). The NDACA is committed to helping anyone with diabetes enjoy a better quality of life. We welcome everyone to our website at www.icanv.com/ndaca; You can also email us at ndaca@icanv.com or call us at 775 856-3839. We are always looking for volunteers to help us with our programs.

Syndrome X

Overeating (Hyoeractive Fork) and Physical Inactivity (Hypoactive Foot)

Recent trends in the lifestyle of many people, such as a high-fat diet and lack of exercise, have created a serious medical condition called Syndrome X. Syndrome X is best described as a number of disorders including the inability of the body to use its own insulin (insulin resistance), high blood pressure (hypertension), high blood fats (dyslipidemia), and being overweight (obesity). Syndrome X is associated with an increased risking of dying from several diseases, such as diabetes, cancers, heart attack, and stroke. The inability of the body to use its own insulin is also an early and important feature in the development of "adult" onset diabetes (now known as Type 2 diabetes mellitus). The deadly quartet ("drop"), dyslipidemia, resistance to insulin, obesity, and pressure elevation is a term used to describe the syndrome. If you do NOT drop these risk factors which are associated with an increased risk of heart disease, you will "drop" from a heart attack!

There is a strong family history of insulin resistance and Type 2 diabetes, but the environmental factors of calorie excess (overeating), reduced activity and obesity also play a critical role. Coupled with an aging population, death from heart disease will become the most common cause of death worldwide if this trend is not reversed.

We must stress weight loss in people that are overweight and urge everyone to exercise regularly. Weight loss improves the ability of insulin to work better, which helps to reduce the risk of getting type 2 diabetes. Weight loss also lowers blood pressure and blood fats. Exercise also helps the body use insulin more efficiently and helps to reduce the amount of body fat. Drugs are now available to help the body use insulin better but are never a substitute for a prudent diet and exercise program.

I stress to my patients that our society is suffering from two HF’s-Hyperactive Fork and Hypoactive Foot. We loved to eat and hate to exercise. The excess food we consume (Hyperactive Fork) coupled with a lack of exercise (Hypoactive Foot) increases the risk of developing Syndrome X. I call this the "deadly duet". It is imperative that we initiate renewed efforts to provide lifestyle counseling to promote ideal body weight (Hypoactive Fork) and encourage a regular exercise program (Hyperactive Foot). Serious health consequences will occur if we do not.

Claude K. Lardinois, M.D., F.A.C.P., F.A.C.N.
Chief, Endocrinology Ioannis A. Lougaris VAMC
Professor of Medicine & Director of Endocrinology
University of Nevada School of Medicine

Insulin and Delivery Systems

by Dan Caruso MD

Insulin was originally extracted from pork and beef pancreases. Pork extracts are still available. Most people requiring insulin use a product cloned from the human insulin gene and produced by yeast. It is then purified into a highly refined product. The insulin is then modified by various proteins or zinc solutions to regulate how fast it enters the bloodstream after being injected. By mixing different types of insulin a person can get by with 2-4 injections a day rather than 6-8 injections daily. The newest way to regulate the speed of insulin entering the body is to induce mutations in the insulin gene that will speed up or slow down its rate of action without reducing the absolute capacity to lower blood sugar. The only FDA approved insulin that has been genetically reengineered is lispro (Lilly Humalog). This insulin works very rapidly and wears off in 3-4 hours. This can reduce the peak blood sugar after a meal. It also can reduce low blood sugars that occur when regular insulin overlaps with an intermediate-acting insulin such as Lente or NPH.

Typically an insulin shot before breakfast will include regular or Humalog to cover breakfast and NPH or Lente to cover lunch. An injection of short-acting insulin covers dinner and a bedtime shot of NPH/Lente will keep the liver from making too much sugar at night time. Some people will take their long acting evening insulin before dinner rather than at bedtime. Sometimes this works; some times the longer acting insulin will kick in after bedtime, causing low blood sugars in the middle of the night. Another possible problem of taking long-acting insulin at dinner is that it may not last until morning.

Another option for insulin therapy is to establish a basal insulin level with Ultralente, an insulin that lasts 16-22 hours. This usually needs to be taken twice daily. Short acting insulin such as regular or Humalog is administered before each meal. This provides more flexibility in the timing of meals and the amounts eaten. However, sometimes it is difficult to deliver enough insulin at night to keep morning sugars down without causing low blood sugars later in the day.

Insulin is most commonly injected with a needle/syringe made specifically for insulin injections. The insulin is drawn from a bottle that contains 1000 units. Most people with type 1 diabetes mellitus get by on a total of 25-75 units per day, depending on their body weight and how much they eat. Insulin also can be delivered by a "pen." This device has an insulin cartridge with an adjustable dial to dial in the number of units, and a needle that screws into the business end of the syringe. The pen can only deliver one type of insulin per injection, unless premixed insulin (70/30, meaning 70% NPH and 30% regular insulin) is used. A few people with type 1 diabetes do well on 70/30 insulin, but there is very limited room to adjust doses with the fixed ratio.

The ultimate mechanical insulin delivery system is an insulin pump. This device is loaded with 2-3 days' worth of short-acting insulin, connected to a thin flexible tube which in turn is connected to a plastic needle inserted into the skin. This setup is called an infusion set. It is replaced every 2-3d by the patient. The plastic needle is left in continuously for the 2-3d. The tubing and pump can be temporarily disconnected to bathe, swim, etc. The pump itself is battery powered and is programmable by the patient (with the help of the doctor) to deliver a basal rate of insulin. The basal rate is adjustable to the nearest 0.1 units/hr every 0.5-1.0 hr. this allows practically endless flexibility in adjusting the basal rate to the individual's needs. At meal times the patient calculates how much insulin is necessary to cover the meal, then pushes buttons on the pump to deliver the necessary amount. This great flexibility does have a price; the pumps costs about $5000, and the infusion sets cost about $150/month. A bottle of insulin will last 1-3 weeks, which raises the operating cost, as does the need for more frequent blood sugar testing. Extra education time with the health care team is needed to get the best use from a pump.

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