Diabetes

DIABETES

The name Diabetes mellitus refers to a group of diseases that affect how the human body uses glucose (blood sugar). Glucose is vital to health. It is an important source of energy for the cells that make up muscles and tissues. It is also the main source of fuel for the brain. 

Even as the underlying cause of diabetes varies by type, it can lead to excess sugar in the blood, no matter what type of diabetes a person may have. Too much sugar in the blood can lead to serious health problems.

The Chronic conditions of diabetes are type 1 and type 2 diabetes. There is also Prediabetes (when the blood sugar levels are higher than normal, but not high enough to be classified as diabetes), which can potentially be reversed, and Gestational diabetes, which normally occurs during pregnancy but which may resolve itself after the baby is delivered.

TYPES

There are several types of diabetes.

Three major diabetes types can develop: Type 1, type 2, and gestational diabetes.

• Type 1 diabetes:

Sometimes known as juvenile diabetes, this type of diabetes occurs when the body fails to produce insulin. People with type 1 diabetes are dependent on insulin, which means they must take artificial insulin daily to stay alive.

• Type 2 diabetes:

This is the most common type of diabetes and it has strong links with obesity. With Type 2 diabetes, the body still makes insulin, unlike in type I, however the cells in the body do not respond to it as effectively as they once did.

• Gestational diabetes:

This typically occurs in women during pregnancy when the body can become less sensitive to insulin. Gestational diabetes does not occur in all women and usually resolves on its own after the child is brought forth.

• Prediabetes

Normal blood sugar levels sit between 70 and 99 mg/dL, whereas a person with diabetes will have a fasting blood sugar higher than 126 mg/dL. People are regarded as having prediabetes or borderline diabetes when blood sugar is usually in the range of 100 to 125 milligrams per deciliter (mg/dL).

The prediabetes level means that blood glucose is higher than usual but not so high as to constitute diabetes.

Although they do not usually experience the symptoms of full diabetes, People with prediabetes are at risk of developing type 2 diabetes.

The risk factors for prediabetes and type 2 diabetes are similar. They include:

• If one is overweight
• If one has a sedentary lifestyle
• If one is more than age 45 years
• If one has a history of hypertension
• If one has a family history of diabetes
• If one has a high-density lipoprotein (HDL) cholesterol level lower than 40 mg/dL or 50 mg/dL
• If one has gestational diabetes or giving birth to a child with a birth weight of more than 9 pounds
• If one is of African-American, Native American, Latin American, or Asian-Pacific Islander descent

If a person is identified as having prediabetes, the doctor will recommend that the individual makes changes in lifestyle that can stop the progression to type 2 diabetes. Losing weight and having a more health-conscious diet can often help prevent the disease.

Less common types of diabetes include;

Monogenic diabetes - A rare condition resulting from mutations (changes) in a single gene.

Cystic fibrosis-related diabetes - A unique type of diabetes that is common in people with Cystic Fibrosis.

What is glucose?

Glucose is an essential nutrient that provides energy for the proper functioning of the body cells. It is a simple sugar found in food.  Carbohydrates are broken down in the small intestine.  The glucose in digested food is then absorbed by the intestinal cells into the bloodstream, and is carried by blood to all the cells in the body where it is utilized. However, glucose cannot enter the cells on its own, it needs insulin to aid in its transport into the cells. Despite the presence of abundant glucose in the bloodstream, the cells will become starved of glucose energy without insulin. In certain types of diabetes, the inability of the cells to utilize glucose gives rise to the situation of 'starving in the midst of plenty'. The abundant, unutilized glucose is excreted in the urine as waste.

What is insulin?

Insulin is a hormone that is produced by beta cells of the pancreas (The pancreas is an organ in the abdomen located behind the stomach.) In addition to helping glucose enter the cells, insulin is also important in regulating the level of glucose in the blood. After a meal, the blood glucose level will rise. In response to the increased glucose level, the pancreas normally will release more insulin into the bloodstream to help glucose enter the cells and lower blood glucose levels. It has to be said that even in a fasting state there is a low steady release of insulin than fluctuates a bit and helps to maintain a steady blood sugar level. In normal individuals, this regulatory system helps to keep blood glucose levels in a tightly controlled range. It is worthy to note that, in patients with diabetes, the insulin is either absent, relatively insufficient for the body's needs, or not used properly by the body. All of these factors cause hyperglycemia (elevated levels of blood glucose).

CAUSES

To be able to understand diabetes, one must understand how glucose is normally processed in the body.

How insulin works

Insulin is a hormone. It comes from the pancreas (a gland situated behind and below the stomach).

• The pancreas secretes insulin into the bloodstream.
• The insulin circulates, enabling sugar to enter the cells.
• Insulin lowers the amount of sugar in the bloodstream.
• As blood sugar level drops, so does the secretion of insulin from the pancreas.

The role of glucose

Glucose (a sugar) is a source of energy for the cells that make up muscles and other tissues.

• Glucose comes from two major sources; food and the liver.
• The liver stores and makes glucose.
• Sugar is absorbed into the bloodstream, where it enters cells with the help of insulin.
• When glucose levels are low, such as when a person has not eaten in a while, the liver breaks down stored glycogen into glucose to keep the glucose level within a normal range.

Causes of type 1 diabetes

The exact cause of this type of diabetes is unknown. What is known is that the immune system (which normally fights harmful bacteria or viruses), attacks and destroys the insulin-producing cells in the pancreas. This leaves the individual with little or no insulin. The effect is that instead of being transported to where it is needed, sugar builds up in the bloodstream.

Type 1 diabetes is thought to be caused by a combination of genetic susceptibility and environmental factors, though those causal factors are is still not clear. Weight however, is not believed to be a factor in type 1 diabetes.

Causes of prediabetes and type 2 diabetes

Prediabetes can lead to type 2 diabetes, and in type 2 diabetes, the cells become resistant to the action of insulin, meanwhile the pancreas is unable to make enough insulin to overcome the resistance. The overall effect is that instead of moving into the cells and organs where it is needed for energy, the sugar builds up in the bloodstream.

Why this happens is still unclear, it is believed that certain genetic and environmental factors play a role in the development of type 2 diabetes. Although being overweight is strongly linked to the development of type 2 diabetes, not everyone with type 2 is overweight.

Causes of gestational diabetes

During pregnancy, the placenta produces hormones to sustain the pregnancy. These hormones make the cells more resistant to insulin.

Normally, a person’s pancreas will respond by producing enough extra insulin to overcome the resistance, except that sometimes the pancreas cannot keep up. When this occurs, too little glucose gets into the cells while too much stays in the blood, resulting in gestational diabetes.

SIGNS AND SYMPTOMS OF DIABETES

The early symptoms of untreated diabetes are related to elevated blood sugar levels, and loss of glucose in the urine.

• Some diabetes patients also complain of fatigue.
• Fluctuations in blood glucose levels can lead to blurred vision.
• High amounts of glucose in the urine can cause frequent urination which may lead to dehydration.
• Dehydration will cause an increased thirst and water consumption.

Relative or absolute insulin deficiency eventually leads to weight loss.

• Weight loss of diabetes occurs despite an increase in appetite.
• Nausea and vomiting can also occur in patients with diabetes.
• Frequent infections to the bladder, skin, and vaginal areas are more likely to occur in people with poorly-controlled diabetes.
• Elevated glucose levels if extreme can lead to lethargy and coma.

Symptoms in men

In addition to the general symptoms listed above, men with diabetes may have erectile dysfunction (ED), a decreased sex drive, and poor muscle strength.

Symptoms in women

Women with diabetes may also have urinary tract infections, yeast infections, and dry, itchy skin.

RISK FACTORS FOR DIABETES

Risk factors for type 1 diabetes are not as understood as those for type 2 diabetes. Family history however is a known risk factor for type 1 diabetes. Other risk factors can include having certain infections or diseases of the pancreas.

Risk factors for type 2 diabetes and prediabetes are many. The following can raise the risk of developing type 2 diabetes:

• Age
• Family history
• Resistance to insulin
• Obesity or being overweight
• Hypertension
• Elevated levels of triglycerides and low levels of HDL (good cholesterol)
• Sedentary lifestyle
• Polycystic ovary syndrome
• Impaired glucose tolerance
• Gestational diabetes during a pregnancy
• Ethnic background: Hispanic/Latino Americans, African-Americans, Native Americans, Asian-Americans, Pacific Islanders, and Alaska natives are at greater risk.

DIAGNOSIS

In type 1 diabetes, symptoms often appear suddenly and are often the reason for checking blood sugar levels. Since symptoms of other types of diabetes and prediabetes come on more gradually or may not be evident, medical authorities recommend that the following people be screened for diabetes:

• Anyone with a body mass index higher than 25, regardless of age, who has additional risk factors, such as high blood pressure, abnormal cholesterol levels, a sedentary lifestyle and having a close relative with diabetes.
• Anyone older than age 45 is advised to receive an initial blood sugar screening, and then, if the results are normal, should be screened every three years thereafter.
• Any woman who has had gestational diabetes, should be screened for diabetes every three years.
• Anyone who has been diagnosed with prediabetes should be tested every year.

Tests for type 1 and type 2 diabetes and prediabetes

Glycated hemoglobin (A1C) test - This blood test, does not require fasting, it indicates a person’s average blood sugar level for the previous two to three months. It measures the percentage of blood sugar attached to hemoglobin, the protein that carries oxygen in red blood cells.

The higher the blood sugar levels, the more hemoglobin there will be with sugar attached. An A1C level of below 5.7 is considered normal, however 6.5 percent or higher on two separate tests indicates diabetes. An A1C between 5.7 and 6.4 percent indicates prediabetes.  

If the A1C test results are not consistent, the test is not available, or certain conditions make the A1C test inaccurate, the doctor may use the following tests to diagnose diabetes:

Random blood sugar test - A blood sample will be taken at a random time. Regardless of when he/she ate last, a random blood sugar level of 200 milligrams per deciliter (mg/dL) which translates to 11.1 millimoles per liter (mmol/L) or higher suggests diabetes.

Fasting blood sugar test - A blood sample will be taken after an overnight fast. A fasting blood sugar level below 100 mg/dL (5.7 mmol/L) is normal. A fasting blood sugar level from 100 to 125 mg/dL (5.8 to 6.9 mmol/L) is considered prediabetes. If it happens to be 126 mg/dL (7 mmol/L) or higher on two separate tests, diabetes would be confirmed.

Oral glucose tolerance test - For this test, the patient fasts overnight, and the fasting blood sugar level is measured. Then he/she is made to drink a sugary liquid, and blood sugar levels are tested periodically for the next two hours.

A blood sugar level less than 140 mg/dL (7.8 mmol/L) is normal. More than 200 mg/dL (11.1 mmol/L) after two hours indicates diabetes. A reading between 140 and 199 mg/dL (7.8 mmol/L and 11.0 mmol/L) indicates prediabetes.

If the doctors suspect type 1 diabetes, a urine test will be done to look for the presence of a byproduct which is produced when muscle and fat tissue are used for energy because the body does not have enough insulin to use the available glucose. The doctor will also likely run a test to check for the presence of the destructive immune system cells associated with type 1 diabetes called autoantibodies.

Tests for gestational diabetes

For this type, the doctor will most likely evaluate the risk factors for gestational diabetes early in the pregnancy:

If the patient was obese at the start of the pregnancy; if she had gestational diabetes during a previous pregnancy; or she has a mother, father, sibling or child with diabetes, the doctor may test for diabetes at the first prenatal visit.

If the patient is at average risk of gestational diabetes, she'll likely have a screening test for gestational diabetes sometime during the second trimester (typically between 24 and 28 weeks of pregnancy).

The following screening tests may be used:

Initial glucose challenge test.

The patient will begin the glucose challenge test by drinking a syrupy glucose solution. One hour later, she will have a blood test to measure the blood sugar level. Although this may vary at specific clinics or labs, a blood sugar level below 140 mg/dL (7.8 mmol/L) is usually considered normal on a glucose challenge test.

If the blood sugar level is higher than normal, it only means a higher risk of gestational diabetes. A follow-up test to determine if she has gestational diabetes will be ordered.

Follow-up glucose tolerance testing.

For the follow-up test, patient will be asked to fast overnight and then have their fasting blood sugar level measured. Then she will drink another sweet sugary solution this time containing a higher concentration of glucose. Blood sugar level will be checked every hour for a period of three hours.

If at least two of the blood sugar readings are higher than the normal values established for each of the three hours of the test, she will be diagnosed with gestational diabetes.

TREATMENT

Depending on the type of diabetes, blood sugar monitoring, insulin and oral medications will play a role in the effort to treat or manage the condition. Eating healthy diet, maintaining a healthy weight and participating in regular physical activity are important factors in the management of diabetes.

Treatments for all types of diabetes

An important part of managing diabetes is maintaining a healthy weight through a healthy diet and exercise plan:

Healthy eating - Contrary to popular perception, there is no specific diabetes diet. A person will need to center their diet on more fruits, vegetables, lean proteins and whole grains that are high in nutrition and fiber and low in fat and calories.  Saturated fats, refined carbohydrates and sweets should be avoided. This is in fact, the best eating plan for the entire family. Sugary foods are OK once in a while.

Understanding what and how much to eat can be a challenge. A dietitian could help create a meal plan that fits into one’s health goals, food preferences and lifestyle.  

Physical activity.

Everyone needs regular aerobic exercise, and diabetes patients are no exception. Exercise lowers blood sugar levels by moving sugar into the cells, where it is used for energy. Exercise also increases the body’s sensitivity to insulin, which means the body will need less insulin to transport sugar to the cells.

People should get doctor's consent to exercise. They should choose activities they enjoy, such as walking, swimming or biking. The important thing is to make physical activity part of the daily routine.

One should aim for at least 30 minutes or more of aerobic exercise most days of the week.  If one hasn’t been active for some time, begin slowly and build up gradually.

Treatments for type 1 and type 2 diabetes

Treatment for type 1 diabetes involves;

• Carbohydrate counting
• Frequent blood sugar checks
• Insulin injections
• The use of an insulin pump,

Treatment of type 2 diabetes primarily involves:

• Lifestyle changes,
• Monitoring of blood sugar,
• Diabetes medications, insulin or both.

Monitoring blood sugar.

Depending on the treatment plan, a person may check and record blood sugar as many as four times in a day or more often if they are taking insulin. Careful monitoring is the only way to make sure that one’s blood sugar level remains within the target range. People with type 2 diabetes who aren't taking insulin generally check their blood sugar much less frequently.

Even with careful management, blood sugar levels can change unpredictably. With help from the treatment team, one will learn how blood sugar level changes in response to food, physical activity, medications, illness, alcohol, stress. Additionally for women, fluctuations in hormone levels.

In addition to daily blood sugar monitoring, doctors will likely recommend regular A1C testing to measure average blood sugar level for the previous two to three months.

When compared with repeated daily blood sugar tests, the A1C testing better indicates how well the diabetes treatment plan is working.

Your target A1C goal may vary depending on one’s age and various other factors, such as other medical conditions one may have.  

Insulin - People with type 1 diabetes need insulin therapy to survive. A lot of people with type 2 diabetes or gestational diabetes also need insulin therapy.

There are many types of insulin available for treatment, these include rapid-acting insulin, long-acting insulin and intermediate options.  

Because stomach enzymes interfere with insulin's action, insulin cannot be taken orally to lower blood sugar. Instead, insulin is injected using a fine needle and syringe or a device that looks like a large ink pen (an insulin pen).

Another option may be an insulin pump. This is a device about the size of a cellphone worn on the body. It comes with a tube that connects the reservoir of insulin to a catheter that is inserted under the skin of the abdomen.

There is also a tubeless pump that works wirelessly. An insulin pump is programed to dispense specific amounts of insulin. It can be adjusted to deliver more or less insulin depending on meals, activity level and blood sugar level.

Oral or other medications.

Sometimes other oral or injected medications are prescribed specially to stimulate the pancreas to produce and release more insulin. Others would inhibit the production and release of glucose from the liver, which means less insulin would be needed to transport sugar into the cells.

There are other medications that block the action of stomach or intestinal enzymes that break down carbohydrates or make the tissues more sensitive to insulin. Metformin among others is generally the first medication that is prescribed for type 2 diabetes.

• Transplantation – A pancreas transplant may be an option among some people who have type 1 diabetes. If successful with a successful pancreas transplant, insulin therapy would no longer be needed. However, transplants aren't always successful, and these procedures like all others are not without risks.

A patient will need a lifetime of immune-suppressing drugs to prevent organ rejection, coupled with the fact that these drugs can have very serious side effects. This is why transplants are usually reserved only for people whose diabetes cannot be controlled or those who also need a kidney transplant.

• Bariatric surgery.

An operation that helps one lose weight by making changes to the digestive system. Although it is not specifically considered a treatment for type 2 diabetes, people with type 2 diabetes who are obese and have a body mass index higher than 35 may benefit from this type of surgery. However, the long-term risks and benefits for type 2 diabetes from this procedure's is not yet known.

Treatment for gestational diabetes

Controlling blood sugar level is essential to keeping the baby healthy and avoiding complications during delivery. In addition to maintaining a healthy diet and exercising, the gestational diabetes treatment plan may include monitoring blood sugar and, in some cases, using insulin or oral medications.

The patient’s blood sugar level during labor will be constantly monitored. If the blood sugar rises, the baby may release high levels of insulin and this can lead to low blood sugar right after birth.

Treatment for prediabetes

For prediabetes healthy lifestyle choices can help bring the blood sugar level back to normal or at least keep it from rising toward levels as seen in type 2 diabetes. Maintaining a healthy weight through exercise and healthy eating can help. Exercising about 150 minutes a week and losing about 7 percent of body weight may prevent or delay type 2 diabetes.

Sometimes medications such as metformin among others are an option if the risk of diabetes is high, including when the prediabetes is worsening or if one has a cardiovascular disease, fatty liver disease.

In other cases statins (medications to control cholesterol), in particular together with high blood pressure medications will be needed. The doctor might prescribe aspirin with a low dosage to help prevent cardiovascular disease if he/she thinks the patient to be at high risk. Healthy lifestyle choices however, remain paramount.

Signs of trouble in any type of diabetes

Because so many factors can affect blood sugar, problems that require immediate care, may arise.  Such as;

High blood sugar (hyperglycemia).

A person’s blood sugar level can go up for many reasons, e.g. not taking enough glucose-lowering medication, eating too much food, being sick etc. therefore as one checks their blood sugar level as directed by doctors, they should watch for signs and symptoms of high blood sugar, which includes;

• Frequent urination,
• Increased thirst,
• Dry mouth,
• Blurred vision,
• Fatigue and

Persons with hyperglycemia, will need to adjust their meal plan, medications or both.

Increased ketones in urine (diabetic ketoacidosis).

If cells are starved for energy, the body may begin to break down fat. This produces toxic acids known as ketones. The things to watch out for are;

• Vomiting,
• Fever,
• Loss of appetite,
• Weakness,
• Stomach pain and
• A sweet, fruity breath.

This condition is more common in people with type 1 diabetes.

Low blood sugar (hypoglycemia).

When blood sugar level drops below the target range, it is known and called low blood sugar (hypoglycemia). If a person is on medication that lowers blood sugar, (e.g. insulin), the blood sugar level can drop for many reasons. Low blood sugar also occur if insulin intake it too much or a glucose-lowering medication that promotes the secretion of insulin by the pancreas is excessive.

For hypoglycemia, check blood sugar level regularly, and watch for signs and symptoms like;

• Blurred vision,
• Confusion,
• Sweating,
• Slurred speech,
• Shakiness,
• Weakness,
• Hunger,
• Dizziness,
• Headache,
• Heart palpitations,
• Irritability,
• Drowsiness,
• Fainting and

Low blood sugar is treated with quickly absorbed carbohydrates, such as fruit juice or glucose tablets.

DIABETES PREVENTION

Type 1 diabetes is simply not preventable because it is caused by a problem with the immune system. Some causes of type 2 diabetes, such as genes or age, cannot be controlled either.

Despite this, many other risk factors can be controlled. Most diabetes prevention strategies involve the making of simple adjustments to diet and fitness routine.

If a person has been diagnosed with prediabetes, a few things as listed below can be done to delay or prevent type 2 diabetes:

• Consume more fruits, vegetables, and whole grains.
• Exercise for at least 150 minutes per week (e.g. walking or cycling).
• Eat smaller portions of food.
• Remove saturated and Trans fats, and also refined carbohydrates, from the diet.
• Try to lose some of your body weight in case one is overweight or obese.

These may only be but a few ways to prevent diabetes.

Living with diabetes can be difficult as well as frustrating. There are times when if even everything has been done right, blood sugar levels may rise.

Nevertheless, one needs to stick with the diabetes management plan, and a positive difference will emerge in the A1C during your next visit to the doctor.