Diabetes Research

As I've been living with Diabetes for about 3 months now, I have learned a LOT, and I do mean LOT about the disease. I figured I'd compile it all into one place so that I could share what I've learned with others. This is primarily from reading a lot on http://www.diabetesforums.com, but a I've also read plenty of websites, books, and all other information I could find on the subject. I've listed my main sources below, but this is certainly not extensive.

Don't take any of this as medical advice, as if you have, or think you may have diabetes, you need to consult a Doctor for medical advice.

So anyway, pardon the extensively long post, but I hope you can learn something.

What is Diabetes?

Diabetes, in a nutshell, is the body's inability to properly control blood sugar levels. There are several mechanisms to maintain proper control, but the primary mechanisms involved in controlling blood sugars are insulin and glucose. The healthy body maintains a proper ratio of insulin to glucose and keeps the body's blood glucose (BG) level within a normal range. Diabetics have to work much harder to allow their body to maintain the proper ratio. Each and every case of diabetes is different, and each individual has to adapt their treatment to their own needs, because no treatment works the same for two different people.

Though there are many variations of Diabetes, Diabetics are typically classified into two categories.

Type 1

Type 1 Diabetes was previously known as Juvenile Diabetes because it is typically diagnosed in children and young adults. Type 1 Diabetes (T1D) is or is caused by an auto-immune disease where the body's immune system attacks the pancreas. Beta Cells are killed off by the body's own immune system to the point where the body's insulin production is severely limited or even eliminated. Type 1 Diabetics (T1s) require insulin therapy because their bodies do not produce enough, or any insulin at all on their own.

Type 2

Type 2 Diabetes (T2D) was previously known as Adult-Onset Diabetes because it is typically diagnosed in adults later in life. Recently, the diagnosis of T2D in youth has been rising due to the "obesity epidemic." As I'm a T2, personally, this doc will be much more heavily focused on T2D.

T2s suffer from Insulin Resistance (IR) have a limited ability to use the insulin that our own body produces. This is the reason that our blood sugars remain high. In contrast to T1s, T2s typically have an excess amount of insulin in their blood. This is because the cells in the body do not properly utilize the insulin in the blood, so the cells do not receive enough glucose. In response, the pancreas produces even more insulin.

Insulin Resistance is made worse by being overweight. This is because fat interferes with the body's ability to properly utilize the insulin in the blood. I will expand further on this later on.

Mechanics of Diabetes

Before getting into the symptoms, complications, and control of diabetes, it is invaluable to understand how diabetes works. I mentioned that there were two primary mechanisms to Diabetes: Glucose and Insulin. Let's take a closer look at the two.

Glucose

Glucose, in the simplest terms, is a simple sugar that is required by cells in living bodies to continue to function. Plants produce their own glucose through photosynthesis, while animals break down food sources into glucose. Without fuel, our cells cannot reproduce or repair themselves, and will deteriorate over time. That is one reason diabetes can affect all aspects of our body and mind.

Certain types of foods yield much more glucose than others. Carbohydrates are our primary source of glucose, and there are several types of carbohydrates. Carbohydrates include both sugars and starches.

Monosaccharides are simple sugars. This includes fructose (from fruits) and glucose (typically from other plants).

Disaccharides are double sugars. These are bonded pairs of simple sugars. These include Sucrose, Lactose, and Maltose. Sucrose is simply table sugar, and this is usually the only sugar labeled on food labels as "Sugar." Sucrose breaks down into 1 Glucose, and 1 Fructose molecule. Lactose is the sugar found in milk, and also only contains one molecule of glucose.

Polysaccharides are complex cargohydrates. These are chains of glucose molecules. These digest more slowly than simple and double sugars, and are found in peas, beans, legumes, grains, potatoes, and other starchy plants.

Each of these types of carbohydrate is broken down during digestion, and the glucose is absorbed through the small intestine, and distributed to the entire body through the bloodstream.

Our bodies need a constant supply of glucose, and so excess glucose, or glucose not needed by the cells when we eat, is stored in the liver and muscles in the form of glycogen. Glycogen is simply long chains of glucose. Between meals, when the body is in short supply of glucose, the muscles and liver release glucose into our blood through glycogenesis, breaking down the stored glycogen.

It is also worth noting that the body is able to break consumed proteins down into glycogen to be stored in, and later released by the liver.

Now that we know how our body supplies itself with glucose, we need to know how it's used. This leads us to our next point.

Insulin

Insulin is a protein, or a hormone, produced by the islet cells, or Beta cells, in our Pancreas. Insulin is used by the body in a number of ways. Primarily of focus for diabetics, and the primary use of insulin, is to act as a transporter of glucose into our cells. Without insulin, glucose is never absorbed by the cells, and remains in the blood stream. As noted earlier, this prevents our cells from getting the necessary energy for maintenance, reproduction, and repair. This also causes high concentrations of glucose in the blood (High blood sugar, or hyperglycemia), which can lead to a plethora of complications, which I will elaborate on shortly.

In addition to transporting glucose into our cells, Insulin is also the hormone that promotes the body to store fats. Keep this in mind, as it is an important mechanic of the low-carbohydrate diet and weight-loss.

As previously mentioned, in T1s, the beta cells in the pancreas have been exhausted or even killed off, and insulin is no longer produced. Without insulin, the body will not receive energy from glucose, the concentration of glucose in the blood will rapidly rise, and many complications will occur.

In T2s, insulin is still produced, but it is not used efficiently by the cells. This typically leads to an elevated level of insulin as well as an elevated level of glucose in the blood. The elevated level of insulin is both caused by, and causes weight gain and excess body fat (as fat is one of the primary causes of insulin resistance).

Symptoms of Diabetes

There can be many symptoms that can lead to the diagnosis of diabetes. In T2s, most of these are caused by hyperglycemia. Diabetics typically exhibit some (but not all) of these symptoms:

• Excessive thirst
• Frequent urination
• Unexplained weight loss
• Glucose in the Urine
• Extreme hunger
• Tiredness or fatigue
• Rapid changes in vision
• Numbness or tingling in the extremities
• Slow-healing sores or infections

If you are experiencing more than one of these symptoms and aren't sure if you may have diabetes, you should see a doctor. There are several different tests that can be performed.

If you have access to a blood glucose meter, you can always check your blood sugar yourself. The most common, and likely the first test that a doctor will do is called a fasting blood sugar test. They simply check your blood sugar after you've fasted for 12 hours. This is certainly NOT a definitive test, as fasting sugars can be perfectly normal, and your average sugar level can be quite high.

A slightly more capable way of testing is a hemoglobin A1C test. This test will show your average blood-sugar level for the past 3 months. Diabetics often have this test done periodically as a way of keeping track of our progress. While this does provide substantially more accurate results, it is still not definitive.

The most commonly accepted way of knowing for sure is called a GTT (Glucose Tolerance Test) or OGTT, or Oral GTT. In this test, you consume a normal level (more than 150g per day) of carbohydrates for 3-4 days prior to the test, and then fast for 12 hours. The doctor will give you a set amount of glucose, and test your sugar at intervals after the ingestion or administration of the glucose. This displays trends, as well as your "peak" sugar, and should allow for a definite diagnosis.

I will not expand too much here on the symptoms, but will go into more detail in the next section on potential complications of diabetes.

Potential Complications of Diabetes

There are a whole slew of complications that can arise from diabetes. These are typically due to elevated levels of glucose in the blood, but there can also be complications caused by low levels of glucose, or even rapidly changing BG levels. It is heavily reported that all of these complications can be prevented, and in many cases reversed, by maintaining healthy blood-glucose levels. Complications that I'll focus on are primarily caused by high blood sugar levels, or rapidly changing blood sugar levels.

Frequent Urination is caused by the kidney's trying to remove excess glucose from the blood stream. The kidneys filter the glucose out and then expel the excess glucose through urination. This can cause dehydration which also leads to excess thirst.

Putting excess strain on the kidneys filtering out high levels of glucose can lead to kidney problems, urinary tract infections, kidney stones, and eventual kidney failure.

Fatigue is another common issue among diabetics. This is caused simply because the cells are not getting enough glucose to provide energy.

High glucose levels cause poor circulation. High blood glucose draws water out of your tissues, causing them to become dehydrated. Dehydration leads to poor circulation as blood is thicker. The poor circulation can cause numbness in hands and feat, and this can lead to Diabetic Neuropathy, which means that your nerve cells are degenerating and dying. This nerve damage can be permanent if elevated blood sugars persist for too long. It is recommended that Diabetics visit a podiatrist at least annually to have their feet checked for signs of neuropathy.

In addition to neuropathy, retinopathy can occur in the eyes due to high, or quickly changing levels of blood sugar. This damages your vision, and can be either temporary, or permanent if it is allowed to go unchecked for too long. It is also recommended that Diabetics visit an ophthalmologist annually for a diabetic eye exam. Optometrists are unable to perform the same level of exam as ophthalmologists and so the ophthalmologist is the recommended course of action.

This same mechanism causes the walls of the blood vessels to thicken. This is a leading cause of high blood pressure and cardiovascular disease in diabetics. Heart disease is the leading cause of death among diabetics.

High Cholesterol is another common worry among diabetics. High cholesterol is caused by increased insulin levels in the blood. The more glucose in our blood, the more insulin the body must produce to combat the elevated glucose levels, and thus the higher our cholesterol becomes. In diabetics, the cholesterol causes fatty plaque to form in the blood vessels and arteries. These plaques dislodging can lead to heart attack or stroke.

Poor circulation also limits the immune system's ability to combat infections. Infections can run rampant in diabetics, and untreated infection can lead to gangrene. Severe damage can require amputation.

I hope you can see that the best course of action is to control your blood sugars. Out of control sugars can lead to a plethora of health problems, many of which can cause death.

Let's take a closer look at methods of controlling diabetes!

Controlling Diabetes

There are several methods of controlling diabetes. As I believe that maintaining tight control is the key to fewer complications, and a longer, healthier life, I will focus most of my time on this section. Before we can get into the methods of controlling our diabetes, we need to understand what "control" is defined as.

What does "normal" mean?

Persons without diabetes maintain near constant blood glucose levels (BG) of 80-100mg/dl, typically hovering right around 85. Dr. Bernstein explains, "There are times when that range can briefly stretch up or down—as high as 160 mg/dl and as low as 65—but generally, for the nondiabetic, such swings are rare." As diabetics, we should aim to remain within these target numbers, although it is most definitely not always possible to do so.

So, what CAN we do? The American Association of Clinical Endocrinologists specializes in diabetes treatment. The AACE recommends that blood sugar levels should be 140 or below two hours after meals. While this is a noble start, many people feel that this number after two hours is still too high. Most diabetics BG "peaks" at around 1h after meals, and so they aim to stay below 140 at all times. There are a lot of us who do aim to stay within the "normal" ranges of 80-120 at all times.

The other common measure of control comes in the form of an hbA1C test, which measures the amount of hemoglobin in the blood and is said to show an approximate 3-month average of BG levels. The AACE recommended A1C of diabetic patients is 6.5% or below, which correlates to an average BG level of 154mg/dl or lower. As you can imagine, most of us feel that this number is unacceptable to us personally, and shoot for much tighter control in the 4.5-5.5 (83-118) range.

The most powerful tool that we, as diabetics, have to combat our disease is our BG Meter. By measuring our BG before and after meals and activities, we are able to determine how the foods we eat and exercises we do affect our BG levels. There are several different methods for achieving these results, and I can tell you from personal experience, that it is achievable.

Controlling with Diet and Exercise

Some T2s are able to control their diabetes with nothing more than Diet and Exercise. Even with Insulin therapy or oral medications, watching your diet and exercise routines is the single most important thing you can do for your health as a whole. As stated earlier, one of the causes of insulin resistance is excess fat. One goal should be to cut down on this fat, as any change in this area can provide many health benefits. These include (but certainly are not limited to): an overall healthier feeling, more energy, lower cholesterol, lower blood pressure, decreased resting heart rate, lower BG levels, decreased risk of heart disease and increased circulation.

The mostly widely accepted method of controlling diabetes through diet is by following a Low Carbohydrate Diet. These come in many forms, but all follow one principal -- restricted carbohydrate intake. These diets are not only used to control BG levels, but also to promote weight loss. Why? As stated earlier, carbohydrates break down into glucose much more quickly and efficiently than any other type of food we eat. This glucose leads to high insulin levels in our blood along with elevated glucose levels. T1's who eat more carbohydrates much inject more insulin to "cover" the carbs they eat, while as T2s, our pancreas or supplemental insulin does the work.

This build-up of insulin in the blood, as we have explored previously, leads to the building of excess fat-mass in our bodies, as well as elevated cholesterol. As stated before, this leads to poor circulation, high blood pressure, and the risk of heart disease, heart attack or stroke. The simple fact is this: limiting carbohydrate intake not only reduces our BG levels, it also reduces the amount of insulin in our blood, which vastly reduces our chances of other complications.

So what are we to eat? It is simply not feasible for a lot of us to eliminate carbohydrates completely from our diets. This is where the Glycemic Index comes in. Our bodies are able to digest certain carbohydrates much faster than others. The slower-digesting carbohydrates allow our bodies more time to react, and thus produce less of a "spike," or sudden rise in our BG levels. These slower foods are lower on the glycemic index. "The glycemic index (GI) is a ranking of carbohydrates on a scale from 0 to 100 according to the extent to which they raise blood sugar levels after eating. Foods with a high GI are those which are rapidly digested and absorbed and result in marked fluctuations in blood sugar levels. Low-GI foods, by virtue of their slow digestion and absorption, produce gradual rises in blood sugar and insulin levels, and have proven benefits for health."

Pure glucose is given a GI of 100, and foods that absorb more slowly are ranked on a scale below that number.

Low GI foods have a GI of 55 and below. These include most fruits and vegetables, pasta, legumes, milk, yogurt, and low-carb products such as cheese, nuts, cooking oil.

Medium GI foods have a GI of 56-69 and include most whole wheat products, basmati rice, sweet potatoes, and table sugar.

High GI foods have a GI of 70 and above and include items such as corn flakes, rice krispies, baked potatoes, watermelon, crossiants, white breads, most breakfast cereals, most white rices, and straight glucose.

This is important to keep in mind when choosing carbohydrates to eat. Eliminating high-carb, high-GI foods from a diabetics diet is the single most effective way of maintaining a stable BG level. This means cutting out things like white breads and rice, potatoes (baked and french fries) and white rices.

That is certainly not all we can eat on a Low Carb diet. Proteins are "free game" because they are digested and broken down into sugars at such a slower rate than carbs. This includes meats. Many of the Low Carb diets recommend sticking to leaner meats such as chicken, turkey, and fish. I tend to lean more towards Dr. Atkins' approach which also allows fattier meats.

Higher levels of fat in the diet is acceptable so long as your insulin levels remain low due to low carb consumption. This helps to prevent the body releasing insulin, which in turn prevents it from storing the fat. Additionally, when there are limited levels of glucose in the blood (due to the low carb load), your body switches to its alternate fuel source: fat. When glucose is not available as a fuel source, the body can also burn fat in a process called lipolysis.

Advocates also point out that with lower levels of insulin in the blood, cholesterol levels actually decrease even when consuming dietary cholesterol. Eating a healthy amount of fats also helps the body feel full. I am a big advocate of the low carb diet because it allows me to eat plenty of food so that I don't feel deprived, and allows me to eat most of the foods that I enjoy.

So what IS low carb? This is where most of the debate focuses between the several low-carb diets. Atkins' "Induction" phase advocates eating fewer than 20g of net carbohydrates per day. A very important distinction here, as "fiber" is not counted toward net carbohydrate intake. Why? Fiber is insoluble and our bodies do not digest this and turn it into glucose. It has no affect on our glucose levels, and thus no affect on our insulin levels. To determine how many grams of net carbohydrates are in a food, we simply take the total carbohydrates, and subtract the fiber grams. Sat your eating a piece of whole wheat bread that contains 12g of carbs per slice, and 3g of fiber per slice, the net carbohydrates in your slice of bread would be 12-3, or 9g.

Dr Bernstein recommends a diet consisting of 6g of net carbs (carbs) for breakfast, 12g for lunch, and 12g for dinner, for a total of 30g per day. On the other end of the spectrum, the American Diabetes Association recommends 60g of carbs per meal for men, and 40-55g per meal for women. Most all of the diabetics that I've spoken with feel that this is too many to maintain healthy BG levels. The key is finding what works for YOU as an individual.

While Diet alone can control BG levels, another important factor is exercise. The muscles burn glucose more quickly than other cells to provide them with energy to expand and contract. Even muscles in rest burn glucose more quickly. Additionally, exercise increases metabolism and reduces insulin resistance. All of these combined point to the fact that exercise is very useful in maintaining a healthy BG.

Building muscle alone is a good practice as well, because any increase in muscle mass yields a net gain in the amount of glucose (and calories, for that matter) your body uses, even while in rest. More muscle mass = less insulin resistance, and more glucose or fat burned.

Controlling Diabetes with Oral Medication

There are several different kinds of medications available today to help with controlling blood sugar. Most of the newer medications come with a very small risk of hypoglycemia (low blood sugar), however the risk is always there.

Sulfonylureas are a class of medications that stimulate insulin secretion. These were the first type of diabetes medications developed and include Glimepiride (Amaryl), Glyburide (DiaBeta, Micronase), and Glipizide (Glucotrol). These coax the pancreas into producing insulin throughout the day, so without appropriate food intake, hypoglycemia is a real possibility. Additionally, some people feel that forcing the already exhausted beta cells to produce even more insulin can lead to even faster beta-cell death, and can lead to progressively less insulin production over time. This can make it harder and harder to maintain good control.

Repaglinide (Prandin) and Nateglinide (Starlix) are medications that stimulate insulin secretion for a much shorter period of time. These are taken directly before meals, and evidence exists that they cause the pancreas to produce more insulin as more carbs are eaten. This more closely resembles natural behavior of the pancreas and reduces, but does not eliminate the risk of hypoglycemia.

Biguanides work mainly on the liver. Glucophage (Metformin) is currently the only drug of this category on the market. This is typically the first line of defense as medications go for T2s. This doesn't stimulate insulin production, but rather prevents the liver from producing too much glucose through glucogenesis. Metformin is also able to reduce the appetite. This makes it the drug of choice among overweight T2s, and is sometimes even prescribed to assist in weight-loss in non-diabetic persons. Additionally, Metformin helps to reduce insulin resistance and allows the body to more readily use the insulin that it produces.

Although there are several other categories of drugs available, these are the most commonly prescribed. Alpha-glucosidase inhibitors slow down the digestion of starch, Thiazolidinediones reduce insulin resistance, and there are several combinations of drugs available as well.

Controlling Diabetes with Insulin Therapy

The third, but certainly not least, way of controlling Diabetes is through insulin therapy. Because diabetics on Insulin usually have to inject themselves subcutaneously (under the skin, not in a vein) with insulin, a lot of people view this option as a last resort. This is a flawed view, as many sources believe that beginning patients on insulin early, or soon after diagnosis, allows the pancreas to "take a break" and can slow the progression of the disease.

Insulin itself, is a natural hormone, and so there are typically far fewer side effects associated with insulin than there are with the oral medications. Diabetics who are unable to maintain solid control on diet and exercise, or oral medications are typically able to sustain much more reasonable numbers using insulin. Insulin is not only for T1 diabetics, but is also used in T2s to augment their body's own natural insulin production, and to give the pancreas a chance to recover. T2's pancreas function declines over time with poor control, as the beta cells must work harder and harder to control BG levels, and this can cause a decline in insulin production, leading to the requirement of insulin in T2s as well.

There are two main types of insulin that are administered: long acting (basal) insulin, and fast acting (bolus) insulin. There are a few different brands of each available, and each has it's own purpose. The bloodstream always needs a small amount of insulin in order to counter-act the liver's glucose release. The basal insulin is typically injected once or twice a day (ever 12 or 24 hours) in order to replicate or augment this basal insulin that naturally occurs in non-diabetics.

The second type is fast acting insulin (bolus), and this should typically be injected from 10-30 minutes before meals. This insulin is used to counter-act the rise in blood sugar that is a direct result of eating. Most diabetics on bolus insulin develop a Insulin to Carb ratio (I:C) to tell them how many units of insulin they should inject based on the number of carbohydrates the meal is going to contain. Bolus insulin is also used to "correct" hyperglycemia quickly, and help the BG return to normal.

When on insulin therapy, you have the greatest risk of hypoglycemia. If there is too much insulin in your blood for the amount of glucose, your cells will consume all of the glucose, and your BG will drop too low. Hypoglycemia typically displays several symptoms that will vary based on the severity of the hypoglycemia. These include (but are not limited to) hunger, sweating, anxiety, tremor, heart palpitations, visual disturbances, confusion or abnormal behavior, seizures, loss of consciousness, and can even cause a coma or death if they are severe enough.

While the risks are great, the rewards can be as well. Diabetics on insulin are typically able to maintain tighter control, and slow the progression of their disease more than those not on insulin.

To make the decision even easier, one of the latest entries into the market of diabetes control is the Insulin Pump. The pump is a medical device that administers small amounts of insulin periodically through the day through an infusion set that is inserted as a syringe would be just under the skin. Users of the pump are able to adjust the amounts of insulin administered throughout the day and adjust the amounts that is administered before meals. Many find this to be the most efficient way of maintaining tight control, as the amounts of insulin administered is very flexible and programmable to meet individual needs.

In Conclusion

In conclusion, I hope that I've given a basic understanding of the mechanics of diabetes. Moreso, I hope that I've shown that the complications that can occur as a result of not controlling your blood glucose levels are not complications that any of us would like to deal with, and that these complications can be easily avoided using the many tools that we have at our disposal as diabetics.

I hope that you've gained some knowledge from reading this, as it's something that I would have liked to read upon first learning that I was diabetic.

Glossary

Beta Cells - The cells in the Pancreas that produce Insulin.

Pancreas - The organ near the upper rear of the abdominal cavity that is responsible primarily for producing and storing insulin.

Insulin - A protein, or hormone produced by all living things. Insulin is the hormone responsible for allowing our body's cells to absorb glucose. Insulin is also a "fat storing hormone" in that it assists our body in converting excess glucose to fat.

Glucose - The simple sugar that all bodies require for energy. This is also known as blood sugar. This is the simplest form of sugar that our bodies can use, and nearly all foods that we eat are eventually broken down by our bodies into glucose to provide our bodies, as well as our brains, with energy.

Hyperglycemia - Excess levels of glucose in the blood -- high blood sugar.

Hypoglycemia - Low levels of glucose in the blood -- low blood sugar.

Sources

Worth noting, many of my sources come from material that I have read on the internet, as well as some of the books that I have read. I've done a lot of reading since I was diagnosed. I've listed most of them below, though there could be plenty left out. Also, some of the information that I have picked up has been second hand information from may folks on forums that have lived with, and coped with Diabetes for far longer than I have. I may not have concrete sources for a lot of this information.

Dr. Atkins' New Diet Revolution - Dr. Robert C. Atkins, Eric Conger

Diabetes Solution - Dr. Richard K. Bernstein

The First Year Type 2 Diabetes: An Essintial Guide for the Newly Diagnosed - Gretchen Becker