DIABETES MELLITUS
Diabetes Mellitus – commonly known as sugar diabetes, or simply diabetes. Th
is disease is characterized by elevated blood sugar and impairment in the body’s ability to use glucose as a fuel. Approximately 26 million Americans have diabetes and 79 million have pre-diabetes. The current diabetes epidemic predicts that by 2050, 1 in every 3 Am
ericans will have diabetes. Because of the complications associated with this disease, 1 in 5 healthcare dollars is currently spent caring for patients with diabetes.
The pancreas is the endocrine gland responsible for the production of insulin.
Diabetes is a disease of elevated blood glucose. There are two main types of diabetes mellitus.
Type 1 Diabetes
Type 1 diabetics have lost the ability to produce the hormone insulin. Without insulin, they cannot use glucose as a fuel. They can become ill or die due to a metabolic disorder called Diabetic Ketoacidosis (DKA). Therefore type 1 diabetics must use insulin to treat their diabetes. About 10% of all diabetics have type 1 Diabetes
Type 2 Diabetes
Type 2 diabetics have a problem with their body not responding adequately to the insulin they produce. This stresses their pancreas to produce extra insulin and over time, the pancreas begins to malfunction, producing less insulin than is needed by the body. Because they have multiple problems causing their diabetes, type 2 diabetes is often treated with diet, exercise plus medications which may include oral medications, injectable diabetes medications or insulin.
BLOOD GLUCOSE Target Goals
Blood glucose target goals for control of blood sugars have been published by diabetes expert groups, such as the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA). Desert Endocrinology encourages most patients to meet the AACE goals of an average fasting glucose of 140 mg/dL or less, and a hemoglobin A1c of 6.5%. The rationale for these guidelines is to reduce a patient’s risk of complications. For example, an average fasting blood glucose above 110mg/dL may incur a higher risk of diabetic eye damage. Checking post-meal blood sugars is important when one recognizes that the bulk of the time we are awake, we are digesting, not fasting. Checking blood glucose levels also helps to recognize low blood glucose events. Low blood glucose levels are potentially dangerous. The brain prefers to use glucose as an energy source, and when it is low, one may feel confused, lightheaded, or may pass out and have a seizure. One may even resemble a drunken, intoxicated individual. For these reasons, low blood glucose levels are to be avoided. The Hemoglobin A1c (HbA1c) is a simple blood test that basically measures the percentage of red blood cells in your body that have sugar attached to them. This is a reflection of how high the blood glucose has been. Because red blood cells only last about 120 days in the blood, the HbA1c test gives us a backwards, retrospective look at the patient’s average blood glucose for 3 months, and allows the endocrinologist to make more accurate and timely adjustments to the patient’s medications.
Exercise
Exercise is an important part of diabetes management for all diabetics. Besides improving strength and stamina, exercise helps patients to control their weight. This in turn improves the patient’s response to insulin, thereby improving blood glucose control, and possibly reducing the need for medication. The single largest consumer of blood glucose in the body are the muscles. For this reason, even taking a short walk around the block after a meal may improve blood glucose control. We often recommend simply walking daily as a very inexpensive form of exercise.
Food
Food for a diabetic is every bit as important as any diabetic medication. In particular the quality and quantity of carbohydrates in the diet have a major impact on blood glucose levels. Excessive carbohydrates in the diet or use of “simple” carbohydrates will elevate blood glucose to higher levels and may therefore require additional diabetes medication. Simple carbohydrates such as white bread enter the bloodstream quickly, as opposed to more “complex” carbohydrates such as whole grains or vegetables. Consultation with a diabetes educator or dietitian may help to analyze a patient’s current diet habits and recommendations can be made to help attain diabetes and weight control. Alternative diets such as “low-carb, higher protein” diets should be discussed with your doctor, as some diabetics with kidney disease may need to actually restrict their protein intake.
Complications
While the short-term complications of poorly controlled blood glucose levels can involve increased urination and dehydration, the long-term complications are principally circulation damage and nerve damage. For example, the combination of poor circulation and numb feet is particularly risky. Such as patient may suffer a simple cut or foot blister, which becomes infected. If the infection goes deeper, into the bone, the infection may not respond to antibiotics and an amputation may become necessary. Because the patient’s feet are numb, they are oblivious to even the early signs of infection. Therefore we recommend daily foot inspections by patients. We recommend they call our office or their foot care provider if they find any signs of infection or injury. Even a simple ingrown toenail can worsen, resulting in an amputation.
Both types of diabetes result in a higher risk of cardiovascular disease throughout the body. This may cause a greater risk of heart disease, stroke, kidney failure, blindness, impotence, amputation and other diseases. Because of the higher risk of complications, our endocrinologists strive to prevent them, rather than wait until they occur. Treatment therefore includes appropriate lowering of blood sugars but also use of other medications such as statins and aspirin to lower cardiovascular disease, and ACE inhibitors to lower the risk of kidney failure. Education, exercise, diet and weight management are also important parts of maintaining the health of a diabetic patient. Other measures may include frequent foot exams, yearly eye exams for retinal damage and yearly flu shots. Daily home blood sugar monitoring is important to determine the response to therapy and allow for more precise medication adjustments. Studies have shown many of the dreaded complications of diabetes can be minimized or avoided by proper care and patient compliance.
Because diabetes is said to be the major cause of adult blindness, a yearly eye examination with photos of the retina are important for all diabetics. The retina is the light sensitive layer in the eye, which forms the images we see. Bleeding and scarring can damage the retina, causing a loss of vision.
Medications
Medications for diabetes are quite varied in how they work. Because type 1 diabetics lack insulin, they must have insulin daily to maintain health and stay alive. Insulin is given via syringe injections, insulin pen, or a miniature computerized pump. Because insulin is a protein-based hormone, it will be destroyed in the acidity of the stomach. This is why there is not yet an insulin pill, but it is currently being developed. A prior attempt to deliver insulin as an inhaled powder was withdrawn by the manufacturer. Currently, there are short-acting and long-acting insulins, and each has a particular purpose. The short-acting insulins start working within 10-20 minutes, and will only last about 4 hours. This makes them ideal to take just prior to meals, as it takes the body about 4 hours to digest a meal. Long-acting insulins serve to maintain proper glucose levels between meals. They may take 2–4 hours to really show an effect, but they may last up to 20–24 hours. By using these different types of insulin, your endocrinologist may fine-tune your insulin program to attain blood glucose target goals, while minimizing the risk of a low blood glucose.
Type 2 diabetics have a metabolically complex disease, and various medications are available to address these problems. Sulfonylureas are the classic diabetes medications such as glipizide, glyburide and glimeperide. They work by promoting the secretion of insulin by the pancreatic islet cells. They are very effective at lowering blood glucose, but since they increase insulin production, they have the risk of causing hypoglycemia (low blood glucose). Biguanides include metformin, perhaps the number 1 selling diabetes medication in the world. It works by minimizing the production of extra glucose from the liver, and improves somewhat the body’s response to insulin. It commonly causes a decrease in appetite, in part due to some nausea. Because of this, patients often note a weight loss with this medication. TZD drugs such as pioglitazone and rosiglitazone are very effective at improving insulin sensitivity to lower blood glucose. Incretin drugs help your body make more insulin and decrease glucose production from the liver. This include DPP-4 inhibitors (sitagliptin, saxagliptin, linagliptin) which are taken orally and GLP-1 receptor agonists which are injectable (exenatide, exenatide extended release, and liraglutide). GLP-1 RA drugs slightly delays the transfer of food from the stomach to the intestines, so the stomach feels full sooner. Though sometimes causing nausea,GLP-1 RA drugs also suppress appetite in some patients, thereby causing potential weight loss. SGLT-2 inhibitors (canagliflozin, dapagliflozin) increase release of glucose through the urine when blood sugars are high and thereby lower blood glucose. Several other anti-diabtetic drugs are currently approved in the US and can be utilized by your endocrinologist when necessary to optimally control your diabetes.
It is important to remember that it may take upwards of 10 to 20 years to evolve into a type 2 diabetic. As one slowly becomes a type 2 diabetic, there is a progressive loss of the pancreatic islet cells, which produce insulin. At the time one is diagnosed there has been more than a 50% loss of islet cells. Over the coming years, further loss of islet cells means eventually the body may not produce enough insulin, and many type 2 diabetics do start insulin therapy. Therefore, patients should never view starting insulin therapy as failure or defeat of their effort to manage their diabetes. It is simply the evolution of their diabetes. Owing to the complexity of type 2 diabetes, optimum control of blood.