sWhat Is the Course of the Disease?
Imagine that you have just been diagnosed with Type II diabetes. What can you expect in the normal course of the disease? You will go blind, and have a heart attack, or maybe a stroke. Possibly both. They will cut off your feet and you will lose the use of your kidneys. But not necessarily in that order. And then you will die. Diabetic ketoacidosis can put you into a coma (mortality rate of 10%.) Hyperosmolar Nonketotic Coma has a better chance of doing you in (mortality rate of 50%.) Even common hypoglycemia can kill you, but hardly counts since it is so easy to fix (as long as you remain conscious.)
Diabetes affects about 30,000,000 people worldwide. It is the third leading cause of death in America. Diabetics have 2 to 4 times more heart disease and strokes than non-diabetics. They have a 25% higher risk of cancer, and a 30% higher risk of dying of cancer as compared to non-diabetics. Up to 24,000 people lose their sight every year because of diabetes. It causes over 80,000 amputations per year. It is the number one cause of kidney failure. As many as 70% of diabetics have nerve damage and high blood pressure.
If this makes you nervous, you are beginning to understand something about Diabetes. Although most, if not all, of these consequences are avoidable, living with diabetes is quite a tightrope act. Not only can it kill you, but it can really mess up your quality of life. The real problem is that diabetes is very insidious. Your blood sugar can creep up to 300 mg/dl while you aren't watching, and you won't notice a thing.
How Does It Develop?
In the 1950's, if you had asked a doctor about the cause of diabetes, more than likely he would have laid the blame on a defective pancreas which had become unable to produce enough insulin. And he would have been partly right. This, indeed, seems to be what happens with Type I diabetes.
By 1960, Rosalyn Yalow and Solomon Benson had used radioimmunoassay to accurately measure the amount of insulin present in the blood. A short while later, Gerald Reaven and his associates at Stanford used the Yalow-Benson technique to discover that diabetics often had more insulin in their blood than non-diabetics. Their cells had just become less sensitive to insulin. (Actually, Sir Harold Hinsworth proposed insulin-sensitive and insulin-insensitive types of diabetics in a January, 1933 Lancet article, but nobody paid much attention.)
As we age, the body's ability to utilize insulin diminishes. The body attempts to compensate for this insulin resistance by increasing blood insulin levels. Excessive secretion allows a new equilibrium to be reached with normal blood sugar and high insulin. This equilibrium may continue for years. But, as the body becomes increasingly resistant to the function of insulin, ever greater amounts of insulin become necessary for the body's cells to utilize blood glucose (enabling cell nourishment.) At some point, the beta cells can no longer increase their production of insulin. The resulting insulin levels, although elevated, can no longer overcome the insulin resistance. Only then will blood sugar rise, and symptoms of adult onset diabetes will present. (Another alternative is the exhaustion of the beta cells, resulting in an actual decrease in insulin production.)
Insulin blood levels rise with age for virtually everyone. Typical average insulin levels for various age groups are:
5, at the age of 10.
10, at the age of 20.
40, at the age of 30.
50, at the age of 40.
65, at the age of 50.
90, at the age of 60.
120, at the age of 70.
If there is a single marker for lifespan, it is insulin sensitivity. Centenarians have low blood sugar, low triglycerides, and low insulin in common. Insulin is the common denominator. Those of us who have high blood sugar, high triglycerides, and high insulin are less fortunate. Anyone over the age of thirty is probably pre-diabetic, and adult onset diabetes is practically inevitable in the absence of preventative measures.
How Can Insulin Resistance Be Recognized?
Approximately 47 million Americans--about 1 in 4 adults(23%)--have the metabolic syndrome. They are all pre-diabetics. So, there is a vast pool of suffering humanity who might be helped by appropriate intervention. That is the bad news.
The good news is that there is now a ICD-9 code (277.7) that will allow physicians not only to treat, but also to bill for pre-diabetes treatment. Concern exists regarding the use of this diagnostic code, because of its potential impact on life insurance policies and health insurance portability. But, the door has been opened to diabetes prevention.
Here are some risk factor guidelines:
Fasting Triglycerides grester than 150 mg/dL.
Triglyceride-to-HDL ratio greater than 3.
Fasting Insulin greater than 20 uU/mL.
Fasting c-peptide greater than 4.6 ng/mL.
HDL cholesterol less than 40 mg/dL for men, or 50 mg/dLfor women.
Blood Pressure greater than 130/85 mm Hg.
Fasting Glucose between 110-125 mg/dL.
120 minute post-glucose challenge between 140-200 mg/dL.
BMI greater than 25.0 kg/m2.
Waist Circumference greater than 40 inches for men, or 35 inches for women.
Age over 40 years.
Diagnosis of Cardiovascular Disease.
Diagnosis of Hypertension.
Diagnosis of Diabetes.
Treatments
Once diagnosed, doctors use two things to control type 2 diabetes:
I. Drugs
A) Oral Hypoglycemic Agents-- Sulfonylureas, Biguanides, Alpha-Glucosidase inhibitors, Thiazolidinedione, Meglitinide, D-phenylalanine Derivative, Incretin Mimetics, Combinations of the above.
B) Insulin--Insulin is always required in Type I diabetes, but there is some division in the medical profession concerning the use of Insulin in Type II. Practitioners who hold the view that Type II diabetics are already hyperinsulinemic tend to avoid insulin therapy whenever possible. On the other hand, some doctors make it a point to prescribe Insulin for Type II diabetes at the very outset. (Their experience having been that the patients will eventually need to go on Insulin, anyway. And later on, it becomes a real chore for the doctor to convince them.)
II.TLC, or Therapeutic Lifestyle Changes (Experimentally found to be superior to drugs.)
A) Diet--While there is currently no consensus in the medical community concerning a therapeutic diet for diabetes, there is agreement that the Standard American Diet is flawed. There is further agreement that diet is useful in its treatment:
1) On one extreme you have the James Alexander/Nathan Pritikin/Dean Ornish/Julian Whittaker group. They advocate practically no sugar, virtually no fat, no salt at all, moderate protein, and lots of complex carbohydrates.
2) In the middle, you have the American Diabetic Association, which offers four ways to plan your diet, "...hopefully one is right for you."-- the Food Guide Pyramid, Rating your Plate, Exchanges Lists, Carbohydrate Counting.
3) On the other extreme, you have the Robert Atkins/Richard Bernstein/Cheryle Hart group which advocates very low carbohydrates, high protein, and high fat.
B) Exercise-- Regular exercise has been shown to substantially improve insulin resistance. (It takes glucose out of the blood to use for energy, lowers blood pressure, increases HDL, and even increases the number of insulin receptors available.)
C) Stop Smoking and Drinking--Usually a good idea. Actually, wine with meals, or one drink per day is probably good for you. But if you want to get well, you really need to stop smoking.
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