Kathryn Jean Lucas, MD
611 N 35th St
Morehead City, North Carolina 28557

inside health

Understanding Diabetes

By: K. Jean Lucas, M.D.

Joan was 30 years old when she had her first pregnancy. She had always been overweight but in the pregnancy, she started gaining excessive amounts of weight and had gained more than 40 lbs by her 6th month. Her physician gave her a test to determine if she had diabetes with the pregnancy; the blood sugar came back elevated. She had to be on a special diet during the pregnancy. When the diet did not control the blood sugar, she started insulin shots. After delivery, the blood sugar was normal. One year after the pregnancy, she still was unable to lose any weight. Over the next several years, she started having increased thirst and urination, and yeast infections chronically. Her physician did a blood sugar test which showed that she had diabetes.

John was a senior in high school when he noted that he was losing excessive amounts of weight despite eating ravenously. He was also excessively thirsty. He would have to drink a can of Coke almost every hour. He was getting up all through the night to urinate. This problem became even more prominent when he tried to go on a long road trip with his family. They had to stop at every rest area for him to urinate. His mother sent him to his physician. Urinalysis showed that he had 4+ sugar in his urine along with 3+ ketones. He was started on insulin shots, and his symptoms improved.

Cynthia had always been overweight. Even as a child, she weighed much more than the other children. When she went through puberty, she gained approximately 80 pounds. After two of her pregnancies in which she had babies over 9 lbs, she also gained weight. When she was 50, her doctor checked her blood and it showed elevated blood sugars. She was put on oral medications and her symptoms of fatigue and thirst improved.

WHAT IS DIABETES?

As all of these patients illustrate, diabetes may occur in many different kinds of situations. Symptoms may vary over time. Many people are found to have diabetes without their having any symptoms at all. Diabetes is a disease in which the blood sugar is elevated. The reasons for the high blood sugar are because insulin, which keeps the blood sugar normal, is either deficient as in the second case, or does not work properly as in the first and third cases. Juvenile onset diabetes or Type I diabetes involves destruction of the cells of the pancreas that make insulin (islet cells). This destruction is initiated by a virus which sets off the immune system. The immune system mistakenly thinks the islet cells of the pancreas are foreign and proceeds to attack these insulin-producing cells. In the first and third cases, the insulin of these women does not work properly. This "insulin resistance" is a genetic problem inherited from their parents. Over many years prior to the onset of the diabetes, the insulin level has been high trying to work properly and keep the blood sugar in the normal range. These high insulin levels may cause weight gain in the middle of the body and cause excessive hunger and craving of sweets. Some people even have hypoglycemia (low blood sugar) several hours after eating because insulin levels are high at the wrong time. Ninety percent of people with diabetes have Type II diabetes or insulin-resistant diabetes as illustrated in our first and third cases. Ninety percent of Type II diabetic patients are overweight with primarily central body obesity. Approximately 13 million people in the United States alone have diabetes, and approximately 6 million of these people do not know they have diabetes.

WHAT ARE THE SYMPTOMS OF DIABETES?

The symptoms of diabetes occur for various reasons. The symptoms of increased thirst and increased urination occur because the excess sugar that is in the blood gets filtered through the kidneys. The kidneys usually hold onto the sugar, but when the blood sugar is excessively high, the kidneys are not able to retain the sugar, and it is lost through the urine. This fluid loss pulls water with it as well as sodium and potassium and makes the person feel weaker, urinate more, and because of the increased urination and loss of fluids from the body, also become excessively thirsty. Other symptoms of diabetes involve the immune system. When the blood sugar is elevated, the body does not fight off infections well. Patients may have frequent infections such as fungal infections of the skin, vaginal yeast infections, or small pustular infections such as Staph infections on the skin.

One indication that the patient may have had diabetes in the past is having a baby weighing 9 lbs. They may have had diabetes during the pregnancy and not have known it. Another symptom of diabetes from the sugar being too high is blurred vision; the abnormality in vision is temporary and caused by sugar getting into the lens of the eye causing swelling of the lens. A patient can have tingling and numbness in the hands and feet because of sugar swelling the nerve. A patient may be excessively hungry because of loss of sugar in the urine which means loss of calories in the urine. Weight loss may occur especially in Type I diabetes because the body is burning fat and muscle in order to provide the body with enough sugar.

Because the insulin level is low, the body does not recognize that it has enough sugar because the sugar can not get into the cells to help the cells function properly. This inability of insulin to allow the sugar into the cells causes the body to go into a state of starvation. In order to obtain the energy it needs, the body begins breaking down components of muscles and fat.

WHO IS AT RISK FOR DIABETES?

Patients with a family history of diabetes are at high risk for developing diabetes later in life. Type II diabetes is more common as you get older and as your weight increases, especially the weight around your waist. If one parent has Type II Diabetes, each son or daughter has a 50% chance of developing diabetes as they get older. If a woman has had diabetes during a pregnancy and remains overweight following the birth of the child, she has a 90% chance of developing diabetes within ten years.

Type I diabetes is not clearly inherited although a tendency towards it may be inherited. It only makes up 10% or less of diabetic population. Most people get this type of diabetes before age 30. Usually these people are not overweight when they develop it.

COMPLICATIONS OF DIABETES

To prevent complications of diabetes, strict control of the blood sugar is the most important goal. In the DCCT trial, which followed many Type I diabetic patients over 7 years, a great reduction in the incidence of complications was seen with improvement in blood sugar. The blood sugar did not even have to be normal to achieve this reduction in complications. A normal blood sugar in a person who does not have diabetes does not vary much and ranges between 60 and 115 even after meals. In a patient with diabetes, the range that is acceptable is 70-140. In the DCCT trial, if the patient had an average blood sugar of 154, the complication rate was greatly decreased.

Diabetic patients can have nerve damage to the nerves in their hands and feet causing tingling and burning in their feet. It may eventually lead to a totally numb foot which can be easily injured without the person knowing it. This may lead to chronic infection of the feet, foot ulcers, and eventually amputations if the infection is not able to be controlled.

Blurred vision may occur when the blood sugar is acutely elevated but chronic changes in the eyes may occur leading to hemorrhages and protein leakage in the eye leading to blindness. Kidney damage may occur because of sugar affecting the kidney's filtering function. Over time the kidneys may quit functioning entirely leading to the patient requiring chronic dialysis. If a patient has diabetes that is not well-controlled and becomes pregnant, they have a higher instances of birth defects, miscarriage, and large babies at delivery.

Type II diabetic patients have a greatly increased incidence of cardiovascular disease. Even at the diagnosis of their diabetes, 50% already have heart disease. It is thought that the patients having to make high amounts of insulin to keep their blood sugar normal prior to development of diabetes can have these vascular problems. Perhaps the high insulin level contributes to the development of fatty plaques. People with Type II diabetes have a higher incidence of not only of heart disease but also of stroke, and peripheral vascular disease.

HOW TO TREAT DIABETES

If a person has Type I diabetes, insulin is the only therapy. The insulin is given to replace what the body does not make. Usually, it is given in two forms, NPH which is a long-acting form, regular which is a short-acting form, and may be given in 2 to 4 shots a day. Some people wear continuous infusion of short-acting insulin and insulin pump.

For Type II diabetes, the defect may not be insulin deficiency but rather insulin resistance. Glucophage (Metformin) is a new drug recently approved in the United States for treatment of Type II diabetes. This medication causes the body to use insulin more normally and leads to lowering of the blood sugar. It may also lead to decreased appetite and weight loss. Precose (acarbose) delays the absorption of carbohydrates in the intestinal tract and causes the blood sugar after meals to be lower. Oral Sulfonylurea medication such as Glucotrol, Micronase, Diabeta, and Glynase are agents that increase the production of insulin by the pancreas. In order to get the body's blood sugar down, the insulin level needs to be increased for a short period of time to do that. Some Type II patients who have had elevated blood sugar for many years do not make much insulin and sometimes they require insulin shots. However, this is a double-edged sword because the insulin may make them hungrier and gain weight.

LIVING WITH DIABETES

Diabetic patients need to follow a certain type of meal plan which involves a good mix of carbohydrates, proteins, and fat in the diet. They may need three meals or three meals and a bedtime snack. Type I diabetic patients usually do not need to lose weight, they just need to control the blood sugar which goes up after eating. Type II patients usually need to lose weight and they need to be on a low fat calorie-controlled diet. These diets may be discussed with them with a visit to their dietician. Diabetes involves a lifestyle change if the patient is not used to eating well-balanced meals spaced a certain amount of time apart. Since the diabetic meal plan is a healthy one for everyone to follow, the whole family should be involved in this type of meal planning.

Newer medications are being introduced all the time which help improve the problem with the defect in Type II diabetes and it may even get to the point where one day we will be able to prevent the development of diabetes by treating the insulin resistance before the diabetes develops.

 For more information about diabetes, you an contact your local chapter of The American Diabetes Association. If you have symptoms of diabetes or you want to be tested for diabetes because it runs in your family, contact your primary care physician.

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