Diabetes:

Diabetes is defined as a metabolic disorder characterized by the inability of the body to utilize sugar properly and as a result the levels of sugar in the blood are elevated. It is a risk factor for cardiovascular disease. It doubles the incidence of events, heart attacks and strokes.

Types of Diabetes:

• Type I or juvenile diabetes appears early in life. It is produced by genetic factors and an acquired immune disorder, usually post-virus infection. The pancreas beta cells are destroyed, ceasing the production of insulin. It always requires the administration of insulin.
• Type II or adult appears later in life. It has genetic factors, but, more important, are the environmental factors such as a life style of overeating and lack of exercise.

Incidence of diabetes: The incidence of diabetics has doubled in the last 10 years. There are 20 million diabetics in the country and only 10 million have been diagnosed. It is predicted that 30% of the children born after the year 2000 will have diabetes when they become adults. There are ethnic variations in the incidence of diabetes: 7% in Anglo-Saxons, 17% in African Americans, and 24% in Hispanics.

Dr. Carl Pepin, President of the American College of Cardiology, recently stated: ” Nationally, the incidence of diabetes has doubled in the past 10 years, with that percentage expected to increase another 165% by the year 2050". One in three Americans born in 2000 will develop diabetes, with a risk of 33% for men and 39% for women. (Published in "today in CARDIOLOGY", September 2003 Vol.6.Number 9).

The symptoms of diabetes are:

• Increased appetite (Polyphagia)
• Increased thirst (Polydypsia)
• Increased urination (polyuria)
• Weight loss

Diabetes may be present for years before any symptoms appear.

Tests and Indicators for diagnosis of diabetes:

1) A fasting blood sugar (FBS) above 100 mg/dL.
2) A blood sugar level over 200 mg/dL two hours after the administration of 75 grams of sugar, this is called an oral glucose tolerance test (OGTT).
3) Two hour postprandial blood sugar levels of over 140 mg/dL indicate diabetes (blood sugar drawn two hours after a meal).
4) A hemoglobin A-1c level over 6%.

Who should check blood sugar at home?

Having a home blood-glucose monitor is beneficial for anyone with diabetes. Individuals, who are able to manage their diabetes with diet and exercise alone, do not have to check blood sugar at home frequently. Regular home checks of blood sugar are important for people with type 2 diabetes that are:
     - Using insulin injections
     - Taking pills for diabetes that are commonly associated with a side effect of low blood sugar, especially pancreas        stimulators such as the class of medicines known as sulfonylureas, repaglinide, or nateglinide.
     - Pregnant women
     - Having a hard time managing blood-sugar levels (people who may need to change or add medicines)
     - Going through a significant illness in addition to diabetes

The fasting blood sugar levels should be maintained between 100-120 mg %. After meals levels should be kept under 140 mg%.

How frequently should you test blood sugar?

For some people, testing once each morning for a few days before each doctor's visit may be adequate. For others, tests two or more times daily may be needed to guide adjustments in medicine doses. A nighttime test reading may be necessary to troubleshoot problems of unstable glucose levels. Your doctor can help determine a practical testing schedule for your needs.

A calendar or graph with your glucose recordings can be a great help to your doctor as he or she tries to advise you about adjustments in treatment plans or goals.

Who should check hemoglobin A1C levels at home?

The U.S. Food and Drug Administration recently approved a home monitoring device that can measure the level of hemoglobin A1C in your blood. The A1C is one of the most important  tests for diabetics because it is a measure that can summarize your sugar control during the previous three months.

The A1C changes gradually, so testing soon after a medication adjustment may not fully reflect your response. A home A1C monitor can provide you with one more way to personally monitor your sugar control. Doing the A1C test once a month is sufficient. However, home monitoring of your A1C is not a substitute for regular visits to your doctor.

Which testing devices are the best?

The most established way to test your blood sugar is with a blood-glucose meter (also called "glucometer"), a machine that analyzes the amount of glucose in one or two drops of blood. Many brands of glucose meters are available, and some provide special functions such as electronic memory to record the times and results of glucose level tests. One brand of A1C monitor is currently available for home use. In order to use a blood-glucose meter or A1C monitor, it is necessary to produce a fresh blood sample (usually from a finger prick) for each reading. Hands should be washed and dried well before each test to ensure accuracy

The tool that is most often used to quickly prick the tip or side of your finger is called a lancet. Most lancets fit into spring-loaded devices. Laser devices that pierce the finger skin without a needle or blade recently have become available for home use, but they are a more expensive.

How do I know my home monitor is accurate?

To ensure the accuracy of any meter you use at home, check its results against a blood test done by your doctor's laboratory. You will need to bring your machine in to the laboratory so that you can obtain a sample near to the same time your blood is drawn. Your blood-glucose machine (or any machine in your doctor's office that reads a blood sample directly from a finger prick) most likely reports the glucose concentration of whole blood. Tests in a laboratory that are done on a tube of blood are usually a measurement of glucose in plasma, the blood product after a centrifuge machine has removed cells. If a whole blood reading (Glucose-meter reading) is accurate, it is usually about 10 percent to 15 percent lower than a plasma-glucose measurement that is obtained near the same time.

Are there other ways to test sugar at home?

Urine tests for sugar are not as accurate as blood tests and are not recommended for most type 2 diabetics.

The U.S. Food and Drug Administration (FDA) recently approved a device resembling a watch that can be used to test sweat-glucose levels. The device estimates blood sugar based upon the sweat-sugar level. This device is not recommended as a substitute for a blood-glucose monitor, but in some cases it may be useful for providing information about the timing of sugar highs and lows. It is an expensive device and it requires a doctor's prescription.

Continuous glucose meters that are implanted in the abdomen are available, but they are not frequently used for people with type 2 diabetes.

Equivalent values for blood sugar and Hemoglobin-A1C levels

Treatment of diabetes:

• Diet: Reduce total caloric intake. The carbohydrates intake should be reduced to fewer than 40%. The 70-30-30 diet (70% carbohydrates, 30% proteins and 30% fats), recommended by the Heart Association should be modified for diabetics. See chapters three and four.
• Exercise: Walk a minimum of 30 minutes/day. See chapter six.
• Oral medications:

  Sulfonylureas stimulate insulin production and secretion by the pancreas; Examples are: Diabinese, Amaryl, Glucotrol, Diabeta, and Micronase.

  Biguanides decrease glucose production by the liver and lessen the insulin resistance by the body; Examples are: Metformin, or Glucophage.

  Glucosidase Inhibitors prevent the absorption of sugar by the bowel Examples are: Precose and Glyset.

   Thiazolidinediones or Glitazones ( GTZ) , primarily make the body respond to insulin (lessens insulin resistance) and decrease the production of sugar by the liver: Examples are: Actos and Avandia. There are some reports of increased incidence of heart attacks and mortality by using Avandia. Large case studies are in progress and the final results are forthcoming. Personally, I prefer to use Actos. Actos has another  beneficial effect by increasing HDL levels (good cholesterol).

  Meglitinides stimulate the release of insulin by the pancreas: Examples are: Prandin, Starlix

• Types of Insulin:

  Fast acting, regular human (injection or inhalation): Examples are regular humulin .  Acts in 15 min. and lasts 6 hrs.

  Intermediate acting, Human NPH and Lente. Acts in 1-3 hrs and lasts 18-24 hrs.

  Long Acting, Human Ultralente and PZI:  Glargine (Lantus) acts within 4-8 hrs.and lasts 28-36 hrs. without peaks and valleys, offers a more uniform effect.

  Mixtures, Examples are: Novolin 70-30, combining short and long acting insulin. Acts within 30 min.and lasts 24 hrs.

  Injection sites are abdomen for faster absorption. Thigh for slower and arm for intermediate absorption.

   

•  Newer agents in use involve the incretins system (incretins are produced in the intestine), either  by taking their place or prolonging their effect on insulin. Incretins stimulate the secretion of insulin, protect the beta-cells, decrease apetite, decrease the secretion of glucogen  lessening the glycemia level. At present there are two agents available: An analog of the incretins, exenatide (Byetta derived from the saliva of a lizzard, is injectable) and an agent that prevents the destruction of incretins: Sitagliptin ( Januvia-oral). Caution: There are reports of pancreatitis in patients receiving Byetta.

 Below, see this algorithm taken from the American Diabetes Association regarding the most effective way to treat diabetes in order to maintain A1c levels below 7.0%

Complications of diabetes: :

Diabetes induces systemic changes in the lining of all the blood vessels. It more than doubles the incidence of heart attacks and strokes, produces renal disease which leads to arterial hypertension and renal failure. It is a common cause of blindness, affecting the retina and producing hemorrhages in the eyes. It induces slow healing, protracted infections, foot ulcers, gangrene of the extremities, peripheral neuropathy, and diabetic keto-acidosis and coma.

Do not wait until the symptoms of diabetes occur. Diabetes is simple to diagnose and to treat. A properly treated diabetic lessens the risk of cardiovascular disease and other complications, expecting a normal life span..

Pre-Diabetes, Syndrome X or "Metabolic Syndrome":

This is the disease of the new millennium. Men and women with this syndrome constitute the group at the greatest risk of death from a heart attack or stroke.

Individual risk factors, when in combination, potentiate their effects. The Syndrome X or Metabolic Syndrome is defined by the National Cholesterol Education Program (NCEP) as the presence of 3 or more of the following 5 risk factors:
     - Waist size over 40 inches in males and 35 in females
     - Elevated triglycerides over 150 mg/dL
     - HDL lower than 40 mg/dL in males and lower than 45 mg/dL in females
     - Blood pressure over 130/85 mmHg
     - Fasting Blood Sugar over 110 mg/Dl

What is the significance of Syndrome X? Statistics show that people with this problem have evidence of increased insulin resistance and abnormal glucose tolerance test which puts them at risk for arteriosclerotic cardiovascular disease in the same proportion than diabetes. This doubles the risk for events (heart attacks and strokes) when compared to the general population.

Common questions:

Q: Does diabetes increase the risk of cardiovascular disease, even if it is properly treated?
A: If diabetes is properly treated, the complications and risk of cardiovascular disease in general are decreased.

Q: Can diet and exercise alone be sufficient to manage diabetes?
A: In some individuals, diet and exercise alone can normalize the blood sugar levels. In these cases, no additional therapy with drugs or insulin is needed.

Q: Does pre-diabetes or metabolic syndrome lead to diabetes.
A: Yes. Metabolic syndrome if unrecognized and untreated leads inexorably to full blown diabetes with all its complications.

Q: If I have metabolic syndrome, what should I do?
A: Reduce your carbohydrate intake as mentioned above, replace purified sugar and starches for fiber-containing carbohydrates and exercise daily. Walking 2 miles a day may suffice for many people. If your lipids are abnormally high, the use of statins is a must. Some physicians recommend the use of glytazones, such as Avandia and Actos even before the fasting blood sugar levels are elevated. Glitazones may have anti-inflammatory effects as well.

Revised:  September 4, 2009