House Call, MD: Health Carefully Explained

by Rebecca Shatsky, MD 2011 | shatsky@myhousecallmd.com

According to commercials for the OneTouch glucose monitoring device, rock and roll legend B.B. King hasn’t let Type II diabetes give him the blues. In commercials, little computerized finger stick devices might even look kind of fun, a sentiment we would guess that few diabetics probably share. But, while drug companies and the popular media may try to downplay the gravity and life-altering nature of this chronic disease, few physicians see diabetes as something to be taken lightly.

If you live in America these days, chances are you know someone who either has or has been affected by Type II diabetes. The disease has ravaged the country leaving no stone unturned. Recently rising to epidemic proportions, diabetes has become the leading cause of kidney failure, amputations and blindness in the US. It is also a major contributor to the number one cause of death in the industrialized world: heart disease.

Unfortunately, even though diabetes has become exceedingly common, few doctors really take the time to explain the disease to their patients. This lack of education has led to widespread confusion amongst patients and poor compliance with treatment regimes, a vicious cycle that benefits no one. So, on that account, we want to take this opportunity to summarize things and simplify, providing the basics without all the confusing medical jargon.

What is Type II Diabetes??

Diabetes is a disease of metabolism (the breakdown of sugar for energy) so to understand diabetes, we have to first look at what normally happens in the body after we eat a meal.

Usually, when we eat a meal rich in carbohydrates (sugar), the sugar that we eat enters our blood steam and causes blood sugar levels to rise. When blood sugar levels rise, the body responds by secreting a hormone from the pancreas, called insulin, which allows the sugar floating around in the blood to be used for energy. When the pancreas releases insulin into the blood, blood sugar levels go back down to their normal pre-meal values. The picture below shows how this occurs in your body.  Simple, right?

In diabetes, however, something in this sequence of events goes haywire and the body either doesn’t respond to the insulin in your blood or doesn’t secrete enough insulin to lower blood sugar levels to a healthy range. When blood sugar levels no longer decrease appropriately in response to insulin, we call this “insulin resistance.”

The idea of insulin resistance is central to the development of Type II diabetes. Most studies suggest that in the early stages of the disease, the body’s response to insulin becomes progressively worse over time (4). With increasing insulin resistance we become more and more unresponsive to the normal (life-sustaining) effects of insulin. It’s a little bit like alcoholism, where the body needs greater and greater amounts of alcohol to get drunk; when we become insensitive to insulin, the pancreas needs to produce and release more and more insulin just to keep the body’s blood sugars in a healthy range.

During the disease development period, the body’s blood sugar levels are normal or mildly elevated before meals and then high directly after. If you are screened for diabetes at this stage, blood glucose levels will be higher than normal, but not quite high enough to be classified as “diabetes.” We call this stage “prediabetes.” Clever, we know (we are a bunch of nerdy doctors after all).

Eventually, the pancreas can no longer produce enough insulin to keep up with your body’s increasing insulin requirements. When this happens blood sugar levels soar out of control, both before and after meals. Blood sugar levels that remain high first thing in the morning (after not eating for hours!) are a true indication that diabetes has developed and that treatment is necessary.  The diagram to the right compares the blood sugar levels of a healthy individual with that of an individual with diabetes after having a drink containing 75g of glucose (called a Glucose Tolerance Test).  As you can see, the blood glucose levels soar out of control in the individual with diabetes.

What’s wrong with a little extra sugar?

While it might not sound so bad to have a little extra sugar floating around in your blood, having poorly controlled blood sugar is actually incredibly damaging to your organs, especially your blood vessels. When the cells in your blood are exposed to high levels of sugar for long periods of time, the sugar attaches to the blood cells making them sticky and less flexible. We can measure the percentage of blood cells that have been affected by high sugar levels with a blood test called the hemoglobin A1C level. The hemoglobin A1C level gives doctors a good estimate of how high blood sugar levels have been for the past three months and can be useful in predicting how much damage may be occurring to various tissues in the body.

The best way to explain the complications of diabetes is to look at the different parts of the body the disease affects. The most pervasive and significant complication of diabetes is damage to blood vessels. Damage to large blood vessel results in an increased risk of heart attack and stroke in diabetics, while injury to small blood vessels damages the kidneys (causing kidney failure) and the eyes (leading to blindness). Damage to small blood vessels can also affect the peripheral nervous system (i.e. all nerves not in your brain or spine) and may cause pain, tingling and numbness in your arms and legs, particularly the feet. Finally diabetes has some dangerous effects on the immune system, which puts diabetics at increased risk of infection and increases the time it takes to heal from injuries and surgeries (4). While some of these adverse effects may occur in all diabetics, it is important to remember that the severity of complications is directly related to the length of time a person has had the disease as well as how well blood sugars are controlled.

Who gets diabetes and why?

There are many different theories as to why things go haywire with the body’s insulin response, but what we do know is that the greatest contributing factors to the development of the disease are obesity, physical inactivity and genetics (1).

The importance of obesity in the development of type II diabetes is demonstrated by the tremendous increase in children and adolescents diagnosed with type II diabetes (2).  Once upon a time, Type II diabetes was unheard of in children; so much so that we used to called it “Adult Onset Diabetes.” However, since the obesity crisis swept the nation, the number of children diagnosed with Type II diabetes has increased dramatically and virtually all childhood cases occur in children who are overweight or overtly obese.

The role of genetics in diabetes is well documented but still poorly understood. Certain ethnic populations are at increased risk for Type II diabetes. Those at highest risk include African Americans, Latinos and American Indians (2). We also now know that having a family history of Type II diabetes markedly increases your risk of developing the disease (so if Grandma Mildred had Type II diabetes, you are at an increased risk of developing it). The exact extent to which having a family history of diabetes increases your risk is still hard to predict since the disease is caused by both environmental factors(obesity), as well as genetics. The take home message: If you do have a family history, it’s essential to tell your doctor so they can screen you sooner rather than later.

What does this mean for me?

The most important thing to keep in mind with diabetes, whether the disease has affected you or your loved ones, is that aggressive treatment makes a difference. The surge in Type II diabetes that has occurred over the past 20 years is, without a doubt, intimately related to the obesity epidemic. And, just like obesity, the first weapon in our arsenal against diabetes is diet and exercise. If diet and exercise are not enough, then the key to staving off complications is strict blood sugar control. We cannot emphasize this point enough. It is absolutely essential to take prescribed diabetes medications every single day and to check and record blood sugar levels on a regular basis. If the medications you are taking aren’t doing the trick, make an appointment to see your doctor so that you can find the right combination of medications for you.

Lastly, although discussion of the prevention and treatment of diabetes could be an entire article in itself, it’s important to be aware of the various resources out there available to diabetics. Most insurance plans have good coverage for diabetes medications and many give out free or low cost glucose monitoring devices. The American Diabetes Association is a great resource for information. There are even health care professionals called “diabetes educators” specifically trained to help diabetics learn to live with their disease and make specific lifestyle changes to decrease their risk of complications (nobody wants to go blind as a result of poor glucose control). Ultimately, the best way to manage this disease is to be proactive and take charge of your own health. Successful control of diabetes isn’t just luck, it’s all about lifestyle.

Questions? E-mail the Author: shatsky@myhousecallmd.com

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References:

1. Braunstein, Glenn D. “Diabetes Mellitus.” Andreoli and Carpenter’s Cecil Essentials of Medicine. By Philip S. Barnett. Philadelphia: Saunders, 2007. 676-95. Print.

2. “Diabetes Research and Statistics.” Centers for Disease Control and Prevention. Web. 18 June 2010. .

3. Ligaray, Kenneth Patrick L., and William L. Isley10. “Diabetes Mellitus, Type 2: EMedicine Endocrinology.” EMedicine – Medical Reference. 10 June 2010. Web. 18 June 2010. .

4 .Powers Alvin C, “Chapter 338. Diabetes Mellitus” (Chapter). Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J: Harrison’s Principles of Internal Medicine, 17e: http://www.accessmedicine.com/content.aspx?aID=2891108.

5. Steppan, CM, ST Bailey, EJ Brown, RR Banerjee, and CM Wright. “The Hormone Resistin Links Obesity to Diabetes.” Nature 409.6818 (2001): 307-12. Print.

by Tania Houspian, PharmD 2011 | houspian@myhousecallmd.com

You open your refrigerator door and take out a milk carton (non-fat of course) to top off  your morning cereal.  As you tilt the carton, expecting a stream of delicious white liquid, you instead get disgusting clumps of a cottage cheese-like substance. It’s safe to say that the milk has passed its expiration date. You, being the sensible human being that you are, throw away the expired milk and settle for a granola bar for breakfast instead and plan to buy a new carton of milk on your way home from work.

Let’s look at another scenario.  You open your medicine cabinet and take out a bottle of Motrin wanting to take a couple of tablets to alleviate the muscle pain from a rough game of basketball last night (those 16 years olds didn’t look so tough at first).  You scan the bottle looking for how many you should take and notice that it expired June 2009. You open the bottle and see that the pills look fine. There is no molding… they don’t smell funny…so you figure it’s fine to take. Besides, you have a stellar conspiracy theory that expiration dates are an evil ploy by pharmaceutical companies to get you to buy medication more often. You pop two tablets and go on with your day.

If you find yourself nodding emphatically saying,  “That’s so true.  I totally do that!” then you’re not alone.  One of the most common questions pharmacists are asked is “Can I take this medication even though it expired last year?” On the other hand, you don’t ever go back to the grocery store and ask the clerk, “Can I drink this milk even though its been expired for a year?”  This paradigm makes sense, though. When there’s proof of spoilage (i.e. stinky cottage cheese instead of milk) we’re way more likely to believe the expiration date. We don’t blame you, old milk tastes horrible but old Motrin still has that delicious sugary coating.

So, what’s the final verdict? Are expiration dates just a way to get you to buy more medications or did your Motrin become ineffective as of June 2009?

The Evil Ploy Side:  The main argument presented by the “Expiration Dates are for Pansies” faction of society is a study performed by the military and presented to the FDA in 2002. In the study, the military evaluated all of their expired stockpiles of medication and discovered that some were still considered stable and efficacious for up to 54 months after their noted expiration date.

Now you can take those results and run with them or you can look at the details of the military’s findings. The military noted that the “degree of stability” depended greatly on the medication, manufacturer, and lot number. They were not issuing a blanket statement saying all medications are good for 54 months after the printed expiration date.  They merely found that some drugs remain good after the date on the bottle.  This fact, though, may be enough for some to call into question the validity of the expiration date on that Motrin bottle.

Here is the take home message: You are not the military.  Earth-shattering, we know. What we mean by that is that you don’t store and care for your drugs the way the military does (just a guess).  The military stores their stockpiled medications in cool, dry, dark, and temperature controlled warehouse-type locations.  Where do most people store their medication?   A few common “store houses”:  medicine cabinet in the bathroom, spare cabinet in the kitchen and, last but not least, purses. Think about all the temperature and humidity changes those locations go through.  Repeated exposure to temperature variations and light affects the stability of medications.  Even though the pharmaceutical company knows the medication will be good for 10 years, they may decide to give it a 5 year expiration date to account for variations in how people store their medications.  The date printed on your bottle of Motrin takes into account all the abuse you dare inflict on your personal medication supply.

Now you say: “So what! I took some expired Motrin (Tylenol, Nyquil, etc.) and nothing bad happened to me!”  Okay, but there’s also a chance that nothing good happened either.  When a medication passes its expiration date it means that the company that manufactured it no longer guarantees it will work for you.  You may not get any relief from your muscle pain, sore throat, runny nose, or whatever symptom you were trying to treat.  Not the kind of medicine we endorse.  The treatment of the aforementioned mild conditions may not be life altering but the issue of efficacy is important with medications that are used to treat life-threatening conditions.  Medications like nitroglycerin, insulin or antibiotics should never be taken past their expiration date.  If these medications don’t work properly, the stakes are much higher (read hospitalization or, even worse, death).

Anytime you ask a health professional if it’s okay to take a medication past its expiration date the response you’re most likely going to get is, “No.” It’s just not worth the possibility of not receiving adequate treatment.  For the skeptics in the room, there is one time that you’ll hear of medications being used past their expiration date: severe shortages.  At those times, desperate times call for desperate measures and the medical community works with the limited resources available.   Next time you look at the back of your medication bottle and see its expired, ask yourself: Is this really a desperate time or can I easily get more medication that’s guaranteed to work?  I think we all know the answer.

Questions? E-mail the Author: houspian@myhousecallmd.com