by Rebecca Shatsky, MD 2011 | firstname.lastname@example.org
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.
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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.