The good news is that keeping blood sugar levels near normal reduces the risk of joint mobility problems. If you already have limited range of motion in your shoulders, hands, fingers, or any of your joints, lowering your blood sugar levels may help improve your range of motion and limit the pain associated with stiff joints.
A Positive Disposition
Blood sugar levels have a direct effect on mental well-being. People with diabetes commonly feel down when blood sugar levels are up. Depression is three times more common in adults with diabetes than it is in the general population. The mechanism of this increased risk is not entirely known. It could be related to the extra stress associated with living with a chronic illness, but because depression is often biochemical in nature, elevated sugar levels in the fluid surrounding the brain may also play a role. In addition, developing complications from diabetes can instill a feeling of helplessness, which is known to contribute to the onset of depression.
The good news is that improving your blood sugar can, in essence, make you a happier person. Researchers at the Harvard Medical School and the Joslin Diabetes Center studied the effects of blood sugar control on mood and disposition. They found that people with lower blood sugar levels reported a higher overall quality of life. Significantly better ratings were given in the areas of physical, emotional, and general health, as well as vitality.
So that’s pretty much the situation. Blood sugar levels influence almost every aspect of our physical and mental well-being. Improving your blood sugar control will enable you to feel and perform better today as well as enjoy a longer, healthier life.
If you need a bit more motivation, there are countless examples of people with insulin-dependent diabetes who have achieved tremendous success in life:
Professional athletes such as Jay Cutler (football), Catfish Hunter (baseball), Bobby Clarke (hockey), Chris Dudley (basketball), Bill Talbert (tennis), Michelle McGann (golf), Kris Freeman (skiing), and Gary Hall (swimming).
Entertainers such as Mary Tyler Moore (the Mary Tyler Moore Show), Halle Berry (movie actress), Jean Smart (Designing Women), Zippora Karz (the New York City Ballet), and Bret Michaels (rock star).
Pioneers Bill Davidson (cofounder of Harley Davidson), Thomas Edison (inventor), and Ernest Hemingway (author).
Even former Miss America Nicole Johnson, former Miss Black USA Kalilah Allen-Harris, and former Mr. Universe Doug Burns.
Unfortunately, there are also people like my late father-in-law, a great man who succumbed to the complications of diabetes, and my wife’s grandmother, who lost her legs, her eyesight, and eventually her life to poor diabetes control. So here’s another “now” benefit of taking good care of yourself: peace of mind. There is something therapeutic about putting in a solid effort. Just knowing that you are doing your best can be a tremendous source of personal satisfaction.
There will be a cure for diabetes some day. It may not come in five years (like my doctor proclaimed twenty-five years ago), but when the day finally arrives, let’s be in the best shape possible and not have any regrets.
Now let’s get to work.
Chapter Highlights___________________________________________
•Managing diabetes takes work and sacrifice. There is no getting around that.
•There are many immediate benefits from managing diabetes, including physical and intellectual performance, emotional stability, safety, and well-being.
•The long-term complications of diabetes can be devastating, affecting virtually every part and system of the body.
•Tightening blood sugar control dramatically reduces the risk of developing long-term complications and dramatically slows the progression of existing complications.
*paraphrasing Ned Flanders from The Simpsons
CHAPTER
3
Basics and Beyond
Managing diabetes is like building a home: Before you can even think about fancy fixtures and color schemes, you need to have a solid foundation. Prior to jumping into the intricacies of blood glucose regulation, let’s take a few moments to get acquainted (or reacquainted) with some diabetes fundamentals. Even if you think you know all the basics, keep in mind that our knowledge of diabetes is constantly expanding. Here’s your chance to get caught up on all the latest facts.
Diabetes by Any Other Name Is Just as Sweet
At the heart of our understanding of diabetes is the hormone insulin. Insulin’s job is to facilitate the movement of nutrients—particularly glucose—out of the bloodstream and into the body’s cells where they can be burned for energy. When not enough insulin is produced or the body’s cells cannot use the insulin properly, blood sugar levels rise above normal and diabetes develops.
If you ask an endocrinologist to describe the different forms of diabetes, you’d better have some snacks handy because you’re in for a long discussion. It’s not just type 1 and type 2 anymore; many other forms of diabetes have been designated: gestational diabetes, LADA (Latent Autoimmune Diabetes of Adulthood), MODY (Maturity Onset Diabetes of Youth), neonatal diabetes, and secondary diabetes. We’ll get to those in a little bit.
In the vast majority of cases diabetes can be grouped into two major classes: the kind caused by loss of the ability to produce insulin and the kind whose underlying cause is insulin resistance (the body’s inability to utilize insulin properly). Now here’s where it gets interesting: People who lose the ability to produce insulin can sometimes develop insulin resistance, and those who have insulin resistance sometimes lose the ability to produce insulin.
Confused yet? Don’t worry. You’re not alone. Let’s see if we can sort it all out.
All forms of diabetes cause blood sugar levels to be too high. Hypoglycemia (low blood sugar) can also occur when insulin or insulinenhancing medications (sulfonylureas or meglitinides) are used in the treatment. All require careful ongoing management, and all can produce a wide range of health problems (complications). However, the similarities stop there. From a physiological standpoint, the various forms of diabetes and their modes of treatment vary like flavors of ice cream. First, let’s look at the vanilla . . . er . . . type 1 diabetes.
Type 1 diabetes involves damage to the pancreas, a slimy organ nestled below the liver. At the base of the pancreas is a cluster of cells called the “islets of Langerhans” (named after the person who discovered them), and contained within the islets are “beta” cells. The beta cells are the cells that constantly measure blood glucose levels and produce insulin, as needed, to keep the blood sugar within a normal range. Along with insulin, beta cells secrete amylin, a hormone that, among other things, regulates the rate at which food digests.
In type 1 diabetes the body’s own immune system destroys the beta cells. Normally, the immune system only attacks things that are not part of your own body, like viruses and bacteria. In an autoimmune disease such as diabetes, however, the immune system fails to recognize a part of your own body as such and attacks it. In the case of type 1 diabetes, the beta cells are attacked and destroyed over a period of months or years. As a result, the blood sugar level goes up and the body’s cells are deprived of the sugar they need for energy.
In type 1 diabetes, the body’s own immune system destroys the insulin-producing beta cells.
There are more than one million people with type 1 diabetes in the United States, and several times that number worldwide. Tens of thousands are diagnosed with type 1 every year. Type 1 diabetes is usually diagnosed during childhood and adolescence, but it can also appear during adulthood. Most people with type 1 diabetes were born with an overactive immune system. We do not entirely understand what exactly triggers the attack on the beta cells of the pancreas. Viruses, major stress, environmental toxins, exposure to certain foods at a young age, and genetic markers have been proposed as potential triggers.
At the time of diagnosis a person with type 1 diabetes will likely have a very high blood sugar level and elevated ketones (acids formed from excessive fat metabolism cou
pled with insufficient sugar metabolism). Blood sugar levels above 180 mg/dl (10 mmol/l) also cause excessive urination, as the kidneys pass some of the sugar into the urine. In essence, high blood sugar causes you to urinate away many of the calories you consume. Consequently, rapid weight loss can occur. Frequent urination also makes you very thirsty. And because you are unable to get sugar into your cells without insulin, your energy level will be quite low and you will be hungry constantly.
Type 1 diabetes can be diagnosed a number of ways: through a blood sugar and urine ketone screening, by evaluating symptoms, or by testing for certain antibodies in the blood. Once type 1 is diagnosed, insulin treatment begins immediately. This initial treatment can provide a rest period for any beta cells that the immune system has yet to destroy. These remaining cells may be able to produce enough insulin to keep blood sugar levels relatively stable for a period of weeks, months, or possibly years. We refer to this as the “honeymoon phase” (or, more appropriately, “the calm before the storm”). Eventually, however, beta cell function ceases completely and insulin requirements go up and stay up. Without insulin, a person with type 1 diabetes will become severely ketotic (have high levels of acids in the blood), go into a coma, and die. This is the reason type 1 diabetes used to be called “insulindependent” diabetes: You depend on insulin to stay alive.
Approximately 90 percent of people with diabetes have type 2 diabetes. Type 2 is very different from type 1 in that there is no autoimmune attack, and the pancreas continues to produce insulin. In fact, for a while, the pancreas may actually produce more insulin than usual.
There are typically three stages to type 2 diabetes: onset of insulin resistance, followed by failure of the pancreas to meet the increased insulin need, followed by a reduction in pancreatic function. Let’s look at these stages one at a time.
Stage 1: The Resistance
In order to do its job of taking sugar out of the bloodstream and packing it into the body’s cells, insulin attaches to something called a “receptor” on the outer surface of the cell. This is similar to the way a key enters a lock in order to open a door. Once insulin attaches to the receptor, a “door” opens and sugar molecules are shuttled into the cell. So for insulin to work, there have to be sufficient receptors on the cell surface, and the insulin must find and properly fit into the receptors. Insulin resistance occurs when there are not enough receptors or the insulin has a hard time finding or fitting into them.
What causes insulin resistance? Typically, it is a combination of genetics (heredity) and lifestyle (the way we live). Having close relatives with type 2 diabetes greatly increases the risk. Certain ethnic groups, including Native Americans and people of African, Hispanic, Asian, and Pacific Island descent, are at a high risk. The aging process plays a role as well. The older we get, the more insulin resistant we tend to become.
Women who have polycystic ovarian syndrome (PCOS) often become insulin resistant due to the overproduction of hormones that oppose insulin’s action. Likewise, hormones produced during pregnancy oppose insulin’s action and can lead to gestational diabetes.
A lack of physical activity can cause insulin resistance in many people, as can stress hormones related to illness, surgery, or emotional turmoil. Steroid medications such as prednisone and cortisone also cause insulin resistance. But the most widespread reason people become insulin resistant is weight gain. Too much body fat, particularly around the middle, limits insulin’s ability to function properly. In fact, gaining as little as ten pounds over a fifteen-year period can cause insulin resistance to double.
The most common reason for people to become insulin resistant is weight gain, specifically too much fat around the middle.
Currently, more than forty-four million Americans are severely overweight. Obese individuals are seven times more likely to develop diabetes than those who maintain a healthy weight. And the problem is not restricted to adults: More than ever before, overweight children and teenagers are developing insulin resistance and type 2 diabetes.
Stage 2: The Production Shortfall
Insulin resistance affects a significant proportion of the worldwide population. Why, then, do only a fraction of those with insulin resistance develop type 2 diabetes? The answer lies in the resiliency of the pancreas.
When insulin resistance occurs, the pancreas needs to produce more insulin to keep blood sugar levels in a normal range. This is sort of like an office where one or two people aren’t doing their job—everyone else has to pick up the slack. In most cases the pancreas can keep up with the added workload. But not everyone’s pancreas has this capacity. If the insulin resistance becomes too much for the pancreas to overcome, blood sugar levels rise above normal. In other words, for type 2 diabetes to develop, you must have both insulin resistance and a limit to the pancreas’s ability to secrete extra insulin.
To understand this concept better, imagine that you are an air conditioner trying to keep your house cool on a hot summer day. If you’re one of those high-powered central air conditioning units that can crank out a bazillion BTUs, you’ll have no problem overcoming the heat and keeping the house cool. But if you’re one of those rusty window units, you’re probably not going to be able to blow enough cold air to keep the house cool on really hot, humid days.
In this example, the heat and humidity are like insulin resistance: They present the challenge to the usual system. The air conditioner is like the pancreas: An efficient system can overcome almost any challenge, but a lesser system will be unable to meet the challenge. You need both very hot weather and a weak air conditioning system to create an oppressive situation.
At this early phase of type 2 diabetes, you can often achieve blood sugar control through exercise (which improves insulin sensitivity) and a healthy diet (which reduces the flow of sugar into the bloodstream). Sometimes you can use oral medications or noninsulin injectables to help the pancreas (or insulin) to work more effectively, and this may be all it takes. But it doesn’t usually stay that way for long.
Stage 3: Function Reduction
Type 2 diabetes is a progressive illness. That is not a good thing. There is nothing hip, cool, or modern about it. It is progressive because it grows worse and becomes harder to control over time. After having diabetes for a number of years, insulin resistance tends to grow worse, and the pancreas struggles to keep up with the huge demand for insulin. Then a new problem sets in: Just like an air conditioner that is forced to run full blast every minute of every day, the pancreas starts to break down. (Heck, if you were asked to work day after day without any breaks and no end in sight, you would break down too . . . or at least find a new job!)
Two things cause the breakdown of the pancreas: overwork and a condition known as glucose toxicity. We can all understand the overwork part: Force those poor little beta cells into relentless slave labor, and many of them are going to die off. Glucose toxicity occurs when high sugar levels do direct damage the pancreas, thereby further reducing its ability to produce insulin.
This is why the treatment for type 2 diabetes becomes more aggressive over time, and it explains why millions of people with type 2 diabetes take insulin injections—some once daily, some several times each day. Does this mean that people with type 2 diabetes can eventually develop type 1? No, it does not. Remember, the type of diabetes is defined by what caused it, not how it is treated. Type 1 diabetes occurs when the body’s own immune system destroys the part of the pancreas that makes insulin. Type 2 is caused by insulin resistance, followed by insufficient insulin production, which is followed by a gradual breakdown of the pancreas.
The type of diabetes you have is defined by what caused it, not how it is treated.
If you don’t currently take insulin for your type 2 diabetes but your health care professional has encouraged you to do so, there is plenty of good news. Insulin is the most potent and effective treatment for elevated blood sugar. It is a more natural substance than pills (today’s insulin formulations are chemically simi
lar to the insulin the body produces), and lacks many of oral medications’ side effects.
The fact is that oral diabetes medications and other injectables have their limits. Unlike insulin, which lowers blood sugar directly, all of the other medical treatments for diabetes work indirectly. This means that they only work when the pancreas has the capability to produce sufficient amounts of insulin and the body’s cells are reasonably sensitive to the insulin. Once the pancreas is unable to keep up with the workload, no amount of medication is going to solve the problem.
Taking insulin is easier and safer than ever before. The latest insulin formulations are much less likely to cause hypoglycemia (low blood sugar) than are older types of insulin. Disposable insulin syringes have short, super-thin needles that you can barely feel. Insulin can also be administered with prefilled pens: Simply dial up your dose and inject. And best of all: When you begin using insulin and experience an immediate reduction in your blood sugar levels, you’re probably going to feel better than you have in years!
The “Other” Diabeteses
Okay, I made that word up.
Remember, diabetes comes in more flavors than just vanilla (type 1) and chocolate (type 2). There are a host of exotic flavors to choose from.
Secondary diabetes (cookies and cream) involves destruction of the beta cells of the pancreas by something other than the body’s own immune system. Potential causes include trauma (accidents/injuries), heavy doses of steroids, pancreatitis, alcoholism, cancer treatment, and infection. Regardless of the cause, the treatment is the same as with type 1: insulin, insulin, and more insulin.
Think Like a Pancreas Page 4
