Diabetes

Diabetes is a chronic complex condition

Diabetes (Diabetes mellitus) unites a group of conditions which are associated with the way our organism utilizes glucose. Glucose is crucial because it is a source of energy for the cells that build up the body’s muscles and tissues. Glucose (sugar) is also the main „fuel” for the brain.

2 main sources supply our body with glucose  –  food and also liver’s reserves. When we do not eat for a certain period of time, our liver starts breaking down the glycogen accumulated there into glucose to provide energy to the body.

Glucose enters the bloodstream from the intestines or the liver and then enters the cells with the help of insulin hormone. This hormone is secreted by special cells in the pancreas and is released into the blood according to the quantities of the consumed carbohydrates in food. Sugar – this are not only the white crystals that we put into food and beverages to sweeten them.  Each carbohydrate food contains sugars – such as pastry, fruit, vegetables and so on. When insulin enters the bloodstream, it decreases the amount of sugar in the blood as it “pushes” it into cells.

Irrespective of diabetes’s type, the main consequence is the higher glucose level in blood plasma. When blood sugar levels are higher chronically, this leads to serious health problems. Nerves and blood vessel nerve endings are most affected - from the smallest – arterioles to the biggest – arteries. 

There may be stages of the condition when it is still reversible. One of these is prediabetes. In this case, your blood sugar level is higher than normal but not yet high enough to be type 2 diabetes. The second is gestational diabetes which appears in pregnancy but it may disappear after the birth of the baby.

Which are the normal glucose levels in blood?

Several factors are relevant:

• Age. The glucose values are different for babies, adults and people in old age – over 80 – 85 years old;
• Whether the test probe is taken before or after a meal;
• When the test is after a meal - what type of food was consumed and how long ago;
• Whether the blood test is taken from the vein or from a capillary (from the finger).
   

Laboratories may differ in their reference (normal) values. The most common ones are the following:

• Glucose in blood serum at an empty stomach: from 3.9 to  6.1 mmol/L;
• Glucose in capillary blood: from 3.5 to 5.5 mmol/L;
• Glucose in blood serum after a meal: up to 7.7 mmol/L;
• Newborns up to 1month age (empty stomach): from 2.8 to 4.4 mmol/L;
• Children from 1 month old to 14 years (empty stomach: от 3.3 до 5.6 mmol/L;
• Adults over 85 - 90 years old – 4.2 – 6.7 mmol/L (empty stomach).

The condition’s chronic phase includes 2 types: Type 1 and Type 2

Type 1 diabetes

The body’s immune system may, for unknown reasons, startя to attack and destroy the pancreas’ own cells which produce insulin. This leads to insulin shortage or total absence of insulin. In this way, sugar that flows into blood via food cannot enter cells and tissues and sugar blood level remains high.

This type of diabetes is called insulin-dependent as the condition is in direct cause-effect relation with insulin shortage in the body. Patients have to inject the hormone to themselves to be able to live. 

Type 1 diabetes can develop at any age although most often the condition develops in childhood or in adolescence.

Risk factors for the development of type 1 diabetes:

• Family history – when a parent, brother or sister have the condition, you are in a higher risk;
• Some viral diseases may trigger the immune system in the wrong way so it can start attacking the insulin cells in the pancreas;
• Presence of some antibodies  – auto-antibodies. Some family members – relatives of patients with type 1 diabetes, have specific auto-antibodies. This is a signal for the increased risk of development of the condition. But not everyone has these auto-antibodies develop the disease;
• Some countries, like Sweden and Finland, have a higher number of patients with this condition.

Overweight is not considered a risk factor for type 1 diabetes.

Type 2 diabetes

Type 2 diabetes is a chronic condition that affects the way your body processes sugar.

With type 2 diabetes, your body cells resist the effects of insulin – the hormone that regulates the movement of sugar into your cells. In the beginning, insulin is produced in a quantity enough for the body’s needs. To counter this resistance, the pancreas tries to produce more insulin but in the end, the gland exhausts without compensating the condition. So again, instead of entering the cells to answer their needs, sugar is accumulated in blood in excessive quantities.

The exact causes for the development of cell insulin resistance are still unknown. Scientists suggest the reason may be a combination between genetic factors and environment factors.

Type 2 diabetes is the form that is most common among patients. People can develop it at any age but most often it appears in the 40s.

Risk factors for type 2 diabetes are:

• Weight. It is already established that excessive weight is strongly connected to diabetes development. The more fat is stored in the body, the more insulin resistant the tissues become. But not everyone with type 2 diabetes is overweight;
• Sedentary way of life. The less active the person is, the bigger the risk. Physical activity helps the body weight control because glucose in food is utilized as energy and is not stored in the body in the form of fat.  Besides, physical activity makes the cells more insulin sensitive;
• Heredity. The risk for developing the condition is bigger when a parent or brother/sister has type 2 diabetes;
• Race.  Scientists still cannot explain the fact that some races’ representatives like Afro-Americans, Spaniards, American-Indians and Asian-Americans are more inclined to develop the disease;
• Age. The risk gets higher with age. One reason is that older people tend to move less, lose muscle mass and gain weight. But in recent decades more often children and young people develop type 2 diabetes;  If you have had a gestational diabetes while pregnant, the risk for developing prediabetes and type 2 diabetes later gets higher. If the baby was weighing more than 4 kg you are also at higher risk to develop the disease.
• Polycystic ovary syndrome. The risk is higher for women with this condition which is characterized by non-regular menstrual cycles, heavier hair growth and weight gaining.
  Hypertension. Non-controlled chronic hypertension over 139/89 (mm Hg) is associated with a higher risk for development of type 2 diabetes.
• Dyslipidemia. The high levels of the total and also the “bad” LDL-cholesterol and the triglycerides, on the one hand, and the low levels of the “good” HDL-cholesterol, on the other, are all associated with a higher risk of developing type 2 diabetes.
   

  Diabetes symptoms

Initial patient complains are due to the high blood sugar levels. There may be cases when the condition is diagnosed only after it triggers a complication like heart attack, stroke or wounds that heal very slowly. Usually symptoms vary according to the extent to which blood sugar level rises. Often symptoms appear sooner and are more hardly demonstrated with type 1 diabetes. On the other hand, type 2 diabetes may go on undiagnosed for a very long time.

Main symptoms for both types of diabetes are:

• Increased thirst and necessity to consume more fluids;
• Frequent urination;
• Extreme hunger attacks;
• Unexplained weight loss;
• Unusual fatigue;
• Irritability;
• Blurred vision;
• Slowly healing wounds;
• Persistent itching all over the body;
• An inclination for frequent infections – for example skin, gums and genitals inflammation.

Diagnosing diabetes

The most proper way to make a diagnosis is a laboratory testing of the blood glucose level:

• Random test of blood sugar levels: When blood sugar level is higher than 11,1 mmol/L, not regarding the time of last meal, we talk about diabetes;
• Test before meal: A result of level between 6.1 to 6,9 mmol/L is considered prediabetes. Higher than 7 mmol / L in 2 separate tests – then we talk about diabetes;
• Oral glucose tolerant test: We measure blood sugar levels in the morning before we eat, then we drink around 200 ml of fluid with 75 gr glucose. Then blood test is taken half an hour later, one hour later and 2 hours later. The most important results are these after the 2nd hour. If blood sugar level then is lower than 7.8 mmol/L, the result is considered normal. We have impaired carbohydrate tolerance when we have results between 7.8 и 11 mmol/L and diabetes when the level is above 11.1 mmol/L;
• Glycated hemoglobin (A1C). It’s not necessary to take this blood test before eating. It demonstrates the average blood sugar level for the last 2 – 3 months. The test measures the percentage of blood sugar connected with blood hemoglobin. The higher the levels of blood sugar in blood serum have been, the more glucose connected to hemoglobin there will be.  When the glycated hemoglobin is higher than 6,5% in 2 separate tests, the disease is here. Result between 5,7 и 6,4 % indicates prediabetes. Levels below 5.7 % are considered normal;
• Urine test: This test can diagnose higher levels of ketones. They are a side product when the organism uses fat and muscle tissue to produce energy when there is not enough insulin to process the present glucose. In this case, sugar can be detected in urine which is not the usual case for healthy people.

Prediabetes – causes and symptoms

It’s a condition in which carbohydrate tolerance is disturbed – the body has difficulties processing glucose in the right way. But still this condition is reversable if we take adequate measures. They include a more balanced diet without doughy, sweet and fat foods, more exercise and losing weight as well as regular control of blood sugar levels.

Prediabetes is associated with the Metabolic syndrome which includes: 

• Borderline blood sugar levels when tested before meal - between 6.1 to 6,9 mmol/L;
• Obesity, esp. in the belly area. Fat tissue in this area is not simply a cosmetic issue.  It is virtually an additional harmful gland with internal secretion which produces a great number of “excess” hormones.  On their part, they increase obesity even more and thus create a vicious circle;
• Hypertension – blood pressure values higher than 139 /89 mm Hg;
• Dyslipidemia  – high levels of the total and the “bad” cholesterol and/or triglycerides and low levels of the “good” cholesterol;Higher levels of uric acid in blood no matter whether there is a pronounced gout or not.

Diabetes in pregnancy (Gestational diabetes)

Some pregnant women develop gestational diabetes without having had symptoms of type 2 diabetes before that. Gestational diabetes is not to be mixed with undiagnosed diabetes that have been existent before pregnancy.  

The placenta produces specific hormones during pregnancy to sustain it. These hormones may do cells more insulin resistant.

Usually the pancreas reacts by producing enough extra insulin to overcome this resistance. But sometimes the pancreas cannot address this situation. When this happens, the glucose that enters the cells is not enough and remains in blood for too long which leads to the development of gestational diabetes.  In many cases this condition disappears after birth and there is no need for any treatment.

Women who are predisposed for this condition:

• Age - over 25 years old;
• Prediabetes that has been diagnosed before that - precursor of the type 2 diabetes;
• Close relatives – a parent or sibling with type 2 diabetes;
• Women that have developed a gestational diabetes before  and women that have given birth to a heavyweight baby the previous time;
  Previous not explained stillbirth;
• Overweight.

Complications during gestational diabetes:

For the baby: 

• Excessive weight and need for a Caesarean section;
• Low blood sugar level (hypoglycemia) after childbirth which sometimes requires glucose intravenous infusion;
• A higher risk of getting overweight and type 2 diabetes later in life;
• Non-treated gestational diabetes may lead to the baby’s death before or soon after childbirth.
   

For the mother:

• Preeclampsia. This condition is characterized by hypertension, losing proteins through the urine, swellings. This is a risky condition for both mother and baby;
• Another gestational diabetes following the first one. Once it has appeared, it’s more likely that it will appear again with the next pregnancy;
• A higher risk for type 2 diabetes to be developed later in life.

Possible complications from diabetes

Acute complications

Formerly, people with type 2 diabetes died most often due to acute complications. These complications develop since cells are energy deprived because glucose cannot enter into them without insulin. Then the body starts to “eat” its reserves and dissolves proteins and fats. This, on the other hand, leads to heavy acidification of blood and the process is known as diabetic ketoacidosis. It is accompanied by nausea, vomiting, acetone mouth smell and stomach pain. If the patient is not given appropriate medical assistance in time, he’ll pass into coma and then death.

Nowadays, few patients reach these stages mainly if they are unaware of the fact that they are ill or when they have missed to take their insulin doses.  Diabetic ketoacidosis is an urgent life-threatening condition which needs immediate medical help.

Chronic complications

Chronic complications develop gradually and over time they can cause disabilities and early death to people that haven’t managed to control their diabetes.

Good news is that when diabetes is treated properly and patients have changed their life style, they can live a normal life till old age.

The longer the condition goes without therapy and the less controlled blood sugar levels are, the higher the risk for complications:

• Cardiovascular diseases. In the world of medicine diabetes has been qualified as serious a disease as the cardiovascular ones because it increases drastically the risks for numerous conditions  such as ischemic heart disease, heart attack, stroke, generalized atherosclerosis, arrhythmia, blocking of limbs’ veins and those of inner organs – intestines, kidneys etc.;
• Peripheral nerve system damage. Excessive blood sugar damages the walls of small blood vessels (arterioles and capillaries) which provide the body’s nerve endings with blood.  These nerves become inefficient in their work and this causes tingling, a sense of burn and pain that usually starts from the foot’s fingers tips and then gradually climbs up. The condition is called diabetic polyneuropathy. It can damage not only the limbs but also internal organs which become inefficient in their work;
• Diabetic foot. The limbs’ reduced sensitivity and bad tissue nutrition in this condition cause chronic foot wounds that sometimes get so sore that an amputation should be performed;
• Kidney damage (diabetic nephropathy). Kidneys contain millions of small clusters of blood vessels (glomeruli) that filter blood waste. High levels of blood sugar can damage this delicate filtering system.  In most complicated cases this can lead to kidney failure which in its final stages requires hemodialysis or kidney transplantation;
• Eye damage (diabetic retinopathy). Type 2 diabetes often damages the retina’s blood vessels which potentially could lead to blindness. The condition increases also the risk for developing cataracts and glaucoma;
• Erectile dysfunction (impotence). This condition is due to damage to the blood vessels that provide the penis with blood and also damaged nerves that participate in erection mechanism;
• Dementia. Type 2 diabetes may increase the risk of dementia as well as Alzheimer's disease. The less controlled blood sugar levels are, the higher the risk. There are still no proofs how these conditions are connected but medical statistics has already identified an association between the two conditions.

Hypoglycemia

One of the complications alongside therapy may be the excessive lowering of blood sugar levels. Usually, this happens with insulin-applying patients but also with patients taking oral medications.

Signs of hypoglycemia include:

• Weakness;
• Shaking;
• Sweating;
• Blurry vision;
• Nausea.
• Each patient has to recognize these symptoms and when they start, he should immediately consume some fast carbohydrates – sugar, glucose syrup, honey, etc. Heavy hypoglycemia cam lead to permanent disabilities and even death. 
  
  

Therapy

Still there is no cure for type 2 diabetes. But when therapy is applied appropriately and the condition is under control, life quality and length are comparable to those of people without this condition.  Getting blood sugar levels normal is a must but is not the only requirement. Recent studies show that the most important aim of the therapy is a complex influence over the increased cardiovascular risk and keeping away the acute and chronical complications of the disease. 

Contemporary treatment includes the following complex measures:

• Regular blood sugar levels control – in laboratories and at home;
• Regular control of other blood indicators that indicate the state of the liver, kidneys, cholesterol fractions, uric acid and proteins;
• Regular check and control of blood pressure and pulse;
• Healthy diet;
• Bodyweight control;
• Regular exercise appropriate to the age and one’s other conditions as well as the overall well-being of the patient;
• Searching for psychological comfort: hobby, social contacts;
• Medication treatment (pills and/or insulin)
• Food additives and herbs.

Medication therapy

Most often patients with type 1 diabetes need insulin therapy which is a type of substitute therapy. Type 2 diabetes more often is treated with oral medicines (pills) but some patients also need insulin addition.

Insulin therapy fears of patients are totally irrational."

 

 

Modern forms of this medicine are extremely precise. There are different types of insulin – fast-acting and slow-acting, also mixed ones etc. which address patients’ needs to the maximum extent.

One concern associated with this medication which has saved millions of lives since its discovery is that it is applied as an injection.  The reason is that if it enters the digestive system it is destroyed and cannot pass into the blood in its active form.

Nowadays the injection process is absolutely facilitated and efficient by means of so-called insulin pens which are designed for strict dosing and minimum pricking.

Pills are many types. They improve in many different ways impaired glucose metabolism. Some stimulate the pancreas to produce more insulin. Others block sugar production from the liver. Some of the medicines are active in the digestive system where they block carbohydrates decomposition. There are other medicines that increase tissue insulin sensitivity.

The first medicine to be prescribed for diabetes worldwide is metformin. It is also prescribed for preventing complications in patients with prediabetes and metabolic syndrome.

The new medicines

Medicines SGLT-2 inhibitors are already in clinical practice. Their function is not only to efficiently lower blood sugar levels but also to be successful in controlling and diminishing cardiovascular risk. These medicaments are prescribed to patients who are with a higher risk for cardiovascular incidents. Their mechanism of action is connected to the extra sugar secretion from blood via the kidneys and urine. In this way, the body total liquids volume is decreased and respectively blood pressure is lowered.

Insulin pumps

This is a high-tech mechanism with the size of a mobile phone that can be programmed at different modes to submit the necessary dose of insulin according to diet, physical activity and other criteria.

Looking into future

• Artificial pancreas – this is a device which measures blood sugar levels on its own at any moment and then automatically submits the necessary insulin into the blood stream. It’s still in the process of development and clinical testing;
• Pancreas transplantation. Many pancreases have been transplanted, some of the transplantations are successful, mainly with patients with type 1 diabetes. But even successful interventions have downsides. They are mainly associated with the necessity for the patient to take medicines for suppressing the rejection of the transplanted organ.  And these medicines could have serious side effects.

The role of food additives

Many different substances and herbs have been studied to find out whether they lower blood sugar levels and what is their role with patients with diabetes. Up to now there is no scientific evidence that herbs or food additives can control such conditions.  But this does not mean that they have no place in the complex approach for managing the condition. Important are not only blood sugar levels but also how other factors that are being controlled.

Experiments have already proved the good effect of products containing alpha-lipoic acid which protects nerve endings from damage when blood sugar levels are high. The acid’s intake may be both prevention and therapy of one of the most common complications - diabetic polyneuropathy.

Cinnamon sometimes may also help controlling blood sugar levels. There are studies showing that people who consume cinnamon regularly have lower glycated hemoglobin compared to other people in the same condition.

Useful may be all other herbs and additives that diminish the “silent inflammation” in the body and lessen the oxidative stress, may be useful.

Consult your doctor about any additives that you plan to take to be sure that they are in harmony with your main therapy course.

Diet with diabetes

Healthy diet principles are valid for all people – whether or not they have diabetes. Absolute bans are no longer relevant. If you are really like eating a candy, do it, but not every day. To compensate for the sweet temptation, you may give up, for example a slice of bread this day. What is important is your diet to be balanced and to have everything necessary for your body’s proper functioning.

Recommended foods:

• Fruit and vegetables are a must. It’s better to choose raw vegetables or steamed ones.
• Carbohydrate foods that are sugar-rich are divided into 2 groups - those that contain "fast" and "slow" carbohydrates. The former lead to a rapid increase of blood glucose that is difficult for the body to cope with. These are foods and drinks containing refined sugar, honey, white flour pasta, sweet grapes, bananas. Prefer "slow" carbohydrates - whole grain bread and pasta, brown rice, unprocessed oatmeal.
• When choosing meat, a better option is meat without fat – chicken breast, white pork, lamb.
• Fish is a very good choice and dietitians recommend it -  not fried but baked in the oven or grilled: mackerel, salmon, sea bass.
• Nuts and legumes are valuable sources of protein. Dairy products are a good option but avoid sweetened yogurts and milk.

Foods to be avoided by everyone, not just people with high blood sugar levels:

• Sugary and sweet sodas;
• Sugary juices
• Packaged foods – waffles, chips, snacks, etc .;
• Fast food industry products - burgers, fries, pizza slices, donuts.

Is there diabetes prevention?

Science has not identified a specific way to prevent insulin-dependent type 1 diabetes until now. Heredity plays a big role in it.

Even when we have the predisposition to type 2 diabetes, lifestyle can delay and even prevent the start of the condition.

Main prevention factors are:

• Maintaining normal body weight and even few kilograms below the average norm for gender, height, and age;

• Physical activity: moderate exercise. 30 minutes a day are enough if you start slightly panting and your heart rate increases up to 120 beats per minute;

• Healthy diet: breakfast, lunch, and dinner; no intermediate bites, except for fruit or vegetables. Forget about sweetened, carbonated and concentrated foods; eating more whole grains, legumes, nuts, fish, olive oil, lean meat. At least two days a week without meat and dairy products;

• Maintaining normal blood pressure;

• Stress-releasing strategy: activities that are stress-relieving for the individual and distracting them from intense professional or other engagements.

Can we die from diabetes

Formerly, patients died shortly after the onset of diabetes ketoacidosis. The survival rate has been much higher now since the discovery of insulin and other medicines.

Nowadays, the main issue associated with diabetes is chronic complications. They can shorten the life span but also impair life’s quality. Most of the patients with diabetes pass away from cardiovascular complications - heart attack, stroke, pulmonary embolism, and other acute circulation disorders. Other very common complications are associated with kidney damage.