DIABETES MELLITUS

DM I   (or IDDM ) and  DM II (or NIDDM)

WHAT IS DIABETES?

Diabetes is a disease resulting in the body’s inability to process sugar.
Sugar is essential for human life. The body uses it to produce energy. Prior to 200 years ago, sugar was very difficult and expensive to obtain.
Because of this, and the basic requirements for sugar to sustain life, the body can produce all of the sugar it needs from other substances. This process, called gluconeogenesis, is performed by the liver.

ENERGY
The body manufactures energy in tiny sub-cellular units called mitochondria, which are located inside the body’s cells. Some cells have many mitochondria, some have only a few or even just one. The mitochondria, micro-energy factories, use sugar and water to create energy and heat.
There is a problem associated with this process however, sugar, regardless of whether it is exogenous (from outside the body, or consumed by eating) or endogenous (from inside the body, by the above mentioned gluconeogeniesis) is a very large and complex molecule and cannot penetrate the cell wall to be utilized by the mitochondria.

INSULIN
This problem has been overcome by an ingenious process utilizing a chemical which we call insulin.
Insulin assists the transfer of sugar through the cell wall by modifying the cell receptor sites for sugar.
Insulin is produced by the pancreas on demand when the body identifies increasing amounts of glucose (sugar) circulating in the blood stream.
Several processes can affect the pancreas’ ability to produce insulin.
When this occurs, and the pancreas cannot release or produce sufficient insulin to process all of the glucose circulating in the blood stream, a build-up of glucose occurs, creating what we call diabetes.

WHY DOES DIABETES OCCUR?

THE PANCREAS
The pancreas’ ability to produce and or release insulin can be altered by disease, trauma or by over use.
The disease process by which the pancreas is damaged is poorly understood, but it is suspected that this is usually caused by viral infections. Viral pancreatitis is probably the cause of what has been referred to in the past as juvenile onset diabetes. Diabetes which starts early in life and which does not seem to be related to abuse or heredity.
A second cause of diabetes is from trauma, for example, pancreatitis caused by alcoholism.
The traumatic insult is from a chemical.
However, the most common cause of diabetes is from over working the pancreas and wearing it out. This has been commonly referred to as adult onset diabetes. Heredity plays a strong role in this process.
Overuse of the pancreas is caused by increased demand over a long period of time.
This can occur by consuming too much sugar, which has become a severe and increasingly common problem in the past century. As is mentioned above, sugar used to be very expensive and difficult to obtain and only the wealthy could afford very much of it and then in comparatively small amounts.
However, in the past century or so, sugar has become increasingly available in our diets and is very cheap. Today the average person can consume enough sugar in a day to provide all the energy their body would normally need for a week. In so-called ‘junk foods’ like twinkies and other snacks and in sweetened soft drinks.

All of this sugar must be processed, and this requires insulin. The more excess sugar we consume, (excess being that amount not required for the body’s immediate energy requirements) the more which will be stored.
The body does not know that sugar is no longer cheap and plentiful, so therefore when it identifies some extra sugar, it stores it for future use. It does this by opening up fat cells and storing the sugar inside in the form of lipids (fat). This process also requires insulin.
Note: it takes a mile of capillaries to support one pound of fat, the heart has to provide circulation for that mile of capillaries. Please see the information page on high blood pressure.

WHAT CAUSES DIABETES TO MAKE PEOPLE SICK?

HIGH SUGAR LEVEL IN THE BLOOD
When the pancreas cannot produce sufficient insulin to control the sugar level, the amount of glucose circulating in the blood stream starts to increase, as the body cannot get rid of it as rapidly as it is coming in.
The elevated sugar levels is what causes the damage to our bodies.
Most of this damage is done through the micro-nervous system. The elevated glucose levels cause damage to the smallest nerves. One of the systems that are supported by these nerves and the most sensitive to the nerve damage are our capillaries.
The most sensitive area of the body to be affected is our kidneys. The kidney filtration system which functions from the smallest capillaries starts to get damaged. The longer the elevated sugar levels persist, the more filtration units are damaged and  become dysfunctional. We have billions of these units but over time, the damage takes it’s toll and eventually the kidneys fail. Since the kidneys filter out many toxins from our blood stream, failure of the filtration system causes toxins to back up. This is the primary  reason that death occurs from diabetes.
There are several other organs in the body which are very sensitive to elevated sugar levels/nerve and capillary damage. The circulation and nerve supply to the feet are the first area to be affected by this specific damage. As the nerves become less sensitive, the patient becomes unable to identify when he or she has damaged their feet. At the same time the circulation is compromised and the body’s ability to fight off infection becomes hampered. This problem progresses to the point that infections of the feet can turn gangrenous and require the foot or lower leg to be amputated to preserve the patient’s life.
A third area which is prone to deleterious affect is the retina of the eyes, as it becomes damaged by progressively worsening circulation, the patient looses their vision and eventually go blind.
Diabetes causes the person to go blind, become crippled and/or  then to require dialysis and eventually leading to a premature death with the last 4 or 5 years of life being miserable.

HOW DO WE TREAT DIABETES?

THE DISCOVERY OF INSULIN
There was no treatment for diabetes until 1935 when we discovered that insulin could be extracted from animal pancreas. We used pig insulin as it is most like human insulin, and is almost as efficient in managing glucose levels.
Exogenous insulin must be kept refrigerated and has to be injected with a needle. However, these are small prices to pay to sustain life and decrease the terrible effects of diabetes. (note: some of the most recently developed artificial,  refined insulins do not require refrigeration)

CHEMICAL (DRUG) TREATMENT, or "pills"
In the 1950’s we discovered a chemical which we called sulfonureas. This family of chemicals cause the pancreas to secrete insulin. They sort of ‘squeeze’ more insulin out of the pancreas even though it is ‘sick’ and cannot efficiently produce and release that which is required. This can be compared to beating a dying horse to force it to continue working.
However, we discovered that not only was it much easier for patients to take a couple of pills every day and thus control their diabetes, we also discovered that using exogenous insulin  (shots) was causing the very cells that we were manipulating to accept the circulating glucose to become ‘insulin resistant’, thus making the problem worse with the treatment we were providing. The longer we could delay having to use exogenous insulin the better off the patient was in spite of the stress we were placing on the pancreas.
In the 1970’s we discovered a new chemical which we call metformin (there is a complex story related to this discovery which I will not address in this page).
Metformin works by decreasing the liver’s ability to manufacture endogenous sugar (gluconeogensis) and also decreases the amount of sugar which is absorbed from the gut. (exogenous sugar) and increases insulin sensitivity.
Due to the fact that it impacts the liver and can in some circumstances cause liver damage, we must monitor the patient’s liver function very closely while they are taking this medicine. However, as it decreases the demand for insulin, (less sugar, less insulin) it is very valuable in sparing the pancreas and delaying the onset of insulin resistance.
In addition to the potential for stressing the liver, the fact that there might be increased sugar remaining in the gut (GI tract) which has a tendency to ferment,  therefore the patient can also experience bloating and cramps as the fermentation process can produce excess gas. Usually this side effect is limited and diminishes as the patient adapts to the process. Sometimes it is so severe however, that the patient has to quit taking metformin.  Fortunately this usually occurs only at elevated doses.
In the past 20 years we have discovered two new chemicals which have had a very positive impact on managing diabetes, these are thiazolidinediones (Actos and Avandia) which decrease insulin resistance at the cellular level thus making the amount of insulin available much more effective, and alpha-glycosidase inhibitor  (Precose) which markedly decreases the amount of glucose absorbed by the gut (GI tract). As with metformin, this also and even more so has the potential of causing GI upset due to gas, cramping and diarrhea.
Oral medicines have a limit to their effectiveness however, and we still must use insulin in advanced cases of diabetes mellitus. The types of insulin available and the methods in which they are used have also greatly improved in recent years providing us with much improved potential in controlling sugar levels.

The invention of home glucose monitoring devices (glucometers) permitting close monitoring and management of sugar levels have also provided a marked improvement in diabetes control. Using this device as directed is the most important single function that a diabetic can perfrom to help control their diabetes other than decreasing sugar consumption and increasing their exercise.

With the excellent medicines which have been developed, we have been able to increase the life span and quality of life for millions of people.
However,  the most important and effective method of improving diabetes and diminishing the dreadful side effects is diet control, excercise and weight loss. This modality however, is solely up to the patient, and is frequently a difficult goal to attain
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PREVENTION

We probably are not able to completely prevent the possibility of developing diabetes.
However, there are many things we can do which will improve our chances of 1) not developing it, and 2) if we do develop it, then to minimize the detrimental effects.
First, just lead a healthy life style.
    1) Exercise regularly
    2) Eat a healthy diet, high in fiber and low in fat. Emphasizing fruits and     vegetables.
    3) Avoid sugars.
    4) Maintain an ideal weight with a BMI not exceeding 27 (25 is better).

Second
    If you do develop diabetes, maintain fastidious control.
    Follow your doctor’s treatment plan and follow up with him/her regularly.
    Take medications as directed
    Monitor your blood sugar levels at home.
    Exercise regularly.
    Establish and maintain control of other health problems (co morbidities)




GLOSSARY
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IDDM (insulin dependent diabetes melitus) or DM I   
This is the more severe form of diabetes where the body cannot produce suffecient insulin to control the sugar level, even with the assistance of the various oral medications (pills) that we have available, and we must use exogenous insulin to keep things under control. i.e.  useing a needle to inject the insulin.
This type of diabetes includes what we used to call Juvenile onset diabetes.

NIDDM (non-insulin dependent diabetes melitus) or DM II  
This is the less severe type of diabetes. In this case the body is still capable of producing some insulin. We use various oral medications, (pills) to enhance the insulin producing capabilities of the pancreas and also to enhance the bodies ability to utilize the available insulin more effeciently and/or to reduce the amount of sugar circulating in the blood stream so not as much insulin will be required.


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