Diabetes

• Metabolism


  The highly regulated processes through which nutrients are broken down, transformed, and otherwise converted into cellular energy to sustain the processes of life and health
• The Body's Energy Systems


  • The body needs a consistent, reliable, 24/7 supply of energy for all its physical, mental and emotional activities
  • This energy is derived from the food we eat. If not, the body utilizes stored energy from previously ingested food, or as a last resort, breaks down its own tissues for fuel
• Digestive System


  1. Breaks down food into usable energy units

  2. Proteins into amino acids

  3. Carbohydrates (starches) into glucose

  4. Oils/fats into fatty acids
• Triglycerides


  The major form of fat storage in the body; they are built from fats and carbohydrates. Food calories that are not used immediately by body tissues are converted to triglycerides and stored in fat (adipose) cells. Hormones regulate triglyceride release from adipose tissue to help meet the body's needs for energy. Hypertriglyceridemia (excess volume of triglycerides in the blood) is linked to coronary artery disease
• Circulatory System


  • Responsible for delivery of the cells' supply of oxygen, which is an essential element for all chemical processes, including digestion
  • Transports nutritive particles such as glucose from the digestive tract to the body tissues
  • Transports metabolic wastes from the tissues to the organs of re-processing or elimination (lungs, kidneys, liver)
• Liver


  • Produces bile (needed to break down ingested oils/fats)
  • Glucose regulation: can build glucose (from fatty acids) and break it down, also converts glucose into the storage form glycogen
  • Stores vitamins and minerals
  • Synthesizes proteins for use in the body
  • Helps build and break down fat stores
  • Metabolizes hormones and drugs
  • Converts fatty acids into ketones
• Ketones


  When glucose supplies are low, the body begins to break down fat cells for energy. This process produces fatty acids as a by-product, some of which are essential to metabolism, but some are quite dangerous to health. The liver can convert fatty acids into ketones, which can keep the heart, brain and muscles fueled. However, ketones are acidic (lower the pH of body fluids). Ketone build-up the blood, called ketoacidosis, can be life threatening
• The preferred cellular fuel source is glucose. If glucose availability is insufficient, amino acids, fatty acids and triglycerides are utilized. Glucose utilization is less complex and most efficient, and involves the fewest potentially detrimental by-products
• Pancreas


  • Synthesizes digestive enzymes that are involved in the breaking down of all digestible food types
  • Helps neutralize chyme (a thick semi-fluid mass of partly digested food that is passed from the stomach to the duodenum)
  • Synthesizes hormones involved in blood glucose regulation
• Pancreatic hormones


  • Glucagon (released by alpha cells in response to low blood glucose)
  • Insulin (released by beta cells in response to high blood glucose)
  • Somatostatin (released by delta cells, a regulator hormone that inhibits the secretion of other hormones)
• Insulin


  • A hormone that creates a 'well fed' state in the body; without insulin the body cannot get the energy it needs from the food it consumes
  • Is released in response to GI enzyme levels (part of the digestive cycle), to high blood glucose, and to parasympathetic nervous system stimulation
  • Facilitates the passage of glucose from the bloodstream into cells by stimulating cell wall insulin receptors
  • Increases uptake of amino acids by cells
  • Is anabolic in function: stimulates conversion of glucose not needed immediately into its storage form glycogen, stimulates the liver to convert excess glucose to fatty acids and then to triglycerides, stimulates conversion of amino acids to proteins

  
• Glucagon


  • Creates a 'find food' state in the body
  • Is released in response to low blood glucose and to sympathetic nervous system stimulation (stress connection)
  • Is catabolic in function: facilitates conversion of liver glycogen stores to glucose, facilitates breakdown of amino acids and stored fat (adipose)
• Diabetes can be defined as a disorder of carbohydrate, protein and fat metabolism resulting from an imbalance between insulin availability and insulin need
• Diabetes mellitus


  A metabolic disease characterized by disordered insulin kinetics – either there is insufficient insulin produced for the body's needs, or the insulin is of poor quality, or there are problems with the uptake of insulin by the tissue cells
• All types of diabetes mellitus have a significant family inheritance connection. Some ethnic groups have been identified as having higher diabetes incidence, for example, North American indigenous peoples, Hispanics, Asians, African Americans
• What is inherited is a susceptibility to becoming diabetic. A triggering element is typically needed to activate the disease. This may be an illness or other stressor. Lifestyle factors are also a substantial component in some cases
• Without healthy insulin kinetics, glucose cannot enter most of the body's cells. Without glucose, cells are malnourished and impaired in the performance of their functions. As well, blood glucose levels rise to unhealthy levels (hyperglycemia), which causes various types of metabolic stress. There are numerous ramifications and secondary effects of these basic realities of diabetes
• Diagnostic Criteria for Diabetes


  • Fasting blood glucose (FPG) ≥7.0 mmol/L (6.1 – 6.9 for prediabetes)
  • Casual blood glucose ≥11.0 mmol/L plus symptoms of diabetes
  • Oral glucose tolerance test ≥11.1 mmol/L 2 hours after sweet drink (7.8 – 11.0 for prediabetes)
• A1c (Hemoglobin A1c)


  The current standard for measuring the body's management of blood glucose. It reflects the average blood glucose level over the past 2-3 months. What is being measured is the percentage of glycated hemoglobin (red blood cells with sugars irreversibly attached). Since rbcs have a lifespan of approximately 3 months, the A1c reading tells a story. It does not provide info about day-to-day glucose ups and downs, so is not used for that type of monitoring/responsiveness. It is used, along with the tests on the previous page, to confirm diabetes diagnosis. It is also seen as an indicator of risk to the kidneys, eyes, and blood vessels. Reducing an elevated A1c by even a point lowers risk of damage to these structures

  
• A1c ranges


  ˂5.7% is normal, 5.7-6.4% is prediabetic, and over 6.5% is diabetic. The goal for a person with diagnosed diabetes is to keep their A1c well under 8%, less than 6.5% if possible
• Type 1 Diabetes


  • Believed to be an autoimmune condition in which the beta cells of the pancreas are attacked
  • The pancreas produces little or no insulin
  • Results in dangerously high hyperglycemia
  • A life-threatening condition that was quickly fatal before the discovery of insulin
  • Is not curable; the person is dependent on an external insulin source
  • Type 1 diabetics are 5-10% of the diabetic population
  • Onset is usually in childhood (used to be called juvenile diabetes), typically before age 30
• Type 2 Diabetes


  • 90-95% of the diabetic population
  • Onset is usually over 40, although childhood onset is on the rise
  • Multiple causation
  • In some cases, the problem is low or poor quality insulin supply
  • In other cases, body cells develop decreased insulin sensitivity, i.e., reduced responsiveness of insulin receptors (insulin resistance)
  • The obesity connection is very strong in insulin resistance (80-90% of Type 2 diabetics are overweight)
  • Inadequate physical activity is a risky co-factor (diet and exercise are both involved in controlling blood glucose)
  • Smoking – nicotine alters insulin effectiveness
  • Circadian rhythm disruptions from sleep deprivation or shift work can accelerate development of Type 2 diabetes
  • Person takes oral medications to increase pancreatic insulin production and/or to improve insulin receptor sensitivity; about 30% need to use insulin from the outset, or eventually as their condition progresses
• Gestational Diabetes


  • Defined as occurring in pregnant individuals who were not diabetic before becoming pregnant; is the onset of hyperglycemia during pregnancy
  • Affects on average 4% of pregnancies, with as much as 20% incidence in at-risk populations
  • Onset is generally at around 24 weeks
  • Usually occurs in people with diabetic family tendency
  • Other key risk factors are obesity and age over 35
  • Use of corticosteroid medication increases risk
  • Diagnosis of gestational diabetes with a previous pregnancy increases risk, as does a prediabetes diagnosis
  • Placental hormones tend to naturally promote insulin resistance; susceptible individuals can become temporarily diabetic
  • May require insulin or oral medication, depending on the case
  • Affected moms are often candidates to develop Type 2 diabetes later on; as are their babies in later life
  • The baby is often quite large as a result of the extra blood glucose
• Prediabetes


  • Impaired fasting glucose or impaired glucose tolerance creating blood glucose at a level that is approaching diabetic diagnosis but not yet there
  • Unless corrective measures are taken, tends to progress to Type 2 diabetes – losing as little as 5% of body weight and moderately increasing physical activity can make a significant difference
  • Current research says that damage to the body, esp. to the heart and blood vessels and to the peripheral nerves, begins during prediabetes (it is not so much a warning sign as an early stage)
  • People are generally unaware that they have prediabetes, so screening is important, especially for those with identified Type 2 diabetes risk factors
  • Current estimate is that 5.7 million Canadians have prediabetes (1 in 3-4 adults)
  • It is recommended that everyone is screened at age 40 and every three years after that, but those with higher identified risk should start earlier and be screened more frequently
• Metabolic Syndrome (AKA Syndrome X)


  • Insulin resistance, prediabetes and metabolic syndrome are closely related; having metabolic syndrome significantly increases the risk of developing Type 2 diabetes and cardiovascular disease
  • Defined as having 3 or more of: central (deep abdominal) obesity, blood pressure of 130/85 or higher, elevated fasting blood glucose, elevated blood triglycerides, high LDL cholesterol and low HDL cholesterol readings
  • The causes are complex and not fully understood, but obviously involve a combination of inherited and lifestyle factors coalescing in disordered energy utilization and storage
  • Key contributors appear to be: genetics, age, diet (N.B. sugared beverage consumption), chronic stress, lack of exercise, smoking, alcohol overconsumption, mood disorder/related medication, insulin resistance and sleep apnea
  • Includes the phenomenon of ectopic fat—fat stored in organs and muscles that are not designed for fat storage
  • Is also associated with fatty liver disease, gout and hyperuricemia, rheumatic diseases, increased coagulation risk, polycystic ovarian syndrome, erectile dysfunction and increased dementia incidence
  • It is estimated that 20-25% of the world adult population has some degree of metabolic syndrome, 30-35% in North America (40+% in people over 60)
  • Although there is a clear connection, metabolic syndrome and obesity are not synonymous; obesity without metabolic syndrome does not convey a large cardiovascular risk, while metabolic syndrome without obesity does
  • Metabolic syndrome, insulin resistance and prediabetes are not stages of one another, rather they are interconnected
• Factors that can destabilize insulin/glucose levels


  • Injury
  • Illness, especially with vomiting
  • Stress
  • Pain, chronic pain syndromes
  • New medications, incl. not diabetes related
  • Pregnancy, puberty, menopause
  • New exercise routine
  • Lack of sleep, disordered sleep
  • Poor eating habits, disordered eating
  • New job, new baby, breastfeeding, etc.
  • Substantial changes such as quitting smoking, a major weight shift, etc.
  • Alcohol and recreational drug use
  • Poor insulin/diabetic meds compliance

  
• Destabilizing factors tend to alter/fluctuate insulin needs and make stability harder to maintain
• Type 1 Diabetes


  • Onset of symptoms is usually rapid, acute
  • Weight loss
  • Intense hunger
  • Intense thirst
  • Constant fatigue/exhaustion
  • Weakness, numbness, paraesthesias (esp. hands and feet)
  • Dizziness, feeling faint
  • Cold/clammy feeling, shaking
  • Intense reaction to sugar consumption (e.g., weakness, sweats, shaking, dizzy, headachy)
  • Frequent urination – urine may have sweet smell
  • Prone to ketosis – may be noticeable acetone breath
  • Disordered, often erratic blood pressure
  • Blurred vision, diplopia
  • Irritability
  • Marked skin changes – itchy, very dry
  • Highly susceptible to bacterial, yeast, fungal infections
• Type 2 Diabetes


  • Symptom development tends to be slow, gradual
  • Many cases go undiagnosed
  • Most S/S are often milder versions of the above
  • Fatigue, lethargy
  • Unusual thirst and frequent urination, esp. at night
  • Unusual hunger unrelated to frequency of eating
  • Noticeable reaction to sugar consumption, unclear postprandial symptoms
  • Hypertension
  • Blurred vision, double vision
  • Skin changes as above; also, acanthosis nigricans – patches of dark, velvety skin in body folds/creases, esp. neck/armpits
  • Slow healing, poor quality healing
  • Higher susceptibility to bacterial, yeast, fungal infections
  • Erectile dysfunction
• Insulin


  All Type 1 diabetics and some Type 2 diabetics must use an external source of insulin. Insulin is broken down in the digestive tract, so it cannot be taken orally and must be injected.
• Insulin injection


  1. Inject into subcutaneous fatty tissue (not muscle and not directly into the blood)

  2. Avoid injection into/near the umbilicus, scars, moles, etc. as they can interfere with uptake

  3. There can be minor redness/irritation present at recent injection sites

  4. Sites must be rotated to prevent tissue hardening and fatty clumps that tend to develop at overused sites

  5. Move each injection site at least a half inch from the previous one, and change the body part being used every 1-2 weeks

  6. Avoid injecting into a body part about to be exercised
• Insulin absorption


  • Absorbed more or less quickly depending on the site used (the abdomen is quickest)
  • There are different types of insulin that are faster and slower acting
  • Most people use more than one type at different intervals in the day
• Good control for insulin-dependent diabetics

  Blood glucose consistently between 4 and 7 mmol/l
• Insulin pumps


  • About the size of a cell phone
  • Consists of a reservoir (insulin cartridge), a battery operated pump, and a computer chip that controls the exact amount of insulin being delivered
  • Attached to a thin plastic tube at the end of which is a soft plastic needle called a cannula
  • The cannula inserts under the skin, usually on the abdomen, although buttocks, thigh and arm sites are also used
  • The insertion point must be changed every two to three days
  • Can deliver a constant rate of insulin, known as the basal rate, 24 hours a day
  • Can deliver a large dose of insulin, called a bolus, before meals, or if excess food is consumed
• Advantages of insulin pumps


  • No need for individual injections
  • Dosage is more accurate (majority opinion)
  • Fewer swings in blood glucose levels
  • Greater flexibility in planning meals
  • Eliminates unpredictable effects of intermediate or long-lasting insulin
  • User can exercise without having to eat large amounts of carbohydrates first
• Disadvantages of insulin pumps


  • Can lead to weight gain
  • If the tubing comes kinked or disconnected, it can lead to diabetic ketoacidocis
  • Can require a full day in an outpatient centre to be trained in how to use it; user error can be an issue (age, mental capacity)
  • Price: $6000 - $7000 for the pump, plus approximately $1200 in supplies yearly
  • May not be suitable with each individual's daily activities (e.g., swimming)
• Insulin pumps are becoming more common as they keep getting smaller and more user-friendly
• Rubbing or massaging recent injection sites speeds the uptake of insulin into the bloodstream, not a desired effect – the intent is paced absorption from the subcutaneous space
• Avoid onsite massage and hydro for 24 hours (10 cm/4 in rule)
• Sites can become, red, irritated, inflamed, with potential for infection