Diabetes By Lisa Glickstein, Ph.D, Triplet Mom Originally printed in June, 2006 Diabetes, an inability of the body to control the level of sugar in the blood, has reached epidemic proportions in the United States. In 2001, nearly one in ten Americans was diabetic and dramatic increases were noted across all age groups and in both men and women. For several reasons, diabetes is more likely to occur in mothers of higher-order multiples. Unfortunately, diabetes is a lifelong condition with considerable risk of complications. Understanding diabetes will hopefully increase motivation to control our own risk factors, or participate fully in education and treatment designed to reduce complications. How is sugar normally handled in the body? Glucose is produced in the body when foods containing sugar, corn syrup, honey, other sweeteners or carbohydrates like bread, pasta, and rice, are digested and broken down. The digestive tract takes up the glucose into the bloodstream. Your body’s cells depend on glucose for energy. In order for glucose to enter the cell, a small protein hormone called insulin needs to bind to the cell, much like a key opening a locked door. Insulin is secreted into the blood by the pancreas, a small organ in your abdomen. The presence of glucose in the bloodstream normally triggers the pancreas to secrete insulin. How would I know if someone was diabetic? High blood sugar leads to increased thirst and increased urination, fatigue, and irritability. In Type I diabetes, these increase rapidly, over a period of days to weeks, and, if not caught, may lead to a medical crisis. As some glucose probably continues to enter the cells during the slower onset of Type II diabetes, the symptoms may be less in severity, but will be the same. Some patients have acute pancreatitis (inflammation of the pancreas) that leads to sudden onset of abdominal pain, fever, and vomiting. What is the difference between juvenile and adult-onset diabetes? First, these designations, or the terms insulin-dependent and insulin- independent diabetes, that many of us remember from childhood, are now out of date. Diabetes is now classified as either Type I or Type II. Type I diabetes is an autoimmune disease. This means that the body mistakenly recognizes the pancreas as a foreign body and the immune system attacks and damages it. Type I diabetes usually begins in childhood; in severe cases, during infancy. Like most autoimmune diseases, Type I diabetes has a genetic contribution, and for this reason, it can run in families. Type I diabetics usually have very limited pancreatic function, if any, and need insulin by injection daily (or through a pump) to survive. In the early stages, the high blood sugar makes patients feel tired and irritable. Later, after the pancreas is completely destroyed, the patient can go into a coma and die if not treated with insulin. In contrast, Type II diabetes is a functional problem with the glucose management system in the body. Usually it begins with insulin resistance – a problem at the cell level in which more and more insulin is needed to open the lock to allow glucose to enter. Insulin resistance is linked to both obesity and polycystic ovarian disease (PCOD). If left untreated, this puts stress on the pancreas to secrete more and more insulin to bring down the blood glucose level, and can eventually damage the pancreas. Once the pancreas is damaged, the patients needs to take insulin, just like the Type I diabetic patient. Because this happens over a much longer timeframe than the quick, immune-mediated, destruction of the pancreas in Type I diabetes, Type II diabetics are not initially at a high risk of coma and death. Rather, most of their problems come from having too high sugar in the blood over long periods of time. Finally, gestational diabetes (diabetes of pregnancy) is treated like Type II diabetes, but normally resolves after delivery. However, women who experience gestational diabetes are more likely to later develop Type II diabetes. Since all pregnancy complications are more likely to occur in higher-order multiple pregnancies, this is yet another risk factor for women members of TMM. Why is diabetes dangerous? First, as already noted, Type I diabetics (and the smaller number of Type II diabetics who are completely insulin-dependent) will die without insulin. The person will gradually slip into a coma and die without treatment. Second, patients who take insulin are at risk of having a low blood glucose “reaction.” If they take too much insulin, take insulin without eating, exercise more than usual, or are ill, the insulin will lower the blood sugar too far. The person will feel shaky, hot and flushed, and disoriented. If the person doesn’t eat some sugar, he or she will lose consciousness and die. Although either of the above scenarios is scary, deaths from them are relatively rare with proper monitoring and treatment. However, much more common is the slow erosion of health due to high blood sugars. Glucose left in the bloodstream damages blood vessels and tissues, particularly the smaller blood vessels in the kidneys, heart and brain, and the nerves in the fingers and toes. Therefore diabetics are at a higher risk of heart attack, stroke, kidney failure, and neuropathy (chronic pain and numbness from nerve damage). In addition, the high blood glucose is a great food supply for bacteria, so diabetics are at higher risk of bacterial infection. Even worse, the immune system cells can function less well in diabetics leading to greater risk of viral infections and even cancer. The combination of infection risk with neuropathy and blood vessel damage in the legs and feet puts diabetics at risk for getting chronically infected lesions in the feet and legs, which may lead, in severe cases, to amputation. How is blood glucose stabilized in people with diabetes? First, blood glucose is monitored frequently with home monitors. These now tiny devices (some as small as a pen or credit card) monitor the glucose in a single drop of blood, taken from a finger-prick. Monitoring before and after eating or exercise can help determine treatment. A doctor prescribes insulin for Type I diabetics based on body weight, diet, and activity level. There are both long-acting and short-acting insulins, and a doctor will prescribe an appropriate combination to be taken prior to meals, two to three times per day. Insulin is a protein hormone and would be broken down in the digestive tract, so it must be injected – luckily, with a tiny needle. In modern regimens, patients can adjust the amount of insulin given based on blood glucose levels, and expected diet and exercise for the day. Insulin can also be given with a special pump about the size of a pager, which is worn at the waist, through a tube and very tiny needle implanted under the skin. The advantage of this treatment is much better control of blood sugar with fewer risks of reactions (as smaller amounts of insulin are given much more frequently). Initially patients with Type I diabetes, particularly children, may need to be hospitalized until blood glucose can be stabilized without significant reactions. For patients with Type II diabetes, there are more choices. In initial stages, diet and weight reduction are usually tried to bring blood glucose levels under control. If the amount of sugar and carbohydrates are reduced in the diet, and weight is lost to reverse insulin resistance of the cells, no other treatment may be needed. There are also several oral medications that are used to make the cells respond better to insulin (Metformin, also called Glucophage), or to induce the pancreas to secrete more insulin (Actos). Metformin is a known treatment for PCOD, so women with this diagnosis are more likely to be started on this drug. Metformin also contributes to weight loss, whereas Actos can lead to further weight gain. Insulin is prescribed as with Type I diabetes, if needed in addition to these treatments to bring blood glucose into line or, if pancreatic damage has occurred. Education and frequent medical visits are also cornerstones of diabetes management. Treatment recommendations, including those for diet, are constantly updated. In addition, the heart, kidneys, and feet need to be monitored for signs of damage and prompt treatment initiated if necessary. Can diabetes be prevented? Type I diabetes cannot be prevented or cured at the present time. Type II diabetes, on the other hand, occurs almost exclusively with obesity. Weight loss and attention to diet, particularly reduction of refined sugar and carbohydrate intake, may be able to reverse insulin resistance. For women with PCOD, who may have a primary dysfunction in the ability to respond to insulin, taking metformin can help to lose weight, regulate menstrual cycles, and reduce the risk of damaging the pancreas and developing diabetes. ----------------------------------------------------- Here are two websites with great information and fun for parents and their kids who use an insulin pump to manage diabetes. www.pumpschoolonline.com Features helpful information on pump use and operation. www.pumpexpeditions.com Features exploration of insulin pump therapy through fun and educational games for people of all ages living with diabetes.