331 lines
16 KiB
Plaintext
331 lines
16 KiB
Plaintext
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(word processor parameters LM=8, RM=75, TM=2, BM=2)
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Taken from KeelyNet BBS (214) 324-3501
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Sponsored by Vangard Sciences
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PO BOX 1031
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Mesquite, TX 75150
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Diabetes Details
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(c) HealthNet, Ltd. 1987
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courtesy of Double Helix at 212-865-7043
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Since blood sugar measurements are widely used in the diagnosis
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of diabetes, it is important to understand some basic concepts of
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hormone regulation to appreciate the mechanism of the various types
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of diabetes. The hormone in question is insulin, a complex chemical
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produced in small clusters of cells in the pancreas, which lies just
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behind the stomach.
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The insulin is absorbed into the blood stream where it is carried
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to the rest of the body. The actions of insulin are several: most
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importantly, it causes the glucose (blood sugar) to leave the blood
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and enter the cells of the various body organs. It is as if there
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were a gate between the blood and the organs, and insulin is the key
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to the gate.
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In addition to facilitating the passage of sugar from blood to
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cells, insulin also allows many other metabolic processes which all
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work toward the storage of energy into fat and other substances, and
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prevent the release of such stores into the blood. In the "fed"
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state, it is obviously advantageous to pack away for future use any
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energy or body fuel not immediately needed, and insulin does this.
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Even in very small quantities, insulin can prevent the breakdown of
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body stores into energy sources.
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It is possible to thus understand the effects of insufficient
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insulin. For one thing, the level of glucose in the blood will
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rise, especially after a meal which causes the digestion and
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absorption through the intestines of large amounts of sugar.
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Nothing stops the glucose from getting into the blood, but once
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there, it has no place to go, and levels rise. The kidney is able to
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block the passage of sugar into the urine up to a point, but once
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levels exceed around 180 milligrams per 10 cc of blood, there is
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some overflow into the urine as well.
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Without insulin, body organs which depend on glucose for energy
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are unable to extract it from the blood and begin to rely on
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alternate sources of energy. Among these are some forms of fat.
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The breakdown products of these fatty substances are highly acid in
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nature, and begin to accumulate in the blood. Called ketones, these
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byproducts are responsible for the condition called ketoacidosis
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which can occur in untreated diabetes.
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The disordered metabolism in diabetes can alter the way in which
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the body handles fats including cholesterol. Over the years, this
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leads to an accumulation of such fats in the small arteries of the
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body. Characteristically, the arteries so affected tend to be those
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of the eyes, the kidney, the heart, and the brain.
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Page 1
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In addition, diabetes can cause blindness, kidney failure, heart
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attack, and stroke. Of course, the better the degree of control, the
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less likely the complications, according to most authorities.
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Types and Causes
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The causes of diabetes are not known, although some clues are
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available. Most cases fall into one of two types, which may be
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quite distinct in their causes.
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The first type, or Type I, is generally acquired in childhood,
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and usually is found to be a near total lack of internal insulin
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production. If untreated, patients often will develop the
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potentially urgent complication of ketoacidosis (discussed
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elsewhere). Such patients are usually thin, and always require
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insulin administration to sustain life.
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The other type, Type II, is generally acquired in adulthood, is
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most common in obese patients, and may be treated with dietary
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measures or occasionally oral medication, with only a small minority
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requiring insulin. Although severe short and long-term complications
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and symptoms may occur in the untreated case, ketoacidosis in
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unlikely.
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Type I diabetes is of unknown cause; it may be caused by a
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preceding virus which affects the pancreas, or an autoimmune process
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within the body. Although a genetic factor may play a role in some
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way the relationship is not clear or overwhelming. In genetically
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equivalent identical twins, only a third to a half of siblings with
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type I diabetes will also develop the disease. Perhaps a
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vulnerability is inherited, and only those exposed to some offending
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agent go on to develop the disease.
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Type II diabetes is highly genetic, with a nearly 100% occurrence
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in identical twins of affected patients. The actual cause is
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unknown, and it often occurs in patients with no family history of
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the disorder. Clearly obesity plays a critical role in bringing out
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the disease in susceptible patients. In general these patients
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retain the ability to produce some insulin, but in response to a
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meal, the response is long delayed, and often inadequate. In
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addition, many patients are resistant to the action of insulin even
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when it is present, especially if obesity is present; in these
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cases, the insulin level may actually be higher than normal, yet
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diabetes occurs due to insulin resistance. The incidence of Type II
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diabetes increases with age.
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Symptoms
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Symptoms of increased blood sugar include fatigue, increased
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appetite if enough blood sugar is wasted into the urine, and
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increased urination as the sugar causes the kidney to produce higher
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volumes to dissolve the excess load. When the latter occurs, thirst
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is increased as well to make up for the lost body fluid.
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As levels of blood sugar rise and ketosis occurs (see above), the
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body fluids become excessively acid. One of the defenses against
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acidity is to decrease the carbon dioxide in the blood, which is
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accomplished by increasing the rate and depth of respiration.
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Page 2
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The full blown picture of ketoacidosis is a dehydrated, obtunded
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or even comatose patient, who is breathing heavily with a
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characteristic odor to the breath from the ketones in the blood.
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The lesser symptoms are as above.
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Diabetics are prone to symptoms from the complications due to
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arterial blockage discussed above. Vision loss, heart problems, and
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loss of kidney can occur. Nerves in the legs, arms, and face can
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become painful or numb for weeks, months, or permanently. Many of
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these complications require the presence of the disease for decades
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or more.
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Diagnosis
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Once the diagnosis is suspected, or an elevated sugar is detected
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on screening lab work, certain criteria have been established for
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doctors to follow. Typical numbers for adequate diagnosis in an
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appropriate setting might include a fasting sugar over 150 mg.%, or
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repeated after-meal levels over 200 mg%.
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The normals vary with age, and certain factors can interfere with
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the test. A controlled glucose "tolerance" test involves the
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administration of a measured amount of oral glucose, followed by
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checks of the blood every 30 to 60 minutes for 2 or more hours.
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Newer normal references consider many factors, and the ultimate
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diagnosis often requires repeated checks and judgment on the part of
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the treating physician.
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Treatment
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General measures common to all diabetics include reduction to
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normal body weight if obesity is present, moderate or even vigorous
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activity if this is considered safe from a general health standpoint
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(exercise has an insulin-like effect), and dietary discretion.
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Years ago, diabetic diets were strictly controlled formulae of
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rigid proportions of fat, carbohydrates, and protein organized into
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"exchanges" which made the diabetic's life highly structured around
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the diet. Today, diet remains crucial in a comprehensive management
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program, but it is recognized that much more flexibility is possible
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without harm. Total calories are determined, ranging usually from
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1500 to 3000 per day.
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Sweets are largely avoided, but not entirely so, and
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carbohydrates are allowed liberally, as is dietary fiber. Vegetable
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fats are encouraged instead of animal or dairy fats, and should be
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moderate.
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Generally, one fifth of the days calories are taken at breakfast,
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with two fifths each at lunch and supper, or adjusted to allow for a
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small snack in between.
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This oversimplification is largely adjusted for individual
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variations, and a comprehensive dietary educational program of a
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personal nature is vital. Dietary professionals often provide such
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training as part of a larger diabetes program.
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When diet and exercise alone are inadequate to normalize blood
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sugars, one alternative for type II diabetics is the use of pills
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Page 3
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which lower blood sugar either by acting like insulin, stimulating
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the pancreas to produce more insulin, or making body cells more
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sensitive to insulin.
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A long-running controversy exists over the report that these
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drugs can increase the risk of sudden death (presumably due to heart
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attacks), but the data is not clear at this time. Most authorities
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agree that the drugs have a genuine place in the management of the
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disease, especially in symptomatic elderly patients who can not or
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will not follow a dietary program, or who do not respond to such a
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program. Excellent control is rarely achieved, but the ease of use
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and lesser concern about overall life expectancy may outweigh the
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theoretical risks. This issue is always best decided by the
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physician and patient considering all the individual factors
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involved. Chlorpropamide, tolazimide, tolbutamide, and gliburide
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are examples of such drugs. Some physicians avoid these drugs
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altogether.
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Insulin is the main means of controlling diabetes which is not
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responding to diet, and is the necessary treatment for type I
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disease. Various types are available, varying in their peak onset
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of action, duration, etc. Often, two types are given in combination.
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Insulin is given by the patient as an injection under the skin using
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disposable very small needles and syringes, after appropriate
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training.
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Although the prospect seems drastic at first, diabetics quickly
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accept this as a routine part of their regimen. In the initial
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phase, many adjustments are necessary, sometimes in the hospital,
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until the right doses are determined. Side effects include allergic
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reactions and hypoglycemic (low blood sugar) episodes.
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Modern medicine stresses the importance of near-normal blood
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sugars in the prevention of complications of diabetes. The optimal
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patient checks her own blood tests through a finger stick one or
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more times daily, checks occasional urine samples for sugar, follows
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a consistent diet and activity program, and adjusts the insulin dose
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as needed within guidelines established by the physician.
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When problems arise, the physician is consulted as a resource,
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and regular medical follow-up is scheduled routinely. The effects
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of various stresses, both physical and emotional, are anticipated
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and allowed for. Occasional low sugar episodes are accepted as a
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price of good control, but are usually easily reversible with a
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light snack.
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Some diabetics use a portable insulin pump which injects insulin
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through an intravenous tube around the clock. It is felt that this
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is comparable to, but not necessarily superior to, a carefully
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applied program of standard injections of long- acting insulin with
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frequent blood sugar monitoring and appropriate adjustment.
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The pregnant woman with diabetes requires special control, since
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even modest blood sugar elevations are potentially harmful to the
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fetus. Stricter criteria apply, and closer management is in order.
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In some women, diabetes appears under the physiologic "stress" of
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pregnancy, only to improve after childbirth. Some such patients go
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on to develop long-standing diabetes in later years.
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Page 4
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Only rarely are things as smooth as the above description, but
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most diabetics will do very well under the guidance of a concerned
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team of a physician, dietician, nurses, and other professionals.
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Many become highly sophisticated about their disease, and groups
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such as the American Diabetes Association and local resources offer
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invaluable support.
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Preventive measures such as immunizations, foot care (diabetes
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predisposes to infections of the feet), and travel precautions are
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also important.
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Prognosis
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It is very difficult to generalize about the prognosis of
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diabetes since it is such a variable disease. It seems fair to say
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that the disease decreases life expectancy, and diminishes quality
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of life through its complications and treatment requirements.
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Only recently has the concept of very rigid control been feasible
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through home blood glucose monitoring, and there is much evidence
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and great hope that tomorrow's diabetic can look forward to a near-
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normal life if such control is maintained.
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Horizons
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Research is proceeding in several directions which may provide
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breakthroughs in diabetes, though none is currently available for
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general application.
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One is an artificial pancreas<61>which takes regular readings of the
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blood sugar, and automatically injects through an intravenous tube
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the appropriate amount of insulin needed on almost an instantaneous
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basis.
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Another is the possibility of transplanting pancreatic tissue
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from a donor into the diabetic patient, although the troublesome
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rejection problems are seen here as in most transplant procedures.
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HealthNet will keep you alert to any meaningful advances in this
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area.
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--------------------------------------------------------------------
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If you have comments or other information relating to such topics as
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|||
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this paper covers, please upload to KeelyNet or send to the Vangard
|
|||
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|
Sciences address as listed on the first page. Thank you for your
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consideration, interest and support.
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Jerry W. Decker.........Ron Barker...........Chuck Henderson
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Vangard Sciences/KeelyNet
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--------------------------------------------------------------------
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If we can be of service, you may contact
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Jerry at (214) 324-8741 or Ron at (214) 484-3189
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--------------------------------------------------------------------
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Page 5
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