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Diabetes Survival Guide
By Stanley Mirsky, M.D., and Joan Rattner Heilman
Stanley Mirsky, M.D., and Joan Rattner Heilman
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WHAT IT MEANS TO BE A DIABETIC
Nobody is delighted to be diagnosed as a diabetic. After all, diabetes is a chronic disease with serious consequences and complications if it isn't kept under control. You must watch what you eat, get regular exercise, and maybe take pills or insulin injections. It is a condition that you will have for the rest of your days. So far, there is no cure.
But diabetes is the one major disorder whose effects on your lifestyle depend to a remarkable degree on how much you know, and how much effort and time you are willing to spend paying attention to it. You can minimize the impact it has on your daily life as well as your future health simply by learning all about it and then living with a few rules that actually would make everyone in the world healthier if they, too, abided by them. At best, you may lose all evidence of diabetes and indeed the disease itself. At least, you may be able to reduce the amount of medication you require--all as the result of eating sensibly. The easy-to-follow plan presented here may change your life.
About 21 million Americans, 7 percent of the population, have diabetes, although many of them are not aware of it. Another 47 million, including 2 million adolescents ages twelve to nineteen, have prediabetes, a condition that may lead to type 2 diabetes later inlife. The prevalence of the disease nearly doubled in the American adult population from 1990 to 2002 and has risen by more than 14 percent since 2003. In adults older than sixty, nearly one in every five has diabetes, and the incidence is rapidly rising in children and adolescents.
Studies estimate the cost of diabetes to be over $132 billion a year, some in direct costs, including hospitalization and treatment, and the rest in lost productivity, disability payments, loss of work time, and premature deaths. Diabetes consumes $1 out of every $10 spent on health care in the United States.
To give you all the bad news at once, Diabetes is the only major disease with a death rate that is still rising. Diabetics are much more likely than others to become blind, lose a foot or a leg, have kidney failure, develop coronary heart disease and stroke. In addition, it is now thought that they are twice as likely to develop Alzheimer's disease.
Now for the good news. Tremendous progress has been made in only the last few years in the prevention and treatment of the disease. It is very likely that a cure will be discovered soon. Most diabetics who not long ago would have died at an early age or would have existed with such dire complications that life would have been hardly worth living, can now lead almost normal lives and can look forward to a respectable, reasonably healthy old age.
the facts about diabetes
• More than nine out of ten of the diagnosed diabetics in the United States have type 2, or noninsulin- dependent diabetes mellitus (NIDDM). If they follow the correct diet, this group--formerly known as "adult-onset diabetics" because the disease usually strikes adults over the age of forty and most commonly over fifty-five--may never need insulin injections except perhaps during periods of stress. The remaining less than 10 percent of diagnosed diabetics have type 1, or insulin-dependent diabetes mellitus (IDDM). Once called "juvenile-onset diabetics" because it typically strikes in childhood, this group will always require insulin and cannot get along with diet alone or even with oral antidiabetic agents. Type 1 and type 2 are two separate disorders, although they share many of the very same problems.
• In the U.S. each year, over thirteen thousand children are diagnosed with type 1 diabetes. And more and more children and teens have type 2, with some clinics reporting that one-third to one-half of all new cases of childhood diabetes are now type 2. According to the American Heart Association, those at especially high risk are African American, Latino, Asian American, and Native American Indian children who are obese and have a family history of type 2.
• All type 1 diabetics require insulin injections because they make little or no insulin themselves.
• Ten to 20 percent of the diagnosed type 2 diabetics are treated with diet and exercise. Thirty to 40 percent take oral drugs to keep their blood sugar within acceptable limits. And 30 to 40 percent require insulin injections or a combination of insulin and oral medications.
• Type 1 diabetes is more prevalent among whites than other racial groups.
• About 11 percent of white Americans ages forty-five to seventy-four have type 2 diabetes, according to the National Institutes of Health. Among African Americans, however, the rate is over 18 percent in the same age range and black women are particularly vulnerable; one in four over the age of fifty-five has diabetes. The forecast is even bleaker for Latinos, especially Mexican Americans and Puerto Ricans, who suffer from diabetes at twice the rate of whites. There is a disproportionately high prevalence of the disease, more than twice that of U.S. adults overall, in Native American and Alaska Native adults. This is true, too, of Asian Americans who have abandoned their traditional foods and adopted a Western diet, high in fat and sugar. They are particularly susceptible to type 2 diabetes and often develop it at much lower weights than people of other races.
• The chances of developing diabetes double with every 20 percent of excess weight and with every ten years of increasing age. They also increase with the accumulation of fat around the middle. A recent study suggests that men with a waist size of 40 inches or more have the highest risk of type 2 diabetes, twelve times more likely than those with a size of 34 inches or less.
• Two in three people with diabetes will develop heart disease. Nearly 80 percent of diabetics die of heart disease or stroke. Adult diabetics are two to four times more likely to have a heart attack or stroke than other people, the same risk as if they have already had a heart attack, according to the American Diabetes Association.
• Gender matters. Before menopause, women have built-in protection against heart attacks, but they lose that protection if they have diabetes.
The DIABETES epidemic
Diabetes in the United States has reached epidemic proportions, with over a million new cases diagnosed every year. What's more, although type 2 diabetes mostly continues to strike older people, more children and teenagers are getting it and much of the blame has been attributed to the long hours they spend in front of the computer or the TV set instead of on their feet.
America's children are growing fatter. The Centers for Disease Control estimates that one in three Americans born in the year 2000 will develop diabetes in their lifetime. Women and minorities face the greatest risk.
WHAT IS DIABETES?
Diabetes mellitus is a metabolic disorder that results in persistent hyperglycemia--an abnormally high amount of sugar in the blood. (On the other hand, hypoglycemia means the opposite--an abnormally low blood-sugar level.) It is thought today that diabetes is actually several different diseases with different causes, all with the same result: the inability of the body to efficiently utilize the carbohydrates we eat as a source of fuel.
Glucose, the sugar molecule that is the end product of carbohydrate metabolism, is the body's primary fuel. It is used immediately for energy, or it is stored in the liver in the form of glycogen to be called upon at a later time. When the body is unable to metabolize carbohydrates, which are derived mainly from sugars and starches, the blood becomes overloaded with glucose. The kidneys are unable to handle the excess and in most cases it "spills" into the urine.
WHAT'S GONE WRONG?
If you have diabetes, something has gone awry in the elaborate system of metabolic checks and balances that the normal body uses to maintain a safe blood-sugar level. Sometimes the pancreas, a large gland located on the left side under the ribs, completely abdicates its job of turning out insulin, the hormone that helps the cells to use glucose as their fuel. Sometimes the pancreas secretes an inadequate amount of insulin, not enough to cope with the carbohydrates you eat. And sometimes the pancreas is unable to "recognize" the high blood-sugar level and so does not produce enough insulin in response to it even though the capacity is there.
In most cases, however, especially in older overweight diabetics, the pancreas continues to produce plenty of insulin, often much more than normal, but it can't perform its function of helping the cells use glucose. So plenty of insulin floats uselessly in the blood, unable to penetrate the cells, while sugar piles up but cannot be utilized.
The reason for this was once thought to be a deficient number of insulin receptors, but it is turning out to be more complex. One important factor seems to be the fat cell that we used to think was nothing but a stain on your shirt. In fact, it is a tiny factory that puts out twelve different substances, including adiponectin and resistin. Not producing enough adiponectin, which prevents diabetes, or putting out too much resistin, which resists the action of insulin, is probably what occurs in diabetics.
HOW DOES YOUR BODY MAKE INSULIN?
Insulin is manufactured by complicated little biochemical "factories" in the pancreas. These are the beta cells, responsible for so much of our well-being. They are located in the islets of Langerhans, one to two million tiny areas of the pancreas comprising maybe 2 percent of the entire gland.
The islets also secrete other hormones--glucagon from the alpha cells, somatostatin from the delta cells, and amylin from the beta cells, for example--which are deposited along with insulin, the main component, into the bloodstream via the tiny blood vessels that surround them. All of these hormones are involved in maintaining normal blood-sugar levels.
When it is working normally, the pancreas responds to every tiny fluctuation in blood sugar, releasing insulin whenever it is needed just as a thermostat turns a furnace off and on to maintain a constant temperature in your house. When the blood sugar rises after we eat, a signal goes to the pancreas, alerting it to move some insulin out.
When there is not enough glucose in the bloodstream to be used for fuel, the liver, stimulated by the glucagon from the islets' alpha cells, releases glucose from its warehouse of stored glycogen. At the same time, amylin alters the sensitivity and secretion of insulin and may help slow the absorption of sugar through the intestines. When a sufficient amount of glucose has been secreted by the liver, somatostatin is responsible for turning off the production before it goes too high.
It takes most people about two to three hours to return to the normal fasting blood-sugar level after a high-carbohydrate meal.
HOW IS INSULIN USED?
In the normal person, starches, sugars, and proteins (58 percent of which is eventually converted into carbohydrate) are broken down by the intestines into glucose, a form of sugar. The glucose is carried throughout the body by the bloodstream, entering the cells with the help of insulin, then burned for energy by the muscles. Some of the leftovers are stored in the muscle cells or converted into fat. The rest is stockpiled in the liver in the form of glycogen, to be called upon later if the blood sugar falls too low.
If there is not enough insulin or if the insulin available cannot help the glucose permeate the cells, this sugar accumulates in the blood, often in very high concentrations. The result is diabetes.
In a nondiabetic, glucose concentration is usually below 100 milligrams per 100 milliliters of blood plasma, and even after a huge overload of sugar rarely goes above 160 to 180 mgs. In uncontrolled diabetics, it can go much higher, frequently reaching 800 or even 1,000 mgs. Though there's obviously plenty of glucose available to feed the body's hungry tissues, it cannot be used effectively and the cells can literally starve, no matter how much you eat.
At the same time, the liver is stimulated to release its stores of sugar and then to begin a process called gluconeogenesis. In a response to an emergency call for more fuel, this important organ takes the huge amounts of amino acids produced by the starving tissues and changes them into more glucose. Fats are also transported to the liver. Now ketones, the end products of the burning of fat instead of carbohydrate for fuel, also overload the kidneys and spill into the urine. This is called ketoacidosis. When this happens, and nothing is done to remedy the situation, the body lapses into a diabetic coma--a real emergency.
By the way, people who are trying to lose weight on a high-fat diet such as Atkins also produce ketones, but this is not dangerous as long as their blood sugar remains normal. It is only when ketones are combined with high blood sugar that ketoacidosis becomes a problem.
TYPE 2 (NONINSULIN–DEPENDENT DIABETES MELLITUS, OR NIDDM)
About 92 percent of diabetics are type 2. If you are in this category, you continue to manufacture insulin, perhaps not enough to cover your needs, or perhaps more than enough, but it cannot be efficiently utilized. You can probably control your diabetes with diet and exercise, or diet combined with oral hypoglycemic drugs that stimulate the release of insulin, delay the absorption of carbohydrates, or lower your blood sugar by suppressing the liver's output of glucose. Or you may require insulin injections to supplement your own supply, or the new drugs called incretins to make your available insulin more effective.
Although your diabetes may have been discovered after you developed specific symptoms such as excessive thirst and urination, more likely you were diagnosed during a routine medical checkup. Or maybe your eye doctor or dentist was the first to suspect it. Most cases of type 2 occur gradually, and never present obvious warning signals.
Heredity plays a very important role for type 2s. We know there must be a genetic predisposition, perhaps resulting in early aging of the pancreatic cells or the shutdown of insulin receptors. When some kind of stress--overweight or pregnancy, for example--is added to the genetic tendency, diabetes is the result. The sumo wrestlers of Japan are programmed by their genes to gain tremendous amounts of weight. They are adored by the sportsmen of Japan, but develop diabetes and heart disease early in their lives. They blaze like meteors across the sky, but the trip is short.
The genetically isolated Pima Indians who live in a remote river valley in the Arizona desert tend to be sedentary, overweight, and diabetic.
Excerpted from Diabetes Survival Guide
by Stanley Mirsky, M.D., and Joan Rattner Heilman Excerpted by permission.
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