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OUT OF BALANCE: Understanding Diabetes
When Sarah was a freshman in high school, she didn't feel right. She stopped at the water fountain — and the bathroom — between almost every class. She lost so much weight that the clothes she bought at the beginning of the school year were hanging off of her by December. At first, she assumed her complaints were related to the stress of getting used to high school, but after a couple of months, she worried that something else was wrong.
"I went to the doctor thinking I had mono or some kind of bladder infection that could be cured with antibiotics," said Sarah. "It never occurred to me that I could have type 1 diabetes."
Patrick, on the other hand, made an appointment with his doctor to confirm what he already knew — that he had type 2 diabetes. "Type 2 diabetes runs all through my family," said Patrick, 56. "I never wondered if I would get it, my question was always when."
Patrick had tried to exercise regularly and keep his weight down, but eventually his genetics got the best of him. "For a couple of weeks, I had noticed the symptoms," he said. "I knew what was coming because I had seen other family members go through it." Patrick had learned about the disease from his parents and his older brother — all type 2 diabetics — so he was ready to begin to take responsibility for his disease right away.
For diabetics like Sarah and Patrick, life is a balancing act. People with diabetes — both type 1 and type 2 — must carefully watch their blood sugar levels. If their blood sugar levels rise too high and stay there for too long, they risk damage to their nerves and blood vessels, which can cause a number of health problems. But if their blood sugar levels drop too low — even for a few minutes — diabetics can become confused and even lose consciousness.
Sarah has not lost consciousness, but once when her blood sugar was very low, she could no longer take care of herself. "I was swimming with some friends, and we were having such a good time that I lost track of how I was feeling," she said. "When I got out of the pool and sat down, all of a sudden I felt like I couldn't move. My mind was fuzzy but racing at the same time."
One of Sarah's friends realized that something was wrong and gave her juice. "I was scared because I couldn't get the juice for myself," Sarah said. "It's like I forgot what I was supposed to do." Since then, Sarah has been much more careful about testing her blood sugar and eating frequently when she's active.
People without diabetes don't have to worry about making these delicate adjustments in their blood sugar levels. Instead, they have a working pancreas, which regulates the amount of sugar in the bloodstream by releasing the hormone insulin.
Diabetics, on the other hand, must regularly test their blood and adjust their diet and exercise — or their oral medications and insulin injections — to meet the changing conditions. People with diabetes cannot properly convert food into energy, either because their bodies do not produce enough insulin or because their bodies don't properly use the insulin they do produce. When it comes to diabetes, insulin is the hormone that holds the key to stable blood sugar levels.
Understanding the Role of Insulin
Insulin is a hormone produced by the beta cells of the pancreas. Basically, insulin allows sugar to pass into the cells so that it can be used for energy. The process begins when you eat foods containing carbohydrates and your blood sugar level begins to rise. (For a complete discussion of the impact of food on blood sugar, see Chapter 10, Diet.)
In a person without diabetes, this elevated blood sugar level causes the pancreas to release insulin, which, in turn, lowers the blood sugar by allowing the cells to use the sugar. In the body, insulin binds to a receptor on the surface of the cell, which allows sugar to pass through the membrane into the cell. Without the insulin, the sugar can't pass through the cell membrane.
A person with diabetes cannot produce enough insulin to meet the body's demand for it, or the body has become resistant to the insulin produced. Without enough insulin present, the sugar can't pass into the cells, so it builds up in the blood and ultimately passes out in the urine. Because the cells don't have sugar to use in the blood, the body breaks down fat to use for energy. Burning fat releases ketones into the urine, which can be very harmful to the body. (Ketones are discussed in more detail in Chapter 15.)
Before meals and during the overnight hours, the beta cells that produce insulin have a chance to rest. Beta cells continue to produce low levels of insulin to balance the sugar continually produced by the liver, but this is usually a fairly small amount. When you are not eating or digesting the food you have eaten, blood sugar levels tend to be relatively low and stable.
When the system works, the blood sugar is kept in the range of about 70 to 120. After eating, the blood sugar can spike to 200 or more, depending on what food was consumed, but this level typically returns to the normal range within two hours of a meal.
NOTE: In the United States, blood sugar levels are measured in mg/dL or milligrams per deciliter. Many other countries measure blood sugar levels in mM/L or millimoles per liter. (To convert from mM/L to mg/dL, simply multiply by 18.) In this book, blood sugar levels will be stated as numbers without the mg/dL label in most cases.
People with diabetes can have wildly varying blood sugar levels, depending on a number of variables, including the type and amount of food eaten, the amount of insulin taken, exercise, stress, illness, and menstrual cycle (in women), among other factors. For example, a person with diabetes might run high blood sugars for hours after eating a high-fat meal because the fat tends to delay and prolong the rise in blood sugars after the meal. In addition, a person with diabetes who is sick may experience blood sugar levels in the 300s or higher — even without eating — because the body is under stress.
The only way a person with diabetes can overcome these unpredictable fluctuations in blood sugar is to test often and adjust medication as needed. A person is said to have well-controlled diabetes when his or her blood sugar levels stay within the normal range most of the time. That said, even a person with well-controlled diabetes will have average blood sugars higher than a person without diabetes.
A diabetic with poor control tends to have large fluctuations in blood sugar levels. At times, the blood sugar may be well over 300 and at other times it may drop into a dangerously low range. It can be exasperating to attempt to balance volatile blood sugar levels, repeatedly correcting the highs and going too low, then correcting the low and ending up too high.
If you have diabetes, don't expect to maintain perfect control. Keep careful track of your blood sugar numbers and diet over time, and look for patterns. Sometimes conditions change for no apparent reason — it could be a change in the seasons, an undefined stress in your life, or a new brand of breakfast cereal. Be vigilant about monitoring your glucose levels, but don't drive yourself crazy. Just do the best you can, one day at a time, one fingerstick at a time.
The Classic Symptoms
High blood sugar affects the entire body. At the earliest stages, it causes certain common systemic symptoms.
Thirst and Urination: The Diabetic Water Cycle
When your blood sugar is high, your blood becomes thicker. Your brain assumes that your blood is thicker because you are dehydrated, so it sends out a thirst message to encourage you to drink more to thin out your blood. Of course, the excessive drinking leads to excessive urination. Excessive thirst (known as polydipsia) and excessive urination (known as polyuria) don't usually appear until your blood sugar rises above 200 or 250.
Be aware that frequent urination may also be caused by a urinary tract infection or another medical problem. If you feel the urge to urinate but only eliminate a small amount of urine, this is more likely a symptom of a urinary tract or bladder infection than diabetes. Either way, you need to follow up with your doctor for an appropriate diagnosis and treatment.
Diabetes can cause short-term, temporary blurred vision, as well as long-term, permanent problems, such as diabetic retinopathy and blindness (discussed in Chapter 16). Temporary blurred vision happens when the blood sugar is high for several days and the lens, which changes shape to focus your vision, becomes bloated and can't change shape fast enough as you shift your focus from near to far. The lens typically regains elasticity when blood sugar levels return to normal. Generally, vision returns to normal after a couple of days of balanced blood sugar levels, but in some cases it can take up to six weeks for the lens to recover.
People with diabetes often experience fatigue when their blood sugar levels are too high. Without enough insulin, blood sugar levels rise and energy levels drop because the cells are not receiving fuel. The cells are literally starving for the sugar that's building up in the bloodstream.
Fatigue can be mild — hey, who doesn't feel tired once in a while? — or it can be so severe that people can't even drag themselves through the day without a nap. Diabetics taking insulin sometimes feel tired after eating a big meal when the blood sugar level rises before the insulin takes effect.
Without enough insulin, the sugar level in the blood climbs to a point where it eventually spills out into the urine. A diabetic with poor blood sugar control will lose weight when a significant number of calories are lost in the urine.
If you experience unusual or unexpected weight loss, have your blood sugar checked. It may be in the 300s or 400s, which will cause serious long-term complications in addition to weight loss. Using dangerously high blood sugar levels to lose weight is not safe.
Infections are common in people with high blood sugar because fungus and bacteria flourish in the high-sugar environment. At the same time the elevated sugar levels compromise the immune system, making it harder for the body to fight off the infection. Common types of infection include yeast infections, urinary tract infections, and gum infections. In addition, high blood sugar can interfere with wound healing, especially wounds on the feet.
Types of Diabetes
There are three types of diabetes:
Type 1: Most or all of the beta cells in the pancreas fail to produce insulin.
Type 2: The pancreas produces insulin, but the body does not respond to it.
Gestational diabetes: The pancreas cannot keep up with the higher demands for insulin when a woman is pregnant.
All three forms of the disease have the same symptoms, but they require different treatments. (The treatments are discussed in Part 2.)
Type 1 Diabetes
Type 1 diabetes is sometimes called insulin-dependent diabetes or juvenile diabetes. The disease lives up to these names because everyone with type 1 diabetes requires insulin and because it usually appears during childhood. Type 1 diabetes can appear in infants or in young adults up to age 30 or older, but most cases are diagnosed in elementary-school-age children.
Sometimes it can be difficult for parents to recognize diabetic symptoms in their young children. Consider four-year-old Andrew, whose mother did not notice the warning signs of diabetes until his preschool teacher pointed out that he was thirsty and used the bathroom more than the other kids his age. The teacher's brother had type 1 diabetes, so she was familiar with the disease and mentioned her concern to Andrew's mother.
"I had assumed that he went to the bathroom so frequently because he was toilet training," Andrew's mother said. "I didn't know anything about diabetes, but I mentioned it to the pediatrician right away. Andrew wasn't overweight, so I didn't think he could have diabetes."
Like Andrew's mother, many people mistakenly believe that people with type 1 diabetes are overweight. In fact, most people who develop type 1 diabetes are average weight or thin. Type 1 diabetes is not linked to obesity and cannot be managed with changes in diet and exercise. That's because in a person with type 1 diabetes, the beta cells in the pancreas have been damaged or destroyed so they can no longer produce insulin. All people with type 1 diabetes depend on insulin injections to remain healthy.
It can be extraordinarily difficult for a person with type 1 diabetes to maintain stable blood sugar levels. Since the pancreas isn't making any insulin, the diabetic must estimate the amount of insulin and carbohydrates required.
Think of your pancreas like a thermostat on your furnace. It turns the furnace off and on many times throughout the day to maintain a reasonably steady temperature. A person with diabetes has a broken thermostat. Instead of a flat temperature, he tends to run hot and cold, with the occasional "just right" in between the extremes. So a diabetic must administer insulin or eat carbohydrates to adjust his blood sugar level throughout the day. Balancing insulin involves educated guesswork, and it won't always result in perfect control.
While every type 1 diabetic has good days and bad days, some people tend to have blood sugar levels that cycle between dangerous highs and dangerous lows several times in a single day. Some doctors call these people with wildly fluctuating blood sugar levels "brittle diabetics." This isn't a separate condition or a type of diabetes; it simply means that a person's diabetes is not under good control. In most cases, blood sugar levels can be stabilized with careful management and consultation with a doctor.
When first diagnosed with type 1 diabetes, many people go through what is known as the "honeymoon period." During this phase, the pancreas continues to produce varying amounts of insulin. Some people maintain stable blood sugar levels and may require very little insulin. Alas, this phase only lasts several months to a year. It may be tempting to imagine that the diagnosis is wrong — you don't have diabetes after all! — but as the months pass and more of the beta cells are destroyed, the disease is fully expressed.
As the parent of a type 1 diabetic, I considered the honeymoon phase a good training period. I had a chance to learn about the disease and become familiar with living with it while my daughter's symptoms were fairly easy to manage.
At first, I was obsessed with trying to figure out how to save her remaining beta cells before the honeymoon ended. I wanted the cells stored so that they could be used at some point in the future when a new treatment is developed (and I sincerely believe it will be). At the time, research was being done on harvested beta cells, but my daughter was not eligible for any of the studies because of her age. Eventually, I had to accept the limitations of medicine at the dawn of the twenty-first century. I reminded myself to feel grateful for the near miraculous treatments that were available. Diabetes care has come a long way just in the last 20 years — and I look forward to what the future will hold.
Within a year of her initial diagnosis, my daughter's blood sugar numbers began to climb and I frequently had to adjust the amount of insulin she was taking. I knew the honeymoon was over, but by that time I felt more prepared to deal with the challenges of full-blown diabetes.
What Causes Type 1 Diabetes?
Type 1 diabetes is an autoimmune disease. It tends to appear in people with a gene tic predisposition to the disease who are then exposed to some kind of environmental trigger, such as viral or bacterial infection. (My daughter had the flu a few months before her diagnosis.) When exposed to a virus or bacteria, the body launches an immune response to search out and destroy the harmful invaders. In a person with type 1 diabetes, the body becomes confused and initiates an autoimmune response, or, more specifically, it mistakenly attacks the beta cells in the pancreas.
Excerpted from "The Complete Guide to Living Well with Diabetes"
Copyright © 2009 Lynn Sonberg Book Associates.
Excerpted by permission of St. Martin's Press.
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