Diabetes

Diabetes is a life-long disease marked by high levels of sugar in the blood.

Causes, incidence, and risk factors

Diabetes can be caused by too little insulin (a hormone produced by the pancreas to control blood sugar), resistance to insulin, or both. To understand diabetes, it is important to first understand the normal process of food metabolism. Several things happen when food is digested:
A sugar called glucose enters the bloodstream. Glucose is a source of fuel for the body.
An organ called the pancreas makes insulin. The role of insulin is to move glucose from the bloodstream into muscle, fat, and liver cells, where it can be used as fuel.
People with diabetes have high blood sugar. This is because their pancreas does not make enough insulin or their muscle, fat, and liver cells do not respond to insulin normally, or both.
There are three major types of diabetes:
Type 1 diabetes is usually diagnosed in childhood. The body makes little or no insulin, and daily injections of insulin are needed to sustain life.
Type 2 diabetes is far more common than type 1 and makes up most of all cases of diabetes. It usually occurs in adulthood. The pancreas does not make enough insulin to keep blood glucose levels normal, often because the body does not respond well to the insulin. Many people with type 2 diabetes do not know they have it, although it is a serious condition. Type 2 diabetes is becoming more common due to the growing number of older Americans, increasing obesity, and failure to exercise.
Gestational diabetes is high blood glucose that develops at any time during pregnancy in a woman who does not have diabetes.
Diabetes affects more than 20 million Americans. About 54 million Americans have prediabetes. There are many risk factors for diabetes, including:
1. A parent, brother, or sister with diabetes
2. Obesity
3. Age greater than 45 years
4. Some ethnic groups (particularly African Americans, Native Americans, Asians, Pacific Islanders, and Hispanic Americans)
5. Gestational diabetes or delivering a baby weighing more than 9 pounds
6. High blood pressure
7. High blood levels of triglycerides (a type of fat molecule)
8. High blood cholesterol level
9. Not getting enough exercise
The American Diabetes Association recommends that all adults over age 45 be screened for diabetes at least every 3 years. A person at high risk should be screened more often.
Symptoms
High blood levels of glucose can cause several problems, including frequent urination, excessive thirst, hunger, fatigue, weight loss, and blurry vision. However, because type 2 diabetes develops slowly, some people with high blood sugar experience no symptoms at all.
Symptoms of type 1 diabetes:

Increased thirst

Increased urination
Weight loss in spite of increased appetite
Fatigue
Nausea
Vomiting
Patients with type 1 diabetes usually develop symptoms over a short period of time, and the condition is often diagnosed in an emergency setting.
Symptoms of type 2 diabetes:
Increased thirst
Increased urination
Increased appetite
Fatigue
Blurred vision
Slow-healing infections
Impotence in men

Signs and tests
A urine analysis may be used to look for glucose and ketones from the breakdown of fat. However, a urine test alone does not diagnose diabetes. The following blood glucose tests are used to diagnose diabetes:
Fasting blood glucose level -- diabetes is diagnosed if higher than 126 mg/dL on two occasions. Levels between 100 and 126 mg/dl are referred to as impaired fasting glucose or pre-diabetes. These levels are considered to be risk factors for type 2 diabetes and its complications.
Random (non-fasting) blood glucose level -- diabetes is suspected if higher than 200 mg/dL and accompanied by the classic symptoms of increased thirst, urination, and fatigue. (This test must be confirmed with a fasting blood glucose test.)
Oral glucose tolerance test -- diabetes is diagnosed if glucose level is higher than 200 mg/dL after 2 hours (This test is used more for type 2 diabetes.)

Diabetes Mellitus

A serious disorder caused by an absence of or insufficient amount of insulin in the bloodstream.
Insulin is a hormone produced by the pancreas in varying amounts, depending on the concentration of glucose (sugar). When the pancreas is unable to secrete enough insulin to maintain a normal concentration of glucose in the blood, the blood-glucose concentration becomes elevated. Large amounts of glucose are then excreted in the urine. Insulin allows glucose to be absorbed by the liver and fat cells, where it is stored as glycogen. In times of stress, exercise, or an emergency, the glycogen is reconverted back to glucose. It also sends glucose to the muscle cells where it is then converted to energy.
More than 12 million Americans are affected by diabetes. There is a 5-6% increase in the number of those affected each year by the disease, primarily due to the population's increased rate of longevity. A rising rate of obesity, a prime cause for incidences of diabetes over the age of 40, also contributes to the increasing frequency of diabetes. It is estimated that for each reported new case of diabetes, there is an unreported one because symptoms of the early stages of adult diabetes tend to go unrecognized. Symptoms usually progress from mild to severe as the disease progresses.
Approximately 300,000 deaths each year are attributed to diabetes. Its prevalence increases with age, from about 0.2% in persons under 17 years of age to about 10% in persons aged 65 years and over. Females have a higher rate of incidence for the disease, while higher income groups in the United States show a lesser incidence than lower income groups. The incident rate is markedly different among ethnic groups; it is 20% higher in non-Caucasians than in Caucasians. However, for reasons as yet unknown, the rate of diabetes in ethnic groups such as Native Americans, Latin Americans, and Asian Americans is especially high and continues to rise.
There are two forms of diabetes mellitus. Type I is called insulin-dependent and type II, non-insulin-dependent. (In June 1997, an Expert Committee of the American Diabetes Association recommended changing the categories of diabetes to Type 1 [formerly Type I-indulin-dependent diabetes mellitus] and Type 2 [formerly Type Il-non-insulin-dependent diabetes mellitus]. This essay uses the conventional terminology, which was widely used at the time of publication.)
Insulin-dependent diabetes (type I) generally starts in childhood, affects approximately 700,000 Americans, and is characterized by severe insulin deficiency. It is probably due to the destruction of the insulin-secreting cells of the pancreas, which is often caused by an autoimmune disorder. Without insulin, the person develops ketoacidosis, a condition where high levels of ketone bodies are present in the blood. When the body is deprived of glucose, which can occur as a result of insulin deprivation or fasting, the body begins to break down fat for fuel. Ketones are the result of this lipid metabolism. The resulting lowered blood pH value leads to the acidosis.
Ketoacidosis is a serious condition and can lead to confusion, unconsciousness, and death if not treated. It can be diagnosed by urine tests which detect ketones in the urine. Untreated or uncontrolled diabetes will lead to ketosis, but fasting or starvation also produces ketones. Other symptoms of ketoacidosis include vomiting, abdominal pain, loss of appetite, and nausea. A very high blood glucose level in insulin-dependent diabetes can also lead to heart failure and coma.
Genetics plays a major role in Type I diabetes. There is also some evidence that children infected with certain viruses—rubella and coxsackie B in particular—may be susceptible to the disease. Diabetes in newborns can result from low birth weight as well as genetic predisposition. Some infants experience temporary diabetes, which may recur later in life.
Non-insulin-dependent diabetes (type II) usually occurs in people over age 40, and affects approximately 15.3 million Americans. This group comprises about 80% to 85% of the diabetic population. Even though they may have more than normal levels of insulin, they are resistant to its action. Unlike those with type I diabetes, people with type II diabetes rarely have ketoacidosis. Instead, insulin action can be impaired by obesity. Therefore, people who gain too much weight and ethnic groups that have changed to higher carbohydrate diets appear to be particularly prone to type II diabetes.
Pregnancy can also elevate a woman's glucose level. This condition is known as gestational diabetes and complicates approximately four percent of all U.S. pregnancies. Although their glucose levels may return to normal after they give birth, these woman may be at risk of developing type II diabetes in the future.
For those people who are in a high risk group for getting diabetes (those who have had relatives with diabetes, adults over the age of 40 who are overweight, and women who have had babies weighing nine pounds or more at birth), there is a quick and simple screening test that requires a drop of blood from the finger and takes about one to two minutes to complete. The test shows if there is a high or low blood-sugar level in the blood. After the results of the screening test, other tests can be done, if necessary. If the screening test shows blood-sugar levels that are either too high or too low, a fasting plasma glucose test can be given. One or more samples of blood are taken after the individual fasts for 10 to 16 hours. Blood-glucose levels of less than 115 milligrams per decaliter (mg/dl) are normal. Fasting plasma glucose levels of more than 140 mg/dl indicate diabetes. The oral glucose tolerance test also starts with a fast but adds a glucose drink taken after the fasting plasma glucose is tested. It is followed by several other tests to determine blood glucose levels. There are other tests used to monitor the condition, including self-tests. The presence of circulating islet antibodies is a good predictor of insulin-dependent diabetes. Research is being done on genetic tests to predict the risk of developing diabetes.
Deaths from ketoacidosis and diabetic coma have decreased over the years. However, long-term complications from diabetes began to increase as diabetics' life span increased. Some of these complications are kidney failure, heart disease, blindness, and nervous system disorders, all of which are believed to be the results of elevated blood-glucose levels. Today, glucose levels are controlled by injecting a rapidly absorbed insulin just before each meal. Added to this dosage, the slowly absorbed insulin can then be injected or pumped in by a prosthetic implant device between meals to maintain low insulin concentrations. The amounts required are determined by frequent blood-glucose measurements.
For overweight, non-insulin-dependent diabetics, controlling diet, avoiding foods high in sugar and carbohydrates, and encouraging weight loss may be sufficient treatment. A regular program of physical exercise is also recommended as an important part of diabetes treatment. Exercise utilizes surplus blood glucose and helps a person to both lose and maintain weight. In addition, non-insulin-dependent-type oral drugs may stimulate the pancreas to secrete additional insulin. It may be necessary to give injections of insulin.
Diabetes can be particularly difficult to manage during adolescence, when elevated levels of certain growth hormones make controlling blood glucose levels difficult. In addition, adolescents sometimes resist the dietary restrictions and close monitoring necessary to maintain good health. The most serious problem diabetic children face is hypoglycemia, or low blood glucose. Common symptoms in young children include misbehavior and irritability, although symptoms can vary from episode to episode. Hypoglycemia is easily treated by eating a sweet food. Parents are advised to inform teachers about symptoms and to enlist their help in maintaining the routines necessary to manage diabetes, including frequent testing of blood glucose levels, eating snacks before exercise, careful diet, and close monitoring of insulin dosage.
A relatively new treatment for type II diabetes is the drug Glucophage (generic name: metformin). Glucophage affects how the body handles its own insulin, increasing its effectiveness. With only a few side effects (diarrhea, nausea, bloating) that fade after the body adjusts to the medication, Glucophage offers an alternative to those who don't respond to changes in diet and exercise

Sources and Dietary Intakes

Antioxidants can be vitamins, minerals, enzymes or plant derived nutrients called phytonutrients. The major vitamin antioxidants are vitamin C, vitamin E, beta-carotene, while selenium is the major mineral antioxidant. Many researchers and nutritionists discuss and report on "antioxidants" as if these were the only sources of importance. A thorough examination of antioxidants and their importance to human health must include a much larger list of compounds that are present in healthy, varied diet. Recommendations by the National Cancer Institute, the U.S.D.A., other government agencies and nutrition experts are to eat a minimum of 5-13 servings of fruits and vegetables per day, depending on calorie needs. Based on these recommendations, a typical varied diet would provide approximately 200-600 mg of vitamin C and 10-20 mg (16,000-32,000 IU) of carotenoids.Overall, polyphenols are the most abundant antioxidants in the diet. Their total dietary intake could be as high as 1 gram/day in a mixed, varied diet of fruits, vegetables, grains, and beverages.Possible intakes of other phytonutrient antioxidants would be anthocyandins "2 oz black grapes 1,500 mg; proanthocyanidins" 100-300 mg/d red wine; catechins "50 mg day" tea (one cup brewed green tea" 240-320 mg catechins), chocolate, apples, pears, grapes, red wine; isoflavones "50 mg/day from soy foods; chlorogenic acid" as high as 800 mg/day coffee drinkers. Although it may seem reasonable that a consistently healthy and varied diet could provide high doses of antioxidants, the average American gets a total of just three servings of fruits and vegetables a day. The latest dietary guidelines call for five to thirteen servings of fruits and vegetables a day, depending on one's caloric intake. For a person who needs 2,000 calories a day to maintain weight and health, this translates into nine servings, or 4½ cups per day.The 2001-2002 NHANES survey of dietary intakes shows that 93% of Americans fail to get even the Estimated Average Requirement (EAR) for vitamin E, let alone the RDA. More than half of adults fail to get even the average requirement for vitamin A. About one-third of non-smokers and two-thirds of smokers fall short on minimum vitamin C requirements.If the governmental dietary recommendations are meant to be taken seriously, then it follows that it would be better for people to achieve recommended amounts of nutrients than to fall short. Obviously, since the average intake of 3 servings or less of fruits and vegetables fails to provide minimum levels of even basic vitamins, intakes of the numerous other antioxidants are sure to be well under optimal and beneficial levels.It has been established that a good multivitamin can fill in gaps in missing vitamins, but availability of broad spectrum antioxidant supplements has lagged behind. Although there is much to be learned about the characteristics of the literally hundreds of dietary antioxidants, it seems reasonable that providing supplements of various antioxidant classes may fill in nutritional gaps and provide many of the benefits missing from the typical American diet.

Safety of Multivitamins and Antioxidants

Nutritional supplements have been widely used and highly valued by American consumers ever since vitamins were discovered and commercialized, beginning in the early decades of the 1900's. According to recent national health survey, as many as 78 million Americans adults use multivitamins on a regular basis. Multivitamin/mineral supplements are an effective means of delivering adequate amounts of most essential nutrients to help people achieve recommended intakes. The great majority of dietary supplements, including multivitamins, are safe for regular use. Despite widespread usage, there have been no specific published reports of toxicity or adverse effects associated with the use of multivitamins.A series of well-publicized clinical trials conducted in diseased patients utilizing relatively high doses of single nutrients or combinations of nutrients (such as vitamin E and/or beta-carotene), have yielded disappointing results, and even suggested the presence of harm. However, those trials were conducted in patients with serious illnesses (ie. cancer or cardiovascular disease) who were on multiple medications or who were current heavy smokers. The results of these trials should be placed in context and are not applicable to the generally healthy population.Advanced levels of antioxidants are a common thread among nearly every population that is less prone to premature chronic degenerative disease. The Japanese have high levels of fruit, vegetables, green tea and soy as part of their traditional diet. Vegetarians have lower levels of heart disease and cancer, compared to the typical mixed diet, likely in part due to higher intakes of antioxidants. While high levels of single nutrients and foods may pose a risk of danger and toxicity, there is no known unsafe intake level of total antioxidants in normally healthy individuals.

Increased fiber intake protects against cardiovascular disease risk factors

Increasing dietary fiber intake to at least 25 grams per day from varied sources provides a significant protective effect against cardiovascular disease. Researchers presumed that fiber intakes of 30-35 grams per day would likely provide an even greater protective effect.Increased dietary fiber intake is associated with reduced levels of a number of cardiovascular disease risk factors. The results of a study published in the American Journal of Clinical Nutrition add to a growing body of evidence linking higher dietary fiber intake with a lower risk of heart disease. Nearly 6,000 men and women were selected from participants in an ongoing trial designed to evaluate the effect of antioxidants on cancer and heart disease incidence over an eight year period.The highest total of insoluble dietary fiber intakes were associated with reductions in the risks of overweight and elevated waist-to-hip ratio, blood pressure, cholesterol, triglycerides, and homocysteine. Fiber from cereals was associated with a lower body mass index, blood pressure, and homocysteine concentration; fiber from vegetables with a lower blood pressure and homocysteine concentration; and fiber from fruit with a lower waist-to-hip ratio and blood pressure. Fiber from dried fruit or nuts and seeds was associated with a lower body mass index, waist-to-hip ratio, and glucose concentrations.The findings of this study illustrate the significance of increasing fiber intake from various dietary sources. The results also indicate that 25 grams total dietary fiber per day is the minimum intake required to attain a significant protective effect against cardiovascular disease, and that total dietary fiber intakes of 30-35 grams/day will likely provide an even greater protective effect.American Journal of Clinical Nutrition, Vol. 82, No. 6, 1185-1194, December 2005

High Antioxidant Levels are Associated with a Reduced Risk of Periodontitis

Periodontitis is an inflammatory disease that affects the supporting tissues of the teeth and is associated with an increased risk of stroke, type-2 diabetes, and heart disease. A new study reveals that increased serum antioxidant concentrations are associated with a reduced risk of periodontitis, even in people who have never smoked.

Periodontitis is an inflammatory condition of the tissue surrounding the teeth which has been linked with an increased risk of stroke, type-2 diabetes, and heart disease. A new report published in the Journal of Nutrition revealed that higher serum antioxidant levels are associated with a reduction in the risk of periodontitis.

The current research examined data from 11,480 participants in the Third National Health and Nutrition Examination Survey (NHANES III), for whom periodontal measurements and serum levels of several antioxidants had been recorded. These antioxidants included alpha-carotene, beta-carotene, selenium, lutein, beta-cryptoxanthin, vitamins A, C and E, and total antioxidant levels.

Mild periodentitis was found in 14% of the subjects and 5% had severe disease. Higher vitamin C and total antioxidant levels were associated with a lower incidence of periodontitis, especially with severe disease. Individuals whose vitamin C levels were in the top 20% of participants had a 39% lower risk of periodontitis than participants with the lowest intakes. For subjects who had never smoked, those with the highest intake of vitamin C experienced only half the risk of periodontitis compared to those with the lowest vitamin C levels.

Vitamin C has a role in collagen synthesis and maintenance of connective tissue, which may explain its benefit in protecting against periodontitis. In addition, it is known as a potent antioxidant that may also help reduce inflammation.

Journal of Nutrition Vol. 137, 657-664, March 2007.

Herbal Medicine for the Treatment of Arrhythmia

In traditional Chinese medicine, arrhythmias are categorized by the characteristic symptoms of palpitations and abnormal pulse. Numerous Chinese herbal medicines are identified to have antiarrhythmic effects, such as xin bao, ci zhu wan, bu xin dan, and several others. However, few clinical trials have been conducted to study their effects and safety. Xin bao is one agent that has begun to be examined. The mechanism of action of xin bao is thought to be through its stimulation and increased excitability of the sinuatrial node. In one observational study, the effects of xin bao were documented in 87 patients with sick sinus syndrome. Xin bao was administered orally 2 to 3 times per day for 2 months. Patients with major symptoms of sick sinus syndrome, which included dizziness, palpitations, and chest pressure, improved significantly after treatment. No serious adverse effects were noted. This study suggests a possible role of xin bao in the treatment of sick sinus syndrome. However, more scientific research on xin bao and other antiarrhythmic Chinese herbs mentioned previously are necessary before any recommendations can be made for their routine use in patients with sick sinus syndrome or other arrhythmias.