Type-2 Diabetes Mellitus
Patient primer prepared by BioSeek Endocrine Clinics
Type-2 diabetes, why me?
- You are not alone in having type-2 diabetes mellitus (T2DM)s. There are more than 20 millions of Americans who have it too, and the rate of new cases is rapidly reaching epidemic proportions. The fast food innovations beginning from the 70s have led to the abundance of relatively inexpensive high carb-high fat foods, while our increasingly urban ways of life have diminished our amounts of exercise from that taken by our forbears. These changes in life-style have led to obesity and increased the risks of diabetes. Some ethnic groups are unusually prone to T2DM. These include American Indians, Polynesians, Asian Indians, Africans, Arabs and Hispanic peoples.
- YourT2DM diabetes can be controlled! With your help and understanding, your diabetes can be well controlled. This is important because if diabetes is left unchecked, it can inflict much damage to the body, such as to the blood vessels of the eyes, kidneys, heart, lower limbs and brain. However if properly managed, complications from diabetes can be minimized without you being precluded from any life-affirming activities on account of your diabetes.
What is T2DM? Diabetes is the inability to maintain blood sugar (glucose) levels generally within a relatively narrow range (65-200 mgs/dl). T2DM is strongly familial and affects family members in a genetically dominant fashion, whereby family members in every generation may become affected especially as they age. Diagnostic criteria for diabetes is a blood glucose level of >125mgs/dl after an overnight fast, and/or blood glucose levels > 200mgs/dl after food, or symptoms of diabetes such as excessive thirst, urination and weight loss and a random blood glucose level > 200mgs/dl. T2DM results from an inability to respond normally to the insulin that the body makes. In type-1 diabetes mellitus (T1DM), the body is unable to make normal amounts of insulin to control the blood glucose, usually because of an immunological attack on their insulin secreting pancreatic islet cells.
What causes T2DM? Patients most often do not respond properly to the insulin that their pancreas makes. Insulin is a hormone that is necessary to maintain life and is important to energy metabolism. Whereas low levels of insulin are found between meals, insulin is secreted into the blood stream by the pancreas after eating. It induces the storage of food nutrients taken in and deposits them into muscles, adipose tissues and liver to provide energy and storage fats and glycogen to be used as energy fuels when fasting. Of the types of food you eat (carbohydrates, proteins and fats), it is carbohydrates that stimulate the most release of insulin. In insulin resistance, the body initially overproduces insulin to compensate for it. However, sooner or later, insulin resistance becomes complicated by a failing ability to maintain the large amounts of insulin needed to overcome it, the blood glucose levels rise and diabetes results.
How does one treat T2DM?
Since the main problem with T2DM is insulin resistance, this must be treated vigorously.
- The first step is to take regular exercise. Walking for 40 minutes daily (or other exercise such as swimming) is the optimal way to do this. You must schedule your week to accommodate this amount of exercise. Hard exercise in short bursts is not what you need, albeit you can do this as well.
- Step two is to modify your diet. Carbohydrate excesses (cane or beet sugar in the form of sweets, catsup or carbonated drinks, fruit juice, breads, pasta, potatoes, rice) should be taken in great moderation. Most vegetables other than rice and potatoes should be eaten daily. Low calorie drinks such as diet sodas, diet iced teas or crystal light are fine too.
Could my diabetes cause me other problems that need therapy?
Sorry to say that it may. Persons with insulin resistance can be in that state for years without diabetes if they can over-produce insulin themselves. This can sometimes be seen by a thickening and often pigmented skin lesion around the neck, under the arms and/or in the groin areas called acanthosis nigricans. Insulin resistance “syndrome” can thus cause problems of which T2DM is but one.
These are the following:
- High blood level of lipids or fats: Typically, this causes blood levels of triglyceride to rise (often with a minor rise in cholesterol) and the protective high-density lipoproteins (HDL) to fall. This profile accelerates damage to the blood vessels over time, it can result in a serious inflammation of the pancreas (pancreatitis) and is associated with fatty liver infiltrates. When seen, a dietary reduction in animal fats is prudent (animal fats and fish-oils are fine or even beneficial)
- High blood pressure (hypertension): High blood pressure (BP) often complicates type-2 diabetes and unfortunately requires its’ own treatment since it can damage blood vessels too. A basic treatment is a thiazide diuretic which counts the body’s inability to secrete excess salt and water into the urine. Thiazide diuretics may induce the body to lose potassium. This problem is monitored at our clinics at the time of your visit and may require potassium supplements. A
- Sex hormone imbalance and polycystic ovarian disease: When obesity occurs early with insulin resistance, women may overproduce “male” hormone from their ovaries. This can result in excess male like hair, irregular periods, infertility and cystic changes in the ovaries. Fortunately, such problems are usually resolved by the measures above for treating insulin resistance.
How should I (my child) be managed from here on?
- BioSeek Clinics take a blood sample for islet cell antibodies which are markers for type-1 diabetes, the more severe kind of diabetes that is caused by an immune mediated destruction of the insulin secreting pancreatic islet cells. Sometimes, this type of diabetes comes on gradually making it readily confused with T2DM. The Clinic also checks on your thyroid functions since this is a common problem that can affect your diabetes and yet be easily treated.
- For women who are pre-menapausal but have sparse and irregular periods or have been infertile, the clinic will check a blood testosterone level along with pituitary LH/FSH amongst other hormones to screen for hormonal problems associated with polycystic ovarian disease (see above).
- The home blood glucose levels you take should be below 125 mgs/dl after an overnight fast and less than 200 mgs/dl 2 hours after eating. The 2 hour post meal blood glucose level is abnormal if > 140mgs/dl and such levels are maintained in diabetes in pregnancy to protect the developing infant. Use your home glucose meter to check your fasting and fed blood glucose levels and keep a record. When you bring your meter to clinic, the meter can be read directly or down-loaded into a printed graphic record of the last 100 tests. You can do this yourself at home too.
- Every 3 months or so at your clinic visit, you will have your glycated hemoglobin (HbA1c) checked on a finger stick drop of blood. HbA1c levels indicate how high your blood glucose levels have been over the past 2-3 months. Normal levels are <6.0% while treatment goals are < 7.0%.
- The blood lipid level should be checked after an over-night fast every year, and if abnormal, should be treated (see above). Once on treatment, the lipid level should be checked every 3 months until near normal at clinic visit and then at least yearly thereafter.
- Your weight and blood pressure are checked regularly
- Once yearly, a urine sample should be taken and sent for microalbuminuria, an early warning sign of kidney problems.
- every two years, an opthalmologist (eye doctor) should check you out too. Opacities in the lens of the eye (cataracts) and damage to the visual part of the eye or retina (retinopathy) can be seen from diabetes, but is treatable.
- An exercise cardiogram is best done every 2-3 years for adults with type-2 diabetes unless known to be abnormal, when it is checked annually.
Can my children get diabetes too? Afraid so! The chances approach 50% over their life-times. You should introduce them to your healthy life-style of carbohydrate restriction and exercise as early as possible. Take them with you on your walks. Should they get to be overweight, then they should be suspected of following in your T2DM foot-steps. Overweight is defined by doctors as the body mass index which is calculated by the semi-clothed weight in kilograms divided by the weight in meters squared. The BMI of children should be below 27 and of adults should be below 30. If your child crosses this line, or acanthosis nigricans is suspected, the overnight fasting level of blood lipids, and glucose should be measured by the clinic. The fasting blood glucose should be below 105mg/dl and when between 105-125, it is impaired fasting glucose, a warning that insulin resistance syndrome may already exist.
Wow! This sure is a lot to remember: Sorry about that, but you will hear the part that is relevant to you again during clinic visits, until it becomes very familiar. You will have diabetes for life. However once your diabetes comes under control, you may need to remember this and continue to do the things and take the drugs that are responsible for the improvement. All of the above medications are given for the purposes mentioned. It is good that you understand what they are. However because the number of the individual drugs taken can be many, you should buy a weekly organizing pill-box from the pharmacy, and lay them out day by day, before your busy work week begins. If you have questions about your diabetes, just ask.