CD-ROM Today 1996 January/CD-ROM Today 1996 January.iso/dp/0175/01756.txt

Text File | 1994-01-17 | 25.2 KB | 421 lines

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$Pretitle{}
$Title{Diabetes and You, part I}
$Subject{Diabetes metabolic metabolism metabolisms diabetics diabetic kidney
kidneys failure carbohydrates starches sugars food foods glucose Blood sugar
insulin ketones ketoacidosis mellitus insulin-dependent noninsulin dependent
pancreas autoimmune hormone injections injection hypoglycemic Diet circulation
Eye Kidney Dental Gestational Pregnancy insulins ketone hyperglycemic
hypoglycemics hypoglycemia pre-eclampsia dm}
$Volume{Y-0}
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Location and Function of the Endocrine Glands*0002901.scf
The Islets of Langerhans*0002905.scf
Structure of the Pancreas*0009801.scf
Diabetes Mellitus*0009802.scf
The Functions of Insulin*0009803.scf
Diseases of the Pancreas*0016001.scf
Anatomy of the Pancreas*0016601.scf
Glossary*0174301.tid}

Copyright (c) 1991-92,1993   Tribune Media Services, Inc.


Health Update

by Dr. Allan Bruckheim

Diabetes and You


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     Diabetes is a chronic metabolic disease that can be treated, but, as yet,
it cannot be cured.  Before the 1920's, diabetics usually died soon after the
diagnosis of their disease.  Diabetes can be controlled, however.  The more
than 11 million people in the United States with diabetes can live long lives,
hold productive jobs, marry and have children.
     Despite this seeming normality, it must be remembered that diabetes can
have serious complications.  It is the fourth leading cause of death in this
country, following only heart disease and cancer.  It kills 150,000 people per
year.  It is the leading cause of blindness (12,000 cases per year) in the
United States.  It causes one-quarter of all cases of kidney failure.  It can
lead to heart disease, stroke, gangrene and nerve damage.  And it is on the
rise, with 750,000 new cases diagnosed each year.
     Diabetes can lead to complications, but with care and proper treatment,
most can be avoided or minimized.  The Centers for Disease Control now says
that between 50 percent and 85 percent of acute and chronic complications
caused by diabetes can be prevented or treated with early diagnosis of
diabetes and careful monitoring.  People with diabetes must incorporate
several precautions against their disease into their daily lives.  They must
watch what they eat and at what times, they must keep a close eye on their
overall health, they must test their blood or urine daily, and they may have
to take medications or injections.  Because of this, diabetics learn to take
an active role in their own treatment.

What is diabetes?

     Essentially, diabetes is the body's inability to use the energy normally
derived from food.  The process by which food is converted into energy or into
components of the body is known as metabolism.
     In a healthy person, the intestines break down carbohydrates (starches
and sugars) in food into glucose--a type of sugar--which is the body's chief
source of fuel.  "Blood sugar" is glucose and is carried by the blood
throughout the body to the cells, which either use it immediately for energy
or store it away for future use.  But it cannot get into the cells by itself.
For glucose to get into the cells, a special hormone called insulin must be
present.
     Insulin is just one of the many hormones the body uses daily.  It is made
within the pancreas, the large gland just beneath the stomach, in special beta
cells within segments of the pancreas known as the Islets of Langerhans.  Beta
cells normally react to high blood levels of glucose by making more insulin.
     Blood-sugar levels in a healthy person rise and fall in response to many
factors.  Certain things such as a recent sugary or starchy meal of emotional
stress can make the level rise, while exercise and fasting can make it fall.
The pancreas keeps regulating the level of blood sugar to make sure that it
meets the body's needs.
     In a diabetic, everything is working except the insulin.  The intestines
break carbohydrates down into glucose.  The blood carries glucose to the
cells, but the cells cannot take in the glucose.  In some diabetics, there is
not enough insulin, while in others, insulin is present, but it does not work
properly.  Unused glucose starts to build up in the bloodstream at the same
time the body starts starving for energy.  When the blood becomes saturated
with glucose, the glucose spills into the urine and the body must produce more
urine, and a diabetic must urinate more frequently to get rid of it.  Fatigue
sets in and the body turns to fat stores for energy.
     Severe, out-of-control diabetes is an emergency.  When the body does not
have enough insulin, or its need for insulin increases suddenly, it starts
breaking down fat for energy.  When fat breaks down in large quantities,
chemicals called ketones are released and build up in the blood, and a
condition called diabetic ketoacidosis develops.
     A diabetic in ketoacidosis may suffer nausea, vomiting and start
breathing deeply and rapidly.  He or she may have a very fruity odor on the
breath, which is caused by acetone, a ketone that can be expelled by the
lungs.  If ketoacidosis is not treated promptly, the person can become
comatose and die.
     The full name for diabetes is diabetes mellitus, Greek for the
"honey-urine disease," because the urine of an untreated diabetic has so much
sugar in it that it is sweet.  Another disease, called diabetes insipidus, has
some similar symptoms to diabetes mellitus, but it is a completely different
disease.

The types of diabetes

     There are two main types of diabetes mellitus:  insulin-dependent and
noninsulin dependent.  These used to be referred to as juvenile-onset diabetes
and maturity-onset diabetes, respectively, but the names were changed because
not everyone who is diagnosed as having juvenile diabetes is a child and some
children have maturity-onset diabetes.  To add to the confusion, some people
with noninsulin-dependent diabetes do use insulin to control their disease,
but most do not.
     The two types of diabetes mellitus are in many ways very different
diseases, and even within these two types of diabetes, there are variations.
Insulin-dependent and noninsulin-dependent diabetes both result in the same
problem:  the inability to properly control blood sugar.  They also can result
in similar long-term side effects.

Insulin-dependent diabetes

     Insulin-dependent diabetes is the less common form of the two major types
of diabetes.  Only about 10 percent of all diabetics are insulin-dependent.
Other names for this kind of diabetes are Type I diabetes and ketosis-prone
diabetes.
     An insulin-dependent diabetic has a pancreas that is not making insulin
or not making enough of it.  Researchers now believe that this type of
diabetes is an autoimmune disease, that is, a disease caused by an
overreactive immune system.  Although much is still unknown, medical
scientists now think that some triggering factor confuses the body's defense
system into attacking the beta cells of the pancreas and killing them.  This
autoimmune reaction may be triggered by a virus or by several viral
infections.
     Heredity and environment are other factors in the development of
insulin-dependent diabetes.  According to researchers, an immune system that
will overreact and attack the beta cells is an inherited characteristic, but
this overreaction still must be turned on by a triggering factor such as a
virus,
     White people who trace their heritage to Northern Europe have a higher
incidence of insulin-dependent diabetes, but it is rarely seen in Orientals.
Blacks and certain American Indian tribes have a high incidence of
noninsulin-dependent diabetes.
     The autoimmune destruction of the beta cells does not happen overnight. A
person can get by quite well with less than a full amount of beta cells making
insulin, but at some point, enough cells are destroyed so that a sufficient
amount of insulin is no longer produced and the symptoms of diabetes start to
appear.
     One subtype of insulin-dependent diabetes is secondary or acquired
diabetes.  It is caused by the surgical removal of the pancreas, either
because of pancreatic cancer or after an injury.
     Symptoms of insulin-dependent diabetes come on relatively quickly.  The
warning signs include frequent urination, extreme thirst, continuous hunger,
weight loss, irritability and fatigue.  Urination and thirst are caused by the
body's need to rid itself of glucose building up in the bloodstream.  Hunger
and fatigue are felt because, even though the body is getting enough food, it
cannot get enough energy out of that food.  Weight loss occurs when the body
must turn to stored energy, and fat is burned off.
     An insulin-dependent diabetic must have regular injections of insulin in
order to survive.  In addition to insulin, diet and exercise must be carefully
regulated in order to maintain good blood-sugar control.

Noninsulin-dependent diabetes

     As the name implies, noninsulin-dependent diabetes means a form of
diabetes where the patient does not have to depend on insulin.  Nine out of 10
diabetics in the United States have noninsulin-dependent diabetes, also known
as Type II diabetes.  Although most people with noninsulin-dependent diabetes
are adults, the disease can occur at any age.
     In noninsulin-dependent diabetes, the pancreas is producing insulin,
although it may not be doing so at normal levels.  Although insulin is
present, blood-glucose levels are still abnormal because something is causing
the body to resist the insulin.
     The cause of this insulin resistance or insulin antagonism is unknown.
Insulin must be able to plug into individual cells to work at sites on the
cell called receptors.  One possible cause of insulin resistance is that the
insulin receptors are impaired.  Another possibility is that even after the
insulin plugs into the receptor site, the cell does not respond to the
insulin.
     Of people who are diagnosed as having this form or diabetes, 80 percent
are overweight.  Some people who are obese have high insulin levels, yet are
insensitive to insulin.  In an obese person, it appears that cells have fewer
insulin receptor sites.  While a fat person's body may be turning out two or
three times the insulin that a lean person's body is making, it is not working
well.  If the overweight diabetic loses weight, often his or her blood-glucose
levels will return to normal.
     Noninsulin-dependent diabetes also can run in families, but again
environment plays a role.  This is one reason why any doctor giving a physical
always asks if there is a family history of diabetes.  Because obesity is also
a factor, it can be difficult to tell if diabetes is due to an inherited
propensity or because the members of a family tend to eat alike and all may be
overweight.
     Symptoms of noninsulin-dependent diabetes come on much more slowly than
do those of insulin-dependent-diabetes.  Symptoms may include frequent
urination, thirst, hunger, fatigue, irritability, and also may include
drowsiness, blurred vision, tingling or numbness in the hands and feet, or
itching.  Another important symptom of noninsulin-dependent diabetes is
recurring or slow-to-heal cuts and sores.  A woman may have recurrent urinary
or vaginal infections.
     Noninsulin-dependent diabetics often can control their condition through
diet and exercise alone, especially with a well-balanced reducing diet that
helps them shed extra pounds.  Other diabetics may need a combination of diet,
exercise and medications.  Medications for this type of diabetes include a
class of drugs called oral hypoglycemic agents that help noninsulin-dependent
diabetics use blood glucose better.
     In some cases, insulin is needed to help treat noninsulin-dependent
diabetes.  The difference is that, for this version of the disease, insulin is
not a requirement.  Many people may need insulin before diet and exercise can
bring their diabetes under control.

How diabetes is diagnosed

     Doctors use urine and blood tests to check for diabetes.  In both, they
are checking glucose levels.  Glucose in the urine can be a sign of diabetes,
although it is not always so.  The doctor also may give a complete physical to
check the heart, eyes and kidneys.
     In the blood, a certain level of glucose is normal.  Usually, the test is
done on blood drawn before breakfast in the morning, and it is called a
"fasting glucose test."  If blood is drawn after a meal, it is a "postprandial
glucose test."
     If a doctor wants to double-check the blood tests, he or she may ask the
patient to take an oral glucose tolerance test, which can detect diabetes even
when a regular blood test will not.  For this test, the patient's blood is
taken and then the patient drinks a liquid with a known amount of glucose in
it.  This is very sweet, but not unpleasant.  More blood samples will be taken
during the hours after drinking the glucose.  Comparing the samples will show
how the body responds to an increase in blood glucose.
     Normally, blood-glucose levels will rise after the drink and then fall
gradually as the pancreas sends out insulin to cope with it.  A diabetic's
blood-glucose level may stay high after the glucose drink or it may fall very
slowly.

Insulin

     Insulin is a natural hormone made in the pancreas of healthy people. Many
diabetics need injections of insulin regularly in order to control their
blood-sugar levels.
     A diabetic who uses insulin may need to have an injection once, twice or
several times a day.  Two diabetics may have extremely different injection
schedules, dosage amounts and even different types of insulin.  It is very
important that diabetics test their blood or urine frequently to make sure
their insulin regimen is working.
     Injected insulin is a replacement for the insulin that a diabetic's
pancreas is not making and it works the same way as normal insulin to lower
blood sugar.  However, injections of insulin do not respond to the body's
needs the way the pancreas responds.  When a healthy body needs to lower
blood-sugar levels, the pancreas can churn out as much insulin as is needed.
When blood-sugar levels fall low, the pancreas stops sending out insulin.
     An injection of insulin will lower blood sugar whether or not it needs to
be lowered.  In other words, if a diabetic takes an insulin injection and then
skips a meal, the insulin will keep on lowering blood sugar even though it
drops below normal and an insulin reaction or insulin shock occurs.  Only by
careful scheduling of injections, meals and exercise, can a diabetic control
blood-sugar levels.
     Insulin is sold in pharmacies as a liquid in vials, and in most states, a
prescription is not needed.  However, hypodermic needles--which are
prescription products--are necessary.  Insulin must be injected.  It is not
effective if swallowed, because it is a protein that is digested by the
stomach and intestines.
     An insulin injection is subcutaneous, that is, the insulin is deposited
just under the skin, rather than into a vein or muscle tissue.  The insulin
spreads from the subcutaneous tissue into the rest of the body quickly.
     Newly diagnosed diabetics who must use insulin are taught how to inject
themselves and where.  Injecting insulin is a relatively simple procedure,
and, even though it is not pleasant, most diabetics get used to it.  New
extra-fine needles that cut down on the discomfort are widely available. There
are also devices that use a jet spray to administer insulin right through the
skin without a needle, but these are expensive.
     The areas of the body that can be used for insulin injections include the
outer side of the upper arm, the stomach (except for a small area around the
navel), the buttocks, the outer area of the hips and the thighs.  A diabetic
soon learns to rotate injection sites.  No site should be used for two
injections in a row.
     The doctor gives the patient a little map of the body that can help mark
injection sites that have been used.  A diabetic should never inject insulin
less than a half-inch from a site injected recently.  Repeated injections in
one site can cause lumps or fat to collect or depressions in the skin to
appear.
     Insulin is absorbed slower from certain injection sites.  Usually
absorption in the thighs is slower than in the abdomen, and slower yet in the
arms.  This difference in absorption rates can result in erratic blood-sugar
control unless it is taken into account.

How to administer insulin

     A diabetic should have all the materials ready before giving himself or
herself a shot of insulin.  Needed are a vial of insulin, a fresh disposable
hypodermic syringe, some clean cotton balls and a bottle of rubbing alcohol.
     The first step is to take the metal protective top off of the vial to
expose the rubber stopper, without removing the stopper itself.  The next step
is to turn the vial upside down and roll it gently between the hands.  The
vial should not be shaken, because that causes bubbles that may throw off the
measurement later.  Then the top of the rubber stopper is wiped with cotton
dipped in alcohol.  This cleans and sterilizes the top.  The vial then can be
put to one side.
     Next, the hypodermic syringe wrapper is opened, with caution not to touch
the needle.  The syringe plunger is pulled down so that it is at the number
for the patient's dosage of insulin and the needle is inserted into the
insulin vial.  The plunger is pressed down to expel air into the vial (this
makes getting insulin out of the vial easier) and is pulled back up to the
right amount.  The needle is removed from the vial and the syringe is set down
so that the needle touches nothing.
     The patient finds his or her injection site and wipes it with cotton and
alcohol.  Then the patient pinches up the skin at the site with one hand and
picks up the syringe like a pencil with the other.  The needle is pushed
quickly through the skin at a 90-degree angle.  The plunger is pushed down to
empty it and the needle is removed from the skin.  The site should be wiped
with alcohol again.

Types of insulin

     Insulin comes from three basic sources.  Natural insulin is collected
from the pancreases of cattle and pigs.  Pork or beef insulin is similar to
human insulin and is highly purified to remove impurities.  Semisynthetic
insulin is animal insulin that has been treated to be more like human insulin.
Synthetic insulin is human insulin that has been manufactured through genetic
engineering.
     Insulins can be rapid-, intermediate- or long acting, depending on how
fast they take action inside the body and how long they last.  For instance, a
rapid-acting insulin (also known as regular or Semilente) can start acting
within an hour of an injection, have its peak effectiveness in two to three
hours after the injection and last for six to eight hours.  An
intermediate-acting insulin (NPH or Lente) can take effect within two to three
hours, have a peak effect within 12 hours and have worn off up to 24 hours
later.  Long-acting insulin (PZI or Ultralente) may start to work in four to
six hours, have a peak effect 14 to 24 hours after injection and last up to 36
hours.
     A patient may be told to use different insulins at different times during
the day so that his or her blood sugar is always under control.  Mixtures of
regular- and intermediate-acting insulins are available or a doctor will tell
the patient how to mix different types of insulin to get the best effect.
     Many years ago, when insulin from pork and cattle pancreases first was
being purified, allergic reactions were more common.  Now, all insulin is very
pure, but some people who use beef or pork insulin may have allergic reaction
to it.  Patients with any itching, redness or swelling at the site of an
injection, at any time, should tell their doctors.  They may need to be
switched to either synthetic or semisynthetic insulin.

Insulin reactions

     An insulin reaction is an emergency and it needs prompt recognition and
proper attention.  The patient and everyone in his or her family must learn
the symptoms of insulin reaction and what to do about it.
     The warning signs of an insulin reaction include irritability, sweating,
paleness, rapid heartbeat, extreme hunger, weakness, faintness, inability to
concentrate, blurred vision, loss of coordination and mental confusion.  Some
people get headaches, feel nauseous, cry during a reaction, or feel symptoms
not on this list and unique to them.
     Because of the patient's confusion and unsteadiness, it is easy for
strangers to think that a diabetic having an insulin reaction is drunk or on
drugs.  This is one reason it is wise for a patient to wear a medical
identification bracelet and carry a wallet card that identifies him or her as
a diabetic.
     The most important thing a diabetic do during a reaction is to eat
something to counteract the low blood sugar.  A glass of milk or orange juice
or even swallowing a packet of plain white sugar work well for most people.  A
diabetic who uses insulin must always carry a supply of quick-acting
sugar--such as candy, sugar packets or special glucose tablets--at all times
to use during an insulin reaction.
     If the reaction is not treated, unconsciousness sets in quickly, and two
things can be done.  A drug called glucagon, if readily available, can be
injected into the buttock.  Glucagon is another hormone created by the
pancreas and it raises blood-sugar levels.  If glucagon is not available, a
finger-full of honey, maple syrup or corn syrup can be rubbed on the inside of
the unconscious person's cheek.  If the person does not respond, an ambulance
should be called immediately.
     After recovering from an insulin reaction, the person should eat
something that is digested slowly, such as a sandwich or a piece of fruit.
This will prevent the high insulin levels from causing another insulin
reaction after the sugar or glucagon has worn off.
     Preventing insulin reactions is as important as knowing how to treat
them.  People who test their blood-glucose levels several times a day usually
don't have reactions because they give themselves appropriate amounts of
insulin or eat a snack to avoid them.
     A diabetic may find it necessary to eat a snack at certain times of the
day to prevent reactions.  He or she may need extra carbohydrates before
exercising and will learn from experience how much is needed.  Eating a snack
before bedtime is also wise to prevent nighttime insulin reactions.

Oral hypoglycemic agents

     Many people with diabetes use medications called oral hypoglycemic
agents, which act to lower blood-sugar levels.  These are an option if diet
and exercise fail to control diabetes, but cannot be used for
insulin-dependent diabetes, except in a small number of cases.  They are not a
substitute for proper diet and exercise.  Hypoglycemic drugs belong to a group
of chemicals known as sulfonylureas.
     Oral hypoglycemic drugs are not oral forms of insulin.  Insulin cannot be
put into tablet or capsule form because it is digested in the intestines.
     No one is exactly sure how oral hypoglycemic agents work to lower blood
sugar.  Apparently, they increase the levels of insulin put out by the
pancreas, but they also seem to decrease resistance to insulin in the body's
cells.  These drugs may do this by increasing the number of insulin receptors
in the cells.
     Oral hypoglycemic agents are most likely to be useful for people who are
diagnosed as having diabetes after age 40 and who are at normal weight or
close to it.  They are most useful for less severe cases of
noninsulin-dependent diabetes.
     Some studies show that oral hypoglycemic drugs may increase a person's
risk of a heart attack.  However, there is some disagreement on this matter. A
doctor will discuss the risks and benefits of these drugs before he or she
prescribes them.
     Six hypoglycemic agents are approved for sale and although they have
similar actions, they are not identical.  One may be more effective than
another for a given patient.  A doctor may try the patient out on one drug and
switch to another if the first is not effective.  Some diabetics find that no
hypoglycemic agent works for them and they must use insulin.
     The six brands of hypoglycemic agents (some are available generically)
and their generic names are:  Orinase (tolbutamide), Diabinese
(chlorpropamide), Dymelor (acetohexamide), Tolinase (tolazamide) Micronase,
Diabeta (glyburide) and Glucotrol (glipizide).
     Oral hypoglycemic agents can cause nausea, skin rashes, water retention
or increased urination.  Some people may become more sensitive to sunlight and
burn more easily.  Most of these side effects decrease over time.  Patients
bothered by them should talk to their doctors.
     Diabetics who take oral hypoglycemics must carefully space their meals
and snacks so that their blood sugar does not fall too low.

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The material contained here is "FOR INFORMATION ONLY" and should not replace
the counsel and advice of your personal physician.  Promptly consulting your
doctor is the best path to a quick and successful resolution of any medical
problem.