More about Diabetes Type 1 and Diabetes Type 2

What is diabetes mellitus? Diabetes is a disease during which the body does not produce insulin or does not use it properly, thereby causing the mechanism that regulates the blood sugar levels to malfunction.

Diabetes Glossary:

Pancreas
Islets of Langerhans
Alpha cell
Beta cell
Glycogen
Glucagon
Insulin receptors
Insulin
Blood sugar levels
Insulin resistance
Types of diabetes
Diabetes symptoms
Low level of blood glucose (hypoglycemia)
High level of blood glucose (hyperglycemia)
Insulin analog
Types of insulin
Pills for Diabetes type 2
Insulin or Pills?
Insulin injections or Insulin Pump?
HbA1C- Glycated hemoglobin
GCT – Glucose Challenge Test (50g)
OGCT – Oral Glucose Tolerance Test (100g)
C-Peptide test
Fructosamine test
Honeymoon
Glycemic Index
Glycemic Load
Acetone in urine
Factors affecting blood sugar levels
The Dawn Phenomenon

Pancreas

The pancreas is a gland organ located next to the stomach. It produces enzymes that aid the digestion process and hormones that regulate blood sugar levels. The hormones, insulin and glucagon, are generated by the regions of the pancreas called islets of Langerhans, constituted of endocrine cells (alpha and beta).

Islets of Langerhans

In 1869 endocrine cell regions were discovered in the pancreas by Paul Langerhans. These regions contain three types of cells:
α, β and δ, which are responsible for the regulation of blood sugar levels. The α cells produce glucagon, the β cells – insulin and the δ cells – somatostatin.

Alpha cell

Endocrine cells in the islets of Langrehans, secreting the glucagon hormone. This hormone operates in the liver, causing it to convert glycogen into glucose thus raising the glucose level in the blood.

Beta cell

Endocrine cells in the islets of Langrehans, secreting the insulin hormone. The hormone is release when the glucose level in the blood is above average. Type 1 diabetes is an autoimmune disease that destroys beta cells, while type 2 diabetes causes superfluous generation of insulin due to insulin resistance, thus exhausting the beta cells.

Glycogen

An animal starch made primarily by the liver and the muscles that functions as the secondary long-term energy storage and prevents hypoglycemia.

Glucagon

A hormone produces by the alpha cells in the pancreas released when the blood sugar level is low so as to raise it and prevent hypoglycemia. The glucagon converts glycogen stores into glucose, first in the liver and subsequently in the muscles. When the body runs out of glycogen, the fat is converted to glucose releasing acetone as a part of the chemical process. The function of the glucagon is opposed to that of the insulin.

Insulin receptors

The insulin receptor is a transmembrane receptor activated by insulin. The merger of insulin and the receptors enables the entrance of glucose into the cells. Fat tissues cause the receptors to be less sensitive to insulin and might even reduce the number of receptors. As a result of a decrease in the number of receptors or in the level of their activity, the entrance of glucose into the cells is decreased or prevented.

Insulin

Insulin is a hormone produced by the beta cells of the pancreas that has extensive effects on metabolism and other body functions. Its primary role is to control the blood sugar level. The pancreas releases small amount of insulin regularly, increasing the amount when the glucose blood level rises.
The insulin operates in two ways:
1. In the liver: prevents the conversion of glycogen into glucose, generating the opposite process instead.
2. In fat tissues and in the muscles: enables the entrance of glucose into the cells, so as to supply them with energy. The excess of glucose is transformed into fat. The cells absorb glucose with the aid of the insulin receptors.
Lack of sensitivity to insulin = insulin resistance = type 2 diabetes .
When insulin is absent or low, glucose cannot be absorbed by the cells of the body.

Blood sugar levels

The desirable blood sugar level is 70-110 mg/dl. When the blood sugar level rises, the insulin prompts the absorption of glucose from the bloodstream into the cells, thereby reducing the blood sugar level. The excess glucose is transformed into fat. When the blood sugar level falls, the glucagon causes the liver to converts glycogen stores into glucose. When the glycogen stores are depleted, the fat tissues are converted to carbohydrates.

The desirable blood sugar level (70-110 mg/dl) is attained, then, by means of positive feedbacks system:

1.  After the consumption of carbohydrates:
•  The blood sugar level rises.
•  The pancreas secretes insulin that causes the cells to absorb glucose.
•  The insulin receptors in the cells enable the absorption process.
•  The blood sugar level falls back to normal.

2.  During physical exercise:
•  The blood sugar level falls.
•  The pancreas secretes glucagon that prompts the conversion of glycogen and the fat tissues into glucose.
•  The blood sugar level rises back to normal.

The incapacitation of the positive feedback system can be attributed to several causes:
1.  The beta cells produce little insulin or none at all.
2.  The body cells do not respond properly to insulin (insulin resistence).
3.  The liver produces unnecessary amounts of glucose.
4.  The alpha cells do not produce glucagon when the blood sugar levels fall.
5.  The beta cells produce too much insulin .

Insulin resistance

Insulin resistance occure when the Insulin receptors do not respond properly to the insulin, the glucose is not absorbed into the cells and the blood sugar level remains high.

Following are the steps of the process:
1.  After the consumption of carbohydrates, the level of the glucose in the blood rises.
2.  The pancreas secretes insulin.
3.  The insulin attempts to carry the glucose to the body cells.
4.   If the insulin receptors in the cells respond properly, the blood sugar level falls back to normal (see phase 6).
5.  Return to phase 2.
6.  The blood sugar level falls back to normal.

The repetition of phases 2 and 5 and the rise in the blood sugar level increase in proportion to the level of the insulin resistance.

Types of diabetes

1.    Type 1 (juvenile diabetes)
Due to a malfunction of the immune system, the body destroys the beta cells in the pancreas thereby preventing the secretion of insulin.
2.    Type 2 (adult diabetes)
Shortage in insulin or lack of its implementation due to insulin resistance. Usually caused by lack of physical exercise, imbalanced nutrition, obesity or genetic predisposition.
3.    Gestational diabetes
The placenta secretes hormones that exacerbate insulin resistance. This usually occurs when a subclinical insulin resistance exists prior to pregnancy, the condition becoming clinical during the gestation period due to placental activity. This condition is diagnosed by means of OGTT - Oral Glucose Challenge Test during the second trimester (24th week).
4.    Pre-gestational diabetes
Pre-gestational diabetes is diagnosed at the very beginning of the gestation period, before the placental activity had attained its peak. This condition indicates high insulin resistance prior to pregnancy.
5.    Pre-diabetes
A subclinical insulin resistance, manifesting itself via blood sugar level between 100 and 126 mg/dl. At this stage it is possible to improve and even cure the condition by means of balanced nutrition and physical activity. It is important to treat pre-diabetes before the condition deteriorates, as some of the damages to health begin to develop as early as this stage.
6.    MODY – Maturity Onset Diabetes of the Young
This type of diabetes afflicts youth who do not suffer from obesity or overweight. This condition usually appears due to strong genetic predisposition without the malfunction in the immune system that causes the destruction of the beta cells that is characteristic to type 1 diabetes. In most cases, this condition can be balanced without insulin.

Diabetes symptoms

Symptoms of Diabetes type 1 and Diabetes type 2 Increased urination
One of the roles of the kidney is to maintain proper blood sugar level. As long as the blood sugar level remains below 180 mg/dl (the margin can vary from one person to another), the kidney maintains the circulation of the glucose in the bloodstream. If the blood sugar level rises above the said margin, the kidney attempts to dump the excess via the urinary bladder. To this end, the kidney produces large quantities of urine that lead to increased urination during the day and the nighttime.
Increased thirst
Large quantities of urine cause the body to lose liquids. The body generates increased thirst so as to compensate for this loss.
Increased hunger
Lack of insulin or its improper application result in lack of exploitation of the carbohydrates consumed as energy sources, simulating a state of malnutrition. The body attempts to compensate for this condition by generating increased hunger.
Fatigue
When the blood sugar level is high, the brain receives less oxygen, generating fatigue. Sugar blood level above 500 mg/dl can result in loss of consciousness.
Acetone odor on the breath
The liver converts fat reserves to glucose so as to provide the body with energy, releasing acetone as the byproduct of the chemical process.

Low level of blood glucose (hypoglycemia)

Hypoglycemia is an acute decline of the blood glucose level without defined margins. One can experience the symptoms of hypoglycemia when the blood glucose level drops from 300mg/dl to 150mg/dl or from 120mg/dl to 50mg/dl. It is therefore important to measure the blood glucose level before making a decision as to the type and the quantity of nutrition.

Causes of hypoglycemia:
•  Excessive injection of insulin
•  Administration of a pill stimulating the pancreas without consuming enough carbohydrates
•  Physical exercise without adequate carbohydrate coverage
•  Mass consumption of monosaccharide (nutrition with high glycemic index).

Symptoms of hypoglycemia:
•  Perspiration
•  Weakness
•  Heightened pulse pressure
•  Increased hunger and cravings for sweets
•  Shakiness
•  Dizziness
•  Confusion and lack of focus

An important note: the presence of one symptom is not enough to diagnose the condition.

Treatment of hypoglycemia:
During hypoglycemia one must both quickly raise the blood glucose level and maintain its long-term stability until the next meal. It is therefore important to consume both simple and complex carbohydrates, for example a slice of whole-wheat bread with jam. The amount of carbohydrates would depend on the blood glucose level and the cause of its fall. In case of consciousness loss, the ambulance must be called or the glucagon kit injected, followed by immediate transportation to the emergency room. Foods with low glycemic index, such as chocolate, ice cream, baked or fried pastry are recommended, since the absorption of carbohydrates from them is slow.

High level of blood glucose (hyperglycemia)

Hyperglycemia is an acute rise in the blood glucose level. This condition can result from untreated or unbalanced diabetes. For instance:
1.  An individual whose fasting blood glucose level is 200mg/dl and is as yet undiagnosed with diabetes experiences continuous hyperglycemia.
2.   The patient’s blood glucose level is usually balanced, but after a consumption of foods rich in carbohydrates combined with lack of insulin administration the blood glucose level had risen to 220mg/dl – a state of temporary hyperglycemia.
3.  Diabetics treated with pills that fail to balance their blood glucose level, whose A1C levels consequently reach 12, experience continuous hyperglycemia.

Symptoms:
1.  Excessive urination (the kidneys attempt to dump the excess glucose in the bloodstream).
2.  Thirst (the body requires liquids due to the kidney activity)
3.   Weakness and fatigue (the brain receives less oxygen).
4.   Acetone odor on the breath (due to the shortage in glucose, the liver engages in a chemical process, converting fat tissues into glucose and releasing acetone as a by-product).
5.   Other diabetic symptoms occur if the hyperglycemia continues and the glucose values remain high.

Treatment:
1.   If the individual experiencing the symptoms was not diagnosed as a diabetic and is not treated as such, a physician should be consulted with all possible speed.
2.   The blood glucose level should be lowered by means of insulin, if a history of insulin treatment exists, its compatibility to the patient proven and the process of administration well known.
A walk can assist in lowering the blood glucose level, if it does not surpass 250mg/dl.

Insulin analog

Genetically engineered form of insulin, of which several types are made available as a result of molecular modifications. The insulin analog contributes to the improvement of the diabetic’s quality of life. The development of different types of insulin analog enables their adjustment to the diabetic’s life style rather than vice versa.

Types of insulin

Rapid-acting:
This group consists of insulin types that begin to take effect minutes after the injection, reaching maximal efficiency in about an hour (or even less). Their activity reaches a halt after a few of hours. The following types appertain to this group: Humalog, NovoRapid, Apidra, Lispro.
Short-acting:
This group contains insulin types that begin to take effect in about half an hour following the injection, reach their maximal efficiency within two hours and cease to be active in 6-8 hours. The following types appertain to this group: Humulin R, Actrapid, Regular.
Intermediate-acting:
This group contains insulin types that begin to take effect in two hours following the injection, reach their maximal efficiency within 4-6 hours and remain active in the body for up to 12 hours. The following types appertain to this group: Humulin N, Insulatard.
Long-acting:
This group contains insulin types that remain active for almost day (18-24 hours) and whose efficiency remains invariable, except for a moderate peak after 6 hours. The injection time (day or night) varies, therefore, according to the patient’s hypoglycemic tendencies. The following types appertain to this group: Lantus, Levemir.
Pre-mixed:
A mixture of two insulin types in the same syringe. For instance, Insulin 70/30 contains 70% of intermediate-acting insulin and 30% of short-acting insulin. The administration of this type of insulin reduces the number of injections but allows for lesser flexibility when compared to the combination of the long-acting and the rapid-acting insulin analogs.

Why is a combination of several types of insulin necessary?
The pancreas secretes low amounts of insulin on a regular basis, increasing production in response to a rise in blood glucose level. A combination of insulin types mimics the pancreas activity. The long-acting insulin simulates the steady secretion of insulin while the rapid-acting insulin stabilizes the blood glucose level after the consumption of carbohydrates.

Blood glucose levels without using insulin analog and without eating carbohydrates
The effect of adding long-acting insulin

Blood glucose levels using long-acting insulin and eating carbohydrates
The effect of adding rapid-acting insulin

Pills for Diabetes type 2

There are two essential types of pills for diabetes treatment:
1.   Pills causing the liver to prevent the conversion of fat tissues into glucose, thus improving the condition of insulin resistance, such as Glucophage, Metformin, Glucomin, Glufor. It is recommended to take these pills with the meal for those with sensitive stomach.
2.   Pills affecting the pancreas, prompting increased production of insulin, such as: Gluben, Glibetic, Glyburide. These medications must be swallowed at the beginning of meals containing carbohydrates. The pills might induce hypoglycemia, as they cause the secretion of insulin.

Other types of pills:
3.  Prandase: delays the absorption of carbohydrates enabling a steadier rise of the blood glucose level.
4.  Januvia (Sitagliptin): crates a proper environment for insulin activity by inducing the secretion of the GLP1 hormone.
5.  Janumet: a combination of Metformin and Januvia.

Insulin or Pills?

The advantages of the pills:
1.   Swallowed orally, rendering injections obsolete.
2.   Long shelf life.
3.   A psychological advantage.

The advantages of insulin:
1.   The pancreas is allowed to rest and rehabilitate rather than being exhausted.
If the pancreas is still active, it can function as a fail-safe for the insulin analog, completing the necessary amount of insulin in case of shortage.
2.   Higher quality of life, enabling freedom in the choice of food and flexibility regarding medicine quantities (extremely restricted with pills that can be consumed either whole, by halves or by quarters).
3.   The insulin is more natural and pure compared to the pill, comprised of chemical substances.
4.   Long-acting insulin, such as Lantus, remains active for 24 hours. It can be combined, if necessary, with a rapid-acting analog such as Novorapid in order to produce greater flexibility.

Insulin injections or Insulin Pump?

A partial list of pros and cons for each method.
Injections:
1.  Lack of perpetual link to a device.
2.   One must think before eating (no reckless consumption).
3.    Everyone needs several doses in order to reach maximal balance. Once one chooses injections, there is no way to adjust the doses in accordance with the time of the day, resulting in more hypoglycemic and hyperglycemic instances.
4.   Injections must be administered at the same time every day, engendering inconveniences, such as the necessity to wake up early for the morning dose or to interrupt an outing with friends for the night dose.
5.   For carb choices with exceedingly low glycemic values one must divide the amount of insulin into several injections.
6.    One must plan in advance one's physical exercise and even that is not enough sometimes –a walk requires eating without the administration of the rapid-acting insulin, but the long-acting insulin remains active and its effects – unavoidable.
7.   Restricts the use of sensors (Continuous Glucose Monitoring System) to those compatible with injections.
8.   Repetitive injections are required in order to correct a high blood glucose level.

Pump:
1.   Different doses of basal insulin (long-acting) in accordance with the hours of the day – less hypoglycemic and hyperglycemic instances.
2.   No need of repetitive injections to adjust the blood glucose level.
3.   A special program for carb choices with exceedingly low glycemic values (long-term trickle).
4.   No inconvenient injection hours – one remains connected to the pump while sleeping and while going out.
5.   During physical exercise, the pump can be disconnected without the need for supplementary nutrition to compensate for the basal insulin previously administered.
6.   Compatibility with all types of sensors (Continuous Glucose Monitoring System).
7.   Unpredictable malfunctions of the pump. Several checks a day are necessary to make sure that the pump operates properly.
8.   Higher but worthwhile cost.
9.   When traveling abroad, there is no need to factor the time difference and its effect on the insulin already injected.
10.   Better balance due to all the advantages.

It is important to point out that there is no single solution to fit everyone. One can apply the two methods alternately, of course.

GCT - Glucose Challenge Test (50g)

This test does not necessarily indicate the existence of diabetes, but it might lead the physician to suspect it. During the test, one swallows 50g of glucose solution followed by the measurement of the blood glucose level an hour later. The performance of this test does not require fasting.
Results:
If the blood glucose level is above 130ml/dl (140ml/dl for the meticulous) after an hour, an additional test – OGTT – is required.
If the blood glucose level is above 200mg/dl diabetes is diagnosed.

OGCT - Oral Glucose Tolerance Test (100g)

The test must be performed after an 8 hour fast.
The procedure entails four blood tests:
1.   A zero time (baseline) blood sample is drawn. The patient is then required to drink 100g of glucose solution.
2.   The second sample is drawn an hour after the consumption of glucose.
3.   The third sample is drawn two hours after the consumption of glucose.
4.   The fourth sample is drawn three hours after the consumption of glucose
Results:
After fast: lower than 95ml/dl
After an hour: lower than 180ml/dl
After two hours: lower than 140ml/dl and higher than 70ml/dl

Diabetes is diagnosed in case of two deviations from the normal range or one result above 200ml/dl.

A1C- Glycated hemoglobin

Glycated hemoglobin is created when glucose molecules fuse with hemoglobin molecules in the red blood cells. Since the average lifespan of a red blood cell is three months, the test reflects the average blood glucose level over the three months preceding it.

C-peptide test

A test that serves to indicate whether the pancreas secretes insulin. The test is performed in order to determine the diabetes type.
Type 1 diabetes will result in low or negative c-peptide level.
Type 2 diabetes will result in average or high c-peptide level.

Fructosamine test

Honeymoon

A condition experienced by type 1 diabetics during which some of the beta cells are still active and the pancreas therefore produces small but insufficient amounts of insulin. Consequently, a diabetic during the honeymoon period requires smaller amounts of insulin analog.

Glycemic Index

Glycemic index is a factor indicating the speed of carbohydrate conversion into glucose and its absorption into the bloodstream. The faster the glucose is absorbed into the blood, the more insulin is secreted by the pancreas. Consumption of carb choices with high glycemic index results in high secretion of insulin that might lead to hypoglycemia in individuals with high insulin sensitivity. The lower the glycemic index of a carb choice, the better it is (full carbs).
Important note: The glycemic index indicates quantity, not quality. That is, the consumption of carb choices with low glycemic index is not limitless.

Glycemic Load

The glycemic load is a factor that includes the glycemic index, alloting most of the weight, however, to the quantity of the consumed carbohydrates. In other words, the glycemic load reflects the amount of insulin required for the carbohydrates, not the pace of its secretion.

Acetone in urine

Acetone in urine is detected due to a quick dissolution of fatty acids. This process is brought about by the lack of glucose in cells requiring energy. One of the following factors can cause it:
1. A shortage of insulin: the cells requiring energy do not receive adequate amounts of glucose.
2. Insufficient consumption of carbohydrates.

Factors affecting blood sugar levels

1.  Nutrition – the carbohydrates in the food are converted to glucose and absorbed into the bloodstream.
2.  Insulin – the body does not generate enough insulin or does not use it properly.
3.  Liver – the liver converts glycogen and fat into glucose. With diabetics, this process may sometimes reach excessive proportions or be badly timed.
4.  Stress – stress generates the secretion of insulin-suppressing hormones, such as cortisol and adrenaline.
5.  Physical exercise – the body expends more energy resulting in higher demand for glucose from the cells. Physical exercise ameliorates the insulin resistance condition.
Note: Blood glucose level above 250ml/dl indicates a shortage of insulin or a condition of high insulin resistance during which insulin has no effect. Physical exercise generates additional demand for energy, causing the secretion of stress hormones, which would raise blood glucose level further still. On that account, physical exercise must be avoided if the blood glucose level is above 250ml/dl.

The Dawn Phenomenon

At times, the liver begins to convert fat into glucose in the early hours of the morning. This condition is called the dawn phenomenon. One can overcome it by selecting one of the following ways:
1. A pill such as Glucophage or Metformin that suppress liver activity.
2. Consuming a low glycemic index meal containing full carbs and protein or fat. The goal is to raise the blood glucose level steadily and naturally over a long period of time so as to prevent liver activity.

A justification of the midnight meal:
A full carb has low glycemic index which drops still more when combined with fat or protein. A carb whose glycemic index is low affects the blood glucose level for a long period of time. It might, consequently, render unnecessary the conversion of fat to carbohydrates by the liver.
If the blood glucose level after fast had risen or remained the same, there is no need for the night meal

Iris Peleg | + 972-54-4608679 | peleg.iris@gmail.com | www.irispeleg.com