Juvenile Diabetes (also called Type I) is likely due to a viral infection that eventually results in the destruction of insulin producing cells in the pancreas. These diabetics are referred to as "insulin dependent" because they can die in 1-2 days without insulin. Adult diabetes (Type II) is a different illness, and is not insulin dependent - even if the patient takes insulin.

Sugar (glucose) is the body’s main source of energy, especially for the brain. The hormone insulin is required for the sugar to enter the body’s cells. Insulin is produced in the pancreas gland. Extremely low blood sugar levels for 5-7 minutes can cause permanent brain damage. Diabetes develops when the blood sugar level is persistently too high. Long term complications include blood vessel disease, heart attacks, nerve damage (neuropathy), blindness, kidney disease, and infections.

Healthy people manufacture approximately 35 units of insulin daily. Newly diagnosed diabetics can make 200 units of insulin daily, but it’s not enough to keep the blood sugar in the normal range - due to "insulin resistance." Insulin is a "key" that unlocks a "door" (called a "receptor"). Diabetes is a disorder where the receptors are either markedly reduced or poorly functioning and is associated with problems with insulin production, elevated blood fat (triglyceride) levels, and often high blood pressure and obesity.

When the receptor and/or insulin problems begin, the pancreas increases it’s insulin production to keep the blood sugar levels normal. When the pancreas reaches it’s maximum insulin production, the blood sugar levels rise and diabetes is diagnosed. Blood sugar levels over 200 are toxic to the pancreas, and insulin production goes down when the blood sugar is greater than 200.

No one knows the cause of diabetes. Insulin resistance has no symptoms. One can be very insulin resistant, and in an early form of diabetes, without knowing it. Family history is very important, as is obesity and lack of exercise. True diabetes symptoms include fatigue, excess thirst and urination, wounds that won’t heal, yeast infections, hunger and weight loss.

The treatment of diabetes is very controversial, and involves diet, exercise, pills, and shots. Many cases, especially early on, can be cured with weight loss and exercise. Even a 30 minute daily walk can be profoundly important - exercise can reverse insulin resistance, particularly by increasing the number of available insulin receptors. Diabetes cured by a low fat (20 grams or less daily) diet and exercise rarely has long term complications.

There is virtually no data that tight versus moderate control of Type II diabetes makes any difference. Poor control results in more complications. The goals appear to be to keep the fasting sugar less than 115-140 (normal 60-120), the after eating sugar to less than 180-200, and the glycohemoglobin (hemoglobin A1C) to less than 7. The glycohemoglobin measures the blood sugar levels 24 hours a day for the past 6 weeks. The liver is responsible for the fasting sugar, the skeletal muscles for the rest of the day. Low blood sugar (hypoglycemia) is very dangerous and must be avoided. Diabetics treated with medication must carry rapidly absorbing candy with them (such as small tootsie rolls) in case symptoms of hypoglycemia develop - particularly feeling weak, faint, dizzy or hungry.

With rare exception, sugar need not be avoided in Type II diabetics. Carbohydrates should make up the majority of the diet, and as long as not eaten to excess, sugar may be enjoyed. It’s the fat that causes the most problem in the diet, along with total calories and weight reduction or maintenance. The yeast in bread may be very harmful as well, and should be markedly reduced if the diabetes control is doing poorly.

Sulfonylureas are the mainstay pills for treatment. They appear to slightly increase insulin production. Amaryl does that and decreases insulin. New medications (Actos, Avandia) are now available that can reverse "insulin resistance." Diabetes management involves reversing insulin resistance and controlling blood sugars after a meal.

Metformin reduces sugar production by the liver, and can cause terrible gastrointestinal side effects. Intravenous dye for X-ray studies can cause severe kidney damage when on this medication (and should be avoided in patients with heart or kidney failure). Prandin increases insulin for an hour, so it’s ideal to take before a meal. Precose and Glycet prevent sugar absorption, and tend to cause terrible bloating and diarrhea. Both medications can be very helpful, however.

Insulin can be given as the short acting regular, the long acting NPH, or the very long Ultra-lente. A 70/30 blend of 70% NPH and 30% Regular Human Insulin is the main insulin used today. Very short acting insulins like Humalog are sensational for controlling after meal sugars. Insulin tends to cause weight gain and an increased risk of blood vessel disease. Insulin may be needed temporarily or permanently.

Combination therapy is commonly used. Keeping the fasting blood sugar level normal does seem to have a profound impact on diabetes control, as is the after meal sugars.

Diabetes requires close follow-up - especially with annual eye and foot exams, and close checking of the blood cholesterol and triglycerides. Sometimes checking the sugar at home becomes necessary. A diabetic needs to maintain a regular schedule, including diet and exercise. Stress, infection, surgery, steroids (pills or injections) can all make diabetes worse. All illnesses are made worse by diabetes, and diabetics require closer attention when they are sick.

October 22, 1999