Diabetes

If you have diabetes, then you have too much glucose in your blood. In diabetes you have continually high blood sugar levels (hyperglycaemia).

Insulin

In order to be able to understand diabetes it is important to first know more about the normal processes by which foods are broken down and used for energy in the body. Different things happen when food is digested:

• Whenever you eat your body turns all carbohydrates, sugars and starch into glucose. Glucose is a source of fuel for all the cells in your body.
• An organ called the pancreas produces insulin. The role of insulin is to take glucose from the bloodstream to the muscles and fat and liver cells, where it can be used as a fuel.

So insulin is a hormone that is produced by the pancreas and it makes sure that the amount of glucose in the blood remains constant. But someone who has diabetes has either too little or no insulin at all. So this means that no glucose is absorbed into the body and too much remains in the blood.
Diabetes can be caused by:

• too little insulin: the pancreas doesn't produce enough insulin and/or
• insulin resistance: the muscles and fat and liver cells react abnormally to insulin.

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Blood sugar levels

Blood sugar levels normally fluctuate between 4.0 and 8.0 mmol/l. When blood sugar levels are determined by lab tests (or with a finger prick test and a meter which calculates the blood sugar levels according to lab values) the values are:

• Normal: Fasted - less than 6.1 mmol/l; Not fasted - less than 7.8 mmol/l;
• Early phase of diabetes: Fasted - between 6.1 and 6.9 mmol/l;
• Diabetes: Fasted - more than 6.9 mmol/l; Not fasted - more than 11 mmol/l.

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Different types of diabetes

Type 1 diabetes is normally diagnosed in children and young adults and was previously known as juvenile onset diabetes. In type 1 diabetes the body suddenly becomes unable to produce any insulin. Only 5-10 % of people with diabetes have this form of the disease. With this type of diabetes, it is necessary to inject yourself with insulin. With the help of insulin therapy and other treatments even children with type 1 diabetes can learn how to control their condition and live a long, happy and healthy life.
Type 2 diabetes is much more common than type 1. It primarily occurs in adults but nowadays is developing more frequently in children as well. The pancreas does not make enough insulin to keep the blood sugar level normal, often because the body becomes more and more sensitive to insulin. Many people with type 2 diabetes do not know that they have it, even though it can have serious consequences. Type 2 diabetes is becoming more and more common as a result of increasing obesity and lack of exercise.
Gestational diabetes is high blood sugar which develops during pregnancy in a woman who has not previously suffered from diabetes. Women with gestational diabetes are at a greater risk of developing type 2 diabetes later in life, as well as heart and cardiovascular diseases.
Risk factors for type 2 diabetes are:

• Older than 45;
• A parent or sibling with diabetes;
• Gestational diabetes, or delivering a baby over 9 lbs;
• Heart disease;
• High cholesterol;
• Obesity;
• Not exercising enough;
• Polycystic ovaries (in women);
• Pre-existing glucose intolerance;
• Some ethnic groups (especially Afro-Americans, Indians and Asians).

Diabetes is often not recognized because so many of the symptoms appear so benign. Recent studies have shown that the early detection and treatment of diabetes can lower the chance of developing complications as a result of the illness.
Your GP can quickly determine if you have diabetes just by testing a drop of blood from your finger. Via a blood glucose meter (s)he can determine how high your glucose level is. If it is above 11 mmol/l (mill moles per liter) then the test is repeated. Before the second test you need to fast (i.e. no eating or drinking) for eight hours. If your glucose level is over 6.0 mmol/l in the second test, then it may be that you have diabetes.

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Symptoms

Type 1 diabetes:

• frequent urination;
• excessive thirst;
• frequent hunger;
• inexplicable weight loss;
• fatigue and irritability.

Type 2 diabetes:

• any of the type 1 symptoms;
• frequent infections;
• blurred vision;
• cuts/bruises that are slow to heal;
• tingling/numbness in the hands/feet;
• receding skin or gums;
• frequent bladder infections.

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Treatment - Self management

Under normal circumstances your blood sugar level will vary. By following the guidelines below you can influence your blood sugar level:

• Exercise regularly;
• Eat a balanced diet;
• Don’t smoke;
• Drink alcohol and fizzy drinks in moderation;
• Drink enough water.

Make sure you get your blood sugar levels checked regularly by your GP. You can also make use of blood glucose meters at home. This will allow you to manage your blood sugar levels.

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Treatment with medication

With type 1 diabetes, sufficient exercise and a balanced diet are of course important. On top of this, it is also treated with insulin. This insulin can be administered with an insulin pen (a small syringe), an insulin pump or an inhaler. In order to be able to manage blood sugar effectively there are different sorts of insulin. In this way insulin is quickly absorbed into the blood and it rapidly takes effect. You take this insulin before eating so that the blood sugar spike that follows a meal is captured. There are also types of insulin that you can take slowly; they are injected once or twice a day so that glucose can be continually taken into the body in small amounts.
Which insulin is the right one depends on the person. Above all it depends on weight, diet, and frequency and type of exercise.
In type 2 diabetes weight loss, diet and exercise are veIn type 2 diabetes weight loss, diet and exercise are very important. Reducing your weight and increasing your exercise increases the sensitivity to insulin so that the blood sugar can be better controlled. If these methods aren't effective in lowering the blood sugar level, then pills or tablets can be taken. If these oral treatments are also ineffective in lowering the blood sugar level, then treatment with insulin is indicated.

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Different types of insulin

There is a difference between:

• fast-acting insulins. They contain regular insulin, insulin lispro, insulin aspart and insulin glulisine;
• medium-acting insulins. They include isophane insulin and can be combined with regular insulin, insulin lispro or insulin aspart and;
• slow-acting insulins. These are insulin detemir and insulin glargine. Mixed insulins means a combination of fast- and medium-acting insulins.

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Tablets for diabetes

There are four groups of oral medicine for the treatment of type 2 diabetes.

• The first group consists of medicines which promotes the release of insulin in the pancreas. These drugs stimulate special receptors ('tentacles') on the outside of the beta cells of the pancreas, which produce insulin, and in this way encourage the production of insulin.
• From the second group of oral medicines, Metformin is the most well-known. Metformin inhibits the production of excess glucose in the liver. This decreases the amount of blood glucose and increases sensitivity to insulin. And because Metformin reduces the glucose in the liver there is therefore no increased chance of having a 'hypo'. Insulin production is not stimulated. It has a beneficial effect on the regulation of the diabetes and reduces the chance of complications.
• The third group of oral medicines slows down the uptake of glucose from the intestines. Acarbose is part of this group. This medication inhibits a number of enzymes which break down carbohydrates in the intestines. This means that the carbohydrates that we eat are broken down less quickly so the glucose is released more slowly and thus is not absorbed into the blood as fast. However in practice, this drug is rarely used.
• The fourth group is a new class of drugs, known as thiazolidinediones (or TZDs for short). There are also called insulin sensitizers because they reduce insulin resistance – the insensitivity of tissue to insulin. TZDs make sure that fats are carried to fat cells much faster, thanks to a complicated mechanism of action. Simultaneously sensitivity to insulin is increased.

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Hypo and Hyper

Blood sugar levels ideally fluctuate between 4 and 8 mmol/l. The treatment of diabetes is therefore designed to achieve these levels. Everything influences your blood sugar levels: eating, drinking, exercising, stress and emotions, flu. This means that your treatment of diabetes might suddenly be affected by a too low or too high blood sugar level. Too low is called hypoglycemia (hypo) and too high is known as hyperglycemia (hyper). Occasional hypos or hypers are not too serious. However if it happens often then perhaps your treatment needs to be re-evaluated. We talk of hypoglycemia (a hypo) when the blood sugar level is below 4 mmol/l.
Characteristics of a hypo are:

• headache;
• sweating;
• shivering;
• dizziness;
• difficulty concentrating;
• tiredness;
• abrupt mood swings;
• hunger.

Having dextrose or a high-sugar lemonade and a sandwich will bring your blood sugar back up. If someone is unconscious then glucose or glucagon can be injected. Glucagon does the opposite of insulin – it increases your blood sugar level. Hyperglycemia (a hyper) is when the blood sugar level is above 10 mmol/l.
Characteristics of a hyper are:

• frequent urination;
• constant and unquenchable thirst;
• fatigue;
• possible abrupt mood swings;
• general overall feeling of illness.

The body is trying to rid itself of the excess sugar. Keeping drinking lots (but nothing sugary!) can help.

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