Lecture # 416: Diabetes

copyright 2008 Cheryl K. Hosken, BSN, MS Psych.

Carl is a 44-year-old man who teaches school. During the past year, his life has changed because he was diagnosed with diabetes. For Carl, this year has been one of discovery about how his body works and about the history of his family.

Carl had never thought about diabetes. However, he learned that his father and other members of his extended family had diabetes, that he carried the genetic pattern, which might also cause diabetes in his own body. As he did more research in his family history, he found that three of his uncles had diabetes.

He also reviewed his own life style. Teaching is difficult and over the past few years, he had a habit of coming home in the afternoon and working on the computer to prepare for the next day's classes. Time passed quickly and soon he ate dinner. Dinner was usually good. His wife prepared appetizing meals and he was hungry. After dinner, he read the paper and watched television until time for bed. On the weekends, he tried to get some exercise by biking and swimming. Nevertheless, he found that his waistline was increasing in size and his efforts to decrease food intake did not help decrease his weight. Gradually, he noticed that he was drinking more water and urinating more frequently. He was irritable with his students and colleagues.

Carl had the feeling that his body was not well, but did not have a diagnosis. Due to his symptoms, his wife urged him to consult the doctor. After the physical exam and laboratory analysis, Carl knew the cause of his problems: diabetes. This was the beginning of a different life for him. His wife was willing to learn about the disease and make changes in their lifestyle. She has been a big help to Carl. He now has a regulated diet and exercise program. Most important of all, he knows the cause of his symptoms and is learning to live with this disease.

Meditate Word By Word On This Verse:
3 John verse 2.

What is Diabetes?
Diabetes is a disease that interferes with the process the body uses in turning food into energy and cell growth. When we eat, the digestive system converts food into chemicals. Sugars and starches (potatoes, flour, rice) are broken down into glucose. Glucose is a simple sugar and is our bodies' principal source of fuel.

After being absorbed by the stomach, glucose goes through the circulation system and is used by cells throughout the body. In response to the sugar that is produced after eating, the pancreas secretes insulin. Insulin is the hormone that regulates glucose in the body. Insulin directs the cells of the body to burn glucose for energy and directs the liver and the muscles to store glucose as glycogen. This is the form of sugar that can be used later as the body needs it.

Question 1: Why is glucose important for our bodies?

 

 

There are two forms of diabetes. The first is called TYPE I. This type usually develops at puberty or even a younger age. Usually, the body's immune system defends it against infection by attacking germs, bacteria, and other foreign invaders. But in TYPE I diabetes, the body mistakenly kills the cells that produce insulin. Therefore, the body is without insulin. People with this form of the disease are called insulin-dependent and must receive daily injections of insulin hormone.

Question 2: TYPE I diabetes usually occurs at the age of:
(Only one of the following answers is correct.)
11-13 years,
in children,
18-25 years of age.

 

 

The other 95% of diabetics have TYPE II diabetes. TYPE II diabetes is not an auto-immune disorder, but insulin resistance. Although the pancreas secretes insulin, the body's cells do not react to it. They are not able to use the glucose circulating the blood for energy. For a time, diet, exercise, and oral agents that stimulate the pancreas to release insulin can control diabetes. However, these oral agents cannot compensate and 4 in 10 persons need to use injectable insulin.

There is a second factor for TYPE II diabetes, and that is obesity. Four of five persons with TYPE II diabetes are overweight. There is evidence that overweight people do not use glucose adequately. The heavier they are, the less their bodies are able to use the glucose in their blood. Since there is a correlation between obesity and insulin insensitivity, weight control becomes an essential part of managing diabetes.

Both types of diabetes bring about the same effects: there is an unhealthy accumulation of unused glucose in the blood that the body does not use. The body is deprived of its glucose energy and is forced to burn its own muscle and fat for energy. As mentioned with Carl, there is a genetic link to having diabetes.

Question 3: TYPE II diabetes is more frequent in:
(Only one of the following answers is correct.)
people who play sports,
members of the legislature,
older, overweight people.

 

 

Symptoms of Diabetes

The following are all symptoms:

The symptoms tend to emerge suddenly and harshly. But a person can have non-dependent diabetes for years without noticeable symptoms. Regardless of whether diabetes comes abruptly or gradually, the early symptoms are the same. When the glucose (sugar) in the blood rises and the kidneys can no longer absorb any more of the glucose, it spills out into the urine. Sugar is an osmotic agent: that means when it travels through the kidneys and out of the body, it pulls water from the body along with it. This explains the frequent urination and unquenchable thirst of diabetics. This constant intake of fluid and outflow causes the body's cells to expand and contract. This causes blurred vision since the eyes are affected.

Question 4: What other parts of the body are affected by diabetes?
(Only one of the following answers is correct.)
every part of the body,
the kidneys, eyes, and nerves,
just the internal organs of the body.

 

 

Diagnosis of Diabetes
There are three major tests for diabetes. Two abnormal test results on two separate days confirm the diagnosis.

  1. Fasting Blood Glucose Test - A person fasts for 8 hours and his blood is tested for the amount of glucose. Abnormal result is 126 milligrams per deciliter
  2. Random Blood Glucose - A sample of blood is tested for the amount of glucose. Abnormal result is 200 milligrams per deciliter.
  3. Oral Glucose Tolerance Test - The patient drinks an extremely sweet glucose solution, then blood samples are taken over the next several hours to determine how the body uses the glucose. Fasting is required before this test begins. Abnormal result is greater than 200 milligrams per deciliter.

If the tests are positive for diabetes, tests may also be done to assess function of the kidney to determine if there are indications of kidney disease.

Treatment
Because diabetes has no cure, the long-range goal of treatment is to prevent complications of the disease. Every day comes the challenge of keeping the blood sugar within a normal range. If the range goes too far upward, there is hyperglycemia or increased sugar in the blood. If it is too low, there is hypoglycemia: too little sugar in the blood. Therefore, checking the blood glucose is a daily habit.

Generally, if the blood sugar is between 70 and 120 milligrams per deciliter, this is acceptable. If a person needs strict control, his range may be decreased to 80 and 110 and no higher after meals than 120-140. Other people may be able to tolerate higher levels of blood sugar without suffering hyperglycemic symptoms.

A cold, emotional stress, or change in activity level can alter the body's ability to burn glucose. Therefore, if the person you care for has other disease processes or short illness, be sure to monitor the blood glucose more frequently. We know through ongoing research that stringent control of blood sugar reduce the rate of complications to the kidneys, eyes, and nerves. If the person you are caring for is elderly or terminally ill, there is less concern about blood sugar control, but there is still the need to try and keep control levels normal as possible for comfort and safety.

Question 5: What is the goal of controlling diabetes?
(Only one of the following answers is correct.)
to keep blood sugar low in the body,
to keep blood sugar lower than normal,
to keep blood sugar within the acceptable range set by specialists.

 

 

Blood Glucose Monitoring
Everyone's blood glucose changes throughout the day depending on activity and food intake. However, with diabetes, the body loses its ability to automatically regulate the amount of glucose in the blood whenever it gets too high or too low.

Glucose is monitored by blood testing and is done several times a day to understand the patient's reactions to food, exercise, insulin, other medications, etc. If the doctor is given information about the blood glucose level, he can better prescribe the most helpful amount of insulin and food choices of carbohydrates in the diet.

Until a few years ago, blood sugar was measured at home by a urine dip method. A reactive strip was dipped in the urine and the results read by a change in color. However, monitoring the blood itself gives a far more accurate reading and is the preferred test method.

How often is the test done? That depends on if the person has TYPE I or TYPE II disease. TYPE I people may test 4 times daily and more often if they are ill. TYPE II persons may only test three times a day. The stick to the finger stings, so the diabetic learns to do this quickly and accurately. It is necessary to keep a record of the blood sugars and the times of day when a person is newly diagnosed. Along with day and amount, make a note about anything that was unusual about the time that the blood sugar was measured. Again, this record assists the doctor.

There are two types of measuring devices. One is a simple strip that changes color and is compared to a strip of colored blocks that give an amount of glucose. The person testing then finds the color that is closest to the colored blocks and that is the amount of blood sugar. Each block usually has a range of 30 so that if the color matches the block that is labeled 120-150, the average would be 135. Before measuring the blood sugar, be sure to wash your hands and clean the diabetic's finger you chose to stick. Stick the finger on the soft side and squeeze it a little to get a large drop of blood. This is important because if the drop of blood is too small, the test may be inaccurate. To get a drop of blood on the strip, put the finger with the drop of blood gently on the strip. Then do the comparisons.

Question 6: How much blood do you need for a glucose test?

 

 

The other measure is an electronic meter, which is easy to use and saves up to 250 test results in its memory. These are more expensive, but also more accurate. The blood is obtained in the same way as above, but the strip with the drop of blood is in the electronic reader. In about 30-40 seconds the result is shown on the screen. There are still newer devices that are being developed so that needle sticks are no longer necessary. The patient will place his finger in the electronic machine and it will read out the blood sugar.

Question 7: The most accurate method of measuring blood sugar is to:
(Only one of the following answers is correct.)
use a test strip,
wet your finger and hold it up in the wind,
use an electronic meter.

 

 

The Diabetic Diet
Good nutrition is helpful for everyone, but it is especially important for the person with diabetes. If the person has non-insulin diabetes, eating proper foods in proper amounts is the best protection against peaks and valleys of blood sugar. The doctor (in the U.S., it is a dietitian) will prescribe the specific guidelines for the diabetic diet. Essentially, we are concerned with protein, fats, and carbohydrates that furnish the body's energy and have an impact on the blood glucose. There is no one recipe for all diabetic diets since every person's body is different and metabolizes food in its own way. However the basic diet looks like this:

The doctor (or dietitian) will have calculated how many calories a person needs daily based on his height, ideal weight, physical activity, and general health. A calorie is a unit that gives us the fuel value of food. If more food is consumed than the body uses, it is stored as fat. A 2000 calorie diet is about an average for a grown working man. From those total calories, we have the following:

Question 8: You are a diabetic and your doctor has given you an 1800-calorie diet for every day. How many calories are for carbohydrate, protein, and fat? How many grams for each?

 

 

Why are grams so important? The grams of each component of the diet can be weighed out on a food scale and be divided into three portions for three meals per day.

Protein has little effect on the blood glucose unless a person eats large quantities of it at once. Protein is meat, poultry, fish, and beans. Very seldom do people eat all the protein that is allotted in their diet. An advantage to this is that decreased intake may help delay diabetic kidney disease.

Fats have an indirect effect on blood glucose. A fat-heavy diet makes a person obese, and obesity causes insensitivity to insulin in the body. Obesity is to be avoided since it contributes to high blood pressure, heart disease, kidney diseases, and stroke. The best types of fats are those from vegetables and nuts. Saturated fats of animals increase atherosclerosis of the arteries.

Carbohydrates are at least half of a diabetic's diet. In fact, it is better to control the amount of carbohydrates than trying to control fat and protein. The emphasis is on carbohydrates because they turn starches and sugars into glucose. It is the total quantity of carbohydrate that makes a difference in blood sugar.

Most older people eat the same things every day and so it is easy to work with them an spread out over the course of a day based on how to get the most even blood sugar throughout the day. Blood glucose testing will indicate whether carbohydrates need to be added or deducted. If someone eats 90 grams of carbohydrate for lunch and his blood sugar is out of bounds two hours later, you need to take some of the lunch carbohydrate and put it somewhere else in the day. The goal is not to get into hyperglycemia or high blood sugar because that is what causes damage to the internal organs of the body.

Question 9: Why are carbohydrates so important to measure in the diabetic diet?

 

 

If a person is dependent on insulin, he can give himself more insulin to bring down his blood sugar. However, he must eat according to his insulin schedule to adequately control the glucose from the starches he eats. For example, if a person takes insulin in the morning before breakfast, he must eat something for breakfast or his blood sugar will be so low that he has hypoglycemia and damages his body. The usual schedule for giving insulin is at 8 A.M. and 4 P.M. Therefore, a person must eat to use the insulin he has injected.

The Need for Exercise
The rewards of physical exercise for the diabetic are adequate weight, lowered blood pressure, and lowered cholesterol. Since the muscles burn glucose during exercise, blood sugar is lowered. However, the blood sugar will rise with exercise if the exercise happens before taking insulin. If a person does exercise on an empty stomach, his blood sugar will fall dramatically. Therefore, diabetics need to exercise according to schedule just as they eat according to schedule. They need to plan exercise 1-2 hours after a meal and check their blood sugar 1 hour after exercise. When referring to physical exercise, I mean such activity as swimming, running, playing a sport such as basketball.

For older people, exercise can mean a 20-minute walk every day. Even people confined to bed can do exercise every day. Of course, the exercise schedule needs to be discussed with the treating physician.

Oral Agents to Control Blood Sugar
Three of four people with diabetes start out on pills to decrease their blood sugar. The drugs are Diabinase or Orinase. These pills stimulate the pancreas to secrete more insulin into the bloodstream. After about 10 years though, most people with diabetes no longer respond to the pills and must use injectable insulin.

Insulin
Until the discovery of insulin in 1921, people with diabetes had only weeks or months to live. It is still necessary to inject insulin into the underlying fat of the skin in order to get it into the bloodstream. Experts in research hope that soon insulin will also be in pill form or in a nasal spray.

Here are the types of insulin:

Short acting (Regular) works in 30 minutes peak effect is 2-4 hours duration 4-8 hours
Rapid acting (Humalog) works in 60 minutes peak effect is 3 hours duration 6 hours
Intermediate acting (NPH) works in 4-6 hours peak effect is 4-14 hours duration 14-24 hrs
Long acting (ultralente) works in 6-14 hours peak effect 14-24 hours duration 20-36 hrs

The trend with TYPE I diabetes is to give three or four shots of the fast acting insulin throughout the day. Of course, that means poking one's finger that often as well. This gives more freedom if one wants to exercise at different times during the day. A Finnsh pastor in Ioshkar-Ola is on this regime. His problem is that he studies and prepares sermons and forgets to eat and give himself insulin! Older people often have a mixed dose of insulins so that they have only two shots per day.

Question 10: What does insulin do for the body?

 

 

To preserve insulin, most people refrigerate it. When insulin is injected, it should not be cold - warm it up by rolling it between your palms. Check to be sure it is fresh and the expiration date has not passed. Be sure that whoever gives the injections rotates the places on the body where injections are given.

Complications of Diabetes
Hyperglycemia or High Blood Sugar
Usually an infection or a cold begins a cycle of high blood sugar. The body tries to fight infection, so the liver releases stored glucose. This reaction also happens with anger, fear, or any intense emotion. At a level above 180, there is thirst and urination and the following symptoms:

To stop hyperglycemia, fast-acting insulin is given to quickly lower blood sugar. If there is vomiting, the person may need to have intravenous fluids. If the person you care for has diabetes and is ill, do these things:

Hypoglycemia or Low Blood Sugar
This condition occurs when the insulin dose is too high making blood sugar too low. This happens when a person doesn't eat regular meals or has unplanned exercise. The early signs of hypoglycemia are:

For this condition, give a concentrated sweet such 3 tablespoons of honey or jam. Then measure the blood glucose in 15 minutes. If the glucose level is below 60 for more than an hour, the brain is affected. Convulsions and hallucinations may occur. The doctor then needs to determine what is causing the drop in blood sugar.

Question 11: We strive for balance of glucose in the blood because extremely high or low sugar causes:
(Only one of the following answers is correct.)
damage to the internal nerves of the body,
coma and brain damage,
appetite to increase,
desire to exercise.

 

 

Long term Effects of Diabetes
Neuropathy
Nerve disease of the legs, feet, and fingertips is common. The main symptom is tingling and then numbness.

Foot ulcers occur when the nerves are damaged and the circulation is poor due to diabetes. Therefore, we must care for and inspect the feet of diabetics. What we want to avoid is amputation of a leg because of a large foot ulcer that becomes infected.

To prevent ulcers, wash the feet in warm water and dry between the toes. Trim toenails after bathing when they are soft. Keep his feet warm at night with a pair of stockings. Shoes and stocking should be worn whenever the person is out of bed for his own protection. You may need to feel inside the shoes for pebbles or other objects that may cause injury to the feet.

Foot ulcers can be very stubborn to heal. Antibiotics and ointments are used. The diabetic also needs to keep his feet elevated. Tennis shoes with extra cushioning can be helpful.

Gastroparesis
This occurs when elevated blood sugar damages the nerves of the stomach so that food does not automatically pass from the stomach to the large intestine. As the food stays in the stomach, there is a feeling of bloating, nausea, and abdominal pain. When this happens, try giving smaller amounts to eat more frequently. The drugs Reglan and Propulsid help the stomach to work more normally.

Internal Nerve Damage
The functions of the bowel and bladder may be interrupted due to nerve damage that activates the muscles for passing stool and urine. There can be constipation or diarrhea. Foods that have high fiber such as oatmeal, vegetables and grains will help the bowel. If the person is incontinent of urine due to neuropathy, he is more prone to infections. Be sure that he urinates on a regular basis throughout the day.

Retinopathy
Diabetes is one of the leading causes of blindness. The tiny blood vessels in the back of the eye can swell and leak fluid causing blurring of vision. Eventually, these blood vessels can bleed into the eye causing difficulty seeing and scar tissue on the retina. The best prevention is to see an ophthalmologist regularly. He can do laser surgery to seal off the blood vessels that bleed.

Kidney Failure
Failure of the kidneys is due to the excessive amounts of glucose they filter daily in an effort to keep the proper balance of the body. If the kidneys fail, retinopathy and neuropathy accelerate. One of the best ways to prevent such complications is to keep blood pressure in normal limits. This is done through medications called ACE inhibitors. If blood pressure is lowered, there is less chance of stroke and heart attack. Of course, all the preventive measures against high blood pressure should be taken - no smoking, limitation of salt in the diet, and decreased intake of cholesterol.

Question 12: What effect does diabetes have on the body?