Understanding Diabetes: A Treatise For The General Public.
What your doctor does not have the time to tell you
⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯
Diabetes, like most diseases, is a condition that has first been described in Egyptian medical texts along with breast cancer and other diseases. When one says “diabetes” the term generally refers to a condition of high blood sugar to the general public, but an expert like me it could be one of two kinds of diabetes.
One, diabetes insipidus, a condition where there is passing of excessively large amounts of dilute urine being passed, literally translating to urine without much taste (due to the dilution). Or it can refer to diabetes mellitus which literally translates to urine that tastes like honey; this type of diabetes is also the one that we are to understand here in the treatise.
Diabetes mellitus can also be further divided into two types based on the cause, as type 1 diabetes or type 2 diabetes. This form of classification has first been done by ancient Indian physicians Sushruta and Charaka who probably first identified them as separate conditions.
Basically, to simply put it in diabetes mellitus irrespective of type, the glucose (sugar) levels in the blood are abnormally high. Though this is not where the story ends or begins and nor should it be for you to understand your condition.
Superfast overview:
To better understand the two types of diabetes for the layperson he must first be explained how sugar (glucose) is regulated in the body. All food that is eaten is converted into 3 primary macronutrients carbohydrates, proteins and fats. Unlike popular belief, all 3 play a role in all metabolic activities of building, processing and storage. All forms of sugars that one eats will basically be converted to glucose for the utilization of the body. The glucose is absorbed from the intestines into the blood and transported all over the body for its use. Our body is made up of cells and all nutrients are absorbed and utilized at a cellular level. Now, we humans defend and demarcate our property with the help of a wall of stone and cement and then we install a gate to regulate who comes in and leaves and for security to prevent unregulated access we put a lock. In the same way, all cells in our body to protect themselves. They too have a wall called plasma membrane present in human cells for “cellular security”. All entry and exit regulated in many ways, but the one of our interest is the insulin receptor and the glucose transporter. The insulin receptor is the lock that opens the gate which is the glucose transporter that allows the glucose in or keeps it out.
The lock which is the insulin receptor is opened by a key which is insulin. The insulin is produced by the pancreas. It is an organ located below the liver which is on the upper right-hand side of the body protected by the last few ribs. The pancreas has 4 types of cells and the cells called beta cells to produce the very important insulin.
As said earlier, insulin is the key that opens the lock to allow the glucose to enter the cell. It does so by binding to its receptor, which opens the gate called the glucose transporter that allows glucose from the blood to enter into the cell. For glucose to be used by the cell it has to enter the cell. Simply having sufficient glucose in the blood is not enough. If the glucose does not enter the cell it basically starves. It is as simple as that, no insulin, cells will not get glucose, and the cells will ultimately die.
Figure 1: glucose absorption by the cell in normal individuals
Figure 2: Lack of glucose absorption in diabetes mellitus due to lack of insulin or low amounts of insulin or reduced insulin receptor sensitivity.
Type 1 diabetes:
Coming back to the two types of diabetes, among them type 1 diabetes is less common in the population. The reason for type 1 diabetes has not been identified with pinpoint accuracy, but we know that it revolves around genetics and autoimmunity both probably going hand in hand with each other. The body’s immune cells, which are the white blood cells that protect us from germs for some unknown reason, attack the pancreatic beta cells that produce insulin. This attack permanently destroys them and there for no insulin is produced at all. All other cells of the pancreas remain more or less functional. Type 1 diabetes will occur at a fairly young age. Since a person does not produce insulin at all his blood glucose will keep accumulating. If the condition is not detected and treated the following events happen. The body thinks that it does not have sufficient glucose (even though it does) since the cells do not get any glucose (due to the absence of insulin), it tells the liver to release any glucose that it may have, this further makes the blood even more glucose laden. This heavy burden of glucose in the blood creates a water imbalance in the body to dilute this very concentrated “sugary” blood. The increased water in the blood is continuously removed by the kidneys and along with it salts that are present in the body. The person then becomes very dehydrated due to heavy urination. Since cells in the body will not get its basic fuel they now use their back up systems to make glucose using fats. This causes a severe accumulation of the by-products of the process and a condition called “diabetic ketoacidosis” develops and it is life-threatening.
Since the type 1 diabetes is characterised basically by the complete absence of insulin there is no other way to treat it than to provide the body with artificial insulin in the form of injections. Originally this insulin was obtained from pigs, but nowadays it is obtained from genetically modified bacteria. It is a permanent condition; there is no cure as of now. However, the quality of life is as good as that of a nondiabetic.
Type 2 diabetes:
Type 2 diabetes is the condition that is most common; it is a lifestyle disease and soon to be a major health crisis in India. India currently has one of the largest population suffering from diabetes and we are among the top 3 in the world. Type 2 diabetes has multiple causes and is most commonly due to obesity, but in India, I feel it is due to lack of physical activity, we Indians are also more genetically prone to diabetes. If caught early when the patient is said to be in the prediabetes stage the patient can be given appropriate counselling, told to exercise, lose weight, modify diet and the condition can be effectively reversed. Otherwise, just like type 1 diabetes, it is lifelong or a chronic disease. In type 2 diabetes there are two potential mechanisms that cause it, both may work individually or could go hand in hand.
In a person who is having type 2 diabetes will often not exercise or have a sedentary lifestyle or in some cases be very obese (sometimes all of them or combinations). Such patients will, due to their lack of activity, have low fuel demands at cellular levels. They will not need as much glucose as a normally active person, and the body will be supplied more glucose than required because the person continues to eat like an active person, sometimes even more. Now days also most of what people eat is junk food. You may think what you eat is healthy but if the proportion of nutrients in the food you are eating is off, even if it is healthy it will not make a positive difference. Now the cells do not need all that excess glucose, so what will they do? Too much of anything is bad. So the cells will usually store it. They will convert it into fat via various processes and store it all over the body as fat, under your skin, in-between organs, in your blood vessels (atherosclerosis). At the cellular level, this fat could block the insulin receptors. So the numbers of “gates” of glucose that are being opened by insulin are now lesser than what it would have been. So less glucose gets into your cells and there is more in the blood, resulting in diabetes. It is a cycle, more glucose, more fat which again means more fat and on and on it goes. This high level of glucose and fat then again gives rise to diabetic complications explained later. Your body in an attempt to save itself has sealed its own fate.
The second possibility is that since there is not much demand for the glucose and excess glucose is present the cells would be forced by the insulin to take up glucose that they do not need (imagine force-feeding at a cellular level, that is what you basically do to yourself). This is because under normal circumstances the pancreases produces insulin based on the glucose levels in the blood and not based on cellular demand of glucose, so more glucose in blood more insulin released, but the cells do not need all that glucose, it could be harmful to take too much of what they do not need. So to prevent that the cell reduces how effectively its receptors respond to the insulin. It jams the locks, makes them difficult to open. The technical term for it is low “insulin sensitivity”. In response the body would ideally increase its insulin production to counteract this; it would work of course, for a while. The person unaware of what is happening to him due to his unhealthy habits would continue his lifestyle as it is unless he has regular check-ups. This would eventually tire out his pancreas slowly shutting down the beta cells that produce the insulin.
You see, just like how your body, in general, gets tired, your organs get tired too. Sometimes a bit too much, most organs recover, but in the case of the pancreas, it is different. Your pancreas cannot be considered a whole organ; it is what I like to call a group of “cellular organs”. Normal organs are large consisting of many cells of the same kind doing the same thing, but the pancreas is tiny, it has 5 different cells in limited quantity doing different things. How long do you think this small group of cells that produce insulin can keep up with the increasing demands before they give away? Not very long obviously. They finally give away and levels of insulin produced fall, resulting in increased glucose levels in blood and the person now has type 2 diabetes. Once again a cycle will begin more glucose, more fat and so on. Type 2 diabetes can occur at any age, usually, initial signs will be seen at middle age since that’s when the negative effects of lack of exercise kick in and obesity would have set in, it needs time to take a hold of your body. Lately, however, it has been noticed that kids in their late teens have started to develop type 2 diabetes.
If untreated the sugar levels would increase to extremely high levels resulting in altered consciousness, lethargy etc, a condition called hyperosmolar hyperglycemic state/coma (HHS) it happens in type 2 diabetics. It is very unlikely to happen, however, unlike the previously described diabetic ketoacidosis which generally happens to type 1 diabetic. Before HHS could happen one of the many diabetic complications would kick in forcing the patient to seek medical attention and thus resulting in the diagnosis of the type 2 diabetic.
Since in type 2 diabetes there is the presence of insulin, it is just that the insulin amount is too low since the pancreatic beta cells losing their activity due to fatigue or the body cells are not sensitive enough to it. Therefore we initially do not need insulin injections to treat. Instead, we can give oral drugs. Theoretically once again the patient is expected to get in line, work out, reduce weight etc, and maybe, if lucky, the condition is reversed and the patient can go off the meds, or at least their dose and the number of drugs can surely be reduced, but does it happen practically? Well, in 99% of the cases no. why? Well most would say the patients circumstances, yes that is true, the patient is now too old, as per him, to work out, or he says he does not have the time, or he has probably never been counselled properly about the condition, or they get bored and quit gym too early or in many cases the condition is detected so far late that so many complications have set in that the patient is not fit enough to step out of his home let alone go to the gym.
As most diabetic will know that they are diabetics too late. The “bad physique” combined with the “age factor” creates a huge "mind block" in the patient about hitting the gym. They may feel they are too old to go to the gym, or in bad shape to hit the gym. Let me tell you, anyone who can walk about or lift the smallest dumbbell at the gym is good enough to hit the gym and age is not a factor, unless you are beyond your 60’s maybe then it’s a bit too late if you have not done so already by now. Walking and jogging is fine but nothing kicks diabetes where it hurts like actual weightlifting at the gym. It is the best work out for all!
Now, what happens when you do not take this advice, or do not make any of the important lifestyle changes and instead simply continue to take the prescribed oral medications? In such patients the oral medications that we provide may work in the following fashion:
1) They increase the sensitivity of the body cells to glucose. Once again exercise (weight lifting specifically) does this naturally since glucose need is increased.
2) They force the pancreas to produce more insulin. Do note that these cells are already fatigued.
3) They cause you to excrete the glucose in your urine in order to eliminate the excess glucose that you. It should be noted that this mechanism of the drug goes very much against the laws of nature. The body of a healthy person will never let a person eliminate sugars in his urine. It is also important to reflect on the fact importance of exercise here once again which would increase the glucose need to the body cells for glucose reducing the need for such drugs.
Drugs that rely on the first two mechanisms are more commonly prescribed. There are many guidelines that decide what is to be prescribed to whom. From the mechanism that I have explained it is clear that the drugs do not really “cure” anything, (diabetes mellitus cannot be cured) but rather just put a band-aid on a gunshot wound. Therefore if no lifestyle changes are applied, the patient's pancreas fatigues further, eventually the insulin sensitivity decreases further or all the pancreatic beta cells slowly die or both. Finally, the patient’s condition negatively progresses and the patient is prescribed injectable insulin like a type 1 diabetics. Initially the insulin will be prescribed with some oral drugs and later on, it will eventually be so bad that only insulin will be given it massively high doses that could possibly kill a healthy lean person if not knock him out. By the time this stage arrives, it is also very likely that the person would have developed some of the complications of diabetes.
Complications of diabetes:
Diabetes goes hand in hand with atherosclerosis and hypertension (high blood pressure) a patient with diabetes will generally have many of them. This gives rise to many additional health issues in the patients. The mechanism for the following conditions is too complicated to explain in simple terms but if I were to put it in a few short lines I would do it like so: No cells like excess glucose, excess glucose kills and destroys organs, if it’s not that, then it’s the fact that the cells cannot use the glucose which is why they die, from starvation.
· Stroke: a condition that occurs without warning where there is a block in the blood vessels of the brain due to a fat globule either released from an atherosclerotic plaque or elsewhere, or it is due to a blood clot, or it can be due to bleeding in the brain. A lot of permanent damage to the brain can be prevented it patient taken to a tertiary care hospital within 2 hours.
· Retinopathy: it is the damage to the nerve cells of the eye that causes blindness in diabetics. Poor glucose control will cause this. Usually, a person with retinopathy is very likely to have nephropathy.
· Nephropathy: excessive glucose damages the kidney cells first causing kidney damage then kidney failure.
· Neuropathy: a condition where there is nerve damage in hands and feet causing loss of sensation, pricking feeling etc.
· Peripheral vascular disease: it is like atherosclerosis of the very fine blood vessels usually in the feet. They get blocked so the tissue does not get nutrients so it dies. Usually, this block is why wounds in such people do not heal and result in ulcers.
· Diabetic foot ulcers: wounds on feet that do not heal would be because of multiple reasons including PVD or because the tissue cannot take up glucose so cells cannot divide and heal the wound.
· Cardiovascular disease/ischemic heart disease/ heart disease: (Heart attack) technically they are not all the same but for the layperson can be assumed to be the same, it is the block of blood vessels of the heart that cause lack of blood supply to the heart usually causing permanent damage to the heart. Occurs suddenly like a stroke. (it is like a stroke but occurs in the heart, though the cause cannot be bleeding like in the stroke it is always a block)
Final note:
There is quite a bit of truth in the claim that diabetes mellitus is a chronic illness, but as clearly explained it does not have to be if you have been diagnosed early. You do not have to let diabetes control your life. You do not necessarily have to be dependent on those drugs especially if you are one of those many type 2 diabetics. The internet is full of examples of people who have managed to hit the gym and go off the drugs and I am here to tell you that you can be one of them. You CAN fight diabetes. You can revert diabetes. So the question is, do you have the will and determination to do it?
Attempts have been made to make this article as accurate as possible. If any scientific error is noted please kindly report it to the author.
For further reading:
Medical News Today:Diabetes: Symptoms, causes, and treatments
Comments
Post a Comment