By Dr George Samra, MB, BS (Sydney), FACNEM
Source: Transcript of a lecture by Dr Samra published in The Hypoglycemic Health Association Newsletter Volume 16 No 2, June 2000.
I wonder how many people here know much about Insulin. When it was discovered, for example? [Audience member During the war?] 1921, I’m sure there was a war somewhere at that stage [laughter]. But, what I’m trying to say there is that with Pancreas, with Diabetes, with Hypoglycemia, these are all modern diseases. There was virtually nothing known about them a hundred years ago. If you went to a doctor before a hundred years ago, does anyone know how you would have been diagnosed with having Diabetes ? [Audience: Testing the urine for sugar] Yes, the doctor would do the taste-test for sugar in the back room.
That was the diagnostic test, but he’d also notice a nail varnish, acetone sort of breath smell. And he’d go to the back room and do the taste test then give you the bad news. Or he’d suspect it from two of the most common symptoms, Polyuria (which means urinating too much) or Polydipsia (which means drinking too much). So were stunned how the Medical Profession can ignore Hypoglycemia as a disease entity, and a part of that is the bad name. Maybe it should be called Dysglycemia, Reactive Hypogylcemia, or Reactive Dysglycemia or other names.
But even Diabetes has a very new history. Insulin being discovered in 1921 was the first hormone to actually be fully described in all its amino acid sequence. So it is a unique situation for people to have to inject themselves a few times a day with a product that keeps them alive.
Todays topic is Preventing Diabetes, or possibly how Hypoglycemics can prevent Diabetes.
I’d like to read to you from the Homepage of the Diabetes Australia Association. It says, Report on Diabetes in Australia.
In 1990, approximately 350,000 Australians had diagnosed Diabetes and an estimated 300,000 had undiagnosed Diabetes, together representing 3.8% of the total population. The figures for Reactive Hypoglycemia are approximately the same nearly 4% of the population.
Diabetes is likely to affect 900,000 Australians by 2000 and 1.15 million Australians by 2010. Australian Aborigines suffer the 4th highest rates of NIDDM in the world. You’ll understand that there are two types of Diabetes, we’ll get into that classification more later, but there is the Juvenile type where they need Insulin, and the Mature type where they need tablets and or diet to control it.
Insulin-dependent Diabetic ranks as one of the most common serious childhood diseases in Australia, and is likely to have a higher incidence in children under 20 years of age than cancer, cystic fibrosis, multiple sclerosis, juvenile rheumatoI’darthritis and muscular dystrophy.
Australia has very high rates of Insulin dependent and also Mature Onset Diabetes Mellitus. Females with IDDM have ten times the rates of cardiovascular mortality (that is, dying from heart attacks and strokes) compared with non-diabetic females. That’s a pretty good reason to try to avoid getting Diabetes.
The incidence of gestational Diabetes is increasing, particularly in ethnic populations. Risk factors for Diabetes such as obesity and physical inactivity are increasing in Australia. Australians with Diabetes experience a reduced life-span and higher rates of eye, heart and renal disease and stroke compared to non-diabetic Australians. The total cost of Diabetes exceeds $1 billion annually (or almost $3,000 for every diagnosed case).
One of the handouts is titled Complications of Diabetes (Figure 1), and certainly with the damage to the eyes, the heart and the circulation, the risk of losing fingers and toes, urinary problems and impotence. Certainly, it is worth trying to prevent this disease.
The main symtoms of Diabetes are Polyuria (which is urinating too much), Polydipsia (which is drinking too much). With kids, the mother might say their child is drinking a lot more than before, they are always thirsty and never satisfied, we perform a urine test and blood test to get the answer.
Weight Loss, Urinary Tract Infections and Vaginal Candidiasis are typical diagnostic symptoms. Why you get more urinary tract infections? Sugar is a good feed for the germs to grow on.
Glucosuria and Hyperglycemia are incidental findings at clinic. If a doctor sees you and gives you a urine test or blood test, he might see a high sugar level on a blood test, or sugar in the urine, and that is a pretty good reason to investigate further.
Juvenile Diabetics frequently present in a coma. Often they have not been diagnosed, there weren’t many clues, so they are in a coma by the time they are picked. It is worth noting that the Pancreas has digestive functions as well. It’s good to look for Amylase and Lipase levels and conduct digestive tests on patients, because often they need some support too.
With blood sugars, the diagnostic levels, obtained from the National Diabetes Data Group are 140mg per 100mL (7.0mm/L) for a fasting reading. Or two hours after a sugar load or meal getting a reading over 11.0 mm/
L. People having random blood sugars over eleven mm/L are certainly likely to have Diabetes.
As I mentioned earlier, there are two types of Diabetes Mellitus. There is the Insulin-Dependent type that we described as Juvenile, and the non-Insulin dependent type, or Mature-onset type.
With the Insulin-Dependent type, it most often presents in people under the age of thirty, there is no associated obesity. They represent only 1/8 of Diabetics, and the onset is characteristically abrupt. Insulin-Dependent Diabetics are prone to Keto Acidosis, their bodies burn up different fuels other than glucose in order to feed the brain such as ketone bodies from fat because the body sugars just aren’t arriving into the tissues where they are required.
Islet-Cell Antibodies are present in over 80%. What this is telling us is that Juvenile Diabetes is really an Auto – Immune disease. Beta-cell destruction involves cell mediated immune mechanisms. The site of Insulin production in the pancreas is called Islets of Langerhans, and contains Beta-cells.
The total number of Beta-cells decreases because they are destroyed by auto-antibodies, which means that their own antibodies are fighting the Juvenile Diabetics own Insulin-making cells.
Polygenetic factor susceptibility involves a HLA-D phenotype on Chromosome 6 as a predisposing factor to Juvenile Diabetes. The environmental factors are stronger than the inherited factors of Juvenile Diabetes. So much so that with identical twins, less than half of them will both have Juvenile Diabetes. The medical explanation for this is that there is probably a virus that has affected one of the twins, and that virus has triggered off Beta cell destruction in the pancreas of that twin. It is widely acknowledged now that the Roto-virus is a likely culprit.
With the Non-Insulin Dependent Diabetes Mellitus (NIDM), this is the sort that Reactive Hypoglycemics should be really wary of. It commonly presents in older patients, people over thirty years of age. NIDM is associated with obestity, and there is a gradual onset as opposed to the Juvenile type that presents very abruptly. The normal B-cell mass appears to be preserved. In other words, even though the pancreas is failing, when the pancreas is examined the B-cell mass and Islets are still in tact and there is no loss of mass. By contrast, if you examine the pancreas of a Juvenile Diabetic, their Islets and Beta-cell mass will be diminished.
NIDM patients have a delayed and decreased relative intake of Insulin, we call this condition Insulin Resistance. This is really a decreased effectiveness in restraining liver glucose uptake and muscular glucose uptake. We’ll be talking a lot more about Insulin Resistance, and really one whole page of the two page handout is about Insulin Resistance.
NIDM don’t always need to be on drugs. Following a strict diet without sugar also helps, certainly eating like a hypoglycemic makes a very big difference to the NIDM, often controlling their disease without medication. Weight loss is useful, and careful drug management is required.
Complications of Diabetes happen for two reasons. Firstly, the person has had Diabetes for a long time. The second, and more important reason, is that some Diabetics don’t carefully manage their disease. They are a bit casual about their intake of sugars, and they don’t really pay attention to things that happen to their body that needs more urgent attention. For example, Diabetics should really have an eye examination every two years to ensure everything is going well, and detect and treat eye problems early.
Eyes conditions such as Macula Oedema, Proliferative Retinopathy, Retinal detachment are much more pronounced in Diabetes, and all of these conditions can lead to blindness if Diabetes is not carefully controlled. Proliferative Retinopathy is a hallmark, it is the way specialists can often diagnose Diabetes when they are looking at the back of your eyeball. The arteries actually proliferate and grow over veins, and start blocking some of the seeing nerves of the eye in the retina. There are a few theories of why this happens. You’ll hear of Diabetics having laser treatment to their retina, in an attempt to stop the arteries multiplying. The retina is the skin in the back of the eyeball that contains all of the nerve endings. People can go blind if these nerves are blocked or damaged.
There is a four times greater chance of Diabetics developing Coronary Atherosclerosis and Myocardial Infarction. Further, Diabetes complications include Nephropathy (kidney disease), Hypertension, Nail infections and Cellulitis. There is Polyneuropathy and Peripheral Neuropathy, Diabetics lose sensation in their finger tips and hands in different ways. The typical polyneuropathy in Diabetes is the glove and stocking type, where you lose feeling below a certain level, and you get pins and needles, tingling and numbness. You lose sensation in your feet. A lot of Diabetics have problems with their feet because they can tread on things without realising and get ulcers and infections in their feet. For this reason Diabetics should see a podiatrist three or four times a year. Diabetics with no feeling in the tips of their fingers struggle to do buttons up.
Impotence and urinary tract infections are also associated with Diabetes. I mentioned earlier why urinary tract infections occur. If Diabetes is poorly controlled, the arteries get bands of narrowing and pain results. Intermittent . means pain in the calf muscles and other muscles that are being used. This occurs because of blocked arterial blood (and oxygen) supplies to the muscles. When a Diabetic is careless about their disease management, it can lead to more serious and unpleasant conditions like ingrown toenail, or losing toes and feet to gangrene.
If you look at the diagram with the title Insulin Facilitates Transport Across Membranes (Figure 2), it shows the action of Insulin. The capital I at level A B and C is Insulin acting at the receptor site, helping glucose to enter the cell and to form Glycogen (which is like a long chain of glucose molecules stuck together). This happens in muscle and also the liver. But what people often forget, and even many doctors seem to forget is that Insulin has functions other than just sugar metabolism. Insulin facilitates transport of most nutrients across membranes, such as fats and proteins. Insulin pushes fatty acids across the membrane to form Triglycerides, and pushes amino acids from the blood to form protein. Insulin makes sugars more complex, it makes the fatty acids have longer chains and become more complex, and Insulin also converts amino acids into proteins.
Insulin is probably the major anabolicbuilding hormone of the body, much more than Growth Hormone or Androgens that some athletes cheat with. Insulin is most responsive to rising levels of glucose, so even though it does all of these things like pushing fats and amino acids into the body cells, Insulin responds to the sugar levels. If the sugar levels are high, the mechanism is triggered and Insulin pushes sugar into the body cells, and also pushes fats and proteins into the body cells. Insulin inhibits Catabolic processes, and actually has the opposite reaction, stopping the breakdown of glycogen, triglycerides and proteins. So it really is a building-block hormone.
This all becomes important when we consider Insulin Resistance. (Figure 3)
If there is disturbance when Insulin binds to the receptors there will be reduced Insulin activity. This condition is known as Insulin Resistance. There is a reduced glucose entry into cells, blood glucose rises and the pancreas responds by producing more Insulin. So if things go wrong at the site on the receptor where Insulin is supposed to help sugar go into the blood, we need to know why.
Eating too much sugar might cause problems at the receptor site and your body might not cope; or possibly the essential minerals arent present in sufficient quantities. The body starts pumping more and more Insulin from the pancreas trying to get the sugar into the body cells. This is called Hyperinsulinaemia when one has excess Insulin.
Insulin Resistance has been estimated to occur in 25 percent of adults in USA, and 1/6 of these people develop Maturity Onset Diabetes. Insulin Resistance is a concept that is very real lately, and there are some clues as to who has it. So it is possible to actually measure Insulin levels and random Insulin levels when measuring sugar levels, and identify people that have got Insulin Resistance and high Insulin levels in their blood even if their blood sugars appear to be under control.
Obesity is a typical condition in people with Insulin Resistance. Maturity Onset Diabetics are really people that have Insulin Resistance that has gone out of control and their pancreas does not cope. High blood pressure is associated with Insulin Resistance. People with Dyslipidaemia, have high Triglycerides, high cholesterol, high LDL and low HDL.
Extra Insulin is being pumped out, this might be caused by taking too much sugar on board, or the sugar just isn’t sending the message to enter the cells, or for some reason the receptor isn’t receiving that message. Even though the Glucose arm is weak in the ABC diagram, B and C arms are fine so your body proceeds to make a lot more triglycerides, it also makes more fat and protein. People with Insulin Resistance have increased muscle mass, but they also have increased complex fats on board, so their Triglycerides and LDL all go above normal levels. If you have a lot more fat on board, your chances of getting cardiovascular disease (arterial disease) is much higher too.
And now onto the syndrome X that everybody is talking about. Most doctors talk about Syndrome X when they see a fat person with high blood pressure, they say “You might have Syndrome X”. The doctor checks the patients cholesterol, triglycerides, and Insulin levels and if they are all above normal levels, the patient is told he has Syndrome X.
These things all tie up. We’re not just talking about a disease with high blood sugar and people needing Insulin. We’re talking about a disease which makes your body go into an anabolic (or building block) mode, to build up more complex fats which are blocking peoples arteries, making them more overweight and storing more fat in their body cells. So its a vicious cycle, that if you don’t watch Insulin Resistance and you don’t avoid HyperInsulinaemia, then bad things are going to happen, not just Diabetes. You get high cholesterol, the arteries go hard with the high cholesterol which leads to Atherosclerosis and heart disease, then high blood pressure, and peripheral arterial disease.
There are some other conditions associated with Insulin Resistance which include, Renal Calculi (kidney stones), Hyperandrogenism (over masculinization) and Non Alcoholic Steatohepatitis (a type of liver disease). Those mechanism have predictable patterns like Syndrome X when you understand how Insulin Resistance works, with not just glucose, but other body fuels like fatty acids and amino acids.
Within Insulin Resistance and Mature Onset Diabetes, Functional Reactive Hypoglycemia is considered to be a predisposing condition. Reactive Hypoglycemia is low blood sugar as a reaction to eating sugar in the first place. It’s a pancreatic problem where the pancreas produces too much Insulin at the wrong time. And it is a condition of hyperInsulinism; the pancreas makes too much Insulin. When the blood sugar crashes Hypoglycemics feel symptoms because the brain relies on blood sugar levels. One can get tired in the head, moody, and depressed. So the symptoms of hypoglycemia are really related to the fact that the brain isn’t getting fuel.
Getting back to Diabetes, excessive consumption of carbohydrate foods (in particular high Glycemic Index foods) is a predisposing factor. Eating sugar, honey and glucose, or things that are regarded as being sugary by nature of the way they affect your blood sugars (the Glycemic Index) will trigger too much Insulin. If your Insulin levels continue to be high, at some time Insulin Resistance can develop and the whole syndrome affecting the heart, vascular system, cholesterol and blood pressure all take over.
Over eating is another predisposing factor, so pay attention how much you take in. The pancreas is producing more Insulin than normal in the above situation, and Insulin Resistance may lead to failure of the pancreatic Beta-cells to produce sufficient Insulin in response to a sugar load, and hypoglycemia results. When and if pancreatic failure occurs, Diabetes occurs. So when you have Insulin Resistance, eventually the pancreas is just pumping out so much Insulin it gives up trying and the blood sugar levels rise. But long before Diabetes occurs there is an attempt by the pancreas to make more Insulin to overcome the resistance of Insulin at the binding site.
Preventing Type One Juvenile Diabetes.
Understanding that this is a kids disease and occurs in people under the age of thirty, it is important to encourage maternal health during pregnancy. The mother should avoid smoking because it affects the vascular system, although it doesn’t really have any direct effects on Diabetes. The mother should also avoid drinking alcohol and taking drugs. She should follow a low sugar diet during pregnancy, and if possible avoid people with viral and bacterial infections because this might be the Roto-Virus that triggers Diabetes in the baby. If the mother is unhealthy during pregnancy and doing all the wrong things, that might well be a predisposing factor.
It is also important to promote a strong immune system for the child. Understanding that identical twins have less than a fifty percent chance of them both having Juvenile Diabetes, there is a notion that you’d want to be the twin who didn’t get it. There must be factors that help prevent developing Diabetes, for example the child without Diabetes might have a better immune system with more Vitamin C in their diet. The Vitamin C helps promote white cell competence, the lymphocytes work better because they can kill off viruses and bacteria better. With a family history of Diabetes, and you want to minimize the chances of your children developing Diabetes you have to do these things to strengthen the child’s immune system.
Diabetes is becoming more common; Zinc is an important dietary mineral, between ten to forty milligrams is needed. Perhaps the children could have liquid zinc formulations as well.
Have children vaccinated against Rotovirus if and when available. The good news is that it will be available one day, but that vaccine doesn’t exist yet. A low immune diet will also improve the child’s chance of not developing Diabetes. The child should consume no dairy products for the first two years of his or her life. Cow protein seems to be a major factor in weak immune systems in adults, so the child should only eat small amounts of beef or veal.
As the children get older, their immune systems will be stronger if they don’t take up smoking or drink a lot of alcohol, because alcohol can damage the pancreas. A low sugar diet is preferable too.
Sugar is not part of a natural human diet. We are getting so much of our food out of tins, packets and jars. If we lived on a farm, and could only eat our own animals and vegetables that would be closer to a natural human diet. You can imagine what a caveman might eat, or an Aboriginal might eat before European settlement. Certainly the diet for Aborigines has changed a lot since then, and they are now getting Diabetes at a ridiculous rate the incidence is four times greater than their white counterpart.
Hepatitis A ad B vaccinations exist and should be given. All of these viruses listed damage the liver, but they can also hurt the pancreas. Particularly the Rota Virus is regarded as the one that triggers the auto-immune breakdown, but I wouldnt be surprised if the E-B Virus does too and immunization should be sought for a high risk child. Avoiding sugar is also away of promoting good behaviour to protect the pancreas from overwork.
Juvenile Diabetes is an immune Diabetes, so supplements are often needed. Chromium and Zinc are very important as receptor site protectors. Selenium is the most important water soluble Anti – oxidant, it is the core of Glutathione and Glutothiame reductase, which are the most potent anti oxidant enzymes in your body. They prevent damage on the inside of one’s body tissue from things like Peroxide, ozone and oxygen free radicals, and neutralize the free radicals into water and oxygen.
Vitamin E is a very important supplement too, it is the most important fat-soluble Anti oxidant. A large part of the body is adipose or fatty tissue. One needs anti oxidants that penetrate into fat-soluble components of the body.
Preventing Type 2 Diabetes.
Avoid obesity, If overweight, lose weight. Avoid over eating. If you can lose weight its good. If you are overweight and you don’t over eat you are protecting yourself too. It’s the excess sugar coming in that really triggers Syndrome X. A fat child can become a fat adult without necessarily going into a sick state where they are going to be at high diabetic and hypertensive risk. Avoid sugar, honey and glucose, and use substitutes if you have a sweet tooth. Eat low glycemic foods that cause blood sugars to rise slowly.
Avoid high cholesterol foods. There is a whole chain of events that Diabetes and Diabetic Complications lead to. Its no good just avoiding sugar and eating lots of bacon and eggs, and greasy food, you have to really have a health mentality when you eat. You should use low-cholesterol substitutes when available. Trim the fat off meat where you can. Remove egg yolk. Fish is very low in cholesterol, as are vegetables.
Avoid excess stress, hypertension and high blood pressure.
However, it’s easier said than done. Humans are funny creatures and a lot of us are to blame for our own stress load, although most of us don’t have enough clarity of mind to recognise it. A fellow turned a hundred in Adelaide last week. He was on his way to Bowls, and he was driving himself, and the journalist was in his way. The journalist asked the man what his secret to longevity was, and I suppose this man would give the best advice. The man replied that he used to worry all the time, and when he turned forty he decided not to worry anymore. He stopped worrying and never worried since.
Smoking might not trigger Diabetes, but certainly all the bad things that Diabetes does smoking makes worse. Including all the vascular repercussions to do with vision, and peripheral circulation and to do with heart attacks.
Exercise thirty minutes a day five days a week. Walking is sufficient, but you should try to be in a pattern of doing something healthy for your body. You are only given one body in your lifetime. If you abuse it and you don’t feed it properly, the machine goes rusty. That rust converts to disease in time.
As in the case with Juvenile Diabetes, Type 2 Diabetics should take Zinc supplements. Zinc is important for Hypoglycemia, but it’s also important for preventing Diabetes. Chromium is also good. You need to be on at least 30 mg of elemental Zinc a day, Legally you are only allowed to have 25 mg of Selenium in formulations, unless they are dispensed by a doctor, or a doctors prescription. Whereas, one drop of the Nutricare Sodium Selenite solution contains 25mg. To replace your daily requirement you need 50 mg. But to prevent Diabetes you probably need 150mg, especially if you are a real candidate for Type 2 Diabetes.
Manganese or Magnesium tablets are also useful.
They are required at our receptor sites for Insulin. Multivitamins are useful because as you get older, your body could be failing to absorb certain minerals.
Vitamin C is an important vitamin for preventing Mature Onset Diabetes and for Hypoglycemics. It is involved in the glycolytic pathway.
A recent extract describes Vitamin E as a preventative in high doses for Diabetes. Diabetic benefited most in their eyes after taking Vitamin E. Retinal flow was increased from 17% below normal levels to similar to non-diabetic levels, although no change in levels of heamoglobin or sugar levels. The high intake of Vitamin E hadn’t improved their blood sugar control, but it had managed to protect their retina from damage, and their kidneys from Nephropathy. There were no major adverse effects of taking high levels of Vitamin E, although there were trends towards high cholesterol levels. The beneficial effects of Vitamin E were probably due to the Anti – oxidant effects and vascular endothelium. Vitamin E was thought to prevent vasoconstriction by acting on pathways mediated by nitric acid and diglycerol alprotein kinase. Certainly, in my opinion Vitamin E is a part of Diabetes prevention. If you know of anyone with Diabetes and very bad eyesight, they should be taking at least 1800 units per day, and this might save their vision if you can convince them.
Another extract involved Karlsburg Type One Diabetes risk study of the general Population frequencies and interpretations of the four major Type One Diabetes -associated Auto – Antibodies studied in 9419 school children. If you recall we discussed Type One Diabetes being an Auto-Immune disease, rather than just a progression disease where your pancreas fails. The immune system goes wrong and this leads to a fast onset. The Karlsburg Type I (Insulin-dependent) risk study on school children aims to evaluate the predictive diagnostic value of Diabetes-associated Auto Antibodies in the general population. School children aged 6-17 years participated in the study. From the results it was recommended that in children older than 5 years the combined antiGAD/IA2 test with cut-off at or greater than the 98th percentile should be used for primary screening followed by by testing for IAA (which is an auto-antibody) and ICA. Subjects at risk for Diabetes have two or more Auto Antibodies at or greater than the 98th percentile. Subjects at risk for rapid progression to Type I Diabetes have two or more Auto Antibodies are at or greater than the 99.8th percentile. So they did Auto Antibody tests on ten thousand children and researchers were able to predict who was going to get Diabetes.
In conclusion, one is not really trying to prevent Diabetes, but is actually looking to prevent diabetic complications such as blindness and amputation of limbs. It is important to stop smoking, limit alcohol intake, follow a low-sugar diet, avoid the Rotovirus, eat sensibly and avoid allergy foods such as dairy, take Selenium and Vitamin E as you get older. Reactive Hypoglycemics should be taking Vitamin C, Zinc, Manganese, Magnesium and Chromium, but particularly Chromium and Zinc.
From the Internet at
Diabetes Care 1999: 22:1245-53
Diabetologica 1999 June;42(6):661-70