1 DIABETES MELLITUS FROM CONVENTIONAL SCIENTIFIC AND TCM PERSPECTIVES - PART ONE

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>DIABETES MELLITUS FROM CONVENTIONAL SCIENTIFIC AND TCM PERSPECTIVES - PART

>ONE

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> DIABETES MELLITUS FROM CONVENTIONAL SCIENTIFIC AND TCM

>PERSPECTIVES - PART ONE

> By Clinton J. Choate L.Ac.

>

> CLINICAL OBSERVATIONS

>

> 1. Background

>

> There is nothing new about diabetes; it has been a

>medical problem since antiquity. The name which was originated by Aretaeus

>(30-90 CE) came from the Greek words meaning 'siphon' and 'to run through',

>signifying the chronic excretion of an excessive volume of urine.

>

> Diabetes mellitus, because of its frequency, is probably

>the single most important metabolic disease and is widely recognized as one

>of the leading causes of death and disability in the United States. It

>affects every cell in the body and the essential biochemical processes that

>go on there.

>

> Diabetes has been linked to the western lifestyle, as it

>is uncommon in cultures consuming a more primitive diet. As cultures switch

>from their native diets to more commercial foods, their rate of diabetes

>increases, eventually reaching the same proportions seen in western

>societies.

>

>

> A great deal of research has been conducted into the

>possible aetiology of diabetes. Most of the prevalent ideas can be

>classified under one of the following categories: heredity, endocrine

>imbalance, dietary indiscretion and obesity, sequelae of infection, and

>severe and continued psychic stress.

>

> Although genetic factors appear important in determining

>susceptibility to diabetes, environmental and dietary factors are also

>important in its development and many have been identified. A diet high in

>refined fibre-depleted carbohydrate is believed to be the causative factor

>in many individuals, while a high intake of high-fibre complex carbohydrate

>foods is protective against diabetes.

>

> Obesity appears to be a significant factor, particularly

>considering the fact that 90% of Type 2 (see below) sufferers are obese.

>Even in normal individuals, significant weight gain results in carbohydrate

>intolerance, higher insulin levels and insulin insensitivity in the fat and

>muscle tissue. The progressive development of insulin insensitivity is

>believed to be the main underlying factor in Type 2 diabetes. Weight loss

>can correct all of these abnormalities in many instances and significantly

>improves the metabolic disturbance of diabetes in most cases.

>

> What has become apparent through years of research is

>that the diabetic condition is not simply a matter of one or two things

>having gone wrong. It is a complex condition with a multitude of metabolic

>imbalances. Consequently, the conventional medical approach of simply using

>insulin or oral drugs to treat diabetes is incomplete and the person

>relying on them to prevent long-term complications remains at risk.

>

> About Blood Sugar

>

> Carbohydrate is the active fuel of the body and is

>ordinarily the main source of energy of the tissue cell. In the normal

>digestive process, food sugars and starches (carbohydrates) are changed

>into sugar glucose. This is stored in the form of glycogen (animal starch)

>in the liver and muscles for later use as a body fuel, at which time it is

>reconverted into glucose. Blood sugar rises somewhat after eating, and in

>healthy individuals returns to normal levels in about an hour or two. The

>amount of glucose in the blood is controlled mainly by the hormones insulin

>and glucagon. Too much or too little of these hormones (or if they are

>somehow ineffective) can cause blood sugar levels to fall too low

>(hypoglycaemia) or rise too high (hyperglycaemia). Other hormones that

>influence blood sugar levels are cortisol, growth hormone and

>catecholamines (epinephrine and norepinephrine).

>

> The pancreas, a gland in the upper abdomen is

>responsible for producing insulin and glucagon. The pancreas is dotted with

>hormone-producing tissue called the islets of Langerhans, which contain

>alpha and beta cells. When blood sugar rises after a meal, the beta cells

>release insulin. The insulin helps glucose enter body cells, lowering blood

>glucose levels to the normal range. When blood sugar drops too low however,

>the alpha cells secrete glucagon. This signals the liver to release stored

>glycogen and change it back to glucose, raising blood sugar levels to the

>normal range. The result of the disturbed metabolism of glucose causes an

>abnormal accumulation of sugar in the blood stream and the diabetic

>condition.

>

> Blood Sugar Ranges

>

> The quantity of glucose in the blood seldom exceeds 160

>milligrams/decilitre (mg/dl) of blood shortly after food sugar has been

>absorbed, nor seldom falls below 60 mg/dl during fasting. This increases

>about 2 mg/dl per decade after age 30. Some mild diabetics will have normal

>fasting blood sugar values and values in the diabetic range only after

>meals. Occasionally very mild cases will have values within normal at both

>times and the diabetic tendency will be evident only when these persons are

>required to handle more than an ordinary amount of carbohydrate.

>

> In the fasting state, blood sugar can occasionally fall

>below 60 mg/dl and even to below 50 mg/dl and not indicate a serious

>abnormality or disease. This can be seen in healthy women, particularly

>after prolonged fasting. Blood sugar levels below 45 mg/dl in a woman or 55

>mg/dl or less in a man indicate a strong possibility of hypoglycaemia.

>

> Higher-than-normal blood sugar levels, for example 140

>mg/dl or higher after an overnight fast, can indicate diabetes mellitus. In

>moderately severe diabetes, after-meal values of 250-350 mg/dl are not

>unusual. If a person with diabetes develops hyperglycaemia and it is left

>untreated, the result can lead to coma or death.

>

> Diabetes is characterised by three well-known syndromes,

>polydipsia (excessive thirst), polyphagia (excessive hunger) and polyuria

>(excessive urination). Laboratory findings reveal high blood sugar and

>glucose in the urine and as the metabolic derangement worsens, excessive

>ketone bodies in the blood and urine. The accumulation of these produces

>acidosis which, if not counteracted, can result in coma and death.

>

> There are three main types of diabetes:

>

> Type 1 or 'Insulin-Dependent Diabetes Mellitus' (IDDM)

>also known as 'Juvenile Onset Diabetes'.

>

> Type 2 or 'Noninsulin-Dependent Diabetes Mellitus'

>(NIDDM) also known as 'Adult Onset Diabetes'.

>

> Gestational diabetes.

>

> Type 1 Diabetes (Insulin-Dependent Diabetes

>Mellitus/IDDM)

>

> Insulin-dependent diabetes is considered an autoimmune

>disease in which the immune system attacks the insulin-producing beta cells

>in the pancreas and destroys them. The pancreas produces little or no

>insulin and it is then almost certain that life-long insulin replacement

>will be necessary. The exact mechanism for the body's immune system attack

>to the beta cells is unknown but the most likely causes are viral

>infection, genetic factors and free radicals.

>

> Interest has been generated lately in the strong

>evidence linking exposure to a protein in cow's milk (bovine albumin

>peptide) in infancy to the autoimmune response and subsequent Type 1

>diabetes. In detailed studies1 it was shown that patients with Type 1

>diabetes were more likely to have been breast-fed for less than three

>months and to have been exposed to cow's milk or solid foods before the age

>of four months. Since the cow's milk protein can enter the mother's breast

>milk, in cases of family history of diabetes it is recommended that the

>mother avoid cow's milk while breast-feeding.

>

> IDDM accounts for about 5 to 10 percent of diagnosed

>diabetes in the USA and develops most often in children and young adults,

>but the disorder can appear at any age. Symptoms usually develop over a

>short period, although beta cell destruction can begin months, even years,

>earlier.

>

> Over time both Type 1 and Type 2 diabetes are

>accompanied by many severe complications, such as blindness, renal failure,

>lower- limb amputations, cardiovascular disease and stroke. For those with

>Type 1 diabetes the object is not to find a way to get off insulin but

>rather to prevent the long-term complications. It is encouraging to note

>that modern research has demonstrated the amount of insulin required could

>be reduced through appropriate life style modifications and the likelihood

>of consequent complications significantly lowered.

>

> Type 2 Diabetes (Noninsulin-Dependent Diabetes

>Mellitus/NIDDM)

>

> The most common form of diabetes is noninsulin-dependent

>diabetes. About 90 to 95 percent of people with diabetes have Type 2. In

>the USA more than 16 million people, over 7% of the adult population, have

>Type 2 with 600,000 new cases diagnosed each year. In many patients, the

>initial diagnosis of Type 2 diabetes is delayed perhaps by as much as 10

>years because symptoms are often absent or very mild during its early

>stages.

>

> Type 2 diabetes usually develops in adults over the age

>of 40 and is most common among adults over age 55. It is particularly

>common among the elderly and in many minority populations, including

>African Americans, Hispanic Americans, American Indians and Asian and

>Pacific Islander Americans, in whom it may occur in 10.50% of adults.

>

> Type 2 diabetics typically have elevated levels of

>insulin, often producing two to three times the normal amount. Rather than

>an insulin deficiency condition it is an " insulin resistance " condition

>whereby the body loses its ability to properly respond to the signals given

>by insulin. We now know that excess insulin brought on by insulin

>resistance is not only associated with elevated blood sugar levels, but

>also with high blood pressure and increased rates of atherosclerosis.

>

> In the treatment of Type 2 diabetes, dietary

>modification has been found to be of primary importance and should be

>diligently followed before using drug intervention since most cases can be

>controlled by diet alone. For all Type 2 diabetics an effective treatment

>approach should employ a broad-based therapeutic regimen. Such a regimen

>would incorporate appropriate diet, prescribed exercise, stress reduction

>techniques and a substantial amount of specific nutritional supplements. If

>adequate control of blood sugar levels remains problematic, conventional

>treatment with insulin and oral agents can be initiated.

>

> Gestational Diabetes

>

> Gestational diabetes develops or is discovered during

>pregnancy. This type usually disappears when the pregnancy is over, but

>women who have had gestational diabetes have a greater risk of developing

>NIDDM later in their lives.

>

> 2. Presenting Symptoms

>

> The clinical manifestations of diabetes in the order in

>which they usually appear are:

>

> frequent, copious urination

> excessive thirst

> rapid weight loss

> excessive hunger

> drowsiness, fatigue

> itching of the genitals and skin

> visual disturbances

> skin infections

> slow healing

> paraesthesia in the hands or feet

>

> Other signs of diabetes include lingering influenza-like

>symptoms, loss of hair on the legs, increased facial hair, small yellow

>bumps anywhere on the body (known as xanthomas-cholesterol) and

>inflammation of the penile skin.

>

> In most juvenile cases the earliest symptoms noted are

>increased urination, thirst and hunger. Other symptoms include

>irritability, nausea or vomiting, weakness and fatigue. Physical findings

>in the adult are mostly attributable to complications, and the first sign

>of the disease may be some dermatological, circulatory, neurological or

>visual complications.

>

> 3. Laboratory diagnosis

>

> The laboratory diagnosis of diabetes depends on finding

>glucose in the urine together with an elevated blood sugar. The newest

>routine diagnostic test for diabetes is a fasting plasma glucose test

>rather than the previously preferred oral glucose tolerance test. A

>confirmed fasting plasma glucose value of greater than or equal to 126

>mg/dl indicates a diagnosis of diabetes.

>

> In certain clinical circumstances physicians may still

>choose to perform the more difficult and costly oral glucose tolerance

>test. When a doctor chooses to perform this test a confirmed glucose value

>of greater than or equal to 200 mg/dl indicates a diagnosis of diabetes.

>According to World Health Organisation standards an oral glucose tolerance

>test is performed by administering 75 grams of anhydrous glucose dissolved

>in water and then measuring the plasma glucose concentration 2 hours later.

>

> Monitoring the Diabetic Patient

>

> There appears to be a strong relationship between blood

>sugar levels and the development of the complications of diabetes.

>Specifically, when blood sugar levels are chronically elevated, the risk of

>complications is very high. To reduce the risk of developing complications

>it is important to control elevations in blood sugar by careful monitoring.

>The availability of home glucose monitoring kits makes this easier now than

>in the past.

>

> 4. Complications or Sequelae of Diabetes

>

> Sometimes a complication of diabetes may give a clue to

>the presence of the disease. The principle complications or sequelae

>associated with diabetes are retinopathy, neuropathy, nephropathy and

>arteriosclerosis. Whether these are the unavoidable consequences of the

>diabetic state over time or whether they may be influenced by controlling

>the diabetes through aggressive monitoring, treatment and life-style

>management, including diet and supplements, remains a central topic.

>

> One of the largest, most comprehensive diabetes studies

>conducted to date2 showed that keeping blood sugar levels as close to

>normal as possible through aggressive management slows the onset and

>progression of eye, kidney and nerve diseases caused by diabetes. In fact

>it demonstrated that any sustained lowering of blood sugar helps, even if

>the person has a history of poor control.

>

> Specifically it found that lowering and maintaining more

>constant blood sugar levels reduced the risk of eye disease by 76%, kidney

>disease by 50%, nerve disease by 60% and cardiovascular disease by 35%.

>

> Since the discovery of insulin nearly 70 years ago, the

>patterns of morbidity from diabetes have changed. Where the major causes of

>death were ketoacidosis and infection, they are now the microvascular and

>cardiovascular complications of diabetes (renal failure and myocardial

>infarction). These complications are responsible for a reduction in the

>life expectancy of a newly diagnosed insulin dependent diabetic by about

>one-third. The basis of managing diabetes in the 90's is an improvement in

>the life-style of the diabetic and prevention of complications responsible

>for morbidity and mortality in diabetes.

>

> Neuropathy (nerve disease)

>

> Diabetic neuropathies are among the most frequent

>complication of long-term diabetes. It is estimated that 60% to 70% of

>diabetics have mild to severe forms of nervous system damage. The femoral

>nerve is commonly involved giving rise to symptoms in the legs and feet.

>Pain is the chief symptom and tends to worsen at night when the person is

>at rest. It is usually relieved by activity and aggravated by cold.

>Paraesthesias are a common accompaniment of the pain. Cramping, tenderness

>and muscle weakness also occur but atrophy is rare. Advanced femoral nerve

>disease is a major contributing cause of lower extremity amputations.

>

> Nerves in the arms, abdomen and back may also be

>affected. Symptoms may include impaired heart function, slowed digestion,

>reduced or absent perspiration, severe oedema, carpal tunnel syndrome,

>alternating bouts of diarrhoea and constipation, bladder atony, urinary and

>faecal incontinence and impotence.

>

> With respect to sexual impotence, diabetes is probably

>the single most common disease associated with erectile failure (termed

>neurogenic impotence in the diabetic). Since diabetes is a metabolic

>disease with vascular and nervous system complications and an erection

>involves all levels of the nervous system from the brain to the peripheral

>nerves, lesions anywhere along the path may be responsible for erectile

>failure. It has been estimated that close to 50% of diabetic males have

>some degree of erectile dysfunction.

>

> Neuropathies usually improve with the control of the

>diabetes. Severe or chronic changes may require several weeks or months to

>show maximum improvement.

>

> Retinopathy (eye disease)

>

> Changes occurring in the eye which are distinctive of

>diabetes involve the narrowing, hardening, bulging, haemorrhaging or

>severing of the veins and capillaries of the retina. This is a serious

>complication known as retinopathy and may lead to loss of vision. Visual

>changes in the earlier stages may include diminished vision, contraction of

>the visual field, changes in the size of objects or photophobia. In the

>more advanced stage, termed 'proliferative retinopathy', haemorrhages,

>retinal detachment and other serious forms of deterioration are observed.

>When the disease progresses to this late stage total blindness may occur.

>

> It usually takes between 10-13 years for diabetic

>retinopathy to develop and it is present in some degree in most diabetics

>who have had the disease for 20 years. In only about half of the diabetics

>who develop it however, is vision markedly impaired and blindness occurs in

>only about 6%. Still, diabetes is the leading cause of blindness in adults

>20 to 74 years old and is estimated to cause from 12,000 to 24,000 new

>cases each year. Two other complications of diabetes, cataracts and

>glaucoma, can also lead to loss of vision.

>

> The development of laser therapy will probably reduce

>the prevalence of diabetes-induced blindness, however this therapy is not

>without occasional side effects (haemorrhage, retinal detachment and loss

>of visual field) and is therefore indicated only for the more serious

>conditions.

>

> Arteriosclerosis (vessel disease)

>

> The diabetic state is associated with earlier and more

>severe vascular changes than normally occur at a given age.

>Cardiovascular-renal disease is the leading cause of death among diabetics.

>Atherosclerosis can be accurately described as the end stage of Type 1 and

>Type 2 diabetes, since the vast majority of diabetes patients will die from

>an atherosclerotic event. Most commonly these events are cardiovascular in

>nature (an estimated 60% to 65% of diabetics have high blood pressure)

>although 20-25% of atherosclerotic events may be cerebrovascular or

>microvascular. The incidence of coronary occlusion in persons with clinical

>diabetes has been estimated at from 8-17% with diabetic adults having heart

>disease death rates about 2 to 4 times as high as the general population.

>The risk of stroke is also found to be 2 to 4 times higher in people with

>diabetes.

>

> Arteriosclerosis obliterans in the lower extremities, a

>form of peripheral vascular disease, may produce disturbances in sensation,

>decrease in muscular endurance, intermittent claudication on effort,

>absence of peripheral pulses in the lower legs and feet and gangrene, and

>ultimately lead to amputation of the extremity. Diabetic gangrene usually

>involves the toes, heels or other prominent parts of the feet and is

>precipitated by trauma, infection or extremes in temperature. Needless to

>say, careful attention to proper foot care, avoidance of injury and

>consistent use of methods to improve peripheral circulation, including

>withdrawal from tobacco use in any form, are critical for the diabetic.

>

> The aetiology of large vessel disease is multi-factorial

>in the diabetic as well as the non-diabetic population with lipoprotein

>metabolism, hypertension, physical activity, obesity, cigarette smoking,

>stress, personality and genetic and racial factors all playing a part.

>

> Nephropathy (kidney disease)

>

> Nephropathy is a common and important accompaniment of

>diabetes and one that in young diabetics takes precedence over heart

>disease as a cause of illness and death. As with eye changes, there is a

>wide variation in the type and degree of renal damage. Nephropathy is less

>frequent than retinopathy and where it occurs is also a development of long

>standing diabetes. Nevertheless, diabetes is the leading cause of end-stage

>renal disease in the US, accounting for about 40% of new cases. In 1995, a

>total of 98,872 people with diabetes underwent dialysis or kidney

>transplantation and 27,851 developed end-stage renal disease.

>

> One study3 reported that among 200 juvenile diabetics

>who survived 20 years after onset, one half had evidence of renal disease.

>Another study found that the majority of these patients have hypertension

>and two thirds show significant albuminuria, but the fully developed

>nephrotic syndrome of hypertension, proteinuria and oedema occurs in less

>than 10% and renal function is impaired in only one half to three quarters

>of those patients.

>

> Like other long-term complications, good blood glucose

>control goes a long way towards reducing the risk of diabetic nephropathy.

>In addition to monitoring the blood sugar levels, periodic monitoring of a

>diabetic patient's kidney function (blood urea nitrogen, uric acid,

>creatinine and creatinine clearance) is important.

>

> Hypoglycaemia

>

> If there is too much insulin in the body compared to the

>amount of blood sugar, and the blood sugar falls below normal levels, a

>condition known as hypoglycaemia occurs. This problem of hypoglycaemia due

>to insulin or oral hypoglycaemic drugs is much more common in Type 1 than

>Type 2 diabetes since the Type 1 diabetic is directly injecting insulin. If

>too much insulin is administered, or the person misses a meal or

>over-exercises, hypoglycaemia may result. In this condition, commonly

>referred to as insulin shock, the brain is deprived of an essential energy

>source. The first sign is mild hunger, quickly followed by dizziness,

>sweating, palpitations, mental confusion and eventual loss of

>consciousness. Before the condition reaches emergency proportions, most

>diabetics learn to counteract the symptoms by eating a sweet or drinking a

>glass of orange juice. In some cases, the only effective measure is an

>intravenous injection of glucose.

>

> Digestive Disorders

>

> Based on the 1989 US National Health Interview Survey,

>diabetics are more likely than the general population to report a number of

>digestive conditions, including ulcers, diverticulitis, symptoms of

>irritable bowel syndrome, abdominal pain, constipation, diarrhoea and

>gallstones.

>

> Oral Complications

>

> Periodontal disease, which can lead to tooth loss,

>occurs with greater frequency and severity among diabetics. Periodontal

>disease has been reported to occur among 30% of people aged 19 years or

>older with Type1 diabetes.

>

> Infections

>

> Studies in clinic, community and hospital populations

>indicate that diabetic subjects have a higher risk of some infections,

>including asymptomatic bacteriuria, lower extremity infections,

>re-activation tuberculosis, infections in surgical wounds and group B

>streptococcal infection. Population-based data suggest a probable higher

>mortality from influenza and pneumonia.

>

> Complications of Pregnancy

>

> The rate of major congenital malformations in babies

>born to women with pre-existing diabetes varies from 0% to 5% among women

>who receive preconception care, to 10% among women who do not receive

>preconception care. Between 3% to 5% of pregnancies among women with

>diabetes result in death of the new-born; the rate for women who do not

>have diabetes is 1.5%4.

>

> Ketoacidosis

>

> Another acute complication more likely to occur in the

>IDDM is ketoacidosis, a condition caused by a lack of insulin leading to a

>build-up of ketoacids. Chemical compounds called ketones are one of the

>natural by-products of fat metabolism. Excessive ketone bodies are formed

>by the biochemical imbalance in uncontrolled or poorly managed diabetes.

>The condition known as diabetic ketoacidosis can directly cause an acute

>life-threatening event, a diabetic coma.

>

> The possibility of ketoacidosis is suggested by:

> Confusion or coma, the patient almost always appearing

>extremely ill.

> Air hunger - an attempt to compensate for metabolic

>acidosis.

> Acetone odour (fruity) invariably on the breath.

> Nausea and vomiting almost always present.

> Abdominal tenderness which may mimic viral

>gastro-enteritis.

> Extreme thirst and dry mucous membranes.

> Diabetic history (present in about 90% of cases).

> Weight loss.

>

> Before the discovery of proper treatment by insulin and

>other intravenous injections, acidosis was the chief cause of death among

>diabetics. Today diabetics can use a simple urine dipstick at home to

>measure the level of ketones (excreted ketoacids) in the urine.

>

> 5. Conventional Medical Treatment

>

> Insulin was the first, and remains the primary means of

>treatment for Type 1 diabetes and is administered by subcutaneous

>injection. This method is necessary since insulin is destroyed by gastric

>stomach secretions when it is taken by mouth. Insulin injections must be

>balanced with meals and daily activities, and glucose levels must be

>closely monitored through frequent blood sugar testing. Many diabetics need

>inject insulin only once a day; others require two or more injections. The

>usual time for a dose of insulin is before breakfast. The dosage is

>initially established according to the severity of the condition, but it

>often has to be reassessed as one or another of the variables in the

>person's condition changes.

>

> During the past several years a large number of

>different classes of drug therapies for patients with both Type 1 and Type

>2 diabetes have been developed. The concept of genetic re-engineering of

>insulins to produce insulin analogs (synthetic insulin) with improved

>properties has enhanced the ability to affect glycaemic control with fewer

>adverse reactions. For Type 2 patients, the number of orally active

>anti-diabetic agents has increased from one class of agents (the

>sulfonylureas - sulfa drugs) to the current total of four classes of

>agents. The three new classes include agents of potentially even greater

>glycaemic efficacy, such as Biguanide 'Metformin'; agents directly

>improving the underlying insulin resistance of Type 2 diabetes,

>specifically thiazolidinediones such as 'Troglitazone'; and finally agents

>that alter the rate of hydrolysis and absorption of oligosaccharides, such

>as the alpha-glucosidase inhibitor 'Acarbose'.

>

> The sulfonylureas as a group have proven to be not very

>effective. After three months of continual treatment at an adequate dosage,

>only about sixty percent of Type 2 diabetics are able to control blood

>sugar levels using these drugs. Furthermore these agents generally lose

>their effectiveness over time. After an initial period of success they fail

>to produce a positive effect in about thirty- percent of the cases at best.

>

> In addition to being of limited value, there is evidence

>that the sulfonylureas actually produce harmful long-term effects.

>Tolbutamide has been reported to be associated with increased

>cardiovascular mortality. Other major side effects of the sulfonylureas are

>hypoglycaemia, allergic skin reactions, headache, fatigue, nausea, vomiting

>and liver damage. Common examples of sulfonylureas include Chlor-propamide

>(Diabinese), Glipizide (Glucotrol), Tolazamide (Tolinase) and Tolbutamide

>(Orinase).

>

> Metformin has been used in the management of Type 2

>diabetes in more than 90 countries for over 30 years. It was approved for

>use in diabetes patients in the United States in 1995. Metformin reduces

>the excessive hepatic glucose production that characterizes Type 2

>diabetes. With reduced hyperglycaemia, glucose uptake by peripheral tissues

>is enhanced while insulin levels remain stable or decline. Metformin also

>lowers elevated cholesterol and lipids, particularly the serum levels of

>triglycerides. Frequency of adverse effects is low at the doses needed to

>obtain the desired metabolic effect.

>

> Troglitazone is a member of a new class of drugs that

>are 'insulin sensitizers'. It was selected on the basis of its effect to

>lower glycaemia without increasing insulin levels, its ability to improve

>lipid levels and absence of significant side effects or adverse events in

>short-term human studies.

>

> The new generation oral drugs do have a specific and

>beneficial place particularly for patients who are on an appropriate diet

>and exercise program, have attained an optimal weight and are still unable

>to adequately control blood sugar levels. However with the increased number

>of oral antidiabetic agents soon to increase even further, the medical

>emphasis upon management of hyperglycaemia in Type 2 diabetes with these

>agents will likely increase. Realistically this is the easiest and least

>time-consuming response that can be made by practitioners to the impact of

>managed care plans. However to prescribe these agents alone and in

>combination for even minimal degrees of hyperglycaemia without an adequate

>trial of diet and exercise will only serve to accentuate the problem. For

>the non-insulin dependent diabetic, dietary and life style changes can

>often provide adequate remediation.

>

> Medical Cost Attributed To Diabetes

>

> Medical cost for persons with diabetes are higher

>because they visit physician's offices, hospital outpatient departments and

>emergency rooms more frequently than their non-diabetic counterparts and

>are more likely to be admitted to hospitals and nursing homes. One estimate

>of the total health-care expenditures for diabetes in the USA is

>approximately $100 billion per year in both direct and indirect costs, or

>about 12% of all health-care expenditures.

>

> 6. Nutritional Therapy

>

> Meal Planning

>

> A non-diabetic produces the constantly varying amounts

>of insulin necessary for obtaining energy from glucose. A diabetic cannot

>achieve this balance. Beyond the basic requirements to provide adequate

>calories and necessary nutrients, there are marked differences in diet

>strategy for the two major groups of diabetic patients: Type 1

>insulin-dependent non-obese patients and Type 2 obese patients who do not

>require insulin. Patients who are on insulin therapy must schedule their

>meals to provide regular caloric intake. In overweight patients, special

>attention must be given to total caloric consumption.

>

> There is no need to disproportionately restrict the

>intake of carbohydrates in the diet of most diabetic patients. In fact, Dr.

>H.P. Himsworth demonstrated in 1930 that if carbohydrates were taken out of

>the diet and replaced by either protein or fats, a person would quickly

>develop insulin resistance and diabetes5. The key here is in the choice of

>high-fibre complex carbohydrates.

>

> One of the first dietary rules for all diabetics is to

>avoid all sugar and foods containing sugar, such as pastry, candy and soft

>drinks. While these refined sugars and other simple carbohydrates like

>white flour must be carefully watched, most diabetics are actually

>encouraged to eat more complex carbohydrates - the same bulky, fibre-rich

>unprocessed foods that are now recommended for everyone. Vegetables are

>ideal. For example, a diabetic can eat a large plate of spinach that

>contains as much carbohydrate as a tablespoonful of sugar, without

>suffering any ill effects.

>

> Spinach, asparagus, broccoli, cabbage, string beans and

>celery are among the so-called " Food Exchange Group A " vegetables that the

>American Diabetes Association (ADA) says can be generously included in the

>diabetic diet. What makes these complex carbohydrates special is their

>ability to slow down the body's absorption of carbohydrates by helping to

>delay the emptying of the stomach and thereby smoothing out the absorption

>of sugars into the blood. Whole grain cereals also have this ability.

>

> Fully one third of diabetic patients in clinical surveys

>have hyperlipidemia, clearly indicating the need for dietary management.

>The most sensible approach is to limit the amount of fat in their diet and

>to substitute polyunsaturated fats for the saturated type when possible.

>Fish and poultry are especially recommended instead of fatty cuts of meat.

>Greasy, fried foods are strongly discouraged.

>

> Obesity is much more likely in people who eat a high-fat

>diet, which is often a high calorie diet, since each gram of fat contains

>nine calories instead of the four calories in each gram of protein or

>carbohydrate. With obesity comes an increased risk of a variety of

>problems, not the least of which is adult-onset diabetes.

>

> Overweight diabetics, by carefully calculating the

>proper daily calorie intake for their body weight and activity level, and

>never exceeding it, can usually bring their weight down to an optimal level

>- a level which is actually 10% less than the standard height and weight

>charts recommend. " The overweight diabetic who successfully brings their

>weight back to normal usually experiences a dramatic improvement in their

>condition. Indeed the symptoms often virtually disappear, " says Charles

>Weller M.D. in his book The New Way to Live with Diabetes6. He goes on to

>state " Weight reduction and control can bring this incurable disease closer

>to complete remission than any medication. "

>

> The need to reduce fat is reflected in the standard diet

>and food exchange lists prepared by the ADA that restricts the intake of

>fat to 35% of calories. The reduction of saturated fats to one-third of the

>fat intake by substituting poultry, veal and fish for red meats, and the

>reduction of cholesterol to less than 300 mg/day are stressed. The

>carbohydrate content is 40-50 per cent of total calories, with unrefined

>carbohydrates recommended to the exclusion of refined and simple

>carbohydrates.

>

> Currently another diet, known as the 'HCF

>(high-carbohydrate high plant-fibre) diet' popularised by James Anderson7

>has substantial support and validation in the scientific literature as the

>diet of choice in the treatment of diabetes. It is high in cereal grains,

>legumes and root vegetables and restricts simple sugar and fats. The

>calorie intake consists of 70-75 per cent complex carbohydrates, 15-20 per

>cent protein and only 5-10 per cent fat, and the total fibre content is

>almost 100 grams/day. The positive metabolic effects of the HCF diet are

>many: reduced after-mealtime hyperglycaemia and delayed hypoglycaemia;

>increased tissue sensitivity to insulin; reduced cholesterol and

>triglyceride levels with increased HDL-cholesterol levels; and progressive

>weight reduction.

>

> In general the HCF diet is adequate for the treatment of

>diabetes. However improvements can be made, primarily by substituting more

>natural (primitive) foods wherever possible. The Modified HCF or MHCF diet

>recommends a higher intake of legumes, along with restrictions of several

>foods allowed on the HCF diet, namely processed grains, and excludes fruit

>juices, low fibre fruits, skimmed milk and margarine. It is noteworthy that

>if patients resume a conventional ADA diet, their insulin requirements

>return to prior levels.

>

> Many diabetics have found it beneficial to eat smaller,

>more frequent meals, rather than the two or three big meals most people

>consume daily. Researchers have found that multiple frequent feedings tend

>to keep blood cholesterol levels lower, for the diabetic and non-diabetic

>alike.

>

> Vitamins and Minerals

>

> Generally a well-balanced diet rich in vitamins and

>minerals is one of the most important factors in the control of diabetes

>and prevention of diabetic complications. One reason for stressing the need

>for proper levels of nutrients is the excessive urination experienced by

>the diabetic.

>

> Normally the body reabsorbs glucose and other

>water-soluble nutrients. When glucose rises to levels above 160-170mg/dl,

>as it does quite frequently in even well controlled diabetic patients, it

>acts as an osmotic diuretic. This process overwhelms the kidney's ability

>to reabsorb glucose and other water-soluble nutrients, thus the increased

>urination, and substantial losses of nutrients such as vitamins B-1, B?6

>and B-12 and the minerals magnesium, zinc and chromium pass out along with

>the urine. Consequently diabetes and its complications are as much a result

>of nutritional wasting as of elevated blood sugar.

>

> In an article in the American Journal of Clinical

>Nutrition where 247 studies were reviewed8, it was found that Type 1 (IDDM)

>diabetics generally had deficiencies in zinc, calcium, magnesium and the

>more active form of vitamin D. Those with Type 2 diabetes (NIDDM) generally

>were found to be low in zinc and magnesium and often low in vitamins B6 and

>C.

>

> The physical body needs all these water-soluble

>nutrients to maintain the integrity of its organ system. Perhaps one of the

>most important nutrients is magnesium. The medical literature is full of

>studies showing that diabetic patients invariably have lower blood levels

>of magnesium than normal, also with higher urinary losses. In a landmark

>study conducted in 1978 by Dr. P. McNair and titled Hypomagnesemia, a Risk

>Factor in Diabetic Retinopathy9, it was demonstrated that diabetics with

>the lowest magnesium levels had the most severe retinopathy, and that low

>magnesium levels were linked significantly to retinopathy more than any

>other factor. The article argued that simply elevating the magnesium

>concentration with supplements would protect the eyes.

>

> Other nutrients are also attracting serious attention.

>Researchers in London recently reported that vitamin D is essential for the

>islet cells in the pancreas to be able to secrete insulin properly10. Their

>studies have shown that individuals with the lowest vitamin D levels

>experienced the worst blood sugar-handling problems and had a greater risk

>of developing diabetes. They found that those with greatest risk of

>developing vitamin D deficiency included the elderly who were either

>institutionalised or stayed indoors, those living in climates where

>sunlight is scarce several months a year, and those with indoor sedentary

>jobs. In an effort to eliminate the widespread vitamin D deficiencies in

>the institutionalised elderly, over 80% of those individuals are now being

>given 800 IU/day vitamin D3 supplements.

>

> Other researchers have found that the diabetic is unable

>to convert carotene into vitamin A. It is advisable therefore for the

>diabetic to ingest at least the recommended dietary allowance of vitamin A

>from a non-carotene source such as fish-liver oil. Diabetics and others on

>low-fat diets often need supplemental amounts of this fat-soluble nutrient.

>Also recommended is a vitamin E supplement, ranging from 400-1200 IU per

>day and a vitamin C supplement ranging from 1000-4000 mg per day to help

>prevent small-vessel disease of the extremities.

>

> Brewer's yeast is another food supplement that is

>recommended for the diabetic patient. The yeast is a rich source of

>chromium-containing GTF (glucose tolerance factor) which is able to

>potentiate the insulin in our bodies. GTF also contains amino acids such as

>glutamic acid, glycine, and cysteine. Both brewer's yeast (9 gm/day) and

>trivalent chromium (150-1000 mcg/day) have been shown to significantly

>improve blood sugar metabolism when taken for several weeks to months. As a

>side benefit it has also been found that brewer's yeast and chromium

>supplementation lower elevated total cholesterol and total lipids, and

>significantly raise the levels of HDL-cholesterol, the beneficial or

>protective fraction of cholesterol.

>

> Chromium is found in foods as both inorganic and organic

>salts. Brewer's yeast contains a form of chromium with high

>bioavailability, chromiumdinicotinic acidglutathione complex. The

>bioavailability of chromium in liver, American cheese and wheat germ is

>also relatively high. Chromium is also available from a variety of sources

>including whole grains, potatoes and apples with skins, spinach, oysters,

>carrots, and chicken breast. Recent research has identified certain

>varieties of barley grown in Mesopotamia to be some of the richest sources

>of chromium.

>

> A 1996 study of 180 Type 2 diabetics, carried out in

>China under the guidance of Dr. Richard A. Anderson11, found that 500 mcg

>of chromium picolinate taken twice daily for four months lowered the

>fasting glucose level to an average of 129, compared to 160 in those taking

>a placebo. In addition, glycosylated haemoglobin (a test of longer-term

>glucose tolerance) averaged an almost normal level of 7.5% in those taking

>chromium - significantly lower than those on placebo. All of the effects of

>chromium appear to be due to increased insulin sensitivity.

>

> Another exceptionally useful trace mineral to combat

>diabetes is vanadium, which lowers blood sugar by mimicking insulin and

>improving the cells' sensitivity to insulin. A growing body of human

>research shows that vanadium compounds, most notably vanadyl sulfate,

>consistently improve fasting glucose and other measures of diabetes. These

>benefits were often extended for weeks after the mineral supplementation

>was discontinued.

>

> In addition to taking supplements, diabetics are

>encouraged to eat the widest possible variety of permitted foods to ensure

>getting the full range of trace elements and other nutrients. It is

>interesting to note that certain nutrients like vitamins B1, B2, B12,

>pantothenic acid, vitamin C, protein and potassium - along with small

>frequent meals containing some carbohydrate - can actually stimulate

>production of insulin within the body.

>

> List of daily nutrients that may be beneficial in the

>treatment of diabetes Nutrient Dose Action

> B1 (Thiamin) 10 mg Decreases sensory neuropathy

> B2 (Riboflavin 10 mg For skin ulcers and eye and

>digestive problems

> B3 (Niacin) Up to 100 mg Positive effect on

>glucose tolerance

> B5 (Pantothenic acid) 250-500 mg Adrenal support

>(anti-stress)

> B6 (Pyridoxine) 500-1000 mg Normalises blood

>sugar, protects nerves

> B12 (Cobalamin) 25 mcg min Maintains normal nerve

>impulses

> B15 (Pangamic acid) 50-100 mg Antioxidant, helps

>atherosclerosis

> Biotin 200-400 mcg Enhances insulin sensitivity

> Inositol 500 mg Improves nerve function

> Vitamin C 1000-4000 mg Benefits eyes and nerves

> Flavonoids (mixed) 1-2 gr Promote insulin

>secretion, uptake of Vit. C

> Vitamin D 400-800 IU Essential for proper

>functioning of islets cells

> Vitamin E 400-1200 IU Improves glucose tolerance

>and insulin sensitivity

> EFA-Omega 3 1 Tbs Protection against hardening of

>arteries

> EFA-Omega 6 400-600 mg General anti-inflammatory

>properties

> Calcium 1000 mg Important in nerve transmission

>and pH bal

> Chromium 150-200 mg Improves glucose tolerance

>sensitivity

> Magnesium 500 mg Helps protect eyes

> Manganese 30-50 mg Cofactor involved in glycaemic

>control

> Potassium 300 mg Maintains insulin sensitivity,

>responsiveness, secretion

> Zinc 100-150 mg Improves synthesis, secretion,

>utilisation of insulin

> Lecithin 3 Tbs Benefits cell membranes, brain and

>nerves

> Spirulina 3-6 gr Stabilises blood sugar levels

> Vanadyl Sulfate 100-150 mg Mimics insulin and

>improves the cells’ sensitivity to insulin

>

> Cautions

>

> 1. Fish oil capsules or supplements containing large

>amounts of para-aminobenzoic acid (PABA) can elevate blood sugar.

>

> 2. Supplements containing cysteine interfere with

>absorption of insulin by cells.

>

> 3. Extremely large dosages of vitamins B1 or C may

>inactivate insulin. Dosages listed above are within normal ranges.

>

> 7. Botanical medicines

>

> Since antiquity, diabetes has been treated with plant

>medicines. The following herbs appear to be the most effective, are

>relatively non-toxic and have substantial scientific documentation to

>attest to their efficacy.

>

> European Blueberry (Vaccinium myrtillus)

>

> Traditional herbalism places great value on European

>Blueberry leaves, a.k.a. Bilberry, as a natural method of controlling or

>lowering blood sugar levels when they are slightly elevated. Results have

>shown the leaves have an active ingredient with a remarkable ability to

>reduce excess sugar in the blood. To use, steep two to three handfuls of

>leaves in 4 cups hot water for half an hour. Drink three cups a day. Modern

>research has demonstrated the berries or extract of the berries offer even

>greater benefit. The standard dose of the extract is 80-160 mg three times

>per day.

>

> Gymnema sylvestre

>

> Native to the tropical forests of India. Used to lower

>blood sugar and help repair damage to pancreatic cells. Therapeutic dosage

>is 400 mg/day. A good source is a preparation by Natrol as a single herb

>5:1 extract containing 300 mg.

>

> Bitter melon (Momordica Charantia)

>

> Composed of several compounds with confirmed

>anti-diabetic properties. 50-60 ml (about 2 oz) of fresh juice per day has

>shown good results in clinical trials. Charantin, the key ingredient

>extracted by alcohol, is a hypoglycaemic agent composed of mixed steroids

>more potent than the drug Tolbutamide that is often used to treat diabetes.

>

> Onion and Garlic

>

> The common bulbs, onion and garlic, have significant

>blood sugar-lowering action as well as lowering lipids, inhibiting platelet

>aggregation, and reducing blood pressure.

>

> Fenugreek

>

> Fenugreek seeds have demonstrated anti-diabetic effects

>in experimental and clinical studies. Administration of the defatted seed

>(in daily doses of 1.5-2g/kg) reduces fasting and after-meal glucose,

>glucagon, somatostatin, insulin, total cholesterol and triglycerides, while

>increasing HDL-cholesterol levels.

>

> Salt Bush (Atriplex halimu)

>

> Rich in fibre, protein, and numerous trace minerals,

>including chromium. Human studies in Israel have demonstrated improved

>blood glucose regulation and glucose tolerance in Type 2 diabetes. Dosage

>used in this study was 3g per day.

>

> Ginkgo biloba

>

> Gingko biloba extract improves blood flow in the

>peripheral tissues of the arms, legs, fingers and toes and is therefore an

>important medicine in the treatment of peripheral vascular disease. It has

>also been shown to prevent diabetic retinopathy. Dosage of the extract

>standardised to contain 24% ginkgo flavoglycosides is 40-80 mg three times

>per day.

>

> Ginseng (Panax ginseng)

>

> Ginseng, besides reducing fasting blood sugar levels and

>body weight, can elevate mood and improve psycho-physiological performance.

>Therapeutic dosage is 100-200 mg daily.

>

> 8. Status of diabetes research

>

> In recent years, advances in diabetes research have led

>to better ways to manage diabetes and treat its complications. Major

>advances include:

>

> New forms of purified insulin, such as human insulin

>produced through genetic engineering.

>

> Better ways for doctors to monitor blood glucose levels

>and for people with diabetes to test their own blood glucose levels at

>home. Development of external and implantable insulin pumps that deliver

>appropriate amounts of insulin, replacing daily injections. Laser treatment

>for diabetic eye disease, reducing the risk of blindness. Successful

>transplantation of kidneys in people whose own kidneys fail because of

>diabetes.

>

> Better ways of managing diabetic pregnancies, improving

>chances of successful outcomes.

>

> New drugs to treat NIDDM and better ways to manage this

>form of diabetes through weight control.

>

> Evidence that intensive management of blood glucose

>reduces and may prevent development of microvascular complications of

>diabetes.

>

> Demonstration that anti-hypertensive drugs called

>ACE-inhibitors prevent or delay kidney failure in people with diabetes.

>

> 9. Diabetes in the year 2010 - what will the future

>bring?

>

> Although there are no definitive preventative measures

>that can be taken against diabetes at this time, except for identifying

>persons at high risk and encouraging appropriate dietary and exercise

>guidelines, research into the causes and control of this disease continues

>to provide the possibility of new cures. With the discovery of insulin in

>the 1920's and the development of oral hypoglycaemic drugs in the 1950's, a

>person who has diabetes can live an active and productive life. The

>importance of early detection and proper management of this chronic disease

>cannot, however, be emphasised too strongly.

>

> The therapy of insulin-dependent diabetes will surely be

>altered dramatically over the next few decades. One can project that there

>will be improved strategies for glucose control in established IDDM. This

>will include the widespread use of mechanical devices, which will involve

>both implantable glucose sensors and implantable insulin infusion systems;

>and successful pancreas, islet or beta cell transplantation, in the absence

>of the need of immunosuppressive therapy to prevent rejection.

>

> An inhaled form of insulin, under development for

>several years, appears to be ready for wide scale application by the year

>2000. Recent studies conducted at the Universities of Miami and Vermont

>involving Type I and Type II patients demonstrated that inhaled insulin is

>at least as effective as injected insulin in controlling the symptoms of

>diabetes and has no side effects. The delivery system, whereby a finely

>powdered form of insulin is inhaled directly into the lungs, promises to

>greatly simplify management of both forms of diabetes. Powdered insulin

>requires no refrigeration and since it is absorbed into the bloodstream

>though the lungs, there will generally be no need for hypodermic needles.

>Type I patients will still require an injection of slow-acting insulin at

>bedtime12. In the future it may also be possible to administer insulin in

>the form of a pill or patch. All of these advances will change the face of

>diabetes, as we know it.

>

> Moreover, we will see the application of immune

>intervention strategies at the time of onset of IDDM, with the reversal of

>the disease process. Ultimately, these strategies will be applied earlier

>in the sequence during a stage that we do not yet recognise as clinical

>diabetes. In these individuals otherwise destined to develop IDDM, the

>disease will be prevented.

>

> Part I – References

>

> 1. Encyclopedia of Natural Medicine, M. Murray and J.

>Pizzorno, Revised 2nd Edition 1998, p.407

>

> 2. New England Journal of Medicine, 329(14), Sept. 30,

>1993.

>

> 3. National Diabetes Data Group, National Institutes of

>Health, Diabetes in America, 2nd Edition. Bethesda, MD: National Institutes

>of Health ( " NIH " ) Publication No. 95-1468. Ch.1 p.13

>

> 4. U.S. Department of Health and Human Services, Centers

>for Disease Control and Prevention, November 1997, National Diabetes Fact

>Sheet: National estimates and general information on diabetes in the United

>States. Atlanta, GA: NIH Publication No. 98-3926

>

> 5. Julian Whittaker, Health & Healing, Sept. 1995, Vol.

>5, No. 9, p.2

>

> 6. Charles Weller, M.D., The New Way to Live with

>Diabetes.

>

> 7. Encyclopedia of Natural Medicine, M. Murray and J.

>Pizzorno, Revised 2nd Edition 1998, p.414

>

> 8. Elson Haas, Staying Healthy with Nutrition, 1992, Ch.

>5, p.100

>

> 9. P. McNair, Hypomagnesemia- A Risk Factor in Diabetic

>Retinopathy, Diabetes, Nov. 1978, 27 (II): 1075-77

>

> 10. Diabetologia; 97; 40:344-347

>

> 11. Clinical Diabetes, Vol. 15, No. 1, Jan/Feb 1997

>

> 12. Researchers will begin their final six-month trial

>on 1000 patients in the fall of 1998 and if successful, expect the product

>to be on the market within two years. US volunteers interested in

>participating in the study can call 1-800-438-1985.

>

> The following websites offer further information on

>diabetes:

>

> American Association of Diabetes Educators

> http://www.diabetesnet.com/aade.html

>

> American Diabetes Association

> http://www.diabetes.org

>

> National Center for Nutrition and Dietetics, Consumer

>Nutrition Hotline (a part of The American Dietetic Association)

> Home page: http://www.eatright.org

>

> The International Diabetes Federation (IDF) Home page:

> http://www.idf.org

>

> National Institute of Diabetes and Digestive and Kidney

>Disease of the National Institutes of Health

> http://www.niddk.nih.gov

>

> Centers for Disease Control and Prevention

> http://www.cdc.gov/diabetes

>

> Department of Veterans Affairs

> http://www.va.gov/health/diabetes/

>

> Health Resources and Services Administration

> http://www.hrsa.dhhs.gov

>

> Part Two

>

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