It is a marker that helps tell the doctor how high and how well controlled a patient’s blood sugar has been over the past three months.  The normal range is below 6.0%.  Diabetics usually have levels around 7.0%.  Patients with uncontrolled diabetes have levels far above 7.0%, as in the case discussed to me by my Modar jan.

Most of the time, doctors do not have the time to sit and discuss these matters with patients and patients do not usually further inquire.  And even if they do discuss the matter, a lot of what they say is lost in translation.  Yet, obtaining information and understanding medical conditions are at the forefront of care.  In order to control medical conditions, it is of utmost importance to understand the disease process and adapt life accordingly. 

As such, in the following, I will attempt to give a better understanding of one of the most common and most important medical conditions that affects many people around the world: DIABETES, or in Dari known as SHAKAR.

What is diabetes?

Diabetes is a disorder of carbohydrate metabolism.  When carbohydrates are metabolized in the body, the product is glucose.  The main regulator of glucose in the body is insulin.  Diabetes is a condition whereby the insulin levels are either absent, deficient or resistant in response to rising glucose levels in the body.

There are two main types of diabetes.  The first is referred to as type one diabetes and is less common than type two diabetes; it usually first manifests in individuals younger than 20 years of age.  Individuals with type one diabetes are usually thin because they have a lack or absence of insulin.  As such, they cannot take up glucose into the cells for energy.  Hence, they have insulin DEPENDENT type of diabetes.  They need to be administered insulin or else their blood sugars fall below normal and they could experience severe hypoglycemia.  The reason for type one diabetes is related to an autoimmune destruction of the cells that produce insulin in the pancreas.  Autoimmune merely refers to the body generating antibodies against the body’s own cells, with total destruction of those cells.  Researchers have postulated that viruses may be the environmental triggers for such autoimmune diseases.

Type two diabetes mellitus is far more common, accounting for 90-95% of cases of diabetes.  Type two usually manifests later in life, typically affecting individuals older than 40 years of age.  It carries a strong genetic predisposition. It has a slower onset, meaning that the symptoms may not be obvious until several years after.  Unlike type one diabetes, those with type two diabetes are overweight.  The mechanism behind type two diabetes has to do with insulin resistance.  This means that over time, with increasing fat tissue, the insulin becomes less sensitive to rising blood sugar levels. This is because adipose (fat) tissue reduces the number of insulin receptors for glucose binding. As such, very high levels of glucose could be circulating in the body without insulin uptake.  This is referred to as resistance and it is strongly tied to obesity, particularly to central obesity (the fat that encircles the waist and stomach area).

So what are the symptoms of Diabetes to watch out for?

High sugar levels in the blood give rise to thirst, referred to as polydipsia; the body will try to remove the excess sugar in the blood, and this leads to increased frequency of urination, referred to as polyuria; because a lack or resistance of insulin does not enable cells to uptake glucose for energy use, the body still feels as though it is in an energy drain.  As such, people feel hungry, referred to as polyphagia.

And in those with type one diabetes who have an absolute lack of insulin and fail to take up glucose, they experience severe weight loss in addition to polyuria, polyphagia and polydipsia.

What are the complications of diabetes?

It is extremely imperative to take heed of the following because if nothing else in this article makes you want to control your blood sugar levels, these complications of the disease surely will.  Diabetes is by far one of the worst chronic diseases to have because it severely affects your morbidity and mortality as well as your prognosis after minor or major surgical procedures.  The following is a list complicatons:

1.  Heart disease

Many people do not know this but the number one cause of heart disease is diabetes.  And the number one cause of death in patients with diabetes is cardiovascular disease.  75% of deaths among those with diabetes are due to heart attack, stroke or congestive heart failure.

The reason for increased risk of cardiovascular disease mainly has to do with the fact that diabetes tricks the body into thinking that there is not enough glucose in the blood.  As a result, the liver starts to break down fat stores, leading to a state of hyperlipidemia or increased fat in the blood as well as increased glucose, hyperglycemia. Increased glucose attaches to protein.  These glycosylated amino acids become more permeable to cells – meaning that they enter cells and vessels more easily – and they lodge in vessel walls, leading to atherogenesis or increased vessel injury.  This increased vessel injury causes plaque formation as does increased lipid levels. Plaque formation decreases vessel elasticity, narrows vessels and may lead to thrombus formation. As such, individuals who are diabetic not only have to control blood glucose but also lipid levels, such as LDL, HDL and triglycerides.  Of the three listed, the most important one to pay attention to is LDL, or low density lipoprotein.  Diabetics must keep LDL levels below 100 mg/dL.  The main drugs used to control lipid levels are the statins.

Diabetic patients with LDL levels above 100 mg/dL should be on a Statin;  normal individuals with LDL levels above 130 mg/dL should also be on a Statin. 

2.  Renal disease (Kidney disease)

Diabetes is the most common cause of kidney failure in the United States and Canada.  Risk factors for kidney disease in diabetic patients are poor glycemic control, hypertension (high blood pressure) and diabetic retinopathy (eye problems resulting from diabetes).  High blood glucose attaches to cellular components in the kidneys affecting absorption of protein as well as increasing narrowing of vessels in the kidneys. This compromises renal blood flow and causes hyperfiltration injury.

One of the main markers of kidney damage is detecting protein in the urine, referred to as proteinuria or microalbuminuria.  Microalbuminuria refers to small amounts of protein in the urine and it is usually the first manifestation of kidney disease.  This usually begins after about 10 years of poor glycemic control.  If glucose levels continue to remain uncontrolled, massive amounts of protein leak into the urine, referred to as proteinuria.  At this point, the kidneys have become severely damaged. 

3.  Diabetic Retinopathy (Eye complications)

Every diabetic patient should have his/her eyes checked at diagnosis and then annually thereafter.  Diabetic patients have increased risk for cataracts and glaucoma, as well as an increased risk for retinal detachment and blindness. 

4.  Peripheral Neuropathy (Peripheral Nerve Disorders)

Diabetes is the most common cause of peripheral neuropathy in the United States and Canada.  Peripheral neuropathy refers to damage to small vessels supplying the nerves of the extremities (legs and feet).  The symptoms of peripheral neuropathy include numbness, tingling, pain, burning, loss of vibratory sensation and even paralysis.

Diabetes is the most common cause of foot ulcers.  Patients usually do not recognize the pain of the ulcers because of the reduced sensation resulting from the neuropathy.  As such, they fail to take care of their feet, further exacerbating their condition.  If the infection becomes severe and spreads, the patient may end up having surgical removal of the leg, or amputation.

It is extremely important for diabetics to take very good care of their feet, by practicing good hygiene. 

5.  Diabetic Gastroparesis (constipation)

Diabetes not only affects the vessels that supply the nerves of the legs and feet, but also the vessels that supply the nerves of the internal organs, mainly the small and large colons.  Most patients experience constipation because of slowed movement of flow through the colon.  Constipation could give rise to a myriad of other conditions, such as diverticulosis, diverticulitis, hemorrhoids and even colon cancer.  Daily intake of a high fiber diet, water, fruits and vegetables is very important.  Or patients could try taking oral Metamucil powder that is easy purchased over the counter at any local drug store.

6.  Dental problems  

Increased sugar in the blood creates a great breeding ground for bacteria.  And one of the places that bacteria are most prevalent is in the mouth.  I saw a 54 year old woman the other day at the ER who had lost both her upper and lower teeth due to her poorly controlled diabetes.  It cannot be stressed enough the importance of taking care of oral hygiene as this may not only affect losing your teeth but also cardiovascular health. 

The good news:

There are several lines of drugs used to control blood sugar levels and not all drugs are suitable for every diabetic patient.  Ace inhibitors are a class of drugs that not only help lower high blood pressure but also protect the kidneys and heart from further damage.  Most hypertensive diabetics are on Ace inhibitors unless otherwise indicated.

Whatever medication the doctor recommends, it is extremely important to control blood sugar levels as closely as possible in order to prevent the wide range of complications of diabetes.  Monitoring blood sugar levels with a finger stick test is a simple way to keep a close check on glucose levels.  The tighter blood sugar is controlled with the use of medications and diet, the less risk for complications.      

As with most medical conditions, type II diabetes is strongly related to obesity and weight gain.  The more one attempts to maintain a regular weight through diet and exercise, the lower the levels of blood glucose and blood lipids which would undoubtedly lower the risk of complications. 

A reduction in glycosylated hemoglobin A1c of only 1% reduces the rate of heart attack in diabetics by 14%.  And for every 10 point reduction in systolic blood pressure, there is a 12% reduction in the risk of heart attack.  Daily exercise and weight loss can affect both measures by not only reducing blood sugar levels but also blood pressure.

Weight reduction of only 4-7% has a huge influence on insulin sensitivity.  Daily exercise, especially weight bearing exercises increases muscle mass.  This means that at rest, muscles take up glucose, further lowering resting glucose levels.  Also, during exercise, exercising muscle does not need insulin for glucose entry.  This further lowers glucose!  One of the interesting facts is that 25% of patients do not even need drugs to control diabetes so long as they learn to control their weight through regular diet and exercise!

With the onset of a New Year and spring, it is the best time to make some necessary changes:  So if you haven’t decided to take up exercise and healthy eating as part of your daily routine, now is the time to start!