Type II Diabetes and Courses of Action by Lewis Sunderland - 12/18/96 I will attempt to define a set of terms which will provide a foundation from which I will attempt to analyze my experiences, suggestions that have been made to me and possible courses of action. The information has been gathered from many sources and the opinions are mine. DEFINITIONS: Type II Diabetes: A Blood Glucose Bio-Feedback Mechanism exists between the body's hormones, the digestion process and the liver to control the release of glucose (a simple form of sugar that serves as the body's fuel) into the blood and thereby balance the energy resources against the energy needs. When blood glucose levels rise, insulin (the only hormone that decreases glucose output) is secreted to bring these levels back down to normal. Type II diabetics have a disease involving insulin resistance and/or inadequate insulin secretion. Insulin: A hormone secreted by the beta cells within the pancreas. Insulin signals the liver to stop producing glucose and releasing it into the blood, assists the cells in absorbing glucose and helps in the conversion of excess glucose into fat. Liver: The liver is an organ with many jobs. One of them is to keep the blood glucose concentration constant. Excess glucose, derived from the digestion of food, is stored away for future use. When the liver receives signals for glucose it releases the stored glucose and when the supply is exhausted, it produces glucose from fat and protein. Glycogen: A storage medium for excess glucose which is created by the liver and stored in both the liver and muscles. This product is converted back into glucose upon need. Storage space is limited and, after it is exhausted, glucose is stored as triglycerides in the adipose(fat) tissue. Glucogen: A hormone secreted by the alpha cells within the pancreas. Glucogen signals the liver to produce glucose from glycogen and introduce it into the blood. Counter-Regulatory (Stress) Hormones: Hormones are released during stressful situations and cause the liver to release glucose and the fat cells to release fatty acids. These hormones include glucogen, adrenaline(epinephrine), norepinephrine, cortisol and growth hormone. Stress situations include emotional stress, intense physical activity, hypoglycemia, and illness. E-Level: Blood glucose level at which the body stabilizes at 2-3 hours after a proper normal meal. This value may fluctuate as the average body demand varies. Hypoglycemia: Having low levels of blood glucose, less than 50-70 mg/dl. In response to this situation, the body releases hormones to instruct the liver to release glucose. There are two types of symptoms: Hormone induced and Neurologic and these include shakiness, anxiety, hunger, pounding/racing heart, nervousness, perspiration, tingling/numbness, fatigue, drowsiness, double vision, difficulty speaking, uncoordinated or slowed thinking and confusion. There are three types of Hypoglycemia: Fasting, Post Prandial(Functional) and Other. Fasting Hypoglycemia occurs 5 hours after eating and is caused by drugs, liver disease, organ failure, tumors that release excessive amounts of insulin, hormone deficiency and enzyme defects. Consult a doctor. Post Prandial Hypoglycemia occurs within 5 hours of eating and is caused by, early diabetes or glucose intolerance, alcohol, partial absence of the stomach due to surgery and quick release of food to the small intestine. "Other" types of hypoglycemia result from prolonged fasting, intense physical activity and unknown causes. These types usually respond to diet modification. Immediate improvement and/or resolution of these symptoms should occur with administration of a carbohydrate which can be quickly converted to glucose, e.g., apple juice, orange juice, sugar, hard candies, cola, honey, raisins, etc. If improvement doesn't occur, consult a doctor. Hyperglycemia: Having chronically high levels of glucose in your blood. Some symptoms are increased frequency of urination, increased thirst and fluid intake, weight loss despite increased hunger and food intake, blurred vision and skin infections. Dawn Phenomenon: Body's normal mechanism that wakes you up and gives you energy to start the day. This is caused by the secretion of Growth Hormone, usually between 4 - 8 am. As a result, insulin activity is depressed and blood glucose level rises. Based upon personal experience, I don't believe this happens if the blood glucose level is above the E-Level. This phenomenon is not a defect but, instead, is there by nature's design and nature tends to conserve energy. Rebound and/or Somogyi Effect. High blood glucose levels resulting from hormone reaction to hypoglycemia. Obesity: Anyone who is overweight and exceeds certain parameters: Real Weight Ratio, Body Mass Index and Waist to Hip ratio. Real Weight Ratio: current body weight exceeds ideal body weight by more than 20%. Body Mass Index (BMI) is > 27. BMI = 4.9 * Weight/(Height * Height) where Weight is in pounds and Height is in feet. Waist to Hip Ratio: > 0.9 in males and > 0.8 in females. Blood Glucose-Alcohol Interaction: Alcohol, when consumed with carbohydrates, can cause an excessive release of insulin. As a result, the blood glucose level will be lowered more than expected and hypoglycemia can occur 3-5 hours after the meal. Blood Glucose Levels: The amount of glucose circulating in your blood. There is disagreement about what the proper levels should be and it is subject to change as more knowledge is obtained. It should be noted that the home tools that we have for measuring these values are not exact and the values obtained should be considered only as a guide. It also should be noted that the low end of the ideal blood glucose levels are at the edge or within the region for hypoglycemia. Values listed are in mg/dl. .....Time of blood test...............Ideal..............Acceptable .....Fasting...............................80-110.............150 .....1 hour after meal..............100-150.............210 .....2 hours after meal..............80-130.............180 .....3 hours after meal..............80-110.............160 Values favored by doctors who advocate "strict" control .....Time of blood test.................Ideal.............Acceptable .....Fasting................................70-100.............70-120 .....Before lunch & dinner.........70-110.............70-140 .....1 hour after meal.................90-150.............80-180 .....2 hours after meal...............80-120.............70-150 .....3 hours after meal...............70-110.............70-130 .....3 am....................................> 70..................> 70 Normal values derived from people without diabetes and hypoglycemic symptoms .....Time of blood test.................Men..............Women .....Fasting................................66-111.............68-110 .....24 hour fasting....................55-103.............34-81 .....48 hour fasting....................50-99...............37-62 .....72 hour fasting....................50-85...............15-68 Oral Medications: Medications used to lower the blood glucose levels. These include sulfonylureas, biquanides and Alpha-Glucosidase Inhibitors. Sulfonylurea drugs lower blood sugar by encouraging the pancreas to produce and release more insulin. Some sulfonylureas are Orinase, Tolinase, Dymelor, Diabeta, Micronase, Glucotrol, Diabinese and Amaryl. Biquanides lower blood sugar by braking the liver's release of glucose and reducing the adsorption of glucose from food being digested in the small intestine. They also help lower high blood fat levels and promote weight loss. Metformin (Glucophage) is an example of this type of medication. Alpha-Glucosidase Inhibitors help lower after-meal blood glucose levels by temporarily blocking the action of enzymes which digest starches(complex carbohydrates). Acarbose(Precose) is an example of this type of medication. Diabetes-Exercise Interaction: Some benefits of proper exercise are: Increase insulin sensitivity, reduction in body fat (reduced obesity), speedup of the Resting Metabolic Rate, reduced triglycerides level, healthier total cholesterol to HDL cholesterol ratio, etc. Blood Glucose-Exercise Interaction: When you start exercising, your body first uses the glucose stored in the muscles. When these stores run low, the body uses the glucose in the blood. Glucose levels in the blood are restored by the liver conversion of glycogen upon signals by the counter-regulatory hormones. After exercise, the body replenishes the stores of glucose in the muscles and liver. However, in diabetics, the blood glucose level tends to rise past the restoration level because of insulin resistance and/or insufficient insulin. A relationship has been found between the exercise intensity and the blood glucose level after exercise. If the energy cost of the exercise is below 80% of the maximum capacity to use oxygen, the counter-regulatory hormone release is low and the blood glucose level falls because more glucose enters the muscle than is released by the muscle. If the energy cost of the exercise is greater than 80% of the maximum capacity to use oxygen, the counter-regulatory hormone release is high and the blood glucose level will rise because more glucose is released by the muscle and pancreas than can be absorbed and utilized. It is possible to lower your blood glucose level into the hypoglycemic range while exercising. Key to protecting yourself is to know your body. Monitoring your blood glucose level before, during (every 30-60 minutes) and after exercise is important. Carbohydrate intake before, during and after exercise and/or pre-exercise medication reduction may be necessary. A doctor should be consulted to see if you have any conditions for which exercise is not recommended. The literature states that type II diabetics should not exercise if the blood glucose level is > 300 or there are ketone bodies in the urine and the blood glucose level is > 240. These situations are indicative of the body's inability to maintain an insulin-glucose balance and intense exercise will only make the situation worse. However, based upon personal experience, I believe that you can exercise if your blood glucose is > 240 if you know that the reason for it is too much eating of the wrong food. Assume that you that you had a "bad" dinner, taken your oral medication at dinner and 2 hours later your blood glucose is > 240. All you can do to help yourself is drink water and perform moderate extended exercise. A mixture of aerobic and weight training (5 lbs) exercises can be performed. Weight training will cause your muscle mass to increase and thereby cause more energy to be consumed in your resting state. Aerobic exercises, e.g., running, intense walking, treadmill, exercise bike, etc. will cause you to burn fat if the exercise period is > 20-25 minutes. The best workout sequence that I have found is: 20-30 minutes warm-up 5-10 minutes stretching 15-30 minutes of intense exercise 5 minutes cool down Metabolic Rate: Your metabolic rate varies depending upon your physical condition and the activities you perform. It is a measure of the rate of energy (glucose) consumption. When you are at rest, e.g., sleeping, your "resting" metabolic rate is lower than when you are awake and active. If you are in good physical condition, your "resting" metabolic rate is higher. Using measured blood glucose level changes, I have tried to measure my relative metabolic rates for different situations: .....Resting.................................................................. ......5 -10 mg/dl per hour .....Preparation & Traveling to Work (2.5 hours)..............30-40 mg/dl per hour .....Treadmill or Exercise Bike (0.5 hours).....................150-200 mg/dl per hour Fat Metabolism and Ketone Bodies: Counter-regulatory hormones cause fatty acids to be released from the fat cells. These fatty acids are broken down by the liver into glucose and several strong acids called ketone bodies. These products are eliminated in the urine . If accumulation exceeds elimination, blood acidity can increase to a dangerous level and, at this point, excretion of these bodies by the urine is accompanied by the loss of important minerals. This is called Keto-Acidosis and symptoms of this situation are nausea, vomiting, slow deep respiration, changes in mental status and eventually collapse of the cardio-vascular system. Fasting: Fasting isn't impossible, only difficult. To be successful, you must have a plan to manage your blood glucose level, ketone bodies elimination, waste product elimination (colon) and intake of sufficient vitamins, minerals and water. As glucose stores are used up in the muscles and blood, they are replenished by the liver. As the glucose liver stores are depleted, fat deposits will be processed to replenish the liver. At some point, protein stores are also used to provide energy. This process is ongoing and begins as soon as the liver's glucose stores need to be replenished. A doctor should be consulted beforehand. Food and Digestion: Food is composed of carbohydrates, proteins, fiber and fats. Digestion of food releases glucose, fatty acids and amino acids into the blood. Fatty acids are stored in the adipose (fat) tissue. Amino acids provides the material for building blood cells, body tissue, hormones and other important substances. Digestion of a mixture of complex carbohydrates, protein, fiber and fat is a slower process than the digestion of simple carbohydrates (sugars) and the byproducts are released into the blood over an extended period of time. Sugars come in different forms: glucose, fructose, lactose, sucrose and dextrose. Thoughts: Our goal is to keep our balance of blood glucose production consistent with the body's demands and to effectively use our insulin production capabilities. Our tools are diet, exercise, oral medication, insulin injections and blood glucose measuring devices. These are not perfect tools and the path is difficult, often confusing and never ending. We have to develop an ability to live with our illness because there is no escape from it. Our carrot is the freedom to pursue a "normal" existence and the stick is the TERRIBLE complications that will surely come. It does not really matter how we came to this point in the road, it only matters how we will travel it in the future. Different people have different opinions on which tools to use. Of course it would be better to use only diet and exercise. However, in the end, we must use whatever is necessary and there is no one way for everyone. I have developed some guidelines for myself: 1. Exercise at least five to six days a week and especially on weekends when I am less physically active. 2. Never exercise without eating if my blood glucose is in normal range in order to prevent rebound. 3. Eat three meals a day with the largest being either breakfast or lunch. This is when I need the energy and my metabolic rate is higher. 4. Never eat a meal after 9:00pm. 5. Exercise in the evening after dinner. 6. Small snacks between meals are useful in providing energy boosts, maintaining a steady blood glucose level and lessening hunger. 7. If my blood glucose is high and I have to eat, drink lots of water and eat a meal high in fiber and low in fats and carbohydrates. 8. If my blood glucose is high, exercise if I can. 9. Drink lots of water, take vitamin and mineral supplements and get at least 6 hours sleep/day. 10. Make a plan to lose weight with many small steps. References: 1. American Diabetes Association Complete Guide to Diabetes, 1996 2. Learning to Live WELL with Diabetes, International Diabetes Center, 1987 3. Diabetes, Your Complete Exercise Guide, Dr. Neil F. Gordon, 1993 4. Diabetes, The Natural Way, Catherine Steven, 1995 5. Numerous files from the Compuserve Diabetes Group's Reference Library 6. Numerous articles from the "Diabetes Interview" 7. Numerous articles from the "Diabetes Forcast" 8. Numerous articles from "Diabetes Self-Management" 9. John Hopkins White Paper on Diabetes, 1996 10. Joslin Diabetes Manual, 12th ed, Krall & Beaser