I believe that the best way to approach any disease is through a holistic or functional medicine approach. At my clinic in Tulsa, Oklahoma, this is how I address medical problems. Diabetes is no exception.
Diabetes Mellitus is an abnormal physiologic response to blood sugar and insulin. We have to understand NORMAL physiology before we can understand why diabetes is abnormal.
Our blood sugar is controlled to a very narrow range. The normal range of blood glucose is 70-100 mg/dL. This range is very important!
Blood sugar <70 - we start to have symptoms of true hypoglycemia. Hypoglycemia can be mild, moderate, or severe.
- Mild Hypoglycemia: nausea, jittery/trembling, cold/clammy/wet skin, rapid heart beat (tachycardia)
- Moderate Hypoglycemia: irritability/anxiety,
- Severe Hypoglycemia:
The brain is a 'Glucose Hog'! It consumes roughly 1/2 of the circulating blood sugar. It requires glucose (almost exclusively) and this is why most of the symptoms associated with true hypoglycemia are neurologic in nature.
Since we don't know (at least our bodies don't know) when we are going to be able to eat again, we have to have a mechanism that increases blood sugar to keep it above 70.
Glucagon is released from the Alpha cells in the pancrease. It is the hormone responsible for making new glucose (gluconeogenesis) in the liver and mobilizing fatty acids for energy utilization.
Blood sugar >100 - this issue is also very important because, at levels above 100, glucose begins to be toxic because these elevated levels increase the formation of Advanced Glycation End-Products (AGE). These are very pro-inflammatory and are responsible for the multiple medical problems that patients with uncontrolled diabetes often end up getting.
Insulin is the hormone responsible for keeping blood sugar below 100. It protects us from the toxic effects of hyperglycemia.
There are 4 tissues that utilize and/or store most of the glucose we consume or create:
- Brain - as stated above, it utilizes a lot of glucose. It does not need insulin to get glucose into its cells
- Liver - stores about 100 grams of glucose in the form of glycogen. That isn't very much. Its about 3 cans of Coca-Cola. The liver requires insulin to get glucose into the hepatocyte (liver cell).
- Muscle - stores a limited amount of glycogen. Muscle needs insulin to get glucose into the myocyte (muscle cell) except during exercise.
- Adipose (fat) - Adipocytes (fat cells) also require insulin to get glucose into them. This is the ultimate repository for continual elevated blood glucose, once liver and muscle sources are full. The excess glucose has to go somewhere and the adipocyte is the storage location.
The take-home point is that excess glucose in the blood is extremely toxic and we have to be able to lower it. Hyperglycemia is very bad!
Insulin stores that extra glucose. It also has a host of other functions such as increasing eicosanoids (increased inflammation). When we think about overall health we would do well to minimize insulin. So, hyperinsulinemia is also very bad.
Hyperglycemia is worse than hyperinsulinemia!
The way to control both is to decrease ingested carbohydrates.
Diabetes Mellitus is essentially an elevated blood sugar due to inadequate amounts of insulin. There are 2 types of diabetes with 2 different causes and 2 different approaches to treatment.
- Type 1 - this type of diabetes is due to an absolute deficiency of insulin. It is most often caused by an autoimmune destruction of the β-cells in the pancreas.
- Type 2 - this type is due to an inadequate amount of insulin due to insulin resistance.
So what is the problem in diabetes? Its just sugar, right?
Elevated blood sugar levels can cause any (or all) of the following - these are the Advanced Glycation Endproducts (AGEs):
- Nerve damage (neuropathy)
- Diabetic retinopathy (eye & vision problems)
- Heart attacks
- Coronary artery disease
- Peripheral vascular disease
- Renal (kidney) failure - can lead to dialysis
- Impaired immunity (frequent infections, diabetic ulcers)
This list is only a portion of the many problems that diabetes can cause.
However, the problem is two-fold. In order to understand the full implications of diabetes, you have to understand the function and purpose of insulin. In short, insulin is the 'storage' hormone of the body. It is the hormone of plenty.
Here are some of the things that insulin does:
- Increases liver, muscle, and adipose tissue uptake of glucose
- Increases lipid synthesis (makes more fat)
- Increases glycogen synthesis (makes more storage form of glucose)
- Increases amino acid uptake by the cells
- Increases potassium uptake
- Decreases breakdown of protein
- Decreases lipolysis (decreases breakdown of fat)
- Decreases gluconeogenesis (less production of glucose from non-sugar substances
In normal physiology, insulin is primarily released in response to elevated blood sugar. Also with eating but that is another story for another day. So, the higher the blood sugar, the higher the insulin level. The higher the insulin level, the more energy we store. This has multiple implications.
Regardless, the goal of diabetes is to control blood sugar - it is very toxic at high levels.
In the case of type 1 diabetes, blood sugar control is through insulin replacement & carbohydrate control. For type 2 diabetics, the goal is to control blood sugar by decreasing carbohydrate intake and increasing the effectiveness of insulin or to increase the volume of insulin.
How Is Diabetes Diagnosed?
There are 4 ways to diagnose diabetes (regardless of the type):
- Fasting blood sugar > 126 mg/dl on 2 separate occasions
- Blood sugar > 200 mg/dl with symptoms of hyperglycemia
- 2 Hour blood sugar > 200 mg/dl on an Oral Glucose Tolerance Test (OGTT)
- Hemaglobin A1c >6.5
What Is An A1c?
Glucose attaches to various substances (blood vessels, nerves, hemaglobin, etc) based on the level of glucose. This 'glycosylation' is based on the amount of blood sugar. The higher the blood sugar level the more glucose attaches to these substances. These are the Advanced Glycation Endproducts mentioned in the video above.
Red blood cells (RBCs) have a lifespan of approximately 100-120 days. Glucose attaches to the hemaglobin in the RBCs as stated above. The hemaglobin with glucose attached is called Hemaglobin A1c. The A1c represents an 'average' of the blood sugar over a 90-120 day period.
Thus, the A1c gives us a pretty good idea of how the blood sugar has been running over the past 3-4 months.
Typically, the A1c goal in the treatment of diabetes is < 7.5.
However, this level of glycosylation is NOT normal. Agreed? We must do better! The problem is that most people think that the way to improve this number is by increase the dose or number of medications, adding insulin, or increasing the amount of insulin.
Diabetes will not improve by adding more medications. It won't improve by adding insulin.
These methods only improve the 'numbers' associated with diabetes (blood sugar levels, A1c, etc) but do NOT improve the disease process.
The only way to improve your diabetes is to decrease the NEED for insulin.
This is nearly always accomplished by decrease the intake of carbohydrates.
The goal is to get your total daily carbohydrate intake to less than 100 grams for sure but preferably less than 50 grams per day.
What is "Pre-Diabetes"?
Pre-Diabetes is a condition of increasing blood sugar levels and/or intolerance to glucose (inability to appropriately handle glucose in the diet after meals). This is most often due to insulin resistance issues.
Basically, if you have pre-diabetes, you have severe metabolic derangement which absolutely must be addressed. Pre-diabetes should serve as a warning that there are serious problems ahead. I think it is similar to have a sign saying "Bridge Out Ahead". If you continue down that road you will see the true severity of the problem. If you don't pay attention to the signs then you'll end up in a bad spot.
Pre-Diabetes is, by itself, a risk factor for cardiovascular disease and future diabetes. Again, there is already metabolic derangement which is causing problems.
These patients are at much higher risk of becoming diabetic!
The good news is that 5 things can prevent diabetes in these patients:
- Healthy weight (BMI of < 25)
- Healthy Diet - I have seen this single intervention CURE diabetes is multiple patients!
- 1 glass of alcohol per day
- No smoking
By the way, there is no such thing as 'Borderline Diabetes'!
Blood sugar levels are contingent upon multiple factors such as exercise, carbohydrate intake (type and quantity), insulin levels and sensitivity, hormone levels, etc. The goals of therapy are to decrease blood sugar levels, both after meals and fasting.
Blood sugar control is accomplished by a variety of interventions. It seems that the medical community has adopted the mentality of controlling increasing blood sugar with increasing amounts of insulin. While this will decrease the damage caused by hyper-elevated blood sugar levels, it is only increasing the amount of systemic insulin which causes more storage of adipose and further exacerbates insulin resistance.
More insulin resistance causes worsening blood sugar levels which will ultimately be treated with increasing levels of insulin. And the problem perpetuates itself.
Remember, insulin is toxic but it is less toxic than elevated blood sugar.
We MUST break this cycle!
Type 1 Diabetes Management:
There are TWO required treatments for optimal health.
- Insulin - Remember, Type 1 diabetes has an absence of insulin. We cannot survive without it but we sure don't want too much of it!
- Control of carbohydrate intake.
I believe that we should manage Type 1 diabetes with appropriate intake of complex, low-glycemic index carbohydrates. This means vegetables NOT grains! Do not listen to the lies that tell you 'whole grains are healthy'. They are carbohydrates. All grains must go! Get your carbs from veggies!
Blood sugar elevations are controlled by adjustments in insulin.
Insulin pumps are the most appropriate therapy in my experience.
The next best is Basal/Bolus insulin therapy. This is much more 'physiologic' than the older regular or NPH insulin therapies.
Basal insulin is long acting insulin that is generally given once a day (larger doses may be given twice a day). There is no peak and the insulin is steadily effective over a 24 hour period.
Bolus insulin is giving a prescribed amount of short-acting insulin in conjunction with carbohydrate intake. Generally, patients are given a prescribed carb/insulin ration so that they will take a set amount of insulin for a set intake of carbohydrates every time you eat.
Type 2 Diabetes Management:
As stated previously, insulin resistance plays a major role in Type 2 diabetes. The key to treatment is in improving insulin sensitivity and decreasing carbohydrate load in the diet.
Don't eat as many carbohydrates. This is like having your house on fire and deciding to throw gasoline on it. Give me a break! Nothing could be worse. Quit eating all of the stuff that is causing the problem.
There are several potential causes of insulin resistance. While we don't know the exact cause, the following factors increase a person's risk of insulin resistance:
- Genetic factors
- Metabolic Syndrome
- Some medications can lead to insulin resistance
So, treatment should be aimed at minimizing the risk factors. If you are obese, then you have to fix that! In fact, if you are obese (and even if you aren't), you have a chance to CURE your diabetes.
For patients that do not chose to listen to the warning signs and don't want to make necessary changes there are a number of medication options.
There are some medications that can be given that are proven to improve blood sugar control and improve diabetes management. There are several different classes of medications that work in different ways to improve blood sugar and/or improve insulin sensitivity.
Regardless, there have been multiple instances where patients have addressed their risk factors, optimized their BMI, increased their exercise, optimized nutrition and they have been able to put diabetes behind them. Their diabetes had been cured.
So you have a choice. You can choose to not make any lifestyle changes and we can treat your Type 2 Diabetes with medications that will likely simply postpone the worsening of your disease. Or you can choose to change your lifestyle, improve your nutrition, lose weight, and start a vigorous exercise program that will dramatically improve your diabetes if not cure it.
When you think about the costs of insulin, medications, complications of diabetes, and labs the cheapest thing you can do is lifestyle change.
What Needs to Be Checked With Diabetes?
- Nephropathy - since diabetes can affect the kidneys, you should have a urine test (microalbumin/creatinine ratio) to make sure your kidneys are working correctly. This test is looking for small amounts of protein leaking into the urine.
- Retinopathy - you should see an eye doctor every year to have a diabetic eye examination
- Neuropathy - you should check your feet daily looking for any lesions, redness, or injuries. You should also have your feet checked with a monofilament exam (in the clinic) at least once per year.
- Diabetes is a coronary artery disease equivalent (meaning diabetics are at the same risk of heart attacks as someone who has already had one). Therefore, you should have your cholesterol checked. The goals for your labs (and blood pressure - 130/85) are slightly different than for non-diabetics.