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Every Month: a Review of Major Teaching Points

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A Power Program for Student Review

Course Coverage 2015

  • Jan Fit To Last
  • Feb Visceral Obesity
  • Mar Modern Malnutrition
  • April Metabolic Syndrome
  • May Prevalent Predicaments
  • June Sugar Diabetes
  • July Diabetes Complications
  • Aug Cholesterol, Atheroma
  • Sept Aging Brain & Body
  • Oct Cancer Considerations
  • Nov Feeling Liverish
  • Dec Energetic Longevity
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Last month’s Twitter Teaching Focus was on Sugar Diabetes…a metabolic disorder that goes way deeper than the blood sugar…while complicating pregnancy, surgery, infections and trauma. The spectrum of diabetes presentations most commonly seen clinically is reviewed in this Countdown….

Diabetes has been a problem for humankind from antiquity, known through the centuries as The Pissing Disease because of its conspicuous expression in thirst and urination. Physicians of ancient Greece examining the urine such patients passed found it sweet to the taste and named it the Sweet Pissing Disorder, or Diabetes Mellitus. An  elevated blood sugar is today’s hallmark of diabetes and indicates a failure of the normal insulin effect.

Insulin failure can be relative or absolute, and partial or total. These differing degrees of insulin failure express themselves differently at the clinical level. Total failure is seen after surgical pancreatectomy (perhaps for cancer) or from an autoimmune disease as in some children with juvenile diabetes. The failed insulin affect allows blood sugars to drift up, to spill into the urine and to begin the metabolic burning of fat to excess.

Diabetic keto-acidosis is a late disaster from a failure to burn sugar and the excessive burning of fat. It can develop in patients with classic diabetes if unrecognized and not treated with insulin, or from an intercurrent infection in a diabetic when it may create a temporary insulin resistance requiring hundreds of units to overcome. In either event enough sugar cannot be burned and blood sugars rise. Energy needs are met by burning more fat and producing its combustion products, called ketone bodies. They depress consciousness and provoke hyperventilation…two clinical hallmarks of the coma of diabetic keto-acidosis. Insulin and fluids are lifesaving. Thousands of units and dozens of liters may be needed.

Another kind of diabetic coma results from severe dehydration. Called hyperosmolar diabetic coma, such patients show little or no keto-acidosis and do not hyperventilate. Usually seen in an elderly individual living alone in a summer heat wave, he or she is often handicapped by a blunted sense of thirst that is common with age. The blood sugar is high and it carries water away from the body in the urine, drying the patient out without prompting any thirst. Skin and mucous membranes are dry and consciousness is depressed. Such a patient’s need for fluids is greater than the need for insulin, although both are necessary.

Insulin’s normal task is to facilitate the transfer of nutrients like glucose and amino acids into the tissues after a meal. Insulin is a hormone made in the pancreas. It enters the portal vein and flows up into the liver, an organ that also receives nutrients from digestion where they are processed for distribution to body parts. When working normally, the liver sweeps randomly released insulin up from the portal vein, and out of the circulation. But when choked with fat (so common today from visceral obesity) liver cells allow insulin to circulate in the blood to excess. Insulin’s target tissues begin to resist being overfed by high levels, and the insulin effect becomes dampened. Metabolic transfers are delayed. A state of insulin resistance is aid to exist. The patient has few or no symptoms nor signs of trouble at this time, but a chronic nutrient delivery back-up does exist and metabolic processes have been slowed. Clinical diabetes is imminent.

Keeping the blood sugar level where it should be is an important normal liver function. During periods of fasting or starvation the liver makes sugar from protein for body organs like the brain, and distributes it through the circulation. With insulin resistance, however, as from a fatty liver and slowed metabolic processes, glucose tolerance testing can demonstrate the delayed clearance of sugar from the blood. A diagnosis of early or ‘chemical’ diabetes can be made. Nutrient transfers do continue but at slower rates, and such patients often feel well or admit to being only a little less energetic. Their overnight fasting blood sugars are routinely normal.

A positive Glucose Tolerance Test in a well-fed fasting patient is early diabetes, and sometimes called chemical diabetes. It is not pre-diabetes. Such patients’ blood sugars are best kept low after meals with a diabetic diet that spreads complex carbohydrate intakes evenly over the day. Simple carbohydrates, like sugars, are best avoided because they are absorbed too quickly. Complex ones like starches and vegetables take more time to digest, and are preferred in any diabetic diet.

Over the years that insulin resistance slowly develops, the pancreas compensates by overproducing insulin. When eventually defeated, it begins to allow blood sugars to drift up after each meal, and they fail to return to normal, even though insulin levels are high and even after an overnight fast. When levels exceed 180 mg % glucose begins to spill into the urine. Normal kidneys keep it within the blood and out of the urine below 180. When sufficient sugar floods the urine, patients develop the symptoms and signs of classic diabetes: thirst, polyuria, fatigue, tissue wasting, debility. They must be treated or will go on to coma and death.

When new diabetics have their blood chemistries restored to normal, they must begin managing their lives in ways that avoid sugars going too low or too high. Too low a sugar can lead to loss of consciousness because the brain needs glucose to function. Too high a blood sugar, while less dramatic, causes tissue damage over the months and years. Sometimes called glycation, it is the focus of this month’s Twitter Teaching. The kind of diabetes most commonly encountered in the clinic these days is called Type II. Typically, it begins with insulin resistance from the fatty liver of visceral obesity, and progresses to a gradual elevation of the blood sugar when the diagnosis is made.

In summary, a metabolic disease from antiquity that we call sugar diabetes has become another of today’s diseases of abundance. It is a product of so much cheap and tasty food: available 24/7, plus the physical inactivity of our automobiled, digital age. It tends to cripple our diabetic patients with blindness and limb loss, or to compromise their lives with heart attacks, strokes and kidney failure.

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