Homeopathic Treatment for Diabetes

The Diabetes Loophole

Diabetes Loophole is a step- by-step manual, your complete guide to reverse diabetes naturally and without any side effects.It was created by Reed Wilson who is an alternative health researcher. And has led his team to find answers to the diabetes epidemic that's been silently ravaging the nation.The secrets in this program helped a 10-year-old's life to begin when his diabetes ended, they also helped an elderly woman reduce her blood sugar level from 450 to normal levels and so many people to reduce their diabetic symptoms.The secrets will help you to reduce your risk of cancer by an incredible 67%, reduce cholesterol by 25 to 30% (as much as statin drugs and without the risky side-effects), reduce high blood pressure by as much as half and reduce the risk of a fatal heart attack by 70%The book by reading the book you will learn things like foods that will help you overcome diabetes and exercizes that will improve your health.When you order for this manual you get other books for free like: Super foods, the antiinflammatory diet, the top 20 inflammatory food and others.Everything in this program is focused on giving you exactly what you need in order to get the kind of freedom you've been denied You'll get results like so many others have before you. All you have to do is order. Read more...

The Diabetes Loophole Summary

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How often should Type diabetics measure their blood glucose levels with a portable meter

Patients with Type 2 DM do not have the high variability of blood glucose values that Type 1 patients have. Consequently, as already mentioned, much fewer measurements are needed to evaluate blood sugar control. When SMBG is recommended by the treating physician, the precise frequency and timing of the measurements is individualized, depending on the type of therapy, drug doses, achievement or not of glycaemic targets and training of the patients. In those using insulin, SMBG should be daily. In the not so frequent case that the patient uses an intensive insulin regimen, measurements should follow the same pattern as in Type 1 DM. Regardless of the frequency of measurements, determination of some post-prandial values (two hours after a meal) is considered essential, especially in cases where fasting blood sugar values are not compatible with HbAlc values.

What are the indications for the use of an insulin pump

According to the American Diabetes Association (ADA), the indications are as follows The following indications for application of a continuous insulin infusion pump have been established 1. Type 1 diabetics, in whom every effort to achieve satisfactory diabetic control with an intensified insulin therapy regimen fails (unsatisfactory HbAlc level, intense fluctuations of blood glucose levels during a 24-hour period, intense 'dawn phenomenon'). 2. Type 1 diabetics who manifest frequent and or severe hypoglycemias, especially in the night. 3. Type 1 diabetics who have developed decreased perception of hypoglycaemia (hypoglycaemia unawareness). 4. Type 1 diabetics who manifest high sensitivity to insulin and need a small total daily dose of insulin. 5. Type 1 diabetics who lead an erratic way of life, who have a circular work schedule, who are submitted to intense physical or mental lassitude at work, who for professional or personal reasons are not in a position to receive their main and...

The Troglitazone in the Prevention of Diabetes Study

The Troglitazone in the Prevention of Diabetes (TRIPOD) study evaluated 236 Hispanic women with gestational diabetes and a mean BMI of 30 kg m2. This trial used 400 mg day of troglitazone, and demonstrated a 55 relative risk reduction of diabetes with a number needed to treat of 15 patients for 2.5 years. The 121 women on placebo developed diabetes at a rate of 12 yearly, compared with 5 among the 114 that received troglitazone. Additionally, lowered plasma insulin levels were found in 89 of individuals on troglitazone. The decreased secretory demands on the P-cells caused by the reduction in insulin resistance not only delayed the development of diabetes, but preserved P-cell function (14). In an analysis of the 84 women who were still nondiabetic 8 months after the study medications had to be stopped, the rate of progression to type 2 diabetes was 21 in the placebo group and 3 in the troglitazone group, for a 92 risk reduction. This would not have been seen if the glitazone was...

Financial And Social Impact Of Type Diabetes

The burdens of type 1 diabetes provide the rationale for current discussions regarding disease prevention. These burdens include medical, social, psychological, and financial elements. Several studies on costs have noted a large financial burden related to diabetes (100), and the most current estimate in the United States places the annual medical and social costs of diabetes at 97 billion (101). Estimates focused solely on type 1 diabetes appear less frequently in the literature. Reports from England and Wales (102), Israel (103), and Spain (104) note meaningful expenses in type 1 diabetes both in the short-term and on a lifetime basis. Studies that describe the economic costs of diabetes often consider the direct or medical costs of the disease and, less frequently, the indirect costs of diabetes. Examples of indirect costs include the value assigned to morbidity, disability, and premature mortality associated with type 1 diabetes. From an economic perspective, the most important...

Are there conditions for the application of basalbolus insulin regimens

Provided there is an indication for their administration, the basic condition is the acceptance of the regimen by the patient, after of course his or her thorough and objective briefing with regard to the necessity, functionality and precise way of application. The details of the treatment should be analysed and it should be emphasized that, together with the multiple injections, it is absolutely essential that the patient regularly monitors (at least four times a day) the glucose levels in the capillary blood. Acceptance by the patient assumes that a powerful incentive exists to achieve the best blood sugar control. This motivation is based on correct briefing and on factors such as age, maturity, educational level and psychological situation of the individual. Often, more than one meeting with the doctor is required before the individual with Type 1 DM is convinced that the intensive regimen constitutes the best choice for managing the disease.

Diabetic Patients Requiring

The course from the onset of diabetes to the clinically evident nephropathy (proteinuria) and then to ESRD lasts 15-25 yr and occurs in approximately one-third of both type 1 and 2 diabetic patients, who then require RRT dialysis or kidney transplantation. In recent years, the frequency of DN has continuously increased, and since 1990 has become the fastest growing cause of chronic kidney disease (CKD) and the leading cause of ESRD worldwide, especially in the industrialized countries (1). Thus, during the last three decades among ESRD patients, the percentage of diabetic patients with ESRD admitted for RRT has dramatically increased in all racial groups, which is a reflection of the growing incidence of diabetes in the general population. DN is now responsible for 44 of all new patients who require RRT in United States, whereas the incident counts and adjusted rates of new patients starting RRT whose ESRD was due to diabetes increased from 2530 (12.5 per million population pmp ) in...

Diabetes in Association with APECED

The prevalence of type 1 diabetes in our Finnish patients with APECED is 18 (see Table 2), in contrast to 0.5 in the background population. Lower frequencies of 2-4 have been reported for patients from the United States and Italy (2,49), but the difference could be merely the result of patient selection (e.g., with respect to age). Of our 16 patients with diabetes, 14 were clinically considered to have type 1 diabetes. The Pre-diabetic patients Non-diabetic patients

Clinical trials of stents versus CABG involving diabetic patients

The Coronary Angioplasty versus Bypass Revascularisation Investigation (CABRI) was one of the largest trials of PTCA versus CABG and had follow-up over a 4-year period (Kurbaan etal., 2001). Complete revascularisation was mandatory, and in the percutaneous group new devices such as atherectomy or stents were allowable at the operator's discretion. A total of 1054 subjects, of whom 125 (12 ) had diabetes, were randomised to CABG or PTCA 37 of the CABG group received an IMA graft. Diabetic patients had a higher mortality rate than non-diabetic patients. Diabetic patients randomised to PTCA had a higher mortality rate than diabetic patients randomised to CABG (CABG vs. PTCA 8 63(12 ) vs. 14 62(23 )). Post-revascularisation angiographic evidence of residual CHD was consistently significantly greater in PTCA than in respective CABG subgroups. At 1 year, diabetic patients treated with stenting had the lowest event-free survival rate (63 ) because of a higher incidence of repeat...

Potential Risks Of Surgery In Diabetic Patients

There have been surprisingly few studies on postoperative mortality and morbidity comparing diabetic with non-diabetic subjects. Diabetes was certainly considered to be a major risk factor for surgery in past decades. An American study in 1963 reported a 5 mortality postoperatively in a large (487) group of surgical diabetic patients, the major causes of death being ketoacidosis, infection and myocardial infarction (Galloway and Shuman 1963). It is likely, however, that methods of management were highly sub-optimal compared with modern management principles. A more recent study (Hjortrup et al 1985), using modern treatment methods, has shown no difference in mortality between diabetic and non-diabetic subjects (2.2 versus 2.7 respectively). Some specific surgical procedures may have increased risk in diabetic patients, however, notably vascular procedures. Thus, aortic and lower limbs revascularization procedures carry increased mortality in diabetic compared with non-diabetic...

Chronic complications of diabetes

The results of the Diabetes Control and Complications Trial in the USA have established unequivocally the relationship between glycemic control and the incidence or progression of diabetic microvascular complications. Such complications occur in both type 1 and type 2 diabetic patients, although the latter patients often die because of major vascular disease before microvascular complications become advanced. More than 40 of type 1 diabetic patients will survive for more than 40 years, half of them without developing significant microvascular complications. The United Kingdom Prospective Diabetes Study (UKPDS) has also provided pivotal information on the relationship between glucose control and complications in type 2 diabetes diabetes mellitus (DM). It has demonstrated, in a significant way, the beneficial effect of an improvement in blood glucose control on subsequent risk of developing specific diabetic complications.

Grafting in Diabetic Patients

Clinical outcomes in diabetic patients following coronary revascularization procedures with bypass surgery (CABG) or percutaneous coronary intervention (PCI) are worse than in nondiabetics. Current evidence suggests that CABG is preferable to PCI for revascularization in patients who have diabetes and multi-vessel coronary artery disease. Most trials have not used contemporary adjunctive therapies, such as GP Ilb IIIa inhibitors and prolonged dual antiplatelet therapy. It is conceivable that implementation of these evidence-based therapies may improve clinical outcomes significantly in diabetic patients who undergo PCI. In the future, emerging technologies, such as drug-eluting stents and soluble receptor for advanced glycation end products, may further improve outcomes after PCI and make it the preferred revascularization modality in diabetics.

Other Issues Relating To Infection And Diabetes

Current guidelines from the Centers for Diseases Control (CDC) recommend that all diabetic patients receive influenza and pneumococcal vaccination. Despite these recommendations, a recent review by the CDC and the Council of State and Territorial Epidemiologists (CSTE) suggested that only 52 of diabetic patients reported receiving the influenza vaccination in the past 12 mo and only 33.2 recalled receiving pneumococcal vaccination at all. When prescribing antibiotics in the diabetic patient, particular caution is warranted to avoid nephrotoxicity as well as the potential for eye toxicity. Also, when administering oral antibiotics, the effects of gastropathy on oral absorption should be considered. Maintenance of good hygiene, particularly in the context of foot care, is crucial in patients with diabetes.

Summary of findings comparing CABG with PTCA in diabetic patients

Recurrent ischaemia leading to angina, repeat revascularisation and cardiac mortality is more common after PTCA than with CABG, because PTCA more commonly results in incomplete revascularisation and an appreciable risk of ischaemia. Incomplete revascularisation is an independent predictor of adverse outcome (Cowley etal., 1993). Whilst several trials have found CABG to be superior to PTCA in diabetes (O'Keefe etal., 1998 Weintraub etal., 1998, 1999), whereas one other trial (Halon etal., 2000) and the Duke University registry (Barsness etal., 1997) did not. Overall, surgical revascularisation for multivessel CHD in diabetic patients, particularly in insulin-treated patients, is associated with a survival advantage compared with PTCA. However, studies with long-term follow-up beyond 10 years have indicated that the survival benefits of surgery may be attenuated. van Domburg etal. (2002) reported on 1041 surgically treated patients (8 diabetes) and 704 (11 ) medically treated patients...

Predictors of restenosis after stenting in diabetic patients

Intravascular ultrasound studies have shown that restenosis in both stented and non-stented lesions is due to intimal hyperplasia (Kornowski etal., 1997 Levine etal., 1997 Van Belle etal., 1997), which is a smooth-muscle-cell proliferative response. In one series of 241 patients (n 63 with diabetes) who had 251 native lesions stented, follow-up angiography with intravascular ultrasound demonstrated the late lumen loss was more pronounced in both stented and non-stented lesions of diabetic patients (Kornowski etal., 1997). Results from registries and clinical trials indicate that diabetic patients have an increased risk of restenosis, repeat revascularisation and death after PCI (Rozenman etal., 2000 Van Belle etal., 2001). A useful retrospective study of clinical trial participants was performed at the Cardialysis Core Laboratory in Rotterdam (West etal., 2004). Restenosis occurred in 550 of 2672 (21 ) non-diabetic and 130 of 418 (31 ) diabetic patients (P 0.001). Reduced body mass...

Structuralfunctional Relationships In Diabetic Nephropathy

Mesangial expansion is the major hallmark of nephropathy in type 1 diabetic patients (42) and is, more or less, related to all other renal structural or functional alterations of the disease. Increased Vv(Mes glom) closely correlates with a decrease in peripheral GBM filtration surface density Sv(PGBM glom) . On the other hand, total filtration surface per glomerulus S(PGBM glom) is highly correlated with GFR across the spectrum from hyperfiltration to renal insufficiency in type 1 diabetes (42-45). Vv(Mes glom) is also related to the AER (42,46) and high blood pressure (20,42). Similarly, but less strongly than for Vv(Mes glom), GBM width is directly correlated with blood pressure and AER and inversely correlated with GFR (42,46). In fact, the rate of development of mesangial expansion and GBM thickening varies among patients (42,46). For example, relatively marked GBM thickening can be seen without remarkable mesangial expansion and vice versa, preventing a precise correlation...

Do diabetic individuals have a higher susceptibility towards infections compared to nondiabetics

Sufficient data do not exist to substantiate the opinion that diabetics, as a whole, have a higher susceptibility towards infections. However, some infections are more common in diabetic patients, and others present nearly exclusively in these people. Moreover, some infections have a more severe clinical course and manifest a higher frequency of complications in diabetics. The increased susceptibility of diabetics to certain infections is due to many factors. The polymorphonuclear neutrophils of diabetics have been found to have decreased chemotactic and phagocytic abilities. Furthermore, it seems that the ability of leukocytes to counter the microorganisms after the process of phagocytosis is diminished.

Animal Studies Of Renal Autoregulation In Diabetes Mellitus

Several studies in streptozotocin diabetic rats and dogs have suggested that hyperglycaemia induces impaired autoregulation of RBF and GFR 52,58-60 . Changes in vasoactive hormone activities have been suggested to contribute to impaired renal autoregulation 61,62 . Furthermore, a rise in growth hormones in diabetic patients induces glomerular structural changes, which may change the regulation of GFR 63 . Diabetic autoregulation impairment develops over time 58,59 , but impaired afferent arteriolar contraction during increased renal arterial pressure can occur in the early course of experimental diabetes 52,64 . Furthermore diabetes has been shown to impair TGF response 60,65 . Other investigators have however shown preserved 66 or even enhanced autoregulatory ability (shift of the autoregulation range to the left (fig. 1)) in rats with short time diabetes 67 .

Genetics Of Hspg Abnormalities In Diabetes

The existence of genetic polymorphisms in the N-deacetylase N-sulfotransferase enzymes has thus far not been reported. Animal experiments performed by Kofoed-Enevoldsen et al 40-42 support the influence of genetic factors in modulating the vulnerability of the N-deacetylase N-sulfotransferase enzyme towards diabetes-induced inhibition, as evident from studies involving different rat strains. Recently, a BamHI restriction fragment length polymorphism in the perlecan gene was found to be associated with diabetic nephropathy in Caucasian insulin-dependent diabetes mellitus 48 . However, in type 2 Japanese diabetic patients the BamHI HSPG2 genotype and allele frequencies were not significantly different between the patients with nephropathy and the patients without nephropathy 49 . No data are available on the role of variants of agrin in diabetes complications.

Coronary revascularization in diabetics

Diabetic patients who have coronary artery disease have significantly worse long-term outcomes compared with nondiabetic patients. The reasons for this are complex but relate, in part, to more extensive atherosclerosis, an increased risk of thrombosis, overexpression of mitogenic cyto-kines, higher oxidative stress, glycated end products, larger and more activated platelets, and more rapid progression of disease. Patients who have diabetes experience higher perioperative mortality rates compared with nondiabetics who undergo bypass surgery (CABG) 1,2 or percutaneous coronary intervention (PCI) 3,4 . Although outcomes after revascularization in diabetics are worse after either modality, CABG seems to be preferable to PCI in most patients who have multi-vessel disease (Fig. 1).

Features Of Pad In Diabetic Patients

Diabetic patients with PAD have several distinct features when compared with non-diabetic patients with PAD. A greater proportion of diabetic patients with PAD have concomitant hypertension (152). In addition, diabetic patients have more distal disease, (152,153) more progressive and severe disease, and they are more likely to undergo surgery and amputation for critical limb ischemia (148,152,153). The rates of gangrene or amputation of lower limbs are as much as 10 to 20 times more frequent in diabetic than in control subjects (154,155). The risk of amputation also increases with age. The annual amputation rates were 14 per 10,000 in patients less than forty-five years of age, 45 per 10,000 in diabetics between age forty-five and sixty-four, and 101 per 10,000 in those over sixty-five. Not surprisingly, duration of diabetes has been found to be a strong risk factor for amputation (155). Interestingly, the type of vessels affected may vary compared with non-diabetic patients with PAD...

Diabetes Mellitus and Clinical Aspects of Breast Cancer

Diabetes Mellitus and Breast Cancer Screening Screening mammography has been shown to reduce breast cancer mortality and is recommended by clinical practice guidelines for all women between the ages of 50 and 69 years. With current antidiabetic treatment, many patients with diabetes do not have additional comorbidity and thus may benefit from screening, yet in several countries diabetes may adversely affect attendance to screening mammography. Beckman et al. 38 found that American diabetic patients were less likely to undergo screening mammography, probably due to compromised attitude of their primary care physicians to preventive medicine and to high costs of mammography. Lipscombe et al. 39 investigated mammography rates in a large Canadian cohort, consisting of 69,168 women with diabetes and 663,519 women without diabetes. Although all patients were fully insured, diabetic patients had about one-third lower chances to perform screening mammography. On the other hand, a study from...

Abnormal Activity Of The Enzymes Responsible For Gag Sulfation In Diabetes

Approximately 40 lower in hepatocytes from streptozotocin diabetic rats as compared with control cells 39 . Furthermore, Kofoed-Enevoldsen et al 4042 found a reduction in N-deacetylase N-sulfotransferase activity in streptozotocin diabetic rats. In humans, the activity or gene expression of N-deacetylase N-sulfotransferase has been evaluated in cell cultures of skin fibroblasts obtained from diabetic patients with without diabetic nephropathy. Neither the activity of N-deacetylase N-sulfotransferase in type 1 diabetics 43 nor mRNA levels of N-deacetylase N-sulfotransferase 1 and 2, in type 2 diabetic patients 44 levels were altered. Interestingly, only the N-deacetylase N-sulfotransferase 2 gene expression was down-regulated by diabetes, but this was only in skin fibroblasts, not in mesangial cells 44 . It should be recognized that N-deacetylase N-sulfotransferase 1 and 2 enzymes are not the only enzymes involved in HS-PG sulfation. Indeed, N-deacetylase N-sulfotransferase 3,...

Distribution Of The Hspg Metabolism Abnormality In Diabetes

The available data are contradictory. Studies using biochemical techniques to measure GAG content in the intima of the aorta of patients with type 2 diabetes mellitus have observed a reduction of HS 46 , suggesting that the abnormalities in HS metabolism are not necessarily restricted to the kidney, although there has not been any examination of any possible relationship with coexistent diabetic nephropathy. The staining of skin basement membranes by JM-403, the monoclonal antibody that reacts with HS-GAG side chains, was significantly reduced in type 1 diabetic patients with diabetic nephropathy, as compared to patients with long-standing diabetes without nephropathy 47 . However, similar findings were observed also in patients with ESRD of non- diabetic origin 47 . The more recently discovered anomalies in HS-PG seem to be restricted, at least in type 2 diabetes, to the kidney taking into account the observation of the tissue distribution of agrin 36 , of the finding that increased...

Glucose Insulin Infusions

During moderate or major surgery, elderly Type 1 and Type 2 diabetic patients should receive insulin, intravenously even if preoperative diabetes control has been good. However, for Type 2 patients undergoing minor surgery, regular glucose monitoring only may be required if their control has been good. For those with poor control, intravenous insulin is appropriate. During surgery the two options are either a combined infusion of glucose, potassium and insulin, or separate glucose potassium and insulin infusions. In this context insulin is necessary to maintain good glycaemic control while preventing proteolysis and lipolysis, while glucose provides energy and prevents hypoglycaemia (Alberti 1991). When glucose is given as 100 mL of 5 dextrose per hour, short-acting insulin doses of 1.5-2.0 U h are usually sufficient together with 10-20 mMol potassium chloride per litre of glucose. Perioperative glucose monitoring is essential. Because of the risks of separate infusions running at...

Favorable Glp Actions In Type Diabetes Beyond The Insulinotropic Effect

GLP-1 inhibits glucagon secretion (32,33). In type 2 diabetes, excessive glucagon secretion in relation to the plasma glucose aggravates fasting hyperglycemia by stimulating hepatic glucose output (34). Exogenous administration of GLP-1 in type 2 diabetic patients leads to a significant suppression of glucagon secretion together with a normalization in fasting plasma glucose (29). The counterregulatory response of glucagon secretion in hypoglycemia is unaffected by GLP-1 administration (35). GLP-1-based therapies will therefore not bear an intrinsic risk for hypoglycemia (36). Concerning gastrointestinal functions, GLP-1 slows gastric emptying and inhibits gastric acid secretion (18). In the central nervous system, GLP-1 acts as a neurotransmitter in the hypothalamus and stimulates satiety directly (37). Continuous GLP-1 application over 6 weeks in type 2 diabetic patients produced significant weight loss due to reduced food intake and increased satiety (37,38). Whether the effects of...

Outcomes in Diabetic Patients

Meta-analyses of ACE inhibitor trials provide compelling evidence that ACE inhibitors reduce cardiovascular events and mortality related to acute myocardial infarction (MI) and heart failure (90,91). Because diabetes is an independent risk factor for CVD (92) and the RAS and diabetes appear to interact at multiple levels, it is possible that diabetes may affect the efficacy of ACE inhibition on CVD. Several recent reports have provided retrospective analyses of data from diabetic subgroups, which participated in large ACE inhibitor trials. Although some of these trials were not designed to specifically address the effects of ACE inhibition in diabetes, comparison of the relative effects of ACE inhibition in the diabetic and nondiabetic subgroups may provide important insight into the role of the RAS in CVD in diabetes. An underlying question regarding the vascular protective effects of antihypertensive therapies is whether these effects are mediated via the reduction in BP or whether...

Endothelial function measures as predictors of diabetes or in prediabetes

There is a wealth of data suggesting a potential role for endothelial dysfunction in insulin resistance (Fonseca and Jawa, 2005). Although the direction of causality remains somewhat debated, circulating elevations in several endothelial-derived factors, cell adhesion molecules and t-PA, have been shown to predict risk for type 2 diabetes independently of other predictors (Meigs etal., 2006). Similar results have been seen with physiological tests of endothelial function. For example, Steinberg etal. (1996) showed that severely obese (mean body mass index 34kg m2) insulin-resistant individuals with normal glucose tolerance have the same degree of impairment in blood flow and vascular reactivity as those people with established type 2 diabetes. Similarly, when Caballero etal. examined endothelial function and vascular reactivity in two groups at risk for developing type 2 diabetes, subjects with impaired glucose tolerance and subjects with normal glucose tolerance but with a parental...

Registry information for PCI with stenting in diabetic patients

Other data also suggest that outcomes after PCI can be similar to those after CABG in diabetic patients with multivessel CHD. In one registry of 9586 patients (n 1714 (18 ) diabetes), 970 patients had multivessel disease CABG was performed in 318 (33 ), PCI in 351 (36 ) and 301 (31 ) were treated medically (Kapur etal., 2003). In-hospital mortality was 3 in the CABG group and 2 in the PCI group, and 1-year mortality was 7 in the CABG group, 9 in the PCI group and 10 in the medical

Potential and Proven Risk Factors for Atherothrombosis in Patients with Type Diabetes

All major pathophysiological pathways leading to accelerated atherothrombosis are disturbed in patients with type 2 diabetes. However, to prove that a risk factor is contributing to a higher risk of cardiovascular disease in patients with type 2 diabetes, two conditions must be fulfilled. First, a potential risk factor has to be associated with cardiovascular risk in longitudinal studies. Secondly, evidence from trials is needed to demonstrate that normalisation of a risk factor reduces the cardiovascular event rate. Many potential risk factors from atherothrombosis in patients with type 2 diabetes have been studied in a cross-sectional setting. With respect to endothelial function, previous studies have shown that subjects with insulin resistance or type 2 diabetes have an impairment in their ability to increase blood flow to peripheral insulin-sensitive tissues, at least partly due to their inability to induce NO-mediated vasodilatation (Creager etal., 2003). However, endothelial...

Abnormal Hspg Metabolism In Diabetes

GAG abnormalities in diabetic nephropathy were originally investigated on the bases that albuminuria implies abnormal GBM permselectivity, and that GAGs, namely HS, were thought to be important determinants of GBM permeability. Indeed, a decreased 35S sulfate incorporation in the GBM of diabetic glomeruli has been observed 14-16 . In experimental animal models of diabetes, a reduced synthesis of glomerular PGs and basement membrane HS-PG was also found 17-19 . However, the finding of the reduced sulfate incorporation is not without controversy, and a marked increase in 35S sulfate incorporation in proteoglycans in diabetic tissues has also been observed 20 . Studies using biochemical techniques to measure the GAG content of kidneys obtained at autopsy demonstrated that the GBM of patients with diabetic nephropathy (it was not specified whether type 1 or type 2 diabetes) contained less GAGs than kidneys of non-diabetic controls 21,22 . That the synthesis of carbohydrate side chains of...

Alternative Proteomics Approach to Define Alterations in Urinary Proteome Profile in Patients With Diabetic Nephropathy

In addition to the classical proteomics approach described above, the alternative proteomics approach has also been applied to DN using CE-TOF MS to differentiate urinary proteome profile of patients with type 2 diabetes from that of the healthy controls (84). The urinary polypeptide pattern of patients with diabetes significantly differs from the normal. Moreover, there is a specific polypeptide pattern of diabetic renal damage in patients with high-grade albuminuria (urine albumin 100 mg L). The urinary polypeptide profiles in diabetic patients can be classified into four types. Type A pattern is typically found in the diabetic state and the occurrence in healthy subjects is low. Type B pattern represents polypeptide profile observed mainly in healthy subjects and the frequency in patients with diabetes is low. Types C and D are the typical patterns of markers for diabetic renal damage of which the frequency in diabetes is increased and decreased, respectively (84). These data...

Defects of hepatic glucose metabolism in diabetes mellitus

Turning our attention to hepatic glucose fluxes following a normal meal in type 1 and type 2 diabetic patients, studies have revealed significant alterations of hepatic glycogen storage (Figure 11.12), glycogen release and gluconeogenesis in both patient groups (Taylor et al.1996 Hundal et al. 2000 Bischof et al. 2001, 2002 Singhal et al. 2002 Krssak et al. 2004). A defect in hepatic glycogen storage was observed in glucokinase deficient maturity-onset diabetes of the young 2 (MODY-2) patients, in whom the impaired hepatic glucokinase activity is held responsible for a reduction in the contribution of glucose (the direct pathway) to hepatic glycogen synthesis (Velho et al. 1996). Lower glycogen synthesis (Bischof et al. 2001, 2002 Krssak et al. 2004) and unsatisfactory suppression of endogenous glucose production (Sinha et al. 2002 Krssak et al. 2004) contribute to postprandial hyperglycaemia in both pathologies. Increased gluconeogenesis is the key to postabsorptive hyperglycaemia in...

Treating Subjects with Type Diabetes with Multiple Injections Basal Bolus Therapy

Multiple injections with fast-acting insulin before the meals and intermediate or long-acting insulin at bedtime (basal-bolus regimen) is the first choice insulin regimen in most type 1 patients, but is not used very much in patients with type 2 diabetes. Nevertheless, prandial glucose regulation is an emerging concept, since epidemiological and mechanistic studies indicate that postprandial glucose contributes significantly to overall glycaemic exposure and also contributes to the vascular complications in type 2 diabetes 34,45 . Adding prandial insulin to basal insulin is a logical approach when the target of HbAlc cannot be achieved by the combination of basal insulin and oral therapy. Basal-bolus therapy represents the most physiological insulin regimen, but is more complex and the patient needs to be more educated and motivated for glucose monitoring. A few studies have evaluated the efficacy of multiple injections in type 2 diabetic patients. In the first study the efficacy and...

Diabetes as a Risk Factor for Stroke

The majority of diabetic patients have multiple risk factors for vascular disease, however diabetes remains an independent risk factor for stroke across all age groups (Wolf etal., 1983). This increased risk is not confined to patients with diabetes but also includes patients with impaired glucose tolerance (IGT), asymptomatic non-fasting hyperglycaemia and hyperinsulinaemia (Coutinho etal., 1999). The increase in risk conferred by diabetes also extends to patients with hypertension who already have a high absolute risk of cardiovascular disease (Kannel and McGee, 1979 Stamler etal., 1993). Accepting that type 2 diabetes is the predominant form of diabetes in stroke patients, the United Kingdom Prospective Diabetes Study (UKPDS) has demonstrated that over a 9-year period 20 of type 2 diabetic patients are likely to experience macrovascular complications (UK Prospective Diabetes Study Group, 1996). This is in contrast to an estimated 9 experiencing microvascular complications over a...

Epidemic Of Type Diabetes

Epidemiological studies had already identified diabetes epidemic in 1970s. The extraordinarily high prevalence of type 2 diabetes was reported in Pima Indians (18) and also in the Micronesian Nauruans in the Pacific (19), and subsequently in other Pacific and Asian island populations (20). These studies showed that transition from traditional lifestyle to Western way of life resulted in obesity, lack of exercise, profound changes in the diet, and finally to type 2 diabetes. Potential for a future global epidemic of diabetes were highlighted. Since the 1970s several other studies have shown that type 2 diabetes has reached epidemic proportions in several developing countries as well as in Australian Aboriginals (21), African-Americans, and Mexican Americans (22). Table 2 shows the trends in the number of diabetic patients worldwide (23). Significant increase in the number of type 1 diabetic patients is expected, but the doubling of the number of diabetic subjects in the following 20...

Effect of Angiotensin Converting Enzyme Inhibition Following Acute Myocardial Infarction on Cardiovascular Outcomes in

The GISSI-3 study examined the short-term effects of ACE inhibition when administered within 24 hours following an acute MI in a population of more than 18,000 patients, including 2790 patients who reported a history of diabetes (10). Retrospective analysis of results from this study revealed that ACE inhibitor treatment provided greater protective effects against 6-week mortality in diabetic patients compared with nondiabetics. The overall risk reduction by ACE inhibitor treatment for the diabetic group was 32 , compared with a risk reduction of 5 for nondiabetic patients. Within the diabetic group, ACE inhibitor treatment reduced mortality rates for both insulin-dependent (IDDM) and noninsulin-dependent diabetes mellitus (NIDDM) patients by 49 and 27 , respectively. Although this report indicates that the benefit of ACE inhibitor treatment in the diabetic group was greater than that for the nondiabetic group, the basis for this difference is unclear. Although the baseline...

Lower Extremity Revascularisation in Patients with Diabetes

Aorta-bifemoral bypass with Dacron grafts often achieve high patency rates in the presence of a patent superficial femoral artery. The standard procedure for infrainguinal occlusive disease is femoral-popliteal bypass or bypass to the crural arteries. The latter may be preferred for patients with diabetes since arterial occlusion in this group is often located more distally. Outcomes of percutaneous revascularisation procedures depend on various factors, including the location and length of the lesion, stenosis and the presence of a collateral circulation (Beckman etal., 2002). Patients with diabetes tend to have more severe arterial occlusive disease below the knee, and with reduced distal collateral supply. The results of percutaneous interventions in patients with diabetes may be worse than in non-diabetics. Iliac artery stenting in patients with diabetes achieves a 90 patency rate at 1-year (Dormandy and Rutherford, 2000), although some groups have shown lower patency rates. The...

Major data and relevance to better understanding of diabetes and metabolism

Several studies in diabetic patients revealed the effects of lifestyle modification or physical exercise on endothelial function. In insulin-resistant subjects, lifestyle modification with exercise and weight reduction over six months improved endothelial function (Hamdy et al. 2003). Interestingly, the relationship between percentage weight reduction and improved FMD was linear. A similar result was seen in patients with type 2 diabetes (Maiorana et al. 2001). Likewise, in patients with type 1 diabetes, FMD could be improved by four months of bicycle exercise (Fuchsjager-Mayrl et al. 2002). However, the positive training effect on endothelial function was not maintained after cessation of regular exercise (Figure 15.5). In all studies, GTN-mediated dilation was unaffected by exercise. Another interesting study assessing FMD in 75 children with type 1 diabetes revealed that even children with diabetes have impaired endothelial function compared to healthy controls (Jarvisalo et al....

Diabetes Mellitus and Cancer A Conclusion

Many studies have suggested that diabetes mellitus type 2 may alter the risk of developing a variety of cancers, and the associations are biologically plausible. One of largest prospective studies worldwide, enrolling 467,922 men and 588,321 women who had no reported history of cancer at the time of enrollment, revealed after 16 years of follow-up that diabetes was significantly associated with fatal colon cancer in men and women, and with PC in men, and significantly associated with liver cancer and bladder cancer. In addition, diabetes was significantly associated with breast cancer in women 61 . These findings strongly suggest that diabetes is an independent predictor of mortality from these cancer entities. When treating cancer patients who have diabetes, clinicians must consider the cardiac, renal, and neurologic complications commonly associated with diabetes continued improvement of cancer outcomes may also depend upon improved diabetes control 62 . Diabetes rates continue to...

Effects of FFAs on local and systemic inflammation and link to insulin resistance

Elevated FFAs cause ectopic lipid deposition in nonadipose tissue, and this lipotoxicity may induce a pro-inflammatory response, which in turn may negatively interfere with insulin signalling. Supporting this concept, the use of high dose salicylate has been proven to decrease plasma glucose in type 2 diabetic patients (236). The molecular basis of this observation relies on decreased activity of a serine kinase called IkB kinase p (IKKP) of the NFkB signalling pathway (237), and subsequent impaired phosphorylation of IRS-1 and PI3Kinase (238). The link between IKKp and FFAs in insulin resistance has been further supported by the report that, in rats, salicylate prevents the deleterious effects of lipid infusion on muscle glucose metabolism and insulin secretion (238). In a recent report Cai and colleagues showed that obesity- or high fat-induced hepatic lipid deposition is accompanied by increased NFkB activity in the liver (239). Studies of genetically modified mice with either...

Effects On Insulin Sensitivity

The thiazolidinediones improve peripheral insulin action not only in patients with type 2 diabetes, but also in other insulin resistant states like impaired glucose tolerance (IGT), polycystic ovary disease, previous gestational diabetes and Werner's syndrome (28-31). In studies using either the hyperinsulinemic-euglycemic clamp study which is currently considered the gold standard to evaluate peripheral insulin sensitivity, or other less direct methods like the frequently sampled intravenous glucose tolerance test, the insulin tolerance test, the oral glucose tolerance test and the HOMA (S), the thiazolidinediones consistently improve insulin-mediated peripheral glucose utilization in obese and lean insulin-resistant, type 2 diabetes patients by approximately 30 to 100 (32). In all these studies, the improvements in insulin sensitivity with the thiazolidinediones has consistently resulted in improved glycemia, lower HbA1c levels and in the case of insulin-resistant IGT impaired...

Factors Predisposing Patients to Severe Hypoglycaemia in Intensified Insulin Therapy

The relationship between impaired symptomatic awareness of hypoglycaemia and an increased rate of severe hypoglycaemia is well established (Hepburn et al., 1990 Gold et al., 1994 Clarke et al., 1995), although affected patients in these studies were not subject to strict glycaemic control. The association between counterregulatory failure and increased risk of severe hypoglycaemia is also well recognised (Ryder et al., 1990). Indeed, counterregulatory failure was proposed as a predictor of risk of severe hypoglycaemia in the subsequent application of intensified therapy (White et al., 1983), and it was not until later that the ability of intensified therapy to cause counterregulatory failure was suggested (Simonson et al., 1985a). It is indeed very important to appreciate that neither asymptomatic nor severe hypoglycaemia are restricted to people using intensified insulin therapy. Apart from a previous history of severe hypoglycaemia, the greatest risk may be the degree of insulin...

Structural And Functional Glomerular Alterations In Diabetes

The first major change after the onset of diabetes is the increased volume of the whole kidney and the glomeruli 19 . These hypertrophical glomeruli have normal structural composition. After a few years the amount of glomerular matrix material is increased 1,3 . Biochemical determinations indicate an increased amount of collagen in the glomerular extracellular matrices 20 . More recently, an increase in collagen type VI in the glomerular matrix of diabetic patients has been documented 21 . On the basis of immunochemical measurement, it has become evident that the HSPG content of glomerular matrix is lower in diabetic patients 22 consistent with previous chemical analyses of the heparan sulfate chains 23,24 . These immunochemical measurements, although yielding reliable quantitative values, were performed with preparations of glomerular matrices which contain firstly, both the basement membrane and the mesangial matrix and secondly a mixture of glomeruli which may be affected to a...

Multifactorial Intervention in Type Diabetes mellitus

Steno Diabetes Centre, Copenhagen, Denmark The prevalence of type 2 diabetes mellitus is rapidly increasing. Patients with type 2 diabetes suffer from micro- as well as macrovascular complications, the latter causing the excess mortality seen in these patients compared to the background population. Several risk factors for the outcome of type 2 diabetes have been identified in prospective epidemiological studies. However, until recently the treatment of type 2 diabetes has been empirical rather than evidence based from randomized intervention studies. Although the diagnosis of diabetes is based on blood glucose levels, it is important to realize that patients with type 2 diabetes mellitus share many clinical features with the metabolic syndrome such as dyslipidaemia, hypertension, hyperinsulinaemia and an increased risk of cardiovascular disease. In cardiovascular medicine a multifactorial treatment approach of several risk factors for cardiovascular disease is generally accepted. We...

Insulin and glomerular function

With regard to the effect of insulin on glomerular filtration rate (GFR), observations in the isolated kidney, in experimental animals, and in humans have yielded contradictory results, as decreased, increased or unchanged GFRs have all been reported (reviewed in 63 ). In healthy subjects under conditions of forced water diuresis - when changes in plasma volume are prevented -euglycaemic hyperinsulinaemia did not affect GFR 64 . Likewise, in a dose-response study in type I diabetic patients under fasting conditions, insulin was without significant effect on GFR 65 . Neither renal plasma flow (as measured with 131I-hippuran) nor renal vascular resistances were affected by acute insulin administration. The role of plasma glucose concentration itself in the induction and or maintenance of hyperfiltration has been controversial. During oral glucose loading, if large fluid volumes are co-administered, plasma volume and, in turn, GFR will increase. On the other hand, a large glucose...

Intermediate Syndromes Double Diabetes

Correctly distinguishing the etiology of childhood diabetes has been an issue for many investigators. An incidence study of diabetes among Swedish youth aged 15 -34 demonstrated that even in this relatively homogeneous population with few structural barriers to diagnosis and optimal treatment, confusion as to the clinical type and etiology of diabetes can occur (42). Patients diagnosed in 1983-84 (n 281) were followed for 3 years. Initially, 75 were classified as Type 1, 19 were Type 2, and 6 were unclassifiable or their diabetes was secondary to another disease process. By 3 years duration, 87 of the Type 1 diabetes patients were still classified as Type 1, and 72 of the initial Type 2 diabetes patients were still in that category. Thus, 13 of Type 1 diabetes and 28 of Type 2 patients (n 43 in all) exhibited an atypical clinical course. Of these, six patients were designated Type 1 at onset on the basis of glycemia, ketonuria and other clinical characteristics. At followup, these...

Insulin Glargine Lantus

Insulin glargine (Lantus) was the first available long-acting human insulin analogue 12 . Glargine is a clear solution and there is no need to thoroughly mix it before injection. Insulin glargine (21A-Gly-30Ba-L-Arg-30Bb-L-Arg-human insulin) differs from native insulin in that the 21 amino acid residue aspargine on the A chain has been substituted with a glycerine residue and 2 arginine residues have been added to the C terminus of the B chain, making glargine soluble in the acidic environment at pH of 4 12 . Glargine precipitates in the neutral pH of subcutaneous tissue, which prolongs its absorption to the blood. The addition of zinc as a hexamer-stabilising agent further prolongs the duration of action. Insulin glargine must not be mixed with other insulins 12 . Clamp studies in normal subjects and type 1 diabetic patients have confirmed that the duration of glargine is longer than NPH insulin and the action profile is flatter. Median duration of action is 23 h for glargine versus...

Treatment of Subjects with Type Diabetes Using Pulmonary Inhalation of Insulin

Several pharmaceutical companies have developed inhaled insulin, and exubera from Sanofi aventis and Pfizer has been approved in several countries. The lungs with their large surface area and the thin alveolar epithelium allow rapid absorption of inhaled insulin 52 . The bioavailability has a range of 15-25 52 . The exubera insulin is a fine powder insulin in doses of 1 or 3 mg, corresponding to approximately 3 and 9 units of human insulin. The clinical trials have shown that the insulin antibody levels increase with the use of inhaled insulin, but this has not been linked to any changes in glycemic control and episodes of hypoglycaemia or allergic reactions 53 . The pharmacokinetic profile of exubera is quite similar to that of rapid-acting insulin analogues, but with a duration of action between that of rapid-acting analogues and fast-acting human insulin 54 . The development of inhaled insulin must be seen in the light of a substantial resistance to insulin therapy in patients with...

Continuous Subcutaneous Insulin Infusion Csii Therapy Using An External Insulin Pump

External insulin pumps have gained popularity because of increased flexibility of dosing, improved glycemic control and a lower incidence of hypoglycemia when compared with traditional insulin injection methods (5,6,45-48). However, CSII requires that patients count carbohydrates, SMBG frequently and carefully control caloric intake to avoid hypoglycemia and excessive weight gain. Failure to deliver rapid-acting insulin (due to pump malfunction, catheter occlusion or catheter disconnection) can lead to hyperglycemia and ketoacidosis within several hours, because of the small depot of sc insulin (two to four units) during typical basal CSII therapy (25,33,45). Although pumps can deliver basal and bolus doses of rapid-acting insulin (insulin Lispro or insulin Aspart in the USA) into the sc tissue with great precision, initial absorption into the circulation can be delayed up to 20 min, with 30 to 50 intra-subject variability (31,32,34,35). Large bolus doses and high basal rates are...

Application of muscle biopsy in diabetes

Insulin resistance in skeletal muscle is a major hallmark of type 2 diabetes (Beck-Nielsen & Groop 1994 Beck-Nielsen 1998 Beck-Nielsen et al. 2003). During the past two decades, skeletal muscle biopsies have been increasingly applied in the search for biochemical and molecular abnormalities responsible for insulin resistance. It is evident that type 2 diabetes is caused by a complex interplay between genetic and environmental factors. The latter include intrauterine malnutrition and postnatal factors such as obesity, physical inactivity and modern Western lifestyle, as well as the metabolic milieu associated with type 2 diabetes and prediabetes, including glucose intolerance, hyperglycaemia, hyperlipidaemia and hyperinsulinaemia (Beck-Nielsen & Groop 1994 Beck-Nielsen 1998 Beck-Nielsen et al. 2003). The choice of study design is therefore extremely important for the interpretation of data obtained (Table 14.1). Novel potential markers of insulin resistance and type 2 diabetes are...

Expression of the Renin Angiotensin System in Diabetes

The production and action of Ang II is regulated at multiple levels, including the availability of angiotensinogen, levels and activities of angiotensin-processing enzymes, angiotensin receptor isotype expression, and postreceptor signaling (Fig. 1). Although quantitation of Ang II levels would provide a direct measure of extracellular RAS activation, these measurements are complicated by the rapid degradation of this peptide (46,47) and its tissue-specific production (26,27,48). Reports on the effects of diabetes on plasma and tissues Ang II levels are controversial. Studies of streptozotocin (STZ)-induced diabetes in rats have reported no effect of diabetes on Ang II levels in plasma, kidney, aorta, and heart (49), reduced renal Ang II but normal levels in plasma Ang II (50), and decreased plasma Ang II in diabetes (51). Similar controversies appear for the effects of diabetes on changes in upstream components of the RAS. For example, recent studies have reported that plasma renin...

Type Diabetes And Possible Association With Viral Infections

Seasonal variation in the diagnosis of Type 1 diabetes has been considered as indirect evidence for environmental exposure in the development of Type 1 diabetes. Recent studies have provided more indirect evidence for an association between viral infections and the pathogenesis of insulin-dependent diabetes, but the final evidence for viruses causing insulin-dependent diabetes is still missing (114). Some communicable diseases occur more frequently during the cold winter months in areas where the climate changes during the year. Therefore infectious diseases could play a role, at least as a triggering factor in the onset of clinical symptoms of insulin-dependent diabetes. development of Type 1 diabetes, this disease is not a common consequence of viral infection. Even though it was suggested in the last century that there might be a connection between mumps and Type 1 diabetes (115), the part that viruses play in Type 1 diabetes is still not clear. Many reports have shown a temporal...

Activity of the Entero Insular Axis and Incretin Hormones in Type Diabetic Patients

Reduced Incretin Effect in Patients with Type 2 Diabetes In healthy human subjects oral glucose elicits a considerably higher insulin secretory response than does intravenous glucose (even if leading to the same glycemic increments). This incretin effect is substantially reduced or even completely lost in patients with type 2 diabetes 86 . The reduction in the incretin effect probably is an acquired defect, since it is also found in patients with diabetes secondary to chronic pancreatitis, whereas chronic pancreatitis without diabetes is characterized by a normal incretin effect 87 . Secretion of Incretin Hormones in Patients with Type 2 Diabetes Cross-sectional analyses of larger cohorts suggest that there is a slight reduction in postprandial GLP-1 secretion following the ingestion of a mixed meal in patients with type 2 diabetes. Subjects with impaired glucose tolerance display intermediate results between healthy controls (normal response) and type 2-diabetic patients (reduced...

Comments on Inhaled Insulin

In type 2 patients the effect of inhaled insulin before meals on HbA1c did not seem to differ from that of fast-acting human insulin. Adding three times inhaled insulin to existing oral therapy is generally more effective than adding another oral hypoglycaemic agent. In the trials, subjects have been more satisfied with inhaled insulin than with subcutaneous insulin treatment. Whether this outcome will be borne out in clinical practice remains to be determined. Inhaled insulin seems to be most suitable in patients with controlled fasting blood glucose using a basal insulin. Smoking is a contraindication for inhaled insulin and inhaled insulin is not recommended in patients with asthma or chronic obstructive pulmonary disease. All candidates for inhaled insulin should have their lung function checked before and after 6 months and then every year. If lung function has declined more than 20 or by more than 500 ml from baseline, inhaled insulin should be discontinued. The long-term effect...

Diabetes Mellitus

Completely revised and updated, this third edition of Atlas of Diabetes Mellitus provides complete coverage of the signs and symptoms of diabetes mellitus and its treatment. Featuring over 120 color plates illustrating the signs and symptoms of insulin-dependent diabetes mellitus (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM) and their treatment, it also contains an instructive review section that covers Treatments with diet, insulin, and drugs Diabetes and pregnancy. With new chapters that discuss diabetes in the adolescent and the diabetic patient at home, the atlas also includes further up-to-date information on islet cell transplantation, diabetes and surgery, the costs of diabetes to both patient and the health system, and clinical trials. Detailed captions for each illustration, as well as bibliographic references and a full index, enhance the book's value as an atlas-text for teaching, residency training and clinical practice. Introduction Pathogenesis Treatment...

The Epidemiology of Diabetes Mellitus

The Epidemiology of Diabetes Mellitus An International Perspective International Diabetes Institute, Caulfield, Victoria, Australia The epidemiology of diabetes mellitus an international perspective edited by Jean-Marie Ekoe, Paul Zimmet, Rhys Williams. p. cm. 1. Diabetes-Epidemiology. I. Ekoe, J.M. II. Zimmet, Paul. III. Williams, D.R.R. (David Robert Rhys)

Assessment Of Diabetesrelated Symptoms

The clinical diagnosis of diabetes is often prompted by symptoms such as polyuria and polydipsia, recurrent infections, unexplained weight loss and, in severe cases, drowsiness and coma. In such cases a single blood glucose determination in excess of the diagnostic values indicated in Figure 2.2 (black zone) establishes the diagnosis. Figure 2.2 also defines levels of blood glucose below which a diagnosis of diabetes is unlikely in non-pregnant individuals. These criteria are unchanged from the 1985 WHO report7. For clinical purposes, an OGTT to establish diagnostic status need only be considered if casual blood glucose values lie in the uncertain range (i.e. between the levels that establish or exclude diabetes) and fasting blood glucose levels are below those which establish the diagnosis of diabetes. Diabetes mellitus likely Diabetes mellitus uncertain Diabetes mellitus likely Diabetes mellitus uncertain Diabetes mellitus unlikely Figure 2.2. Unstandardised (casual, random) blood...

Syndromes Of Insulin Resistance

Insulin resistance is an important feature of type 2 diabetes, and failure of insulin action in the peripheral insulin sensitive tissues, skeletal muscle, and adipose tissue is a major part of disease pathogenesis. Rare inherited syndromes of extreme insulin resistance have been vital in identifying genes involved in the insulin signaling pathway. One of these, Rabson-Mendenhall syndrome, consists of pineal hyperplasia, facial dysmorphism, phallic enlargement in males, short stature, acanthosis nigricans, and premature dentition. Diabetes mellitus presents between 3 and 7 yr of age, with death from ketoacidosis in the second decade. The diabetes is highly insulin resistant. Survivors develop later widespread microvascular disease (69). The syndrome is caused by insulin-receptor mutations leading to defective binding capacity (70). A model of treatment for this condition has been described, using monoclonal antibodies acting as a substitute for the normal ligand, thereby activating the...

Diabetes Mellitus Diagnosis and Classification

Centre de Recherche CHUM, Montreal, Canada 2International Diabetes Institute, Melbourne, Australia Diabetes mellitus may present with clear and classical symptoms (thirst, polyuria or ketoacidosis) or may be accompanied by specific complications. The lack of sensitivity and specificity of some of these 'diabetic symptoms' has already been discussed (see previous chapter). However, when the symptoms and or specific complications are present, the diagnosis of diabetes is confirmed by a single, unequivocally elevated blood glucose measurement as shown in Figure 3.1 (1). Severe hyperglycemia found under conditions of acute infective, traumatic or other stress may be transitory and should not in itself be regarded as diagnostic of diabetes. If a diagnosis of diabetes is made, one must feel confident that the diagnosis is fully established since the consequences for the individual are considerable and lifelong (2). For the asymptomatic persons at least one additional plasma blood glucose...

Cardiovascular Disease and Diabetes

Diabetes, both type 1 and type 2, is increasing in prevalence and it is estimated that three million individuals in the UK will have type 2 disease by 2010 (Gale, 2002 Fisher, 2003). Overall the numbers of people with type 2 far exceed those with type 1 and, in addition, they are usually middle aged or elderly and often present with concomitant CVD risk factors. However, comments such as 'Diabetes mellitus, and particularly non-insulin dependent diabetes mellitus increases the risk for all manifestations of vascular disease' (Laakso, 1998) and 'CVD complications occur more often in patients with NIDDM than in patients with IDDM' (Laakso and Lehto, 1997) can easily be misconstrued. Epidemiological studies measure outcome in a number of different ways. While absolute numbers can be counted, other measurements, adjusted for the size of the group, are more commonly used. For example, a rate (of an event) can be calculated as the number of such events per 100 000 people per year. Another...

Diabetes Mellitus and Breast Cancer Possible Associating Mechanisms

Four major mechanisms may contribute to the association between type 2 diabetes mellitus and breast cancer (fig. 2) activation of the insulin pathway, activation of the insulin-like growth factor (IGF)-1 pathway, altered regulation of endogenous sex hormones, altered regulation of adipocytokines. The Insulin Pathway and Breast Cancer Insulin is a polypeptide hormone secreted from pancreatic p-cells in response to elevation in glucose levels 7 . The first step in activation of the insulin pathway is binding of insulin to the insulin receptor (IR). The primary targets for insulin are skeletal muscle, adipose tissue and the liver, however many other tissues, including normal breast tissue and breast cancer, express the IR. The IR is a tyrosine kinase receptor, composed of two extracellular a-subunits and two transmembrane p-subunits. Insulin binding leads to autophosphorylation of tyrosine residues in the intracellular subunits and thus activates the tyrosine kinase. Once activated, the...

Mortality from Cerebrovascular Disease Type diabetes

Clinical aspects of stroke disease in people with diabetes are described in Chapter 7. Mortality from cerebrovascular disease is barely mentioned in epidemiological studies of patients with type 1 disease and usually only gets a passing mention in studies of patients with type 2 diabetes (Barrett-Connor and Khaw, 1988 Manson etal., 1991 Moss etal., 1991 Lehto etal., 1996). Cerebrovascular disease is generally manifest in later years and most cohort studies of younger patients do not continue follow-up beyond their 40s. Further, cerebrovascular disease complications are not as frequent as heart disease and many studies will therefore be too small, with too few events, to draw any conclusions. This lack of data has led some to suggest that 'in the patient with insulin-dependent diabetes mellitus the frequency of stroke and death from stroke is less than in the patient with non-insulin dependent diabetes mellitus' (Bell, 1994). None the less it is a significant cause of mortality in...

The Range Of Diabetes In Youth

Surveys for diabetes among children and young adults from many geographic locations reveal a spectrum of clinical characteristics. The majority of young European-origin patients appear to fit the clinical picture of Type 1 diabetes, while the prevalence of Maturity-onset Diabetes of Youth (MODY) is estimated at 1-3 (9). In other ethnic groups Type 2-like syndromes are reported more frequently among children, although no consensus on defining characteristics has yet emerged. Winter's classic case-series, published in 1987 (1), described 12 of 129 African American patients with an atypical disease course, an absence of the Type 1 diabetes-associated HLA variants and no detectable islet cell antibodies (ICA). C-peptide levels in these patients were intermediate between those of Type 1 diabetes patients and non-diabetic subjects. Additional characteristics resembling Type 2 diabetes were observed, such as obesity and a high prevalence of diabetes among relatives. These patients were...

How is gestational diabetes diagnosed

Diagnosis is carried out in one or two phases. The first phase is a 50 g oral glucose tolerance test at the 24-28th week of gestation, which the pregnant woman receives regardless of prior food ingestion. Venous plasma glucose values above 140mg dl (7.8mmol L) one hour after glucose ingestion are considered abnormal, although some authors suggest a lower level (130 mg dl 7.2 mmol L ). When a cut-off point of 140 mg dl (7.8 mmol L) is used, around 80 percent of gestational diabetic women are detected, whereas with 130 mg dl (7.2 mmol L) as cut-off, around 90 percent are detected. At the same time, however, the false positive rate is increased, i.e. women wrongly considered to have gestational diabetes. This particular glucose tolerance test is not accepted by all, though it is easy and cheap, as it includes only one blood glucose measurement, regardless of food intake. If an abnormal result is found in the 50 g oral glucose tolerance test, a second oral glucose tolerance test follows,...

Longterm Diabetes Complications As Used For Defining Diabetes Thresholds

Diabetes mellitus is characterised by hyperglycaemia, which is associated with long-term damage, dysfunction and failure of various organs. Several studies30,31 have confirmed relationships between hyperglycaemia and the risk of developing such micro- and macrovascular complications as retinopathy, neuropathy, nephropathy and cardiovascular disease. However, many have compared the rates of each condition in subjects already classified according to the diagnostic criteria as having diabetes or not. Few studies consider whether the current diagnostic glucose levels represent the best level for predicting an increased risk of such complications, and no formal statistical threshold for any complication has been consistently demonstrated. The relationships of FPG and 2 h PG with the development of retinopathy were evaluated in a study undertaken in the Pima Indian population over a wide range of plasma glucose cutpoints23. Both variables were similarly associated with retinopathy,...

Type Diabetes and

John Phillips, a 6-year-old boy, was always very active, and his parents became concerned when the counselors at summer camp told them that he seemed to not have much energy. When he got home from camp, John's parents noticed that he was thirsty all the time and running to the bathroom. He was very hungry but seemed to be losing weight, despite eating more than enough. John's parents took him to the pediatrician, who did several blood glucose tests and told them that their son has type 1 diabetes mellitus (T1DM), which used to be called juvenile diabetes or insulin-dependent diabetes. This story has a happy ending because John's parents were willing to do the necessary things to bring John's glucose under control. John is just as energetic as ever, but he has had to get used to a few inconveniences in his daily routine. (I cover such daily lifestyle changes in Part III.) The following sections detail the symptoms and causes of this type of diabetes.

Diagnosis Type Diabetes

Diagnosis of type 2 diabetes (Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, Casual plasma glucose greater than or equal to 200 mg dL plus typical symptoms of diabetes. In the absence of unequivocal hyperglycemia associated with acute metabolic decompensation, the results should be confirmed by repeat testing on a different day. At the present time A1C should not be used to diagnose diabetes.

Tracing the History of Diabetes Treatment

More than 2,000 years ago, people writing in China and India described a condition that must have been diabetes mellitus. The description is the same one that the Greeks and Romans reported urine that tasted sweet. Scholars from India and China were the first to describe frequent urination. But not until 1776 did researchers discover the cause of the sweetness glucose. And it wasn't until the nineteenth century that doctors developed a new chemical test to actually measure glucose in the urine. Later discoveries showed that the pancreas produces a crucial substance that controls the glucose in the blood insulin. Since that discovery was made, scientists have found ways to extract insulin and purify it so it can be given to people whose insulin levels are too low. After insulin was discovered, diabetes specialists, led by Elliot Joslin and others, recommended three basic treatments for diabetes that are as valuable today as they were in 1921 Although the discovery of insulin...

The Aetiology Of Type Diabetes Evidence Of A Nongenetic Contribution

The most striking evidence of a non-genetic contribution to Type 1 diabetes relates to the fact The Epidemiology of Diabetes Mellitus. An International Perspective. Edited by Jean-Marie Ekoe, Paul Zimmet and Rhys Williams. 2001 John Wiley & Sons Ltd. that the concordance rate in monozygotic twins is far below unity (1,2,3). Since monozygotic twin partners have identical genes, this difference can only be attributed to the influence of non-genetic exposures. Two additional lines of evidence provide support for the non-genetic contribution. First, the huge variation in the incidence of Type 1 diabetes between Caucasian populations (16) cannot be explained by the geographical distribution of susceptibility genes. Second, the rising incidence of Type 1 diabetes, as observed in many European populations (17), cannot possibly be explained by increased size of the pool of susceptibility genes (18) and must be attributed to increased susceptibility in individuals at genetic risk and or the...

Special Considerations for Living with Diabetes

The way that diabetes develops is different for each age group. In this part, you are shown those differences and how to manage them. I will have a lot more to say about children with type 2 diabetes mellitus (T2DM). You also find out about some of the special economic problems of people with diabetes, which relate to jobs and insurance. Lastly, this part covers all the new developments in diagnosing, monitoring, and treating diabetes and helps correct a lot of misinformation about diabetes treatment.

Identifying symptoms of type diabetes

Following are some of the major signs and symptoms of type 1 diabetes. If you experience the following symptoms, ask your doctor about the possibility that you have diabetes 1 Increase in hunger Your body has plenty of extra glucose in the blood, but your cells become malnourished because you lack insulin to allow the glucose to enter your cells. As a result, you become increasingly hungry. Your body goes through hunger in the midst of plenty. Type 1 diabetes used to be called juvenile diabetes because it occurs most frequently in children. However, so many cases are found in adults that doctors don't use the term juvenile any more. Some children are diagnosed early in life, and other children have a more severe onset of the disease as they get a little older. With children over age ten, the early signs and symptoms of diabetes may have been missed by parents, counselors, or teachers. These kids have a great deal of fat breakdown in their bodies to provide energy, and this fat...

Diabetes and labour

Buchanan TA, Metzger BE, Freinkel N and Bergman RN. Insulin sensitivity and B-cell responsiveness to glucose during late pregnancy in lean and moderately obese women with normal glucose tolerance or mild gestational diabetes. Am J Obstet Gynecol 1990 162 1008-1014. Girling J and Dornhorst A. Pregnancy and Diabetes Mellitus, in Textbook of Diabetes 3rd ed, Pickup JC, Williams G, Editors. 2003, Blackwell Oxford. pp. 65.1-65.39. Greene MF, Hare JW, Krache M, Phillippe M, Barss VA, Saltzman DH, Nadel A, Younger MD, Heffner L and Scherl JE. Prematurity among insulin-requiring diabetic gravid women. Am J Obstet Gynecol 1989 161 106-111.

Choosing Between Pancreas And Islet Transplantation As Treatments For Diabetes

Since pancreas transplantation has been shown to be very effective in controlling acute and chronic complications of diabetes over long periods of time, and islet transplantation has not, pancreas transplantation must be viewed as the more effective option. However, individual recipients who do not want to undergo the extensive surgery and potentially complicated postoperative course of organ transplantation may logically choose islet transplantation. This should be done, however, with the full knowledge that the majority of islet recipients need to return to insulin-based treatment and that intrahepatic islet transplant recipients do not have restored glucagon secretion during hypoglycemia. The latter is a significant issue given the number of islet transplant recipients who return to insulin treatment and are once again at-risk for hypoglycemia. There are few data that address the impact of islet transplantation on the secondary complications of diabetes mellitus. However, it can be...

Blood Pressure And Stroke Risk Among Diabetics

Mogensen CE (ed.) THE KIDNEY AND HYPERTENSION IN DIABETES MELLITUS. Copyright 2004 by Martin Dunitz, a member of the Taylor & Francis Group, plc. All rights reserved. majority of participants in the epidemiological studies included in these overviews did not have diabetes, where data do exist, the association between blood pressure and the risk of stroke appears to be similar among diabetics to that among non-diabetics (Figure 1). Similar continuous relationships have been observed among diabetic participants in clinical trials 8 . + Diabetics Non-diabetics Figure 1. Association between usual systolic blood pressure and fatal stroke among individuals with and without diabetes. Previously unpublished data from the first round of overview analyses of the Asia Pacific Cohort Studies Collaboration demonstrating similar associations between usual systolic blood pressure and the risk of fatal stroke among participants with and without diabetes (Personal Communication Woodward M, 2003). Data...

Diabetes and vascular disease

Complications of macrovascular disease are responsible for 50 of the deaths in patients with type 2 diabetes mellitus (DM), 27 of the deaths in patients with type 1 diabetes for 35 years or less, and 67 of the deaths in patients with type 1 diabetes for 40 years or more (1,2). The rapid progression of macroangiopathy in patients with type 2 diabetes may reflect diverse phenomena some intrinsic to the vessel wall angiopathic factors such as elevated homocysteine and hyperlipidemia deleterious effects of dysinsulinemia and excessive or persistent microthrombi with consequent acceleration of vasculopathy secondary to clot-associated mitogens (3,4). As a result of these phenomena, cardiovascular mortality is as high as 15 in the 10 years after the diagnosis of DM becomes established (5). Because more than 90 of patients with diabetes have type 2 diabetes and because macrovascular disease is the cause of death in most patients with type 2 as opposed to type 1 (insulinopenic) diabetes, type...

Insulin Analogues in Children and Teens with Type Diabetes Advantages and Caveats

Type 1 diabetes mellitus (T1D) is a chronic, metabolic disorder that most commonly presents during childhood and is characterized by absolute insulin deficiency. T1D is caused by selective immune-mediated autoreactive T-cell destruction of beta cells in the pancreatic islets of Langerhans 1 . Insulin deficiency leads to chronic hyperglycemia and other disturbances of intermediary metabolism. As a result, individuals who have diabetes are at risk of developing progressive long-term microvascular (eg, retinopathy, nephropathy, and neuropathy) and macrovascular (eg, cerebral, coronary, and peripheral vascular disease) complications 2 . The seminal trial in T1D, the Diabetes Control and Complications Trial, proved in adults and adolescents that the onset and progression of the microvascular complications can be prevented or delayed by tight control of blood glucose levels 2-4 . Although advanced complications are rare in youth, the demonstration of glycemic memory in follow-up studies of...

Serum Creatinine And Other Measures Of Gfr In Diabetes

Steno Diabetes Center, Niels Steensens Vej 2, 2820 Gentofte, Denmark The measurement of renal function or the glomerular filtration rate (GFR) in diabetes can be used 3) to measure progression of chronic renal disease i.e. diabetic nephropathy. The evaluation of progression in renal disease is important in the clinical setting for the monitoring of development of renal insufficiency and evaluation of the effectiveness of treatment in the individual. In research it is important to evaluate the impact of putative promoters of progression in renal disease in observational studies or to assess and compare the rate of progression in experimental groups in clinical trials. In order to obtain a valid assessment of the rate of decline in GFR it is necessary with regular measurements of GFR over a period of at least (2)-3 years applying a method with high precision and accuracy 1 . This is due to the usually rather slow rate of decline in GFR in diabetic nephropathy. The ideal method for...

Glomerular Effects Of Sulf In Insulindeficient Diabetes Mellitus

SULF have been extensively used in the treatment of type 2 diabetes. However, the renal effects of SULF in diabetes have not been determined. A study of complications in patients with type 2 diabetes investigated the effects of intensive glycemic control with insulin or SULF (UK Prospective Diabetes Study) (55). These results revealed a reduction in proteinuria and renal failure, in association with improved glycemic control. However, owing to either the relatively few number of patients who developed renal disease or the confounding effects of combinations of sequential therapies in individual patients, no conclusive differences were detected between insulin- and SULF-treated groups. Since this trial, other studies have proven inconclusive (56,57). Therefore, the current status of clinical knowledge does not render definitive conclusions regarding any beneficial or deleterious renal effects by exogenous SULF or an endogenous SULF-like ligand. In an attempt to extend prior...

Diabetes Classification Beyond Stamp Collecting

Humans appear to have a powerful instinct to classify. In part this may spring from a purely intellectual and aesthetic requirement to create some sort of order from the bewildering chaos of observable natural phenomena. This inbuilt taxonomic imperative is likely, however, to have more utilitarian roots. To be able to manipulate the natural world to improves one's comfort and or survival, one needs to understand its nature. The classification of natural phenomena into related groups is an essential first step towards this comprehension. Given the powerful threat represented by illness, it is not surprising that the classification and reclassification of disease has been a continued obsession of the healing professions since their earliest recorded history. In Chapter 2, Max de Courten provides a balanced and thorough account of how we have reached the currently accepted glycaemic criteria for the diagnosis of diabetes mellitus, and its classification into sub-types. In this short...

Testing for prediabetes

Testing for prediabetes involves finding out your blood glucose level , the level of sugar in your blood. Prediabetes exists when the body's blood glucose level is higher than normal, but not high enough to meet the standard definition of diabetes mellitus (which I discuss in the section Testing for diabetes, later in this chapter). Testing is done by measuring a random capillary blood glucose. If the level is greater than 100 mg dl, a fasting plasma glucose or oral glucose tolerance test is performed. Table 2-1 shows the glucose levels that indicate prediabetes i If the glucose before the test (the fasting plasma glucose) is between 100 and 125 mg dl, the person has impaired fasting glucose, the glucose before eating (see Table 2-1). The glucose in the fasting (no food for 8 hours) state is not normal but not high enough to diagnose diabetes. Diagnosing Prediabetes Prediabetes Diagnosing prediabetes can be the best thing that ever happened to a person It could be the wake up call...

Genetic Associations With Diabetes

Recent advances in the genetic epidemiology of Type 1, Type 2 and MODY may soon make it possible to distinguish them based on genetic markers. Inheritance in European-origin MODY families usually follows that of an autosomal dominant pattern, with vertical transmission of disease from one generation to the next, and approximately 50 of siblings affected (28). Reports of non-Type 1 in other ethnic groups show vertical transmission in only a subset of such families (4). Work in Europeans and US whites has identified several associations of MODY with specific mutations (29) the HLA-DR and -DQ alleles linked to Type 1 diabetes are not found in MODY patients (27, 65). Indeed, some investigators suggest that patients with early-onset Type 2 diabetes can be distinguished from MODY patients on the basis of inheritance patterns (66). There is widespread consensus that Type 2 diabetes, in contrast to MODY, is a genetically heterogeneous condition (45, 67). Familial aggregation is common,...

Risk Factors The Epidemiology Of Obesity And Hyperinsulinemia In Children

It is well accepted that overweight as a child is a risk factor for obesity in adulthood. Using data from the Fels Longitudinal Study, Guo et al. (76) correlated girls' percent ideal body weight aged 10-18 with their percent ideal weight at age 35 all coefficients exceeded 0.6. We know that obesity, impaired glucose tolerance and insulin resistance are important metabolic risk factors for Type 2 diabetes mellitus (77, 78), and they are also suspected to be important etiologic components of youth-onset disease. among youth aged 12-19 years (82). Cross-sectional anthropometric surveys of Mexican American children were conducted in Brownsville, Texas in 1972 and again in 1983 (83). Mean BMI and triceps skinfold increased significantly over the 11-year interval except among boys 15 years old. In preparation for an intervention study in 4th grade Mexican American children in Texas, baseline data were collected in 1997-98 on 173 subjects 21 of boys and 18 of girls were overweight, defined...

Current approach to diabetes care in primary care

The management of diabetes has, rightly, been given a high priority within general practice in recent years, with marked improvements in the level of pro-active care, reduction in risk factors, and prevention of co-morbidities being observed as a result. However, it is only recently that the direct relationship between type 2 diabetes and obesity has been accepted by the majority of clinicians. This chapter seeks to describe the way in which overweight type 2 diabetics might be managed in primary care. The distinction between type 1 and type 2 diabetics may be made at a very early stage in treatment, and the criteria for deciding when insulin treatment is required is dealt with elsewhere. It is also assumed that the ongoing management of diabetics, including annual reviews and dealing with complications is not within the remit of this chapter and will also be covered elsewhere in the book. While up to 80 per cent of an individual's predisposition to developing type 2 diabetes is...

Could development of gestational diabetes represent the first manifestation of Type DM

It is very possible that several cases of gestational diabetes represent preexisting undiagnosed Type 2 DM. Occurrence of Type 2 DM in pregnancy is considered to have increased in recent years, since this type of diabetes can now be diagnosed at younger ages with increasing frequency. Insulin usage in pregnancy does not allow the easy and precise evaluation of Type 2 DM and this problem is bigger in peoples with a high prevalence of Type 1 DM, such as in Scandinavia. Correspondingly, in peoples with a high prevalence of Type 2 DM, maybe half of all diabetic cases at pregnancy are Type 2. During prenatal screening, a young woman with diagnosed Type 1 DM monitored at the Diabetes Outpatient Clinic, is enquiring about safety of her pregnancy. Although complications in neonates of mothers with gestational diabetes are usually minimal, Type 1 DM pregnancies incur a high risk for teratogenesis in the neonate due to hyperglycaemia and other difficulties, especially if the mother suffers from...

Type and Type diabetes

The same blood glucose criteria apply to the diagnosis of all types of diabetes. The two main types are Type 1 (insulin-dependent diabetes or juvenile-onset diabetes previously) and Type 2 (non-insulin-dependent or maturity-onset diabetes previously). People with Type 1 diabetes are usually unable to survive without insulin treatment People with Type 2 diabetes are usually able to survive without insulin treatment A subset of people with Type 2 diabetes have maturity-onset diabetes of the young (MODY). This usually starts under 25 years of age and forms 2-5 per cent of Type 2 diabetes. Fifty per cent of parents and 50 per cent of siblings have glucose intolerance it is slowly progressive and seldom needs insulin. Various gene defects have been identified. Early-onset Type 2 diabetes starts between 25 and 40 years of age. Ninety per cent of parents and 68 per cent of siblings have glucose intolerance. It is associated with obesity. Insulin is often needed and microvascular...

Causes of Type Diabetes

The reasons that type 2 diabetes occurs are different from those that trigger type 1 diabetes. Unlike people with type 1 diabetes, who become unable to produce insulin, people with type 2 diabetes produce insulin. But, either the body does not respond to insulin's action (it's resistant) or there is just not enough insulin to go around or both. Either problem leads to the same outcome insulin can't deliver glucose to the cells that need it, and there's too much glucose in the blood. Virtually all cells in the body contain special proteins called receptors that bind to insulin. They work like a lock and key. In order for glucose to enter the cell, insulin (the key) must first fit into the insulin receptor (the lock). But for some reason, in some people with type 2 diabetes, there is a faulty lock, or insulin receptor. The key doesn't open the lock, and glucose is shut out of the cell. And in some people with type 2 diabetes, there are not enough locks, or insulin receptors, on the...

Presentation of diabetes in children

The majority of diabetic children will be insulin-dependent. However, Type 2 diabetes is found sometimes especially in overweight teenagers. Diabetes presents with the same symptoms as in adults. Additional features may include growth retardation, difficulties at school, behavioural problems, and bed-wetting or regression from toilet training. The symptoms may be difficult to discern in very small children in whom urine (preferably blood) glucose screening should form part of general assessment in illness.

Principles Of Insulin Treatment

Since insulin was first administered on January 11, 1922 (1), treatment of patients with type 1 diabetes has attempted to restore the metabolic abnormalities associated with autoimmune P-cell destruction and insulin deficiency. The ensuing decades have seen many advances in our understanding of insulin physiology, pharmacokinetics, and therapeutics, and the resultant development of purified insulin, recombinant human insulin, and insulin analogs. However, complete metabolic normalization with exogenous insulin therapy in such patients remains infrequent. The Diabetes Control and Complications Trial (DCCT) established conclusively that this inadequate metabolic control results in the long-term microvascular complications of diabetes (2). To minimize these complications, insulin-treatment regimens must mimic the complex secretion of insulin by the P-cells of the healthy pancreas. This task, however, remains a challenging goal (3).

How do commercially available insulin preparations differ from each other

Commercially available insulin preparations are separated into five main categories (Table 28.1) depending on time of onset and duration of their action 1. Insulins of very rapid onset and very brief duration of action, which include only insulin analogues (insulin Lispro, insulin Aspart and insulin Glulisine). Diabetes in Clinical Practice Questions and Answers from Case Studies. Nicholas Katsilambros et al. 2006 John Wiley & Sons, Ltd. ISBN 0-470-03522-6 Table 28.1. Characteristics of insulin preparations Table 28.1. Characteristics of insulin preparations Insulin preparations Very-rapid-acting insulin Insulin Lispro Insulin Aspart Insulin Glulisine Rapid-acting insulin Soluble (regular) insulin Insulins of intermediate action Isophane insulin (NPH) Zinc insulin (Lente) Insulins of delayed action Insulin Glargine Insulin Detemir Zinc insulin of extended Mixtures of insulin *The peak of action of this insulin is mild *The peak of action of this insulin is mild 2. Insulins of rapid...

Graph One shot of intermediateacting insulin

If you take one shot of long- or intermediate-acting insulin, there are several ways to get the bolus of insulin you need for meals. Some people with type 2 diabetes may be able to make enough insulin to cover the post-meal increase in blood glucose. For these people, providing the basal insulin helps their pancreas to do its job better. Another option is to take oral diabetes medications. These medications can provide the coverage needed for meals. Still another possibility is to take a combination of insulins. You can take a rapid- or short-acting insulin along with your morning shot of NPH insulin. This gives you a bolus of insulin to cover your breakfast meal. You can either use pre-mixed insulins or mix two types of insulin in one injection.

Type Diabetes Management

Because your body no longer makes insulin, insulin injections play a big role in your diabetes care plan. How much insulin you need to take depends on your blood glucose level, or what you predict the level will be after a meal. Naturally, food also plays an important role in your diabetes management plan, because it contributes glucose to your blood. Usually, physical activity can lower your blood glucose level, decreasing your dose of insulin. So, you'll need to account for exercise and physical activity in your diabetes management plan.

Eating Well for Type Diabetes

A person with type 1 diabetes takes insulin (see Chapter 10) to control the blood glucose. At this time, doctors and their patients cannot match the human pancreas in the way that it releases insulin just when the food is entering the bloodstream so that the glucose remains between 80 and 120 mg dl. Therefore, the diabetic patient needs to make sure that his or her food enters as close to the expected activity of the insulin as possible. Most people with type 1 diabetes take two different types of insulin one that acts soon after the injection and has a brief period of activity, and a second that acts more slowly and lasts longer. The rapid-acting insulin is meant to cover the food eaten at meals, while the slower acting insulin covers the rest of the time, particularly overnight when a lot of circumstances tend to raise the blood glucose. Fortunately, you can take a new type of insulin when you start to eat or even in the middle or at the end of a meal. (See Chapter 10 for more...

Causes of Gestational Diabetes

Like the other types of diabetes, the exact cause of gestational diabetes is unknown. However, experts do have some clues. During pregnancy, the placenta, which is the organ that nourishes the growing baby, produces large amounts of various hormones. Hormones are important for the baby's growth. However, these hormones may also block insulin's action in the mother's body, causing insulin resistance. All pregnant women have some degree of insulin resistance. Gestational diabetes usually appears around the 24th week of pregnancy. This is when the placenta begins producing large quantities of the hormones that cause insulin resistance. The period between the 24th and 28 th weeks of pregnancy is the usual time to screen for gestational diabetes. Because insulin resistance seems to cause gestational diabetes, it is more like type 2 diabetes than type 1 diabetes. And having

Used to have type diabetes but now I have type diabetes I started taking insulin last year

Lots of people, more than 40 percent of adults with diabetes, use insulin. Because there are about 90 adults with type 2 diabetes to every 5 adults with type 1 diabetes, this means there are a lot of people with type 2 diabetes taking insulin. People with type 1 diabetes must use insulin to make up for their pancreas no longer making it. You don't necessarily have type 1 diabetes just because you need insulin. Many people with type 2 diabetes take extra insulin to overcome their body's resistance to the insulin already being made by the pancreas. Type 1 and type 2 diabetes, while having a lot in common, have different causes. The type of diabetes you have does not change as you age or if you lose or gain weight or change treatments. insulin resistance that lasts until the baby is born. The glucose challenge helps you find out whether your body is able to overcome the insulin resistance on its own. You are given a glucose drink to finish at a certain time, without regard to eating. If...

Insulin Resistance Syndrome

Reaven, at his Banting Lecture in 1988 (3), first proposed a widespread role for insulin resistance in common diseases such as coronary heart disease, Type 2 diabetes, obesity and hypertension. He proposed an insulin resistance syndrome (IRS) (or Syndrome X) as a unifying theory for a cluster of adverse metabolic changes (Table 9.1). Each of these changes have been independently shown to be related to a risk of cardiovascular disease. Insulin resistance is also a strong marker for the risk of developing Type 2 diabetes and therefore a Table 9.1 Metabolic and related disorders associated with the insulin resistance syndrome Table 9.1 Metabolic and related disorders associated with the insulin resistance syndrome

Drug or Chemicalinduced Diabetes

Insulin secretion may be impaired by many drugs. They may not, by themselves, cause diabetes but may precipitate diabetes in persons with insulin resistance (71,72). Classification is ambiguous in such cases as the primacy of -cells destruction or where insulin resistance is unknown. Pancreatic -cells destruction may occur with the use of certain toxins such as Vacor (a rat prison) and pentamidine (73-75). There are also many drugs and hormones which can impair insulin action. The list shown in Table 3.3 is not all-inclusive, but reflects the more commonly recognized drug-, hormone-, or toxin-induced forms of diabetes and hyperglycemia.

Newly Diagnosed Type Diabetes

When you are first diagnosed with type 1 diabetes, you will meet your diabetes management team, which consists of your physician, the diabetes educator, and the nutritionist. The physician will answer your questions about diabetes and recommend an initial insulin regimen. The nutritionist will teach you about carbohydrate counting, give you a carbohydrate exchange book (the ADA publishes a good one), and explain The diabetes educator will teach you how to use a glucose monitor, how to keep a logbook, and how often you should monitor your glucose levels and will set your target glucose levels. She will also teach you how to draw up insulin in a syringe and give an injection. Even if you were prescribed insulin pens from the start, you should still know how to draw up insulin in a syringe just in case a pen is not available. The educator will go over the symptoms of low glucose reactions and how to treat them. She will also show you how glucagon works and instruct you and a family...

Certified Diabetes Educator

The certified diabetes educator (CDE) will educate you about the kind of diabetes you have and your medication options. She will educate you about the importance of controlling glucose, lipids, and blood pressure to prevent complications and about the effects of exercise and emotions on glucose control. She will also show you how to use glucose monitors, how to treat high and low glucose levels, and how to exercise safely. If you are on insulin, she will teach you how to inject insulin and how to use your insulin pens or pumps.

Prevention of Stroke in Diabetic Patients Hypertension

Been shown to reduce the risk of stroke recurrence in hypertensive stroke survivors (INDANA Project Collaborators, 1997). Whilst it is accepted that hypertension is a major determinant of stroke risk in diabetics, the majority of patients have multiple risk factors such as dyslipidaemia, ischaemic heart disease and peripheral vascular disease that may influence the choice of antihypertensive therapy. Trial evidence suggests that tight diabetic control may not directly reduce the risk of stroke and TIA (UK Prospective Diabetes Study (UKPDS) Group, 1998) and clinicians therefore also need to direct attention towards the management of other modifiable vascular risk factors such as hypertension. The United Kingdom Prospective Diabetes Study The United Kingdom Prospective Diabetes Study incorporated a randomised controlled trial (also called the 'Hypertension in Diabetes Study', or HDS) to establish if tight control of blood pressure ( 150 85mmHg) reduced morbidity and mortality in...

On the Go with Insulin

Wear a medical ID bracelet or necklace that says you have diabetes. Don't get separated from your supplies. Carry your insulin, syringes and or insulin pump and infusion sets, lancets, glucose meter, blood and ketone test strips, glucagon kit, glucose gel or tablets, and snacks with you. Check with the airlines to meet security requirements. Some states require a prescription only for lispro, glargine, and aspart. Other insulins are available over the counter, as are syringes. In other states, you need a prescription for all insulins and the syringes. If you are traveling and your insulin is lost or destroyed, ask a pharmacist for help. Take twice as much insulin and blood testing equipment as you think you'll need. Getting extra diabetes supplies when you're away from home can be difficult. Keep insulin out of direct sunlight and protect it from very hot or very cold temperatures. If flying, keep your insulin supply with you instead of packing it in bags that might get too hot or too...

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Diabetes 2

Diabetes 2

Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...

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