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Diabetes

As with most things in life, both too much or too little of something can be harmful. Blood sugar (glucose) is no different. Because of this, our body has a well-designed monitoring and regulating system keeping blood sugar within an ideal range. This balancing mechanism is quite complicated, but we will try to sum it up for you here. There are two major organs and two major hormones involved in this process that are important to know about and understand.

Let’s start with the pancreas. The pancreas produces the two important blood sugar regulating hormones, insulin and glucagon. Basically, insulin is released after we eat a meal, and it helps our cells to take up and use glucose. In doing so, it lowers blood sugar levels. Glucagon on the other hand is released when our sugar levels are low, like when we skip a meal or burn up a lot of energy from exercise. Think of glucagon as a switch which activates the backup generator which kicks in when sugar levels drop. It gets our body, specifically liver and muscles, to release stored glucose (glycogen) to help stabilise falling glucose levels and helps to tide us over until our next meal. Essentially glucagon does the opposite of insulin, it helps to increase blood glucose when necessary. The other important organ is the liver. As mentioned already, the liver is like a backup battery, saving excess glucose in the form of glycogen when its switch, glucagon is activated. The switch is triggered when our sugar levels drop. Amazingly, even after all its stored glycogen is used up, the liver, under the influence of glucagon, can still make emergency glucose from amino acids.

Knowing this, we can gather that a healthy pancreas and liver are essential for balancing blood sugar levels.

Types of diabetes

Diabetes mellitus can occur in two ways depending on the underlying cause. These two forms of diabetes are known as Type 1 and Type II.

Type I diabetes

In Type I diabetes the special insulin producing cells in the pancreas (called beta cells) are dysfunctional and don’t produce insulin sufficiently, or at all, when its needed. These cells can become dysfunctional after certain viral infections, auto-immune disease (where the immune system incorrectly attacks its own healthy cells) or as a result of hereditary factors which make them spontaneously degenerate. Because of this, Type I diabetes can occur quite suddenly and can develop even in young patients and children.

Type II diabetes

This form of diabetes is far more common than Type I diabetes and accounts for around 90% of all diabetics. Type II diabetes typically starts in older patients over the age of 30 but even more commonly between the age of 50-60. Unlike Type I diabetes, Type II starts more gradually and is typically linked with being overweight which is the major risk factor for Type II diabetes. In this form of diabetes, the pancreas is able to produce sufficient insulin, in fact blood insulin levels can be high, but the cells and tissues of the body don’t respond sufficiently to it. This phenomenon is known as insulin resistance. The development of insulin resistance doesn’t occur over night, rather it is a gradual process which is typically closely associated with weight gain and development of obesity.

Type II diabetes can occur with or as a result of a complex metabolic diseases known as metabolic syndrome which consists of the following combination of features:

  • Overweight – especially weight gain around the waist and tummy – a waist circumference of >94cm in men and 80cm in women.
  • Presence of insulin resistance (high fasting insulin levels).
  • Abnormal cholesterol profile, typically high triglyceride levels, low HDL (good cholesterol) and high LDL levels (bad cholesterol).
  • Raised blood pressure (higher than 140/90).

The effect of diabetes on the body

Think of insulin as a key which unlocks the door so that glucose can enter our cells. Every time our blood sugar levels go up, the pancreas releases all the keys (insulin) so that all the locks on the cells can be opened and allow the glucose in, and in doing so, blood glucose levels reduce. If the key is missing (like in Type I diabetes), no matter how much glucose arrives at the door, it can’t get into the cell because it’s locked, or in the case of Type II diabetes there is an abundance of keys being produced but none of them fit the locks. Either way glucose can’t get into cells where it is burnt up as an energy source or stored for later in the form of glycogen. If it can’t be taken up, used and/or stored for later, it accumulates in our blood at high levels.

The problem is that glucose is the preferred fuel for all our cells, and if they cannot use it up, cells need to find other sources of energy to survive. Luckily there are no glucose locks on brain cells, and no keys needed. They don’t rely on insulin and glucose can readily enter the brain independently of insulin. But what do all of the rest of our cells live off if glucose is excluded? Although not ideal and sustainable long term, there is a backup mechanism in place: fat! In the absence of insulin fat cells are broken down and fatty acids are released into the blood which become the temporary back up source of energy for all cells except the brain. Burning up stored fat may sound like a good idea but there are consequences if this goes on inevitably. This back up mechanism is designed as a very short term solution for when you forget your lunch at home. It’s not designed to be a permanent solution. One of the consequences is raised cholesterol levels, the risks of which we are well aware of but probably more concerning is two other conditions called ketosis and acidosis. Burning up fatty acids leads to increased levels of acids in the liver and blood (acidosis) which if not controlled can cause the blood to become too acidic, and leads to the build of acetone and ketone bodies known as ketosis.

Similarly, lack of insulin also causes the body to activate another back up mechanism and fuel source: protein! Stored proteins start breaking down and releasing their amino acids into the blood, and as a result of this, muscle and other protein rich structures in the body are compromised and are broken down.

So the body can temporarily rely on back up energy sources in the short term, but what does all that excess, locked out glucose do? Firstly, the body tries to get rid of it by excreting it in the urine. Usually there is never glucose in our urine but in these circumstances it becomes necessary and the presence of glucose in urine is one of the ways in which diabetes is diagnosed. High glucose levels in the blood harms blood circulation, especially the very tiny blood vessels, which leads to increased risk of heart attacks, strokes, kidney damage and risk of blindness from damage to the retina. Nerves are also damaged and can lead to numbness and loss of sensation especially in the feet and hands, a condition known as peripheral neuropathy. With a loss of sensation we become injury prone, because we don’t feel it when we stub our toe, walk on something sharp or when a pair of new shoes is causing a blister. This, together with poor circulation, is dangerous to diabetics because poor circulation means these injuries don’t heal properly, potentially causing conditions like diabetic ulcers and in severe cases even gangrene.

Causes and risk factors of diabetes

So, who is typically at risk of developing diabetes mellitus?

Risk factors for developing Type I diabetes include:

  • Family history: Having a parent or sibling with type 1 diabetes increases the risk of a person getting it too, and if both parents have type 1 diabetes, the risk is even higher.
  • Age: Type 1 diabetes usually develops in younger adults and children. Typically, children are younger than 14 years old when they receive a diagnosis. Although it can develop at any age, type 1 diabetes later in life is rare.
  • Genetics: There are certain genetic combinations which increase the risk of Type I diabetes.

Your risk of developing Type II diabetes is increased if you:

  • are 40 years or older,
  • are overweight,
  • have a parent, sister or brother with diabetes,
  • have high blood pressure (above 140/90 mmHg),
  • have low HDL (good cholesterol),
  • have high levels of other lipids (fats),
  • have had diabetes during pregnancy, and
  • delivered a large baby (4 kg or more).

Signs and symptoms to look out for

Remember, because type II diabetes develops gradually, and one can be relatively insulin resistant for years before actual Type II diabetes sets in, there may be no obvious direct or classic diabetes symptoms. This is why screening is so important – we discuss this later under diabetes tests.

The classic signs and symptoms of established diabetes (Type I and II) include:

  • Increased thirst (known and polydipsia)
  • Increased urination and frequency of urination (known and polyuria)
  • Increased hunger (known as polyphagia)
  • Weight loss or weight gain (depending on stage and type)
  • Fatigue
  • Irritability
  • Loss of vision
  • Nausea and vomiting
  • Fruity smell on the breath Other things to watch out for:
  • Numbness of extremities
  • Slow healing of cuts, scrapes and wounds
  • Dry mouth
  • Itchy skin
  • Reoccurring infections like boils, bladder infections, yeast, and fungal infections
  • Features of metabolic syndrome (overweight, high blood pressure, abnormal lipid profile)

Unpacking the different basic diabetes tests

There are various tests used to screen for and monitor diabetes. We briefly unpack the major ones here:

1. Fasting insulin test

High levels of fasting insulin is typical in patients with insulin resistance. Since insulin resistance can occur months to years before actual type II diabetes or positive diabetes tests, this is an important early warning test to consider if you are at risk of Type II diabetes or are showing some of the early warning signs thereof but still have a normal fasting glucose test.

Abnormally low insulin levels are also typical in untreated Type I diabetes as the pancreas is not producing enough. Similarly, someone with a very low glucose level may have too much insulin. In this case this test is also useful.

This is a lab test which requires a sample of blood to be taken in a fasting state, i.e. measured after not eating or drinking anything except water for at least 8 hours. Because of this, it’s typically measured in the morning before breakfast.

Normal fasting insulin = Less than 10mIU/L

2. Blood glucose (Fasting)

This is the most simple test to screen for diabetes or monitor how well diabetes is being managed. It gives a real time measurement of how much glucose is in the blood at the time of taking the test. Because glucose levels fluctuate significantly depending on what you eat and when last you ate, typically a fasting blood glucose is used, i.e. measured after not eating or drinking anything except water for at least 8 hours. Because of this, it’s typically measured in the morning before breakfast. This can be measured instantly with a simple finger prick using a device called a glucometer, or for the most accurate reading, a sample can be drawn and sent to a pathology lab for testing. A random glucose is also possible but less accurate than the fasting glucose. Normal level = 3.9 to 5.5 mmol/L

Prediabetic = 5.6 to 6.9 mmol/L

Diabetic = More than 7.0 mmol/L (on more than one occasion)

3. Urine glucose test

This is a simple screening test that can be done on a urine sample using a urine dipstick test to detect any glucose in the urine. In non-diabetics there should be no glucose in urine, so if it is present it is strongly suggestive of established diabetes and needs to be confirmed with blood tests.

4. Glucose tolerance test (GTT)

Also known as an oral glucose tolerance test (OGTT), this test needs to be conducted at a pathology lab depot or clinic and cannot be done at home. Essentially this test challenges and measures the body’s blood sugar control mechanism by testing fasting glucose first (so you have to arrive fasting), then drinking a glass of glucose water (75g glucose), wating a while and then taking a few more blood glucose tests to see how blood glucose levels react over time, typically 2 hours later. It gives your doctor an assessment of how well your body tolerates and manages glucose and is a very sensitive test for diabetes mellitus and is typically used when your fasting glucose test is borderline or inconclusive.

After 2 hours:

Blood glucose of 7.8 mmol/L or less = Normal glucose tolerance

Blood glucose of 7.8 – 11.1 mmol/L = Impaired glucose tolerance (pre-diabetic)

Blood glucose of > 11.1 mmol/L = diabetes

5. Glycosylated haemoglobin test (HbA1c)

This is another lab test which needs a blood sample taken and is useful for screening, diagnosis, and to monitor how well your blood glucose is controlled over time by giving an estimated average blood glucose level over the last 2-3 months.

Normal level = less than 5.7% (39 mmol/mol)

Prediabetic = 5.7 to 6.4 % (39-46 mmol/mol)

Diabetic = More than 6.5% (48 mmol/mol)

What are the complications of diabetes?

Long standing and poorly controlled diabetes significantly increases the risk of developing ‘complications’ which are common health problems that arise because of a specific, pre-existing disease. These are largely due to the harmful effects diabetes has on blood vessels and nerves, leading to several serious complications. These are a few of the major ones:

  • Nerve damage (diabetic neuropathy) often causing numbness and pain especially in the extremities such as the feet.
  • Kidney damage leading to weakened kidney function and chronic kidney disease (CKD).
  • Damage to the retina which negatively affects vision (diabetic retinopathy).
  • Wounds which do not heal such as diabetic ulcers especially on the feet and lower limbs.
  • Cardiovascular disease and increase risk of heart attack and stroke. There are also complications from the management of diabetes. Diabetics who inject themselves with insulin must carefully control the dose as too much insulin can cause blood glucose to drop dangerously low (hypoglycaemia).

What treatments are available?

Depending on the type of diabetes you have and the severity thereof, your doctor may prescribed oral diabetic medication or insulin or a combination thereof. It’s important to work closely with your doctor and monitor your condition and your response to treatment carefully by having regular check-ups and monitoring tests like HbA1c for example. Its also important to monitor your own fasting glucose levels using a glucometer on a regular basis.

A common misconception amongst diabetics is that if they are on medication or insulin that’s all that needs to be done to manage their diabetes. Some even think that once on medication they can eat what they like! Simply switching sugar to artificial sweeteners or sodas to ‘sugar free’ is not the answer! All diabetics should ideally consult a dietitian and follow a formal diabetic diet, irrespective of what medication they take. There are also important lifestyle changes that need to be made too which will all help to control diabetes more effectively.

Important lifestyle interventions include:

  • Following a controlled diabetic diet
  • Drinking at least 1.5 litres of water per day
  • Weight management
  • Regular exercise
  • Stress management
  • Stopping smoking
  • Limiting alcohol consumption
  • Foot care
  • Psychological counselling.

Other dietary considerations to discuss with your dietitian is to make sure your diet comprises mainly of alkaline foods, typically from fresh fruit and vegetables.

Other related conditions and the risk thereof also need more stringent screening, monitoring, and management if necessary. They include:

  • Blood pressure
  • Cholesterol levels
  • Peripheral circulation
  • Retinal health
  • Kidney function
  • Neurological assessment
  • Cardiovascular health
  • Metabolic syndrome
  • Mental health.

What supporting therapies should one consider?

There are several remedies which can be used to support the specific vulnerable systems in diabetic patients which include the circulatory system and heart, kidneys, immune system, digestive system (including pancreas and liver), as well as skin infections, and importantly to promote general wellbeing and quality of life. Some of these include:

Circulatory system and heart:

A.Vogel Crataegus Oxy, an extract of fresh Harthorne berries which act as a Cardiac Tonic, assists in promoting the function of the heart and assists with impaired heart performance, specifically due to congestive and ischemic heart disease. A.Vogel Ginkgoforce, a well-known herbal medicine which supports circulation and circulatory disorders which cause coldness, discomfort, and heaviness of the legs.

Kidneys:

A.Vogel Nephrosolid which consists of four key herbs which act as a tonic to support the function of the kidneys, bladder, and urinary tract.

Immune system:

A.Vogel Echinaforce, a unique fresh plant extract uniquely made from 95% upper parts and 5% roots of the Echinacea pupurea plant, which is scientifically proven to modulate and support the immune system. Digestive system and pancreas: A.Vogel Molkosan a prebiotic food supplement made from lacto-fermented whey which assists in promoting better digestive health. Used extensively by Dr Alfred Vogel as a pancreatic tonic, it was one of his most important supportive remedies for his diabetic patients.

Liver support:

A.Vogel Boldocynara, a herbal tonic to support the function of the liver and gallbladder, promoting healthy liver function, production and flow of bile and support digestion.

Supporting Ph balance:

A.Vogel Multiforce, a source of calcium, magnesium, phosphorus and potassium, as well as citrate and bicarbonate salts (alkalising minerals) and has a systemic alkalinising effect which supports body’s acid buffering mechanism by providing essential alkaline minerals required to combat a typical acidogenic diet (high in animal protein and low/deficient in fruit, vegetables and minerals) and lifestyle, thereby assisting in addressing the negative consequences thereof. If you are on a potassium or calcium restricted diet – check with your doctor before taking Multiforce.

Managing skin infections including athlete’s foot and toenail fungus:

Thursday Plantation Tea Tree Oil is a topical antiseptic made from 100% pure tea tree essential oil and a treatment of superficial wounds, cuts, abrasions, insect bites/stings, boils, nail infections and athlete’s foot.

Supporting general wellbeing, and quality of life:

Bio-Strath Tablets, a 100% natural, Swiss plasmolysed herbal yeast supplement containing more than 60 essential nutrients in a unique, highly bioavailable intracellular format including 11 vitamins, 20 amino-acids, 19 minerals and trace elements and uniquely, 11 building substances. Bio-Strath strengthens and supports the immune system, helps to restore and maintain natural energy, increases vitality and supports recovery from illness.

Useful links and additional reading:

  1. American Diabetes Association. Standards of Medical Care in Diabetes-2018 Abridged for Primary Care Providers. Clinical diabetes: a publication of the American Diabetes Association, 2018. 36(1): p. 14-37.
  2. Diabetes South Africa.
  3. Diabetes Education Society of South Africa.
  4. Guyton, A.C. and J.E. Hall, Textbook of Medical Physiology. 11th ed. 2006, Philadelphia: Elsevier Saunders.
  5. Huang, P.L., A comprehensive definition for metabolic syndrome. Disease models & mechanisms, 2009. 2(5-6): p. 231-237.
  6. Fox, S.I., Human Physiology. 8th ed. 2004, New York: McGraw-Hill Publishing.
  7. Sweet Life – online diabetic community.
  8. The Heart and Stroke Foundation of South Africa.