What is Type 2 Diabetes?

Type 2 diabetes mellitus (T2DM or “diabetes” in this article), also known as adult onset or non-insulin dependent diabetes, is an acquired disorder in the way the body metabolizes sugar (glucose), which fuels all the body’s cells. It accounts for 90% or more of the diagnoses of diabetes in adults.¹ While ethnicity and heredity can have contributions, the cause is almost always related to sedentary lifestyle, obesity, and poor food choices. Consuming inappropriate amounts of simple carbohydrates like bread, pasta, baked goods, candy, sugar, white flour products, and processed foods is the main culprit, especially when combined with too little physical activity.

Normal Glucose Metabolism

When we eat, the level of glucose in our blood stream rises. In response, the pancreas releases insulin to shuttle this glucose from the blood stream into the cells of the body. It does this by binding to insulin receptors on the cell membrane causing a ‘door’ to open for the glucose to enter the cells. It results in a reduction of blood glucose and an increase in intracellular glucose to provide energy for the cells to function properly and stay healthy.

Disordered Glucose Metabolism

When we eat too many simple carbohydrates at a sitting, blood sugar raises very high (hyperglycemia) and very fast. The pancreas responds by releasing large amounts of insulin into the bloodstream (hyperinsulinemia). This causes the characteristic spikes in blood sugar described by many people with T2DM or pre-diabetes. The high blood sugar from the carbohydrates is quickly followed by low blood sugar because of the excess insulin response. When this cycle is habitually repeated and increased levels of insulin are regularly released into the bloodstream the insulin receptors on the cell membranes become less responsive and fewer ‘doors’ open up on the cell to let glucose in. This condition is called insulin insensitivity. Once the body becomes insensitive to insulin the pancreas has to work even harder to lower the blood sugar and supply glucose to starving cells. This extra work wears out the pancreatic beta cells (insulin producing cells) and they become progressively less efficient. This leaves the body with the double insult of insulin insensitivity and lowered insulin production, otherwise known as type 2 diabetes mellitus.

There are other, less mainstream, causes or contributors to T2DM that Naturopathic physicians and some conventional doctors consider.  For instance, insulin receptors and/or beta cells can be inhibited by heavy metals, chemical, plastic exposure, mineral imbalances, and even viruses.  Depression and anxiety may also contribute to the disease.  Approaching each person individually to help identify and treat these exposures can lead to better recovery of sugar regulation.

Complications of Uncontrolled Diabetes

Hyperglycemia (high blood sugar levels) causes the glycosylation (sugar coating) of tissues in the body. Glycosylation diminishes the function and integrity of those tissues causing the diabetic related diseases listed below. The list is not comprehensive, but highlights the major diseases and complications:

1. Cardiovascular Disease (CVD). Adults with diabetes have risk of stroke and heart disease death rates about 2 to 4 times higher than adults without diabetes.⁷ CVD is caused by, hyperinsulinemia, dyslipidemia (abnormal amounts, usually high, of cholesterol and fats in the blood), and hyperglycemia – all hallmarks of diabetes. These lead to disease of the large blood vessels around the heart, called atherosclerosis, which is between 2 and 6 times more common in people with diabetes than in people who do not have diabetes and tends to occur at younger ages 2. This atherosclerosis greatly increases one’s chance for angina pectoris, myocardial infarction, transient ischemic attacks, stroke, and peripheral arterial disease. Diabetic cardiomyopathy is heart failure due to diseased heart musculature with impairment in left ventricular functions in the absence of coronary artery disease. It is a common condition, ~60% of diabetics may have it to some degree, largely due to hyperglycemia and insulin resistance syndrome that cause left ventricular hypertrophy (enlargement). The enlargement impairs the ability of the heart to efficiently circulate blood through the body, leading to an accumulation of fluid in the lungs (pulmonary edema) or legs (peripheral edema) and eventually heart failure. The severity of the disease is directly proportional to the HbA1c level (a measure of the glycosylation, or sugar coating, of red blood cells).³
2. Diabetic Retinopathy occurs when high glucose levels in the blood damages the small blood vessels of the retinas, causing them to leak. This results in severe visual impairment and blindness. It is the leading cause of blindness in adults 20-74.⁷
3. Diabetic Nephropathy is the number one cause of chronic kidney failure in the US accounting for up to 80% of the cases of end-stage renal failure. It is the result of sugar damage and scarring of the nephrons (filters of the kidney). It is exacerbated by high blood pressure, also a common result of diabetes, and in a vicious cycle, it causes an increase in blood pressure. It is accountable for the death of 10-20% of diabetics.²
4. Diabetic Neuropathy is damage to the nerves as a result of diminished blood flow (ischemia) due to vascular disease, metabolic changes that impair nerve cell function, and direct glycosylation². It affects up to 50% of people with diabetes. The symptoms include impaired sensation or pain in the feet or hands, peripheral neuropathy, slowed digestion, carpal tunnel syndrome, erectile dysfunction, or other nerve problems.⁷ Almost 30 percent of people with diabetes ages 40 years or older have impaired sensation in the feet, which can lead to foot ulcers. Severe forms of diabetic nerve disease are a major contributing cause of lower-extremity amputations. In 2006 approximately 65,700 lower limb amputations were performed on diabetics.⁷
5. Other Complications:
   • Uncontrolled diabetes can lead to acute life-threatening events such as diabetic ketoacidosis and hyperosmolar coma.⁷
   • Gum disease is about twice as common in young adults with diabetes.⁷
   • People with diabetes are more susceptible to bacterial or fungal infections² and their ability to recover is often compromised. For example, they are more likely to die with pneumonia or influenza than people who do not have diabetes.⁷
   • Diabetics over 60 years are 2 to 3 times more likely to report an inability to walk one-quarter of a mile, climb stairs, or do housework compared with non-diabetics in their age group.⁷
   • Diabetic are twice as likely to have depression, which can complicate their disease management. In addition, depression is associated with a 60 percent increased risk of developing type 2 diabetes.⁷
   • Patients with diabetes have an increased risk of developing a myriad of other problems like muscle infarctions, Dupuytren’s contracture, adhesive capsulitis, and sclerodactyly. They may also develop ophthalmologic disease unrelated to diabetic retinopathy like cataracts, glaucoma, corneal abrasions, optic neuropathy; hepatobiliary diseases like nonalcoholic fatty liver disease, cirrhosis, gallstones; dermatologic disease like tinea infections, lower-extremity ulcers, diabetic dermopathy, necrobiosis lipoidica diabeticorum, diabetic systemic sclerosis, vitiligo, granuloma annulare, acanthosis nigricans; depression and dementia are also common.²
6. Premature death among people with diabetes is at least double their peers of the same age without diabetes.⁷

Diagnosis of Type 2 Diabetes

T2DM is often a silent disease that presents only upon screening. It can present with hyperglycemic symptoms such as increased frequency and volume of urine, thirst, and orthostatic hypotension (dizziness accompanying positional change, like standing) and dehydration. Hyperglycemia can also cause weight loss, nausea and vomiting, and blurred vision. Symptoms may come and go as blood sugar levels fluctuate.²

Who should be screened for diabetes and when?¹

• All adults over age 45
• Consider starting earlier if BMI > 25 and any of the following:
  • Inactivity, 1st degree relative with diabetes, high risk ethnicity, gestational diabetes history, hypertension, low HDL cholesterol, high triglycerides, Polycystic Ovarian Syndrome (PCOS), pre-diabetes, cardiovascular disease
• Normal tests should repeat at least every 3 years. Consider more frequent testing with higher risk factors.

Diabetes is diagnosed via measures of glycosylated Hg (HbA1c, “hemoglobin A1C”) or timed/random measures of plasma glucose. The criteria for diagnosis are as follows and in the absence of symptoms must be found twice for diagnosis:

• HbA1c ≥ 6.5%
• 8-12 hour fasting blood glucose (FBG) > 126 mg/dL
• 2-hr oral glucose tolerance test (OGT) > 200 mg/dL
• Random glucose > 200 mg/dL

Incidence

The number of people in the western world with the disease is staggering and increasing at a fast pace. 347 million people have T2DM worldwide with the number of people dying from high blood sugar related illness at 3.4 million in 2004, according to the WHO⁴. The number of Americans diagnosed with diabetes has more than tripled since 1980², and according to the CDC, 25.8 million Americans have diabetes, and 7 million of them do not know they have the disease. These numbers are on the rise, the United States population is expected to reach 30.3 million people by 2030.²

If You Are Pre-Diabetic, Diabetes Is Not Inevitable! Treat It Now!

Pre-Diabetes, also known as Impaired glucose tolerance, is an intermediate condition between healthy insulin secretion/function and diabetes. The HbA1c is higher than normal but not quite at diabetes levels. A 2005–2008 study show that 35 percent, or 79 million, U.S. adults ages 20 years or older had pre-diabetes.⁷ People in this category are also at a higher risk of developing T2DM, heart disease, and stroke, but they don’t have to. The disease can be turned around with aggressive diet and lifestyle changes. The further one goes down the path to diabetes the harder it is to reverse; taking control as early as possible is key to avoiding it and the devastating diseases associated with it. Pre-diabetes diagnostic criteria include:

• HbA1c: 5.7-6.4%
• FBG: 100-125 mg/dL
• 2 hr OGT> 140-199 mg/dL

Children and Type II Diabetes

Children are now being diagnosed with what used to be and adult only disease!

The incidence of T2DM in children and adolescents (<20yo) is increasing, in North America, its incidence almost doubled in Japan between 1976-80 and 1991-5—from 7.3 to 13.9 per 100,000 junior high school children. These trends coincide with the prevalence of rising weight and lowered physical inactivity worldwide.¹ In the past T2DM was almost always diagnosed in people greater than 40. According to the Center’s for Disease Control (CDC), obesity and the sedentary lifestyle of young people, as well as exposure to their mother’s high blood sugar in the womb, may be major contributors to the increase in T2DM in this population. “…A sizeable proportion of patients have hypertension, hypertriglyceridemia, albuminuria, sleep apnea, and depression, and these factors may worsen over time.⁶ Here’s the extra scary part… the earlier one develops diabetes the higher their risk for the associated complications such as cardiovascular disease, the younger they will be expected to develop them, and the worse they are expected to fare. In addition, many of the pharmaceuticals used to control hyperlipidemia, blood pressure, and blood sugar for adults are not suitable for children, complicating their treatment and compromising their prognosis.⁶ This may be a generation of children that will be outlived by their parents. The work must begin with urgency to slow or stop the progress of this disease in at risk children (and their families) in order to preserve their long-term quality of life.

Conventional Treatment of Diabetes

The goal of allopathic and naturopathic treatments is careful control of cardiovascular risk factors. This involves normalization of plasma glucose, lipids, and blood pressure, combined with smoking cessation, if necessary. Conventional medicine attempts to control diabetes by dietary and lifestyle adaptations, a variety of oral hypoglycemic agents, and/or subcutaneous insulin therapy. Although T2DM is often called non-insulin dependent diabetes, insulin is often indicated in more progressed cases. All medications for diabetes come with the risk of hypoglycemia (low blood sugar) and its serious effects. Below is an outline of the American Diabetes Association 2011 Standards of Care position statement for treating diabetes. It extends beyond glucose control to help manage some of the more severe side effects.

Glucose Control

• Biguanides (Metformin)
  • What it is: This is usually the first line of treatment for T2DM and is often use to prevent disease development in those with pre-diabetes. It increases utilization of glucose at the level of the tissue and suppresses gluconeogenesis (sugar production) in the liver.
  • The risks: Depletes folic acid, vitamin B12 levels, can cause gastrointestinal distress like nausea, vomiting, abdominal pain, diarrhea, anorexia, headaches, fatigue, and the rare but very serious condition lactic acidosis.
• Sulfonylureas (Glipizide)
  • What it is: This is second line treatment to Metformin, used when Metformin and lifestyle fail to lower Hemoglobin A1c (a blood test to check glycosylation levels) below 7%. It increases insulin production in the pancreas.
  • The risks: Can cause hypoglycemia, nausea, rash, pruritus, fatigue, hypersensitivity, and weight gain.
• Thiazolidinedione (Avandia)
  • What it is: This is used for those that cannot control their sugar levels with Metformin and cannot use insulin. It works by increasing peripheral sensitivity to insulin.
  • The risks: This class of drugs is associated with an increased risk of heart failure. Other side effects are weight gain, liver damage, edema, anemia, increase in fracture risk, pleural effusion, Stevens-Johnson syndrome, and macular edema.
• Insulin
  • What it is: This injected medication is used for all type 1 diabetics and those type 2 diabetics that are unable to control their glucose levels with other pharmaceuticals and lifestyle. There are multiple forms of insulin categorized by their length of action – rapid, regular, intermediate, and long acting.
  • The risks: Side effects include weight gain, hypoglycemia, and retinopathy.

Weight Control

Bariatric surgery: The ADA recommends considering bariatric surgery for complicated type 2 patients if BMI > 35.

Blood Pressure Control

Because of the increased risk of CVD, blood pressure is managed more tightly to less than it would for non-diabetics to below 130/80.

• Pharmaceuticals such as ACE inhibitors, Angiotensin Receptor Blockers (ARBs), and thiazide diuretics.
• The DASH diet is often recommended.

Lipid Management

Statins are considered first line, even if multiple lipid goals are unmet.

• Antiplatelet Therapy – Aspirin or Clopidogrel are used to prevent coronary events.

Natural Treatment of Diabetes

The allopathic treatments and goals listed above highlight the severity of this disease and the major body systems involved. Naturopathic medicine takes a step back from the protocol above to uncover the reason a person has diabetes, then begins treatment adhering to the Naturopathic therapeutic order, which insists upon a priority of gentle treatments before more invasive ones such as pharmaceuticals and surgeries. Our purpose is to effect the most long-lasting and significant change for the patient by giving them the tools to take control of their disease and improve their quality of life. (Read an article on natural treatment of diabetes).

REFERENCES:

1. “2011 National Diabetes Fact Sheet.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 26 Jan. 2011. Web. 22 Oct. 2012. . ADA
2. Beers, Mark H. The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2006. Diabetes Mellitus (DM): Diabetes Mellitus and Disorders of Carbohydrate Metabolism: Merck Manual Professional. Web. 22 Oct. 2012. .
3. Bell, David SH, MB, FACE. “Diabetic Cardiomyopathy.” Diabetes Care 26.10 (2003): 2249-251. Diabetes Care. American Diabetes Association. Web. 22 Oct. 2012. .
4. “Diabetes.” WHO. N.p., Sept. 2012. Web. 22 Oct. 2012. .
5. “Dr. Jeffrey McCombs, DC.” Web log post. Dr Jeffrey McCombs DC. N.p., 1 Aug. 2012. Web. 04 Dec. 2012. .
6. Fagot-Campagna, Anne, K. M. Venkat Narayan, and Giuseppina Imperatore. “Type 2 Diabetes in Children.” BMJ 322.7283 (2001): 377-78. Web.
7. “National Diabetes Information Clearinghouse (NDIC).” National Diabetes Statistics, 2011. U.S. Department of Health and Human Services, Feb. 2011. Web. 22 Oct. 2012.
8. “New Paradigms In Diabetic Care.” New Paradigms In Diabetic Care. N.p., n.d. Web. 22 Oct. 2012. .
9. Scragg, Arthur. “Vitamin D and Type 2 Diabetes Are We Ready for a Prevention Trial?” Diabetes Oct. 2008: 2565-566. Diabetes. American Diabetes Association. Web. 04 Dec. 2012. .

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