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Diabetes Mellitus, Type 1

Introduction

What should I know about Type 1 Diabetes Mellitus?

Diabetes mellitus, a term that means “the running through of sugar," was first identified in the 1st century AD. (1) The disease was described in old books as “the melting down of flesh into urine." Diabetes mellitus is a chronic condition where there is less insulin than what the body needs. This can be low insulin, a problem with the release of insulin, insulin that cannot work in the cells that need it, or insulin that is inactivated before it is able to function. Diabetes mellitus is a disease in which the body does not produce or does not use insulin effectively. It is not simply hyperglycemia, or too much glucose (sugar) in the blood.

Insulin is a hormone produced in the pancreas by the beta cells in the Islets of Langerhans. The release of insulin by these special cells is regulated by the amount of glucose in the blood. It is responsible for transporting glucose (from carbohydrates) into the cells for energy production. After a meal, when blood sugar increases, insulin release increases. Between meals, when blood sugar is low, insulin release is low. Insulin is released from the pancreas directly into the liver where some is used and some is broken down and eliminated from the body. The rest is released into the general blood circulation. By helping to move glucose into the cells, insulin decreases blood sugar. Insulin also decreases the breakdown of stored fat and builds triglycerides. Insulin is involved in the production of protein. The proper growth and development of children is dependent on insulin.

Diabetes can affect people of any age. It increases the risk of chronic conditions like heart disease, retinopathy (a disease of the retina) and blindness, peripheral neuropathies (a disease of the nervous system), circulation problems that can lead to amputation, problems with the immune system, and skin ulcers and poor wound healing.

Diabetes is diagnosed by lab tests, either a fasting plasma glucose (FPG) or a two-hour plasma glucose (OGTT – oral glucose tolerance test). There are two forms of diabetes mellitus: type 1 (also called IDDM, insulin dependent diabetes mellitus, or juvenile onset) and type 2 (NIDDM, non-insulin dependent diabetes, or adult onset).

Type 1 diabetes is a condition where the beta cells in the pancreas do not release insulin. This is called an absolute insulin deficiency. This means that the individual has hyperglycemia and begins to break down their fats and protein in order to meet the energy demands of the body. This breakdown of fats and protein makes the insulin dependent diabetic build up waste products called ketone bodies, which causes a condition called ketoacidosis. Insulin dependent diabetics need a constant supply of insulin to prevent ketoacidosis and maintain a stable blood sugar.

Type 1 diabetes usually occurs in people younger than 30 years of age. It is thought that the disease is a caused by something in a person’s family history (genetic factor) that responds abnormally to the beta cells in the Islets of Langerhans. Islet cell antibodies have been found in 60-95 percent of persons with type 1 diabetes. (2) Sometimes this unusual response by the body can be started by a virus, a vaccination, or a toxic fungus.

Statistic

International Diabetes Federation, 2007.

  • Diabetes currently affects 246 million people worldwide and is expected to affect 380 million by 2025.
  • Diabetes is the fourth leading cause of global death by disease.
  • In 2007, the five countries with the largest numbers of people with diabetes are India (40.9 million), China (39.8 million), the United States (19.2 million), Russia (9.6 million) and Germany (7.4 million).
  • Each year a further 7 million people develop diabetes.
  • Each year 3.8 million deaths are attributable to diabetes.
  • Every 10 seconds two people develop diabetes.

Sudaram Medical Foundation, 2007.

  • It is currently estimated that there are 35 million diabetics in India. The number is expected to increase by another 60% by the year 2025.

Diabetes New Zealand, 2006.

  • Approximately 11,000 people in New Zealand have Type 1 diabetes.

Persatuan Diabetes Malaysia, 2007.

  • There are an estimated 24,000 people with type 1 diabetes in Malaysia today.

National Diabetes Information Clearinghouse, National Institute of Health. 2002.

  • Type 1 Diabetes accounts for 5 to 10% of all diabetes cases in the US
  • One in every 400 to 500 children and adolescents has type 1 diabetes

Signs and Symptoms

The following list does not insure the presence of this health condition. Please see the text and your healthcare professional for more information.

Initial symptoms of diabetes include frequent urination, thirst, weight loss despite an increased appetite, fatigue, and irritability. Dizziness, lethargy, irritability, loss of coordination, and perspiration are common during episodes of low blood sugar (blood glucose 250mg/dl) among insulin-dependent diabetics can lead to ketoacidosis which requires medical attention. Increased thirst, nausea, vomiting, and an acetone or "fruity" odor to the breath are common with ketoacidosis.

Diabetic coma, or ketoacidotic coma, is a life threatening complication of type 1 diabetes. As the make up of the blood changes, a severe imbalance occurs between the amount of water in the blood plasma and the amount of electrolytes. Symptoms include abdominal pain, nausea, vomiting, and shortness of breath (Kussmaul breathing). Signs include flushing, decreased reflexes, and "fruity" breath.

General

  • Frequent urination
  • Thirst
  • Weight loss despite increased appetite
  • Fatigue
  • Irritability
  • Low blood sugar episodes (blood glucose <60mg/dl) can be marked by dizziness, lethargy, irritability, loss of coordination and perspiration
  • High blood sugar episodes (blood glucose >250mg/dl) can be characterized by increased thirst, nausea, vomiting, and a "fruity" odor to the breath

Treatment Options

Conventional

Treatment goals for diabetes include avoiding hyperglycemia, hypoglycemia (low blood sugar), and decreasing, slowing down, or avoiding the long-term complications of the disease. Therapy should be special for each person depending on his or her condition. It is important to realize that the disease will probably get worse throughout the patient’s lifetime, and that the treatment plan may need to be changed to control blood sugar and avoid other health problems.

The treatment of diabetes involves making sure that insulin is controlling blood sugar properly. Along with a program of a healthy diet and exercise, insulin is the treatment of choice for the patient with type 1 diabetes. The patient or caregiver also needs to monitor blood glucose very carefully to decrease the risk of future complications. This is usually done at home with a blood glucose meter. A small amount of blood is taken with a fingerstick, and the amount of blood sugar is measured by the machine. Insulin doses can be changed based on this information.

Insulin is a protein and a hormone. All insulin products on the market are from the pancreas of pigs or made synthetically. Animal-derived products are being phased out, although a few purified pork insulins are still available. Human insulin is a biosynthetic product that is made by using baker’s yeast, or a strain of the bacteria E. coli that does not cause disease. Insulin lispro or insulin aspart are also biosynthetic products on the market to treat diabetes. They are a little different from human insulin in order to get a specific effect.

Insulin is given by injection underneath the skin in a very specific dose to control blood glucose. Insulin must be injected because it is a protein and can be digested in the gastrointestinal (GI) tract. Insulin can be measured and injected with a traditional insulin syringe or with a pen-injection system. Insulin can also be given by using an infusion pump, which automatically injects a continuous dose of insulin. This is an alternative to giving daily injections at different times during the day. The following list summarizes the various insulin formulations currently on the market.

Commercially Available Insulin Formulations
Rapid-acting
Human Insulin Lispro
Human Insulin Aspart

Short-acting
Human Insulin (rDNA)
Pork Purified Insulin

Intermediate-acting
Isophane Human Insulin (rDNA)
Pork Purified Isophane Insulin
Human Insulin Zinc Suspension (rDNA)
Pork Purified Insulin Zinc Suspension

Long-acting
Human Insulin Zinc Suspension (rDNA), Extended
Insulin Glargine

Human Insulin (rDNA) Mixtures
Isophane Insulin + Insulin 50/50
Isophane Insulin + Insulin 70/30
Insulin Lispro + Protamine 0.19mg (50/50 Mix)
Insulin Lispro + Protamine 0.28mg (75/25 Mix)

Nutritional Suplementation


Chromium

The way that chromium affects blood sugar was first discovered in animal studies in the 1950's. In the 1970's, it was discovered that chromium is important in special intravenous (IV) feeding solutions called total parenteral nutrition (TPN solutions). It was discovered that when chromium was missing from the TPN solution, after several months, blood sugar increased in patients. Chromium was added and blood sugar in TPN patients returned to normal. Various studies support that chromium has a positive effect on blood glucose. (3)

It is thought that chromium helps insulin by moving glucose and other nutrients into the cells of the body. (4) This helps to maintain muscle mass during times when the diet does not provide enough calories. Chromium also stabilizes the body’s metabolism. Chromium can lower cholesterol and triglycerides. Chromium may also decrease hunger and limit food cravings. Insulin is involved in the regulation of the center in the brain the makes one feel full and stop eating. Insulin is also important in the development of a brain chemical linked to the craving for carbohydrates.

Most Americans are at risk for low chromium because of a diet rich in refined sugars. Individuals who eat diets high in refined sugars tend to eliminate 300 percent more chromium in their urine than those whose diets are low in refined sugars. Individuals who live in countries with high levels of chromium that comes from diets rich in unrefined grains have a lower rate of diabetes and atherosclerosis (hardening of the arteries). People who exercise regularly eliminate two to six times the normal amount of chromium in their urine on days of exercise. (5) Many athletes make this problem worse by using high-carbohydrate supplements. The elderly also are at risk for low chromium due to not enough chromium in the diet and poor absorption. Women can have a drop in chromium levels during the third trimester (seventh, eighth, and ninth months) of pregnancy. (6)

There is a disagreement among healthcare professionals over what is the best chromium to use. Chromium is only active in certain forms. The most important of these forms is glucose tolerance factor (GTF). Dr. Walter Mertz of the United States Department of Agriculture did research with GTF chromium. He found that chromium was a crucial part of the process where insulin attaches to cells. GTF chromium is safe and usually does not cause side effects.

Chromium picolinate is another popular form of chromium that is used to regulate blood sugar levels. (7) Even though chromium picolinate is considered safe, a recent study in lab animals at Dartmouth College and The George Washington Medical Center reported that certain doses of chromium picolinate caused damage to chromosomes. (8) More information is needed about this supplement because other studies have reported that it is safe and effective.

For diabetics, adding chromium or other blood sugar regulating agents to their diet should be done slowly, especially if they are on other medication to control their diabetes. With lifestyle and dietary changes, only a small dose of chromium may be needed.


Magnesium

Magnesium is involved in the breakdown of glucose in the body and release of insulin. (9) Low magnesium may make diabetes worse in some people. (10) Hypomagnesemia (low magnesium in the blood) happens in about 25 percent of diabetic patients. (11) Many Americans are below the RDA (Recommended Dietary Allowance) for magnesium. Many experts feel that the RDA for magnesium needs to be increased.

Magnesium is eliminated from the body by the kidneys. Individuals with kidney disease should consult a healthcare professional before using a magnesium supplement. Too much magnesium may cause diarrhea.


Vanadium

Vanadium is a trace mineral that is very important for plant nutrition, but what it does for human nutrition is not clear. It works with enzymes in the body. High amounts of vanadium are found in the kidneys, liver, and bone. Fat cells temporarily store vanadium for quick release into the body. Supplementing with vanadyl sulfate and other forms of vanadium has been reported to improve diabetes. (12) , (13)

Animal studies have reported that when vanadium was given to diabetic rats, their increased blood glucose returned to normal. Other studies have reported that vanadyl sulfate not only lowers blood glucose in diabetic animals, but also decreases cholesterol and triglycerides. (14) In one study in diabetic rats, researchers found that vanadium may protect the pancreatic beta cells. (15)

Vanadium pentoxide and vanadyl sulfate are active forms of vanadium that are easily absorbed by the body. Vanadium appears to be safe even at high doses. Doses should be increased gradually, especially if it is given with GTF chromium.


Alpha-Lipoic Acid (ALA)

Alpha-lipoic acid (ALA) is an antioxidant made by the body. ALA is also known as alpha-lipoate or thiotic acid. Lipoates are small water and fat-soluble molecules that are easily absorbed from the gastrointestinal tract. It is also used in heart disease and for AIDS patients. (16) Alpha-lipoic acid affects insulin and blood sugar in type 1 diabetics. (17) , (18) ALA may be effective in the treatment of diabetic neuropathy. (19) In a recent study, about 97 percent of diabetic patients treated with ALA daily for three weeks reported an improvement in their neuropathy symptoms. (20) There are no known toxicities with ALA. It is important to monitor blood glucose closely in diabetics supplementing their diet with ALA.


Zinc

Zinc deficiency is found in patients with problems in blood glucose control. (21) In clinical studies, diabetic animals and humans with zinc deficiencies improved when supplemented with zinc. (22) , (23) Zinc helps to regulate insulin production by the pancreas and glucose use by muscle and fat cells. Very high doses of zinc may cause diarrhea, dizziness, lethargy, vomiting, and loss of muscle coordination.

Herbal Suplementation


Evening Primrose

Evening primrose oil (EPO) contains gamma-linolenic acid, which is an omega-6 fatty acid. (24) , (25) Omega-6 fatty acids may decrease inflammation. Using essential fatty acids such as EPO may prevent zinc deficiency, possibly improving the immune system. (26) Fatty acids are an important part of the normal functions of the human body. The human body can produce all of the fatty acids it needs except for omega-3 and omega-6 fatty acids. Both of these must come from the diet or with the use of supplements. A balance of these two fatty acids is very important. Essential fatty acids are needed for building cells and hormones. Modern diets often do not provide enough fatty acids.

Diabetics who cannot make gamma-linolenic acid (GLA) from linoleic acid will need a quality GLA supplement. (27) , (28) This is very important for proper nerve function and for the prevention of diabetic neuropathy. (29) , (30) Evening primrose oil has been reported to be beneficial for patients with diabetic neuropathy. (31)


Gymnema

Gymnema is a rain forest vine found in Central and Southern India, which has a long tradition in the treatment of diabetes. The Indian name is Gurmar, which means, “sugar destroyer." Its use has been documented in Ayurvedic medical texts for over 2,000 years in the treatment of “sweet urine." The leaves of gymnema are thought to increase insulin secretion, and several studies report control of hyperglycemia in diabetic laboratory animals. (32) , (33) A decrease in body weight has also been reported.

Human studies have reported decreased blood glucose during therapy with gymnema. (34) , (35) Improved lab test results and the need for less prescription medications have also been reported. In some studies, patients with diabetes were able to stop taking prescription diabetes medication and control their blood glucose with gymnema alone. (36) Other studies report that gymnema controls blood glucose by decreasing the absorption of glucose in the intestines. (37)

Because gymnema leaf powder acts like an anesthetic on the taste buds that can last for several hours, some researchers feel that gymnema may be a possible agent to use for weight control and to decrease the craving for sweets. (38) A recent study also reports decreases in cholesterol with the use of gymnema. (39) Gymnema may be useful for athletes to want to develop more lean muscle mass compared to body fat. Another study suggested that gymnema may be safe and effective for weight reduction, BMI and promoting healthy blood lipids. (40)


Bitter Melon

Bitter melon or karela fruit has been used in South America and the Orient as a food and also as a febrifuge (fever reducer), abortifacient (an agent that causes abortion), emmenagogue (increases menstruation), anthelmintic and vermifuge (agents that remove intestinal worms), antiviral, emetic (induces vomiting), and agent for diabetes. (41) Recent studies have looked at the benefits of the fruit in diabetes and hyperinsulinemia, HIV viral infection (AIDS), and certain cancers. (42) , (43)

Bitter melon has been reported to improve glucose control in humans. (44) , (45) Research reports that molecules with insulin-like activity may be present in bitter melon seeds. (46) A few studies say that bitter melon may increase glucose use in the liver rather than having any effect on insulin release. (47) Bitter melon has also been reported to lower cholesterol and triglycerides in diabetic patients. Some reports have said that bitter melon extracts did not lower blood sugar in laboratory animals. (48) , (49) It is recommended that a standardized extract of bitter melon always be used.

Diet & Lifestyle

Diet: Diabetes and obesity have increased over the past 50 years in the United States. People don’t eat enough fresh foods, and there are fewer micronutrients in the soil (like chromium and vanadium) where food is grown. Fad diets of high protein, low or high fat, and low or no carbohydrates are not the answer. While this type of diet may help take weight off at first, it is not a long-term answer. Carbohydrates alone are not the cause because humans were eating carbohydrates long before these problems arose. It is true, however, that people are eating excessive amounts of carbohydrates, and it would be better to moderate that habit.

There are several ways to support and improve insulin regulation by using natural agents, but the real key is to change the selection of foods in the diet. In general, the American diet is made up of a large amount of carbohydrates, especially refined carbohydrates. People limit their intake of fresh vegetables and fruits, and quality sources of protein and legumes, and they do not take in enough essential fats. As of 1985, the typical American diet was 46 percent carbohydrates, 43 percent fat (poor quality), and only 11 percent protein. With the average American eating approximately 150 pounds of sugar a year, there is a continuous demand for more insulin to be released. The average person drinking two “big gulp" drinks a day is receiving about 54 teaspoons of sugar. Using diet drinks does not work either because they contain sodium. This is particularly a problem for diabetics with hypertension (high blood pressure). While current research shows that dietary fat and cholesterol are definite problems, this situation is only made worse by the continuous, increased amount of carbohydrates along with the fat. Dietary fat is then stored because of excess insulin that is released while eating a high amount of carbohydrates.

Many experts over the years have praised the low-fat, high-carbohydrate diet. The problem with this diet has been that it does not cause weight loss. In fact, a diet with too many carbohydrates has been linked to increased LDL cholesterol and triglycerides. (50) The other thing to be aware of is that many prepared foods may be labeled low fat, but are loaded with refined sugars, which increase insulin release, and therefore, fat storage.

The obvious first step is to eat foods that will cause the least amount of insulin to be released. This will not only benefit the diabetic, but many individuals wanting to lose weight will benefit from this approach as well. The first concept to understand is the glycemic index - the fact that certain foods actually cause a sharper rise in insulin release than others. The glycemic index was first developed to help diabetics control postprandial (after meals) insulin blood sugar regulation, since this is the most difficult part of controlling blood sugar. Foods that do not cause a rapid rise in blood sugar will not cause increased insulin release. For example, in the past, it was thought that all complex carbohydrates were equal. It is now known that grains have different glycemic indexes. It is valuable to look at glycemic index when choosing foods that contain different amounts of carbohydrates. Proteins and fats do not have a glycemic index.

Legumes: Almost all legumes have a moderate glycemic index. They also provide a source of water-soluble fiber that is valuable for lowering cholesterol. They also provide phytoestrogens, which may provide health benefits.

Vegetables: Some vegetables have a high glycemic index and should be used in moderation if one is trying to actively control blood sugar. These include white potatoes (baked), carrots, beets, and turnips. However, if an individual is eliminating other sources of refined sugar in the diet and is decreasing the amount of complex carbohydrates (breads and pastas), he/she should be able to eat these vegetables with moderation.

Dairy products: Most dairy products have a low glycemic index. However, some people do not tolerate dairy very well.

Fruits: Fruits are generally in the middle of the road in terms of glycemic index; but dried fruits, which are concentrated, have a higher index. Drinking fruit juices will definitely increase blood sugar release. Therefore, fruit juices should be limited or diluted with three-fourths water.

Most sweeteners such as honey, molasses, sugar, and white grape juice concentrate tend to have a high glycemic index. Rice syrup and granulated rice sweeteners may be used instead. The artificial sweetener aspartame may increase insulin resistance over time.

Grains: Grains such as rice, wheat, and corn tend to have a high glycemic index, but grains such as buckwheat, millet, barley, rye, and bulgur are actually quite low. For successful weight loss and blood sugar control, this group of foods should be used in moderation. Also, the addition of fats such as olive oil or butter (in moderation) can lower the glycemic index.

Fiber: Fiber is an important part of the diet for a number of reasons. It is well known that fiber helps prevent constipation. However, fiber also controls sugar and cholesterol and helps in the prevention of colon cancer and diverticulitis. Most individuals with diabetes or insulin resistance do not realize that they run a 75 percent risk for developing atherosclerosis. Decreasing cholesterol levels with the use of fiber is one way to combat this problem.

Fiber is the indigestible part of plant food that acts as roughage for the body. There are two types of fiber. Water-soluble fiber is found in fruits, vegetables, and legumes in the form of guar, pectin, and gums. These products form a gel in the gastrointestinal tract that allows for a food to be held there longer, causing in a slow rise in blood sugar. This type of fiber also helps to lower cholesterol. Insoluble fiber is made of cellulose, hemicellulose, and lignins, and can be found in grains and bran. This food also takes longer to be broken down and used for energy, but its main value is in adding bulk and preventing constipation.

Food Nutrient Groups and Their Importance in Insulin Regulation

Proteins: Protein is important in every individual’s diet. It is needed for growth and for building tissues. Proteins are made of amino acids. These amino acids are absorbed through the small intestine and used by the body as needed. The body can manufacture most amino acids, but there are eight essential amino acids that must come from the diet. These eight can best be found in eggs, poultry, fish, and meat. Nuts, seeds, legumes, and grains can provide some of these essential amino acids as well. Protein intake is needed for tissue healing and body functions.

Carbohydrates: Carbohydrates is the class of foods that are likely to be eaten in excess. They are easy to get, are filling, and tend to be satisfying (like desserts). They are an energy source that eventually gets broken down into sugar. There are complex and simple sugars. Simple sugars are found in fruit and fruit products, white and brown sugar, maple syrup, and honey. These simple sugars increase insulin release. Carbohydrates are the main reason for the late night craving for sweets that occurs for so many individuals. Because of its fiber content, fruit, however, does have the advantage of being broken down in the stomach, with the sugar released over time. However, fruit should not be overeaten, since it does contain, in some cases, a large amount of fructose, a type of sugar. Complex carbohydrates provide the advantage of fiber, but too many complex carbohydrates are not good for the metabolism. Carbohydrates should come from vegetables.

Fats: Fats are an important part of the diet. Americans eat poor sources of dietary fat for the most part. Most of the fats come from margarine, partially hydrogenated oils, or oils that have been commercially heated. Monounsaturated fats, such as olive oil, benefit by helping to control cholesterol. The use of omega-3 fatty acids, especially from vegetable sources (flax seed), can provide benefits. Because of the shortage of quality oils in the diet, most people actually need more essential fatty acids, in particular, the omega-3 fatty acids. These fatty acids are important as anti-inflammatories, for the health of nerve tissue, as well as being key nutrients for the health of every cell in the body.

Exercise: Along with diet, exercise is the most important step diabetics can take toward blood sugar control. Today, there is more stress and less physical activity than even a generation ago. Exercise can decrease the risk for heart problems in diabetic patients. Regular exercise can improve heart and lung health, make insulin work better, and increase HDL cholesterol while decreasing LDL cholesterol. (51) Exercise also helps to regulate blood sugar. At a minimum, diabetics should get 30 minutes of some form of exercise at least four days a week, but more would be beneficial. Anyone who is over 40, or a brittle diabetic, and has not been exercising, should check with their health care professional before starting any exercise program.

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