Defining Diabetes

Diabetes is becoming more and more prevalent.  If you do not have diabetes, I am sure that you know someone who does.  As of yet, there is no "cure" for diabetes.  However, diabetes can be prevented and controlled.  Patients with controlled diabetes can live a normal life span.  The key to controlling and possibly preventing diabetes is to understand its cause.  With proper understanding it becomes easier to adhere to the practices and treatments that will keep diabetes in check.

In our body, sugar or glucose is used by our cells, especially muscle cells, for fuel.  This is the main reason why we eat, to provide fuel for our body.  Glucose is delivered to our cells by way of our blood vessels.  Elevated levels of sugar in the blood stream cause damage.  Since we have blood vessels going to every organ system of the body, diabetes can adversely affect them all.  I like to think of Insulin as a key that unlocks and opens the doors from the blood stream to the cells.  This allows glucose to exit from the vessels to be used for fuel.  Diabetes occurs when there is too much sugar in the fuel lines instead of in the cellular engine.  There are two types of diabetes, type I and type II.  Patients with type I diabetes have an absolute lack of insulin.  This is usually due to a destructive immune response.  It is felt to be triggered by a viral infection and it results in the destruction of all the cells that make insulin.  A patient who has had their pancreas removed surgically would functionally have the same disease.  These patients must take insulin.  I will not discuss this type any further but will now focus on type II diabetes.

This is the type of diabetes that is taking our country by storm.  It is truly reaching epidemic proportions.  It is closely related to being overweight.  It is caused by a resistance to the effect of insulin initially and then a gradually increasing lack of it as the disease progresses.  The problem originates because of abdominal fat stores.  These stores release short fatty acids, which like glucose can also be used for fuel and enters the cells through the same doors.  It is like a bus load of students who have arrived at a museum.  Once they are in line to enter if another bus load arrives and mixes with them it will take much longer for them to all get inside.  The only was to get them in quicker is to open up twice as many doors.  If you have equal amounts of glucose and fatty acids competing to get into a cell it will take twice as much insulin to open enough doors for the glucose to exit out of the blood vessels.  For a time the pancreas just spits out more and more insulin to keep the blood glucose level normal.  Over time, though, the pancreas is no longer able to produce a sufficient amount of insulin to keep up with the demands and the blood sugar begins to rise.  When the pancreas completely burns out, it becomes functionally like type I diabetes.

Diabetes does not begin when the blood sugar rises but many years before that.  If you have more than an inch or two extra around your waist, you are putting stress on the pancreas and increasing your chance for diabetes.  Though there is no cure for diabetes, most of type II diabetes can be prevented.  It is all about the supply and demand for blood sugar.  What we eat greatly influences how much sugar is delivered to the blood stream.  How much we exercise is the major determinant in how much sugar the cells use up for fuel.  In a person who is prone to diabetes the proper diet and adequate amounts of exercise during the time when blood sugars are still normal will completely prevent diabetes for developing.  Waiting until the blood sugar rises may be too late.  We all need to be concerned with this whether or not we have been told that we have a problem.  With this definition in mind, stay tuned as I discuss the treatments for diabetes in more detail next week.

Sleeping Soundly

We all know how wonderful a good night's sleep feels.  It is hard to beat the feeling of waking up, feeling refreshed, and being ready to tackle the day.  For many, such a morning is more a dream than a reality.  Too many wake up feeling sluggish, tired and ready to go back to bed.

Poor sleep has been linked to poor health.  For those that snore and wake up tired, ask your spouse or family member if they ever see you stop breathing between snoring.  You could have a condition called obstructive sleep apnea.  It not only will give you a headache on waking up, it will make you tired during the day.  It has even been linked to an increased risk of having a car accident.  It puts a stress on the heart, raises blood pressure and increases the chance of having a stroke.

Most of us know what stress will do to our sleep.  When the heart is pounding, our limbs are shaking and our mind is racing, it is hard to fall into the calmness of sleep.  What we really need is not to just get to sleep but to sink into a deep sleep.  Medically we refer to that as "REM" sleep.  During this stage our muscles become so relaxed that they are essentially paralyzed.  This is what makes sleep so refreshing.  Most researches feel that patients with fibromyalgia are not able to get into that deep stage and thus wake up feeling stiff, sore and tired.

The drug companies would have you believe that the cure for insomnia is to simply take a pill that will allow you to flit off into dreamland with the butterflies.  Sedative medications do make one feel sleepy but they do not induce REM sleep.  What research I have seen in regards to a patient's ability to function the next day universally shows that people who use sleeping pills score more poorly on their ability to perform tasks than those that do not.  To truly help insomnia, the underlying cause must be found and corrected.  If it is due to obstructive sleep apnea, your physician can order a sleep test to diagnose and guide treatment.  If it is due to side effects of medications, those can be adjusted.  If acid reflux is the cause, there are treatments for it.  The same is true for those getting up frequently to urinate.  Some may have uncontrolled pain from arthritis or other conditions.  The majority of patients I see likely suffer from stress that affects their sleep.  Many don't want to acknowledge that their stress is affecting them in this way.  I have many patients who would be willing to take a "sleeping pill" but not to take a medication to control their anxiety.

Lastly, our behaviors can make sleep both better or worse.  There is something to be said for having a bedtime.  Getting off schedule can be a serious problem as any shift worker can likely attest.  Keeping stimulation low prior to going to bed is helpful.  This is a good time to stay off the computer, put down any work and let the mind relax.  Stay away from food and beverages prior to bed, especially anything with caffeine.  Never use alcohol to help you sleep.  It may make you calm as you go to bed but invariably it will trigger you to be more alert and awake four hours later when you need to be in that deep stage.  Regular exercise is so important. By working your muscles earlier in the day, they are much more likely to relax later.  If you do wake up at night resist the urge to turn over and look at the clock.  When your mind is asked to look at the numbers, compute what that means and elicit a negative response to having only slept till 2:00 AM, you have now activated your brain to the point that makes it even harder to fall asleep.  Keep your eyelids shut.  Focus on calm, regular breathing.  More often than not you will be able to drift back to sleep.  In the morning you will be ready for a brand new day!

How Hard to Push

It is not uncommon that I am asked about exercise.  Am I working out hard enough? How much is too much?  We have all heard of people who have gone out to exercise and had a heart attack and died. What is one to do?  How should one start and with how much intensity?

First of all, make sure that you meet with your doctor prior to starting an exercise program.  For the vast majority of people it will be quite safe to start exercising without any further testing. There are some patients who will need to make sure that there are no blockages in the heart arteries prior to beginning.  Your doctor will make that judgement.

The best way to start exercising is slowly and gradually.  It is more important to build a habit in the beginning than it is to build muscles and endurance.  The worst thing that can happen is to jump into a program aggressively and get injured.  That will just lead to discouragement, making it even harder to get back into a regular regimen. I would start just three days a week.  It may be for only 5 or 10 minutes.  Every day build it up little by little.  Ultimately, you want to be doing some sort of exercise for 45 minutes at a time, four days a week.  That is the goal.  More is even better.

The intensity with which you work out will vary depending on the activity.  In the beginning, I do not suggest that you track your heart rate.  Again, it is more important to just make the habit of exercising.  Certainly if you feel short or breath or dizzy, stop exercising and check your heart rate.  To calculate your heart rate, count the number of beats in fifteen seconds and multiply that by four.  If you feel your pulse and there are 20 beats in fifteen seconds, your heart rate is 80 beats per minute.  The maximal predicted heart rate for steady cardiovascular exercise can be calculated by subtracting your age from 220 and taking 80% of that.  If someone is 56 years old, 220-56 is 164.  My way of figuring out 80% is to take 10%, double it and subtract it again.  In this case 10% is 16, doubling it is 32; 164-32=132.  This is not a number that if surpassed will lead to immediate death.  It is just a recommendation to keep you at a steady level.  If short burst of exercise raise your heart rate above this level and do not cause dizziness, excessive shortness of breath or chest discomfort, that is acceptable.

If during exercise you start to feel any of the above mentioned symptoms, it is not time to panic.  It is time to stop and let your heart recover.  Lay down so that blood will get to your head.  Get some fluid in you.  Make sure you stay well hydrated during your work out. If you exercise for more than 30 minutes, you need to have a water bottle with you.  If you go for more than 45 minutes, you should add carbohydrates and electrolytes such as a sport drink or energy bar.  If resting for five minutes does not result in feeling better, you should get assistance.  Remember, keep moving but let's make sure to use common sense.

What is Health?

I came across an interesting article in the New England Journal of Medicine this week that gave me cause to think about health in general and how it is measured.  The study was looking at asthma and studied it in two ways.  The first was by measuring the amount of air a person exhales in one second.  This is quite standard and is used frequently to see how well one is doing with their disease.  The second measurement was to simply ask the patient if they were feeling short of breath or not.

There were three groups of patients.  One group received an inhaler containing albuterol.  Again this is a very standard medication used to treat asthma.  It relaxes the muscles that surround the airways allowing for improved passage of air.  Another group received acupuncture and the third group received a fake treatment-or placebo.  In regards to the air measurement, the medication was overwhelmingly effective compared to the other two arms.  However, by symptom scores the acupuncture and the medication were rated the same.  The question then is asked, which group was healthier?  It is easy to say that it is the group with the best airway measurements but that is not why patients come to see the doctor.  They do not come and state, "doc, I just don't feel like I am getting enough air out of my lungs in the first second that I breath."  They say, "I am short of breath."  From a doctor's standpoint, what recommendations do I give my patients?  I would enjoy hearing what you think about this.

As I have contemplated this further, I have thought that we cannot just go by how a patient is feeling.  There are plenty of medical conditions that can be detected at an asymptomatic state.  If nothing is done at the time, the disease can progress with possible deadly consequences to follow.  For example, why would anyone agree to undergo screening for colon cancer?  This requires taking medication to flush out the colon, go to a facility where powerful sedative medications are given so that a scope can be inserted into the colon.  None of that is going to make a patient feel any better.  However, if a polyp is found, cancer is averted.  The consequences of not finding colon cancer at an early stage are far worse than what it takes to have a colonoscopy performed.  Another example is hypertension.  It is called the silent assassin for a reason.  For many years there will be no symptoms in patients with elevated blood pressure.  Eventually, though, the heart will either weaken, develop arrhythmias or succomb to a hear attack due to blood vessel blockages.  Strokes can occur in the same fashion.  Therefore, the answer to the question, "why would a doctor recommend that a patient who feels fine take a medication that may have side effects?" is that it just may save their life.

Continuing with the theme of hypertension, let me ask: Who is healthier?  A patient with a blood pressure of 120/78 who is taking three medications to keep his blood pressure down, is overweight, does not exercise and eats out about twice a week? or a patient with a blood pressure of 120/78 who is on no medications but exercises five days a week, keeps his weight down and watches what he eats?  The answer seems obvious does it not?  However, I frequently see patients who will look at the number, take the pills and make no effort to do more on their own feeling that everything is just fine.


In summary, health, I believe is more than how we feel, though that is an important component.  Health is also how we live.  Health is more than the absence of disease.  Healthy living lowers our risk for future disease as well.