The Final Exam Will Be Before Thanksgiving

H & E: 10:00-11:00Scribe: Teresa Kilborn

Friday, November 13, 2009Proof: Ashley Holladay

Dr. Pillion Diabetes Mellitus Page 1 of 7

The final exam will be before Thanksgiving. Unfortunately, the audio was less than quality once again. Any place where (…) appears, there was an abrupt skip in the audio.

Introducing the problem [S2]
We’ve had the lecture on the pancreas and how it works to regulate blood sugar. Today we’re going to talk about two different diseases. Type II may comprise 4 other diseases. They contribute mightily to both dental and optometric problems. There is a large increase in the number of people who have these diseases.
Today, statistics show that if you are Caucasian the chances are 1 in 3 that you would have a child with diabetes and if you are African American or Hispanic the chances are 1 in 2. It amazing that in this day in age that a disease has increased in prevalence as much as diabetes has.
Most of it is due to our lifestyle. Too much sitting and not enough working. We don’t utilize as much energy as we use to. There is a lot of societal impact that we really can’t change.
Who gets type I and who gets type II?
Type I is more common among children.
Type II is more common among adults.
When he went to school it was called maturity onset diabetes and it was defined as someone over the age of 40 that developed high blood sugar.
That definition is obviously wrong now because ½ of the children that come into children’s with diabetes have type II.
In 1990, the number of teenagers with type II diabetes was zero and now ½ of the teens with diabetes have type II.
It’s like HIV; it’s a disease that didn’t exist the way we know it just over a decade ago.
We’ve redefined what we call diabetes, and as we do the number of people who have diabetes keeps getting larger and larger.
Type I is a defect of the pancreas.
Pancreatic beta cells don’t secrete insulin as they should.
We don’t know a specific organ were the defect is in Type II.
It is a transitional disease. Initially, insulin resistance occurs due to the over utilization and over secretion of insulin as a result of excessive amounts of dietary food intake. We respond to food intake by secreting more insulin and as we do so our body because less and less insulin sensitive because the number of insulin receptors on our target cells decreases. When we hammer a cell with a lot of hormone, it binds to the receptors and the receptors become internalized, the cell becomes less responsive. It is a normal feedback mechanism that is protective. But if we feed ourselves over and over, don’t utilize glucose, then we bombard the pancreas with glucose all the time, it secretes insulin all the time, and our muscles and fat become less insulin sensitive.
If you took two people and you injected them both with insulin, one thin and one chubby/obese, the thinner one may have a blood glucose that goes down from 150 to 100 whereas the same 1 unit of insulin in the obese person who had type II diabetes their blood glucose may go down from 200 to 195. You can sense that the same amount of insulin in the obese person will have less effect because of their insulin resistance. So when the chubby person eats a meal their blood glucose goes up, they produce more insulin. The insulin in the chubby person’s blood after a meal might be 5 times greater than a normal individual after a meal. That high level of insulin is a bad thing. It makes the organs less insulin sensitive and it wears out the pancreas. If the person continues like this, it’s like a window air conditioning unit; it is going to wear out sooner. The person who is overweight and has a predisposition to diabetes either genetic or due to weight problem is more likely to have their pancreas fade over time.
The type II diabetic patient goes through a period early on in the disease where they are making lots of insulin. Later they go into a stage where they can’t make as much insulin and then at the end they aren’t making much at all. At the very end of type II diabetes they become essentially type I diabetic, that is they are both insulin resistance and they don’t make insulin (or hardly any) and thus they are insulin dependent. The other names of these diseases used to be insulin dependent diabetes for type I and insulin independent for type II. Those names don’t work anymore because some type II people require insulin to get their blood sugar down so you can’t really classify them as insulin independent.
There are some names out there such as brittle diabetes, touch diabetes, or pre-diabetes, you should be familiar with what these terms mean.
Touch of diabetes- someone whose blood sugar is high some of the time, but not others. So if you are not being treated by a good physician and you test your blood sugar one day it is 130 and the next it is 270, you may say that you have a touch of diabetes. That is wrong. They have diabetes. Touch diabetes doesn’t exist. This is really mild diabetes that is not under good control. If someone tells you this then it is a red flag
Brittle diabetes- someone that has diabetes and it goes up and down like a rollercoaster. One day they may be 400 then 30 then 350 then 120, 400, 60. This usually a type I that is taking an insulin therapy regimen that is not very effective. Another red flag.
Pre-diabetes- a real condition. Many of us are pre-diabetic and many of our parents probably are if they are not already diabetic. One way to distinguish someone who is pre-diabetic is that their pancreas is still functioning under suboptimal conditions so that it is able to keep blood sugar under control unless it is presented with a real challenge. If they get prednisone added to their regimen, they don’t get pre-diabetic over night, they are pre- diabetic over night, pre-diabetic means their blood sugar control is marginal and if something else happens then it gets out of control. Pre-diabetic means that their pancreas is secreting a suboptimal amount of insulin and the tissues are responding to it sub optimally. When they are presented with challenges then their blood sugars gets too high.
If you have two people one of whom is pre-diabetic and one who is not pre-diabetic, you give both a thanksgiving dinner and then you check their blood sugar two hours later, the non-diabetic will have gone up but then down to below 140. The pre-diabetic’s blood sugar will be 140-199 and if the diabetic was here then their blood sugar would be above 200. It’s a matter of degrees. It’s difficult to draw a line, but we have numbers to put people in categories. We use the blood sugars values right after a meal or when you first wake up in the morning to categorize people as diabetic, pre-diabetic or normal. You should know these numbers. You may be in a position where you tell a patient to check their blood sugar level first thing in the morning before they have breakfast to see what their blood sugar is. There are caveats to this though.
When does it occur?
It can occur anytime throughout life. You can have a viral infection of your pancreas anytime. Type I diabetes is diagnosed more often in younger people because they are more likely to get an infection of pancreatic destruction. If they are going to get it any time in their life it is more likely that they get it as a teenager than when they are 40,50 or 60 years old, but it can happen.
Where is the diagnosis made?
One of two ways:
Go to a doctor: a physician, dentist, or optometrist without major symptoms, but mention that you have minor symptoms and they can help diagnosis you with it. Many cases of diabetes are diagnosed by the optometrist. Some by the dentist. To make the diagnosis you have to know what to look for. The average person with type I, when they come out with the disease, they get very suddenly and very hard and they are in the emergency room with a blood sugar of 700-800. They get very sick, they throw up, they urinate, they get dehydrated, and it is very serious
This is not the case with type II. Type II is insidious. You get to an old age and you have symptoms that you associate with old age and not disease but that’s the way diabetes presents itself. The average person has diabetes for seven years before diagnosis. Think about your eyes, teeth, kidneys, heart and legs being untreated for seven years before the diagnosis is made.
SQ: Before the diagnosis is made, if you were to test your blood glucose levels it would present as an elevated number? Yes, and at health fairs where they typically screen for high blood pressure and such they are now screening for diabetes by testing HbA1C. Diabetes is silent. It has been controversial and only in the past year has the American diabetes association acknowledged that a high HbA1C…
How is it treated
Type I diabetes is treated with daily insulin replacement. It is a lifelong disease. If they are stranded in the desert or in a panic room they will die. It is a very serious situation and they have to make arrangements to have insulin therapy with them at all times. Insurance covering for medications and supplies is a must.
Type II is treated with diet, exercise, oral drugs, and insulin. The drugs that we use for diabetes, the oral hypoglycemic, are not always the best course of action to take. A lot of clinicians believe actually in treating type II diabetes with insulin at the beginning. Most type II diabetics don’t like the idea of going on lifelong insulin therapy which requires blood sugar testing and pricking your finger.
The story has changed [S3]
So the story has changed, in the 1920s, this was the typical type I diabetic. This young lady was treated with state of the art care in the 1920’s which was at the time to limit her diet to bread and water. She would die pretty much as a prisoner of war.
1922, they isolated insulin from dogs and it was a summer research project for a medical student. He took out the pancreas from a dog, ground it up, extracted it with alcohol, and injected it back into the dog. It rescued the dog from dying from diabetes. About six months later they started putting it into humans.
Just after starting treatment this young lady looked absolutely normal.
You can see the side effects of diabetes: your body starts to break down muscle and fat. You body produces glucose because the cells in your body can’t get glucose into them. Glucose remains high in the blood stream and when it gets above 200, it goes across the glomerular filter; you can’t resorb it, and comes out in your urine. You become glycosuric. When glucose goes out in your urine it takes water with it. As that happens you get dehydrated and when that happens, the concentration in your blood falls…and when it gets below a pH of 7, insulin won’t bind to it’s receptor anymore. The reason the pH goes down is because some of the glucose gets converted to ketoacids like acetoacetetic acid and ketone bodies and they are acidic and they make the blood pH get lower and lower. Ketoacidosis is what the term is called.
Part 1: Treating and Curing Type 1 Diabetes [S4-5]
It happened not only in the 1920s, but it happens today. If a kid or a young adult with type I diabetes don’t get their insulin then they can go into ketoacidosis and their blood sugar is typically above 500
…they fall down out in the street, they have a bracelet, how do you know if their blood sugar is too high or too low? Because they could go unconscious either because their blood sugar is too high or too low. Why would they go unconscious with a low blood sugar? They might not have eaten, they might have taken too much insulin, or they might have exercised. If they took too much insulin or if they skipped a meal, it could cause them to pass out and even die from too low of a blood sugar. If one of us comes across someone like this passed out,how do you know if they have too high or too low blood glucose? It would be nice if you had a glucose meter where you could prick their finger, put it on a strip, and have the answer in a few seconds (HI or LO). High is above 500; low is below 40. Probably they would be one of those extremes. Some meters will give you the exact number. Be aware of what glucose meters are out there and be familiar with how to read them.
But if you didn’t have one in your office, you have two courses of action, given that they may have a blood glucose of 700 or 30, if you were to give them a little bit of sugar you would save their life if they were at 30 and not that big of an impact if they were at 700. Usually the first thing you want to do is give them something that will raise their blood glucose up. What hormone raises blood glucose?... (I believe the answer was glucagon) Most of us produce both of them all the time and we “goose” up one or the other depending on it we are in a post absorptive phase after a meal or a non post absorptive period between meals.
Between meals we make more glucagon and after meals we make more insulin. All of the time we make both. As a diabetic you stop making insulin because your cells have been destroyed. If you’re not sure then you’re going to give glucagon.
The problem with giving glucagon to someone that is unconscious is glucagon comes as a dry powder and a dilutent. You have to draw up the dilutent with a syringe shot it into the vial with powder, so it is not very user friendly. If you’ve never done it, he advises to get a kit of glucagon emergency, practice it one time with an orange because it could save someone’s life.
Everyone with type I diabetes is advised to buy a glucagon emergency kit once a year and then throw it out because it goes out of date. Before you throw it out though, practice with it.
For a really small person, you would want to give them ½ of the normal amount. A vial contains 1 mL when you draw it up, and if you have a small person ½ mL is good.
After you inject, their blood glucose will go up, they will wake up. If their blood sugar was 700 and you gave them glucagon, then their blood sugar may go up to 800. They wouldn’t change, they wouldn’t wake up, they wouldn’t get better. But if their blood sugar was 30 and you gave them glucagon they would come up to 50 or 80. Then you would give them…
Glucagon causes cramping and vomiting. All of that food that you just put in their mouth is going to come up which is not good because you can’t just give them another shot of glucagon. You only get one chance.
In the mean time, call 911. They will hang an IV line and get glucose running in that way. It’s not easy to get glucose into someone that is in hypoglycemic coma or shock because they have clenched down. If someone is in a hyperglycemic crisis you do want to get the paramedics there very quickly
What does this guy have? Type II diabetes.
Type I: pancreatic beta cells are destroyed, insulin secretion decrease, glucose levels go up, ketoacidosis can occur, fat is broken down, ketones are released, pH falls, insulin binds but not its receptor, severe dehydration.
Long term complications of diabetes: [S6]
Long term complications shared by both type I and type II
there are a couple of studies that show that they are related to the degree of hyperglycemia so we thinkthat the underlying theme is that glucose reacts with protein amino groups to form what we call glycosylated proteins and all of the proteins in our body.
The higher the glucose in our body the more the reaction it is a 1:1 reaction. So if my blood sugar is 100 and hers is 200, then she is going to have twice as many glucose molecules attached to her proteins as I do. And if her blood sugar is 300 then she is going to have 3 times as much as I do.
What you do about diabetes and the fact that we have long term complications, what do you think about the fact that we have glycosylated proteins? Do you think it is a good thing or a bad thing? Probably a bad thing. It’s probably what causes nephropathy, neuropathy, retinopathy, glaucoma, cataracts, depression, gangrene, erectile dysfunction, cardiovascular disease, and cerebral vascular disease. All of these things are probably related to our proteins getting glycosylated more than they should be.
So if you can find the drug that deglycosylated proteins that would be a good thing and a way to treat diabetes.
Normal response to a meal: Insulin is released [S7]
Here is the normal way the… the vagus nerve to release insulin.