The pancreas, insulin, and their role in diabetes.

Sitting quietly behind your stomach is the pancreas, whose name comes from the Greek words pan meaning all, and kreas meaning flesh. The pancreas has two main functions. One part of this organ produces digestive hormones to help break down our foods, and these are secreted directly into the duodenum, or small intestine. The other part of the pancreas contains groups of specialized cells called islet cells which produce endocrine hormones. These islet cells are surrounded by blood vessels and release their hormones directly into the blood stream. One of the very important hormones released by the pancreas is insulin.

Insulin is a protein, like many other hormones. When your body detects a rise in blood sugar after you have eaten, it is time for insulin to do its stuff. Insulin binds with receptors on each cell it comes in contact with, and this activates the cell to absorb glucose from the blood stream into the cell. If insulin isn't present or isn't doing it's job effectively, you have a condition called hyperglycemia, or too much glucose in your blood.

Classic symptoms of hyperglycemia are the three polys (poly comes from the Greek word for many)

• Polyphagia (frequent hunger)
• Polyuria (frequent urination)
• Polydipsia (frequent thirst)

People with hyperglycemia feel hungry because their cells are unable to absorb the sugar in the blood, and the body reacts as if it needs more food. All the excess sugar in the blood eventually winds up in the urine, and this acts as a diuretic, as the body tries to bring more water in to dilute the urine. This is why polyuria occurs. Because the hyperglycemic person is producing so much urine, they naturally feel thirsty as their body tries to replace the water.

Diabetes is the disease where your body does not produce or use insulin effectively, resulting in high levels of blood glucose, or hyperglycemia. The word diabetes comes from ancient Greek meaning to pass through. This refers to the excessive amounts of urine produced by someone with hyperglycemia. Later the word mellitus was added, from the Latin word meaning honey . This is because the urine contains so much sugar.

There are many other symptoms diabetics might experience. You may have several of them or none at all. They include blurred vision, weight loss, impotence, recurring infections or rashes, dry mouth, dry and itchy skin, and slow healing of wounds.

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Two different types of diabetes.

There are two main types of diabetes. Type 1 Diabetes is a condition where a person generally doesn't produce insulin at all, or not enough to meet the bodies needs. This can be caused by a genetic condition, or by a virus or cancer which damages the pancreas and keeps it from producing insulin. Type 1 diabetics are usually diagnosed at a younger age, typically by their teenage years. Only about 10% of diabetics are Type 1.

Type 2 Diabetes is a condition called insulin resistance. The pancreas is still producing insulin, but for various reasons the receptors are being sluggish and the insulin isn't doing its job of activating the cells properly. Type 2 diabetes usually appears in adults, around middle age, and is sometimes called "adult onset diabetes". It is seen more often in overweight individuals and can sometimes be brought under control simply by losing weight.

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Diabetes is diagnosed through blood tests.

Diabetes is diagnosed by measuring how quickly your body can clear glucose from the blood. A standard part of most routine blood work is the fasting blood glucose level, or checking your blood glucose after an overnight fast. Your body should have been able to clear most of the glucose from the blood during this time, bringing levels down below 110 mg/dl.

If your glucose level is high after the fasting test, you will probably be given an oral glucose tolerance test. You start out fasting for at least 10 hours before this test, and your blood is drawn and the "fasting" sugar level checked. Then you drink a very sugary drink with a measured amount of glucose. Your blood is then drawn again 4 times - 30 minutes, 1 hour, 2 hours and 3 hours after you drink the glucose. If your insulin is working normally, your blood glucose should rise and then fall again as it is cleared out of the blood. In a diabetic the glucose levels rise higher than normal, and then fall much more slowly. You may have to repeat one or both of these blood tests to confirm a diagnosis of diabetes, since a lot of things can affect the results.

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After the diagnosis: managing diabetes.

Managing Type 1 Diabetes

If you are a Type 1 Diabetic you aren't producing insulin, and must replace it somehow. The insulin can't be taken by mouth because your stomach acids would destroy it, so you will put it directly under your skin, via an insulin injection. You can use a syringe to inject insulin, or an insulin pen. Syringes are basically the same as the needle the nurse uses to give you your flu shot. They are cheaper, easy to get, simpler to use with few complicated parts, and more flexible as far as the types and amounts of insulin you can inject. If the thought of using that needle really makes you squeamish, the insulin pen is a little less scary. It looks like a large pen, and comes with a premeasured cartridge of insulin. You can get disposable pens or refill a pen and use it for several years. You still need to stick yourself with a needle, but then you just press a button to release the insulin. You can see some examples of insulin pens at Diabetes Monitor. Insulin pens are more expensive, but some people just keep them to use as a convenience if they will be away from home.

You can also get your insulin injection through an insulin pump. A catheter is placed permanently under your skin, and a pump can be attached which will deliver a measured amount of insulin under the skin. One advantage of the pump is that you can adjust the insulin to your diet, rather than adjusting the diet to your insulin. If you overeat, you can just give yourself an extra hit from the pump. Another obvious advantage is that you don't have to stick a needle in your skin several times a day. You do need to get used to having the pump attached to your body in some way, and be able to manage it at night while you sleep, if you are active in sports, and when you take a shower or swim. Also if the pump is disattached you aren't getting ANY insulin and you would need to have a backup method of injection.

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Managing Type 2 Diabetes

Type 2 diabetics are still producing insulin, they are just not producing enough, or using it efficiently. For some reason the extra fat cells of overweight people can cause or aggravate this condition. Sometimes if a person gets down to his or her ideal body weight, they can bring their blood sugar level under control without needing medication. So the key to managing Type 2 diabetes is proper diet, regular exercise and monitoring your blood sugar levels to make sure they stay in a safe range. This will prevent any other health problems from developing because of having chronic high blood sugar. See the sections below on diabetic diet and exercise for more information. If a person isn't able to get their blood sugar under control through diet or exercise, there are medications that can help with this.

There are several medicines available for Type 2 diabetics to take orally. Some help your body to produce more insulin, some help your cells to bind with the insulin more effectively, some slow down the absorption of sugar in your gut. The five different classes of oral medications are sulfonylureas, meglitinides, biguanides, thiazolidinediones, and alpha-glucosidase inhibitors. Each class of drug contains several different types which can be taken in combinations or separately, depending on your metabolism, how well you handle side effects and whether you are allergic to any of the drugs.

Two drugs have recently been approved for injection by diabetics as well. These are Pramlintide and Exenatide, both meant to be injected along with a meal. Pramlintide is the synthetic form of the hormone amylin which is produced by the pancreas cells along with insulin. It can help increase insulins effectiveness in both type 1 and type 2 diabetics. Exenatide can help increase insulin secretion when blood glucose levels are high, and is only for type 2 diabetics.

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Monitoring your diabetes, for both Type 1 and Type 2 Diabetics

Self-monitoring blood glucose

Depending on your type of diabetes, you may need to check your blood glucose levels as much as 7 or 8 times a day. Type 2 diabetics who don't take insulin may only need to check it once or twice a day. You need to prick your finger with a special lancet, which is a clicking device that causes virtually no pain. You will squeeze a drop of blood from your finger, place it on a special test strip and insert it into a meter which gives you the glucose reading. There are all types of meters, some simple and inexpensive, and some more advanced. There are "continuous glucose monitors" which give a constant glucose reading through sensors placed on the abdomen or upper arm, but you generally need to get an actual blood test before making a treatment decision (ie: taking insulin) based on these readings, because they aren't considered completely accurate.

The A1C test

The A1C test measure the amount of hemoglobin in your blood that is coated with glucose. This gives an average of how well you are managing your blood sugar levels over several months, rather than a snap shot of a particular moment. This test is usually done in a doctors office rather than at home, but you can eat and drink normally before the test. A normal reading for someone who is not a diabetic is 5%, but an uncontrolled diabetic can get a reading of a high as 25%. Things that affect your hemoglobin, such as low iron level or recent bleeding, may alter the results of this test.

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Diabetic diet

A diabetic needs to eat a diet with a consistent amount of calories, carbohydrates, proteins and fats each day. This helps you regulate your weight, and also keep a balance with the amount of insulin you are taking or producing, and amount of sugar in your bloodstream. If you are working with a dietician he or she may recommend that you follow an exchange diet. This diet assigns a certain number of protein, fat or carbohydrate exchanges to different foods. You will work out a diet where you can eat so many of each type of exchange for each meal or snack. If you are allowed 3 protein exchanges, for example, you would be able to choose those exchanges from a list of foods which are high in protein. The American Dietetic Association has a list of diabetic exchanges for the typical American diet.

If you are diabetic you should try to eat the same amount and type of food on the same schedule each day. This helps your body to regulate the insulin it needs, so you don't have any surprises. You still need to get a variety of foods in your diet. This seems like contradictory advice, but an example is if you eat potatoes for your starch one day, try rice the next, eat a variety of different types of fruits and vegetables, alternate red meat some days with fish or tuna on others, etc. Choose whole grain carbohydrates as much as possible. Whole wheat bread, brown rice, whole grain pasta - you get the picture. Less processed foods are healthier for you, and your body processes them more slowly, which makes it easier to regulate your blood sugar. Eat lots of fiber. It's been shown to help regulate blood sugar. High fiber foods are whole grains, fresh fruits, fresh vegetables, nuts and legumes. Eat less saturated fats and trans fats, just like everyone else should be doing. Heart disease is a complication of diabetes, so you need to be extra careful with your lifestyle. Eat some protein and/or fat with each meal and snack, rather than just carbohydrates. Protein and fat are digested more slowly and help you to feel more satisfied, which helps with weight control.

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Get regular exercise

Exercise is very important in diabetes management. It helps you maintain your ideal weight just by burning calories and creating lean muscle. It clears excess sugar out of the blood stream and helps to keep those levels low. Regular exercise makes your body more sensitive to insulin. This is a good thing, but you need to be aware that you might not be used to the drop in blood sugar when you first start an exersize routine.

Exercise is proven to help regulate blood sugar and keep weight under control. It's also great for mental health! Make sure your doctor thinks the method you choose is OK for you, and then make it a habit. You will look and feel amazingly better once you start a regular exercise routine.

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