From the Doctors' desk

The History of Diabetes

People have been aware of diabetes for thousands of years. Learn how discoveries over the ages have led to today's understanding of diabetes.

By Krisha McCoy, MS

Scientists and physicians have been documenting the condition now known as diabetes for thousands of years. From the origins of its discovery to the dramatic breakthroughs in its treatment, many brilliant minds have played a part in the fascinating history of diabetes.

Diabetes: Its Beginnings

The first known mention of diabetes symptoms was in 1552 B.C., when Hesy-Ra, an Egyptian physician, documented frequent urination as a symptom of a mysterious disease that also caused emaciation. Also around this time, ancient healers noted that ants seemed to be attracted to the urine of people who had this disease.

In 150 AD, the Greek physician Arateus described what we now call diabetes as "the melting down of flesh and limbs into urine." From then on, physicians began to gain a better understanding about diabetes.

Centuries later, people known as "water tasters" diagnosed diabetes by tasting the urine of people suspected to have it. If urine tasted sweet, diabetes was diagnosed. To acknowledge this feature, in 1675 the word "mellitus," meaning honey, was added to the name "diabetes," meaning siphon. It wasn't until the 1800s that scientists developed chemical tests to detect the presence of sugar in the urine.

Diabetes: Early Treatments

As physicians learned more about diabetes, they began to understand how it could be managed. The first diabetes treatment involved prescribed exercise, often horseback riding, which was thought to relieve excessive urination.

In the 1700s and 1800s, physicians began to realize that dietary changes could help manage diabetes, and they advised their patients to do things like eat only the fat and meat of animals or consume large amounts of sugar. During the Franco-Prussian War of the early 1870s, the French physician Apollinaire Bouchardat noted that his diabetic patients' symptoms improved due to war-related food rationing, and he developed individualized diets as diabetes treatments. This led to the fad diets of the early 1900s, which included the "oat-cure," "potato therapy," and the "starvation diet."

In 1916, Boston scientist Elliott Joslin established himself as one of the world's leading diabetes experts by creating the textbook The Treatment of Diabetes Mellitus, which reported that a fasting diet combined with regular exercise could significantly reduce the risk of death in diabetes patients. Today, doctors and diabetes educators still use these principles when teaching their patients about lifestyle changes for the management of diabetes.

Diabetes: How Insulin Came About

Despite these advances, before the discovery of insulin, diabetes inevitably led to premature death. The first big breakthrough that eventually led to the use of insulin to treat diabetes was in 1889, when Oskar Minkowski and Joseph von Mering, researchers at the University of Strasbourg in France, showed that the removal of a dog's pancreas could induce diabetes.

In the early 1900s, Georg Zuelzer, a German scientist, found that injecting pancreatic extract into patients could help control diabetes.

Frederick Banting, a physician in Ontario, Canada, first had the idea to use insulin to treat diabetes in 1920, and he and his colleagues began trying out his theory in animal experiments. Banting and his team finally used insulin to successfully treat a diabetic patient in 1922 and were awarded the Nobel Prize in Medicine the following year.

Diabetes: Where We Are Today

Today, insulin is still the primary therapy used to treat type 1 diabetes; other medications have since been developed to help control blood glucose levels. Diabetic patients can now test their blood sugar levels at home, and use dietary changes, regular exercise, insulin, and other medications to precisely control their blood glucose levels, thereby reducing their risk of health complications.

Understanding the Types of Diabetes

Diabetes management varies, depending on what type of diabetes you have. This guide will help you understand the many different types of diabetes.

By Krisha McCoy, MS

Medically reviewed by Pat F. Bass III, MD, MPH

If you have diabetes, your body has problems producing or effectively using insulin, which can cause your blood glucose levels to be out of control. There are several different causes of insulin problems, and your treatment plan will depend on which type of diabetes you have.

Type 1 Diabetes: An Autoimmune Disease

With type 1 diabetes, which used to be called juvenile diabetes, your body does not produce insulin or produces very little. Type 1 diabetes is known as an autoimmune disease because it occurs when your immune system mistakenly attacks the insulin-producing cells in your pancreas.

Type 1 diabetes usually develops in children and young adults and accounts for 5 to 10 percent of diabetes cases in the United States. Symptoms may include thirst, frequent urination, increased hunger, unexplained weight loss, blurry vision, and fatigue.

People who have type 1 diabetes need to take insulin injections daily to make up for what their pancreas can’t produce.

Type 2 Diabetes: The Lifestyle Connection

Type 2 diabetes, which used to be called adult-onset diabetes, is the most common form of diabetes, accounting for 90 to 95 percent of diabetes cases. While most people who develop type 2 diabetes are older, the prevalence of type 2 diabetes in children is on the rise.

The exact cause of type 2 diabetes is largely unknown, but the disease tends to develop in people who are obese and physically inactive. People who have a family history of diabetes or a personal history of gestational diabetes are also at increased risk of developing type 2 diabetes.

Symptoms of type 2 diabetes usually develop gradually, and are similar to symptoms of type 1 diabetes

Treatment for type 2 diabetes usually includes dietary changes, regular physical activity, and oral diabetes medications to help control blood glucose. If left untreated, serious health conditions such as heart disease or stroke can develop.

Gestational Diabetes: A Pregnancy Concern

Gestational diabetes is a condition that occurs in 3 to 8 percent of pregnant women during late pregnancy. Its cause is thought to be pregnancy-related hormonal fluctuations and a shortage of insulin that often occurs during pregnancy.

Many women with gestational diabetes have no symptoms, so it is important to get screened for this condition during pregnancy. Gestational diabetes can lead to problems such as high-birth-weight babies, breathing problems in the baby, and high blood pressure in the mother during pregnancy. Gestational diabetes is usually treated with dietary changes and exercise, and sometimes insulin injections

Women who have had gestational diabetes have a 40 to 60 percent chance of developing type 2 diabetes within 5 to 10 years after their pregnancy.

Other Types of Diabetes

Latent autoimmune diabetes in adults, or LADA, is a less common form of diabetes that usually affects people over the age of 30. In LADA, what looks like type 2 diabetes at first eventually develops into a condition more closely resembling type 1 diabetes.

People with LADA make enough insulin at first, but their immune system later begins making antibodies against insulin-producing cells of the pancreas. Patients will usually require insulin injections as part of their treatment. It is estimated that up to 10 percent of people with type 2 diabetes have LADA.

"Double diabetes" occurs when someone with type 1 diabetes develops resistance to the insulin they are taking, a hallmark of type 2 diabetes. This condition is more and more frequently seen in children, especially those who are overweight or obese.

All types of diabetes require attention to keep blood glucose in check, but the medical plan differs by diabetes type. Getting the right diagnosis is the first step.

Depressed Diabetes Patients Have High Risk for MI

Patients with depression or diabetes have an increased risk of MI, but the risk is even higher in patients with both conditions, according to a new study.....

The authors suggest that, "Collaborative care models that incorporate cardiology, mental health, and primary care may improve outcomes in this complex patient population." Evidence indicates that depression worsens cardiovascular outcomes in type 2 diabetes.

To analyze specific endpoints such as MI, Dr. Jeffrey F. Scherrer at the St. Louis Veterans Affairs Medical Center in Missouri, and colleagues examined Veterans Administration data on over half a million patients who were free of cardiovascular disease in 1999 and 2000.

The cohort consisted of 77,568 patients with major depressive disorder (MDD), 40,953 with type 2 diabetes, 12,679 with comorbid MDD and type 2 diabetes, and 214,749 people with neither condition.

During seven years of follow-up, MI rates were 3.5% in the MDD group, 5.9% in the diabetes group, 7.4% in patients with both, and 2.6% in the control group.

Compared to controls, multivariate-adjusted hazard ratios for MI were 1.29 for those with depression only, 1.33 for those with diabetes only, and 1.82 among patients with both conditions, the investigators reported online June 16th in Diabetes Care.

Receipt of at least 12 weeks of an antidepressant, however, was significantly associated with a lower risk of an incident MI.

"The current study confirms that MDD is associated with a greater hazard of incident MI in patients with type 2 diabetes," Dr. Scherrer and colleagues conclude.

They suggest several possible mechanisms for their findings. For instance, MDD may impair diabetes self-care and increase inactivity and other behavioral risk factors. It might also induce physiologic changes; depressed patients have been shown to have abnormal glucose levels and glucose tolerance, as well as increased coagulation and fibrinolysis.

And conversely, insulin resistance in type 2 diabetics can interfere with MDD treatments, making it hard to bring patients out of their depression.

"It is possible that patients who have had depression and/or diabetes for longer periods of time, especially longer than our observation period, may be at an even greater increased risk of incident MI," the authors say.

Diabetes Care June 16, 2011

Managing Diabetes With Exercise: 6 Tips for Nerve Pain

By Rebecca Buffum Taylor

WebMD Feature

Reviewed by Brunilda Nazario, MD

What kind of exercise is safe - and fun - if you have nerve pain from diabetes, called diabetic neuropathy? And how can you stay motivated after that first flush of inspiration fades?

"It depends on where you're starting," says Dace L. Trence, MD, an endocrinologist and director of the Diabetes Care Center at the University of Washington Medical Center in Seattle. "For the person who has been doing nothing, you would certainly want to start doing something that's comfortable and enjoyable and can be maintained."

If you have diabetic nerve pain in your feet, legs, arms, or hands, consider this: research published in The Journal of Diabetes Complications in 2006 showed significant benefits of exercise in controlling peripheral neuropathy. The study showed that for people who took a brisk, one-hour walk on a treadmill four times a week, exercise slowed how quickly their nerve damage worsened. There's no quick fix here, though; the study lasted four years.

Let's face it: when it comes to managing a lifelong condition like diabetes, it makes sense to think long-term. It's all about lifestyle changes to protect yourself from diabetic nerve damage. Becoming more active can help you control blood sugar levels, feel good, and lighten the load on painful feet and legs, especially if you're overweight. These tips can help you start and stick with an exercise plan for more than the first few days.

Before You Start: Safety First

If you have nerve pain, get the go-ahead to start any new form of exercise from your doctor. You don't want to make diabetic neuropathy worse - and most diabetic people are at higher risk of heart and circulation problems, so your doctor may want to check your heart, eyes, and feet.

Be cautious about exercising if your blood sugar is over 250, says Trence. "For some people it may be a little higher or lower," she says, "but it's an approximate number above which, clearly, we want people to watch and see what happens. See what your own body does."

Check your blood glucose before and after exercise so you learn how your body and medications responds to different kinds of activity, advises the American Diabetes Association (ADA).

Tip 1. Go for Low-Impact Exercise

Knowing you're doing something safe -- especially if you have painful neuropathy or loss of sensation removes one barrier to exercise: fear. Change to something that would be low-impact or even non-weight-bearing, says Trence, such as aerobic classes where you're sitting in a chair or using an exercise ball. Other options:

Swimming. Water supports your muscles, bones, and joints as you swim, especially helpful if you're overweight or have diabetic nerve pain in your feet. A longtime favorite of exercise experts over the years, swimming avoids the pounding on your feet, knees, and hips from a high-impact sport like jogging.

Yoga."I think yoga is underutilized in people with diabetes," says Trence. "It's a wonderful exercise, particularly for people who need to be more controlled in their movements and not be pounding the pavement."

Cycling.Biking is safely low-impact - as long as you stay safely aboard - and you can ride outside for a change of scenery, or ride with a friend on stationary bikes in a health club.

Tip 2. Shoot for 30 Minutes, 5 Days a Week.

The American Diabetes Association (ADA) advises being active for 30 minutes a day, five days a week. The good news? Vigorous yard work like raking leaves and housework like vacuuming count as "activity."

Start with a short warm up period to help prepare your muscles, heart and lungs. Gentle stretches for five to 20 minutes help reduce injury.

Build slowly over time, so you keep feeling successful and having fun.

Don't worry if, some days, you can't do a full 30 minutes all at once. You can meet your daily goal of 30 minutes with 10 minutes of yard work in the morning, 10 minutes of vacuuming after lunch, and a brisk 10-minute walk after dinner.

Start with simple things, says Trence, like parking farther from the door or using the stairs when you can.

Tip 3. You Don't Have to Sweat.

All exercise isn't alike. Aerobic exercise raises your heart rate, helps you lose weight, and does make you sweat. But all your exercise doesn't have to be so hard that you need to sweat to reap the benefits. Try strength training, like lifting weights, and working on your flexibility by stretching or taking a yoga class.

Mix it up. Try a combo of activities that build your aerobic fitness, strength, and flexibility. You'll get more benefits - and be less prone to injury and boredom.

Mix it up. Try a combo of activities that build your aerobic fitness, strength, and flexibility. You'll get more benefits - and be less prone to injury and boredom.

Modification is the key. If you can't do a regular push-up, for instance, you can do a few push-ups against a wall, so it's a lot less work for your arms and shoulders. Go for a sense of success: if you feel successful, you're more likely to stay with it.

You don't have to spend money for club dues. With so many exercise videos and DVDs out now, says Trence, people can exercise at home and try new things.

Tip 4. Make It Fun.

Choose activities you enjoy - or at least enjoy some aspects of. Otherwise, it's a cinch you'll back out when your commitment flags. So don't join the dance workout at the Y just because your wife loves it - though if you're a music lover, a dance class could be just your style. Bowling might be right up your alley. But if you've never had any hand-eye coordination or "ball sense," then taking up tennis or volleyball may not be your thing.

Think back to high school or college: what did you love to do back then? Were you a great softball player, golfer - or love to shoot hoops? Look for a club, gym, or community center where you can join a pick-up league.

Find people at your fitness level, so you won't feel overly frustrated.

Fun is unique to each person. For you, something may be fun because it's new. For others, pleasure is something familiar and comfortable. Know thyself, and trust thyself.

Tip 5. Make It Social.

Behavioral medicine experts all agree: social support helps keep you going when the going gets tough. And what's tougher than trying to make lifestyle changes?

Make regular weekly dates with a friend, neighbor, or family member to walk or exercise with you. You may be more likely to stay committed since you won't want to let the other person down.

Consider joining a local walking or hiking club, so you get outside, get some fresh air, and meet new people. You may find it's easier to exercise when you let others do the planning.

Check out groups like a softball team, volleyball team, or cycling club. Your local Y might have a swim team for adults. Or a local school may need a volunteer coach.

Tip 6. Try Something New

In the wake of the fitness boom, you have more choices than ever for new forms of exercise. Avoid boredom or feeling like exercise is a chore by trying something new.

Try a water aerobics class or other swim class at your local pool.

Take a class in a new sport or activity, like golf, badminton, kayaking, or ballroom dancing.

Try yoga, tai chi, and other exercise that enhances your mind/body connection, encourages relaxation, and brings on a sense of well-being.

The bottom line? The more fun you have with it, the more likely you'll create a healthy, active lifestyle that invigorates you and helps you manage diabetes for a lifetime.

Obesity: Genetics is no excuse

22/10/2009 | Channel: New management strategies, Obesity, Diet & Exercise

Matthew Capehorn presents his view that genetics are only partly responsible the obesity epidemic.

Obesity is a chronic, relapsing condition. As with smoking, drinking too much alcohol and using illicit drugs, if you have that predisposition to addictive or harmful behaviour – such as eating too much – you may well have it forever. In this respect, it is easy to see why some people tend to put weight back on even after a successful weight loss intervention. In fact, one could argue that eating too much is the worst addiction to have because we cannot totally abstain from food, and so we are continually teasing ourselves with something that we often abuse in excess. However, what is the true cause of obesity? Is it a genetic predisposition that leads us to eat too much, or is it the obesogenic environment in which we live? The Foresight Report (Government Office for Science, 2007) suggested that there are many factors that are responsible for obesity which may, in part, explain why the obesity epidemic has been so difficult to manage or conquer.

We now have evidence to suggest there is a “greedy gene”. However, does this mean that there is no hope for overweight or obese people, and because it is “in my genes” it is pointless wasting valuable NHS resources on weight management programmes? We have known for some time that obesity is linked with an increased prevalence of many common and serious conditions, such as heart disease and diabetes, and that relatively small amounts of weight loss, such as 10 kg, correlate to a significant reduction in morbidity and mortality (Jung, 1997). In one study of 2436 people in Copenhagen it was found that body weight was increasing by approximately 1 kg each year, and that even weight maintenance in this obesogenic environment would convey health benefits compared with allowing people to let their BMI and waist circumference increase (Heitmann and Garby, 1999).

In a study involving 2726 Scottish children, the fat mass and obesity-related gene variant was linked with increased energy intake and may be present in over half of participants (Cecil et al, 2008). It appears to have a role in the control of food intake and food choice rather than the regulation of energy expenditure. The suggestion is that having the gene may lead children to eat around 100 extra calories at every meal, and possibly more in adults. It may even encourage those with the gene to target more fatty or sugary, calorie-dense foods in preference to healthy options. In reality, it might be responsible for 10 kg of weight in a morbidly obese person of 170 kg, but it does not explain the other 160 kg. This is more likely to be due to poor dietary choices, inadequate education, or physical inactivity through choice or the social environment in which we live.

Is it really useful to an individual to know that there is an obesity-related gene? Does it not give them a further excuse for over-indulgence? We have had a generation of people believing that it is “my glands”, or they are “big boned”, or it is “all muscle”. Now we see people who insist that they eat just one lettuce leaf a week, and in the absence of any proven metabolic problems, say their weight must be due to their genes. When put on a calorie-deficit diet, in combination with an exercise programme, or with appropriate pharmacotherapy, they still lose weight.

Our species has not significantly changed genetically for millions of years, and yet the obesity epidemic has started to spiral out of control over the past generation (Zaninotto et al, 2006). This cannot be explained by an obesity gene alone. It would seem too coincidental that studies have shown a direct correlation between the rise in obesity prevalence with the increasing use of the motor car and other labour saving devices (Prentice and Jebb, 1995).

It would be foolish to dispute a genetic effect, but most obesity is likely to be associated with rather weak genetic tendencies that are modifiable by diet and exercise. Regular exercise and a healthy, calorie-controlled diet remain the best way to control and lose weight, despite any possible genetic causes. In the long term, society needs to address its obesogenic tendencies and perhaps we need to identify, and ultimately learn how to manipulate, the control system for body weight so that any solutions work in harmony with, as opposed to against, our genes.

Diabetic Foot Ulcers Tied to Earlier Death

Among people with diabetes, those who develop foot ulcers seem to die earlier than those without the complication, a new study finds.

Lead researcher Marjolein M. Iversen, of Bergen University College in Norway, stated, "Our study revealed that a history of foot ulcer is a significant marker of higher risk of death not only for people in hospital settings but also in community health care."

In the study, researchers found that among more than 65,000 Norwegian adults, those with a history of diabetic foot ulcers had a higher death rate over 10 years.

Over time, diabetes can damage the blood vessels and nerves, especially if a person's blood sugar is poorly controlled. Poor circulation and nerve damage in the feet makes people vulnerable to sustaining cuts or other injuries that go unnoticed and progress into poorly healing ulcers, or sores. Severe cases can ultimately lead to amputation.

Compared with other diabetic adults, those with a history of foot ulcers were 47 percent more likely to die during the study period. The risk was more than two-fold higher when foot ulcer patients were compared with non-diabetic adults.

People with a history of foot ulcers did tend to be older, have poorer blood sugar control and have higher rates of heart disease and stroke, depression and kidney dysfunction. But those factors only partly explained the higher death risk attributed to foot ulcers, the researchers report.

The findings are based on 65,126 adults taking part in a long-term health study; 1,339 had diabetes and no history of foot ulcers, while 155 had a history of the complication.

Over 10 years, half of those who'd suffered foot ulcers died, compared with 35 percent of diabetics without the complication and 10.5 percent of non-diabetic adults.

In general, experts recommend that people with diabetes take a number of measures to prevent foot ulcers -- with good blood sugar control being key to cutting the risk, as well as the risk of other diabetes complications.

Other recommendations include getting a complete foot exam at least once per year; regularly doing a self-check to spot any cuts, blisters or other abnormalities in the skin or toenails; and wearing socks and shoes at all times to cut the risk of foot injuries.

Diabetes Care, December 2009.

Only 7% of the 60 Million with Prediabetes Are Aware...........

Measuring glycated hemoglobin levels may be an appropriate means of catching patients with prediabetes....

Ronald Ackerman, MD, MPH, of Indiana University, and colleagues reported inPreventive Medicine that, HbA1c testing yielded similar probabilities for developing diabetes and heart disease as those estimated by using the 2003 American Diabetes Association definition for prediabetes. "The A1c test may provide a badly needed, clinically practical indicator of the composite risk for incident diabetes and cardiovascular disease," they wrote.

Fasting plasma glucose and two-hour plasma glucose, two commonly used tests for assessing diabetes and prediabetes, are limited because they require a patient to return on a separate day after an overnight fast and remain in the office for 2-3 hours which is a potential barrier to test completion, the researchers said.

Measuring HbA1c is easier -- it requires only one blood draw. In June 2009, the International Expert Committee, which represents several major diabetes groups, recommended using HbA1c to diagnose diabetes.

The recommendations of the committee have stirred up some controversy, still, the researchers said, only about 7% of patients with prediabetes -- who are thus at risk for later diabetes and heart disease -- are aware of their status.

To estimate the risks of developing diabetes and cardiovascular disease for adults with different HbA1c levels, Ackerman and colleagues assessed data from the National Health and Nutrition Examination Survey (NHANES) 2003-2006.

Among adults who met the 2003 ADA definition for prediabetes, the probabilities for developing Type 2 disease over 7.5 years and cardiovascular disease over 10 years were 33.5% and 10.7%, respectively.

The researchers found that using HbA1c alone -- with a range of 5.5% to 6.5% defining prediabetes -- would identify a population with comparable risks for diabetes and heart disease (32.4% and 11.4%, respectively).

But using a slightly higher cutoff -- beginning at 5.7% -- would identify increased risks of 41.3% for diabetes and 13.3% for heart disease.

These risks are comparable to those seen in patients enrolled in the Diabetes Prevention Program, which had an enrollment criteria of both elevated fasting plasma glucose and impaired glucose tolerance, the researchers said.

Thus, they concluded, using a bottom cutoff of 5.7% for diagnosing prediabetes may be more appropriate.

Either way, they said, HbA1c measurement "should be considered a means of identifying greater numbers of patients at risk for diabetes and heart disease" -- especially because "of its practical nature and wide availability."

The study was limited by its use of cross-sectional data, and it may be lacking in generalizability. For instance, a greater number of African Americans would be identified as having prediabetes than if using fasting plasma glucose or two-hour plasma glucose testing, the researchers noted.

Practice Pearls

  • Explain that measuring glycated hemoglobin (HbA1c) levels may be an appropriate means of detecting patients with prediabetes.
  • Note that an HbA1c in a range of 5.5% to 6.5% defines prediabetes and identifies a population with risks for diabetes and heart disease comparable to that defined using results of fasting and two-hour glucose testing.

Ackerman RT, et al "Identifying adults at high risk for diabetes and cardiovascular disease using hemoglobin A1c" Am J Prev Med 2011; 40(1): 11–17.

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