Also known as 'blood sugar', diabetes is a common disease in Egypt, and I think each family has at least one relative afflicted with it. It is not always hereditary – it can sometimes be brought on after trauma or stress. Diabetes used to be a ‘family secret' and young men or girls who were seeking their ‘better halves' for marriage usually hid this fact in shame. The good news is that diabetes can be reversed, or at least well controlled, and people with diabetes can live long and normal lives. The two major forms of diabetes are type 1 (previously called insulin-dependent diabetes mellitus, IDDM, or juvenile-onset diabetes) and type 2 (previously called noninsulin-dependent diabetes mellitus.) The GENERAL signs and symptoms of diabetes are: • Increased thirst • Urinating all the time - especially at night • Extreme tiredness • Weight loss • Blurred vision • Genital itching or regular episodes of thrush • Slow healing of wounds. In TYPE 1 DIABETES, the signs and symptoms will usually be very obvious, developing quickly, usually over a few weeks. People who are Type 1 diabetic must use manufactured insulin, usually in by injections, to replace the natural insulin that is no longer produced by their body. In people with TYPE 2 DIABETES, the signs and symptoms will not be so obvious or even non-existent in people with Type 2 diabetes. If you're older you may put the symptoms down to ‘getting on a bit'. Taking early action is key so if any of the symptoms apply to you, ask your GP for a diabetes test. In both types of diabetes, the symptoms are quickly relieved once the diabetes is treated. Early treatment will also reduce the chances of developing serious health problems. The disease process is more severe and onset is usually in childhood: Beta cells in the pancreas that produce insulin are gradually destroyed. Eventually insulin deficiency is absolute. Without insulin to move glucose into cells, blood glucose levels become excessively high, a condition known as hyperglycemia. Because the body cannot utilize the sugar, it spills over into the urine and is lost. Weakness, weight loss, and excessive hunger and thirst are among the consequences of this "starvation in the midst of plenty." Patients become dependent on administered insulin for survival. Many of the signs of Type 1 and Type 2 diabetes are similar. In both, there is too much glucose (Definition: Glucose is known as a monosaccharide or "simple" sugar. It occurs mainly in plant and animal tissue. It is usually found in the blood and is the principal source of energy for most living things. Glucose in the blood is a product of digestion and is taken into the cells for energy production which in turn fuels most of our bodily functions) in the blood and not enough in the cells of your body. High glucose levels in Type I are due to a lack of insulin because the insulin. Type 2 diabetes is the most common form of diabetes: Type 2 diabetes occurs when the body's cells become resistant to insulin that is being produced; producing cells have been destroyed. Either way, your cells aren't getting the glucose that they need, and your body lets you know by giving you these signs and symptoms. People with Type 2 sometimes need to use insulin when their cells become too resistant to the insulin that they produce naturally and oral medications are no longer working. (Alternative name: Maturity Onset Diabetes; Noninsulin-dependent Diabetes Mellitus). The disease mechanisms in type 2 diabetes are not wholly known, but some experts suggest that it may involve the following three stages in most patients: The first stage in type 2 diabetes is the condition called insulin resistance. Although insulin can attach normally to receptors on liver and muscle cells, certain mechanisms prevent insulin from moving glucose (blood sugar) into these cells where it can be used. Most type 2 diabetics produce variable, even normal or high, amounts of insulin. In the beginning, this amount is usually sufficient to overcome such resistance. Over time, the pancreas becomes unable to produce enough insulin to overcome resistance. In type 2 diabetes, the initial effect of this stage is usually an abnormal rise in blood sugar right after a meal (called postprandial hyperglycemia). This effect is now believed to be particularly damaging to the body. Eventually, the cycle of elevated glucose further impairs and possibly destroys beta cells, thereby stopping insulin production completely and causing full-blown diabetes. This is made evident by fasting hyperglycemia, in which elevated glucose levels are present most of the time. INSULIN: Insulin is a hormone produced by the beta cells of the pancreas that permits glucose to enter cells and helps the body use glucose for energy. Insulin controls the amount of glucose in the blood. The two major forms of diabetes are type 1 (previously called insulin-dependent diabetes mellitus, IDDM, or juvenile-onset diabetes) and type 2 (previously called noninsulin-dependent diabetes mellitus, NIDDM, or maturity-onset diabetes). Both diabetes type 1 and type 2 share one central feature: elevated blood sugar (glucose) levels due to insufficiencies of insulin, a hormone produced by the pancreas. Insulin is a key regulator of the body's metabolism. It normally works in the following way: - The pancreas is located behind the liver and is where the hormone insulin is produced. - Insulin is used by the body to store and utilize glucose. - During and immediately after a meal the process of digestion breaks down carbohydrates into sugar molecules (including glucose) and proteins into amino acids. Right after the meal, glucose and amino acids are absorbed directly into the bloodstream, and blood glucose levels rise sharply. - The rise in blood glucose levels signals important cells in the pancreas, called beta cells, to secrete insulin, which pours into the bloodstream. Within ten minutes after a meal, insulin rises to its peak level. Insulin then enables glucose and amino acids to enter cells in the body, particularly muscle and liver cells. Here, insulin and other hormones direct whether these nutrients will be burned for energy or stored for future use. (Note that the brain and nervous system are not dependent on insulin; they regulate their glucose needs through other mechanisms). When insulin levels are high, the liver stops producing glucose and stores it in other forms until the body needs it again. As blood glucose levels reach their peak, the pancreas reduces the production of insulin. About two to four hours after a meal, both blood glucose and insulin are at low levels, with insulin being slightly higher. The blood glucose levels are then referred to as fasting blood glucose concentrations. INSULIN ABNORMALITIES: Insulin resistance: Normal or even excessive levels of insulin (to compensate for this resistance), eventually followed by a drop in insulin production. In addition, researchers are trying to determine the factors that might promote insulin resistance: both obesity and insulin resistance at different phases are marked by elevated levels of free fatty acids and the hormones resistin and leptin. It is not known yet if elevated levels are simply a product of obesity or play some causal role in diabetes. Insulin resistance is associated with a chronic low inflammatory response, which involves a number of immune factors, such as TGH-beta 1 and C-reactive protein. Such factors can cause damage over time and may be responsible for the association between insulin resistance and heart disease. WHEN AND WHAT TO EAT: For diabetes, when you eat is as important as what you eat. Eating meals that are approximately the same size and combination of carbohydrates and fats at the same time every day helps to keep blood sugar regular and predictable. The best diet is one that is low in fat, low in salt and low in added sugars. Complex carbohydrates such as whole grains, fruits and vegetables are preferable over simple carbohydrates like sugary soft drinks and candy. THE DANGERS OF FASTING: For people with diabetes taking certain tablets and/or insulin to manage their condition, the greatest danger is that of hypoglycaemia (low blood glucose levels; ‘hypo'). It is also possible that people could develop high blood glucose levels during a fast if they omit their medication, or if they are less physically active than normal. If you are intending to fast you should attend your diabetes clinic for an assessment of your current level of diabetes control. Your healthcare team or doctors should discuss with you any difficulties experienced in previous fasts and how you coped with them. They can advise on any adjustment of medication that may be required to enable you to fast safely. To reduce the possibility of becoming hypoglycaemic you should rest as much as possible during the fast. If you are fasting and feel hypoglycaemic you must take some sugary fluids and follow it with starchy food. This breaking of the fast is permitted since Islam states a person should not put their health at risk and becoming hypoglycaemic could do just that. There is also the danger of the blood glucose level becoming too high when normal levels of medication are not taken. This can lead to diabetic ketoacidosis (DKA), a condition requiring hospital admission. The symptoms of DKA include feeling very thirsty and passing a lot of urine. If someone is fasting and does not take in fluids to reduce their thirst, this will accelerate dehydration and they will require urgent admission to hospital. ALCOHOL & DIABETES: Although I should not mention this, due to the nature of our mainly-Moslem citizens in Egypt, it is a (hidden) fact that some Moslems drink; whether lightly or profusely is not our concern for this article. For Christians, there is no need to give up alcohol, but be aware that alcohol makes hypoglycaemia more likely to occur. However, as long as your diabetes is well controlled, moderate amounts of alcohol can be drunk before, during or soon after a meal without affecting short-term blood glucose control. Never drink on an empty stomach as the alcohol will be absorbed too quickly into your blood stream. If you are drinking throughout the evening, snack on something starchy like crisps or chips, and do not substitute alcoholic drinks for your usual meal or snacks as this may lead to hypoglycaemia. HYPOGLYCAEMIA: Serious hypoglycaemia can occur with larger quantities of alcohol, particularly if you are treated with insulin and especially if too little carbohydrate is eaten. If this could apply to you, always make sure you take some carbohydrate before going to bed after drinking. Useful snacks include toast, cereal and sandwiches, although chips or pizza on the way home may be an easier, albeit unhealthier, option. It is vital you keep your blood glucose levels topped up with carbohydrate and always remember to take something at breakfast. Monitor your blood glucose levels closely. Remember you may be less aware of your hypo symptoms when you are drinking so always wear some form of diabetes identification. A hypo can be confused with drunkenness when there is the smell of alcohol on your breath. Continuous heavy drinking can lead to raised blood pressure so again try to limit your intake. All types of alcoholic drinks contain calories so if you are watching your weight think about cutting back further. If you have neuropathy (nerve damage), drinking alcohol can make it worse and increase the pain, tingling, numbness and other symptoms associated with nerve damage. Drinking low carbohydrate beers and cider offer no benefit because of their higher alcohol content. Low alcohol drinks can be useful if you are driving, but few are alcohol free, so remember if you drink enough of them you may still be over the limit. Low alcohol wines are often higher in sugar than ordinary ones, so if you do choose these, just stick to a glass or two. Drinks with a high sugar content, e.g. sweet sherries, sweet wines and most liqueurs should be limited. Mixer drinks should be ‘diet' or ‘sugar free' such as diet tonic water and diet cola. Moderate alcohol consumption in line with recommended daily guidelines can be beneficial for your heart. Wine, especially red wine, may offer greater benefit than spirits or beer. However there is currently insufficient evidence to suggest that you take up drinking if you are currently ‘tee total'. And, never drink and drive. GENETIC FACTORS: Genetic factors play an important role in type 2 diabetes, but the pattern is complicated, since both impairment of beta cell function and an abnormal response to insulin are involved. Researchers have identified a number of genetic factors that may be responsible for selected or more general cases of diabetes: Researchers have identified genes responsible for maturity-onset diabetes in youth (MODY), a rare genetic form of type 2 diabetes that develops only in Caucasian teenagers. (This is not the diabetes associated with obesity that is now being seen increasingly in young people.) A defective fatty-acid binding protein 2 (FABP2) gene may result in higher levels of unhealthy fat molecules (particularly triglycerides), which may be critical in the link between obesity and insulin resistance in some people with type 2 diabetes. Alterations in five genes that beta cell and pancreas function have been identified that may plan an important role in inherited cases of type 2 diabetes. Variations in a gene that regulates a protein called calpain-10 is proving to affect insulin secretion and action and may play a role in type 2 diabetes in certain populations. There is some disagreement, however, about its significance. Calpains are enzymes that play a wide role in many essential cellular functions. Evidence is now strongly suggesting that genetic activation of these enzymes may be important in many aging-related diseases. Defective genes that regulate a molecule called peroxisome proliferator-activated receptor (PPAR) gamma may contribute to both type 2 diabetes and high blood pressure in some patients. A defective gene has been detected that reduces activity of a protective substance called beta3-adrenergic receptor, which is found in visceral fat cells (those occurring around the abdominal region). The result is a slow-down in metabolism and an increase in obesity. One theory suggests that some cases of type 2 diabetes and obesity are derived from normal genetic actions that were once important for survival. Some experts postulate the existence of a so-called "thrifty" gene, which regulates hormonal fluctuations to accommodate seasonal changes. In certain nomadic populations, hormones are released during seasons when food supplies have traditionally been low, which results in resistance to insulin and efficient fat storage. The process is reversed in seasons when food is readily available. Because modern industrialization has made high-carbohydrate and fatty foods available all year long, the gene no longer serves a useful function and is now harmful because fat, originally stored for famine situations, is not used up. WHEN DIABETES IS SECONDARY TO OTHER ISSUES: Conditions that damage or destroy the pancreas, such as pancreatitis, pancreatic surgery, or certain industrial chemicals can cause diabetes. Polycystic ovaries are highly associated with diabetes. Certain drugs can also cause temporary diabetes, including corticosteroids, beta-blockers, and phenytoin. Rare genetic disorders (Klinefelter's syndrome, Huntington's chorea, Wolfram's syndrome, leprechaunism, Rabson-Mendenhall syndrome, lipoatrophic diabetes, and others) and hormonal disorders (acromegaly, Cushing's syndrome, pheochromocytoma, hyperthyroidism, somatostatinoma, aldosteronoma) are associated with or increase the risk for diabetes. Type 2 diabetes is caused by a complicated interplay of genes, environment, insulin abnormalities, increased glucose production in the liver, increased fat breakdown, and possibly defective hormonal secretions in the intestine. The recent dramatic increase indicates that lifestyle factors (obesity; sedentary lifestyle) may be particularly important in triggering the genetic elements that cause this type of diabetes. LIVING A NORMAL LIFE: Until the 1920's, when insulin was first discovered, people usually died from Type 1 diabetes. Today with all the advances of medicine that are available, a person diagnosed with Type 1 diabetes can live a very normal, long life. However, there are many adjustments that need to be made and skills that need to be learned, but these can be incorporated into a daily routine, and can become just as automatic as brushing your teeth! Working with your doctors and a nutritionist, will give you the tools you need. It is nothing to be ashamed of. On the contrary, you should let your friends know about it, in order to prepare the right food for you if you are invited over for a meal! By Hoda Nassef
