Understanding Diabetes: A Treatise For The General Public.

Understanding Diabetes: A Treatise For The General Public.

What your doctor does not have the time to tell you
Raghuvir Keni, Pharm.D
Department of Pharmacy Practice
Manipal University
raghuvirkeni@hotmail.com

Diabetes like most diseases is a condition that has first been described in Egyptian
medical texts along with breast cancer and other diseases. When one says diabetes the term
generally refers to a condition of high blood sugar to the general public, but an expert like me
it could be one of two kinds of diabetes.

One, diabetes insipidus, a condition where there is passing of excessively large

amounts of dilute urine being passed, literally translating to urine without much taste (due to
the dilution). Or it can refer to diabetes mellitus which literally translates to urine that tastes
like honey; this type of diabetes is also the one that we are to understand here in the treatise.

Diabetes mellitus can also be further divided into two types based on the cause, as
type 1 diabetes or type 2 diabetes. This form of classification has first been done by ancient
Indian physicians Sushruta and Charaka who probably first identified them as separate
conditions.

Basically to simply put it in diabetes mellitus irrespective of type, the glucose (sugar)
levels in the blood are abnormally high. Though this is not where the story ends or begins and
nor should it be for you to understand your condition.

Superfast overview:

To better understand the two types of diabetes for the lay person he must first be
explained how sugar (glucose) is regulated in the body. All food that is eaten is converted
into 3 primary macronutrients carbohydrates, proteins and fats. Unlike popular belief all 3
play a role in all metabolic activities of building, processing and storage. All forms of sugars
that one eats will basically be converted to glucose for the utilization of the body. The
glucose is absorbed from the intestines into the blood and transported all over the body for its
use. Our body is made up of cells and all nutrients are absorbed and utilized at a cellular
level. Now, we humans defend and demarcate our property with the help of a wall of stone
and cement and then we install a gate to regulate who comes in and leaves and for security to
prevent unregulated access we put a lock. In the same way all cells in our body too protect
themselves. They too have a wall called plasma membrane present in human cells for
cellular security. All entry and exit regulated in many ways, but the one of our interest is
the insulin receptor and the glucose transporter. The insulin receptor is the lock that opens the
gate which is the glucose transporter that allows the glucose in or keeps it out.

The lock which is the insulin receptor is opened by a key which is insulin. The insulin
is produced by the pancreas. It is an organ located below the liver which is on the upper right

Disclaimer: This is a patient education leaflet aimed to help lay person better understand and thus better
manage their disease and is not meant for any other purpose.
 Understanding Diabetes: A Treatise For The General Public.

hand side of the body protected by the last few ribs. The pancreas has 4 types of cells and the
cells called beta cells produce the very important insulin.

As said earlier, insulin is the key that opens the lock to allow the glucose to enter the
cell. It does so by binding to its receptor, which opens the gate called the glucose transporter
that allows glucose from the blood to enter into the cell. For glucose to be used by the cell it
has to enter the cell. Simply having sufficient glucose in the blood is not enough. If the
glucose does not enter the cell it basically starves. It is as simple as that, no insulin, cells will
not get glucose, and the cells will ultimately die.

Figure 1: glucose absorption by cell in normal individuals

Figure 2: Lack of glucose absorption in diabetes mellitus due to lack of insulin or low
amounts of insulin or reduced insulin receptor sensitivity.

Type 1 diabetes:

Coming back to the two types of diabetes, among them type 1 diabetes is less
common in the population. The reason for type 1 diabetes has not been identified with pin
point accuracy, but we know that it revolves around genetics and auto immunity both
probably going hand in hand with each other. The bodys immune cells, which are the white
blood cells that protect us from germs for some unknown reason, attack the pancreatic beta
cells that produce insulin. This attack permanently destroys them and there for no insulin in
produced at all. All other cells of the pancreas remain more or less functional. Type 1

Disclaimer: This is a patient education leaflet aimed to help lay person better understand and thus better
manage their disease and is not meant for any other purpose.
 Understanding Diabetes: A Treatise For The General Public.

diabetes will occur at a fairly young age. Since a person does not produce insulin at all his
blood glucose will keep accumulating. If the condition is not detected and treated the
following events happen. The body thinks that it does not have sufficient glucose (even
though it does) since the cells do not get any glucose (due to absence of insulin), it tells the
liver to release any glucose that it may have, this further makes the blood even more glucose
laden. This heavy burden of glucose in the blood creates a water imbalance in the body to
dilute this very concentrated sugary blood. The increased water in the blood is continuously
removed by the kidneys and along with it salts that are present in the body. The person then
becomes very dehydrated due to heavy urination. Since cells in the body will not get its basic
fuel they now use their back up systems to make glucose using fats. This causes a sever
accumulation of the by-products of the process and a condition called diabetic ketoacidosis
develops and it is life threatening.

Since the type 1 diabetes is characterised basically by the complete absence of insulin
there is no other way to treat it than to provide the body with artificial insulin in the form of
injections. Originally this insulin was obtained from pigs, but now days it is obtained from
genetically modified bacteria. It is a permanent condition; there is no cure as of now.
However quality of life is as good as that of a nondiabetic.

Type 2 diabetes:

Type 2 diabetes is the condition that is most common; it is a lifestyle disease and soon
to be a major health crisis in India. India is currently has one of the largest population
suffering with diabetes and we are among the top 3 in the world. Type 2 diabetes has multiple
causes and is most commonly due to obesity, but in India I feel it is due to lack of physical
activity, we Indians are also more genetically prone to diabetes. If caught early when the
patient is said to be in the prediabetes stage the patient can be given appropriate counselling,
told to exercise, lose weight, modify diet and the condition can be effectively reversed.
Otherwise just like type 1 diabetes, it is lifelong or a chronic disease. In type 2 diabetes there
are two potential mechanisms that cause it, both may work individually or could go hand in
hand.

In a person who is having type 2 diabetes will often not exercise or have a sedentary
life style or in some cases be very obese (sometimes all of them or combinations). Such
patients will, due to their lack of activity, have low fuel demands at cellular levels. They will
not need as much glucose as a normal active person, and the body will be supplied more
glucose than required because the person continues to eat like an active person, sometimes
even more. Now days also most of what people eat is junk food. You may think what you eat
is healthy but if the proportion of nutrients in the food you are eating is off, even if it is
healthy it will not make a positive difference. Now the cells do not need all that excess
glucose, so what will they do? Too much of anything is bad. So the cells will usually store it.
They will convert it into fat via various processes and store it all over the body as fat, under
your skin, in-between organs, in your blood vessels (atherosclerosis). At the cellular level this
fat could block the insulin receptors. So the numbers of gates of glucose that are being
opened by insulin are now lesser than what it would have been. So less glucose gets into your

Disclaimer: This is a patient education leaflet aimed to help lay person better understand and thus better
manage their disease and is not meant for any other purpose.
 Understanding Diabetes: A Treatise For The General Public.

cells and there is more in the blood, resulting in diabetes. It is a cycle, more glucose, more fat
which again means more fat and on and on it goes. This high level of glucose and fat then
again gives rise to diabetic complications explained later. Your body in an attempt to save
itself has sealed its own fate.

The second possibility is that since there is not much demand for the glucose and
excess glucose is present the cells would be forced by the insulin to take up glucose that they
do not need (imagine force feeding at a cellular level, that is what you basically do to
yourself). This is because under normal circumstances the pancreases produces insulin based
on the glucose levels in the blood and not based on cellular demand of glucose, so more
glucose in blood more insulin released, but the cells do not need all that glucose, it ould be
harmful to take too much of what they do not need. So to prevent that the cell reduces how
effectively its receptors respond to the insulin. It jams the locks, makes them difficult to open.
The technical term for it is low insulin sensitivity. In response the body would ideally
increase its insulin production to counteract this; it would work of course, for a while. The
person unaware of what is happening to him due to his unhealthy habits would continue his
lifestyle as it is, unless he has regular check-ups. This would eventually tire out his pancreas
slowly shutting down the beta cells that produce the insulin. You see just like how your body
in general gets tired, your organs get tired too. Sometimes a bit too much, most organs
recover, but in the case of pancreas it is different. Your pancreas cannot be considered a
whole organ; it is what I like to call a group of cellular organs. Normal organs are large
consisting of many cells of the same kind doing the same thing, but the pancreas is tiny, it has
5 different cells in limited quantity doing different things. How long do you think this small
group of cells that produce insulin can keep up to the increasing demands before they give
away? Not very long obviously. They finally give away and levels of insulin produced falls,
resulting in increased glucose levels in blood and the person now has type 2 diabetes. Once
again a cycle will begin more glucose, more fat and so on. Type 2 diabetes can occur at any
age, usually initial signs will be seen at middle age since thats when the negative effects of
lack of exercise kick in and obesity would have set in, it needs time to take a hold of your
body. Lately however it has been noticed that kids in their late teens have started to develop
type 2 diabetes.

If untreated the sugar levels would increase to extremely high levels reseulting altered
consciousness, lethargy etc, a condition called hyperosmolar hyperglycaemic state/coma
(HHS) it happens in type 2 diabetics. It is very unlikely to happen however, unlike the
previously described diabetic ketoacidosis which generally happens to type 1 diabetic. Before
HHS could happen one of the many diabetic complications would kick in forcing the patient
to seek medical attention and thus resulting in the diagnosis of the type 2 diabetic.

Since in type 2 diabetes there is presence of insulin, it is just that the insulin amount
are too low since the pancreatic beta cells losing their activity due to fatigue or the body cells
are not sensitive enough to it. Therefore we initially do not need insulin injections to treat.
Instead we can give oral drugs. Theoretically once again the patient is expected to get in line,
work out, reduce weight etc, and may be, if lucky, the condition is reversed and the patient
can go off the meds, or at least their dose and the number of drugs can surely be reduced, but

Disclaimer: This is a patient education leaflet aimed to help lay person better understand and thus better
manage their disease and is not meant for any other purpose.
 Understanding Diabetes: A Treatise For The General Public.

does it happen practically? Well, in 99% of the cases no. why? Well most would say the
patients circumstances, yes that is true, the patient is now too old, as per him, to work out, or
he says he does not have the time, or he has probably never been counselled properly about
the condition, or they get bored and quit gym too early or in many cases the condition is
detected so far late that so many complications have set in that the patient is not fit enough to
step out of his home let alone go to the gym. Most diabetic will know that they are diabetics
too late. The bad physique combined with the age factor creates a huge mind block in the
patient about hitting the gym. They may feel they are too old to go to the gym, or in bad
shape to hit the gym. Let me tell you, anyone who can walk about or lift the smallest
dumbbell at the gym is good enough to hit the gym and age is not a factor, unless you are
beyond your 60s maybe then its a bit too late if you have not done so already by now.
Walking and jogging is fine but nothing kicks diabetes where it hurts like actual weight
lifting at the gym. It is the best work out for all!

Now what happens when you do not take this advice, or do not make any of the important
lifestyle changes and instead simply continue to take the prescribed oral medications? In such
patients the oral medications that we provide may work in the following fashion:

1) They increase the sensitivity of the body cells to glucose. Once again exercise (weight
lifting specifically) does this naturally since glucose need is increased.
2) They force the pancreas to produce more insulin. Do note that these cells are already
fatigued.
3) They cause you to excrete the glucose in your urine in order to eliminate the excess
glucose that you. It should be noted that this mechanism of the drug goes very much
against the laws of nature. The body of a healthy person will never let a person
eliminate sugars in his urine. It is also important to reflect on the fact importance of
exercise here once again which would increase the glucose need to the body cells for
glucose reducing need of such drugs.

Drugs that rely on the first two mechanisms are more commonly prescribed. There are
many guidelines that decide what is to be prescribed to whom. From the mechanism that I
have explained it is clear that the drugs do not really cure anything, (diabetes mellitus
cannot be cured) but rather just put a band aid on a gunshot wound. Therefore if no
lifestyle changes are applied, the patients pancreas fatigues further, eventually the insulin
sensitivity decreases further or all the pancreatic beta cells slowly die or both. Finally the
patients condition negatively progresses and the patient is prescribed injectable insulin
like a type 1 diabetics. Initially the insulin will be prescribed with some oral drugs and
later on it will eventually be so bad that only insulin will be given it massively high doses
that could possibly kill a healthy lean person if not knock him out. By the time this stage
arrives it is also very likely that the person would have developed some of the
complications of diabetes.

Disclaimer: This is a patient education leaflet aimed to help lay person better understand and thus better
manage their disease and is not meant for any other purpose.
 Understanding Diabetes: A Treatise For The General Public.

Complications of diabetes:

Diabetes goes hand in hand with atherosclerosis and hypertension (high blood pressure) a
patient with diabetes will generally have many of them. This gives rise to many additional
health issues in the patients. The mechanism for the following conditions is too
complicated to explain in simple terms but if I were to put it in a few short lines I would
do it like so: No cells like excess glucose, excess glucose kills and destroys organs, if its
not that, than its the fact that the cells cannot use the glucose which is why they die, from
starvation.

Stroke: a condition that occurs without warning where there is a block in the
blood vessels of the brain due to a fat globule either released from an
atherosclerotic plaque or elsewhere, or it is due to a blood clot, or it can be due
to bleeding in the brain. A lot of permanent damage to brain can be prevented
it patient taken to a tertiary care hospital within 2 hours.
Retinopathy: it is the damage to the nerve cells of the eye that causes blindness
in diabetics. Poor glucose control will cause this. Usually a person with
retinopathy is very likely to have nephropathy.
Nephropathy: excessive glucose damages the kidney cells first causing kidney
damage then kidney failure.
Neuropathy: a condition where there is nerve damage in hands and feet
causing loss of sensation, pricking feeling etc.
Peripheral vascular disease: it is like atherosclerosis of the very fine blood
vessels usually in the feet. They get blocked so the tissue does not get
nutrients so it dies. Usually this block is why wounds in such people do not
heal and result in ulcers.
Diabetic foot ulcers: wounds on feet that do not heal would be because of
multiple reasons including PVD or because the tissue cannot take up glucose
so cells cannot divide and heal the wound.
Cardiovascular disease/ischemic heart disease/ heart disease: (Heart attack)
technically they are not all the same but for the lay person can be assumed to
be the same, it is the block of blood vessels of the heart that cause lack of
blood supply to the heart usually causing permanent damage to the heart.
Occurs suddenly like stroke. (it is like stroke but occurs in the heart, though
the cause cannot be bleeding like in the stroke it is always a block)

Final note:

There is quite a bit of truth in the claim that diabetes mellitus is a chronic illness, but as
clearly explained it does not have to be if you have been diagnosed early. You do not have to
let diabetes control your life. You do not necessarily have to be dependent on those drugs
especially if you are one of those many type 2 diabetics. The internet is full of examples of
people who have managed to hit the gym and go off the drugs and I am here to tell you that
you can be one of them. You CAN fight diabetes. You can revert diabetes. So the question is,
do you have the will and determination to do it?

Disclaimer: This is a patient education leaflet aimed to help lay person better understand and thus better
manage their disease and is not meant for any other purpose.