Two things cause the breakdown of the pancreas: overwork and a condition known as glucose toxicity . We can all understand the overwork part: force those poor little beta cells into relentless slave labor, and many of them are going to die off. Glucose toxicity occurs when high sugar levels do direct damage to the pancreas, further reducing its ability to produce insulin.
This is why the treatment for type 2 diabetes needs to become more aggressive over time, and it explains why millions of people with type 2 diabetes take insulin.
Does this mean that all these people with type 2 who take insulin now have type 1?
No, it does not.
Remember, the type of diabetes is defined by what caused it, not how it is treated.
Type 1 diabetes occurs when the body’s own immune system destroys the pancreas cells that make insulin.
Type 2 is caused by insulin resistance, followed by insufficient insulin production, which is followed by a gradual breakdown of the pancreas.
The type of diabetes you have is defined by what caused it, not how it is treated.
If you don’t currently take insulin for your type 2 diabetes, but your health care professional has encouraged you to do so, there is plenty to get excited about. Insulin is the most potent and effective treatment for elevated blood sugar. It is a more natural substance than pills (today’s insulin formulations are chemically similar to the insulin the body produces) and lacks many of the side effects associated with oral medications and noninsulin injectable medications.
The fact is, oral diabetes medications and noninsulin injectables have their limits. Unlike insulin, which lowers blood sugar directly , all of the other medical treatments for diabetes work indirectly . This means that they only work when the pancreas has the capability to produce sufficient amounts of insulin and the body’s cells are reasonably sensitive to the insulin. Once the pancreas is unable to keep up with the workload, no amount of other medication is going to solve the problem.
Taking insulin is easier and safer than ever before.
The latest insulin formulations are much less likely to cause hypoglycemia (low blood sugar) than older types of insulin.
Disposable insulin syringes have short, super-thin needles that you can barely feel.
Insulin can also be administered with prefilled pens: simply dial up your dose and inject.
There is even an inhaler that lets you take insulin with no injection at all.
And best of all: when you begin using insulin and experience an immediate reduction in your blood sugar levels, you’re probably going to feel better than you have in years!
The Other Diabeteses
Okay, I made that word up.
Remember, diabetes comes in more flavors than just vanilla (type 1) and chocolate (type 2). There are a host of exotic flavors to choose from.
Secondary diabetes (cookies and cream) is a form of insulin-dependent diabetes caused by something other than the body’s own immune system destroying the beta cells of the pancreas. Potential causes include trauma (accidents and injuries), heavy doses of steroids, pancreatitis, alcoholism, cancer treatment, and infection. Regardless of the cause, the treatment is the same as with type 1: insulin, insulin, and more insulin.
Gestational diabetes (strawberry) is a temporary form of diabetes caused by insulin resistance that develops during pregnancy.
Pregnant people with gestational diabetes usually require insulin to control their blood sugar levels.
This is because most oral medications pass through the placenta and may affect the baby’s development.
After delivery, when the mother’s production of insulin-opposing hormones drops off and weight comes down, most new moms stop requiring insulin injections.
However, their risk for developing type 2 diabetes later in life is markedly increased.
MODY (marshmallow) stands for maturity-onset diabetes of the young.
Unlike type 2 diabetes, which is typically caused by insulin resistance, MODY involves a single genetic defect that limits the pancreas’s ability to secrete sufficient amounts of insulin.
It actually belongs to a group of conditions known as monogenic diabetes.
MODY is not associated with being overweight.
It is frequently diagnosed during early puberty, perhaps because of the increased demand for insulin at this age.
Depending on how defective the beta cells become, oral medications or insulin may be required to treat MODY.
Neonatal diabetes (butter pecan) is a rare form of diabetes that occurs in the first six months of life.
Similar to MODY, neonatal diabetes is monogenic: it involves a single genetic mutation that limits the beta cells’ ability to produce insulin.
In some cases, neonatal diabetes disappears during infancy but then reappears later in life.
In other cases, diabetes persists and remains permanent.
Insulin is almost always required to treat neonatal diabetes and promote healthy growth and development.
LADA (mint chocolate chip) refers to latent autoimmune diabetes of adulthood.
Think of it as an incomplete, slowly developing form of type 1 diabetes that is compounded by mild to moderate insulin resistance.
Some people call it “type 1½” because it shares characteristics with both type 1 and type 2 diabetes.
With LADA, the immune system attacks the beta cells of the pancreas, but the attack is incomplete.
Many beta cells survive and continue to secrete insulin, sometimes for years.
Many people with LADA can manage their blood sugar with oral medications or low doses of insulin for an extended period of time, but eventually true insulin dependence develops and treatment requires intensive insulin therapy.
Unlike the gazillions of books that explore the many treatment options for type 2 diabetes, this book focuses on the use of insulin, with or without the addition of other diabetes medications. The subject matter applies to everyone with type 1 diabetes, secondary diabetes, and neonatal diabetes, those in the later stages of LADA, as well as millions who have type 2 diabetes, gestational diabetes, or MODY and require insulin.
The Gold Standard: Nondiabetes
To “think like a pancreas” is to come as close as possible to matching a normal, nondiabetic state.
Whether you have diabetes or not, blood sugar comes from two sources: internal and external.
Internally, sugar is stored and secreted into the bloodstream by the liver and, to a much lesser extent, the muscles.
External sources of sugar are the foods we eat, mainly carbohydrates but also protein, particularly for those following low-carbohydrate diets.
Whether the sugars come from food or our liver, our bodies convert them into a specific type of sugar called glucose .
Glucose is the preferred energy source for most cells of the body.
Some cells, such as brain cells and nerve cells, will only burn glucose for energy.
Muscles burn mostly glucose during the early stages of exercise.
Thus, having a steady supply of glucose is necessary for proper body function and survival.
Glucose happens to be a fairly large molecule. It can’t break through the membranes of our body’s cells without a little help. Insulin’s job is to take glucose out of the bloodstream and pack it into the body’s cells so that it can be burned for energy. Insulin has another important job: blocking the release of sugar from the liver and muscles. Instead, insulin packs sugar into the liver and muscles so that it can be stored for use at another time.
When a person without diabetes has not eaten for a while, their blood sugar level can begin to drop. This can occur between meals, during sleep, and during exercise. When the blood sugar begins to drop, the pancreas decreases its production of insulin and increases its production of another hormone, glucagon. This reduces the amount of sugar being taken out of the bloodstream and stimulates the liver to release some of its stored-up sugar. As a result, blood sugar levels remain stable.
In a way, the pancreas acts like a thermostat that keeps your house comfy-cozy. When the temperature goes up, the thermostat kicks on the fan and air conditioner. When the temperature goes down, the thermostat kicks on the heat. Either way, the temperature stays within a comfortable range.
In your body, when the blood sugar level begins to rise, the pancreas secretes extra insulin, which brings the blood sugar level down. When the blood sugar starts to drop, the pancreas eases back on insulin production and begins producing glucagon, which brings the blood sugar back up. This system helps keep the blood sugar within a range that is comfy-cozy for your body, approximately 60, 110 mg/dl (3.3, 6.1 mmol/l).
A better title for this book would probably be Think Like Islet Cells , because it is this select group of pancreatic cells that acts like our blood sugar thermostat. (But who would want to read a book called Think Like Islet Cells ?
Think Like a Pancreas sounds much cooler!) Truth be known, beta cells do more than just measure glucose levels and secrete insulin.
They also secrete a second hormone called amylin .
Amylin’s job is to work with insulin, particularly at mealtimes, to keep blood sugar from spiking too high right after eating.
We will discuss amylin in more detail later. Let’s turn now to the factors that affect our blood sugar levels on a daily basis.
Blood Sugar Balancing: The Major Players
There are a few major factors that affect our blood sugar on a regular basis (see Table 3-2 ) and a number of minor factors that pop up on special occasions (see Table 3-5 later in this chapter). Learning to keep them all in balance is what ultimately maintains the blood sugar within a healthy range. Let’s start with the major factors.
Factor 1: Insulin
Insulin lowers blood sugar, plain and simple. However, the action of insulin varies depending on its concentration, the rate at which it is absorbed into the bloodstream, and how sensitive the body is to it.
Insulin is measured in units. A unit of insulin should lower the blood sugar the same amount no matter what kind of insulin you use. A unit of fast-acting insulin will lower your blood sugar the same as a unit of long-acting insulin; it just does so in a shorter period of time.
An exception is when using any insulin that is not the standard U-100 concentration.
U-100 means that there are 100 units of insulin in every cubic centimeter (cc) or milliliter of fluid.
In some instances, concentrated insulin such as U-200 (200 units per cc), U-300 (300 units per cc), or U-500 (you get the idea) is used in people requiring very large doses so that they don’t have to take as large a volume when injecting.
Some people choose to dilute their insulin to allow dosing in more precise increments with standard insulin syringes.
For example, a child who is very sensitive to insulin may have their insulin diluted to U-10 by mixing 90 units of neutral diluent with 10 units of insulin.
The resulting mixture would be 10 percent as potent as normal U-100 insulin.
One unit (as measured on an insulin syringe) would actually be equivalent to one-tenth of a unit of U-100 insulin.
A summary of insulin types is given in Table 3-3 .
Be aware that the precise action times can vary from person to person.
And because insulin is injected (or infused, in the case of an insulin pump) into the fat below the skin, the exact onset, peak, and duration can vary from day to day or even meal to meal.
Also note that Technosphere inhaled insulin (brand name Afrezza) acts differently because the insulin is inhaled and absorbed through the lungs rather than going through the fat layer below the skin.
Premixed insulins, such as 75/25, 70/30, and 50/50, contain a combination of NPH (intermediate-acting insulin) and either regular or rapid-acting insulin. For example, Humalog Mix 75/25 contains 75 percent NPH and 25 percent Humalog. Novolin 70/30 contains 70 percent NPH and 30 percent regular insulin.