Tag: Obesity

Diabetes affects nearly 463 million people worldwide. In America, where the standard American diet consists of high carbohydrate foods, diabetes affects about 10% of the population, with 90% of all cases being type 2 diabetes. 

Given the rising trend in the rates of obesity, it appears the incidence of diabetes will continue to rise. Bariatric surgery is currently the most effective and long-term treatment for obesity. Weight loss surgery procedures are meant for patients to achieve a significant degree of weight loss. With patients attaining successful weight loss results, bariatric surgery is a viable solution for diabetic patients.  

How Excess Weight Causes Diabetes

The exact mechanism of how obesity leads to insulin resistance is still not fully known. Recent research proposes that overeating and obesity places stress on a particular cellular organ (organelle) called the endoplasmic reticulum. This organelle is responsible for the processing of nutrients within the cell.

When nutrients are too plentiful, as might be the case in obese patients, the cell sends out signals to the cellular surface to shut down the glucose transport system, thereby inhibiting the action of insulin on the surface of the cell. This ultimately prevents glucose entry into the cell, leading to persistently higher glucose levels in the blood.

Other theories suggest that obesity causes increased levels of fatty acids in the blood, resulting in chronic inflammation. This might result in a response in the immune cells located in adipose tissue to produce toxic chemicals. This somehow inhibits the action of insulin at the level of the cellular insulin receptor or prevents the pancreas from producing enough insulin. Either way, the result is a blood glucose level that is too high. 

How Weight Loss Surgery Improves Diabetes in Obese Patients

If the inflammation theory mentioned above is the leading cause for insulin resistance, then it would seem logical that losing weight would decrease the state of chronic inflammation, thereby improving the action of insulin at the cellular level and lowering blood glucose levels.  

When considering the endoplasmic reticulum theory, a patient is consistently eating less, resulting in fewer nutrients available for the cells. 

This should then result in a lower stimulus for the cell to prevent the entry of glucose, thereby improving the action of insulin at the level of the cell, lowering blood glucose level, decreasing overall improved glycemic control.  

Aside from losing weight and eating less, it also appears that preventing food from coming into contact with the first part of the intestine (duodenum) seems to result in hormonal changes that improve insulin sensitivity. This effect appears to be independent of the weight loss. 

The prevention of food from coming into contact with the duodenum occurs in the gastric bypass and duodenal switch due to the anatomic changes that divert food away from the duodenum. In most type 2 diabetics, glycemic control is improved if not normal within days of surgery, even before any degree of significant weight loss.

A June 2014, an article published in The International Journal of Clinical Practice reported that surgery — compared to conventional treatment — results in better blood sugar control. Many patients even go into remission within days of their bariatric procedure.

Read the entire ASMBS Fact Sheet on type 2 diabetes and bariatric Surgery

Nearly all individuals who have bariatric surgery show improvement in their diabetic state. Bariatric surgeries have shown the following statistical results as it relates to type 2 diabetes: 

• Surgery improves type 2 diabetes in nearly 90 percent of patients
• Surgery causes type 2 diabetes to go into remission in 78 percent of individuals
• Improved health and increased longevity last for years, if not a lifetime.

The primary goal of diabetes treatment and management is to keep the blood sugar/glucose levels as close to a normal range as possible (around 100 mg/dl) while avoiding drops in the glucose level to the degree that the patient develops symptomatic hypoglycemia. The techniques to accomplish this center around lifestyle changes (diet, exercise, weight loss, close medical follow-up/monitoring), the use of medications, and bariatric surgery. 

Learning about the disease and being an active participant in the management process is critical to long-term glycemic control. The goal of treatment is to keep the HbA1C level no more than 7-8% and preferably less than 7.  You should pay attention to those medical conditions that will accelerate the long-term consequence of the disease, such as hypertension (high blood pressure), elevated cholesterol (heart disease), and excess weight. 

Medications

The goal of medicine that treats diabetes is to lower the blood glucose levels by either replacing the insulin that is lacking, improving the body’s production of insulin, or improving the absorption of glucose from the blood into the cells of our body. There are several different classes of drugs that we will below. 

Insulin

Insulin is the most common type of medication used in type 1 diabetes treatment. The goal is to replace the insulin that the body fails to produce. Several types of insulin are classified as short and long-acting. 

A diabetic patient will take insulin by frequent, intermittent injections or a continuous infusion through various pumps. Ultimately, the amount of insulin required is dependant on the patient’s blood sugar levels, how much natural insulin they might make (if any), and how sensitive their body is to the insulin. 

Some of the common drug names for insulin are:

1. Short-Acting Insulin:  Regular Insulin (Humulin and Novolin), Insulin Aspart (NovoLog, FlexPen), Insulin Isophane (Humulin N, Novolin N)
2. Long-acting insulin: Insulin Degludec (Tresiba), Insulin Detemir (Levemir), Insulin Glargine (Lantus), Insulin Glargine (Toujeo)
3. Combination Insulins (short and long-acting): NovoLog Mix 70/30 (Insulin Aspart Protamine-Insulin Aspart), and many other combinations

Injectables

Amylinomimetic drugs are injectable medications used before meals. They are meant to delay emptying the stomach, thereby delaying the digestion and absorption of the meal. This results in a slower, more controlled rise in glucose levels, which will sometimes prevent the rapid spikes in glucose levels when a diabetic eats. The medication also seems to reduce appetite. Pramlintide (SymlinPen 120, SymlinPen 60) is one of these medications.

For type 2 diabetics, the body makes insulin, however, the cells no longer respond well to the insulin the body makes. The goal of treatment with the following medications is to help the cells respond to insulin better to improve glucose absorption.  

Common Medications to Manage Diabetes 

1.   Alpha-glucosidase inhibitors, medications that help your body break down starchy foods and simple sugars more efficiently. Some of the common names are Acarbose (Precose) and Miglitol (Glyset)

2.   Biguanide class of medication decrease how much glucose the liver produces. The most common biguanide is Metformin (Glucophage, Metformin Hydrochloride ER, Glumetza, Riomet, Fortamet). Metformin can also be combined with other drugs to have a synergistic effect.  

3.   Dipeptidyl Peptidase-4 (DPP-4) Inhibitors help the body continue to make insulin by stimulating increased production from the pancreas. Some of the more common drugs in this class include Linagliptin (Tradjenta), Saxagliptin (Onglyza), and Sitagliptin (Januvia). 

4.   Glucagon-like Peptide-1 Receptor Agonists (GLP-1 receptor agonists) are similar to the natural hormone called incretin. These medications stimulate the growth of the cells in the pancreas that make insulin. In some patients, these medications decrease appetite and delay gastric emptying, which may positively benefit weight. These medications include Dulaglutide (Trulicity), Exenatide (Byetta), Liraglutide (Victoza), and Semaglutide (Ozempic)

5.   The Meglitinide class of medications helps your body release insulin. However, in some cases, they may lower your blood sugar too much, resulting in hypoglycemia. Some of the common brands include Nateglinide (Starlix), Repaglinide (Prandin) and Repaglinide-Metformin (Prandimet)

6.   Sodium-glucose transporter (SGLT) 2 Inhibitor works by decreasing glucose absorption in the kidney. As a result, excess glucose is lost through the urine. Some of the common medications in this class include Dapagliflozin (Farxiga), Dapagliflozin-Metformin (Xigduo XR), Canagliflozin (Invokana), and Empagliflozin (Jardiance).

7.   Sulfonylureas are among the oldest diabetes drugs still used today. They work by stimulating the pancreas to make insulin. These drugs include Glimepiride (Amaryl), Glipizide (Glucotrol), and Glyburide (DiaBeta, Glynase, Micronase). These medications are often combined with other medications such as metformin to achieve a synergistic effect (Glyburide-Metformin, known as Glucovance).

8.   Thiazolidinediones are an additional class of medications that work by decreasing glucose in your liver. They may also improve insulin sensitivity at the level of the fat cell, thereby improving glucose absorption and utilization. Options include Rosiglitazone (Avandia) and Pioglitazone (Actos). 

Medications to lower blood glucose levels are often used in conjunction with other medicines to reduce the long-term damage diabetes tends to have on our organs. These include anti-hypertensive medications used to lower blood pressure and protect the kidney from the damaging effect of frequent high glucose levels. Other medications that protect the organs are medications to lower cholesterol levels. These medications reduce the development of atherosclerosis/heart disease that is more likely to be accelerated in diabetic patients. 

Diabetes is a hormonal condition in which an individual experiences consistently high blood sugar levels. When the glucose levels in the blood are persistently too high, this can ultimately impact the body’s organs and tissues, resulting in long-term damage. 

Understanding Insulin

Diabetes is due to either the pancreas not producing enough insulin or the body’s cells not responding properly to the insulin produced. 

Insulin is a hormone made by the Beta-cells in the pancreas. It is the primary hormone that stimulates glucose uptake from the blood into most cells of the body by interacting with an uptake receptor on the surface of the cells. When the body is deficient in insulin (Type 1 DM) or the body is insensitive to insulin’s actions due to a problem with the insulin receptors on the cells surface, then the blood glucose levels can remain too high. 

Ultimately one or both of these problems is the leading cause for all forms of diabetes mellitus.[69] Glucose is vital to normal cellular function and life. It’s the primary source of “fuel” for the cells in our body; however, too much of a good thing can become harmful.  

The glucose level in our blood comes from several sources:

1. The intestinal absorption of food (carbohydrates)
2. The breakdown of glycogen in the liver and muscle (the quick storage form of glucose) and gluconeogenesis
3. The generation of glucose from non-carbohydrate substrates in the body (primary from protein and ketone bodies).  

Insulin works by inhibiting the breakdown of glycogen or the process of gluconeogenesis. It also interacts with particular receptors on the surface of most of the cells in our body to stimulate glucose transport into fat and muscle cells. Insulin stimulates glucose storage in the form of glycogen in the liver and muscle for future use when we have not recently eaten. 

Insulin is released into the blood by beta cells (β-cells), found in the pancreas, when these cells sense rising blood glucose levels, typically after eating. 

If the amount of insulin available is insufficient (Type 1 DM), or if cells respond poorly to the effects of insulin (Type 2 DM), then glucose is not absorbed by the body’s cells. The net effect is persistently high blood glucose levels leading to the long-term complications discussed in this article. 

Diabetes Treatments

Insulin Injections

Patients with type 1 diabetes who fail to make enough insulin can treat their diabetes with insulin injections. The patient must monitor their glucose levels frequently and supplement the body with various insulin doses to keep the glucose level in a “close to normal range.” Additionally, the patient needs to eat a low carbohydrate diet to prevent the glucose levels from spiking too high. 

Prevention and treatment of type 2 diabetes generally involves lifestyle changes such as losing weight, eating a low carbohydrate diet, and regular physical exercise. Type 2 diabetes may be treated with various oral medications that help the body’s cells to utilize glucose more effectively. Occasionally type 2 diabetics may also need insulin injections when the oral medications fail to keep the glucose levels low enough.   

Weight Loss

The third and probably most crucial lifestyle change a patient with diabetes should make is to lose weight. Weight loss can prevent progression from pre-diabetes to full-blown type 2 diabetes. Losing weight will also decrease the risk of developing hypertension and elevated cholesterol. In many cases, even a modest degree of weight loss can result in partial remission of the disease.   

Bariatric Surgery

Weight loss surgery can be an extremely effective treatment for obese patients with type 2 diabetes. Most patients after surgery can maintain normal blood sugar levels with little or no medications, and long-term complications and death associated with diabetes are decreased.  

The body mass index cutoffs for surgery are in debate. However, most physicians agree that anyone with a body mass index over 35 should be considered a candidate for bariatric surgery. There is some evidence that patients with a BMI between 30 and 35 should be considered when medications and lifestyle changes fail to lead to reasonable glucose control.

In 2018, The American Society for Metabolic and Bariatric Surgery (ASMBS) issued a position statement on the role weight loss surgery plays in treating class 1 obesity (BMI 30.0–34.9 kg/m2). It states, “Particularly given the presence of high-quality data in patients with type 2 diabetes, bariatric and metabolic surgery should be strongly considered for patients with BMI 30 to 35 kg/m2 and type 2 diabetes.” This position is supported by the American Diabetes Association (ADA); however, most insurance companies still do not cover these procedures until the body mass index is over 35.

How to Diagnose Diabetes

Normal glucose levels are typically less than 110. Diabetes mellitus is diagnosed by demonstrating any one of the following:[65]

• Fasting plasma glucose level ≥ 126 mg/dl. For this test, blood is drawn after a period of fasting, most commonly in the morning before the first meal
• Plasma glucose ≥ 200 mg/dL two hours after a 75-gram oral glucose load. This test is referred to as the oral glucose tolerance test.  
• Symptoms of high blood sugar and plasma glucose ≥ 200 mg/dL either while fasting or not fasting
• Glycated hemoglobin (HbA1C) ≥ 6.5.

A positive result on any of the tests should be confirmed by repeating the method on a different day. The fasting AM test is preferable because of the ease of measurement and the time commitment of formal glucose tolerance testing, which takes two hours to complete and offers no prognostic advantage over the fasting test.

Most endocrinologists consider two fasting glucose measurements above 126 mg/dL a considered diagnosis for diabetes mellitus. An individual is considered to be pre-diabetic when the fasting glucose levels are 110 to 125 mg/dL, or when the plasma glucose is between 140 to 200 mg/dL, two hours after the glucose tolerance test.

Diabetes mellitus (DM) is an endocrine (hormonal) disorder characterized by frequently high blood sugar levels over a prolonged period of time. Our glucose (sugar) levels in our blood are tightly regulated by insulin (a hormone made by the pancreas), which is designed to keep our blood sugar level in a reasonably narrow range. When the glucose levels in the blood are persistently too high, this will ultimately impact the body’s organs and tissues, resulting in long-term damage and possibly death. The name “diabetes” comes from the Latin meaning of “pass-through,” referring to increased urination and Mellitus, aka sweetened. In the past, diabetes mellitus was referred to as sweet urine.

Symptoms of Diabetes

The most common initial symptoms of diabetes are frequent urination, thirst, and increased hunger. The persistently high glucose levels in the blood cause kidneys to excrete glucose into the urine (sweet urine). Before measuring the glucose levels in the blood, physicians would suspect the diagnosis of diabetes when the patient’s urine tasted sweet. The increased glucose in the urine results in decreased water absorption by the kidneys, leading to increased urine production and fluid losses that ultimately cause dehydration and increased thirst.

Furthermore, the lower levels of glucose in the body’s cells stimulate increased appetite and hunger. If the glucose level gets too high, then many acute complications can arise, such as diabetic ketoacidosis, hyperosmolar hyperglycemic state, diabetic coma, and even death. Other less specific signs of diabetes are blurred vision, headaches, fatigue, mental fog, and poor wound healing.

Complications of Diabetes

Long term, persistently elevated glucose levels will ultimately lead to damage to small blood vessels limiting blood flow to the regions of the body that these vessels serve. The most common long-term complications from this damage are seen in the vital organs such as the heart (cardiovascular disease leading to heart attacks), brain (leading to strokes), and the kidney (leading to kidney failure and ultimately dialysis).

Additionally, damage to the body’s smaller blood vessels often leads to poor blood flow to the feet, which can cause foot ulcers, damage to the nerves causing neuropathy (numbness, tingling, and burning pain), and damage to the small blood vessels in the eyes leading to visual impairment and even blindness.

Types of Diabetes:

Diabetes is due to either the pancreas not producing enough insulin or the body’s cells not responding properly to the insulin produced. There are three main types of diabetes mellitus:[2]

• Type 1 diabetes, commonly referred to as Juvenile diabetes, results from the failure of the pancreas to produce enough insulin due to the loss of cells in the pancreas that make insulin. Typically type 1 DM occurs in childhood or adolescence. Although, some individuals may have a slow loss in the insulin-producing cells, leading to a form of Type 1 DM that presents later in life.  It is believed that the loss of these insulin-producing cells is caused by an autoimmune disorder that leads to the death of these cells in the pancreas. The cause of this autoimmune response is unknown.
• Type 2 diabetes, known as insulin resistance, is when the body’s cells fail to respond to insulin properly. This form of diabetes is often referred to as “non-insulin-dependent diabetes mellitus” (NIDDM) or “adult-onset diabetes .”The cause of this type of diabetes is not clearly known; however it is most commonly associated with a combination of excessive body weight and insufficient exercise.
• Gestational diabetes is the third main form of diabetes and occurs when pregnant women without a previous history of diabetes develop high blood sugar levels. Typically, the glucose levels normalize after delivery, making this form of diabetes a less serious condition.

Diabetes Statistics

Diabetes is the 7th leading cause of death worldwide and is the most expensive long-term disease to treat. As of 2019, an estimated 463 million people had diabetes worldwide, accounting for about 8% of the world’s population. In the US, where the diet of most individuals is higher in carbohydrates and obesity is more prevalent, the rates approach 10% of the population.

Type 2 diabetes accounts for about 90% of all cases. Given the rising trend in the rates of obesity, it appears the incidence of diabetes will continue to rise. Additionally, due to the long-term health consequences of diabetes, the risk of early death has nearly doubled, resulting in almost 4 million deaths a year.  As such, it is not surprising that the cost of diabetes treatment in the United States is over $300 billion, with the average medical expenditures for patients with diabetes being twice that of non-diabetics.

Diabetes has come to be a household term. With the obesity epidemic on the rise, diabetes can be one of the first signs of an unhealthy lifestyle. Diabetes is a disease that is characterized by higher than normal levels of sugar in the blood and not enough insulin to manage these levels

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