Insulin Resistance – Part 2

Type 2 diabetes is the type of diabetes that occurs later in life or with obesity at any age. Insulin resistance precedes the development of type 2 diabetes, sometimes by years. In individuals who will ultimately develop type 2 diabetes, it has been shown that blood glucose and insulin levels are normal for many years, until at some point in time, insulin resistance develops.

At this point, high insulin levels are often associated with central obesity, cholesterol abnormalities, and/or high blood pressure (hypertension). When these disease processes occur together, it is called the metabolic syndrome.

One action of insulin is to cause the body's cells (particularly the muscle and fat) to remove and use glucose from the blood. This is one way by which insulin controls the level of glucose in blood. Insulin has this effect on the cells by binding to insulin receptors on the surface of the cells. You can think of it as insulin "knocking on the doors" of muscle and fat cells. The cells hear the knock, open up, and let glucose in to be used. With insulin resistance, the muscles don't hear the knock (they are resistant). So, the pancreas is notified that it needs to make more insulin, which increases the level of insulin in the blood and causes a louder knock.

The resistance of the cells continues to increase over time. As long as the pancreas is able to produce enough insulin to overcome this resistance, blood glucose levels remain normal. When the pancreas can no longer produce enough insulin, the blood glucose levels begin to rise. Initially, this happens after meals, when glucose levels are at their highest and more insulin is needed, but eventually while fasting too (for example, upon waking in the morning). When blood sugar rises abnormally above certain levels, type 2 diabetes is present and can be diagnosed.

While the metabolic syndrome links insulin resistance with abdominal obesity, elevated cholesterol, and high blood pressure; several other medical conditions are specifically associated with insulin resistance. Insulin resistance may contribute to some of the conditions listed.

1. Type 2 Diabetes
2. Fatty liver disease
3. Arteriosclerosis
4. Skin Lesions

• Acanthosis nigricans
• Skin tags

5. Reproductive abnormalities in women

• Polycystic ovary syndrome (PCOS)
• Hyperandrogenism

6. Growth abnormalities

A doctor can identify individuals likely to have insulin resistance by taking a detailed history, performing a physical examination, and simple laboratory testing based on individual risk factors.

In general practice, the fasting blood glucose, A1c, and insulin levels are usually adequate to determine whether insulin resistance and/or diabetes are present. The exact insulin level for diagnosis varies by assay (by laboratory). However, a fasting insulin level above the upper quartile in a non-diabetic patient is considered abnormal.

Management of insulin resistance is accomplished through lifestyle changes such as diet, exercise, and disease prevention, and medications. Insulin resistance can be managed in two ways. First, the need for insulin can be reduced. Second, the sensitivity of cells to the action of insulin can be increased.

The need for insulin can be reduced by altering the diet, particularly the carbohydrates in the diet. Carbohydrates are absorbed into the body as they are broken up into their component sugars. Some carbohydrates break and absorb faster than others. These carbohydrates increase the blood glucose level more rapidly and require the secretion of more insulin to control the level of glucose in the blood. Since foods are rarely eaten in isolation, it can be argued that the glycemic index of each food is less important than the overall profile of the whole meal and associated drinks.

Several studies have confirmed that weight loss, and even aerobic exercise without weight loss, increase the rate at which glucose is taken from the blood by muscle cells as a result of improved sensitivity.

Over the past decade, insulin resistance has gained significance, in its own right, as a contributor to the metabolic syndrome. Timely intervention can delay the onset of overt type 2 diabetes. Future studies must assess longer intervals than research to date in order to determine the duration for treatment to prevent the development of type 2 diabetes and related complications.

Lifestyle changes in nutrition and physical activity are clearly important to delay the development of type 2 diabetes in individuals with insulin resistance and are the primary recommendation for prevention of diabetes in high-risk individuals. Metformin is the only drug recommended by guidelines, for those patients at highest risk. Education about these changes must be directed to all groups at risk for type 2 diabetes. Childhood obesity is epidemic and on the rise in the developed countries. Changes must be made in homes and school cafeterias to ensure healthier nutrition.

Please read this recent blog by Gretchen Becker on insulin resistance. Then read this blog by David Mendosa on insulin resistance and cocoa

Insulin Resistance – Part 1

Many do not consider this a diabetes complication, but I am including it as one.  Diabetes and insulin resistance are well linked and generally, insulin resistance precedes diabetes or metabolic syndrome. You can prevent or stop insulin resistance in its tracks by being physically active, losing extra pounds, and, in some cases, taking the prescription drug metformin.

If you have insulin resistance, your body doesn't respond as well as it should to the insulin it makes. That leaves your blood glucose levels higher than they should be. As a result, your pancreas has to make more insulin to manage your blood glucose.

Insulin resistance is a condition in which the cells of the body become resistant to the hormone insulin.

• Insulin resistance may be part of the metabolic syndrome, and it has been associated with higher risk of developing heart disease.
• Insulin resistance precedes the development of type 2 diabetes.
• Insulin resistance is associated with other medical conditions, including fatty liver, arteriosclerosis, acanthosis nigricans, skin tags, and reproductive abnormalities in women.
• Individuals are more likely to have insulin resistance if they have any of several associated medical conditions. They also are more likely to be insulin resistant if obese or of Latino, African-American, Native American, or Asian-American heritage.
• While there are genetic risk factors, insulin resistance can be managed with diet, exercise, and proper medication.

You may also have heard of "insulin resistance syndrome," as being called metabolic syndrome. It includes:

• Waist size of 40 inches or more in men and 35 inches or more in women.
• High levels of triglycerides (a type of fat in the blood): Your levels are 150 units or higher, or you're taking medicine to control your triglycerides.
• Low levels of "good" (HDL) cholesterol: Less than 40 units for men and less than 50 units for women.
• High blood pressure: Your blood pressure is 130/85 or higher, or you're taking medicine to treat high BP.
• Blood glucose levels that are above normal: Your fasting blood glucose levels are 100 mg/dl or above, or you're taking medicine to treat high blood glucose levels.
• Pregnancy is also a cause in insulin resistance
• Infection or severe illness promotes insulin resistance
• Stress also promotes insulin resistance
• Inactivity and excess weight will activate insulin resistance
• During steroid use insulin resistance rises to the extreme

You can't tell that you have insulin resistance by how you feel. You'd need to get a blood glucose meter that checks your blood glucose levels. Likewise, you wouldn't know if you have most of the other conditions that are part of insulin resistance syndrome (high blood pressure, low "good" cholesterol levels, and high triglycerides) without seeing your doctor.

If you already have insulin resistance, you can take actions that will help your health.

• Exercise. Go for at least 30 minutes a day of moderate activity (like brisk walking) 5 or more days a week. If you're not active now, work up to that if you are medically able.
• Get to a healthy weight. If you're not sure what you should weigh or how to reach a weight loss goal, ask your doctor. You may also want to talk with a nutritionist and a certified personal trainer.
• Eat a healthy diet. Think fruits, vegetables, nuts, beans, fish, legumes, and other protein.

Some people with insulin resistance may also need to take the prescription drug metformin to help control it.

Warning: Another source says this - Thiazolidinediones (TZDs) comprise another class of diabetes drugs which increase sensitivity to insulin, including pioglitazone (Actos) and rosiglitazone (Avandia). These medications are no longer used routinely, in part because of liver toxicity that requires monitoring of liver blood tests. This class of diabetes drugs is known for increasing or causing weight increase.

The person's body may not be producing enough insulin to meet their needs, so some glucose can't get into the cells. Glucose remains in the bloodstream, causing high blood glucose levels. In many cases, the person may actually be producing more insulin than one might reasonably expect that person to need to convert the amount of food they've eaten at a meal into energy. Their pancreas is actually working overtime to produce more insulin because the body's cells are resistant to the effects of insulin. Basically, the cells, despite the presence of insulin in the bloodstream, don't become unlocked and don't let enough of the glucose in the blood into the cells.

Scientists don't know exactly what causes this insulin resistance, and many expect that there are several different defects in the process of unlocking cells that cause insulin resistance. Medications for type 2 diabetes focus on different parts of this insulin-cell interaction to help improve blood glucose control. Some medications stimulate the pancreas to produce more insulin. Others improve how the body uses insulin by working on this insulin resistance. Physical activity also seems to improve the body's ability to use insulin by decreasing insulin resistance, which is why activity is so important in diabetes management.

Diabetes During Pregnancy – Part 2

Why did I change the topic from gestational diabetes to diabetes during pregnancy. The material is pointing to all types of diabetes and this made the topic more comprehensive than just covering only gestational diabetes. Part 1 was for all women. Hopefully this part will cover the rest.

Most women who have gestational diabetes deliver healthy babies. However, untreated or uncontrolled blood sugar levels can cause problems for you and your baby.

Complications in your baby can occur as a result of gestational diabetes, including:

• Excess growth. Extra glucose can cross the placenta, which triggers your baby's pancreas to make extra insulin. This can cause your baby to grow too large (macrosomia). Very large babies are more likely to require a C-section birth.
• Low blood sugar. Sometimes babies of mothers with gestational diabetes develop low blood sugar (hypoglycemia) shortly after birth because their own insulin production is high. Prompt feedings and sometimes an intravenous glucose solution can return the baby's blood sugar level to normal.
• Type 2 diabetes later in life. Babies of mothers who have gestational diabetes have a higher risk of developing obesity and type 2 diabetes later in life.
• Death. Untreated gestational diabetes can result in a baby's death either before or shortly after birth.

Complications in the mother can also occur as a result of gestational diabetes, including:

• Preeclampsia. This condition is characterized by high blood pressure, excess protein in the urine, and swelling in the legs and feet. Preeclampsia can lead to serious or even life-threatening complications for both mother and baby.
• Subsequent gestational diabetes. Once you've had gestational diabetes in one pregnancy, you're more likely to have it again with the next pregnancy. You're also more likely to develop diabetes, typically type 2 diabetes, as you get older.

About 25 years ago, a family friend developed gestational diabetes and did what was necessary to have a healthy baby. When the doctor told her that she could have gestational diabetes with future children, she told the doctor she would not. I don't know what she did, but she had two more children and did not have gestational diabetes. About a year ago, she surprised me when she sent me an email and asked why she now had type 2 diabetes.

I asked her if the doctor had told her this could happen, and she admitted that he had, but after her third baby was born, he said that her chances had gone down. I asked if she had eased up on her care and forgot what she had done to avoid gestational diabetes. This caused a pause in our emails and I did not push it. A month has now passed since she finally replied. I know how difficult her response was and she had to admit that she had stopped the level of care she had set for herself with the children, but that she was now off all medications and would work to stay off for as long as she could.

I congratulated her for that and asked if she knew that she was now in a battle to manage diabetes for the remainder of her life. Yes, was her response and her children and husband were helping her. She also stated that her husband also has type 2 diabetes and the children are aware of the possibility of genetics and the odds of type 2 diabetes affecting them.

I could write a lot more, but instead I will urge you to read this which is a reasonable discussion of gestational diabetes. Then I suggest reading this article which covers the three types of diabetes.

Diabetes During Pregnancy – Part 1

Diabetes and pregnancy is a special concern because what the mother does during pregnancy can definitely affect the baby and its life for good or bad. Let me be very clear that this is not an easy topic for me and my children were born without gestational diabetes and other complications. As such, I may miss some points that are important.

Whether you are a person with type 1 diabetes, type 2 diabetes, or do not have diabetes, there are some steps every woman needs to take before starting a family. Yes, starting a family requires more planning when you are a mother-to-be with diabetes, but these steps should also be carefully considered for all mothers-to-be. 

The following are all important:

See an OB GYN if at all possible or a doctor that does understand pregnancy. Set up an appointment approximately three to six months before you plan to conceive. For women without diabetes, some of these will not be done.

• Order an A1C test to find out if your diabetes is controlled well enough for you to stop using birth control.
• Test your blood and urine for diabetes-related kidney complications.

• Look for other problems linked with diabetes, like organ, nerve, or heart damage.

• Take your blood pressure.

• Rule out thyroid disease (if you have type 1 diabetes).

• Check your cholesterol and levels of a type of blood fat called triglycerides.

• Suggest an eye exam to screen for glaucoma, cataracts, and retinopathy.
• Do other blood work looking for various vitamin and mineral deficiencies.

• Recommend pre-conception counseling.

Pre-conception counseling is important for all women planning to conceive, but is especially important for women with diabetes and those that have had gestational diabetes with a previous child. The session will be educational and should help you become physically, emotionally, and healthy for pregnancy. The points for discussion will include at least the following:

1. Your weight: Try to reach your ideal body weight before you get pregnant. If you have a few extra pounds, losing them will help prevent complications from diabetes. If you’re underweight, adding pounds can make you less likely to deliver a low-birth-weight baby.

2. Your lifestyle: If you smoke or drink alcohol, you'll need to stop. Smoking during pregnancy affects both you and the baby before, during, and after birth. When you smoke, the nicotine (the addictive substance in cigarettes), carbon monoxide, and other toxins travel through your bloodstream and go directly to your baby. These substances can:

• Deprive you and the baby of oxygen.
• Raise the baby’s heart rate.
• Boost the chances of a miscarriage or a stillbirth.
• Increase the odds of a premature, low-birth-weight baby.
• Make the baby prone to future problems with the lungs or breathing.

Drinking alcohol during pregnancy can lead to a pattern of birth defects that includes mental retardation and certain physical problems. No amount of alcohol is known to be safe while pregnant, and there’s no safe time during pregnancy to drink.

3. Prenatal vitamins: At least one month before you get pregnant, start taking a daily vitamin that has folic acid. It’s been shown to lower the risk of having a baby with a neural tube defect like spina bifida, a serious condition in which the brain and spinal cord don’t form normally. The CDC recommends you take 400 micrograms of folic acid daily before conception and throughout pregnancy. Most drugstores sell over-the-counter prenatal vitamins that don’t require a prescription.

4. Your blood sugar: The doctor will check to see if your blood sugar is in control. This is key, because you may not know you’re pregnant until the baby has been growing for 2-4 weeks. High blood sugar during the first 13 weeks can cause birth defects, lead to miscarriage, and put you at risk for diabetes complications. Get screened for gestational diabetes at 24 weeks, even if you don’t have symptoms.

5. Your medications: You'll need more insulin during pregnancy, especially the last 3 months. The doctor will tell you how to adjust your dose. If you take diabetes pills, the doctor may switch you to insulin, because some of these drugs can harm the baby. So can some high blood pressure treatments used with diabetes. Bottom line: Discuss all medications and dietary supplements you take with your doctor.

6. Meal planning: You’ll need to make some changes while you’re pregnant to avoid swings in blood sugar levels. You’ll also need to take in more calories to feed your growing baby.

Sexual Dysfunction in Men and Women – Part 2

Continued from prior blog.

Issues for both sexes:

• Urinary infections are more common in people with poorly controlled diabetes and can cause discomfort for women during intercourse and for men during urination and ejaculation. These generally are temporary complications, but they can recur. Sexual activity should be stopped during treatment of urinary tract and yeast infections, which also are relatively common in people with diabetes.
• Sexually transmitted diseases (STDs) can be transmitted easily because of the dry, cracked skin found in many people who have diabetes. This makes it important to practice safe sex.
• Chronic high blood glucose levels can lead to reduced testosterone and may contribute to decreased sexual interest (libido).
• Chronic high blood glucose can lead to abnormal nerve function, leading to pain with only light touch.
• Heightened sense of pain associated with neuropathy can make sexual relations uncomfortable.
• Because intercourse is exercise, people with diabetes should watch for signs of hypoglycemia (low blood glucose) after sex.

Other factors:

• People with diabetes (particularly men whose disease is poorly controlled) may have too little or too much of certain hormones, such as prolactin, testosterone, or thyroid hormone. Generally these conditions can be treated with pills.
• Certain drugs for heart problems, high blood pressure, anxiety, depression, pain, allergies, and weight control sometimes cause impotence. Switching medications may solve the problem.
• Stress and other mental health problems can cause or worsen sexual dysfunction, as can smoking and alcohol use.
• Physical problems not caused by diabetes, such as accidents that injure nerves, prostate surgery, and spinal cord injuries, can cause impotence.

See your doctor: Make an appointment to see your doctor if you are experiencing sexual dysfunction. Your doctor should perform a physical exam, which includes:

• Medical history, including questions about morning erections (a sign that the impotence probably is not due to a physical problem); how long the problem has occurred; and whether you are experiencing anxiety or stress
• A physical exam and review of diabetes complications
• Lab tests to check hormone levels
• Review of medicines taken
• Occasionally additional testing, including measurements of erections, an ultrasound, and/or neurological and other tests done at the doctor's office or by you at home.

People with diabetes can lower their risk of sexual and urologic problems by keeping their blood glucose, blood pressure, and cholesterol levels close to the target numbers their doctor recommends. Being physically active and maintaining a healthy weight can also help prevent the long-term complications of diabetes. For those who smoke, quitting will lower the risk of developing sexual and urologic problems due to nerve damage and also lower the risk for other health problems related to diabetes, including heart attack, stroke, and kidney disease.

For information from another source, please read this article.

Sexual Dysfunction in Men and Women – Part 1

In my research for this topic, the sources on the first ten pages were between 7 to 1 and 9 to 1 about the problem happening for men. In addition, many of the listings were about men that did not have diabetes. I don't believe for a minute that women don't have problems and I base that on TV advertising recently for products for women in menopause and post menopause to make sex less painful (diabetes not mentioned).

Out-of-control blood sugar levels can lead to blood vessel and nerve damage that hamper sexual performance and enjoyment. This can cause diabetes-related sexual dysfunction in men as well as in women. Men and women with diabetes also should be aware of sexual function issues that affect both sexes.

Other factors can cause or exacerbate sexual dysfunction, including psychological issues, self-consciousness, and fear of failure. If you are experiencing impotence or sexual dysfunction, it's important to see your doctor for an accurate diagnosis of your condition.

Sexual problems (sexual dysfunction) are common among people with diabetes, particularly in older men who have had diabetes for years. In addition, many medical experts believe that women with diabetes experience sexual difficulties as a result of complications from the disease. People who experience sexual difficulties can lead more enjoyable, fulfilling sexual lives by learning about common causes and symptoms of sexual difficulties, treatment options, and how to talk it over with a sex partner.

At any given time an estimated 30 million American men experience impotence (erectile dysfunction), defined as the inability to achieve or maintain an erection sufficient for intercourse more frequent than one out of four times. Sexual difficulties in people with diabetes are not always related to their disease.

Impotence can occur in men of any age, but it most often affects older men. A recent study of 1,300 males found some degree of erection difficulty in 52 percent of participants ages 40 to 70. Over 50 percent of the estimated 10 million men with diagnosed type 2 diabetes experience impotence. In men whose diabetes is well controlled, the rate of impotence is about 30 percent. Approximately 35 percent of women with diabetes may experience some form of sexual dysfunction related to their disease. Of people with complications from diabetes, 50 to 70 percent of men and 40 to 50 percent of women may have sexual difficulties because of nerve damage.

Sexual dysfunction in men:

• Diabetes can cause nerve and artery damage in the genital area, disrupting the blood flow necessary for an erection. This is more common in older men who have had diabetes for a long time. High cholesterol, high blood pressure and obesity - all common among men with diabetes - as well as smoking, can contribute to the problem.
• Some men with diabetes experience retrograde ejaculation, which means that the ejaculate goes backward into the bladder instead of being discharged during climax. This condition does not affect orgasm, but it can make it difficult to father a child.

Sexual dysfunction in women:

• Diabetes-related nerve damage can cause vaginal dryness that makes intercourse uncomfortable.
• Nerve damage also can lead to loss of sensation in the genital area, making orgasm difficult or impossible to achieve.

Continued in the next blog.

Our April Support Group Meeting

Our April meeting on April 11 turned out to be more relaxed than I thought it would be. Jason had received the materials from Brenda and was ready to have the presentation. First, Tim had Brenda's daughter give us an update on Brenda's progress and recovery. Brenda has returned home, but has a full-time nurse and other people coming in during the weekdays for physical therapy and speech therapy. Then Tim introduced the new person, Joyce and asked for a vote for membership. The voice vote was unanimous and Jason was given the floor.

Learning how to interpret blood glucose readings is the topic and Jason felt with what he and Brenda had prepared before the heart problem, we should understand more about our food intake or reducing foods or eliminating some foods from our menu. Jason continued that by using the health logs to adjust medications if the doctor allowed or recommended this for certain illnesses, it should be possible if we understand our blood glucose readings.

Tim brought up the first slide which explained the necessity of testing before a meal and testing at various times after the meal. The before meal test (preprandial test) should be determined by the type of medication being taken. Oral medications can vary on how quickly the medication takes effect and the same applies to insulin.

The after meal test is more variable and depends on the medication, the individual, and the food consumed. Only testing will help you decide the best time to test postprandial. Jason said his best time is about 2 hours after last bite and I know that several of you test about 90 minutes after first bite and a few test at 90 minutes after last bite. Others test a one hour after first or last bite. All times are fine and only you can determine this from tests. The one warning Jason stated is being consistent with first or last bite.

Jason then said that he tested every 15 minutes after last bite to determine when he had the highest blood glucose reading and stopped when he had the reading start down. Jason said to do this with several different meals and many different food combinations. Most were all near 2 hours when his blood glucose levels peaked.

Jason said that without the twin tests, preprandial and postprandial, one reading is worthless as it does not tell you what the increase in blood glucose levels are and you will not know what foods or food combinations may be causing the spike in blood glucose levels.

Then Jason asked if we wanted him to cover hypoglycemia and hyperglycemia since Bob has written about both? Only one person said he would still want it talked about. Tim asked if the resources I had used were part of what Brenda and Jason had prepared. Jason answered that I have been part of the discussion and much of what I had written was from the same sources.

Jason said several of what they had came from my blogs and they had borrowed the book that I used. Gale asked to speak and said she would like to work with the person that wanted Jason to cover the topics as she felt that if she could get their notes and use my blogs, she could explain it to her. The person said she would accept that, as she was the only one that felt there was something she missed and at the same time did not want to hold the group back.

Tim asked Jason and me if we would supply information and answer questions Gale had that would help. Both of us said we were available by email or telephone to assist if needed. Our newest member, Joyce, who had joined that evening, asked if she could participate since she was not aware of what had been covered in my blogs. She admitted that she did not understand the terms other that she was guessing that one was about having lows and the other about having highs from something the doctor had talked about when she was still in shock from her diagnosis.

Gale agreed and thanked her for speaking up. Tim asked if anyone else would want to do this. No one spoke up and Tim asked Stan, who had joined the previous meeting, if he was having any problems. Stan said that my blogs were what he needed and had read many of them. He continued that the blogs on the complications were what he needed and he was asking me questions that he had, and I was helping him gain confidence in researching different topics.

With that, Tim ended the meeting. Several people gathered around Gale and Tim decided to let that happen. I was ready to leave and several of us headed home.