Read an Excerpt

Dr. Bernstein's Diabetes Solution

Little, Brown

Chapter One

The Basics

Diabetes is so common in this country that it touches nearly everyone's life-or will. The statistics on diabetes are staggering, and a diagnosis can be frightening: diabetes is the third leading cause of death in the United States. According to the most recent statistics compiled by the National Institutes of Health (NIH), which cover through 1996, there were 10.3 million diagnosed diabetics in America, and approximately 5.5 million who have not yet been diagnosed. This number has no doubt increased. Nearly 800,000 new diabetics will be diagnosed per year, according to NIH statistics; that's three new cases every two minutes.

Even more alarming, the incidence of type 2-or what was once known as maturity-onset diabetes-among children eighteen years old and younger has skyrocketed. A Yale University study of obese children between ages four and eighteen appeared in the March 14, 2002, issue of the New England Journal of Medicine. The study found that nearly a quarter had a condition that's often a precursor to diabetes. According to USA Today's story on the report the same day, "The incidence of type 2 diabetes, the form that usually occurs in adults, has increased in young people, especially Hispanics, blacks, and Native Americans. Some regional studies suggest the incidence of type 2 in children has jumped from less than 5%, before 1994, to up to 50%." That children are increasingly getting a disease that once targeted fifty- to sixty-year-olds presents a new and frightening potential public health disaster.

Each year, tens of thousands of Americans lose their eyesight because of diabetes, the leading cause of new blindness for people ages twenty-five to seventy-four. Ninety-five percent of diabetics have type 2 diabetes. Because 80 percent of type 2 diabetics are overweight, many inappropriately feel that the disease is their own fault, the result of some failure of character.

Since you are reading this book, you or a loved one may have been diagnosed recently with diabetes. Perhaps you have long-standing diabetes and are not satisfied with treatment that has left you plagued with complications such as encroaching blindness, foot pain, frozen shoulder, inability to achieve or maintain a penile erection, or heart or kidney disease.

Although diabetes is still an incurable, chronic disease, it is very treatable, and the long-term "complications" are fully preventable. For nearly sixty years, I've had type 1 diabetes, also called juvenile-onset or insulin-dependent diabetes mellitus (IDDM). This form of diabetes is generally far more serious than type 2, or non-insulin-dependent diabetes mellitus (NIDDM), although both have the potential to be fatal. Most type 1 diabetics who were diagnosed back about the same time I was are now dead from one or more of the serious complications of the disease. Yet after living with diabetes for nearly sixty years, instead of being bedridden or out sick from work (or dead, the most likely scenario), I am more fit than many nondiabetics who are considerably younger than I. I regularly work 12-hour days, travel, sail, and pursue a vigorous exercise routine.

I am not special in this regard. If I can take control of my disease, you can take control of yours.

In the next several pages I'll give you a general overview of diabetes, how the body's system for controlling blood sugar (glucose) works in the nondiabetic, and how it works-and doesn't work-for diabetics. In subsequent chapters we'll discuss diet, exercise, and medication, and how you can use them to control your diabetes. If discussion of diet and exercise sounds like "the same old thing" you've heard again and again, read on, because you'll find that what I've observed is almost exactly the opposite of "the same old thing," which is what you've probably been taught. The tricks you'll learn can help you arrest the diabetic complications you may now be suffering, may reverse many of them, and should prevent the onset of new ones. We'll also explore new medical treatments and new drugs that are now available to help manage blood sugar levels and curtail obesity.

THE BODY IN AND OUT OF BALANCE

Diabetes is the breakdown or partial breakdown of one of the more important of the body's autonomic (self-regulating) mechanisms, and its breakdown throws many other self-regulating systems into imbalance. There is probably not a tissue in the body that escapes the effects of the high blood sugars of diabetes. People with high blood sugars tend to have osteoporosis, or fragile bones; they tend to have tight skin; they tend to have inflammation and tightness at their joints; they tend to have many other complications that affect every part of their body, including the brain, with impaired short-term memory.

Insulin: What It Is, What It Does

At the center of diabetes is the pancreas, a large gland about the size of your hand, which is located toward the back of the abdominal cavity and is responsible for manufacturing, storing, and releasing the hormone insulin. The pancreas also makes several other hormones, as well as digestive enzymes. Even if you don't know much about diabetes, in all likelihood you've heard of insulin and probably know that we all have to have insulin to survive. What you might not realize is that only a small percentage of diabetics must have insulin shots.

Insulin is a hormone produced by the beta cells of the pancreas. Insulin's major function is to regulate the level of glucose in the bloodstream, which it does primarily by facilitating the transport of blood glucose into most of the billions of cells that make up the body. The presence of insulin stimulates glucose transporters to move to the surface of cells to facilitate glucose entry into the cells. Insulin also stimulates centers in the brain responsible for feeding behavior. Indeed, there is some insulin response even as one begins to eat, before glucose hits the bloodstream. Insulin also instructs fat cells to convert glucose and fatty acids from the blood into fat, which the fat cells then store until needed. Insulin is an anabolic hormone, which is to say that it is essential for the growth of many tissues and organs. In excess, it can cause excessive growth-as, for example, of body fat and of cells that line blood vessels. Finally, insulin helps to regulate, or counterregulate, the balance of certain other hormones in the body. More about those later.

One of the ways insulin maintains the narrow range of normal levels of glucose in the blood is by regulation of the liver and muscles, directing them to manufacture and store glycogen, a starchy substance the body uses when blood sugar falls too low. If blood sugar does fall even slightly too low-as may occur after strenuous exercise or fasting-the alpha cells of the pancreas release glucagon, another hormone involved in the regulation of blood sugar levels. Glucagon signals the muscles and liver to convert their stored glycogen back into glucose (a process called glycogenolysis), which raises blood sugar. When the body's stores of glucose and glycogen have been exhausted, the liver, and to a lesser extent the kidneys and small intestines, can transform some of the body's protein stores-muscle mass and vital organs-into glucose.

Insulin and Type 1 Diabetes

As recently as eighty years ago, before the clinical availability of insulin, the diagnosis of type 1 diabetes-which involves a severely diminished or absent capacity to produce insulin-was a death sentence. Most people died within a few months of diagnosis. Without insulin, glucose accumulates in the blood to extremely high toxic levels; yet since it cannot be utilized by the cells, many cell types will starve. Absent or lowered fasting (basal) levels of insulin also lead the liver, kidneys, and intestines to perform gluconeogenesis, turning the body's protein store-the muscles and vital organs-into even more glucose that the body cannot utilize. Meanwhile, the kidneys, the filters of the blood, try to rid the body of inappropriately high levels of sugar. Frequent urination causes insatiable thirst and dehydration. Eventually, the starving body turns more and more protein to sugar.

The ancient Greeks described diabetes as a disease that causes the body to melt into sugar water. When tissues cannot utilize glucose, they will metabolize fat for energy, generating by-products called ketones, which are toxic at high levels and cause further water loss as the kidneys try to eliminate them (see the discussion of ketoacidosis and hyperosmolar coma, in Chapter 21, "How to Cope with Dehydration, Dehydrating Illness, and Infection").

Today type 1 diabetes is still a very serious disease, and still eventually fatal if not properly treated with insulin. It can kill you rapidly when your blood glucose level is too low-through impaired judgment or loss of consciousness while driving, for example-or it can kill you slowly, by heart or kidney disease, which are commonly associated with long-term blood sugar elevation. Until I brought my blood sugars under control, I had numerous automobile accidents due to hypoglycemia, and it's only through sheer luck that I'm here to talk about it.

The causes of type 1 diabetes have not yet been fully unraveled. Research indicates that it's an autoimmune disorder in which the body's immune system attacks the pancreatic beta cells that produce insulin. Whatever causes type 1 diabetes, its deleterious effects can absolutely be prevented. The earlier it's diagnosed, and the earlier blood sugars are normalized, the better off you will be.

At the time they are diagnosed, many type 1 diabetics still produce a small amount of insulin. It's important to recognize that if they are treated early enough and treated properly, what's left of their insulinproducing capability frequently can be preserved. Type 1 diabetes typically occurs before the age of forty-five and usually makes itself apparent quite suddenly, with such symptoms as dramatic weight loss and frequent thirst and urination. We now know, however, that as sudden as its appearance may be, its onset is actually quite slow. Routine commercial laboratory studies are available that can detect it earlier, and it may be possible to arrest it in these early stages by aggressive treatment. My own body no longer produces any insulin at all. The high blood sugars I experienced during my first year with diabetes burned out, or exhausted, the ability of my pancreas to produce insulin. I must have insulin shots or I will rapidly die. I firmly believe-and know from experience with my patients-that if the kind of diet and medical regimen I prescribe for my patients had been utilized when I was diagnosed, the insulin-producing capability left to me at diagnosis would have been preserved. My requirements for injected insulin would have been lessened, and it would have been much easier for me to keep my blood sugars normal.

Blood Sugar Normalization: Restoring the Balance

According to the NIH, nearly 200,000 people die annually from both type 1 and type 2 diabetes and their long-term complications-and it is the NIH's contention that diabetes is grossly underreported on death certificates. (Is a diabetic's death from heart disease, kidney disease, or stroke, for example, really a death from diabetes?)

Certainly everyone has to die of something, but you needn't die the slow, torturous death of diabetic complications, which often include blindness and amputations. My history and that of my patients support this.

The Diabetes Control and Complication Trial (DCCT), conducted by the NIH's National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), began in 1983 as a ten-year study of type 1 diabetics to gauge the effects of improved control of blood sugar levels. Patients whose blood sugars were nearly "normalized" (my patients' blood sugars are usually closer to normal than were those in the intensive care arm of the trial because of our low-carbohydrate diet) had dramatic reductions of long-term complications. Researchers began the DCCT trying to see if they could, for example, lessen the frequency of diabetic retinopathy by at least 33.5 percent.

Instead of a one-third reduction in retinopathy, they found more than a 75 percent reduction in the progression of early retinopathy. They found similarly dramatic results in other diabetic complications and announced the results of the study early in order to make the good news immediately available to all. They found a 50 percent reduction of risk for kidney disease, a 60 percent reduction of risk for nerve damage, and a 35 percent reduction of risk for cardiovascular disease.

I believe that with truly normal blood sugars, which many of my patients have, these reductions can be 100 percent.

The patients followed in the DCCT averaged twenty-seven years of age at the beginning of the trial, so reductions could easily have been greater in areas such as cardiovascular disease if they had been older or followed for a longer period of time. The implication is that full normalization of blood sugar could totally prevent these complications. In any case, the results of the DCCT are good reason to begin aggressively to monitor and normalize blood sugar levels. The effort and dollar cost of doing so does not have to be remotely as high as was suggested in the DCCT's findings.

The Insulin-Resistant Diabetic: Type 2

Different from type 1 diabetes is what is officially known as type 2. This is by far the more prevalent form of the disease. According to statistics from the American Diabetes Association, 90-95 percent of diabetics are type 2. Furthermore, as many as a quarter of Americans between the ages of sixty-five and seventy-four have type 2 diabetes. A recent study, published by Yale University, discovered that 25 percent of obese teenagers now have type 2 diabetes.

(A new category of "pre-diabetes" has been recently called latent autoimmune diabetes, or LADA. This category applies to mild diabetes with onset after the age of thirty-five, in which the patient has been found to produce an antibody to the pancreatic beta cell protein called GADA, just as in type 1 diabetes. Eventually these people may develop overt diabetes and require insulin.)

Approximately 80 percent of those with type 2 diabetes are overweight and are affected by a particular form of obesity variously known as abdominal, truncal, or visceral obesity. It is quite possible that the 20 percent of the so-called type 2 diabetics who do not have visceral obesity actually suffer from a mild form of type 1 diabetes that causes only partial loss of the pancreatic beta cells that produce insulin. If this proves to be the case, then fully all of those who have true type 2 diabetes may be overweight. (Obesity is usually defined as being at least 20 percent over the ideal body weight for one's height, build, and sex.)

Continues...

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Excerpted from Dr. Bernstein's Diabetes Solution by Richard K. Bernstein Copyright © 2003 by Richard K. Bernstein, M.D.
Excerpted by permission. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

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