Talk:Diabetes mellitus/Archive1

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Contents 1 Foot and lower limbs need more attention 2 Double diabetic ketoacidosis 3 Sports and DM? 4 Diet and exercise in type-2 DM 5 role of insulin 6 units

Foot and lower limbs need more attention

I'm really not a medical person so I'm reluctant to actually contribute to the article - but I work on creating software health interventions to help people perform self care regarding diabetes related pedal complications. This is also one of the primary concerns of Diabetes Australia this year. The prevalence of foot complication in this group is between 3-6% (in Australia at least). Common pedal complications include; foot ulcers, infections, cellulitis, peripheral vascular disease, neuropathy, fractures and the need for amputation. Lower limb complications in people with diabetes have been estimated to cost the health care system about $300 million per year in Australia. So it's a big issue - but only briefly mentioned in the article. Melody

This page has been listed on the Wikipedia:pages needing attention list as "not up to the standards of scientific knowledge". Can you please let us know what is wrong with it, so we can correct it? -- Karada 22:23, 23 Sep 2003 (UTC)

several things:

• reorganization of information to make more sense, removing duplicate information
• verifying to ensure correctness of data
• general polishing up of grammar, style, structure.

I guess there might be others suggestions too, but these should do for starters. --Alex.tan 06:12, 24 Sep 2003 (UTC)

Double diabetic ketoacidosis

This article has a section on diabetic ketoacidosis, but we have an entire article on it in the 'pedia. Wouldn't it be better to just link to it? We could have a sentence or two on the condition with a link to the article. Having a section in this article on it seems to be redundant. —Frecklefoot 14:40, 28 Jan 2004 (UTC)

F, I agree that a pointer would do the trick, but I would observe that a general article on DM is all some folks will ever see. Since DKA is a large and ominous looming bit for diabetics, it should be mentioned here. The details of the biochemistry (even in outline) might not need to be here, but the tricky business with absence of carbohydrate triggering inhibition of fat processing and so to DKA probably needs to be said in an era of Atkins dieters.

Altogether, as with most subjects DM, it's not easy to determine what level of coverage is needed when. My bias is to include more than less, on the general principle that people can ignore stuff, but may need stuff that's been unsaid. ww 17:10, 7 Apr 2004 (UTC)

Sports and DM?

I'm curious, does sports help Diabetic people, namely Type 2? And does the dosage of metformin depend on the obesity of the person? As in, if the type 2 diabetic loses weight, does he/she stop or at least decrease the metformin dosage? Thank you

Exercise (ie, some sports -- billiards is not a good example, nor is the usual sort of 10-pin bowling) causes an increase in glucose uptake into (particularly muscle) cells that would ordinarily require insulin. Thus, all other things being equal (and they NEVER are), a brisk 45 minute hike would decrease one's need for insulin. Blood glucose levels would decrease as though more insulin had been present. Even in Type 2s with insulin resistance.

Metformin's major effect is to inhibit release of stored glucose (kept internally as glycogen in liver cells). If done incorrectly, this release will tend to keep blood glucose levels high. In nondiabetics, this is controlled by the blood insulin level which is in turn dependent on blood glucose level which is in its turn dependent on recent ingestion of carbohydrates. Low insulin level means not much recent carb intake, so disassemble some glycogen into glucose and dump into the blood. High insulin levels mean lots of recent carb intake and so don't dump glucose into the blood, but take it in and convert it to glycogen stores for later use. In Type 2's, due to insulin resistance, insulin levels are odd and somewhat decoupled from blood glucose levels (and recent carb ingestion) and so the liver's glucose release response is often inappropriate. Metformin reduces some of this inappropriateness.

For reasons which are only now becoming dimly understood, fat tissue beyond some amount (probably a proportion of body weight, varying with individual and with gender) is connected with insulin resistance and perhaps with insulin (and other hormone) secretion. Fat tissue produces several signaling chemicals (ie, hormones more or less), and a considerable amount of entirely unexpected inflammation (ie, agitated immune system cells more or less -- think disturbed wasp nest) has also been found in fat tissue. It is clinically observed that weight reduction (ie, less fat tissue mass, amputation or wasted muscles apparently doesn't count) -- even a surprisingly small reduction in some cases -- reduces cellular insulin resistance, sometimes enough to get one off diabetic medication entirely. Even metformin. Quite what going on is obscure.

On the other (athletic) hand, many diabetics have vascular damage (heart, periphery, kidneys, eyes, ...) which make them poor candidates for some kinds of sports. American or Australian football, rugby, basketball (all that jumping and abrupt starts and stops), tennis (same as basketball w/o the jumping), ... are possibilities. And nerve damage (neuropathy of various sorts) are contraindications for some kinds of things as well. For these folks, exercise may not be a good idea. Who belongs in which group is an individual matter depending on one's 'degree' of diabetes, presence of complications, response to exercise, ...

It is critical for diabetics that their medical care folk (in many places this will be a physician, but not always) be not only adequately informed about diabetes (not always, regrettably, true) and involved with the case (rather than distantly 'consulting' now and again) and available to answer such questions in an understandable to the patient way. Diabetes mellitus is rarely a problem which can be handled sensibly on a 'set something up and forget it' basis. Things change too much, and too rapidly for this. And people vary too much. The downside if such a procedure is (wrongly) followed is high. Amputation, blindness, kidney failure, ... rates are too high to accept casually without clear thought. No one should unthinkingly do something which increases their risk of any of them, if there is any alternative at all.

Sorry there's no blanket (fits all) answer to any of your questions. It's the nature of the beast, regrettably. ww 15:09, 11 Jun 2004 (UTC)

Diet and exercise in type-2 DM

I am a doctor recently self-diagnosed with DM, with a pretty high reading. Having controlled my own sugar levels, I found I was able to help many patients get off their medicines and control their sugar with diet and exercise alone. Note that I refer only to Type-2 diabetics.

From my experience, here are some suggestions to be tested for yourself, esp if you've been struggling unsuccessfully to control your blood sugar levels:

1. Eat less. (Assuming you are not undernourished/ emaciated). Aim for a BMI of 21 or 22, comprising mostly muscle! 2. Eat less carbohydrate - certainly not the American diabetes assoc recommendation of 60%!! 35-40% is good enough. 3. Ideally, eat soon after exercise, when the muscles are glycogen-depleted and most responsive to glucose. the first two hours after exercise are best. 4. You may have a cup or two of tea/coffee besides the meals. Use a sugar substitute. 5. Walk twice a day, for 30 mins and 1 hr, in any order. It doesn't have to be very brisk. 6. Build some muscle - don't need to go overboard. 7. Your target is to keep the blood sugar level within 80-100 mg/dl round the clock, for the rest of your life. It is possible.

If your blood sugar is very high, fast completely a day, then go on to eggs, cheese and yogurt (all sparingly) for a day. Walk a lot in this time. Take medicines which don't put a load on your pancreas - the sulfonylureas do that, so avoid them, whatever anyone says. After 2 days, get to a normal diet, eating less as suggested above. In about a week, check again, and if normal, try cutting out the medication. Check your sugar levels again in 2 days.

Get a glucometer, and check your blood sugar at intervals, esp after eating different kinds of meals to see how each is affecting you. Once you get a general idea, you can check once in 2 weeks or so.

Read "Diabetes solution" by Richard Bernstein, esp if you're in bad trouble. Use the book very strictly till your sugar is and has been under control for 2 months, then you can relax a bit and try things, like eating a fruit on and off, always checking to see if you're still in control. Diabetes type-2 has been called a lifestyle disease. In a nice article by the editors of Prevention magazine, they gave it the silver-lining award: a type-2 diabetic has to do what all people should be doing anyway: eating a bit less, and exercising regularly. With that, things can be completely normal - no complications, no problems. Indeed, many people (and I include myself) find themselves much happier and focused, with a major change in their lifestyle and life. Diabetes in my opinion is a mental problem - you can handle it, or you can breakdown. Depends on you entirely (with just a little know-how and a little medical help).

--210.18.159.10 18:59, 25 Jun 2004 (UTC)AVS

role of insulin

I edited this section. I hope you think it slightly clearer. I corrected an apparent error (perhaps unintended). Insulin directly stimulates glycogen synthesis, but it is glucagon that stimulates glycogen breakdown to glucose (usually insulin and glucagon levels are reciprocal, so that insulin is falling while glucagon is rising, but one does not regulate the other). In diabetes, esp type 2, liver glucose output is usually excessive, rather than reduced. Does this make sense? Alteripse 12:27, 21 Jul 2004 (UTC)

Alterprise, I suspect that phrase was mine, and if so, it was intentional as it reflected what I understood about the details. It was my impression that low insulin levels resulted in glycogen breakdown, without necessarily requiring glucagon. I have finessed quantitative levels as I've never come across anything numeric on this. Though I was/am less clear on the mechanism: eg, default setting of the mechanism is glycogen --> glucose, inhibited in the presence of higher insulin levels, unless glucagon is present? Liver cells must be somewhat crazy listening to so many different instructions from so many different sources. In any case, I think I remember being told that many diabetics (especially after some years) have deranged glucagon secretion/control in any case. How close was/am I? ww 13:41, 21 Jul 2004 (UTC)

You are mostly right. Glycogen breakdown requires either low insulin levels or high glucagon levels. Luckily glucagon's ability to stimulate glycogenolysis exceeds insulin's ability to inhibit it or we would not be able to reverse insulin-induced hypoglycemia with glucagon. I spent 2 years of my life doing research on the nature of insulin regulation of glycogen synthesis (via the phosphatase enzymes) but that was long ago. And yes, some people w diabetes, esp type 1, lose their ability to release glucagon in response to hypoglycemia after years (mechanism complex and sometimes reversible). I added some more on this to the glycogen article. Let me know if I need to clarify further. Alteripse 17:28, 21 Jul 2004 (UTC)

I removed new statement It is the chief metabolic control signal throughout the body. because I can't figure out how one would defend that statement to someone who wanted to say the same thing about thyroid hormone, cortisol, or growth hormone. All have sweeping multisystem effects on many metabolic pathways, and deficiency of any or excess of any lead to major changes in metabolism. It also seems excessively vague to me. Can you think of a way to refine or clarify what you meant? I wouldn't disagree with "It is an important metabolic control signal throughout the body", but I'm not sure that adds much to what we already say. What do you think? Alteripse 00:55, 22 Jul 2004 (UTC)

A, I was trying for something acessible (and memorable) to the layman, not precision in medical or phsiological terms. Your qualms re thyroid, cortisol, and growth hormone are apt, just off the point I was trying for. ww 13:45, 22 Jul 2004 (UTC)

OK, I thought about it. How about: insulin is the principal signal in converting many of the bidirectional processes of metabolism from a catabolic to an anabolic direction. Is that understandable? Does it say what you intended? Alteripse 00:59, 22 Jul 2004 (UTC)

A, I would observe that, though more accurate and certainly more precise, the extra concepts make the comment less striking/memorable for those I had in mind with my original version to which you objected. A tightrope WP articles must eternally walk, I fear. I can live with this, though I'd hope someone could come up with something both accurate AND striking (I've spent 20 minutes pondering and haven't).

units

On another point, I propose that this and related articles be subject to a rule: BOTH units are given if one is mentioned (in re mg/dl vs mmol/l). The first is almost never used in the US, and I gather the second is nearly universal in Europe. Comments from others on this? Please? ww 13:45, 22 Jul 2004 (UTC)

From a chemistry point of view, mmol/l seems to make more sense to me as that: i) measures the concentration of molecules of the stuff and, perhaps more importantly, ii) the units for the normal range are smaller and therefore easier to remember. The standard accepted units in Singapore, Malaysia and Australia are the mmol/l units, AFAIK. Alex.tan

• Both US and systeme international are appropriate given our readership-- and I've never heard of a third system. Many glucose meters are have the ability to switch back and forth between the two systems. I put both in the diagnosis section. Alteripse 13:31, 24 Jul 2004 (UTC)