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Diabetes. We can help in some cases.
Professor Christopher D. Saudek, M.D. explains the path of glucose in diabetes.
In someone with diabetes, the body’s ability to secrete insulin -- and the counter-regulatory hormone glucagon -- is
impaired. The pancreas is an elongated organ that extends across the abdomen, below the stomach. In addition to
secreting certain enzymes that aid in food digestion, the pancreas also manufactures hormones responsible for regulating
blood glucose levels.
Scattered throughout the pancreas are more than a million tiny nests of cells known as the islets of Langerhans. Each islet
contains several different types of cells. The majority are beta cells, which produce and store the hormone insulin until it is
needed. Also located in the islets are alpha cells, which make and store glucagon, a hormone that counteracts the effects
of insulin.
After a meal, carbohydrates are broken down into smaller molecules as food travels through your digestive tract. Complex
carbohydrates (found in starchy foods, such as pasta and potatoes) are long strings of glucose that require more digestion
than simple sugars (such as sucrose in candy or table sugar). Digestion begins in the mouth. A salivary enzyme called
amylase breaks down carbohydrates into smaller molecules that pass through the esophagus and stomach and into the
small intestine. Another type of amylase from the pancreas and enzymes in the intestine then split the partially digested
carbohydrates into simple sugar molecules small enough to be absorbed across the intestinal wall.
The absorbed glucose and other simple sugars then travel to the liver via the portal vein. Once there, the simple sugars
are converted into glucose in the liver, which in turn releases glucose into the bloodstream according to how much your
body needs for energy. Some of the unused glucose is stored in the liver and muscle tissue as glycogen for future energy
needs and the rest is stored as triglycerides in adipose (fatty) tissue.
After you eat a meal that contains carbohydrates and glucose enters the bloodstream, it triggers a response by the
pancreas and causes the cells in the islets of Langerhans within the pancreas to produce and release insulin. The insulin,
in turn, allows glucose to move from the bloodstream into the cells in your body, where it is used for energy.
If you have type 1 diabetes, the pancreas produces little or no insulin, and glucose remains in the bloodstream
instead of entering cells. If you have type 2 diabetes, the pancreas produces and releases insulin, but the cells are not
sensitive enough to it and insufficient glucose enters the cells. The glucose remaining in the bloodstream signals the
pancreas to produce even more insulin. Eventually, however, the pancreas is not able to produce enough insulin to
overcome the reduced responsiveness of cells to insulin.
To recap:
In someone without diabetes, beta cells sense the rising blood glucose levels and secrete insulin into the
blood. Once in the bloodstream, insulin helps glucose enter the body’s cells, where it is “burned” for energy
or converted to glycogen by the liver and muscles and stored there for future energy needs. As a result,
blood glucose levels return to normal, and insulin secretion decreases.
On the other hand, a drop in blood glucose levels - for example, when one hasn’t eaten for several hours --
stimulates the alpha cells to secrete glucagon into the blood. Glucagon raises blood glucose levels by
signaling the liver to convert stored glycogen back into glucose and release it into the bloodstream. Normally,
the secretion of these hormones by the pancreas is perfectly balanced: Beta and alpha cells continuously
monitor blood glucose levels and release insulin or glucagon as needed.
But in someone with diabetes, this delicate balance is impaired because the beta cells produce little or no insulin, the body’
s cells are resistant to insulin, or a combination of both is at work. Regardless, glucose cannot enter cells effectively and
remains in the bloodstream. The result is persistently high blood glucose levels (hyperglycemia). Without treatment,
hyperglycemia can lead to serious long-term complications, such as heart, eye, and kidney disease.
Type 2 diabetes usually develops gradually over many years and the initial symptoms may be almost unnoticeable. In
fact, many people find out that they have type 2 diabetes when a routine laboratory test shows high blood glucose levels.
Increasingly endocrinologists are using the hemoglobin A1c (HbA1c) test -- which is now used to monitor glucose control in
existing patients -- to diagnose diabetes.
If you have any of the common symptoms that suggest the presence of diabetes, your doctor can order a blood glucose
test to confirm or rule out the diagnosis. Three blood tests commonly used to diagnose prediabetes and diabetes:
casual plasma (blood) glucose
fasting plasma glucose (FPG)
oral glucose tolerance test (OGTT)
Blood glucose levels naturally fluctuate, so don't get exceptionally worried if they go up for no apparent reason -- we can
never explain every rise and fall. Food and drink, stress or an illness can also provoke a temporary jump, and a cortisone
injection (into a knee or shoulder, for instance) will predictably raise blood glucose a lot.
Your average blood glucose level (HbA1c) is the best indication of how well you are managing your diabetes over time.
That doesn't mean you shouldn't monitor your blood glucose levels at various points in the day. Finger-stick tests can give
an early indication that your glucose is rising faster than it should.
The HbA1c test measures the amount of glucose attached to hemoglobin -- the oxygen-carrying protein in red blood cells
that gives blood its color. As blood glucose levels rise, so does the amount of glucose attached to hemoglobin. Since
hemoglobin circulates in the blood until the red blood cells die (half of red blood cells are replaced every 120 days), the
HbA1c test measures average blood glucose levels over the previous two to three months.
The American Diabetes Association recommends keeping your HbA1c levels at less than 7%, which is equivalent to an
average blood glucose level of about 170 mg/dL or less.
HbA1c tests are usually performed every three months to see if you are maintaining your blood glucose within the target
range. If you have stable blood glucose levels and are meeting your treatment goals, you may need less frequent HbA1c
testing.
Keep in mind that blood glucose naturally goes up and down, and sometimes the fluctuations are unpredictable. No matter
how hard you try, your levels will not be normal every time you test. As long as they don't stay too high, you should be in
good shape.
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