A growing problem

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Post by Kirsty Machon15 Aug 2004

For many people, the word ‘diabetes’ conjures up images of insulin injections, highly restricted diets and, perhaps, that pale, sickly kid at school who wasn’t allowed to have any lollies or paddle pops. The reality, as KIRSTY MACHON explains, is somewhat more complex.

There are two distinct types of diabetes ,both of which are related to abnormalities in the way the body deals with sugar.

The type of diabetes described above, requiring daily insulin injections, is called ‘type 1’ diabetes .Sometimes referred to as insulin-dependent or juvenile-onset diabetes, it’s probably the most well known type of diabetes ,but in fact it’s the least common. Only about 10-15% of people with diabetes fall into this category.

The more common form of diabetes is ‘type 2’, also called adult-onset or mature-onset diabetes .This condition is more likely to strike people in middle age or beyond (although both types of diabetes can emerge at any age), and while it doesn’t usually require insulin injections, it can have serious health consequences. It’s also the fastest-growing disease in the world.

Type 2 diabetes is closely linked to ‘lifestyle factors’ quite similar to those associated with heart disease: high levels of fats in the blood, ageing, too much alcohol, smoking, and not enough exercise.

Diabetes is also emerging as a concern for HIV-positive people, who may be more likely to develop diabetes as a long-term side effect of HIV treatment.

Why do people get diabetes and how might HIV drugs be related?

Diabetes used to be called ‘sugar diabetes ’, and while this name gives a hint at the nature of the condition, it is misleading. Diabetes is a complex disease of the metabolism, the means by which your body converts and breaks down the food you eat, and converts it into energy.

For the body to function, food must be converted into glucose, a type of sugar which can be readily absorbed, ‘taken up’ and then used by the body’s tissues and cells. Your body can make glucose from many types of foods, especially foods containing carbohydrates (starches and sugars).

The glucose which is extracted from food by your digestive system travels around your body in the bloodstream. In order to get from the blood into the cells where energy is needed, your body has to have adequate levels of a hormone called insulin, which is produced by the pancreas.

People who are diabetic either cannot produce insulin, or they do not produce adequate amounts of insulin. Without insulin, the glucose can’t get from the bloodstream into the cells where it’s needed, and glucose levels build up in the blood.

When you have too much glucose in your bloodstream (called hyperglycaemia), it can cause physical effects and symptoms. These symptoms can include:

  • tiredness (you’re not getting enough energy into your tissues and muscles);
  • frequently needing to pee (because your body is trying to rid itself of the excess glucose by pissing it out);
  • constant thirst (because of the increased need to pee);
  • blurred vision and eye problems (because diabetes  causes problems with circulation and this can damage the blood vessels in your eyes).

There is also a condition referred to as ‘pre-diabetes ’which can indicate that you are at risk of developing type 2 diabetes .Nearly one in four Australians over the age of 25 has pre-diabetes .Diagnosis of this condition is made through blood tests which can determine whether your body’s glucose metabolism is normal, and/or whether you have reduced glucose tolerance.

If you have pre-diabetes ,it doesn’t necessarily mean that you will develop diabetes ,but it does mean the risk is significantly higher.

Over the long term, diabetes can cause a range of potentially serious problems, like eye problems, kidney problems, poor ability to heal from minor wounds (particularly in the extremity of the body like toes), and an increased risk of heart disease.

Diabetes is not uncommon. Declines in the effectiveness of insulin can actually be caused by factors associated with other diseases of so-called ‘affluence’: eating too much, eating too much fat, drinking too much, and not getting regular exercise. All these factors have a toll on your metabolism — this is why diabetes often develops in middle age.

There is also evidence that extremely high fat diets in young children can also lead to the development of diabetes ,or pre-diabetes conditions, in young people including teenagers.

However, since the advent of HIV combination treatments, doctors and researchers have noted small but significant increases in the incidence of diabetes among positive people, and clinical research has demonstrated a decline in insulin sensitivity and the body’s ability to deal with glucose, in HIV-positive people taking some antiviral treatments.

It appears that this is all related to the complex long-term effects of HIV treatments on the metabolism, which are also being blamed for changes to fat metabolism and storage in the body — hypertriglyceridaemia (high blood fat levels), lipodystrophy (abnormal fat redistribution) and lipoatrophy (fat loss) — and an increased risk of heart disease.

HIV drugs don’t directly ‘cause’ diabetes the relationship is far more complicated and intricate. But some drugs appear to be more likely to create these problems than others, because of things they are observed to do to fat levels and to insulin in the body and in test tubes. For example, indinavir (Crixivan) has been demonstrated to impair the effectiveness of insulin quite immediately — and it seems the higher the dose of indinavir, the greater this effect. Other protease inhibitors have also been associated with increased risk of diabetes .

What can we do?

Obviously, for many positive people HIV treatments are a fact of life and can’t be eliminated. But even in people who are HIV-positive and taking treatments, the main risks for diabetes are similar to those for diabetes among HIV-negative people. These include:

  • increased triglyceride levels (a kind of fat in the bloodstream);
  • ageing;
  • a diet high in fats;
  • too much alcohol;
  • having a family relation such as a father or mother with diabetes 
  • high blood pressure;
  • being overweight — especially having a fat tummy or pot belly;
  • being of Aboriginal, Torres Strait Islander or Pacific Islander descent.

The good news about this is that many of these ‘risk factors’ can be managed. Admittedly, you can’t stop yourself getting older or change whether your dad is a diabetic, but you can do something about your diet, and the experts agree this is the key to preventing diabetes from developing in the first place, living well with diabetes if it does develop, and reducing its impact on your life.

What does this mean for me?

What this definitely does not mean is that you have to subject yourself to a boring, plain and dull diet regime of steamed vegetables and iceberg lettuce salads, or that fat or sugar or carbohydrates must never pass your lips.

Some diet manias, particularly low carbohydrate, high-protein diets like Zone and Atkins, claim to reduce the risk of developing diabetes .But they are based on theories which are dubious and controversial in the general population, and could actually do serious damage over the long term if you also have HIV. Your body needs its carbohydrates (grain foods, wholegrain breads, pasta, beans and lentils) just as much as it needs protein.

A lot of the old thinking around diabetes is now changing. Research now shows, for example, that small amounts of sugar don’t ‘push up’ your blood glucose levels any more quickly than some starchy foods, like white rice or potatoes. These foods don’t have to be immediately banished from your diet — but they should be a moderate part of an all-round diet with a focus on fresh and nutrient-rich foods like vegetables, fruit and breads.

This is where something called the Glycaemic Index (GI) comes in. The GI is a measure of how quickly particular foods convert to blood glucose. Foods which metabolise more slowly are better, as this helps keep blood glucose levels stable. Foods which cause glucose levels to rise fairly quickly are called ‘high GI’ foods and include white bread, sugar and potatoes. Other foods raise blood sugar levels more slowly, like whole grain rice.

In general, people with diabetes are advised to eat high GI foods in moderation, and ensure that they are balanced out by low GI foods at each meal. Some foods, like chocolate bars, which have very high GIs, and not much other nutritional substance, might not be so advisable, particularly between meals.

Some foods are now labelled according to their GI index, and tables rating common foods can be downloaded from the internet. You can have a look at how particular foods match up on the GI index, and choose low GI foods.

There are some other important things that can help keep diabetes under control. Being overweight is associated with diabetes , however, many people with HIV-associated diabetes aren’t actually overweight. If you have a fat belly associated with HIV drugs, it’s also possible you have significant loss of fat in other parts of your body. So you need to follow different advice from the usual low-fat diet approach. An HIV-experienced dietitian can help you plan a diet to suit your particular circumstances. He or she might also be able to help with things like shopping on a budget, cooking skills or equipping your kitchen.

It may help to control glucose levels if you eat smaller meals at more frequent intervals throughout the day. This ensures that glucose gets released into your body more regularly, and not in big hits followed by big slumps (ever noticed how tired you feel after a big, heavy meal?)

Exercise is important too. This doesn’t mean embarking on a great program of aerobic heroism or mountain-scaling, just making sure that you walk, swim, play sport or even get a bit of resistance work in, like light weight lifting, each day.

Some people with type 2 diabetes will go on to need medical treatments, such as metformin. Diet and exercise alone isn’t going to change the world for everyone. But it’s a good foundation for ensuring that you control your diabetes  — and not the other way around.

Diabetes facts

  • The fastest-growing disease in the world.
  • About one million Australians are diabetic.
  • Type 2 (adult-onset) diabetes accounts for 85–90% of cases.
  • About half of all people with diabetes don’t know they have it.
  • Every ten minutes in Australia, a person is diagnosed with diabetes .
  • Some HIV treatments can increase the risk of developing diabetes .
  • Most people with diabetes don’t have to inject insulin to control it.
  • The best way to control type 2 diabetes s usually through diet and exercise.